Revised March 23, 2008
GOALS AND OBJECTIVES
RESIDENT ROTATION IN NEUROLOGY
2008-2009
Rotation Coordinator:
Steven Glyman, M.D.
1707 W. Charleston Blvd. #230
Chief, Division of Neurology
University of Nevada School of Medicine
Las Vegas, Nevada 89102
OVERVIEW
EDUCATIONAL PURPOSE
The purpose of this four-week rotation is to provide education and experience in the care
of patients with known or suspected neurologic disease. The residents provide inpatient
consultations for University Medical Center. Residents see patients with neurologic
conditions at the UMC outpatient clinic, the VA ambulatory clinic, and the UNSOM
faculty clinic.
The general internist should possess a broad range of competency in neurology. He or
she should be able to perform and interpret a detailed neurologic examination; should be
competent in the primary and secondary prevention of neurologic diseases; and should be
familiar with the presenting features, diagnosis and treatment of common neurologic
disorders.
The general internist may encounter neurologic disorders in various settings, including
ambulatory care, hospital, long-term care and home care. In communities where a
neurologist is not available, the general internist may be a consultant for some complex
neurologic disorders (for example, control of status epilepticus).
At the conclusion of this rotation residents will have gained insight into the diagnosis and
management of patients with neurologic diseases, their role as subspecialty consultant,
diagnostic methods of neurologic diseases, the natural history of neurologic disease, and
strategies for cost-effective and evidence-based evaluation and treatment. This
curriculum is based, in part, upon the report of the Federated Council for Internal
Medicine Task Force on the Internal Medicine Residency Curriculum. Neurology
encompasses the prevention and management of disorders of the central and peripheral
nervous systems. Other conditions, such as headache, may be caused by non-neural
dysfunction but are often considered under the category of neurology.
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Teaching Methods
The resident will see each new consultation first, create a note with recommendations,
and then present the patient to the attending neurologist. The attending will evaluate the
patient and provide teaching and feedback, after which final recommendations will then
be made. The resident will be working closely with the attending neurologist providing
daily progress notes and follow-up recommendations for the care of each patient. Daily
rounds will occur with the attending physician at which time instruction in the unique
aspects of the consultative process will be provided. Residents will be required to
continue their regular Morning report and Noon conference core curriculum. The resident
and attending will review and discuss each required reading.
Patients seen in the neurology clinic will be seen and staffed in an analogous manner.
Mix of Diseases
The patients seen will represent the very wide spectrum of neurology disorders
encountered in our inpatient setting and outpatient clinics.
Common Clinical Presentations
Residents will become knowledgeable of the diagnosis, management, and complications
of the following neurologic disorders encountered in an inpatient setting: central nervous
system infections (meningitis, encephalitis, brain abscess, epidural abscess),
cerebrovascular disease (stroke, transient ischemic attack), epilepsy, multiple sclerosis,
neuromuscular diseases (myopathy, amyotrophy, Guillain-Barre syndrome, Myasthenia
gravis), subarachnoid hemorrhage, subdural hematoma, and toxic encephalopathies.
The resident will become knowledgeable of the diagnosis, management, and
complications of the following neurologic disorders encountered in an outpatient setting:
dizziness, vertigo, altered sensation (including localized pain syndromes and
radiculopathies), weakness/paresis (both generalized and localized), abnormal speech,
abnormal vision, disturbed gait or coordination, headache, seizure, tremor, dementia’s
and impaired memory, sleep disorders, hearing loss, Parkinsonism, peripheral
neuropathies and spinal disc syndromes. Common presentations include:
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Abnormal speech
Abnormal vision
Altered sensation
Confusion
Disturbed gait or coordination
Dizziness, vertigo
Headache
Hearing loss
Localized pain syndromes: facial pain, radiculopathy
Loss of consciousness
Memory impairment
Seizure
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Sleep disorder
Tremor
Weakness/paresis (generalized, localized)
Common Procedures
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Caloric stimulation test
Tensilon (edrophonium chloride) test (optional)
Halsted – Baranay maneuver
Lumbar puncture
Ordering and Understanding Tests
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Anticonvulsant drug levels
Carotid Doppler echo scans
Computed tomography, magnetic resonance imaging of central nervous system
Digital intravenous angiography
Electroencephalography, evoked potentials (visual, auditory, sensory)
Electromyography, nerve conduction studies
Muscle biopsy
Myelography
Screen for toxins, heavy metals
Sleep study
Patient Characteristics
The patient population is diverse, male and female, of all ages from adolescent to
geriatric, representing most ethnic and racial backgrounds, from all social and economic
strata. The hospital serves primarily the indigent population of the city of Las Vegas.
Types of Clinical Encounters
All patient encounters are in the inpatient setting on a consultative basis from other
clinical services or from an ambulatory physician who has referred a patient for
admission.
Close interaction with various other healthcare team members including care managers,
discharge planners, home health agencies, inpatient nurses, respiratory therapists, physical
therapists, and patient care technicians occurs daily.
Resident Supervision
Residents have constant on site supervision as well as daily personal supervision in their
patient care.
Didactic Teaching
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Morning Report
Residents rotating on the neurology service are required to maintain greater than
60 % attendance at morning report. Morning Report begins at 8 a.m. on Monday
through Thursday and at 8:30 a.m. on Friday.
Noon Conference
Residents rotating on the neurology service are required to maintain greater than
60% attendance at noon conference. Noon conference occurs daily, Monday
through Friday. These sessions cover the basic core curriculum, and other
curriculum topics such as ethical issues, geriatrics, computer systems and
informatics, health care systems, occupational and environmental health issues,
and other topics of concern. An infectious disease topic is presented at least once
during each month.
Attending Rounds
Didactic discussions will be held regarding all consultative activities and patients
seen during the month. Teaching rounds by the attending physician will occur
every day for 45 - 60 minutes after regular management rounds. Each resident is
required to review neurology topics.
Core Reading Materials
Adams and Victor's Principles of Neurology 8th ed., Ropper AH, editor
Harrison’s Principle’s of Internal Medicine, 16th ed., Kasper DL, editor. McGraw
Hill
The Washington Manual of Medical Therapeutics, 32nd ed.
The Washington Manua Neurology Survival Guide, Rengachary D, editor.
Lippincott Williams & Wilkins
Ancillary Educational Materials
Subspecialty Texts of Neurology, Pulmonary Medicine, Nephrology,
Endocrinology, Infectious Diseases, Rheumatology as well as General
Medical
References (Harrison’s Principles of Internal Medicine, Cecil’s
Textbook of Medicine) are available 24 hours a day, seven days a week in the
resident lounge.
Savitt Medical Library On-Line
Residents have access to the on-line services of Savitt Library (the main library of
the University of Nevada - Reno) via their computer in the resident room, Suite
300 of the 2040 W. Charleston Building. Access to this room is available 24
hours a day, seven days a week.
Full text is available for many peer-review journals including, but no limited to:
ACP Journal Club
Annals of Internal Medicine
British Medical Journal
Cancer
Circulation
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Journal of the American College of Cardiology
The Lancet
New England Journal of Medicine
Stroke
Also available on-line:
Harrison’s Principle’s of Internal Medicine, 16th ed.
Merck Manual, 17th ed.
Guide to Clinical Preventive Services, 2nd ed.
The Cochrane Library
Medline and Grateful Med Databases
Pathological Material and Other Educational Resources
Residents are encouraged to review the pathological reports on patients for whom they
have consulted and to follow the hospital care of those patients. If a patient with whom
the resident has consulted should die and have an autopsy, the resident is encouraged to
attend the post-mortem session.
Training Sites
University Medical Center
All of the inpatient endocrine consultation experience occurs at University
Medical Center (UMC) under the supervision of one of the full-time neurology
faculty. The resident will also participate in the UMC outpatient neurology clinic
each Monday.
II. Competency-based Goals and Objectives
Neurology
(Only a single level of competency is described, as this is a resident-level rottion
undertaken once during residency)
Learning Venues
Evaluation Methods
1. Direct patient care/consultations
2. Attending Rounds
A. Attending evaluation
B. Direct Observation
3. Residency core lecture series
C. Nurse evaluations
4. Self study
D. Written Examination
5. Morning Reports
E. Resident/Self Evaluation
F. Patient Evaluation
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Level Specificity
This will occur
during either PGY2 or -3 level, with
no difference in
expectations or
standards for each
year
Competency: Patient Care
Learning
Venues
1,2
Evaluation
Methods
A, B, E
1, 2
A, B, E
NA
1, 2
A, E
NA
1, 2, 3, 4, 5
A, B, D, E
NA
1, 2, 3, 4, 5
A, B, D, E
Competency : Medical Knowledge
Learning
Venues
Evaluation
Methods
Demonstrate knowledge of the
established basic biomedical, clinical and
social sciences
Acquire and critically evaluate current
medical information and scientific
evidence
Apply this knowledge toward clinical
problem-solving and clinical decisionmaking for individual patients
1, 2, 3, 4, 5
A, B, D, E
NA
1, 2, 3, 4
A, B, D, E
NA
1, 2
A, B, D, E
NA
Gather accurate, essential information
from the medical interview, physical
examination, laboratory data (including
blood work, fluid analysis and
radiographs), and review of medical
records
Provide consultation and direct the
management of patients with neurologic
disease
Become familiar with the procedures
inherent to the practice of neurology
including lumbar puncture, and caloric
stimulation tests.
Become familiar with the tests common
to neurology including
electroencephalography, computed
tomography and magnetic resonance
imaging of the central nervous system,
electromyography and nerve conduction
studies, muscle biopsy, myelography,
anticonvulsant drug levels, and carotid
doppler scans.
Make informed decisions and
recommendations about preventive,
diagnostic and therapeutic options and
interventions based upon clinical
judgment, scientific evidence and patient
preference
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Level
NA
NA
Level
Apply this knowledge toward the
education of patients, families, medical
students, fellow residents and other
health professionals
1, 2
A, B, D, E
Competencies: Interpersonal and
Communication Skills
Learning
Venues
Evaluation
Methods
Maintain comprehensive, timely and
legible medical records
Supervise, lead, manage, and teach more
junior house staff and medical students
Effectively communicate with
consultants, peers, other allied health
professionals, as well as patients and their
families
Communicate with patients and their
families regarding end-of-life issues,
categorization, organ donation, and
requests for autopsies
Ensure adequate transfer of information
when transferring patient to care of
another physician or signing out to
coverage
Communicate efficiently and effectively
with referring physician, regarding
diagnosis, treatment and follow-up.
1, 2
A, B, C
NA
1, 2
A, B, C, D, E
NA
1, 2
A, B, C. E
NA
1, 2
A, B, C, E, F
NA
1, 2
A, B, C, E
NA
1, 2
A, B, C, E
NA
Competency: Professionalism
Learning
Venues
Evaluation
Methods
Demonstrate respect, compassion,
integrity, and altruism in relationships
with patients, families, and colleagues
Demonstrate sensitivity and
responsiveness to the gender, age,
culture, religion, sexual preference,
socioeconomic status, beliefs, behaviors
and disabilities of patients and
professional colleagues
Always act in a moral, ethical and
professional manner
Responsibly represent this residency
program, the department of Internal
Medicine, the University of Nevada
1, 2
A, B, C, E, F
NA
1, 2
A, B, C, E, F
NA
1, 2
A, B, C, E, F
NA
1, 2, 3, 5
A, B, C, E, F
NA
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NA
Level
Level
School of Medicine, the University
Medical Center and the profession of
medicine
Respect and defend each patients’
autonomy and privacy and always act in
the patients’ best interest
Competency: Practice-Based Learning
Access current information from the
scientific and practice literature to
support and improve your clinical
practice
Develop and maintain a willingness to
learn from errors and use errors to
improve the quality of patient care
Incorporate case studies with relevant
research outcomes and report those
findings during clinical rounds.
Review the outcomes of patient care in
order to reflect on the approach taken in
the delivery of care.
Utilize established practice guidelines for
individual diseases to devise care
strategies.
Identify limitations of one’s medical
knowledge in evaluation and
management of patients and use medical
literature (primary and reference) to
address these gaps in medical knowledge.
Competency: System-Based Practice
Understand need for effective
communication between multiple
caregivers (i.e. emergency room, critical
care unit, nurses, physicians, transporters,
outpatient clinic, radiology, laboratory).
Understand clinical trial design and the
statistical methods for evaluating
scientific studies, in cooperation with
attendings and research nurses/personnel.
Learn appropriate use of medical and
non-medical subspecialties
1, 2
A, B, C, E, F
Learning
Venuses
1, 2, 4, 5
Evaluation
Methods
A, D, E
1, 2, 4
A, E
NA
1, 2, 3, 4, 5
A, B, E
NA
1, 2, 3, 4, 5
A, B, E
NA
1, 2, 4
A, B, E
NA
1, 2, 4,
A, E
NA
Learning
Venues
1, 2, 3, 4
Evaluation
Methods
A, E
Level
1, 2, 3, 4, 5
A, B, C, E
NA
1, 2, 4
A, B
NA
8
NA
Level
NA
NA
Understand and access all resources
available and necessary to provide
optimal patient care
Apply evidence-based and cost-conscious
strategies toward disease prevention,
diagnosis and disease management
Develop lifelong strategies to optimize
care for individual patients
VI.
1, 2, 4
A, B, E
NA
1, 2, 4
A, B, E
NA
1, 2, 4
A, B, D, E
NA
EVALUATION
A. Of Residents
All clinical faculty are required to complete the standard ABIM resident
evaluation form. All clinical faculty are encouraged to provide face-to-face
feedback with the residents.
B. Of Rotation and Preceptor
All residents have the opportunity to evaluate the rotation, and the clinical faculty
member, at the completion of the rotation. The form is included at the end of this
document. These evaluations are then converted to type and shared anonymously
with the clinical faculty.
The program director also discusses the rotation with the residents to ensure
rotation quality and satisfaction.
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Neurology Rotation Resident Check List
1. Evaluation reviewed at mid-month and end of rotation by the supervising faculty
member and resident.
2. Completed assigned readings.
3. Attended all assigned clinical activities (excluding scheduled time away, required
clinics and emergencies).
4. Completed required case report abstracts and/or posters assigned by the supervising
faculty member.
5. Demonstrated understanding of the basic principals of neurologic consultation and
management.
6. Received verbal feedback at end of rotation.
Intern/Resident Signature___________________________ Date_________________
Supervising Faculty_______________________________ Date_________________
All items must be completed for rotation credit and checklist returned to the
Department of Medicine by the month’s end.
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