Neurology

NEUROLOGY

NEUROLOGY ROTATION INFORMATION

Rotation goals: be confident in your neurologic exam, able to describe abnormalities found and potential etiologies, formulate a basic plan for diagnostic evaluation/treatment for common neurologic disorders that reflect our patient population (ie, migraines, epilepsy, compression neuropathies, sleep disorders.)

1. 1-2 weeks before the start of your rotation, please provide a copy of your AMION schedule to Dr. Brophy via email. (Gwendolyn.m.brophy.civ@mail.mil.) 

   1. Please provide a contact phone number so we can reach you should a consult or patient opportunity arise

2. Trying to incorporate one half-day experience at the Intrepid Center (Concussion Clinic)

   1. Goal is to better understand some of the additional treatment services available for our complex TBI patients.

   2.  Please provide what days you would be available for this experience

3. Clinic starts with patient care at 0800 with the last check-in generally at 1500.  If you will be late, you must notify the appropriate staff.

4. On the first day of your rotation, you should report to Dr. Brophy’s office. If she is not available, please speak to one of the other neurologists.

   1. You will receive:

      1. brief orientation to the Neurology Clinic.

      2. a three-ring binder that has the suggested Family Medicine Neurology rotation reading list

5. Bring your own stethoscope to use

6. Review the following day’s schedule to select patients that you feel would be most beneficial to your learning.

7. Let the assigned staff neurologist know that they have a scheduled patient that you would like to see.

8. Expect mostly outpatient experience with occasional inpatient consult

9. You will see and evaluate new patients on your own, presenting them to the assigned staff and writing the notes

10. Procedural opportunities may arise, for example botox, let staff know if you are interested in these opportunities

READING LIST FOR FP NEUROLOGY ROTATIONS

WEEK 1:

NEURO EXAM:

https://neurologicexam.med.utah.edu/adult/html/home_exam.html

VIDEO NEURO EXAM:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7347716/

HEADACHES:

1. Frequent Headaches: Evaluation and Management - https://www.aafp.org/afp/2020/0401/p419.html

2. Migraine Headache Prophylaxis - https://www.aafp.org/afp/2019/0101/p17.html

3. Acute Migraine Headache: Treatment Strategies – https://www.aafp.org/afp/2018/0215/p243.html

4. Cluster Headache - https://www.aafp.org/afp/2013/0715/p122.html

WEEK 2:

SEIZURES

1. Unprovoked First Seizures in Adults: Management Recommendations from the AAN - https://www.aafp.org/afp/2015/1101/p835.html

2. Epilepsy: Treatment Options - https://www.aafp.org/afp/2017/0715/p87.html

3. Febrile Seizures: Risks, Evaluation, and Prognosis - https://www.aafp.org/afp/2019/0401/p445.html

NEUROPATHY:

1. Peripheral Neuropathy: Differential Diagnosis and Management - https://www.aafp.org/afp/2010/0401/p887.html

2. Treating Painful Diabetic Peripheral Neuropathy: An Update - https://www.aafp.org/afp/2016/0801/p227.html

WEEK 3:

DEMENTIA:

1. Evaluation of Suspected Dementia - https://www.aafp.org/afp/2018/0315/p398.html

2. Neuropsychological Evaluation in Adults - https://www.aafp.org/afp/2019/0115/p101.html

3. Alzheimer Disease: Pharmacologic and Nonpharmacologic Therapies for Cognitive and Functional Symptoms - https://www.aafp.org/afp/2017/0615/p771.html

4. Dementia with Lewy Bodies: An Emerging Disease - https://www.aafp.org/afp/2006/0401/p1223.html

5. Frontotemporal Dementia: A Review for Primary Care Physicians - https://www.aafp.org/afp/2010/1201/p1372.html

WEEK 4:

 1. Multiple Sclerosis: A Primary Care Perspective - https://www.aafp.org/afp/2014/1101/p644.html

2. Dizziness: Approach to Evaluation and Management - https://www.aafp.org/afp/2017/0201/p154.html

3. Tremor: Sorting Through the Differential Diagnosis - https://www.aafp.org/afp/2018/0201/p180.html

4. Muscle Weakness in Adults: Evaluation and Differential Diagnosis - https://www.aafp.org/afp/2020/0115/p95.html

ADDITIONAL READING:

A collection of articles and references has been assembled into a binder for the resident to use while on service.  It includes in-depth discussion of common topics such as migraine and neuroanatomy among others.

In addition, all of the staff neurologists have reference books available for the resident to use as needed.   

Curriculum Description – Neurology and neurological issues are estimated to account for approximately 10-15% of the Family Physician’s practice according to the AAFP.  Therefore, having competency diagnosing the more common neurological disorders and knowing when to obtain consultation are important skills that a family physician must have.  Neurology curriculum centers around the neurological development, anatomy, pathology, and treatment of neurological conditions.  Equally important to the curriculum are the psychosocial factors involved in delivering often devastating diagnoses and providing education, counseling, and support to patients and families affected. 

Curriculum Goals:

The ACGME has outlined six core competencies for all residents in training. The primary goal of the Neurology experience is for residents to develop the following 6 competencies in the context of evaluating and treating adults and children with all aspects of neurological disorders.

1. Patient care that is compassionate, appropriate, and effective for the treatment of health programs and the promotion of health.

2. Medical Knowledge about established and evolving biomedical, clinical, and cognate sciences, as well as the application of this knowledge to patience care.

3. Practice-based learning and improvement that involves the investigation and evaluation of care for their patients, the appraisal and assimilation of scientific evidence, and improvements in patient care.

4. Interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and other health professionals.

5. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to patients of diverse backgrounds.

6. Systems-based practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

Rotation

PGY2 – 1 month Neurology rotation which consists of a combination of outpatient, inpatient consultation service with staff neurologist, and self-paced readings.

The resident will work with all available neurologists, mostly in the Neurology clinic.  The resident should ensure they have AHLTA access to CP NEUROLOGY prior to their fist day on the rotation.  A copy of a Neurology note template will be provided.

A collection of online articles and hard copy articles will be provided at the start of the rotation as well.

Instruments such as ophthalmoscopes, reflex hammers, pinprick and tuning forks are available for use during the rotation.  The resident should bring his/her own stethoscope, however.

They should review the schedule of all available neurologists for that day, specifically looking for new patients.  The resident is encouraged to chose among the available new patients for those patients they feel would be more instructive and beneficial for them to evaluate.  They should alert the assigned neurologist that they wish to see a particular patient, preferably the day before the actual appointment.

During their first few patient encounters, the resident will take a history on the patient, then present the patient to the Neurology staff.  Then, the staff and the resident will perform a complete neurologic exam together. After that, the resident will be expected to perform a complete neurologic exam on every patient they evaluate.

The resident will write up the full H&P on every patient that they evaluate, placing it into AHLTA and checking with the staff for any corrections or improvements.  The staff will place all medication, radiology, consult and lab orders.  The staff will also code the note and close it out.

When inpatient consults are available, the resident is encouraged to work with the on-call neurologist to see and evaluate those patients as well.  As with the clinic, the resident will be expected to perform a complete neurologic exam and write the H&P in Essentris.

Throughout the course of the rotation, the resident will have opportunities to observe procedures.  EMG/NCS are done by the Intrepid Center neurologist twice a month, generally on Mondays. It is strongly encouraged that the resident observe at least one of those, if possible.

Other procedures include Botox, occipital nerve blocks and lumbar punctures.  If interested, supervised performance of those procedures by the resident may be possible. 

Other Learning Activities

Didactics – Residents receive instruction on key topics at Morning Report and during the weekly lecture series to include such topics as TBI, seizure, stroke, delirium, dementia, Bell’s palsy, and Parkinson’s disease. 

Longitudinal Learning – Residents will also cover neurology topics by direct patient contact while on the following rotations: Adult Medicine (PGY-1, PGY-2, and PGY-3), ICU (PGY-1), Elder Clinic (PGY-2), Geriatrics (PGY-2), Emergency Medicine (PGY-1, PGY-2) as well as throughout their residency in clinic experiences and with electives.

Simulation Room – Residents will have access to the simulation room throughout their residency on both an elective basis and for skills assessment stations to perfect such techniques as the lumbar puncture.

ACGME Program Requirements:

Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care throughout their Adult Medicine experience, which must include neurological curriculum.

Administrative Information:

Last review: July 2020

Family Medicine Coordinator: Aaron Davis, DO

Neurology Coordinator:   Gwen Brophy, MD

Length of rotation:  1 month

Number of months to be completed: PGY2 – 1 month

Maximal time away allowed from rotation: 5 days

Number of half days in FM clinic: PGY2 – 4

Preferred clinic times: Tues-Wed PM, Fri AM/PM

A.M. Report attendance required: Yes

Thursday afternoon conference attendance required: Yes

FM call required: Yes

Responsible for hospitalized FM panel patients: Yes; a supplementary note must be completed

Responsible for OB panel patients: Yes

Selected Rotation Specific Objectives by ACGME Competency Category:

The following is a listing of selected knowledge, skills and attitudes (K.S.A.s) that residents are expected to gain competency in during their rotation on the Neurology. It is understood that not all the K.S.A.s will be attained on a single rotation, but they will be developed and attained throughout the 3 years of residency or rotating on Neurology; specific K.S.A.s that are not developed on the Neurology rotation will be developed during the other rotational experiences.

The rotation specific objectives will be reviewed with each resident prior to rotating on the I.T. in order to clarify which objectives the resident is trying to attain. The resident will hold on to the curriculum, and use it as a reference point for areas to focus on during the rotation. At the end of the rotation, the rotation specific objectives will be reviewed with their advisor, and those attained will be checked. This review will be kept in the resident’s file, in order to document the resident’s progress.

Rotation Specific Objectives

Patient Care:

Gather essential and accurate information about their patients:

PGY-1

___ Perform and adequate history and neurological exam

___ Perform adequate patient presentations

PGY-2

___ Assess the acuity and prognosis of the clinical problem as it relates to the need for immediate management and the requirement for expert assistance.

___ Formulate a detailed plan of management and investigation for the neurological patient

PGY-3

___ Manage the family and psychosocial issues that accompany the long-term care of patients with debilitating neurological conditions, including home care, community resources, and the use of a multidisciplinary team.

___ Function as the junior attending by teaching and leading the team and assisting juniors in performance of the above tasks.

Perform competently all medical and invasive procedures considered essential for the area of practice: Proficiency will be determined by several factors including understanding of indications, total attempted, total completed, skill level, confidence and outcome of procedure

PGY-1

Gain experience and exposure to the following procedures

                     ___ Lumbar puncture

                     ___ Mini Mental Status Exam/MOCA

                     ___ Cranial nerve exam

PGY-2

Gain experience and exposure to the following procedures

                     ___ Complete neurological exam

                     ___ Communicate accurately findings of neurological exam

Master the following procedures

                     ___ Mini Mental Status Exam/MOCA

                     ___ Cranial nerve exam

PGY-3

Master the following procedures

                     ___ Complete neurological exam

                     ___ Communicate accurately findings of neurological exam

Medical Knowledge

Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care.

-The resident should gain understanding of pathophysiology, presentation, initial evaluation, inpatient management and appropriate follow-up of patients who have the following included (but not limited to) conditions:

PGY-1

___ Traumatic Brain Injury

___ Headaches and associated warning signs of emergent conditions

___ Stroke, Transient Ischemic Attack

___ Seizure disorders

___ Syncope, dizziness, vertigo

___ Bell’s Palsy

___ Loss of Consciousness/coma

___ Increased intracranial pressure

___ Deficits and their anatomical correlation

PGY-2

___ Dementia

___ Delirium

PGY-3

___ Parkinson’s Disease

___ Myasthenia gravis

___ Multiple Sclerosis

___ Movement disorders

___ CT and MRI interpretation

___ Polyneuropathies

___Encephalopathy

___Guillain-Barre’ Syndrome

___ Aphasia/Apraxia

ALL:

Didactic lectures on all required medical knowledge topics at morning report or noon lecture.  Annual scheduled lectures will include:

___ Traumatic Brain Injury

___ Seizure Disorders

___ Stroke

___ Delirium/Dementia

___ Bell’s Palsy

___ Parkinson’s Disease

___ Headaches

Practice-Based Learning and Improvement

Use information technology and on-line medical information to support education:

ALL

___ Utilize hospital’s evidence-based medicine resources (Up To Date; FPIN; Ovid; Medical Letter; Prescribers Letter; other resources on Clinical Portal) to obtain current information on patient management.

Identify strengths, deficiencies, and limits in one’s knowledge and expertise; and set learning and improvement goals:

PGY-2

___ Set specific learning goals at the beginning of the rotation based on knowledge and skill gaps

Facilitate the learning of students and other health care professionals

PGY-1

___ Residents will participate in teaching medical students on relevant topics of patient care.

PGY-2

___ Residents will participate in teaching team members on relevant topics of patient care.

PGY-3

___ Residents will participate in teaching team members on relevant topics of patient care both on inpatient rotations and in clinic precepting.

Interpersonal and Communication Skills

Work effectively with others as a member or leader of a health care team or other professional group

PGY-1

___ Monitor the performance and education of medical students

___ Communicate effectively with physicians, other health professionals, and health related agencies

___ Interactions with other physicians and health care professionals will be collaborative with the patients’ interests held foremost.

PGY-2

___ Prepare the PGY1 residents for rounds ensuring they have the data needed.

PGY-3

___ Educate patients on conditions and effectively and compassionately communicate bad news as well as treatment plans.

___ Lead and conduct family meetings as needed to discuss care of admitted patients.

___ Communicate effectively with physicians, other health professionals, and health related agencies

___ Interactions with other physicians and health care professionals will be collaborative with the patients’ interests held foremost.

Provide information using effective nonverbal, explanatory, questioning and writing skills

PGY-1

___ Demonstrate skills for complete, concise and relevant patient presentations to staff attendings and consultants.

___ Complete daily progress notes on all assigned patients.

PGY-2

___ Demonstrate skills for complete, concise and relevant patient presentations to staff attendings and consultants.

___ Complete daily progress notes on all assigned patients.

PGY-3

___ Demonstrate skills for complete, concise and relevant patient presentations to staff attendings and consultants.

___ Complete daily progress notes on all assigned patients.

Professionalism

Residents must demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles.

PGY-1

___ Residents will be on-time to all work-related events, will complete all administrative work within hospital/departmental policies and will present themselves with an appropriate/professional appearance/demeanor at all times.

PGY-2

___ Residents will be on-time to all work-related events, will complete all administrative work within hospital/departmental policies and will present themselves with an appropriate/professional appearance/demeanor at all times.

___ Performs consults while on Neurology service, communicating to the consulting residents and ensuring appropriate education as well as patient information is conveyed.

PGY-3

___ Residents will be on-time to all work-related events, will complete all administrative work within hospital/departmental policies and will present themselves with an appropriate/professional appearance/demeanor at all times.

Systems-Based Practice

Demonstrate an awareness of and responsiveness to the larger context and system of health care.

PGY-2

___ Residents will gain an understanding of the larger context of neurological care within the existing military and civilian healthcare organizations within the region.  This will be accomplished via discussions with faculty, direct consultation with medical services at other centers and facilitation of transfers of care when appropriate to other centers.

___ Residents will learn to recognize their own practice limitations and master the appropriate necessity, timing, and resources for consults.

­­­___ Incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate by utilizing applying EBM principles and utilizing EBM databases

Specific Expectations of Residents:

ALL:

1. Record all procedures in New Innovations in a timely manner and assign a supervising physician

2. Complete rotational evaluation on New Innovations within 2 weeks of completion of rotation.

3. Complete curriculum review within 2 weeks of completing the rotation with resident advisor; denote on the curriculum areas where competency was attained

4. Required attendance at:

a.  Morning report

b. Academic conferences

5. Routine call responsibilities

6. Coverage on OB panel patients and deliveries

7. Family Medicine Clinic as scheduled.

Evaluation: 

Resident Evaluation:

Daily evaluation

The Neurology attending should provide daily and weekly oral feedback to the residents on progress and performance. Attendings will also provide feedback on the quality of written communication by critically reviewing resident chart entries

-Mid-rotation feedback:

With Neurology attending at completion of week 2. Resident must ensure time is scheduled with staff.  Written feedback required if resident is failing at mid-rotation evaluation or at any other time

-Final Evaluation

All attendings should be sent an evaluation by the resident via New Innovations. Evaluations should be completed within two weeks after rotation.

Methods of Evaluation:

Portfolio:

The following items will be entered in the residents training record by the GME coordinator:

-Procedures documented in new innovations

-Resident New Innovations evaluation

-Rotation specific objectives completed

-Team leader/preceptor evaluations

Staff Evaluation: (the staff is evaluated by the resident)

-Residents evaluate staff using the annual New Innovations staff evaluation

Rotation Evaluation: (the rotation is evaluated)

-Resident assesses quality of the rotation by completing the New Innovations standard rotation evaluation form. Evaluations should be completed within two weeks after rotation.

Recommend reading list:

It is expected that residents will read the items on the rotation reading list over the course of the rotation.  There is a list of hyperlinks to online articles that are specifically geared towards the FP providers, as well as a binder with physical copies articles written for neurologists that offer a more in-depth review of several topics.

They will check off in the knowledge portion of the goals and objectives those conditions they have seen. They should check off each of the specific conditions they have gained knowledge in, and they should have checked off all the knowledge specific objectives by the time they have completed their Neurology rotation.

- A comprehensive reading list of selected topics has been assembled which will be given to the resident prior to the start of the rotation.

- Aids to the Examination of the Peripheral Nervous System, published by WB Saunders. (available from the Neurology staff during the rotation.)

- AAN Continuum series—Recommended readings for residents (available from the Neurology staff, but several of these articles have been assembled into a binder for the resident to reference throughout the rotation)

References:

1. Program Requirements for Graduate Medical Education in Family Medicine; effective July, 2014.

2. AAFP’s Residency Solutions: Recommended Curriculum Guidelines for Family Medicine Residents: http://www.aafp.org/online/en/home/aboutus/specialty/rpsolutions/eduguide.html; the following curriculum guidelines were referenced in delineating specific objectives for the Neurology rotation: none.