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PGY-3 and 4 Denver Health Medical Center (DHMC)

Inpatient, Consult, and Outpatient Clinic Service


 
 

PGY-3 and 4 Denver Health Medical Center (DHMC): Inpatient, Consult, and Outpatient Clinic Service

 

Description of Rotation or Educational Experience

Residents will rotate at the DHMC for 1-3 month assignments. Senior residents (PGY-3 or 4) will be responsible for leading the neurology team. In the leadership role, the senior neurology resident is responsible for making certain all consults are seen in a timely manner, assigning primary patients to junior residents and students, reviewing pertinent evaluation, lab and test results for all patients on the team with junior residents and students, overseeing and supervising the junior residents and the medical student patient care responsibilities, and communicating with the attending all team issues. The senior resident will also have primary responsibility for neurology inpatients and inpatient consultations from other services, including the medical and surgical ICUs and the Emergency Department. The resident will also participate in outpatient clinics where the resident will see return and new patients from the general neurology clinic pool. Care of all patients will be under the direct supervision of the senior neurology residents and attending neurology faculty. The senior neurology resident will review all EEGs (inpatient and outpatient) performed during their rotation. Increasing independence from faculty in regards to leading the team and EEG interpretation will occur as the resident progresses from PGY-3 to PGY-4.

 

Patient Care

Goals: Progressively from PGY-3 to PGY-4, residents will

·        become expert in history taking and the neurologic examination of patients with neurologic disease

·        be able to guide other team members on the best clinical approach to the patient with neurologic disease, including: localization of the problem within the nervous system, formulation of differential diagnosis, and an efficient workup for the most likely diagnosis

·        understand the indications for diagnostic studies, including: lumbar puncture, EMG/nerve conduction studies, myelography, CT/CTA scanning, MRI/MRA scanning, and angiography

·        increase their experience with evaluating CT and MRI scans and other neuroradiology films

·        begin to interpret EEG and EMG/nerve studies (PGY-3) and then master basics of EEG and EMG/nerve studies interpretation (PGY-4)

  • become experts in the management of patients with common neurologic conditions including stroke, meningitis/encephalitis, metabolic encephalopathy, neuropathy, headache, Parkinson’s disease, among others
  • direct and provide consultation service to the medical, surgical, obstetric and gynecologic, pediatric, rehabilitation medicine, and psychiatry services
  • consult on the management of patients with neurological disorders who require emergency and intensive care
  • provide consultation with assessment and plans for patients with neurology complications from HIV

 

Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.  Residents are expected to demonstrate proficiency in problem solving, clinical reasoning and technical skills applicable to the practice of evidence-based medicine.  These proficiencies include appropriate use of biomedical information for decision-making; demonstrate caring and respective behavior in interactions with patients and their families, including counseling and education. Residents will be able to work effectively with healthcare professional, including those from other disciplines in order to develop and implement management plans.

 

Competencies: Residents should

  • be able to obtain an orderly and detailed history from the patient, conduct a thorough general and neurological examination, and organize and record data
  • present patient cases and their complete diagnostic and therapeutic plans
  • be able to state indications for and limitations of clinical neurodiagnostic tests and their interpretation
  • be able to correlate the information derived from neurodiagnostic studies with the clinical history and examination in formulating a differential diagnosis and management plan
  • participate in the evaluation of and decision making for patients with disorders of the nervous system requiring surgical management
  • interact with the neurosurgery service in the appropriate circumstance
  • understand and help guide the application of the basic principles of rehabilitation for neurological disorders
  • manage consultation of patients with acute neurological disorders in an intensive care unit and an emergency department
  • participate in neuroimaging decisions and film reviews that ensures an increasing (PGY-3 to 4) familiarity with and knowledge of all relevant diagnostic and interventional studies necessary to correlate findings with other clinical information for the care of patients - at a minimum this must include magnetic resonance imaging, and computerized tomography and neurosonology
  • begin to counsel patients under attending faculty supervision (PGY-3) or counsel patients independently (PGY-4) in appropriate and compassionate methods of end-of-life palliative care, including adequate pain relief and psychosocial support and counseling for patients and family members about these issues
  • have opportunities for increasing responsibility and professional maturation
  • participate in night call
  • have faculty supervision with daily faculty rounds and review of all patients seen on inpatient consultation, the neurology inpatient service, and the emergency room
  • have faculty supervision for all patients seen in the outpatient clinics
  • will be able to recognize and begin to manage (PGY-3) or be able to manage (PGY-4)  physical, sexual, and emotional abuse (where appropriate)

 

Objectives:

Accurately perform and document complete and focused histories and physical examinations with a special emphasis on the neurological examination that are based on the pathophysiology of presenting complaints, and that address relevant psychosocial and family issues.

 

Identify and prioritize patients' problems, formulate appropriate differential diagnoses, and develop appropriate plans for treatment and/or management.

 

Perform complete and focused case presentations that are accurate and well organized; prepare and maintain complete, accurate, well-organized medical records.

 

Perform selected diagnostic and therapeutic procedures including, but not limited to lumbar puncture, mental status testing, EEG interpretation, and Tensilon testing.

 

Residents should demonstrate interpersonal, oral and written communication skills that enable them to establish and maintain effective professional relationships with patients, families and other members of healthcare teams. 

 

Medical Knowledge

Goals: Residents will

  • demonstrate extensive knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care 
  • be expected to demonstrate their knowledge of core concepts and principles neurological illnesses (this includes disease pathogenesis and treatment as well as health maintenance, disease prevention, and an understanding of the broad range of factors that impact the origin and progression of disease)

 

Competencies: Residents will

  • regularly attend seminars and conferences in the following disciplines during this rotation: neuropathology, neuroradiology, neuro-ophthalmology, neuromuscular disease, cerebrovascular disease, epilepsy, movement disorders, critical care, clinical neurophysiology, behavioral neurology, neuroimmunology, infectious disease, neuro-otology, neuroimaging, neuro-oncology, sleep disorders, pain management, neurogenetics, rehabilitation, child neurology, the neurology of aging, and general neurology; there will be gross and microscopic pathology conferences and clinical pathological conferences (M&Ms) as well as conferences dedicated to the basic sciences on which clinical neurology is founded, including neuroanatomy, neuropathology, neurophysiology, neuroimaging, neuropsychology, neural development, neurochemistry, neuropharmacology, molecular biology, genetics, immunology, epidemiology, and statistics
  • to begin to apply (PGY-3) or be able to apply (PGY-4) the principles of bioethics and in the provision of appropriate and cost-effective evaluation and treatment for patients with neurological disorders when specific situations arise
  • have an established reading program (PGY-3) or begin to focus a reading program on areas of weakness (PGY-4) in regards to functional neuroantatomy, clinical neurology and current literature

 

Objectives

Demonstrate increasing (PGY-3 to 4) knowledge of the scientific principles that underlie the current understanding of neurological illnesses affecting the central and peripheral nervous system including, but not limited to, stroke, epilepsy, Parkinson’s disease, tremor and other movement disorders, multiple sclerosis, peripheral neuropathy, Alzheimer’s disease and other dementias, delirium, and malignancies and infectious diseases involving the nervous system. Apply these principles in the discussion of health maintenance and common disease processes, and in the evaluation and management of patients.

 

Demonstrate an understanding of the cultural, ethnic, and societal beliefs and behaviors that influence a patient’s response to health and disease. 

 

Demonstrate knowledge of common neurological problems and differences across age, gender, and other groups.

 

Demonstrate an understanding of the scientific basis and appropriate interpretation of common diagnostic methods including computerized axial tomography, magnetic resonance imaging, Doppler studies, catheter angiography, electroencephalography, electromyography, and lumbar puncture.

 

Demonstrate an understanding of medical-legal responsibilities and how they relate to the duty and ability to act within the legal parameters, including abiding by those duties to protect and respect patient confidentiality.

 

Demonstrate knowledge of the theories and principles that govern ethical decision-making for patients with diseases of the central and peripheral nervous system and how these apply to major ethical dilemmas in medicine.

 

Practice- Based Learning and Improvement

Goal: Residents will

  • demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life long learning
  • demonstrate skills and habits for self-directed and life-long learning, incorporating the practice of evidence-based medicine 

 

Competencies: Residents will

  • identify strengths, deficiencies and limits in one’s knowledge and expertise
  • locate, appraise and assimilate evidence from scientific studies related to their patients’ health problems
  • use information technology to optimize learning
  • participate with increasing independence (PGY-3 to 4) in the education of patients, families, students, residents and other health professionals
  • teach other residents, medical students, nurses, and other health care personnel, formally and informally

 

Objectives

Recognize the need to engage in lifelong learning to stay abreast of medical and other scientific advances.

 

Locate, evaluate and apply information for solving problems and making decisions that are relevant to the care of individuals and populations.

 

Use evidence-based approaches to decide whether to accept new findings, therapies and technologies for incorporation into medical practice.

 

Systems Based Practice

Goals: Residents will

  • 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
  • demonstrate the understanding of patient care and the interaction with the patient, family, and healthcare team in the context of the healthcare system (this includes and appreciation of issues of referral, confidentiality and the delivery of cost-effective health care)
  • understand the context of care for individuals in a “safety-net” health care system (i.e. for people with low socioecomonic status)

 

Competencies: Resident will be expected to

  • work effectively in various health care delivery settings and systems relevant to their clinical specialty
  • coordinate patient care within the health care system relevant to their clinical specialty
  • incorporate considerations of cost awareness and risk-benefit analysis in patient care
  • advocate for quality patient care and optimal patient care systems
  • work in interprofessional teams to enhance patient safety and improve patient care quality
  • participate in identifying systems errors and in implementing potential systems solutions

 

Objectives

Identify and prioritize patients' problems, formulate appropriate differential diagnoses, and develop cost-effective diagnostic plans as well as evidence-based plans for treatment and/or management.

 

Demonstrate an understanding of medical-legal responsibilities and how they relate to the duty and ability to act within the legal parameters, including abiding by those duties to protect and respect patient confidentiality.

 

Demonstrate an appreciation of the overall care of the patient with an understanding of the interaction of primary care and specialty care. This includes the roles and responsibilities of the various members of the healthcare team.

 

Professionalism

Goal: Residents will

  • demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles 
  • be expected to demonstrate the highest standards of professional integrity and exemplary behavior, as reflected by a commitment to continuous professional development, ethical practice, and an understanding of and sensitivity to diversity (this includes a responsible attitude toward patients and their families, health care professionals and other staff members)

 

Competencies: Residents will

  • show compassion, integrity, and respect for others
  • be responsive to patient needs that supersedes self-interest
  • respect for patient privacy and autonomy
  • be expected to be show sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation

 

Objectives

Act in an ethically responsible manner, displaying integrity, honesty, and appropriate boundaries with patients, their families, patients' representatives, and fellow health care professionals.

 

Demonstrate an understanding of and respect for cultural differences in communication with and management of patients

 

Balance one’s own needs and values with one’s professional responsibilities towards patients and recognize the limits of one’s knowledge, skills, and behavior through self-reflection and seek to overcome those limits.

 

Demonstrate the ability to protect patient’s privacy in discussions, medical records, and interactions with other health care professionals.

 

Interpersonal and Communication Skills

Goal: Residents will

  • demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates 
  • be expected to demonstrate interpersonal, oral and written communication skills that enable them to establish and maintain effective professional relationships with patients, families and other members of healthcare teams 

 

Competencies: Residents will

  • communicate effectively with patients and families across a broad range of socioeconomic and cultural backgrounds
  • communicate effectively with physicians, other health professionals, and health related agencies
  • work effectively as a member of leader of a health care team or other professional group
  • act in a consultative role to other physicians and health professionals
  • maintain comprehensive, timely, and legible medical records

 

Objectives

Communicate effectively, both orally and in writing, with patients, patients’ families, colleagues, and others with whom neurologists must exchange information in carrying out their responsibilities.

 

Develop the skills to discuss sensitive issues including diagnosis, treatment options, and prognosis with patients and their families in an effective, compassionate, non-judgmental manner appropriate to their needs, including counseling on prevention and psychosocial issues.

 

Identify and prioritize patients' problems, formulate appropriate differential diagnoses, and develop appropriate plans for treatment and/or management.

 

Perform complete and focused case presentations that are accurate and well organized; prepare and maintain complete, accurate, well-organized medical records.

 

Residents should demonstrate interpersonal, oral and written communication skills that enable them to establish and maintain effective professional relationships with patients, families and other members of healthcare teams. 

 

Teaching Methods

  • Performance of designated neurology inpatient admissions, inpatient consultations, ED consultations, and outpatient clinic evaluations
  • Presentation all patients to the attending, which includes diagnostic and therapeutic plans
  • Formal teaching rounds with neurology faculty are scheduled daily on all neurology inpatients, neurology consultations, and ED patients to accomplish goals and objectives
  • Case based and clinical teaching by attending in outpatient clinics to accomplish goals and objectives
  • There will be a gradual assumption of more responsibility by the PGY-3 and 4 residents as the year progresses on this rotation
  • Performance of night call
  • Residents will be expected to fill out a systems based practice/practice-based learning matrix regarding patient case encountered (twice a year)
  • Specific literature review assigned by attending faculty (once a year)
  • Residents will supervise and teach junior residents, interns and medical students
  • Required attendance at M & Ms, weekly conferences, grand rounds and journal club
  • Review of EEGs with attending faculty

Assessment Methods

  • Direct observation by faculty of history, examination and interactions during case presentations
  • Direct observation of  formulation, diagnostic approach, and disposition planning during case
  • Clinical records review by program director
  • Monthly evaluations by attending faculty
  • Evaluation by other providers, staff, and patients
  • Performance on in-service examination
  • Direct observation of history, examination and interactions during case presentations
  • Program director review of clinical case matrices (twice a year)
  • Performance of clinical examination skill evaluations directly witnessed by attending faculty (total of 4 adult subspecialized categories during PGY-3 and/or PGY-4)

 

Assessment Methods (How Program Director Performs Evaluation of Rotation)

  • Monitor all evaluations
  • Semi-annual review with Program Director
  • RITE exam scores
  • ABPN Clinical Evaluation exercises (oral)
  • Number of residents who have passed ABPN certification

Level of Supervision

Attending supervision:

All program faculty members supervising residents must have a faculty or clinical faculty appointment in the School of Medicine. Faculty schedules will be structured to provide residents with continuous supervision and consultation.

 

Residents must be supervised by faculty members in a manner promoting progressively increasing responsibility for each resident according to their level of education, ability and experience. Residents are expected to formally present all patients to their attending faculty. The PGY3 and 4 residents will be expected to supervise junior residents and rotators. They will also oversee the junior residents in their teaching and supervision of the medical students. The senior resident should clarify patient care and other issues with the junior resident (when needed) prior to discussion with an attending resident.

 

Neurology resident’s clinical activities will be supervised at all times by a faculty member of the Department of Neurology, of the University of Colorado. The senior residents will have an increasing level of independence in transition from PGY-3 to PGY-4. 

 

Lines of responsibility for neurology residents:

The senior residents should discuss patient evaluation, diagnostic and treatment options with a junior resident prior to presentation to the attending in most circumstances. The senior resident is responsible for supervision and back-up of junior residents on the service. As always, ultimate responsibility resides with the attending physician. All orders for patients on the neurology inpatient service are written by the neurology resident assigned as the primary resident. For patients with neurology is a consultant, responsibility for writing orders resides with the primary team. Under special circumstances, with the approval of the primary service, neurology residents may write orders on consultations. 

Educational Resources

1.      Adams and Victor’s Principles of Neurology. 9th Edition. Eds: A. Ropper and M. Samuels Excellent basic textbook of clinical neurology.

2.      The Little Black Book of Neurology. Alan J. Lerner. Mosby. Good to carry on call or in clinic for quick reference for differential diagnosis and treatment basics.

3.      Localization in Clinical Neurology. 4th Edition. 2001. P. Brazis, J.C. Masdeu, J. Biller. Text for localization. Excellent source for clinical anatomy – localization based on clinical presentation; includes expected findings of various clinical disorders. Authors have been instrumental in designing ABPN (Board Examination) material.

4.    Basic Clinical Neuroscience. 2nd Edition. 2008.  Paul A Young, Paul H Young and Daniel L Tolbert. Excellent review of clinical neuroscience that is very important for Boards and RITE. Also provides important pathophysiology behind clinical evaluation findings.

5.    Giacomini MK, Cook DJ Users' guides to the medical literature: XXIII. Qualitative research in health care B. What are the results and how do they help me care for my patients? Evidence-Based Medicine Working Group. JAMA. 2000 Jul 26;284(4):478-82. PMID: 10904512 [PubMed - indexed for MEDLINE]

6.    Giacomini MK, Cook DJ. Users' guides to the medical literature: XXIII. Qualitative research in health care A. Are the results of the study valid? Evidence-Based Medicine Working Group. JAMA. 2000 Jul 19;284(3):357-62. PMID: 10891968 [PubMed - indexed for MEDLINE]