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PGY-3 and 4 Pediatric Neurology rotation:

Outpatient and Inpatient Service


 
 

PGY-3 and 4 Pediatric Neurology rotation: Outpatient and Inpatient Service

 

Description of Rotation or Educational Experience

The primary goal of the Pediatric Neurology Rotation is to ensure that residents develop basic competence based knowledge of the broad spectrum of child neurological disorders. This includes working with patients in both consultation and outpatient settings who have neurological disorders.

 

Patient Care

Goals: Residents will

·        become expert in history taking and the neurologic examination of pediatric patients with neurological disorders

·        be able to guide other team members on the best clinical approach to the patient with neurological disorders, including clinical presentations, formulation of differential diagnosis, and an efficient workup for the most likely diagnosis

  • increase their experience with evaluating CT and MRI scans and other neuroradiology films in the field of pediatric neurology
  • direct and provide consultation service to the medical, surgical, obstetric and gynecologic, pediatric, rehabilitation medicine, and psychiatry services
  • learn differential diagnosis, treatment and work-ups for pediatric neurology disorders and how they manifest clinically.
  • Understand basic concepts of neuropsychopharmacology, neuropsychology and supportive care of patients with neurological disorders and their families
  • evaluate cognitive ability in medically ill patients
  • interface with pediatric neurology residents in an interdisciplinary approach
  • collaboratively work to provide a comprehensive care to patients with neurological disorders

 

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 will

  • 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 neurological disorders 
  • interact with general pediatric and ICU service in the appropriate circumstance
  • understand and help guide the application of the basic principles of neuropharmacology including but not limited to the use of anticonvulsants
  • manage consultation of patients with acute neurological disorders in an intensive care unit and an emergency department
  • begin to counsel patients under attending faculty supervision (PGY-3) or counsel patients independently (PGY-4) in appropriate and compassionate methods, including adequate psychosocial support and counseling for patients and family members
  • formulate and communicate therapeutic plans, counseling and access to therapies in the health care system and the consequences of these actions for the patients
  • interact and communicate when appropriate with schools and educational counselors
  • have opportunities for increasing responsibility and professional maturation
  • have faculty supervision with daily faculty rounds and review of all patients seen on inpatient consultation, and outpatient psychiatry clinic
  • 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 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.

 

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. 

 

Display proficiency in assessment skills by interviewing, diagnosing, and presenting treatment plans for new patients in the presence of attending neurologists.

 

Display proficiency in pharmacotherapy and supportive therapy by managing at least 20 outpatients with attending pediatric neurologists present briefly at the end of each session.

 

Display proficiency in crisis intervention by managing exacerbations of illness in outpatients by utilizing more intensive outpatient, partial hospitalization or triage to inpatient services.

 

 

 

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 common neurological diseases in childhood and their differential diagnosis
  • demonstrate knowledge and competency in performing the neurological examination in infants and children
  • recognize abnormal patterns of neurodevelopment
  • be expected to demonstrate knowledge on specific neuro genetic and developmental syndromes
  • understand basic assessment of patient safety
  • be proficient in the interpretation of neuro-diagnostic studies in infants and children
  • understand ethical/legal issues regarding consent to treatment in medical settings.

 

 

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, 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
  • begin to apply (PGY-3) or be able to apply (PGY-4) the principles of pharmacology and supportive therapy in the provision of appropriate and cost-effective 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 child neurology

 

Objectives

Demonstrate knowledge of the scientific principles that underlie the current understanding of child neurology

 

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 problems and differences across age, gender, and different cultures among other groups.

 

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 neurological disorders 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 
  • implement models of care based on the use of evidence to improve practices

 

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
  • gather data from appropriate sources, including the patient medical record, hospital staff, family, and other pertinent individuals and outside agencies.
  • work as a member of the multidisciplinary team to maximize the care of the complex medically ill patient.

 

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 at all levels of socioeconomic 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
  • engage in meaningful interaction with a variety of consultees to define the consultation question, discuss the clinical findings, and discuss the clinical recommendations.
  • advise and guide the consultees about the use and monitoring of medications.

 

 

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
  • demonstrate respect for patients with disabilities
  • demonstrate respect for other members of the staff
  • complete assigned tasks
  • manage personal stress responsibly

 

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 child neurology inpatient consultations, ED consultations, and outpatient clinic evaluations
  • Presentation all patients to the attending, which includes diagnostic and therapeutic plans
  • Formal teaching rounds with child neurology faculty are scheduled daily on all inpatient 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
  • 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

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
  • 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

Maria BL. Current Management in Child Neurology. Third Edition. 2005

Normal M, MCGillivray. Congenital Malformations of the Brain. Oxford 1995

Fenichel GM. Clinical Pediatric Neurology. A signs and symptoms approach. Elsevier 5th Edition. 2005