Neurology

Neurology Competency-Based Curriculum

Educational Rationale

Neurologic problems account for a considerable amount of outpatient and hospital-based care. General and primary care internists need to recognize, diagnose, and manage common neurologic conditions; appreciate those circumstances when expert consultation will be appropriate; and understand the indications, contraindications, and cost-effective utilization of neurodiagnostic studies.

Goals

A. Knowledge

Upon completion of training, we expect our residents to:

1. Acquire sufficient knowledge and experience to recognize the various neurologic disorders.
2. Accurately diagnose neurologic diseases.
3. Provide satisfactory care for patients with common and uncomplicated neurologic diseases.
4. Identify those circumstances when consultation and/or referral is appropriate.
5. Learn to use relevant diagnostic imaging and laboratory and other studies in a selective, efficient, and properly cost-effective manner.
6. Learn those aspects of ophthalmology, rehabilitation, and pain management to understand their roles in diagnosis and management of neurologic diseases.
7. Increase knowledge in the topics follow.

  1. Diagnostic Techniques in Neurology
    1. Imaging studies
    2. Cerebrospinal fluid studies
    3. EEG
    4. EMG and nerve conduction studies
    5. Evoked potentials
  2. Headache
    1. Symptomatic headache
    1. Pseudotumor cerebri
    2. Temporal arteritis
    2. Chronic headache disorders
    1. Migraine
    2. Cluster headache
    3. Tension headache
    4. Chronic daily headache
    3. Evaluating the patient with headache
    4. Treatment
  3. Neuromuscular Disorders
    1. Differential diagnosis of weakness
    1. Amyotrophic lateral sclerosis
    2. Peripheral neuropathy
    3. Neuromuscular junction disorders
      1. Myasthenia gravis
      2. Eaton-Lambert syndrome
    4. Myopathies (see also Rheumato1oqy)
      1. Muscular dystrophies
      2. Metabolic myopathies
    5. Evaluating the weak patient
    6. Treatment
  4. Peripheral Nerve Disorders and Autonomic Neuropathy
    1. Signs and symptoms of peripheral neuropathy
    2. Differential diagnosis
    1. Hereditary neuropathies
    2. Toxic/metabolic neuropathies
    3. Neuropathies associated with systemic illness
    4. Compression neuropathies
    3. Evaluating the patient with peripheral neuropathy
    4. Treatment
  5. Coma and Mental Status Changes (delirium)
    1. Differential diagnosis
    1. Supratentorial mass lesions
    2. Infratenorial mass lesions
    3. Metabolic causes of coma
    4. Psychogenic coma
    2. Evaluating the unresponsive patient
    1. Physical examination
    2. Laboratory investigations
    3. Treatment
    1. Treatment of raised intracranial pressure
  6. Dementia
    1. Subarachnoid hemorrhage
  7. Stroke-Brain Attack
    1. Evaluating the patient with suspected cerebrovascular disease
    1. CT and MR imaging
    2. Carotid ultrasound and transcranial Doppler
    3. MR angiography
    4. Conventional angiography
    5. Cardiac studies
    2. Treatment
    1. Risk factor modification
    2. Blood pressure management
    3. Anticoagulants
    4. Anti-platelet agents
    5. Thrombolytic therapy
    6. Endarterectomy
  8. Sleep disorders
    1 Understand the pathophysiolgy, presentation, diagnosis and management of
    1. Sleep Apnea and sleep-related breathing disorders
    2. Insomnia
    3. Parasomnias
  9. Seizure Disorders
    1. Pathophysiology, etiology
    2. Signs, symptoms, varied presentations
    3. Diagnostic criteria and tests
    4. Management of acute seizures
    5. Chronic management of patients with epilepsy
  10. Movement Disorders
    1. Differential diagnosis
    1. Hypokinetic movement disorders
      1. Parkinson's disease and parkinsonism
    2. Hyperkinetic movement disorders
      1. Tremor
      2. Dystonia
      3. Tics
      4. Chorea, athetosis and ballism
      5. Rigidity (e.g., neuroleptic malignant syndrome)
    3. Evaluation
    4. Treatment
      1. Hypokinetic movement disorders
      2. Hyperkinetic movement disorders
  11. Multiple Sclerosis
    1. Differential diagnosis
    2. Evaluation
    1. Physical examination findings
    2. Imaging studies
    3. Cerebrospinal fluid studies
    4. Evoked potentials
    3. Treatment
    1. Corticosteroids
    2. Beta interferons and glatirameracetated (immune-modulating meds)
    3. Symptomatic treatment
  12. Infections of the Nervous System (See also Infectious Disease)
    1. Differential diagnosis
    1. Meningitis
      1. Acute
      2. Chronic
    2. Encephalitis
    3. Abscess
    4. Lyme Disease
    5. AIDS
    2. Evaluation
    1. Cerebrospinal fluid analysis
    3. Treatment

B. Skills

Upon completion of training, we expect our residents to:

1. Know the neurologic evaluation.
2. Be able to lead and function as part of a team providing neurologic care.
3. Know the indications and contraindications and cost effective utilization of neurodiagnostic studies.
4. Know the indications, contraindications, proper performance of lumbar punctures.
5. Understand how to interpret the results of cerebrospinal fluid analysis.
6. Identify those circumstances when consultation or referral is appropriate.

C. Attitudes

Upon completion of training, we expect our residents to appreciate those attitudes valued by neurologists, including:
1. The necessity of establishing a diagnosis.
2. Understanding how a discerning clinical evaluation can suggest the diagnosis of neurologic disease.
3. Recognizing the limitations of technology and the importance of clinical insight.
4. Making difficult judgments when certainty is elusive.
5. Balancing intervention with patience.
6. Recognizing limitations of our interventions.
7. Appreciating the unique circumstances of caring for patients with chronic, often incurable diseases.
8. Learning the importance of pain management.

Experiences

In order to achieve the goals and objectives for the residency program the following experiences have been established for the purpose of teaching Neurology to residents.

1. The Inpatient Experience (IP)

The residents assigned to this rotation will be responsible for supervising evaluation of inpatient consultations and patients admitted to the neurology service as well as the continued follow up of these patients during their hospitalization. Essential in this role is the development and refinement of clinical evaluation skills of patients with digestive diseases. These skills include the development of appropriate differential diagnosis, assessing the need for hospitalization, diagnostic evaluation strategies and treatment plans. Essential in this rotation will be developing skills in providing consultation services, to include communicating with the referring physicians and ensuring support for continuing care of the patients' neurologic condition. A resident will be called upon to perform literature research on topics appropriate to the case at hand. They will participate actively in the teaching activities of the consultation team.

Second year residents will also become certified in the use of NIH Stroke Scale (NIHSS). They will participate in the Brain Attack Team (BAT) in the assessment and treatment of patients with acute stroke. (This may be completed separately from the Neurology Experence)

2. The Ambulatory Experience (AM)

All residents will participate in outpatient activities appropriately supervised by dedicated attending faculty members in the division of Neurology. The goals of this experience will be for the residents to gain expertise in the outpatient evaluation and management of digestive problems. The experience provides an opportunity to develop an understanding for the natural history of these conditions over an extended period of time.

Clinical sites for the outpatient experience will include:

1. Internal Medicine Faculty Practice-Office of Dr. Danielle Haskins
2. Institute of Neurology (ACC)-Dr. Guha Venkatraman and Dr. Mangala Nadkarni
3. The Center for Sleep Disorders at Cooperman Barnabas-Dr. Mangala Nadkarni

3. Didactic Conferences (DC)

Numerous monthly conferences are held for the residents throughout the month. They cover a variety of topics in all the major medical subspecialties. Residents will be required to attend each of the conferences that do not conflict with their clinical duties. There is a monthly morning report dedicated specifically to neurology (NMR). Attendance at this is mandatory of residents on neurology elective.

Evaluations

Assessment Methods (of Resident)

The evaluation methods that apply to these rotations include some or all of the following:

• Evaluation of resident competence by faculty attendings (AE)- Formal formative evaluations should occur at the completion of the specific rotation. It is to be based on direct observation on rounds, at conferences, and at the bedside. All faculty members are encouraged to complete the form prior to the completion of the rotation and review their impressions directly with the resident. All completed evaluation forms are returned to the Program Director for review and placed in the resident's permanent file.
• Mini CEXs may be used when warranted, particularly in the beginning of the academic year.
• Self-evaluation by In-service training examination scores
• MKSAP study plan (MKSAP)
• Participation and presentations at didactic conferences (DC)
• Multi Source evaluations by patients and staff (MS)

Assessment Method (of Program)

Residents have the ability to evaluate teaching faculty and experience at the end of each rotation. They are encouraged to use this opportunity to give constructive feedback.

Residents are encouraged to maintain a high level of communication with the Program Director and faculty. These informal meetings can be used to disseminate information, receive timely feedback, and for other purposes.

Annually, all residents are required to complete and return an evaluation form of the faculty and the program. Evaluations are collected in a fashion to assure the anonymity of the resident. The feedback received during informal meetings, formal meetings, and the semi-annual evaluation form will be used to make programmatic change.

Competency Based Goals & Objectives:

1) Medical Knowledge

Goals and Objectives-PGY1 Learning Activities* Assessment
Describe the epidemiology neurologic, genetics, natural history, clinical expression of the neurologic illness encountered in the inpatient setting. IP, AM, DC, BAT, NMR AE, DC, MKSAP
Summarize an approach to the evaluation of the common presentations of neurologic disorders IP, AM, DC, BAT, NMR AE, DC, MKSAP
Describe structure and function of central and peripheral nervous systems IP, AM, DC, BAT, NMR AE, DC, MKSAP
Generate and prioritize differential diagnoses for patients with neurologic illness IP, AM, DC, BAT, NMR AE, DC, MKSAP
Develop rational, evidence-based management strategies for patients with digestive disease IP, AM, DC, BAT, NMR AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Summarize an approach to the evaluation of common neurologic presentations IP, AM, DC, BAT, NMR AE, DC, MKSAP
Distinguish patients with functional neurologic disorders from those with other "organic" neurologic illness IP, AM, DC, BAT, NMR AE, DC, MKSAP
Interpret diagnostic tests used in the evaluation of outpatients with suspected neurologic illness IP, AM, DC, BAT, NMR AE, DC, MKSAP
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation of outpatients and inpatients with neurologic disorders. IP, AM, DC, BAT, NMR AE, DC, NMR MKSAP

2) Patient Care

Goals and Objectives-PGY1 Learning Activities* Assessment
Effectively perform a comprehensive history and complete physical examination in patients with neurologic symptoms IP, AM, DC, NMR, BAT AE, DC, MKSAP, NMR
Appropriately select and interpret laboratory, imaging, and pathologic studies used in the evaluation of neurologic illness IP, AM, DC, NMR, BAT AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Construct a comprehensive treatment plan and assess response to therapy. IP, AM, DC, NMR, BAT AE, DC, MKSAP, NMR
Counsel patients concerning their diagnosis, planned diagnostic testing and recommended therapies. IP, AM, DC, NMR, BAT AE, DC, MKSAP, NMR
Utilize validated instruments in the assessment of function and quality of life to monitor and adjust therapy. IP, AM, DC, NMR, BAT AE, DC, MKSAP, NMR

3) Practice-Based Learning and Improvement

Goals and Objectives-PGY1 Learning Activities* Assessment

Identify and acknowledge gaps in personal knowledge and skills in the care of hospitalized and ambulatory patients with related diseases 		IP, AM, DC, NMR, BAT AE, DC, MKSAP, NMR
Develop and implement strategies for filling gaps in knowledge and skills of patients related diseases IP, AM, DC, BAT AE, DC, MKSAP
Integrate and apply knowledge obtained from multiple sources to the care of inpatients and outpatients IP, AM, DC, NMR, BAT AE, DC, MKSAP, NMR
Demonstrate ability to critically assess the scientific literature IP, AM, DC, BAT AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment

Effectively use technology to manage information, support patient care decisions, and enhance both patient and physician education. 		IP, AM, DC, BAT AE, DC, MKSAP
Demonstrate ability to critically assess the scientific literature IP, AM, DC, NMR, BAT AE, DC, MKSAP, NMR
Set and assess individualized learning goals IP, AM, DC, BAT AE, DC, MKSAP
Analyze clinical experience and employ a systematic methodology for improvement IP, AM, DC, BAT AE, DC, MKSAP
Develop and maintain a willingness to learn from errors, and use errors to improve the system or processes of care IP, AM, DC, BAT AE, DC, MKSAP

4) Interpersonal Skills and Communication

Goals and Objectives-PGY1 Learning Activities* Assessment
Apply empathy in all patient encounters IP, AM, DC, BAT AE, DC, MKSAP
Demonstrate effective skills of listening and speaking with patients, families and other members of the health care team IP, AM, DC, BAT AE, DC, MKSAP
Present patient information concisely and clearly, verbally and in writing IP, AM, DC, NMR, BAT AE, DC, MKSAP, NMR
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Reliably and accurately communicate the patient's and his/her family's views and concerns to the attending IP, AM, DC, BAT AE, DC, MKSAP
Compose clear and timely admission and progress notes and consultations IP, AM, DC, BAT AE, DC, MKSAP
Counsel patients, families and colleagues regarding side effects and appropriate use of specific medications, providing written documentation when appropriate IP, AM, DC, BAT AE, DC, MKSAP
Teach colleagues effectively IP, AM, DC, BAT AE, DC, MKSAP

5) Professionalism

Goals and Objectives-PGY1 Learning Activities* Assessment
Be prompt and prepared for all clinical duties IP, AM, DC, NMR, BAT AE, DC, MKSAP, NMR
Recognize the importance of patient primacy, patient privacy, patient autonomy, informed consent, and equitable respect and care to all IP, AM, DC , BAT AE, DC, MKSAP
Respect patients and their families, staff and colleagues IP, AM, DC , BAT AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Model ethical behavior by reporting back to the attending and referring providers any key clinical findings IP, AM, DC , BAT AE, DC, MKSAP
Demonstrate integrity IP, AM, DC , BAT AE, DC, MKSAP
Respond to phone calls and pages promptly IP, AM, DC , BAT AE, DC, MKSAP

6) Systems-Based Practice

Goals and Objectives-PGY1 Learning Activities* Assessment
Demonstrate effective collaboration with other health care providers, including nursing staff, ancillary staff, therapists, primary care physicians, and consultants in the care of patients with related diseases IP, AM, DC, BAT AE, DC, MKSAP
Develop an understanding of the hospital resources available to the evaluation and management of patients with problems encountered by the subspecialty. IP, AM, DC, BAT AE, DC, MKSAP
Demonstrate a knowledge of and commitment to the rules governing confidentiality of patient information. IP, AM, DC, BAT AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Discuss how the health care system affects the management of inpatients with related diseases. IP, AM, DC, BAT AE, DC, MKSAP
Determine cost-effectiveness of alternative proposed interventions. IP, AM, DC, BAT AE, DC, MKSAP
Design cost-effective plans based on knowledge of best practices IP, AM, DC, BAT AE, DC, MKSAP
Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the health care system, cost of the procedure, insurance coverage, and resources utilized IP, AM, DC, BAT AE, DC, MKSAP

Teaching Methods

All residents participate in patient care duties, didactic conferences and independent reading. They will learn at the bedside from attendings, nurses and physician extenders, pharmacists, social workers, case managers, peers, and patients.

Level of Supervision

Interns are supervised in their care of patients by more senior medical house staff (PGY- 2/3 and Chief Residents) and faculty.

PGY2/3 residents have direct and indirect supervision by Chief Resident and Faculty

References

Harrison's principles of internal medicine. McGraw Hill

Adams RD, Victor M. Principles of Neurology. McGraw Hill

Stooper and Coombs. Neurologic and behavioral diseases.

Weiner, HL, Levitt L. Neurology for the house officer, 3rd edition, 1993

Useful neurology journals

  1. New England Journal of Medicine
  2. Archives of Neurology
  3. Stroke
  4. Seminars in Neurology
  5. Headache
  6. Annals of Neurology
  7. Neurology Clinic

Faculty

Haskins, Daniells, M.D., Director, Stroke Center
Ruderman, Marvin, M.D., Division Chief
Geller, Eric, M.D.
Marx, Tatyana, M.D.
Mendelson, Stuart, M.D.
Natkarni, Mangala, M.D., Director, Sleep Center
Sobelman, Joseph, M.D.
Widdess-Walsh, Peter, M.D.