Department of Neurology

Adult Acute General Neurology Service

The core educational objectives during the Adult Acute General Neurology Service at the Vanderbilt University Hospital (VUH) are:

1) To acquire the knowledge, skills, and attitudes to perform a thorough neurological exam

2) To diagnose and manage the complete range of acute and non-acute neurological illness.

The Adult Acute General Neurology Service includes faculty-supervised care to a diverse population of patients with the full range of neurological illness. The resident assumes an ascending level of responsibility based upon maturation of knowledge, skills and attitudes applicable to the educational goals of this experience. The resident will assume a leadership role for education and patient care. The specific educational goals for these experiences include [specific core competencies indicated in brackets]:

· Practical experience in obtaining an orderly and detailed history from the patient, conducting a thorough general and neurological examination, and organizing and recording data [patient care, medical knowledge]

· Understanding the indications for and the limitations of clinical neurodiagnostic tests and their interpretation [patient care, medical knowledge, systems-based practice]

· The ability to correlate information derived from neurodiagnostic studies with the clinical history and examination in formulating a differential diagnosis and management plan [patient care, medical knowledge]

· Participation in the evaluation of and decision making for patients with disorders of the nervous system requiring invasive interventions such as surgery [patient care, medical knowledge and communication skills]

· Participation in the management of patients with psychiatric or neuro-psychiatric disorders [patient care, medical knowledge, interpersonal and communication skills]

· Participation in the management of the patient with acute neurological disorders in the neuro-intensive care unit [patient care, medical knowledge, interpersonal and communication skills]

· To better understand the principles of bioethics and the provision of appropriate and cost-effective evaluation and treatment of patients with neurological disorders [practice based learning and improvement, professionalism, systems-based practice]

· Participation in end-of-life palliative care including adequate pain relief and psycho-social support and counseling for family members about these issues [patient care, professionalism, interpersonal and communication skills]

Service Schedule
6:30 a.m. Resident rounds: 1st year neurology resident, intern, students
7:30 a.m. Morning Report: 1st and 3rd year neurology residents, intern, students
8:15 a.m. Attending rounds: 1st and 3rd year neurology residents, intern, students

Rounds are expected to conclude at 10:50 on Tuesdays, 11:50 on other weekdays in order to facilitate residents ability to attend didactic conferences.

Faculty supervised teaching rounds are held seven days per week. During these rounds, residents present cases and their diagnostic and therapeutic plans. [patient care, medical knowledge, practice based learning and improvement, interpersonal and communication skills, professionalism, system based practice]

The Vanderbilt Adult Acute General Neurology service is responsible for managing patients with essentially non-stroke pathology (e.g. multiple sclerosis exacerbations, intractable epilepsy disorder, chemotherapy for CNS/PNS malignancies). There is typically one attending for the general service – however, as this service may consist of patients from the subspecialty departments (e.g. epilepsy, neuro-oncology, movement disorders), one may have to correspond and round with other attending physicians.

Resident Responsibilities
1st Year Junior Neurology Resident: Admit and manage patients to the Vanderbilt General Neurology Service. [patient care, medical knowledge, practice based learning and improvement, interpersonal and communication skills, professionalism, systems-based practice]

· Write a complete admission history and physical exam note that includes chief complaint, history of present illness, past medical history, allergies, medications, family history, social history, complete review of systems, general medical examination, neurologic examination, impression including localization and differential diagnosis, and plan of evaluation, management and treatment. [patient care, medical knowledge]

· Be knowledgeable of all patients under one’s care, including the latest laboratory and/or imaging data. [patient care, medical knowledge, professionalism]

· Write complete progress notes on all inpatients daily. Interns and/or medical students should be reviewed by the neurology resident. The neurology resident should independently write a complete daily progress note on every patient that includes patient complaints, physical and neurologic examination, medications, laboratory and diagnostic results, impression and plan, as opposed to writing an addendum to an intern or student note. [patient care, medical knowledge, interpersonal and communication skills]

· Pre-round and enter all daily notes for all inpatients prior to daily attending rounds. [patient care, professionalism]

· Weekend rounds are the sole responsibility of the 1st year neurology resident on the General Neurology Service. Cross-covering for weekend rounds is not allowed.

· Clinical decisions should first be cleared with the attending before they are put in place, and the resident is expected to keep the attending abreast of major changes in patient care or status. [patient care, practice-based learning and improvement, interpersonal and communication skills, professionalism]

· When admitting a patient, a full History and Physical note must be available within 24 hours. If another 1st year neurology resident has entered a full and complete admission note as outlined above, then the accepting 1st neurology resident must enter an accept note that includes a concise HPI, comprehensive neurological examination, assessment and plan. This must be a separate document and not an addendum to an intern or student admission note. [patient care, interpersonal and communication skills, professionalism]

· All patients admitted to the General Neurology Service must have a complete evaluation performed by a 1st year neurology resident. All patients admitted to the General Neurology Service must have a complete admission note as described above written by a 1st year neurology resident. [patient care, interpersonal and communication skills]

· Discharge summaries must be written on all patients by the 1st year neurology resident assigned to the General Neurology Service at the time of patient discharge. It should include the principal and secondary diagnoses, listings of major procedures and imaging studies, a brief summary of the patient’s hospital course, the patient’s neurologic condition upon discharge, recent medication list and allowable activity and diet, and follow-up arrangements. [patient care, medical knowledge, professionalism]

· The 1^st year neurology resident should never hesitate to contact the senior resident or attending physician if there are questions regarding patient care and/or responsibilities.

· At the conclusion of service time complete comprehensive evaluations on the attending, senior resident, intern, and student performances [practice-based learning and improvement]

3^rd Year Senior Neurology Resident: Senior residents assume an ascending level of responsibility for patient care and teaching. With appropriate faculty supervision, the resident will function as an “attending physician in training” and take a leadership role in education and patient care.

· Primary clinical responsibility for the overall care of all patients on the General Neurology Service both through daily rounds with the attending physician and service-related work [patient care, medical knowledge, practice based learning and improvement, interpersonal and communication skills, professionalism, system-based practice]

· Supervise all procedures (i.e. lumbar punctures) and provide bedside and didactic teaching to junior neurology residents, interns, and students [patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills]

· Senior residents teach and demonstrate the delivery of care that is compassionate and appropriate for the condition requiring hospitalization. They should highlight important clinical findings and provide appropriate neuroanatomic and neuroscience correlation. [patient care]

· Review and provide guidance on documentation including admission, daily notes, and discharge summaries. Provide feedback so that residents are able to evaluate their own learning in an effort to improve patient care. [patient care, medical knowledge, practice based learning and improvement, interpersonal and communication skills]

· Neurologic Examination: Senior residents should demonstrate in a one-on-one setting a complete neurological examination. Subsequent to that instruction, the senior resident should observe the junior resident perform at least two complete neurological examinations over the course of the rotation. Senior residents should provide feedback and instruction based on this observation. [patient care, medical knowledge, practice based learning and improvement, interpersonal and communication skills]

· Didactic Teaching: Senior residents lead morning report three days weekly. Topics are focused on the evaluation and management of patients presenting with acute neurologic illness. Interns rotating on the neurology service attend the same lecture series and schedule as students on the Third Year Neurology Clerkship. This curriculum has recently undergone a complete revision and provides a very broad based overview of neurology on a rotating schedule, appropriate for interns. [practice based learning and improvement]

· Encourage reading in standard texts and medical literature to enhance the acquisition of medical knowledge in the neurosciences. [medical knowledge]

· During the course of the rotation, demonstrate, observe, and provide feedback to the resident to insure adherence to ethical principles, sensitivity to diverse patient populations, and adoption of professional responsibilities. [professionalism]

· Encourage residents to effectively call on system resources to provide optimal care. Encourage discussions help residents better understand the role of a neurologist in the larger context of our healthcare system, especially in the area of their effort to aid other physicians in providing optimal care and value. [systems-based learning and improvement]

· The senior resident will be off one day on the weekend and will cover for the junior on their day off.

· The senior neurology resident should never hesitate to contact the attending physician if there are questions regarding patient care and/or responsibilities.

· At the conclusion of service time complete comprehensive evaluations on the attending, junior resident, intern, and student performances [practice-based learning and improvement]

Intern Responsibilities: The off-service intern on neurology service is primarily responsible for patient care under the direct supervision of the junior and senior resident, and the attending physician.

· Admit (evaluate, write note, and orders) and manage patients to the Vanderbilt General Neurology Service. [patient care, medical knowledge, practice based learning and improvement, interpersonal and communication skills, professionalism, systems-based practice]

· Be knowledgeable of all patients under one’s care, including the latest laboratory and/or imaging data. [patient care, medical knowledge, professionalism]

· Write complete progress notes on all inpatients daily. The intern should independently write a complete daily progress note on every patient that includes patient complaints, physical and neurologic examination, medications, laboratory and diagnostic results, impression and plan, as opposed to writing an addendum to a student note. Medical student notes should be reviewed and countersigned by the intern. [patient care, medical knowledge, interpersonal and communication skills]

· Pre-round and enter all daily notes for all inpatients prior to daily attending rounds. [patient care, professionalism]

· Clinical decisions should first be cleared with the attending before they are put in place, and the intern and resident are expected to keep the attending abreast of major changes in patient care or status. [patient care, practice-based learning and improvement, interpersonal and communication skills, professionalism]

· When admitting a patient, a full History and Physical note must be available within 24 hours. If another intern or 1st year neurology resident has entered a full and complete admission note as outlined above, then the accepting intern must enter an accept note that includes a concise HPI, comprehensive neurological examination, assessment and plan. This must be a separate document and not an addendum to a student admission note. [patient care, interpersonal and communication skills, professionalism]

· Teaching responsibilities are primarily directed towards students. Teaching responsibilities include obtaining and writing admission notes and daily notes as well as formulating and entering physician orders and conducting general medical exams.

· The intern should never hesitate to contact the senior resident or attending physician if there are questions regarding patient care and/or responsibilities.

· At the conclusion of service time complete comprehensive evaluations on student performances [practice-based learning and improvement]

Attending Faculty Responsibilities

· Hold supervised teaching rounds seven days per week. Residents present cases with their diagnosis and therapeutic plans during these rounds. [medical knowledge, practice-based learning and improvement, interpersonal and communication skills]

· Identify teaching points from the inpatient clinical caseload. [medical knowledge, practice-based learning and improvement]

· Assign appropriate reading and research to residents and students. [medical knowledge]

· Conduct follow-up discussions at the beginning or end of rounds. [medical knowledge]

· Faculty members are encouraged to schedule brief presentations by students and residents, reviewing assigned topics. [medical knowledge, practice-based learning and improvement, interpersonal and communication skills]

· Encourage and monitor senior residents to junior residents and junior residents to intern and student teaching. [practice-based learning and improvement]

· Complete rounds by 10:50 on Tuesdays, 11:50 on other weekdays, so as to facilitate residents ability to attend scheduled didactics.

· At the conclusion of service time complete comprehensive evaluations on the resident, intern, and student performances [practice-based learning and improvement]