Neurology Rotation Specific Objectives
Neurosurgery residents at the University of Toronto are required to spend at least 3 months on a clinical neurology service as part of their training. They will rotate to one of three different teaching hospitals within the University: Sunnybrook Health Sciences Centre, Toronto Western Hospital/Toronto General Hospital, and St Michael's Hospital. The following is a description of the rotation-specific objectives for neurosurgery residents undertaking their neurology rotations as intermediate level residents:
To develop the clinical skills, professional attitudes, and knowledge base for the practice of consultation-based Neurology through exposure to adult neurological disorders and approach to the adult neurological patient. Appreciate the full spectrum of neurological illness (especially that which is non-operative) and the role for neurosurgery within this.
The trainee will function as a junior consulting member of the inpatient Neurology service including the Stroke service and the General Neurology service. An ambulatory experience will also be scheduled during the rotation. Attending Adult Neurology staff will supervise the trainee and evaluate their progress
MEDICAL EXPERT/CLINICAL DECISION MAKER
- Obtain a complete neurological and pertinent general history from an adult taking into account age and mental state.
- Distinguish between signs and symptoms that are physiological and those that are the result of a psychological disorder
- Formulate an appropriate differential diagnosis and provisional diagnosis with respect to common signs or symptoms involving the nervous system.
- Outline a plan of investigation including laboratory tests, neuroimaging, and other investigations. Judgment should be exercised taking into account the patient's age, general health risk, cost of investigations, and epidemiology of the disease.
- Outline a therapeutic plan again with consideration of the general risk, benefit, cost, as well as the patient's role in a making such decisions.
- Perform an appropriate general physical and neurological exam with respect to the patient's age and mental state. Learn subtleties of the neurological examination and correlate with specific neurological functions and dysfunctions.
- Localization following cerebrovascular accident.
- Neurological examination of the comatose patient
- Lumbar puncture and interpretation of CSF analysis
- Tensilon (edrophonium) test
- Cold-caloric vestibular testing
- Examination of the comatose patient for brain death criteria
- Familiarity with assessment and management of acute stroke patients, along with an understanding on the indications for tPA administration and endovascular treatment
Basic principles underlying the interpretation, indications, contraindications, and potential value or limitations of the following tests in any clinical situation where their use may be contemplated
- electrophysiology: nerve conduction studies, electromyography, evoked potentials
- CSF analysis
- interpretation of imaging studies with a focus on MRI
Clinical features, presenting signs and symptoms, natural history, and prognosis, for the major neurologic disorders including:
- Vascular disorders
- Epilepsy and epilepsy syndromes
- Headache disorders
- Cranial neuropathies
- Movement disorders (esp. Parkinson's and variants)
- Neuromuscular disorders
- Ischemic cerebrovascular disease
- Hemorrhagic cerebrovascular disease
- Demyelinating disorders
- Peripheral neuropathies
- Role of surgery in the therapy of neurological disorders including indications and contraindications for its use
- Indications for, side effects, dosages, and mechanisms of action of the major agents used in neurologic therapeutics
- Teratogenic effects of the major drugs used in neurological therapeutics
- Neurological manifestations of major systemic disorders including:
·Cardiovascular disorders and complications of cardiac surgery
·Endocrine disorders and electrolyte disturbances
·Infectious disorders of the nervous system and other systemic infections. Major bacteria causing nervous system infections including classification, and antibiotic sensitivities.
·Neoplastic disorders, paraneoplastic disorders, and the neurological complications of chemotherapy and radiation therapy
·Major neurotoxicologic agents and their effects
·Biochemical basis for the major neurologic syndromes resulting from inborn errors of metabolism
- Obtain and synthesize relevant history from patients/families/communities.
- Listen effectively.
- Discuss appropriate information with patients/families and the health care team.
- Communicate effectively and regularly (daily) with patients, parents, and families to review medical status and establish therapeutic relationships.
- Discuss appropriate information with patients/families.
- Be considerate and compassionate in communicating with patients and families; willingly provide accurate information appropriate to the clinical situation, with a reasonable attempt at prognosis.
- Communicate effectively with the health care providers including neurology staff, neurology nurses, ward nurses, consulting physicians, residents, medical students and discuss appropriate information.
- Communicate appropriately with service providers when ordering investigative procedures.
- The trainee must ensure there has been adequate communication about the patient with the person who will actually be doing and/or reporting the diagnostic study.
- Consult effectively with other physicians and health care professionals.
- Lead and contribute effectively to interdisciplinary team activities.
- Be an effective teacher of medical students, residents, allied health professionals, and patients.
- Be informed of the management plans proposed by the referring physician or other consultants for every inpatient to effectively coordinate the neurological aspects of the patients care.
- Contribute effectively to discharge planning for every inpatient with emphasis on the neurological aspects of the patients' ongoing care (e.g. long-term care facility, homecare, parent education).
- Discharge planning must be discussed with the referring physician(s) and other consultants.
- Be an effective teacher of medical students, residents, and patients on the Neurology service.
- Utilize resources effectively to balance patient care, learning needs, and outside activities.
- Allocate finite health care resources wisely.
- Work effectively and efficiently in a health care organization.
- Demonstrate appropriate judgement in triaging patients for access to resources which are limited.
- Utilize information technology to optimize patient care, life-long learning and other activities.
Demonstrate the following professional skills in time management:
- Recognize that effective use of time depends upon punctuality.
- Recognize that effective use of time requires planning.
- The trainee is expected to develop clinical skills that are both accurate as well efficient.
- Prioritize use of one's time based on the needs of the patient population
- Establish routines for carrying out regular activities and adhere to them.
Maintain complete and accurate medical records:
- Record and maintain a complete and accurate medical record for patients seen; this record will include the patient's history and the findings on physical examination (including the neurologic examination), a differential diagnosis, a provisional diagnosis, a plan for management, appropriate progress notes, and a comprehensive discharge summary.
- Clinic letter for outpatient consultations should be dictated the day of clinic to ensure their completeness and accuracy.
- Effectively coordinate the work of the health care team.
Reserve time for reading and keeping current with the neurological literature:
- Utilize information technology to optimize patient care, life-long learning and other activities. The trainee must be adept at accessing the medical literature and assessing its relevance/accuracy.
- Identify the important determinants of health affecting patients.
- Contribute effectively to improved health of patients and communities.
- Recognize and respond to those issues where advocacy is appropriate.
- Take action when needed to protect the health of the general population (ie. contacting the Ministry regarding driver's licensure in epileptics)
- Learn about community resources and related patient support groups; provide assistance to access programs (e.g. home care, occupational and physiotherapy, drug plans, application for nursing homes etc)
- Educate, be able to generate and access information (e.g. printed material, video tapes web sites) and be available as a resource person to counsel patients effectively on neurological disorders.
- Counsel patients on the importance of taking responsibility for their own well-being and recognize the important determinants predisposing to neurological disorders (e.g. risk factors for transient ischemic attack (TIA) and stroke, teratogenic effects of anti-epileptic drugs).
- Understand the role of national and international bodies (e.g. Heart and Stroke Foundation, Epilepsy Canada) in the promotion of neurological health, and the prevention, detection, and treatment of neurological disorders.
- Counsel patients and others about aspects of prevention of neurologic disorders, including risk factors, and genetic and environmental concerns.
- Recognize that treatment for a patient with a neurological disorder may require in addition to specific medical and surgical interventions, the elimination of risk factors and genetic counseling.
- Develop, implement and monitor a personal continuing education strategy.
- Critically appraise sources of medical information.
- Facilitate learning of patients, house staff/students and other health professionals.
- Development and implementation of a personal continuing education strategy is expected of the trainee. This will be monitored by the attending staff and evaluated by the knowledge level and "evidence of reading" demonstrated by the trainee with respect to the patients on the inpatient service and their neurological disorders.
- Present teaching rounds on a Neurology topic for the purpose of educating oneself and peers.
- Be able to critically assess the neurologic literature as it relates to patient diagnosis, investigation and treatment:
- The evaluation of neurological literature is a skill to be acquired over time and may not be mastered during this rotation.
- Deliver highest quality care with integrity, honesty and compassion.
- Exhibit appropriate personal and interpersonal professional behaviors.
- Practice medicine ethically consistent with obligations of a physician.
- Demonstrate personal and professional attitudes consistent with a consulting physician role:
- Include the patient in discussions concerning appropriate diagnostic and management procedures.
- Show appropriate respect for the opinions of fellow consultants and referring physicians in the management of patient problems and be willing to provide means whereby differences of opinion can be discussed and resolved.
- Be willing and able to appraise accurately his/her own professional performances and show that he/she recognizes his/her own limitations with regard to skill and knowledge by appropriately consulting other physicians and paramedical personnel when caring for the patient.
- Be willing and able to keep his/her practice current through reading and other modes of continuing medical education and develop a habit of maintaining current his/her clinical skill and knowledge base through continuing medical education.