Department of Psychiatry and Human Behavior

Department of Psychiatry and Human Behavior

Butler Hospital - Rhode Island Hospital – the Miriam HospitalRevised Date 4/5/2010

Neurology
Overview of Rotation
Neurology rotations in the Brown Psychiatry Residency constitute a core training experience during which residents learn to perform competent neurological evaluations and treatment of neurological illnesses. The rotation requires a high degree of organization and efficiency, as well as a strong commitment to professionalism. This latter quality is a core value, which should guide residents in decision-making about which steps to take on behalf their patients, as well as their own education.

Description of Rotation

Residents are provided with two months of neurology during their PG1 year. The assignment consists of one-month rotations at Rhode Island Hospital, Butler Hospital or a neurological outpatient practice under the auspices of the Miriam Hospital. Each resident’s assignments are scheduled in order to give the resident broad clinical experience in all areas of neurology.
Butler Hospital: The Neurology Service at Butler Hospital consists of consultations on inpatients and Day Hospital patients, care of inpatients with neurological disorders on the Behavioral Neurology and Senior Specialty Services and care of outpatients in the neurology offices of Dr. Salloway and Dr. Rickler.
Rhode Island Hospital:The neurology consultation service at RIH provides a varied intensive exposure to a wide variety of acute neurologic conditions. Psychiatric residents rotating on neurology are closely supervised by chief residents and service attendings. The intensive experience gives the resident a strong basis of neurologic experience.
Miriam Hospital: This outpatient neurology rotation gives residents a broad exposure to the assessment and treatment of common neurologic problems such as headache management, and the management of many neurological illnesses such as stroke, epilepsy and dementia. There is more exposure to outpatient setting than inpatient setting at Miriam.
I. GENERAL INFORMATION
Name of Rotation / Neurology
Chiefs of Service / James Gilchrist, MD (Rhode Island Hospital),
Norman Gordon, MD (the Miriam Hospital);
Kenneth Rickler MD (Butler Hosptial)
Contact Information / James Gilchrist, MD (Rhode Island Hospital):
Norman Gordon, MD (the Miriam Hospital):
Kenneth Rickler, MD ()
Residency Coordinator / Roberta Swanson: (401) 455-6375
II. FACULTY
Drs. Salloway, Wilterdink, Blum, Donnelly, Feldmann, Rizvi, Sachs, Gordon, Rickler. Friedman, Chang, and Weinman
III. TOPICS/TEACHING METHODS/MATERIALS USED DURING THIS ROTATION
Topics to be covered are based upon:
The patient population cared for by the team over the course of the rotation and
The weekly afternoon seminars
Cases selected for presentation
Principal teaching methods:
Attending Rounds
Weekly afternoon seminars
Educational materials provided/referred to residents:
Reading: Each attending and resident is expected to utilize current medical literature in the planning of therapeutic and diagnostic interventions.
Computer-assisted educational materials: All housestaff have access to full-text literature search and retrieval capacity through the hospitals’ computer networks. Terminals are located on all floors and in the residents’ offices.
Other: Residents are given articles as part of their weekly afternoon seminar series and by faculty on service.
IV. SPECIFIC AREAS & EXPECTATIONS
Residents are expected to regularly review relevant:
Neuroimaging studies
Laboratory testing results
neuropsychological testing results.
On this rotation, residents may act as consultants to other clinical services such as surgery or psychiatry. Among the attendings' responsibilities is the application of cost-effective care measures and principles to the actual care of the patients on the service. Residents are expected to communicate as needed with discharge planning specialists.

V. EVALUATIONS

Evaluation of the resident's successful completion of the goals listed below will be carried out by the attending.
Evaluation of the attending's successful completion of the goals listed below will be carried out by the resident.
Evaluation of the rotation will be completed as part of the annual resident retreat report.

VI. RESPONSIBILITIES OF ATTENDING ON ROTATION

The ward attending is ultimately responsible for all inpatient care of Neurology Ward Patients.
The attending will be available to the ward house staff Monday morning through Friday afternoon, 24 hours daily and on Saturday morning.
The attending will write admission notes on all patients admitted to the ward service Monday through Friday and daily progress notes Monday through Saturday.
The attending will attend rounds each day Monday through Saturday.
The ward attending is responsible for the clinical education of all housestaff and students rotating on the ward service. This is generally accomplished by informal as well as formal bedside teaching related to conditions of patients admitted to the ward service.
The attending will review all neurological imaging studies with the residents.
The attending is responsible for monitoring the progress of the resident on rotation throughout the month and communicating his impressions of the resident's performance to the resident throughout the month.
The attending will at some time observe each resident in interactions with patients and families, in the performance of aspects of history taking and physical examination, and will review residents’ admission and progress notes in order to be able to evaluate the residents’ clinical and communication skills.
The attending will complete an electronic evaluation for each resident at the end of the month.
VII. RESPONSIBILITY OF RESIDENT ON ROTATION
Rhode Island Hospital:
The residents on the consult service will evaluate all patients for whom a neurology consultation is requested as delegated by the chief resident.
The resident will write a complete consultation note on all patients evaluated and will write regular follow-up notes on these patients, following up on the patient’s neurologic progress and the results of recommended neurodiagnostic tests.
The resident will communicate directly with the primary physician and/or primary housestaff when urgent diagnostic testing or intervention is required and otherwise as appropriate.
Residents will attend attending consult rounds each weekday, gather all clinical data required, including xray films, for complete clinical case presentations to the attending physician.
In cases requiring immediate attention, the resident will consult with the chief resident and/or attending physician regarding urgent interventions.
The residents assigned to the consultation service will work out between themselves an equitable schedule for sharing the daytime and afternoon/evening assignments.
Butler Hospital:
Resident is responsible for evaluating inpatient and Day Hospital consultations
Resident is responsible for assisting Dr. Rickler on Monday, Wednesday, and Thursday, Dr. Weinman on Tuesday, and Dr. Chang on Friday, with the evaluation and management of selected inpatients on the Behavioral Neurology or Senior Specialty Services.
Residents will see outpatients with Dr. Salloway or Dr. Rickler in their offices
Miriam Hospital:
Resident will attend regular outpatient hours in Dr. Gordon’s office at 450 Veterans Memorial Parkway in East Providence
Resident will perform initial H&P on new patients and present cases to Dr Gordon, with an evaluation and treatment
Resident will accompany Dr Gordon to the Miriam hospital to consult on inpatients as needed
Resident will attend Neurology Grand Rounds at RIH on Wednesday mornings from 8 am to 9.30am.

VIII. SCHEDULE DURING THIS ROTATION

Morning Rounds Monday, Tuesday, Thursday, Friday at 8:00 Neurology Library #322 (RIH)
Noon Resident Conference Monday, Thursday, Friday Neurology Library #322 (RIH)
Grand Rounds Wednesday 8am George Auditorium (RIH)
Neuroradiology Wednesday 12 noon Neuroradiology conference room (RIH)

IX. GENERAL EDUCATIONAL OBJECTIVES

Objectives - By the end of this rotation, the resident will be able to:
Rhode Island Hospital, Miriam Hospital:
Obtain an orderly and detailed neurologic history, conducting a thorough general and neurological examination, and organizing and recording data
Obtain an understanding of the pathophysiology of cerebrovascular disease, its acute management, and diagnostic evaluation
Develop the skill set needed to evaluate and manage patients with acute neuromuscular disorders and other inpatient neurologic disorders including but not limited to seizures, cerebral neoplasms, elevated intracranial pressure, multiple sclerosis and CNS infections
Be familiar with the indications for and limitations of clinical neurodiagnostic tests and their interpretation as well as to correlate the information derived from these neurodiagnostic studies with the clinical history and examination in formulating a differential diagnosis and management plan
Prepare and present case presentations
Develop an appreciation for cost-efficient care, proper utilization of resources, the importance of after-hospital care planning, and patient autonomy
Work in a coordinated fashion with a multi-disciplinary team
Additional educational objectives for Butler Hospital:
Develop careful history taking skills and skills at neuropsychiatric assessment and differential diagnosis
Better understand brain systems relevant to neurology and psychiatry.
Be knowledgeable about neurological syndromes affecting psychiatric patients
Interpret brain CTs and MRIs
X. GOALS AND OBJECTIVES FOR THIS ROTATION – COMPETENCY-BASED
Competency/Description
1. Patient Care / Goals and Objectives / Evaluation Method
Resident must be able to provide care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. / Residents
-Learn to gather essential and accurate information about their patients
-Prepare and present case presentations
-Assess severity of illness and demonstrate prioritization skills necessary to make interventions in a timely manner
-Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment
-Counsel family and patients
-Develop the ability to communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families.
-Work with health care professionals, including those from other disciplines, to provide patient-focused care / - Residents are evaluated by their attending
- Performance at morning report
2. Medical Knowledge / Goals and Objectives / Evaluation Method
Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. / Residents
-Will learn to generate a differential diagnosis and unique treatment plan for each patient encounter, learn to judiciously use diagnostic tests, laboratory studies to narrow the diagnosis
-Will demonstrate an investigatory and analytic thinking approach to clinical situations
-Learn to effectively communicate their investigatory and analytic thinking approach via written notes and at clinical conferences and didactic teaching sessions
-Will keep abreast of new scientific knowledge, which is obtained via didactic sessions, Grand Rounds, critical review of scientific literature, computer and web-based resources
-Will actively participate in conferences
-Understand and apply basic principles of physiology and pathophysiology to common diseases; understand the diagnosis and prognosis and management options for these illnesses
-Will know and apply the basic and clinically supportive sciences which are appropriate to their discipline / - Feedback of both oral and written presentations will be provided
- Presentation skills, management decisions and knowledge are evaluated at morning rounds
3. Interpersonal and Communication Skills / Goals and Objectives / Evaluation Method
Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients’ families, and professional associates. / -Residents will approach patients/families with a friendly, interested, and respectful demeanor.
-Residents will scrupulously maintain patient confidentiality, and specifically reassure patients/families of the confidentiality of their personal and medical information
-Residents will make every effort to safeguard patient/family dignity.
-Residents will know and be able to describe the proper boundaries of the physician/patient relationship, and will consistently and conscientiously avoid any breach of these boundaries.
-Residents will make explanations in clear, common-parlance language, avoiding use of medical jargon, and using graphic aids (including informal sketches) where helpful to get points across.
-Residents will ask patient’s/family’s concerns and questions and address these specifically and directly to ensure that patient/family have received information in the desired degree of detail.
-Residents will clearly identify differences in patient/family and medical perspectives, bringing such differences into open discussion, and explaining the rationales for medical actions that differ from patient/family preferences and values.
-Residents will negotiate priorities for problems to be addressed in the particular visit, once all issues have been identified.
-Residents will write clearly and legibly when hand-writing instructions or other information for patients/families
-Residents will help to ensure that written or printed information for patients/families is language-congruent and literacy appropriate using straightforward language and comprehensible and culturally appropriate illustration.
-Written communications in patient charts will effectively permit subsequent caregivers to understand the nature of the patient interaction and the goals and plans for the encounter as well as future encounters when applicable / - Attendings rate their residents on rounds, bedside teaching interactions
- Observation by chiefs, other residents on a day to day basis
- Feedback from nursing staff, other disciplines
4. Professionalism / Goals and Objectives / Evaluation Method
Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population / -Residents will ask patients/family members how they wish to be addressed
-Residents will openly support and assist patients/families in dealing with health challenges and their administrative complications.
-Residents will know and avoid breach of the boundaries of the physician/patient relationship, including but not limited to strict avoidance of sexual or romantic suggestiveness or involvement with patients/family members.
-Residents will make reasonable efforts to act as advocates for their patients.
-Residents will place patient safety as their first priority without compromising their own safety or the safety of others that they are supervising.
-Residents will recognize and support patient’s rights to receive full information regarding the risks, benefits, and when appropriate, costs of appropriate treatment options, and to be advised of potential conflicts of interest on the part of their physicians.
-Residents will truthfully report medical errors of their own to their attending, or Risk Management and to follow hospital protocols in the face of errors. Residents will encourage and facilitate reporting of medical error on the part of professional colleagues.
-Residents will seek professional help for personal impairments that may compromise patient care; will assist impaired colleagues to obtain professional help; and will take responsibility for interceding to protect patient safety when impaired colleagues do not respond appropriately to their own duties in this regard.
-Residents shall not withhold needed medical care from patients/families wishing to receive it, irrespective of ability to pay for such care.
-Residents will participate with an attitude to support the appropriate decisions of patients or recognized family decision makers to withhold or withdraw life-sustaining treatment from patients in terminal conditions.
-Residents will fully and clearly inform patients and families of the benefits and risks of all proposed diagnostic and therapeutic interventions, with the purpose of facilitating the ability to make an informed decision, even if the eventual decision is not the one the physician prefers for the patient.
-Residents will avoid any form of coercion of patient/family decision making.
-Residents will make every effort to elicit and to accommodate, to the fullest extent of their ability, differing religious and cultural needs and values in delivering medical care– but are under no obligation to accommodate requests based upon any form of identity-group prejudice.
-Residents will clearly and openly identify and repudiate statements of prejudice made by professional colleagues, and will not permit their actions as physicians to be influenced by such prejudice.
-Residents will cultivate the ability to identify and articulate their own cultural values and preferences, comforts and discomforts; and to be self aware in attempting to deliver fair and optimal medical care to all patients– including recognizing their obligation to transfer care to another physician should the occasion arise in which personal values or biases interfere with such care delivery to any patient or family.
-Demonstrate understanding of and sensitivity to end of life care and issues regarding provision of care. / - Residents evaluate each other each month and rate their interpersonal skills with each member of the team as well as with patients/families
- Attendings rate their team on rounds, bedside teaching interactions
- Observation by chiefs, other residents on a day to day basis
- Feedback from nursing staff, other disciplines
- Patient satisfaction surveys
5. Practice-Based Learning and Improvement / Goals and Objectives / Evaluation Method
Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. / -At the end of this rotation, the resident should be able to identify gaps in knowledge based upon experience, introspective awareness, and feedback for the month. The resident is expected to regularly review both textbook and primary source literature to maintain up to date understanding of specific topics that have arisen in practice.
-The resident should actively seek feedback and advice on practice from peers, mentors, staff, and patients alike to gain greater objective insight into their strengths and weaknesses.
-The resident should be able to obtain scientific literature, appraise quality, and assimilate data through the use of up to date resources to improve their practice and care of patients’ health problems.
-The resident will gain basic skills in literature search methodologies using standard web-based medical literature search engines such as Ovid, MD Consult, Pubmed.
-The resident will have familiarity with a variety of computer and hand-held computer based resources for looking up medications, dosing, and other topics of use to the general internist
-The resident will actively participate in lectures and discussions with peers and experts on the topics related to the care of their patients.
-The resident is expected to take a proactive and interactive approach to enhancing their knowledge. The resident is expected to “think out loud”, ask for clarification and guidance, and actively seek input on their practice and knowledge base from their mentors. / - Day to day knowledge base evaluated by feedback on differential diagnoses, management plans
-morning rounds
-conferences
6. Systems-Based Practice / Goals and Objectives / Evaluation Method
Resident must demonstrate an awareness of and responsiveness to a larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. By the end of their training, residents are expected to have attained competence in the following goals. / -The resident will learn how to work within a multidisciplinary team to develop a care plan for their patients.
-The resident will become familiar with hospital and community based health care professionals and their roles in groups such as social work, mental health professionals, PT, OT, dietitians, and VNA etc.
-The resident will evaluate how interacting with the above groups and health professionals affects their own practice..
-The resident will practice cost-effective health care and resource allocation that does not compromise quality of care.
-The resident will learn about a variety of insurances and how they affect patient referrals and prescriptions. They will learn the legal rights of the uninsured and will work with the appropriate services to assist patients who are under- or un-insured.
-The resident will learn how to interact and advocate effectively with other physicians, ancillary caregivers, community agencies, landlords, and insurance companies etc. via spoken and written communications when it effects the health of their patients.
-The resident will learn about the various community resources available for patients and will work with case managers and social workers to enable patients to access these resources. The resident will learn to work with translator services for optimal and appropriate patient care / - Evaluations from attending
- Feedback from team members
- Observation by chiefs and other faculty

XI. OTHER IMPORTANT INFORMATION FOR RESIDENT DURING THIS ROTATION

Residents should be mindful of the unique opportunity with which they are presented during this rotation. In caring for sick, hospitalized patients in a supervised environment, you are being given the chance to study in a protected environment while caring for patients with the illnesses you are studying. We urge you not to waste this time but rather to embrace your responsibilities and to study and teach based upon the needs of your patients.

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