Transcript Clinical Neurosciences Clerkship

Stephen Deputy, MD - Director, Clinical Neurology Clerkship
[email protected] 250-8139
James Breazeale - Academic Coordinator
[email protected] 568-4090
Neurology
Chief Resident :
Baton Rouge
office
Dr. Lourdes Lago: [email protected]
Dr. Charles Barkemeyer – (225)-358-1179
Duties of Students
Equipment
Each student should own or have access to the following equipment in
order to adequately exam patients with neurological disorders:
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Ophthalmoscope (Welsch Allyn or Pan-Optic head)
Snellen Eye Chart
Reflex Hammer (preferably Queen Square type and not Tomahawk
type)
Flashlight (or penlight)
Tuning Fork (C-128 for vibration sense detection +/- C-256 or 512
for hearing)
Your Brain!!!!
Duties of Students
Didactic Lectures
 Neurology Resident-Led Clinical Case Studies
 Applicable Neuroradiology
 Faculty-led Student Professor’s Rounds
 Neurology Review
Lectures are held on Thursday afternoons (see calendar)
and are mandatory for all students with the exception of
those rotating in Baton Rouge
Duties of Students
Didactic Lectures
Neurology Resident-Led Clinical Case Studies
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2 Cases; one is a Stroke case and the other is an
Epilepsy case
Read the cases and be ready to answer the
discussion points prior to attending the lecture
Audience participation is expected
Duties of Students
Didactic Lectures
Applicable Neuroradiology Lecture
Reviews various types of Neuroimaging Modalities
 Reviews Neuroanatomy from a Neuroradiology
perspective
 Reviews the Neuroradiographic findings of some
common pathologies
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Faculty-Led Student professor’s Rounds
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Students assigned to University Hospital are responsible for
bringing a case to the conference
Only one student presents
Be sure to include pertinent details from the Chief Complaint,
HPI, PMHx, PSHx, Social Hx, Medications and their Dosages
Present the Physical Examination and a DETAILED Neurological
Examination
Be prepared to discuss a pertinent Differential Diagnosis
based on Localization of the disease process
Discuss the results of Diagnostic Studies
Discuss Treatment and Outcome of the patient
Neurology Review Lecture
Briefly touches on important clinical aspects of
multiple Neurological Disorders to help as a study
guide for the SHELF Exam
 Topics include: CNS Infections, Auto-immune
disorders, Epilepsy and Sleep disorders, Vascular
disorders, Headache and Pain syndromes, Trauma,
Degenerative disorders, Altered Mental Status,
Movement disorders, Structural abnormalities, Toxic
and Metabolic disorders, Psychiatric conditions,
Neuromuscular disorders, Anatomy and Localization.
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Progress Notes
Progress notes should be written as frequently as the patient’s condition
warrants. These can be written on hospital Progress Notes sheets but
should be identified as L3 with signature and should be cosigned by
staff or resident.
Each medical student is expected to be an active participant of the team
to which he/she is assigned. Responsibilities include, but are not
limited to, participating in all work rounds (except when didactic
lectures are occurring), reviewing all pertinent laboratory studies
obtained on his/her assigned patient (including blood work, CSF
results, neuroimaging results, and electrodiagnostic studies), and
writing daily progress notes on the patients that they are assigned to
follow.
The official Student Leave Policy During the Neurology Clerkship
essentially states that students should try and minimize absences during
required clerkships. During this short 2 week rotation, you will be allowed no
more than 1 day for an excused personal absence. It is expected that you
inform your resident as well as other students on the team of any planned
absence so that your patient care duties can be covered. You must also
inform the clerkship administrative assistant (JB) as well as the Clerkship
Director in writing (by email) of your planned absences at the beginning of
the 2 week block and receive permission to take said absence, otherwise it
will be considered unexcused. Unexcused absences may be grounds for
failing or repeating the clerkship. In the event a student needs to take more
than 1 day off for personal matters, this student will generally need to make
up extra time within the clerkship at the clerkship director’s discretion. The
LSUHSC policy regarding absences from Junior Clerkships are listed in the
Duties for Students document.
Work Hours
In recognizing the time commitment required of medical students during
clinical rotations and taking into account the effects of fatigue and sleep
deprivation on learning, clinical responsibilities, and student health and
safety, the following duty hour limitations have been adopted by the LSU
Clerkship Directors as of 5/22/08 and are to be followed without exception:
1. Duty hours must be limited to 80 hours per week averaged over a fourweek period, inclusive of all clinical and didactic learning activities.
2. Students who are assigned to overnight call in the hospital should not
have patient care responsibilities after 1:00 PM on the following day.
3. Students will be expected to attend mandatory didactic activities even
after overnight call.
Any breech of the outlined work hour limits described above should be
reported directly to the Director of the Clinical Sciences Curriculum, the
Associate Dean for Student Affairs, the Assistant Dean for Student Affairs,
or the Assistant Dean for Undergraduate Medical Education.
On Call
In-house call is not required during your
Neurology Clerkship
(However, if you have a particularly good resident and wish to take call electively
to gain further clinical experience, please feel free to do so)
Junior Neurology Clerkship
Passport
Neurology Passport
The Junior Neurology Clerkship Passport is your link to
documenting your directly observed neurological
examination and pertinent neurological history taking skills,
patient log, and student presentations. It has been designed
to allow faculty to be better able to assess the performance
of each student during the Junior Neurology Clerkship. The
Passport is to accompany each student during each day
during the rotation and must turned in at the end of the
rotation in order for the student to be able to sit for the final
written examination. Do not leave your Neurology
Clerkship Evaluation Form with any attending physician
or resident to be filled out “later”. Lost or misplaced
Passports may be reconciled on a case-by-case basis by the
Clerkship Director. Each Passport will have the following
components:
Clinical Neurosciences Passport
I. Neurological Examination Competency Form
II. Neurological History Taking Competency Form
III. Student Presentations Form
IV. Patient Log
Basic Competencies:
Neurological Examination Skills
One of your learning goals during the clerkship is to improve
your competency in performing a neurological examination.
 During your Neurology Clerkship you will be asked to formally
demonstrate your neurological examination skills on at least
one of the patients that you are taking care of (though the
more you do, the better you will get with these skills).
 Have an attending physician or neurology resident sign off on
the Basic Competencies form that corresponds to your specific
rotation (Adult or Child Neurology).
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Basic Competencies
Adult Neurology: Neurological Examination Skills.
Minimum Criteria
The Neurological Examination demonstrates completeness by:
 Containing components from each of the six sub-sets of the
neuro exam (mental status, cranial nerves, motor, sensory,
coordination and gait)
Application of the Neurological Examination by:
 Correctly interpreting normal and abnormal findings to aid in
localization of the disease process.
 Use of the neurological examination to quantify the severity of
any neurological deficits identified.
Professionalism:
 The approach to the patient during the examination shows
respect for the patient’s privacy and dignity.
Basic Competencies
Child Neurology: Neurological Examination Skills.
Minimum Criteria
The Neurological Examination demonstrates completeness by:
Containing components from each of the six sub-sets of the neuro exam
(mental status, cranial nerves, motor, sensory, coordination and gait),
even if just by observation.
 Pertinent “non-neurological” aspects of the examination are
demonstrated (head circumference, dysmorphic features, cutaneous
findings, etc).
Application of the Neurological Examination by:
 Correctly interpreting normal and abnormal findings in an age-specific
fashion
 Use of the neurological examination to aid in localization of the disease
process
Professionalism:
 The approach to the patient shows courtesy and respect for the child’s
modesty and parental concerns
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Basic Competencies
Overall Student Competence (circle one):
Strong
Acceptable
Unacceptable
(needs to be repeated)
I observed this student perform this skill and attest that
he/she met the specified criteria
Signed:________________________________________________
Printed Name/Title:_______________________________________
Basic Competencies:
Taking a Pertinent Neurological History
Your neurological history should include information
concerning the onset and evolution of any neurological
complaints as well as their chronicity.
 The history should also allow for some degree of localization of
the disease process.
 Be sure to include how the deficits functionally impair the
patient
 Present your history to an attending physician or resident and
get your basic competency card signed
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Basic Competencies
Adult Neurology: Pertinent History Taking Skills.
Minimum Criteria
The history contains enough information to begin the
process of localization
 The history contains enough information to gain an
understanding of the chronology and severity of the
disease process
 Information is obtained concerning psychosocial
functioning of the patient as it pertains to his/her
illness
 Medication dosages and allergies are accurately listed
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Basic Competencies
Child Neurology: Pertinent History Taking Skills.
Minimum Criteria
The history contains enough information to begin the
process of localization
The history contains enough information to gain an
understanding of the chronology and severity of the
disease process
A thorough developmental history/school performance
history is identified
Medication dosages and allergies are accurately listed
Basic Competencies
Overall Student Competence (circle one):
Strong
Acceptable
Unacceptable
(needs to be repeated)
I observed this student perform this skill and attest that
he/she met the specified criteria
Signed:________________________________________________
Printed Name/Title:_______________________________________
Student Presentations
Students are encouraged to prepare and present brief
presentations concerning some aspect of the disease
(diagnosis, treatment, prognosis, etc.) that their patient
has. This demonstrates independent learning which is
strongly encouraged during the clerkship
 Each time that you give a presentation to your team,
please document the date and topic of your talk. Have
the resident or attending sign your passport and provide
comments about the quality of the presentation
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Patient Log
The Liaison Committee on medical Education requires that each
clerkship specify the number and kinds of patients that students
must evaluate in order to achieve the objectives of the clerkship.
The Neurology Clerkship Grading Committee has determined that
each student must be involved in the care of at least two patients
with the following conditions:
 Paroxysmal Disorders
 Vascular Disorders
 Neuromuscular Disorders
 Progressive Degenerative Disorders
It is recommended that students care for at least One patient from
each of these categories through the 2 weeks of the clerkship.
Examples of common disorders within each category specific to each
rotation are listed in the Duties for Students document
Patient Log
Paroxysmal Disorders
Adult Neurology examples include: Headaches, Seizures, Epilepsy,
Channelopathies, etc.
Child Neurology examples include: Headaches, Seizures, Epilepsy, Myotonia
or other Channelopathies, etc.
Vascular Disorders
Adult Neurology examples include: Stroke, Intracranial Hemorrhage,
Hypertensive Encephalopathy, Hypoxic-Ischemic Encephalopathy.
Child Neurology examples include: Childhood Stroke, Neonatal
Intraventricular Hemorrhage or Periventricular Leukomalacia, HypoxicIschemic Encephalopathy.
Patient Log
Neuromuscular Disorders
Adult Neurology examples include: Myopathies, Guillan-Barre Syndrome, CIDP,
Charcot-Marie-Tooth, Diabetic Neuropathy, Amyotrophic Lateral Sclerosis,
Traumatic or Focal Neuropathies, etc
Child Neurology examples include: Congenital Myopathies, Muscular Dystrophy,
Guillan-Barre Syndrome, Spinal Muscular Atrophy, Charcot-Marie-Tooth Disease
Myasthenia Gravis, Erb’s Palsy, etc.
Progressive Degenerative Disorders
Adult Neurology examples include: Alzheimer’s Disease and other Dementia’s,
Huntington’s Disease, Parkinson’s Disease, Vascular Dementia, etc.
Child Neurology examples include: Leukodystrophies, Neurodegenerative
Disorders, Metabolic Disorders, Brain Tumors, etc.
Neurology Clerkship Evaluation
Clerkship Competencies (6 Domains)
 Medical Knowledge
 Patient Care
 Interpersonal Relationships and Communication
 Practice-Based Learning and Improvement
 Systems based Practice
 Professional Behavior
Neurology Clerkship Evaluation
 Always Exceeds Expectations for level of training*
 Sometimes Exceeds Expectations for level of
training*
 Meets Expectations for level of training*
 Does Not Meet Expectations for training*
(*Guidelines for the various expectations for each item graded are
available on the Student Web Page in a document entitled “The
Neurology Clerkship Clinical Evaluation” contained within the LSU
Department of Neurology Home Web Page)
Neurology Clerkship Evaluation Form
Does Not Meet Expectations for level of training
A grade of “Does Not Meet Expectations” for
Competency Domains 1-5 should prompt a
meeting of the student with the Clerkship Director
to develop a plan for remediation and may be
grounds for failure of the clerkship. The evaluating
faculty member should contact the clerkship
director for clarification.
Medical Knowledge
1. Demonstrates adequate understanding of the
pathology, pathophysiology, and anatomic features
of neurological diseases.
2. Participates regularly in activities that advance
knowledge and competence
Patient Care
1. Takes a pertinent and thorough Neurological
History containing information which provides some
degree of neurological localization and allows for an
understanding of the chronology and severity of the
disease process.
2. The history contains accurate medication dosages,
formulations and drug allergies
Patient Care
3. Is able to demonstrate a thorough Neurological
Examination that contains pertinent aspects from
each of the 6 realms of the neurological exam and
contains enough detail to localize the disease
process.
4. Generates a pertinent Differential Diagnosis that
takes into account disease localization and prioritizes
the most likely diagnosis
Patient Care
5. Develops an appropriate Diagnostic Plan specific
to the unique aspects and needs of their patients
6. Develops an appropriate Treatment Plan specific to
their patient’s illness
7. Provides effective care with respect to the patient’s
psychosocial level of functioning and their cultural
beliefs
Interpersonal Relationships and
Communication
1. Clearly and accurately presents patients findings to
team members
2. Maintains clear, complete, accurate, timely and
legible medical records
3. Shows empathy and respect to patients and their
families
Practice Based Learning and
Improvement
1. Uses evidence from practice guidelines and
scientific studies to develop appropriate diagnostic
and treatment plans
2. Shows an eagerness to learn, identifying their own
questions and reviewing the literature concerning
their patients’ illness
Professional Behavior
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Maintains honesty and integrity in written
documentation
Establishes professional relationships with patients
and families
Reliably fulfills patient care responsibilities without
frequent reminders
Functions as a respectful and helpful team member
Arrives on time and leaves only when work is done or
for didactic sessions
Seeks feedback and/or responds well to constructive
criticism in order to improve performance
Professional Behavior
A grade of “Does Not Meet Expectations” for
Professional Behavior items shall prompt a Physician
Evaluation Form, which will be completed by the
Clerkship Director and discussed with the student.
The evaluating faculty member must contact the
Clerkship Director for clarification. Unprofessional
behavior may also be grounds for failure of the
clerkship.
Each student’s Clinical Grade will then be based on the
following format (averaged per individual Blocks):
Honors: Score is greater than +0.75 SD’s above the mean
High Pass: Score is between -1 SD’s below the mean and +0.75
SD above the mean
Pass: Score is between -2 SD’s below the mean and -1 SD’s
below the mean
Fail: Score is below -2 SD’s below the mean*
*Students may also be in jeopardy of failing the course for behavior
deemed to be unprofessional.
The Written Examination
› Beginning with the 2009 Academic Year, the Clinical
Neurosciences Clerkship started to use the USMLE
SHELF examination as it’s instrument to assess student’s
clinical knowledge. This test has been extended to the
Junior Neurology Clerkship as well. The test is highly
geared towards adult neurology. In order to prepare for
this examination, it is strongly encouraged that each
student review the supplied curriculum of reading
materials contained within the LSU Neurology department
website www.medschool.lsuhsc.edu/neurology
Click on the L3 Students tab
Other Sources to Aid in Preparation for the SHELF
Examination
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Neurology Case Files (Lange Case Files)
Blueprints Neurology (Blueprints Series)
USMLE World Step 2 CK (Neurology Questions)
Neurology Pre Test Self-Assessment and Review
The Neurology Chapter contained within your
Internal medicine Textbook
The Written Examination
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Students are required to obtain a score of at least 59 on the
SHELF examination in order to pass the clerkship.
Those students who score less than 59 will need to either
repeat the SHELF examination at the end of their Junior
year and score a passing grade in order to receive a Pass
final grade for the clerkship.
SHELF scores will be weighted compared to other students
taking the examination in your block. Each student who
passes the SHELF will thus be given an Honors, High Pass
or Pass based on their weighted score.
The Written Examination Grade
Passing SHELF scores will be translated into a Written Examination
Grade for the course based on the following paradigm generated
for each group of students taking the SHELF at any one time:
 Honors: Score is greater than +0.5 SD’s above the mean
 High Pass: Score is between -0.5 SD below the mean and +0.5
SD’s above the mean
 Pass: Score is between 59 and -0.5 SD below the mean
 Fail: Score is less than 59
Final Clerkship Grade Schemata
Each student will receive a Final Assigned Grade for their
Neurology Clerkship based on a combination of their Clinical
Grade and their Written Examination Grade as follows:
Honors: Need to have Honors for both the Clinical and Written
grades.
High Pass: The lowest of the Clinical and Written Grades must be a
High Pass or a combination of Pass and of Honors with the
Clinical and Written grades
Pass: The lowest of the Clinical and Written Grades is a Pass
Fail: The Clinical Grade is a Fail or The student is unable to score a
passing grade on the SHELF examination despite repeated
attempts (LSU School of Medicine Policy), or possible if the
student engages in unprofessional behavior that cannot be
rectified per the Clerkship Director’s discretion.
Student Feedback about the Junior Neurology Clerkship
Useful Aspects of the Clerkship:
 Counterproductive/Needs Improvement Aspects of the Clerkship:
 Changes that you would suggest for the Clerkship:
 How did your clerkship experience help you to prepare for the
Neurology SHELF examination?
 What could have been done differently to help you better prepare
for the Neurology SHELF exam?
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Student Feedback about the Junior Neurology Clerkship
Note: Your feedback is extremely important and will allow us to
continually update and adjust different aspects of the Clinical
Neurosciences Clerkship. Following the completion of the SHELF
examination, each student will receive notification from New
Innovations and asked to complete the Neurology Clerkship
Student Feedback. Answers are stored and returned to the
clerkship coordinator anonymously. Negative feedback will in no
way influence your final grade. Please feel free to directly email
the Clerkship Director (Dr Deputy) at [email protected] if you
have any further suggestions or comments about your
experiences during the rotation.
Where Can I Get More Information?
 Check out the student website on the Department
of Neurology Web Page
http://www.medschool.lsuhsc.edu/neurology
Click on the Students tab
Questions???
Now go out there with an open mind and
discover the amazing complexities of the art
of Clinical Neurology