University of Virginia Health System

WELCOME TO THE NEUROLOGY CLERKSHIP !

The purpose of this clerkship is to give you a firm grounding in fundamental neurologic concepts, and in the recognition and initial management of emergent and common neurological problems.  The clerkship relies on the idea that you will do self-directed learning with the experiences that we provide.

CLERKSHIP GOALS

Learning Objectives

By the time you are finished with the rotation, you should be able to:

1. Obtain an adequately detailed history from a patient with neurologic (or potentially neurologic) complaints, performing at the level appropriate for a practicing physician (non-neurologist);
2. Perform a "screening" neurologic examination (as defined by the American Academy of Neurology Core Clerkship Curriculum recommendations) on every patient
3. Conduct a more detailed neurologic examination of systems associated with patient complaints or abnormalities found on screening exam
4. Demonstrate the skills of clinical localization of lesions within the nervous system on the basis of history and physical findings;
5. Recognize, appropriately respond to, and initiate management of these common neurologic complaints and syndromes

• Focal weakness
• Somatosensory deficits (e.g. Numbness, tingling)
• Gait and movement disorders
• Dizziness (e.g. Vertigo, light-headed)
• Specific cognitive loss (e.g. Aphasia, amnestic disorder)
• Altered level of consciousness (e.g. Delirium, coma)
• Headache
• Back and neck pain
• Acute ischemic stroke/intracranial hemorrhage
• Seizures/epilepsy

1. Recognize the key features and initiate management of these neurologic emergencies:
   • Coma
   • Status epilepticus
   • Acute spinal cord dysfunction.              

MANDATORY CASE EXPOSURES

A new nation-wide rule requires all clerkships in all U.S. medical schools to specify-ahead of time-a minimal list of the exact types and numbers of patients that every student must see to pass the clerkship, and must document and oversee that all students comply with this.

• Limb weakness
• Somatosensory deficit (e.g. Numbness, tingling)
• Gait and/or movement disorder
• Dizziness (e.g. Vertigo, light-headed)
• Specific cognitive loss (e.g. Aphasia, amnestic disorder)
• Altered level of consciousness (e.g. Delirium, coma)
• Headache
• Back and/or neck pain
• Acute stroke and/or intracranial hemorrhage
• Seizures/epilepsy

It is your responsibility to seek out and document exposure to all 10 of these problems.  You will do that in two ways.

• FIRST, when you see a patient that meets any of these 10 items, record the level of exposure and date in your "Passport" (see below).  Record the same information online that same day.
  • A single patient may satisfy more than one item (e.g. a stroke patient may have right sided weakness and a walking problem, so you can satisfy two items).
  • You must have at least 5 patient complaints or problems addressed from seeing real patients during the clerkship.
• SECOND, our prepared didactic activities-problem sets (see below)-have each been designed to satisfy all 10 items each. 
  • The 9 problem sets cover all 10 items. 
    • For each problem set that you complete, record the date in your Passport on the relevant line indicating the item that was addressed.
    • Note that a given problem may satisfy more than one of the 10 items.
  • You must address all 10 patient complaints or problems in this way.  That is, for each patient complaint or problem, you must have addressed it with a problem set and/or a live patient.

• You must document all of the above in your Passport, and you must submit that Passport at the end of the clerkship in order to be eligible for a grade for the clerkship.
• In addition, the School of Medicine requires that you keep track of the same information on-line in a timely manner. Oasis, the clerkship's evaluation system is accessible through http://oasis.med-ed.virginia.edu/index.html 

OVERALL APPROACH

The core philosophy of this clerkship is that people learn best when they actively participate in their own learning, not when things are spoon-fed to them.  It is your job to learn while you are here, and take a responsible and professional approach to the experience.

We will teach you, spend time with you, encourage you, give you resources and experiences, and frame a structure and context within which your learning can grow.  Ultimately, though, you are the single most important engine driving the type and amount of learning you get from this clerkship.  We expect you to take that responsibility seriously and "go after" learning experiences.

We try to balance patient care assignments.  Since we must use multiple services and sites, and the patient mix within a service can change unpredictably, clinical experiences may vary.  No matter.  Your job is to use whatever clinical experiences you happen to have as a starting point for learning.  We supplement clinical experiences with conferences, exercises, and other activities that are relatively standardized across all students.  In this way, we help each of you build the same explicit "skeleton" of core knowledge and skills in neurology.  Beyond these issues, the purpose of your clinical activity is to put those tools into action, and in an individualized way put "meat" on that skeleton.

ACTIVITIES AND SCHEDULES

Attendance

• The four weeks are divided into two, 2-week blocks.  The first block begins on Monday of week #1 and ends on Friday of week #2. The second block begins Monday of week #3, and ends on Friday of week #4. You are off on Saturday and Sunday between weeks #2/3, and after Friday of week #4
• On the first day you have a morning orientation session, and an afternoon workshop.
• Each week you have teaching conferences Tuesday mornings (8am) and afternoons (4pm) and Thursday mornings (8am).
• You have a teaching conference on the first three Friday afternoons.
• You are released from clinical responsibilities after Thursday of week #4. 
• On the last day you will take a closed book NBME Neurology Subject Shelf Exam.
• You are expected to round with your assigned services each day that the service rounds, including weekends, and participate in all activities below.  Students can expect one day off per week, and one full weekend off in each 4 week block (unless making up other absences).
• Attendance will be recorded at all these mandatory activities.

Absences and Remediation

• E-mail is the required method of communication for all clerkship related issues
• All absences must be approved by the Neurology Clerkship Director on or before the first day of the clerkship (except for family/personal emergencies).
• As soon as you know that you may want to be absent, it is your responsibility to contact, immediately, the Neurology Clerkship Director.  It is inappropriate to commit to an event or make travel commitments before requesting that time off.
• With appropriate and advanced notice, for absences that meet criteria for an excused absence, we may excuse no more than three days of absence for important personal/family events (e.g. weddings). Otherwise, we expect you to be present all day, everyday, for the entire 4 week clerkship, and we expect you to join morning rounds on the 1st and 3rd weekends if your assigned team rounds those days. ACLS training, Admissions Committee Meetings, Applicant Interviews and Tours, and Alumni Association functions are not excused reasons for absence from the clerkship.
• If you have an illness or family/personal emergency, you must inform the Neurology Clerkship Coordinator, and also the resident or attending on your assigned clinical team, as soon as possible.
• Any unexcused absence, or any absences for any reason in excess of three days, will have to be made up for on at least an equal time (day for day) basis.

First day of the Clerkship

On Monday of week #1, please meet at 8:00 am in the 4th Floor Camp Heart Auditorium Conference Room.  After a brief orientation, you will join your assigned clinical service at 8:30 am (see below).  In the afternoon, starting at 3:00 pm, we will reconvene in Ohrstrom Library, 2^nd floor, McKim Hall for a conference for all students based on a pretest and review.

Clinical Activity

• You are expected to round with your assigned services each day that the service rounds, including the first and third weekends.  If your team rounds on both weekend days, you may "split" a weekend, such that you come on either Saturday or on Sunday.
• On all services, you are expected to behave as a responsible, professional team member.   
• As each service dictates, we want you to ask questions, participate in discussions, write chart notes, and assist in patient evaluation and care. 
• When assigned patients to follow, you are expected to be knowledgeable about your patients, the progress of their care, and literature/general reading in relevant areas.  You are expected to write appropriate daily notes on the patients you follow in the inpatient setting.  Please advise your resident that you've placed noted for review and countersigning in chart.
• You will be asked to submit the name of attendings and residents to evaluate you.  At least one attending (or post-doctoral fellow) is required for each service assignments.  These evaluations are the sole documentation of your attendance and performance on the clinical serices.
• On inpatient UVA services, you should be available (i.e., in the hospital, library, etc.) until 5:00 pm.  Students not on call should still try to pick up at least one new patient each day, either by working up an "early" admission or by picking up a patient after morning rounds. 

On-Call

• All neurology clerkship students have one mandatory assigned on-call session.
• The on-call experience is a time for one-on-one interaction with a neurology resident.  This can be one of the best learning experiences of the clerkship. Call is intended to be a time to evaluate patients presenting with still undiagnosed neurological problems, and to review and participate in the evaluation and management of neurological emergencies. 
• If you are on the General or Stroke inpatient service you will usually have an on-call night coinciding with the call schedule of your neurology resident.  Otherwise, students on other UVA services will take call with either a General or Stroke service neurology resident.
• You should page the junior neurology resident on-call (pic # 1354) at 5:00 pm of your on-call session.   From then on you should accompany the on-call junior neurology resident on consults, calls to the emergency department and intensive care units, and assist with emergencies involving neurology patients.  To get the most out of the one night on-call, you should be with the resident and/or intern at all times, not just available by pager.
• If you are on weekend call; you should expect to spend approximately 6 hours after teaching rounds are completed, or until 5 pm, whichever comes first.
• The on-call session may be a good time to have the on-call junior or senior neurology resident discuss the three neurological emergencies on the Passport (see below).
• You are required to stay in the hospital at least until 11:00 pm weekdays and 6 hours after rounds are completed on weekends.  If the neurology resident does not need help with patient care issues, you may leave at that point. 
• Those of you at Roanoke have no night call there.  However, you will spend part of a weekend day (between week 1 and 2, or between week 3 and 4) with a neurologist on his/her "call," as determined by Dr. Ahmad and his group.
• Students on the Charlottesville outpatient service (NOPU) will be assigned a weekend call date.  They should round with the consult service (page 1317 to establish meeting time and place).  After rounds, contact the resident on call and work with them for the remainder of the day.

The "Passport"

• All students receive a "Neurology Clerkship Passport." This is a critical document that must be turned in at the end of the clerkship (i.e. no grade without it!) 
• The Passport components are valuable feedback and teaching components of the clerkship.  The purpose of this format is to give you autonomy in getting feedback and teaching.  Thus, it is your responsibility to seek these out.  You must get each required component initialed by your residents and/or attendings before turning in the completed Passport. 
• For each two week block an attending should conduct and sign off on the feedback evaluation.  (In NOPU, the NOPU resident may sign)
• There may be less time pressure in inpatient rather than outpatient settings for an attending to watch the student perform patient examinations. So, you should approach your inpatient attending to coordinate time(s) to do this.  It may be easier to do the exam in stages, doing one or a few components at a time.  Avoid waiting until the last two days to complete this. 
• Midpoint during each 2-week block is a good point to get feedback from an attending.  By this time, everyone will know one another and attendings will have an idea of your areas of strength as well as areas needing improvement.  Please seek out this feedback.
• The night on-call is a good time to ask the on-call junior or senior neurology resident to go over and sign-off on the neurological emergencies (status epilepticus, coma, acute stroke).   If it is a busy night, it may not be possible to review all three, so you may want to do this before or after the on-call night with a neurology resident on your service.
• The minimal list of patient complaints/problems must be appropriately completed and documented on both the passport (see above).
• Observing or attempting a lumbar puncture is optional, but a good idea if you get the chance.

Required Conferences

Student Morning Conference

• Tuesdays and Thursdays, 8:00 - 8:30 am, 4th Floor Camp Heart Auditorium Conference Room.
  •  Neurology faculty will present clinically-relevant topics in Neurology.   
• Tuesdays, 4:00 - 5:00 pm, NNICU Conf Room (6^th floor University Hospital).
  • Senior neurology residents review films, neuroanatomy, and clinical correlations.
• Attendance is mandatory for all students assigned to services at UVA.  If you are on an inpatient service you will need to see your patients before the 8:00 am conference. 
• Attendance will be recorded at start of each session.
• Please arrive promptly.

 Neurology Grand Rounds

• Fridays at 12:05 - 1:00 pm, Camp Heart Auditorium 
• 1^st, 2^nd, and 3^rd weeks.  Attendance recommended, not required.

Problem Set Review Sessions

• Fridays at 2:30 - 4:00pm, Ohrstrom Library in McKim Hall. 
• Enclosed in the Neurology Clerkship Packet is a book with 9 clinical problem sets.
• Each problem has a series of questions.  You are expected to read about and be able to answer these questions.  You may use any resources you like (e.g. books, journals, residents, attendings, fellow students).
• Reviewing these problems, reading and thinking about them, and writing responses to the questions are key learning activities in this clerkship.  Knowing answers to the questions is less important than knowing why they are the answers.
• Each Friday afternoon, you will meet with a neurology attending to discuss three problem set cases.  On week #1, problem sets #1, #2, and #3 will be reviewed.  On week #2, problems sets #4, #5, and #6 will be reviewed.  On week #3, problem sets #7, #8, and #9 will be reviewed.  You are expected to arrive ready to answer and discuss the questions in the problem sets. 
• The problem sets end up addressing all 10 items of the clerkship's minimal list of patient complaints and problems, and if you miss a session for an excused absence you remain responsible for that content.
•  Students assigned to Roanoke should review the problem sets with the teaching attendings there.

Last Week of the Clerkship

All students must be in Charlottesville on the last day of the clerkship (usually friday).

All students are excused from all clinical activities on the last day of the clerkship.  Thus, you finish your clinical activities after the last Thursday of the clerkship. (Wednesday, when the shelf exam is on a Thursday)

All students will take the NBME "shelf examination" in neurology on the last day of the clerkship (see below).

Medical School policy requires that all clinical responsibilities be accomplished prior to sitting for the shelf exam. Exceptions may only be granted by Dr. Pearson in Student Affairs.

Roanoke Students

•        In each 4-week rotation, a total of 6 students are assigned to 2-week rotations in Roanoke.  The first block starts 9:00 AM on Tuesday of week #1 and ends noon Friday of week #2.  The second block starts 9:00 AM Monday of week #3, ends noon Thursday of week #4.

•       Please refer to note from Dr. Ahmad for details on the Roanoke schedule.

 Completion of Problem Sets:

•      You should review the problems with Roanoke faculty members for the weeks you are assigned. 

•       While at Roanoke, you have no night call.   However, you will spend part of a weekend day (between week 1 and 2, or between week 3 and 4) with a neurologist on his/her "call," as determined by Dr. Ahmad and his group.

•       Detailed instructions for your Roanoke rotation are included in the orientation booklet you have received.  You MUST bring your medical bag, as well as all materials for the clerkship to the office each day.

READINGS

Text for problems sets, online cases, question set, exam preparation, and general study.

• We recommend Clinical Neurology, 3^rdEdition, by Fowler & Scadding (2004; Oxford; ISBN 0-340-80798-9).
• Some students also like Lange's Clinical Neurology, by MichaelJ.Aminoff, DavidA.Greenberg, & RogerP.Simon (2005, McGraw-Hill).
• Neurological Examination
• A particularly excellent, brief, and readable book is Neurological Examination Made Easy, by Geraint Fuller (2004, Elsevier; ISBN 0443074208).
• Neuroanatomy
• A nice overview emphasizing the "forest" with mnemonics and clinical focus, is Clinical Neuroanatomy Made Ridiculously Simple, by Stephen Goldberg (2003, Medmaster; ISBN 0940780577)
• Neurological Differential Diagnosis, 2^nd Edition, by John Patton (1996, Springer-Verlag, New York; ISBN: 3540199373).
• More detailed reading about your patients
• Neurology in Clinical Practiceby Bradley, Daroff, Fenichel, and Marsden

We look forward to working with you over the next month.

David S. Geldmacher, M.D.  Clerkship Director                                    dsg8n@virginia.edu

Karen Marie Vale, Clerkship Coordinator                                          kvale@virginia.edu                                                                                       2001 McKim Hall                                                                                       924-5548