University of Virginia Health System

Adult Neurology Residency Training Program

Year-by-Year Description

PGY-1  |  PGY-2  |  PGY-3  |  PGY-4

PGY-1

General Overview

The UVA Neurology Program includes a preliminary training year. This year will include 9 months of internal medicine (typically 1 month Acute Cardiology, 1 month Cardiac Care Unit [CCU], 1 month Neurology Intensive Care Unit [NNICU], 2 months General Medicine, 1 month Heme/Onc, and 3 subspecialty months  [for example, pulmonary, renal and infectious disease]), 1 month of neurology inpatient service, 1 month of emergency medicine and 1 month of pediatrics.

PGY-2

General Overview

In 2007, we initiated a nightfloat system. Residents spend most of the year on the adult inpatient service, which is divided into a general neurology service and a stroke service, as well as night float. Roughly equal amounts of time are spent on each. They also spend time in the epilepsy monitoring unit during the first half of the year, and in the neurological intensive care unit (NNICU) during the second half of the year. Residents are also exposed to pediatric neurology during this year when they are consulted while on call.  Residents may also spend 2 weeks on the psychiatry inpatient unit and will have some elective time. We have also developed a novel "systems-based practice" rotation where the resident spends time with other disciplines and systems that are directly involved with the health care delivery of patients with neurological disorders. These systems include: physical and occupational therapy, social work, nursing, hospice, pharmacy services, and others involved in health care policy and finance. (See below.)

Outpatient Unit

Second-year residents begin to develop their own outpatient practices by following patients who have been under their care in the hospital, or who have been seen in the Emergency Unit or Neurologic Outpatient Unit. New diagnostic patients add to the total.

Residents attend their weekly, half-day outpatient clinics throughout the three years of residency training, with the goal of building their practices and providing continuous follow-up of a group of patients over three years. Residents also attend neuromuscular and epilepsy clinic once a month and can arrange elective time in other subspecialty sections.

One attending is always in the outpatient unit solely to provide patient staffing and teaching for residents and medical students.

Adult Neurologic Inpatient Service

On the Adult Neurologic Inpatient Service, residents work closely with interns and medical students and are under the supervision of a senior resident and attending neurologists who are available to the residents at all times. Residents are responsible for evaluation of patients admitted to their care on the service and in the NNICU, with particular reference to history, physical, neurologic examination, and choice of appropriate laboratory procedures. Every patient's case is considered an individual study, which should include a review of the literature when appropriate.

The inpatient services include a general neurology service and a stroke service.  Each service is supervised by an attending physician and consists of two teams, each of which has one first year Neurology resident, one intern and a variable number of students.  A third year Neurology resident serves as the Ward Senior and is responsible for teaching and guiding team decision-making.

Overnight call alternates between the stroke and general services.  On call duties include seeing new consults from the Adult and Pediatric Emergency Departments and inpatient services as well as fielding calls from outside institutions and families.  An intern is always on call with the Neurology resident, assisting with new consults and helping care for patients on the Neurology inpatient services. 

First year Neurology residents on an inpatient service have the following daily call cycle:

• Day 1 - Short call - admits to own service 7am-4pm Mon-Fri
• Day 2 - Long call - admits to own service 7am-4pm and both services 4pm-approximately 9pm Sun-Thurs. On Friday and Saturday, admit from 7am to 7am the next day. (There is no Night Float on week-end days.)
• Day 3 - Post call - Long call team hands over opposite team patients at Morning Report at 8am.
• Day 4 - Pre call/clinic day - no admissions. Leave hospital when work is done. Resident has PM clinic and intern may as well.

Due to resident preference, we have recently enacted a Neurology Night Float system.  Residents rotate and average one week of Night Float every 5 or 6 weeks.  The Night Float resident has the following call schedule:

• Night Float - admits 9pm-8am Sun-Thurs. On Friday and Saturday, there is no Night Float resident. The Night Float resident usually leaves the hospital by 10:30 am, and has the weekends off.

New patient admissions are presented everyday during Morning Report or bedside rounds.  The Long call team presents new patients in Morning Report, which is attended by the Neurology attendings and serves as an opportunity for the entire group to learn from the expertise of the various members of the inpatient service.  It also serves as a forum for transfer of care for some patients admitted the previous day.  Following Morning Report, we round in the Neurological Intensive Care Unit.  Afterwards, the Night Float resident rounds with the stroke and general teams separately to present overnight admissions and learn at the bedside. 

The daily routine, including conferences is summarized as follows:

• Everyday routine: Pre-rounds 7am-8am, Morning report 8am-8:30am, NNICU  rounds 8:30 to 9:00, bedside rounds 9:00, noon lecture 12pm-1pm (except Fri)
• Monday and Thursday: Neuroradiology rounds at 10am-10:30
• Tuesday: Rounds with Dr. Wooten (if not on service) at 10:30am
• Friday: Grand rounds 12pm-1pm, sometimes followed by Interesting Case  Conference, meeting with the chiefs, meeting with the residency director, or Dr. Wooten Neuroanatomy rounds

Epilepsy Monitoring Unit

The second-year resident assigned to the Inpatient Epilepsy Unit / Comprehensive Epilepsy Program assists with the diagnostic evaluation, drug therapy, and clinical studies of adult and pediatric patients. The service focuses on complex patients with long-standing, poorly controlled seizures who are admitted for 24 hour video and EEG monitoring, medication adjustments, ictal and interictal SPECT neuroimaging, and/or presurgical evaluation. The team, which consists of a neurology resident, epilepsy/EEG fellow, and attending neurologist, rounds daily and reviews laboratory studies and continuous 24 hour video and EEG monitoring together.

Because patients in the Epilepsy Unit, although they have poorly controlled seizures, are ambulatory and not usually critically ill, the resident takes call from home 24 hours a day for 6 days each week throughout this rotation. The resident also attends two weekly one-half day adult and pediatric epilepsy clinics in addition to his/her weekly adult neurology clinic. This rotation provides residents with experience in working with the latest technology and treatment regimens found in a comprehensive program designed to stay at the forefront of research, diagnosis, and management of epilepsy.  

NNICU

Residents learn to manage the care of critically ill patients under the supervision of critical care attendings and senior housestaff while rotating in the NNICU. PGY2 residents take this rotation in the second half of the year, and PGY3 residents take it in the first half. The team is comprised of a critical care attending and fellow, the NNICU resident, and medical students. Neurology, anesthesiology, and neurosurgery residents rotate through the unit in 2-4 week blocks, taking in-house call every 4 days. While on call, the NNICU resident is the house officer who physically remains in the NNICU at all times and is responsible for the moment to moment critical care management of all NNICU patients.

While caring for both neurologic and neurosurgical patients in the NNICU, the resident becomes involved with the following treatment regimens (among others):

• Status epilepticus intervention
• Management of patients receiving intra-arterial or systemic thrombolysis for acute ischemic stroke
• Management of subdural or intraparenchymal cerebral hemorrhages.
• Management of acute cord trauma
• Intensive monitoring before epilepsy surgery
• Ventilatory support
• Circulatory support
• Management of hypertension
• Management of elevated intracranial pressure
• Stabilization/monitoring of pre-and post-embolization and surgery

Elective

PGY-2 residents are given about 7 weeks of elective time their first year. Two weeks of elective are spent in an innovative “systems-based practice and practice-based learning” (SBP-PBLI) rotation. During the SBP-PBLI rotation, the resident spends time with other health care providers and participants, such as community pharmacists, hospice workers, medical directors of insurance carriers, our business manager, support group advocates, home health providers, etc. The resident also has time set aside for “surfing the internet”, learning what resources in neurology are available to care providers, patients and their families. Another 2 weeks is spent on a neuro-ophthalmology rotation with Dr. Steven Newman. The remaining 3 weeks are literally elective. For more information on electives and a list of electives offered, see "Electives Program" under PGY-4 Year.

PGY-3

Summary

PGY3 residents continue developing their clinical skills on the Adult and Pediatric Neurology Consultation Services, in the Neurologic Outpatient Unit as Assistant Director, in the Nerancy Neuro Intensive Care Unit (NNICU), and on the elective rotation. Residents continue their outpatient practice and participate in the regional epilepsy program by assisting an attending neurologist and epilepsy fellow in seeing patients in the field clinics. This involves one or two, three-day trips to clinics that are located primarily in south-west Virginia.

Consultation Service

The period during which the resident manages the Neurologic Consultation Service is a very active one since the department receives numerous consultation requests daily within the University of Virginia Health Sciences Center. The resident is responsible for providing neurologic consultation on patients in the hospital and emergency room Monday through Friday (8am - 5pm) and during weekend rounds. Residents on the Adult and Pediatric Consultation Services alternate weekend coverage of those services, including back-up for the first-year resident, so each resident has every other weekend free. The team is also responsible for providing follow-up consultation on patients seen in emergency consultation by the first-year resident on call during the previous night. Patients are often managed through consultation, although certain patients may be transferred from the consulted service to the Neurologic Inpatient Service for specific studies or therapy. Residents learn to manage a broad range of concurrent neurologic illness in medical and surgical patients while on the consultation service.

Pediatric Neurology

Training in pediatric neurology is obtained during a 10 week rotation. The team includes a second-year adult neurology resident, pediatric neurology attending, and students. Pediatric neurology inpatients are admitted to the Pediatrics Services, and their care and management are coordinated by the services involved. The primary responsibilities of the resident on the Pediatric Neurology Consultation Service is to cover the Pediatric Inpatient Services, Newborn ICU, Pediatric ICU, Pediatric Emergency Room, and Kluge Children's Rehabilitation Center Monday through Friday (8am - 5pm) and during weekend rounds. (As mentioned above, weekend coverage of the consultation services alternates between the two residents.) The resident on the Pediatric Neurology Service takes call from home at night as back-up to the second-year resident on night call for the neurology services. The resident also attends the weekly general pediatric neurology clinic four afternoons a week and Comprehensive Epilepsy Program's pediatric clinic, and monthly brain tumor clinic in the neurosurgery department.

Outpatient Unit

When rotating on the Neurologic Outpatient Unit, the resident functions as assistant director of the unit, thereby becoming experienced in the running of an outpatient practice. In assisting with the general administration of the unit, the resident orients rotating residents and medical students, determines emergent patient assignments, communicates with the patients' primary physicians, and ensures the efficient operation of the unit. One sees patients in the Diagnostic Section Monday through Friday and assists with the supervision and teaching of family medicine and neurosurgery residents and medical students. An attending neurologist is always available in the unit for consultation, patient staffing, and assistance when emergent patients need to be seen. This rotation as well as the weekly continuity clinics prepares residents for the changing practice patterns of increasing ambulatory care that are being seen nationally.

NNICU

The experience in the NNICU during the PGY-3 year is similar to what it is during the PGY-2 year, except that the rotation is done during the first half of the year. Residents continue building their expertise in the management of critically ill neurologic and neurosurgical patients.

Elective

Residents have 6-10 weeks of elective time during the second year. We have an outstanding electives program. For more information on electives and a list of electives offered, see "Electives Program" under PGY-4 Year.

PGY-4

Summary

The fourth year of training gives residents the opportunity to manage the Adult Neurologic Inpatient Service, thereby gaining valuable administrative and supervisory experience for their future goals in academic or private practice. They also learn about the management of psychiatric patients on an acute care ward and in clinics at Western State Hospital (WSH). As in the PGY-3 year, fourth-year residents continue their outpatient practice (including a half-day each of diagnostic and follow-up clinics during electives) and attend the field clinics in southwestern Virginia. The majority of the third year, however, constitutes elective time, which is described in more detail below.

Adult Neurologic Inpatient Service

The senior resident assigned to the Adult Neurologic Inpatient Service (the ward senior) is responsible for the general administration of both the general and stroke services. This resident is expected to be familiar with all patients on the service, to evaluate patients admitted to the NNICU, and to provide assistance to first-year residents on patients presenting particular diagnostic challenge. He /she is responsible for coordinating admissions to the service, daily morning report, and neuroradiology rounds. The senior resident orients the medical students, interns, and first-year neurology residents, and provides backup for emergent consultations. Senior residents exercise maximum responsibility (with attending back-up) for the care of patients and supervision of students and housestaff, thus meeting program goals and ACGME requirements for increasing responsibility.

Psychiatry

Residents are now spending two weeks on inpatient psychiatry during their PGY2 year and two weeks on psychiatry consultation service their PGY4 year.  Additional time on psychiatry rotations is available as elective.  The electives of neuropsychology and behavioral disorders are also available and very popular. 

Epilepsy Monitoring Unit

Each senior resident spends two 2 week blocks in the EMU.

Electives Program

The flexible electives program makes it possible for residents to discover their preferences for fellowship training or future practice patterns, or to have an intensive period of research in areas of current interest. Residents can hone skills acquired during the first two years with clinical rotations such as EEG, EMG, or neuroradiology; begin to develop a subspecialty; or continue projects in their particular areas of clinical or research expertise. Newly defined electives are now available in neurodegenerative diseases and neuro-oncology. Residents elect rotations in clinical programs, research programs, or a combination of the two and work with faculty within or outside the department, depending on their interests. Attending or participating in conferences related to the elective and making correlations between clinical and investigational neurology are encouraged.

Electives include:

• Neuromuscular Disorders
• Epilepsy
• Electromyography  (EMG)
• Electroencephalogram (EEG)
• Movement Disorders
• Neurodegenerative Movement Disorders
• Fontaine Specialty Clinics
• Neuro-oncology
• Neuropathology
• Neuro-oncology/Neuropathology
• Neurological Rehabilitation
• Dementia
• Neurological Behavior
• Headaches and Vertigo
• Pain
• Sleep
• Alternative Therapies for Neurologic Disorders
• Neuroradiology

Clinical Program

The resident may spend time in the following:

• Alzheimer's Disease Program (and related disorders)
• F. E. Dreifuss Comprehensive Epilepsy Program
• EEG/EP, EMG, and Neurovascular Laboratories
• Movement Disorders Program
• Nerancy Neuro Intensive Care Unit
• Neuromuscular Disease Program
• Neurologic Outpatient Unit
• Pediatric Neurology Program
• Comprehensive Stroke Program
• Neuro-oncology
• Neuro-ophthalmology
• Neuropathology
• Neuroradiology
• Neurosurgery
• Pain Management
• Psychiatry
• Subspecialty areas of other departments

Research Program

The resident may get involved with one of the many clinical or basic research projects within the Department of Neurology or in other departments within the School of Medicine or University. The University of Virginia School of Medicine is in the top one-third of 125 medical schools in the United States in amount of research funding by the National Institutes of Health.
(Detailed descriptions of ongoing research in the departments of Neurology and Neuroscience are available from the coordinator of the training program or by clicking the link below.)

 Faculty Research

Clinical Research

The neurology department has an extensive program of clinical research, which includes both clinical drug trials and other research protocols in the following areas: Alzheimer's disease and related disorders, cerebrovascular disease, critical care neurology, epilepsy, electroencephalography/evoked potential studies, epidemiology of neurologic illness, electromyography, neuromuscular disease, Parkinson's disease, and other movement disorders. The department has been involved in pioneering a number of the drugs currently used in the treatment of neurologic illness (e.g. rt-PA, ticlopidine, cabergoline, pramipexole, selegiline HCl, tolcapone, carbamazepine, clonazepam, felbamate, sodium valproate, and vigabatrin).

Clinical research is carried out in the clinical laboratories, the Neurology Clinical Trials Center at Fontaine, the Neurologic Outpatient Unit, Western State Hospital, and the General Clinical Research Center (GCRC). The GCRC, supported by the NIH, provides services for approximately 200 research protocols by means of its outpatient unit; inpatient beds; metabolic kitchen; core, exercise physiology, sleep studies, and computer data management laboratories; and statistical consultant. A formal, post-residency track in clinical investigation is sponsored by the GCRC for those seriously interested in a career track in clinical research.

Basic Research

A strong and diverse program of basic research within the department gives residents the opportunity to start or continue their research in the following general areas:

• Intracellular physiology
• Messenger RNA regulation
• Mitochondrial genetics and biochemistry
• Molecular biology
• Neuroanatomy
• Neurochemistry
• Neuroendocrinology
• Neuroimmunology
• Neuropathology
• Neuropharmacology
• Neurophysiology
• Developmental neurology and plasticity
• Electron microscopy
• Imaging studies

Residents may also work with investigators outside the department to accommodate specific interests. The department has unified its basic research efforts primarily in Cobb Hall where the laboratories of neuroscientists from other departments are also located. The research program is designed to foster fundamental research in the nervous system and to stimulate interdisciplinary thinking and work that ultimately aids in the clarification of major clinical problems in neurologic diseases. Ongoing collaborative projects are maintained among the neuroscientists, including active participation in the interdisciplinary Neuroscience Graduate Program and Medical Scientist Training Program.