Division of Neurology

McMaster Objectives: Hamilton General Hospital

Outline of the Rotation

In this rotation, residents will see all of the Emergency Room consultations and most of the inpatient general neurology consultations at the Hamilton General. Inpatient stroke patients are often seen by the Stroke service. They will also participate in the general neurology outpatient clinic and attend the various rounds available at this site. They will report to the Staff neurologist to review the cases or the senior neurology resident when one is available. They will dictate consultation notes summarizing the findings and recommendations, and record written notes in the chart. They will then follow the cases through the investigations and treatment.

Residents in their senior years will be encouraged to take on a different role. When possible, they will supervise more junior residents and take an active part in their education. They will still report to the Staff neurologist who will take ultimate responsibility for the cases. Usually it should be possible for the senior resident to combine this role with additional half-day outpatient clinics.

  1. Medical Expert/Clinical Decision-Maker
  2. Communicator
  3. Collaborator
  4. Manager
  5. Health Advocate
  6. Scholar
  7. Professional

1. Medical Expert/Clinical Decision-Maker

General Requirements

  • Demonstrate diagnostic and therapeutic skills for ethical and effective patient care.
  • Access and apply relevant information to clinical practice.
  • Demonstrate effective consultation services with respect to patient care and education.
  • Provide scientifically based, comprehensive and effective diagnosis and management for outpatients with neurological disorders.

Clinical Skills

For a patient with a neurological complaint or disorder, the physician will be able to:

  • Obtain a complete neurological history from adults obtaining collateral history where necessary.
  • Perform an appropriate physical examination.
  • Determine whether a patient’s symptoms and signs are the result of an organic or psychological disorder. Where they are due to an organic disorder, the resident must determine whether they result from unifocal, multifocal or diffuse involvement of the nervous system and, where possible, appropriately localize the lesion(s).
  • Formulate an appropriate differential and provisional diagnosis.
  • Outline an appropriate plan of laboratory investigation.
  • Outline an appropriate therapeutic plan.
  • Exhibit appropriate clinical judgment in outlining a differential diagnosis and an investigative and therapeutic plan.

Technical Skills

  • Perform lumbar puncture
  • Identify and describe abnormalities seen in common neurological disorders on plain x-rays, cerebral and spinal angiograms, computerized tomography (CT) of the brain and spinal column, magnetic resonance imaging (MRI) of the brain and spinal column, CT Angiogram and where applicable perfusion scans.
  • With regard to a specific patient or clinical history, evaluates the relevance of a specific report on the following investigative procedures: electroencephalogram; motor and sensory nerve conduction study; electromyography; evoked responses; electronystagmogram; audiogram; perimetry; psychometry; cerebrospinal fluid (CSF) analysis; plain x-ray; angiogram; ultrasound; and CT and MRI scans of the neuraxis.

Knowledge

As a basis for clinical competence, the neurologist must be familiar with and able to describe or discuss:

  • The anatomic and physiologic basis of the normal neurological examination taking into account the effect of age.
  • The pathophysiology of neurologic symptoms and signs in the major, primary and secondary neurologic disorders; (examples of these include seizures, spasticity, tremor, aphasia, etc.).
  • The basic principles underlying the interpretation of the major clinical tests such as nerve conduction studies, electromyography, electroencephalography, evoked potentials, perimetry, electronystagmography, audiometry, psychometry and CSF analysis; the indications for, and potential value of and limitation and contraindications for, the tests in any clinical situation where their use is being contemplated.
  • Residents will demonstrate knowledge in neurologic conditions that present to the Emergency Room, as well as those that are commonly seen in hospitalized patients on other medical services including the ICU, CCU, cardiology wards, internal medicine wards, and surgical wards.
  • The indications for, side effects and dosages of the major agents used in neurologic therapeutics.
  • The mechanism(s) of action of the major drugs used in neurological therapeutics.

2. Communicator

General Requirements

  • Establish therapeutic relationships with patients/families.
  • Obtain and synthesize relevant history form patients/families/communities.
  • Listen effectively
  • Discuss appropriate information with patients/families and the health care team.

Specific Requirements

Communicate effectively with patients, their families and medical colleagues (particularly referring physicians), and other health care professionals in the outpatient settings.  The Neurologist will:

  • Communicate effectively and regularly with patients and their families.
  • Be considerate and compassionate in communicating with patients and families, willingly provide accurate information appropriate to the clinical situation, and with a reasonable attempt at prognosis.
  • Communicate effectively and appropriately with nurses and paramedical personnel.
  • When ordering investigative procedures, ensure there has been adequate communication about the patient with the person who will actually be doing and/or reporting the diagnostic study.

3. Collaborator

General Requirements

  • Consult effectively with other physicians and health care professionals.
  • Contribute effectively to other interdisciplinary team activities.

Specific Requirements

  • Be an effective teacher of other physicians, particularly the referring physician, as well as a teacher to the patient and family members.
  • Senior residents will supervise and teach junior residents and students on the neurology consult team as well as the referring teams.

4. Manager

General Requirements

  • 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.
  • Utilize information technology to optimize patient care, life-long learning and other activities

Specific Requirements

Be proficient in professional skills related to the specialty in the hospital setting.

Demonstrate the following professional skills in time management:

  • Recognize that effective use of time depends on punctuality.
  • Recognize that effective use of time requires planning.
  • Develop speed as well as accuracy in clinical skills.
  • Reserve time for reading and keeping current with the neurological literature.
  • 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 every patient seen.

Effectively coordinate the work of the health care team.

  • Indicate where other allied health personnel may improve patient care.
  • Identify where an important role(s) can be played by disease focused lay groups with regard to helping the patient and/or family and to facilitate its happening.

5. Health Advocate

General Requirements

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.

Specific Requirements

Learn about community resources and related patient support groups, provide assistance to access programs (e.g. home care, occupational and physical therapy, 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 and other health care personnel 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.

Understand the role of national and international bodies (e.g. Alzheimer, Stroke, Multiple Sclerosis Societies) in the promotion of neurological health, and the prevention, detection, and treatment of neurological disorders.


6. Scholar

General Requirements

Develop, implement and monitor a personal continuing educational strategy.

Critically appraise sources of medical information.

Facilitate learning of patients, house staff/students and other health professionals.

Contribute to development of new knowledge.

Specific Requirements

Be able to critically assess the neurological literature as it relates to patient diagnosis, investigation and treatment:

  • Develop criteria for evaluating neurological literature.
  • Critically assess the neurological literature using these criteria.
  • Be familiar with the design of experimental and observational studies, especially randomized controlled trials.
  • Be able to calculate absolute risk reductions, relative risk reductions and numbers needed to treat or harm.

7. Professional

General Requirements

Deliver highest quality care with integrity, honesty and compassion.

Exhibit appropriate personal and interpersonal professional behaviours with patients/families, peer residents and other health care professionals.

Practice medicine ethically consistent with obligations of a physician.

Specific Requirements

Demonstrate personal and professional attitudes consistent a consulting physician role:

  • Periodically review their own personal and professional performance against national standards set for the specialty.
  • Be willing to 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.