Division of Neurology

McMaster Objectives: Inpatient Stroke Neurology

All trainees in Neurology will spend a minimum of 3 months on the Integrated Stroke Unit at the Regional Stroke Centre, the Hamilton General Hospital. Stroke is the most common serious neurological disorder and residents may wish to further their experience and expertise by an additional 3 months on the unit.

General Objectives

Residents must demonstrate the knowledge, skills and attitudes relating to age, gender, culture and ethnicity pertinent to stroke neurology. In addition, all residents must demonstrate an ability to incorporate age, gender, cultural and ethnic perspectives in research methodology, data presentation and analysis.

On completion of the educational program, the graduate physician will be competent to function as a consultant stroke neurologist. This requires the physician to:

  1. Provide scientifically based, comprehensive and effective diagnosis and management plan for patients with stroke, TIA, or stroke mimics.
  2. Communicate effectively with patients, their families, medical colleagues (particularly referring physicians), and the multi-disciplinary stroke team.
  3. Counsel patients and their families and others on aspects of prevention of stroke disorders, including risk factors, and genetic and environmental concerns.
  4. Maintain complete and accurate medical records.
  5. Effectively coordinate the work of the stroke care team.
  6. Be an effective teacher of other physicians (including medical students and junior residents), other stroke team members, and patients and their family.
  7. Be proficient in professional and technical skills related to the specialty.
  8. Demonstrate personal and professional attitudes consistent with a consultant physician role.
  9. Be willing and able to appraise accurately his or her own professional performance.
  10. Be willing and able to keep his or her practice current through reading and other modes of continuing medical education.
  11. Be able to critically assess the stroke literature as it relates to patient diagnosis, investigation and management.
  12. Be able to participate in clinical or basic science studies as a member of a research team.

Specific Objectives

At the completion of training, the resident will have acquire, along with those outlined by the Royal College of Physician and Surgeons of Canada Education Committee Objectives of Training and Specialty Training Requirements in Adult Neurology, the following competencies and will function effectively in the following CanMEDS roles as:

  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, education and legal opinions.

Specific Requirements

Provide scientifically based, comprehensive and effective diagnosis and management for patients with stroke disorders.

Clinical Skills

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

  • Obtain a complete neurological history from the patient and/or their designate, obtaining a collateral history where necessary.
  • To obtain an accurate and complete history and carry out a competent neurological examination in an inpatient setting.
  • Obtain a history and physical examination in the Intensive Care Unit and in the Emergency room on patients with stroke as part of the stroke team consultation service.
  • 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).
  • Clinically localise the site of lesion accurately
  • Formulate an appropriate differential and provisional diagnosis.
  • Outline an appropriate plan of laboratory investigation.
  • Outline an appropriate plan of diagnostic imaging investigation.
  • Outline an appropriate therapeutic plan.
  • Exhibit appropriate clinical judgment in outlining a differential diagnosis and an investigative and therapeutic plan, taking into account matters such as the patient's age, general health, risk and cost of investigative procedures, risk and cost of therapeutic interventions, and epidemiology of the disease.

Technical Skills

  • Identify and describe abnormalities seen in stroke disorders on ultrasonography, cerebral angiograms, computerized tomography (CT) of the brain, and magnetic resonance imaging (MRI) of the brain. CTA and perfusion scans if available.
  • With regard to a specific patient or clinical history, evaluates the relevance of a specific report on the following investigative procedures: electroencephalogram; evoked responses; perimetry; psychometry; cerebrospinal fluid (CSF) analysis; plain x-ray; angiogram; ultrasound and CT, MRI scans of the neuraxis.
  • Identify and describe gross and microscopic specimens taken from the normal nervous system and from the nervous system of patients affected by the major stroke disorders.

Knowledge

  • As a basis for clinical competence, the neurologist must be familiar with and able to describe or discuss:
  • the clinical features, including presenting signs and symptoms, natural history, and prognosis, for the major stroke disorders and syndromes including: cerebral ischemia, cerebral hemorrhage, stroke mimics and stroke complications such as seizures and dysphagia.
  • the gross and microscopic anatomy of the nervous system, and in particular the vascular system; this includes the recognition of the structures in both anatomical and neuro-imaging formats.
  • the mechanisms underlying cerebral ischemia and hemorrhage.
  • the role of trophic factors in the nervous system
  • cerebral blood flow and cerebral metabolism
  • the anatomical and physiological basis of speech, memory, learning and behaviour
  • the anatomic and physiologic basis of the normal neurological examination
  • the pathophysiology of neurologic symptoms and signs in the secondary complications of stroke; (examples of these include seizures, spasticity, incontinence, dysphagia, etc.)
  • the basic principles underlying the interpretation of the major clinical tests used in stroke such as electroencephalography, evoked potentials, perimetry, psychometry and CSF analysis; the indications for, and potential value of and limitations and contraindications for, the tests in any clinical situation where their use is being contemplated
  • the indications for, side effects and dosages of the major agents used in stroke therapeutics
  • the mechanism(s) of action of the major drugs used in stroke therapeutics
  • the role of surgery in the therapy of stroke disorders including indications and contraindications for its use
  • the role of rehabilitative medicine in the treatment of neurological disorders
  • the basic histopathologic reactions which occur in the nervous system with stroke
  • the pathologic changes (gross and microscopic) occurring in stroke disorders
  • the biochemical basis for the stroke syndromes resulting from inborn errors of metabolism (e.g. MELAS)
  • the basic procedures used in clinical epidemiology and the clinical epidemiology of stroke disorders

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2. Communicator

General Requirements

  • Establish therapeutic relationships with patients/families.
  • Obtain and synthesize relevant history from 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 stroke team members), and other health care professionals. 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, with a reasonable attempt at prognosis.
  • Communicate effectively and appropriately with nurses, and all stroke team members.
  • 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.

Counsel patients and their families and others about aspects of prevention of stroke disorders, including risk factors, and genetic and environmental concerns. The neurologist will:

  • Recognize that complete patient care requires that, in addition to the need for making a correct diagnosis, a search for risk factors for the disorder be undertaken.
  • Recognize that treatment for a patient with a stroke disorder may require in addition to specific medical and surgical interventions.

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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 (including medical students and junior residents), other stroke team members, and patients and families. The neurologist will:

  • Provide instruction to medical students and more junior physicians at a level appropriate to their clinical education and professional competence.
  • Willingly share knowledge with others with whom they are associated, thus ensuring the most effective delivery of health care to patients.
  • Participate in multi-disciplinary ward rounds where and when appropriate.

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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.

Demonstrate the following professional skills in time management:

  • Recognize that effective use of time depends upon 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 stroke 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; this record will include the patient's history and the findings on physical examination (including the neurological examination), a differential diagnosis, a provisional diagnosis, a plan for management, appropriate progress notes, and a comprehensive discharge summary.

Effectively coordinate the work of the stroke team:

  • Organize and supervise the more junior physicians and medical students on a ward and/or consultation service in a manner that ensures the efficient and effective delivery of health care for the patients.
  • Indicate, by the treatment plan, that for the optimal treatment of many patients with a stroke disorder, a team approach is necessary -- members of the team will include nurses, physiotherapists, occupational therapists, speech therapists, psychologists, and social workers.
  • 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.

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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. CCAC, home care, occupational and physiotherapy, outpatient rehabilitation, etc) and participate in their activities.
  • 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 effectively on stroke disorders.
  • Counsel patients and families on the importance of taking responsibility for their own well-being and recognize the important determinants predisposing to stroke disorders
  • Understand the role of national and international bodies in the promotion of vascular health, and the prevention, detection, and treatment of stroke disorders.

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6. Scholar

General Requirements

  • Develop, implement and monitor a personal continuing education 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 stroke literature as it relates to patient diagnosis, investigation and treatment:

  • Develop criteria for evaluating stroke literature.
  • Critically assess the stroke 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.

Be able to participate in clinical or basic science studies as a member of a research team:

  • Be able to describe principles of good research.
  • Use the above principles, and be able to judge whether a research project is properly designed

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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 members of the stroke team.
  • Practice medicine ethically consistent with obligations of a physician.

Specific Requirements

Demonstrate personal and professional attitudes consistent with a consulting physician role:

  • Periodically review his/her 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.