Medical Student/Clerkship

The Neurology Clerkship is a vital part of medical students’ clinical training. The goal of this clerkship is to have students learn to begin the evaluation of patients with neurologic symptoms and illnesses, by working with the faculty and residents. The clerkship provides a clinical foundation in neurologic history taking, performing an accurate and complete neurologic examination, and synthesis in the evaluation of patients. It also hopes to provide a scholarly approach to neurologic practice and even inspire those who may are consider entering Neurology or a related area of Neuroscience.

The rotation requires that students practice all aspects of the neurologic physical examination, as well as taking detailed histories — the essence of a competent neurologic encounter. As students care for their patients with different neurologic conditions they have the opportunity to develop competence in the neurologic exam as well as with managing commonplace and complicated neurologic conditions. Throughout the rotation students will encounter patients with strokes, epilepsy, and many other neurologic disorders. Students will also have abundant opportunity to review the pertinent neuroradiology of their own clinical cases, and the Internal Medicine that impacts much of neurologic disorders.

There are daily didactics and a weekly live patient conference. In addition, there is a unique case conference with the departmental chairman, Dr Clifford Saper, during which a student has the opportunity to present a patient history and exam. The case is then analyzed along clinical, physiologic, pathologic, and neuroanatomic principles so that the patient’s symptoms and pathophysiology of the disease are understood on a more basic anatomic and physiologic basis.

The BIDMC Neurology faculty is dedicated to teaching. Students will rotate through two different services during the clerkship, which allows for greater diversity and exposure to different areas of Neurology and patient populations.

We hope you enjoy this unique clerkship experience.

HISTORY TAKING: obtain accurate, efficient, appropriate, and thorough history.

History Taking: develop and demonstrate the ability to take an accurate, efficient and thorough (including psychosocial background) neurological history.

PHYSICAL EXAM: perform and interpret findings of a complete and organ-specific exam.

Physical Examination: develop and demonstrate the ability to select and perform a neurological examination, including the ability to demonstrate competence, and accuracy of eliciting and interpreting signs.

DIAGNOSIS I: articulate a cogent, prioritized differential diagnosis based on initial history and exam.

Diagnosis: develop and demonstrate the ability to identify the neurological problem(s) for diagnosis, select the appropriate tests/procedures as necessary, and make an accurate interpretation of the diagnosis.

DIAGNOSIS II: design a diagnostic strategy to narrow an initial differential diagnosis demonstrating knowledge of pathophysiology and evidence from the literature.

Understanding Basic Mechanisms: develop and demonstrate the ability to consider the basic mechanisms of neurological and psychosocial disease and principles of therapy for the neurology patient.

MANAGEMENT: design a management strategy for life-threatening, acute, and chronic conditions demonstrating knowledge of pathophysiology and evidence from the literature.

Approach to Management: develop and demonstrate the ability to establish treatment goals, consider the risk/benefits, and monitor and make the appropriate modifications to the management of the neurology patient.

COMMUNICATION I: present patient information concisely, accurately, and in timely fashion to members of a health care team in a variety of settings and formats including verbally and in writing.

Record Keeping and Verbal Presentation: develop and demonstrate the ability to maintain legible, accurate and detailed follow-up notes on patient care; develop and demonstrate the ability to give an accurate and succinct presentation.

COMMUNICATION II: keep patient and family involved and informed.

Patient and Families: develop and demonstrate a caring approach to patients, develop a style of giving clear and appropriate information that will keep the patient/family informed and involved.

PROFESSIONALISM I: be selfless, reliable, honest, and respectful of patients, colleagues and staff.

Professional Relationships: develop and demonstrate the ability to form collaborative relationships and develop a style of giving clear and appropriate information, and demonstrate the ability to accept constructive criticism.

PROFESSIONALISM II: take initiative and responsibility for learning, achieving personal growth and improvement, and supporting the learning objectives of others.

Reliability/Integrity: develop and demonstrate the ability to develop and convey an enthusiastic attitude, be available when needed, and maintain composure under stressful situations.

PROFESSIONALISM III: demonstrate knowledge and affirmation of ethical standards.

Initiative/Self-Directed Learning: develop and demonstrate an eagerness to learn. The student should identify his/her own questions about the practice of neurology, seek out answers to such questions, read the literature related to patients’ neurological problems, and give a realistic evaluation of his/her own progress.

Neurology Inpatient Ward Services

The Neurology ward services admit patients from the ED, transfers from the ICU, transfers from other hospitals, and planned admissions from home. Students have the opportunity to follow patients through their hospital course, participating in the initial evaluation, diagnosis, treatment, and discharge. Students are involved in all aspects of patient care, including the evaluation of patients, team rounds, patient and family discussions, discussions and clinical conferences about Neurology patients, and note writing.

There are two Neurology ward services:

• The General Neurology and Epilepsy Service: admits patients with all neurologic conditions (except :stroke and other vascular illnesses , including CNS infections, mass lesions, Guillain Barre syndrome, multiple sclerosis and other inflammatory disorders, severe gait and movement disorders, and dementia. Many patients present with illnesses not yet diagnosed, and students participate in the diagnostic workup and management. The Epilepsy service (with a separate attending neurologist and fellow but the same resident and student team) includes a Long Term Monitoring Unit, which uses video EEG to help characterize epileptic seizures and seizure-like events, diagnose epilepsy, safely adjust and change anti-seizure medications, and evaluate patients for the possibility of epilepsy surgery.
• Stroke Service: The Stroke Service admits patients with vascular neurologic disorders, especially strokes. While most patients have ischemic strokes, hemorrhages, or transient ischemic attacks, some have other, less common conditions such as complex migraine, reversible cerebral vasoconstrictive syndrome, vasculitis or transient global amnesia. For students, stroke patients have among the most educational neurologic examinations.

Consultation Services

The Neurology Consultation services evaluate and help manage patients admitted to other wards or ICU teams, with possible or confirmed neurologic disorders needing urgent evaluation, diagnosis and management. Students have the opportunity to evaluate and examine patients from a neurologic perspective, integrating the patient’s acute and chronic medical problems. Students learn about common and rare complications of systemic medical illnesses with neurologic manifestations.

There are two Neurology Consultation services:

• West Consult: The West Consultation service evaluates patients on the BIDMC West campus. Common problems include encephalopathy, seizures, vascular disease, movement disorders, and cognitive deficits, including aphasia.
• East Consult: The East Consultation service evaluates patients on the BIDMC East Campus and also covers Neurology consultations in the ED, 8-11 am. Many East campus patients are on the Oncology or OB-GYN services. Common consultations include encephalopathy, ataxia, weakness, sensory loss, headaches, infection, seizures and several neurologic illnesses related to cancer or pregnancy and deliver, as well as those occurring on general medical services.

Daily Routine

Stroke and General/Epilepsy Services

7 a.m.: Students, the junior residents, and chief resident round on all patients.
9 a.m.: Case management rounds, the junior residents discuss discharge planning with nursing, case management, and physical/occupational therapy.
9:30 a.m.: Didactics
10:30 a.m.: Attending rounds, students will have the opportunity to present their patients, assessment and ideas for further workup and treatment.
12 p.m.: Didactics and Lunch
1 - 5 p.m.: Patient/Family meetings, documentation, coordination of care, direct admission of transfers or patients from home

East and West Consult Services

The consult services start at 8 a.m. Typical mornings include seeing new consults and following up on prior consults. Typical afternoons include attending rounds and coordination with primary teams to discuss recommendations. Students attend the same didactics as the Stroke and General services.

Neurologic Written Assessments

The case should be written up in detail in the hospital chart (or OMR). When presented orally, it is not necessary to recount a whole list of normal findings. Rather, the history should be presented in detail, and only the relevant positive findings should be enlarged upon. The broad categories should be detailed and, if normal, presented as such.

History

• Chief complaint
• History of present illness
• Review of system
• Neurological review of systems
• Past medical history
• Past neurological history
• Family history (all illnesses, not confined to neurological ones)
• Social history
• Habits
• Allergies
• Toxic exposure
• Medication(s)

Examination

• General medical examination (skin, HEENT, CV, resp, GI, GU)
• Neurological examination Mental status examination
• Cranial nerves, 1 through 12
• Motor examination
• Sensory examination
• Reflexes
• Coordination
• Gait and stance

Diagnosis

• Anatomical lesion
• Differential diagnosis
• Illness

Management

• Testing
• Management
• Treatment

Call Structure

• You will be on call every 4th
• Your call will be assigned on the first day of the rotation (so you may be on call on the first night). Below is a sample of the potential call schedules depending on which day of the week you are assigned.
• You will have the last weekend of the rotation free unless you need to make time up due to absences during the rotation.
• There is no call the night before the shelf (the last Thursday of the rotation) or on the Friday of the shelf unless a student is required to make up for missed time.
• You will be assigned to take call with a junior resident or with the ED resident until 10 p.m.
• There is no overnight call as part of this rotation.
• You are not expected to come in after a call night if the day after call is a weekend day or holiday.
• When on call, you should attempt to admit or evaluate at least one new patient including completing a full history and physical exam.
• When possible, review your write up of your patient with the resident during the call or the following morning.
• If you anticipate needing weekday time for appointments (e.g. dental) Tuesday or Thursday afternoons do not have didactics scheduled and are free aside from PCC responsibilities.

Required Instruments

Each student should try to have:

• Ophthalmoscope
• Reflex hammer
• 128 Hz tuning fork
• Penlight
• Do not use nonsterile needs for sensory testing

The grade students receive from the clerkship is weighted from three different components:

• Faculty and resident assessment = 70%
  • Each member of your team (residents, attendings and preceptor) will complete evaluations of your performance. All members of your team are weighted equally.

• 1:1 Bedside examination evaluation = 15%
  • In the last 2 weeks of your rotation you will have an opportunity to have an observed live patient encounter with a preceptor. Your preceptor will present you with a patient whom you will interview and examine for 1 hour. The preceptor will observe you and you will then present findings and assessment and receive feedback.

• Shelf Examination = 15%
  • The Neurology Shelf examine of the National Board of Medical Examiners is held on the last Friday of each rotation. You will be emailed the time and location for your particular examination. You will not have clinical responsibilities on the day of the shelf examination. There are no shelf criteria for grade levels. The shelf score is used as a weighted contribution. If your score is less than 5th percentile nationally you will need to repeat the shelf before receiving your grade for the rotation.

Student will receive a grade of honors with distinction, honors, pass or unsatisfactory based on the summation of their performance on these components. This grading system is uniform across all the neurology clerkships sites.

Advanced Neurology Clerkship (NN501M.23)

In concert with the clerkship director and associate clerkship director, you can develop your own clerkship in the four-year program. Please contact the program director for further details.

• ICU
• Epilepsy
• Vascular
• Movement disorders
• Cognitive neurology
• Concussion clinic
• Headache disorders
• Neuromuscular disorders
• Autonomic disorders
• Sleep
• Neuroimmunology
• Neurogenetics
• Neuro-oncology