Appendix 2: Goals and Objectives of Specific Rotations

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PEDIATRIC NEUROLOGY IN-PATIENT SERVICES

includes ED, general inpatient consultations, PICU, NICU, and PEMU/Epilepsy.

The Child Neurology Inpatient Service at Columbia University Medical center is a busy service that accommodates trainees at many levels. It is covered primarily by CN residents (PGY3-5) and adult neurology rotators, but the team may be comprised at various times by medical students, outside pediatric resident rotators, and pediatric residents. Our CN residents rotate on the service in the latter part of their first year and hence function more as a PGY4 than PGY3.

The educations goals of the rotation for PGY-3 residents are to master history-taking and neurological examination skills, to develop neurological reasoning and problem-solving strategies, to make independent clinical formulations, to learn how to present clinical information and to develop a clinical approach to the diagnosis and management of neurological emergencies. PGY-3 residents are carefully supervised by the attending faculty in all aspects of their work. The service makes daily attending rounds, 7 days a week, and the educational experience includes numerous conferences and didactic sessions, including Chief of Service, Grand rounds (adult and pediatric), Neuroradiology conference, and, the noon conference series.

Evaluation: Performance evaluations are completed by faculty supervisors by using the E*Value system.

PGY-3 Rotation

Specific Objectives:

Patient Care

To develop competence in obtaining the neurological history and performing the neurological examination in children, including neonates.
To perform a focused neurological examination on the comatose pediatric patient of all ages.
To learn the special techniques of neurological examination in the critically ill newborn and pediatric patient including caloric testing, coma assessment, brain death examination as applies to differing age of children (e.g. neonates), apnea testing, and hypothermia treatment and the use of ECMO.
To perform in-hospital consultations on patients with neurological complaints in a variety of settings, including the emergency room, intensive care units, and the medical, and surgical in-patient services.
To develop and implement a comprehensive plan of diagnostic testing, therapeutic management and disposition for patients presenting with acute neurological conditions.
To develop an approach to the evaluation and treatment of neurological emergencies, including stroke, seizure, and alterations in consciousness.
To learn the indications for acute neurosurgical intervention in critically ill patients
To learn the basic principles of assessing severity of CNS insult in the management of the critically ill neurological pediatric patient so as to assist PICU/NICU staff in assessing neurodevelopmental outcome required to determine aggressiveness of care.

Medical Knowledge

To recognize the symptoms and signs common neurological conditions, including emergencies.
To become familiar with clinical neuroanatomy, and to use this knowledge as a basis for clinical reasoning.
To develop skill at making a well-informed synthesis of neurological as part of clinical problem-solving
To acquire knowledge of the pathophysiology and epidemiology of common neurological problems, such as stroke, epilepsy, headache, vertigo, encephalopathy and coma, acute spinal cord conditions, and acute neuromuscular weakness.
To learn the indications for appropriate neurodiagnostic tests and the fundamentals of their interpretation.
To develop knowledge of the indications for diagnostic testing and medical procedures.

Interpersonal Skills and Communication

To interact and communicate effectively and compassionately with patients and family members in a professional, ethical and culturally sensitive manner.
To develop skills in communicating with patients who have neurological impairment and their parents.
To develop and improve the interpersonal and communication skills, both written and oral, necessary to (i) transmit an accurate neurological history and exam to other physicians, (ii) present cases on rounds and in conferences, and (iii) to provide competent counseling to patients and families.
To write a comprehensive, problem-oriented note on children admitted to hospital when consulted.

Professionalism

To demonstrate the professional habits of punctuality, responsibility, honesty, integrity, compassion, and cultural sensitivity in responding to requests for neurological consultation.
To show appropriate respect for and cultural sensitivity to patients and their families
To demonstrate an appreciation for end-of-life care and issues regarding provision or withholding of care
To serve as an effective neurological consultant, competent to admit and manage the care of children with neurological disease while demonstrating the professional attributes of integrity, empathy, and compassion.
To be compliant with ethical and legal standards, work hour guidelines and the requirements of patient confidentiality.

Systems-Based Practice

To demonstrate the ability to interact with many other entities and services within the medical center, including the Departments of Pediatric Emergency Medicine and Radiology, in the urgent evaluation, treatment, and admission of patients with acute neurological conditions.
To demonstrate the ability to reference and utilize electronic information systems to access medical, scientific and patient information.
To develop awareness of hospital protocols, triage guidelines and standards of practice that have an impact on the evaluation and management of patients with acute neurological problems.
To learn how to make triage decisions and urgent diagnostic and management recommendations for children with acute neurological problems.

Practice-Based Learning and Improvement

To use the medical literature, including electronic databases, in the diagnosis, management, and recommendations of patients with neurological diseases.
To become familiar with hospital information systems in the evaluation and treatment of neurological patients.

PGY-4 Rotation

The second year of training builds upon a foundation of clinical skills and knowledge established during the first-year rotations. The goals of the second-year experience include an expansion of significant clinical responsibility on the Pediatric Neurology side and increased independence in the assessment of neurological emergencies. During the second year, residents also have the opportunity to explore subspecialties of neurology. They become mentors and role models for junior residents and medical students, and begin to develop research, educational, and leadership initiatives.

Evaluation: Performance evaluations are completed by faculty supervisors by using the E*Value system.

Specific Objectives:

Patient Care

All listed for PGY-3 and additionally

To demonstrate a sophisticated localization and differential diagnosis of neurological lesions
To be able to elicit subtle neurological findings on physical examination
To evaluate comatose patients to determine brain death taking the age of child into account.
To learn rapid triage, diagnosis, and management of neurologically ill children in response to demands for pediatric neurological consultation
To develop and implement a comprehensive plan of diagnostic testing, therapeutic management and disposition for patients presenting with acute neurological conditions.
To develop and refine an approach to the evaluation and treatment of neurological emergencies, including status epilepticus, neurometabolic crises, increased intracranial pressure, acute ischemic stroke, myasthenic crises, cerebral hemorrhage, arteriovenous malformations, subarachnoid hemorrhage, cerebral venous thrombosis, acute demyelinating neuropathies, and spinal cord compression.
Be able to perform neurological procedures without supervision

Medical Knowledge

All listed above for PGY-3 and additionally

To recognize the symptoms and signs common pediatric neurological conditions, including emergencies.
To gain proficiency with clinical neuroanatomy, and to use this knowledge as a basis for clinical reasoning.
To develop advanced analytical skills needed to make a well-informed synthesis of neurological as part of clinical problem-solving in setting of multiple neurological problems
To acquire knowledge of the pathophysiology and epidemiology of common neurological problems, stroke, epilepsy, headache, vertigo, encephalopathy and coma, acute spinal cord conditions, acute neuromuscular weakness, and the neurological complications of alcohol and drug addiction, among other conditions.
To learn the neurodevelopmental correlates of various neurological conditions, including static encephalopathies, neurodegenerative, neurogenetic and neurometabolic disorders.
To understand the indications, contraindications and risks of commonly used medications and procedures in child neurology
Independently present up-to-date scientific evidence to support hypotheses
To learn the indications for appropriate neurodiagnostic tests and the fundamentals of their interpretation.
To develop greater depth of knowledge of the indications for diagnostic testing and medical procedures.

Interpersonal Skills and Communication

All listed above for PGY-3 and additionally

Progressively assume a leadership role, facilitating interactions between team members, including establishing expectations, and overseeing patient care
Be able to engage patients in shared decision-making or ambiguous or controversial scenarios
Effectively discuss informed consent, resuscitation status, and death and dying with patients and families
To master skills in communicating regardless of cultural and educational background with children with neurological disorders and their parents.
To develop and improve the interpersonal and communication skills, both written and oral, necessary to (i) transmit an accurate neurological history and exam to other physicians, (ii) present cases on rounds and in conferences, and (iii) to provide competent counseling to patients and families.
To supervise the care provided by the junior residents, provide advice and assistance as needed, and organize service and teaching activities effectively and productively for the benefit of the team.

Professionalism

All listed above for PGY-3 and additionally

To serve as an effective neurological physician, competent to admit and manage the care of patients with neurological disease while demonstrating the professional attributes of integrity, empathy, and compassion with decreasing reliance on attending input.
To be compliant with ethical and legal standards, work hour guidelines and the requirements of patient confidentiality.
Demonstrate progress in meeting some or most program requirements including the starting scholarly projects
Display initiative in career planning after the completion of residency
Exhibit concern for the educational development of fellow residents and students

Systems-Based Practice

All listed above for PGY-3 and additionally

To demonstrate the ability to interact with many other entities and services within the medical center, including the Departments of Emergency Medicine and Radiology, in the urgent evaluation, treatment, and admission of patients with acute neurological conditions.
To demonstrate the ability to reference and utilize electronic information systems to access medical, scientific and patient information.
To develop awareness of hospital protocols, triage guidelines and standards of practice that have an impact on the evaluation and management of patients with acute neurological problems.
To become adept at making triage decisions and urgent diagnostic and management recommendations for patients with acute neurological problems.
To develop effective time management and triage skills in responding to demands for neurological consultation throughout Columbia University Medical Center.

Practice-Based Learning and Improvement

To develop greater proficiency in using the medical literature, including electronic databases, in the diagnosis, management, and recommendations of patients with neurological diseases.
To participate in discussion forums that emphasize evidence-based medicine and practice-based learning, including Chief of Service Rounds, Fellows’ Evening Conferences and Evidence-Based Medicine noon conferences.
To enhance skill in the use of information systems in the evaluation and treatment of pediatric neurology disorders.
Demonstrate continual self-evaluation to correct deficiencies and develop new skills
Demonstrate teaching initiative and skills with patients, students, and colleagues

PGY-5 rotation

For the senior PGY-5 pediatric neurology resident, the Pediatric Neurology Consultation Service rotation is an important step in the formation of an independent neurological consultant. The senior resident role comes with an increase in clinical responsibility, autonomy in decision-making, and leadership expectations. Although the attending neurologist assumes ultimate responsibility for patient care and management decisions, it is the senior resident who serves as team leader, responsible for the important organizational tasks of the service, including the triage of consultation requests and the timing of rounds. PGY-5 residents are expected to function as increasingly skilled and informed neurological consultants as they advance through their training.

The consultation service rotation, with its steady caseload of challenging neurological problems, is the educational experience that most closely resembles the work of a practicing consultant neurologist in the acute hospital setting. As noted, the consultation service responds to over 1000 request for consultation each year, and makes daily rounds, 7 days a week. In the evening, the senior pediatric neurology resident covers the hospital consultations alternating coverage along with the senior adult neurological resident rotating on the pediatric neurology consult service.

Specific Objectives: