Overall Goals and objectives by Core Competencies.
Patient Care
Vascular neurology residents must be able to provide patient care that is compassionate, appropriate and effective for the treatment of stroke and the promotion of health in the inpatient and outpatient setting.
Objectives:
- Perform a history and physical examination which is logical, reliable and purposeful based upon the patient’s chief complaint.
- Integrate history, physical findings, and diagnostic information in an efficient and accurate manner to arrive at a diagnosis and treatment plan for a variety of cerebrovascular conditions including acute ischemic stroke, intracranial hemorrhage, sinus venous thrombosis, AVM and other malformations, and subarachnoid hemorrhage.
- Become competent and proficient at the delivery of intravenous thrombolysis within a 3-hour time window, including the selection of appropriate patients for intravenous rtPA, and management of patients before and after rtPA administration.
- Demonstrate the ability to provide acute stroke consultations, including thrombolysis and advanced stroke care, via telemedicine.
- Become competent in the interpretation of diagnostic tests related to outpatient stroke care including MRI, MRA, Dopplers, C02 reactivity, transthoracic and transesophageal echocardiograms, conventional cerebral angiograms, SPECT scans, hypercoagulable serologic tests, as well as tests of infection and inflammation.
- Demonstrate the ability to integrate various sources of medical records into a concise and comprehensive evaluation of the patient’s cerebrovascular condition.
- Demonstrate the ability to arrive at an appropriate differential diagnosis based on history, examination and laboratory data.
- Demonstrate ability to develop an appropriate diagnostic work up and treatment plan based on the integration of history, examination, imaging and laboratory data.
- Recognize radiographic signs of early stroke and hemorrhage on CT and MRI in the context of emergency evaluation of acute stroke.
- Perform in-hospital consultations in patients with stroke and learn how to diagnose and manage patients on medical and surgical services with stroke. The resident will consult on inpatients with other active medical or surgical issues. The resident will learn how to manage stroke arising as a complication from medical or surgical disease.
- Learn medical management for primary and secondary stroke prevention in the outpatient setting. Learn the indications for antiplatelet therapy, anticoagulation, statins and other antilipid agents, cardiac medications, antihypertensives by class including subpopulations likely to benefit by each class.
- Learn indications for and applications of surgical and interventional approaches to primary and secondary stroke prevention, including endarterectomy, surgical revascularization techniques such as EDAS, endovascular stenting, coiling and clipping of unruptured aneurysm.
- Demonstrate awareness of ongoing clinical studies, and be able to refer patients appropriately to experimental treatments and ongoing clinical trials. This should be an active process including periodic review of literature when appropriate to individual patients.
- Recognize and respond to psychosocial aspects of medical, neurological and cerebrovascular problems in the outpatient setting.
- Become proficient at appropriate medical discharge planning for inpatients with stroke, including appropriate recommendations for rehabilitation services, visiting nurse, anticoagulation follow up, and diagnostic testing.
- Demonstrate role as a consultation neurologist in the outpatient setting, including effective integration of medical and surgical components of the patient’s history.
- Understand the role of follow up care from hospital-based diagnosis and management of stroke to the clinic setting.
- Become proficient at appropriate ongoing outpatient care including an understanding of appropriate intervals of follow up, including via telemedicine, and the role of the neurologist in chronic management of cerebrovascular conditions.
- Demonstrate ability to integrate allied professional care into the treatment plan such as visiting nurse services, outpatient rehabilitation services, neuropsychological and psychiatric care.
Medical Knowledge
Objectives:
- A. Basic knowledge.
- Learn anatomy and common variants for all major extracranial and intracranial cerebral vessels.
- Understand stroke pathophysiology including cerebral blood flow, blood-brain barrier, procoagulant state, bleeding diatheses, metabolic and cellular processes in ischemia, inflammation, brain edema and increase intracranial pressure, secondary consequences from intracranial bleeding.
- Understand mechanisms of stroke recovery and restoration of function in the subacute and chronic phase.
- Understand pharmacology and use of stroke treatment agents including antiplatelet agents, anticoagulants, thrombolytic agents, neuroprotective agents, cardiac medications, anti-inflammatory agents, hemostatic agents, anti-migraine medications, vitamins, interactions between medications, and medications that increase stroke risk.
- Understand the etiology and pathophysiology of unusual stroke causes such as vascular malformations, Moya Moya disease, pituitary apoplexy, meningoencephalitis, CNS vasculitis, MELAS and other metabolic disorders.
- Knowledge of vascular causes of spinal cord disease.
- Understand the basic principles of neuroimaging including CT, CTA, MRI, MRA, MR spectroscopy, PET, SPECT, arteriography.
- Understand mechanisms and pathophysiology of increased intracranial pressure, hypertensive encephalopathy, and posterior reversible encephalopathy syndrome.
- B. Patient management-based knowledge.
- Recognize signs and symptoms of acute stroke and understand stroke mimics.
- Understand the phenomenology of all major stroke syndromes, including motor, sensory, language, visual-spatial, amnestic, cerebellar and brainstem syndromes.
- Understand the functional anatomy of all major stroke syndromes, including motor, sensory, language, visual-spatial, amnestic, cerebellar and brainstem syndromes.
- Understand etiology and pathophysiology of cerebrovascular diseases including ischemic stroke, subarachnoid hemorrhage, sinus venous thrombosis, and intracranial hemorrhage with regard to patient care.
- Knowledge will include:
- Risk factors of each stroke subtype including genetic, medical and sociocultural risks.
- Mechanisms of different subtypes including small vessel disease, large vessel disease, embolism, intracranial hemorrhage, and subarachnoid hemorrhage.
- Mediating factors in stroke pathophysiology including the impact of concurrent illness and medications.
- Become familiar with all important clinical trials pertinent to treatment of ischemic stroke, ICH and subarachnoid hemorrhage and utilize that information in management of acute stroke patients.
- Demonstrate knowledge of mechanical interventions for stroke including angioplasty, stenting, endarterectomy, EC-IC bypass, EDAS, and aneurysm clipping and coiling, and the criteria for which each is to be recommended.
- Demonstrate knowledge of management options for AVM, dural AVF, and other vascular malformations.
- Understand practical application of major imaging modalities including CT, CTA, MRI, MRA, MR spectroscopy, PET, SPECT, arteriography.
- Demonstrate knowledge of application of ultrasound technologies including Doppler, transthoracic and transesophageal echocardiogram, and non-invasive lower extremity flow studies.
- Understand principles and application of electroencephalography and evoked potentials in the management of stroke.
- Recognize early and late neurological worsening in acute stroke and demonstrate knowledge of management strategies, both with regard to cerebrovascular causes of worsening and medical causes.
- Understand principles of stroke recovery including factors that predict recovery in the acute phase, role of rehabilitation interventions, and the course of recovery.
- Demonstrate familiarity with the application of rehabilitation techniques, their underlying mechanisms, and clinical application.
Practice Based Learning And Improvement
Objectives:
- Demonstrate use of evidence-based medicine during formal weekly Divisional clinical case presentations and during discussions with the Attending physician.
- Readily access information from NYPH information technology systems and established medical databases.
- Demonstrate efficient and accurate note-writing for initial consultation and follow up consultation notes.
- Recognize limitations of one’s knowledge base and need for life-long learning.
- Use of existing medical libraries and drug information sources including on-line sources.
- Maintain records of caseload and practice experience in a systematic manner, incorporating information from patient records, electronic databases, and other sources of information.
- Demonstrate incorporation of current literature into diagnostic evaluation and management of acute stroke patients.
Interpersonal and Communication Skills
Objectives:
- Listen to and understand stroke inpatients using verbal and nonverbal communication, including understanding nuances of communicating with stroke patients with aphasia and other cognitive impairments.
- To develop and maintain a therapeutic relationship with acute stroke patients and their families by instilling feelings of trust, integrity, and reliability.
- Learn to transmit often complex medical information in a clear and concise manner, appropriate to the level of understanding of the patient and family.
- To communicate and collaborate effectively with allied health professions in the hospital setting.
- To educate patients, their families, and other health professionals about medical, psychosocial, and behavioral issues about stroke.
- To communicate information about stroke recovery and post-stroke care to patients and their families.
- To demonstrate effective communication, both written and verbal, with professionals on a consultation role in the acute hospital setting. This will include the clear and meaningful formulation of the consultation question and appropriate use of specific consultation services.
- Demonstrate competence in integration of consultation information into the management and treatment plan for inpatient stroke patients.
- Maintenance of up-to-date medical records, incorporating electronic and written records of history, examination and laboratory information.
- Understand and demonstrate proper maintenance of confidentiality with patients, families and health care professionals regarding medical information, prognosis, palliative care, and other sensitive material.
- Demonstrate ability to discuss iatrogenic and other in-hospital complications to patients, families, and allied health professionals in an honest, complete, and sensitive manner.
- To learn how to supervise a resident and medical student team.
- To be able to effectively teach material pertaining to vascular neurology to the house staff and medical students rotating on service.
Professionalism
Objectives:
- Demonstrate responsiveness to communication from patients, families and allied health professionals in a timely manner.
- Establish back-up coverage plans for situations in which work load exceeds the resident’s capacity (e.g. multiple simultaneous acute stroke emergencies) or illness or other contingencies necessitate a schedule change.
- Arranging for continuity of care with regard to patients to be followed up in the outpatient setting.
- Demonstrate ethical behavior, integrity, honesty, compassion, and confidentiality in the delivery of care, including matters of informed consent, professional conduct, and conflict of interest.
- Demonstrate respect for patients, families and allied health professionals.
- Review of professional conduct of themselves, peers, and other senior colleagues in a constructive, forthright, and sensitive manner.
- Be able to provide constructive criticism to junior residents and medical students in a sensitive and forthright manner.
- Demonstrate ability to incorporate constructive criticism into improvement of professional performance.
- Demonstrate awareness of safety issues, including acknowledging and remediating medical errors should they arise.
- Demonstrate leadership in teaching and mentoring junior residents and allied health professionals in the hospital setting with regard to knowledge and management of acute stroke.
Systems-Based Practice
Objectives:
- Demonstrate ability to access and utilize community, national, and allied health professional resources in the management of acute hospital care.
- Demonstrate knowledge and application of current practice guidelines for acute stroke including thrombolysis, blood pressure and other medical management, diagnostic testing, and in-hospital treatment of acute stroke.
- Demonstrate knowledge and use of ED and hospital protocols for acute stroke, including IV thrombolysis, IA thrombolysis, mechanical clot extraction, and other acute interventional approaches to acute stroke.
- Demonstrate accurate and appropriate use of medical data in the development of management plans for acute stroke patients.
- Demonstrate knowledge and appropriate application of legal and administrative aspects of acute stroke care including issues of capacity to consent to procedures and research studies.
- Demonstrate sensitivity to ethical issues in acute stroke care and work with ethics committee consultation when necessary.
- Demonstrate knowledge and application of end-of-life protocols such as palliative care, withdrawal of life support and hospice care.
- Participate in quality improvement efforts for the hospital.
- Participate in Morbidity & Mortality conferences to discuss improvements in protocols and management.
9/14/04 Approved by the Core Competencies Committee 7/17/04
- 1 Cultural diversity includes issues of race, gender, language, age, country of origin, sexual orientation, religious/spiritual beliefs, sociocultural class, educational/intellectual levels, and physical disability. Working with a culturally diverse population requires knowledge about cultural factors in the delivery of healthcare. For the purposes of this document, all patient and peer populations are to be considered culturally diverse.
- 2 Regarding sociocultural issues, for the purposes of this document, “family” is defined as those having a biological otherwise meaningful relationship with the patient. Such “significant others” are to be defined from the patient’s point of view.