Neurology Clerkship Learning Goals and Objectives
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.
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.
Medical Student Responsibilities
Stroke and General/Epilepsy Services
7 am-10am: Rounding, Students, the junior residents, and chief resident round with the attending, students will have the opportunity to present their patients, assessment and ideas for further workup and treatment.
12 pm: Didactics and Lunch
1-5 pm: Patient/Family meetings, documentation, coordination of care, direct admission of transfers or patients from home
**Students are responsible for attending PCE, PCC and RLIC activities when scheduled
East and West Consult Services
Daily routine: the consult services start at 8 am. 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.
- 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
- Toxic exposure
- General medical examination (skin, HEENT, CV, resp, GI, GU)
- Neurological examination
- Mental status examination
- Cranial nerves, 1 through 12
- Motor examination
- Sensory examination
- Gait and stance
- Anatomical lesion
- Differential diagnosis
- 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 pm.
- 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:
ii. reflex hammer
iii. 128 Hz tuning fork
v. Do not use nonsterile needs for sensory testing
Neurology Clerkship Grading
Grading in the neurology clerkship follows the HMS Grading System for the PCE
Students will be evaluated by attending neurologists and neurology residents who have worked with a student for a minimum of 3 days. Rotating residents from other services will not evaluate students during their Neurology Clerkship.
HMS and BIDMC Policies
Policy on Student Conduct
BIDMC Policies for Contact Exposures
PCE Log Requirement:
Students are required to record their encounter with each log topic once, inclusive of the highest level of patient interaction displayed in that encounter during the rotation. Individual clerkship directions may choose to use the PCE Log for additional purposes, so long as students meet the minimum requirement of recording the highest level of encounter with each one of the specified topics.
HMS Policy on Mistreatment:
Harvard Medical School and its affiliated hospitals are committed to a culture of mutual respect and trust and to providing an environment free from discrimination, sexual harassment, unprofessional relationships, and abuses of authority. We take student mistreatment seriously and aspire to a culture of zero tolerance for instances of abuse, mistreatment, and disrespect. All faculty, students, house officers, fellows, and staff are expected to contribute to sustaining an environment of collegiality and mutual support that is conducive to learning and working. Students experiencing mistreatment personally or witnessing such behavior in others are expected to report such incidents in clerkship surveys and/or through an anonymous online form accessible through the HMS Student Service site.
HMS Ombuds Office:
As an impartial complaint handler, the Ombudsperson strives to see that people are treated fairly and equitably at Harvard Medical School, Harvard School of Dental Medicine, and the Harvard School of Public Health. The Ombudsperson is a designated neutral person and, as such, does not advocate for any individual or point of view. The office is independent of any existing administrative or academic structures and is responsible only to the dean of each school. The official supplements the existing resources available to members of our communities.
Elective Neurology Rotation
Advanced Neurology Clerkship (NN501M.23)
In concert with the clerkship director and associate clerkship director, you can develop your own clerkship in the 4 year. Please contact the program director for further details.
- Movement Disorders
- Cognitive neurology
- Concussion clinic
- Headache disorders
- Neuromuscular disorders
- Autonomic disorders