NeurologyResidencyManual 2014‐2015 Welcome! The following residency program manual contains important information about the neurology residency program and its policies and procedures. Please read it completely upon your beginning your training here and refer to it as needed. If you have any questions about the contents herein, we are happy to clarify them. This manual is frequently updated, so we ask you to remain abreast of changes. It is posted on-line at the department website so that the most recent version is always readily available. Sincerely, Justin A. Sattin, MD Neurology Residency Program Director 1 TableofContents Part I - Program Overview .......................................................................................................... 4 Introduction................................................................................................................................ 4 Mission Statement ..................................................................................................................... 4 Program Administration ............................................................................................................. 6 Resident Selection Process ...................................................................................................... 8 Salary and Benefits ................................................................................................................... 9 General Program Requirements ............................................................................................. 12 Rotation Schedule ................................................................................................................... 16 Call Schedule .......................................................................................................................... 18 Continuity Clinics ..................................................................................................................... 19 Conference Schedule .............................................................................................................. 20 Evaluations .............................................................................................................................. 21 Promotion to the Next PGY Level ........................................................................................... 24 Grievance Policy ..................................................................................................................... 25 Moonlighting Policy ................................................................................................................. 26 Physician Impairment and Resources ..................................................................................... 27 Part II - Specific Goals and Objectives ................................................................................... 28 The ACGME Core Competencies ........................................................................................... 28 Overall Goals and Objectives .................................................................................................. 32 UW and VA General Neurology Service ................................................................................. 35 UW and VA Stroke Service ..................................................................................................... 38 UW and VA Hospital Consult Service ..................................................................................... 43 Epilepsy Rotation .................................................................................................................... 46 Neuromuscular Medicine & EMG Laboratory Rotation ........................................................... 52 2 Pediatric Neurology Rotation ................................................................................................... 60 Neuropathology Elective ......................................................................................................... 65 Neurosurgery Rotation ............................................................................................................ 68 Night Float Rotation ................................................................................................................. 71 Ward Senior Rotation .............................................................................................................. 74 Specialty Clinics Rotation ........................................................................................................ 76 Psychiatry Outpatient Clinics and Consult Service ................................................................. 80 Headache Elective .................................................................................................................. 83 Movement Disorders Elective .................................................................................................. 87 Multiple Sclerosis and Clinical Neuro-Immunology Elective .................................................... 91 Sleep Medicine Elective .......................................................................................................... 96 Neuro-Ophthalmology Elective .............................................................................................. 100 Neuroradiology Elective ........................................................................................................ 103 Research Elective ................................................................................................................. 105 Neuropsychology Elective ..................................................................................................... 109 Part III – Neurology Department Clinical Policies ................................................................ 112 UWHC Electroneurodiagnostic Technologist Call Policy and Procedure for STAT EEG, Continuous ICU EEG and Video EEG ................................................................................... 112 Appendix A – UW Hospital Policies ...................................................................................... 116 3 Part I - Program Overview Introduction The purpose of this handbook is to provide useful general information for neurology residents, to define responsibilities of the resident at each level of training and to improve academic development. The material presented is not inclusive, rather it focuses on how the faculty, residents and support staff function as a team of professionals dedicated to advancing care for patients with neurological diseases; and work together to train the next generation of neurologists and other clinicians caring for patients with neurological diseases. Our department’s website is located at http://neurology.wisc.edu/. The residency program in Neurology is a three-year learning experience designed to train the physician in the field of neurological disorders. The participating institutions include The University of Wisconsin Hospital and Clinics (UWHC) and the William S. Middleton Veterans Administration Hospital (VA). The responsibilities of the resident outlined here are applicable to both of these institutions. Although the administration policies of the respective hospitals may be unique, they should not take precedence over the professional duties and assignments of the Neurology resident. Mission Statement The Department of Neurology Residency Program emphasizes a team approach with close interaction with attending faculty physicians, resident colleagues as well as other ancillary health care professionals. The residency program seeks to develop and nurture each resident’s lifelong curiosity about the workings of the nervous system. In addition, the program will help develop each resident’s skills in critical reasoning, evaluation of scientific literature, and verbal and written communication to facilitate understanding of neurological disorders and their treatments for patients and society. Faculty and residents will strive to provide the highest quality of care to every patient. It is our unwavering view that the patient comes first. Our primary service responsibility is to provide exceptionally compassionate patient care delivered with the highest standards of professionalism, as we would wish for ourselves and our families. The primary educational goal of the residency program is the development of each resident into a competent board-certified neurologist with skills and expertise in neurological history-taking, 4 neurological examination, and the ability to proceed thoughtfully through the diagnosis and management of patients based on clinical history, examination findings, and laboratory testing. Faculty and residents will strive in their service and care of each patient to make every case a learning experience, and they will specifically devote efforts to the differential diagnosis in every case prior to consideration of imaging and electrodiagnostic studies. To further these purposes we will commit ourselves to:  Respect the patients and their families and maintain appropriate professional behavior at all times.  Communicate clearly and honestly with patients, their family and others who care for patients.  Examine patients skillfully, diagnose their problem accurately, and apply the safest and most effective treatments.  Learn the scientific foundation of neurology in order to treat patients rationally and assess the merits of new diagnostic tools and treatments. We must learn the basic principles of neuroanatomy, neurophysiology, neuropharmacology, neuropathology, as well as related molecular biology and biochemistry.  Develop the skills and habits that keep us up-to-date on discoveries in neurology. We will sharpen the skills needed for critical analysis of the clinical and basic science literature so that we can distinguish between valuable discoveries for our patients and unsound claims which compromise patient care and/or waste money. We will establish patterns of conference attendance, systematic reading, and review of the literature that will help us serve our patients well.  Educate ourselves in other medical areas such as internal medicine, psychiatry, neurosurgery, and physical medicine acknowledging that a basic understanding of these disciplines is fundamental to the best practice of neurology.  Encourage honesty, compassion, self respect, industry and efficiency in one another.  Practice cost-effective medicine.  Develop competence in each of the ACGME’s six Core Competencies.  Maintain our own health so that we can effectively and safely take care of our patients.  Seek that each of our graduates achieves certification by the American Board of Psychiatry and Neurology. 5 Program Administration Program Director The Residency Program Director is appointed by the department chair. He/she is responsible for the supervision of the residents' education and training. He/she chairs the residency and competence development committees and also functions as a liaison between the faculty and the residents. The program director serves as a readily available resource for any resident encountering a professional or personal problem. Program Coordinator The Residency Program Coordinator is a staff administrator who assists the Program Director in the day-to-day and long-range operations of the residency program. A small sample of the specific duties include: submitting time sheets to the GME office, communicating with residents and faculty (by phone, e-mail or memo) regarding clinical assignments, organizing didactic conferences, proctoring examinations, managing resident’s orientation, and assisting with resident recruitment. Chief Resident One senior (PGY-4) resident will be chosen to serve as chief resident during his/her final year of Neurology training. The Chief Resident shall be an individual who is accomplished academically and possesses excellent clinical skills. The Chief Resident is selected by the faculty with input from all residents. In this position, he/she is expected to assist in the management of clinical problems, provide clinical and personal guidance to junior colleagues, participate actively in the academic programs of the department, and with the Program Director, manage the Residency Training Program. He/she will be expected to attend regularly scheduled meetings of the Residency Committee as a resident representative. Committee Structure Residency Committee:  This committee is responsible for the general oversight of the residency program. It is responsible for reviewing applications to the program, interviewing candidates, and developing the rank list. 6  With input from the competency and curriculum committees, along with the various clinical section heads, the residency committee oversees the development of rotation goals and objectives, milestones, and evaluation tools.  The committee is chaired by the Program Director and other members include the Chief Resident, the Program Coordinator, the Chairman of the Department, and various faculty representing different divisions of the department. It meets monthly. Clinical Competency Committee:  This committee reviews resident performance with respect to the six core competencies defined by the ACGME (patient care, medical knowledge, interpersonal and communication skills, practice-based learning and improvement, systems-based practice, and professionalism).  In the ACGME’s Next Accreditation System, residents are expected to achieve specific milestones relevant to neurology. The Competence Development Committee’s mission includes the assessment of each resident’s progress toward these milestones.  The committee advises the program director regarding resident promotion and, if necessary, remediation.  The committee will also consider issues that affect resident performance, such as fatigue, stress, affective disturbance, and substance abuse. Curriculum Committee:  This committee is chaired by a senior (PG4) resident. The committee works with the program director to develop the didactic curriculum. Members of the committee include the Program Director, Program Coordinator, one resident from each year of training, and various faculty. Grievance Committee:  This is an ad hoc committee created when a grievance is filed by a resident per the Grievance Policy. The Program Director will appoint 3 faculty members to review and respond to the filed grievance. Program Evaluation Committee:  This committee is responsible for the annual review of the residency program. It is responsible for reviewing and discussing resident performance, faculty development, graduate performance, program quality and developing an action plan. 7  The committee is chaired by the Program Director and other members include the Chief Resident, the Program Coordinator, the Chairman of the Department, and various faculty representing different divisions of the department. It meets annually. . Resident Selection Process The University Of Wisconsin Department Of Neurology seeks well rounded candidates with a track record of academic success and great potential for the future. Desirable attributes include: strong intellectual abilities as documented by success in past academic performance, sincere interest in a career in neurology, and excellent interpersonal and communication skills. Applications to our program are only accepted via ERAS. All applications are reviewed in their entirety by the Residency Committee, which will objectively rate each application with regard to: academic performance in college and medical school, performance on USMLE (COMLEX scores will not be accepted), interpersonal communication (personal statement, etc.), extracurricular activities, research accomplishments, and letters of recommendation. The most highly rated applicants are invited for in-person interviews. Applicants accepted for interview will be presented to the Department of Internal Medicine for consideration for PGY1 year. The program director for Internal Medicine will communicate to the program director of Neurology which candidates are acceptable to Internal Medicine. The candidates are invited for a dinner on the night before the interview, so as to meet the residents and learn about the program from them. The residents attending the dinner will evaluate each candidate. On the following day, candidates have a structured interview day which includes a breakfast meeting with the Program Director for an overview of the program. Subsequently each candidate will be interviewed by no fewer than 3 faculty members. A tour of the hospitals and lunch with the residents will follow. There are two rank lists: One list containing all ranked candidates and another list containing only those candidates deemed acceptable for a PGY1 slot by the internal medicine program. The former list is submitted to ERAS for our advanced postion(s). The latter list is submitted for our categorical positions. All candidates must meet the UWHC qualifications for appointment (see Appendix 1) and attest to this by signing an agreement form provided by GME office. 8 Salary and Benefits Residents are employees of UWHC. Residents are not employees of the University of Wisconsin School of Medicine and Public Health or the Department of Neurology. Residents are expected to be acquainted with the UWHC Appointment Information, and abide by its requirements. The Neurology Department is responsible to enforce the appointment requirements. Salary and benefits are maintained by the UWHC. 9 The University of Wisconsin-Department of Neurology also provides resident support independent of the UWHC as follows. Educational Fund Each resident who is in good standing will have an educational fund to help offset the cost of materials required to become a neurologist. The educational fund is structured in the following manner:  Beginning on July 1st of the PG2 year (first year neurology training), each resident will be allocated $3500 that can be spent over the three years of neurology training. Unused funds will carry over each year, but the remaining balance at the end of the PGY4 year will be forfeited.  Each resident’s educational fund balance will be maintained by the program coordinator, and requests for reimbursement will be handled by the program coordinator.  The educational fund may be frozen at any time by the program director for resident failure to complete regularly required professional activities such as delinquent medical records, incomplete patient logs, or incomplete duty hours documentation.  PGY1 residents in the Internal Medicine program will be authorized an educational fund of $300 for the PGY1 year with reimbursement to occur once training commences in the neurology program. Unused monies will not carry over to the PGY2 year.  Funds may be used to purchase medical equipment.  Funds may be used for the cost of personal digital assistants (PDAs) used in the care of patients.  Funds may be used to for travel and registration expenses to travel to a scientific meeting covered under the following policy. Professional Meetings and Travel Policy The Department of Neurology recognizes the value and need of residents to receive educational experiences outside the institution. Moreover, effective 1 July 2010, ACGME requires that all neurology residents attend one professional meeting during the course of residency. Accordingly, each resident in the Department of Neurology is allotted one week each academic year to attend an elective professional educational meeting. The following guidelines will apply to the attendance of such meeting.  The meeting will be the annual meeting of one of the following societies: o American Academy of Neurology o American Neurological Association o Society for Neuroscience o Child Neurology Society 10 o o o American Heart Association- American Stroke Association American Epilepsy Society American Association of Neuro-electrodiagnostic Medicine  A resident may petition the Residency Director if he or she wishes to attend a meeting not listed above. However, the meeting must offer AMA category I CME credit and be relevant to the field of neurology or its subspecialties.  A resident must declare which meeting he or she wishes to attend and obtain approval from the program director, who will usually delegate authority for this to the residency coordinator. The resident must, at least two months in advance of the meeting, make arrangements through the chief resident for coverage of his or her clinical responsibilities, including outpatient clinic schedules.  Documentation of attendance at the chosen meeting will be required and will be placed in the resident’s personnel file. Acceptable documentation will be a certificate of attendance and/or a statement of CME credit awarded. Academy of Neurology Membership The department requires that each resident join the AAN upon program entry. Initial and yearly dues are paid for by the Department of Neurology. This ensures that residents are informed about all AAN activities and provides a yearly subscription to the journal Neurology. Cellular Phones and Pagers Each resident is provided a pager by the department of neurology. Cellular phones are allocated according to clinical service (general neurology, stroke, consults, and pediatric neurology) and are to be used only for patient care responsibilities. Cell phone usage is monitored monthly by the residency coordinator. Resident Offices Resident offices are located in the UWMF Centennial Building in the Department of Neurology. A resident library with textbooks, personal desk space, telephones, and computers is provided. 11 General Program Requirements The Neurology Residency Program will at all times strive to meet the requirements set forth by the ACGME—both the Common Program Requirements and the individual requirements established by the Neurology Residency Review Committee. Specific requirements follow: Conference Attendance The educational program exists for the benefit of the residents. Conferences for residents require a significant time commitment on behalf of the faculty facilitator and therefore attendance at such conferences and lectures is required. Attendance will be taken at all required conferences. Documented attendance must be greater than 70%. Failure to maintain this level of attendance may result in may result in freezing or forfeiture of the resident’s education fund. Duty Hours As described below in “Physician Impairment and Resources”, duty hour regulations were imposed by the ACGME on all training programs in July 2003. The ACGME has created a mandatory set of duty hour regulations designed to reduce sleep deprivation and fatigue among physicians in training. Full (100%) compliance with these regulations is expected of our neurology residents. Residents must take personal responsibility for tracking their duty hours, and must notify their current attending or program administrator immediately when any violation is imminent. Residents are expected to enter duty hours into the Med Hub program continuously, at a minimum each week. Failure to do so may result in freezing of educational allowance or suspension. Continuous failure to comply may result in termination. For full details about duty hours (definitions, regulations, etc.) see: http://www.acgme.org/acWebsite/dutyHours/dh_Lang703.pdf 12 Medical Records As part of the clinical care provided, it is expected that the resident write a medical record note on each inpatient on every day of hospitalization. A note may not be required each day on Consults, but on any day in which an evaluation is performed a note should be written. For outpatient visits, a note must be written, typed into an electronic medical record system (where available), or dictated on the same day of service. All documentation should be completed in a timely fashion in order to facilitate optimal communication among providers. As in private practice, failure to complete dictations (or any documentation) in a timely manner may result in to freezing of educational allowance or suspension from clinical duties. Continuous failure to comply may result in termination. Medical record documentation is also used for billing purposes. It is the resident’s responsibility (and part of the resident’s education) to learn what documentation is appropriate for each level of service. The Program will ensure that education on billing and regulatory compliance is presented yearly, and will provide pocket cards to the resident for quick reference regarding necessary documentation/billing level of service. Scholarly Work Per ACGME requirements, each resident must participate in scholarly work. Scholarly work can be evidenced by any of the following: Journal Club:  Each resident will be assigned a journal club date in each year of training. The resident is responsible for choosing an article for review and selecting the appropriate faculty member to supervise the meeting. The resident will prepare and present the article during Journal Club with discussion surrounding relevance/importance of the article, study design, patient population studied, statistics used, conclusions drawn, and the validity of the conclusions. The resident must provide a thoughtful critique and be prepared to put the article in the context of the body of neurologic knowledge. Conferences:  Morning report – Each resident will be assigned morning report sessions throughout the year. The resident will present a patient case with emphasis on neurological history and exam, differential diagnosis, and discussion of relevant literature.  Conferences – Part of the conference series will include anatomy and physiology. Since it is felt that the best learning occurs with teaching, residents will be assigned these lectures. 13  Grand Rounds – Each senior resident will be required to present at the Department of Neurology Grand Rounds during the final year of training. Any resident may present at Grand Rounds at any additional time if so desired.  Wisconsin Neurological Society – Each resident is encouraged to present at the Annual Meeting of the Wisconsin Neurological Society. Residents may present unusual case reports or original research. Research:  There are multiple opportunities for resident involvement in research. Research electives are available to each resident. Faculty members have multiple ongoing projects, a list of which will be maintained by the residency coordinator. Publication:  In addition to publication arising from research, residents are invited to be a co-author with a faculty member for review articles, book chapters, editorials, or any other material that is published in peer-reviewed publications. Teaching Responsibilities Teaching is an essential part of the resident’s duties. Residents are expected to impart basic knowledge on a daily basis to medical students, rotating residents, and more junior residents. All members of a health care team learn from one another, and thus a resident will ultimately teach their supervising faculty as well as other allied health professionals. The actual structure of this teaching varies by month and by resident. Some faculty members require that each resident will give one or more short educational talks during the month. Some faculty will want the senior residents to take an active role in teaching during rounds, while others may want resident teaching to occur outside the realm of formal team rounds. Some residents are comfortable giving didactic talks to others, while some prefer to teach with “pearls” as they are relevant to patient care being provided. We allow for these variations in assessing teaching skill, but do expect that residents take an active role in teaching. A resident will be assigned the bedside teaching of rotating medical students, and this session will occur weekly on Tuesday afternoon. Every effort is made to provide maximal education during formal rounding with the faculty. There may be opportunities to learn outside of rounds, but not all members of the team will be present due to duty hour regulations, etc. Therefore, team rounds are the “showplace” for teaching, especially teaching at the bedside. 14 It is expected that rounds not conflict with educational conferences. At times rounds must be stopped prematurely, or carried on by the attending without residents so that they may be excused for conference. It is the resident’s responsibility to notify attending physicians that he or she must be excused to attend required conferences. Allied health personnel should be made aware of the conference schedule and asked not to disturb residents with pages unless critical for patient care. These principles hold for all residents on neurology teams, including nonneurology residents. Faculty Mentoring The Program Director will serve as primary mentor to each resident until such time as their career interest becomes defined. At that time, the Program Director will continue to serve in a mentoring capacity, but will help the resident to establish contact with an appropriate primary mentor matched to their career interest. Thereafter it is expected that the resident will meet with the primary mentor on a regular basis as needed to help achieve their career goals. Links of Interest for Neurology Residents  AAN: http://www.aan.com/  ABPN: http://www.abpn.com/  ANA: http://www.aneuroa.org/  ACGME: http://www.acgme.org/  USMLE: http://www.usmle.org/  AMA: http://www.ama-assn.org/ 15 Rotation Schedule Training year PGY1 PGY2 Rotation No. of weeks Neurology 4 weeks Neurosurgery 4 weeks Psychiatry 4 weeks Geriatrics 4 weeks Gen. Med. Wards 16 weeks Emergency Med. / Vacation 8 weeks Cardiology 4 weeks Intensive Care 4 weeks Night Float 4 weeks Stroke 8-12 weeks General 8-12 weeks Pediatrics 8-12 weeks Night float 2-4 weeks Epilepsy 8-12 weeks Neuromuscular 2 weeks Specialty Clinics 2-4 weeks 16 Training year PGY3 PGY4 Rotation No. of weeks Stroke 4-8 weeks General 4-8 weeks Consult 4-8 weeks Pediatric 4-8 weeks Epilepsy 4-8 weeks Night float 6 weeks Neuromuscular 6 weeks Electives 5-6 weeks Ward Senior 12 weeks Consults 12 weeks Night float 6 weeks Electives / Vacation 22 weeks Notes The above rotation schedule is typical, but there may be minor changes from year-to-year. Further, the schedule can be modified at any time by the Chairman or Residency Director to meet service requirements or catastrophic emergencies. The training requirements mandated by the ACGME will be maintained at all times. 17 Call Schedule The University of Wisconsin Neurology Residency Program uses a night-float call system to help meet the requirements of the ACGME of resident work hour restrictions. Residents may not spend more than 2 consecutive weeks on night float, and no more than 6 weeks total per academic year. The following system is in place: Type of Call Time Period Daytime Call 8am – 4pm (3pm on Fridays) Short Call 4pm – 8pm Monday-Thursday Night Float 8pm – 8am Sunday-Thursday Friday Call Friday 3pm – Saturday 8am Saturday Call Saturday 8am – Sunday 8am Sunday Call Sunday 8am – 8pm All residents share in short call, with progressively fewer calls each training year. Friday and Saturday call are shared by the PG2 and PG3 residents. A PG4 resident is always available as telephone backup to help out with difficult patient evaluations and if the demands of the service exceed the capability of the on-call resident. Each resident is guaranteed 1 day off in 7, and typically 2 of 4 weekends free from any duty requirement. Important Notes Regarding Call  This is a team effort designed to provide the best possible care for our patients as we develop the clinical skills in the next generation of doctors. You should never feel out of your depth, as there is always more experienced backup—the senior resident, your attending, or even other experts in the department. If you find that you cannot contact your regular supervisor, you may always page the Program Director. Never be afraid to ask for help or to say that you’re not sure how to do something.  If unexpected patient care needs create resident fatigue sufficient to jeopardize patient care, the attending physician should be paged immediately. The attending will then be responsible for arranging or providing patient care. 18 Continuity Clinics Each resident will have an outpatient clinical practice. The residents will provide ongoing care for patients with neurological disease at both the UWHC outpatient clinic facilities and at the VAH outpatient clinic. One half-day per week clinic will alternate weekly between the two facilities. At both locations the residents will work under the direct supervision of an attending neurologist. The clinic organization and explanation of clinical duties are described below. Each resident continuity clinic at the UWHC and VAH will be a general neurology clinic with wide exposure to neurological disease. The UWHC clinics are staffed by Drs. Seeger, Beinlich, Dulli and Gardon. The VAH clinics are staffed by Drs. Liao, Jones, Kotloski and Rutecki. Each resident will have a mix of 1-2 new patients and 2-4 follow up patients per clinic. Both facilities are supplied with adequate clinical space, ophthalmology equipment, and computer and telephone access. Diagnostic equipment required to exam each patient, such as tuning forks, reflex hammers, etc. are the responsibility of each resident. 19 Conference Schedule Up-to-date conference schedules can be found via the following URL. The tables below show the general schedule: http://residents.neurology.wisc.edu/mo_schedule.html Attendance at the following AM conferences is required of all residents, including the night float: Conference Day & Time Morning Report Tuesdays and Fridays at 8am Neuropathology 1st, 3rd, and 5th Wednesdays at 8:30am Neuroradiology 2nd Wednesday at 7:30am Pediatric Neurology Case Conference 4th Wednesdays at 8am Neuromuscular Conference 1st and 3rd Thursdays at 8am Pediatric Neurology Conference 2nd and 4th Thursdays at 8am Attendance at the following PM conferences is required of all residents, except the night float: Conference Day & Time Stroke Conference Mondays at noon Residents’ Meeting 1st Tuesday at noon Book Club Wednesdays at noon Chairman’s Rounds Thursdays at noon Epilepsy Conference Fridays at noon Grand Rounds Fridays at 2:30pm Journal Club Monthly (at a faculty member’s house) 20 Evaluations Introduction Evaluation of the residents’ progress toward competence as independently practicing neurologists is an extremely important component of residency training. This is accomplished in a variety of ways as described below. Formative Evaluations Formative evaluations are those performed in the midst of training in order to provide real-time feedback that can be used to improve one’s performance while still on a rotation. Residents will be evaluated by multiple people throughout the academic year. Evaluators may include faculty, nursing staff, patients, resident colleagues, and medical students. In turn, the resident will evaluate faculty and resident colleagues with whom they worked. All evaluations are distributed and completed electronically using the Med Hub system. Evaluations will be sent to appropriate persons by email for electronic completion at the end of each rotation. Residents will have the opportunity to review and comment on these evaluations at least during each semi-annual review with the program director; ad hoc meetings with the program director can be arranged as well. Chair Rounds Chair Rounds are held each Thursday at 12:00pm. The purpose of this educational exercise is to practice, under the expert guidance of our chair and without the time pressure of a busy clinical service, the essential task of history-taking and examination of patients with neurological diseases. Chair rounds also serve as a venue for the clinical skills (NEX) exams, which have replaced the oral board examination previously needed for ABPN certification. Core competencies of Patient Care, Professionalism, and Interpersonal and Communication Skills are emphasized. Semi-Annual Evaluation At the end of a six month block, the resident will be asked to perform a self-evaluation exercise. This will begin by running reports from Med Hub. Other reports include duty hours and conference attendance. The resident will review his/her performance on mock oral exams and the in-service (RITE) exam if relevant to the time period of the evaluation. These data are used for completion of the “Resident Six Month Evaluation Form”. The resident must complete short answers with regard to their assessed strengths and weaknesses, short- 21 and long-term educational goals, career goals, improvement project progress, research, honors/awards, etc. The resident then schedules an appointment to meet with the Residency Program Director for the Semi-Annual Review. The printed reports and Six Month Evaluation Form are reviewed together, and then the Program Director adds summary comments including pertinent details of the discussion held during the review, a written summary evaluation of performance, and future plans as discussed during the review. When possible, the resident will be offered constructive criticism for improvement of his/her performance including suggestions for extra reading or clinical experience via elective rotations. RITE Exams Each year in the spring each resident will take the Residency In-service Training Exam (RITE or In-service exam). This day-long test is a self-assessment exercise. Time off from clinical duties and call is provided for the residents in order to take the examination. Additional in-service exam sponsored by the AANEM (to assess learning in the area of neuromuscular diseases and physiology) will be offered. Several weeks after each exam is completed, a detailed scoring sheet is provided along with an assessment of where each resident stands compared to peers across the country. This exam primarily measures Medical Knowledge. The detailed scoring sheet provides sub scores for each subspecialty area of neurology, so that residents can make an educational plan for future learning directed towards areas in which their knowledge is insufficient. The exam results are reviewed in the Semi-Annual evaluation with the program director, but are not used for decisions regarding promotion or graduation. NEX Exams In preparation for the American Board of Psychiatry and Neurology certifying exam, all residents are required to pass 5 clinical skills exams known as NEX Exams. The exams are unique patients unknown to the resident that come from the following categories: Adult Ambulatory, Adult Neurodegenerative, Child Ambulatory, Neuromuscular, and Critical Care. The exams will be conducted by active faculty who are board-certified by the ABPN. These exams generally occur during the PG3 and PG4 years of training. Final (Summative) Evaluation In addition to the typical six-month evaluation for the final six months of training, an additional form is completed by the Program Director attesting that the resident has “demonstrated sufficient competence to enter practice without direct supervision”. All reports, evaluations, and correspondence will be kept on file in the Department of Neurology. 22 Resident Evaluations of the Program and Faculty Each year, the resident will have the opportunity to evaluate the overall program and the faculty. These are confidential (i.e. the faculty will not know which resident performed which evaluation). In addition, the residents as a group meet on an annual basis to review the program, which results in a report written by the chief resident. These evaluations are reviewed by the Program Evaluation Committee, which also reviews:  Written comments from the faculty  The most recent report of the GMEOC  The most recent communication from ACGME  The summary report of the most recent ACGME resident survey  Resident performance and outcome assessment  Performance of program graduates on the certification examination If deficiencies are found, the group prepares an explicit plan of action, which is then approved by those present and documented in the minutes of the meeting. There are multiple other opportunities for the residents to provide feedback about the program. The residents meet as a group with the Program Director each month to discuss a variety of topics pertinent to the residency. Each individual resident’s semi-annual meeting with the Program Director provides another such opportunity, and the final such meeting with the outgoing senior residents provides perhaps the best opportunity for graduating residents to share their thoughts on the program with the Program Director. 23 Promotion to the Next PGY Level The Clinical Competency Committee will review the performance of each resident at mid-year and year-end. The committee will review all available materials regarding resident performance, and will determine which of the following actions will be taken for each resident:  Promotion to the next PGY level or graduation  Promotion to the next PGY level contingent upon remediation  Remediation without promotion  Contract non-renewal If remediation is necessary, a faculty mentor will be appointed to work with the resident. A remediation plan will be created by the Program Director and the mentor. The mentor will work through the remediation plan with the resident over a prescribed period of time, and regular progress evaluations will be performed. If remediation, contract non-renewal, or termination is necessary, a formal process will be initiated with the cooperation and involvement of the GME Office to ensure that the resident is given adequate opportunity for remediation and given due process. 24 Grievance Policy In the unlikely event that a resident has grievance related to his or her service as a resident, the following policy will be in effect. Please note that UWHC maintains separate policies titled “Resident Grievances related to Employment Concerns” and “Evaluation, Discipline, Promotion, Non-Renewal or Dismissal of Residents”. See sections VI and VII of the UWHC Appointment Information document included appended herein (Appendix 1). The Neurology Residency Program will follow these policies. Department of Neurology Grievance Process Resident grievances may be filed in writing with the Program Director or the Chair of the Department. The Program Director will meet with the resident regarding the grievance within 5 working days to review the grievance. The Program Director will then reply in writing to the resident within 3 working days of the meeting. If the resident is not satisfied with the written response to the grievance, the resident may petition to have the grievance reviewed by other faculty members. The Program Director will then appoint an ad-hoc Grievance Committee to review the grievance. This committee will meet and issue a written reply within 10 working days to the resident. If the resident is dissatisfied with the response to the grievance, he/she may appeal the response to the Department Chair. Within 10 business days, the Chair will issue the final written response to the grievance. If the resident is not satisfied with the response, he or she may file an appeal at the institutional level in accordance with the above noted policies. 25 Moonlighting Policy The Department of Neurology neither encourages nor discourages moonlighting. If a resident chooses to engage in moonlighting, the University of Wisconsin GME institutional policy must be followed. For full details, please refer to this policy as well as the ACGME’s statement about moonlighting. Please note the following:  Residents wishing to participate in moonlighting activities must submit a request in writing to the program director. The program director or designee will evaluate all requests on an individual basis.  Approval of any request shall be for no longer than one program year.  The resident is asked to regularly report the number of hours and the nature of the work in moonlighting experiences to the program coordinator.  The program administration will monitor resident performance to assure that factors such as resident fatigue are not contributing to diminished learning or performance, or detracting from patient safety. Moonlighting permission may be revoked during the course of the year if it is determined by the program director that the moonlighting activity is interfering with the resident’s training program in any way.  It is the resident’s responsibility to obtain a state medical license as necessary.  The professional liability insurance (malpractice) coverage provided for residents by UWHC does not extend to moonlighting activities. 26 Physician Impairment and Resources Sleep and Duty hours It has been recognized that sleep deprivation leads to impaired performance on cognitive tasks. Thus, when physicians are sleep deprived, they are at higher risk for committing medical errors and place their patients at risk. Furthermore, sleep deprivation may put the resident at personal risk, since fatigue is associated with increased rates of motor vehicle accidents. The ACGME has created a mandatory set of duty hour regulations designed to reduce sleep deprivation and fatigue among physicians in training. Full (100%) compliance with these regulations is expected of our neurology residents. A resident must take personal responsibility for tracking their duty hours, and must notify their current attending or program administrators immediately when any violation is imminent. Residents will undergo yearly education about the importance of sleep issues by reviewing the SAFER program. Finally, residents must know that there are ways of notifying the UW GME Office and/or the ACGME about potential work hour violations. Within our own department, it is expected that the Program Director be notified so that appropriate back-up systems can be implemented to prevent work hour violations—the Program Director will guarantee that there are no ramifications for notification. Physician Impairment/Confidential Counseling Confidential counseling, support and assistance with issues such as psychological, marital, legal, and financial problems are available to all residents and their immediate family, at no cost, through the Resident Assistance Program. This program is also available to assist residents with issues of impairment including substance abuse, mental disorders and physical disabilities. Information is available in the UW GME Office. The residency program director supports and counsels residents at the six-month reviews and on an as-needed basis. Residents may seek help from the program director, program coordinator, mentor, and/or chief resident. Often the program director works with GME staff to provide the necessary help and referrals. 27 Part II - Specific Goals and Objectives The ACGME Core Competencies Introduction It is the mission of our training program to ensure that our graduates have demonstrated competency in the six core areas as designated by the ACGGME. It is the goal of our program to develop life-long self-evaluation and self-improvement skill. To accomplish these goals, the resident’s progress toward competency throughout their three years of neurology training will be evaluated both by faculty, program director, and by the resident. At the time of each 6-month evaluation with the program director, the resident will formulate an action plan to move towards competency and proficiency in the following areas:       Patient Care Medical Knowledge Interpersonal Communication Professionalism Practice-Based Learning and Improvement Systems-Based Practice. Patient Care Neurology residents must be able to provide scientifically based, comprehensive, and effective diagnosis and management for patients with neurologic disease. The resident is expected to progress to full clinical competence as a neurologist during the three year training program. Clinical skills include the ability to perform a complete history and physical examination, and generate a rational differential diagnosis, workup, and management plan. Technical skills will include the ability to identify and describe abnormalities on neuro-imaging studies, the ability to perform LPs and EMGs, and the ability to appropriately interpret the results of imaging, EMG, EEG, LP, etc. in the context of patient care. Expectations will vary by year of training, as residents will develop competence at different rates. Medical Knowledge The resident is expected to develop an extensive, detailed body of knowledge regarding the neurosciences, neuroanatomy, and clinical neurology. It is expected that this knowledge be demonstrated and applied to patient care. Knowledge will be gained via didactic teaching 28 (required and non-required conferences, educational conferences, national meetings) and by independent study and reading. Expectations will again vary by year of training, but certain standards of knowledge are required for promotion. The resident must continually assess areas of strength and weakness so as to properly focus further learning (see Practice-Based Learning and Imrovement below). Interpersonal and Communication Skills Excellent physicians communicate clearly and succinctly with patients, families, other physicians, and all other allied health staff. The ability to successfully interact with others during routine work time as well as during times of stress is crucial for optimal patient care. This includes maintaining accurate, timely, and legible medical records. Neurologists must also be able to provide genetic counseling and palliative care when appropriate. All patient-related communication must remain within the guidelines of HIPAA rules and regulations. Professionalism It is the expectation of our training program that neurology residents will behave in a professional manner at all times in which they represent the University of Wisconsin Department of Neurology, the University of Wisconsin Hospital and Clinics, and the William S. Middleton VA Hospital. Unprofessional behavior will be grounds for dismissal. Six essential elements of professionalism:  Be present—the resident must be in attendance for all patient care duties and for all didactic teaching. If illness or other circumstances prevent attendance, the appropriate persons should be notified. 70% attendance at required conferences will be required for promotion.  Be presentable—the resident will dress in a manner that signifies professionalism. For example, male residents must wear ties and female residents should wear similarly appropriate professional clothing during regular day time duty hours on days when patient contact will occur. White coats will be provided by the GME office and residents should wear a clean coat at all times. Tattoos and body piercings are not to be displayed, with the exception of ear piercing or tattoos/piercings with cultural or religious significance. The wearing of scrubs is prohibited except after normal business hours and immediately post-call.  Be punctual—residents should strive to arrive on time for all clinical duties and didactic sessions. Clinical imperatives often cause unavoidable tardiness, but professionalism demands that the appropriate people be notified whenever practical (i.e. the resident might call ahead to clinic and ask the MA to notify all patients that he/she will be arriving late). Furthermore, it is appropriate to apologize to those who are inconvenienced by tardiness—patients are usually very understanding of our clinical demands, but simply request that we keep them informed. 29  Be prepared—the resident should accomplish all assigned tasks related to clinical patient care within the limitations of the ACGME duty hour regulations (see below). Paperwork and dictations must be completed in a timely fashion.  Be positive (and respectful)—the resident shall strive to be respectful of patients, staff, and colleagues at all times. At times, every person experiences emotions such as anger and frustration, which must be successfully managed in interactions with patients, families, and other health care professionals.  Be proficient—the resident will be expected to consistently demonstrate appropriate knowledge and procedural skills for his/her level of training. The resident must understand his/her limitations and know when to ask for help. Included in the concept of professionalism are the virtues of integrity, honesty, and compassion. The resident must be committed to life-long learning habits and continuing medical education. The resident will comply with the regulations set forth by the University of Wisconsin Hospital and Clinics including all training sites. Finally, the resident must exhibit respect for all persons regardless of their cultural, ethnic, religious, and socioeconomic background. No one is perfect, and all of us will have moments of unprofessional behavior. It is the expectation of the University of Wisconsin Department Of Neurology that any breaches in professionalism that occur are met with remorse on the part of the resident. Furthermore, it is expected that the resident will use such breaches as lessons to prevent similar problems in the future. Failure to comply with the above standards of professionalism shall result in a resident entering remediation. Consistent non-compliance with the above standards, or failure to remediate, shall result in dismissal. Practice-Based Learning and Improvement: Neurology residents must be able to investigate and evaluate their patient care practices, and appraise and assimilate scientific evidence to improve their patient care practices. Residents should participate in the collection and analysis of patient data via patient logs and as part of quality assurance projects. Systems-Based Practice Neurology residents must be trained to recognize that they are part of a large and intricate health system that has implications for their ability to care for patients and impacts upon their patients’ human needs and financial resources. This awareness of the context in which we practice as neurologists requires competence in the following areas: 30  Recognize the limitation of resources for health care and demonstrate the ability to act as an advocate for patients within their social and financial constraints.  Willingness to participate in utilization review and comply with documentation requirements in medical records Develop awareness of practice guidelines and utilize them as appropriate.   Develop awareness of local and national resources that may enhance our patients’ quality of life in dealing with chronic neurologic diseases.  Develop the ability to lead health care teams and delegate authority in a responsible and appropriate manner.  Develop skills for the practice of ambulatory medicine (time management, clinic scheduling, effective communication with referring physicians).  Utilization of consultants and referrals for optimal management of patients with complicated medical illnesses.  Demonstrate awareness of the importance of cross-coverage and accurate medical data transfer in caring for patients with neurologic illnesses. 31 Overall Goals and Objectives Overall Goal The overall goal of our training program is to develop superb clinical neurologists. Clinical Training Objectives: At the end of the training program, the resident will have developed…  Competence in the comprehensive diagnosis and management of all forms of neurological disease (Patient Care);  A rich knowledge base in both clinical and basic neuroscience, as well as the fundamentals of internal medicine (Medical Knowledge);  Competence in obtaining an appropriate medical history (including sensitive issues such as sexual history) in a professional and humane manner (Interpersonal and Communication Skills, Professionalism);  Competence in communicating diagnosis and treatment plans, and competence in communicating potentially sensitive information such as terminal prognosis (Interpersonal and Communication Skills, Professionalism);  Competence in communicating succinctly and clearly with other healthcare professionals, with a proper respect for the principles of HIPAA regulations (Interpersonal and Communication Skills, Professionalism);  Skill in self-assessment and self-improvement (Practice-Based Learning and Improvement); and  Skill in practice assessment, as well as both practice- and systems improvement, to enhance quality of care and improve patient safety (Practice-Based Learning and Improvement, Systems-Based Practice). Specific Academic/Research Goals: At the end of the training program, the resident will have developed…  A scholarly approach to the practice of clinical neurology, including the incorporation of evidence-based medicine into clinical decision-making (Practice Based Learning and Improvement);  Basic knowledge of clinical trial design and statistical testing, as well as the ability to utilize this knowledge for critical interpretation of medical literature (Medical Knowledge, Practice-Based Learning and Improvement);  First-hand experience at the process of clinical research, ideally via participation in a clinical or translational research project (or even by assisting with patient enrollment into an ongoing project) (Interpersonal and Communication Skills, Professionalism, PracticeBased Learning and Improvement); and 32  First-hand experience at the process of data presentation and peer-review, ideally via submission of one abstract or manuscript during the course of training (Interpersonal and Communication Skills, Medical Knowledge, Professionalism). Goals by Year of Training We expect each resident to progress to full clinical competence (within each of the six Core Competencies) during the four year training program. The following are the expected goals by year of training, documenting that increasing patient responsibility and professional maturation are expected over time. PGY-1 (Preliminary Internal Medicine):  The resident will develop an adequate knowledge base in internal medicine and attain basic competence in the medical care of patients.  The resident will provide medical care for patients within the confines of the team, but will gain skill and develop confidence in independent decision making related to medical issues (under supervision of senior residents and supervisory faculty).  The resident will develop skill at interpersonal communication and will develop a foundation for a professional and ethical practice of medicine.  The resident will begin to learn how the health care system functions.  The resident will learn basic skills in self-evaluation and practice-improvement. PGY-2 (Neurology):  The resident will develop an adequate knowledge base in neurology and the neurosciences.  The resident will attain basic competence in the medical care of neurology patients.  The resident will provide medical and neurological care for patients within the confines of the team, and will gain skill and develop confidence in independent decision making related to both medical and neurological issues (under supervision of senior residents and supervisory faculty).  The resident will continue to develop skill at interpersonal communication and begin developing basic teaching skills.  The resident will solidify his/her foundation of the professional and ethical practice of medicine.  The resident will continue to learn how the health care system functions, especially as relevant to the patient with neurologic disease. 33 PGY-3 (Neurology):  The resident will develop competence in basic neurologic knowledge and will begin to attain a more sophisticated and deep knowledge base in neurology and the neurosciences.  The resident will have developed basic competence in the medical care of neurology patients, and will begin to work on finer points such as improving patient safety, costeffectiveness of care, and transitioning the patient to outpatient care. This will come as the resident transitions from a junior role to a senior role as a team leader.  The resident is expected to supervise the junior residents and both create and direct the care plan for the patient (under the guidance of the supervisory faculty member).  The resident will continue to master skill at interpersonal communication and will not only demonstrate professional and ethical practice of medicine, but help more junior residents to foster their professionalism.  The resident will continue to master teaching skills.  The resident will learn how he/she can best manipulate the health care system for the welfare of his/her patients. PGY-4 (Neurology):  The resident will develop an extensive knowledge base in neurology and the neurosciences that is both broad and deep.  The resident will have developed competence at using the medical literature to guide patient care decisions (evidence based medicine).  The resident will demonstrate competence in all facets of the care provided to neurology patients and will demonstrate that he/she is prepared for practice after graduation. To this end, the resident should direct all care and practice independent decision making (under the guidance of the supervisory faculty member).  The resident will demonstrate competence at clear and succinct interpersonal communication with colleagues, patients, and families.  The resident will demonstrate skill at teaching medical professionals and non-medical persons including patients and families.  The resident will demonstrate Professionalism at all times and will demonstrate skill at leading others.  The resident will demonstrate self-evaluation skills, continuous desire for selfImprovement, and a life-long learning plan.  The resident will have competence at understanding the health care system, and will be able to work efficiently and effectively within it for the benefit of his/her patients. 34 UW and VA General Neurology Service Introduction The UW Department of Neurology has the duty to provide the best possible care for the patients served on the wards at the UW and VA Hospitals. Patients admitted for evaluation and treatment of neurological problems, require inpatient care that is comprehensive, cost-effective, and compassionate. This rotation typically occurs in the PG2 and PG3 years for a total of 4 months. Goals The resident on the General Neurology Service will develop competence at inpatient and intensive-care management for a variety of neurological conditions. The resident will also develop skills at teaching and supervising medical students. In addition, the resident will respond to consultation requests from the UW-ER and the VA-UC and develop skills at triaging patients to the general or one of subspecialty services. Objectives Patient Care: The resident should be able to…  Independently obtain an accurate and comprehensive medical history  Independently obtain an accurate and comprehensive general and neurological examination  Efficiently admit and discharge patients Medical knowledge: The resident should be able to…  Utilize a systematic approach to the diagnosis of neurological disease, based on the skills of localizing neurological lesions, constructing a sound differential diagnosis, and judicious use of diagnostic tests and treatments.  Know how to access written materials including clinical practice guidelines related to patients under his or her care.  Impart basic neurology knowledge to rotating medical students and other residents. Interpersonal and Communication Skills: The resident will…  Demonstrate skills in effective communication (both written and verbal) with patients their families, colleagues and co-workers in order to better treat neurological disease.  Become proficient in communication with allied health staff in day-to day contacts and during multidisciplinary discharge planning rounds.  Responsible for teaching basic neurological skills and knowledge to the rotating medical students and residents. 35 Professionalism: Residents will…  Well-represent the UW Department of Neurology with their actions and communications. The highest standards of professionalism must be maintained at all times, especially in interactions with patients and their families, with other physicians, and with allied health staff.  Be responsible for tracking duty hours Practice-Based Learning and Improvement: The resident will…  Be responsible for tracking patients and procedures performed via the electronic patient/procedure log. These data can be used by the resident in the 6-month selfevaluation to determine where further patient experience is needed. Systems-Based Practice: The ward resident will…  Learn to interact with allied health services including nursing staff, PT, OT, Speech Pathology, Dietary, Social Work, and PMR/Rehabilitation in caring for the patient and planning post-hospital care.  Learn the most efficient manner for completing the necessary workup and the coordination of neurological care in the outpatient setting will be developed. Schedule The resident of the General Neurology Service will pre-round daily M-F and attend any morning conference. The resident will then attend and direct the multi-disciplinary discharge conference at the UWHC at 9:00AM daily. The resident will then attend Attending rounds, which should finish by 11:00 AM. The resident will attend his or her weekly continuity clinic each week, and provide call coverage to the UW and VA Emergency Rooms. The resident will participate in the normal neurology call schedule. Duty Hours The estimated hours per week is 60 hours. Residents are required to document duty hours and notify the attending physician and program director if he or she is in danger of exceeding the ACGME duty hour limits. Evaluation 36 At the end of the rotation, the supervising faculty will submit an electronic formative evaluation which will be reviewed by the program director with the resident at the semi-annual summative evaluation. Suggested Reading The resident is expected to read in a directed fashion about patients they are caring for, as guided by supervisory faculty members.  Selected chapters from Neurology in Clinical Practice, 3rd edition; Bradley, Daroff, Fenichel, and Marsden eds; © 2000;  Selected chapters from Principles of Neurology (Adams, Victor, Ropper, eds.  The Clinical Practice of Critical Care Neurology; Widjicks; © 1997;  Localization in Clinical Neurology, 4th edition; Brazis, Masdeu, and Biller eds; © 2001;  Current Psychotherapeutic Drugs, Klein and Rowland;  Neurological Differential Diagnosis, 2nd Edition (Patten, © 1996);  Manter and Gatz’s Essentials of Clinical Neuroanatomy and Neurophysiology, 9th Edition (Gilman, ed., © 1992); or  Selected readings as directed by attending physicians. 37 UW and VA Stroke Service Introduction This is a month-long rotation on the inpatient stroke service at the UW Hospital and the William S. Middleton Memorial VA Hospital. Residents rotate on this service during their PGY1, PGY 2 and PGY 3 years. The rotation emphasizes inpatient care of acute stroke patients. A small number of consultations for stroke patients on other services is also provided. Outpatient experiences are available, but optional. The inpatient stroke team consists of an attending neurologist who specializes in cerebrovascular disorders (Drs. Bradbury, Chacon, Jensen, and Sattin), the adult neurology resident rotating on service, several medical students, and the stroke program coordinator, Chris Whelley, RN. Occasionally there is an internal medicine resident pursuing an elective rotation. Pharmacy interns and other observers sometimes rotate on the service as well. Following are the goals and objectives of this rotation as they relate to the overall training program in neurology and the ACGME-defined competencies. Please refer to the separate stroke service orientation manual for more comprehensive and specific information. Goals PGY 1 Rotator:  Perform the NIH Stroke Scale (NIHSS) independently  Understand indications and contraindications to IV tPA use  Offer basic interpretation of acute head CT studies  Direct screening and management of stroke risk factors PGY 2 Rotator:  Independently evaluate acute stroke patients for tPA candidacy  Interpret, with guidance, advanced neuroimaging studies such as CTA and MRI/A  Make, under direct supervision, management decisions regarding intra-arterial therapies  Understand principles of post-thrombolysis care  Diagnose and manage a variety of specific cerebrovascular conditions including intracerebral hemorrhage, arterial dissection, and venous sinus thrombosis  Demonstrate knowledge of general inpatient management of stroke patients  Implement evidence-based secondary stroke prevention strategies 38  Be familiar with basic concepts in stroke rehabilitation  Be familiar with current research priorities in cerebrovascular diseases PGY 3 Rotator:  Should be well versed in above topics  Independently interpret advanced neuroimaging  Make, with indirect supervision, management decisions regarding intra-arterial therapies Objectives Patient Care: Residents will . . .  Develop their skills in obtaining accurate historical information from patients and caregivers, with particular emphasis on ascertaining the time of stroke onset.  Be able to clearly communicate to patients and families the risks, benefits, and alternatives to intravenous and intra-arterial thrombolysis.  Learn to discuss the mechanisms of stroke and hospital course with patients.  Be able to counsel patients on risk factor modification and long term outcomes. Medical Knowledge: Residents will . . .  Learn how to classify stroke into ischemic vs. hemorrhagic and their various subtypes, and about the vascular pathologies underlying them.  Learn basic concepts of cerebral hemodynamics, neuroimaging, and neurointensive care.  Develop their skills in lesion localization and the formulation of robust differential diagnoses that go beyond cerebral infarction.  Become proficient in the interpretation of neuroimaging studies including CT and MRI, and the use of such information for clinical decision making.  Learn about stroke risk factors and how these influence stroke classification and treatment.  Learn the evidence supporting acute and preventive stroke treatments including tissue plasminogen activator (tPA), antiplatelet agents, anticoagulants, anti-hypertensives, and HMG-CoA reductase inhibitors.  Gain knowledge on laboratory and diagnostic technologies and their appropriate uses. 39 Practice-Based Learning and Improvement: Residents will . . .  Systematically review recent stroke cases during dedicated conferences and use the feedback generated to improve upon subsequent patients’ care.  Learn to critically appraise the stroke literature, with emphasis on clinical trial design and stroke outcome measures.  Become familiar with authoritative sources of stroke practice guidance, such as American Stroke Association scientific statements, and how to access these resources on-line.  Maintain a patient log for tracking number and various diagnosis of patients seen during the rotation to ensure an adequate educational experience. Interpersonal and Communication Skills: Residents will . . .  Become skillful listeners, and develop specific proficiency in communicating with aphasic stroke patients through non-verbal means.  Specifically learning to ascertain a precise time of stroke symptom onset or time the stroke patient was last known well.  Learn to communicate rapidly and efficiently with other team members in order to ensure that acute stroke therapies can be provided in a timely manner.  Learn to clearly communicate neurological assessments and plans to patients, their families, and members of the multidisciplinary care team.  Become proficient in discussing end of life care. Professionalism: Residents will . . .  Demonstrate sensitivity to the personal, cultural, and religious values that influence patients’ medical decisions in the context of stroke, and a compassionate approach to end of life care.  Adhere to ethical principles by respecting confidentiality of medical information. Systems-Based Practice: Residents will . . .  Learn ethical, regulatory, and legal aspects of stroke care, including the difference between standard and investigational stroke treatments. 40  Demonstrate the ability to work in a multidisciplinary fashion with nurses, case managers, social workers, therapists, primary care physicians, and the various medical and surgical specialties related to stroke.  Learn how to triage patients and allocate resources such as intensive care unit beds and MRI scans so as to provide high quality, cost-effective care.  Become familiar with clinical practice guidelines and participate in the creation and review of stroke program policies and procedures relevant to patient care. Schedule Interdisciplinary rounds begin at 0900 each weekday except for Wednesdays, when they begin at 0930 due to the neuropathology conferences. These take place in the work room next to the D6/4 nursing station. Work rounds follow thereafter. When on backup stroke call, Drs. Sattin and Chacon have UW clinics on Monday and Wednesday afternoons and VA clinics on Tuesday and Thursday afternoons. Attendance at these clinics is welcomed but not required. Stroke conference occurs each Monday at noon in the clinic conference room, H6/492. Neurovascular conference occurs on the 2nd and 4th Mondays of each month at 1600 in the Juhl conference room, 4th floor near the Atrium elevators. It is an interdisciplinary working conference mostly involving complex aneurysm and AVM cases. Neurosurgery and interventional neuroradiology run the conference, with input from the stroke service on selected cases. Duty Hours The number of work hours per week is estimated to be 60-70. Residents are excused from stroke service duties during their continuity clinics, during which time their responsibilities will be covered by the general neurology or neuromuscular resident. Residents will have at least one day off each week, free from any and all clinical responsibilities. The resident will be responsible for tracking duty hours and reporting any risk of violation immediately to their attending physician, the stroke program medical director (Dr. Sattin), or the residency program director (Dr. Stanek). These physicians will be responsible for immediately remedying the situation. Evaluation The residents will be provided feedback on an ongoing basis during the rotation. At the conclusion of the rotation, they will be formally evaluated using the on-line evaluation tool. 41 Evaluation of the rotation is also an important priority. Residents are encouraged to bring questions and concerns to the stroke program’s medical director, Dr. Sattin. Suggested Reading  American stroke association guidelines: http://my.americanheart.org/professional/guidelines.jsp  Chapters 23 (Brainstem Syndromes), 38 (Neuroimaging), and 57 (Vascular Diseases of the Nervous System); Neurology in Clinical Practice, 3rd edition; Bradley, Daroff, Fenichel, and Marsden eds; © 2000.  Chapter 20 (Vascular Syndromes of the Cerebrum); Localization in Clinical Neurology, 3rd edition; Brazis, Masdeu, and Biller eds; © 1996.  Stroke: A Clinical Approach, 2nd edition, by Louis Caplan; © 1993.  Selected patient-specific reading. 42 UW and VA Hospital Consult Service Introduction One of the primary clinical responsibilities of a practicing neurologist is to serve as a consultant for patients with a variety of neurological problems in the hospital setting. Consults may be in regards to primary neurological diseases, neurological complications of systemic diseases, or the neurological complications associated with medical and surgical therapies. While the resident should focus on the most common reasons for consultation requests, special emphasis will be placed on evaluations of the altered mental state, especially stupor and coma, and brain death. This rotation is 3 to 4 months in duration, and occurs during the PG4 year, for senior residents who have gained extensive experience in evaluating and treating a variety of neurological conditions and emergencies. Goals At the end of this rotation, the resident should be able to:  Serve as independent consultant for the spectrum of neurological problems, especially altered mental status, common complications of medical procedures, and common complications of anesthesia and surgery  Lead or participate in the consult service in an efficient and effective manner, providing excellent medical care to our patients and excellent teaching to our medical students  Demonstrate professionalism and communication skills appropriate for a neurological consultant Objectives Patient Care: The residents will…  Develop skills in bedside evaluation of hospitalized patients.  Develop skills in discussing end-of-life issues with families of patients seen in consultation.  Demonstrate competence of evaluation of patients in coma and brain-death examinations Medical knowledge: The resident will…  Read selected works as listed below.  Learn and understand the best medical evidence for determining prognosis of outcomes in patients with devastating neurological injuries.  Learn the definition of brain death and apply it as appropriate. 43  Be expected to keep up on background reading, with reading to occur in a patientspecific fashion. Appropriate use of the primary literature and review articles is expected.  Demonstrate extent of medical knowledge by teaching basic neurology knowledge to rotating medical students. Interpersonal and Communication Skills: The resident will…  Present patients to faculty succinctly and completely  Communicate clearly with the service who requested the consult via timely oral and written communication that is concise. Practice-Based Learning and Improvement: The resident will…  Be responsible for tracking consults, the diagnoses involved, and be entered into the web-based Case Log. Professionalism: The resident will…  Promptly answer calls for consultation requests.  Dress in appropriate attire and present himself or herself in a professional manner at all times.  Be responsible for tracking duty hours and reporting them to the supervisory faculty Systems-Based Practice: The resident will…  Learn the constraints of acting as consultant as opposed to supervising inpatient care.  Develop skill in identifying the most efficient manner for completing the necessary workup and the coordination of follow up neurological care in the outpatient setting (if needed). Schedule The resident will be in charge of the Consult Service each weekday from 8:00 AM to 5:00 PM. Attending teaching rounds with the staff attending will occur daily at 3:00PM, or at another mutually agreed upon time. The resident is also expected to attend his or her own continuity clinic each week. 44 Duty Hours There are no additional call responsibilities beyond the normal neurology call schedule during this rotation. The total hours per week is expected to be 60. Residents will adhere to all duty hours restrictions required by ACGME and will log duty hours electronically. The resident is expected to notify the staff attending and the program director if he or she is jeopardy of violating duty hour restrictions. Evaluation  Formative feedback should be solicited from the referring service residents and faculty  Electronic evaluations will be submitted by the staff attending(s) on the consult service  It is recommended that the Critical Care clinical skills exercise (NEX) be done during the time spent on the consult service Suggested Reading  The Diagnosis of Stupor and Coma, 4th edition; Plum and Posner, 2008  Selected chapters (relevant to consults seen) from Neurology and General Medicine, 3rd edition; Aminoff ed., © 2001  Selected chapters (relevant to consults seen) from Iatrogenic Neurology, Biller, ed; © 1998  Selected chapters (relevant to consults seen) from Hospitalist Neurology, Samuels, ed.; © 1999  Selected readings as recommended by the consult attending. 45 Epilepsy Rotation Introduction The UW Department of Neurology strives to provide the best possible care for patients with epileptic disorders, both at the UW and VA Hospitals. Each resident will rotate on this service for 4 months during the PG2 and PG3 years, with additional elective time available for PG4 residents who are so interested. The rotation encompasses both inpatient and outpatient care. Goals This rotation has two separate but interrelated goals. First, each resident on the epilepsy service will develop the skills necessary to evaluate, treat, and counsel patients and families with epileptic disorders. Secondly, each resident will learn the principles of electroencephalography and develop confidence in correctly interpreting EEG studies, including long-term monitoring studies of patients in the epilepsy monitoring and intensive care units. As the resident gains knowledge and clinical skills, responsibilities will be increased at the discretion of the attending physician. Independence is encouraged, but at all times each resident will be appropriately supervised by the faculty. Teaching responsibilities are numerous and will include presentations at morning report as well as medical student teaching. Objectives Patient Care: During the first month  Obtain accurate and sufficient histories to characterize seizures and to define risk factors for developing epilepsy  Review AAN practice guidelines and learn to incorporate them into the evaluation and treatment of patients with epilepsy  Demonstrate communication skills to educate patients and families regarding epilepsy diagnosis and treatment  Work with health care professionals (i.e. nursing staff, neurophysiology techologists, ancillary staff) to provide patient-focused care  Attend Epilepsy clinics, admit and manage monitoring patients  Review electrophysiological studies and apply findings to care of patients with epilepsy 46 During the second through fourth months  Formulate patient management plans regarding appropriate diagnostic and therapeutic interventions During all months  Will go to Meriter Hospital and see patients with the attending pediatric neurologist in the neonatal ICU Medical Knowledge 1. Epilepsy During the first month  Explain the recognition and treatment of status epilepticus, a medical emergency  Take a personal initiative in self-education (including perusing recent literature). This includes review of standard texts of EEG interpretation and epilepsy disorders. As includes review of teaching files of normal and abnormal EEGs  Describe the importance of neuroimaging in the evaluation of patients with epilepsy During the second through fourth months  Be able to classify seizure types and epileptic syndromes  Verbalize rational approach to the management of epilepsy including choice of appropriate antiepileptics  List the pharmacokinetics of antiepileptics and mechanisms of action  Explain the utility of epilepsy monitoring and the evaluation of intractable epilepsy, especially the use of surgical treatment of epilepsy  Characterize the unique situation of epilepsy in women of child bearing age  Verbalize the appropriate restrictions including driving, for patients with epilepsy 2. Electroencephalography During the first month 47   Describe the principles of EEG generation and recording Achieve an orderly approach to the interpretation of EEG studies  Identify normal and abnormal EEG patterns During the second through fourth months  Describe the developmental features of EEG from infancy to the elderly  Recognize abnormal EEG findings and correlate EEG findings with clinical epilepsy syndrome and seizure types  Achieve skills in creating and dictating neurophysiology reports  Explain the principles of evoked potential generation including visual, brainstem-auditory, and somatosensory evoked potentials  Correlate video recordings of seizures with EEG tracing  Describe the principles of Wada testing  Dictate at least five EEG studies  Interpret continuous EEG recordings from patients in the epilepsy monitoring and intensive care units. During all months  Review representative neonatal EEG studies with attending pediatric neurologist when at Meriter Hospital Interpersonal and Communication Skills  Develop techniques to obtain accurate history from patients, and gain the patients’ confidence and trust  Create reports that accurately convey EEG findings and relate these findings to the clinical setting  Interact effectively with other members caring for patients including nursing and technical staff  Create clinic and hospital notes that are concise and accurate Professionalism  Show respect, compassion, integrity and ongoing professional development  Verbalize ethical principles with adherence to confidentiality, HIPAA principles, and appropriate informed consent 48  Determine psychosocial issues that complicate care, especially as it relates to the possibility of patient history of physical or sexual abuse and the diagnosis of nonepileptic seizure  Be punctual and appropriately attired  Keep patient logs up-to-date on E-Value Practice-Based Learning and Improvement  Appraise literature to better understand epilepsy syndromes and their etiology and clinical presentation  Assess studies that evaluate treatment options for specific seizure types and epilepsy syndromes  Apply and use the International League Against Epilepsy (ILEA) website that aids in understanding epilepsy syndromes and seizure management. Systems Based Practice  Identify the importance for proper diagnosis and treatment of epilepsy as to the effect of diagnosis on insurability and driving privileges  Assess efficiencies of the UW and VA systems regarding patients referred from other centers, and develop management plans that are effective and not redundant or wasteful of medical resources  Make decisions regarding the cost considerations of choosing appropriate antiepileptic drug therapy  Identify advocacy programs for patients with epilepsy 49 Schedule AM Monday Tuesday Epilepsy Clinic EEG reading with Dr. Rutecki VA Wednesday EEG teaching with Laura Michor Dr. Jones PM Admit monitoring patients Thursday Epilepsy Clinic UW Friday Review monitoring patients Drs Beinlich and Rutecki EEG reading with Dr. Stafstrom EEG review with Dr. Jones EEG reading with Dr. Zawadski Grand Rounds Read EEGs with Dr. Tunnell In addition to above, each resident will attend Morning Report daily and Neuropathology and Neuroradiology Conference on Wednesday mornings. Each resident will attend noon didactic conferences and round on inpatients that are undergoing EEG monitoring. Each resident will go with Dr. Rutecki to the Central Wisconsin Center on the 4th Thursday of the month to see patients. Each resident will go to Meriter Hospital 2 times a month to evaluate neonates in the NICU under the direction of the attending Pediatric Neurologist, and review representative EEGs performed on neonates. Each resident will attend Wada studies when scheduled at the VA on Wednesday AMs. It is also recommended that each resident observe the technical performance of EEG, and attempt to perform a technically satisfactory EEG during each monthly rotation. Duty Hours The estimated number of work hours per week is 45. In addition to service clinics, residents are required to attend his or her continuity clinic that occur one half-day per week. There is no call responsibility other than participating in the regular neurology call schedule. It is the responsibility of each resident to be in constant communication with the supervisory attending and program director regarding duty hours. In the event that any of the ACGME duty hours regulations are in jeopardy of being violated, the attending physician and program director must be notified immediately. Evaluation 50  Review of objectives met at the end of each month long rotation with one epilepsy faculty member  Electronic evaluation via Med Hub by the supervisory attending at the end of each rotation  Semiannual review with the program director Suggested Reading  The Treatment of Epilepsy: Principles and Practice, Wyllie  Spehlmann’s EEG Primer, Fisch and Spehlmann  Evoked Potentials in Clinical Medicine, Chiappa  Selected teaching files and EEG trainings maintained in the EEG laboratory 51 Neuromuscular Medicine & EMG Laboratory Rotation The following describes both the Neuromuscular Medicine rotation and the EMG Laboratory rotation. Two months of Neuromuscular Medicine are required, and occur during the PG2 and PG3 years. The EMG Laboratory rotation is required and occurs during the PG3 or PG4 year. Additional months of Neuromuscular Medicine or EMG Laboratory can be taken as elective during the PG3 and PG4 year. 1. Neuromuscular Clinic Staff: Drs. Barend Lotz and Andrew Waclawik Goals  To provide excellent training in diagnostic evaluation and management of patients with a wide spectrum of neuromuscular diseases  Good coordination of care between the various services involved in the diagnostic evaluation and care of these patients and their primary care provider.  Gradually increasing responsibility in assessment and management for these patients. Objectives Patient Care: Residents will…  Learn the unique skills of the neuromuscular exam to accurately predict disease location and diagnosis. Medical Knowledge: Residents will…  Learn clinical skills necessary to diagnose neuromuscular conditions affecting different stations of the motor unit (anterior horn cell diseases, peripheral neuropathies, neuromuscular transmission disorders, myopathies).  Understand the principles of clinical genetics and genetic counseling applicable to patients with hereditary neuromuscular conditions.  Gain knowledge of laboratory and diagnostic studies and their appropriate uses.  Acquire the knowledge of the most current concepts in therapies applicable to neuromuscular diseases. Interpersonal and Communication Skills: Residents will… 52  Become skillful listeners, and develop specific proficiency in communicating and examining patients with severe disabilities.  Learn to communicate rapidly and efficiently with other team members in order to ensure that appropriate therapies can be provided in a timely manner.  Learn to clearly communicate neurological assessments and plans to patients, their families, and other health providers involved in evaluation and management of patients with neuromuscular disorders. Professionalism: Residents will…  Learn ethical, regulatory, and legal aspects of care, including the difference between standard and investigational treatments.  Demonstrate sensitivity to the personal, cultural, and religious values that influence patients’ medical decisions in the context of the wide spectrum of neuromuscular conditions, including end-of-life issues.  Adhere to ethical principles by respecting confidentiality of medical information. Practice-Based Learning and Improvement: Residents will…  Learn to critically appraise the neuromuscular literature, with emphasis on clinical trial design and outcome measures.  Become familiar with authoritative sources of practice guidance, such as American Association of Electrodiagnostic and Neuromuscular Medicine or American Academy of Neurology, and how to access these resources on-line.  maintain a log for tracking of patients seen in clinic to ensure an adequate educational experience Systems-Based Practice: Residents will…  Demonstrate the ability to work in a multidisciplinary fashion with nurses, case managers, social workers, therapists, primary care physicians, and the various medical and surgical specialties related to neuromuscular diseases.  Understand the clinical utility of different laboratory/diagnostic tests and will implement them in a rational, cost efficient way to provide high quality, cost-effective care. 53 2. Electromyography Laboratory Staff: Drs. Barend Lotz, Andrew Waclawik MD, Brad Beinlich MD, Jenny Liao MD. Technologists: C. Zachman RN, MS (EMG Lab Manager); S Zachman RN The standard didactic training takes place at the UW Hospital, and once a certain degree of expertise has been reached, the residents may arrange additional training at the EMG Laboratory at the VA hospital. At the beginning of the rotation residents will received a UW Electrophysiology Laboratory Manual. Goals  To provide excellent, comprehensive training in electromyography, including advanced techniques.  To understand the clinical utility and limitations of different electrodiagnostic tests in evaluation of patients various neurological disorders.  Gradually increasing responsibility and independence in electrodiagnostic evaluation of patients in the EMG Laboratory. Objectives Patient Care: Residents will…  Develop their skills in various electrodiagnostic techniques including: o standard motor and sensory nerve conduction studies of upper and lower extremities and cranial nerves; o repetitive nerve stimulation techniques; o basic autonomic studies; o standard concentric needle EMG evaluations; o Single Fiber EMG techniques, o laryngeal EMG. Medical Knowledge: Residents will . . .  Learn the neurophysiological basis of EMG and nerve conduction studies  Be able to relate neurophysiological findings to patients’ clinical diseases  Understand the indications for and contraindications to EMG 54 Interpersonal and Communication Skills: Residents will…  Become skillful listeners, and develop specific proficiency in communicating with patients in the EMG Laboratory.  Learn to prepare the EMG test reports and communicate the test results to referring physicians. Professionalism: Residents will…  Learn ethical, regulatory, and legal aspects of electrodiagnostic medicine, including the difference between standard and investigational EMG techniques.  Demonstrate sensitivity to the personal, cultural, and religious values that influence patients’ medical decisions in the context of EMG testing.  Adhere to ethical principles by respecting confidentiality of medical information. Practice-Based Learning and Improvement: Residents will…  Learn to critically appraise the neurophysiological literature, with emphasis on critical assessment of different electrodiagnostic techniques.  Become familiar with authoritative sources of clinical electromyography practice guidance, such as American Association of Electrodiagnostic and Neuromuscular Medicine statements, and how to access these resources on-line.  Maintain a log for tracking of patients seen in EMG Lab to ensure an adequate educational experience. Systems-Based Practice: Residents will …  Demonstrate the ability to work in a multidisciplinary fashion with various medical and surgical specialties that refer patients for electromyographic evaluation. 3. Muscle and Nerve pathology Staff: Drs. Barend Lotz, Shahriar Salamat, Andrew Waclawik. UWHC Neuromuscular Pathology Laboratory Manager: Ms. Jean Mitchell. 55 Goals  To introduce residents to basic concepts of interpretation of muscle and nerve biopsies.  To introduce the residents to the technique of muscle and nerve biopsy (in the operating room, or in the neurology out-patient clinic for needle muscle biopsies).  To understand the clinical utility and limitations of nerve and muscle biopsies in evaluation and management of patients with neuromuscular disorders. Objectives Patient Care / Medical Knowledge: Residents will . . .  Learn the indications and clinical utility of muscle and nerve biopsies  Learn how to select the muscle biopsy site to assure the highest diagnostic yield  Understand the basic principles of muscle and nerve specimen processing (histology, histochemistry, immunostaining, electron microscopy, teased fiber analysis) Residents will be able to incorporate the biopsy results into the clinical decision-making process with regard to diagnosis and management of patients with neuromuscular disorders.   Residents will have an opportunity to assist in muscle and nerve biopsies (in the operating room, or in the neurology out-patient clinic for needle muscle biopsies)  Residents will actively participate in the Tuesday afternoon Muscle and Nerve Pathology/ Neuromuscular case conference. Interpersonal and Communication Skills: Residents will…  Learn the terminology used in muscle and nerve pathology reports.  Learn to prepare the muscle or nerve biopsy reports and communicate the test results to referring physicians. Professionalism: Residents will…  Learn ethical, regulatory, and legal aspects of neuromuscular pathology practice including the difference between standard and investigational neuropathological techniques.  Adhere to ethical principles by respecting confidentiality of medical information. 56 Practice-Based Learning and Improvement:  Residents will learn to critically appraise the neuropathological literature, with emphasis on assessment of different neuropathological techniques in diagnosis of neuromuscular disorders. Systems-Based Practice:  Residents will demonstrate the ability to work in a multidisciplinary fashion with various medical and surgical specialties that refer patients for muscle or nerve biopsies. Schedule (MDA stands for Muscle Dystrophy Association)  Monday Tuesday EMG OR Open muscle / nerve biopsies AM Wednesday EMG Thursday EMG 8:00-9:00 Needle muscle biopsies (UW clinic) 9:00-12:00 EMG (UW or VA lab) Neuromuscular / MDA clinic 1:00-3:30 EMG PM Friday 3:30-5:00 Neuromuscular case conference EMG OR Muscle / nerve pathology lab OR Self study 57 Neuromuscular / MDA clinic Grand rounds / self study Duty Hours There are no call or weekend duty responsibilities beyond the normal neurology call schedule. Estimated duty hours for the rotation is 40 hours per week. Each resident is required to log duty hours, and notify the program director if he/she is in jeopardy of exceeding duty hours limits. Evaluation  Direct observation and daily feedback by the EMG/Neuromuscular training staff  Electronic evaluation after each rotation.  All residents, at all level of training, are expected to take every year a self-assessment exam offered by AANEM. Suggested Reading CLINICAL TEXTBOOKS  Katirji B, Kaminski HJ, Preston DC, Ruff RL, Shapiro BE, editors. Neuromuscular Disorders in Clinical Practice. Boston: Butterworth-Heinemann; 2002. Excellent reference book covering all areas of Neuromuscular Diseases.  Mendell JR, Kissel JT, Cornblath DR, editors. Diagnosis and Management of Peripheral Nerve Disorders. New York: Oxford University Press; 2001.  Griggs RC, Mendell JR, Miller RG. Evaluation and treatment of myopathies. Philadelphia: F.A. Davis Company; 1995.  Karpatti G, Hilton-Jones D, Griggs RC, editors. Disorders of voluntary muscules, 7th edition. Cambridge: Cambridge University Press; 2001.  The Guarantors of Brain. Aids to the examination of the peripheral nervous system, 4th edition. Edinburgh: W.B. Saunders; 2000. 58 ELECTRODIAGNOSTIC MEDICINE  UW Electromyography Laboratory manual  Daube JR, Rubin D. Clinical Neurophysiology,3rd edition. Oxford University Press; 2009. Excellent, comprehensive textbook, covering all areas of clinical neurophysiology (not only EMG)  Kimura Jun. Electrodiagnosis in diseases of nerve and muscle, 3rd edition. Oxford: Oxford University Press; 2001. All resident should read this EMG primer “cover to cover”  Dumitru D, Amato AA, Zwarts M. Electrodiagnostic Medicine, 2nd edition. Philadelphia: Hanley & Belfus, Inc; 2002. A very comprehensive, currently probably most comprehesive textbook in this field.  Preston DC, Shapiro BE. Electromyography and neuromuscular disorders. ClinicalElectrophysiologic correlations. Boston: Butterworth-Heinemann; 1998  Brown WF, Bolton CF, editors. Clinical Electromyography, 2nd edition. Boston: Butterworth-Heinemann;1993. 59 Pediatric Neurology Rotation Introduction Neurology residents will rotate on the Pediatric Neurology for 3 months, which will be incorporated in their first and second year of Neurology training (PGY 2 and PGY3). The rotation encompasses both inpatient and outpatient care, as well as a consulting service during normal working hours. Since the clinical rotation will not provide practical experience in all pediatric neurological diseases, it is expected that the resident will supplement their experience with reading. Neurology residents may also elect to spend extra time on Pediatric Neurology, with additional inpatient and/or outpatient exposure. The Pediatric Neurology team consists of an attending pediatric, the adult Neurology resident rotating on the Pediatric Neurology service, and one or more medical students. The medical students are either 3rd or 4th year students doing their basic Neurosciences clerkship (3 weeks) or 4th year students who have already completed the basic Neurosciences clerkship and have chosen an elective in Pediatric Neurology (4 weeks). The team may also include a Pediatric resident electing to obtain formal training in Pediatric Neurology. Goals  Describe normal developmental milestones.  Interpret neurologic tests and examination findings appropriately for children of different ages (including but not limited to variances seen in CSF, EEG, physical examinations).  Feel comfortable in performing a thorough neurologic examination in children of all ages.  Complete a reasonable differential diagnose and manage common neurologic disorders seen in children.  Diagnose and manage neurologic emergencies in children and be able to perform telephone triage when on call. Objectives Patient Care: Residents are expected to:  Communicate effectively with patients and their parents/families in a caring and respectful manor.  Obtain fundamental and accurate information about their patients, those admitted to the Pediatric Neurology Service and Pediatric Neurology Consult Service, including the initial history and physical examination and the daily progress notes.  Formulate patient management plan regarding diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment until such time that the workup and/or interventions do not require further follow up as deemed appropriate by the Pediatric Neurology attending. 60  Be able to use the information to support further pediatric care and aid in patient and family education.  Be able to counsel and educate patients and their families.  Work with health care professionals, including those from other disciplines, to provide patient-focused care.  When on call, the house officer will field all phone calls related to pediatric neurological emergencies and concerns, from parents, outside physicians, and inpatient providers.  Attend Pediatric Neurology outpatient clinics as time permits, obtain a history of present illness and formulate a plan. Medical Knowledge: Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care.Residents are expected to:  Take a personal initiative in self-education (including perusing recent literature) and demonstrate an investigatory and analytic thinking approach to clinical situations. This encompasses reading textbooks as well as review of recent scientific literature.  Know and apply the basic and clinically supportive sciences which are appropriate to Pediatric Neurology.  Be able to perform a complete neurologic examination on children of all ages, including behaviorally/developmentally/cognitively challenged patients.  Attend all educational conferences related to Pediatric Neurology during the monthly rotation. Interpersonal and Communication Skills: Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. Residents are expected to:  Create and sustain a therapeutic and ethically sound relationship with patients and their families.  Use appropriate listening skills and exchange information using effective nonverbal, explanatory, questioning, and writing skills during all interactions with patients and their families.  Work effectively with others as a member or leader of the Pediatric Neurology service, including other interdisciplinary teams. 61 Professionalism: Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to:  Show respect, compassion, and integrity; and a commitment to excellence and on-going professional development. The highest standards of professionalism must be maintained at all times.  Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, and informed consent.  Demonstrate sensitivity and responsiveness to patients’ and their families culture, age, gender, and disabilities. Practice based learning and improvement: Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to:  Evaluate both the Pediatric Neurology rotation and the attending Pediatric Neurologist at the end of the rotation. The Pediatric Neurologist will evaluate adult Neurology residents in similar manner using a computer based data collection system, as well as, by direct observation by Pediatric Neurology attendings, during their performance of routine inpatient and outpatient duties. Each resident’s performance will be discussed informally on an ongoing basis with the attending, as well as at a designated time at the end of the rotation, again by the involved attending(s).  Be able to use both pediatric textbooks and review of current literature (both online databases and other information technology) to assimilate data from scientific studies related to their patients’ health problems.  Access online database to review prior dictations, laboratory data, imaging studies and basic demographics regarding their pediatric patient population.  Be able to use knowledge about their own population of pediatric patients and the larger pediatric population from which their patients are drawn to help direct patient care.  Apply knowledge of study designs/methods to the appraisal of the literature regarding diagnostic and therapeutic effectiveness.  Facilitate the learning of students and other health care professionals.  Track the number of consults and admissions, the diagnoses involved, and any complications that occur in these patients. Cases must also be entered into the UW Hospital and Clinics Neurology Case Log. These data will be used to ensure that an adequate educational experience is obtained in pediatric neurology. These data can also be used by the resident in their 6-month self-evaluation (in conjunction with in-service scores) to direct further study. 62 Systems based practice: Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to:  Understand how their pediatric patient management affects other health care professionals, the University of Wisconsin Hospital and Clinics organization, as well as, society in general.  Acknowledge the cost and benefits of therapeutic and diagnostic choices without compromising quality of care.  Help pediatric patients and their families with health care system complications that may arise during inpatient and outpatient care settings.  Know when to call upon other healthcare providers in order to assess, coordinate, and improve the health care of the pediatric patients. Duty Hours The estimated average number of work hours per week is 55-65. Neurology residents will be excused from formal duties during continuity clinic hours (one 4-5hour period per week) with pediatric resident or attending physician covering all pediatric responsibilities It is the responsibility of each resident to be in constant communication with the supervisory attending and program director regarding duty hours. In the event that any of the ACGME duty hours regulations are in jeopardy of being violated, the attending physician and/or program director must be notified immediately. It will be that attending’s responsibility to rectify the situation immediately by appropriate means. Evaluation  Electronic evaluation by the supervisory attending(s). Suggested Reading  Clinical Pediatric Neurology, 3rd edition; Fenichel, © 1997.  Chapters 8 (Developmental Delay and Regression in Infants), 31 (The Floppy Infant), 66 (Developmental Disorders of the Nervous System), 67 (Developmental Disabilities), 68 (Inborn Errors of Metabolism of the Nervous System), 69 (Neurocutaneous Syndromes), and 84 (Neurological Problems of the Newborn); Neurology in Clinical Practice, 3rd edition; Bradley, Daroff, Fenichel, and Marsden eds; © 2000.  Diseases of the Nervous System in Childhood (Clinics in Developmental Medicine, 2nd edition, MacKeith Press; Jean Aicardi, © 1998 63  Selected readings as recommended by the pediatric neurology attendings and individual literature searches for individual patient neurologic diseases. 64 Neuropathology Elective Introduction An understanding of the pathologic basis of neurologic diseases is essential for understanding the clinical manifestations of disease, as well as the potential mechanisms of treatment. This rotation is taken during the PG3 year, and additional elective months may be taken if desired. Goals  The resident will become familiar with the gross and microscopic pathologic findings of normal anatomy as well as neurologic diseases.  The resident will become familiar with modern diagnostic pathology techniques (special stains, studies, etc.) Objectives Patient Care: Residents will…  Gain basic skills in neuropathology.  Learn how to relate pathology results to the clinical diagnosis and proper management of patients with all manner of neurologic disease.  Observe at least one brain extraction from a corpse.  Participate in brain cuttings  Participate in surgical case evaluations with the attending neuropathologist Medical knowledge: Residents will be able to…  Verbally describe and visually distinguish major neoplasms of the CNS and PNS including glial neoplasms (all grades of astrocytomas, oligodendrogliomas), neuroectodermal tumors, ependymal tumors, meningiomas, neuronal tumors and nerve sheath tumors.  Visually identify normal CNS, PNS and muscle slides.  Complete all Clinical Pathologic Cases (CPCs).  Complete at least half of the museum cases.  Evaluate pathologic slides of the major neurodegenerative conditions (Alzheimer’s dementia, Parkinson’s disease) and participate in staging of Alzheimer’s Disease using current guidelines. 65 Interpersonal and Communication Skills: Residents will…  Present neuropathological results to faculty succinctly and completely  Learn to create a concise neuropathological report Professionalism: The resident will…  Promptly attend case conferences as listed below.  Dress in appropriate attire unique to the pathological suite and present himself or herself in a professional manner at all times.  Document duty hours, and notify the Program Director immediately if there are any situations that could put the resident in violation of work hours restrictions. Practice-Based Learning and Improvement: The resident will…  Be responsible for tracking the number and diagnoses of pathology cases seen during this rotation. Cases must be entered into the web-based Case Log. These data will also be used to ensure that an adequate educational experience is obtained. These data will be reviewed with the program director during 6-month self-evaluation to direct further study. Systems-Based Practice: Residents will…  Learn the systems issues unique to ordering, the performance of, and reporting results of pathologic tests. Schedule The resident will be present in the pathology suite Monday through Friday 8:00AM to 4:00 PM. The resident will attend brain cutting on Monday and Thursday afternoons, and participate in daily sign out rounds. During free time, he or she will review the CPC cases and museum cases housed in the pathology department. The resident will attend the neuromuscular case conference on Tuesday afternoons, and attend all regularly scheduled neurology residency conferences. The resident will also attend his or her regularly scheduled weekly continuity clinic while on this rotation. Duty Hours The estimated average number of work hours per week is 50-60. There are no call responsibilities required during these rotations except the standard neurology call schedule. It is the responsibility of each resident to be in constant communication with the supervisory attending regarding duty hours. In the event that any of the ACGME duty hours regulations are in jeopardy of being violated, the supervisory attending physician must be notified immediately. It will be that attending’s responsibility to rectify the situation immediately by appropriate means. 66 Evaluations  Written (electronic) evaluation by attending Neuropathologist(s) with regard to accomplishment of the objectives listed above.  The program director's semi-annual evaluation. Suggested Reading  Manual of Basic Neuropathology, 3rd edition, Poirier, Gray, and Escourolle, eds.; © 1990.  Selected reading as recommended by attending Neuropathologist. 67 Neurosurgery Rotation Introduction The neurosurgical rotation for neurology residents is a month-long required rotation that occurs during the PG1 year for categorical residents and sometime during the PG2-4 years for advanced residents who haven’t yet had a neurosurgical rotation. The rotation is designed as an immersion program. Goals     To give the neurology resident a basic working knowledge of the surgical management of diseases of the nervous system. To educate the neurologist regarding indications for, limitations of, and possible complications of surgical treatment. To give neurology residents a concentrated patient care experience with exposure to patients with neuro-oncological conditions. To give the neurology resident learning opportunities to manage patients with neurological disease who require intensive care. Objectives Patient Care: The resident…    Will develop skills of history-taking and examining patients with neurosurgical diseases. Will develop skill in discussing end-of-life issues with patients with neuro-oncological diseases. Will become proficient in the management of patients with disorders of intracranial pressure. Medical Knowledge: The resident…     Will attend clinical conferences and didactic sessions as indicated in the schedule below Will read selected works as listed below during the rotation Will learn the neuro-radiographical appearance of neurosurgical trauma and oncology. Will learn the indications for surgical intervention in patients with neurovascular disorders Interpersonal and Communication Skills: The resident …   Will prepare concise clinical notes and discharge summaries for patients under his/her care. Will present patient clinical information to faculty and other residents in a concise orderly manner. 68 Practice-based Learning and Improvement: The resident…   Will enter all patient encounters into the electronic patient log to be reviewed with the program director at the semi-annual evaluation. Will attend and participate in Neurosurgical Morbidity and Mortality Conference Professionalism: The resident…    Will promptly attend clinical conferences, clinics and patient care rounds as indicated below. Will dress in appropriate attire and present himself or herself in a professional manner at all times. Will document duty hours, and notify the Neurology Residency Program Director immediately if there are any situations that could put the resident in violation of work hours restrictions. Systems-based practice: The resident…   Will learn to function as an integral member of the neurosurgical team Will understand the limitations of surgical intervention for a variety of neurological issues. Schedule The resident will be present in the hospital Monday through Friday from 5:30AM to 7:30 PM, and attend rounds, clinics and conferences according to the following schedule: Monday: 5:30-7:00 AM 8:00 -9:00AM 9:00 3:00-4:00 PM 4:00 -5:00PM 6:30-7:30 PM Tuesday: 5:30-7:00 AM Inpatient rounds with Red Team followed by Chief Rounds 8:00 Neurosurgery Clinic: Dr. Kuo 6:30-7:30 PM Inpatient rounds with Red Team Wednesday: 5:30-7:00 AM 7:00-8:30 AM 8:30-9:30 AM 9:30 6:30-7:30 PM Inpatient rounds with Red Team followed by Chief Rounds Pediatric Neurosurgery Conference –Puletti Room Neurosurgery Clinic: Drs. Dempsey or Dr. Iskandar (peds) Inpatient Case Conference – Okazaki Room Vascular Case/Neuro-oncology Case Conference Inpatient rounds with Red Team Inpatient rounds with Red Team followed by Chief Rounds Morbidity and Mortality Conference / Grand Rounds Neuropathology lecture Neurosurgery Clinic: Dr. Dempsey Inpatient rounds with Red Team 69 Thursday: 5:00-6:30 AM Inpatient rounds with Red Team followed by Chief Rounds 6:30-7:30AM Anatomy Conference – Puletti Room 9:00-12:00 Neurovascular clinic: Dr. Nieman 1:00 – 4:00PM Neurosurgery Clinic: Dr. Baskaya 6:00-7:00 PM Inpatient rounds with Red Team Friday: 5:00-6:30 AM Inpatient rounds with Red Team followed by Chief Rounds 6:30 – 7:30AM Anatomy conference 7:30 Operating room 2:30-3:30 Neurology Grand Rounds 6:00-7:00PM Inpatient rounds with Red Team When not assigned to clinic or attending conferences, residents will be expected to participate in patient care by seeing consults and/or ER evaluations, participate in NICU rounds, and attend OR sessions as an observer. Duty Hours There are no call or weekend responsibilities during this rotation. The total hours per week is estimated to be 70. Residents will adhere to all duty hours restrictions required of a neurology resident during this rotation. Residents will log all duty hours. Note that while neurosurgical residents have a duty hours exemption allowing for up to 88 total hours per week, this exemption does not apply to neurology residents. Evaluation At the end of the rotation, Dr. Ramirez, Neurosurgery Program Director, will solicit input from residents and faculty regarding the performance of the neurology resident. A composite evaluation will be submitted electronically by Dr. Ramirez. Suggested reading       An Introduction to Neurosurgery, 5th ed. Jennett and Lindsay. Neurology and Neurosurgery Illustrated. Lindsay and Bone. Neurological and Neurosurgical Intensive Care. Ropper, etal. Hanbook of Neurosurgery. 6th ed. Geenberg. Neuro-oncology. Berger. Selected neuro-oncology papers as recommended by staff. 70 Night Float Rotation Introduction The UW Department of Neurology has the duty to provide the best possible care for the patients served on the wards at the UW and VA Hospitals. Patients admitted for evaluation and treatment of neurological problems require inpatient care that is comprehensive, cost-effective, and compassionate. Our department also provides neurological care to patients on the medical and surgical services and in the ER setting. To offer neurological expertise in a timely fashion, at least one resident is present in the hospital at all times. The night float rotation was created in large part to comply with the ACGME duty hour regulations. Residents at all levels of training participate in this rotation, with the exception of PG2 residents during their first 4 months of residency. The night float resident will provide consultative services to the UW-ER and VA-UC, and the other inpatient services. The resident may also admit patients to one of the Neurology Services and provide coverage for the Neurology inpatients. Independence in clinical decision making will be fostered, but the senior resident and the on-call faculty member will maintain close supervision either by phone or in person. Medical students will take call with the resident during some part of the night, giving the resident an additional teaching and supervisory role. The night float resident will also attend teaching conferences in the morning, which include morning report, Neuro-Pathology and NeuroRadiology conferences. Objectives Patient Care: The resident…  Will develop skills of history-taking and examining patients with neurological disease.  Will become adept at triaging consultations and admissions, focusing care on the most acutely ill patients.  Will become proficient at managing acute clinical changes in patients under the care of the neurology services, especially the unique challenges of sundowning patients and patients who suffer an acute stroke or acute seizure.  Will develop skills of arranging follow up care for patients seen in the ER that require further neurological evaluation or treatment.  Will ensure that patient calls to the after-hours line are answered in a timely manner 71 Medical knowledge: The resident…  Will keep up on reading the same material required of all residents for Wednesday Book Club, although the night float resident will not be physically present for the session.  Will attend the clinical and didactic conferences as listed above.  Will present one or more interesting cases at the Friday morning report. Interpersonal and Communication Skills: Residents will…  Become adept at presenting patients to faculty concisely and completely, typically via telephone.  Become proficient at communicating clearly with the consulting services  Learn efficient dictating skills so that consulting and inpatient care team services have immediate access to documentation on all patients.  Continue to develop the skills of teaching basic neurological skills and knowledge to the rotating medical students. Professionalism: Residents…  Must remember that they represent the University of Wisconsin’s Department of Neurology with all of their actions and communications. The highest standards of professionalism must be maintained at all times, in interactions with patients and their families, allied health care workers and with other physicians.  Will be responsible for tracking duty hours and logging them in the electronic record, and notify the program director of any situation that could put the resident in violation of work hours restrictions. Practice-Based Learning and Improvement: The resident…  Will log all patient encounters into the electronic patient log to be reviewed with the program director at the semi-annual evaluation. Systems-Based Practice: The resident…  Will be responsible for patients with a variety neurological conditions ranging from chronic to emergent.  Is required to make efficient and cost-effective use of the limited ancillary services available after hours.  Is required to triage and prioritize consultation requests.  Should recognize situations in which the help and expertise of a backup resident is needed, and call for that backup assistance without delay. 72 Schedule The resident will be on service in the hospital Sunday through Thursday 8:00 PM to 8:00AM the following day. Residents are expected to attend the AM conferences which end at 9:30 AM at the latest. Residents on night float are excused from noon didactic sessions and continuity clinic responsibilities. Residents will be scheduled in blocks of not greater than 2 weeks, and no resident may perform more than 6 weeks of night float per year. Duty Hours There are no additional call or weekend responsibilities while on night float. The total hours per week is expected to be 60. Residents are to notify the program director immediately if a situation arises that puts the resident in jeopardy of exceeding he work hours limits. Evaluation At the end of the evaluation, the staff attendings of the various inpatient services will all be asked to submit an electronic evaluation regarding the performance of the resident. Suggested reading  Adams and Victor’s Principles of Neurology  Merritt’s Neurology  Neurology and General Medicine, Aminoff  On Call Neurology, Marshall and Mayer 73 Ward Senior Rotation Introduction and Goals One important aspect of medical training is that residents should be afforded progressively greater responsibility over time; the purpose of the ward senior rotation is to provide a formal mechanism for this. The ward senior assumes oversight over the entire adult inpatient service— general, stroke, and consults, with the goal of functioning at the attending level in terms of patient management and disposition. The ward senior provides mentorship and oversight for the junior residents on service, as well as serving as a backup for the junior residents when the services are unusually busy. Objectives Patient Care: The resident…  Will perfect skills of history-taking and examination of patients with neurological disease, and help impart such skills to the junior residents.  Will become adept at triaging consultations and admissions, focusing care on the most acutely ill patients and helping the junior residents learn to do the same. o On weekdays from 0800-noon, the ward senior will triage ED consults and respond to stroke codes while the inpatient teams are making rounds.  Will become highly proficient in managing acute clinical changes in patients under the care of the neurology services, helping the junior residents develop competence in managing acute mental status changes, stroke, and seizure.  Will serve as a back-up to the on-call junior residents when the number of consultations becomes excessive (generally > 3, but could be less if the patients are particularly sick). This includes both ED and floor consultation requests and outside phone calls. Medical knowledge: The resident…  Will help select and present cases for the Tuesday morning report.  Will lead bedside teaching for the medical students.  Will select patients for the clinical skills evaluations (NEX) required for board certification. Interpersonal and Communication Skills: Residents will…  Develop expertise in presenting patients concisely and help the junior residents to the same.  Become proficient at communicating clearly with the consulting services 74 Professionalism: Residents…  Must remember that they represent the University of Wisconsin’s Department of Neurology with all of their actions and communications. The highest standards of professionalism must be maintained at all times, in interactions with patients and their families, allied health care workers and with other physicians. Practice-Based Learning and Improvement: The resident…  Will participate in the review of physician-level data, both clinical and patient satisfactionrelated. Systems-Based Practice: The resident…  Will learn to make efficient and cost-effective use of medical resources, and teach the junior residents to do the same. Schedule The ward senior will make rounds each weekday with the team that either admitted the most patients or who has the most complicated service. From 0800-noon, the senior will triage ED consults and stroke codes, caring for the most sick patients and triaging non-emergent patients to the appropriate team. He/she will also serve as a backup to the junior residents when the service becomes very busy, either due to consults, outside phone calls, or both. This role is shared with the consult resident. The ward senior will also staff the Friday VA clinic, supervising the internal medicine residents. Duty Hours Because backup call is from home, it is not anticipated that the ward senior will come even close to violating any duty hour restrictions. As with all rotations, and resident who is in jeopardy of the same shall immediately notify the program director. Evaluation At the end of the evaluation, the staff attendings of the various inpatient services will all be asked to submit an electronic evaluation regarding the performance of the resident. Suggested reading Because of the higher-level nature of this rotation, it is expected that the resident’s reading will focus on the finer points of diagnosis and management of the particular patients seen on service. This will serve to foster the ward senior’s knowledge and provide a means to educate the other members of the team. 75 Specialty Clinics Rotation Introduction and Goals The department of neurology has a number of specialty clinics that allow the resident to broaden the scope and increase the depth of his/her outpatient experience. The resident will see uncommon diagnoses concentrated within our tertiary care subspecialty clinics, and can see the entire spectrum of a disease via interactions with multiple patients at different time points in the same disease. The resident will be assigned to work with one attending in their specialty clinic during each half day of this elective. The attending may wish the resident to observe clinical interactions or may ask the resident to first see patients independently and then staff with the attending thereafter. The degree of independence allowed to each resident will be determined by the attending and agreed upon by the resident, although it is expected that the degree of independence will increase with increasing seniority in the residency program. Each resident is required to spend 2 months on this rotation, which do not have to be consecutive. This rotation is typically done in the PG3 or PG4 year. Currently available specialty clinics in adult neurology include: movement disorders, epilepsy, headache/pain, neuromuscular diseases, multiple sclerosis, sleep disorders, neuro-ophthalmology, stroke, and ALS. See the following table. Several of these clinical experiences will or can expand upon the various subspecialty elective rotations including sleep, headache, and movement disorders that are available to all residents. Additionally, the clinics can complement the required clinics of the epilepsy and neuromuscular disease rotations. 76 Specialty Clinic Options Monday Movement Dr. Dent AM Tuesday Wednesday Thursday MS Dr. Fleming Epilepsy Dr. Rutecki, Jones, Tunnel, and Maganti Botox Dr. Dent Memory Dr. Seeger Movement Dr. Dent Friday Neuroophthalmology Dr. Dreizin( 20 S. park) MS Dr. Fleming Movement Dr. Dent Movement/Dr.Dent Movement/Dr.Gallagher Neuromuscular Dr. Lotz PM Epilepsy Dr. Maganti Movement Dr. Dent Sleep Dr. Jones/Dr. Maganti every other week Epilepsy clinic Dr.Maganti, Tunnel, Jones Objectives Patient Care:  Residents will develop basic skills in the diagnosis, evaluation, and management of neurologic patients in the outpatient specialty clinic setting. Medical knowledge:  Basic knowledge with regard to subspecialty care of neurologic diseases will be obtained through background reading as detailed below, with reading to occur in a subspecialtyand patient-specific fashion. Interpersonal and Communication Skills:  Residents will present patients to faculty succinctly and completely.  Residents will develop subperb skills in the dictation and completion of patient reports. These reports will be completed in a timely manner in accordance with hospital policies.  Residents will learn to communicate clearly with patients and families. 77 Professionalism:  Residents will dress in accordance with the standards of the outpatient clinic. Scrubs are only permitted to be worn by a resident coming off an overnight call shift and are otherwise prohibited. Practice-Based Learning and Improvement:  Each resident will be responsible for tracking the number and diagnoses of subspecialty cases seen in clinics. Cases must also be entered into the web-based E-Value Case Log. These data will be used to ensure that an adequate educational experience is obtained in each subspecialty area. These data can also be used by the resident in their 6-month self-evaluation (in conjunction with in-service scores) to direct further study. Systems-Based Practice:  The outpatient subspecialty practice of neurology is quite different from inpatient care. The resident must learn how to manage the time pressures of outpatient practice while delivering tertiary-level care. The resident will learn how to perform efficient outpatient evaluations and appropriately utilize ancillary services. Residents will become proficient in the use of the UW Epic electronic record and the VA CPRS systems. Schedule Prior to the rotation, the resident will review with all attendings the clinic schedules. It is expected that each resident will attend 8 one-half day sessions each week. In addition, each resident will attend his or her own continuity clinic each week. Duty Hours The estimated average number of work hours per week is 40-50. During this rotation, each resident will participate in the normal call schedule. It is the responsibility of each resident to be in constant communication with the supervisory attending regarding duty hours. In the event that any of the ACGME duty hour regulations are in jeopardy of being violated, the supervisory attending physician (or the program director) must be notified immediately. It will be the notified attending’s responsibility to rectify the situation immediately by appropriate means. Evaluation Each resident will be evaluated by each of the supervisory attendings at the end of the rotation using the standard rotation evaluation. This evaluation will be submitted electronically and reviewed at the mid-year and year-end summative evaluation with the program director. 78 Suggested reading The reading for this rotation varies considerably depending on the subspecialities that are covered during the rotation. Residents should discuss this at the beginning of the rotation with each attending. At a minimum the AAN Clinical Practice Guidelines that pertain to the subspecialty should be reviewed. 79 Psychiatry Outpatient Clinics and Consult Service Introduction Patients with neurological disease often have psychiatric co-morbidities. A neurologist must have a good understanding of psychiatric disease and the ability to provide basic care for patients with psychiatric illness. This rotation is one month in duration, taken during the PG1 year. It is designed to meet the requirement of ACGMC that all neurology residents have a one month experience in psychiatry that is staffed by a board-certified psychiatrist. Two weeks of the experience will be on the psychiatry consult service at UWHC and the Middleton VAH. Note: It is best to work directly with the psychiatry attending in evaluating patients for suicide risk, depression, psychosis and psychiatric medication side-effects. The other two weeks will be in various outpatient clinics. Goals  To adequately prepare our residents for the board certification examinations (approximately 25% or more of the written board examination tests knowledge of psychiatric disease).  To educate residents in how to best care for patients with neurological and psychiatric disease and to do so in accordance with the July 2004 mandate from the RRC to guarantee one month of psychiatry training.  To develop the knowledge base required for a good understanding of the mechanisms, diagnosis of, and treatment of patients with psychiatric disease. . Objectives Patient Care: Residents will…  Develop basic skills in the diagnosis, evaluation, and management of patients with psychiatric disease. Medical knowledge: Residents will…  Develop a working knowledge of the DSM – V.  Learn basic non-pharmacological treatment of neurological disease.  Strengthen knowledge of neuropharmacology with respect to antidepressants and antipsychotics. Interpersonal and Communication Skills: Residents will…  Present patients to faculty succinctly and completely  Learn to communicate clearly with patients, families, staff, and colleagues as necessary  Learn the proper format of the psychiatric patient report. 80 Professionalism: The resident…  Must remember that he/she represent the University of Wisconsin Departments of Neurology and Psychiatry with all of their actions and communications while on this rotation. The highest standards of professionalism must be maintained at all times, especially in interactions with patients with the unique needs of patients with psychiatric disease. Practice-Based Learning and Improvement: The resident will…  Be responsible for tracking the number and diagnoses of psychiatric cases. Cases must be entered into the web-based Med Hub Case Log. These data will be used to ensure that an adequate educational experience is obtained in psychiatry. These data can also be used by the resident in their 6-month self-evaluation (in conjunction with in-service scores) to direct further study. Systems-Based Practice: The resident will…  Learn about the unique constraints placed upon on the care of patients with psychiatric disease by our health care system.  Learn about the barriers that exist and how to work within these constraints to provide effective psychiatric evaluation and management.  Demonstrate an understanding of the unique ethical and medico legal circumstances that can impact upon the care of patients with psychiatric disease. Schedule During the inpatient portion of the rotation, the resident will see and staff psychiatry consults with the psychiatry resident and psychiatry staff attending throughout the day depending on the number and acuity of psychiatry consults. Time between consults will be spent in reading of selected psychiatry texts and readings as suggested by the staff attending. Residents will continue to see his or her own weekly continuity clinic and participate in the neurology resident call schedule. During the outpatient portion, the resident will attend a variety of clinics; an example schedule follows the key below: UWCC/VACC: Neurology Continuity Clinic at UW or VA VAMH: VA Mental Health Clinic (Kat Dutra): VA Building 22, Room 125, 1-4:30 p.m. Geri: UW Geriatric Psychiatry Clinic at WisPIC, 6001 Research Park Blvd (Art Walaszek) CAP: UW Child & Adolescent Psychiatry Clinic (Peggy Scallon & Brooke Kwiecinski): WisPIC 12:15-5 p.m. ITC: UW Immediate Treatment Clinic (Alexander Fritz): 1102 S. Park St., 1-5 p.m. 81 OPC: UW Adult Outpatient Psychiatry Clinic (Jake Behrens, Claudia Reardon, and others): WisPIC, 1-5:15 p.m. Monday Tuesday Wednesday Thursday Friday VAMH ITC Week 1 VACC CAP OPC VAMH ITC Week 2 UWCC CAP OPC Duty Hours There is no additional call responsibility for psychiatry call. Estimated work hour total is 45 hours per week. Residents must log duty hours and notify supervisory attending or program director if duty hours restrictions are in danger of violation. Evaluation Electronic evaluation will be submitted by the attending physician on the UW Psychiatry Consult service at the end of the rotation and will be reviewed with the program director at the semiannual summative evaluations. Suggested Reading  Synopsis of Psychiatry: Kaplan and Sadock  Selected readings as directed by supervisory attendings.  DSM-IV (most recent edition) 82 Headache Elective Introduction and Goal This rotation is one month clinical experience elective that occurs during the PG3 or PG4 year. The primary educational goal is to provide excellent training and exposure to various headache and pain syndromes and appropriate management techniques. The faculty supervisor for this rotation is Dr. Susanne Seeger. Objectives Patient Care:  During this rotation residents will learn and develop skills in diagnosis and management of patients with headache syndromes. The supervising attending physicians will evaluate clinical competence at the end of the rotation in the electronic evaluation. Medical Knowledge: Residents will acquire knowledge in different aspects of the headache medicine through background reading (see list below), review of the relevant literature in the course of evaluation of specific patients, and interaction with the Headache clinic staff physicians.  Residents will be able to identify history and physical exam red flags that are characteristic of secondary headache disorders and the appropriate steps to evaluate these headaches, including neuroimaging and other diagnostic testing.  Residents will be able to identify, properly classify, and understand treatment approaches to primary headache disorders: o Migraine (with and without aura) o Tension-type headache o Cluster headache and other trigeminal autonomic cephalalgias  Residents will be able to identify treatment approaches available for status migrainosis.  Residents will be able to identify chronic daily headache syndromes, and establish appropriate treatment plans for management of these syndromes including: 83 o o o o o Medication overuse headache Transformed chronic migraine Chronic tension-type headache Hemicrania continua New daily persistent headache (NDPH)  Residents will be able to identify indications for re-evaluation of patient with a chronic history of headaches.  Residents will be able to identify unique concerns related to women with headaches, including menstruation related headaches, role of birth control in headache management, and headache in pregnancy.  Residents will understand the indications, risks and benefits, side effects, and monitoring required for commonly used headache medications, including but not limited to: o Beta Blockers o Tricyclic antidepressants o Antiepileptic medications including topiramate, valproic acid, and gabapentin o Calcium channel blockers o NSAIDS o Combination abortive medications (Excedrin, Fiorecet) o Triptans o SSRIs o Supplements/Herbals including magnesium, riboflavin, Co-enzyme Q10, feverfew, and butterbur  Residents will gain exposure to alternative treatments for headaches, including chemodenervation, trigger point injections, physical therapy, and cognitive behavioral therapy. Interpersonal and Communications Skills:  Residents will demonstrate professional, effective interpersonal and communication skills when communicating with supervising physicians, other health care providers, patients and families.  Residents are expected to maintain comprehensive and timely medical records.  Communication skills will be periodically assessed by supervising staff physicians 84 Professionalism  The highest professional and ethical standards are expected from residents during this rotation. They are expected to demonstrate compassion, integrity, patient privacy and be respectful for patients, their colleagues and other health care providers.  Competence in professionalism will be assessed by supervising staff physicians. Practice-based Learning and Improvement:  During the rotation residents will see a wide spectrum of cases in the clinic. Patient encounters will be logged in the resident Patient Log for review with the Program Director.  Residents will receive frequent feedback from staff physicians working with them. Learning and improvement goals will be periodically reviewed.  Residents will incorporate all available learning sources, including information technology to optimize their learning of all aspects of headache treatment. Systems-Based Practice:  Residents are expected to coordinate optimal diagnostic evaluations and patient management with cost awareness within the available health care delivery systems.  Residents will learn to utilize available resources for patients with headaches.  Residents are expected to advocate for quality patient care and work with other health care professionals to enhance patient safety.  Competence in system-based medicine will be evaluated by staff physicians. Schedule The rotation takes place at the UW Pain and Headache Clinic at UW East. Each resident will spend the entire week at the clinic except when in his or her own Continuity Clinic or attending Grand Rounds. 85 Duty Hours There are no call or weekend responsibilities during this rotation except for the standard resident call schedule. The total hours per week at this clinic is expected to be 32. Evaluation At the end of the rotation, an evaluation of the resident will be performed by the supervising faculty and submitted via E-Value. Suggested Reading     Wolff’s Headache and other head pain, 7th ed. Silberstein, et al. Headache in Clinical Practice. Silberstein, etal. UW Adult Headache Treatment Guidelines. Selected papers as recommended by staff 86 Movement Disorders Elective Introduction This is an outpatient clinical rotation with the opportunity to work with a variety of attending physicians. There will be opportunities to participate in surgical treatments as well. Each resident will be expected to spend 1 month in the rotation with the option of additional time during elective months. The faculty supervisor is Dr. Dent. Goals  Identify and classify abnormal movements (tremor, chorea, myoclonus, etc.)  Demonstrate working differential diagnosis of all movement disorders and understand distinguishing clinical features  Know the appropriate evaluation for major symptoms/syndromes/diseases  Implement a reasonable treatment plan for patients with movement disorders  Realize long term complications of treatment modalities  Be familiar with indications for deep brain stimulation (DBS)  Demonstrate ability to interrogate DBS patients’ implantable pulse generator (IPG), turn it on/off, and check the battery  Demonstrate knowledge of safety concerns for patients with deep brain stimulators Educational Objectives Patient Care: Residents will . . .  Develop their skills in obtaining historical information specifically related to movement disorders.  Develop descriptive vocabulary of abnormal movements to enhance communication with other professionals.  Demonstrate the ability to perform a thorough evaluation of abnormal movements and related syndromes.  Formulate rational treatment and management plans.  Understand basic indications and mechanisms of treatment modalities including medication management, Botox therapy, and surgical treatment. 87 Medical Knowledge: Residents will . . .  Learn how to classify abnormal movements.  Demonstrate knowledge of the mainstream theories regarding pathophysiological mechanisms of common movement disorders.  Know the neuropharmacologic mechanisms of frequently used medications and common side-effects.  Become familiar with major novel treatments that are under development. Interpersonal Communication Skills: Residents will . . .  Become skilled in obtaining a comprehensive history from patients and their families, especially related to their level of disability and the impact this has on their independence and daily activities.  Demonstrate compassion and insight into the patient’s abilities/disabilities that may affect their interaction with the resident in clinic.  Understand the importance of a multi-disciplinary approach to patient management.  Develop vocabulary specific to movement disorders and create notes that accurately reflect patients’ clinical behaviors.  Become familiar with rating scales commonly used by movement disorder specialists.  Maintain accurate, thorough and timely medical records. Professionalism: Residents will . . .  Learn ethical, regulatory, and legal aspects concerning care of the patient with a movement disorder.  Know the difference between FDA-approved and off-label uses of medications and interventions.  Demonstrate sensitivity to the personal, cultural, and religious values that influence patients’ medical decisions in the context of their disease-specific problems and disabilities, including end of life issues. Practice-Based Learning and Improvement: Residents will . . .   Learn to critically appraise the movement disorder literature to keep abreast of current diagnostic and treatment developments. Become familiar with authoritative sources of movement disorders practice guidelines developed by the American Academy of Neurology and the Movement Disorders Society and how to access these documents on-line. 88  Maintain a patient log for tracking number and various diagnoses of patients seen during the rotation to ensure an adequate educational experience. Systems Based Practice: Residents will . . .  Be able to individualize evaluations, diagnostic testing, and develop treatment plans with respect to the health delivery systems available to specific patients.  Demonstrate awareness of financial, safety and other psychosocial issues common to patients living with movement disorders.  Become knowledgeable of available patient resources including other health care professionals and patient advocacy groups. Schedule The schedule below is subject to change—specifics will be clarified at the beginning of each rotation. MVD stands for movement disorders clinic.  AM PM Monday Clinic with Dr. Dent / Nancy Ninman Self Study Tuesday Clinic with Drs. Dent & Gallagher / Nancy Ninman Wednesday Thursday Friday Botox clinic with Dr. Dent VA clinic Dr. Gallagher OR UW clinic with Dr. Dent / Nancy Ninman MVD clinic with Dr. Dent Clinic with Dr. Dent / Nancy Ninman OR Botox clinic with Dr. Jones VA MVD clinic with Dr. Gallagher Duty Hours 89 The estimated number of work hours per week is 32. In addition to movement disorder clinics, residents are required to attend his or her continuity clinic that occur one half-day per week. There is no call responsibility other than participating in the regular neurology call schedule. It is the responsibility of each resident to be in communication with the supervisory attending and program director regarding duty hours. In the event that any of the ACGME duty hour’s regulations are in jeopardy of being violated, the attending physician and program director must be notified immediately. Evaluation The residents will be provided feedback on an ongoing basis during the rotation. At the conclusion of the rotation, they will be formally evaluated using the online evaluation tool. Evaluation of the rotation is an important priority. Residents are encouraged to bring questions and concerns to the movement disorders program director, Dr. Dent. Suggested Reading  Fahn, S and Jankovic J. (2007) Principles and Practice of Movement Disorders (Book & DVD) Chapter 1 has good overview. Book & DVD are excellent reference material.  www.mdvu.org/classrooms/cme (create free user account for access) Core Curriculum in Movement Disorders  Pahwa R, Factor SA, Lyons KE et al. Practice Parameter: Treatment of Parkinson disease with motor fluctuations and dyskinesia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2006: 66(7): 983-95.  Miyasaki JM, Shannon K Voon V, et al. Practice Parameter: evaluation and treatment of depression, psychosis and dementia in Parkinson disease (an evidence based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. 2006. 66: 96-1002.  Zesiwicz TA, Elble R, Louis Ed, et al. Practice parameter: therapies for essential tremor. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2005 64: 2008-20. 90 Multiple Sclerosis and Clinical Neuro-Immunology Elective Introduction This is an outpatient clinical rotation with the opportunity to work with a variety of attending physicians. It is generally taken as a 1 month elective rotation during the PG3 or PG4 year. Faculty: Dr. John Fleming, Dr. Michael Carrithers, Dr. Chris Luzzio Goals  Identify and classify CNS demyelinating and inflammatory diseases  Demonstrate working differential diagnosis of the patient with a demyelinating disease and understand distinguishing clinical features  Know appropriate work-up for major symptoms/syndromes/diseases  Implement a reasonable treatment plan  Realize long term complications of treatment modalities  Be familiar with indications for immune-modulating therapies  Demonstrate knowledge of the management of symptoms and chronic disease Objectives Patient Care: Residents will . . .  Develop skills in obtaining historical information specifically related to multiple sclerosis.  Learn and demonstrate typical abnormal exam findings in patients with multiple sclerosis.  Demonstrate how to perform a thorough work-up of demyelinating diseases and related syndromes.  Be able to formulate a rational treatment and management plan.  Understand basic indications and mechanisms of treatment modalities, including medication management and immune-modulating therapies. 91 Medical Knowledge: Residents will . . .  Learn how to classify CNS demyelinating diseases.  Demonstrate knowledge of the mainstream theories regarding pathophysiological mechanisms of common demyelinating diseases.  Know the neuropharmacologic mechanisms of frequently used medications and common side-effects.  Be familiar with major novel treatments that are under development. Interpersonal Communication Skills: Residents will . . .  Become skilled in obtaining a comprehensive history from patients and their families, especially related to their level of disability and the impact this has on their independence and daily activities.  Demonstrate compassion and insight into their patients’ abilities and disabilities that may affect their interaction with the resident in clinic.  Realize the importance of a multi-disciplinary approach to patient management.  Develop vocabulary specific to multiple sclerosis and create notes that accurately reflect their patients’ condition.  Become familiar with rating scales commonly used by multiple sclerosis specialists.  Maintain accurate, thorough and timely medical records. Professionalism: Residents will . . .  Learn ethical, regulatory, and legal aspects concerning care of the patient with a CNS demyelinating disease.  Know the difference between FDA approved and off-label uses of medications and interventions.  Demonstrate sensitivity to the personal, cultural, and religious values that influence patients’ medical decisions in the context of their disease-specific problems and disabilities, including end of life issues. 92 Practice-Based Learning and Improvement: Residents will . . .    Learn to critically appraise multiple sclerosis literature to keep abreast of current diagnostic and treatment developments. Become familiar with authoritative sources of multiple sclerosis practice guidelines developed by the American Academy of Neurology and how to access these documents on-line. Maintain a patient log for tracking number and various diagnoses of patients seen during the rotation to ensure an adequate educational experience. Systems Based Practice: Residents will . . .  Be able to individualize evaluations, diagnostic testing, and develop treatment plans with respect to the health delivery systems available to patients.  Be aware of financial, safety and other psychosocial issues common to patients living with multiple sclerosis.  Become knowledgeable of available patient resources including other health care professionals and patient advocacy groups. Schedule The schedule is subject to change—specifics will be clarified at beginning of each rotation.  AM PM Monday UW clinic with Dr. Carrithers Self study Tuesday VA clinic with Dr. Carrithers Wednesday UW clinic with Drs. Fleming and Luzzio Self study 93 Thursday Self study Friday UW clinic with Drs. Fleming and Luzzio Duty Hours The estimated number of work hours per week is 32. In addition to multiple sclerosis clinics, residents are required to attend his or her continuity clinic that occur one half-day per week. There is no call responsibility other than participating in the regular neurology call schedule. It is the responsibility of each resident to be in communication with the supervisory attending and program director regarding duty hours. In the event that any of the ACGME duty hour’s regulations are in jeopardy of being violated, the attending physician and program director must be notified immediately. Evaluation The residents will be provided feedback on an ongoing basis during the rotation. At the conclusion of the rotation, they will be formally evaluated using the online evaluation tool EValue. Evaluation of the rotation is an important priority. Residents are encouraged to bring questions and concerns to the multiple sclerosis faculty. Suggested Reading  Noseworthy, J. H.; Lucchinetti, C.; Rodriguez, M.; Weinshenker, B. G., Multiple sclerosis. N Engl J Med 2000, 343 (13), 938-52.  Polman, C. H.; Reingold, S. C.; Edan, G.; Filippi, M.; Hartung, H. P.; Kappos, L.; Lublin, F. D.; Metz, L. M.; McFarland, H. F.; O'Connor, P. W.; Sandberg-Wollheim, M.; Thompson, A. J.; Weinshenker, B. G.; Wolinsky, J. S., Diagnostic criteria for multiple sclerosis: 2005 revisions to the "McDonald Criteria". Ann Neurol 2005, 58 (6), 840-6.  Lucchinetti, C.; Bruck, W.; Parisi, J.; Scheithauer, B.; Rodriguez, M.; Lassmann, H., Heterogeneity of multiple sclerosis lesions: implications for the pathogenesis of demyelination. Ann Neurol 2000, 47 (6), 707-17.  Henderson, A. P.; Barnett, M. H.; Parratt, J. D.; Prineas, J. W., Multiple sclerosis: distribution of inflammatory cells in newly forming lesions. Ann Neurol 2009, 66 (6), 73953.  Interferon beta-1b is effective in relapsing-remitting multiple sclerosis. I. Clinical results of a multicenter, randomized, double-blind, placebo-controlled trial. The IFNB Multiple Sclerosis Study Group. Neurology 1993, 43 (4), 655-61.  Jacobs, L. D.; Beck, R. W.; Simon, J. H.; Kinkel, R. P.; Brownscheidle, C. M.; Murray, T. J.; Simonian, N. A.; Slasor, P. J.; Sandrock, A. W., Intramuscular interferon beta-1a therapy initiated during a first demyelinating event in multiple sclerosis. CHAMPS Study Group. N Engl J Med 2000, 343 (13), 898-904. 94  Johnson, K. P.; Brooks, B. R.; Cohen, J. A.; Ford, C. C.; Goldstein, J.; Lisak, R. P.; Myers, L. W.; Panitch, H. S.; Rose, J. W.; Schiffer, R. B., Copolymer 1 reduces relapse rate and improves disability in relapsing-remitting multiple sclerosis: results of a phase III multicenter, double-blind placebo-controlled trial. The Copolymer 1 Multiple Sclerosis Study Group. Neurology 1995, 45 (7), 1268-76.  Polman, C. H.; O'Connor, P. W.; Havrdova, E.; Hutchinson, M.; Kappos, L.; Miller, D. H.; Phillips, J. T.; Lublin, F. D.; Giovannoni, G.; Wajgt, A.; Toal, M.; Lynn, F.; Panzara, M. A.; Sandrock, A. W., A randomized, placebo-controlled trial of natalizumab for relapsing multiple sclerosis. N Engl J Med 2006, 354 (9), 899-910.  Mikol, D. D.; Barkhof, F.; Chang, P.; Coyle, P. K.; Jeffery, D. R.; Schwid, S. R.; Stubinski, B.; Uitdehaag, B. M., Comparison of subcutaneous interferon beta-1a with glatiramer acetate in patients with relapsing multiple sclerosis (the REbif vs Glatiramer Acetate in Relapsing MS Disease [REGARD] study): a multicentre, randomised, parallel, open-label trial. Lancet Neurol 2008, 7 (10), 903-14.  Kappos, L.; Radue, E. W.; O'Connor, P.; Polman, C.; Hohlfeld, R.; Calabresi, P.; Selmaj, K.; Agoropoulou, C.; Leyk, M.; Zhang-Auberson, L.; Burtin, P., A placebo-controlled trial of oral fingolimod in relapsing multiple sclerosis. N Engl J Med 2010, 362 (5), 387-401.  Cohen, J. A.; Barkhof, F.; Comi, G.; Hartung, H. P.; Khatri, B. O.; Montalban, X.; Pelletier, J.; Capra, R.; Gallo, P.; Izquierdo, G.; Tiel-Wilck, K.; de Vera, A.; Jin, J.; Stites, T.; Wu, S.; Aradhye, S.; Kappos, L., Oral fingolimod or intramuscular interferon for relapsing multiple sclerosis. N Engl J Med 2010, 362 (5), 402-15.  Clifford, D. B.; De Luca, A.; Simpson, D. M.; Arendt, G.; Giovannoni, G.; Nath, A., Natalizumab-associated progressive multifocal leukoencephalopathy in patients with multiple sclerosis: lessons from 28 cases. Lancet Neurol 2010, 9 (4), 438-46.  Fleming, J. O.; Carrithers, M. D., Diagnosis and management of multiple sclerosis: a handful of patience. Neurology 2010, 74 (11), 876-7. 95 Sleep Medicine Elective Introduction For neurology residents, sleep medicine is a 1 month elective rotation (residents and fellows from the departments of psychiatry, internal medicine, pediatrics and surgery may rotate for 3 or 6 month longitudinal experience). Goals  To equip trainees with the basic clinical knowledge and skills to evaluate primary and co-morbid sleep disorders including: o sleep apnea o insomnia o nocturnal movements (e.g. restless legs syndrome)  Describe the basic attributes and findings of a polysomnogram  Understand effective treatment options for the aforementioned sleep disorders Objectives Patient Care: The resident will . . .  Document in the medical record a clinical sleep history with details pertinent to the patient’s problem. Target behaviors include: o document the chief clinical sleep complaint o compute body mass index o document blood pressure o document any history of hypertension o document history of motor vehicle accidents in patients who complain of snoring or excessive daytime sleepiness  Evaluate a chief complaint of daytime sleepiness or fatigue. Target behaviors include: o compute and document the patient score on the Epworth Sleepiness Scale o list/document the 4 symptoms of the narcoleptic tetrad o document a positive or negative history of snoring o administer, correctly score, and document the Berlin questionnaire for obstructive sleep apnea  Identify common abnormal respiratory events and movement events in at least one clinical polysomnogram during the rotation. Target behaviors include: 96 o o o  correctly identify 20 apneas and 20 hypopneas on a sample polysomnogram differentiate periodic from non-periodic limb movements in a sample clinical polysomnogram. distinguish epochs of REM and NREM sleep on a sample clinical polysomnogram. Identify common sleep disruptive elements of sleep hygiene, including medication use, diet, habitual pre-sleep activities, employment work schedule, and regularity of bed and rise times. Target behaviors include: o document habitual bed and rise times o document the consumption of alcohol and stimulants o document use of sleep altering medications o document bedtime ritual behaviors Medical Knowledge: The resident will . . .  Incorporate basic concepts of sleep physiology and sleep diagnoses into clinical encounters  Demonstrate a basic understanding of management approaches for common sleep disorders (sleep apnea, insomnia, restless legs syndrome and narcolepsy) Interpersonal and Communications Skills: The resident will . . .  Demonstrate communication skills that enable them to establish and maintain professional relationships with colleagues in respiratory therapy, nursing and psychology Professionalism: Residents will . . .  Learn ethical, regulatory, and legal aspects concerning care of the patient with a sleep disorder.  Know the difference between FDA approved and off-label uses of medications and interventions.  Demonstrate sensitivity to the personal, cultural, and religious values that influence patients’ medical decisions in the context of their disease-specific problems and disabilities. 97 Practice-Based Learning and Improvement: Residents will . . .  Learn to critically appraise the sleep disorders literature to keep abreast of current diagnostic and treatment developments.  Become familiar with authoritative sources of sleep disorders practice guidelines and how to access these documents on-line.  Maintain a patient log for tracking number and various diagnoses of patients seen during the rotation to ensure an adequate educational experience. Systems-Based Practice: The resident will . . .  Use sleep clinic templates within a sophisticated computerized medical record Schedule Residents will attend clinics 4 half-days per week at Wisconsin Sleep under the direct supervision of the attending staff. Residents will spend the rest of time reviewing sleep studies and reading about sleep disorders. Residents will attend his or her weekly continuity clinic during this rotation. Duty Hours The estimated work hours is 40 hours per week. Residents will participate in the neurology resident call schedule but have no additional call responsibilities while on this rotation. Evaluation Supervising faculty will submit an electronic summative evaluation at the end of the rotation. This evaluation will be reviewed with the program director at the mid-year and year-end evaluations. The evaluation for this rotation is based on the following:  End-of--rotation examination  Global rating scales completed by faculty mentors  Successful completion of 4 web-based case studies  Dictated reports  Observation of polysomnogram review  Completion of competency checklist by the sleep laboratory director 98 Suggested Reading Principles and Practice of Sleep Medicine, Kryger Roth and Dement, eds. 99 Neuro-Ophthalmology Elective Introduction This is a one-or two-month outpatient elective that can be done simultaneously with another, such as neuroradiology or neuropathology. The resident with work with neuroophthalmologists in the neurology and ophthalmology departments. Goals The goal for this rotation is for the resident to learn the anatomic and physiologic basis of neurologic disease that involves the visual system, and apply that knowledge clinically. Objectives Medical Knowledge: Residents will…       Learn the anatomy of the afferent visual system. Learn the anatomy of the oculomotor system Learn the anatomy and pharmacology of control of the pupils Learn to interpret visual fields Become familiar with ocular coherence tomography Diagnose these optic nerve conditions o Optic neuritis—demyelinating, NMO and other autoimmune optic neuropathies o Arteritic and non-arteritic anterior ischemic optic neuropathy o Optic perineuritis o Anomaluous optic discs o Optic nerve tumor—optic glioma, optic nerve sheath meningioma  Diagnose these eye movement disorders o Nystagmus—downbeat, upbeat, pendular,, congenital, horizontal o III nerve palsy o IV nerve palsy o VI nerve palsy o Skew deviation o Convergence/divergence insufficiency o 1 ½ syndrome o Saccadic pursuit o Hypometric saccades o Overshoot saccades o Ocular dysmetria, ocular flutter, and opsoclonus 100       Diagnose trigeminal autonomic cephalgias, including hemicranias continua, paroxysmal hemicranias, SUNCT syndrome, and cluster headache Diagnose these cortical visual disturbances o Charles Bonnet syndrome o Posterior reversible encephalopathy syndrome o Palinopsia o Visual object agnosia o Visual snow o Prosopagnosia o Simultanagnosia o Visual neglect Identify and grade papilledema Learn the mechanisms, signs, and symptoms of idiopathic intracranial hypertension Learn to read an ophthalmology consult Distinguish between monocular and hemianopic binocular vision loss Patient care: Residents will             Take a basic vision history Learn to interpret visual fields Use the direct ophthalmoscope well Diagnose and manage anisocoria, including Horner syndrome and Adie syndrome Diagnose and manage idiopathic intracranial hypertension Diagnose and manage ocular myasthenia Diagnose non-organic vision loss Diagnose and manage the optic neuropathies discussed above Diagnose and manage cavernous sinus disorders Diagnose and manage superior oblique myokymia Learn to interpret OCT for neuro-ophthalmology Learn to interpret VEPs Interpersonal Communication: Residents will…       Become skilled in taking an appropriate vision history Provide written materials to patients related to their neuro-ophthalmic problems Develop a vocabulary appropriate to neuro-ophthalmology Learn to understand an ophthalmology consult Communicate effectively with patients about their neuro-ophthalmic disease, workup, prognosis, and treatment Communicate effectively with referring physicians and the health care team 101 Professionalism: Residents will…     Show compassion and integrity toward patients Respect patients’ privacy Learn the legal aspects of managing patients with visual impairment Show sensitivity to personal values that influence patients’ medical decisions. 102 Neuroradiology Elective Introduction It is important that neurology residents become proficient in the interpretation of radiolographic studies. Proficiency is typically obtained on every rotation that is required of all residents. Additionally, residents will attend the neuroradiology boot camp held each fall, as well as the monthly neuroradiology conference. Residents can also gain additional experience in neuroradiology by taking an elective rotation. While not required, it is highly recommended that all residents take this rotation, which is typically done in the PG3 or PG4 year. Goals  Develop a methodological approach to image interpretation  Understand the limitations of each imaging technique  Become independent in the ability to interpret neuroradiologic studies and generate appropriate differential diagnoses from the findings Objectives Patient Care: The resident will learn how to relate radiology results to the clinical diagnosis and proper management of patients with all manner of neurologic disease. Medical knowledge: Residents will . . .  Learn the basic physics of neuroimaging, especially CT and MRI. Normal imaging as well as pathological abnormalities will be emphasized.  Methodically evaluate neuroradiologic studies and identify all pertinent findings in neuroradiologic studies.  Generate appropriate differential diagnoses based upon neuroradiologic findings. Interpersonal and Communication Skills:  Residents will learn what constitutes an accurate radiological report of findings. While neurology residents are not expected to prepare radiology reports, they should be familiar with the structure of such reports. 103 Professionalism:  Residents will act in a professional manner while interacting with radiology faculty, staff, and patients. The resident will be responsible for tracking duty hours via the electronic monitoring system. Practice-Based Learning and Improvement:  The resident will be responsible for tracking the number and diagnoses of radiology cases seen during this rotation. Cases must be entered into the electronic patient log. These data will also be used to ensure that an adequate educational experience is obtained. Systems-Based Practice:  Residents will learn the systems issues related to ordering, performance, and reporting results of radiologic tests. The resident will learn how to most effectively work with radiology services to provide effective evaluation and management to their patients. Schedule Each resident will attend daily read-out sessions as scheduled by the attending radiology faculty. Residents are encouraged to physically attend several imaging studies with qualified technical staff. Each resident will attend all scheduled neurology resident conferences as his or her own weekly continuity clinic. Residents will participate in the neurology resident call schedule. Duty Hours The estimated average number of work hours per week is 50-60. There are no call responsibilities required during these rotations beyond regular neurology call. It is the responsibility of each resident to be in communication with the supervisory attending regarding duty hours. In the event that any of the ACGME duty hours regulations are in jeopardy of being violated, the supervisory attending physician must be notified immediately. It will be that attending’s responsibility to rectify the situation immediately by appropriate means. Evaluation Written (electronic) evaluation by attending Neuroradiologist(s) will be submitted at the end of each rotation. Suggested Reading  Imaging of the Nervous System, Latchaw etal.  Fundamentals of Neuroimaging, Woodruff 104 Research Elective Letter from Dr. Gallagher Many labs on the UW campus and elsewhere perform research relevant to neurology. You are welcome to work in any of these labs or to design a clinical research project. In the list below we have provided a list of research programs in neurology that can sponsor your work. Please identify a research mentor (typically the director of your chosen research group) and meet with this person ahead of time to make sure they can accommodate you during the time frame you have in mind. Also make sure an IRB approval, if needed, is in place to cover your work. If you have questions about this process, please feel free to talk to me. Although you may not finish your chosen project during your rotation, we would like the experience to culminate in completed work that is presented in some form—as a poster, grand rounds, neurology research day talk, or (best yet) a peer-reviewed publication. Please submit an outline of the project sections as described below. Your research plan must be approved by Dr. Gallagher in addition to your chosen mentor before your begin your rotation. Outline for Required Project Description (1-2 pages, please include references): Background: Summarize specific scientific literature relevant to your project. Point out current gaps in knowledge and how your project will address these. Hypothesis: For the phenomenon you are studying or the intervention you are planning, what is your expectation of the outcome? Research plan: Describe the subject group (humans or animals) or materials and methods you will use, what data you will collect, and how the data will be analyzed. By the end of the rotation, this section should be of sufficient detail that your work could be replicated. Expected results: Describe the results you expect to see and state whether such results will prove your hypothesis. Are there limitations that may make the study inconclusive? Conclusions: You may leave this section to the end of the rotation. What is the significance of your results and how do they fit in with the existing literature. References: We recommend that you use citation software to prepare this. Research Programs in Neurology: Mike Carrithers: The Carrithers laboratory focuses on novel immune-mediated repair mechanisms relevant to the pathogenesis of multiple sclerosis (MS) and other inflammatory diseases. Current projects focus on development of cell therapies for MS in pre-clinical models and on the pharmacogenomics of existing treatments. In our most recent work, we designed genetically modified macrophages that mediate protection and recovery in a mouse model of MS and identified a specific gene that is necessary for therapeutic responses to anti-integrin treatment. Future goals are to assess the role of immune-based methods in the optimization of stem cell treatments and to identify approaches to individualized treatment of MS patients. 105 Catherine Gallagher: Dr. Gallagher’s research aims to develop new neuroimaging biomarkers for the pathology and progression of Parkinson’s disease. In particular, the lab is interested in how disease-related changes in brain connectivity affect cognition in Parkinson’s disease. Currently we are recruiting Parkinson’s and control subjects to participate in a longitudinal MRI study, and are preparing to analyze novel image sequences from the first time point. Data analyses will include looking for associations between standardized cognitive and motor evaluations and brain imaging parameters such as functional and structural connectivity, volumetric studies, and quantification of white matter hyperintensity volume. Bruce Hermann: Our research involves prospective imaging (structure, DTI, resting fMRI) , neuropsychological (intelligence, panguage, memory, executive function, psychomotor speed), psychiatric (depression, anxiety, ADHD) and social assessment of children with new onset epilepsies. We have a large database which should make it possible to carve out a specific project. In addition, Dave Hsu is overseeing EEG/cognition/behavioral research. We also have a large prospective dataset including approximately 80 controls and 80 adults with TLE with similar data. David Hsu: I apply quantitative mathematical methods to EEG data to see if we can extract more information from such data. A recent project involves pseudo-wavelet analysis of EEG from children with epilepsy and comparison with neuropsychological data (obtained by Drs. Bruce Hermann and Jana Jones in one of their projects) to identify whether electrical brain activity at certain frequencies is associated with better (or worse) performance on tests of intelligence and attention. In the next phase of this project, we will apply memory kernel analysis to this same data set. We also hope to test whether peripheral nerve stimulation (using TENS devices) can enhance (or impair) performance on tests of intelligence and attention and whether the EEG changes as well. In addition, we are collaborating with Dr. Iskandar (of Pediatric Neurosurgery) in a project to study intracranial pressure waveforms using some of the same quantitative methods. Jana Jones: Anxiety in children with epilepsy. Chris Ikonomidou: My research focuses on how environmental factors may interfere with normal brain development and cause neurologic impairment. My group has investigated impact of alcohol, sedative and antiepileptic drugs, drugs of abuse, oxygen, hypoxia-ischemia and trauma on the developing rat and mouse brain. We described that during the early postnatal period these factors can cause massive apoptotic cell death in the brain and also impair cell birth and neurogenesis. I am also interested in studying the impact of cancer chemotherapy on brain structure and function. In this topic we are moving towards the clinic and want to prospectively study the impact of cancer chemotherapy in children on brain development and function using multimodal imaging, blood and CSF biomarker analysis and neuropsychological evaluation. More recently I developed interest in neuromodulation and its potential application in treatment of intellectual disabilities and in prevention of epileptogenesis. Matt Jensen: Stem cells and Stroke. Paul Rutecki: My research is on cellular neurophysiology of the CA3 region of the hippocampus and focuses on synaptic and membrane alterations associated with epilepsy and how they may be targets for anti-epileptic treatments. These studies are done in hippocampal slices made from rodents and use extra- and intracellular recording techniques. In addition, I 106 also study whole animals after traumatic brain injury to evaluate for post-traumatic epilepsy and behavioral abnormalities after TBI. These studies use video/EEG monitoring to characterize seizures and behavioral testing such as fear conditioning and water maze learning. Tom Sutula: Introduction No field is growing faster than the neurosciences. This is evidenced by the growth of research in the neurosciences, both basic science and clinical. Our department continues to expand in both arenas, with a departmental mission of bringing basic science advances to the clinical care arena (“bench to bedside”). Research will be allowed during elective time at the discretion of the program director after discussion with both the resident and the faculty member who will agree to sponsor such an elective and serve as “mentor” for the resident. Goals A written proposal for what is to be accomplished during this elective must be generated prior to starting. The resident will:  Learn and practice the scientific method and rigorous scientific technique while carrying out their project/experiment. Techniques learned may include: o laboratory skills  molecular and genetic studies  animal experiments  chemical/biochemical experiments o clinical research skills  clinical trial methodology  epidemiology  biostatistics  Ideally, author a manuscript or abstract  Learn about the informed consent process and develop an understanding of HIPAA’s impact upon clinical research. In accordance with NIH Clinical Research standards, any resident participating in clinical research will be required to participate in Human Subjects Protection training (obtaining a Certificate of Completion for Web Based Course on Protection of Human Research Subjects). Objectives Patient Care:  Patient care may be developed in clinical research projects. Residents will learn to care for patients within the confines of a clinical research study if applicable Medical knowledge: 107  Medical knowledge will be obtained through background literature review in the research topic of interest. Residents will develop practical knowledge of statistical analyses. Interpersonal Communication:  Good communication with other researchers is necessary for collaboration in research. The resident will learn how to obtain informed consent, enroll the patients, and communicate with regulatory personnel. Professionalism:  Residents will maintain the highest standards of professionalism, especially in interactions with patients or with other research colleagues. The resident will be responsible for tracking duty hours and reporting them to the supervisory attending. Practice-Based Learning and Improvement:  The resident will be responsible for working with supervisory staff and co-participants in troubleshooting the methods of the proposed research. Systems-Based Practice:  Research requires fastidious compliance with regulatory guidelines such as HIPAA for patient-based research and animal safety regulations for basic science research. The resident will learn how to complete projects within this regulatory environment. Schedule The resident will create his/her schedule depending on the nature of the research project. However, the resident will at all times attend all of the daily conferences and didactic sessions, and attend his or her weekly continuity clinic. Duty Hours It is estimated that the average number of work hours per week is 50 hours. Residents will participate in the call schedule and constantly document duty hours. In the event that any of the ACGME duty hours regulations are in jeopardy of being violated the supervisory attending physician must be notified immediately. Evaluation The resident will receive an end of rotation evaluation submitted electronically at the end of the rotation by the faculty supervisor of the project. The evaluation will be reviewed with the program director at the mid-year and year-end summative evaluation. 108 Neuropsychology Elective Introduction Neuropsychology is an applied science concerned with the study of brain-behavioral relationships. The neuropsychologist utilizes tests of known reliability and validity to objectively measure the integrity of cerebral functions. Understanding the proper use of neuropsychological testing should be incorporated into the resident’s daily practice (e.g., mental status examinations, dementia rating scales, geriatric depression scales). This rotation is an elective that is one month in duration and typically taken during the PG4 year. Goals The main goal of the rotation is to acquire an understanding of brain-behavior relationships, the proper use of neuropsychological testing and the different roles of a clinical neuropsychologist. Duties will include accompanying and assisting Dr. Hermann and his colleagues in the daily clinical activities of a neuropsychologist including interviewing patients, administering, scoring, and interpreting neuropsychological test and providing feedback to patients, residents, and attending staff. Objectives Patient Care:  Residents will learn the basic skills in the diagnosis, evaluation, and management of patients with neurocognitive and neuropsychiatric diseases Medical knowledge:  Residents will demonstrate an understanding of the principles and methods of neuropsychological testing, especially anatomical localization derived from test results and utility of results in determining neurologic diagnoses.  Basic knowledge with regard to the clinical course, diagnostic criteria, and management principles of these diseases will be obtained through clinical interactions, didactic teaching, and background reading as detailed below, with reading to occur in a patientspecific fashion. Interpersonal and Communication Skills:  Residents will become proficient in communicating clearly with patients, families, staff, and colleagues the results of neuropsychological tests.  Residents will learn the basics of creating comprehensive test reports that will be reviewed by the staff attending. 109 Professionalism:  The resident must maintain the highest standards of professionalism at all times, especially in interactions with patients and with other health care providers. The resident will be responsible for tracking duty hours and reporting them to the supervisory attending. Practice-Based Learning and Improvement:  The resident will be responsible for tracking the number and diagnoses of patients seen and number of tests performed. Cases must be entered into the web-based E-Value Case Log. These data will be used to ensure that an adequate educational experience is obtained in neuropsychometric testing. These data can also be used by the resident in their 6-month self-evaluation (in conjunction with in-service scores) to direct further study. Systems-Based Practice:  Neuropsychometric testing is not always approved by insurance companies and appropriate use of testing must be learned. During this rotation, the resident will learn about how to work within the constraints of our current health care system to provide neuropsychometric testing/consultation in an appropriate fashion. Schedule Residents will attend the neuropsychology clinic daily. They will participate in administering of tests to patients and review results with technicians and staff. Residents are encouraged to undergo testing of themselves during the rotation to understand the patient perspective of the testing. Residents will attend all regularly scheduled conferences and didactics. In addition, each resident will attend his or her own weekly continuity clinic. Duty Hours The estimated average number of work hours per week is 40-50. There is no call responsibility during this rotation other than the regular neurology call. It is the responsibility of each resident to be in communication with the supervisory attending regarding duty hours. In the event that any of the ACGME duty hours regulations are in jeopardy of being violated, the attending physician must be notified immediately. It will be that attending’s responsibility to rectify the situation immediately by appropriate means. 110 Evaluation At the end of the rotation, the faculty attending will submit an end-of-rotation evaluation electronically. The evaluation will be reviewed with the program director at the mid-year and year-end summative evaluation. Suggested Reading  Neuropsychological Assessment. M. Lezak. 111 Part III – Neurology Department Clinical Policies UWHC Electroneurodiagnostic Technologist Call Policy and Procedure for STAT EEG, Continuous ICU EEG and Video EEG A. Stat EEG: PURPOSE: 1. Purpose of a Stat EEG is to: a. Determine the cause of unexplained mental status changes in any patient. These include: i. patients who present with acute mental status changes in the hospital or ER, in whom you cannot find any other cause; ii. patients with known epilepsy who have unexplained mental status changes, iii. neurosurgical patients who suddenly deteriorate with no other explainable cause; iv. general medical patients who have acute mental status changes with or without twitching, v. suspected anoxic injury/myoclonus. vi. patients with acute mental status changes and twitching b. Confirm and manage ongoing acute status epilepticus i. Confirm diagnosis by observing ongoing seizure activity in patients where clinical diagnosis is questionable ii. Confirm cessation of electrographic seizure activity where convulsive activity has stopped. 2. Please keep in mind however, that following anesthesia/surgery, a patient may not wake up right away and similarly a patient with a GTC seizure may not wake up right away. Please be judicious in ordering stat EEGs in these cases. Please look for other causes (such as raised ICP; effect of drugs such as Propofol). Prior to ordering a Stat EEG, please EXAMINE the patient, as you may find a cause for altered mental status as nothing replaces the clinical exam. A STAT EEG in a patient on propofol and fentanyl drip is very unlikely to yield a cause for mental status changes. 3. Lastly the yield of a Stat EEG is extremely low, studies show that seizures/status epilepticus was detected in only 5% of cases with 95% over a 1 year period not giving any helpful information. Policies are designed to avoid excessive use of Stat EEG. 4. Please order a Stat EEG ONLY after radiological studies are completed in patients that need emergent imaging. For patients that likely are in status, EEG should be obtained and seizures treated before imaging studies are performed. It is not efficient or economical to apply EEG electrodes, remove them for imaging studies and then apply them again. 112 POLICY: 1. Any service can order a stat EEG without a Neurology consult. 2. Stat EEGs can be requested during regular business hours by calling the EEG department at 263-8483, weekdays 7 am to 4:30 pm, without any prior authorization. Requests for Stat EEGs between 4:30 pm and 7 am on weekdays, and all day during holidays/weekends, require approval of the on-call Epilepsy/Clinical Neurophysiology attending physician or the Neurophysiology fellow on call. There are no exceptions to this policy. B. Continuous ICU EEG monitoring: PURPOSE: 1. Purpose of ICU EEG is to: a. Monitor treatment response in a patient who is being treated for status epilepticus b. Monitor patients placed in barbiturate coma for increased ICP c. In patients with aneurysmal subarachnoid hemorrhage as a part of SARA protocol d. In patients with a hypothermia protocol and following anoxic injury to evaluate for progress/ improvement e. Any neurosurgical or neurology ICU patient with unexplained mental status change f. Any medical/surgical ICU patient with unexplained mental status change with or without abnormal movements. 2. ICU EEGs are NOT to be requested to monitor patients for spells in the hospital as they require Video Telemetry to be informative. POLICY: 1. All ICU EEGs are to be preceded by a stat EEG, even in cases of aneurysmal subarachnoid hemorrhage. 113 2. NO ICU EEGs will be performed without a Stat EEG 3. ICU monitoring EEGs may be requested following a Stat EEG during regular business hours (7 am to 4:30 pm) on weekdays with no prior authorization. 4. When patients are unhooked from ICU EEGs in the middle of the night on weekdays or any time on weekends (for radiological studies or other reasons), the clinical neurophysiologist/ fellow approval is required to reattach the leads to the patient before daytime hours. 5. For PEDIATRIC ICU EEG, communication between the on-call adult neurophysiologist/fellow and the pediatric Neurology attending may be required to determine best course of action for pediatric patients. 6. Ccontinuous ICU EEG and Video EEG can be requested during regular business hours by calling the EEG department at 263-8483, weekdays 7 am to 4:30 pm, without any prior authorization. Requests for ICU monitoring and Adult Video EEG between 4:30 pm and 7 am on weekdays, and all day during holidays/weekends, require approval of the on-call Epilepsy/Clinical Neurophysiology attending physician or the Neurophysiology fellow on call. There are no exceptions to this policy. REPORTING OF RESULTS: 1. All ICU monitoring EEGs will be downloaded at 4 pm and 8 am daily. Reports will be completed shortly thereafter and dictated or transcribed into Epic. The team will be notified of the results by the fellow or attending. If any ordering team would like the results prior to them being transcribed in Epic, they can contact the on call EMU attending that would be responsible for reviewing these studies. PROCEDURE: Weekdays after 4:30pm Monday-Friday, all weekends and Holidays    Residents and/or staff can reach the EEG tech on call by paging EEG pager #0125. Once the study is completed, it will be downloaded and EEG tech will notify on call Neurophysiologist or EEG fellow who will review the study (remotely) and notify the treating team of the result. If while performing the study, the technologist notices a pattern that is concerning, he/she will leave the leads on until the study has been read by the on-call Epilepsy/Clinical Neurophysiology attending physician or the 114  Neurophysiology fellow and a decision is made regarding continuous EEG monitoring. For PEDIATRIC stat video EEG, EEG tech on call should continue to notify either Dr. Stafstrom or Dr. Zawadzki via e-mail that a study is being started and needs to be followed. For any concerns regarding these policies, please contact the Medical Director of Neurodiagnostics. Rama Maganti, MD Medical Director EEG Lab, Epilepsy Program Director (Aug 2012) 115 Appendix A – UW Hospital Policies 116 2014-2015 UNIVERSITY OF WISCONSIN HOSPITAL AND CLINICS APPOINTMENT INFORMATION FOR RESIDENTS AND FELLOWS IN GRADUATE MEDICAL EDUCATION PROGRAMS The University of Wisconsin Hospital and Clinics (UWHC) and its affiliates are committed to providing a training program for Residents* that meets all requirements for programs** accredited by the Accreditation Council for Graduate Medical Education (ACGME). The Program Director will be responsible for determining the educational program, the professional responsibilities, specific hours of duty and the rotation schedules necessary to comply with the ACGME requirements. I. Responsibilities of the Resident A. Residents are expected to: 1. Participate in safe, compassionate and cost-effective patient care under a level of supervision commensurate with their achieved cognitive and procedural skills. 2. Participate fully in the educational activities of their program and, as required, assume responsibility for teaching and supervising other Residents and students. 3. Fulfill the educational requirements of the training program established for their specialty and demonstrate the specific knowledge, skills and attitudes to demonstrate the following: a) Patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. b) Medical knowledge about established and evolving biomedical, clinical, and cognate (e.g., epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. c) Practice-based learning and improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care. d) Interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and other health professionals. e) Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. f) Systems-based practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system for health care and the ability to effectively call on system resources to provide care that is of optimal value. 4. Participate in institutional programs and activities involving physicians, and adhere to applicable laws (including U.S. Selective Service registration), regulations, rules, policies, procedures and established practices of the sponsoring institution and all other institutions to which they are assigned. 5. Participate in institutional committees and councils, especially those related to patient care review activities and residency education. 6. Learn and apply reasonable cost containment measures in the provision of patient care. II. Professional activities outside the educational program. Also see UWHC GME policy on Outside Activities including Moonlighting – Resident/Fellow and the UWHC Code of Ethics*** *To be concise, whenever the term “Resident” is used in this document, it is intended to include all residents and fellows in ACGME accredited training programs. **Further use of “program(s)” in this document will refer to ACGME-accredited programs. ***All UWHC GME policies referred to in this document are available on the uwhealth.medhub.com website. All other UWHC policies are on the UW Health intranet U-Connect. 2014-2015 UWHC Appointment Information for Residents & Fellows Page 1 of 11 A. The primary responsibility of the Resident is to the care of his/her patients and the continuity of care at the hospital to which they are assigned. B. Outside activities shall not adversely affect residents’ primary responsibility to patients at the training institution. No compromise of a patient’s medical care shall occur to fulfill an outside activity obligation. 1. Residents are expected to take into consideration duty hour requirements, patient load, reading requirements, rotations, and other training responsibilities, when scheduling outside activities (e.g., moonlighting), so as not to compromise their capabilities. 2. Residents must follow ACGME, UWHC and departmental policies regarding the scheduling and reporting of outside activities. UWHC policies regarding outside activities are included in the UWHC Code of Ethics. 3. All clinical moonlighting hours must be recorded in MedHub as duty hours and will count toward the 80-hour work week. 4. Programs must not require Residents to engage in moonlighting. 5. UWHC does not provide any liability coverage for moonlighting activities. The resident or the institution/employer where the moonlighting takes place must provide coverage for the moonlighting activities. 6. UWHC does not allow internal moonlighting for non-Board-eligible residents except as Healthlink superusers. 7. Residents training in subsequent sub-specialty training programs may be allowed to do internal moonlighting if the requirements in the UWHC GME policy on Outside Activities including Moonlighting are met. 8. PGY-1 residents are not permitted to moonlight. 9. The procedures for obtaining approval are detailed in the above mentioned policy. 10. All alleged infractions of this policy will be reviewed initially by the Program Director, then by the Designated Institutional Official. Appeals of any decisions may be considered according to the Grievance and Appeals Policy. III. Appointment, promotion and stipend A. Appointments. Also see UWHC GME policies on Resident Selection & Appointment and Evaluation, Discipline, Promotion, Non-Renewal or Dismissal of Residents. 1. Non-discrimination statement. The UWHC does not discriminate on the basis of sex, age, race, color, national origin, religion, sexual orientation or disability or any other applicable legally protected status in appointments to, or conduct of, residency programs. Allegations of such discrimination shall be referred to the UWHC Human Resources Department or GME Office. a) Harassment/discrimination. It is UWHC's policy to provide a work environment free from unlawful discrimination and harassment for all persons. Discrimination and harassment are unacceptable and will not be tolerated. Complaints of discrimination and harassment will be investigated and resolved in accordance with this policy and any applicable federal, state and local laws. A copy of the UWHC Equal Employment Opportunity and No Harassment/ Discrimination/Retaliation Policy # 9.27 is available on UConnect. Harassment or discrimination should be reported to a Labor Relations Consultant in the Department of Human Resources (263-6500) or the GME Office. b) Ethical/religious Beliefs. No Resident shall be penalized for refusing to perform medical procedures he/she finds contrary to his/her ethical or religious beliefs, provided that the Resident has given reasonable notice of such beliefs. However, Residents must complete the training required by the applicable accreditation body before UWHC can certify that the Resident has completed the training program. 2. Initial appointments. Residency and fellowship appointments made through the matching process are made for one year. Residency and fellowship appointments 2014-2015 UWHC Appointment Information for Residents & Fellows Page 2 of 11 made outside the matching process are made for the period specified in the appointment letter, not to exceed one year. 3. Probationary/remedial appointments. If a Resident has been placed on probation due to inadequate scholarship or professional growth and the terms of the probation extend beyond the training year, a special limited-term appointment based on the terms of the probationary letter will be provided. 4. Non-renewal of appointment. Four months written notice with specific reasons for non-renewal is given to a Resident whose appointment may not be renewed. If notice of non-renewal is given less than four months prior to the end of the current appointment, the notice period will run four months from the date it is given, and the Resident will remain at the level in effect at the time notice was given for the fourmonth period. A special limited-term appointment will be provided. 5. Terminations. Terminations for cause during the training year do not require a four-month notice 6. Resident resignation. Residents are required to give three months’ notice, in writing, when intending to leave the program prior to a normal completion date. B. Stipends. 1. Stipend rates. It is the objective of the hospital to maintain house staff stipend levels at the mean of Midwest teaching hospitals. Annual stipend rates will be based on the mean levels reported in the AAMC Council of Teaching Hospitals annual survey and will be adjusted on a yearly basis as necessary. 2. Determination of stipend levels. A Resident’s annual stipend is stated in the letter of appointment. The stipend level is determined by counting the number of years after receiving an MD or DO (or equivalent degree) that have been spent in a training program accredited by the Accreditation Council for Graduate Medical Education that apply toward board certification in the current specialty in which they are training. Residents may receive up to one additional stipend level for a chief resident year or non-accredited research year completed during their training at UWHC. C. Promotions. Appointments beyond the initial appointment are made for one year, except as specified in Section III.A. 3 or 4 above or Section III.D below. A Resident is promoted to subsequent levels in the program unless the Department Chair or Program Director determines that the Resident has demonstrated inadequate scholarship and professional growth. Semi-annual evaluations are provided to apprise Residents of their progress. D. Program closure/reduction policy. Also see UWHC GME policy on GME Program Closure or Reduction. It is the policy of the UWHC to inform Residents as soon as possible of a decision to reduce the size of or close a training program. In the event of such a reduction or closure, UWHC will make every effort to allow Residents already in the program to complete their education. If Residents are displaced by the closure of a program or reduction in the number of trainees, UWHC will make every effort to assist the Resident in identifying a program in which they can continue their education. IV. Requirements of appointment A. Medical school graduation. Appointment to a residency/fellowship program is contingent upon graduation from a LCME-accredited or ECFMG-certified medical school. PG 1s must show proof of medical school graduation at orientation. Graduation of PG 2s will be verified through the AMA profile or the ECFMG. Graduation of PG 3s and above is verified by the WI Department of Safety and Professional Services during full licensure application. B. USMLE or COMLEX. 1. Requirements. a) All PG levels. All Residents entering training at UWHC must have passed USMLE Steps I and II CK (or COMLEX Levels I and 2. b) All PG Levels. All Residents entering training at UWHC must show evidence of passing USMLE Step II CS by October 1st of their first training year at UWHC. 2014-2015 UWHC Appointment Information for Residents & Fellows Page 3 of 11 c) PG 3 and above. All residents appointed to a PG 3 level and above must have passed USMLE Step III or COMLEX Level 3. 2. Exam fees. All exam and reporting fees are the responsibility of the Resident. 3. Score reports. Exam score reports must be sent directly from the examining authority to the UWHC GME Office, 600 Highland Avenue, Room H4/831, Mail code 8320, Madison WI 53792. Full WI licensure (not a TEP) or score reports available to Programs through ERAS or ECFMG reports will be accepted in lieu of exam results sent directly from the examining authority. C. Wisconsin licensure. 1. Requirements. In the State of Wisconsin, all physicians beyond their first year of postgraduate training are required to obtain a Wisconsin medical license. Failure to obtain and maintain a valid and appropriate Wisconsin medical license will result in termination of appointment. a) WI temporary educational permit (TEP). PG1s must apply for a temporary education permit (TEP) to be effective at the beginning of their PG 2 year. At UWHC, the TEP is intended to be used from the first day of the PG 2 year until the full medical license is obtained. b) Full WI medical license. A full WI medical license is a contingency of appointment to a PG 3 year or above at UWHC. 2. License fees. The hospital will pay for the TEP fee ($10) obtained for the PG 2 year for residents that completed their PG 1 year at UWHC. The hospital will reimburse PG 2 residents for the initial license application fee ($165 or $150) upon receipt of full licensure. All other licensure fees are the responsibility of the Resident. D. Drug Enforcement Administration (DEA) registration. 1. Requirements. All Residents will be issued DEA registration upon full licensure. Applications are submitted by the GME Office. Residents must maintain their DEA registration throughout their training at UWHC. 2. Registration fees. The hospital will pay initial application and renewal fees until the last year of training at UWHC. Residents in their last year of training must pay the application or renewal fees for their DEA. Following receipt of the DEA, Residents may request a pro-rated reimbursement from the GME office. E. National Provider Identifier. All residents are required to obtain an NPI. It is the Resident’s responsibility to maintain the correct address information with the NPPES. F. WI Medicaid Enrollment for Prescribing/Referring/Ordering Providers. All residents are required to be enrolled as a prescribing/referring/ordering provider for WI Medicaid, once they are fully licensed and have a DEA. G. Pre-training health assessment and drug screen. In compliance with state law and hospital policy, all Residents must undergo a pre-training health assessment through the Employee Health Service. All Residents must also complete a urine drug screen in accordance with UWHC Pre-employment Drug Testing Policy #9.23 before beginning training. Residents will not be allowed to begin their training program prior to being cleared for work by the Employee Health Service. H. Annual tuberculosis (TB) testing. All Residents must have a TB test at least annually, as required by State regulations and UWHC policy. In conjunction with the pre-training health assessment and annual TB testing, Residents will be fit-tested for appropriate respiratory protection prior to caring for patients. I. Annual Influenza Vaccine. All Residents are required to receive an influenza vaccine or provide documentation of medical or religious waiver by December 1 of each year. See UW Health Influenza Vaccine Policy #9.75. J. Certification of cardiopulmonary resuscitation & other life saving interventions. 1. BLS/CPR. All incoming Residents are required to show current certification or become certified in basic life support or CPR within the first 3 months at UWHC. Certification must be kept up-to-date throughout training at UWHC. 2014-2015 UWHC Appointment Information for Residents & Fellows Page 4 of 11 2. ACLS/PALS. Those Residents required to be certified in ACLS or PALS must also show current certification or be certified within the first 3 months at UWHC. Residents required to be certified in ACLS or PALS must keep their ACLS or PALS certification up-to-date throughout their training at UWHC, as well as their BLS/CPR certification 3. ATLS/Advanced PALS. Those Residents who must be certified in ATLS or Advanced PALS must achieve certification prior to the rotations or PG level for which it is required and must keep their ATLS or Advanced PALS certification up-to-date throughout their training at UWHC, as well as their BLS/CPR and ACLS/PALS certifications. 4. Training fees. Training sessions are held in the hospital throughout the year and are offered at no charge to the Resident. Fees for training obtained outside the UW EEC program will not be reimbursed. 5. Residents are released from other responsibilities to attend the training sessions for certification or re-certification (UWHC Certification Cardiopulmonary Resuscitation and Other Life Saving Interventions Policy # 9.35). K. Dress code. White coats are furnished to Residents. They are laundered by the hospital. Hospital issued photo ID badges are required to be worn. Residents are expected to dress in a professional manner as outlined in the UWHC Dress and Appearance Policy for All Employees #9.16. L. Duty hours. Also see UWHC GME policy on Resident Duty Hours. All Residents must take joint responsibility with their program for abiding by the duty hours requirements of the ACGME and their program. If a Resident finds him/herself in a situation where s/he is approaching the limits of the requirements, s/he must notify his/her Program Director immediately. Patterns of problems experienced by the Resident should be reported to the Program Director and/or the GME Office for correction or the Duty Hours Hotline at 263-8013. M. Caregiver background check. Under Wisconsin law, all Residents must complete a Background Information Disclosure (BID) Form prior to the start of training and every four years thereafter. The Hospital will then perform a criminal and regulatory background check, as required by state law. If certain offenses are disclosed or discovered, the hospital is required by law to terminate an appointment. Completion of the Background Information Disclosure Form and not having a forbidden offense are conditions of all Resident appointments. N. New arrests or convictions. All Residents have a continuing obligation to report any new arrests and/or convictions as they occur, to the GME Office, who will immediately report the information to a Human Resources (HR) Department's Employee and Labor Relations Consultant (ELRC) (608/263-6500). A Resident may be subject to disciplinary action and/or sanctions if they provide false information on a BID form or if they fail to report new arrests, convictions, findings, or license limitations (UWHC Pre-Employment and Renewal Caregiver Background Checks Policy # 9.03). O. Additional conditions of appointment. Each Resident shall notify the Senior Vice President for Medical Affairs or designee within 10 days following the receipt of any of the following. Failure to notify shall constitute grounds for corrective action. 1. Any voluntary or involuntary loss or lapse of any license, registration or certification regarding professional practice; any disciplinary or monitoring measure and any change in such discipline or monitoring measure by any licensing or registration body or certification board that licenses, registers, or certifies clinical professional practice. 2. Any settlements, judgments, or verdicts entered in an action in which the practitioner was alleged to have breached the standard of care other than those arising out of his/her employment by the UWHC or his/her training at the UWHC. 3. Pending disciplinary or other adverse action by a governmental agency or any other action adversely affecting his or her privileges at another health care facility. 4. The voluntary or involuntary termination of medical staff membership or voluntary or involuntary limitation or reduction of clinical privileges at another hospital or institution. The affected Resident shall provide the hospital with complete information 2014-2015 UWHC Appointment Information for Residents & Fellows Page 5 of 11 as to the reasons for the initiation of corrective or disciplinary action and the progress of the proceedings. 5. Each Resident shall notify the Senior Vice President for Medical Affairs or designee within 30 days following the receipt of any notice of complaint or investigation by any licensing or registration body or certification board that licenses, registers, or certifies clinical professional practice. Failure to notify shall constitute grounds for corrective action. P. Notification. The Senior Vice President for Medical Affairs will forward to the Program Director of the applicable training program and Chair of the applicable clinical service a copy of any notice received under sections III.,L, M, or N. Q. No restrictive covenants. No residency or fellowship program sponsored by the UWHC may require that a trainee sign a non-competition guarantee. R. Restriction or Suspension from Clinical Rotations. Residents may be subject to restriction or suspension from clinical rotations by their Program Director, Department Chair or the Senior Vice President for Medical Affairs, or suspension or dismissal from the house staff by the Senior Vice President for Medical Affairs during the term of the appointment for misconduct in violation of standards, rules and regulations of the Medical Staff of the UWHC, the hospital, and its affiliated hospitals or for failure to perform at the academic or clinical level required by their program. V. Leaves. See also the UWHC GME policy on Resident Absences and Leaves. When scheduling leave time, Residents must adhere to the requirements of UWHC, their RRC and specialty board, and get approval from their Program Director. In some cases, the GME Office and the Designated Institutional Official (DIO) must also give approval. Residents should be aware that any leave time taken may extend the length of time required to complete their training. In some cases, space for such additional training time may not be available at this hospital or at the time desired. All leave time must be requested and recorded through the residency management system, MedHub. In addition, the GME Leave Request form must be filled out and forwarded to the GME office where indicated below. A. Family/medical leave. State and federal FMLA/WFMLA laws mandate minimum family and medical leave benefits. 1. Family leave. UWHC will grant one week of paid family leave for the father/partner following the birth of a child or for either parent following adoption of a child. (See medical leave section regarding paid medical leave after childbirth). In addition, UWHC will grant unpaid family leave (leave due to birth of a child, adoption or a serious health condition of a spouse, parent or child, which necessitates the Resident’s care) in compliance with state and federal laws. In order to meet notice requirements, the Resident must contact the GME Office as soon as possible after deciding that he/she intends to take family leave. (Leave Request form required) 2. Sick leave. The Program Director may approve up to one week of paid sick leave per year if needed. For any sick leave exceeding one week, the Resident and program must notify the GME Office. 3. Return to work. Any sick or medical leave of more than 5 days requires being cleared to return to work through UWHC Employee Health. (UWHC Fitness for Duty: Health Service Clearance to Return to Work/Continue Work Policy# 9.22) 4. Medical leave. The hospital will grant unpaid medical leave in compliance with applicable state and federal laws. In the event of a short-term disability (i.e. a temporary inability to work as a result of illness, injury, childbirth, etc), the hospital may grant paid leave for a “usual and customary” recovery period. Paid leave after childbirth shall be four weeks, unless the Resident has continuing medical complications certified by her treating physician. All cases will be individually evaluated by the UWHC Director of Employee Health or designee to determine disability, reasonable recovery period, follow-up requirements, and will consult with the Program Director re: any necessary work-related accommodations. (Leave Request form required) 2014-2015 UWHC Appointment Information for Residents & Fellows Page 6 of 11 5. The Designated Institutional Official (DIO) will determine whether some portion of the leave will be paid. Any approved paid leave longer than 6 weeks will be paid at 75% of stipend, mirroring the long-term disability policy. Paid medical leave will never exceed six months (at which time the hospital-provided long term disability insurance may begin), and in some instances may not cover the entire length of absence. B. Personal leave. A Resident may be granted a leave of absence without pay at the discretion of the Program Director. All unpaid leaves must be reported to the GME Office by the Resident and program. (Leave Request form required) C. Bereavement leave. In the event of the death of a Resident’s spouse/partner, or the child, parent, grandparent, brother, sister, grandchild, (or spouse of any of them), of either the Resident or his/her spouse/partner, or any other person living in the Resident’s household, the Resident is granted time off with pay to attend the funeral and/or make arrangements necessitated by the death. However, time off with pay cannot exceed three (3) workdays. Reasonable additional time off without pay may be granted in accordance with religious or personal requirements and must be reported to the GME Office by the Resident and program. (Leave Request form required if more than 3 days) D. Military leave. Residents may take time off for military service as required by federal and state statutes. The Resident is required to provide advance documentation verifying the assignment and pay to the GME Office. (Leave Request form required) 1. UWHC will pay the excess of a Resident's standard wages over military base pay for military leaves of three (3) to thirty (30) days to attend military schools and training. 2. For Residents who are recalled to active duty, UWHC will pay the difference between the Resident’s wages and the active duty military pay for up to one year (average hospital pay over the past year minus military pay). For the first month of recall, UWHC will pay the difference between the Resident’s base pay and hospital pay. For the next eleven months, UWHC will pay the difference between the Resident’s total monthly military pay (limited to base pay, Basic Allowance for Housing and Basic allowance for Subsistence) and the Resident’s hospital pay. If the Resident’s active duty pay is more than his/her hospital pay, UWHC will not compensate any wages E. Military Family Member Qualifying Exigency Leave (if eligible under the FMLA). Eligible Residents with a covered military family member serving the National Guard or Reserves may take up to 12 weeks of unpaid leave for a qualifying exigency arising out of the fact that the covered military member is on active duty or is called to active duty status. F. Vacation. UWHC Residents are entitled to three (3) weeks paid vacation per year. Three weeks of vacation equals 15 weekdays and 6 weekend days. Vacation may only be taken in full-day increments. This vacation time is to be used during the fiscal year in which it is allotted. In exceptional circumstances, if the Resident is unable to use all allotted vacation during the training year due to service requirements; he/she may carry over unused vacation with prior approval of the Program Director (not to exceed one and a half weeks) to the following year. When the Resident is leaving UWHC permanently, accrued vacation entitlement must be used prior to termination. G. Professional meetings. Each Resident is entitled to a maximum of one (1) week to attend professional meetings each year with pay. The meeting is to be approved in advance by the Program Director and attendance documented. This meeting is in addition to vacation leave. H. Holiday leave. When program patient care responsibilities allow, with Program Director approval, UWHC legal holidays will be observed, and paid leave given. Residents don’t earn or use floating holidays, extra VA holidays or state furlough days. Holidays taken should never exceed the number of UWHC legal holidays as indicated in MedHub. If Residents request time off for religious holiday, in lieu of state holidays, they should be allowed comparable leave where scheduling permits. I. Career development leave. Each Resident is entitled to a maximum of one (1) paid week for fellowship and other employment searches per residency program. Unpaid leave may be granted for additional time. All time used must be approved by the Program Director. 2014-2015 UWHC Appointment Information for Residents & Fellows Page 7 of 11 The GME Office must be notified of any unpaid time granted. (Leave Request form required for any unpaid leave) J. Witness leave. Residents may take time off without loss of pay during regularly scheduled hours of work when subpoenaed as a witness in a matter directly related to their work duties. However, when not called for actual testimony, but instead on call, the Resident shall report back to work unless authorized otherwise by his/her Program Director. Residents needing time off for witness leave must provide advance notice to their Program Director and provide a copy of the subpoena. If a Resident is subpoenaed as a witness in a matter not directly related to their work duties, the Resident must use vacation or, if none is available, take time off without pay. The Resident and program must report unpaid leave to the GME Office. (Leave Request form required for any unpaid leave) K. Jury duty leave. Residents may take time off without loss of pay during regularly scheduled hours of work for jury duty. However, when not impaneled for actual service, but instead on call, the Resident shall report back to work unless authorized otherwise by his/her Program Director. Residents needing time off for jury duty must provide advance notice to their Program Director and provide a copy of the jury summons. L. Time off to vote. An Resident eligible to vote in an election who finds it impossible to vote during non-working hours may be absent from work for up to three (3) hours without loss of pay during regularly scheduled work hours to vote, including travel time. The supervisor can designate the time of day for the absence. The Resident must notify his/her Program Director before Election Day of the intended absence and must submit a written statement in advance to their Program Director explaining why they cannot vote during non-working hours. NOTE: All Residents are strongly urged to vote during non-working hours or by absentee ballot. Contact the clerk of your municipality for more information. M. Exam leave. Residents may take time off without loss of pay for up to 2 days per year to take required licensure or certifying Board exams. Time must be scheduled ahead of time with approval of the Program Director. N. Accrual of leave time. No leave time described in Section IV is accrued for Residents except as described in Section IV. F. Vacation above. VI. Benefits A. Liability insurance. Comprehensive liability protection is provided for all Residents for any training-related incident. Protection is granted for specific training activities approved by the Program Director and the UWHC Risk Management Office for activities that take place outside the UWHC. No protection is provided for activities outside the scope of the training program, such as moonlighting or unapproved electives not related to the program. Additional information on coverage can be found in the Liability Protection for Health Professionals information on Uconnect, the UWHC intranet. B. Disability insurance. All Residents are covered by a hospital paid long-term disability plan. Details on the current disability insurance plan are available in the GME Office. C. Optional insurance and benefit plans. Residents employed by UWHC are eligible for a variety of optional insurance plans, at additional cost. Resident contributions for these insurance plans can be made through payroll deduction. Additional information on these plans, including enrollment deadlines and premiums, is available in the GME Office and Human Resources Benefits Office. 1. Health insurance. Residents can choose from a variety of comprehensive health plans, including one fee-for-service plan and several health maintenance organizations (HMOs). Individual and family coverage is available. Most HMO plans include basic dental coverage. Residents are also eligible for supplemental major medical, dental, and vision insurance coverage. 2. Life insurance. Residents are eligible for two term life insurance plans, the supplemental life insurance and the UW Employees Inc plan. 2014-2015 UWHC Appointment Information for Residents & Fellows Page 8 of 11 3. Accidental death and dismemberment insurance (AD&D). AD&D insurance pays benefits for accidental loss of life, sight, or limb. Residents are eligible for individual or family coverage. 4. Tax sheltered annuity/deferred compensation programs. Residents are eligible to participate in a variety of tax-sheltered annuities and deferred compensation retirement plans. Contributions to the tax sheltered annuity (403b) and deferred compensation plans are made on a pre-tax basis, reducing federal and state taxable income. The contributions purchase retirement benefits that are not taxable until distribution is made, usually at retirement. 5. Employee reimbursement account (ERA). The ERA program allows Residents to pay for certain expenses, including dependent care and/or approved out-of-pocket medical expenses, with pre-tax rather than after-tax income. The amount of contribution directly offsets taxable income, resulting in reduced federal and state income tax, and social security tax liability. 6. Benefit Continuation The Resident’s insurance benefits will continue during a paid leave and up to three months of an unpaid leave under the same circumstances and conditions as existed prior to the leave, as long as the Resident continues to pay his/her share of the premiums. Beginning the fourth month of an unpaid leave, the Resident will be responsible for the entire health insurance premium. D. On-call meals. 1. In-house call. Residents scheduled to be on in-house call at UWHC overnight are provided with the evening meal the night they are on-call and breakfast the following day. 2. Home call. Core specialty residents who are on-call from home and required to be in the hospital during the night and are unable to return home are provided with a prorated breakfast and lunch the following day. Residents in programs averaging 65-88 hours/week will receive the extended meal card rather than the pro-rated card. 3. Extended call. Core specialty residents working 14-hour shifts will be provided with an extended meal card in lieu of the pro-rated home call card. 4. Food in workrooms. The hospital delivers food to the house staff workroom (F5/606) and the resident workroom at AFCH every evening for Residents who are oncall and are unable to obtain an evening meal during cafeteria hours. 5. Meriter, St. Mary’s and Veterans Administration hospitals provide meals, with limits established by the individual hospital. E. On-call rooms. On-call rooms are provided for Residents required to be in the hospital overnight. A workroom with computers, a television, refrigerator, and microwave oven is also available (F5/606) and at the AFCH. F. Parking. Parking is available to Residents. Fees are set annually by the University of Wisconsin. Additional information can be obtained in the GME Office. G. Safe escort. An after-hours safe escort to a distant parking lot is available by calling UWHC Security. Access details are posted on MedHub. H. Inclement weather car service. During periods when local weather conditions indicate a reasonable probability that Residents who are parked on UWHC grounds may have difficulty getting their car started, UWHC will provide free jump starts Contact the Security Office if assistance is needed. Access details are posted on MedHub. I. Safe Ride Home. In the event of fatigue following an extended duty period, a Resident will be reimbursed for taxi fares home and back to the hospital, if needed. J. UW affiliate photo ID (WISCARD). The University of Wisconsin affiliate photo ID allows Residents to access library services and recreational facilities on the UW campus. The ID also qualifies Residents for discounts at various local businesses. K. Membership on Medical Staff committees. Residents have voting representation on the UWHC Medical Board and its committees. These representatives are selected jointly by the Chair of the Medical Board and the President of the House Staff Association. 2014-2015 UWHC Appointment Information for Residents & Fellows Page 9 of 11 L. Counseling and support services. Confidential counseling, support and assistance with issues such as psychological, marital, legal and financial problems are available to all Residents and their immediate family at no cost through the Life Matters Employee Assistance Program. Information is available in the GME Office. M. Physician impairment. See also the UWHC GME Impaired Resident Summary policy. The Life Matters Employee Assistance Program is available to assist Residents with issues of impairment including substance abuse, mental disorders and physical disabilities. Information is available in the GME Office. N. Ombudsperson. The Ombudsperson is available to serve as a neutral, independent and confidential resource, for faculty, Residents and students, for dealing with conflicts with your colleagues that arise during the course of your training. The Ombudsperson can listen to your concerns, clarify procedures, discuss options and when appropriate, may act as an intermediary. The Ombudsperson can be reached by calling 265-9666. O. Resident Confidential Complaint Hotline. Residents that have exhausted intradepartmental complaint resolution mechanisms may call the hotline at 263-8013 for additional assistance. VII. Appeals of Resident Evaluation, Discipline, Non-renewal or Dismissal Decisions. The UWHC GME policy on Appeals of Resident Evaluation, Discipline, Non-renewal or Dismissal Decisions details the process that provides residents with fair, reasonable, and readily available procedures for appeals and due process. The intent of the policy is to minimize conflict of interest by adjudicating parties in addressing academic or other disciplinary actions taken against residents that could result in dismissal, non-renewal of a resident’s agreement, non-promotion of a resident to the next level of training, or other actions that could significantly threaten a resident’s intended career development. VIII. Resident Grievances related to Employment Concerns. The UWHC GME policy on Resident Grievances related to Employment Concerns details the process that: A. Provides residents with fair, reasonable and readily available procedures for grievance and due process. It is recognized that misunderstandings, disputes or disagreements may occur related to the: 1. Work environment 2. Issues related to the program or faculty 3. Interpretation of the terms of UWHC Graduate Trainee Appointment Information Document 4. Application of the program’s and/or hospital’s policies and procedures affecting residents. This list shall hereby be called employment concerns. B. The policy does not apply to academic or other disciplinary actions taken against residents that could result in dismissal, non-renewal of a resident’s agreement, non-promotion of a resident to the next level of training, or other actions that could significantly threaten a resident’s intended career development. See UWHC GME policies on Evaluation, Discipline, Promotion, Non-Renewal or Dismissal of Residents and Appeals of Resident Evaluation, Discipline, Non-Renewal or Dismissal Decisions. C. This procedure does not apply to allegations of discrimination based on sex, age, race, national origin or disability. Such allegations shall be submitted to the UWHC Human Resources Department. IX. GME Appeals Committee. The GME Appeals Committee, a standing committee of the Medical Staff, is appointed to deal with grievances and appeals of non-renewal decisions filed by Residents. Members are appointed by the President of the Medical Staff. The committee consists of two members of the Medical Staff plus one alternate and three Residents plus one alternate. The Committee Chairperson is appointed by the President of the Medical Staff from among the committee members. The alternate(s) serve in case of a conflict of interest of any member. X. Additional Resources The following UWHC policies and resources are available on uconnect, the UWHC intranet. UWHC Bylaws and Rules & Regulations of the Medical Staff 2014-2015 UWHC Appointment Information for Residents & Fellows Page 10 of 11 UWHC Code of Ethics UWHC Liability Protection for Health Professionals UWHC Equal Employment Opportunity and No Harassment/ Discrimination/Retaliation Policy # 9.27 UWHC Pre-employment Drug Testing Policy # 9.23 UWHC Pre-Employment Health Assessment Policy # 9.20 UWHC Certification Cardiopulmonary Resuscitation and Other Life Saving Interventions Policy # 9.35 UWHC Dress and Appearance Policy for All Employees # 9.16 UWHC Pre-Employment and Renewal Caregiver Background Checks Policy # 9.03 UWHC Fitness for Duty: Health Service Clearance to Return to Work/Continue Work Policy # 9.22 UWHC Employee Assistance Program Policy # 9.15 UW Health Influenza Vaccine Policy #9.75. The following UWHC GME policies are available on uwhealth.medhub.com,the residency management system. UWHC GME policy on Outside Activities including Moonlighting - Resident/Fellow UWHC GME policy on Resident Selection & Appointment UWHC GME policy on Evaluation, Discipline, Promotion, Non-Renewal or Dismissal of Residents UWHC GME policy on GME Program Closure or Reduction UWHC GME policy on Resident Duty Hours UWHC GME policy on Resident Absences and Leaves UWHC GME Impaired Resident Summary policy UWHC GME policy on Appeals of Resident Evaluation, Discipline, Non-renewal or Dismissal Decisions UWHC GME policy on Resident Grievances related to Employment Concerns For incoming residents, all of the above policies are available on a CD upon request from the GME office, uwgme@uwhealth.org or 608-263-0572. APPROVAL: Graduate Medical Education Committee March 20, 2013. GMEOC November 20, 2013 2014-2015 UWHC Appointment Information for Residents & Fellows Page 11 of 11
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