Harborview Medical Center

Inpatient Neurology Service

Faculty Content
Will Longstreth, MD

Department of Neurology, Box 359775
Harborview Medical Center
325 9th Avenue
Seattle, WA 98104-2420

(206) 744-3251
Email: wl@uw.edu

Overall Educational Purpose
The main purpose of this rotation entails the introduction of first year medicine residents to the essentials of clinical neurology. Most important is the ability to perform a detailed neurologic history and neurologic examination. With this information, residents will learn to form an initial plan for patients with a variety of common neurologic conditions. This plan often includes imaging of the nervous system. Residents will be introduced to concepts dealing with the appropriate ordering of neuroimaging studies, the initial interpretation of such studies, and the influence of these results on initial management plans.

Team Structure
The inpatient neurology service is divided into two teams. Each team comprises a neurology attending, a senior neurology resident, a junior neurology resident, two first-year medicine residents, and one to two third or fourth-year medical students. The post-call team's ranks swell to include a mid-level practitioner, pharmacist, and dietitian.

Principle Teaching Methods
Case discussion and review
All patients admitted to the neurology inpatient service are cared for by the teams described above, which alternate call. Much of the teaching involves discussions and reviews of these patients by the team members. Typically, the medicine resident will present information collected on a patient and will review and discuss this information with the neurology residents and attending.

All patients on the neurology service are seen on work rounds and reviewed by the team. On weekdays, neuroimaging rounds follow work rounds. During these sessions, all of the patient’s neuroimaging studies are reviewed with a neuroradiologist. Attending rounds are conducted at least three times a week at variable times. Typically, these rounds concentrate on clinical questions raised during work rounds or neuroimaging rounds. Alternatively, they may focus on other topics of general interest to the team.

The activities described above are supplemented by conferences that include general conferences, discipline-specific conferences such as neuroradiology and neuropathology, and disease-oriented conferences such as related to stroke and epilepsy. The required conferences for the medicine residents include the patient management conferences held on Tuesday mornings and the medicine resident core conferences held mostly on Friday mornings. These latter conferences cover the essentials that the medicine residents are expected to learn during the rotation. The conferences concern: clinical neuroimaging; stupor and coma including meningitis; stroke including the use of antithrombotics; and epilepsy including the treatment of status epilepticus. In addition, on the first Friday morning after starting the rotation, which always begins on a Wednesday, the medicine residents have an orientation and a review of the neurologic examination.

Educational Content
Mix of Diseases
Harborview Medical Center has a mission to care for certain otherwise underserved patients, and such patients are well represented on the neurology service. The main groups of patients seen include those with stupor and coma, stroke, and epilepsy. Few cases represent pure neurologic problems but rather with an overlap with medical problems, neurosurgical problems, and psychiatric problems. Patients with infectious diseases of the nervous system are not as common as these other categories of patients but are well represented on the service.

Patient Characteristics
Patients of all ages appear on the service, although the vast majority are adults. Many ethnic groups are represented, and cultural and language differences are often an added challenge. Both men and women are seen in approximately equal numbers.

Types of Clinical Encounters
Virtually all of the patients are seen in an inpatient setting. The medicine residents will often initially evaluate a patient in the Emergency Room or the Urgent Care Clinic along with a neurology resident. In addition, the medicine residents are encouraged but not required to attend outpatient general neurology clinics, which occur twice a week. In the outpatient setting, they have the opportunity to see conditions not commonly seen on inpatient service, including headache, cervical and lumbar pain syndromes, dizziness, multiple sclerosis, movement disorders such as Parkinson’s disease, peripheral neuropathies, and other conditions.

In their work on the wards and in the intensive care units, the medicine residents may have opportunities to learn and practice procedures common to this work. Supervision for the procedures is provided either by the neurology residents or the critical care fellows. The rotation also provides the opportunity to perform lumbar punctures under supervision. In addition, lumbar punctures are also performed in a weekly outpatient procedure clinic.

A full array of services is available for diagnosis and treatment of patients with neurologic diseases. Neuroradiology has available a variety of imaging modalities including CT, MR, and conventional angiography. Non-invasive vascular evaluations are available for both the extracranial and intracranial vessels feeding the brain. Echocardiograms are also often performed as part of stroke workups. Nuclear Medicine has available SPECT to assess cerebral blood flow. An electrodiagnostic laboratory is able to perform electromyography, nerve conduction velocity studies and a full array of evoked potential studies. The Regional Epilepsy Center is located at Harborview Medical Center so conventional electroencephalography as well as inpatient video EEG monitoring is available to the neurology service. Other services with which the neurology service commonly interacts, given the nature of the patients, include Neurological Surgery, Rehabilitation Medicine, and Psychiatry.

Rotation Specific Schedule
Each morning begins with a morning report during which the activities on the neurology service are briefly reviewed. These activities include cross-cover activities from one team to the other, new admissions to the service, and consultations that need followup. Work rounds are then performed by each of the teams and are followed by neuroimaging rounds. On weekends and holidays, the imaging rounds are held informally on an ad-hoc basis. Attending rounds are scheduled variably and are either held late in the morning or early in the afternoon. General neurology clinic occurs on Monday afternoon and Thursday morning. Medicine residents are invited but not required to attend clinic.

The patient care conferences are held on Tuesday mornings at 7:00 to 8:00 a.m. The didactic talks for medicine residents are held mostly on Friday mornings at 11:00 a.m. to noon. The orientation for the medicine residents and review of the neurologic examination is held on the first Friday of the rotation.

Brain cutting is held on Thursday morning and Neurology Grand Rounds are held on Thursday afternoons.

Specialty conferences are scattered throughout the week, including Epilepsy conference on Monday, late in the morning, Neurosurgery and Neuropathology conferences on Wednesday morning and Stroke conference on Friday afternoon.

Call and Weekend Responsibilities
The medicine residents are on call every fourth night. There are four residents, two on each team. They are always on call with a neurology resident. A senior neurology resident and neurology attending are always available for backup. If a medicine resident is not on call or post-call on a weekend day, they do not come to the hospital.

Principal Educational Materials
Recommended Readings
Senior neurology residents and attendings make papers available pertinent to the patients being cared for the medicine residents. In addition, a set of key references is available and filed in the neurology team room. A collection of key figures and information is included in transparencies to aid in teaching. Additional references are available through the online databases organized in “Healthlinks.” A Department of Neurology library at Harborview is well stocked with journals and books, with access available to medicine and neurology residents 24 hours a day upon request.

Pathologic materials
The Division of Neuropathology in the Department of Pathology is located at Harborview Medical Center and is fully accessible to the members of the neurology service. Brain cuttings are performed on Thursday mornings and are open to all physicians with an interest. Teaching files are also available through Neuroradiology, although with the weekday neuroimaging rounds, typically little need exists to turn to these files for interesting material.

Methods Used in Evaluating Resident and Program Performance
At the end of the rotation, the resident is evaluated in writing and their performance reviewed with them verbally by every attending and fellow he or she has interacted with for a substantive amount of time. The evaluator rates the resident on a nine-point scale in each component of the clinical competence (i.e., patient care, medical knowledge, practice based learning improvement, interpersonal and communication skills, professionalism, system based learning, educational attitudes, leadership, overall clinical competence).

The resident is given the opportunity to evaluate in writing the quality of the curriculum and the extent to which the educational goals and objectives of the rotation have been met. The resident also evaluates the teaching competence of each attending and fellow with whom the resident has interacted for a substantive amount of time.

Explicit Lines of Responsibility for Care of Patients on this Service
The first year medicine residents report directly to the neurology resident with whom he or she is working. In regular hours, this is the junior neurology resident. In off-hours, this is the on-call neurology resident. The neurology resident, in turn, reports to the neurology chief resident who, in turn, reports to the neurology attending. As needed, help is sought from other services, depending on the problem. In the intensive care units, critical care fellows and attendings are available for consultation.


Last Revised February 25, 2004 by Will Longstreth, MD