Harborview Medical Center
Inpatient Neurology Service
Will Longstreth, MD
Department of Neurology, Box 359775
Harborview Medical Center
325 9th Avenue
Seattle, WA 98104-2420
Phone: (206) 744-3251
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.
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
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
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.
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
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.
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
Methods Used in Evaluating Resident and
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
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