CLEVELAND VETERANS AFFAIRS MEDICAL
CENTER
NEUROLOGY SERVICE
To: Medical Students
From: John S. Stahl, MD, PhD, VA Neuroscience Clerkship Director
Re: What you need to know
Welcome to the Neuroscience rotation at the Louis Stokes Cleveland
Veterans Affairs Medical Center. We hope you will get the most out of your month with us.
At the VA, a single neurology service covers inpatient and consultative duties, as well as
two outpatient clinics. Volume tends to be lower than at UHC, but there is a wide variety
of diagnostic problems to see. Furthermore, since reimbursement issues are a minor
concern, the team has the leisure to investigate complex diagnostic issues in the
inpatient setting. The VA setting will reward the student who takes the initiative to
insert himself or herself into cases, irrespective of whether the cases present in the
clinic, on the consultative service, or on the ward service.
The following is a semi-organized list of all the things you will need
to know:
WHERE: The Neurology workroom is in room 2424 (ext. 4853 or 4854).
Most neurology inpatients are on Ward 52. Neurology clinics occur in the orange hallway on
the ground floor near admitting. Meet in room H104.
WHO: The team consists of the attending, one senior (PGY4) resident,
1-2 junior (PGY2) neurology residents and/or 1-2 psychiatry rotators, plus students (you).
The attending, junior residents, and rotators switch services on the first of the month.
The senior resident switches on the fourth of the month. The senior resident carries the
service pager (31317) from 8A-4P and organizes the workload for the team. From 4P-8A the
service pager is carried by whoever is on call. The senior resident generally handles the
consults during the day while the junior residents are occupied with service patients.
However, the senior resident can divide up the work as he/she sees fit. Make a point of
sticking to the senior resident to assure you get a crack at new evaluations, since the
senior resident will usually be too busy to look for you.
Other people you should know of: Deborah Downey, RN (x5216, page
388-1042) is the service nurse and handles a lot of the outpatient administrative issues.
Nancy Adams, PhD (x4253, page 982-8957) is the neuropsychologist. Kathy House (x4243, page
982-7543) is the unit social worker. Robert Ruff, MD, PhD is the service director. Other
important names and telephone numbers are posted on the bulletin board in the workroom on
the 2nd floor.
WHEN: Work rounds start in the workroom on the 2nd floor. Times are
resident/attending dependent, but generally things start somewhere between 7-8 AM. The day
ends when the work is done and/or you are released by the senior resident. Leaving early
because things are quiet is discouraged, because at the VA you never know when the new
patients will appear.
Other important times for the VA:
Monday, 10:00 AM: interdisciplinary rounds (MD's, nursing, social
work, therapy, etc. discuss patient disposition).
Monday, 1:00 PM - whenever (generally 5:30, can be as late as 7 PM):
outpatient clinic
Tuesday 9 AM - 12:30 (sometimes 1)PM: "screening clinic."
The name is historical rather than accurate. This clinic is a mixture of multiple
sclerosis, dizziness, epilepsy, new patients, emergent referrals, and some people who can
only come to a Tuesday clinic. Epilepsy patients should be left to Dr. Swartz and her PA
Jo Altemus unless Dr. Stahl/Leigh or Nurse Downey volunteer your services to Dr. Swartz.
Thursday: although this is your lecture day, you are strongly
encouraged to make an appearance before or after lectures to maintain participation in the
cases you are following.
OTHER ISSUES:
Computer: all work at the VA is conducted via the CPRS computer
system. You will need an ID, access code, and signature code in order to participate in
patient care. These can be obtained from the education office, x-4111 and should be
obtained prior to starting the month. Do not ask residents for their codes.
Constructing follow-up computer notes via "cutting and pasting" is discouraged,
as it generally leads to inclusion of old data that may no longer be valid, and fills the
record with extraneous junk. Moreover, even if you have repeated all aspects of the exam,
a reader faced with a verbatim copy of a previous exam has no way of knowing that the exam
was actually repeated.
Parking: On-site parking is scarce at the VA during regular working
hours. Off-site parking is available at 116th St and Euclid Avenue, but the shuttle
between the VA and the off-site lot only operates between 6:30AM and 6:30 PM. For those
with parking at CWRU, it is recommended that you park at your regular site and then walk
to the VA. The VA Police are highly vigilant and will ticket students and MD's who park
illegally.
Write-ups: At the VA, the number of new admissions is
smaller than at UHC, so keep in mind that you may choose consults or outpatients as well
as inpatients as the subjects for your write-ups. If an outpatient, then the patient need
not be new to the clinic, but the problem being assessed/evaluated should be a new problem
for that patient, and the write-up should include a discussion of the differential as well
as a diagnostic plan. Please note that these academic ponderings should not be entered
into the patient chart - they are for learning purposes only. We recommend that you form
your assignment write-ups by cutting and pasting your chart notes to Word, and then
extending the discussions. Since the focus of this month is on the neurologic examination,
your write-ups should document the neuro exam in detail - statements such as "II-XII
intact," or "non-focal" are not acceptable.
Call: call requirements are the same as for other clerkship sites.
Because resident call at the VA is not taken in-house, you will need to arrange with the
resident on-call to telephone or page you if they are going in to see a consult.
Alternatively, instead of choosing a night to be "on-call," you might simply
stay late working with residents to complete the consults called in during the day. You
can repeat this tactic until you have stayed late for the number of days equivalent to the
"on-call" requirement. This strategy is in fact more likely to generate contact
with new patients than waiting at home for a call that might not come.
Outpatient clinics, the ropes:
1) Obtain an exam room. Available rooms (those assigned to
Neurology) are listed on the blackboard. Place your name on the board next to the room
number.
2) Obtain a patient (Nurse Downey or one of the attendings will
assign).
3) Review the case just enough (5 minutes, max) so that you can
ask an attending for guidance if you have no clue how to proceed, and so that the patient
thinks you have some idea who he/she is.
4) Bring patient to room.
5) Do further review in the presence of the patient. For
established patients, be sure to review the plans from at least the most recent 2-3
neurology notes (not just the most recent one) to assure that aspects of the plan have not
become unhinged and also that all tests ordered have been followed up on.
6) Interview/examine.
7) Write up history and examination on the computer in your exam
room.
8) Present to attending. Ideally choose the attending who has
been most closely associated with the patient in the past. If that attending is occupied,
ask him/her if you should present the patient to a different attending. Make sure you have
agreed with attending as to follow-up interval and called to his/her attention any rx that
needs to be refilled so the patient will not run out of medications prior to the next
neurology appointment.
9) Complete the encounter form (add attending name, level of
service (new or established, don't use consultation section), diagnoses (one primary
diagnosis and up to two secondary diagnoses. Avoid using the write-in diagnosis unless you
are pretty sure the clerk is going to be able to match the diagnosis you devise with an
ICD-9 code). Write on front the follow-up (e.g., "RTC 3 months").
10) Complete the note, identify the attending as a cosigner, and
sign. Note that if the attending disagrees with an aspect of your exam, demonstrates
additional important findings, or uncovers additional important history, these points
should be added to your note. Therefore, stay alert and take notes when the attending is
seeing the patient with you! 11)go back to #2. You should try to complete steps 3-7 in 45'
for new patients and 30' for old patients.