Neuroscience Clerkship

 

 

Neuroscience Clerkship Clinical Sites


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.