Essentials of Training

Core Rotations

Stroke Service

The PGY2 neurology resident spends two months on the Stroke Service at Presbyterian University Hospital. Three neurology residents will be on the stroke service at all times as well as a senior internal medicine resident. The Stroke Service is a very busy clinical service supported strongly by the community, and conventional referrals throughout Western Pennsylvania, Southern New York, Eastern Ohio and Northern West Virginia, as well as increasing numbers of telemedicine referrals from those regions. Three Interventional Vascular physicians are available in addition to other stroke faculty. Attending rounds start daily at 9 am. All images are reviewed with faculty and discussions of patient care center around evidence based medicine. Equal emphasis is given to acute care issues and secondary stroke prevention. The neurology residents cooperate with the Vascular Neurology Fellows in managing new patients as well as emergency room consults and transfers. The resident is given the opportunity to manage many patients who require t-PA, intra-arterial thrombolysis, intra-arterial clot retrieval, and stenting of carotid or vertebrobasilar arteries, as well as intracranial hemorrhages. PGY-3 and PGY-4 neurology residents serve as senior residents on the service. Record keeping is electronic. Many patients are evaluated remotely via telemedicine before transfer to the UPMC stroke service. Residents are introduced to this important educational opportunity depending on their individual level of interest.

Neurology Consultation Service

The PGY2 neurology resident will spend one or two months on the Neurology Consultation Service at Presbyterian Hospital. This includes consultations from Presbyterian Hospital, Montefiore Hospital, Western Psychiatric Institute and Clinic, and Magee Women’s Hospital. The PGY2 resident will always be with a PGY3 or PGY4 resident, who serves as the senior resident on the service. In most cases, two medical students as well as a psychiatry resident will be on the service; occasionally residents from other services such as Internal Medicine may be on the service. All consultations are seen initially by a resident or medical student and then presented to the attending physician. All imaging is reviewed and case discussion centers on the literature and evidence-based medicine. Emergency room consultations are also seen by the consult team during the day. The resident encounters an exceptionally wide variety of cases on this service, many demanding acute management, including patients from medical and surgical intensive care units, the neurosurgery and trauma services, surgical subspecialty services, transplantation services and the transplant ICU, and internal medicine and medical subspecialty services. A wide variety of psychiatric and obstetrical/gynecologic patients are also seen.

Presbyterian Ward Service

PGY-2 residents spend one or two months on the neurology ward service. The service includes all patients other than stroke admitted to neurology. The PGY2 residents will be with a PGY3 or PGY4 resident during their rotation. Attending rounds are made daily, with a strong emphasis on bedside teaching and evidence-based medicine. Historical and physical findings, localization, differential diagnosis, and management are discussed thoroughly, and imaging is reviewed daily. The PGY2 resident is given progressive responsibility for medical decision making as he/she progresses through the year. The service offers exposure to acute and chronic neurological problems, including complex diagnostic issues. A wide variety of patients with MS, epilepsy, headache, nervous system infections, spinal cord disease, movement disorders, and neuromuscular disorders, is encountered. The residents are able to follow most patients after discharge in resident continuity clinic or subspecialty clinic.

Oakland VA Hospital

The PGY(2) resident also rotates one or two months at the Oakland VA Hospital. This is a very large VA facility serving the needs of Western Pennsylvania as well as some sites in Ohio and West Virginia. Mornings are spent in the general and subspecialty outpatient clinics. The gamut of neurological disorders is encountered and the consequences of traumatic brain injury diagnosed and managed. On Thursday mornings, a lumbar puncture clinic is held. As on other services the PGY2 resident is always with a PGY3 or PGY4

Epilepsy Monitoring Unit/EEG (Presbyterian Hospital)

PGY-2 residents man the EMU service, and admit and manage patients with a variety of episodic behaviors. Many patients are admitted for EEG analysis of seizures to determine suitability for epilepsy surgery or grid placement. Attending rounds are made daily, and EEGs reviewed daily.
This rotation serves as the residents’ introduction to clinical EEG interpretation.
A primer on EEG interpretation is required reading.

Child Neurology

Each resident spends one month each year on the child neurology service. The residents are supervised by child neurology residents, and evaluate and manage neurology inpatients and consultations, including emergency room consultations. Also, urgent consultations from pediatric outpatient clinics are seen. Attending rounds are made daily on all patients. Pediatric EEG interpretation, including stat EEGs, is incorporated into this rotation. Weekly case conferences and neuroimaging rounds are choice components of this experience. Residents are given progressive responsibility for case management as they proceed through the program. The adult neurology resident on the child neurology rotation can view the daily adult didactic conferences via teleconferencing.

Night Float

Night call is coordinated by a night float system. A senior and junior neurology resident work together. Duty hours begin at 6pm and end at 8am, from Sunday night through Friday night. When the resident departs on Saturday morning, he or she does not return until Sunday at 6pm. Each rotation is for two weeks. The residents cover calls from the neurology inpatient and stroke services, manage new admissions, and cover neurology consults from the emergency room and hospitals. If any patient seen in the emergency room is discharged without admission, the case must be discussed with a neurology attending. Weekend shifts are covered by the remainder of the residents who are not on night float, and are infrequent. These are the daytime shifts on Saturday and Sunday, and the Saturday night shift. Neurology residents never work during the day after being on at night.

Intensive Introduction to Clinical Neurology (Boot Camp)

PGY-2 neurology residents begin their training in July in the classroom with this unique activity. This course, lasting three to four weeks, is extremely popular with our residents, and intensively reviews functional neuroanatomy and the principles of neurological localization through the study of multiple cases. The neurological examination is taught as an exercise in functional neuroanatomy. Many introductory lectures on neuroimaging and EEG interpretation are included. The sessions begin daily with lectures on common topics in neurology by the faculty; early-afternoon lectures are given by senior neurology residents covering neurological emergencies. At the end of the course, the residents each examine the program director, and must explain the anatomy underlying each structure or system tested, and must demonstrate professional technique appropriate to a neurologist. The course prepares new residents for clinical services, and is received enthusiastically. Night call is very light during this course.

Neurocritical Care

PGY-3 residents take a one month block in neurocritical care. The team is spearheaded by members of the neurology department who are neurocritical care specialists. Teaching and care rounds are made daily and the residents are able to participate in adult neurology didactics and grand rounds. Emphasis is placed on management of intracranial pressure, blood pressure and cerebral perfusion. Opportunities for multiple procedures are abundant. A reading list of seminal papers is supplied. This rotation is Monday through Friday with no dedicated night call. Attention is directed to neuromuscular emergencies, such as myasthenia or acute demyelinating neuropathies as well as central nervous system conditions.

Psychiatry

This is a required one-month rotation generally taken in the PGY-4 year. The resident rotates at the Western Psychiatric Institute and Clinic (WPIC). Goals are proficiency in basic psychiatric diagnosis, recognition of psychiatric emergencies, and comprehensive knowledge of drugs employed to manage psychiatric disorders, and the side effects of these agents. Emphasis is also placed on addiction and recognition and management of withdrawal syndromes. Basic management of depressive disorders, and acute management of delirium are also stressed. Sections from the Handbook of Clinical Psychiatry are required reading.