Proposal for changes in the structure of the neurology residency program

The forthcoming GME meeting will be discussing changes to the current residency training structure. The current residency's rotation structure, academic schedule, responsibilities of residents and the on-call schedule can be modified for more efficient working and learning. The following is my version of a better-structured program, assuming a total of 18 residents (6 in each year). I am distributing these suggestions to the GME committee and to the residents for review and comments. These suggestions are meant to serve as a springboard from which a discussion can ensue, both by the faculty and the residents.

Current Neurology residency rotation structure

PGY2
4 months as junior resident at ENC floor
4 months as junior resident at VA floor
2 months in New Neurology at VA
1 month Neuroradiology
1 month vacation

PGY3
3 months of Child Neurology
2/3 months as floor senior resident at ENC/VA
2 months HAC floor senior resident
1 month New Neurology at VA
1 month EEG/EMG
1 month neuropathology
1 month elective

PGY4
7 months as consult resident at ENC / HAC / VA
1 month as floor senior resident at VA
1 month New Neurology at VA
3 months elective

Chief residents
2 chiefs are selected from PGY4 and are responsible for on-call and teaching schedules for the year.

Proposed Rotation structure

PGY2
4 months as junior resident at ENC floor
4 months as junior resident at VA floor
2 months in New Neurology Clinic at VA
1 month Neuroradiology
1 month vacation

PGY3
2 months as consult resident at ENC
2 months as consult resident at HAC
2 months as consult resident at VA
3 months of Child Neurology
1 month EEG
1 month elective
1 month vacation

PGY4
2 months as chief resident at ENC
2 months as chief resident at HAC
2 months as chief resident at VA
1 month Neuropathology
1 month psychiatry
1 month EMG
1 month Neurosurgery / NICU / Rehab
1 month elective
1 month vacation

Chief residents
Apart from the PGY4s who are in charge of a particular site (named 'chief residents' above), there will be two 'Super Chief residents' who will be responsible for planning the on-call and teaching activities for the year.

Site structure

ENC
The PGY4 is in overall charge of the floor and consult service. Rounds with the PGY2s on the in-patients and also rounds on the consults that have been seen by the PGY3. Also is in charge of directing and allocating responsibilities to medical students and other rotators on the neurology service. Two PGY2s are directly responsible for the neurology floor patients. One PGY3 is directly responsible for consults from the ED and other services at ENC.

HAC (no neurology floor service)
The PGY4 is in overall charge of the adult and child neurology consult services. Rounds with the PGY3s (adult and pediatric neurology consult residents) with the respective consult attendings. Also is in charge of directing and allocating responsibilities to medical students and other rotators on the neurology service. One PGY3 is directly responsible for the adult consults and from the ED, Urgent Care and other services. The PGY3 rotating through child neurology is responsible for the pediatric consults from the ED, Urgent Care and other services.

VA
The structure is similar to that at ENC. However, see the 'Comment on the VA' section.

Attending structure

ENC and HAC
1 attending of the month is responsible for morning report, rounding on adult neurology consults at ENC and the non-stroke patients at ENC floor. A second attending would be responsible for consults at HAC for the month. Stroke attending and fellow are responsible for all consult and floor stroke patients. 2-3 attendings would be responsible for conducting morning report for the entire year.

Call structure

PGY2s will do in-house calls at the ENC and VA and will be responsible for floor patients and consults from the ED and other services. They will call either the stroke beeper (for stroke patients) or the Chief resident on call (for non-stroke patients). PGY3s will do in-house calls at HAC and will be responsible for adult and pediatric neurology consults form the ED and other services. They will call either the stroke beeper (for stroke patients) or the Chief resident on call (for non-stroke patients). One of the Chief residents (PGY4s) will be the second on call for non-stroke patients who are seen by the in-house resident at the ENC, HAC or VA.

Currently, 3 residents stay in-house every night for calls. If this were to continue, the PGY2s and PGY3s would to do q4 calls for the first two years and the PGY4s would do back-up calls from home when they are chief residents (since there would be 3 chief residents for each month, they could share the back-up calls for the month). The possibility of covering the West Roxbury VA service from home should be explored; that would reduce the required number of residents in-house to 2 per night and would dramatically reduce the call burden on the residents.

Comment on the VA

Currently, the JPVA consists of an in-patient neurology service (run by 2 PGY2s and 1 PGY3/4), a consult service (run by 1 PGY4) and a new neurology clinic (run by 1 PGY2, 1 PGY3/4). In addition, the biweekly resident continuity clinics and the EEG/EMG rotations occur at the VA. The VA has an academic conference schedule similar to the one at ENC and at its core consists of daily morning reports and noon conferences. With the proposed consolidation with the West Roxbury VA, the neurology in-patient service and consult service would move to west Roxbury while the New Neurology, specialty and resident continuity clinics would remain at JPVA. If the residency program were to provide residents to both the VAs, the current group of residents at JPVA would be distributed over two sites; which is likely to cause almost total collapse of the teaching program that currently exists at the JPVA. Traditionally, bulk of the residency teaching has occurred at the JPVA and the VA rotations were an important and useful component of the training program. The practicalities of having a teaching schedule in a merged VA system should be discussed extensively; and if such a schedule cannot be assured the program should consider withdrawing its residents partly or completely from the VA.

Comment on the Child Neurology rotation

Currently, PGY3s spend 1.5 months at NEMC and 1.5 months at HAC during the child neurology rotation. Spending the entire 3 months at NEMC that has a well-structured program can strengthen the rotation. The consult team at HAC (1 PGY3 and 1 PGY4) can take care of the pediatric consults from the ED and the pediatric service. Also, the PGY3s and PGY4s may benefit from having a biweekly or monthly longitudinal pediatric neurology clinic based at HAC.

Suggested daily schedule at BMC

7.30 AM - 9.30 AM: Residents' round on floor patients; consult resident does follow-ups.
9.30 AM - 10.30 AM: Morning report at ENC conducted by an academic attending (the floor residents, consult residents and Chief residents from ENC and HAC should attend this)
10.30 AM - 11.30 AM: Attending of the month rounds with team on floor patients
12.30 PM - 1.30 PM: Noon conference
3.30 PM - 5.00 PM: Consult rounds with attending of the month
5.00 PM - 5.30 PM: Sign-out to on-call resident

Suggested noon conferences at BMC

4 week schedule; total of 20 conferences per 4 weeks
4 stroke conferences: 3 case presentations; 1 lecture/talk by attending, fellow or resident. Topics should be selected at the beginning of the year (e.g. pathophysiology of various types of strokes, localization in stroke, role of heparin, antiplatelet therapy, etc.)
4 case presentations: history and physical exam prepared and presented by a resident. An attending will discuss differential and management. Focus on approach to general neurological problems. E.g., dizziness, one extremity weakness, confusion, change in mental status etc.
2 sleep conferences: Lectures by attending on topics selected at the beginning of the year. E.g., normal sleep characteristics, interpreting sleep study, indications for sleep studies, parasomnias etc.
2 movement disorder conferences: Lectures by attending on topics at the beginning of the year. E.g., tremor, dystonia, myoclonus, Huntington, Parkinsonism, anti-Parkinson medications etc.
2 neuromuscular conferences: Lectures on anatomy of peripheral nerves, focal neuropathies, generalized neuropathies, GBS, myopathies etc.
2 seizure conferences: Lectures on differential of seizure disorders, epileptic syndromes, anti-epileptic medications, work-up and management of first seizure, etc.
2 neuroradiology conferences: Discuss imaging of patients with neuroradiology staff.
2 psychiatry conferences: Lectures on psychotic disorders, depression, anti-psychotics, anti-depressants etc.

Other conferences at BMC

4 Grand Rounds
4 neuroscience seminars by neuroscience faculty
4 board review sessions
1 journal club

Suggested noon conferences at VA
(assuming current structure)
4 week schedule; total of 20 conferences per 4 weeks
4 seizure conferences
4 neurobehavior conferences
4 neuroanatomy conferences with Dr Romanul
4 neuroscience conferences
2 neuromuscular conferences
2 radiology conferences (review imaging of patients)


-- Anonymous, February 24, 2000