23-24 Neurology Clerkship Syllabus.112823

Directors and Department Contacts Neurology Clerkship Directors Laurie Knepper, MD Katherine Cobb-Pitstick, MD Associate Professor of Neurology Vice Chair Education, Neurology Clerkship Director Department of Neurology Headache Center – University Center, Suite 300 Phone: 412-647-9494 Pager: 412-958-2801 knepperle@upmc.edu Assistant Professor of Pediatrics Assistant Neurology Clerkship Director University of Pittsburgh School of Medicine Director, Medical Student Education Division of Child Neurology UPMC Children's Hospital of Pittsburgh UPMC Headache Center CHP Faculty Pavilion 8119 412 - 692-7877 cobbpitstickkm2@upmc.edu Allison Weyer, MD Julia Kofler, MD Assistant Professor of Radiology Department of Radiology Division of Neuroradiology: UPP 21 412-647-3530 weyerag2@upmc.edu Associate Professor of Pathology Interim Director, Neuropathology Co-Director and Neuropathology Core Leader, Alzheimer’s Disease Research Center S701 Scaife Hall 412-624-6353 koflerjk@upmc.edu Neurology Clerkship Coordinator Jill Sheon, MPPM Senior Medical Student Coordinator Department of Neurology Office address: 1213 Kaufmann | Phone: 412-692-2083| Fax: 412-624-2302 |  sheonkj@upmc.edu Mailing address: Kaufmann Medical Bldg. | 3471 Fifth Avenue | Suite 811 | Pittsburgh, PA 15213 3 | P a g e

Neurology is a field with many diseases that often lead to slowly progressive disability (neurodegenerative diseases, demyelinating diseases) or sudden disability (stroke, traumatic brain injury, seizures). When patients are admitted with neurologic disorders safe discharge planning is key to ensure the patient will be able to safely take care of themselves at home, have an adequate support system and follow up neurology care. It is possible at discharge that they will be unable to work, walk or drive. Discharge planning involves a multidisciplinary team including nurses, social workers, discharge care coordinators and physicians who communicate regularly and work closely together to facilitate discharge of patient to home, a skilled nursing center or a rehab facility. As an intern and resident, you will need to understand the complexity of discharge planning, insurance restraints, and the specific needs of patients before they leave the hospital. Our Neurology Unit director, Michelle Nagy and our nurses, care coordinators and social workers will be working with you one morning during this clerkship to help you understand this essential process. A questionnaire must be completed post- session. The objectives of this experience are: 1. To learn what is needed for a safe hospital discharge for patients with neurologic disorders and who makes up the multidisciplinary discharge team. 2. To understand the impact of insurance coverage issues, including but not limited to prior authorizations required for placement and medications, the cost of medications, and issues facing patients without insurance coverage. 3. To address patient concerns and their available support systems before discharge 11. Neurology (Formative) Neurologic Physical Exam/Lumbar Puncture Hybrid OSCE a. Scheduled at the beginning of the rotation to review/practice the neurologic exam. This is a required session. Refer to your individual schedule for your OSCE time. This is formative and will NOT be graded . b. Students will receive immediate feedback from the Standardized Patient regarding their neurologic physical exam regarding their professionalism and captured versus missed exam components. c. Lumbar puncture: part of this OSCE includes a simulation experience for obtaining informed consent, practicing a lumbar puncture on a mannequin, entering orders into the electronic health record and writing a procedure note. 12. EMR Exercise a. Students are to submit a new patient note by 5:00 pm on the second Friday of the clerkship via email to Dr. Knepper ( knepperle@upmc.edu ) and to Jill Sheon, Clerkship Coordinator ( sheonkj@upmc.edu ). b. The EMR note accounts for 10% of the final grade. c. Students receive a grade (out of 100) and narrative feedback on this note. If a student scores 91 points or higher, the student is not required to write a second note. Students who score 90 points or below are required to complete a second EMR note, which must be written on a different new patient . This second note is due by 5:00 pm on the last day of the clerkship. The student will receive a grade and narrative feedback on this note. Overall, the highest score of the two notes submitted will count towards the final grade. 13. NBME Clinical Neurology (SHELF) Exam a. The exam is administered on the last day of the rotation. b. A half-day before the exam is given off as study time (either the same morning of the exam or the afternoon before) 14. Professionalism a. Timely assignment submission b. Timely attendance and participation in zoom didactics c. Students are not to use cell phones or laptops/iPads during rounds or clinical conferences. d. Please refer to the UPSOM Absence Policy/Attendance section for further details e. Be respectful of all patient care team members and all Neurology and UPMC employees. f. REMEMBER that patient care is a top priority. 15. CEPAERS – The AAMC Core Entrustable Professional Activities for Entering Residency Form must be completed at the end of the rotation. 6 | P a g e

 Each student is required to submit documentation of a new patient encounter in the first 2 weeks of the clerkship.  The First EMR Note is due by 5:00PM on the second Friday of the clerkship via email to Dr. Knepper ( knepperle@upmc.edu ) and the clerkship coordinator, Jill Sheon ( sheonkj@upmc.edu ).  Students will receive a grade (out of 100 points) and narrative feedback on this note. If you score 91 points or higher , you are not required to write a second note (but may do so if you wish). Students who score 90 points or below will be required to complete a second EMR note, which must be written on a different new patient .  The Second Note is due by 5:00PM on the last day of the clerkship. You will receive a grade and narrative feedback on this note. Overall, the highest score of the two notes submitted will count towards the final grade.  Physician Note Reviewers : Drs. Knepper, Cobb-Pitstick, Fadhil, Levin, Mack, Ojha, Stakic, Al- Ramadan, Pilato Identify each note as follows : Neurology EMR Note 1_Last NameFirst Initial Neurology EMR Note 2_Last NameFirst Initial Please do not save with special characters in the file name. This should be a word document sent as an email attachment. Reviewers will not access the EMR with patient information to find your note. The 4 Core Competencies (Entrustable Professional Activities – EPAs) https://www. aamc .org/cepaer : EPA 5 – Document a clinical encounter in the patient record- Entering residents should be able to provide accurate, focused, and context-specific documentation of a clinical encounter in either written or electronic formats. The patient record is a legal document that provides a record of the transactions in the patient-physician contract. Use a patient note to filter, organize, and prioritize information, into a cogent narrative. Record a problem list, working and differential diagnosis and plan. Comply with requirements and regulations regarding documentation in the medical record. Verify the authenticity and origin of the information recorded in the documentation (e.g., avoids blind copying and pasting). Record documentation so that it is timely and legible. Accurately document the reasoning supporting the decision making in the clinical encounter for any reader (e.g., consultants, other health care professionals, patients and families, auditors). Document patient preferences to allow their incorporation into clinical decision making. EPA 1 – Gather a history and perform a physical examination. EPA 2 - Prioritize a differential diagnosis following a clinical encounter. EPA 3 – Recommend and interpret diagnostic and screening tests. EMR note must include : A. Patient Initials, Your name B. Date seen. C. Chief complaint /reason consulted. The History of Present Illness- This must capture the patient’s entire disease course, as well as recent worsening. It should include: 1. A Clear time course from when disease was diagnosed and clinical course until current event. (i.e., MS initially diagnosed in 2003, details of diagnosis and treatment of this disease and then details of recent symptoms and how patient came to be admitted) 2. Appropriate details – positive and negative – should be considering localization with these questions. 3. The patient’s words and perspectives - when appropriate- especially the Chief Complaint 4. Reference review of prior EMR notes – DO NOT COPY and PASTE List pertinent lab and imaging results, with dates, (reports can be copied in and note if you reviewed images). 5. Include pertinent positive + negative questions with respect to localization and differential ( this is not the same as ROS ) 6. Clarify how history was obtained– patient, spouse, emr, outside records, telephone, etc. 9 | P a g e

WITNESSED PATIENT EXAM (10% of grade) Student will perform a neurological exam, witnessed by an attending or resident, who afterwards will complete and sign the Witnessed Exam Form. This can be done at any time during your clerkship. The form is due to clerkship coordinator by 5PM on the last day of clerkship. Form can be found on Navigator under Other Assessments and Other Forms. See below. A. History 1. Did student introduce themselves? ___ 2. Did the student display appropriate listening skills? ___ 3. Was time allowed to answer patient questions? ___ B. The Exam 1. Mental status/speech/language (2) a. Orientation, recent, remote memory ___ b. Speech- name, repeat, read, comprehension ___ 2. Cranial nerves (6) a. II – Visual fields, pupils, fundi, acuity (1) ___ b. III, IV, VI – eye movements (1) ___ c. V – face sensation (1) ___ d. VII, VII (1) ___ e. IX, X, XII (1) ___ f. XI (1) ___ 3. Motor Bulk, Tone, Strength (all 4 extremities) (3) ___ 4. Deep Tendon Reflexes (5) ___ Biceps, Brachioradialis, Triceps, Knee, Ankle Plantar stimulation (test for Babinski) 5. Sensory Exam (2) ___ 6. Pinprick (1) Vibration (1) all 4 extremities 7. Cerebellum Exam (2) ___ Coordination - Finger to nose/heel to shin (1) Gait, standing, walking and tandem (1) Total Score (20) ___ Final Grade Score A. Outstanding (100% 19-20 B. Very Good (90%) 16-18 C. Acceptable (80%) 13-15 D. Unsatisfactory (60%) < 12 Signed by Neurology Physician Preceptor (only) (who witnessed the exam): _____________________/Date: _____ 12 | P a g e

arteries stenting, and embolization of cerebral aneurysms, cerebrovascular and spinal arteriovenous shunting disorders. In addition, students will participate in UPMC Mercy inpatient stroke service and weekly outpatient neuro interventional clinic where they see patients independently and perform bedside evaluations. Mercy Professional Building 3 rd Floor, Suite 311 Pittsburgh, PA 15219 Walk into the hospital, take the purple elevators to the 3 rd floor. Turn left & go through the door that says, “Mercy Professional Building.” Stroke/Neuro Interventional is the 1 st door on the left (Rm 311). Pittsburgh VA Medical Center VA Pittsburgh Healthcare System (VAPHS) Neurology Rotation Site Director: Ann Van Cott, MDOn the Neurology rotation at the Oakland Campus of the VAPHS, each student will have exposure to a broad variety of neurological conditions in both an outpatient setting and on an active inpatient consult service.  Neurology clinics are held daily from 8:00 am to noon in Neurology Clinic on 10 East.  The clinic is staffed by both residents and attendings.  Students will work with a resident while he/she is examining patients and will participate in discussion with the attending.  If possible, students will see veterans individually and staff cases directly with the neurology attending. In the afternoon, the students evaluate neurology consults in the hospital and ED and assist in caring for inpatients.  The students will be assigned both new consults and follow up patients to evaluate independently.  Over the course of the four-week rotation, each student will have the opportunity to perform the primary evaluation of several patients per week.  Students will also be expected to attend daily neurology rounds (when not in a didactic session) that start every afternoon in the neurology conference room on 10 East.  Inpatients will be presented by the resident and student and the cases will be reviewed by an attending with development of a diagnostic and treatment plan. The VAPHS Neurology Office and Clinic is on the 10th floor, East Wing - 412 -360 -6185.  Dr. Van Cott supervises the medical student rotation and will contact you prior to the beginning of your rotation. Please note: --In order to be up to date on VAPHS COVID vaccination requirements, trainees rotating at the VA must have completed a primary COVID vaccination series AND received at least one dose of the COVID bivalent booster. --You are required complete the online credentialing process at the VA prior to the start of your rotation.  The department of neurology and the VA will contact you before your rotation starts with detailed instructions.  This process takes 4-5 weeks to complete. Children’s Hospital of Pittsburgh of UPMC Pediatric Neurology Rotation Site Director: Katherine Cobb-Pitstick, MD Students assigned to the Pediatric Neurology Service will report to Children’s Hospital of Pittsburgh of UPMC in Lawrenceville. Students will spend one week rotating with the Child Neurology Ward service. Students will also spend one week rotating with the Child Neurology Inpatient Consult service. During Ward and Inpatient Consult service, students will round daily with the attending physician and neurology team. Students will have the opportunity to observe EEG and video EEG monitoring in pediatric patients. They will also participate in child neurology weekly neuroradiology rounds and an EEG didactic with a CHP senior technologist. The Pediatric Neurology Offices are located at the Faculty Pavilion, 8 th floor, 45 th Street and Penn Avenue. On their first day of the rotation, students should contact the child neurology fellow corresponding to their assigned service to arrange to be situated with their team or in the outpatient clinic. If the assigned fellow is not available, another child neurology fellow will be able to assist the student. Outpatient Fellow: 412-864-9084 Consult Fellow: 412-864-9073 Ward Fellow: 412-864-9423 15 | P a g e

LCME STUDY LOUNGE AND STORAGE SPACE In coordination and compliance with LCME guidelines, it is ensured during your rotation you will have allocated space at each site to work and store your belongings . Element 5.11 of the LCME standard addresses the space and storage guidelines as such: “A medical school ensures that its medical students at each campus and affiliated clinical site have adequate study space, lounge areas, personal lockers or other secure storage facilities, and secure call rooms if students are required to participate in late night or overnight clinical learning experiences.” The below list contains the site and location of each space for your use during your Neurology rotation. Children’s Hospital of Pittsburgh Faculty Pavilion, 8 th Fl. Work room in the Pediatric Neurology Department. It is a locked floor. Room includes desks and computers which are available to the students. Neurology Inpatient Ward and Consult Service 1213 suite in Lillian Kaufman Building has many workstations and cubicles, a kitchen and a bathroom. It is locked but the code is room number backward – you may leave your belonging there safely. Presbyterian 4 th Fl, Stroke Institute Door is locked by key punch code. Computers are available for use during rounds. Outpatient Clinic Liliane S. Kaufman Building, 8 th Fl., Suite 810, Neurology Outpatient Clinic Room 810.27, Locker 8 is for medical student use. The Room is a quiet, private space. A student exam room has been set aside for students in the Kaufman clinic. A conference room is available for students in the headache center with computers, leave belongings in Dr. Knepper’s office at headache. The MS clinic has a room for medical students. Room 1213, Neurology Education Office. This quite space has many cubicles and a mini kitchen. It is used shared by the Neurology fellows and residents. Medical students are welcome to leave their belongings, study, and work with a computer. Email the medical student coordinator for the door combo. Passavant A secure private room within the Passavant Neurology clinic is available for students to leave their belongings, study, work with a computer. Student is issued key which is returned at end of clerkship. Shadyside Hospital Aiken Medical Building, 3 rd Fl., Suite 300 . Secure, private room in the Suite. Students will need to check in at the front desk. Work room has computers for students and space for belongings. Veteran Affairs Medical Center Neurology Department, 10 th Fl., Rm. 10E132 Work room with computers, phones, and space for belongings located within the Neurology department. Competent Medical Service A student shall be dedicated to providing competent medical service with compassion and respect for human dignity. In all instances, the student must maintain the dignity of the person, including respect for the patient's modesty and privacy. 18 | P a g e

Attendance Policy The Neurology Clerkship follows the UPSOM Absence Policy : https://www.omed.pitt.edu/sites/default/files/policy_on_absence_and_attendance_0.pdf ALL ABSENCES require completion of the UPSOM Absence Request Form for MS3 and MS4 Students located on the home page of our Navigator site under "Quick Resources".  Submit the request form for approval to the Medical Student Coordinator ( sheonkj@upmc.edu ) at least three weeks in advance of the rotation. 1. Same-day absences require completion of the UPSOM Absence Request Form . 2. Emergency absences require notification to the clerkship director ( knepperle@upmc.edu ) and the medical student coordinator ( sheonkj@upmc.edu ). An UPSOM Absence Request Form will need to be completed/submitted once the situation permits for this to occur . Students may not miss any part of the clerkship without permission/valid excuse. Unexcused absences, should they occur, must be made up and will factor into the professionalism grade as well as clinical evaluations. Students who miss more than 2 excused days may receive an incomplete grade and remedial action will be taken with delay of final grade. All absences are reported to Dean Alda Gonzaga’s office. OMED has a COVID policy . If you feel you have Covid or have been exposed, email the clerkship director, medical student coordinator, Dr. Alda Gonzaga, and Dr. Raquel Buranosky. Preceptors (attending physicians, fellows, and residents) will report unexplained student absences or tardiness to the clerkship director, and this information will be forwarded to Dr. Baranosky. Unexplained student absences will affect the professionalism component and clinical evaluations of the final grade. Students with disabilities need to submit UPSOM approved documentation and request for accommodations for the rotation and SHELF exam prior to the onset of the clerkship or at orientation . Without paperwork, these accommodations cannot be granted. UPSOM Resources (also on the Neurology Navigator site): -- Policies and Procedures for Clerkships https://www.omed.pitt.edu/policies-and-procedures -- Student Affairs Code of Conduct https://www.omed.pitt.edu/sites/default/files/student_affairs_code_of_conduct_0.pdf -- Office of Learning Environment https://www.ole.pitt.edu 21 | P a g e

Neurology Clinical Resources Recommended Reading*  Neurology BluePrints  Raven Neurology Review – Clinical Neurology for the Medical Student Clerkship, Paul Johnson, MD 2017 – there is also a kindle version.  Raven Stroke Neurology review– free ebook: ravenneurologyreviewcom.files.wordpress.com  Free Neuroimaging e-book at ravenneurologyreview.com. * Clerkship Coordinator has copies of Blueprints or the Raven Review. Students sign out and borrow copies. Coordinator’s office is in the Kaufmann building: Suite 1213 LKB Books listed below are available in UPSOM Health Science in electronic versions. Can access this link via Core chart or EPIC in HSLS link – Neurology Books- online. Practical Neurology / Biller, J., Fourth Edition, 2012 Localization in Clinical Neurology: Brazis, Masdeu, Biller, Introduction to Clinical Neurology/ Gelb, D., Pediatric neurology: a color handbook / James F. Bale, Jr. ... [et al.]. * Neuroanatomy Online Texts at HSLS online: Clinical Neuroanatomy, edited by Stephen G. Waxman Color Atlas of Neurology, edited by Reinhard Rohkamm Neuroanatomy: An Illustrated Colour Text, edited by Alan Crossman Reference source Adams and Victor's principles of neurology / [edited by] Allan H. Ropper, Martin A. Samuels. * Merritt's neurology. Videos Neurological Exam Available on Navigator. The neurologic exam is demonstrated by Drs. Knepper and Yanta. Coma exam https://www.youtube.com/watch?v=CUaEwgfKOEc The Coma Exam – Netter Collection of Medical Illustrations: Part 1 The Brain- online HSLS library NEJM - Lumbar puncture video http://www.nejm.org/doi/full/10.1056/NEJMvcm054952 Neuroradiology Interactive Websites https://radiologyassistant.nl/neuroradiology learningneuroradiology.com http://headneckbrainspine.co http://www.med-ed.virginia.edu/courses/rad/ Course website 22 | P a g e