Medical Students Program

Neurology and Rehabilitation Clerkship

The six-week Neurology and Rehabilitation Medicine Clerkship introduces students to the care of patients with neurological disorders and conditions, as well as the role of rehabilitation medicine in improving patients’ functional status and quality of life. During the neurology portion of the rotation, emphasis is placed on performing, documenting, and presenting verbally histories and physical examinations of patients with neurological diseases, developing a differential diagnosis, assessment, and treatment plan, participating in the treatment of neurology patients, and understanding the impact of neurological illness on the patient and the patient’s family. Each student will have direct patient contact with supervision from neurology residents, fellows and faculty.

Neurology Rotations

The neurology service is divided into two different components: during one 3-week component of the clerkship, students rotate on an inpatient service (although two services – neuro-oncology and pediatric neurology – will combine inpatient consults with outpatient clinic time.) During the other three-week component of the clerkship, students spend two weeks rotating on a mixture of outpatient clinics (with an average of 6 half-days of clinic per student), and one week rotating on a rehabilitation medicine service at Roper Hospital.

The Neurology and Rehabilitation Medicine Clerkship is divided into the following components:

Inpatient Rotations

1. General Adult Neurology Wards (MUSC)
2. VA Adult NeurologyWards/Clinic
3. Neurovascular Stroke Inpatient Service
4. Neuroscience ICU
5. Pediatric Neurology Consult Service/Clinic
6. Neuro-Oncology Consult Service/Clinic

Outpatient Rotations

Mixture of ~ 7 clinics per week (4-5 on week 6)
Clinics in different subspecialties
Stroke

1. Cognitive / behavioral neurology
2. Neuropsychology
3. Movement disorders
4. General neurology
5. Headache / botulinum toxin injections
6. Neuromuscular disease
7. EMG
8. Pediatric neurology
9. Epilepsy

Some clinics are located off campus

1. MUSC North Charleston, 8992 University Blvd, 2nd floor, Charleston
2. MUSC East Cooper, 1600 Midtown Ave, 2nd floor, Mount Pleasant
3. MUSC West Ashley, 2125 Charlie Hall Blvd, 2nd floor, Charleston
4. Ralph H. Johnson VA Medical Center, 109 Bee St. 1st floor, Charleston
5. MUSC Children’s After Care, 2250 Mall Drive, North Charleston

Day Float

During outpatient rotation, the majority of students spends one day on “Day Float,” a rotation that participates in the evaluation of acute neurologic emergencies. The goal of student participation in Day Float is to allow every student to participate in at least on BAT (Brain Attack Team) acute stroke evaluation.

Rehabilitation Medicine Rotation

Each student will spend a week at Roper Hospital to participate in Rehabilitation Medicine.

During the rehab medicine week, students will have opportunities to observe or participate in a wide variety of interdisciplinary rehab medicine activities, including physical therapy, occupational therapy, speech language pathology evaluations, recreational therapy, group therapy / support groups, and / or evaluations for wheelchair placement or assistive devices; the individual activities that each student is involved in largely depend on the activities of their assigned patient(s). Each student is expected to actively see new patients, perform appropriate rehabilitation-focused history and physical evaluations on new patients, present their patient to the attending, and to follow those patients over the course of the week. Access to the electronic medical record (EMR) at Roper Hospital is restricted to read-only access; however, students are expected to write at least one H&P or progress note in Microsoft Word, so that their attending will have the opportunity to review your note.

Didactic experiences

Students on the neurology and rehabilitation medicine clerkship participate in a wide variety of formal didactic experiences over the course of their six week clerkship, including:

• Neurology history and examination workshop
• Neurologic Emergency and Procedure Simulator Session (SIM Lab)
• Medical Student Noon Lectures
• Medical Student General Neurology Review Session
• Morning Report
• Resident Noon Lectures
• Grand Rounds

In addition, medical students have optional small group didactics at 4:30 PM led by residents and faculty on a wide variety of topics related to neurology.

Other Clerkship Requirements

Clerkship Procedures & Diagnoses (PxDx) Log

Patient experiences / PXDX log: Each medical student is expected to see (and document having seen) at least one patient with each of the following five types of neurologic conditions, which were derived from the diagnoses recommended by the American Academy of Neurology:

1. Change in mental status. This can include patients with: dementia, toxic-metabolic encephalopathy, coma, or change in mental status due to a functional or structural neurologic process (such as head injury, stroke, brain tumor, etc.).
2. Change in vision. This can include patients with: blurred vision, double vision, or loss of vision due, or potentially due, to a neurologic condition (e.g., MS, optic neuritis, stroke, ICH, etc).
3. Paroxysmal disorder. This can include headache (including primary or secondary headaches), syncope, TIA and seizures.
4. Change in sensation. This can include: dizziness, peripheral neuropathy, radiculopathy, plexopathy, and sensory changes/loss secondary to lesions of the spinal cord and/or brain.
5. Change in tone, strength, or movement. This can include: spasticity, weakness, tics, tremor, parkinsonism, dyskinesias, chorea, and/or ataxia.

Direct observation:

All students must have a history and full neurologic examination performed and observed by a faculty member. Faculty members are asked to comment upon whether or not the student demonstrates satisfactory performance in the following areas while obtaining a patient history:

• Washes hands or uses hand sanitizer
• Introduces self and explained role
• Elicits chief complaint
• Obtains appropriate history
• Demonstrates thoughtfulness and sensitivity to the patient and their concerns
• Demonstrates appropriate communication skills

The faculty observer is also asked to review whether or not the student demonstrated satisfactory performance in the following aspects of their neurologic exam:

• Mental status exam
• Cranial nerve exam
• Sensory exam
• Coordination exam
• Motor exam
• Reflex testing
• Gait evaluation

Procedures:

Students are required to complete the following activities (most of which will be completed during the rehabilitation medicine week):

1. Observe physical therapy
2. Observe speech therapy, cognitive therapy or recreational therapy
3. Participate in counseling a patient about rehabilitation needs and plan
4. Address pain from headache / back pain

Addressing pain from headache and back pain may occur on the neurology rotation instead of the rehab medicine rotation. Students are also encouraged to document other procedures or activities they observe, participate in or perform on the neurology clerkship.

In addition, students are required to perform the following activities during their neurology weeks (either inpatient or outpatient):

1. Full cranial nerve examination
2. Motor examination (including evaluation of strength and tone)
3. Full mental status examination (including evaluation of orientation, language, attention, knowledge and memory)
4. Full sensory examination (including evaluation of vibratory, proprioceptive, temperature, and sharp/dull sensation)
5. Coordination and gait examination
6. Neurologic examination in a patient who is comatose, obtunded or encephalopathic

Clerkship Objectives

Neurology and Rehabilitation Clerkship Objectives

At the end of this rotation, the student should be able to do the following:

Medical Knowledge for Practice (MK) objectives

1. Describe the known causes and pathogenesis, epidemiology, risk factors, and the course of commonly encountered conditions in neurology (MK3)
2. Describe the normal structure and function of the nervous system. (MK1)
3. Describe how altered structure and function of the nervous system is exhibited through common neurologic conditions and aging. (MK4)
4. Describe the scientific principles underlying diagnostic methods, including laboratory and radiologic testing, and treatment approaches (pharmacologic and non-pharmacologic) that may be applied to major diseases and conditions. (MK5)
5. Explain how preventive measures, health behaviors and social determinants affect disease, injury and health in individual patients and across populations.(MK7)
6. Describe the etiology, pathogenesis, and course of commonly encountered conditions seen in a rehabilitation hospital, such as spinal cord injury, traumatic brain injury, and stroke. (MK3)
7. Describe common medical complications that affect patients in the rehabilitation setting (e.g., decubitus ulcers, deep venous thrombosis, spasticity, neurogenic bowel and bladder, and autonomic hyperreflexia), and strategies to prevent these complications (MK4)
8. Describe ways that commonly utilized therapeutic modalities (including speech language pathology, physical therapy, occupational therapy and recreational therapy) can be used to improve the functional status of patients with rehabilitative care needs (MK6)

Patient Care (PC) objectives

1. Obtain a complete and reliable neurologic history appropriate to the age and presentation of the patient. (PC1)
2. Perform a focused, thorough, and reliable neurologic examination on patients who are alert and cooperative as well as patients with an altered level of consciousness. (PC1)
3. Assess and describe a patient’s functional status based on the findings of the history and physical exam (PC1)
4. Recognize abnormal findings on the neurologic examination and localize these findings to the most likely causative site within the nervous system. (PC2)
5. Formulate a differential diagnosis based on lesion localization, time course, relevant historical features, and interpretation of commonly used laboratory and radiologic test data. (PC2)
6. Develop an appropriate evaluation and management plan utilizing patient information and preferences, evidence-based medicine and clinical judgment. (PC3)
7. Work within a neurologic care team to follow patient progress and ensure continuity of care that is safe and effective. (PC6)
8. Counsel patients and their families on the plan for their neurologic condition and prevention of neurologic disease with evidence-based information. (PC5)
9. Describe the risks, benefits, and procedure of a lumbar puncture. (PC7)
10. Obtain a complete and thorough history on a patient presenting for admission to an acute rehabilitation medicine unit, with appropriate focus on the patient’s functional status and goals for rehabilitation (PC1)
11. Work within a multidisciplinary care team to follow to follow a patient admitted to an acute rehabilitation hospital (PC6)
12. Using input from therapeutic subspecialties including physical therapy, occupational therapy, speech-language pathology and recreational therapy, develop a multidisciplinary management plan for a patient admitted to an acute rehabilitation hospital (PC3)

Interpersonal and Communication Skills

1. Demonstrate effective and professional interpersonal and communication skills, including interviewing patients from diverse cultural and socioeconomic backgrounds. (CS2)
2. Demonstrate sensitivity, honesty, and compassion during difficult conversations with patients regarding their neurologic disease (CS3)
3. Create clear and organized progress notes which include appropriate information for the review by other health professionals. (CS5)

Professionalism (PR)

1. Demonstrate honesty, integrity, respect, and compassion in all interactions with patients, peers, faculty, staff, and other health care professionals in all settings. (PR1)
2. Demonstrate ethical, patient-centered decision-making and respect for the confidentiality of patient information in all settings (i.e., clinical, academic, electronic or web-based). (PR2)
3. Demonstrate sensitivity and responsiveness to the personhood of the patient inclusive of culture, ethnicity, spirituality, gender, age, disabilities, family-context and other aspects of personal and health beliefs, practices and decisions. (PR3)
4. Demonstrate accountability for academic and patient care responsibilities, and a commitment to continuous professional development. (PR4)
5. Demonstrate responsiveness to patient needs that supersedes self-interest (PR5)

Personal and Professional Development (PD)

1. Acknowledge personal limitations and mistakes openly and honestly, and critically evaluate mistakes to promote professional development. (PD1)
2. Demonstrate strategies for analyzing, identifying and improving personal deficiencies in knowledge and skills by setting learning and improvement goals (PD2)
3. Demonstrate a commitment to personal health and well-being, and recognize and address personal attributes, attitudes, and behaviors that may adversely influence one’s effectiveness as a physician. (PD3)

Systems Based Learning

1. Develop quality, cost effective plans for patients with neurologic disease (SL2)
2. Describe how health and health care disparities can affect neurologic disease (SL4)

Interprofessional Collaboration

1. Recognize the role of members of a multidisciplinary rehabilitation team and describe when it is appropriate to refer to different healthcare professionals within the team. (IP1)
2. Work with other health professionals to establish and maintain a climate of mutual respect, dignity, diversity, ethical integrity, and trust. (IP2)
3. Develop management plans collaboratively with interprofessional clinicians from other health related fields (i.e., physiatrists, physical therapy, occupational therapy, speech and language therapists) in providing care for individual patients, families of patients, or groups of patients. (IP4)