EEG 2/Clinical Neurophysiology

RESIDENT EDUCATION CURRICULUM

Description of Rotation

The Clinical Neurophysiology/EEG Section of the Department of Neurology has redefined its educational programs for Neurology residents. The following rotations are offered: 1. One-month “basic rotation” mandatory for all Adult Neurology residents and for Pediatric Neurology residents. 2. Additional “level 2” one month rotation including EEG, evoked potentials (EPs) and polysomnography (psg). 3. Advanced EEG-EP-psg elective rotation of up to three consecutive months in the EEG Laboratory for residents interested in learning more about EEG and clinical neurophysiology and those who have a potential interest in fellowship training in EEG/clinical neurophysiology. Participation in this elective requires prior successful completion of the introductory 2 month EEG rotation and requires permission from the EEG section head, based on specific request by the interested resident. The principles of intraoperative monitoring (EEG, EP) will be introduced here 4. Elective in clinical neurophysiology/epilepsy/sleep disorders. This elective month requires permission from the Clinical Neurophysiology/EEG head, based on specific request by the interested resident.

Educational Purpose

1. To provide an experience that will allow the resident to increase their knowledge of anatomy of the central nervous system and the clinical presentation and pathophysiology of epilepsy, sleep disorders, and other diagnosable entities. 2. To provide an experience that will allow the resident to achieve understanding of electrodiagnostic studies correlating it with the basic science of neurophysiology and clinical presentation. 3. To learn the indications for ordering, diagnostic evaluation and interpretation of EEGs, evoked potentials (visual evoked potentials, brainstem auditory potentials, somatosensory evoked potentials), and sleep studies (polysomnograms, multiple sleep latency tests, multiple wakefulness test, etc). 4. To provide training and supervision that allows development of skills necessary to provide accurate diagnosis in clinical neurophysiology studies.

Assessment Summary

The resident will work one-on-one with staff, and get immediate feedback about his/her performance after every patient encounter/work-up. It is expected that the resident will improve their performance based on the feedback they receive and as the rotation progresses.

Resident performance will be assessed in the six core competencies: 1. Patient Care (PC) 2. Medical Knowledge (MK) 3. Interpersonal and Communication Skills (ICS) 4. Practice Based Learning and Improvement (PBLI) 5. Professionalism (P) 6. Systems Based Practice (SBP)

By the end of the rotation, the resident should receive and/or complete the following assessments: 1. Verbal feedback from preceptors 2. Global written assessments (METS) 3. Procedure Logs 4. Written examination 5. Testing of residents performance through direct observation and record review Expectations Additional One Month Rotation in EEG – evoked potentials (EPs) and polysomnography (psg) In addition to the curriculum in the Basic Rotation, the additional two-month rotation is directed toward developing technical skills in EEG as well as introduction to the evoked potentials and polysomnography. This rotation must follow the Basic Rotation. Extended time away during this rotation is discouraged. There will be more concentration on EEG design to answer the clinical question being asked by the referring physician. There will be more emphasis on electrodiagnostic impression writing and interpretation of abnormal results. There will be continued EEG case sessions with staff and fellows, as well as an EEG unknowns quiz at the end of the rotation. Resident is required to read Fisch’s (Fisch and Spehlmann’s primer) book.

Orientation This occurs on the first day of the rotation by the staff attending assigned to the clinic/lab. Orientation to the EEG machine will evolve over the first month of the clinical rotation.

Supervision Residents will actively participate in the clinics/lab supervised both by EEG staff physicians as well as EEG fellows when available.

Mix of Diseases  Epilepsy including status epilepticus in adults and children  Encephalopathies (including ICU monitoring of head trauma)  Coma; persistent vegetative state; electrocerebral inactivity  Sleep disorders  Conditions diagnosable by evoked potentials such as hearing screening, multiple sclerosis, surgical monitoring, etc Patient Characteristics

Patients will be referred to the EEG laboratory from either physicians in the outpatient department or from the inpatient hospital services for further diagnosis of a wide variety of epilepsy and other disorders. Children and adult, of various ethnic backgrounds and socioeconomic backgrounds with acute and chronic neurological disorders will be encountered during the EEG rotation. Adults over the age of 18 will be encountered in the EEG clinic.

Procedural Skill Acquisition 1. Normal and abnormal findings in EEG and video/EEG monitoring 2. Interpretation of EEG and EEG monitoring findings 3. Interpretation of visual, brainstem auditory and somatosensory evoked potentials (EPs) 4. Analysis of polysomnography (psg) techniques with staff supervision 5. Writing and dictating electrodiagnostic interpretations with clinical correlations

Conferences

The residents should continue to attend the mandatory Neurology conferences including Neurology Grand Rounds. In addition, the residents are required to attend the weekly EEG/Epilepsy conferences (schedule to be determined)

References: Resources recommended for learning skills:

Fisch & Spehlmann’s EEG primer Current Practice of Clinical Encephalography (Ebersole & Pedley), Lippincott Williams & Wilkins Comprehensive Clinical Neurophysiology by Kerry Levin, Hans O. Luders, Saunders; 2000. AAN Practice Guidelines: http://www.aan.com/professionals/practice/index.cfm You schedule will be as follows: Mon: Continuity Clinic Tues: Dr. McGuire at Children’s Hospital Wed: University EEG readings for adult residents or Children’s Hospital Clinic for pediatric fellows Thursday AM: Baptist Clinic w/ Dr. Olejniczak PM: Resident Lectures Friday: University EEG readings with Dr. Olejniczak (and or sleep disorders and evoked potentials)

PATIENT CARE Teaching Methods Assessment Strategy Objectives EEG-2 Demonstrate basic technical knowledge of EEG Direct Patient Care Global rating equipment (electricity, analog and digital filters) and EEG case conference Checklist evaluation of live performance procedural skills (electrode placement; basic montages) Didactic Lectures Record review Demonstrate the basic knowledge of normal EEG Staff and resident instruction and Case logs features during wakefulness, stages N and REM sleep in supervision Observed performance on volunteers children and adults. Understand clinical indications for those studies Demonstrate basic technical and procedural skills of EEG case conference Global ratings EEG analysis; this should include completion of at least Didactic Lectures Checklist evaluation of live performance 5 study interpretations (with report writing or dictation) Staff and resident instruction and Record review on patients referred to the EMG laboratory. supervision Case logs Observed performance with EEGs patients with staff/fellow supervision. Review of abnormalities in previously recorded EEGs Demonstrate basic knowledge of the principles of EEG case conference Global ratings polysomnography (psg) and evoked potential (EP) Didactic Lectures Checklist evaluation of live performance studies (visual evoked potentials – VEPs; brainstem Staff and resident instruction and Record review auditory evoked potentials – BAEPs; somatosensory supervision. Review of previously Case Logs evoked potentials – SSEPs) recorded psg and EP abnormalities MEDICAL KNOWLEDGE Teaching Methods Assessment Strategy Objectives EEG-2 Apply knowledge of EEG studies and develop a study that Didactic lecture Global ratings accurately diagnoses the patient’s symptoms. Familiarize Clinical teaching Case Logs oneself with principles of psg and EP studies Record review Characterize the main features of EEG examination as being Clinical teaching Global ratings normal or abnormal. Departmental Conferences In-training examination Analyze abnormalities seen on EEG exam and determine Didactic lecture Global ratings underlying pathology (neurogenic, neuromuscular junction defect Case conferences In-training examination or myopathic) Clinical teaching End of course quiz Correlate findings in EEG with clinical manifestations and Didactic lecture Global ratings write/dictate an electrodiagnostic impression (for 5 patients), Case conferences In-training examination demonstrating comprehension of the etiology of the patient’s Clinical teaching End of course quiz symptoms

INTERPERSONAL AND COMMUNICATION Clinical neurophysiology/ EEG Rotation Interpersonal and Communication Objectives EEG-2 Teaching Methods Assessment Strategy

Establish excellent rapport and communication with their Clinical practice Global ratings patients and their families Modeling 360 degree evaluation Work as an integrated member of the Epilepsy Center and Clinical practice Global ratings EEG/clinical neurophysiology Lab Modeling 360 degree evaluation Present case presentations in an organized and detailed Clinical practice Global ratings manner Modeling 360 degree evaluation Educate their patients and their families as appropriate to the Direct patient care Global rating clinical situation in a manner that is geared to the patients educational level Modeling Demonstrate the ability to provide consultants with a report that Clinical rounds Global ratings can be easily interpreted. Modeling PRACTICE BASED LEARNING AND IMPROVEMENT Clinical Neurophysiology/ EEG Rotation Practice Based Learning and Improvement Objectives EEG-2 Teaching Methods Assessment Strategy Research clinical questions regarding their patient’s health Electronic medical record Self assessment problems using information technology to access on-line medical Medline/OVID searches- patient Global ratings information to support their own education and to improve patient centered care and education Case presentations Evaluate the clinical literature applying knowledge of Teaching conferences Global ratings of Journal club epidemiology, biostatistics, and research study design Journal Clubs performance Integrate the feedback they receive from Staff physicians such that Modeling Global ratings (METS) their performance will improve as the rotation progresses.

PROFESSIONALISM Clinical Neurophysiology/ EEG Rotation Professionalism Objectives EEG-2 Teaching Methods Assessment Strategy Demonstrate respect, compassion, integrity, and honesty Direct patient care Global ratings Modeling Interact responsibly with patients and families taking into Modeling Global ratings consideration age, disability, culture and gender issues Demonstrate exemplary interaction with their colleagues Modeling Global ratings Demonstrate appropriate use of the EMR in regards to patient Direct patient care Global ratings respect and confidentiality Modeling Self-assess their performance and the means for Modeling Global ratings improvement Recognize mistakes that occur and take measures to learn Direct patient care Global rating from them so that the do not recur Modeling Self assessment SYSTEM BASED PRACTICE Clinical Neurophysiology/ EEG Rotation System Based Practice Objective EEG-2 Teaching Methods Assessment Strategy Utilize appropriate resources to better care for their patients. Direct patient care Global ratings Review of evidence based medicine Focused Record Review and guidelines of the AAN Departmental conferences Identify obstacles to good patient care, engaging other Direct patient care Global ratings members of the health care team such as child-life and social 360 degree evaluation work, appropriately consulting other subspecialists or generalists. Communicate with the specialized services or laboratories in Direct patient care Global ratings order to obtain timely information on their patients Modeling 360 degree evaluation Consider ethical, legal, and cost-effective standards of Role modeling Self assessment practice Clinical teaching Focused record review Focused record review