Description of Rotations

The inpatient neurology ward team at Yale-New Haven Hospital consists of one senior (PGY‑4) neurology resident, two junior (PGY-2) neurology residents, rotating medicine and psychiatry (PGY-1) residents, and medical students. The junior neurology residents on the inpatient ward service are responsible for all aspects of patient care under the guidance of the senior resident and attending physician. This includes evaluation of patients in the ED, admission to the floor or Neuro ICU, management of floor and ICU patients, discharge from the hospital, and arrangement of follow-up care. The neurology residents are also responsible for supervising and educating the medical students rotating on the neurology service.

The daily schedule for the Ward service is as follows:

Time

Monday

Tuesday

Wednesday

Thursday

Friday

6:30 AM

Pre-rounding

7:30 AM

Morning Report

Morning Report

8:00 AM

Work Rounds

Grand Rounds

Work Rounds

8:30 AM

Neuro-ICU Rounds

Neuro-ICU Rounds

10:00 AM

Floor Rounds

12:00 PM

Journal Club/M&M

Yale Noon Conference

Neuropathology Conference

Yale Noon Conference

VA Noon Conference 

1:00 PM

Brain Cutting

Tumor Board

4:30 PM

Neuroradiology Conference 

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The Yale Consult team receives vital exposure to a wide range of neurological complications of systemic disease, as well as the more common primary neurological disorders. This rotation provides the senior neurology resident a valuable opportunity to practice the often complex but important skill of effective neurological consultation and team management. Due to the large size of the service a 2nd consult resident (any PGY level) assists the senior resident with evaluating consults. Together, the two residents see all inpatient consults except pediatric patients. Rounds are held daily on weekdays with the consult attending and the team usually had 1-2 medical students. The consult team acts as the main liaison between the Neurology Department and other services in the hospital for inpatient care, and thus must provide prompt, courteous, useful and thorough evaluations.

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Residents receive comprehensive full-time exposure to performance and interpretation of EMGs and NCVs. They perform EMGs 3 days per week and attend Neuromuscular/MDA Clinic 2 days per week. Supervision is by the attendings in the Neurophysiology lab – usually providing a ratio of 2 attendings to 1 resident, and is thus a highly educational experience for the residents.

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The epilepsy monitoring unit at Yale consists of six adult beds, and two pediatric beds, equipped with state-of-the-art closed-circuit video monitoring with EEG (CCTV-EEG). Patients are referred from throughout the world for intensive monitoring for purposes of

  1. diagnosis, to differentiate seizures from non-epileptic events (i.e. psychogenic, cardiogenic, pulmonary, and sleep disorders)
  2. medication adjustment, and
  3. surgical evaluation for refractory epilepsy.

Inpatient monitoring is incorporated into surgical evaluation which is done in several phases. Phase I describes the initial CCTV-EEG monitoring, to both confirm the diagnosis of epilepsy and once confirmed, to characterize and localize typical seizures electrographically. Attempts are also made to obtain ictal and interictal SPECT, PET, ESP-MRI, and neuropsych testing. Phase II includes Wada/cerebral angiography to localize language and memory. Phase III consists of intracranial EEG recording, with either strip, depth, or grid electrodes. Every week there is a multi-disciplinary conference, involving neurology, neurosurgery, neuropsychology, and radiology, where individual patients and the results of their evaluations are reviewed, and recommendations regarding surgical interventions are made.

The residents are an integral part of the epilepsy team, and participate in all aspects of patient care. Responsibilities include admission notes and daily progress notes, analysis of video-EEG, epilepsy clinics, and neurophysiology conferences. While on this block residents also read routine inpatient and outpatient EEGs with an attending.

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The Pediatric Neurology rotation provides vital exposure to the diagnosis and management of neurological disorders in children. Neurology residents serve as consultants to the Yale-New Haven Hospital Pediatric Ward Service, including the newborn special care units and the pediatric ICU. The residents also provide the initial evaluation of neurological cases in the pediatric emergency room. In addition to the ward responsibilities, the house staff also attend several pediatric neurology clinics during the week.

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The Department of Neurology maintains a consultative service at Gaylord Rehabilitation Hospital, providing residents exposure to the basic principles of neuro-rehabilitation. The patients are divided into four inpatient wards covering rehabilitation in Stroke, Spinal Cord Injury, Traumatic Brain Injury, and Pulmonary Disease.  Neurology residents serve as neurological consultants under the supervision of an attending neurologist from the Yale Neurology Faculty.  They also have access to various other departments at Gaylord including Occupational Therapy, Physical Therapy, Speech Therapy, Sleep Disorders Clinic, Brace Clinic, Post-polio Clinic and Industrial Rehab.  EMG’s, Selective Nerve Blocks, Baclofen Pump refills, and Botox injections are performed on a scheduled basis. The residents present patients and round with a neurology attending on Wednesday and Friday mornings. 

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At the Cornell Scott-Hill Health Center, neurology residents attend a clinic and provide comprehensive neurologic care. In this unique setting, residents learn how to provide care to patients with limited access to healthcare and how to manage resources. Residents are also exposed to a wide range of neurologic illnesses with complex presentations. The clinic is held on Friday afternoons with one attending physicians and 2 residents of any PGY level.

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Longitudinal care is an important component of a physician's treatment of patients. This skill is acquired during the Residency Program through a continuity clinic. Each resident in the Residency Program has a continuity clinic that meets on average ½ day per week. There are continuity clinics at the VA Medical Center and Yale-New Haven Hospital. Patients assigned to the resident in these clinics become the primary responsibility of that resident. The resident, with supervision by the assigned attending, performs all aspects of neurological care for those patients, including follow-up care and problems that arise between visits, other than acute admission to the hospital. Night coverage for these outpatients is generally shared between residents.

Yale Continuity Clinics

The home of the Department of Neurology's outpatient clinic is at the garden level of the Yale Physician's Building at 800 Howard Avenue. Residents spend half a day there each week seeing patients in follow-up after discharge from the hospital or new referrals. To ensure continuity, a system is in place so that residents who take care of a patient in the hospital also see that patient in their own clinic. Residents book their patients in either a dedicated stroke continuity clinic on Monday afternoons or a general neurology clinic on Tuesday aftenoons. There is also a Neurology Urgent Access Clinic (NUAC) on Thursday afternoons for new patients needing urgent evaluations referred by primary care physicians or the Emergency Room. Patients seen in the NUAC clinic are then followed by the resident in his or her Monday or Tuesday afternoon continuity clinic. The clinic is equipped with an electronic record system, and all clinic notes are entered electronically. Both inpatient and outpatient imaging are available for review through an electronic database.

VA Continuity Clinics

The outpatient center at the VA is a recently renovated, spacious clinic, where residents have continuity clinic three times per week - Tuesday morning, Wednesday afternoon, and Friday afternoon. Tuesday morning clinic is a new consult clinic while follow-ups are seen in Wednesday and Friday afternoon clinics. The resident, with supervision by the assigned attending, performs all aspects of neurological care for those patients, including follow-up care and problems that arise between visits, other than acute admission to the hospital. Night coverage for these outpatients is generally shared between residents.

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The goal of the Neuro-Oncology Service at Yale is to teach residents how to diagnose, manage and treat patients with tumors of the nervous system. The service consists of a ward junior, the senior ward resident, the Neuro-Oncology fellow/PA and the Neuro-Oncology attending. Patients on the neuroscience floor are followed exclusively by the service and the junior resident is responsible for daily progress notes, orders and discharge paperwork. The team is not responsible for patients receiving routine chemotherapy in the Smilow Cancer Hospital and those patients are managed by medical oncology hospitalist team. The general neurology consult service sometimes follows these patients at the request of the Neuro-Oncology service if the chemotherapy requires a more involved approach. This allows the residents to take a more managerial role during the treatment phase of the patient's stay.collapse

Some neurological subspecialties care for patients predominantly, or even exclusively, in the outpatient setting. Residents are exposed to these subspecialties during the Subspecialty Clinic Rotation as well as by participating in subspecialty clinics during other rotations. The available subspecialty clinics include MS, movement disorders, neurodegenerative disorders, spinal cord injury/neurorehabilitation, neuromuscular disorders, stroke, neuro-ophthalmology, neuro-oncology, neuro-ID and epilepsy. The clinics are mainly held at the Yale Physicians Building except Neuro-HIV, MS or Neuro-Oncology clinics, which are held at the Nathan Smith Center, Temple Medical Center and Smilow Cancer Hospital, respectively. The weekly schedule during this rotation is as follows:

Time

Monday

Tuesday

Wednesday

Thursday

Friday

7:30 AM

Morning Report

Morning Report

8:00 AM

Grand Rounds

8:30 AM

General Neurology Clinic

Stroke Clinic

Multiple Sclerosis Clinic

Neuro-Oncology Clinic

9:00 AM

Movement Disorders Clinic

12:00 PM

Journal Club/M&M

Yale Noon Conference

Neuropathology Conference

Yale Noon Conference

VA Noon Conference

1:00 PM

Neuro-HIV Clinic or Resident Stroke Continuity Clinic

Resident Continuity Clinic

Neuro-ophthalmology Clinic or VA Continuity Clinic

Neurorehabilitation/
SCI Clinic

VA Continuity Clinic or Hill Health Clinic

4:30 PM

Neuroradiology Conference 

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This rotation is designed to give PGY-2 and PGY-3 residents intensive exposure to acute care neurology. The residents act as consultant to the ED, evaluating all patients coming in with primary neurological complaints. They are responsible for admissions, discharges, and arranging follow-up from the ED. Furthermore, the residents run all acute stroke alerts and administer tPA if indicated. The ED work hours are from 8:00 AM to 7:30 PM, Monday thru Friday. The ED block is 1 month long with all weekends off as this is often a challenging rotation. The resident does attend continuity clinic one afternoon per week and the Float resident covers ER consults during those afternoons.

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The Night Float Rotation was designed to increase continuity of care for inpatients during nighttime while meeting the work hour requirements for residency training mandated by the ACGME. PGY-2 and PGY-3 neurology residents participate in the ½ month blocks and spend the other ½ month as Float or Jeopardy resident. Night Float works 6 nights per week, with Saturday off. There are 2 night-float residents at YNHH. There is a Inpatient Night-Float resident that covers all of the inpatient Neurology services, including the Neuro-ICU (Inpatient Night-Float) and a Consult Night-Float resident that evaluates all consults, stroke codes and chill alerts in the hospital (inpatient and ER for adult and pediatrics).

Inpatient Night-Float

The Inpatient Night Float block was designed to increase continuity of care for inpatients during nighttime hours while meeting the residency hour requirements mandated by the ACGME. Both PGY-2 and PGY-3 neurology residents cover as the Inpatient Night Float resident in ½ month blocks during the academic year. Inpatient Night Float works 6 nights per week, and Saturday is off. This duty begins at 5:30 p.m. and ends at 6:30 a.m the next day Monday through Friday nights. On Saturday mornings the Inpatient Night Float resident rounds with the ward team and leaves the hospital by 10:30 a.m. The resident has Saturday night off and returns on Sunday night at 7:30 p.m for sign-out. During the time they are on duty, the Inpatient Night Float resident attends to all matters pertaining to the Yale Neurology inpatient, Epilepsy and neuro-ICU services. Daytime activities such as continuity clinics are not scheduled during this rotation.

Consult Night-Float

The Consult Night Float block was designed to provide coverage for consultation services, including the Emergency Department, inpatient consultations requested from other specialties, and pediatrics. Both PGY-2 and PGY-3 neurology residents cover as the Consult Night Float in ½ month blocks during the academic year. Consult Night Float works 6 nights per week, and Saturday is off. This duty begins at 7:30 p.m. Sunday-Friday and ends no later than 8:00 a.m. Monday-Saturday. At night, the consult night float is the senior resident in-house, and takes responsibility for management and disposition decisions. The Consult Night Float attends to all new consultations in the Emergency Department and Pediatric Emergency Department, as well as provide new consultations to other services in the hospital, provide urgent follow-up for existing consultation patients, and cover the Yale Medical Group-Neurology answering service (except the Epilepsy Service) as needed. The Consult Night Float responds to all stroke alerts and all chill alerts (cardiac arrest cooling protocols). The Consult Night Float is responsible for admitting patients from the ED to the inpatient service and serves as the primary resident physician for these patients until sign-out is given at 6:30 a.m. to the Yale Junior residents. Consults and admissions regarding Epilepsy patients are discussed with the Epilepsy Fellow. Interesting cases are presented during morning report by the Consult Night Float resident, which allows for direct discussion and teaching with a Neurology attending. Daytime activities such as continuity clinics are not scheduled during this rotation.

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The Jeopardy Rotation was created to provide backup support in case of unplanned absences for residents. The half-month block alternates with the Consult Night-Float rotation and the resident is expected to be available 6 days a week with one day off. The Jeopardy resident also occassionaly takes weekend call at Yale.

The Float Rotation was created to provide coverage for residents to attend continuity clinic. The half-month block alternates with the Inpatient Night-Float rotation. The Float resident covers junior residents on the inpatient service and the ER resident during the week for one afternoon so that they may attend their continuity clinic at Yale or the VA. The Float resident also attends their own continuity clinic once a week and occasionally takes weekend call at Yale.

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Each resident typically spends 3 months on electives during each of their last two years. Residents are provided guidance by the Program Director, Chairman, and other faculty members in selecting these electives. These electives can be taken in any area that will help further the residents goals for his/her career development.

Clinical Electives

Many residents spend their elective time enhancing their knowledge and skills in aspects of clinical neurology in which they are particularly interested. The possibilities for this are unlimited, since there is a large number of clinical specialties represented at Yale, and when not available locally residents can spend elective time at other institutions with strengths in specific subspecialties. Many of our residents use their elective time in this way to broaden their experience, or to enhance their competitiveness for clinical practice. Examples of clinical electives available to our residents locally include:

  • Neuroradiology
  • Neuropathology
  • Neuro-oncology
  • Stroke
  • Epilepsy
  • Neuroimmunology / Multiple Sclerosis
  • Neuromuscular Disease
  • Clinical Neurophysiology/EMG/EEG
  • Headache / Chronic Pain
  • Neuro-rehabilitation
  • Sleep
  • Movement Disorders
  • Neuro-AIDS / HIV
  • Neuro-otology
  • Functional MRI / Behavioral Neurology
  • Neuro-informatics

Research Electives

Many residents choose to spend elective time pursuing a clinical or basic science research project in collaboration with one of the many faculty members in Neurology or in other departments at Yale University. Many of these projects culminate in presentations at national meetings. Previous experience in research is not necessary. Click here to learn about research opportunities.

Mini-Fellowships

Elective time during the second or third year of neurology training can be organized into mini-fellowships. This allows residents to address topics in greater detail than usually afforded in a clinical elective. Previous residents have arranged mini-fellowships in clinical neurophysiology, epilepsy, stroke, and basic neuroscience research. These fellowships can be undertaken in conjunction with a clinical research project. In some cases, these mini-fellowships can decrease the time required in a formal fellowship, or offer more flexibility in post-graduate training.

Flexible Training in Neurology

The Yale Neurology Residency Curriculum meets the guidelines of the American Neurological Association, and endorsed by the Accreditation Council for Graduate Medical Education to support education designed to maximize efficient development of neurologist investigators. This goal is achieved in part through the availability of Research Electives in clinical neurology and basic neuroscience, as well via the availability of the Clinical Neuroscience Career Development Track and Mini-Fellowships, while also meeting all of the requirements for eligibility to sit for the examination of the American Board of Psychiatry and Neurology to become board certified in adult neurology.

Off-Campus Electives

Residents are encouraged to take off-campus electives at other institutions and/or in other countries. To this end both PGY-3 and PGY-4 residents are allowed a “Golden Elective” as one of their three electives. During this 4 week block the residents do not have any Continuity Clinic or call responsibilities. This allows residents to explore off-campus and away electives. These electives are invaluable for those residents seeking exposure to areas of neurology that are not available at Yale University, and can give insight into the approach to clinical care at other institutions or countries.

There are many possibilities available for away electives. One example that has been attractive to our residents is to learn Clinical Neurology at Charles University in Prague, Czech Republic. This successful and popular elective is run by Martin J Stransky, one of our faculty, who is based in Prague for much of the year. Dr. Stransky directs a large clinic and has a number of leadership positions in Prague (http://www.narodni.cz). The Prague elective is open to all residents and is tailored in length and content to the residents' particular interests. Along with a rich historical tradition in neurology (e.g. Purkinje), Prague has several prominent teaching hospitals with a full range of neurological services, including gamma knife surgery and PET scanning. Limited funds are available to defray some of the expenses incurred by travel to Prague.

During elective months, residents continue to attend their Continuity Clinics an average of once every week.

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