Description:
The Stroke Service cares for patients in three levels of acuity: a dedicated Neurological Intensive Care Unit (NSICU), a stroke step-down unit, and stoke patients on the regular medical-surgical unit. The Stroke Team consists of a Stroke Attending, one of six stroke-dedicated faculty members with fellowship training in Vascular Neurology, one Stroke Fellow in their first or second year of Vascular Neurology fellowship (PGY5 or 6), a PGY-4 neurology resident, and two PGY-2 neurology residents. There is also a full complement of medical students, including two to three Mount Sinai medical students in their third year of medical school and a variable number (zero to three) of medical students visiting from both US and foreign medical schools.
Teaching rounds on the Stroke Service are held seven days a week. Teaching rounds are led by the Stroke Fellow in conjunction with the Stroke Attending. The PGY-2 neurology resident is responsible for providing accurate and up-to-date patient presentations, interim histories, exam findings, laboratory results and radiographic information. Medical students help to collect this information on the patients they are following before teaching rounds begin. The PGY-4 neurology resident is called upon to synthesize this information and help to determine a treatment plan under the guidance of the Stroke Fellow and Stroke Attending. Teaching is done by both the Stroke Attending and Stroke Fellow both during bedside rounds and, more formally, after bedside rounds are finished. Monday through Friday, stroke rounds concludes by a review of each day's new neuroimaging studies in the Neuroradiology Reading Room with a Neuroradiologist.
The PGY-4 stroke senior resident is the primary delegator of responsibilities and facilitator of multi-level education. During the weekdays, the stroke fellow or senior carries the dedicated stroke pager, utilized for acute strokes potentially warranting t-PA or a neurovascular procedure. The stroke fellow or senior resident triages acute-stroke patients, coordinating with relevant services including the stat laboratory, patient transport, and CT scan. Often with medical students at the bedside, the senior resident performs the initial history, exam, and NIH Stroke Scale, pursues rule-out criteria for t-PA, teaches the students relevant clinical pearls pertaining to stroke localization and acute management, and informs and discusses with the patient's family members the risks and benefits of clot lysis. The senior resident must have the forethought to involve the PGY-2 resident on the unit as to the appropriate triage (NSICU, stroke unit, or floor bed), as well as the self-reflection and humility required to know when to involve the stroke fellow or attending in a patient's initial management.
The PGY-4 or fellow documents the initial consultation; the PGY-2 writes an admissionnote and orders, and places the patient on the online Signout system; and the stroke fellow further documents a note or addendum as warranted. If the patient is critically ill, the PGY-4 collaborates with the NSICU team to co-manage the patient until they are stabilized. The resident delegates a medical student, ideally one present at the initial evaluation, to follow the patient, discuss them on daily attending rounds, and document progress notes for resident co-signature. The PGY-4 coordinates the team, and serves to oversee and educate the PGY-2 residents in particular.
Goals
To build the resident's clinical knowledge and skills in the care of stroke inpatients.
To teach residents to develop the advanced knowledge and skills related to the assessment and management of stroke patients in the acute and subacute setting.
To provide exposure to comprehensive/interdisciplinary care for patients with stroke (including nursing, social work, rehabilitation medicine, etc).
To give residents an opportunity to lead the Neurology Inpatient Stroke team and to foster efficient leadership skills.
Objectives
The resident will:
Recognize the uncommon presentations of TIA and acute stroke syndromes (Patient Care, Medical Knowledge). Solidify their understanding of how to manage non-routine stroke diagnoses and complex stroke patients (Patient Care, Medical Knowledge)
Lead the neurology stroke housestaff team on work rounds (Patient Care)
Supervise the work of the junior neurology resident, particularly overseeing their skills in note-writing, neurological examination, case presentation, communication and patient management skills (Patient Care)
Supervise the work of the medical students on service, particularly overseeing the development of their skills in history-taking, neurological examination, admission and progress note-writing and case presentation (Patient Care)
Provide compassionate and empathetic care to stroke patients and their families (Patient Care)
Gather essential and accurate information on all stroke patients seen in consultation in the ED in order to efficiently develop and carry out a diagnostic and therapeutic plan, to be overseen by the stroke neurologist on service (Patient Care)
Develop the ability to locate and assess scientific evidence related to the treatment of neurology patients and incorporate their findings into clinical practice (Practice-Based Learning and Improvement)
Integrate formative feedback from attendings, colleagues and students into daily practices (Practice-Based Learning and Improvement)
Effectively communicate and collaborate with nurses, nurse managers, case managers, social workers, physical therapists and consultants from other medical specialties as part of the interdisciplinary patient care team (Professionalism, Interpersonal and Communication Skills, Systems-Based Practice)
Effectively teach medical students, junior residents and interns on the stroke service at a level appropriate to their development (Interpersonal and Communication Skills)
Provide clear and directed performance feedback to the junior neurology residents on the stroke service based on the goals and objectives for their rotation (Interpersonal and Communication Skills)
Provide clear and directed performance feedback to medical students on the stroke service based on the goals and objectives for their rotation (Interpersonal and Communication Skills)
Provide clear and directed performance feedback to neurosurgery and psychiatry interns rotating on the neurology inpatient service based on the goals and objectives of their rotation (Interpersonal and Communication Skills)
Understand the legal, ethical and cultural complexities of decision-making in post-stroke patients (Professionalism, Interpersonal and Communication Skills)
Demonstrate respect for patient confidentiality and autonomy (Professionalism)
Recognize the complex social, family and community issues surrounding acute, critical illness such as stroke (Professionalism, Systems-Based Practice)
Learn to advocate for patients with and navigate through government and commercial insurance providers in order to ensure optimal inpatient care and post-hospital placement for stroke patients (Systems-Based Practice)