Training template for Paediatric Neurology. Associate Prof Jo Wilmshurst (HOD
Paediatric Neurology and Neurophysiology). Red Cross War Memorial ...
Training template for Paediatric Neurology Associate Prof Jo Wilmshurst (HOD Paediatric Neurology and Neurophysiology) Red Cross War Memorial Children’s Hospital University of Cape Town Ideal training time: 2 years Outcome goals: Completion of Mphil degree Exit exam in the sub-speciality of Paediatric Neurology Publication in peer reviewed literature (1 case series + 1 prospective study minimum) Presentation of work at National and International congress 3 mthly formal and informal assessments will occur to monitor progress. Shorter training periods accepted. Tailored to the specific outcome goals e.g. updating clinical neurophysiology exposure Inclusion criteria: Must be a paediatrician – with qualifications recognized by the HPCSA.
1.1
The overall aims of the training programme 1.1.1 The training programme aims to equip candidates to practise in the subspeciality of Paediatric Neurology. This encompasses the study, assessment and management of a wide spectrum of neurological diseases from the newborn period to adolescence. General consensus accepts that it should include expertise in cerebral palsy, childhood epileptic syndromes, strokes, disorders of the spine, hydrocephalus, neuro-cutaneous disorders, neuromuscular disorders, children with movement disorders, CNS tumours, neuro-degenerative disorders, neuro-metabolic/inborn errors of metabolism disorders, mental retardation, language and communication (autism) disorders, ADHD and learning disorders, headaches, sleep disorders, neuronal migration disorders, disorders of the cerebellum, neuro-psychiatric disorders and complimentary involvement in neurosurgical patients 1.1.2 The paediatric heritage therefore has to be superimposed on psychiatry, psychology, developmental, education, social work, the communication sciences, occupational and physical therapy and many more 1.1.3 Because of the nature of this subspeciality, professionals who practice in the field have to develop some unique characteristics. They need to be intellectually eclectic, dealing with gradation rather than absolutes. Their view has to be longitudinal and developmental. They have to deal with nature versus nurture interactions and often have to bridge gaps between science and clinical practice. They have to be committed to multidisciplinary collaboration in problem solving
1.2
Specific outcomes On completion of training the candidate must be able to manage children with special needs as pertaining to abnormalities of the neurological systems. They should have the skills to act as a resource for other professionals. They must be able to assist in training, research and the development of programmes, whether the focus is prevention, intervention or therapeutic
1.3
Training 1.3.1 Objectives: At the end of the training the candidate must be able to pass an examination approved by the HPCSA specialist committee 1.3.2 Knowledge: 1.3.2.1 Basic sciences: A sound knowledge and experience in the following fields are essential: neuro-anatomy, neuro-embryology of the brain neuro-physiology including a good working knowledge of the basics of EEGs and their interpretation as they pertain to children, EMGs and nerve conduction studies, evoked potential studies basic biochemistry (neuro-metabolic investigations) neuro-radiology including CT brain scans, MRI scans, Spect scans and ultra sound selective histopathology including muscle, nerve and neuronal histology selective and clinically applied neuro-genetics (recurrence risks, prenatal diagnosis, gene localisation and gene imprinting) pharmacology of CNS drugs (eg anti-epileptics) basic statistics and research design 1.3.2.2
Clinical training:
A two-year attachment to a recognised paediatric neurology training unit with exposure to as wide a range of paediatric neurology cases as possible. Exposure to the following cases is essential. Cerebral palsy, childhood epileptic syndromes, strokes, disorders of the spine, hydrocephalus, neuro-cutaneous disorders, neuromuscular disorders, children with movement disorders, CNS tumours, neuro-degenerative disorders, neuro-metabolic/inborn errors of metabolism disorders, mental retardation, language and communication (autism) disorders, ADHD and learning disorders, headaches, sleep
disorders, neuronal migration disorders, disorders of the cerebellum, neuro-psychiatric disorders Competence in neurological emergencies (coma, status epilepticus, raised intracranial pressure, metabolic disorders, trauma and non-accidental injuries) Neonatal neurology with an understanding of the principles of ante-natal brain development, brain injury and its investigations Suitable time spent in adult neurology, either on regular clinical ward rounds, case discussions and attendance at conferences Exposure and involvement in research projects, attendance and presentations at relevant conferences Suitable time spent in child and adolescent psychiatry (Attendance at clinics)
Principles of therapy:
familiarity with physio, occupational and speech therapy thorough knowledge of drugs used in paediatric neurology principles underlying rehabilitation principles of management of behavioural disorders (counselling and psychotherapy, drugs) awareness of range of alternative therapies knowledge of therapy aids (hearing and visual aids, seating mobility [aids, orthoses, communication aids]) awareness of neurosurgical procedures and forms of therapy
Clinical skills:
developmental assessment an understanding of the common psychometric tests detailed neurological examination interpret results of investigations (EEG, EMG, nerve conduction, evoked potentials, metabolic and biochemical, CT and MRI scans) perform EMG, nerve conduction skin biopsy muscle biopsy raised intracranial pressure monitoring perform tests to determine brain death lumbar punctures subdural punctures
Academic:
teaching skills (under/postgraduate, formal and informal skills) communication skills (to parents, children, peers and colleagues) demonstrate adequate knowledge of clinical research methods, biostatistics, epidemiology and ethics, essential in patient-based research projects the candidate must participate in research during the training period that must lead to at least one presentation at a national Paediatric conference, but the submission of one manuscript to a peer-reviewed journal would be preferable
Ethical issues:
The candidate must be able to: implement ethical standards discuss and comprehend relevant ethical issues
Completion of a log book to record training activities is required.
The training schedule is divided between mainly out-patient clinic (part 1) activities. There is usually enough protected time during these months to work on research projects, spend time attached to the neurophysiology staff and to gain exposure to allied disciplines (e.g. adult neurology, neurodevelopment etc). The alternate months are spent attached the in-patient duties (part 2) and includes assessment and management of the admitted patients, acute admissions and referrals. Part 1: Clinic Neurology SR rotation Alternating monthly with SR for wards Aim of this attachment Clinic related: Gain exposure to general and sub-speciality clinics Gain exposure to affiliated training clinic areas (e.g adult neurology, neurosurgery, developmental, ophthalomology, neuropsychiatry, neuropsychology, etc) Gain exposure to ancillary therapies (e.g. OT, physio, ST, - spend time with each) Additional training: Spend time in neuroradiology – e.g. Mondays with the MRI list (Set up time to attend neuroradiology reporting with Tracy/Nicky when fully staffed again. Will need to discuss with them- need to avoid last minute teaching tutorials pre exams) Report at least 5 EEGs a week, be available to assess others of interest Report (preliminary) all video EEG telemetry Assist with all NCS – make preliminary reports Gain confidence in interpreting NCS/BAERS/VEP/ERG Research / reading Aim to complete at least one retrospective study and one prospective study. Set timelines and stick to them. Read around complex patients / learn to critic management in the department to ensure up to date with latest guidelines. Additional duties Should be first present at all joint clinics. Available until 16h00 for cover of S25 issues/walk-ins/repeats/sedation. Until 13.00 try to use in-tray for non-urgent requests, plan with sister for sedations. After 13.00 staff must know how to reach fellow (or alternate contact person) if any patient concern (e.g. walk-ins, very abnormal EEGs etc) Staff in S25 should be informed of whereabouts when not in unit: must be available telephonically. If cover needed for teaching or if need time for research offsite- to be arranged with SR covering wards/referrals. Available to help ward/referral fellow if hospital too busy to manage alone. Complete the neurology database Free time between clinics and S25: (3 afternoons a week and 1 morning 3:4 weeks- excludes one afternoon for teaching at Somerset – not always part of the fellows training)
Day / time Monday
Activity
Goal
07.30-08.30
Plan week’s activities EEGs to report Research data to collect Papers to read
Plan week carefully to gain optimal knowledge
08.30-12.00
Gen neurology clinic
Build confidence in neuro assessment & Mx recommendations. Keep record of all these for LOG BOOK
12.00-12.45
Working ward round with on call consultant
12.45-13.30
Developmental multidisciplinary meeting
13.30-14.00
EEG meeting
14.00-17.00
EEG reporting Assist with NCS Research work / reading
Gain in-sight into combined services Provide input into cases presented. Keep record of cases presented for LOG BOOK. Discuss interesting / challenging cases. Every week 5 EEGs should have been prepared / reported. Keep record for LOG BOOK. Should be able to report basic EEGs Should be able to interpret NCS Should complete at least one prospective and one retrospective review
Comment
Always discuss unusual cases with Consultant either acutely or at WR sessions.
It is the priority of the clinic SR to attend. Not all the 5 cases will be presented – only the interesting conundrums. But the reports will be checked with the clinical technologist / consultant.
Tuesday 07.30-08.30
Neuroradiology meeting
Be aware of possible pts who may be discussed. Keep record of number of cases and range of pathology for LOG BOOK
Best to keep MRI book with short summary of key events. Also to add new comments which arise from the meeting.
08.30-09.00 09.00-13.00
Neuromuscular clinic
13.00-14.00
Neurology journal club
14.00-15.30
1. 5th yr Student teaching Somerset Hospital (alt weeks or months depending on internal arrangement with second tutor: 2. If not teaching -.reading, neurophysiology preparation etc
15.30-17.00
Research / reading
Record number and range of pts seen for LOG BOOK Build awareness of latest data in literature Present regularly at JC Reinforce / build teaching skills. Keep record for LOG BOOK
It is essential to be on time for this clinic – arriving before the consultant would be great! NB if teaching students at Somerset – leave JC 15 mins early. This is not necessarily a fixed arrangement depending on leave and last minute unavoidable swops To avoid further chaos on ward / referral clinic SR covers during this time.
Wednesday 07.30-08.00 08.00-09.00
Departmental grand round lecture presentations (D3)
09.00-11.00
Grand round E2/hospital neurology round (starts E2)
11.00-12.45
Developmental clinic / Neuropsych clinic
12.45-16.00
Epilepsy clinic and case discussions
16.00-17.00 Thursday 07.30-08.00
Research / reading
08.00-12.00
HIV neuro clinic 1:2 / general neurology clinic
12.00-12.30
Prepare cases for exam practice
12.30-14.00
Case presentations to consultant Ward cover duties / referrals
14.00-15.30
15.30-17.00 Friday 07.30-08.00 09.00-12.00 12.00-13.00
Be aware of other topics presented Be part of the neurology presentations (record LOG BOOK) Attend this round to keep up to date with ward patients and identify interesting cases to go back and exam. Aim to gain exposure in both areas Keep record in LOG BOOK Develop confidence in managing pts with epilepsy. Keep record for LOG BOOK of number of cases seen and range of conditions
Gain skills in presentations of neuroHIV complications. Keep record in LOG BOOK Try to present one case each meeting. Keep list for LOG BOOK Prepare one case per week. Keep record for LOG BOOK
Ideally build up list of own patients see regularly.
Both SRs present – find cases for each other
This is not necessarily a fixed arrangement depending on leave and last minute unavoidable swops. Rotating registrar teaching from 13h30: provide ward cover and use opportunity to teach 6th year students (prescribed tutorials according to roster) Teaching may happen on Thurs or Friday. NB End of block student convening/examining and quarterly registrar assessments: convening on occasion.
5th yr student teaching (alternate Thursdays) at Somerset Hospital Ward/referral cover to be provided by other SR
Research /reading
1:4 Fridays Neurocutaneous Clinic 1:6 Histopathology meeting High risk clinic D3 meeting
Multidisciplinary clinic
Keep list of patients for LOG BOOK Keep record of all biopsies for path meeting Present 1:4
Be prepared to comment on cases with neuro issues.
13.30-14.00
14.30-17.00
1. If changing with ward SR prepare handover as below. 2. Review MRI admissions expected on Sunday, ensure folders pulled by ward clerk and anticipate problems/ patients requiring longer than one night stay.
Other activities: Work in team with clinics SR – support each other. Share weekend on-call E2 ward rounds. Maintain research topics – prepare protocols and research projects Attend monthly research meeting.
Part 2: Ward Neurology SR rotation Alternating monthly with SR for clinics Day / time Activity Monday
07.30-08.00
WR with rotating ward registrar 1. Hand over weekend problems 2. Review new admissions. 3. MRI patients- review notes from last clinic visit to establish plan for the admission- may require extra investigations or neurology team review. Ensure TTO done early and follow up appt booked to see own Dr for results. 4. Prepare for any new referrals (i.e. Check appts made/biopsy dates etc)
08.00-12.00
See new referrals.
12.00-12.45
Working ward round with on call consultant
12.45-13.30
Developmental multidisciplinary meeting
13.30-14.00
14.00-17.00
EEG meeting
1. Referrals 2. Consolidate plans on ward patients. 3. Check for new up country admissions to clerk
Goal
Comment
Priority = MRI admissions go smoothly (IV line up & consent/request forms done. Clear plan of chain of activities in place ready for 12.00 cons WR.
Reg and SHO see patients & make a plan, present new referrals and admissions. Formulate plan for admission (in reality this may need to be done primarily by the SR depending on how busy the GIT/general service is.) Rotating reg should present new patients.
Build confidence in neuro assessment & Mx recommendations. Keep record of all these for LOG BOOK Tie up management plan for all inpatients, pending admissions and referrals Gain in-sight into combined services Provide input into cases presented. Keep record of cases presented for LOG BOOK. Discuss interesting / challenging cases. Every week 5 EEGs should have been prepared / reported. Keep record for LOG BOOK. Check aware of all ward activities and loose ends tied up. Allocate with rotating reg who will formally present pts and Mx plan for grand round Wed (may need to read up around condition child has).
Touch base with all wards to pick up other issues early. Always discuss referrals with Consultant either acutely or at WR sessions. Always document consultation in pt folder and inform ward reg. This is a business round but the rotating reg / SHO should still practice presenting pts in a problem orientated manner. If the ward is very busy this meeting is the priority of the clinic SA to attend. Not all the 5 cases will be presented – only the interesting conundrums. But the reports will be checked with the clinical technologist / consultant. Ideally any new pts have had initial clerk done by student/SHO/Registrar, but they are often tied up with other ward responsibility or post call. SR need to wrap this up.
Tuesday Be aware of possible pts who may be discussed. Keep record of number of cases and range of pathology for LOG BOOK Identify problem patients and admissions expected for the day. Record number and range of pts seen for LOG BOOK
07.30-08.30
Neuroradiology meeting
08.30-09.00
Working ward round with rotating reg
09.00-12.15
Neuromuscular clinic Ward / referrals still priority.
12.15-13.00
E2 sub-speciality meeting
Present and respond to pts with neuro issues. Keep record for LOG BOOK
13.00-14.00
Neurology journal club
Build awareness of latest data in literature Present regularly at JC
14.00-15.30
15.30-17.00
1. 5th yr Student teaching Somerset Hospital (alt weeks or months depending on internal arrangement with second tutor: (Ackermann).. 2. If not teaching - attend to ward patients/referrals/follow ups. Ensure patient’s results and plans consolidated for Grand round on Wednesday. Possibly working ward round with on call consultant. Ward patients/referrals/follow ups. Ensure patient’s results and plans consolidated for Grand round on Wednesday. Possibly working ward round with on call consultant.
Wednesday 07.30-08.00
Business round to trouble shoot pts
08.00-09.00
Departmental grand round lecture presentations (D3)
09.00-11.00
11.00-11.30
Grand round E2/hospital neurology round (starts E2) 1. Presentations by SHO/registrar (SR if no junior has familiarised themselves with pt). 2. Review ward attendees ( should be prepared before) Discuss new referrals/country cases which need ward admission dates.
Reinforce / build teaching skills. Keep record for LOG BOOK
Best to keep MRI book with short summary of key events. Also to had new comments which arise from the meeting.
May be required to interrupt attendance for new referrals/phone calls/ward issues. Best to check before the meeting if neuro cases up for discussion. Warn consultant on-call – if Muscle clinic busy consultant unlikely to make the E2 meeting. NB if teaching students at Somerset – leave JC 15 mins early.
This is not necessarily a fixed arrangement depending on leave and last minute unavoidable swops To avoid further chaos on ward / referral clinic SR covers during this time.
Check all ready for Wed grand round
Check all ready for grand round Be aware of other topics presented Be part of the neurology presentations (record LOG BOOK) Co-ordinate this round, control patients seen, who presents, ensure all management plans recorded in folder and working book. Ensure planned admissions scheduled evenly i.e. weeks are not overloaded with
- Put day ward attendees in book with clerk in order for folder to be pulled beforehand.
admissions. Keep record in LOG BOOK of complex admissions coordinated.
11.30-12.45
Review ward patients and referrals not sorted out on grand round. Develop confidence in managing pts with epilepsy. Keep record for LOG BOOK of number of cases seen and range of conditions
12.45-16.00
Epilepsy clinic and case discussions
16.00-17.00
Review outstanding ward problems/patients/referrals
Thursday 07.30-08.00
Prepare for teaching ward round E2
08.00-10.30
Ward / Referrals / EEG reporting
10.30-12.00
E2 grand round / tea
Try to present one case each meeting. Keep list for LOG BOOK
12.30-14.00
Case presentations to consultant Ward cover duties / referrals
Prepare one case per week. Keep record for LOG BOOK
14.00-15.30
Ward cover duties / referrals
07.30-08.00
1. Ward/referrals/reports. 2. Prepare for D3 meeting 1:4 Fridays
09.00-12.00
1:4 Fridays Neurocutaneous Clinic 1:6 Histopathology meeting
12.00-13.00
D3 meeting
Basically tidy up time. Encourage rotating registrars to present interesting cases and prepare relevant literature / data around condition. Plan cases, warn consultant what presenting, check if other disciplines presenting case need neuro input on. Both SRs present – find cases for each other This is not necessarily a fixed arrangement depending on leave and last minute unavoidable swops. Rotating registrar teaching from 13h30: provide ward cover and use opportunity to teach 6th year students (prescribed tutorials according to roster) This may happen on Thurs or Fridays. NB End of block student convening/examining and quarterly reg assessments: convening on occasion.
5th yr student teaching (alternate Thursdays) at Somerset Hospital Ward/referral cover to be provided by other SR
15.30-17.00 Friday
Ideally build up list of own patients see regularly.
Plan interesting cases for D3 meeting Keep list for LOG BOOK. Keep list of patients for LOG BOOK Keep record of all biopsies for path meeting Present 1:4 Be prepared to comment on cases with neuro issues.
Ideally co-prepare presentations with rotating registrar. Attend unless unavoidable problems in ward/referrals which cannot wait. Often need to follow up of presentations from other wards.
13.30-14.00
14.30-17.00
Weekend handover with rest of E2 teams. 1. Wards/referrals/reports. 2. Review MRI admissions expected on Sunday, ensure folders pulled by ward clerk and anticipate problems/ patients requiring longer than one night stay.
Other activities: Work in team with clinics SR – support each other. Share weekend on-call E2 ward rounds Maintain research topics – prepare protocols and research projects Attend monthly research meeting.
