The UNC Adult Neurology Residency Program is a four-year (PGY-1 to PGY-4), categorical training program and starting from academic year 2018-2019, we increased our complement to seven adult neurology residents per year. We will match seven PGY-1 positions to start in June 2019.
There is a different emphasis in each of the three years of training. During the first year in neurology (PGY-2 year), the majority of the trainee’s time is spent managing patients who are admitted to the hospital with neurological disease or presented in our emergency room and other clinical services with neurological complaints. During the first year of neurology, residents also have extensive exposure to EEG and EMU patients though a dedicated four-week rotation with our epilepsy team. They also begin their exposure to pediatrics neurology (four weeks), critical neurological care at the dedicated neurocritical care ICU (four weeks) and often spend elective time at the neurosurgery clinics, subspecialty clinics and neuroradiology.
In the second neurology year (PGY-3 year), residents obtain more exposure to outpatient neurology subspecialty clinics in cognitive neurology, movement disorders and neuroimmunology as well as subspecialty clinical labs and services within the neurophysiology suite (EEG/epilepsy and EMG/neuromuscular disorders). They also continue to gain knowledge in pediatric neurology (four weeks) and have elective time to pursue their research or clinical interests. This is also when our residents can select away-rotations to pursue their interests in academic, international or clinical neurology. By the end of the year, all residents carry the responsibility of senior neurology consult services.
In the third neurology year (PGY-4 year), there is more elective time to help develop the resident’s specific and clinical career interests (about 3 months). The remainder of the year is spent supervising the ward and consultation services, as well as participating in outpatient subspecialty clinics and pediatric neurology (four weeks). Rotations in this year are designed to further expose trainees to a large volume of complex patient care issues.
All major neurology services are staffed by residents and include the adult neurology ward service, the adult inpatient and ER consult service, the neuroscience ICU service and outpatient clinics. A night float system accounts for all nighttime coverage with no 24-hour call throughout all clinical rotations. Residents are free to design elective time to cover their topics of interest from among UNC rotations. They can also choose to have away rotations at an institution of their choice or take an international neurology elective. Electives must be approved by the program director.
Neurology is a core rotation for all medical students at the University of North Carolina School of Medicine and it is common to have three or four third- and second-year medical students on our inpatient and outpatient services. Each medical student is assigned to a junior resident on the inpatient team. Close interactions with medical students create ample opportunities for bedside teaching and mentorship for our junior and senior residents.
Adult neurology ward service
The neurology ward service is generally comprised of a hospitalist neurology attending physician and one senior resident who supervises two clinical ward teams. Each clinical ward team is comprised of one junior resident (PGY2) and one intern. We have interns for inpatient neurology from the psychiatry and rehabilitation medicine departments as well as neurology interns who are in their internal medicine year of training.
The service is a “resident-driven” care system, and the senior resident is responsible for supervising the two clinical teams (comprised of junior, intern and medical student) in the evaluation and management of neurology patients admitted to the service. On the clinical team, junior residents, interns and medical students share and see patients together, formulate the plan of care and lead all family meetings and discussions. Each clinical team carries about 10-15 patients on a given day.
The attendings provide close supervision and resident/student education with three to four hours of bedside teaching each day. Due to the night float system, overnight in-house call is kept to a minimum. Short call from 4:30 – 8 PM is served by the junior–intern clinical team every other evening. During the first two weeks of the ward service in July and August, the senior resident takes call in house along with the clinical team to help solidify the junior’s clinical exam skills and help facilitate consults. Senior residents take senior backup call an average of every fourth night from home.
Neurology inpatient and ER consult service
The consult service is generally comprised of a neurology attending, one senior resident, two junior residents, and three or four second and third year medical students. Residents are responsible for providing neurologic consultation for patients in the hospital and the emergency room (Monday through Friday from 8 AM – 4:30 PM and during weekend rounds 8 AM – 2 PM). During this rotation the resident has their maximum exposure to acute neurology including acute stroke evaluations and administration of tPA, status epilepticus diagnosis and treatment, meningitis and encephalitis evaluation and treatment as well as acute neurology of trauma. The senior resident is responsible for taking all consultation requests and supervising the junior members of the team. Attendings work closely with the residents and provide supervision and bedside teaching throughout the day during morning and afternoon rounds. Senior residents take senior backup call an average of every fourth night from home. There is no call requirement for the junior residents on this rotation.
Residents on the night float service are responsible for the care of neurology inpatients as well as for consultation requests from 8 PM to 8 AM. Two residents share the night float duties, splitting the week (Sunday to Wednesday and Thursday to Saturday). They are supervised by an on-call senior resident and an on-call attending. The night float resident is responsible for presenting new patients admitted to the neurology service to the ward team each morning at the end of the night float shift.
Neuroscience Intensive Care Unit
Residents spend one month at the Neurosciences Intensive Care Unit. This rotation is designed to teach the evaluation and management of patients with acute neurological emergency disorders. The unit team is comprised of ICU attendings, residents, fellows, nurse practitioners and one to two medical students. Attendings provide close supervision and resident/student education with three to four hours of bedside teaching each day. There is no call requirement for residents on this rotation. This rotation is mandatory for all PGY2 residents and can be done as an elective rotation during PGY3 and PGY4 year.
Residents on the pediatric neurology rotation see neurology patients in both inpatient and outpatient settings. Inpatient opportunities include consultations from the ward teams and direct evaluation of patients admitted to the pediatric neurology service. There are inpatient ward and teaching rounds daily. The outpatient activities include pediatric neurology clinics five days a week. According to the American Board of Neurology and Psychiatry, adult neurology residents should have three months of pediatric neurology included in their training. During each year of training residents have a mandatory four-week rotation in pediatrics neurology.
Epilepsy Monitoring Unit/EEG
This rotation is designed to teach the evaluation and management of patients with disorders of consciousness, and the indications for clinical neurophysiological studies including EEG, long-term monitoring and evoked potentials. Residents work within the epilepsy team consisting of a neurology attending, fellows, physician assistants and medical students. This is a mandatory four-week rotation during the PGY2 year. During the rotation residents will see patients in epilepsy monitoring units, and read routine and urgent EEGs under one-on-one mentorship by an epileptologist. Residents gain a basic knowledge of interpretation of clinical neurophysiological studies and develop an understanding of the information these studies can provide as well as their limitations. Residents also gain an understanding of the basic management of epilepsy patients and learn to integrate the diagnostic evaluation and care of these patients with the results of the tests.
Advance Neurophysiology rotation
This is an elective rotation that provides residents with practical knowledge and experience using neurophysiologic tests to assess consciousness and diagnose sleep and epilepsy-related disorders. Residents become familiar with the technical aspects of electroencephalography (EEG), polysomnography (PSG), multiple sleep latency tests (MSLT), actigraphy, and intra-operative monitoring (IOM) as well as the interpretation and clinical application of the findings. Two to three afternoons per week, residents attend the adult epilepsy clinic and participate in the evaluation and management of patients with paroxysmal events or sleep disorders.
A dedicated two-week rotation in the subspecialty clinics provide in-depth learning of the nuances in history taking and neurological examination in outpatient settings. During this rotation the resident works one-on-one with subspecialty division attendings in evaluating new and established patients, and participating in interdisciplinary team meetings and didactics organized by each division. Residents have mandatory two-week rotations at each subspecialty: neuromuscular, multiple sclerosis, neurocognitive and movement disorders clinics. There is no call assignment during this rotation.
Residents also can choose to have an elective one-week rotation at subspecialty clinics such as epilepsy, sleep, stroke, botox and deep brain stimulation.
Acute Neurology Clinic
Residents in the acute neurology clinic evaluate patients presenting to the general neurology clinic with acute or urgent neurologic problems. One morning per week, the acute neurology resident performs lumbar punctures (LP) at the LP clinic. The residents gain experience in the diagnosis and management of various acute neurological disorders under the direct supervision of the attending assigned to the acute outpatient service.
EMG/Nerve conduction studies
Residents on the neuromuscular-EMG/NCV rotation see neuromuscular patients in both inpatient and outpatient settings. Their time is apportioned between inpatient and outpatient clinical opportunities and the EMG section of the clinical neurophysiology laboratory. Inpatient opportunities include consultations from hospital-wide ward teams and direct evaluation of patients admitted to the adult and child neurology services. The outpatient clinical activities include MDA (Muscular Dystrophy Association), ALS, myasthenia gravis and autonomic disorder. Residents on the rotation participate in the clinics on two to three half-day sessions per week. Residents electing to spend three consecutive months on the rotation will spend a significant time (up to six half days per week) performing clinical EMG/NCV tests in the clinical neurophysiology laboratory under the mentorship of a faculty attending.
Continuity Resident Clinic
Starting with PGY2, all neurology residents have a weekly continuity clinic where they provide direct neurological outpatient care to patients from local community and from all around the state. It is a half-day of clinic per week during which time the resident is excused from all other clinical obligations to attend. The continuity resident clinic is staffed by one core teaching faculty and one rotating subspecialty faculty. The core faculty remains constant, which facilitates the development of a mentoring relationship between resident and staff.
Residents commonly see a variety of general neurology patients, return patients from their inpatient services, and subspecialty consultations. The outpatient resident continuity clinic schedule is gradually expanding as a reflection of our residents’ abilities to provide efficient and compassionate patient care. As residents progress in their training, they become more autonomous and independent in their decision-making. About six months before graduation, a typical resident clinic schedule includes two new patients and three return patients per clinic.
Electives routinely available to residents include:
- Stroke and Vascular Neurology
- Neuroradiology/Interventional Neuroradiology
- Neurosciences Intensive Care Unit
- EMG/Neuromuscular Disorders/Autonomic Disorders/Autonomic Testing Lab
- EEG/Epilepsy Monitoring Unit/Epilepsy clinics
- Sleep Medicine
- Movement Disorders/Deep Brain Stimulation
- Memory and Cognitive Disorders
- Multiple Sclerosis/Neuroimmunology
- International neurology elective
- Away elective
- Physical Medicine and Rehabilitation
- Clinical Research/Trials/Basic Research
The adult neurology residency program includes a preliminary (intern) year. Rotations during this year include neurology (two months), psychiatry (one month), emergency medicine (one month), and internal medicine (eight months). Rotations on internal medicine services have been selected to include rotations on subspecialties felt to be most helpful in caring for patients with neurologic diseases and may include: general medicine wards, MICU, CCU, general cardiology, rheumatology, endocrine, infectious diseases, and oncology.
PGY-2 (Thirteen four-week blocks)
During PGY–2 year, about 75% of the cases will be vascular neurology and other neurological emergencies (e.g., AIDP, neuro-oncological cases, complicated demyelinating disease, and status epilepticus). “Bread and butter” neurology cases (uncomplicated neurodegenerative diseases, demyelinating diseases, brain tumors, and seizure disorders) are seen. A large minority of cases will be unusual presentations not seen outside of an academic tertiary–quaternary care facility.
EEG – 1 block
Neurological ICU – 1 block
Pediatric Neurology – 1 block
Elective – 1 block
Inpatient ward junior – 5 blocks
Consult service junior – 4 blocks
PGY–3 (Thirteen four-week blocks)
During the PGY-3 year residents explore outpatient neurology and solidify their knowledge in clinical neurophysiology. They progressively increase their responsibilities by covering the night float rotations and providing senior services on the neurological consultation team. This is also the year when most of the seniors schedule their international neurology and away rotations.
Pediatric Neurology – 1 block
Elective – 2 blocks
Night float – 3 blocks
Subspecialty clinics – 1 block
Consult service junior – 2 blocks
Consult service senior – 2 blocks
PGY–4 (Thirteen four-week blocks)
During PGY-4 year, six months of the year residents provide supervision and leadership on inpatient ward service and consultation service. They also provide some coverage during the night. The rest of the time is spent on electives and subspecialty clinics to solidify their outpatient neurology skills or pursuing their future research or quality improvement projects.
Pediatric Neurology – 1 block
Elective – 2- 3 blocks
Night float – 2 blocks
Subspecialty clinics – 1 block
Inpatient ward senior – 2 – 3 blocks
Consult service senior – 2 – 3 blocks
Additional benefits provided by the Department of Neurology:
- The Department pays the registration fee for the ABPN certification exam for all residents who successfully complete the residency training program.
- Four weeks of paid vacation each year, one week of which includes either Christmas or New Year’s Day.
- Paid membership to the American Academy of Neurology.
- Annual book and travel allowance for all residents.
- Senior residents (PGY-4) are provided with additional funds to pay for travel and registration to attend the annual AAN meeting.
- Supplemental travel funds will be provided to any resident presenting original work at meetings or medical conferences.
- Meal allowance for each in-house overnight on-call period to be used in the many UNC Hospitals eateries.