NEUROLOGY RESIDENCY PROGRAM

Welcome to the Neurological Institute of New York at Columbia University Medical Center and New York Presbyterian Hospital! This brief summary provides information about our Neurology Residency Program.

The Neurology Residency Program at Columbia is one of the premier neurology training programs in the country. Established in 1948, the program has a long-standing tradition of academic excellence and prestige.

The basic goals of the Neurology Residency Program are: to provide the highest caliber of training and mentorship for residents in neurology, and to produce graduates who are exceptional neurologists, clinical investigators, neuroscientists, educators and leaders.

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I. Program size and NRMP codes

Since July 2007, the program has offered positions for ten neurology residents per year, including combined 4-year Medicine/Neurology positions.

The program in Pediatric Neurology enrolls 2 residents per year.

II. Hospital Centers

1. Columbia University Medical Center [Columbia/New York Presbyterian Hospital]
2. Harlem Hospital Center

III. Core Curriculum in Adult Neurology

The neurology residency at Columbia provides a state-of-the art training that emphasizes clinical skills, advanced neuroimaging and therapeutics, subspecialty depth, research opportunities and resident scholarship. Throughout their training, Columbia neurology residents participate with increasing independence in all aspects of patient care. Residents are exposed to every aspect of adult and pediatric inpatient neurology, neurological emergencies, neurocritical care, ambulatory neurology, psychiatry, and all the neurological subspecialties. The program offers a wealth of learning opportunities in the form of an extensive elective program, encompassing every discipline within neurology and psychiatry, as well as allied fields including neuroradiology, neuropathology, epidemiology and biostatistics, medical ethics, and neuroscience.

The collegial environment at Columbia and its subspecialty organization foster excellence in all areas of neurology. Education is a central mission of Columbia neurology, and the faculty is very invested in the activities of the residency program. There are abundant opportunities for learning, from bedside and clinical rounds to formal conferences and seminars. The large and diverse patient volume provides our trainees with an unsurpassed depth of clinical experience. Because our two teaching hospitals serve a large urban population, residents have exposure to both common neurological problems encountered in our local community, as well as to patients referred to Columbia University Medical Center for tertiary and quaternary care of rare and complex neurological disorders. Clinical teaching occurs against a background of exceptionally strong neuroscience, as understanding the underlying neurobiology of neurological disorders is an essential element in the training and development of future neurologists. Faculty members are readily accessible and offer many opportunities for personal interactions between trainees and renowned experts in neuroscience and all subspecialty areas of neurology.

IV. Recent changes and highlights in the Residency Program

In the last several years, we brought about important changes in the neurology program, each described below. These changes have made a substantial impact on the educational experience at Columbia:

We expanded the residency program.
We eliminated night call for junior residents on the ward services
We re-organized the in-patient services to promote continuity of care
We established clinical and research mentorship programs
We opened a new state-of-the art intensive care unit
We established a new hospitalist service
We established a neuroscience curriculum for residents

1. Our program expanded

Our residency program was expanded by 25%, from 8 to 10 adult neurology residents per year, effective July 2007, in order to (i) enhance the educational curriculum, with an emphasis on increasing ambulatory and subspecialty exposure, and (ii) to establish a flexible research pathway for neuroscientists.

For residents, the program expansion has reduced service demands on the individual resident and created many opportunities for increased exposure to the ambulatory setting and subspecialty clinical neurology. For residents seeking a career in clinical research or neuroscience, the curriculum change allows sustained academic activity over consecutive months, a pre-requisite for effective research and the preparation of successful career grant applications.

2. Re-organization of the in-patient neurology services at Columbia University Medical Center

In 2008, the two in-patient neurology services at CUMC, the Merritt Neurology Service and the Stroke Service, were re-organized in order to (i) eliminate night call duty for junior [PGY-2] residents, (ii) promote continuity of patient care and (iii) enhance the education and supervision of all residents.

These changes were driven by the residents themselves, who proposed the idea in Spring 2008. Each ward service team now consists of two junior residents, a senior resident, a clinical attending neurologist, and a teaching attending neurologist; in addition, the teams include rotating residents in Psychiatry, subinterns and 5 to 6 Columbia P&S medical students on their neurology clerkship and subinternship rotations.

The junior residents admit patients only during the day, signing out their clinical responsibilities at 6:00 pm to a night float team consisting of a junior [PGY-2] resident and a senior [PGY-3] "night consult" resident.

As a result of this new arrangement, the junior residents on the ward services are never post-call during the week. Junior residents can provide a continuity of care to patients and their families, maintain their continuity clinics without the interruption of call duty, and fully partake of the Department’s many academic conferences during the week.

For the senior PGY-3 night consult resident, the new arrangement includes the presentation of all admitted patients to the ward and stroke service teams on morning rounds. This approach allows a direct review of the resident’s history, bedside examination and clinical management, and represents a superb opportunity for residents to function as neurological consultants.

Over the last several years, the number of patients admitted to the neurology service at CUMC has remained stable at an average of 6 per day, equally divided between the Stroke Service and the Merritt Neurology Service.

3. Clinical and Research Mentorships

All first year [PGY-2] neurology residents are paired with a faculty neurologist who serves as a clinical mentor. The clinical mentorship program, administered by Dr. Melodie Winawer, enables residents to establish regular and long-term contact with a faculty adviser who is available to review clinical skills, provide opportunities to see patients in the office, or simply offer encouragement and support during the early months of residency.

The research mentorship program is a more formal arrangement between the residency program and the Department that begins during the second year of neurology training, and is administered by Dr. Mitchell Elkind. Every PGY-3 and PGY-4 resident is matched with a faculty research mentor who will supervise and guide the resident through a research project. The goal of the program is to provide each resident with training and experience in clinical research. Research projects are presented as posters or platforms at Resident Research Day in June. Residents are further encouraged to submit their final projects for presentation at meetings and publication.

Individuals with career research ambitions are matched to Columbia clinician-researchers to plan their fellowship and grant application process during the second and third years of the residency. The electives are a valuable means of exploring the subspecialties of neurology, and it is possible for senior residents to begin taking advantage of Columbia’s many academic resources, including the School of Public Health, to develop the next stage of their careers.

In addition to clinical research mentorship, the neurology training program offers research tracks funded through the NIH for clinician-scientists, with the eventual goal of establishing a career as an independent laboratory investigator.

4. Our new Neurological Intensive Care Unit

The state-of-the-art 18-bed combined Neurological-Neurosurgical intensive care unit opened in 2006, and has transformed the neurology service at Columbia. The facility, under the direction of Dr. Stephan Mayer, is equipped with the most sophisticated medical technology, including its own CT and MRI scanners, and provides advanced care to the most complicated and urgent neurological cases, often transferred from outside hospitals. The NICU has its one of the most competitive fellowship training programs, and is engaged in cutting edge clinical and translation neurocritical care research. The NICU plays an essential role in the education of Columbia neurology residents.

5. Our neuro-hospitalist service

Beginning in 2006, an-inpatient hospitalist service, headed by Dr. Laura Lennihan, neurocritical care specialist and medical internist, was developed to provide care for patients transferred out of the NICU. These individuals often present a complex array of acute neurological problems, medical illness, and unique rehabilitation requirements. To meet the needs of this population, the hospitalist service provides a multidisciplinary approach involving four nurse practitioners who provide care and medical coverage for patients, 6 days a week. Nonetheless, in its emphasis on neurorehabilitation and system-based medicine, the service carries out a potentially important educational function in the training of neurologists.

V. Highlights of the Education Program

Teaching Conferences

Columbia Neurology offers many teaching conferences and lectures throughout the year. The Grand Rounds series is a showcase of neurology that offers a range of clinical topics, basic science, translational research, and neuroepidemiology as well as occasional lectures on ethics, history, music, literature and art. Prominent leaders in the field as well as junior scientists beginning their careers present their work at Grand Rounds in the Neurology Institute.

Throughout the academic year are many conferences, seminars and workshops, including Chief of Service rounds, Morning Report, subspecialty conferences in every field of neurology, Morbidity & Mortality rounds, Evidence-Based Medicine conferences and the noon conference core lecture series.

The noon conference series is a year-long curriculum that begins in July with a two-month block of core lectures on clinical neuroanatomy, the neurological exam, and neurological emergencies. The purpose of the introductory block is to provide a foundation of practical knowledge for junior residents who are just starting their neurology training. From September through June, the noon conference series features 3-to-4 week blocks of subspecialty neurology, provided by experts in the field, and covering in detail neuromuscular disease, epilepsy, stroke, movement disorders, neurocritical care, neuro-oncology, neuroimmunology, pediatric neurology and neuroethics, among others.

The Ambulatory Block for Junior Residents

The emphasis of the first year of neurology training is firmly on clinical skills, systems-based practice, and exposure to neurological emergencies, neurocritical care, and hospital-based neurology. And yet, much of subspecialty neurology resides in the ambulatory, out-patient domain. To provide all junior residents with experience in the real-life practice of neurology and subspecialty neurological problems that are not routinely encountered in the hospital, the ambulatory block rotation is a highlight of training. The experience is based in the Division of General Neurology, and is directed by Dr. Kirk Roberts. Residents examine and evaluate patients alongside the general neurology attendings on this month-long call-free rotation. In addition, residents rotate through a number of divisions and out-patient clinics in the Neurological Institute, including Movement Disorders, Epilepsy, Neuromuscular, Neuro-oncology and Aging & Dementia.

Clinics

i. During the PGY-2 year, residents begin a weekly continuity clinic in general neurology lasting the duration of their residency. The clinics are staffed by members of the general neurology division, under the direction of Dr. Peter Kim.

ii. During the PGY-3 and PGY-4 years, residents spend 6-month blocks in subspecialty clinics (movement disorders, epilepsy, neuromuscular, neuro-oncology, pain/headache, multiple sclerosis), while maintaining their continuity clinic. In other words, senior residents have two afternoons in clinic each week: a general neurology clinic and a subspecialty clinic.

Journal Club

Every month, the Resident's Journal Club meets to discuss a recent article from the neurology literature. The Club has existed for decades, and provides a welcome and informal opportunity to learn the latest findings and debate the literature. The Journal Club is attended by faculty and residents alike, with subspecialty experts ready to lend their opinion. Not infrequently, the article under discussion is the work of a Columbia faculty member, providing a direct opportunity to exchange ideas with a research leader in the field.

Neuroethics at Columbia

With the increasing emphasis on ethics in medicine, the residency program in neurology, together with Columbia Center for Bioethics [http://www.bioethicscolumbia.org/], has pioneered a curriculum in neuroethics. The curriculum includes quarterly ethics conferences, led by a faculty preceptor, to explore and discuss topics of importance to practicing and academic neurologists, including terminal issues, medical futility, informed consent and health proxy.

Psychiatry Training

Beginning in 2006, the ACGME and American Board of Psychiatry and Neurology (ABPN) have required that all neurology residents participate in a one-month psychiatry training experience. The New York State Psychiatric Institute and Columbia’s Department of Psychiatry have collaborated with the Neurology Residency Program to provide a four-week clinical experience, based on the in-patient the 9 Garden North psychiatry ward. Residents are supervised by staff psychiatrists as they evaluate and treat the common psychiatric conditions and emergencies including bipolar disorder, major depression and schizophrenia. The didactic curriculum includes lectures and case conferences on the evaluation of suicidality, assessment of the agitated patient, informed consent and capacity, voluntary versus involuntary commitment, confidentiality, substance abuse, intoxication and withdrawal, sociopathy, and the medical psychiatric patient.

VI. Harlem Hospital Center

Columbia Neurology residents spend 4 or 5 months of their 3-year training on the neurology ward and consultation services of Harlem Hospital. Harlem Hospital Center is a 300-bed community hospital that has been affiliated with Columbia University since 1962, and is academic home to some of Columbia’s finest educators, including Chief of Neurology Dr. John Brust. The clinical emphasis of Harlem Hospital is on common neurological problems, such as stroke and epilepsy, as well as trauma, infections, addictions and the neurological problems of the inner city. As a teaching institution, Harlem Hospital represents a perfect counterpoint to the tertiary care, subspecialty and translational research orientation of Columbia University Medical Center. For Columbia neurology residents, Harlem Hospital has provided a superb foundation for basic clinical neurology and problem-solving. For the community, the presence of Columbia Neurology in the heart of Harlem means access to the finest neurological care.

A comparison between the two teaching hospitals of the Columbia Neurology Residency Program is provided below:

VII. Block diagram

The first year of training provides an exposure to basic clinical neurology, clinical neuroanatomy, the neurological emergencies, neurocritical care and stroke.

During the second year, residents gain exposure to the subspecialties of epilepsy and neuromuscular disease, become team leaders on the consultation and ward services, participate to an increasing extent in medical education, and develop their research projects.

The third year of training provides an opportunity to gain expertise in all of the neurology subspecialties, accomplish research, consolidate a large body of neurological knowledge in preparation for board certification, and to plan the next career step, whether fellowship training, research or clinical practice.

Electives:

VIII. Salary & Benefits

Salary, benefits, malpractice and academic policies are determined by the Accreditation Council of Graduate Medical Education (ACGME), and vary by region; at Columbia, this information about the Neurology Residency can be found at: http://infonet.nyp.org/GME/

The 2009-2010 salary scale for all Columbia University residents is:

A complete benefits package is provided to all residents, comprising

medical coverage
dental coverage
disability insurance
life insurance.

Subscription to the journal Neurology
Membership in the American Academy of Neurology
Academic allowances for travel and educational materials

IX. Work Hours and Call Schedule

The frequency and duration of overnight call for residents is closely regulated and monitored by the ACGME. In addition, New York State imposes careful restrictions on residents’ call schedules.

Resident schedule requirements for New York State are:

• no more than 80 work hours per week
• minimum 10 hours between shifts
• each shift is no longer than 24 hours + 3 hours of information transfer (27 total)
• at least 24 hours of consecutive free time each week, averaged over 1 month

The residency program has enacted many recent changes to limit the on-call duty hours of residents, to improve the continuity of patient care, to reduce the amount of signing out, and to maximize the opportunity for residents to attend conferences and clinics. Currently, junior residents take overnight call at a frequency of every 4th night during about 4 ½ months of the PGY-2 year. While on the Merritt Ward Service and Stroke Service, amounting to 3 ½ months of the PGY-2 year, junior residents do not take overnight call. Senior [PGY-3 and PGY-4] residents on ward and consult services take overnight call at a frequency of 3 times per month. All of these arrangements fall well within the work hours guidelines. In addition, the program has developed several means to facilitate the timely departure of residents from the hospital, including a night float system for admissions and cross-coverage care, extensive support from nurse practitioners and the Hospitalist Service, and an early start time for morning rounds on the in-patient services at 7:00 am.

The average number of admissions to the Neurology Service at CUMC is 6 per 24-hour cycle, divided between the two in-patient services, Merritt and Stroke. At Harlem Hospital, the average is one admission per day. The consultation services at both hospitals have extensive and continuous supervision and from the attending staff. At CUMC, attending faculty and fellows of the Stroke Service, Neurocritical care service and Epilepsy Service all aid the consultation service in the prompt evaluation and treatment of neurological emergencies.

X. Resident Evaluations

The evaluation of resident performance is multi-dimensional, and includes observation and feedback from attending staff, nurse practitioners, social workers, and medical students. The Department uses E*Value, a web-based evaluation system, to evaluate and document resident performance.

Current residents are asked to build a Neurology Portfolio containing their clinical and scholarly accomplishments, especially with regard to the core competencies of graduate medical education. The portfolio includes, but is not limited to, documentation of cases, procedures, systems-based practice, teaching activities, committee participation and presentations at conferences, including Morbidity & Mortality rounds, Journal Club, and Resident Research Day. Much of this information will eventually be needed for licensure and board certification in the future. Resident evaluation also takes into account in-service examination scores, performance on the simulated oral board exams, academic output and publications.

All residents meet individually with the Residency Program Director, Dr. Blair Ford, and the Chairman of Neurology, Dr. Timothy Pedley, on a semi-annual basis to review their performance and portfolio.

XI. Campus Recreation

XII. Summary

The Neurology Training Program at Columbia offers a rich and challenging educational experience that combines clinical excellence, sub-specialty depth, unparalleled exposure to the entire range of neurological disease, exciting research and scholarship opportunities, dedicated mentorship, and collegiality. Graduates of the program are poised to develop successful careers of their choice, whether in research, neuroscience, education or clinical practice. The opportunity to work and live as a resident in one of the world’s great cities, a vibrant metropolis full of culture and excitement, is an essential part of the experience at Columbia.