Clinical Care

We feel strongly that the best way to learn pediatric neurology is to do it. Pediatric neurology residents have the opportunity to develop their skill managing an extensive variety of patients in both the outpatient and inpatient settings.

Outpatient:

Starting in the PGY3 year (i.e. the initial neurology year spent primarily on the adult neurology service) the weekly resident continuity clinic is a critical element of the pediatric neurology training program. Residents see patients specifically assigned to them and follow them longitudinally through their three years of training. The residents also handle outpatient management issues for their patients over the phone between visits. The goal is for them to essentially have their own “practice” during those 3 years of training.

During the PGY4 and PGY5 years residents spend 4 months of the year working in the outpatient pediatric neurology clinics. Residents see patients in sub-specialty clinics such as epilepsy, movement disorders, cerebral palsy, neurorehabilitation, neuromuscle, neurofibromatosis, tuberous sclerosis, Rett syndrome, neuroimmunology, neonatal neurology, and headache. During the PGY4 and PGY5 year residents can spend dedicated elective time in any of the subspecialty clinics or other clinics such as neuro-ophthalmology, neuro-otology, neuro-oncology, neurocritical care follow-up, genetics, sleep medicine, and others.

Inpatient:

On inpatient rotations residents supervise the care of patients on the neurology ward service and consult on patients with neurological problems on other floors of the hospital and in the emergency department. St. Louis Children’s Hospital provides tertiary and quaternary care for the city of St. Louis, the surrounding region, the Midwest, the US, and international patients. Thus, the variety of patients our residents see is outstanding. We also have strong relationships with the intensive care units in the hospital which include the Pediatric Intensive Care Unit, Neonatal Intensive Care Unit, and Cardiac Intensive Care Unit. Our frequent consults there give our residents the chance to further develop their skills in critical care neurology. Our division policy is that generally any patient admitted to the hospital who does not have a neurologist will follow-up with the resident that cares for them if out-patient follow-up is needed.

Although in-house call is taken during the PGY3 adult neurology year, all call during the PGY4 and PGY5 year is at home. At night during the last two years the on-call resident takes the first call responsibility for out-patient issues for all faculty and resident patients, phone consultation for outside emergency departments generally in the Missouri/Illinois area, and calls from the St. Louis Children’s emergency department and in-patient services. At night there is always attending backup for any issue that the resident needs assistance in managing. Our attendings encourage residents to call with any questions.

Electrophysiology:

Electrophysiological tests are a common tool in pediatric neurology. Residents can obtain experience in EMG during the outpatient portion of their adult time in PGY3 year, as there is a dedicated neuromuscle clinic day every week of this rotation. During in-patient rotations, residents get extensive experience with EEG and video EEG monitoring. Residents can spend additional time learning these modalities during the elective portion of their PGY4 and PGY5 year.

 

 

 

 


Rotations

 

  

PGY3 year

Six months of the PGY3 year are spent on the inpatient adult neurology services at Barnes-Jewish Hospital. The residents share rotation schedules and inpatient responsibilities with the PGY2 adult neurology residents for that year. Rotations include the consults, acute stroke team (including exposure to telemedicine), stroke ward service, general neurology ward service, night float consults, and time in the neurological/neurosurgical ICU (one of the largest in the country). An additional 2-3 months are spent on the inpatient consult and inpatient neurology ward services at St. Louis Children’s Hospital. The remaining 2-3 months include adult outpatient sub-specialty clinics, EEG, EMG, electives and career development.

PGY4 year

Five months of the PGY4 year are divided between the inpatient consulting service and the Neonatal ICU consulting service at St. Louis Children’s Hospital.

Consult service – The neurology consult service handles consults from the PICU, CICU, Emergency Department, and hospital floors. Residents covering the consult service also take calls from community pediatricians, outside hospital critical care physicians, emergency medicine doctors, and neurologists.

NICU service – The Neonatal Neurology consult service handles consults in the NICU (one of the largest in the country) and infants in the CICU.

 

  

12th Floor Neurology Ward Service – Several months during PGY4 year are spent as the supervising fellow of the 12th floor neurosciences service of St. Louis Children’s Hospital. This floor is largely dedicated to the care of general neurology, neurosurgery, neurorehabilitation and epilepsy monitoring patients. The pediatric neurology resident supervises the floor team of pediatric residents in the care of neurology patients. The 12th floor fellow also assists our epileptologists in the care of the Epilepsy Monitoring Unit (EMU) patients with the help of nurse practitioners.

Outpatient: Three months of PGY4 are spent on the outpatient clinic rotation at St. Louis Children’s Hospital. The resident rotates through the various faculty sub-specialty clinics including epilepsy, movement disorders, cerebral palsy, headache, tuberous sclerosis, neurofibromatosis, neurorehabilitation, Rett syndrome, neuroimmunology, neonatal neurology, and neuromuscle.

PGY4 residents have 2 months for research, career development, required electives or subspecialty electives of residents’ interest.

PGY5 year

Each PGY5 spends 2 months of service time as the 12th Floor Neurology fellow or consulting fellow, as described above. This supervising and teaching role prepares trainees for independent practice and supervision.

The PGY5 year contains at least 6 months of elective time that may be used for basic science or clinical research and resident-designed electives both within neurology or interfacing subspecialties. Our residents have applied for and participated in the national R25 research mentorship and funding program. Recently, our residents have designed their own electives in global health, neurogenetics, neurocritical care, neuroimmunology, neuro-oncology, stroke, psychiatry, and ethics.

The remainder of the PGY5 year is spent completing requirements in adult neurology specialty clinics, as well as opportunities in neuroradiology, neuropathology, neuro-oncology, sleep medicine, neuro-ophthalmology, neuro-otology, and additional training in EEG, EMG, etc.


Call

PGY3 year

During the neurology inpatient ward services and adult neurological/neurosurgical ICU rotations, the residents take in-house call every fourth night. During the night float rotation, the resident works 6 nights of 12 hour shifts 7 pm-7 am with one night off per week. During outpatient and pediatric consult months there is no call, but residents may be on jeopardy for sick call.

PGY4 year

During the PGY4 year, the residents take at home call. The on-call resident takes all neurology calls from St. Louis Children’s Hospital and all telephone consult calls from outside hospitals. The resident also takes parent phone calls for neurology patients.

PGY5 year

During the PGY5 year, the residents take at home call one Sunday per month with 2-3 occasional other calls per year.

Continuity Clinic

The pediatric neurology continuity clinic begins during the resident’s PGY3 year. Residents spend one half-day each week in clinic and typically see 3-7 patients per clinic. Patients are assigned to a specific resident’s schedule and follow-up with that resident during their entire three years of training. The clinic is typically staffed by three attending physicians. Generally, all inpatients who do not have a neurologist at the time of admission are followed in clinic by the resident that cared for them during their hospitalization if they need on-going care. Residents handle all outpatient calls on their own patients during office hours. PGY4 residents receive nursing staff assistance during their busy in-patient rotations.