Clinical Neurophysiology is a subspecialty of Medicine, principally in Neurology that is concerned with the utilization of a variety of testing techniques to enhance the diagnostic evaluation of the neurological patient, both adult and child. Our purpose is to train physicians who have successfully completed training in adult or child neurology in Clinical Neurophysiologic testing so that they may be recognized as Electrodiagnostic Consultants in the practice of Clinical Neurophysiology. Trainees will be expected to master their ability to perform and interpret electrophysiological testing in the context of the six core competencies as defined by the ACGME:
- Patient Care that is compassionate, appropriate and effective in performing electrophysiological evaluations
- Medical Knowledge in the basic and clinical neurosciences related to the practice of Clinical neurophysiology
- Practice-Based Learning and Improvement to prepare for life-long learning and ongoing development in clinical neurophysiological testing skills
- Systems-Based Practice within the health care system to provide optimal care as pertains to clinical neurophysiology
- Interpersonal-Communication Skills development between Electrodiagnostic Consultant Trainees and patients, technicians, and physicians
- Professionalism in commitment to the responsible and ethical practice of Clinical Neurophysiology
Clinical Neurophysiology Curriculum
The Clinical Neurophysiology Curriculum is designed to optimize exposure for Trainees in the two principal areas of Clinical Neurophysiology, namely Electroencephalography (EEG) and Electromyography (EMG). Additional exposures to such diverse areas as Sleep, Autonomic Testing, Somatosensory Evoke Potentials (SEP), Intraoperative Monitoring, and Chemodenervation are also provided. There is no set sequence of rotations, as this depends on the specific interests of the Trainee, in combination with the programmatic needs of the Clinical Neurophysiology Sections. In addition, one of the three positions that are offered is focused on Pediatric Clinical Neurophysiology. The Pediatric Clinical Neurophysiology Trainee spends some time in the adult Clinical Neurophysiology Laboratories, and in turn the adult Clinical Neurophysiology Trainees spend a similar, shorter period of time in the Pediatric Clinical Neurophysiology Laboratories.
Four basic and somewhat typical curriculum modules are shown below; however it is emphasized that these may vary depending on programmatic needs and the individual trainee’s needs:
Clinical Neurophysiology with emphasis on EEG:
- Adult EEG: 8 months
- Pediatric EEG: 1 month
- Sleep: 1 month
- Adult EMG: 2 months
Clinical Neurophysiology with emphasis on EMG:
- Adult EMG: 8 months
- Adult EEG: 2 months
- Pediatric EEG: 1 month
- Sleep: 1 month
Clinical Neurophysiology without equal emphasis on EMG and EEG:
- Adult EEG: 2-5 months
- Pediatric EEG: 1-5 month
- Sleep: 1 month
- Adult EMG: 5 months
Pediatric Clinical Neurophysiology:
- Adult EEG: 1 month
- Pediatric EEG: 8 months
- Sleep: 1 month
- Adult EMG: 2 months
Didactic Curriculum: Lectures and Conferences
Clinic Neurophysiology Didactic Lectures
Refractory Epilepsy Conference
Pediatric Epilepsy Surgery Conference
Neurology Basic Science and Clinical Lecture Series
Neurology Grand Rounds
Muscle & Nerve Biopsy Conference (Bi-weekly)
Clinical Neurophysiology Conference
Adult Epilepsy Journal Club
Pediatric EEG/Epilepsy Reviews
At the end of their training, the Trainee is expected to be able to assess an epilepsy patient, and to determine the need for EEG testing (both routine studies and video monitoring). In addition, they will be able to master the technical aspects of the recording, including the identification of potential sources of error and artifact. Finally, they will be able to read and interpret EEG and video monitoring studies, including the generation of a complete and final report. This is all done under a graduated program, stressing progressive levels of independence and supervision throughout the course of their training. Additional exposure will be offered in the area of assessment of patients for epilepsy surgery.
Trainees will participate in all aspects of performance of Clinical Electromyography, beginning wit the assessment of the patient, so as to identify what specific procedures would need to be performed in order to have a complete study of the patient. Similar to EEG, the Trainee will be expected to achieve progressively increasing levels of independence throughout the course of their training, such that by the end of the year they will be able to perform EMG studies of a basic to moderately complex level or higher. This includes the ability to perform and analyze both nerve conduction studies, neuromuscular transmission studies, and the needle electrode examination. At the conclusion of the study, they will be able to generate a complete report, including the clinical interpretation.
Other Clinic Neurophysiology Studies
Trainees will spend variable, but shorter amounts of time in the areas of sleep, autonomic studies, chemodenervation, intraoperative monitoring and evoked potentials. In these areas of less emphasis, the Trainee will be able to understand when such studies are indicated and be able to understand the basics of each of these different investigations or therapies.
On Call Schedule
The Clinical Neurophysiology Trainees do not have in-house call, except for approximately 2-3 nights per year when they are covering residents in the basic program, so that these Trainees may attending their annual retreat or training examination. Clinical Neurophysiology Trainees take at-home night call, covering the Epilepsy Service, with attending backup-up, for a maximum of 2 weekends per month when on that rotation. At-home call is shared with the other CNP fellow(s) on a non-Epilepsy rotation, who covers for 7 days per month.
- The adult and pediatric epilepsy staff discussed the issue of weekend call. It was agreed that in keeping with other programs, the MCW program would now require fellows on the EEG rotation to come in and round on some weekends during the months they are covering the epilepsy monitoring units, whether at Children's Hospital or Froedtert Hospital. A maximum of 2 weekends a month will be allotted for this.
- Starting July 2010, in the Froedtert rotation, the fellow who comes in to round during those weekends will also be on "first-call" for in-house STAT EEG interpretation. The EEG rotating fellow will not be placed on the weeknight call pool. The non-EEG fellow sharing the call pool will be required to go on in-home call for 7 days a month, divided into two blocks of 4 weeknights and one weekend.
At this level in post-graduate medical education, training in Clinical Neurophysiology is a complex series of steps in achieving mastery in various Clinical Neurophysiology testing procedures. In the venue provided in this training program, the trainee to staff ratio is extremely low, typically the trainee is directly working one-on-one with staff on a regular basis.
The Clinical Neurophysiology Fellow
The Clinical Neurophysiology Fellow is a Trainee who has already finished their basic training in Clinical Adult Neurology or Clinical Pediatric Neurology. They are thus expected to have a reasonable measure of independence in assessing needs for testing in Clinical Neurophysiology for patients. The Trainee is expected to practice within their capabilities and level of expertise. Feedback on this is given on a regular basis to the Trainee by the Clinical Neurophysiology Attending Staff.
Clinical Neurophysiology Staff
The Clinical Neurophysiology Staff are ultimately responsible for the patient’s care, safety and quality of testing as delivered by the Clinical Neurophysiology Trainee. Each Clinical Neurophysiology Staff has the ultimate responsibility that is not relinquished, except to another Clinical Neurophysiology Staff. Trainees perform clinical neurophysiology procedures with Clinical Neurophysiology Staff either on site, or else Staff is directly and immediately available by pager or telephone.
Program Director: Clinical Neurophysiology
The Program Director is responsible for the organization, curriculum and administration of the educational activities. In addition, the Program Director is ultimately responsible for the quality of the Program, including regular resident evaluations which are made with input from the Clinical Neurophysiology Staff with whom the Trainee is most closely affiliated with during that period of time. The Program Director is also ultimately responsible for maintaining ACGME Certification.
Clinical Neurophysiology Trainee Evaluation
Each Trainee’s progress and development in their training to master Clinical Neurophysiologic procedures is regularly documented by the Program Director, in conjunction with input from other Clinical Neurophysiology Staff. In general, the mechanisms of evaluation are accomplished by:
- Informal regular discussion and feedback given to Trainees during the course of their performance of Clinical Neurophysiologic procedures by the staff that are immediately supervising them.
- A quarterly formal evaluation of the Clinical Neurophysiology resident by the Program Director, in conjunction with the staff with whom they have worked in that quarter.
- There will be a semi-annual “360 degree” assessment of the Trainees made by the Clinical Neurophysiology technical and administrative staff as well as patients.
- The Clinical Neurophysiology Trainee will be responsible for maintaining a log of their procedures as stipulated by the Program Director. This serves the purpose of giving the Trainee an accurate idea of how many procedures they have performed, which in turn will form part of the final report that the Program Director will make upon their successful completion of the Program.
- Clinical Neurophysiology Trainees are instructed to bring any matters of concern promptly and immediately to the attention of the Staff who are supervising them. Issues that require further consideration are to be taken up by the Program Director.
- The Clinical Neurophysiology Trainee will participate in two annual in-service examinations during the course of their training. This includes the American Society of Clinic Neurophysiology (EEG) that is typically given in March. The American Association of Neuromuscular and Electrodiagnostic Medicine (EMG) administers an in-service examination that is typically offered in May. Results are discussed with Trainees by Staff.
- The Program Director is responsible for a written, final evaluation for each Clinical Neurophysiology Fellow completing the Clinical Neurophysiology Program that comments upon scope of training achieved by that Trainee during their year of Fellowship. Particular emphasis on performance during their final period of training, commentary on the numbers of procedures performed, and commentary on their ability to perform Clinical Neurophysiologic procedures in a competent way in the context of independent practice.
Each Clinical Neurophysiology Trainee has the protection of the Fair Procedures as established by the Department of Neurology and the Medical College of Wisconsin in all matters relating to academic discipline and grievances.
A Clinical Neurophysiology Training Program monitors its own performance by seeking maintenance of high standards in performance, while trying to continuously improve. The Program is required to maintain the high standards as established by the ACGME which regularly assesses and re-certifies this Program (current re-certification is for 5 years, until 2012). In addition, internal reviews are performed midway between each external review by the ACGME.
Other mechanisms to promote program evaluation are accomplished by:
- An annual meeting of the Clinical Neurophysiology Staff to review the strengths and weaknesses of the Clinical Neurophysiology Training Program. Opportunities to improve are also discussed and implemented as needed.
- Evaluation by the Clinical Neurophysiology Trainees that are integrated into evaluations of the Clinical Neurophysiology Staff by the residents in the basic program. These evaluations go directly to the Medical College of Wisconsin, which in turn assesses these evaluations and provides feedback to the Departmental Chair.
- Assessment of faculty by the Program Director as to their commitment to teaching and research.
- Evaluation of the Clinical Neurophysiology Program by the Department of Neurology’s Education Committee, which oversees all educational activities in the Department of Neurology.
The Clinical Neurophysiology Staff represent a large percentage of the total faculty in the Department of Neurology, both in the Adult and Pediatric Divisions. A list of this faculty, with their specific areas of interests/expertise, is listed in parentheses after their name.
Brian-Fred Fitzsimmons, MD
Program Director, Clinical Neurophysiology
Chad Carlson, MD, Associate Professor (EEG, MEG)
Christopher T. Anderson, MD, Assistant Professor (EEG, MEG)
Paul E. Barkhaus, MD, Professor (EMG)
Humberto Battistini, MD, Assistant Professor (Sleep, Intraoperative Monitoring, EEG, Evoked Potentials)
Michael J. Collins, MD, Associate Professor (EMG)
Jonathon Florczak, MD, Assistant Professor (EMG, EEG, Evoked Potentials)
Wendy Peltier, MD, Associate Professor (EMG)
Manoj Raghavan, MD, PhD Associate Professor (EEG, MEG)
Pediatric Neurology Division
Kurt Hecox, MD, Professor (EEG)
Christopher Inglese, MD, Professor (EEG)
Priya Monrad, MD, Assistant Professor (EEG)
Michael Schwabe, MD, Assistant Professor (EEG)
Adjunct Clinical Neurophysiology Faculty
Thomas Prieto, PhD (Autonomic Laboratory)
Bernd Remler, MD
Clinical Physiology Laboratories
The Clinical Neurophysiology Laboratories are present in all three principle institutions that comprise the Medical College of Wisconsin’s Clinical Neurophysiology Program. These include Children’s Hospital of Wisconsin (CHW), Froedtert Hospital (FH), and the Milwaukee Veteran’s Administration Medical Center (MVAMC). All three institutions provide EEG and EMG studies. Sleep studies are available at the CHW and FH. The autonomic laboratory is available at FH. The newest addition to the clinical neurophysiology program is the MEG Laboratory.
There is office space for Faculty and Clinical Neurophysiology Trainees. The latter usually have their office at FH. There are excellent library resources at all three institutions, including internet access. In addition, multi-media instructional materials in EMG are available to enhance training experience.
Medical College of Wisconsin Affiliated Hospitals, Inc.
Clinical Neurophysiology Trainees that are accepted into the Medical College of Wisconsin Medical Education Program are employed by a corporation formed and sponsored by the Medical College of Wisconsin and its affiliated institutions. The Medical College of Wisconsin Affiliated Hospitals, Inc. (MCWAH) provides stipends and fringe benefits while establishing policies and assuming oversight of accreditation for pediatric neurology as well as the other training programs on campus.
Prerequisites for Appointment
- Candidates must hold an MD or DO degree or accepted equivalent.
- US or Canadian medical school graduates must have passed USMLE I
- Graduates of Osteopathic schools must have passed NBOME I or USMLE I
- International graduates must have a current and valid ECFMG certificate
- Candidates must have successfully completed their basic training and be Board Eligible in Adult Neurology or Pediatric Neurology.
- Clinical Neurophysiology Trainees must be eligible for a Wisconsin Medical License and be fully licensed to practice in Wisconsin 90 days prior to starting their year of training in Clinical Neurophysiology.
- Prospective candidates should submit three original letters of recommendations to the Program Director (Paul E. Barkhaus, MD). At least one of these letters should be from a Clinical Neurophysiologist who is a staff at their Training Program and who is very familiar with the candidate’s skills and potential in Clinical Neurophysiology.
- Candidates must also submit their curriculum vitae to the Program Director (Paul E. Barkhaus, MD).
- Upon completion of their application (CV and three letters of recommendation), the Program Director and Clinical Neurophysiology Staff will review applications and invite candidates that they deem most qualified for a personal interview and visit to the Program. Interviews are typically scheduled on Fridays, beginning in mid-August.
- Following completion of the personal interview, the pool of candidates will be reviewed and positions offered to candidates who are considered to have the most potential and be the most compatible for training in this Program. Candidates who are accepted will be offered a formal contract for signature within 45 days of acceptance.