Advanced General Neurology Fellowship

Overview

This 1-year fellowship program at Massachusetts General Hospital is designed to provide advanced experience, training and mentoring to prepare the candidates for careers in academic neurology institutions. They will acquire skills, knowledge and expertise in the evaluation and care of patients with a wide range of neurological disorders referred to tertiary neurology centers that include the widening spectrum of autoimmune disorders, neurology of infectious diseases and in the evaluation of ill-defined complex neurological issues. The program also aims at preparing the neurologists for careers as clinician-educators devoted to teaching of modern neurology skills and knowledge to medical students and to the training of residents in neurology.

The core of program is the strongly patient care-focused experience. This is reflected in the core fellowship clinics, subspecialty clinic rotations, inpatient consultative duties, and conference schedule and teaching opportunities and assignments. The fellowship is one of immersion in this clinical experience and is conducive to learning by evaluation, treatment, and monitoring of a selected group of patients with complex and unusual neurological disorders with close precepting by dedicated and expert faculty. The fellows are expected to produce scholarly articles including reviews based on their clinical experience working with the faculty. An important aspect of this intense Fellowship program is the ready access and daily interactions with the accomplished and dedicated faculty with expertise in wide areas of neurology subspecialties and in education. The Fellowship is now integrated in to the newly-created Division of Neuro-immunology and Neuro-infectious Diseases at Massachusetts General Hospital, headed by Dr. Venna.

Objectives

• Refinement of skills in history-taking and neurological examination to uncover and recognize clues to systemic disorders relevant to neurological syndromes in the areas of neuro-immunology, multi-system disorders (eg, sarcoidosis), neuro-rheumatology, neurologic infectious diseases, and metabolic and toxic neurologic disorders
• History elicitation for clues of occupational and toxic exposure and medication and travel history that may bear on the neurological syndrome
• Refinement of examination skills in recognizing physical signs of systemic illness and multi-system disorders
• Refinement of skills in the dermatological and ophthalmic examination, which often provide clues to the neurological syndrome
• Familiarity with and appropriate utilization of esoteric and evolving laboratory tests in the diagnosis of complex and unusual neurological syndromes; understanding the correct methods of testing, interpretation, and test limitations

Clinician-Educator Role

An explicit expectation and one aim of this fellowship is to develop your skills as clinician-educators. The fellowship has woven into its fabric many opportunities to refine and expand advanced skills of neurological examination and teach them to medical students and neurology residents and fellows. During daily clinical discussions, journal club presentations, inpatient consultations, and interactions with neurology residents, there are ample opportunities to accomplish this. With Dr. Reda’s guidance fellows have many occasions to give clinical talks to and precept Harvard medical students during their neurology clerkship examinations.

Scholarly work

Fellows are encouraged and expected to prepare scholarly articles including case reports, case series and reviews based on their experience in the fellowship. Faculty gladly guide the fellows as needed.

Structure

The chief experience is in the fellows’ core clinics. Patients screened and selected for our clinics reflect the emphasis on the broad and ever-widening spectrum of known or suspected immune-mediated neurological disorders. Some have neurological syndromes associated with known systemic autoimmune connective tissue diseases while others have autoinflammatory conditions such as neurosarcoidosis or Behçet disease. Many will turn out to have paraneoplastic autoimmune neurological disorders, often with occult neoplasms.

A proportion will be “mysteriomas”, patients referred to us, often as a last resort, with neurological disorders that could not be fully diagnosed or adequately treated elsewhere. Our fellowship training is aimed at skills and knowledge applied to such situations appropriate to advanced neurology at the tertiary referral center that is MGH. From time to time, we will see “bread and butter neurology,” such as patients with migraine, epilepsy, neuropathies, parkinsonian syndromes, etc.

In the fellows’ clinic, we schedule one hour for all patients whether new referral or follow-up to suit the general complexity of the disorders that we see. It is best to complete the assessments in 45 minutes and be ready to present to attending faculty in the remaining time.

We may occasionally need to accommodate an extra patient or two at the end of the clinic session because of urgency of the patient’s needs. This happens infrequently, but we must be flexible.

In the neuro-infectious diseases clinic, you will evaluate and treat a wide range of neurological syndromes associated with HIV infection in all its stages and severities. In addition, there will be patients with neurological complications of other infections such as Lyme disease, syphilis, cysticercosis, viral encephalitides, etc. These clinics are run by the AGAIN fellows in association with an ID/HIV fellow assigned to the clinic for the year. Often other ID fellows and internal medicine residents rotate through the clinic.

In these core clinics, the fellows’ role is of the primary neurologist responsible for investigations, treatment, coordination of care, follow-up, and being available for patients and families as needed. Core preceptor faculty are constantly and readily available for supervision in all these areas. We team up with various consultants especially in infectious diseases, rheumatology, immunology, dermatology, and psychiatry; faculty in these specialties work closely with us to enable the best possible care to our many patients with complex medical issues. Our team includes a patient service coordinator (PSC), a neuroscience nurse, infusion center nurses, and neurology clinic administrators, all readily available to assist as needed.

We discuss particularly challenging cases in depth in the weekly Fellows’ Meetings Tuesday afternoons on Wang 7 where we review important papers as well. In addition, we have a fine forum to present the difficult to diagnose or difficult to treat patient cases in the meetings of the Division of Neuroimmunology and Neuro-infectious Diseases held on Monday afternoons on Wang 7 where most of the faculty from the fellowship, the MS-NMO group, the neuro-ID division, and the autoimmune encephalitis unit offer expert advice.

Clinics

Core Fellowship Clinics

• Fellowship Clinic: Three half-day clinic sessions staffed by core fellowship preceptors.
• Neuro-ID Clinic: One half-day weekly, staffed by Drs. Nagagopal Venna and Shibani Mukerji, joined by a fellow in infectious diseases.
• Autoimmune Encephalitis Clinic: Twice a month, staffed by Dr. Jenny Linnoila.

Interdisciplinary Clinics

We collaborate with outstanding subspecialist colleagues in neurology and rheumatology to provide broad exposure in fields that closely overlap with the core focus of the fellowship.

Multiple Sclerosis: NMO spectrum and related demyelinating disorders. Rotations in these clinics give exposure to the diagnosis and management of disorders of common interest to the fellows. The rapidly changing and evolving immunotherapies in this field have potential applications in autoimmune neurology in general and there is indeed diagnostic overlap as well.

Ataxia Unit: Founded in 1993 by Dr. Jeremy Schmahmann, this clinic gives fellows a unique and extraordinary opportunity to see patients with multisystem neurological disorders including a wide range of spinocerebellar ataxias and related conditions under the expert tutelage of Dr. Schmahmann.

Neuro-rheumatology: This has been a long-standing rotation for the fellows and has proven to be most valuable in providing an opportunity to see patients with many systemic autoimmune connective tissue disorders under expert faculty supervision. The experience gives a fuller picture of diseases such as SLE, systemic vasculitides, IgG4-related disease, Behçet disease, etc, many of which have interesting neurological implications and complications. Moreover, core therapies we use for patients in autoimmune neurological disorders are borrowed and adapted from advances in rheumatology. The overlap between this specialty and the goals of the AGAIN fellowship is of major significance. Many of the fellows’ clinic patients including those with neurosarcoidosis will be co-managed along with our rheumatologist colleagues.

Neuro-ophthalmology/Skull Base Neurology: These clinics offer experience in the finer aspects of neuro-ophthalmology under the supervision of Dr. Bart Chwalisz with emphasis on the evaluation and management of unusual skull base and neuro-inflammatory disorders including pituitary disorders and cranial neuropathies. Dr. Chwalisz is himself a graduate of the AGAIN fellowship program and a gifted neurologist and teacher.

Consults & Conferences

Inpatient Consultative Services

Neurology colleagues on the Raymond D. Adams, C. Miller Fisher, neurosciences ICU, and comprehensive consultative inpatient service teams often request our advice regarding the diagnosis and management of complex acute and subacute neurological disorders.

Fellows and faculty evaluate such patients and offer advice, literature support, and follow-up as needed. The precepting faculty can be matched to the specific patient conditions based on their subspecialty interest and expertise as well as availability (Drs. Reda, Linnoila, Mukerji, Mateen, Matiello, Klawiter, Venna, and Chwalisz, for example). Documentation of such “super-consults” can be brief and to the point and with relevant references, as these patients are already under the care of our excellent neurology teams. Patients seen in such circumstances often will be followed up longer term in the AGAIN fellows’ clinics, giving us the valuable experience of longitudinal observation into the recovery phases of their illnesses. These consults are much appreciated by the referring teams and round out the clinical experience for the fellows; moreover, they are wonderful opportunities to interact with and teach our residents and medical students.

Conferences

Weekly fellows’ clinical conference, Caviness conference room, Tuesdays 2:30-4 pm. This is a place to discuss especially interesting/challenging cases seen in recent clinics or hospital consultations, allowing us to go in depth regarding diagnosis, investigations, and treatment plans. Each week, fellows will present and discuss a paper or topic of special interest or relevance. We use the early part of the meeting for practical patient care issues with PSC Shakiera White and Owen O’Connor, RN. Fellowship administrative coordinator Tania Dash or her temporary replacement Kamilah Welch will join briefly for any fellowship administrative issues and assistance. From time to time we invite other providers who help us coordinate the care of patients, especially those requiring infusion regimens.

Neuroradiology conference, Lunder 8 conference room, Wednesdays 1-2 pm. Fellows and faculty use this forum to present selected cases from their clinics and inpatient consultations. The neuroradiology team is emailed patient information a day or two ahead so that the neuroradiology fellow and faculty can review the cases and gather key references. Fellows make note of important outcomes from this discussion in the patient’s chart. The conferences are scheduled every weekday on Lunder 8 but AGAIN fellows use Wednesdays for their cases. Over the years, residents and neuroradiology fellows and staff have come to look forward to the cases we bring from the fellows’ clinics as they tend to be unusual, interesting, and challenging.

Weekly Chief’s Rounds, Lunder 7 conference room, Tuesdays 12-1 pm. Dr. Venna or Dr. Cudkowicz discuss the case of the week presented by RDA service residents. These alternate with similar case discussions at BWH by senior faculty including Drs. Samuels and Ropper.

Division meetings, Wang 7 Fisher conference room, Mondays 1:30-2:30 pm. The AGAIN fellowship program is an integral part of this division and fellows are expected to attend these conferences as the topics are relevant to the Fellowship. Typically, the first Monday is devoted to the MS/NMO unit, the second Monday is for the autoimmune encephalitis group, the third Monday is for the neuro-infectious diseases group, and the fourth Monday is for presentations by the Fellows, typically of challenging cases so that we can tap into the collective wisdom of the division’s faculty. Rachel Mayer helps administratively for these conferences.

Neuro-ID Journal Club, Cox 8 conference room, monthly on Thursdays, 1-2 pm. Neurology and ID fellows present seminal papers or review a neuro-ID topic. Pamela Hearon in the ID department coordinates these with the fellows.

Interdisciplinary conferences, Lunder 7 conference room, monthly on Wednesdays, 12-1 pm. We started these in 2010 and they are now integrated into the neurology resident teaching noon conferences. This is a forum for experts in non-neurology medical disciplines that are of relevance to neurologists, highlighting important concepts and advances in fields that interface with neurology. These have been much appreciated and have served an important missing piece in neurology education. The AGAIN fellows invite speakers and coordinate conference schedules with fellowship faculty, fellowship coordinator Tania Dash, and the neurology chief residents.

Neuroscience conferences, Lunder 7 conference room, every 3 months. This series was introduced in 2014 by department chair Dr. Merit Cudkowicz to bring clinical and basic neuroscientists together around a patient with a known neurological disease. The idea is to provide a relatively informal forum where the clinical and neurobiology aspects are discussed in the presence of the patient and their family member(s) to highlight advances in the understanding of pathogenesis, diagnosis, and treatment as well as outline future prospects in combating the disease. An important aspect is to try to inspire residents, fellows, and faculty to engage in research to advance the field. On average these will occur once every 3 months. Fellows and faculty work with Dr. Cudkowicz to select topics and gather the clinical and neuroscience experts for the discussion. Tania Dash assists with coordination.

Combined neurology-rheumatology clinical conferences, quarterly. These are held under the auspices of Rheumatology Grand Rounds. AGAIN fellows present interesting cases of an interdisciplinary nature to audiences of fellows and faculty mostly from the division of rheumatology. Neurology Fellows present twice in the year. There are very well received by all and are an excellent venue for discussing difficult-to-diagnose and difficult-to-treat conditions.

Requirements & Application

Admission to the fellowship program requires completion of an ACGME-accredited neurology residency program.

To apply, please send a letter of intent, your curriculum vitae, and at least 3 letters of recommendation by email to all three of:

• Nagagopal Venna, MD, MRCP-I, MRCP-UK at nvenna1@mgh.harvard.edu
• Haatem Reda, MD at hreda@mgh.harvard.edu
• Fellowship program administrator Altrecia Henry at aehenry@partners.org