Fellowship Training Activities

The fellowship spans a two-year period, with each training year divided into two six-month terms. Each term ends with a Periodic Comprehensive Evaluation. Some training activities will be concentrated in a specific term while others will occur throughout the majority of the fellowship. Training activities consist of clinical service delivery rotations, didactic learning, clinical research, participation in clinic administration, and teaching/supervision of others. The core clinical service delivery experience is based in the outpatient Neuropsychology Assessment Service, which is part of the Behavioral Health Directorate. Other clinics or units will include Inpatient Brain Injury/Neuropsychiatry Program, NICOE Speech Language Pathology, WRNMMC Neurosurgery Clinic, and WRNMMC inpatient medical units. Across all rotations, a minimum of 55 clinical cases are completed in year one, and a minimum of 100 clinical cases in year two.

Clinical Training Rotations

Outpatient Neuropsychological Assessment 

2-Year Core Clinical Experience

Objectives:

• Acquire advanced knowledge of neuropsychology, clinical neurology, neuroanatomy, and neuropathology, with an in-depth understanding of brain-behavior relationships and neurobehavioral syndromes
• Develop advanced clinical interview / neurobehavioral status exam skills
• Acquire advanced proficiency in psychometric test administration and interpretation skills, including highly specialized test procedures (Wada and intraoperative cortical mapping)
• Develop advanced understanding of multiple neuropsychological normative systems, including Wechsler Intelligence/Memory Scales, Heaton norms for the Expander Halstead-Reitan Battery, and the Mayo Older American Normative Studies
• Develop skills necessary to integrate symptoms, history, medical data, and neuropsychological data into a comprehensive neuropsychological report
• Develop knowledge necessary to determine care needs and recommend a treatment plan based on neuropsychological evaluation results
• Acquisition of a basic working knowledge of neurosurgery
• Gain expertise in applying neuropsychological knowledge and skills to military-related conditions and referral questions (e.g., comorbid PTSD, aeromedical waiver evaluations, military medical retirement)

Experiences:

• Receive direct instruction in administering a wide range of neuropsychological tests at the beginning of the training cycle
• Conduct comprehensive neuropsychological evaluations in the WRNMMC Neuropsychology Assessment Service with adult and older adult patients from a variety of referral sources (including neurology, neurosurgery, geriatric medicine, primary care, behavioral health, flight medicine, and medical evaluation boards) with written report and face-to-face feedback to patients and families (1 to 3 evaluations per week)
• Utilize psychometrist assistance for half of cases during year 1 and for all cases during year 2
• As a member of an interdisciplinary team, conduct Wada testing and intraoperative cortical mapping and serve as lead neuropsychologist for at least one of these (if opportunities are available)

NICOE Outpatient Assessment Rotation

6-Month Rotation, Year 1 or 2
Objectives:

• Expand outpatient neuropsychological assessment skills in the context of a multidisciplinary outpatient traumatic brain injury service
• Gain expertise in applying neuropsychological knowledge and skills to complex military-related mild TBI cases

Experiences:

• Conduct outpatient neuropsychological assessments with predominantly mild TBI patients
• Attend multidisciplinary clinic meetings
• Provide various psychological and/or neuropsychological treatment services as fellow’s training schedule permits (optional)

Inpatient Neuropsychological Assessment 

1-Year Rotation, Year 1 or 2

Objectives:

• Acquire inpatient consultation skills in the context of a brain injury treatment team
• Acquire advanced knowledge in the evaluation and management of mild traumatic brain injury in the military environment
• Develop effective communication skills with professionals from different disciplines

Experiences:

• Participate in weekly Inpatient Brain Injury/Neuropsychiatry Team meetings, advising the team on patient care needs from a neuropsychological perspective 
• Conduct inpatient neuropsychological evaluations, including brief but comprehensive neuropsychological testing
• Prepare brief written reports and convey neuropsychological findings and recommendations in person to the interdisciplinary Inpatient Brain Injury/Neuropsychiatry Program

Neuropsychological Interventions 

3-Month Rotation, Year 2

Objectives:

• Acquire skill in group-based outpatient cognitive rehabilitation
• Gain familiarity with the acute inpatient rehabilitation environment
• Gain familiarity with outpatient resources for patients with a history of TBI
• Learn compensatory strategies for improving a patient’s ability to communicate and interact with the inpatient environment while in the acute stage of recovery

Experiences:

• Shadow and then co-facilitate an outpatient cognitive rehabilitation group at the NICOE under the supervision of a speech-language pathologist (this may be substituted with a different neuropsychological intervention experience if available and if approved by the Fellowship Director)
• As a member of an inpatient rehabilitation team, assess acutely injured patients’ communication skills, make recommendations for compensatory strategies, and monitor effectiveness under the supervision of a speech-language pathologist
• Cognitive rehabilitation co-treatment of individual patients with a speech-language pathologist (optional)
• Instruct patients and monitor progress in a program of computer-based cognitive exercises through the NICOE Brain Fitness Center (optional)

Clinical Supervision 

3-Month Rotation, Year 2

Objectives:

• Acquire skill in providing clinical supervision

Experiences:

• Train a psychology intern in a brief inpatient neuropsychological test battery
• Provide case supervision to a psychology intern, including supervision of test administration, interpretation of neuropsychological test results, and documentation (at least 5 cases)
• Attend Psychology Internship faculty meetings

Off-Site Elective in Neuropsychology Subspecialty 

Optional 3-Month Rotation, Year 2

This optional rotation is for exceptionally advanced fellows who have demonstrated ability to manage their time extremely effectively and who have completed (or nearly completed) the fellowship research project requirement. The interested fellow must seek approval from the Fellowship Director, research the possibilities, and provide the Fellowship Director with enough information about the potential off-site experience to substantiate that it would provide appropriate training for a neuropsychology fellow. It is then the Fellowship Director’s responsibility to contact the potential off-site clinical supervisor to work out the details, make the final decision, and, if necessary, draft a memorandum of understanding.

Didactic Activities and Teaching Rounds

Neuropsychology Distance Learning Series 

2-Year Cycle

This is a 2-hour, weekly multisite video teleconference that provides didactic training, case conference, and board exam preparation. The objective of the series is for fellows to develop an up-to-date, research-based understanding of foundational concepts and contemporary issues in clinical and experimental neuropsychology. The WRNMMC Postdoctoral Fellowship Training Program in Clinical Neuropsychology is the host site, and the content is organized by the Fellowship Director.

Didactic training includes discussions of required reading materials that are selected by the Fellowship Director with input from the other participating programs’ faculty. Fellows across sites are assigned to lead the weekly reading discussions. The series is divided into four terms over a 2-year cycle, each governed by a major theme:

• Psychometric properties of neuropsychological tests and procedures
• Neuropsychological aspects of specific diseases
• Neuroanatomy and neurobehavioral signs and symptoms
• Conceptual foundations, advanced topics, and diversity in neuropsychology

Case conferences are assigned by week to participating fellows across sites. Fellows may present a case that illustrates a rare syndrome or condition or a challenging case for which they would like others’ feedback and suggestions. 

Board exam preparation involves faculty-led fact-finding exercises, periodic ethics vignette discussions, and challenging questions from the faculty following each fellow’s case presentation.

Medical Neuroscience Course 

12-Week Intensive Course, Year 1

This is typically offered at Georgetown University School of Medicine in the Fall (or through another Institution based on availability). The course is attended on an audit basis. Fellows are expected to attend all lectures, labs, and review sections. Auditing students are not allowed to take the course’s final examination, but it is required that they complete the weekly quizzes and provide the results to the Fellowship Director. If extenuating circumstances such as illness or family emergencies occur and prevent attendance at some of the course sessions, the fellow must attend a minimum of 85% of the instructional hours to meet the fellowship requirement for the course. There is no fee for fellows to audit the course.

Teaching Rounds

• Neurology rounds (1 hour per week both years)
• Physical Medicine and Rehabilitation multidisciplinary rounds (1 hour per week for year 2)
• Fellows may attend other relevant teaching rounds that have variable availability, including neurology grand rounds, neurosurgery rounds, epilepsy rounds, tumor boards, and neuroradiology case conferences.

Diversity Rounds

Fellows and faculty bring an article or a case that illustrates a neuropsychologically relevant issue of a specific minority group or underserved/underappreciated population to share with the group. The goal is to add to the fellow’s knowledge base in preparation for working with a culturally and interpersonally diverse range of patients.

One Off-Site In-Depth Training Activity 

This training requirement can be fulfilled by attending workshops, seminars, or CE sessions relevant to neuropsychology at professional conferences and conventions, such as those held by the American Psychological Association, the American Academy of Clinical Neuropsychology, the National Academy of Neuropsychology, or the International Neuropsychological Society. The Fellowship Director will request that WRNMMC fund the fellow’s travel, lodging, and conference registration, but full funding cannot be guaranteed. If full funding cannot be secured, the fellow may either pay his or her own way or opt for a locally offered workshop or all-day seminar relevant to neuropsychology.

Other On-Site Training Activities

Since WRNMMC is a large academic medical center, there are a number of opportunities to hear guest speakers and attend workshops and other training activities related to neuropsychology, clinical psychology, diversity topics, healthcare ethics, and military healthcare issues offered through various medical and behavioral health departments and training programs. The Fellowship Director highly encourages fellows to attend these as they become available. The NICOE also frequently hosts guest speakers, providing opportunities to learn about various aspects of TBI care. 

Clinical Research

Each fellow is required to serve as the primary investigator for a research project in clinical neuropsychology with a military relevant focus, to include analysis of data and presentation or publication. At the Fellowship Director’s discretion, a quality improvement project may also fulfill this requirement as long as it involves 1) subject matter that could benefit healthcare provision outside of the setting in which the project is conducted, 2) data analysis to address a hypothesis, and 3) presentation or publication. Individual supervision in clinical research is available on an as needed basis, and monthly group supervision is provided.

In addition to the above requirement, fellows can find numerous opportunities to become involved in ongoing research projects at WRNMMC or the NICOE, which is optional. A fellow might also choose to initiate a second research project after completing the first, but involvement in research beyond the one required project must not interfere with the fellow’s clinical work or other required training activities. 

Administration and Teaching

Training activities in clinic administration include: 

• Completion of a program development or process improvement project relevant to administration in neuropsychology (e.g., expand an underdeveloped product line in clinical neuropsychology, developing/implement a novel assessment or treatment protocol) 
• Review the Neuropsychological Assessment Service’s consultation requests for 2 weeks, including providing education and feedback to referral sources 
  In addition to the Clinical Supervision Rotation, training activities in teaching include:
• Provide a lecture on a neuropsychology-related topic 
• Provide at least 1 case presentation during the Neuropsychology Distance Learning Series case conference, explaining case formulation and recommendation choices to peers

Training Resources

Fellowship Director

The Fellowship Director is a clinical neuropsychologist board certified by the American Board of Professional Psychology/American Board of Clinical Neuropsychology. The Fellowship Director is one of the core supervisors and has regularly scheduled meetings with each fellow individually every week. Within the first week following entry into the program, the fellow will meet with the Fellowship Director to review the Fellowship Handbook, the nature and structure of supervision, and procedures for grievance. You can file a grievance when:

• You have a complaint about the quality of care you received,
• A provider or facility behaved inappropriately, or
• You have any other non-appealable issue.

The grievance may be against any member of your health care team. This includes your TRICARE doctor, your contractor, or a subcontractor. and conflict resolution.  Fellows acknowledge this review with a written signature.

Clinical Supervision

Supervisors of clinical work assume primary clinical responsibility for cases supervised. 

The fellowship has formally designated core training supervisors who are integral to neuropsychological service delivery in the WRNMMC Neuropsychological Assessment Service or the National Intrepid Center of Excellence. Core supervisors are appropriately credentialed (i.e., licensed) to practice psychology in a federal government setting and have credentials in and/or demonstrate substantial competence in the advanced practice of clinical neuropsychology. Core supervisors are distinguished from adjunct supervisors in that they are clinical neuropsychologists who meet weekly with the fellow for at least 1 year of the 2-year program. At all times each fellow has at least one core supervisor.

Adjunct supervisors are engaged in neuropsychological or neuropsychologically relevant medical service delivery, cognitive rehabilitation, and/or research relevant to neuropsychology. They are intended to broaden the range of the fellow’s clinical and professional experience. They are appropriately credentialed to practice psychology in the setting in which their practice occurs, or when the supervisor is a provider from another discipline he/she is appropriately credentialed according to the standards of his/her discipline (e.g., physician, speech language pathologist). Supervisors of clinical research have demonstrated competence in clinical investigation.

Fellows receive:

• 2 to 4 hours of regularly scheduled individual supervision in outpatient neuropsychological evaluation and professional activities with core supervisors every week over the full duration of the training program
• Immediate feedback on bedside examination technique and interpretation while rounding with the trauma consultation physician for 2 hours a week for the duration of the 12-month inpatient trauma consultation rotation 
• 1 to 2 hours of supervision in inpatient neuropsychological evaluation and consultation every week for the duration of the inpatient neuropsychological evaluation rotation
• 1 to 2 hours of supervision in neuropsychological interventions every week for the 3-month duration of the neuropsychological interventions rotation
• 1 to 2 hours of supervision in providing clinical supervision every week for the 3-month duration of the clinical supervision rotation
• 1 hour of group supervision in clinical research every month throughout the training cycle; individual supervision of clinical research varies in frequency according to the different stages of the fellow’s research project 

Each fellow maintains a supervision log that is periodically accessed by the Fellowship Director to ensure fellows receive adequate time in supervision (Appendix B.2).

The program fosters an atmosphere of mutual respect and courtesy between supervisor and fellow, and adheres to the ethical principles and professional conduct standards of the American Psychological Association.

Work Space

The Neuropsychological Assessment Service, which provides fellows their office space, is located on the 6th floor of WRNMMC’s specialty outpatient services building in clinic space shared with the Adult Outpatient Behavioral Health Clinic and the Neurology Clinic. This includes a large conference room with video teleconference equipment, a patient check-in desk, and a patient waiting area. Additional conference rooms are located on other floors of the building and are available to reserve for fellowship meetings and training events. Each fellow has an office furnished with contemporary furniture, telephone, bookshelves, cabinet, and filing space.  Offices are suitable for individual evaluation and treatment. Inpatient units are located in a different building on campus that is connected by indoor walkways, a 5 to 10 minute walk from fellows’ offices.

Computer Equipment

Each fellow's office is equipped with a state of the art desktop computer loaded with word processing, database, and spreadsheet software.  These computers have internet access and network access to a secure Neuropsychology Assessment Service shared drive (to facilitate supervision of report drafts, research database storage, and general document sharing within the Neuropsychological Assessment Service) and an electronic medical record program that serves as the official location for documentation for all clinical encounters within the Department of Defense. Fellows are also issued a laptop computer with numerous programs used in administration and scoring of neuropsychological tests. Statistical analysis software is available on network-connected computers in the Darnall Biomedical Learning Resource Center.

Medical Library and Electronic Resources

The Darnall Biomedical Learning Resource Center (DBLRC) serves the staff, faculty, and trainees of WRNMMC as well as supporting the Bureau of Medicine and clinics in the National Capital Area. It is located at WRNMMC and is accessible via indoor walkways, approximately 5 to 10 minutes from the fellows' offices. The DBLRC consists of a medical library and computer lab.  Resources available to WRNMMC include over 6000 Medical, Dental, Nursing & Allied Health Books, CDs, and DVDs, and numerous current journal subscriptions, including many online journals with full text access relevant to neuropsychology and other aspects of psychological practice. By connecting to the DBLRC intranet site from their office computers, fellows can conduct online literature searches using multiple databases, including PubMed, and access all of the DBLRC eBook holdings, some of which are used for fellows' assigned reading. Library staff provide assistance with the following: literature searches, document delivery/interlibrary loan, and electronic journal access.

Clerical Support

Fellows have two sources of clerical support:  Clerical support personnel of the Department of Behavioral Health Acute and Outpatient Services provide clerical support for fellows and staff.  The enlisted Army Mental Health Specialists and Navy Hospital Corpsmen assigned to the Department assist with special clerical needs as well.