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WE ARE NOW ACCEPTING APPLICATIONS FOR 2019-2020 Endovascular Fellowship

Established in 1994, our program is currently one of only seven ACGME-accredited INR (officially designated 'ESN' for Endovascular Surgical Neuroradiology) fellowships in the nation. In 2002, it was the first such accredited program.

I.    INTRODUCTION

Welcome to the Endovascular Surgical Neuroradiology Fellowship Program at the Washington University School of Medicine.  We are excited to have the opportunity to work with you over the next 12 months.  The purpose of this document is to help introduce you to the fellowship.  This manual should be read in conjunction with the orientation materials for residents and fellows.  If you have any questions regarding any issues related to the goals, objectives and policies of the program, please feel free to contact Dr. Cross at 314-362-5949.

II.  BRIEF PROGRAM DESCRIPTION

     The objective of the training program is to provide you with an organized, comprehensive, supervised and full-time educational experience in this specialty.  The ESN program is a one-year clinical fellowship spent on one single clinical rotation at one institution.  Fellows will alternate between primary and secondary responsibilities on the clinical service on a weekly basis.  The clinical training involves the supervised performance of endovascular surgical neuroradiology procedures, with integration of the techniques into appropriate patient management.  Appropriate management includes the recognition of the importance of signs and symptoms, the understanding of indications for and contraindications to endovascular surgical neuroradiology procedures, an awareness and familiarity with medical or surgical alternatives for treatment, and effective use of interpersonal skills in communicating with the patient and other medical personnel.  The successful performance of endovascular surgical neuroradiology procedures also requires a thorough understanding of imaging techniques, combined with skill in percutaneous image guided techniques.  Over the course of the 12 month training program, you are expected to gradually assume greater responsibility for all of these aspects of patient care.

As per the ACGME requirements for this specialty, fellowship training is open to residents who have completed ACGME-approved Radiology, Neurological Surgery and Neurology residencies.  Briefly stated, the ACGME requirements for prerequisite training are completion of a diagnostic neuroradiology fellowship for Radiology applicants, prerequisite experience as described above during or after residency for Neurosurgery residents, and completion of a vascular neurology fellowship for Neurology residents.

III. Goals and Objectives

 The primary goal of the Endovascular Surgical Neuroradiology (ESN) Fellowship Program is for our trainees to become capable of independent practice in our specialty without direct supervision.  You will receive a letter stating this after successful completion of our 12-month training program.

The Accreditation Council for Graduate Medical Education (ACGME) has defined six general competencies to define the educational goals and objectives of post graduate medical training.  Listed below are the educational objectives for our program expressed within this context.  The ACGME-defined competency is bracketed prior to each definition.  Listed with each particular objective are the tools with which we will assess your progress towards attaining this competency.

 As graduates of accredited residencies in Radiology, Neurological Surgery or Neurology, you are expected to have already attained competency in all of these except the first two, patient care and medical knowledge pertaining to the specialty.  This is a 12-month clinical fellowship aimed at providing you the specialized technical skills, experience and knowledge base to allow you to practice independently in the specialty of Endovascular Surgical Neuroradiology.  Nevertheless, you will also be evaluated for competence in these other criteria as well.

Our objectives are for you, the ESN trainee, over the course of this 12-month training program, to become competent in:

A.  The care of patients with diseases or conditions amendable to neuro-endovascular therapy [Patient Care].  This entails the safe, efficient and appropriate utilization of endovascular neurosurgical and interventional radiological techniques and proper pre, peri, and post-procedural management.  Quarterly reviews of global faculty evaluations, case-logs, and 360-degree evaluations by support staff will be used to assess performance.

B.  Continuous learning, using up-to-date medical evidence, in the case of patients with diseases or disorders amenable to neuro-endovascular therapy [Medical Knowledge].  Performance will be assessed by global faculty evaluations and documentation of participation at morning teaching conferences, particularly the monthly Morbidity & Mortality Conference and the weekly Friday Vascular Conference.

You will be expected to have attained competency during your previous residency training in:

C.  Self-evaluation using scientific evidence, "best practices" and self-assessment programs [Practice Based Learning and Improvement].  Performance will be assessed global faculty evaluations and documentation of participation and participation at the quarterly Morbidity & Mortality Conference.

D.  Effective communication with patients, peers, referring physicians and other members of the health care team concerning informed consent, patient care, safety issues and results of procedures [Interpersonal and Communication Skills].  Performance will be assessed global faculty evaluations and 360-degree evaluations from nurses and technologists on the neurointerventional service.

E.  High standards of professional conduct, demonstrate altruism, compassion, honesty and integrity.  Follow principles of ethics and confidentiality and consider religious, ethnic, gender, education and other differences in interacting with patients and other members of the health care team [Professionalism].  Performance will be assessed global faculty evaluations and 360-degree evaluations from nurses and technologists on the neurointerventional service.

F.  Understanding the relationships of local and national health care systems and how changes to improve the system involve individual and group efforts.  Optimize coordination of patient care within one's own practice [Systems-Based Practice].  Performance will be assessed global faculty evaluations and 360-degree evaluations from nurses and technologists on the neurointerventional service.

IV.  PRE-REQUISITE OBJECTIVES

Prior to the ESN year, you are expected to have gained the following basic skills and knowledge and the ACGME pre-requisite of 6 months training in neurosurgery, vascular neurology and neurointensive care unit. 

A.  The use of needles, catheters, guidewires and angiographic devices and materials.
B.  The basic radiological sciences, including radiation physics, radiation protection and the pharmacology of radiographic contrast materials.
C.  Angiography and image interpretation.
D.  The proper use and interpretation of laboratory tests and methods that are adjunctive to endovascular surgical neuroradiology     procedures, such as physiological monitoring, noninvasive neurovascular testing and noninvasive neurovascular imaging.
E.  The evaluation of patients with neurological disease.
F.  The basic and clinical neurosciences, including neuroanatomy, neurobiology and the pathophysiology and natural history of neurologic disorders, especially cerebrovascular and neoplastic conditions.
G.  The clinical aspects of patient assessment, treatment planning and patient management related to endovascular surgical neuroradiology therapy, including the fundamentals of invasive monitoring and neurointensive care management.
H.  The clinical indications, risks and limitations of endovascular surgical neuroradiology procedures.
I.  The use and administration of analgesics, antibiotics, anticoagulation agents, neuroanesthetic agents, and other drugs commonly used in endovascular surgical neuroradiology procedures.

V.  SCOPE OF THE SPECIALTY

     Endovascular surgical neuroradiology is a subspecialty that uses catheter technology, image interpretation, guidance and clinical expertise to diagnose and treat diseases of the central nervous system.  The unique clinical and invasive nature of this subspecialty requires special training and skills.  The program must include training and experience in the following:

A.  signs and symptoms of disorders amenable to diagnosis and treatment by endovascular surgical neuroradiology techniques;
B.  neurological physical examinations to evaluate patients with neurological disorders;
C.  pathophysiology and natural history of these disorders;
D.  indications for and contraindications to endovascular surgical neuroradiology procedures;
E.  clinical and technical aspects of endovascular surgical neuroradiology procedures;
F.  medical and surgical alternatives;
G.  preoperative and postoperative management of endovascular patients;
H.  neurocritical care management;
I.   fundamentals of imaging physics and radiation biology; and,
J.  interpretation of radiographic studies pertinent to the practice.

VI.  SUGGESTED READING 

  1. Pearse Morris, M.D. Interventional and Endovascular Therapy of the Nervous System:  A practical guide.  Springer-Verlag, New York, 2002.
  2. Connors JJ and Wojak J.  Interventional Neuroradiology

VII.  CLINICAL DUTIES

The ESN fellowship consists of 12 continuous months spent in clinical endovascular surgical neuroradiology training, during which the fellow will carry out all of the following under close supervision of the ESN staff:  perform clinical preprocedural evaluations of patients, interpret preliminary diagnostic studies, consult with clinicians on other services, perform diagnostic and therapeutic endovascular surgical neuroradiology procedures, generate procedural reports, and participate in short-term and long-term post-procedure follow-up care, including neurointensive care.  Fellows will become familiar with the outcome of all endovascular surgical neuroradiology procedures.  Fellows will serve as consultants under the supervision of the ESN staff.  Direct interactions of fellows with patients will be closely observed to ensure that appropriate standards of care and concern for patient welfare are strictly maintained.  Communication, consultation, and coordination of care with the referring clinical staff and clinical services must be maintained and documented with appropriate notes in the medical record. 

VIII.  LINES OF SUPERVISION

During the 12-month training program, your supervision will be the responsibility of the primary ESN faculty.  You, in turn, will have supervisory responsibility for Diagnostic Neuroradiology and Vascular Neurology fellows, as well as Radiology, Neurology and Neurosurgery residents that rotate on the diagnostic neuroangiography service.  You will teach and supervise these trainees in pre- intra- and post-procedural management, as well as technical aspects of diagnostic neuroangiography.

XI.  GRADED RESPONSIBILITY

Over the course of the year, we will monitor your progress in all aspects of patient care and medical knowledge.  As you gain technical procedural skills, experience and knowledge, you will be given increasing responsibility for aspects of the procedure as well as pre- and post-procedural patient management.  How quickly you gain responsibility will depend on the complexity of the situation, your personal experience with the situation or previous similar situations as well as the experience of each of the primary ESN faculty.

We will also monitor your performance regarding the remaining four competencies.  You will receive formal feedback at least once per quarter on your progress (see section XVI below).  You will be given increased responsibility for the diagnosis, evaluation, procedural treatment and clinical management of our patients as you gain experience and competence.  It is our goal that you will be capable of independently performing all these tasks by the end of the fellowship.

X.  RESEARCH

 The research experience is tailored to the talents and goals of the individual trainee.  At a minimum, the trainee will develop an understanding of clinical research methodology and develop a systematic approach to critiquing and reviewing medical literature.  Your progress towards this objective will be monitored by observing your performance at teaching conferences.  Individual participation in research projects will also provide an opportunity to develop skills in research techniques.

A.  Academic experience is an important part of the ESN fellowship.  Different fellows have different levels of research interest.  Some fellows may want to undertake substantial projects in which they are the principal investigator.  Others may not want to make such a large commitment to research, but instead become involved in ongoing projects with the faculty of the section.

B.  During the first several weeks of the fellowship, each fellow should review the list of section ongoing and potential project ideas and/or formulate ideas on their own.  Along with the members of the section, each fellow should develop a plan for their academic activities for the year.  Each fellow should have a definitive plan prior to August 1st.

C.  Each fellow should pair-up with one of the staff members as their project advisor or mentor.  In some cases, the fellow will be the principal investigator and others, the fellow will assist the faculty with an ongoing research project.  It will be the responsibility of the faculty mentor to monitor progress.

D.  The primary purpose of academic time is to provide fellows with time to work on their project(s) and conferences.  On those days when no fellows are on vacation or at a meeting, one fellow will be assigned to the academic rotation.  The distribution of academic time among the fellows in the section will be related to the level of each fellow's academic undertakings.

XI.  CALL PROCEDURE

A.  Call for the ESN service will generally be taken one week at a time, from 07:00 Monday morning through the following 07:00 Monday morning.  Call duties will not exceed, on average every other week coverage.  Call is taken from home.

B.  The fellows are the primary individuals responsible for call for interventional neuroradiology emergencies.  The fellow should gather all information appropriate to the clinical evaluation of the problem.  A plan should then be formulated.  At this point the responsible attending must be contacted for confirmation of this plan.
C.  The nurse and technologist are not to be called until the plan has been discussed with an attending and patient consent obtained.  In case of emergency procedures, it is sufficient to verify that the patient agrees to the procedure via the referring physician.  At this point, the technologist and nurse may be called.  (Actual patient consent must always be obtained by a member of the ESN service for any procedure.)

XII.  DUTY HOURS

A.  Duty hours include all clinical and academic activities related to the ESN program.  They are limited to 80 hours per week, inclusive of in-house call activities, averaged over a 4-week period.

B.  At least one in 7 days, averaged over a 4-week period, must be free of all educational or clinical activities.

C.  At least 10 hours free from education or clinical activities is provided after daily duty or in-house call.

D.  Finally, on-site duty must not exceed 24 consecutive hours, with up to 6 additional hours to participate in didactic activities or to provide continuity of care.

E.  Monitoring:  Duty hours, including call, are monitored on a monthly log on a clipboard in the angio reading room.  This is also the conference attendance log.  You must mark down the number of hours worked per week, and any instance where you provided more than 24 hours of continuous service.  The Fellowship Director reviews this log on a monthly basis.

XIII.  MOONLIGHTING

A.  Extramural moonlighting is not permitted
B.  Internal moonlighting opportunities exist.  The fellow must have the Fellowship Program Director's permission to participate in this.  If this interferes with the fellow's ability to achieve the goals and objectives of the educational program, they will not be able to continue moonlighting.  Time spent in these activities must be counted on the duty hour log and are part of the 80-hour limit.

XIV.  VACATION/INTERVIEW/MEETING TIME POLICY

A.  According to Washington University policy, each fellow is allotted 15 days of vacation time.
B.  All fellows are allowed and encouraged to attend at least one ESN-related meeting or symposium.  Priority for meeting time will be given to fellows presenting papers.  Meeting time will not be charged to vacation time.
C.  All requests for vacation, meeting and interview time must be cleared by the Fellowship Director.

XV.  CONFERENCES

Fellow's conference responsibilities include the following:
A.  Weekly ESN Conferences are held on Monday's at 4:00 pm. Conference participation (mandatory) includes didactic lectures and journal clubs on topics related to the core curriculum for Endovascular Surgical Neuroradiology.  Talks will be provided by faculty and fellows on a rotating basis.  The lecture and journal club topics schedule will be created by the ESN fellows at the beginning of the academic year, based on the ESN Core Curriculum document.   This schedule will be reviewed by the program director for completeness. The attending physician on the clinical service will be responsible for the conference.

B.  Morbidity and Mortality Conference is held on the last Wednesday of the month at 8:00 am.  Attendance at this conference is mandatory and you must sign in on the attendance sheet.  ESN fellows are responsible for the monthly morbidity and mortality conference.  Case assignment will be made one week prior to conference.  Prior to the conference, a written morbidity and mortality sheet for each patient (HIPAA compliant) must be prepared by the responsible fellow for distribution at the conference.  The blank sheets will be emailed as an attachment and can be saved for use throughout the year.

C.  Cerebrovascular surgery/ESN case conference is held every Friday morning at 8:00 am in the ESN reading room.  ESN fellows are responsible for organizing the presentation of cases.  Attendance at this conference is mandatory and you must sign in on the attendance sheet.

D.  The Neuroradiology Section holds conferences every week on Monday, Tuesday, Wednesday and Friday mornings at 7:00 am. Monday's conferences alternate between a Didactic conference and Physics lectures.  Tuesday's conference is a Fellow Follow-up conference.  (A neuroradiology fellow presents several instructive pathologically-proven cases and leads a discussion on imaging, clinical and pathological features of the disease entity). Wednesday's conferences can be a Journal Club (covering general neuroradiological topics), a research conference, Morbidity and Mortality conference (held quarterly), or a Guest Speaker from another Department at the Medical School. Topics cover a broad range of neurological disorders and have included pathology of brain tumors, clinical features of MS and Alzheimer's disease and surgical options for treatment of aneurysms). Friday's Eye Openers conference is a clinical conference where instructive cases seen on the brain, spine, pediatric and ESN services are presented by residents and discussed.  Mandatory conference participation is required for the first 8 weeks of the academic year.  Orientation lectures are given for each clinical service along with the required ACGME core lectures.

E.  A combined neuropathology/neuroradiology/neurosurgery conference is held quarterly on Wednesdays at 7:00 am.  Clinical, imaging and pathological aspects of different neurological diseases are discussed.

XVI.  EVALUATIONS

     Each quarter you will formally review your case logs and the results of the global faculty and 360 evaluations with the fellowship program director.  This will provide you and us an opportunity to ensure that you are making adequate progress for attaining the first two competencies, and that the remaining four competencies have been met.  If you are not making adequate progress, these meetings will provide a formal opportunity to provide direction.  In addition, you will have formal opportunities to evaluate the staff and program.

     A.  FELLOWS
1.  Each fellow will be evaluated four times/year (quarterly) in a meeting with the fellowship program director.  This will provide an opportunity for discussion between the fellow and an attending staff member.  All attending staff members will have input into each fellow's evaluation, which becomes part of their permanent record (the fellow's file).  This record is accessible for review by the fellow.
2.  The evaluation process is an opportunity for two-way communication.  This will be a time for the fellows to express any concerns they have regarding the fellowship and recommendations for improving it.
3.  During the quarterly evaluation, the fellow's case log will be reviewed including a breakdown of individual cases.
4.  At two of these four meetings, evaluations of the fellow's performance by one of the radiology technologists will also be included.
5.  Summative Evaluation:  At the completion of the program, the fellowship program director will provide a summary evaluation for the permanent record (the file).  This evaluation will be in the form of a letter that documents their performance over the year and verifies that the fellow has demonstrated sufficient competence to enter practice without direct supervision.

     B.  STAFF
1.  At the end of the year, the program will evaluate faculty performance related to the educational program.
2.  The fellows will complete a confidential questionnaire regarding the faculty's clinical teaching abilities, commitment to education program, clinical knowledge, professionalism, and scholarly activities.

     C.  PROGRAM
1.  The fellows will complete a confidential evaluation of the program.
2.  A formal program (education) committee will take place at the end of the academic year, consisting of both fellows and the ESN faculty.  This is to provide another opportunity for the fellow to suggest improvements to the program, to discuss whether the goals and objectives were met, to discuss the written evaluations of the staff and program.

XVII.  FELLOW SELECTION POLICY

The selection process generally begins in conjunction with the neuroradiology training program, also sponsored by the WUSM/BJH/SLCH Consortium.  The diagnostic neuroradiology program has 9 ACGME-approved diagnostic neuroradiology fellowship positions, 7 positions are used for a one-year diagnostic neuroradiology fellowship and two positions are set aside for trainees preparing for our ACGME-approved Endovascular Surgical Neuroradiology (ESN) fellowship.

Internal Washington University applicants are selected through an interviewing and application process in the winter 18 months before the start date for the training program.  To apply, candidates are directed to contact Peggy Winkler, our education coordinator and submit the universal fellowship application form.  Click here to download the application.

     Applications are considered for an interview based on the strength of the application.  An applicant's folder is complete when it contains the following documentation:

     - Completed Universal Application
     - Curriculum Vitae
     - Personal Statement
     - Dean's Letter
     - Copy of ECFMG Certificate (if applicable)
     - Visa-size photo
     - Copies of medical school diploma and transcript
     - 3 Letters of Recommendation
     - USMLE scores
     - If not a permanent US resident, a copy of applicant's visa, passport, ECFMG certificate

     ESN candidates selected for interviews meet with ESN faculty, including the three core faculty and several vascular neurosurgery faculty and current ESN fellows.  After the interviews, the ESN faculty meet to discuss the applicant and relative rank compared to other current applicants.  A position may be offered after this meeting, or after other candidates have been interviewed, depending on the strength of the application.

     ESN applicants that are offered positions must complete the following prior to matriculation in the program:

     - obtain a permanent Missouri Medical License
     - be board exam eligible (board certification is preferable)
     - obtain ACLS training before beginning fellowship training

XVIII.  DISCIPLINARY POLICY

The policy of the Endovascular neuroradiology Fellowship training program is based on the document of disciplinary action, suspension and termination produced by the Graduate Medical Education Consortium and the Washington University Radiology training program.

A.  Formal disciplinary action may be taken for academic reasons or for behavioral problems including, but not limited to the following:
     1.  Failure to satisfy the academic or clinical requirements of the training program as outlined in the endovascular goals.
     2.  Professional incompetence, misconduct or conduct that is inconsistent with or harmful to patient care or safety.
     3.  Conduct that calls into question the professionalism, ethics or judgment of the trainee or that could prove detrimental to patients, employees, staff, volunteers or operations.
     4.  Violation of the bylaws, rules, regulations, policies or procedures of the consortium, School of Medicine, Hospital, Department, Division or training program.
     5.  Unethical practice in a clinical or scientific endeavor.
B.  Academic or behavioral problems will be discussed with the fellow at the next quarterly review of the fellow performance or sooner if indicated.
C.  If indicated, formal disciplinary action may include:
     1.  Verbal warning
     2.  Written warning
     3.  Mandatory professional counseling through Employee Assistance and/or other services available through Washington University Human Resources
     4.  Probationary status
     5.  Extension of the fellowship program ranging from a month to a year
     6.  Denial of certification of satisfactory completion of the fellowship program
     7.  Reduction, limitation or restriction of the fellow's clinical responsibilities
     8.  Suspension, termination or non-reappointment of employment and training
D.  The fellow will be notified in writing of the probationary status and any remediation needed.  The probationary period will end if/when the fellow demonstrates satisfactory improvement in the area(s) of deficiency.
E.  The program director and the chairman will notify the trainee in writing of the specific action taken and the reason for the suspension of the contract.  A copy of this notification will be submitted to the Associate Dean for Graduate Medical Education and the Hospital GME office.  This letter will advise the fellow of his/her right to file a grievance according to the policies of the department and the GME Consortium.
F.  Suspension, dismissal or non-renewal of contract will be submitted to fewer than four months prior to the date of intended action.  However, immediate suspension may be invoked in cases where the behavior is felt to place the safety or health of the patients or personnel in jeopardy.

     XIX.  GRIEVANCE POLICY

A.  The interests of the fellow are best served when problems are resolved as part of the regular communication between the fellow and departmental officials in charge of the training program.
B.  Thus fellows are encouraged to make every effort to resolve disagreements or disputes over academic or disciplinary decisions or evaluations by discussing the matter with the Program Director.  If satisfactory results are not obtained, grievances can then be brought to the Chief of Neuroradiology.
C.  If satisfactory results are not obtained, grievances can then be brought to the Chairman of the Department of Radiology.  The Office of the Associate Dean for Medical Education (Graduate Medical Education) is available to provide confidential guidance in this effort.
D.  If satisfactory results are still not obtained, then the grievance can be presented to the Associate Dean for Medical Education.

 The GME consortium policy and description of how grievances are handled is described at http://gme.wustl.edu/About_the_GME_Consortium/Policy/Pages/DisciplinaryorDismissalActionsDecisions.aspx.  Refer to the section title "Procedure for Review of Academic and Disciplinary Decisions Relating to Residents and Clinical Fellows."

XX.  OFFICE SPACE

Four workstations, with computers and connected to the Mallinckrodt network, are available in the Neuroradiology Offices for fellow use.  Fellows may also take advantage of any available office space.
 

ESN Clinical Prerequisite rotations

  • Neurology Neurosurgery Intensive Care Unit (6 months)

ESN will rotate through the Neurology/Neurosurgery Intensive Care Unit (NNICU) for 6 months.  Their experience will be one of graded responsibility.  During that period of time, they will be supervised by both an NNICU fellow and attending and will take in-house call at intervals not exceeding every third night.  They, along with other residents on the service, will be responsible for following and providing care for patients that they admit during their days on call.  They will learn the general principles of respirator management (including the indications for intubation, extubation and weaning) blood pressure management, fluid and electrolyte management and the placement of catheters for the supportive care and pharmacological treatment of ischemic and hemorrhagic stroke.  During the NNICU rotation, they will participate in daily didactic conferences, which will cover topics including, principles of neurologic critical care, diagnosis and management of common diseases seen in the NNICU, nutritional and pharmacological issues in these patients management and a weekly Neurosurgery-Interventional Neuroradiology Joint Treatment Conference devoted to the management of aneurysms and vascular malformations that is attended by NNICU, Neurosurgery and Interventional Neuroradiology faculty.

Acute intracranial hemorrhage due to vascular malformations and aneurysms are generally admitted to the Neurosurgical Service in the NNICU.  NNICU admits to the Neurosurgery service each year approximately 50 intracerebral hemorrhages (half of which are due to arteriovenous malformations) and 175 aneurysms (both ruptured and unruptured).  Rotation on this service will give the ESN opportunities to observe, evaluate and manage patients of all ages with these conditions.

Evaluations will be completed by the NNICU faculty on a monthly basis and a letter documenting successful completion of the rotation will be provided by the NNICU program director. These evaluations are reviewed by Dr. Cross with the ESN residents.

  • Barnes-Jewish Stroke Service (1 month)

  The ESN will participate in morning work rounds and teaching rounds with Stroke Service attending neurologist and resident staff.  He/she will see all in-hospital stroke consults (including those at St. Louis Children's Hospital) and share 24/7 Emergency Room coverage for tPA with the Chief Residents with individual case review for each case by the attending.  Chief Residents have direct line patient responsibility under the supervision of the attending.

  This service admits 10-15 patients per week with all varieties of stroke but primarily ischemic stroke and primary intracerebral hemorrhage.  Most are admitted acutely through the emergency room or by transfer from outlying hospitals within a few hours of presentation.  Average length of stay is 5.2 days so there is rapid turnover.  Rotation on this service will give the VNR opportunities to observe, evaluate and manage patients of all ages with a wide variety of disorders of the cerebrovascular and nervous systems.

By making regular patient management rounds with the attending faculty, trainees will learn about the effectiveness of procedures for inpatient management of patients with stroke, both ischemic and hemorrhagic as well as emergent management of patients with stroke in the emergency department.  Work rounds and teaching rounds encompass extensive discussions regarding appropriate ordering and clinical correlation of diagnostic brain and vascular imaging including cranial and spinal MRIs and CTs, magnetic resonance imaging, cerebral angiography, carotid and intracranial Doppler studies, single photon emission tomography (SPECT), photon emission tomography (PET) transesophageal and trans-thoracic echocardiography.  In addition, the ESNs will learn the evidence base for ordering and interpretation of the appropriate biochemical and molecular testing for strokes in patients of different age groups.

Evaluations will be completed by the Neurology faculty at the end of the month and a letter documenting successful completion of the rotation will be provided by the Vascular Neurology program director.  These evaluations are reviewed by Dr. Cross with the ESN residents.

  • Vascular Neurosurgery (1 month)

ESN residents are assigned to the service for Drs. Dacey and Zipfel, two primary vascular neurosurgeons, for a week block and are responsible for the perioperative and intraoperative care of those attendings' patients, in conjunction with the PGY-2 and surgical intern.  Residents receive an introduction to inpatient and outpatient clinical neurosurgery.  ESN residents are instructed in proper techniques for history-taking, physical examination and interpretation of radiological studies relevant to neurological surgery in the outpatient department, in the inpatient wards, in the neurosurgical ICU and in the Emergency Room.   They will be expected to assist in the placement of ventriculostomies, intracranial pressure monitor placement and burr hole placement for subdural hematoma.

  The ESN resident is directly supervised by the senior neurosurgery residents and is further directed by the chief resident and the attending physicians.  The residents work primarily in two teams, each of which is supervised by a chief resident.  The senior neurosurgery residents and the chief resident provide supervision of the ESN resident at rounds and with patient care.  Senior neurosurgery residents and attendings provide assistance with all aspects of patient management: in the evaluation of patients in the outpatient setting, the emergency room in the hospital and in the operating room.

On the inpatient units, ESN residents report directly to their respective attendings regarding the patient's clinical findings and course during their hospitalization.  All consultations are evaluated with an attending and both the attendings and residents contribute to the documentation of the patient's' clinical course in the hospital chart.  The service operates with the expectation that the residents will keep the attendings continuously apprised of the clinical course of their patients and that they will make clinical decisions in conjunction with under the supervision of the attendings.  An extensive system of communication including cell phones and beepers is available to facilitate this communication.

In the Emergency Room, the chief residents and attendings are contacted by the resident regarding the management of emergency room patients prior to their disposition and, depending on the severity of the patient's condition, the patient is either admitted or the chief residents and the attendings discuss further management.

ESN residents are directly supervised in the operating room by senior residents, chief residents, and/or attendings.  Neurosurgical attendings are present for the key portions of all neurosurgical cases and are directly available for all operative treatment.

Evaluation of trainee performance and competencies is performed on the New Innovations program by either Dr. Dacey or Dr. Zipfel.  Dr. Zipfel will provide a letter documenting successful completion of the director.  These evaluations are reviewed by Dr. Cross with the ESN residents.

XXI.  WASHINGTON UNIVERSITY GRADUATE MEDICAL EDUCATION

     The compliance documents and University procedures regarding institutional policies for residents and fellows are on the web at http://gme.wustl.edu/About_the_GME_Consortium/Policy/Pages/Home(default).aspx

For more information or an application please write or call:

Peggy Winkler (Education Coordinator)
Washington University School of Medicine
Mallinckrodt Institute of Radiology
Campus Box 8131
510 S. Kingshighway Boulevard
St. Louis, Missouri 63110-1076
Phone: 314-362-5949
Fax: 314-362-4886
winklerp@wustl.edu