Advanced Vascular Neurology Fellowship

New York Presbyterian Hospital - Columbia University Medical Center also offers a 1 -year advanced fellowship training program in advanced vascular neurology for fellows who have completed a one year Vascular Neurology fellowship.

• A. Demographics.

  • Host Institution: New York Presbyterian Hospital -Columbia University Medical Center, 710 West 168^th St. New York, NY 10032
  • Specialty/Subspecialty: Advanced vascular neurology
  • Mailing Address: The Neurological Institute at Columbia University Medical Center 710 W. 168th Street New York, NY 10032
  • Phone Number: 212-305-8389
  • Fax Number: 212-305-3471
  • Program website: 
    • http://columbianeurology.org/education-and training/fellowship­programs/
  • Program Email: jzw2@cumc.columbia.edu
  • Program Director: Joshua Z Willey MD, (address above), tel (212)305-8389, fax (212)305-3471, email jzw2@cumc.columbia.edu.
  • Alternate Program Contact: Emerita Verdejo, tel (212)305-1338, ev2203@columbia.edu.

• B. Introduction:

  • History: The Division of Stroke and Cerebrovascular Diseases within the Department of Neurology has offered Stroke Fellowship training for post-Neurology Residency since 1983 when the Division was founded by former Vascular Neurology Program Director, Dr. JP Mohr. Over 50 Fellowship trainees have completed the program, and now hold academic and clinical positions throughout the US and abroad. The fellowship is an accredited 1-year ACGME training program. The advanced vascular neurology fellowship program after the ACGME certified year has been an additional option for training under StrokeNET or the Neuro-epidemiology T32 program for the past 15 years. Over that time period 30 trainees have completed the advanced vascular neurology training program.
  • Advanced vascular neurology training is offered as a 12 month program.
  • Pre-requisites of the program are successful completion of a US or Canada based vascular neurology fellowship program with certification by the program director that the trainee is ready for the independent practice of vascular neurology.
  • The goal of the advanced fellowship program is to build on the fellow’s clinical knowledge and expertise gained from the vascular neurology training, and to further develop their skills as a researcher by providing them with protected research time. The fellow is expected to complete research projects already started during their ACGME vascular neurology year, and to pursue new research initiatives while gaining more in-depth knowledge on conducting and executing large clinical trials. This protected research time provided during the advanced vascular neurology year helps provide the necessary resources for conducting independent research after completion of the program.
  • N/A

• C. Resources:

  • The following are the core teaching staff:

Name, Degree, Title, and Position	Full-Time Yes/No	Certification* (by ABPN-Neuro and/or ABPN-Child Neuro.)
Randolph S. Marshall, MD-Professor Neurology, Director of Stroke Division	Yes	ABPN Neurology
J.P. Mohr, MD, MS – Daniel Sciarra Professor of Neurology	Yes	ABPN Neurology
Mitchell S.V. Elkind, MD – Professor Neurology, Program Director of NeuroEpidemiology	Yes	ABPN Neurology
Olajide Williams, MD – Associate Professor	Yes	ABPN Neurology
Joshua Willey, MD – Program Director of Vascular Neurology	Yes	ABPN Neurology
Jose Gutierrez, MD- Assistant Professor of Neurology	Yes	ABPN Neurology
Eliza Miller, MD – Assistant Professor of Neurology	Yes	ABPM Neurology
Soojin Park, MD – Assistant Professor of Neurology	Yes	ABPN Neurology
Imama Naqvi MD – Assistant Professor of Neurolohu	Yes	ABPN Neurology

• All of the faculty are involved in teaching under direct and indirect supervision during the clinical rotations described below.
  • Facilities: The inpatient portion takes place at the Milstein Hospital, the main teaching hospital of the Columbia University College of Physicians and Surgeons. The facilities include a dedicated neurology ward, a 4-bed Stroke Unit, 18-bed Neuro-ICU, dedicated Neurology floor with Neurology nursing staff, 2 Nurse Practitioners and 24-hour house staff support. Neuroradiology imaging as well as the ICAVL-certified Neurosonology lab support are available. The research mentorship, funded by NIH StrokeNet, can be under Dr. Hooman Kamel at the Brain and Mind Research Institute, the main research center for New York Presbyterian Hospital East  Campus or on the West campus.

• D. Educational Program:

  • Clinical: The medical subspecialty of advanced vascular neurology is devoted to the comprehensive multisystem care of the critically-ill stroke patients. The physician assumes the primary care role for his or her patients in the stroke step down, ICU, and emergency room and coordinating both the neurological and medical management of the patient. Hence, the Core Curriculum is evenly split between neurological and medical diseases and conditions, and fellowship training includes rotations throughout the continuum of care for the most complex vascular neurology cases. The advanced vascular neurologist defragments and harmonizes the care of his or her patients by taking responsibility for various elements of care that might otherwise be provided by multiple subspecialists (i.e., cardiology, endocrinology, infectious diseases, pulmonary medicine, and neurology). Expertise in advanced vascular neurology involves proficiency with standard forms of ICU monitoring (i.e., cardiovascular hemodynamic monitoring and mechanical ventilation) as well as specialized forms of neurological monitoring (i.e. ICP and continuous EEG monitoring) and interventions (i.e., hypertensive hypervolemic therapy, therapeutic hypothermia). The advanced vascular neurologist works closely with neurosurgeons, neuroradiologists, neurologists, emergency medicine, and other medical and surgical subspecialists, as well as with nurses and other care providers in an environment that fosters multi-disciplinary collaboration. The ultimate goal of clinical care is to support the acutely ill stroke patient, provide appropriate therapies to treat the primary injury, minimize secondary neurological injury and medical complications, and expedite and facilitate the patient’s transition to a recovery environment. The training program exists in the context of a team of stroke care and hospitalist physicians who provide comprehensive care.

  • The research component of the year constitutes a majority of the fellow’s training, and is sponsored through an NIH grant (NIH StrokeNet). This would consist of numerous responsibilities and goals, including the following:

    • Gaining advanced training and knowledge in planning and conducting clinical research. This would be done under the mentorship of StrokeNet leaders through monthly webinar series on Advanced Topics in Vascular Neurology presented by faculty at leading institutions around the US. StrokeNet also performs Grand Rounds discussions and teaching sessions on research methodology for trainees. In addition, the trainee will gain further knowledge in bio-statistics under the supervision of research mentors.

    • Creating a multicenter database within the state of New York of young patients with ischemic stroke. This database will include many of the centers in the StrokeNet Regional Coordinating Center in New York, with the goal of improving collaboration among hospitals and performing large trials to further our knowledge of the epidemiology and treatment of stroke in young patients. Each center will have access to the multicenter database and its de-identified data, and will be able to use it for future research. To date, there are only a couple large multicenter database within the United States that focus on stroke in the young. We plan to collect both retrospective and prospective data within our database.

    • Perform large multistate epidemiological studies surrounding ischemic stroke

  • Clinical responsibilities include but are not limited to daily teaching rounds with vascular neurology, neuro-critical care, and hospitalist faculty and the post call house staff team, acute stroke page responsibilities, daily Neuro-ICU rounds, and care of the critically ill patient on the step down units. The fellow is expected to participate in presentations and discussions of the pathophysiology, neuroradiological and hemodynamic characteristics of different stroke conditions, evidence-based acute and long-term treatment modalities and neuro-rehabilitation. Fellows are responsible for teaching residents and medical students while on the Inpatient service. The research supervision will be under Dr. Hooman Kamel, and will include assistance from statisticians affiliated with New York Presbyterian Hospital. The trainee will also attend monthly research meetings and will collaborate on further projects with members of the research team (including residents, medical students, and summer interns).

  • The advanced vascular neurology fellow serves under the supervision of neurology faculty with expertise in neurological emergencies, hospitalist neurology, and cardiovascular disease attendings who are directly responsible for patient care for those patients with severe neurological diseases admitted to the neurology services. The advanced fellow reports to and reviews all patients with the supervising attending. Another neurology attending supervises the consult service and yet another supervises the outpatient clinics. The advanced fellow in turn supervise the management of patients with the neurology residents and those rotations on the service from other departments (medicine, psychiatry, and neurological surgery). 

  • Fellows are required to play active roles in recruitment, data collection and follow-up, as well as develop original research projects under the mentorship of the faculty. In addition to the developments of a research faculty fellows also received research training in study design, statistical analysis, and research integrity. Fellowship research activities are expected to progress to independent research projects supervised by research mentors and to be presented at national meetings.

  • There are weekly Divisional clinical case conferences, dedicated didactic sessions, and monthly Research Updates presented by the faculty and House staff, a monthly Webinar series on Advanced Topics in Vascular Neurology presented by faculty at leading Institutions around the US, as well as the weekly Grand Rounds hosted by the Department of Neurology.

    • List of Core topics covered in Didactic Lectures and Conferences:     

      Topic

      Neuro-ICU Protocols

      Transcranial Doppler and Cerebrovascular Ultrasound

      Neuro-Imaging Of Stroke

      Intracranial pressure monitoring

      Diagnosis and Treatment of Acute Stroke

      Cerebral Hemodynamics

      Management of Complications of Acute Stroke

      Mechanical circulatory support

      Case Studies in Acute Stroke Decision Making

      Cardioembolic Causes of Stroke

      Neuromuscular respiratory failure

      Antiplatelet Agents and Stroke

      Status Epilepticus

      Genetics of Stroke

      Sepsis

      TIA’s: Epidemiology, etc.

      Rare Causes of Stroke and Named Stroke Symptoms

      Cardiac arrest

      Management of ICH

      Experimental Models of Stroke/Basic Science of Ischemia

      Cardiovascular disease prevention with medications

      Cardiovascular disease prevention with surgery

      Non-arterioventions shunt lesions

      Neurological complications of pregnancy

      Neurological injury Recovery and Repair

  • E. Supervision and Evaluation:
    • At the completion of clinical rotations, the attending will complete written evaluations using the Medhub system.  After completion of rotations, fellows will present at monthly morbidity and mortality conference, where they receive verbal and written feedback on difficult clinical scenarios. Every three months, every fellow will have a meeting with either the program director or the division head, over the course of the year to review progress and improvement.  During this meeting, the program director or division head will review written feedback, review progress in research training, give direct verbal feedback and discuss career planning. At completion of fellowship training, the program director will complete a summary evaluation that confirms competence to begin practice without direct supervision.

Goals and objectives

Goal(s):

The goal of the Advanced Vascular Neurology program is to further trainees expertise in the care and management of the complex stroke and cardiovascular disease patient. This includes learning to triage, diagnose, and treat patients with acute stroke, and to develop skills to diagnose and treat complex cerebrovascular problems. Mastery of a core of medical knowledge, and development of interpersonal skills and professionalism to manage stroke in an increasingly complex medical environment is expected.

Advanced Vascular neurology fellows must be able to provide patient care that is compassionate, appropriate and effective for the treatment of stroke and the promotion of health in the inpatient and outpatient setting.

Patient Care

Competency:

Fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

Objectives:

By the end of this program, fellows will be able to:

• Perform a history and physical examination that is logical, reliable and purposeful based upon the patient’s chief complaint.
• Integrate history, physical findings, and diagnostic information in an efficient and accurate manner to arrive at a diagnosis and treatment plan for a variety of cerebrovascular conditions including acute ischemic stroke, intracranial hemorrhage, sinus venous thrombosis, AVM and other malformations, and subarachnoid hemorrhage.
• Demonstrate competency and proficient at the delivery of intravenous thrombolysis within a 3-hour time window, including the selection of appropriate patients for intravenous rtPA, and management of patients before and after rtPA administration.
• Demonstrate competency in the interpretation of diagnostic tests related to stroke care including MRI, MRA, carotid duplex and transcranial Doppler, C02 reactivity, transthoracic and transesophageal echocardiograms, conventional cerebral angiograms, SPECT scans, hypercoagulable serologic tests, as well as tests of infection and inflammation.
• Demonstrate the ability to integrate various sources of medical records into a concise and comprehensive evaluation of the patient’s cerebrovascular condition.
• Demonstrate the ability to arrive at an appropriate differential diagnosis based on history, examination and laboratory data.
• Demonstrate ability to develop an appropriate diagnostic work up and treatment plan based on the integration of history, examination, imaging and laboratory data.  This will include a consideration of when care can be provided as an inpatient versus outpatient, with an added recognition of considering cost of care.
• Perform in-hospital consultations in patients with stroke and learn how to diagnose and manage patients on medical and surgical services with stroke. The resident will consult on inpatients with other active medical or surgical issues. The resident will learn how to manage stroke arising as a complication from medical or surgical disease.
• Demonstrate an understand of medical management for primary and secondary stroke prevention in the outpatient setting and indications for antiplatelet therapy, anticoagulation, statins and other antilipid agents, cardiac medications, antihypertensives by class including subpopulations likely to benefit by each class.
•  Demonstrate an understanding of the indications for and applications of surgical and interventional approaches to primary and secondary stroke prevention, including endarterectomy, surgical revascularization techniques such as EDAS, endovascular stenting, coiling and clipping of unruptured aneurysm.
• Demonstrate awareness of ongoing clinical studies, and be able to refer patients appropriately to experimental treatments and ongoing clinical trials. This should be an active process including periodic review of literature when appropriate to individual patients.
• Recognize and respond to psychosocial aspects of medical, neurological and cerebrovascular problems in the hospital setting.
• Demonstrate proficiency at appropriate medical discharge planning for inpatients with stroke, including appropriate recommendations for rehabilitation services, visiting nurse, anticoagulation follow up, and diagnostic testing.
• Demonstrate understanding of the role of follow up care from hospital-based diagnosis and management of stroke to the clinic setting.

Medical Knowledge

Competency:

Fellows must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care.

Objectives:

By the end of this program, fellows will be able to:

• A. Basic knowledge.
  • Learn anatomy and common variants for all major extracranial and intracranial cerebral vessels.
  • Understand stroke pathophysiology including cerebral blood flow, blood-brain barrier, procoagulant state, bleeding diatheses, metabolic and cellular processes in ischemia, inflammation, brain edema and increase intracranial pressure, secondary consequences from intracranial bleeding.
  • Understand pharmacology and use of stroke treatment agents including antiplatelet agents, anticoagulants, thrombolytic agents, neuroprotective agents, cardiac medications, anti-inflammatory agents, hemostatic agents, anti-migraine medications, vitamins, interactions between medications, and medications that increase stroke risk.
  • Understand the etiology and pathophysiology of unusual stroke causes such as vascular malformations, Moya Moya disease, pituitary apoplexy, meningoencephalitis, CNS vasculitis, MELAS and other metabolic disorders.
  • Knowledge of vascular causes of spinal cord disease.
  • Understand the basic principles of neuroimaging including CT, CTA, MRI, MRA, MR spectroscopy, PET, SPECT, arteriography.
  • Understand mechanisms and pathophysiology of increased intracranial pressure, hypertensive encephalopathy, and posterior reversible encephalopathy syndrome.
• B. Patient management-based knowledge
  • Recognize signs and symptoms of acute stroke and understand stroke mimics.
  • Understand the phenomenology of all major stroke syndromes, including motor, sensory, language, visual-spatial, amnestic, cerebellar and brainstem syndromes.
  • Understand the functional anatomy of all major stroke syndromes, including motor, sensory, language, visual-spatial, amnestic, cerebellar and brainstem syndromes.
  • Understand etiology and pathophysiology of cerebrovascular diseases including ischemic stroke, subarachnoid hemorrhage, sinus venous thrombosis, and intracranial hemorrhage with regard to patient care.
  • Knowledge will include:
    • Risk factors of each stroke subtype including genetic, medical and sociocultural risks.
    • Mechanisms of different subtypes including small vessel disease, large vessel disease, embolism, intracranial hemorrhage, and subarachnoid hemorrhage.
    • Mediating factors in stroke pathophysiology including the impact of concurrent illness and medications.
• • Become familiar with all important clinical trials pertinent to treatment of ischemic stroke, ICH and subarachnoid hemorrhage and utilize that information in management of acute stroke patients.
  • Demonstrate knowledge of mechanical interventions for stroke including angioplasty, stenting, endarterectomy, EC-IC bypass, EDAS, and aneurysm clipping and coiling, and the criteria for which each is to be recommended.
  • Demonstrate knowledge of management options for AVM, dural AVF, and other vascular malformations.
  • Understand practical application of major imaging modalities including CT, CTA, MRI, MRA, MR spectroscopy, PET, SPECT, arteriography.
  • Demonstrate knowledge of application of ultrasound technologies including Doppler, transthoracic and transesophageal echocardiogram, and non-invasive lower extremity flow studies.
  • Understand principles and application of electroencephalography and evoked potentials in the management of stroke.
  • Recognize early and late neurological worsening in acute stroke and demonstrate knowledge of management strategies, both with regard to cerebrovascular causes of worsening and medical causes.
  • Understand principles of stroke recovery including factors that predict recovery in the acute phase, role of rehabilitation interventions, and the course of recovery.
  • Demonstrate familiarity with the application of rehabilitation techniques, their underlying mechanisms, and clinical application.

Practice Based Learning and Improvement

Competency:

Fellows must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. Residents are expected to develop skills and habits to be able to meet the following goals:

• Identify strengths, deficiencies, and limits in one’s knowledge and expertise;
• set learning and improvement goals;
• identify and perform appropriate learning activities;
• systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement;
• incorporate formative evaluation feedback into daily practice;
• locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems;
• use information technology to optimize learning; and,
• participate in the education of patients, families, students, residents and other health professionals.

Objectives:

By the end of this program, fellows will be able to:

• Demonstrate use of evidence-based medicine during formal weekly Divisional clinical case presentations and during discussions with the Attending physician.
• Readily access information from NYPH information technology systems and established medical databases.
• Recognize limitations of one’s knowledge base and need for life-long learning.
• Use of existing medical libraries and drug information sources including on-line sources.
• Maintain records of caseload and practice experience in a systematic manner, incorporating information from patient records, electronic databases, and other sources of information.
• Demonstrate incorporation of current literature into diagnostic evaluation and management of acute stroke patients.

Interpersonal and Communication Skills

Competency:

Fellows must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. Residents are expected to:

• communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds;
• communicate effectively with physicians, other health professionals, and health related agencies;
• work effectively as a member or leader of a health care team or other professional group;
• act in a consultative role to other physicians and health professionals; and,
• maintain comprehensive, timely, and legible medical records, if applicable.

Objectives:

By the end of this program, fellows will be able to:

• Demonstrate ability to listen to and understand stroke inpatients using verbal and nonverbal communication, including understanding nuances of communicating with stroke patients with aphasia and other cognitive impairments.
• Demonstrate ability to develop and maintain a therapeutic relationship with acute stroke patients and their families by instilling feelings of trust, integrity, and reliability.
• Clearly transmit often complex medical information in a clear and concise manner, appropriate to the level of understanding of the patient and family.
• Communicate and collaborate effectively with allied health professions in the hospital setting.
• Educate patients, their families, and other health professionals about medical, psychosocial, and behavioral issues about stroke.
• Demonstrate effective communication, both written and verbal, with professionals on a consultation role in the acute hospital setting. This will include the clear and meaningful formulation of the consultation question and appropriate use of specific consultation services.
• Demonstrate competence in integration of consultation information into the management and treatment plan for inpatient stroke patients.
• Maintain up-to-date medical records, incorporating electronic and written records of history, examination and laboratory information.
• Demonstrate proper maintenance of confidentiality with patients, families and health care professionals regarding medical information, prognosis, palliative care, and other sensitive material.
• Demonstrate ability to discuss iatrogenic and other in-hospital complications to patients, families, and allied health professionals in an honest, complete, and sensitive manner.
• Demonstrate ability to supervise a resident and medical student team.
• Effectively teach material pertaining to vascular neurology to the housestaff and medical students rotating on service.

Professionalism

Competency:

Fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate:

• compassion, integrity, and respect for others;
• responsiveness to patient needs that supersedes self-interest;
• respect for patient privacy and autonomy;
• accountability to patients, society and the profession; and,
• sensitivity and responsiveness to a diverse patient population, including but not limited to
• diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.

Objectives:

By the end of this program, fellows will be able to:

• Demonstrate responsiveness to communication from patients, families and allied health professionals in a timely manner.
• Establish back-up coverage plans for situations in which work load exceeds the resident’s capacity (e.g. multiple simultaneous acute stroke emergencies) or illness or other contingencies necessitate a schedule change.
• Arranging for continuity of care with regard to patients to be followed up in the outpatient setting.
• Demonstrate ethical behavior, integrity, honesty, compassion, and confidentiality in the delivery of care, including matters of informed consent, professional conduct, and conflict of interest.
• Demonstrate respect for patients, families and allied health professionals.
• Review of professional conduct of themselves, peers, and other senior colleagues in a constructive, forthright, and sensitive manner.
• Be able to provide constructive criticism to junior residents and medical students in a sensitive and forthright manner.
• Demonstrate ability to incorporate constructive criticism into improvement of professional performance.
• Demonstrate awareness of safety issues, including acknowledging and remediating medical errors should they arise.
• Demonstrate leadership in teaching and mentoring junior residents and allied health professionals in the hospital setting with regard to knowledge and management of acute stroke.

Systems-Based Practice

Competency:

Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

• work effectively in various health care delivery settings and systems relevant to their clinical specialty;
• coordinate patient care within the health care system relevant to their clinical specialty;
• incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate;
• advocate for quality patient care and optimal patient care systems;
• work in interprofessional teams to enhance patient safety and improve patient care quality; and
• participate in identifying system errors and implementing potential systems solutions.

Objectives:

By the end of the rotation, trainees will be able to:

• Demonstrate ability to access and utilize community, national, and allied health professional resources in the management of acute hospital care.
• Demonstrate knowledge and application of current practice guidelines for acute stroke including thrombolysis, blood pressure and other medical management, diagnostic testing, and in-hospital treatment of acute stroke.
• Demonstrate knowledge and use of ED and hospital protocols for acute stroke, including IV thrombolysis, mechanical clot extraction, and other acute interventional approaches to acute stroke.
• Demonstrate accurate and appropriate use of medical data in the development of management plans for acute stroke patients.
• Demonstrate knowledge and appropriate application of legal and administrative aspects of acute stroke care including issues of capacity to consent to procedures and research studies.
• Demonstrate sensitivity to ethical issues in acute stroke care and work with ethics committee consultation when necessary.
• Demonstrate knowledge and application of end-of-life protocols such as palliative care, withdrawal of life support and hospice care.
• Participate in quality improvement efforts for the hospital.
• Participate in Morbidity & Mortality conferences to discuss improvements in protocols and management.

TEACHING METHODS FOR THIS FELLOWSHIP

• Direct observation and instruction by the Attending physician.
• Record Review
• Small Group Discussion
• Didactic Instruction

TRAINEE ASSESMENT METHODS FOR THIS FELLOWSHIP

• MedHub trainee evaluations

PROGRAM EVALUATION METHOD FOR THIS FELLOWSHIP

• E-Value Activity assessment (blinded)

LEVEL OF SUPERVISION

• Directly supervised by the Attending Physician on the respective service / rotation
• Biannual meeting with Program Director

EDUCATIONAL RESOURCES

• Hammer Health Sciences Library
• On-line educational resources – MedLink, PubMed, Online journal library, etc.

Please contact me if there are any questions. Sincerely,

Joshua Z Willey MD, MS
Program Director, Vascular Neurology and Advanced Vascular Neurology Training Programs, Columbia University Medical Center