Overall Goals of the Program

COLUMBIA UNIVERSITY MEDICAL CENTER VASCULAR NEUROLOGY RESIDENCY OVERALL GOALS & OBJECTIVES

Goal(s):

The goal of the Vascular Neurology program is to aide trainees in developing expertise in the care and management of stroke patients in all phases of stroke. This includes teaching patients about primary stroke prevention, learning to triage, diagnose, and treat patients with acute stroke, and to develop skills to diagnose cerebrovascular problems in the outpatient setting and telemedicine. 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.

Vascular neurology residents 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

ACGME 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:

1. Perform a history and physical examination that is logical, reliable and purposeful based upon the patient’s chief complaint.
2. 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.
3. Demonstrate competency and proficiency at the delivery of intravenous thrombolysis a time and tissue based approach, including the selection of appropriate patients for intravenous rtPA, and management of patients before and after rtPA administration.
4. Demonstrate competency and proficiency in the acute and hospital care of intracerebral hemorrhage including management of blood pressure, intracranial pressure, and selection for surgical intervention.
5. Demonstrate competency and proficiency in the care of subarachnoid hemorrhage including prevention of aneurysmal re-bleeding, monitoring and treating for vasospasm, and evaluation of non-aneurysmal etiologies.
6. Demonstrate competency in the interpretation of diagnostic tests related to inpatient and outpatient stroke care including acute MRI and CT modalities, carotid duplex and transcranial Doppler, C02 reactivity, transthoracic and transesophageal echocardiograms, conventional cerebral angiograms, hypercoagulable serologic tests, as well as tests of infection and inflammation.
7. Demonstrate the ability to integrate various sources of medical records into a concise and comprehensive evaluation of the patient’s cerebrovascular condition.
8. Demonstrate the ability to arrive at an appropriate differential diagnosis based on history, examination and laboratory data.
9. 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.
10. Recognize radiographic signs of early stroke and hemorrhage on CT and MRI in the context of emergency evaluation of acute stroke.
11. Perform in-hospital consultations in patients with stroke, including via telemedicine, 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.
12. 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 dyslipidemia agents, cardiac medications, antihypertensives by class including subpopulations likely to benefit by each class.
13.  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.
14. 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.
15. Recognize and respond to psychosocial aspects of medical, neurological and cerebrovascular problems in the outpatient setting.
16. 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.
17. Demonstrate role as a consultation neurologist in the outpatient setting, including effective integration of medical and surgical components of the patient’s history.
18. Demonstrate understanding of the role of follow up care from hospital-based diagnosis and management of stroke to the clinic setting.
19. Demonstrate proficiency at appropriate ongoing outpatient care including an understanding of appropriate intervals of follow up and the role of the neurologist in chronic management of cerebrovascular conditions.
20. Demonstrate ability to integrate allied professional care into the treatment plan such as visiting nurse services, outpatient rehabilitation services, neuropsychological and psychiatric care.

Medical Knowledge

ACGME 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.
  1. Learn anatomy and common variants for all major extracranial and intracranial cerebral vessels.
  2. 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.
  3. Understand mechanisms of stroke recovery and restoration of function in the subacute and chronic phase.
  4. 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.
  5. Understand the etiology and pathophysiology of unusual stroke causes such as vascular malformations, RCVS, Moya Moya disease, pituitary apoplexy, meningoencephalitis, CNS vasculitis, MELAS and other metabolic disorders.
  6. Knowledge of vascular causes of spinal cord disease.
  7. Understand the basic principles of neuroimaging including CT, CTA, MRI, MRA, vessel wall imaging, arteriography.
  8. Understand mechanisms and pathophysiology of increased intracranial pressure, hypertensive encephalopathy, and posterior reversible encephalopathy syndrome.
• B. Patient management-based knowledge
  1. Recognize signs and symptoms of acute stroke and understand stroke mimics.
  2. Understand the phenomenology of all major stroke syndromes, including motor, sensory, language, visual-spatial, amnestic, cerebellar and brainstem syndromes.
  3. Understand the functional anatomy of all major stroke syndromes, including motor, sensory, language, visual-spatial, amnestic, cerebellar and brainstem syndromes.
  4. 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:
       1. Risk factors of each stroke subtype including genetic, medical and sociocultural risks.
       2. Mechanisms of different subtypes including small vessel disease, large vessel disease, embolism, intracranial hemorrhage, and subarachnoid hemorrhage.
       3. Mediating factors in stroke pathophysiology including the impact of concurrent illness and medications.
  5. 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.
  6. 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.
  7. Demonstrate knowledge of management options for AVM, dural AVF, and other vascular malformations.
  8. Understand practical application of major imaging modalities including CT, CTA, MRI, MRA, MR vessel wall imaging, arteriography.
  9. Demonstrate knowledge of application of ultrasound technologies including Doppler, transthoracic and transesophageal echocardiogram, and non-invasive lower extremity flow studies.
  10. Understand principles and application of electroencephalography and evoked potentials in the management of stroke.
  11. 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.
  12. Understand principles of stroke recovery including factors that predict recovery in the acute phase, role of rehabilitation interventions, and the course of recovery.
  13. Demonstrate familiarity with the application of rehabilitation techniques, their underlying mechanisms, and clinical application.

Practice Based Learning and Improvement

ACGME 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:

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

Interpersonal and Communication Skills

ACGME 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:

1. 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.
2. Demonstrate ability to develop and maintain a therapeutic relationship with acute stroke patients and their families by instilling feelings of trust, integrity, and reliability.
3. Clearly transmit often complex medical information in a clear and concise manner, appropriate to the level of understanding of the patient and family.
4. Communicate and collaborate effectively with allied health professions in the hospital setting.
5. Educate patients, their families, and other health professionals about medical, psychosocial, and behavioral issues about stroke.
6. Communicate information about stroke recovery and post-stroke care to patients and their families.
7. 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.
8. Demonstrate competence in integration of consultation information into the management and treatment plan for inpatient stroke patients.
9. Maintain up-to-date medical records, incorporating electronic and written records of history, examination and laboratory information.
10. Demonstrate proper maintenance of confidentiality with patients, families and health care professionals regarding medical information, prognosis, palliative care, and other sensitive material.
11. Demonstrate ability to discuss iatrogenic and other in-hospital complications to patients, families, and allied health professionals in an honest, complete, and sensitive manner.
12. Demonstrate ability to supervise a resident and medical student team.
13. Effectively teach material pertaining to vascular neurology to the housestaff and medical students rotating on service.

Professionalism

ACGME 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:

1. Demonstrate responsiveness to communication from patients, families and allied health professionals in a timely manner.
2. 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.
3. Arranging for continuity of care with regard to patients to be followed up in the outpatient setting.
4. Demonstrate ethical behavior, integrity, honesty, compassion, and confidentiality in the delivery of care, including matters of informed consent, professional conduct, and conflict of interest.
5. Demonstrate respect for patients, families and allied health professionals.
6. Review of professional conduct of themselves, peers, and other senior colleagues in a constructive, forthright, and sensitive manner.
7. Be able to provide constructive criticism to junior residents and medical students in a sensitive and forthright manner.
8. Demonstrate ability to incorporate constructive criticism into improvement of professional performance.
9. Demonstrate awareness of safety issues in self and others that may affect patient care, including recognition of impairment from fatigue, mental health difficulties, or substance abuse.
10. 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

ACGME 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:

1. Demonstrate ability to access and utilize community, national, and allied health professional resources in the management of acute hospital care.
2. 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.
3. Demonstrate knowledge and use of ED and hospital protocols for acute stroke, including IV thrombolysis, thrombectomy, and other acute interventional approaches to acute stroke.
4. Demonstrate accurate and appropriate use of medical data in the development of management plans for acute stroke patients.
5. 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.
6. Demonstrate sensitivity to ethical issues in acute stroke care and work with ethics committee consultation when necessary.
7. Demonstrate knowledge and application of end-of-life protocols such as palliative care, withdrawal of life support and hospice care.
8. Participate in quality improvement efforts for the hospital, including how to initiate a quality of care review (Keep-safe) and the principles of a root cause analysis in cases with an adverse event.
9. Participate in Morbidity & Mortality conferences to discuss improvements in protocols and management.

TEACHING METHODS FOR THIS RESIDENCY

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

RESIDENT ASSESMENT METHODS FOR THIS RESIDENCY

• MedHub Clinical competency milestone achievement
• MedHub mid rotation assessment
• MedHub  resident assessment

PROGRAM EVALUATION METHOD FOR THIS RESIDENCY

• MedHub evaluation (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.