Rotation Specific Goals and Objectives

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The goals and objectives for each rotation are stated below.

List of Rotations:

Inpatient stroke service (including consults)
Outpatient continuity clinic
Neurology Intensive Care Unit
Doppler laboratory
Rehabilitation

Inpatient Stroke Service

Description:

This rotation is broken into 1 week blocks throughout the year, consisting of direct inpatient care of stroke patients. Fellows work under the direct supervision of the Vascular Neurology Attending to manage the inpatient stroke service. The rotation includes triage and diagnosis of acute stroke patients who come through the Emergency Department and via telemedicine, transfer of patients from outside hospitals, and consultations regarding stroke patients on other inpatient services in the hospital. Because of the intensity of the work fellows work no more than 1 week at a time, handing over patient care responsibility to their fellow colleagues.

The goal of the inpatient rotation is to provide an opportunity for residents to assess and treat patients with a wide range of stroke etiologies. Under the supervision of an Attending Vascular Neurologist, residents help oversee admission, evaluation and treatment of patients on both, a primary as well consulting service basis. The rotation 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 and a 46-bed Stroke Unit Neurology nursing staff, and 24-hour housestaff support. Consultations on neurological emergencies, and in particular acute stroke, will also be performed under supervision via telemedicine. 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 in the inpatient setting. Over the course of the rotation increased independence is expected by the vascular neurology follow including towards the end of the year in an attending physician role (“pretending”) while indirectly supervised by faculty.

Objectives:

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

Perform a history and physical examination which is logical, reliable and purposeful based upon the patient’s chief complaint. (PC)
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, intracerebral hemorrhage, sinus venous thrombosis, AVM and other malformations, and subarachnoid hemorrhage. (MK, IPCS)
Demonstrate facility with looking up and applying information acquired in stroke epidemiology, basic science, clinical neurology, neuroanatomy and neuroimaging, critical care, neurosonology and neurorehabilitation to acute management of patients. (PBLI, MK)
Demonstrate an understanding of diagnostic studies relevant to the history and physical examination of each individual patient, including relevant hematological panels, echocardiography, ultrasonography, computerized tomography and magnetic resonance imaging modalities. (MK, PBLI, SBP)
Demonstrate competency at the delivery of intravenous thrombolysis using time and tissue based approaches, including the selection of appropriate patients for intravenous rtPA, and management of patients before and after rtPA administration. (PC, SBP)
Recognize radiographic signs of early stroke and hemorrhage on CT and MRI in the context of emergency evaluation of acute stroke. (MK, PC)
Recognize and respond to psychosocial aspects of medical, neurological and cerebrovascular problems in the inpatient setting. (IPCS, P)
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. (PBLI, SBP, PC, P)
Demonstrate competency in the interpretation of diagnostic tests related to inpatient stroke including MRI, MRA, Doppler’s, C02 reactivity, transthoracic and transesophageal echocardiograms, conventional cerebral angiograms, hypercoagulable serologic tests, as well as tests of infection and inflammation. (MK)
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. (SBP)
Participate in weekly presentations and discussions of the pathophysiology, neuroradiological and hemodynamic characteristics of different neurovascular conditions, evidence-based acute and long-term treatment modalities and neuro-rehabilitation. (MK)
Teach the housestaff as well as the medical students on rounds and during daily presentations of consulted upon patients. (IPCS, P)

Faculty:

All faculty in the stroke division

Outpatient Continuity Clinic

Description:

The Vascular Neurology resident will enjoy continuity of care in a private setting under the direct supervision of faculty, and in the resident-staffed stroke clinic. The resident staffed stroke clinic is focused on follow up of patients discharged from the inpatient stroke service at NYP-Columbia, a population with limited access to care, low health literacy, and psycho-social barriers to care. The trainee will become familiar with how to deliver care to patients who are under- or un-insured with low health and English literacy, and significant barriers to care due to economic hardship. Faculty supervisors will review strategies on care in this environment. The NYP-Columbia stroke clinic will include in person and telemedicine based home visits. This yearlong rotation will complement our vast inpatient consultation experience and allow for a largely independent, yet supervised, outpatient care of acute and chronic conditions most frequently associated with strokes. 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 outpatient setting. The vascular neurology trainee will also care for patients in the RAVEN clinic, a rapid TIA and minor stroke outpatient clinic, to develop competency in caring for patients in the acute setting in both the emergency department and on an expedited rapid outpatient manner.

Goals:

To develop skills to teach patients primary stroke prevention, to diagnosis cerebrovascular diseases in the outpatient setting, and to learn systems that facilitate communication with referring doctors and other professionals regarding medical information about their patients.

Objectives:

By the end of this part of training, fellows should be able to:

Understand the role of follow up care from hospital-based diagnosis and management of stroke to the clinic setting. (SBP)
Demonstrate the ability to integrate various sources of medical records into a concise and comprehensive evaluation of the patient’s cerebrovascular condition. (PBLI)
Demonstrate the ability to arrive at an appropriate differential diagnosis based on history, examination and laboratory data and 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 and be able to present it to the supervising faculty member in a logical and concise manner. (MK, IPCS, P)
Become competent in the interpretation of diagnostic tests related to outpatient stroke care including MRI, MRA, Doppler’s, C02 reactivity, transthoracic and transesophageal echocardiograms, conventional cerebral angiograms, hypercoagulable serologic tests, as well as tests of infection and inflammation. (MK, PC)
Demonstrate ability to develop an appropriate diagnostic work up and treatment plan based on the integration of history, examination, imaging and laboratory data. (PC, MK, PBLI)
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 health care related disparities aspects of medical, neurological and cerebrovascular problems in the outpatient setting and learn how to deliver optimal prevention and rehabilitation care in patients who are under-insured or un-insured. (IPCS, P)
Demonstrate role as a consultation neurologist in the outpatient setting, including effective integration of medical and surgical components of the patient’s history. (P, IPCS, SBP)
Become proficient 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. (MK, SBP)
Demonstrate ability to integrate allied professional care into the treatment plan such as visiting nurse services, outpatient rehabilitation services, neuropsychological and psychiatric care. (SBP, P)

Faculty:

All faculty

Neurological Intensive Care Unit Rotation

Description:

This rotation is based in the new 18- bed CUMC Neuro–ICU, which is equipped with video EEG monitoring in every room, multiple cooling devices, multi-modality monitors, as well as advanced neuroimaging (3 – T MRI, and 64 slice CT scanner) located in the ICU. Fellows will gain proficiency in the medical management of the critically ill patient. Upon completion, fellows will be proficient in the management of a wide range of neurological and general critical care patients.

Goals:

To acquire medical knowledge and skills to care for seriously ill patients with stroke, including those with intracerebral hemorrhage, subarachnoid hemorrhage, large stroke, and stroke in the context of multiple medical problems.

Objectives:

By the end of this rotation fellows should be able to:

Learn to obtain histories from patients or family members of patients with acute neurological disorders requiring intensive care management, including severe acute ischemic stroke, cerebral hemorrhage, subarachnoid hemorrhage, aneurysms, arteriovenous malformations, cerebral venous thrombosis, myasthenia gravis, acute demyelinating neuropathies, CNS infections, status epilepticus, head trauma, coma, spinal cord compression, brain tumors, and increased intracranial pressure. (PC, IPCS, PBLI, P)
Learn the special techniques of neurological examination in the critically ill neurological patient, including caloric testing, coma assessment, brain death examination, apnea testing, etc. (PBLI, PC)
Learn the principles of management of the critically ill neurological patient, including management of acute ischemic stroke with thrombolytics, management of vasospasm after SAH, ICP management, general management and interpretation of findings from neurosurgical devices such as external ventricular drains, blood pressure control, ventilation, anticonvulsant use and more aggressive measures in status epilepticus, EEG monitoring, hypothermia and treatment of fever in the neurologically injured patient, management of metabolic and neuroendocrine complications such DI and SIADH. (MK, PC, PBLI)
Learn the indications for acute neurosurgical intervention in critically ill patients. (MK, PBLI)
Learn the principles of triage and bed management. (SBP, P, IPCS)
To learn under graded supervision to perform procedures appropriate to the care of critically ill patients including placement of arterial lines, central venous lines, lumbar puncture/drains, continuous EEG monitoring, brain oxygen monitoring, microdialysis, ventriculostomy management, ventilator management, and others. (PBLI)
Learn the principles of medical ethics as relevant to neurological patients and end-of-life care. (IPCS, P)
Attend the Critical Care lecture series and Evidence-Based Medicine discussions on relevant topics. (MK)

Faculty:

Shivani Goshal, MD, Program Director
Jan Claassen, MD
David Roh, MD
Sachin Agarwal, MD
Soojin Park, MD

Doppler/Neurosonology Lab Rotation

Description:

Our ICAVL-designated Neurosonology lab is fully equipped to perform bedside and outpatient Doppler ultrasound of the extra- and intracranial vasculature with bubble-TCD, vasoreactivity studies and HITs monitoring. Trainees rotating through the lab will have exposure to patterns in ultrasonography monitoring in patients with various stroke etiologies. Reading of Doppler and TCD studies will be done under the guidance of Doppler faculty with the use of an online repository of illustrative cases. The neuro-sonology rotation will be bolstered by a total of 6 small group discussion with the program director and fellows where relevant cases from the last month will be discussed in a team-based learning environment.

Goals:

To learn basic principles of neurosonology and to become facile in the performance and interpretation of Doppler ultrasound in the diagnosis and treatment planning for stroke patients.

Objectives:

By the end of this rotation fellows should be able to:

To learn ultrasound techniques: carotid Doppler’s, transcranial Doppler’s, B-mode and M-mode transcranial Doppler’s, C02 reactivity, HITS analysis and bubble TCD interpretation. (PBLI)
To learn interpretation of waveform and velocity profiles in patients with ischemic stroke, arteriovenous malformations, intracranial and extracranial stenosis, tandem lesions, vasospasm after subarachnoid hemorrhage, etc. (MK, PBLI, PC, SBP)
To be able to present ultrasound findings in written and verbal communication with ordering physicians in a concise and understandable manner. (IPCS, P)
To show ability to independently interpret carotid and transcranial Doppler ultrasound by the end of residency. (PBLI)

Faculty:

Randolph S. Marshall, MD
Joshua Willey, MD

Rehabilitation Medicine

Description:

This 2-week rotation is designed to provide exposure and education in the field of Physical Medicine and Rehabilitation (PM&R) to Vascular Neurology fellows. Faculty from the PM&R department at the Columbia NYPH campus offer didactic and hands-on sessions to accomplish these goals. In-patient and out-patient experiences are provided with participation in morning work rounds and afternoon review of rehabilitation programs carried out in the inpatient unit. The rotation will be supplemented by basic understanding and review of neuro-psychological testing.

Goals:

To introduce Vascular Neurology fellows to the aspects of stroke recovery and rehabilitation that are used in post-stroke intervention and follow up care of acute stroke patients.

Objectives:

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

To gain proficiency in components of physical medicine exam and history-taking. (MK, PBLI, PC)
To gain experience in the scales used to assess functional recovery and disability (SBP, PBLI)
To understand the challenges involved in interpretation of physical data from patients with motor and sensory deficits, gait disturbance, speech and language dysfunction, and visual impairment. (IPCS, PBLI, PC)
To attend the Interdisciplinary didactic sessions covering basic and clinical aspects of rehabilitation and recovery. (MK)
To learn principles and manifestations of post-stroke spasticity and its treatment. (MK, PBLI, PC)
To study lesion anatomy and functional recovery. (MK)
To gain knowledge and experience in the interface/logistics between stroke neurology and rehabilitation medicine. (IPCS, SBP, P)
To learn about advances in rehabilitation medicine treatments through exposure to research protocols (MK, PBLI)

Faculty:

Joel Stein, MD
Akin Beckley, MD
MaryKay Pavol PhD

Research Rotation

Description:

The Division of Stroke & Cerebrovascular disease is a rich network of academic clinicians involved in innovative and frontrunner research. As the recipient of a Stroke Trials Network grant as a regional coordinating center , the Stroke division has excelled, in part, in pioneering several locally run trials in stroke epidemiology, neuropharmacology, neurogenetics, functional brain imaging, and neurorehabilitation. We are the active participants in the multiple local and multicenter multi-disciplinary clinical trials. Residents will participate in these and their own research projects under the mentorship and supervision of a faculty member. Mentors will meet weekly with residents to discuss clinical research methods, ongoing clinical trials and to facilitate research projects. Mentorship of the research project is an obligation and commitment on the part of the faculty member. For some residents the research project developed during this year of residency will be the basis for a continuation of research in subsequent fellowship years.

Goals:

The goal of research rotations is to learn basic clinical research methods and to engage in both ongoing and independent research projects.

Objectives:

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

To participate in ongoing clinical studies in the inpatient and outpatient settings under the supervision of Attending physicians and other investigators. (PBLI, IPCS)
To understand the role of clinical research in the advancement of stroke clinical care. (SBP)
To gain knowledge of clinical research methods through attendance of weekly ongoing research meetings available through division-wide activities, individual investigator lab meetings, journal clubs, and university offerings. (MK)
To learn standard scales and other evaluation tools used in clinical research, including the NIHSS, Fugl-Meyer, Barthel Index, modified Rankin scale, MMSE, Boston Diagnostic Aphasia Exam, and other neurocognitive evaluation tools, and apply them in the evaluation of clinical research patients in the inpatient and outpatient setting. (SBP, PBLI)
To conduct at least one literature search in a research area of interest under the supervision of an Attending physician or other investigator. The topic may be either related to a patient condition or to an ongoing research project in which the resident is participating. (MK)
To pursue a research interest under the mentorship of an Attending physician or other investigator, with a goal of presentation at a national meeting or publication in a peer reviewed journal. Topics for research will depend on ongoing studies and research interests of the resident and faculty, and may currently include stroke epidemiology, cerebrovascular pathophysiology (inflammation/coagulation, metabolic syndrome), cerebral hemodynamics (Doppler/TCD/vasoreactivity), neuroimaging (acute stroke imaging, advanced MRI techniques, fMRI), AVM, motor physiology, cognitive and behavioral aspects of stroke, stroke recovery, acute stroke management, stroke systems of care, health literacy, stroke education, and public policy. (MK, P, IPCS)
To develop a novel protocol and pursue local IRB approval under faculty supervision. (SBP)

Faculty:

All faculty