Western University, Canada - London Ontario

| Tuesday September 19, 2017
8:24 PM

The Charles Drake Clinical Fellowship in Neurovascular Therapy

Program director: Mel Boulton, MD, PhD, FRCSC

Contact person: Dr. Mel Boulton, MD, PhD, FRCSC
Address: C7-124 University Hospital
339 Windermere Road
London, Ontario
N6A 5A5
Phone: (519) 663-3602
Fax: (519) 663-3601

Number of positions: 1-2 positions every two years
Available: 2017
Application deadline: Aug 31 2016

University of Western Ontario, London, Ontario Canada

FOR: Dr. ______________________

Educational Objectives

Vascular neurosurgery and interventional neuroradiology are subspecialties that use clinical expertise, neurological clinical skills, neuroradiological imaging, catheter technology and endovascular skills, and open cranial surgical skills to diagnose and treat vascular diseases of the central nervous system. Combining these two subspecialties into a career path can be an exciting and highly rewarding opportunity. The unique clinical and invasive nature of this combined subspecialty requires special training and skills. The Charles Drake Fellowship program is specifically geared towards this goal and includes training in:

1) signs and symptoms of disorders amenable to diagnosis and treatment by neurovascular therapeutic techniques;

2) neurologic examinations of patients to evaluate neurologic disorders;

3) pathophysiologic mechanisms and natural history of these disorders;

4) indications and contraindications to neurovascular procedures;

5) clinical and technical aspects of neurovascular procedures;

6) medical and surgical alternatives;

7) preoperative and post-operative management of neurovascular patients;

8) neurointensive care management;

9) fundamentals of imaging, radiation physics, and radiation biology; and

10) integration of information available from imaging studies, pertinent to the neurovascular practice.

In this program, the objective of training is to give the Fellow an organized, comprehensive, supervised, full-time educational experience in neurovascular therapy. This experience includes the management of patients with neurologic disease, the performance of interventional neuroradiology and neurovascular surgery procedures, and the integration of neurovascular surgery and interventional neuroradiology therapy into the clinical management of patients. This training program is not meant to duplicate or replace the existing fellowship program in diagnostic neuroradiology at UWO.

Training in interventional neuroradiology and neurovascular surgery will be conducted in an environment conducive to investigative studies of a clinical or basic science nature.
This fellowship program in neurovascular surgery and interventional neuroradiology is being administered by RCPSC accredited programs in neurologic surgery and diagnostic neuroradiology.

Educational Program

The training program will offer didactic and clinical experiences that encompass the full clinical spectrum of neurovascular surgery and interventional neuroradiology therapy.

Preparatory Requirements
Either prior to or as a component of the Charles Drake Fellowship program in neurovascular surgery and interventional neuroradiology, trainees will spend time in preparatory training acquiring the basic skills needed to learn both neurovascular surgery and interventional neuroradiology. Prior to commencing the fellowship, the candidate will have completed either Canadian or American residency training in neurologic surgery, preferably with some emphasis on neurovascular surgery. In certain situations and depending upon satisfactory credentials, internationally trained neurosurgeons will be considered for the training program.

Preparatory Training
As a component of the fellowship, preparatory training will provide trainees with a "hands-on" experience in which they learn knowledge-based and procedural skills from an interventional neuroradiology specialist in the following areas:

1) the use of needles, catheters, guidewires, and angiographic devices and materials;
2) the basic radiologic sciences, including radiation physics, radiation protection, and the pharmacologic characteristics of radiographic contrast materials;

3) angiography and basic image evaluation relevant to the specialties of neuroradiology and neurosurgery;
4) the proper use of and indications for laboratory tests and methods that are adjunctive to interventional neuroradiology and neurovascular surgery procedures, such as physiologic monitoring, noninvasive neurovascular testing, and noninvasive neurovascular imaging;

5) the evaluation of patients with neurologic disease;

6) the basic and clinical neurosciences including neuroanatomy, neurobiology, and the pathophysiology and natural history of neurologic disorders, especially cerebrovascular and neoplastic conditions;

7) the clinical aspects of patient assessment, treatment planning, and patient management related to neurovascular surgery and interventional neuroradiology therapy, including the fundamentals of invasive monitoring and neurointensive care management;

8) the clinical indications, risks, and limitations of neurovascular surgery and interventional neuroradiology procedures; and

9) the use and administration of analgesics, antibiotics, anticoagulants, neuroanesthetic agents, and other drugs commonly used in interventional neuroradiology and neurovascular surgery procedures.

This "hands-on" experience will include catheter-based diagnostic angiography. The Fellow will ideally have been involved in the performance of at least 100 catheter-based diagnostic angiographic procedures before entering neurovascular surgery and interventional neuroradiology training. In some instances depending upon skills assessment these procedural requirements will be met simultaneously with involvement in endovascular and surgical therapeutic procedures, given the decreased use of diagnostic angiography and its replacement by non-invasive imaging modalities.

The director of the Charles Drake Fellowship program will be responsible for documenting that the applicant has completed the appropriate preparatory training.

Research Training
A period of 3 to 6 months laboratory-based involvement in small and large animal surgery is recommended at the commencement of the training program. Ongoing educational skills projects in rat microsurgery and in the endovascular coiling of swine aneurysm models, and in laboratory models of cerebral ischemia, provide the Fellow with the opportunity to begin clinical skills training in a relaxed environment. Also, since the Fellowship is geared toward those pursuing academic careers in neurovascular therapy, the research experience is most beneficial at an early stage such that the Fellow is more likely to have successful peer-reviewed publication activity by the time of completion of the fellowship. The Drake Fellow is encouraged to become involved in the animal laboratory. On the education side, the rat microvascular anastomosis protocol is very useful for the Fellow's preparation for the performance of carotid surgery, and the occasional ECIC bypass in the OR. And there are a number of investigation protocols, including device assessment labs, that are extremely useful in that the Fellow may comfortably perform endovascular procedures in swine aneurysm models well before he/she is ready to do so in humans.
Clinical Training
A period of 18 to 24 continuous months will be spent in clinical neurovascular surgery and interventional neuroradiology training, during which the trainee will have the opportunity to perform all of the following under close supervision: clinical pre-procedural examinations of patients, evaluation of preliminary diagnostic studies, consultation with clinicians on other services, diagnostic and therapeutic neurovascular interventional neuroradiology and surgery procedures, generation of procedural reports, and participation in short-term and long-term post-procedural follow-up care, including neurointensive care. The continuity of care must be of sufficient duration to ensure that the Fellow is familiar with the outcome of all neurovascular surgery and interventional neuroradiology procedures. Direct interactions of trainees with patients will be closely observed to ensure that appropriate standards of care and concern for patient welfare are strictly maintained. Communication, consultation, and co-ordination of care with the referring clinical staff and clinical services must be maintained and documented with appropriate notes in the medical record.

Service Expectations
Ideally the initial part of the Drake fellowship is devoted to laboratory research (3-6 months) combined with or followed immediately by catheter neuroradiology. It is a distinct contrast from the surgical focus that neurosurgeons have typically had at the early stage of their careers. As confidence is gained in catheter techniques and the interpretation of diagnostic cerebral angiography, the trainee will reach the level at which the consultant staff will engage him/her more and more in the therapeutic aspects. This usually takes some months, and of course everyone is different. This period of time also involves participation in the outpatient clinics which are usually conducted Mondays, Wednesdays and Fridays of each week. These clinics are exclusively neurovascular in nature, both with consultant neuroradiology staff and vascular neurosurgery staff. Nonetheless, there is considerable flexibility in allowing the Fellow to participate fully in the technical performance of catheter angiography and sign-out and reporting with all the neuroradiologists on a day-to-day basis in concert with rounding and outpatient clinics.
Throughout the fellowship, an attempt is made to tailor the Fellow's time spent in radiology and surgery based on the level of technical and clinical performance. As may be expected based on the varying strengths of neurosurgery training programs across and from outside Canada, there is not a consistent background in vascular neurosurgery expertise following the completion of neurosurgery residency training. The Fellow will ideally be fully focused on gaining experience and expertise in catheter angiography techniques, both in the neurovascular laboratory and in the clinical setting. Once on a reasonably good footing there, the timing is good to formally rotate on the clinical vascular neurosurgery service. It is encouraged that the Drake fellow take on a small amount of second call responsibility, to be discussed with the chief neurosurgery resident during this time. This obligation, while modest, serves to provide support to the resident staff when needed and serves to ensure good communication with the team. It should be noted that in the past year or two, due to resident numbers there has been little if any call taken by fellows. But it is encouraged that the Fellow discuss this one-on-one with the senior neurosurgery resident.

However, outside of periodic second call, the Fellow will be expected to be involved with all vascular neurosurgery procedures to the degree possible. Once the Fellow has reached a high level skill set, and has completed a sufficient amount of neuroradiology and vascular neurosurgery, he/she will quite comfortable moving freely between areas and services. This level truly embodies the goal for the Drake fellow.
Academic Expectations
Concomitant with the Fellowship, fellows are encouraged to pursue a Master's degree with the Department of Medical Biophysics at Western. Course requirements are fulfilled by the Fellow's attendance at weekly one-hour seminar sessions, completion of the mandatory course in Scientific Communication, and the preparation, submission and successful defense of the Master's thesis in the spring of the Fellow's final year. Master's supervisors include either Dr. Lownie or Dr. Boulton, or both as co-supervisors.

The fellowship program director will establish clearly defined procedures for regular evaluation of the Fellow's knowledge, skills and overall performance, including the development of professional attitudes, consistent with being a physician. The assessment must include cognitive, motor, and interpersonal skills as well as clinical judgment.

The program director, with participation of members of the teaching staff, shall:

1) At least semi-annually evaluate the knowledge, skills and professional growth of the Fellow, using appropriate criteria and procedures.

2) Communicate evaluation results to the Fellow in a timely manner.

3) Advance the Fellow to positions of higher responsibility on the basis of evidence of their satisfactory progressive scholarship and professional growth.

4) Maintain a permanent record of evaluation for the Fellow and have it accessible to the Fellow and other authorized personnel.

5) Provide a written final evaluation for the Fellow who completes the program. The evaluation must include a review of the Fellow's performance during the final period of training and should verify that the Fellow has demonstrated sufficient professional ability to practice competently and independently. This final evaluation is part of the Fellow's permanent record maintained by the institution.

Mandar S. Jog
Mel Boulton