Clinical Curriculum

Overview

A major goal of the vascular neurology fellowship is to provide a rigorous, yet well-rounded, clinical experience within the inpatient and outpatient settings. Fellows will rotate through various institutions that will provide a diverse range of patient populations and cerebrovascular pathology from which to learn. Fellows will also learn from a strong faculty presence with various stroke subspecialty interests to facilitate close faculty/fellow interaction during the one year of training.

Our fellowship rotations are one week in duration rotated at regular intervals throughout the year. Rotations are designed to provide exposure to multiple settings including the inpatient wards, outpatient clinics, and telemedicine. Rotations are divided amongst our four fellows according to the following:

Fellows will spend a total of 12 weeks in each rotation and will have 4 weeks of vacation time.

The clinical curriculum is meant to treat our fellows as junior faculty and develop significant autonomy in managing cerebrovascular disorders. The curriculum is also flexible to the fellows' career goals and provides significant time to develop their research projects and manuscripts to provide the most well-rounded educational experience.

Inpatient Rotations

Fellows will rotate through various institutions that will provide clinical exposure to a variety of pathologies and patient populations. Ultimately, the role of the vascular neurology fellow is to be the junior faculty on the inpatient service. This role requires making important inpatient clinical decisions (with the supervision of the stroke faculty) and guiding the residents/stroke nurse practitioners through inpatient admissions/consults and stroke codes to the point where the fellow creates a productive learning environment for every team member on the inpatient rotations. Fellows are expected to quickly gain progressive autonomy in stroke clinical decision-making to provide them the confidence in managing patients with cerebrovascular disorders upon graduation.

Fellows will be responsible for the management and oversight of stroke codes and the inpatient stroke census at our two comprehensive stroke centers, UC San Diego Hillcrest Medical Center and UC San Diego Jacobs Medical Center. Fellows will be encouraged to lead morning rounds, perform bedside neurological examination teaching, and will supervise and guide the neurology residents in managing stroke codes, admissions, and inpatient consultations.

During stroke codes, fellows are expected to manage patients quickly and efficiently, read and assess relevant neuroimaging (CT, CTA, MRI, perfusion studies) accurately, guide neurology residents through the decision-making process of acute stroke treatment, and work collaboratively and coordinate streamlined delivery of stroke care among all involved healthcare providers (e.g. nursing, ED team, ICU team, endovascular team, pharmacy, imaging technicians). Faculty directly supervise the fellows during each stroke code either at bedside with the fellow or via telephone.

When rotating at the San Diego Veterans Administration (VA) Medical Center, the vascular neurology fellow will manage stroke code activations only (both Emergency Department and inpatient settings) with the UC San Diego neurology resident as first-responder. Note that there is no daily inpatient rounding or wards management on the VA rotation for the stroke fellows. The fellow will also attend one half-day of clinic at the VA and will gain significant independence in outpatient stroke clinical care. In general, the VA rotation allows fellows to gain ongoing autonomy in the emergent and outpatient settings, provides significant research time, and provides fellows opportunities to understand stroke process of care by participating in VA quality council meetings.

Telemedicine Rotation

UC San Diego boasts a premier telemedicine experience for our vascular neurology fellows. The fellow will have the opportunity to take part in a robust telemedicine program that facilitates rapid access to acute stroke treatment in areas that are remote to any neighboring Comprehensive Stroke Centers.

The vascular neurology fellow is responsible for managing telestroke code activations under direct faculty supervision. Stroke faculty are logged into each telestroke code consultation with the fellow to provide on-the-spot feedback and teaching during and after the consultation. Fellows are trained in the independent management of telestroke code consultations with progressively minimal assistance from the stroke faculty as the year progresses.

Experience in telemedicine ranges from gaining skills in identifying and examining codes that may be mimics to efficiently administering intravenous thrombolytics and facilitating urgent transfers for endovascular therapy within a telemedicine systems of care. By the time fellows graduate from the fellowship, fellows have traditionally accumulated on average 200-300 telestroke consultations as evidence of the extensive experience obtained in the remote evaluation and management of a stroke patient.

Currently, the UC San Diego stroke center conducts telestroke code consultations with the following spoke sites:

• Rancho Springs Medical Center
• Inland Valley Medical Center
• Eisenhower Medical Center
• El Centro Regional Medical Center

Outpatient Clinic

Fellows will rotate through various stroke faculty clinics to provide a thorough understanding of stroke prevention practices. Clinic also provides the opportunity to establish post-hospital discharge continuity that will facilitate longitudinal learning about the nuances of continued stroke workup, prevention, and recovery.

The outpatient clinics are scattered amongst the various inpatient rotations to supplement the knowledge gained from the wards. Fellows will engage in one half-day clinic per week within each of their rotations. Each rotation is assigned a different outpatient faculty mentor from which the fellows will learn the various approaches to outpatient stroke management.

Facilities in which fellows would be attending outpatient stroke clinic include the following:

• UC San Diego Hillcrest Medical Center (Medical Offices North)
• UC San Diego Sulpizio Cardiovascular Center
• San Diego Veterans Administration (VA) Medical Center

On-Call

Vascular neurology fellows are on-call approximately one weeknight per week and every fourth weekend. Call responsibilities include triaging stroke codes from multiple different institutions to gauge the prospect of thrombolysis and/or endovascular therapy, conducting telemedicine consultations, facilitating acute stroke transfers, and providing consultative input for patients with stroke requiring neurointensive care management.