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  • 1. The Johns Hopkins University School of Medicine COMBINED NEUROLOGY/RADIOLOGY/NEURORADIOLOGY RESIDENCY TRAINING PROGRAM V3. November 26, 2001
  • 2. JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE COMBINED NEUROLOGY/RADIOLOGY/NEURORADIOLOGY RESIDENCY TRAINING PROGRAM I. GOALS AND OBJECTIVES OF TRAINING PROGRAM A. General Goals The principal goal of this combined residency training program in the Departments of Neurology and Radiology is to provide the best environment to develop academically-oriented neurologically-trained radiologists, who may enter various aspects of Neuroradiology including interventional neuroradiology, or functional imaging. The secondary goal of the program is to fulfill the requirements of the American Board of Neurology and Psychiatry and the American Board of Radiology for clinical certification. Currently, there are four approved combined neurology/radiology programs in the USA: at Emory U., Cornell U., U of Wisconsin and the Cleveland Clinic. Funding for the trainees participating in this new program will be sought from the Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center (as a new program to meet developing goals within the delivery of acute neurological services), and from the Departments of Neurology and Radiology. This program will also help meet our institutional and departmental needs to expand acute neurological services both at JHH and JHBMC. B. Clinical Goals The program is divided into four distinct components: The first year is a PGY1 in internal medicine. Years 2 and 3 are spent in Neurology, to offer a full complement of clinical activities in general neurology and in the neurologic subspecialties of pediatric neurology, neuromuscular, neurovirology/neuroimmunology, neurogenetics, cognitive neurology, epilepsy, movement disorders, neuro-ophthalmology, and neuro-critical care. Years 4-5 are spent in Diagnostic Radiology which will offer a full complement of clinical activities in radiology including chest, cardiovascular interventional radiology, musculoskeletal, nuclear imaging, breast imaging, GI and abdominal imaging, and pediatric imaging. Years 6-7 are spent in Neuroradiology which offers a range of training activities including computerized tomography (CT), magnetic resonance imaging (MRI), MR spectroscopy, vascular interventional, carotid ultrasound, and PET scanning. Summary of Program (see enclosed table) PGY1: Internal Medicine. This would include 4 months of training in Internal Medicine, 3 months CCU/MICU, 3 months Chest Radiology, 1 month GI Radiology and 1 month vacation. PGY2 and 3: Neurology. 24 months of Neurology: 21 months of Clinical Adult Neurology (16 with primary responsibility in patient care, 3 months elective, 2 vacation months). 6 months will be spent in Adult Neurology in an outpatient setting. A continuity clinic will extend through the 24 months of PGY2-3, 3 months in Clinical Child Neurology PGY4 and 5: Diagnostic Radiology. 24 months of Diagnostic Radiology: (excluding 4 months completed during the PGY1 year): 1 month of Chest Radiology, 4 months 1
  • 3. of Bone Radiology, 2 months of GI Radiology, 3 months of GU Radiology, 4 months of Ultrasonography, 3 months of Pediatric Radiology, 2 months of Mammography, 4 months of Nuclear Medicine, and one month of elective. 2 months vacation. PGY6 and 7: Neuroradiology: 24 months of Neuroradiology: 16 months of graduated responsibility for invasive procedures in angiography, myelography (2 months), computed tomography (3 months), magnetic resonance imaging (6 months), magnetic resonance spectroscopy (1 month), and positron emission tomography (2 months), elective (2 months). Six months will be completed in Vascular/ Interventional Radiology. 2 vacation months. C. Research Goals Its our belief that our profession will advance only by building from a firm mastery of clinical knowledge. The entire training program is dedicated to the acquisition of the highest order of clinical skills relating to neurological illness. Interest in research is cultivated from the initial year of training onwards. During the clinical training program research opportunities are limited because of the lack of elective periods in this compacted training program, however, we anticipate that trainees will undertake a subsequent clinical or research fellowship after clinical training. To this end, the Department of Neurology has made extensive use of the NIH’s K08 and K23 awards to facilitate the training of clinician scientists within the department. Since 1989 we have had 32 K08/K23 awards to our trainees, and over 90% are still currently engaged in academic/scientific careers with approximately 65% having achieved independent funding. D. Teaching The Neurology and Radiology faculty will provide teaching in both general neurology, specific areas of subspecialty neurology, in general radiology and neuroradiology. These training and teaching activities go on in both the inpatient and outpatient environments. The radiology faculty provide teaching in general radiology and neuroradiology in both inpatient and outpatient environments. The major goal of the program is to provide supervision in the evaluation, imaging and treatment of disorders of the nervous system, and to provide this supervision in a graded or graduated manner to allow the resident to mature into an independent decision maker II. TRAINING PROGRAM A. Recruitment 1) Prerequisites All applicants to the combined program must be eligible for entry into the PGY1 internship year at JHBMC, which is an accredited training program in internal medicine. 2) Process of Review All applications are reviewed by the program steering committee (PSC) which consists of Drs Justin McArthur (NRO), Ehlias Mehlem (RAD), Norman Beauchamp (NRAD), David Youssem (NRAD), Jack Griffin (NRO), Charles Wiener (MED-JHH) and Roy Ziegelstein (MED- JHBMC). Applications will be stratified by level of qualification and competitiveness. The top applicants will be interviewed for the combined residency slots. All applicants will be interviewed by the residency program Director (Justin McArthur) and the co-directors. 3) Criteria of Acceptance 2
  • 4. Results of interviews, evaluations letters of reference, medical school grades, and Dean's letter are collated and used to rank candidates. The decision to admit a candidate is made by the director and co-directors. Candidates will be ranked according to tangible, eg publications, commendations, and intangible qualities, eg personality, humanistic qualities. Given the length and rigor of this program, particular attention will be given to the individual commitment of applicants. The program will not participate in a match. B. Program Description 1) Faculty a. Residency Training Director - Justin C. McArthur, MB,BS; MPH acts as overall Director of the combined program, and, in addition is the Director of the Neurology residency program, and Deputy Director of the Department of Neurology (CV enclosed) The Residency Training Director has authority to make decisions regarding resident activity, supervision, and performance evaluation. These activities require two to three hours per week of designated supervisory time. Additional duties are performed on an ad hoc basis concurrently with the Director's routine clinical activities. b. Co-Directors and members of the PSC: Dr Ehlias Mehlem, Program Director Radiology Residency Dr Norman J. Beauchamp, Jr., (MD, MHS) Vice Chairman, Director of Clinical Operations, Radiology Dr David Youssem, Director of Neuroradiology Dr John W. Griffin, Professor/Chairman Neurology. Dr Charlie Wiener, Professor of Medicine, Vice-Chair and Residency Director Medicine, Johns Hopkins Hospital. Dr. Roy Ziegelstein, Director Medicine Residency Program, Johns Hopkins Bayview The director and co-director will meet on a bimonthly basis to review progress and problems in the program. Issues related to clinical performance will be dealt with by the Co-Director responsible for those years of training, ie YRS 1 MED and RAD, 2-3 NRO, YRS 4-5 RAD, and YRS 6-7 NRAD. c. Faculty mentor: Each resident will be assigned a faculty mentor from one of the departments who is working in a field of Neuroimaging to provide additional guidance for career development, education and fellowship choices. 2) Trainees a. Length of Training Program: Seven years b. Number of Residents at Each Level: one intern every other year, and one resident for every other year. Total for first 7 years = 4 3) Teaching/curriculum: YR 1: INTERNAL MEDICINE/INTRODUCTORY RADIOLOGY: Structure of program: This would include a minimum of 4 months of training in Internal Medicine, 3 months CCU/MICU, and 4 months in Radiology (3 months Chest Radiology, 1 months in GI Radiology). 1 vacation month. 3
  • 5. Details of program: For each year of the program there are specific educational goals. The chief purpose of the internship is to learn how to evaluate and to treat general medical patients admitted to the hospital, under the direct supervision of residents and attending faculty. The PGY-I year emphasizes the importance and value of dedication to the patient, professionalism, team work and scholarship. Approximately 6 months are spent on the general internal medicine hospital service (3-4 of which are spent on an assigned Firm). 4 months will be spent in Diagnostic Radiology on the Chest and GI rotations. The program has been structured so that the trainee begins the program with the Radiology orientation in July. Interns see outpatients one half-day per week and do two weeks of block ambulatory care. Scholarship also is emphasized. During the PGY1 year, each intern, with the help of the faculty preceptor, prepares a 15-minute slide presentation concerning an instructive patient or clinical topic. Patient Care - Multiple levels of patient care experience are offered to the trainee on a basis of progressively increasing level of responsibility. The call schedule is usually every fourth night. A night float team cares for all patients admitted after 1:00 a.m. Typical work weeks will include an approximately 60-70 hour time commitment with an expected maximum of 75 hours. Such a week would include six days of patient care duties, 1-2 days of night call, and one weekend day off. Most call days are 14-15 hour days with the opportunity for up to 4-6 hours of sleep. Methods of Documentation of Competency in Procedures: The interns will maintain a database of all procedures performed to document their clinical exposure during their training. The most commonly performed invasive procedures will be central line placement, arterial punctures, lumbar punctures, Swan-Ganz catheter placement, and thoracentesis. Ad Hoc availability for patient care review is maintained by assigned attending physicians for each clinical service and by the Program Director and Department Chairman. (Details of curriculum and learning objectives are provided in Appendix A) YRS 2-3: NEUROLOGY TRAINING PROGRAM: Structure of Program The 24 month training program is divided into one year segments. There are two major affiliations in our neurology training program. The first is with the Bayview Medical Center. This critical part of our program allows for primary inpatient care in a community-based hospital with a majority of admissions from the Emergency Room comprising mainly cerebrovascular disease, seizures, CNS infections and medically-induced neurologic disease. These acute neurologic problems are more prevalent at JHBMC than at JHH, which has a higher proportion of elective admissions for epilepsy monitoring, treatment of neuromuscular disease or normal pressure hydrocephalus. The JHBMC rotation offers a unique combination of autonomous direct patient contact with an excellent group of well trained academic faculty supervisors. This degree of autonomy while maintaining supervision is unique to the JHBMC. For this reason the training opportunities provided there are essential to the clinical development of our residents. The second affiliation is with Sinai Hospital. This affiliation provides access to a second population of community-based neurological diseases including stroke, dementia, and neurorehabilitation patients. Again, direct faculty mentoring is available on a full-time basis from hospital-based neurologists with a JHU appointment providing a unique opportunity for a one- 4
  • 6. on-one learning experiences. This affiliation represents a unique opportunity to practice neurology in an environment similar to that of most active neurologic practitioners today, and represents an important learning opportunity for our trainees. Details of training program: YR 2: The first year includes 6 months of primary patient care at either the Johns Hopkins Hospital or Johns Hopkins Bayview Medical Center on their respective adult neurology services; 2 months of pediatric neurology primary care on the pediatric service of the Johns Hopkins Hospital; 1 month of Neurosciences Critical Care; 1 month will be spent in the Adult Neurology Outpatient service, and 1 month of vacation during the first year. Note that a 3 month elective block is scheduled into the program bridging the end of PGY2 and beginning of PGY3. This elective period will be used for and elective in the neurological sciences, neuropathology and pathophysiology, or cognitive neurology, and will serve to introduce the trainee to the ongoing research within the Institution. A continuity clinic will extend through the 12 months of the PGY2 year. YR3: The second year is made up of 3 months of inpatient consultation on the adult neurology service, 2 months of Neuromuscular outpatient, 1 month of Epilepsy/EEG outpatient, 1 month of Pediatrics, and 2 months of Adult Outpatient. A month of vacation is provided in this year. A continuity clinic will extend through the 12 months of the PGY3 year. Patient Care - Multiple levels of patient care experience are offered to the trainee on a basis of progressively increasing level of responsibility. Typical work weeks will include an approximately 65 hour time commitment with an expected maximum of 75 hours. Such a week would include six days of patient care duties, two days of night call, and one weekend day off. Most call days are 14-15 hour days with the opportunity for up to six hours of sleep. All clinical activities of first year residents are reviewed by an assigned senior resident including physical examination, plan of formulation, order writing, and procedures. This review system allows first year residents to have complete patient care responsibility while receiving immediate and daily opportunities for review of diagnostic and therapeutic planning. Additional supervision is also supplied by the chief resident and assigned attending physician. Supervision - The supervision of the patient care process is provided by the faculty and senior clinical residents. This supervision involves frequent dual assessments of the patient, clinical data base, testing results, and outcome variables. Review of quality of care is undertaken at both the department level and divisional level. Both illustrative problems and solutions are discussed in the grand rounds, morbidity and mortality rounds, and case conference forums on a weekly basis. Ad Hoc availability for patient care review is maintained by assigned attending physicians for each clinical service and by the Program Director and Department Chairman. Methods of Documentation of Competency in Procedures: The residents maintain a database of all patients seen, to document their exposure to different neurological diseases during their training. The two most common procedures performed by neurology residents are the lumbar puncture and the electromyogram. Lumbar punctures are supervised by senior residents in the wards and in our outpatient lumbar puncture clinic. Competency in the performance of this technique is certified by the chief resident after an appropriate level of independence in accomplishing this procedure is demonstrated by Year I residents. Faculty supervision of lumbar puncture occurs in the Neurosciences Critical Care Unit, and on the inpatient units for difficult cases. The second procedure is the electromyogram. This procedure is performed in the neurophysiology laboratory under the observation of a trained 5
  • 7. electromyographer. Residents do not perform this procedure independently. Less commonly performed procedures include insertion of central lines and insertion of lumbar drains. These procedures are most often performed in the Neurosciences Critical Care Unit under direct observation of either a faculty member or a trained fellow who is Board certified or Board eligible in Neurology or Anesthesiology. (Details of training objectives and curriculum are provided in Appendix B) Ongoing experience in Diagnostic Radiology during Neurology training. During PGY2-3 years, the resident will attend Radiology Grand Rounds (a combined clinical presentation and lecture series) to provide ongoing experience in Diagnostic Radiology. The resident will also attend monthly journal clubs and selected research seminars, and join clinical conferences, eg the weekly Neurovascular Conference (Thursday 8:00 am) and Neuroradiology Grand Rounds. YEARS 4-5 RADIOLOGY TRAINING: Structure of Program: The basic goals of this phase of the combined program is to provide training in all areas of clinical imaging through a series of rotations at JHH and JHBMC. The defined areas of coverage are chest, gastrointestinal, genitourinary, musculoskeletal, nuclear medicine, ultrasound, computed tomography, pediatric radiology, breast imaging, and edical physics.m The program will offer the opportunity for residents to perform, and interpret non-invasive and invasive diagnostic and interventional procedures under close supervision. The procedures shall include diagnostic Xrays, CT scans and ultrasound. Other percutaneous minimally- invasive procedures (image-guided biopsies, and medication installation), CT, MRI, ultrasound and plain film radiography and nuclear medicine studies. Residents will be given graduated responsibility in the performance and interpretation of non-invasive and invasive procedures. Responsibility for these procedures will include pre- and post-procedural patient care. The residents will become familiar with all aspects of administering and monitoring sedation of the conscious patient, and will have advanced cardiac life support training. Details of training program (Details of curriculum and learning objectives are provided in Appendix C) YR4: This year includes rotations through the major areas of Radiology including: 2 months on Chest Radiology (note that 2 months will be spent on Chest during the PGY1 year, with a total of 4 months); 4 months of Bone Radiology; 1 month of GI Radiology (note that 2months will be spent on GI during the PGY1 year, a total of 4 months); 3 months of GU Radiology, 2 months of Breast Imaging, and 1 vacation month. YR5: This year includes rotations through these major areas of Radiology: 4 months of Ultrasonography; 3 months of Pediatric Radiology; 4 months of Nuclear Medicine; 1 elective month, and 1 vacation month. Patient Care - Multiple levels of patient care experience are offered to the trainee on a basis of progressively increasing level of responsibility. Typical work weeks will include an approximately 60 hour time commitment with an expected maximum of 70 hours. Such a week would include six days of patient care duties, 1-2 days of night call, and one weekend day off. Most call days are 14-15 hour days with the opportunity for up to six hours of sleep. 6
  • 8. Supervision - The supervision of the patient care process is provided by the faculty and senior clinical residents. All clinical activities of YR4 (first radiology year) residents are reviewed by an assigned senior resident including interpretation and any procedures. Additional supervision is also supplied by the assigned attending physician. Diagnostic reports generated by residents will be closely reviewed for content, level of diagnostic confidence, grammar and style. Feedback will be provided by the faculty supervisor, and the reports must be co-signed. Review of quality of care is undertaken at both the department level and divisional level. Both illustrative problems and solutions are discussed in the regular conferences, morbidity and mortality rounds, and case conference forums on a weekly basis. Ad Hoc availability for patient care review is maintained by assigned attending physicians for each clinical service and by the Program Director and Department Chairman. Methods of Documentation of Competency in Procedures: The residents maintain a database of all radiologic procedures performed to document their exposure during their training. The most commonly performed invasive procedure will be image-guided biopsy. Competency in the performance of this technique is certified by the faculty after an appropriate level of independence in accomplishing this procedure is demonstrated by Year 4 residents. Ongoing Experience in Neurology During Diagnostic Radiology: During PGY4-5 years, the resident will attend Neurology Grand Rounds (a combined clinical presentation and lecture series) to provide ongoing experience in Neurology. The resident will also attend monthly journal clubs (held in evening at faculty’s homes), and selected research seminars and join clinical conferences, eg the weekly Neurovascular Conference (Thursday 8:00 am). In addition, the resident will attend 1-2 half day per month outpatient sessions with Neurology faculty to maintain clinical skills. YEARS 6-7 NEURO-RADIOLOGY TRAINING: Structure of Program: The basic goals of this phase of the combined program is to provide training in specific areas of neuroradiology through a series of rotations at JHH. The defined areas of coverage include non-invasive and invasive diagnostic and interventional procedures performed under close faculty supervision. These will include diagnostic catheter- based cerebral angiography, other percutaneous minimally-invasive procedures (image-guided biopsies, spinal canal access for myelography, spinal fluid analysis and medication installation), CT, MRI, MR/CT angiography, ultrasound of the central nervous system and vessels (including its vascular structures) and plain film radiography related to the brain, head (including organs of special sense), skull base, neck and spine, and nuclear medicine studies of the central nervous system. There will be exposure to positron emission tomography (PET) and magnetic resonance spectroscopy (MR), MR functional activation studies, diffusion, and perfusion MR imaging. Residents /fellows will be given graduated responsibility in the performance and interpretation of both non-invasive and invasive procedures. Responsibility for these procedures will include pre- and post-procedural patient care. The trainees will become familiar with all aspects of administering and monitoring sedation of the conscious patient, and will also have advanced cardiac life support training. Details of training program (Additional details of curriculum and learning objectives are provided in Appendix D) 7
  • 9. YR6: This year includes rotations through these major areas of Neuro-Radiology including: 4 months of CT scan; 2 months myelography/fluoroscopy; 2 months ultrasonography; 2 months MRI; 1 month elective and 1 month vacation. YR7: This year includes rotations through these major areas of Neuro-radiology including: 3 months MRI/MR spectroscopy; 2 months spine imaging; 4 months angiography/interventional radiology; 1 month elective; and 1 month vacation. Patient Care - Multiple levels of patient care experience are offered to the trainee on a basis of progressively increasing level of responsibility. Typical work weeks will include an approximately 60 hour time commitment with an expected maximum of 70 hours. Such a week would include six days of patient care duties, 1-2 days of night call, and one weekend day off. Most call days are 14-15 hour days with the opportunity for up to six hours of sleep. Supervision - The supervision of the patient care process is provided by the faculty and senior clinical residents. All clinical activities of YR6 (first Neuro-Radiology year) residents are reviewed by an assigned clinical Neuroradiology fellow including interpretation and any procedures. Additional supervision is also supplied by the assigned attending physician. Diagnostic reports generated by residents will be closely reviewed for content, level of diagnostic confidence, grammar and style. Feedback will be provided by the faculty supervisor, and the reports must be co-signed. Review of quality of care is undertaken at both the department level and divisional level. Both illustrative problems and solutions are discussed in the regular conferences, morbidity and mortality rounds, and case conference forums on a weekly basis. Ad Hoc availability for patient care review is maintained by assigned attending physicians for each clinical service and by the Program Director and Division Chairman. Methods of Documentation of Competency in Procedures: The residents maintain a database of all radiologic procedures performed to document their exposure during their training. The most commonly performed invasive procedures will be angiography and myelography. Competency in the performance of these techniques is certified by the faculty after an appropriate level of independence in accomplishing this procedure is demonstrated by Year 6-7 residents. 8
  • 10. Appendix Appendix A. Internal Medicine Training Appendix B. Neurology Training Appendix C. Radiology Training Appendix D. Neuro-radiology Training 9
  • 11. Appendix A MEDICINE TRAINING Overview of the Program Each year, the program has specific educational goals. The chief purpose of the internship is to learn how to evaluate and to treat general medical patients admitted to the hospital. During the Junior Assistant Resident (JAR) year, residents learn ambulatory and subspecialty medicine. Two, nine-week block rotations in ambulatory medicine provide a broad education in outpatient medicine and an opportunity to work one-on-one with senior faculty. With this foundation of inpatient and outpatient skills, Senior Residents (SARs) assume two important roles: leading the care and teaching of the team on the inpatient service, and anchoring the outpatient care of the Firm by spending block periods in the Firm's outpatient practice. Each of the three years, PGY-I, PGY-II and PGY-III, emphasizes the importance and value of dedication to the patient, professionalism, team work and scholarship. PGY-I Approximately eight months are spent on the general internal medicine hospital service (five to six of which are spent on the Firm). Experiences with Oncology, ICU, Cardiology, Ambulatory General Medicine and vacation round out the year. Interns see outpatients one, half-day per week and do two weeks of block ambulatory care (Case 0.5). The call schedule is usually every fourth night. A night float team cares for all patients admitted after 1:00 a.m. 10
  • 12. Appendix B NEUROLOGY TRAINING: 1. Conferences A weekly conference schedule is included as Appendix 2. The major teaching conferences in the program are: daily noontime didactic lectures; Grand Rounds; weekly CNS and PNS Pathological Conferences; Chairman's Rounds. Major weekly specialty conferences include: Neuromuscular Conference; Peripheral nerve conference; Neurovascular Conference; Neuro-ophthalmology Conference; Movement Disorders Conference; Pediatric Neurology Grand Rounds; Epilepsy Conference; and Clinical Neurosciences Conference. Mortality and Morbidity Conference is held bimonthly during Grand Rounds. Additional research conferences are held weekly in each of the Neurology Divisions. Daily teaching includes "walking" ward rounds with the designated attending physician and with primary care physicians. Daily interactions with the faculty occur at the patient's bedside for all level residents assigned to the ward rotations, consult rotations, and Neurosciences Critical Care Unit rotations. Outpatient care is reviewed in the clinic by faculty (part-time for JHH, FT for JHBMC) (see Appendix 3). 2. Rounds Morning report occurs every morning at 7.30am at JHH. Consult cases and overnight admissions are discussed and the chief residents teach on aspects of management. Inpatient teaching attending rounds are held approximately two-three times a week with weekend bedside rounds also occurring on Saturdays and Sundays. 3. Outpatient-Program Each resident is assigned to his/her own personal “continuity” clinic for the two years of his/her training. The resident also rotates through a faculty member's clinic on a monthly basis, and also rotates through subspecialty clinics in seizures, movement disorders, and neuro- ophthalmology. 4. Didactic Teaching The Neurology Training Program incorporates many elements into the learning environment for its residents. Formal didactic sessions in Neuroanatomical Localization, Natural History of Diseases of the Nervous System, Neurodiagnostics, and Therapeutics are offered on a weekly basis at the departmental and divisional conference level and throughout the year for all residents through a daily lecture series. 5. Informal Teaching Teaching sessions at the bedside are still considered the back bone of neurologic teaching. These sessions are offered on a daily or every other day basis to all residents in the training program. Informal data review and decision-making sessions are available to residents through the subspecialty conference mechanism. Evidence-based decision making is stressed throughout the program. Residents present at Grand Rounds on a rotating basis. They are responsible not only for a detailed case presentation, but for presenting a discussion of the neurological problem. Residents should be encouraged to participate in the teaching of neurology residents, rotating medica residents, and medical students, including the presentation of at least one didactic lecture annually. 6. Ethics of Medical Care 11
  • 13. Ethical practice of medicine is discussed as a part of regular patient care duties in all sites of the training program. Dr Mike Williams (NRO), co-chair of the JHH Ethics committee plays a n important role in this area, especially on training in end-of-life decision-making, and brain death pronouncements. Specific opportunities to discuss ethics of neurologic practice are found within the grand rounds, clinical case conference, pediatric clinical conference, and neurosciences critical care unit family conference meetings. These represent regular opportunities in which ethical factors are directly discussed in relation to other aspects of patient care decision making. 7. Research Exposure to laboratory-based and clinical research occurs throughout all two years of training. The Chairman and faculty encourages participation in the regularly scheduled divisional research conferences, as time permits. This allows for exposure to ongoing research activities and to research faculty without a direct "hands on" commitment which might distract from the primary goals of clinical training. As biological significance, experimental design, research ethics and testing methodology are discussed at these conferences, the overall exposure adds significantly to the scientific background of our trainees. 8. Self Learning Self learning and group learning are promoted as necessary requirements to complete the training program and as essential professional behavior. This aspect of learning takes two forms: first: comprehensive reading of didactic material such as text and monographs, and second: selected literature review related to clinical problems requiring additional medical input. Computer-assisted literature review is provided to resident trainees via the Meyer Neurosciences Library and PubMed; additional services are available from the Meyer librarian. 12
  • 14. Appendix C RADIOLOGY TRAINING 1. Chest 1st Year: 3.Develop skills at interpreting PA and lateral chest roentgenograms in a systematic fashion. 4.Acquire knowledge of normal chest and cardiac anatomy as seen in computed tomography. 2nd Year: 1.Interpretation of ventilation and perfusion lung scans. 2.Technique for performance of pulmonary angiogram. 3.High-resolution CT scan 4.Magnetic resonance imaging of thorax 2.Musculosketal 1st Year: 1.Development of working skills in conventional radiology of musculoskeletal conditions with an emphasis on recognition of traumatic injury. 2.Understanding of radiographic findings in common orthopaedic and rheumatologic conditions and following common surgical procedures. 2nd Year: 1.Introduction to MRI, CT, US and Nuclear Medicine as applied to the musculoskeletal system. 2.Night rotation in the Emergency Department. 3.Joint aspiration and biopsies 3. Abdominal Imaging 1st year: 1.Develop skills at interpreting basic imaging studies including CT, IVP, Barium studies (UGI, BE, SBS). 2nd Year: 1.Learn basic interpretation of body MRI studies. 2.Develop additional skills in CT, US and general radiology. 1.Performance of abdominal biopsies. Learn and perform advance CT techniques including CT angiography, 3D imaging and volume imaging. 4. Breast Imaging 2nd Year (3 week rotation): 1.Develop knowledge regarding the technical aspects of performing screening and diagnostic mammography. 2.Develop skills at interpreting screening and diagnostic mammograms in a systematic fashion and employing the standardized BIRADS lexicon in reporting. Must be able to distinguish benign from malignant disease. Must reliably detect abnormalities. 3.Develop skill with correct utilization of standardized mammography lesion descriptors and final assessment categories. 4.Performance of image-guided (mammographic or sonographic) pre-operative needle-wire localizations of breast lesions. 5.Performance of image-guided (stereotactic or sonographic) cyst aspiration procedures. 13
  • 15. 5. Nuclear Medicine 1st Year: 1.Understand the principles of radiotracer technique including Radiopharmacology, Biodistribution, Physics and Instrumentation. 2.Understand the principles of radiation biology, contamination and decontamination radiation protection of patients and personnel. (ALARA, effects of distance, time and shielding, handling radioactive materials). 3.Understand normal distribution of various radiopharmaceuticals. 4.Identify scans based on radiotracer distribution. 2nd Year: 1.Acquire skills for interpretation of: Bone scan Esophageal transport imaging Gastric emptying studies Hepatobiliary studies (acute cholecystitis, sphincter of Odi dysfunction) Renal scans (MAG3, DTPA, DMSA) Scintimammography Lymphoscintigraphy including sentinel node detection 2.Acquire skills for interpretation of the following studies: Monoclonal antibody imaging (anti CEA, prostascint) CSF scans (VP and LP shunts, Ommaya reservoir, CFS leaks) Brain SPECT (dementia, trauma, brain tumors) Brain death imaging Clinical PET (cancer diagnosis and staging, epilepsy, myocardial viability) Gated blood pool imaging – planar and SPECT Myocardial perfusion imaging with T1-201 and Tc-99m Sestamibi Planar, SPECT, gated SPECT 6. Ultrasound 1st Year: 1.Acquire a basic understanding of ultrasound physics principles and instrumentation. 2.Learn ultrasound cross-sectional and vascular anatomy. 3.Must be able to distinguish normal from abnormal in the abdomen, pelvis, superficial organs, pregnancies and vascular system. 4.Become familiar with endocavitary scanning techniques. 5.Learn to detect basic ultrasound emergencies. 2nd year: 1.Acquire knowledge about Doppler physics and Duplex Imaging. 2.Acquire hands-on scanning skills. 3.Interpret more complex obstetrical ultrasound cases, more complex vascular ultrasound cases (carotid, liver duplex, TIPPS) and specialized small parts ultrasound (prostate, complex scrotal cases). 4.Ultrasound emergencies such as ectopic pregnancy, ovarian and testicular torsion, acute olecystitis, hydro-pyonephrosis and deep venous thrombosis.ch 5. Perform Ultrasound or CT guided organ biopsies and fluid aspirations. 6.Pediatrics 1st Rotation: 1.Watches all fluoroscopy 14
  • 16. 2.Performs UGI and VCUG exams on children older than 1 year 3.Learns to recognize malrotation, GE reflux, VU reflux, pyloric stenosis. 2nd Rotation: 1.Performs familiar fluoro exams. 2.Barium enemas, to recognize colonic aganglionosis, inflammatory bowel disease, meconium ileus, intussusception, malrotation, swallowing of dysfunction. 3.Learns to recognize ICU pathology: RDS, chronic lung disease, edema, meconium aspiration, tubes and catheters and their proper positions. 3rd & Subsequent Rotations: 1.Performs all exams with or without attending in the room, depending on degree of familiarity. 2.Learns to recognize microcolon, tracheobronchomalacia, diaphragm paralysis. 3.Learns to recognize congenital cardiac disease, dwarfing syndromes, postoperative complications. 4.Learns to recognize bowel pathology, lung infiltration, abnormal fluid collections. 5.Learns to recognize intracranial pathology, abnormal bowel, congenital renal abnormalities, normal and abnormal appearance of the maturing pelvis, testicular torsion. 8. CV/Interventional Radiology 1st Rotation (second year of residency): 1.Understand the process of scheduling patients for CVDL procedures. 2.Become familiar with the terminology and the inventory within the Angio suite. 3.Understand and be able to use the equipment in the Angio suite. 4.Be able to perform a history and physical exam. 5.Be able to write a consultation on a patient and obtain informed consent for the procedures. 6.Understand the principles of conscious sedation and how to use the proper medications during a procedure. 9. Other Required Components 1. Fellow Participation In Research Fellows should be encouraged to undertake investigative study of either a clinical or basic science nature. At least one project of such merit that it could be submitted for publication should be encouraged. The fellows should learn the fundamentals of experimental design, performance, and interpretation of results. They should participate in clinical, basic biomedical, or health services research projects and should be encouraged to undertake at least one project as principal investigator. They should submit a least one scientific paper or exhibit to a regional or national meeting. The opportunity also must be provided for fellows to develop their competence in critical assessment of new imaging modalities and of new procedures in radiology. 15
  • 17. Appendix D. NEURO-RADIOLOGY TRAINING AND LEARNING OBJECTIVES: 1st year: 1.Develop skills in the interpretation of plain films of the skull. 2.Learn to interpret CT scans with particular emphasis on studies performed on individuals presenting with acute or emergent clinical abnormalities (infarction, spontaneous intracranial hemorrhage, aneurysmal subarachnoid hemorrhage, traumatic brain injury, infection, hydrocephalus, and brain herniation). 3.Become familiar with CT appearance of (a) traumatic (fractures and soft tissue injuries) of the orbit, skull base, face and petrous bones and (b) inflammatory (sinusitis, orbital cellulitis, otitis, mastoiditis, cervical adenitis and abscess) lesions. 4.Learn to identify airway compromise and obstruction. 5.Learn the appearance of traumatic lesions of the spine with emphasis on findings of spinal instability.Become familiar with the CT and MRI findings of degenerative disease. 6.Develop skills in fluoroscopically guided lumbar puncture, lumbar myelography, recognition and treatment of contrast reactions. 2nd year: 1.Develop skills in common carotid angiography, cervical myelography, head and neck spirations.a 2. Become familiar with the utility of new MR sequences (Diffusion/Perfusion, functional R and MR Spectroscopy).M 3. Develop skills in internal carotid and vertebral angiography, spine biopsies, CT angiography, CT perfusion studies, head and neck biopsies. The twelve-month training program must consist of at least: 4 weeks or equivalent dedicated training in pediatric neuroradiology 4 weeks or equivalent dedicated training in head and neck radiology. 4 weeks or equivalent dedicated training in spine radiology including image guided procedures. 6-8 weeks or equivalent dedicated training in vascular neuroradiology. During this period there should be a special emphasis on catheter neuro- angiography. Experience in micro-catheter techniques for thrombolysis treatment of acute stroke is strongly recommended. Fellows should learn to correlate catheter angiographic findings with those seen on non-invasive vascular imaging studies including MRA, CTA and sonography. 2-4 weeks or equivalent dedicated experience performing and interpreting vascular sonography. 24-26 weeks or equivalent dedicated training in general adult diagnostic neuroadiology. Didactic Components/ Conferences Fellows must participate in one or more weekly departmental conferences in neuroradiology, one or more interdepartmental conferences with allied clinical departments (eg, neurology, neurosurgery, orthopedic surgery, neuropathology, head and neck surgery and ophthalmology) as well as institutional conferences in clinical neurosciences (eg, grand rounds) that are held at least monthly. Fellows should be encouraged to attend and participate in local extramural conferences and should attend at least one national meeting or postgraduate course in neuroradiology while in training. 16
  • 18. Fellows should be encouraged to present the radiological aspects of cases which are discussed during daily work rounds and in clinical conferences related to the allied disciplines such as neurosurgery and the neurological sciences. They should also prepare clinically or pathologically proved cases for inclusion in the teaching file. There must be daily "film reading" conferences interpretation sessions requiring fellows to reach their own diagnostic conclusions, which should must then be reviewed and criticized by faculty/staff. These conferences need not be limited to clinically current cases, but may be based on cases that are already within the teaching file . Diagnostic reports generated by fellows should be closely reviewed for content, level of confidence, grammar and style. Feedback must be provided and the reports must be co-signed. Fellows are required to maintain documentation (procedure log) of the invasive cases that they have performed. The program director must review the log with the fellow at least quarterly in the course of the training year. A minimum number of invasive procedures per year as follows: 2500 total examinations (including plain radiographs, CT, MR, ultrasound, catheter angiograms and imaged guided invasive procedures) Of these 2500 examinations, there should be at least: 1000 neuroradiological CT scans 1000 neuroradiological MR scans Fellows must have participated in and documented the following: At least 50 catheter based angiographic procedures; At least 50 image guided invasive procedures (CT, MR, or fluoroscopically guided); Participation in at least 5 intracranial microcatheter procedures is highly recommended. Fellows should be encouraged to participate in the teaching of diagnostic radiology fellows and medical students, including the presentation of at least one didactic lecture. Other Required Components 1. Fellow Participation In Research Fellows should be encouraged to undertake investigative study of either a clinical or basic science nature. At least one project of such merit that it could be submitted for publication should be encouraged. The fellows should learn the fundamentals of experimental design, performance, and interpretation of results. They should participate in clinical, basic biomedical, or health services research projects and should be encouraged to undertake at least one project as principal investigator. They should submit a least one scientific paper or exhibit to a regional or national meeting. The opportunity also must be provided for fellows to develop their competence in critical assessment of new imaging modalities and of new procedures in neuroradiology. 3.Interchange with Students and Fellows in Other Specialties Neuroradiology fellows should be encouraged to participate in the research projects of staff persons and fellows in other specialties. They should attend clinical conferences in other specialties and serve as consultants to these conferences. It is desirable that they participate in 17
  • 19. the clinical teaching of medical students and also in the pre-clinical curriculum in subjects such as neuroanatomy and neurophysiology. 18
  • 20. Appendix E. EVALUATION FORMS A. Trainee Trainees are evaluated on the basis of their intellectual, ethical and practical abilities on a monthly basis (see evaluation sheets Appendix E). These evaluations are made in writing by the supervising attending physician, and reviewed by the program Director. Verbal feedback is offered to residents during their rotations and at the end of each assigned rotation by the supervising faculty member. These evaluations are reviewed approximately every 6 months with the resident by the Program Director, or immediately if a problem is identified. Yearly formal evaluations are performed by the Program Director, and the respective co-director from the relevant discipline. Unsatisfactory progress in a trainee's abilities can be identified by either a supervising resident or faculty member. Additional methods of assessment include the yearly specialty and in-service examination for Neurology (RITE) in YRS 2 &3 and a yearly oral examination of each trainee during the Neurology phase. During Radiology, the yearly in-service examination will be completed. When unsatisfactory progress is identified, a meeting with the Program Director is necessary with identification of both the problem and a solution process. The solution usually includes increased faculty supervision, remedial reading and perhaps an increased amount of real-time supervision of the resident’s activities. B. Faculty Monthly faculty evaluations of the faculty are completed by the participating residents. These are reviewed by the Program Director and members of the steering committee (see Appendix E). C. Overall evaluation of the program: The Training Director, residents and the steering mmittee will evaluate the program yearly, using a form developed specifically for this purpose.co 19