Fellows Corner

By: Eugene Lin & Ameer Hassan

A warm welcome to all the Neuro-Endovascular Fellows! On the behalf of all SVIN faculty members, fellows and residents, I want to welcome all Neuro-Endovascular Fellows who have started fellowship. We are all proud to welcome you to our ranks as you embark on this magnificent journey during the course of your fellowship.

I am sure you are excited about starting this new chapter in your training. During this year, you will gain the clinical and procedural skills to become a competent interventional neurologist. The learning curve, especially early in the academic year, is steep and all the new content can be overwhelming. Identifying a mentor at your institution or elsewhere who shares some common interests is a valuable first step and can ensure you get the most out of your fellowship.

For the first time, we turn from a clinically-heavy training program to a procedural training environment. Always remember, you are a Neurologist first. For those of you still in Neurology residency, be diligent in your training. Spend your fourth year filling any clinical holes or areas that you would like to improve on. You will not have this opportunity once you start your interventional fellowship. However, once you start your interventional fellowship, you still need to take care of the whole patient.

Dr. Eugene Lin

Dr. Ameer Hassan

Interest in Interventional Neurology has grown in leaps and bounds as our members have continued to lead the charge in expanding the role of interventions ranging from expansion of the window for mechanical thrombectomy to advances in aneurysm embolization to treatment of AVM’s and chronic subdurals.  However, the path to a successful career is built on a strong foundation with an emphasis on building the correct skillset to adapt to an ever-growing field, to nurture an interest in clinical research, and to successfully navigate the contracts and negotiations.  Upon completing fellowship, we have all strived to expand the treatment of stroke patients and improve the volume and outcomes of neurointerventional cases at a new practice.

Graduates who have worked hard to complete a fellowship, have the challenge of either integrating within a system previously established or embarking on a path to establish and elevate the level of stroke care in a region that may not have had immediate access to the latest in interventional neurology.  Finding the right job helps to jumpstart a fulfilling career and reflects the hard work and countless hours spent during medical training. 

For those who have almost reached that destination, finding a job becomes a priority. Once you have an updated CV and are dressed for success, make use of the recruiters who have likely sent countless emails as they are familiar with places requesting locums or have a permanent position available.  Local representatives may have contacts across the nation on places that have potential to expand. Network as much as possible at the SVIN annual meeting, this being a great opportunity to meet faculty and potential future partners from around the country.  Reach out to previous seniors and graduates from other programs you have met over the years and especially program directors. Be confident and if you have a region of the country in mind, call the primary stroke centers in that area to see if they are interested in establishing a comprehensive stroke center, that’s how I found my program.

Once you receive those job offers, the importance of being rewarded for the time you will be spent working or building the program becomes paramount.  The challenges of employed versus private practice can play a large role in how the practice develops as you need to navigate exclusivity contracts, learn in short order how the other specialties in the field work together at the institution, and what parameters may restrict your practice.

As the individual helping to establish the service line, knowing the current infrastructure is important including angiography setup, backup equipment, and clinic facilities.  Having a timeline commitment is crucial especially if they have not established a biplane angiography suite or dedicated clinic space for outpatient.  In addition, being compensated with directorship pay can be important and typically includes reaching a goal of becoming a comprehensive stroke center, establishing or expanding clinical research, and educating peers, staff and administrators.  The trend in the field has been one of attrition due to increased documentation, responsibility and compliance paired with a progressive decrease in negotiated amount.  Other areas to focus on include wRVU productivity and call pay.  It can be important to reach out to mentors and colleagues to get a sense what is fair rather than relying on the CFO recommendation based on MGMA (which for our specialty really doesn’t exist).  Finally, for those not as well versed in legal terminology finding an experienced, trustworthy lawyer who can help to avoid missed clauses that may result in an unpleasant surprise.

Further focusing on new attendings who decide to establish a new practice, it is important to identify the necessary resources required to successfully establish a new service line.  Potential areas of improvement in establishing a new practice include:

  1. Establishing best practices in stroke care with a strong stroke program:
    1. Transitioning from a Primary Stroke Center to a Comprehensive Stroke Center or equivalent
    2. Ensuring best practices are captured with Get with the Guidelines/Target stroke
    3. Founding a core neuroscience committee
      1. Developing, establishing, and educating staff on clinical practice guidelines
      2. Establishing and developing Quality Improvement projects
      3. Assessing educational outreach activities
      4. Establishing, coordinating and expanding affiliated Primary Stroke Centers and community hospitals to develop a stroke/telestroke network
    4. Verifying appropriate availability of imaging and staffing
      1. CT, CTA, CTP, MRI available 24 hrs, carotid u/s, tcds, 2d echo, TEE
      2. Imaging applications – Viz.AI, Rapid or other automated identification of LVO, Remote/Cloud access
      3. Neurointensivists, vascular surgeons, neurosurgeons, neurologists, neuroradiologists, backup call
    5. Performance Review and peer review
      1. Provides a structured pathway to drive progressive improvement of treatment times.
  2. Increasing presence in the community:
      1. EMS outreach and education
        1. Stroke pre-notification (try to get your local EMS on ASES EMS or similar educational tool)
        2. Triage guidelines (work with your referral hospitals to make it easy for transfers, typically a transfer hotline is best), LVO protocols
        3. Timely case feedback and outcome
      2. Educational outreach to PSC
        1. Stroke education dinners
        2. Follow-ups on interesting cases, mechanical thrombectomies, aneurysm treatments
        3. Coordinate lunch or dinner presentations for your local neurosurgeons and ENT’s showcasing your expertise in AVMs, AVFs and tumor embolizations
      3. Annual Stroke symposiums for physicians, staff nurses, ems, (This is a great way to get your new program’s name out there)
      4. Community outreach (dessert with the doc, stroke awareness days, and try to work with a local or regional foundation to hold a fundraiser for stroke education, coordinate with local AHA activities).

            Being the leading society for interventional neurology with the ultimate goal of improving outcomes in stroke and cerebrovascular disease, empowering our new graduates so that they are successful with their first job helps to ensure that is achievable.