“A Word to the Wise”: Neuro-Endovascular Fellow’s Corner

Daniel Vela-Duarte, MD, MSCR
Graduating fellow Miami Cardiac and Vascular Institute, Baptist Neuroscience Center, Miami,

Starting position: Interventional Neurology – NeuroInterventional Surgery 
Cleveland Clinic Florida – Indian River Hospital, Vero Beach, FL.   

As a recently graduated fellow, seeking advice from my mentors was a daily exercise while learning during procedures, both by the hand of their expertise and from their previous experiences. Observing the results of their thought process was vital for communication with the patient and their families. Different elements were taught to shape my decision-making for the best of our patients. Consequently, I asked several leaders in neurointervention to give their best advice to a graduating NeuroEndovascular fellow. In the current edition of “The Core,” I am delighted to bring you these pearls of wisdom.”

Sandra Narayanan, MD
Associate Professor, Departments of Neurology and Neurological Surgery, University of Pittsburgh. Member-at-Large (Interventional Neurology), Society of NeuroInterventional Surgery

“Always remember where you come from and how you became who you are. Don’t burn bridges.  Many invested in your career; do the same for others.”

Mohammed Almekhlafi, MD, MSc
Associate Professor, Department of Clinical Neurosciences, Radiology and Community Health Sciences. University of Calgary, Alberta, Canada.

“In the beginning, stick to your guns: the tools you know, procedures you’re familiar with, etc. Only after you establish a good record you can be adventurous! Don’t hesitate in declining the cases in which endovascular therapy is risky or inferior to other options. “No” is also an option! Keep in touch with your mentors and ask for their input on your first cases.”

Yafell Serulle, MD, PhD
Assistant Professor of Neurosurgery, Lenox Hill Hospital, New York.
Director of Neuroendovascular Surgery, Phelps Hospital/Northwell Health

“You have accomplished a lot by completing your training; now it is the time to put this knowledge at the service of your patients. Always think of patients first, Never stop learning, and surround yourself with great partners.”

L. Fernando González, MD
Professor of Neurosurgery

Cerebrovascular and Endovascular Neurosurgery, Johns Hopkins University Baltimore, Maryland

“Maintain a clear reason of why you are doing a particular intervention. Question yourself if there is a simpler, more effective alternative to do so. Value risk and determine if it is worth it. Also, find return on spending all time, devices, Resources. Ask yourself what the gain is. Always have a shortlist of alternative plans in mind. If the aneurysm ruptures, have your balloon ready or have potential next coils at short reach. Ask yourself whether the catheter you are using allows you to deliver X in case Y happens. If the microwire you are using doesn’t perform as expected, what’s your alternative? Always think of alternatives!”

Charles Matouk, MD
Associate Professor, Departments of Neurosurgery and Radiology & Biomedical Imaging Chief, Section of Neurovascular Surgery, Yale University | Yale-New Haven Hospital

“Keep patients and their loved ones in the forefront of your mind. Your relationship with them will guide you through the difficult decisions of clinical practice. Don’t be afraid to reach out to senior colleagues for sage advice — they were once where you are now. Be humble, gracious, and hungry for experience. Practicing Neurointervention is the privilege of a lifetime.”

Pascal Jabbour, MD
The Angela and Richard T. Clark Distinguished Professor and Division Chief, Neurovascular Surgery & Endovascular Neurosurgery

“If you have never seen it done, don’t do it during your first year! Run your complex cases by your senior partner and schedule them a day your partner is around. Don’t let the last complication you had affect the next case you are doing. Be open for criticism and new ideas; learning never ends!”

Shazam Hussain, MD
Associate Professor, Cleveland Clinic Lerner College of Medicine
Director, Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Ohio.

“I would tell people to be confident in their skillset and take their time to settle into their new role as an attending staff.  Usually, the first six months are the time to get to know the new facility, personnel, and, most importantly, yourself in the new role! Always be thoughtful, and if a crazy case comes your way early on, always reach out to your partners and mentors to bounce things off them.  We love to hear from our former fellows and see the successes they become!”

Dorothea Altschul, MD

Director of Neurointerventional Neurosurgery, Valley Hospital, Ridgewood, New Jersey. Social Media Assistant Editor for Journal of NeuroInterventional Surgery

“The transition from fellow to attending is a giant leap on the journey of becoming a well-balanced and independent physician. My advice is to focus on the clinical aspects of the disease, on developing your style of care and daily habits. Figure out what aspects of the field are most appealing to you, so you can progress towards doing more of that type of work as you advance in your career.”

Waleed Brinjikji, MD

Associate Professor, Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA. Editor-in-Chief, The Neuroradiology Journal.

“Take any opportunity you can to watch how your more senior partners or other neurointerventionalists around the country/world do complex cases, especially if you are interested in trying new techniques or procedures. Try to personally follow up with your patients when you can rather than relying on trainees or others -You will learn a lot more that way-. If you are working at a place that trains fellows, you should still be very hands-on during cases. You still need the reps, and your goal is a happy patient and a happy referring doc.”

Ashutosh Jadhav, MD, PhD
Vascular and Interventional Neurology at Barrow Neurological Institute, Phoenix, Arizona. Section Chair of Endovascular & Interventional Neurology Section, AAN; Editor-in-chief Journal of Stroke: Vascular and Interventional Neurology

“The first job is a great opportunity to continue growing and learning. Choose partners that will foster your development, challenge you to push the envelope, and complement your strengths and weaknesses.”

Jenny Tsai, MD
Assistant Professor of Clinical Neurosciences, Michigan State University.

Interventional and Vascular Neurology, Spectrum Health West Michigan

Diversity, Equity, and Inclusion & Young Professionals Committee Chair, SNIS

“You are just starting to perfect your art as you enter practice. Don’t take on hard cases to start; you need to build your confidence. Hold your peers and your mentors close. They will encourage you along, remind you that we all share some challenges, and guide you when you need help. Complications will happen and bring on some tough days. Be there for your patients and their families as they cope. Learn from your missteps, but remember to take care of yourself, too.”

Eytan Raz, MD, PhD
Assistant Professor, Department of Radiology at NYU Grossman School of Medicine Section of Neurointerventional Radiology, NYU Langone Health, New York.

“You have learned from your mentors throughout your fellowship, and now it is time to dedicate yourself to perfecting the art independently. With patience, go ahead and develop your way to serve your patients. It is your time to shine, but carefully and humbly. The attention to detail will make a huge difference in your practice. Be available, passionate, and enthusiastic since you are lucky enough to do the best job in the whole world.”

Fawaz Al-Mufti, MD
Vice Chair of Neurology for Research, New York Medical College
Associate Professor of Neurology, Neurosurgery and Radiology, New York Medical College and Director of the Neuro-endovascular Surgery Fellowship

“Treat your patients like you’d like your family to be treated, be compassionate, sympathize, listen and give honest advice. Neurointervention is a team sport so treat your team well, they will be there when you need them. You trained hard so in the heat of a challenging case, trust your training, remember to breathe, adapt, improvise, and roll with the punches. Always have a contingency plan, share that plan with your team. Don’t be swayed by your last case, dust yourself off, learn from your mistake and move on – remember it is the procedure not the proceduralist.”

Gabor Toth, MD
Associate Professor, Cleveland Clinic Lerner College of Medicine Director, NeuroEndovascular Fellowship, Cleveland Clinic, Ohio.

“First of all, enjoy the fruits of your labor. You should be proud; you deserve to celebrate after many challenging years of arduous training. You know a lot, but you don’t know everything. Ask for advice from your colleagues if needed. Keep learning and remember the pearls of wisdom your mentors had taught you. Patience is key, don’t try to change the world in one day. Stay humble. Be kind to your coworkers. Be curious, innovative and trust your instincts.”

James Milburn, MD
Interventional Neuroradiology at Ochsner Medical System. 
Vice-Chair of Radiology. Associate Editor of JNIS. Former Education Chair of SNIS.

“Be humble; you will learn a lot in your 1st ten years of practice. When you start a job, show respect for those who came before you.  Keep your mentors close and ask their advice often.”