Information for Vascular Neurology Fellows

Stroke & Vascular Neurology Fellowship Program at the University of Florida 2010-2011

Information for Vascular Neurology Fellows Table of Contents

TABLE OF CONTENTS

Overview ...... 1 The ACGME & Fellowship Requirements ...... 1 Job Description for the PGY V Resident in Vascular Neurology ...... 1 ACGME STATEMENT OF GOALS & OBJECTIVES FOR Vascular NEUROLOGY RESIDENCIES ...... 2 ACGME Core Competencies ...... 3 Vascular Neurology Rotations with Competency Based Goals & Objectives by Rotation ...... 4 Research & Mentorship ...... 14 Environment & Personnel ...... 14 Fellow Responsibilities ...... 14 Documentation of Experience ...... 15 Conferences...... 15 Resident Supervision ...... 15 Teaching by Residents ...... 16 Documentation of Experience ...... 16 Resident Assessment ...... 12 Resident Evaluation of Faculty & Program ...... 12 Economic, Ethical & Legal Issues ...... 13 Medicare Compliance ...... 13 Laboratory & Radiology Requests...... 14 License requirements ...... 14 Prescription requirements ...... 14 Patient Confidentiality (HIPAA) ...... 15 Institutional Policies ...... 16 Cost-awareness ...... 16 Impaired physician policy ...... 16 Sexual Harassment ...... 16 Medical-legal issues ...... 16 Quality Assurance...... 16 Duty Hours ...... 17 On-call Schedule (duty Hours) ...... 17 Outside Employment ...... 17 Vacation ...... 18 Faculty ...... 19 Facilities ...... 22

Information for Vascular Neurology Fellows Table of Contents

Hospital & Outpatient Facilities ...... 22 Administrative Offices ...... 23 Library & computer facilities ...... 23 Other computer resources...... 23 Benefits ...... 25 Insurance: ...... 25 Vacation and Leave ...... 26 Meals ...... 27 On-Call Quarters/Work Room ...... 27 Book allowance ...... 28 Travel to meetings ...... 28 Miscellaneous benefits ...... 28 Working environment ...... 28 If there are problems ...... 28 Technical Requirements for Fellows ...... 29 Gainesville & Environs ...... 30 About Gainesville ...... 30 Housing ...... 30 Recreation...... 30 Restaurants ...... 31 Attachment 1: eligibility and selection of fellows ...... 32 Attachment 2: Procedure for Grievance, Suspension, Nonrenewal or Dismissal ...... 35 Attachment 3: A Neurologist’s Guide to Using ICD-9 Codes for Cerebrovascular Diseases ...... 38 Attachment 4: Medical Cost Awareness for New Housestaff ...... 43 Attachment 5: Impaired Physicians Policy ...... 46 Attachment 6: Sexual Harrassment ...... 47 Attachment 7: Institutional Outside Employment Policy...... 49 Attachment 8: Goals and Objectives for Vascular Neurology ...... 51 Attachment 9: The ABPN Vascular Neurology Core Competencies Outline ...... 63 Attachment 10: Program responsibilities, Physician responsibilities & fellow responsibilities ...... 72 Attachment 11: Policy/procedures for duty hours ...... 75 Attachment 12: Handoff Communication Policy ...... 77 Attachment 13: Lines of supervision for vascular neurology residents/fellows ...... 84 Attachment 14: Policy on fellow work environment ...... 86 Attachment 15: Policy on outside employment/moonlighting within the fellowship program ...... 87 Attachment 16: policy on promotion & graduation...... 89

Information for Vascular Neurology Fellows Overview telemedicine, multimodality stroke imaging and OVERVIEW observational interventional neuroradiology. Interventional techniques include, but are not The University of Florida’s Stroke and limited to, intra-arterial tPA, acute angioplasty and Neurovascular Fellowship is a one-year training stenting, MERCI mechanical thrombectomy, and program designed to provide comprehensive, state- Penumbra aspiration thrombectomy. Fellows will of-the-art clinical and research training and a fully participate in structured clinical trials and will have competitive academic background. Physicians who the opportunity to develop/participate in ongoing have completed training in Neurology may elect to investigator-driven studies in clinical research. The engage in additional training in Vascular Neurology PGY V Vascular Neurology fellow works in close in order to receive intensive clinical and research conjunction with faculty expert in these procedures. training in ischemic and hemorrhagic PGY V fellows are expected to be competent in skills cerebrovascular disease including acute stroke, learned during the core residency training. Written stroke prevention, ultrasonography (including TCD faculty evaluations are required quarterly, and a and duplex scans), cardiac imaging, intensive care written summary and formative evaluation will be stroke management, remote stroke telemedicine, provided by the Program Director after the first six multimodality stroke imaging and observational months. A summative evaluation will be provided interventional neuroradiology. Interventional at the conclusion of the one year training program. techniques include, but are not limited to, intra- Conferences, Teaching and Research: The PGY V arterial tPA, acute angioplasty and stenting, MERCI Vascular Neurology fellow will attend regularly held mechanical thrombectomy, and Penumbra aspiration thrombectomy. Fellows will participate Vascular Neurology conferences and Neurology conferences, and will be responsible for organizing in structured clinical trials and will have the monthly teaching conferences for Neurology opportunity to develop/participate in ongoing Residents and students. The fellow will also investigator-driven studies in clinical research. participate in the education of Neurology Residents rotating on the Vascular Neurology service. The THE ACGME & FELLOWSHIP Vascular Neurology Fellow is encouraged to REQUIREMENTS participate in faculty research and to present at departmental, local and national meetings. The requirements for Vascular Neurology Residency Programs are set by the Accreditation Evaluation: The PGY V Vascular Neurology fellow Council for Graduate Medical Education (ACGME), is expected to demonstrate competency in patient and are enforced by periodic reviews of the care as demonstrated by their ability to assess and programs by the ACGME’s Residency Review Com- manage patients on the in-and out-patient Vascular mittees (RRCs). Current ACGME requirements can Neurology services. Competency in medical be found at the ACGME’s website, www.acgme.org. knowledge of Vascular Neurology will be assessed Our program was fully accredited in 2009. in the course of one-on-one faculty supervision as described above. Practice-based learning and improvement will be assessed by the expectation JOB DESCRIPTION FOR THE PGY V for fellows to research relevant literature, organize RESIDENT IN VASCULAR NEUROLOGY teaching conferences for residents, and develop scientific presentations. Interpersonal and PGY V – Fellowship Training: Physicians who communication skills and professionalism will be have completed training in Neurology may elect to assessed on the basis of close faculty supervision, engage in additional training in Vascular Neurology by evaluation by Neurology residents and students, in order to receive intensive clinical and research by review of the fellow’s written and dictated training in ischemic and hemorrhagic reports, and by 360: evaluations by office, clinic and cerebrovascular disease including acute stroke hospital staff. The fellow is expected to follow treatment, stroke prevention, ultrasonography hospital policies and procedures at all time, to (including TCD and duplex scans), cardiac imaging, respect the integrity of the patient, and to work intensive care stroke management, remote stroke exclusively to further the health of his/her patients.

Information for Vascular Neurology Fellows Overview Systems-based practice will be fostered by Be able to take a detailed history including discussions of the roles of Vascular Neurology in vascular risk factors of the stroke patient clinical practice, including such issues as and perform the NIHSS. reimbursement and the ethical and cost-effective Articulate neuroanatomy as it applies to use of diagnostic tests and procedures. It is also localization of symptoms of stroke. expected that residents who complete training will that the American Board of Psychiatry and Be facile with current stroke therapies Neurology’s Examination with Additional available for the stroke patient presenting Qualifications in Vascular Neurology. within therapeutic time windows. Participate in clinical trials and basic research for treatment of cerebrovascular ACGME STATEMENT OF GOALS & disease. OBJECTIVES FOR VASCULAR Participate in teaching neurology residents NEUROLOGY RESIDENCIES and students regarding stroke evaluation The goal of the Vascular Neurology Fellowship is to and management. provide comprehensive training in the diagnosis Understand neurointerventional and management of patients with a wide spectrum approaches in the treatment of stroke of cerebrovascular disease, and comprehensive patients. training in researching a wide spectrum of Utilize appropriate neuroimaging cerebrovascular diseases. Emphasis will be placed techniques in the diagnosis and evaluation on education and development of skills required for of stroke: the management of patients with cerebrovascular o Magnetic Resonance Imaging (MRI) disease. During the one year period of training the o MRI Diffusion- weighted Imaging Vascular Neurology Fellow will be trained in the (DWI) following areas of vascular neurology: o MRI Perfusion-weighted Imaging Ability to provide a detailed history and (PWI) neurological examination of the stroke o MRI SPECT patient including the use of het National o MR Angiography (MRA) Institute of Health Stroke Scale (NIHSS) o Computed Tomographic (CT) scans Scoring System. . Heat CT Treatment of stroke patients in both in- . CT Angiography (CTA) patient and out-patient settings. . CT Perfusion (CTP) Training in management of cerebrovascular Be facile with ultrasound techniques patients in the intensive care unit. including carotid duplex Doppler and Appropriate use of neuroimaging transcranial Doppler in the assessment of techniques such as CT, MRI, CT Perfusion, the stroke patient: and CT angiography. o Carotid duplex Doppler Appropriate use of ultrasound techniques o Normal carotid U/S including carotid duplex Doppler and o Carotid U/S detection of stenosis transcranial Doppler for diagnosis and o Carotid U/S detection of treatment of stroke patients. occlusion/dissection Involvement in clinical trials and research o Transcranial Doppler (TCD) related to cerebrovascular disease. o Ability to do 16 vessel TCD o TCD normal flow velocities By the end of their training period, the Vascular o Use of continuous TCD for emboli Neurology Fellow is expected to: detection

o Use of TECT to detect PFO

Information for Vascular Neurology Fellows Overview o Use of TCD adjunctive therapy for 8. Participate in the education of patients, families, thrombolytics students, residents and other health professionals

Fellows are expected to have developed Interpersonal and Communication Skills: competencies in the six core competencies Fellows must demonstrate interpersonal and designated by the ACGME during their neurology communication skills that result in the effective residency. During the vascular neurology training exchange of information and collaboration with patients, their families, and health professionals. fellows are expected to develop competencies in Fellows are expected to: these six areas as they apply to this specialty. The ACGME core competencies are listed below. The 1. Communicate effectively with patients, families, specific areas of patient care and medical and the public, as appropriate, across a broad knowledge as they apply to vascular neurology, and range of socioeconomic and cultural backgrounds the particular skills and knowledge that apply to the 2. Communicate effectively with physicians, other other competencies, are detailed in the narrative health professionals, and health related agencies that follows this section. 3. Work effectively as a member or leader of a health care team or other professional group 4. Act in a consultative role to other physicians and ACGME CORE COMPETENCIES health professionals 5. Maintain comprehensive, timely, and legible Patient Care: Fellows must be able to provide medical records patient care that is compassionate, appropriate, and effective for the treatment of health problems and the Professionalism: Fellows must demonstrate a promotion of health. commitment to carrying out professional responsibilities and an adherence to ethical principles. Medical Knowledge: Fellows must demonstrate Fellows are expected to demonstrate: knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral 1. Compassion, integrity, and respect for others sciences, as well as the application of this knowledge 2. Responsiveness to patient needs that supersedes to patient care. self-interest 3. Respect for patient privacy and autonomy Practice-Based Learning and Improvement: 4. Accountability to patients, society and the Interpersonal and Communication Skills: profession Fellows must demonstrate the ability to investigate 5. Sensitivity and responsiveness to a diverse patient and evaluate the care of patients, to appraise and population, including but not limited to diversity assimilate scientific evidence, and to continuously in gender, age, culture, race, religion, disabilities, improve patient care based on constant self-evaluation and sexual orientation and life-long learning. Fellows are expected to develop skills and habits to be able to meet the Systems-Based Practice: Fellows must following goals: demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as 1. Identify strengths, deficiencies, and limits in one’s the ability to call effectively on other resources in the knowledge and expertise system to provide optimal health care. Fellows are 2. Set learning and improvement goals expected to: 3. Identify and perform appropriate learning activities 1. Work effectively in various health care delivery 4. Systematically analyze practice using quality settings and systems relevant to their clinical improvement methods, and implement changes specialty with the goal of practice improvement 2. Coordinate patient care within the health care 5. Incorporate formative evaluation feedback into system relevant to their clinical specialty daily practice 3. Incorporate considerations of cost awareness and 6. Locate, appraise, and assimilate evidence from risk-benefit analysis in patient and/or population- scientific studies related to their patients’ health based care as appropriate problems 4. Advocate for quality patient care and optimal 7. Use information technology to optimize learning patient care systems

Information for Vascular Neurology Fellows Overview 5. Work in inter-professional teams to enhance communication skills that result in the effective patient safety and improve patient care quality exchange of information and collaboration with 6. Participate in identifying system errors and patients, their families, and health professionals. implementing potential systems solutions Fellows are expected to: 1. Communicate effectively with patients, families, and the public, as appropriate, across VASCULAR NEUROLOGY ROTATIONS a broad range of socioeconomic and cultural WITH COMPETENCY BASED GOALS & backgrounds OBJECTIVES BY ROTATION 2. Communicate effectively with physicians, other health professionals, and health related agencies Overall Competency-based Program Goals: 3. Work effectively as a member or leader of a

health care team or other professional group Core Competencies: 4. Act in a consultative role to other physicians and health professionals Patient Care: Fellows must be able to provide 5. Maintain comprehensive, timely, and legible patient care that is compassionate, appropriate, and medical records effective for the treatment of health problems and the promotion of health. Professionalism: Fellows must demonstrate a commitment to carrying out professional Medical Knowledge: Fellows must demonstrate responsibilities and an adherence to ethical knowledge of established and evolving biomedical, principles. Fellows are expected to demonstrate: clinical, epidemiological and social-behavioral 1. Compassion, integrity, and respect for others sciences, as well as the application of this 2. Responsiveness to patient needs that knowledge to patient care. supersedes self-interest 3. Respect for patient privacy and autonomy Practice-Based Learning and Improvement: 4. Accountability to patients, society and the Interpersonal and Communication Skills: Fellows profession must demonstrate the ability to investigate and 5. Sensitivity and responsiveness to a diverse evaluate the care of patients, to appraise and patient population, including but not limited assimilate scientific evidence, and to continuously to diversity in gender, age, culture, race, improve patient care based on constant self- religion, disabilities, and sexual orientation evaluation and life-long learning. Fellows are expected to develop skills and habits to be able to Systems-Based Practice: Fellows must meet the following goals: demonstrate an awareness of and responsiveness to 1. Identify strengths, deficiencies, and limits in the larger context and system of health care, as well one’s knowledge and expertise as the ability to call effectively on other resources in 2. Set learning and improvement goals the system to provide optimal health care. Fellows 3. Identify and perform appropriate learning are expected to: activities 1. Work effectively in various health care 4. Systematically analyze practice using quality delivery settings and systems relevant to their improvement methods, and implement clinical specialty changes with the goal of practice improvement 2. Coordinate patient care within the health care 5. Incorporate formative evaluation feedback system relevant to their clinical specialty into daily practice 3. Incorporate considerations of cost awareness a. Locate, appraise, and assimilate evidence and risk-benefit analysis in patient and/or from scientific studies related to their population-based care as appropriate patients’ health problems 4. Advocate for quality patient care and optimal 6. Use information technology to optimize patient care systems learning 5. Work in inter-professional teams to enhance a. Participate in the education of patients, patient safety and improve patient care families, students, residents and other quality health professionals 6. Participate in identifying system errors and implementing potential systems solutions Interpersonal and Communication Skills: Fellows must demonstrate interpersonal and

Information for Vascular Neurology Fellows Overview Overall Program Goals: fellow will encounter a wide variety of 1. To prepare the physician for the independent cerebrovascular pathology and will interact with practice of vascular neurology by providing the multidisciplinary team including training based on supervised clinical work with neuroradiologists, neurosurgeons, and Critical Care increasing responsibility for outpatients and Medicine. The patient care experience will be inpatients. This training will be separate and supplemented with practical and didactic teaching distinct from the training required for sessions. The fellow will also take part in the certification in general and pediatric neurology. monthly journal club which includes discussions on (Competencies Addressed: Patient Care, stroke topics. The resident will also take part in Medical Knowledge) weekly Neurology Grand Rounds, weekly 2. To provide a foundation for evidence-based Neuroscience Seminar, weekly medicine to facilitate the interpretation and Neuroradiology/Neuropathology Case Conference, implementation of clinical research in vascular neurology. (Competencies Addressed: Medical monthly Neurovascular Case Conference, monthly Knowledge, Practice Based Learning and Stroke Lecture Series, and monthly journal club Improvement) discussions of stroke topics. 3. To provide an opportunity to develop an investigative career in vascular neurology. Rotation Goals: (Competencies Addressed: Medical Knowledge) • Perform detailed neurological histories and 4. To provide a basic understanding of physical examinations of stroke patients. ultrasonography and establish familiarity with (Competencies Addressed: Patient Care, performing and interpreting vascular imaging Medical Knowledge, Practice-Based Learning studies. (Competencies Addressed: Medical and Improvement, Interpersonal and Knowledge) Communication Skills, Professionalism, 5. To develop the many personal attributes Systems-Based Practice) necessary for becoming an effective physician, • Understand the indications and basic including honesty, compassion, reliability, and interpretation of diagnostic brain imaging for effective written and oral communication skills. stroke. (Competencies Addressed: Patient (Competencies Addressed: Interpersonal and Care, Medical Knowledge, Practice-Based Communication Skills, Professionalism) Learning and Improvement, Systems-Based 6. To gain teaching skills by educating and Practice) supervising residents and medical students • Understand the clinical evaluation and rotating on the inpatient stroke service at treatment of acute stroke. (Competencies Shands Hospital at the University of Florida. (Competencies Addressed: Practice Based Addressed: Patient Care, Medical Knowledge, Learning and Improvement, Interpersonal and Practice-Based Learning and Improvement, Communication Skills, Systems Based Practice) Interpersonal and Communication Skills, 7. To participate in both clinical and educational Professionalism, Systems-Based Practice) activities (both hospital and community based) • Understand the pathophysiology, diagnosis that relate to stroke and stroke prevention. and management of common neurovascular (Competencies Addressed: Patient Care, disorders, including: ischemic stroke, Interpersonal and Communication Skills, hemorrhagic stroke, subarachnoid Systems Based Practice) hemorrhage, and other cerebrovascular malformations. (Competencies Addressed: Name of Rotation: Vascular Neurology Inpatient Patient Care, Medical Knowledge, Practice- Care Based Learning and Improvement, Supervisor: Michael F. Waters, MD, PhD Interpersonal and Communication Skills, Rotation Length: 6 months Professionalism, Systems-Based Practice) • Understand secondary stroke prevention Rotation Description: Vascular neurology measures. (Competencies Addressed: Patient inpatient care includes patients on the Neuro ICU, Care, Medical Knowledge, Practice-Based Neuro IMC, and Stroke Unit, as well as the Learning and Improvement) emergency department and other service floors • Opportunity to observe neurointerventional housing stroke patients with other comorbidities. cases and visit the OR. (Competencies The fellow will be responsible for inpatients on Addressed: Medical Knowledge, Practice- these services, and will follow patients from Based Learning and Improvement, admission through treatment and discharge. The 5

Information for Vascular Neurology Fellows Overview Interpersonal and Communication Skills, Interdisciplinary Working Group; Professionalism, Systems-Based Practice) Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, Rotation Objectives: and Metabolism Council; and the Quality of Care • Gain an understanding of the neuroanatomy and Outcomes Research Interdisciplinary and pathophysiology of acute cerebrovascular Working Group. The American Academy of disease. (Competencies Addressed: Patient Neurology affirms the value of this guideline. Care, Medical Knowledge) (STROKE. 2006;37:1583.) • Develop clinical skills in recognizing acute stroke syndromes. (Competencies Patrono C, Coller B, FitzGerald G, Hirsh J, and Roth Addressed: Patient Care, Medical Knowledge, G. Platelet-Active Drugs: The Relationships Practice-Based Learning and Improvement, Among Dose, Effectiveness, and Side Effects – Interpersonal and Communication Skills, The Seventh ACCP Conference on Professionalism, Systems-Based Practice) Antithrombotic and Throbolytic Therapy. Chest. • Learn basic strategies for management of 2001 Jan;119(1 Suppl):39S-63S. stroke patients. (Competencies Addressed: Fisher, Marc. Approaches to Cerebrovascular Patient Care, Medical Knowledge, Practice- Disease. Barcelona, Spain: Prous Science, 2006. Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Name of Rotation: Vascular Neurology Outpatient Care Bibliography/Study List: Supervisor: Anna Khanna, M.D. Rotation Length: 4 ½-day clinics per month for Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P. 12 months Antithrombotic and thrombolytic therapy for ischemic stroke: the Seventh ACCP Conference Rotation Description: The Neurovascular on Antithrombotic and Thrombolytic Therapy. Outpatient Clinic provides follow-up care and initial Chest 2004; 126(3 Suppl): 483S-512S. evaluation for cerebrovascular patients, ongoing management of stroke risk factors, and evaluation Adams H, Zoppo G, Alberts M, Bhatt D, Brass L, and care of disabilities caused by prior strokes, Furlan A, Grubb R, Higashida R, Jauch E, Kidwell including physical, cognitive and psychological C, Lyden P, Morgenstern L, Qureshi A, problems. The goal of this rotation is to familiarize Rosenwasser R, Scott P, and Wijdicks E. fellows with the spectrum of patient care challenges Guidelines for the Early Management of Adults that arise in an outpatient setting. The fellow will with Ischemic Stroke: A Guideline from the independently evaluate patients, present their American Heart Association/American Stroke findings and propose a management plan to an Association Stroke Council, Clinical Cardiology attending physician, see the patient with an Council, Cardiovascular Radiology and attending to clarify salient history and examination Intervention Council, and the Atherosclerotic features, and implement the final management plan Peripheral Vascular Disease and Quality of Care jointly developed with the attending physician. It is Outcomes in Research Interdisciplinary encouraged that patients seen in the outpatient Working Groups: The American Academy of clinic be followed in the fellow’s continuity clinic. Neurology affirms the value of this guideline as The fellow will order and follow-up on test results an educational tool for neurologists. Stroke. related to the management plan, and communicate 2007 May;38(5):1655-711. Epub 2007 Apr 12. these test results to the patient. Practical and didactic teaching sessions will supplement the Goldstein L, Adams R, Alberts M, Appel L, Brass L, patient care experience. The resident will also take Bushnell C, Culebras A, DeGraba T, Gorelick P, part in weekly Neurology Grand Rounds, weekly Guyton J, Hart R, Howard G, Kelly-Hayes M, Neuroscience Seminar, weekly Nixon JV, Sacco R. AHA/ASA Guideline: Neuroradiology/Neuropathology Case Conference, Primary Prevention of Ischemic Stroke – A monthly Neurovascular Case Conference, monthly Guideline from the American Heart Stroke Lecture Series, and monthly journal club Association/American Stroke Association discussions of stroke topics. Stroke Council; Cosponsored by the Atherosclerotic Peripheral Vascular Disease 6

Information for Vascular Neurology Fellows Overview Rotation Goals: question posed by the referring physician or • Learn the neurologic significance of symptoms, clearly communicate how further evaluation or signs, and test results for cerebrovascular management by the referring physician should disorders seen in outpatients. (Competencies proceed. (Competencies Addressed: Patient Addressed: Patient Care, Medical Knowledge, Care, Medical Knowledge, Practice-Based Practice-Based Learning and Improvement) Learning and Improvement, Interpersonal and • Develop neurologic history and examination Communication Skills, Professionalism) skills that facilitate eliciting pertinent clinical • Learn to elicit key aspects of the history and information in the time-limited fashion that is exam that enable initial management to proceed germane to the outpatient service. in a timely fashion required in an outpatient (Competencies Addressed: Patient Care, practice. (Competencies Addressed: Patient Medical Knowledge, Practice-Based Learning Care, Medical Knowledge, Practice-Based and Improvement, Interpersonal and Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Communication Skills, Professionalism, Systems-Based Practice) Systems-Based Practice) • Understand how to translate the medical • Learn the common pharmacologic and non- significance of symptoms, signs, test results, pharmacologic treatment options for diagnoses, and management plans into language management of common and treatable stroke that patients and families can understand. risk factors and disabilities. (Competencies (Competencies Addressed: Patient Care, Addressed: Patient Care, Medical Knowledge, Medical Knowledge, Practice-Based Learning Practice-Based Learning and Improvement, and Improvement, Interpersonal and Systems-Based Practice) Communication Skills, Professionalism) • Communicate test results and their significance • Understand the anatomic localization of specific to patients, and discuss test results of uncertain neurologic and cerebrovascular symptoms and significance with attending staff. signs. (Competencies Addressed: Medical (Competencies Addressed: Patient Care, Knowledge, Practice-Based Learning and Medical Knowledge, Practice-Based Learning Improvement) and Improvement, Interpersonal and • Learn the appropriate use of common Communication Skills, Professionalism) pharmacologic and non-pharmacologic • Learn how to develop a neuroanatomic treatments for stroke prevention and treatment localization of patient-specific symptoms and of disabilities caused by cerebrovascular events. signs, and an initial differential diagnosis to (Competencies Addressed: Patient Care, discuss with the supervising outpatient Medical Knowledge, Practice-Based Learning attending. (Competencies Addressed: Patient and Improvement) Care, Medical Knowledge, Practice-Based • Seek to understand the impact of chronic Learning and Improvement, Interpersonal and disability caused by stroke on the daily lives of Communication Skills) outpatients and their families. (Competencies Addressed: Patient Care, Medical Knowledge, Bibliography/Study List: Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Stroke Rehabilitation: A Function-Based Approach Professionalism, Systems-Based Practice) by Glen Gillen EdD OTR FAOTA and Ann Burkhardt MA OTD OTR/L BCN FAOTA (April Rotation Objectives: 27, 2004) • Learn to translate your understanding of the medical significance of symptoms, signs, test Stroke Recovery and Rehabilitation by Joel Stein results, diagnoses, and management plans into (Dec 1, 2008) language that patients and families can understand. (Competencies Addressed: Patient Stroke (American Academy of Neurology) by Louis Care, Medical Knowledge, Practice-Based R. Caplan (Oct 1, 2005) by J. P. Mohr, Dennis Learning and Improvement, Interpersonal and Choi, James Grotta, and Philip Wolf Communication Skills, Professionalism) • Learn how to dictate outpatient letters that Acute Ischemic Stroke: An Evidence-based reflect an understanding of the reason(s) for Approach by David M. Greer (Oct 5, 2007) consultation and either answer the clinical 7

Information for Vascular Neurology Fellows Overview Stroke: A Practical Approach by James D Geyer and disorders, including: ischemic stroke, Camilo R Gomez (Sep 1, 2008) hemorrhagic stroke, subarachnoid hemorrhage, and other cerebrovascular malformations. (Competencies Addressed: Name of Rotation: Neurocritical Care Patient Care, Medical Knowledge, Practice- Supervisor: Andrea Gabrielli, MD, FCCM Based Learning and Improvement, Rotation Length: 4 weeks (1 month) Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Rotation Description: The Neurovascular ICU • Understand patient management after service will care for cerebrovascular patients in the neurosurgical and interventional procedures. adult neurocritical care unit. The Vascular (Competencies Addressed: Patient Care, Neurology fellow will be an integral part of the Medical Knowledge, Practice-Based Learning neurocritical care team. S/he will round on all and Improvement, Interpersonal and inpatients in the critical care unit and be personally Communication Skills, Professionalism, responsible for any acute stroke admissions. Systems-Based Practice) Patient care will also include the performance of Transcranial Doppler ultrasound if needed. The Rotation Objectives: fellow will have responsibility for and follow • Gain an introduction to the neuroanatomy patients from admission through treatment and and pathophysiology of acute cerebrovascular discharge from the ICU. A wide variety of acute disease. (Competencies Addressed: Patient cerebrovascular problems will be encountered and Care, Medical Knowledge) the resident will interact with the multidisciplinary • Develop clinical skills in managing team including vascular neurosurgeons and neurological emergencies. (Competencies neurointerventionalists. Practical and didactic Addressed: Patient Care, Medical Knowledge, teaching sessions will supplement the patient care Practice-Based Learning and Improvement, experience. Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Rotation Goals: • Learn basic strategies for management of • Perform a detailed neurological history and blood pressure in the ICU. (Competencies physical exam of critically ill patients. Addressed: Patient Care, Medical Knowledge, (Competencies Addressed: Patient Care, Practice-Based Learning and Improvement) Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Bibliography/Study List: Communication Skills, Professionalism) • Understand the indications and basic Burchardi, H., Aims of Sedation/Anesthesia. interpretation of monitoring and diagnostic Minerva Anetesiol 2004 70:137-43. testing in the ICU. (Competencies Addressed: Gehlbach, B. K., and J. P. Kress, Sedation in the Patient Care, Medical Knowledge, Practice- intensive care unit. Curren Opinion in Critical Based Learning and Improvement) Care, 2001. 8:290-8. • Understand and practice management of blood pressure in the NICU. (Competencies Hogarth, D. K., and J. Hall, Management of sedation Addressed: Patient Care, Medical Knowledge, in mechanically ventilated patients. Current Practice-Based Learning and Improvement, Opinon in Critical Care, 2004. 10:40-6. Interpersonal and Communication Skills, Inouye, S. K., Delirium in older persons. New Professionalism) England Journal of Medicine, 2006. 354:1157- • Understand the clinical evaluation and 65. treatment of neurological emergencies in the ICE, i.e. coma, hypertensive crisis, malignant Inouye, S. K., et al., A multicomponent intervention stroke, cerebral edema, etc. (Competencies to prevent delirium in hospitalized older Addressed: Patient Care, Medical Knowledge, patients. New England Journal of Medicine, Practice-Based Learning and Improvement, 1999. 340:669-76. Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Kistler, J. P., A. H. Ropper, and R. C. Heros, Therapy • Understand the pathophysiology, diagnosis of ischemic cerebral vascular disease due to and management of common neurovascular 8

Information for Vascular Neurology Fellows Overview atherothrombosis. (1). New England Journal of Rotation Goals & Objectives: Medicine, 1984. 311(1): p. 27-34. The overall intent of the elective is to provide trainees with specific knowledge of clinical utility, Kistler, J. P., A. H. Ropper, and R. C. Heros, Therapy interpretation, and standards of performance of of ischemic cerebral vascular disease due to neuroimaging studies. Goals include acquiring atherothrombosis. (2). New England Journal of specific skills to perform/interpret neuroimaging Medicine, 1984. 311(2): p. 100-5. studies. The ICU Fellow should develop knowledge of technical aspects, indications, and interpretation Le Roux, P. D., et al., Predicting outcome in poor- of commonly used neuroimaging studies. Two grade patients with subarachnoid hemorrhage: different objectives may be accomplished: a retrospective review of 159 aggressively 1. To acquire expertise in all clinical and basic managed cases. Journal of Neurosurgery, 1996. aspects of a given modality including 85(1): p. 39-49. research, indications, performance and interpretation of imaging studies of a given Maybert, M.R., et al., Guidelines for the management disorder (e.g., stroke) by working in the of aneurismal subarachnoid hemorrhage. A neuroICU. statement for healthcare professionals from a 2. The recognition of herniation syndromes by special group of the Stroke Council, American CT scan, including subfalcine, transtentorial, Heart Association. Stroke, 1994. 25 (11): p. and tonsillar herniations, brain edema 2315-28. recognition by CT scan and MRI, intracranial hemorrhage, principles of cerebral angiogram Sloan, M. A., et al., Sensitivity and specificity of recognition, perfusion scans, spine x-rays – transcranial Doppler ultrasonography in the recognition of bone injuries and spine MRI – diagnosis of vasospasm following subarachnoid recognition of soft tissue injuries. hemorrhage. Neurology, 1989. 39(11): P. 1514-8. Patient Care Neuroimaging is best learned as an integrated Tissue plasminogen activator for acute ischemic aspect of the clinical care of patients. More in-depth stroke. The National Institute of Neurological neuroimaging through formal preceptorships and Disorders and Stroke rt-PA Stroke Study Group. rotations at neuroimaging centers is also desirable. New England Journal of Medicine, 1995. The rotating Fellows should be able to review the 333(24): p. 1581-7. neuroimaging studies of their own patients and document their interpretation. Their evaluation should be checked against the interpretation of an Name of Rotation: Neuro Radiology attending neurologist, neurointensivist, or Supervisor: Keith Peters, MD neuroradiologist. However, it is expected than the Rotation Length: 4-6 weeks (1 -1 ½ months) rotating fellow will spend most of his/ her elective time with the neruroradiologist attendings Rotation Description: Neuroimaging plays a reviewing images major role in the evaluation of patients with neurologic disorders. The utility of various Medical Knowledge neuroimaging studies is rapidly increasing in both The Fellow will acquire skill in correlating clinical and research settings. Fellows rotating neuroimaging data with clinical, anatomic, and should focus their learning beyond their rotation in pathologic data and apply this knowledge to clinical the neuroICU to the technical aspects, indications, problem-solving, clinical decision-making, and and interpretation of these studies. The major critical thinking. Furthermore he/she will neuroimaging modalities include computed participate in neurology, neurosurgery, tomography (CT), magnetic resonance imaging neuropathology, and neuroimaging/neuroradiology (MRI), single photon emission computed conferences, especially those with multidisciplinary tomography (SPECT), positron emission participation related to neuroradiology. tomography (PET), carotid and transcranial ultrasound as well as interventional neuroimaging, Practice-Based Learning and Improvement Interventional neuroimaging procedures include 1. Lectures catheter angiography and myelography. 2. Individual interpretation session of highly representative cases (a teaching file). 9

Information for Vascular Neurology Fellows Overview 3. Daily self-studies of course materials and 4. Use information technology or other available reference textbooks or papers (acquiring methodologies to access and manage knowledge of basic principles, applied information, support patient care decisions, anatomy, pathophysiology, diagnostic criteria, and enhance both patient and physician and clinical applications). education. 4. Daily interpretation sessions with neuroradiologist Neuroradiology Faculty Coordinator: Dr. Keith 5. Weekly conferences with faculty (discussion Peters, Department of Neuroradiology. of current cases, Q&A, differential diagnosis). CCM Faculty Oversight: Dr. Andrea Gabrielli ( CCM Anesthesiology), Dr Philip Efron ( CCM Surgery) Interpersonal and Communication Skills Vascular Neurology Faculty Oversight: Dr Michael ICU Fellows rotating in neuroradiology are Waters (Vascular Neurology) expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with Name of Rotation: Neurorehabilitation patients, families, and other members of the health Inpatient Care care team. They will provide effective and Supervisor: James Atchison, DO professional consultation to other physicians and Rotation Length: 2 weeks ( ½ month) health care professionals and sustain therapeutic and ethically sound professional relationships with Rotation Description: The neurorehabilitation patients, their families and colleagues, use effective inpatient care services, located at Shands Rehab listening, nonverbal, questioning, and narrative Hospital, provides care for patients recovering from skills to communicate with patients and families, stroke. The fellow will study the application and interact with consultants in a respectful, benefits of various neurorehabilitation techniques appropriate manner and maintain comprehensive, and gain clinical experience managing patients in timely, and legible medical records. the acute recovery phase of recovery following stroke. The fellow will learn how to functionally Professionalism assess patients post-stroke and prescribe a The rotating Fellow is expected to demonstrate therapeutic program. S/he will also become behaviors that reflect a commitment to continuous familiar with the post-acute phase of recovery from professional development, ethical practice methods, neurologic injury, including community reentry, an understanding and sensitivity to diversity and a driving evaluations, vocational assessment and responsible attitude toward their patients, their retraining. The fellow will become familiar with the professional, and society, demonstrate respect, use of neuroimaging techniques such as the head CT compassion, integrity and altruism in relationships and MRI in neurorehabilitation. The fellow will with patients, families and colleagues, demonstrate learn about neuropsychological assessment of sensitivity and responsiveness to gender, age, cognitive domains and the role of culture, religion, sexual preference, socioeconomic neuropsychological testing in rehabilitation status, beliefs, behaviors and disabilities of patients practice. S/he will learn the principles of cognitive and professional colleagues, adhere to principles of rehabilitation and behavioral management. The confidentiality, scientific/academic integrity, and fellow will also learn neuropharmacologic informed consent and recognize and identify management. The fellow will become proficient deficiencies in peer performance. with the use of commonly use used functional assessment measures and gain experience with the System-Based Practice prescription of assistive and adaptive equipment. 1. Identify areas for improvement and Outcome predictors will be studied, along with implement strategies to enhance knowledge, follow-up care services for the neurologic patient. skills, attitudes and processes of care. This rotation will be full time for a duration of 6 2. Analyze and evaluate practice experiences weeks. During this rotation the fellow will not take and implement strategies to continually part in weekly Neurology Grand Rounds, weekly improve the quality of patient practice. Neuroscience Seminar, weekly 3. Develop and maintain a willingness to learn Neuroradiology/Neuropathology Case Conference, from experience and use experience to monthly Neurovascular Case Conference, monthly improve the system or processes of care. Stroke Lecture Series, however s/he will take part

Information for Vascular Neurology Fellows Overview in the monthly journal club discussions of stroke Rotation Objectives: topics. • Know the treatment options for neuropathic pain. (Competencies Addressed: Patient Rotation Goals: Care, Medical Knowledge, Practice-Based • Develop skills in the diagnosis and Learning and Improvement, Systems-Based management of common complications post Practice) stroke such as hemiplegia, hemiparesis, • Know the neurorehabilitation assistive dysphagia, ataxia, paresthesia, neuropathic devices used to enhance mobility and ADL pain, aphasia, anosognisia, neglect, apraxia, performance. (Competencies Addressed: and depression. (Competencies Addressed: Patient Care, Medical Knowledge, Practice- Patient Care, Medical Knowledge, Practice- Based Learning and Improvement, Based Learning and Improvement, Interpersonal and Communication Skills, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Professionalism, Systems-Based Practice) • Participate in dysphagia evaluation, including • Understand the general principles of the modified barium swallow. (Competencies neurorehabilitation and neuroplasticity in the Addressed: Patient Care, Medical Knowledge, nervous system as it relates to patients with Practice-Based Learning and Improvement, neurological disabilities and the roles of Interpersonal and Communication Skills, physical therapy, occupational therapy, and Professionalism, Systems-Based Practice) speech therapy in managing neurological • Understand basic stroke rehabilitation. problems. (Compentencies Addressed: (Competencies Addressed: Patient Care, Patient Care, Medical Knowledge, Medical Knowledge, Practice-Based Learning Interpersonal and Communication Skills, and Improvement, Interpersonal and Professionalism, Systems-Based Practice) Communication Skills, Professionalism, • Understand the principles of chronic pain Systems-Based Practice) management, including the management of • Develop skills in therapeutic prescription neuropathic pain. (Competencies Addressed: writing and functional goal setting. Patient Care, Medical Knowledge, Practice- (Competencies Addressed: Patient Care, Based Learning and Improvement, Medical Knowledge, Practice-Based Learning Interpersonal and Communication Skills, and Improvement, Interpersonal and Professionalism, Systems-Based Practice) Communication Skills, Professionalism, • Understand approaches toward the Systems-Based Practice) evaluation and management of the aphasias • Understand when to refer for and dysphagias. (Compentencies Addressed: neuropsychological testing and what the Patient Care, Medical Knowledge, results of the testing mean. (Competencies Interpersonal and Communication Skills, Addressed: Patient Care, Medical Knowledge, Professionalism, Systems-Based Practice) Practice-Based Learning and Improvement, • Gain exposure to orthotics and Interpersonal and Communication Skills, adaptive/assistive equipment applications in Professionalism, Systems-Based Practice) the neurorehabilitative population. • Learn approaches toward cognitive (Competencies Addressed: Patient Care, remediation. (Competencies Addressed: Medical Knowledge, Interpersonal and Patient Care, Medical Knowledge, Practice- Communication Skills, Professionalism, Based Learning and Improvement, Systems-Based Practice) Interpersonal and Communication Skills, • Become familiar with the more commonly Professionalism, Systems-Based Practice) used functional assessment tools and • Learn how to approach return to work and predictors of functional outcome. driving safety issues following stroke. (Competencies Addressed: Patient Care, (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning Medical Knowledge, Interpersonal and and Improvement, Interpersonal and Communication Skills, Professionalism, Communication Skills, Professionalism, Systems-Based Practice) Systems-Based Practice)

Information for Vascular Neurology Fellows Overview Bibliography/Study List: • The Fellow will be allowed to scrub and may participate in surgical procedures under the AAN Continuums Series – American Academy of supervision of the Neurosurgery Chief Neurology Resident or Faculty.

Gordon et al. Physical Activity and Exercise Neurosurgery Outpatient: Recommendations for Stroke Survivors. An • The Vascular Neurology fellow will see American Heart Association Scientific outpatients under the supervision of the Statement from the Council on Clinical faculty and will participate in pre and post- Cardiology, Subcommittee on Exercise, Cardiac operative neurosurgical evaluation. Rehabilitation, and Prevention; the Council on Rotation Goals: Cardiovascular Nursing; the Counsel on • Perform an efficient initial assessment of Nutrition, Physical Activity, and Metabolism; patients with neurosurgical disease, including and the Stroke Council. Circulation 2004; history and physical examination. 109:2031-41. (Competencies Addressed: Patient Care) • Formulate a rational surgical intervention Stroke Rounds Series – Abrams, Stroke plan for patients with increased ICP, Rehabilitation 2004 subarachnoid hemorrhage, unruptured aneurysm, ICH, sinus thrombosis, or AVM. Ward NS, Cohen LG. Mechanisms underlying (Competencies Addressed: Patient Care, recovery of motor function after stroke. Arch Medical Knowledge) Neurol 2004: 1844-88. • Assist in selected surgical procedures (e.g., ventriculostomies, VP shunt placement, Wolf et al. Effect of constraint induced movement simple craniotomies) under direct therapy on upper extremity function 3 to 9 supervision of Neurosurgery Chief Resident months after stroke. The EXCITE randomized or faculty. (Competencies Addressed: Patient clinical trial. JAMA 2006; 296:2095-2104. Care) • Demonstrate a solid foundation of knowledge of anatomy, physiology and pharmacology Name of Rotation: Endovascular Neurosurgery related to neurosurgery patients, particularly Supervisor: Brian Hoh, MD regarding common vascular neurology Rotation Length: 1 month abnormalities. (Competencies Addressed: Medical Knowledge, Practice Based Learning Rotation Description: Vascular Neurology fellows and Improvement) will be able to spend a month (or more) on the • Understand the pharmacokinetics, effects, Neurosurgery service, participating in both and risks of the therapeutics commonly used inpatient and outpatient settings. This elective is in (Vascular) Neurosurgery. (Competencies under the supervision of the Neurosurgery faculty. Addressed: Medical Knowledge) In both the inpatient and outpatient settings, the • Demonstrate a foundation for clinical vascular neurology fellow will be involved primarily neurosurgery problem-solving and decision- in cerebrovascular disease within the specialty of making. (Competencies Addressed: Medical Neurosurgery (e.g., intracerebral hemorrhage, Knowledge, Practice Based Learning and subarachnoid hemorrhage, arterio-venous Improvement) malformations). • Demonstrate familiarity with classic and current aspects of the (Vascular) Neurosurgery Inpatient: Neurosurgical literature. (Competencies • The Vascular Neurology fellow will Addressed: Medical Knowledge) participate in the direct care of patients with neurosurgical diseases, under the supervision Rotation Objectives: of the Neurosurgery attending. • Learn the indications for each of the surgical • The Vascular Neurology fellow will assist techniques available, the principles members of the Neurosurgical team as underlying each technique, and how they are appropriate. applied to clinical problems, including • This elective will include care in the ED, ICU, ventriculostomies, VP shunt placement, and the operating room. 12

Information for Vascular Neurology Fellows Overview simple craiotomies, etc. (Competencies member’s laboratory or by arrangement with Addressed: Patient Care, Medical Knowledge) another faculty member at the University of Florida • Learn the anatomy, physiology and School of Medicine. The fellow will also evaluate pharmacology related to neurosurgery eligibility for, and enroll patients in, clinical patients, particularly regarding common research studies and clinical trials. S/he will vascular neurology abnormalities. collaborate with the principal investigators and (Competencies Addressed: Medical research coordinators in the administrative and Knowledge) regulatory aspects of clinical projects. In addition, • Develop the ability to formulate a rational the faculty mentor will work with the fellow prior to surgical intervention plan for patients with and early in the training period to design and increased ICP, subarachnoid hemorrhage, implement an independent research project. The unruptured aneurysm, ICH, sinus thrombosis, scope of this project will vary based on the fellow’s or AVM. (Competencies Addressed: Patient interest and career goals and may range from a Care, Medical Knowledge, Practice-Based small project that can be completed in on month Learning and Improvement, Interpersonal (such as a case report) to the initial development of and Communication Skills, Professionalism, larger scale projects to be completed during an Systems-Based Practice) optional non-accredited research-based fellowship • Develop the ability to review their own year. The faculty mentor will use this endeavor as practice to guide their learning. an opportunity to teach the principles of research (Competencies Addressed: Practice-Based design and statistical analysis. The fellow will be Learning) expected to present the results of these projects at • Develop an understanding of how Vascular Stroke Conference, submit abstracts to national Neurologists and Neurosurgeons collaborate meetings and prepare manuscripts for publication. for optimal patient care. (Competencies Addressed: Interpersonal and Rotation Goals: Communication Skills) • When involved in clinical research, fellow • Gain an understanding of cost, risks and demonstrates the ability to incorporate benefits of surgical techniques for patients research, such as clinical trials, in the care of a with increased ICP, subarachnoid cerebrovascular patient. (Competencies hemorrhage, unruptured aneurysm, ICH, Addressed: Patient Care, Interpersonal and sinus thrombosis, or AVM . (Competencies Communication Skills, Professionalism) Addressed: Systems-Based Practice) • Fellow should demonstrate knowledge about • Develop attitudes that foster honesty, good clinical practices and human subjects respectfulness towards patients and peers, protection in the conduct of clinical research. dedication to patient care, and willingness to (Competencies Addressed: Patient Care, acknowledge mistakes. (Competencies Medical Knowledge, Interpersonal and Addressed: Professionalism) Communication Skills, Professionalism, Systems-Based Practice) • Fellows should be able to use research to Name of Rotation: Research guide their own growth in Vascular Supervisor: Michael Waters, MD PhD Neurology. (Competencies Addressed: Rotation Length: 1 month Practice-Based Learning and Improvement) • Fellows should demonstrate the ability to Rotation Description: communicate effectively and interact with After acceptance into the fellowship program and research subjects and their families, clinic and prior to beginning the training year, each fellow will research staff, referring physicians, and be assigned to one of the Stroke Service attending research collaborators. (Competencies neurologists who is actively engaged in Addressed: Interpersonal and extramurally funded research. This assignment will Communication Skills, Professionalism) be made after consultation with the fellow • Fellows should develop and demonstrate regarding his/her research interests. The faculty attitudes that foster honesty, respectfulness mentor will be responsible for ensuring that the towards research patients and their families, fellow actively participates in an ongoing research good work ethics and willingness to project broadly related to the field of acknowledge mistakes. (Competencies cerebrovascular disease either in that faculty 13

Information for Vascular Neurology Fellows Overview Addressed: Patient Care, Interpersonal and • Demonstrate the ability to meet all research Communication Skills, Professionalism) goals and deadlines. (Competencies • Fellows should demonstrate knowledge of Addressed: Professionalism) how research can improve the delivery of care for patients and communities. (Competencies Addressed: Professionalism, RESEARCH & MENTORSHIP Systems-Based Practice) As outlined in the requirements above, you must Rotation Objectives: engage in research during your year of fellowship. • Demonstrate the conduct of clinical research Formal didactic teaching provides training in in the most compassionate manner. neuroepidemiology, outcomes research, clinical (Competencies Addressed: Patient Care, trial design, and biostatistics. The fellowship offers Interpersonal and Communication Skills, collaborative research opportunities with the Professionalism) University of Florida’s Vascular Neurology, • Demonstrate an in-depth understanding of Neuroradiology and Neurovascular Surgery the research being conducted. (Competencies services. Ample additional research opportunities Addressed: Patient Care, Medical Knowledge, are tailored to fellow interest. You must choose a Interpersonal and Communication Skills, faculty mentor who will assist you in developing a Professionalism, Systems-Based Practice) research project. The project should result in a • Demonstrate the ability to use computerized paper or chapter that is submitted for publication. and non-computerized information systems to facilitate research to instill the value of life- long learning. (Competencies Addressed: ENVIRONMENT & PERSONNEL Practice-Based Learning and Improvement) • Demonstrate ability in extracting information The activities of the residency program take place at and salient features from the history and Shands Hospital, at the Shands/UF Medical Plaza examination of patients, and their caregivers, (out-patient clinics), and at the McKnight Brain upon which to base a differential diagnosis Institute, which houses the Departmental Offices, and management plan. (Competencies conference rooms, and residents’ room. Faculty and Addressed: Practice-Based Learning and staff are listed in a subsequent section. Improvement) • Demonstrate the ability to communicate effectively with research subjects and their FELLOW RESPONSIBILITIES families. (Competencies Addressed: Patient Care, Interpersonal and Communication Vascular Neurology fellows are supervised by the Skills, Professionalism,) stroke service attendings, with gradually increasing • Demonstrate the ability to communicate responsibility over the course of the year. You will effectively, interact and coordinate with clinic perform the initial detailed evaluation, write full and research staff (schedulers, nurses, notes, write orders, and devise and implement a research coordinators), and with patients’ management plan for all acute stroke patients and referring physicians. (Competencies stroke clinic patients. During your first months of Addressed: Patient Care, Interpersonal and Communication Skills, Professionalism) residency, you will present each patient to the • Demonstrate the ability to communicate and attending physician prior to executing your plan; interact with your research mentor and other when you are deemed competent to do so, you may research collaborators. (Competencies proceed with your management plan prior to Addressed: Interpersonal and discussing it with the attending. For non-acute Communication Skills, Professionalism) inpatient consults and follow-up inpatient • Demonstrate the ability to recognize and deal management, general neurology residents will effectively with ethical issues that arise in the perform the initial detailed evaluation, write full conduct of research. (Competencies notes, and write orders under your supervision. Addressed: Patient Care, Medical Knowledge, You will be, in turn, supervised by the attending. Practice-Based Learning and Improvement, Vascular Neurology fellows are required to Interpersonal and Communication Skills, formulate a differential diagnosis, develop a Professionalism) 14

Information for Vascular Neurology Fellows Overview diagnostic plan, and propose therapeutic Research Training tutorials and exams interventions for every patient. You will be asked to offered by the University of Florida College re-evaluate your diagnosis and treatment, if needed, of Medicine during the first two weeks of and/or to review the relevant literature. training 15. Teach residents and medical students You will be responsible for attending all during daily rounds conferences that take place in your subspecialty 16. Participate in the Longitudinal Resident as service. You will also have teaching responsibilities Teacher Program offered by the Faculty (see below). Development Office. Graduates of this program are expected, after passing the ABPN Neurology Boards, to sit for the ABPN’s Examination for Special Qualification in Vascular Neurology.

Fellow mandatory duties and responsibilities include: DOCUMENTATION OF EXPERIENCE 1. Evaluation of acute stroke patients in the Emergency Department Residents are responsible for maintaining a HIPPA- 2. Supervise acute care of stroke patients (on compliant log of all cases, which must be entered the inpatient stroke service) and critically through the New Innovations™ web-site. ill neurological patients (in the Neuro ICU) in the inpatient setting CONFERENCES 3. Have one outpatient clinic session per month You will attend regularly held Vascular Neurology 4. Learn and interpret diffusion- and conferences and Neurology conferences. You will perfusion-weighted MRI and MRA; and also be responsible for organizing monthly teaching perfusion CT and CTA conferences and journal club for Neurology 5. Learn and perform, under supervision, Residents and students. transcranial Doppler studies 6. Organize monthly Neurovascular Case Vascular Neurology Conferences: Conferences, the monthly Stroke Lecture Series, and the monthly Stroke Journal Club. Neurovascular Case Conference – 3rd 7. Attend all weekly and monthly Vascular Monday of the month, 12:00 PM Neurology Conferences (see below) Stroke Lecture Series – monthly 8. Alternate night and weekend call to provide Stroke Journal Club – monthly 24/7 coverage for Stroke Alerts, on a Neurology Grand Rounds – Tuesdays, 11:30 weekly basis AM 9. Participate in ongoing clinical trials Neuroscience Seminar Series – involving stroke patients Wednesdays, 4:00 PM 10. Obtain consent for and enter patients’ data Neuroradiology/Neuropathology Case into our computerized Stroke Database on a Conference – Fridays, 7:00 AM weekly basis 11. Create and maintain a Portfolio and Patient Log using New Innovations™ RESIDENT SUPERVISION 12. Complete all evaluations and other paperwork in a timely manner Vascular Neurology fellows are supervised by the 13. Complete NIHSS and mRS training and stroke service attendings, with gradually increasing certification during the first two weeks of responsibility over the course of the year. During training your first months of residency, you will present 14. Complete CITI training in human subjects each patient to the attending physician prior to protection and bioethics and HIPAA & executing your plan; when you are deemed 15

Information for Vascular Neurology Fellows Overview competent to do so, you may proceed with your topics on a rotational basis over a 2 year period. management plan prior to discussing it with the Typically, sessions are 1 ½ to 2 hours in length and attending. occur approximately once per month.

In the outpatient Stroke Clinic you will the primary Participants in the Longitudinal Resident as Teacher resident provider for your patients. You will program are required to participate in the required perform detailed histories and physicals, formulate topic sessions (Setting Goals and Expectations, plans for diagnosis and management, and follow Evaluations, Giving Useful Feedback, and Preparing patients over time with supervision from your an Effective Lecture) and develop a teaching faculty attending. portfolio reflective of their teaching development and products from the Resident as Teacher For acute ED and inpatient stroke cases, you will program. function as a primary resident provider, either alone or assisted by a general Neurology resident. Program participants who attend 50% of the total You will perform an appropriate history and topics are eligible to receive a certificate indicating physical, formulate a plan for diagnosis and that they have completed the “Resident as Teacher management, and follow the patient over time with Program”. the support of your faculty attending. For additional information about the Longitudinal For non-acute inpatient stroke cases, you will Resident as Teacher program, visit their website at function as a senior resident by assisting the more http://facultydevelopment.med.ufl.edu/resident-as-teacher- junior resident staff in triaging and delegating the program/ day’s workload. You will also be in charge of organizing subspecialty education for the students DOCUMENTATION OF EXPERIENCE and junior residents. These duties will be performed with the support of your faculty You are required to maintain a case log of your attending. clinical experience, including the numbers of procedures, patients examined in the outpatient A vascular neurology attending will be available to setting, and all admissions and consultations on you at all times by page for prompt communication patients in the inpatient setting. While there is an and consultation when/if needed. educational need for such information to be collected, there is an equally important requirement TEACHING BY RESIDENTS that protected health information, as defined under the Health Insurance Portability and Accountability You will be responsible for organizing monthly Act (HIPAA) be protected from unauthorized teaching conferences and journal club for disclosure. We therefore require that patient logs Neurology Residents and students. You will also be kept absolutely secure. For this reason we participate in the education of Neurology Residents require all Vascular Neurology Fellows to utilize the rotating on the Vascular Neurology service. Case Logs module in the New Innovations software Vascular Neurology fellows are encouraged to suite. Case Logs should be updated monthly so that present at departmental, local and national we can ensure that all fellows are being exposed to meetings. the clinical material that is necessary for your medical education. Additionally you will be responsible for participating in the Longitudinal Resident as Teacher Program offered by the Faculty Development Office. The goal of this program is to improve the teaching skills of residents, thereby enhancing the educational experience of both residents and medical students throughout their clinical training. The Longitudinal Resident as Teacher Program has been designed for PGY-2 and higher residents. Class sessions cover 15 different 16

Information for Vascular Neurology Fellows Overview

The McKnight Brain Institute at the University of Florida

Information for Vascular Neurology Fellows Assessment Graduates of this program are expected, after RESIDENT ASSESSMENT passing the ABPN Board in Neurology, to sit for the ABPN’s Examination for Special Qualifications in Your performance will be assessed throughout the Vascular Neurology. program, and the assessment results will be used to provide feedback in order to improve your RESIDENT EVALUATION OF FACULTY & performance. The assessments include: PROGRAM Semi-annual Global Neurovascular Fellow Competency Rating. Each faculty member Faculty evaluation by fellows is an essential part of you work with will evaluate you in all 6 any program. You will complete an on-line Core Competencies: patient care, medical evaluation form for faculty supervising your knowledge, practice-based learning & program and rotations. This should be completed improvement, interpersonal & honestly and sincerely. Since in any year there are communication skills, professionalism, and only one or two Vascular Neurology fellows, you system-based practice. (December & June) may have concerns about anonymity. To preserve Monthly on-line evaluations of fellow anonymity as much as possible, your evaluations performance by supervising faculty. will be reviewed by the Program Director of the Semi-annual review of your Portfolio and Core Neurology Residency Program, who will Patient Log. incorporate this data with evaluations from core residents and present it to the Vascular Neurology Semi-annual review by Nursing/Allied Program Director semi-annually, and to the Healthcare professionals. Department Chair annually for annual faculty Semi-annual peer-to-peer evaluations evaluations. for/by all department residents and fellows. Routine review of your communications At the end of the year you will be asked to evaluate with patient PCPs. the program on-line. This is your opportunity to Routine review of Stroke and Vascular suggest how rotations, and the overall program, can Neurology Fellowship Program Patient be improved. These evaluations will be compiled by Satisfaction Survey. the Core Neurology Residency Program Director Constant evaluation of your performance with core residents’ assessments of their Vascular with real time feedback from the faculty. Neurology rotations and interactions, and will be provided to the Vascular Neurology Program Evaluations are maintained on the New Director annually for review and discussion. Innovations™web-site, to which you have access. You may request that faculty review any evaluation Independent of this written evaluation, you are with you. The faculty meets to evaluate each encouraged to share your ideas for program resident twice a year. A letter is prepared improvement with the faculty at any time. You will summarizing your progress and recommendations be expected to attend annual faculty meetings of the faculty. You will discuss this evaluation with where program development is discussed. the Program Director.

Images from the Aquilion ONE’s “4-D” video representations of whole brain perfusion and CT angiogram UF’s Toshiba Aquilion ONE 320 slice whole brain CT scanner

Information for Vascular Neurology Fellows Economic, Ethical & Legal Issues that did not include all of the specified information. ECONOMIC, ETHICAL & LEGAL In 2001 the University of Florida negotiated a ISSUES settlement with the government which involved a payment of around $8,000,000 and entered into an Institutional Compliance Agreement. Under this MEDICARE COMPLIANCE agreement, residents are required to attend annual educational sessions that review the terms of the House officers are paid, in part, by funds from agreement and review special requirements for Medicare. For many years Medicare also neurologists. reimbursed attending physicians for their care of You must, therefore, become aware of Medicare the same patients, and it was considered adequate requirements for documentation of billing (which documentation of service if the attending physician are becoming the standard for all compensation by merely countersigned the resident’s note. As of July third parties), since you must not only comply with 1, 1996, Medicare required that attending these regulations during your residency, but you physicians (whom they now call teaching must also comply once you go out in practice. For physicians) independently document their each level of billing Medicare requires that specific involvement with the patient. Medicare will only information be included in the history, examination, pay the teaching physicians for the time they spend review of records and films, diagnostic in direct patient care. They will not pay for the time considerations, plan and treatment. When dictating teaching physicians spend with residents and about a patient seen in conjunction with an fellows, even though the attending is still legally attending, fellow’s letters should contain: responsible for the patient and even if the teaching time indirectly benefits the patient. The teaching A statement that you saw the patient in physician must document that he or she has conjunction with Dr. [Attending’s name]. personally provided the requisite level of service. Medicare will allow the teaching physician to Although it is the attending’s responsibility to reference the resident/fellow’s notes for some document his or her involvement in the case, it is aspects of documentation, such as past medical helpful if your note corroborates this by stating that history, review of systems, and social history, but the attending independently obtained the history the teaching physician must personally document from the patient and examined the patient fully, key portions of the history, examination, and discussed the diagnostic impression and plan with decision-making. New rules announced in you in detail, and that your dictation reflects his or November of 2002 allow the teaching physician to her input. Of course, you should only document rely more heavily on the resident/fellow’s notes for what actually occurred. Do not use rote statements documentation of the teaching physician’s that may not apply in every case. involvement. This makes it even more important that resident/fellow’s notes are complete and Make sure your dictation contains documentation of support the level of billing. services required for the bill rendered. For billing at the highest level, a detailed history of present Audits of teaching hospitals in the past decade have illness, a review of systems that contains 10 routinely resulted in large settlements of up to $40 systems or pertinent positives plus a statement that million assessed against medical schools. The “all other systems were negative,” and a past settlement agreements have typically included an medical, family, and social history are required. Institutional Compliance Agreement that details Your physical examination must contain sufficient requirements for education of employees (including detail (a comprehensive examination must include house officers), internal or external audits of documentation of 3 vital signs, examination of compliance, and specification of penalties for non- carotid pulses, heart (and/or pulses), ophthalmic compliance. Penalties include $1000/day penalty examination, and a complete neurological for each employee who has not received education examination, including orientation, memory, in the specified time period, and similar penalties attention, language, fund of knowledge, CN 2-12 for failure to refund charges that were not (you may state CN 2-12 intact, or provide details supported by proper documentation, such as a note when there are abnormalities), strength, tone, 13

Information for Vascular Neurology Fellows Economic, Ethical & Legal Issues observation for abnormal movements, sensation, may not put down Atube placement@ as a diagnosis, reflexes, coordination, gait and station. In addition, even if this is why you are requesting an x-ray. Not you should specifically note if you and your only is this required for reimbursement, but clinical attending reviewed records and/or films, and pathology and radiology faculty are liable for briefly summarize what of importance was derived prosecution for fraud if they bill for a procedure from these reviews. You should document all without appropriate documentation. requests for records, and all discussions with other physicians about the case (be specific about who was involved in these discussions). You should LICENSE REQUIREMENTS document all diagnoses that apply, as well as diagnoses you have considered as important in the You must have an unrestricted Florida Medical differential. License (not a temporary license that the institution provides for your residency/fellowship) to order To document involvement in the case, the attending conscious sedation on any patient, or to order any can write or dictate a separate note or letter. The patient to be restrained. In addition, to order attending may refer to your note for documentation conscious sedation you must be accredited by the of history and examination findings that he or she institution. At Shands at UF you will need to has personally confirmed. formally apply for accreditation through the Chief of Staff’s Office (395-0301) and be granted privileges Bills that are submitted for patients seen by to perform these procedures. Residents/fellows residents/fellows and attending physicians must with temporary licenses will be given a number that include a GC modifier code. It is helpful if you must be indicated on every pharmaceutical remember to check this code on the billing sheet for prescription provided by the resident. each out-patient you see with an attending. Residents/fellows with permanent State licenses must include their license number on prescriptions. LABORATORY & RADIOLOGY REQUESTS PRESCRIPTION REQUIREMENTS It is necessary that each request for laboratory or radiologic examinations include an appropriate All prescriptions must be written on special fraud- diagnosis, that is, a diagnosis that justifies the test. proof prescription pads that will be provided to Thus, if you are requesting a chest x-ray on a patient each fellow. Please remember to carry your with Guillain-Barr to rule out pneumonia, you personal prescription pad with you. Fellows with should not put Guillain-Barré as the diagnosis, but temporary licenses will be given a number that rather, fever, cough, or aspiration. In most must be indicated on every pharmaceutical instances, this is self-evident; however, you must be prescription provided by the fellow. Fellows with aware of particular regulations. For example, you permanent State licenses must include their license number on prescriptions.

UF Stroke Program’s Compumedics Multi-Dop X digital system 14

Information for Vascular Neurology Fellows HIPAA Compliance You may access medical records on any patient for PATIENT CONFIDENTIALITY whom you are caring, either as their resident (HIPAA) physician, or as a consultant, or covering for another resident. You may also access medical records for valid teaching purposes (for example, You must respect the confidential nature of medical presentation to the Neuropathology Conference). information. You must have the patient’s You may not access medical records of any other permission to speak to anybody else about the patient, including not only famous patients, but also ’ patient s medical condition, even to first degree other faculty, medical students, or even members of relatives. If the patient is not present to ask, you your own family. Remember that the Hospital must have the patient’s written permission. Information System tracks every record access, and flags suspicious events. If asked, you will have to be You must routinely exercise care that your able to justify every record review. Unauthorized discussions of patient information with colleagues access can be a cause for reprimand, probation and are not overheard by anyone who is not entitled to eventually dismissal. the information (do not, for example, discuss patients with your colleagues on elevators, even if Following implementation of the Health Insurance you don’t refer to the patients by name). Whenever Portability and Accountability Act (HIPAA) in April possible, you should make presentations at the of 2003, breaches of confidentiality become bedside rather than in the hallway, after requesting punishable by fines, and intentional breaches are that persons who should not be privy to the punishable by fines and imprisonment. You are information leave the room. An exception can be required to have HIPAA training for Shands and for made of patients who share the room with your the VA (training is separate). HIPAA also increases patient. You should also make others, such as the regulation of protected health information for medical students and secretaries, aware that casual research. You must obtain IRB (Institutional Review talk about patients’ medical information that may Board) approval before initiating any research that breach confidentiality is not to be tolerated. entails review of patient records or other protected health information.

Century Tower and the University Auditorium on the University of Florida campus

Information for Vascular Neurology Fellows Institutional Policies Center each year dealing with medical-legal issues. INSTITUTIONAL POLICIES Attendings will discuss such issues when relevant to the care of individual patients.

COST-AWARENESS QUALITY ASSURANCE It has become increasingly important that we Fellows participate in quality assurance by filling inform ourselves about the cost of our medical out quality assurance forms on each patient practice. ATTACHMENT 3 addresses general issues admitted to the hospital, and by participating in related to cost-awareness. Specific policies relating quality assurance reviews. It is essential that forms to cost of services will be addressed in the context of individual patient care. Development of are completed during the month that any death or complication has occurred. Complications and algorithms regulating management of specific deaths are discussed at monthly Departmental neurological problems (paths) will impact on our management of patients increasingly in coming Meetings. years. One aspect of practicing cost-effective medicine is the appropriate ordering of lab tests.

Recurring orders for lab tests (i.e., qam CBC and metabolic profile) are to be discouraged. They are usually unnecessary, they are costly and they cause pain and contribute to anemia.

IMPAIRED PHYSICIAN POLICY

Faculty, staff, peers, family or other individuals who suspect that a member of the housestaff is suffering from a psychological or substance abuse problem are obligated by law to report such problems. Individuals suspecting such impairment can either report directly to the Physician's Recovery Network (PRN) or can discuss their concerns with the Program Director, Chairman, or Director of Graduate Medical Education. The specific regulations are in ATTACHMENT 4.

SEXUAL HARASSMENT

Inappropriate professional behavior in any form is not permissible. The Institutional policy regarding gender harassment is provided in ATTACHMENT 5.

MEDICAL-LEGAL ISSUES

Fellows must be aware of medical-legal issues relating to informed consent, standard of care, competency, restraints, HIV testing, confidentiality, The McKnight Brain Institute reflec ted in the and similar issues, and must know how to windows of the Academic Research Building document their care so that it complies with medical and legal requirements. Fellows are encouraged to attend seminars given at the Health

Information for Vascular Neurology Fellows Duty Hours averaged over a four-week period, during which they are free from all educational, clinical, and DUTY HOURS administrative responsibilities. Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Fellows may remain in house for ON-CALL SCHEDULE (DUTY HOURS) up to six additional hours to participate in didactic activities, transfer care of patients, and maintain All call for Vascular Neurology fellows is at- continuity of medical and surgical care; but they home/pager call. Fellows are expected to maintain may not admit or consult upon new patients during pager contact during daytime hours each work-day, this time. There must be at least a 10-hour time overnight on their duty nights, and 24 hours a day period provided between all daily duty periods and during weekend duty. Vascular Neurology fellows after in-house call. are on call every other week, with five nights (Monday through Friday) of weekday nigh coverage If a fellow recognizes, or is observed to show, signs followed by one day (Saturday) of 24-hour of fatigue, or if a fellow must go home because they coverage. One day per week (Sunday) is free from would otherwise exceed the limits of contiguous in- all call responsibilities. house service, the fellow should request relief from the fellow designated as a back-up fellow, or from Vascular Neurology fellows will not see every the attending physician. patient brought to the Emergency Department on a Stroke Alert. The on-call General Neurology Hours spent in outside employment (see below) are resident will perform an initial evaluation all counted toward the duty hour total. Fellows must patients brought to the Emergency Department on a complete appropriate UF forms and apply through Stroke Alert and all Stroke Alert patients on the the Program Director to participate in any outside wards. When the Neurology resident requires employment and all such hours must be pre- consultation, the on-call Vascular Neurology fellow approved. will be notified via page. Most on-call consultation will not require the Vascular Neurology fellow to report to the hospital, although it is possible that it OUTSIDE EMPLOYMENT will be necessary for the on-call fellow to report to The institutional policy regarding Outside the hospital at times. Should the on-call Vascular Employment (formerly referred to as Neurology fellow deem it necessary, s/he will page “ ” the Vascular Neurology attending. Fellows must moonlighting ) is provided in ATTACHMENT 6. log and all pages/calls and on-call time spent in the The Department of Neurology’s policy is more hospital and report it weekly. restrictive than the institutional policy. We do not permit our neurology residents/fellows to engage All time spent in hospital, or at home, responding to in non-programmatic outside professional a call is monitored and counted towards the weekly employment except in specific circumstances, which duty hour limit of 80 hours. Fellows who spend include Compensation and Pension Examinations at twelve (12) hours in patient care and program the VA and staffing the Emergency Room at the VA... requirements followed by twelve (12) hours of active call duty will be considered to have spent 24 Fellows must understand that outside employment hours on continuous duty. In such circumstances, hours apply to the calculation of resident duty the fellow may participate in limited activities, as hours (see above). Therefore, approval will not be defined below, for an additional six (6) hours. This given to outside employment that exceeds these period of activity must be followed by a minimum of limits. Fellows must inform the Program Director of ten (10) hours of rest prior to returning to duty. the dates and times of all outside employment, and obtain the Program Director’s approval in The fellow duty hours as specified above are to be advance. The Program Director is responsible for in compliance with ACGME requirements at all submitting a summary annual report of outside times. Fellows may not work more than 80 hours a professional employment of housestaff to the GMEC week, averaged over a four-week period. Fellows indicating that the Program Director is aware of the must get at least one day (24-hours) off in seven, activities and approves. 17

Information for Vascular Neurology Fellows Duty Hours The ACGME expects programs to monitor and Florida; and (c) most importantly, that violation of approve any outside employment, even if it occurs the Department’s outside employment policy by the during annual leave (vacation) time. Vacation is resident will lead to disciplinary action, which could considered time during which the resident may include dismissal from the program. recoup strength and resources so that s/he may return to the residency refreshed. This purpose is defeated by working during that time. VACATION

Housestaff who are tempted to consider non- There are institution-wide provisions for annual programmatic outside professional employment leave that are stipulated in the section on BENEFITS despite these restrictions should consider: (a) that in this document. Fifteen days of annual leave are they are not covered by the College of Medicine’s allowed each year. All vacations must be approved malpractice insurance for non-programmatic in advance by the program director. All vacations outside employment; (b) that they may not must be approved in advance by the program represent themselves as agents of the University of director or designee.

The Baughman Center at Lake Alice, on the University of Florida campus

Information for Vascular Neurology Fellows Faculty Neurological Surgery; Director of the Fellowship in FACULTY Endovascular Surgical Neuroradiology. Dr. Hoh completed his internship in surgery, residency in Michael F. Waters, M.D., Ph.D., Assistant Professor neurological surgery, and fellowship in of Neurology and Neuroscience; Director, University endovascular neurosurgery and interventional of Florida Stroke Program; Director, Stroke and neuroradiology at Harvard University at the Vascular Neurology Fellowship Program. Dr. Massachusetts General Hospital. He received the Waters received a master's degree in genetics from Boston Neurology Society's Stanley Cobb award Penn State University. He attended medical school and the New England Neurosurgical Society's at the University of Florida, where he also earned William Scoville award for his research on his Ph.D. in biochemistry and molecular biology. He aneurysms and arteriovenous malformations received formal neurological training at David (AVMs). He won the Anspach 2006 Research Geffen School of Medicine at the University of Award for his research on carotid stenosis, and California, Los Angeles (UCLA) and completed a the American Association of Neurological fellowship in neurogenetics with Dr. Stefan Pulst. Surgeons 2007 Young Clinician Investigator Prior to coming to the University of Florida, Dr. Award for his research on aneurysms. In 2009, he Waters served as the director of the Stroke Program was awarded the American Association of at Cedars Sinai Medical Center and Assistant Neurological Surgeons Robert D. Florin Award for Professor of Medicine at UCLA. Dr. Waters' socio-economic research of aneurysms, the Anna research interests include genetic mechanisms of Orthwein Chair of Research from the Brain Aneurysm Foundation, and was also awarded a stroke, including cerebral cavernous malformations, Mentored Clinical Scientist Development Award CADASIL, and sickle cell anemia. In addition, he has from the National Institutes of Health (NIH). He active research in gene discovery and the has published over 45 peer reviewed papers and pathophysiology of dominant cerebellar ataxias. Dr. four book chapters. He has made over 110 Waters is a member of the American Academy of presentations at scientific meetings. Neurology and the American Society of Human Genetics. J. Duffy Mocco, M.D., M.S., Assistant Professor of Neurosurgery. After finishing his internship in Tetsuo Ashizawa, M.D., Chairman, Department of general surgery at New York Presbyterian Neurology; the Melven Greer Professor of Neurology. Hospital, Dr. Mocco spent one year performing a Dr. Ashizawa completed his Neurology residency post-doctoral research fellowship evaluating the training at Baylor College of Medicine where he was pathophysiologic mechanisms of stroke under appointed Chief Neurology Resident. He then Drs. David Pinsky and E. Sander Connolly at completed fellowship training in Neuromuscular Columbia University. Following this year Studies and Neurochemistry with the Muscular completed a residency in neurological surgery at Dystrophy Association at Baylor. His special the New York Neurological Institute, part of the interests include Spinocerebellar Ataxia Sub-type Columbia University Medical Center. 10, Myotonic Dystrophy Type 1, Huntington’s Simultaneous to completing his neurosurgical Disease, Friedreich’s Ataxia, Parkinson's Disease training, Dr. Mocco completed a Masters of and Myasthenia Gravis. Science degree in Biostatistics at Columbia Bayard D. Miller, M.D., Clinical Assistant Professor; University, with a concentration on clinical Director of Outpatient Services; Program Director, research methodology and analysis. Following his Neurology Clerkship. Dr. Miller received his MD and residency, Dr. Mocco completed an endovascular did his neurology training here at the University of neurosurgery fellowship under the tutelage of Dr. L.N. Hopkins at the world renowned Gates Stroke Florida. He rejoined the Department from private Center, while concurrently studying the inter- practice in 2004 and is a superb clinician-teacher. relationship between cerebrovascular biology and Brian L. Hoh, M.D., F.A.C.S., Assistant Professor of intravascular hemodynamics at the Toshiba Neurosurgery, Radiology and Neuroscience; the Stroke Research Laboratory. During the William Merz endowed professor of Neurological aforementioned years of training Dr. Mocco Surgery; Associate Program Director of received numerous awards, including the Congress of Neurological Surgeons James Garber 19

Information for Vascular Neurology Fellows Faculty Galbraith Award, the New York Society of international meetings, and educated hundreds of Neurosurgery outstanding research award, visiting physicians. Drs. Bova and Friedman Columbia University's Department of recently received NIH R01 funding to support Neurosurgery George L. Becker Award, and an their continuing research efforts. He is a NIH/AMSA/AAMC Biomedical Research Forum Gubernatorial Appointee to the Florida Center for Award. Dr. Mocco was awarded one of only two Brain Tumor Research. national Brain Aneurysm Foundation Research Grants to support his investigations into the Chris Firment, M.D., Assistant Professor of contribution of hemodynamic stress on cerebral Neurosurgery and Radiology. aneurysm initiation. The Congress of Neurological Surgeons awarded Dr. Mocco the Wilder Penfield Andrea Gabrielli, M.D., Professor of Anesthesiology Research Fellowship to support his clinical and Surgery; Clinical Unit Chief, Hyperbaric research evaluating new applications of a class of Medicine; Medical Director, Cardiopulmonary medications thought to aid recovery after Services. A native of Italy, Dr. Gabrielli completed subarachnoid hemorrhage. Dr. Mocco has over his residency in General Surgery at the State 100 accepted peer reviewed publications, 17 University of Rome, Italy, his Internal Medicine solicited editorials, and nine book chapters. He is residency at Catholic Medical Center and his also co-editor of a text book on neurosurgical residency in Anesthesiology at Beth Israel Medical operative technique. Dr. Mocco's scientific Center. He completed fellowships in Cardiothoracic interests are focused on translational efforts to Anesthesia at the Cleveland Clinic Foundation and treat ischemic and hemorrhagic stroke. Critical Care Medicine at the University of Florida College of Medicine. Dr. Gabrielli’s clinical interests William Friedman, M.D., Chairman, Department include critical care medicine, advanced mechanical of Neurosurgery; Professor; Director, Preston Well ventilation, neurotrauma, cardiothoracic and Center for Brain Tumor Therapy. Dr. Friedman transplant anesthesia, and hyperbaric medicine. completed his surgical internship and neurosurgical residency at the University of A. Joseph Layon, M.D., F.A.C.P., Professor of Florida in Gainesville. He is the author of more Anesthesiology, Surgery, Medicine and Nephrology; than 250 articles and book chapters and has Associate Director, Burn Center; Medical written a book on radiosurgery. He is a member of Director/Division Chief, Division of Critical Care numerous professional organizations. Most Medicine; Medical Director, Gainesville Fire Rescue. notably, he is a Past-President of the Congress of Dr. Layon completed his residency in Internal Neurological Surgeons, Past President of the Medicine at Cook County Hospital and his residency Florida Neurosurgical Society, and Past President in Anesthesiology at the University of Florida of the International Stereotactic Radiosurgery College of Medicine, where he also completed his Society. He is the Past Editor of Neurosurgery On fellowship in Critical Care Medicine. Dr. Layon’s Call, the Internet homepage of organized clinical interests include clinical anesthesiology, neurosurgery. He is a member of the Shands critical care medicine, thermal injuries, AIDS, Hospital Board of Directors. In 1986, Dr. Friedman perioperative immune dysfunction, emergency began collaborative work with Dr. Frank Bova, medicine, prehospital care, and trauma. which led to the development of the University of Florida radiosurgery system. This system was Anthony Mancuso, M.D., Professor of subsequently patented by the University of Otolaryngology and Head and Neck Surgery; Florida and licensed to Philips, then Sofamor- Chairman, Department of Radiology. Danek. The commercial version of the system has become one of the most popular radiosurgical David Meurer, M.D., Clinical Assistant Professor, systems worldwide. Drs. Friedman and Bova Department of Emergency Medicine; Medical g received the 1990 UF College of Medicine Clinical Director, ShandsCair Adult Team. Upon graduatin from UF College of Medicine, Research Prize in recognition of this Dr. Meurer completed accomplishment. Dr. Friedman is the leader of a his residency in Emergency Medicine at the multidisciplinary radiosurgery team which has University of Florida College of Medicine. He came treated over 2800 patients, published more than to the Division of Emergency Medicine at Shands in 120 papers and chapters, produced many Gainesville in 1993. Dr. Meurer’s clinical interests 20

Information for Vascular Neurology Fellows Faculty include EMS and pre-hospital medicine, farm emergencies, hazardous materials response including radiation emergencies, disaster medicine, environmental emergencies (snake bites, space, altitude, and diving emergencies, etc), development of clinical guidelines, and the use of PDAs in clinical medicine.

Joel Moll, M.D., F.A.C.E.P., Clinical Assistant Professor, Department of Emergency Medicine; Medical Director, Department of Emergency Medicine.

Keith Peters, M.D., Associate Professor of Neurosurgery and Radiology.

Joseph A. Tyndall, M.D., M.P.H., F.A.C.E.P., Chairman, Department of Emergency Medicine; Chief of Emergency Services, Shands at the University of Florida; Program Director, Emergency Services Residency Program; Clinical Associate Professor. Dr. Tyndall graduated from the University of Maryland School of Medicine, where he also completed the Residency Program in Emergency Medicine and was Chief Resident. Dr. Tyndall served as Residency Program Director at the Brooklyn Hospital Center in Brooklyn New York. Dr. Tyndall has also held the positions of Associate Medical Director at the Brookdale University Hospital and Medical Center in Brooklyn New York and has had faculty appointments as Assistant Clinical Professor at the Weill Medical College of Cornell University and the State University of New York Health Sciences Center in Brooklyn. Dr. Tyndall also holds an Executive Masters Degree in Public Health in the area of health services management from the Department of Health Policy and Management at the Mailman School of Public Health of Columbia University in New York. He has wide ranging interests in resident education and research which include asthma, trauma and health services research.

Information for Vascular Neurology Fellows Facilities o University of Florida Physician FACILITIES Practices (Gainesville and Jacksonville)

HOSPITAL & OUTPATIENT FACILITIES The primary teaching hospital for the Vascular Neurology Fellowship Program is Shands at the Shands Hospital at the University of Florida was University of Florida. established in 1958 and is the primary teaching Shands at UF is the primary teaching hospital and hospital for the UF College of Medicine. Shands assembles more than 500 physicians representing HealthCare is a private, not-for-profit organization 110 medical specialties work with a team of and is one of the Southeast's premier health healthcare professionals to provide quality care for systems. Shands includes eight hospitals: two patients Shands at the University of Florida was academic medical centers; three community established in 1958. It is a 618-bed tertiary care hospitals; and three specialty hospitals. Shands center with 144 intensive care beds. Shands at UF HealthCare also includes two home-health agencies features four Centers of Excellence including Cancer, and more than 80 affiliated UF outpatient practices Cardiovascular medicine, Neurological services, and located throughout north central and northeast Transplantation. In addition, the hospital has been Florida. designated a Level 1 Trauma Center with its own Approximately 1,500 University of Florida faculty Trauma Ward/Unit. A new 192-bed patient tower and community physicians on the Shands medical was completed in late fall of 2009. staff provide care in over 110 specialty and Shands at UF was also named as a Comprehensive subspecialty medical areas, from primary care to Stroke Center by the Agency for Health Care highly complex care, including cancer, Administration in fall of 2009. Shands at UF is now cardiovascular, neurology, neurosurgery, stroke, one of only 14 AHCA-designated stroke centers in and transplantation services. Patients come to the state and the only one in north central Florida. Shands from every county in the state, from Designation as a Comprehensive Stroke Center throughout the nation and from more than a dozen identifies Shands at UF as a hospital actively countries. participating in the full spectrum of state-of-the-art The Shands HealthCare system is comprised of: stroke care and research. It encompasses not only leading-edge technologies and therapeutics for Two Academic Medical Centers acute stroke patients, but also system-wide o Shands at the University of Florida initiatives on stroke prevention, rehabilitation, (Gainesville) education, community awareness and clinical and o Shands Jacksonville (Jacksonville) basic science research. Three Community Hospitals o Shands Live Oak (Live Oak) The Neurology service at Shands UF shares a 34- o Shands Lake Shore (Lake City) bed ward with Neurosurgery. Intensive care is o Shands Starke (Starke) provided in the newly opened Neurological Three Specialty Hospitals Intensive Care Unit (Ward 82), Medicine Intensive o Shands Cancer Hospital Care Unit (Ward 52), Surgical Intensive Care Unit (Gainesville) and the Intermediate Care Unit (Ward 94), with o Shands Rehab Hospital neurology residents serving as either primary (Gainesville) caregivers or consultants. o Shands Vista Behavioral Health The Shands Rehab Hospital employs a (Gainesville) multidisciplinary team of specialists, therapists and Outpatient programs other healthcare professionals, all dedicated to o Shands HomeCare (Gainesville) helping people improve the quality of their lives o Shands Rehab Centers (Gainesville) while dealing with the effects of trauma and disease. Shands Rehab Hospital is a 40-bed Magnet hospital, the only comprehensive rehabilitative hospital 22

Information for Vascular Neurology Fellows Facilities within 65 miles, and one of only 10 rehabilitation wet lab space, including tissue culture facilities. centers in the state designated by the Florida Brain This lab space is available for any fellows wishing to and Spinal Cord Injury Program as a brain and do basic science research. spinal cord injury rehabilitation center. Accredited by the Joint Commissions on Accreditation of Healthcare Organizations (JCAHO), this hospital is LIBRARY & COMPUTER FACILITIES the leading organization that sets standards of care Residents and Fellows can access literature in many for rehabilitation programs and hospitals, and has ways. In the residents’ room, a small collection of been accredited by the Commission on reference books are available. The Greer Library in the Accreditation of Rehabilitation Facilities (CARF) for departmental offices has a nice selection of neurology comprehensive inpatient rehabilitation, brain injury journals and texts, plus selected medicine and and spinal cord injury. Approximately 25% of the neurosurgery journals. Finally, the Health Center Library patients at Shands Rehab are recovering from is conveniently located in the Communicore center, stroke. Comprehensive communication training adjacent to the Stetson Medical Science Building, the and psychological therapy are combined with Biomedical Sciences Building and Shands at UF. In physical and occupational therapies to provide a addition, Fellows have access to a number of program that succeeds in returning patients to their computerized databases via the computers in the homes and communities. residents’ room. Accessible databases include: Free Medline searches available through the Informatics Outpatient Clinics for the Department of Neurology nd are located on the third floor of the Shands Medical Laboratory on the 2 floor of the Health Center Library, Plaza. The total space includes 36 examining rooms, which has Medline on CD ROM discs. Medline is also accessible from any of the departmental computers that two large conference rooms with view boxes and are on the network, including the computers in the computers, four nurses’ stations with computers, Residents’ Room. Medline, Toxline, and several other six procedure rooms, offices for staff, check-in and databases are available via the Health Center Library check-out areas, and a large waiting room. The web-page. The Department of Neurology also subscribes Department of Neurology uses from 10 to 20 rooms to Neurobase, a multi-authored neurology text on CD- at any one time. ROM. The course syllabi from the latest American Academy of Neurology meetings are available on CD- ROM. ADMINISTRATIVE OFFICES

The McKnight Brain Institute, attached to Shands at OTHER COMPUTER RESOURCES UF and the University of Florida College of Medicine provides leadership for strong basic science and Fellows should be able to take advantage of the clinical programs in the Neurosciences, including increasing resources available via computer. We Neuroscience, Neurology, Neurosurgery, and expect fellows to be computer-literate. If you are Psychiatry. This facility houses the administrative not, consult with your fellow residents/fellows or offices and research laboratories of the Department knowledgeable faculty. The residents have of Neurology, including the Division of Vascular computer stations provided for their use in the Neurology and its Fellowship Program. The residents’ room. Some of the programs and McKnight Brain Institute is one of the world's facilities you may access include: largest research institutions devoted to the challenges resulting from brain and nervous system On the computer hard drive: disorders. The building opened in September of Microsoft Word (word processor) 1998 and was renamed in 2000 following a $15mM Microsoft Excel (spreadsheet program) gift from the McKnight Brain Research Foundation Microsoft Access (database program) to study age-related memory dysfunction. The Microsoft Powerpoint (presentation McKnight Brain Institute provides world-class program) facilities for research, including sophisticated brain Medlink Neurology (text-book of imaging laboratories, a 15T research MR unit, a Neurology) state-of-the-art linear accelerator. Additionally the On the Local Network: vascular neurology Program Director has 1000 ft2 of 23

Information for Vascular Neurology Fellows Facilities SMS (on-line clinical records, including `On the Internet: web-based viewing of many notes, labs, and Web access to Shands Hospital Information radiology reports). System Stentor: Web-based viewing of current Web access to electronic signature imaging. documents Health Center Library Medline searching Neurology Examination site (Nadeau & (see above) Valenstein) E-mail UF facilities

Alligator in Lake Alice on the University of Florida campus

Information for Vascular Neurology Fellows Benefits responsibility to notify the Fringe Benefits Office BENEFITS within 30 days of any of the above events.

Life Insurance, Term group life insurance of The following information is subject to change. To $10,000 is provided at no cost. Coverage is through access the most current information about Policies First Allmerica Financial Life Insurance Company. and Procedures, including Benefits, please go on- For any questions on coverage or claims, please line to: http://housestaff.medinfo.ufl.edu/ contact the Fringe Benefits Office at 395-8016. Compensation and benefits will be determined by Accidental Death and Dismemberment. the College of Medicine with the advice of the Premiums are paid by the College of Medicine. Graduate Medical Education Committee. Coverage is through First Allmerica Financial Life Financial Support: The College of Medicine sets Insurance Company. This coverage pays an the annual stipend for residents and fellows at each additional $10,000 on top of the $10,000 from life level of medical education. An attempt is made to insurance if death is accidental. Dismemberment bring this stipend to the 50th percentile of the benefits are paid on a pro-rated basis. College of Teaching Hospitals data for hospitals in Disability Insurance. All active full-time College of the southern region. Exceptions to these stipend Medicine housestaff members working at least 30 levels must be approved by the Graduate Medical hours a week are provided Long Term Disability Education Committee. Insurance. The policy is underwritten by Provident All full-time residents, fellows and clinical post- Life and Accident. The monthly benefit is equal to doctoral associates appointed through a 60% of the first $3,333 monthly salary to a department in the College of Medicine are eligible to maximum monthly benefit of $2,000 reduced by receive the College-sponsored fringe benefit benefit offsets. The benefits as set forth under this program. Benefit costs are employer-paid. policy will begin after the insured's sixth month of total disability. The maximum benefit period due to sickness and accident is to age 65. A special INSURANCE: conversion feature is provided.

The College of Medicine recognizes the need to Workers' Compensation. All housestaff who are provide insurance coverage in a variety of different injured on the job should immediately go to the categories. Shands Emergency Department. Blood and body fluid exposures are treated exclusively through the Health Insurance. This policy is underwritten by Shands Department of Employee Health. Incident First Allmerica Financial Life Insurance Company reports should be filled out within 24 hours and can with premiums paid by the College of Medicine for be obtained through each department training both individual and dependent coverage. See office. In addition, to assure prompt payment of the Summary of Health Insurance Benefits Appendix A. workers' compensation claims, each resident Refer to plan booklet for details or call the UF should sign a "Statement of Authorization" form to Fringe Benefits Office at 352-395-8016. release their medical record to the UF Workers' Compensation Office. These forms will be given at COBRA (Title X of the Consolidated Omnibus Budget the time and place of treatment. Reconciliation Act of 1985). In the event of termination, under COBRA, residents have the option to continue The University of Florida is required to report all their health insurance policy at the current industrial accidents to the Division of Worker's premium plus 2% for a maximum of 18 months. Compensation within seven days of the Eighteen month continuation is also available in the department's first knowledge of an employee's on- event of reduction in hours or layoff. Thirty-six the-job-accident. In order to meet this time limit, month continuation is available in the event of the University of Florida Worker's Compensation divorce, death, retirement and a dependent losing Office, Room 422, Stadium West, should receive the that status because of age. It is the resident's appropriate notifications no later than four days after knowledge of the accident or injury. 25

Information for Vascular Neurology Fellows Benefits Professional Liability Insurance. As an employee Housestaff shall be entitled to utilize sick leave for of the University of Florida, residents are personally death, or in special cases severe illness in the immune from civil liabilities that may arise from immediate family (spouse, parents, brothers, any acts or omissions committed in the course of sisters, children, grandparents, and grandchildren employment. Pursuant to Section 768.28 Florida of both housestaff and spouse). The number of days Statutes, the Florida Board of Regents (BOR), the allowed will be determined by the director of the state agency which operates UF, is vicariously housestaff program. When sick leave is taken, such responsible for any civil claims or actions arising leave shall be reported when used. from the acts of its employees and agents. The BOR is protected for such liabilities through the J. Hillis Annual Leave: Annual leave shall be requested of Miller Health Center Self-Insurance Trust Fund and approved by the program director prior to the (TF), a self-insurance program which is managed by date taken. Annual leave should not be fragmented the University of Florida. into less than one-week periods except under unusual circumstances and must be taken at the Personal professional liability protection is afforded time approved by the program director. Annual by the Trust Fund while residents act as a good leave may be advanced to housestaff proportionate Samaritan, are involved in community service work to expected service. This advance leave cannot which has been pre-approved by your college, or exceed the amount of the leave accrual rate for a while on a job assignment outside of Florida. one-year period. The amount of advanced leave will Questions regarding professional liability should be not exceed that which can be earned during the directed to the Trust Fund at 352-395-8028. remainder of the housestaff leave year. Annual leave which has been granted but not earned by the housestaff member at the time of separation from VACATION AND LEAVE the academic department will require an appropriate reduction for the value thereof in the Members of the housestaff shall be entitled to leave final stipend payment. Annual leave accruals are with pay for the purpose of annual and sick leave normally based on an annual rate of fifteen (15) during the training period July 1 through June 30, workdays for all post-graduates provided this does depending upon the length of appointment, as not exceed that allowed by the appropriate board. described in this section. Leave will be granted and Housestaff may be permitted to carry over unused charged in one-day increments for each workday of leave to a new year, as consistent with department leave requested and approved. If specialty board policy, however, carryover must be approved by the regulations for annual and sick leave accrual and program director and an excess of twenty-five (25) usage differ from that outlined in this rule, written workdays cannot be accumulated. notification of the board policy shall be completed by the program director and submitted to the Dean Military Leave: Absences for temporary military for approval. The total maximum time a housestaff duty (e.g. two-week annual training) may be taken member can be away from a program in any given from annual leave or if insufficient annual leave is year or for the duration of the residency program accumulated, the housestaff member must be shall be determined by the requirements of the placed on leave without pay for such absences. If specialty board involved. All absences must be activated from reserve to active duty status, the approved by the program director. housestaff member will receive thirty (30) days full pay before going on leave without pay. Insurance The College of Medicine recognizes a variety of policies will remain in effect for dependents during categories of leave: period of active duty for one year. Additional Sick Leave: All housestaff shall accrue sick leave at extensions require special approval from the Dean the rate of 10 working days per year of full of the College of Medicine. employment if consistent with board requirements. Holidays: Housestaff shall be entitled to observe all If excessive time is taken, the house officer must official holidays designated by the Department of extend his/her training to fulfill board Administration for state employees except when requirements. they are on call for clinical responsibilities. When on duty or call for clinical responsibilities on 26

Information for Vascular Neurology Fellows Benefits designated holidays, the assignment will be will be responsible for payment of insurance considered as part of the residency and will not premiums. Such coverage may be purchased for a result in extra remuneration. See ATTACHMENT 15 time period consistent with COBRA regulations. The for the list of all official holidays observed at the total time allowed away from a program in any teaching institution. given year or for the duration of the housestaff program will be determined by the requirements of Leave of Absences the specialty board involved. Any absences must be made up in accordance with specialty board policy. (1) Educational Assignment: Housestaff shall be The house officer will be paid for makeup or eligible for absence pertaining to educational and extended time. Schedule accommodations may be training provided it is allowed by the appropriate made for a house officer who is pregnant if these board and agreed to, in writing, by the program changes are approved by the program director. In director. special circumstances, leave may be granted for (2) Licensure Examination Leave: Housestaff house officers involved in adoption with the taking American specialty board and state licensure advance approval of the program director. Paternity examinations will be authorized leave at the leave may be granted with the advanced approval of discretion of the program director. The amount of the program director. absence authorized will not exceed the time actually Unused Leave: All unused leave is considered non- required for taking the examination and for travel payable leave, and there is no entitlement for lump- to and from the place of examinations. Only one sum payment for unused leave upon separation or licensure and one specialty exam shall be completion of training. authorized per housestaff member. Any additional absence will be charged to annual leave or leave without pay if annual leave is not available. MEALS

Maternity and Paternity Leave: Requests for Meals for overnight call residents are provided by maternity and paternity leaves must be submitted the hospitals to which the residents rotate. As a to the program director for approval. The duration general rule residents who do not appear as on of maternity leave before and/or after delivery will overnight call on the call schedule are not entitled be determined by the housestaff member and her to meals. physician in consultation with the program director. Approved absences for greater than six months will be unusual and require special approval. The ON-CALL QUARTERS/WORK ROOM circumstances of the request and the impact on other members of the housestaff program will be The Neurology Work Room at Shands is located at considered. Pay status during such leave will be Ward 65. It has 3 computers, 2 printers, a bookshelf determined by the length of unused vacation and with general neurology and subspecialty text books, sick leave accumulated. Accrued annual leave may lockers, a refrigerator, white board, round table for be used prior to the house officer being placed on discussion and a couch. On-Call Quarters for leave without pay. Any illness caused or residents/fellows on night call is located at ward 54. contributed to by pregnancy, miscarriage, abortion, As a general rule, living quarters and laundry, other childbirth and recover therefrom (including than on-call, are not provided by the institution. uncomplicated pregnancy) shall be treated as a Some departmental exceptions to this may exist for temporary disability and the house officer shall be residents who are sent to specific rotations outside allowed to use sick leave credits when certified by of the immediate home area. Departmental policies his/her physician. will govern provision of living quarters at these sites. When accrued annual and sick leave time has been exhausted, leave will be unpaid. While on unpaid The Department provides 2 lab coats for each leave, house officer's insurance benefits will be fellow, and also provides laundering for these. covered by the academic department for up to two (2) months. After two (2) months, the house officer 27

Information for Vascular Neurology Fellows Benefits BOOK ALLOWANCE There are several mechanisms to deal with personal stress, whether related to the reasonable demands A book allowance of up to $500.00 per year is of residency or to factors outside of the residency, provided for each fellow. such as family problems, parenting issues, family illness, depression, anger, anxiety, or other issues. Vascular Neurology and Neurology faculty members TRAVEL TO MEETINGS are always available to counsel you. It is understandable, however, that you may not wish to Travel expenses up to $1000.00 are provided for confide in faculty within the Department. The Office each fellow to attend at least one national neurology of House Staff Affairs, under the direction of Dr. meeting during their residency. In addition, the Timothy Flynn, is available to all residents and Department will support resident attendance at any fellows. This office can assist residents and fellows meeting in which the resident presents a paper. obtain counseling, housing, financial planning, spouse employment, child care and provides other MISCELLANEOUS BENEFITS benefits. Sharon Wallace, in the HouseStaff Office, has years of experience assisting residents and Low-interest loans are sometimes available through fellows. A third mechanism, if you want completely the Resident Loan Assistance Program. confidential assistance to deal with stress, is the Resident Assistance Program (RAP), which provides Lab coats and laundry (for lab coats) are provided. short-term counseling (3 visits) free of charge to residents/fellows and their families. RAP is funded by the College of Medicine. Neither your Program WORKING ENVIRONMENT Director nor the Office of Housestaff Affairs has any knowledge of these visits. The RAP counselor may The institution is required to provide adequate arrange referrals for longer-term care (not covered patient support services (such as intravenous financially under this plan). To arrange an services, phlebotomy services and laboratory appointment, please call (352) 265-5493 or (866) services, as well as messenger and transporter 643-9375, 24 hours per day, seven days a week. services). An effective laboratory, medical records, and radiologic information retrieval system must be Please see the ATTACHMENTS 1 and 4 for in place to provide for appropriate conduct of the institutional policies on discipline and substance educational programs and quality and timely abuse. The Department is obligated to follow these patient care. Also, appropriate security measures policies. must be provided to residents in all locations including but not limited to parking facilities, on- call quarters, hospital and institutional grounds, and related clinical facilities. If you perceive that the working environment does not meet these and other reasonable requirements, please report the perceived deficiency to the Program Director or to the Office for Housestaff Affairs.

IF THERE ARE PROBLEMS

We hope that you will feel free to call upon any of the Vascular Neurology faculty, Neurology faculty or on the Program Director at any time. Stress that results from program requirements should be discussed with fellow residents and faculty, so that ShandsCair Flight Program helicopter adjustments can be made in the program to eliminate unwarranted stress.

Information for Vascular Neurology Fellows Technical Requirements for Fellows 4) Intellectual-Conceptual, Integrative, and Quantitative Abilities: These abilities include TECHNICAL REQUIREMENTS FOR measurement, calculation, reasoning, analysis and FELLOWS synthesis of complex information. 5) Behavioral and Social Attributes: A The Vascular Neurology Program has the right not candidate must possess the emotional health to accept fellows into the program who do not meet required for full utilization of his or her intellectual minimum technical requirements. These are the abilities, the exercise of good judgment, the prompt same as requirements of the institution for completion of all responsibilities attendant to the admission to medical school, and are stated as diagnosis and care of patients, and the development follows: of mature, sensitive, and effective relationships with 1) Observation: The candidate must be able patients. Candidates must be able to tolerate to observe demonstrations and experiments in the physically taxing workloads and to function basic sciences, including but not limited to effectively under stress. They must be able to adapt physiologic and pharmacologic demonstrations in to changing environments, to display flexibility, and animals, microbiologic cultures, and microscopic learn to function in the face of uncertainties studies of microorganisms and tissues in normal inherent in the clinical problems of many patients. and pathologic states. A candidate must be able to Compassion, integrity, interpersonal skills, interest observe a patient accurately at a distance and close and motivation are all personal qualities that are at hand. In detail, observation necessitates the assessed during the admission and education functional use of the sense of vision and other processes. sensory modalities.

2) Communication: A candidate must be able to speak, to hear, and to observe patients in order to elicit information, describe changes in mood, activity, and posture, and perceive nonverbal communications. A candidate must be able to communicate effectively and sensitively with patients. Communication includes not only speech but reading and writing. The candidate must be able to communicate rapidly, effectively and efficiently in oral and written form with all members of the healthcare team.

3) Motor: Candidates must have sufficient motor function to elicit information from patients by palpation, auscultation, percussion, and other diagnostic maneuvers. A candidate must be able to execute motor movements reasonably required to provide general care and emergency treatment to patients. Examples of emergency treatment Alligator by Lake Alice on the University of Florida campus reasonably required of physicians are: The administration of intravenous medication, the application of pressure to stop bleeding and the opening of obstructed airways. Such actions require coordination of both gross and fine muscular movements, equilibrium, and functional use of the senses of touch and vision.

Information for Vascular Neurology Fellows Gainesville & Environs are hundreds of attractions in Gainesville, including GAINESVILLE & ENVIRONS city parks, area freshwater activities, nature trails and other sites of interest within a short driving distance from Gainesville. ABOUT GAINESVILLE

Gainesville is the largest city and county seat of HOUSING Alachua County. The City provides a full range of Information about housing can be obtained from municipal services, including police and fire the Office of Housestaff Affairs, the Neurology protection; comprehensive land use planning and Office, and (most critically) from your fellow zoning services; code enforcement and neighborhood improvement; streets and drainage residents. These are an abundance of attractive apartment complexes, many with swimming pools, construction and maintenance; traffic engineering and some with tennis courts, within a short distance services; refuse and recycling services through a franchised operator; recreation and parks; cultural of the Medical Center. and nature services; and necessary administrative services to support these activities. Additionally, the RECREATION City owns a regional transit system, a municipal airport, and a 72-par championship golf course. Exercise & fun: Within Gainesville, there are many places to walk, jog, or bike. You have access to Gainesville is home to Florida's second largest and facilities at The University tennis, racquetball, oldest university, and the third-largest university in swimming, and golf, among other sports. Gainesville the United States. The University of Florida and is just a little over one hour's drive from the Gulf Shands Hospital at UF are the leading employers in (Cedar Key), and about 2 hours from the beaches of Gainesville and provide jobs for many residents of the East Coast. North and mid-Florida cities are surrounding counties. Known for its preservation of easily accessible: Jacksonville (90 minutes), St. historic buildings and the beauty of its natural Augustine (2 hours), Orlando (2 hours -- with Walt surroundings, Gainesville's numerous parks, Disney World and other "attractions", Tampa (2.5 museums and lakes provide entertainment to hours) and Sarasota (3 hours). The Gainesville thousands of visitors. Because of its beautiful Health & Fitness Center offers discounts through landscape and urban "forest," Gainesville is one of the House Staff Office. the most attractive cities in Florida. Culture: The Performing Arts Center, opened in Famous Residents of Gainesville (past and present) 1992, provides a world-class concert hall that has include Bo Didley, Tom Petty, Don Felder, Bernie hosted many fine performers, including the New Leadon, River Phoenix, Malcolm Gets, Harry Crews, York City Opera, the Royal Philharmonic Orchestra, Marty Liquori, Gabriel Schwartzman, Peter Taylor, the Beaux Arts Trio, Branford Marsalis, Russian Mary McCauley, Joe Haldeman, Bob Vila, and Maya National Orchestra, The Czech Philharmonic Rudolph. Orchestra, and David Copperfield. Broadway shows Gainesville has built a reputation as one of the most such as Miss Saigon, Mama Mia, Hairspray, Annie desirable communities in Florida. In fact, Gainesville are often featured at the Performing Arts Center. In has been recognized for years by Money magazine addition, Rock and Country Stars such as Sir Elton as one of the nation's most livable cities. Gainesville John, Cher, David Benoit; Manhattan Transfer, has been recognized as "Tree City USA" by the Rascal Flatts, etc have concerts at the O'Connell National Arbor Day Foundation, a Top Ten bicycling Center or Performing Arts Center. The Harn Art community by Bicycling Magazine, and "One of Museum, and the Florida Museum of Natural America's great running towns" by Runner's World History (containing the largest butterfly exhibit) are free to the public and they also provide an attractive Magazine. setting for varied exhibits. Gainesville has an active Additionally, the Gainesville area offers unique community of artists and writers, and exhibits take opportunities to visit and interact with natural, place both on campus and at various festivals in historical and entertaining areas of Florida. There Gainesville and surrounding communities. 30

Information for Vascular Neurology Fellows Gainesville & Environs Sports entertainment: The University of Florida Upscale Continental: Leonardos 706*, Steve’s Café* has one of the finest and most competitive Mildreds*, Ivey’s Grill*, Dinner*, Paramount Grill*; undergraduate athletic programs in the country. 101 Downtown* Football, basketball, baseball, volleyball, tennis, golf, track, swimming and gymnastics are all nationally Steak and Seafood: Mark’s Prime*, MT Chop House*, competitive. Athletic facilities are first-rate, and Stonewood Grille*, Grill Masters with the exception of football, tickets are usually Sushi: Dragonfly*, Fuji Sushi, Ichiban Sushi, Miya not difficult to obtain. Sushi, Bento’s, Shining Star, Rolls and Bowls, Sushi Matsuri, Miraku, Yamato RESTAURANTS Specialty pizza: Satchel’s, Leonardos Pizza of Numerous restaurant "chains" are represented in Millhopper, Mellow Mushroom, Lou’s Pizza Gainesville. You may wish to try one-of-a-kind local Specialty burger/BBQ: Copper Monkey, Third Place restaurants: Pub and Grille, The Top, Ruby Tuesdays, Oriental: Mr. Han's, Szechuan Palace, Szechuan Newberry’s Backyard Bar B Q, Joe’s Place Omei, Tim's Thai, Bahn-Thai; Dragonfly*, Liquid Brunch: Ivey’s Grill, Ivy House, O!O Tapas and Tinis, Ginger, Bento’s Café, Taste of Saigon II, Chutnees*, Paramount Grill, Leonardos 706, Fletchers, Indian Cuisine, Maui Terriyaki, Shooting Star Emilianos, Best Western Grand; 101 Downtown Japanese Grill and Sushi, Chop Stix Café, Merlion Singapore Cuisine; Miya Sushi (Korean and Bistro: Bistro 1245; Harvest Thyme Café; New Deal Japanese) Cafe, Tapas 12 West; Mario’s Wine Bar and European Bistro; Panache Wine and Cheese; Third Italian/Mediterranean: Napolitano's, Amelia's*, Place Pub and Grille; O!O Tapas and Tinis Ristorante Denenos*, Carrabba’s Italian Grill, Manuel’s Vintage Room*, Ti Amo, Pomadoro Cafe, Ice cream/gelato/desserts: Gelato Di Prata, D’Lites , Alessandro Ristorante*; The Gelato Company, Uppercrust, Flour Pot, Peterbrooke Chocolatier Seafood: Cedar River; Caribbean Cove; Bonefish Grill*, the Calypso Café, Northwest Grille*, Ballyhoo (* = moderately expensive). Grill*, Blue Water Bay Restaurant

Cuban/Latin/New Orleans: Emilano's Cafe*, Mi Apa, Green Plantain, Harry’s, Carribean Cove*, Chez Café, Virtually Cuban

University of Florida mascots, Albert and Alberta, visit around town

Information for Vascular Neurology Fellows Gainesville & Environs

ATTACHMENT 1: ELIGIBILITY AND SELECTION OF FELLOWS

Resident Eligibility

Applicants with the following qualifications are eligible for appointment to the University of Florida Vascular Neurology Fellowship Program:

• Applicants must be either Board Certified in Neurology or be eligible to sit for the American Board of Psychiatry and Neurology’s Certification Examination in Neurology. • Applicants must have successfully completed, or be completing, an Accreditation Council for Graduate Medical Education (ACGME)-accredited Neurology residency training program. • Applicants must be eligible for and possess a Florida State Medical License on the start date of the fellowship (July 1st). Because of this requirement, applicants must: o Have graduated from medical schools in the United States and Canada accredited by the Liaison committee on Medical Education (LCME). o Have graduated from colleges of osteopathic medicine in the United States accredited by the American Osteopathic Association (AOA). o International Medical Graduates (IMGs) are required to meet all fo the eligibility requirements of the ACGME. Graduates of medical schools outside the United States and Canada must meet on of the following qualifications: • Have received a standard certificate from the Educational Commission for Foreign Medical Graduates (ECFMG) -OR- • Have a full and unrestricted license to practice medicine in a US licensing jurisdiction. • Candidates for fellowship programs must have passed USMLE Step 3 or COMLEX Level 3 prior to appointment. • All medical graduates must be one of the following: o United States Citizen o Lawfully Employable [i.e., EAD (Employment Authorization) card holder, PR (Permanent Resident) card holder, RA (Resident Alien) card holder, or Refugee/Asylum with either the letter granting asylum or refugee/asylum stamp in their passport.] o Eligible for an ECFMG sponsored J-1 Visa

Fellow Selection • All programs must select from among eligible applicants on the basis of the preparedness, ability, aptitude, academic credentials, communication skills, and personal qualities such as motivation and integrity. 32

Information for Vascular Neurology Fellows Gainesville & Environs • Programs must not discriminate with regard to sex, race, age, religion, color, national origin, disability, or veteran status. IMGs should be of the same high quality as U.S. applicants.

Application Process Prospective applicants are asked to submit the following documents:

• Current Curriculum Vitae

• A personal statement explaining the applicant’s interest in vascular neurology and reasons for pursuing a fellowship in this specialty

• Copies of USMLE’s (for DO’s, copies of Comlex)

• Copy of the applicant’s Medical School Diploma

• Copy of Neurology Residency Certification. If the applicant is currently in a Residency Program, a letter from your Program Director stating that you are in good standing is acceptable.

• Copies of the applicant’s transcripts. For IMGs, we will need a copy of your ECFMG certificate. Please note that if you are on a visa, we can only sponsor J-1 visas.

• Three (3) letters of recommendation. A letter from your Program Director counts as one of these letters.

Technical Requirements for Fellows

The Vascular Neurology Program has the right not to accept fellows into the program who do not meet minimum technical requirements. These are the same as requirements of the institution for admission to medical school, and are stated as follows:

1) Observation: The candidate must be able to observe demonstrations and experiments in the basic sciences, including but not limited to physiologic and pharma¬cologic demonstrations in animals, microbiologic cul¬tures, and microscopic studies of microorganisms and tissues in normal and pathologic states. A candidate must be able to observe a patient accurately at a dis¬tance and close at hand. In detail, observation neces-sitates the functional use of the sense of vision and other sensory modalities.

2) Communication: A candidate must be able to speak, to hear, and to observe patients in order to elicit infor¬ma¬tion, describe changes in mood, activity, and posture, and perceive nonverbal communications. A candi¬date must be able to communicate effectively and sensitively with patients. Communication includes not only speech but reading and writing. The candidate must be able to communicate rapidly, effectively and efficiently in oral and written form with all members of the healthcare team.

Information for Vascular Neurology Fellows Gainesville & Environs 3) Motor: Candidates must have sufficient motor function to elicit information from patients by palpa¬tion, auscultation, percussion, and other diagnostic maneuvers. A candidate must be able to execute motor movements reasonably required to provide general care and emergency treatment to patients. Examples of emergency treatment reasonably required of physicians are: The administration of intravenous medication, the application of pressure to stop bleeding and the opening of obstructed airways. Such actions require coordination of both gross and fine muscular movements, equilibrium, and functional use of the senses of touch and vision.

4) Intellectual-Conceptual, Integrative, and Quantitative Abilities: These abilities include measurement, calculation, reasoning, analysis and synthesis of complex information.

5) Behavioral and Social Attributes: A candidate must possess the emotional health required for full utilization of his or her intellectual abilities, the exercise of good judgment, the prompt completion of all responsibilities attendant to the diagnosis and care of patients, and the development of mature, sensitive, and effective relationships with patients. Candidates must be able to tolerate physically taxing workloads and to function effectively under stress. They must be able to adapt to changing environments, to display flexibility, and learn to function in the face of uncertainties inherent in the clinical problems of many patients. Compassion, integrity, interpersonal skills, interest and motivation are all personal qualities that are assessed during the admission and education processes.

Information for Vascular Neurology Fellows Attachment #1

ATTACHMENT 2: PROCEDURE FOR GRIEVANCE, SUSPENSION, NONRENEWAL OR DISMISSAL

INTENT: Each training program is responsible for the conduct of that training program and for the policy on defining satisfactory performance of the resident as a student. The sponsoring institution wishes to ensure that the application of such policies are not arbitrarily illegal, unjust or create unnecessary hardship. Therefore, a policy and procedure for addressing resident dissatisfaction is established.

POLICY STATEMENT: Context of the institutional and program requirements. Each program must develop fair and consistent standards for the residents. If a resident feels that a decision by the program violates standards of fairness then the resident is afforded a process whereby individuals outside the program may review such decisions.

DESCRIPTION:

The position of the resident presents the dual aspect of a student in graduate training while participating in the delivery of patient care.

The University of Florida College of Medicine is committed to the maintenance of a supportive educational environment in which residents are given the opportunity to learn and grow. Inappropriate behavior in any form in this professional setting is not permissible. A resident's continuation in the training program is dependent upon satisfactory performance as a student, including the maintenance of satisfactory professional standards in the care of patients and interactions with others on the health care team. The resident's academic evaluation will include assessment of behavioral components, including conduct that reflects poorly on professional standards, ethics, and collegiality. Disqualification of a resident as a student or as a member of the health care team from patient care duties disqualifies the resident from further continuation in the program.

Grievances: A grievance is defined as dissatisfaction when a resident believes that any decision, act or condition affecting his or her program of study is arbitrary, illegal, unjust or creates unnecessary hardship. Such grievance may concern, but is not limited to, the following: academic progress, mistreatment by any University employee or student, wrongful assessment of fees, records and registration errors, discipline (other than nonrenewal or dismissal) and discrimination because of race, national origin, gender, marital status, religion, age or disability, subject to the exception that complaints of sexual harassment will be handled in accordance with the specific published policies of the University of Florida and the College of Medicine (as contained in the University's Housestaff Manual).

Prior to invoking the grievance procedures described herein, the resident is strongly encouraged to discuss his or her grievance with the person(s) alleged to have caused the grievance. The discussion should be held as soon as the resident becomes aware of the act or condition that is the basis for the grievance. In addition, or alternatively, the resident may wish to present his or her grievance in writing to the person(s) alleged to have caused the grievance. In either situation, the person(s) alleged to have caused the grievance may respond orally or in writing to the resident.

If a resident decides against discussing the grievance with the person(s) alleged to have caused such, or if the resident is not satisfied with the response, he or she may present the grievance to the Chair or Associate Chair/UFHSC-J. If, after discussion, the grievances cannot be resolved, the resident may contact the Employee Assistance Program or alternatively, the Director of Graduate Medical Education (DGME). The DGME will meet 35

Information for Vascular Neurology Fellows Attachment #1 with the resident and will review the grievance. The decision of the DGME will be communicated in writing to the resident and constitute the final action of the University.

Suspension: The Chief of Staff of a participating and/or affiliated hospital where the resident is assigned, the Dean or Senior Associate Dean/UFHSC-J, the President of the Hospital, the Chair or Associate Chair/UFHSC-J or Program Director may at any time suspend a resident from patient care responsibilities. The resident will be informed of the reasons for the suspension and will be given an opportunity to provide information in response.

The resident suspended from patient care may be assigned to other duties as determined and approved by the Chair or Associate Chair/UFHSC-J. The resident will either be reinstated (with or without the imposition of academic probation or other conditions) or dismissal proceedings will commence by the University against the resident within thirty (30) days of the date of suspension.

Any suspension and reassignment of the resident to other duties may continue until final conclusion of the decision-making or appeal process. The resident will be afforded due process and may appeal to the DGME for resolution, as set forth below.

Nonrenewal : In the event that the Program Director decides not to renew a resident's appointment, the resident will be provided written notice which will include a statement specifying the reason(s) for nonrenewal.

If requested in writing by the resident, the Chair or Associate Chair/UFHSC-J will meet with the resident; this meeting should occur within 10 working days of the written request. The resident may present relevant information regarding the proposed nonrenewal decision. The resident may be accompanied by an advisor during any meeting held pursuant to these procedures, but the advisor may not speak on behalf of the resident. If the Chair or Associate Chair/UFHSC-J determine that nonrenewal is appropriate, he or she will use their best efforts to present the decision in writing to the resident within 10 working days of the meeting. The resident will be informed of the right to appeal to the DGME as described below.

Dismissal: In the event the Program Director of a training program concludes a resident should be dismissed prior to completion of the program, the Program Director will inform the Chair or Associate Chair/UFHSC-J in writing of this decision and the reason(s) for the decision. The resident will be notified and provided a copy of the letter of proposed dismissal; and, upon request, will be provided previous evaluations, complaints, counseling, letters and other documents that relate to the decision to dismiss the resident.

If requested in writing by the resident, the Chair or Associate Chair/UFHSC-J will meet with the resident; this meeting should occur within 10 working days of the written request. The resident may present relevant information regarding the proposed dismissal. The resident may be accompanied by an advisor during any meeting held pursuant to these procedures, but the advisor may not speak on behalf of the resident. If the Chair or Associate Chair/UFHSC-J determine that dismissal is appropriate, he or she will use their best efforts to present the decision in writing to the resident within 10 working days of the meeting. The resident will be informed of the right to appeal to the DGME as described below.

Appeal: If the resident appeals a decision for suspension, nonrenewal or dismissal, this appeal must be made in writing to the DGME within 10 working days from the resident's receipt of the decision of the person suspending the resident or the Chair or Associate Chair/UFHSC-J . Failure to file such an appeal within 10 working days will render the decision of the person suspending the resident or the Chair or Associate Chair/UFHSC-J the final agency action of the University.

The DGME will conduct a review of the action and may review documents or any other information relevant to the decision. The resident will be notified of the date of the meeting with the DGME; it should occur within 15 working days of the DGME's receipt of the appeal. The DGME may conduct an investigation and uphold, modify or reverse the recommendation for suspension, nonrenewal or dismissal. The DGME will notify the resident in writing of the DGME's decision. If the decision is to uphold a suspension, the decision of the DGME is the final agency action of the University. If the decision is to uphold the nonrenewal or dismissal, the resident may file 36

Information for Vascular Neurology Fellows Attachment #1 within 10 working days a written appeal to the Dean of the College of Medicine or for residents based primarily in Jacksonville, to the Senior Associate Dean/UFHSC-J. Failure to file such an appeal within 10 working days will render the decision of the DGME the final action of the University.

The Dean or Senior Associate Dean/UFHSC-J will inform the DGME of the appeal. The DGME will provide the Dean or Senior Associate Dean/UFHSC-J a copy of the decision and accompanying documents and any other material submitted by the resident or considered in the appeal process. The Dean or Senior Associate Dean/UFHSC-J will use his or her best efforts to render a decision within 15 working days, but failure to do so is not grounds for reversal of the decision under appeal. The Dean or Senior Associate Dean/UFHSC-J will notify in writing the Chair or Associate Chair/UFHSC-J, the DGME, the Program Director and resident of the decision. The decision of the Dean or Senior Associate Dean/UFHSC-J will be the final agency action of the University. The resident will be informed of the steps necessary for the resident to further challenge the action of the University.

Approved Institutional Committee for Graduate Medical Education 03/13/97.

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ATTACHMENT 3: A NEUROLOGIST’S GUIDE TO USING ICD-9 CODES FOR CEREBROVASCULAR DISEASES

INTRODUCTION

ICD-9-CM codes for cerebrovascular diseases is not “user friendly”. This presentation is designed to assist neurologists in choosing proper ICD-9-CM codes by using a cross-walk to more familiar terms. The user is strongly encouraged to re-refer to ICD-9-CM Volume 1 after choosing a code here to be sure there are no other instructions which would indicate using a different code for this situation.

THIS GUIDE HAS NOT BEEN OFFICIALLY ACCEPTED BY CMS OR THE NATIONAL CENTER FOR HEALTH STATISTICS. IT IS POSSIBLE THAT CERTAIN MEDICARE CARRIERS OR OTHER THIRD PARTY REVIEWERS MAY DISAGREE WITH THESE CODING CHOICES.

Acute Inpatient Coding:

Use the appropriate acute stroke codes (see appendix 1). Add the manifestations if possible, or consider adding risk factors (if addressed).

Outpatient coding:

If the patient is seeing you for the first time for a stroke as an outpatient, and your consultation or new visit centers on managing or working up the acute event, then use the acute stroke codes.

If, on the other hand, you are managing a stroke patient who has already had a workup and/or is being seen in followup of the acute event, then use the late effects codes (see appendices 2 & 3) if you are following the sequelae.

It is not unreasonable to use a risk factor code if that is what is addressed in the visit, but it is more likely that these will be used as secondary codes (if addressed in the visit).

Information for Vascular Neurology Fellows Attachment #2

DIAGNOSIS SUGGESTED ICD-9-CM CODE

Transient cerebral ischemia and related syndromes (Note – these are four digit codes) Vertebral artery TIA or syndrome 435.1 Transient cerebral ischemia, Vertebral artery syndrome Basilar artery TIA or syndrome 435.0 Transient cerebral ischemia, Basilar artery syndrome Vertebrobasilar (artery)TIA or syndrome 435.3 Transient cerebral ischemia, Vertebrobasilar artery syndrome Carotid artery TIA or syndrome 435.8 Other specified transient cerebral ischemia TIA in any other cerebrovascular 435.8 Other specified transient cerebral ischemia territory (Middle cerebral, Posterior cerebral, Anterior cerebral, etc) TIA without territory specified 435.9 Unspecified transient cerebral ischemia Amaurosis fugax 326.34 Retinal vascular occlusion, Transient arterial occlusion Transient global amnesia 437.7 Transient global amnesia

Occlusion or stenosis of precerebral (extracranial) arteries WITHOUT infarction (stroke) (Note - these are five digit codes) Basilar artery occlusion or stenosis 433.00 Occlusion and stenosis of precerebral arteries, Basilar artery, without mention of infarction Vertebral artery occlusion or stenosis 433.20 Occlusion and stenosis of precerebral arteries, Vertebral artery, without mention of infarction Carotid artery occlusion or stenosis 433.10 Occlusion and stenosis of precerebral arteries, Carotid artery, without mention of infarction Multiple and bilateral precerebral 433.30 Occlusion and stenosis of precerebral arteries, Multiple and (extracranial) artery occlusion or bilateral arteries, without mention of infarction stenosis Precerebral (extracranial) artery 433.90 Occlusion and stenosis of precerebral arteries, unspecified occlusion or stenosis without territory precerebral artery, without mention of infarction specified

Occlusion or stenosis of precerebral (extracranial) arteries WITH infarction (stroke) (Note - these are five digit codes) Basilar artery occlusion or stenosis 433.01 Occlusion and stenosis of precerebral arteries, Basilar artery, with infarction Vertebral artery occlusion or stenosis 433.21 Occlusion and stenosis of precerebral arteries, Vertebral artery, with infarction Carotid artery occlusion or stenosis 433.11 Occlusion and stenosis of precerebral arteries, Carotid artery, with infarction Multiple and bilateral precerebral artery 433.31 Occlusion and stenosis of precerebral arteries, Multiple and occlusion or stenosis bilateral arteries, with infarction Precerebral artery occlusion or stenosis 433.91 Occlusion and stenosis of precerebral arteries, unspecified without territory specified precerebral artery, with infarction

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Occlusion or stenosis of intracerebral arteries WITH infarction (stroke) (Note - these codes have five digits) Middle cerebral artery infarction 434.01 Occlusion of cerebral arteries, Cerebral thrombosis, with cerebral (stroke), thrombotic infarction Middle cerebral artery infarction 434.11 Occlusion of cerebral arteries, Cerebral embolism, with cerebral (stroke), embolic infarction Anterior cerebral artery infarction 434.01 Occlusion of cerebral arteries, Cerebral thrombosis, with cerebral (stroke), thrombotic infarction Anterior cerebral artery infarction 434.11 Occlusion of cerebral arteries, Cerebral embolism, with cerebral (stroke), embolic infarction Posterior cerebral artery infarction 434.01 Occlusion of cerebral arteries, Cerebral thrombosis, with cerebral (stroke), thrombotic infarction Posterior cerebral artery infarction 434.11 Occlusion of cerebral arteries, Cerebral embolism, with cerebral (stroke), embolic infarction Any other intracerebral artery infarction 434.01 Occlusion of cerebral arteries, Cerebral thrombosis, with cerebral (stroke), thrombotic infarction Any other intracerebral artery infarction 434.11 Occlusion of cerebral arteries, Cerebral embolism, with cerebral (stroke), embolic infarction Cerebral thrombosis (no artery 434.01 Occlusion of cerebral arteries, Cerebral thrombosis, with cerebral mentioned) infarction Cerebral embolism, (no artery 434.11 Occlusion of cerebral arteries, Cerebral embolism, with cerebral mentioned) infarction Lacunar infarction (stroke) 434.91 Cerebral artery occlusion, unspecified, with cerebral infarction Cerebral infarction (stroke) with no 434.91 Cerebral artery occlusion, unspecified, with cerebral infarction vascular territory specified

NOTE THAT THE “DEFAULT” CODE FOR ISCHEMIC STROKE IS:

434.91 Cerebral artery occlusion, unspecified, with cerebral infarction If the only term documented is “Stroke”, then use this code. Use this code when the vascular territory is unknown. Because of the lack of specificity of this code please “upgrade” to a more specific code as soon as the vascular territory and mechanism of stroke are known.

Hemorrhage (bleed) Nontraumatic subarachnoid hemorrhage 430 Subarachnoid hemorrhage Intracerebral (intraparenchymal) 431 Intracerebral hemorrhage hemorrhage Intraventricular hemorrhage 431 Intracerebral hemorrhage Nontraumatic subdural hemorrhage 432.1 Subdural hemorrhage Nontraumatic extradural (epidural) 432.0 Nontraumatic extradural hemorrhage hemorrhage “Intracranial” hemorrhage without 432.9 Unspecified intracranial hemorrhage further site or type specification

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Other cerebrovascular diagnoses Nonruptured cerebral aneurysm, any 437.3 Cerebral aneurysm, nonruptured territory Cerebral atherosclerosis (useful when 437.0 Cerebral atherosclerosis attributing a manifestation such as vascular dementia) Diffuse cerebral ischemia 437.1 Other generalized ischemic cerebrovascular disease (nonatherosclerotic) Hypertensive encephalopathy 437.2 Hypertensive encephalopathy Cerebral arteritis (vasculitis) 437.4 Cerebral arteritis Add code for the primary disease if present! Moyamoya disease 437.5 Moyamoya disease Venous sinus thrombosis (noninfectious) 437.6 Nonpyogenic thrombosis of intracranial venous sinus Infectious (pyogenic) venous sinus 325 Phlebitis and thrombophlebitis of intracranial venous sinuses. phlebitis or thrombophlebitis Binswanger’s disease Use two codes: 437.1 Other generalized ischemic cerebrovascular disease 290.12 Presenile dementia with delusional features Carotid artery dissection 443.21 Dissection of carotid artery Vertebral artery dissection 443.24 Dissection of vertebral artery Dissection of other artery, or artery not 443.29 Dissection of other artery named. Cerebral amyloid angiopathy 437.8 Other and ill-defined cerebrovascular disease

Eponyms The codes indicated for use here by the index of ICD-9-CM are not compatible with the specificity of the vascular territory. Please strongly consider coding the vascular territory of infarction instead! Claude syndrome 352.6 Multiple cranial nerve palsies Foville syndrome 344.89 Other specified paralytic syndrome Wallenburg syndrome 436 Acute,, but ill-defined cerebrovascular disease Weber syndrome (Weber-Gubler) 344.89 Other specified paralytic syndrome (Weber-Leyden) Millard-Gubler 344.89 Other specified paralytic syndrome

Example

Late effects codes are used to describe conditions that occur at any time after the acute event. Use them for inpatient or outpatient care subsequent to the initial inpatient admission or outpatient evaluation.

Example: Stroke: Patient is right handed admitted for left hemisphere stroke with aphasia and flaccid right hemiparesis.

Code during the acute admission:

434.91 Cerebral artery occlusion, unspecified

342.01 Flaccid hemiplegia, affecting dominant side.

784.3 Aphasia

Code after the acute admission: 438.21 Late effects of cerebrovascular disease, Hemiplegia affecting dominant side 438.11 Late effects of cerebrovascular disease, Aphasia 41

Information for Vascular Neurology Fellows Attachment #2

Late Effects Codes Cognitive defects 438.0 Speech and language deficit, unspecified 438.10 Aphasia 438.11 Dysphasia 438.12 Other speech and language deficits 438.19 Hemiplegia/hemiparesis affecting unspecified side 438.20 Hemiplegia/hemiparesis affecting dominant side 438.21 Hemiplegia/hemiparesis affecting nondominant side 438.22 Monoplegia/monoparesis of upper limb affecting unspecified side 438.30 Monoplegia/monoparesis of upper limb affecting dominant side 438.31 Monoplegia/monoparesis of upper limb affecting nondominant side 438.32 Monoplegia/monoparesis of lower limb affecting unspecified side 438.40 Monoplegia/monoparesis of lower limb affecting dominant side 438.41 Monoplegia/monoparesis of lower limb affecting nondominant side 438.42 Other paralytic syndrome: Use additional code to identify that Syndrome such as: Locked in state (344.81) Quadriplegia/quadriparesi (344.00-344.09) Other paralytic syndrome affecting unspecified side 438.50 Other paralytic syndrome affecting dominant side 438.51 Other paralytic syndrome affecting nondominant side 438.52 Other paralytic syndrome, bilateral 438.53 Alterations of sensation: Use additional code to identify the altered sensation 438.6 Disturbances of vision: Use additional code to identify visual disturbance 438.7 Apraxia 438.81 Dysphasia 438.82 Facial weakness or droop 438.83 Ataxia 438.84 Vertigo 438.85 Other late effects of cerebrovascular disease: Use additional code to identify the 438.89 late effect Unspecified late effects of cerebrovascular disease 438.9

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ATTACHMENT 4: MEDICAL COST AWARENESS FOR NEW HOUSESTAFF

In an academic health center, residents are responsible for the majority of patient care decisions involving clinical resources such as radiology, laboratory, and length of time patients spend in the hospital. To adequately prepare themselves for future practice in any setting, housestaff must be aware they will be entering a competitive marketplace in which physician performance is measured and reported routinely.

The two most common measures of performance in healthcare are cost and quality. It is the relationship between the patient=s outcome and the cost of supporting that outcome which defines the value a healthcare provider can claim to provide. Increasingly, medical care payment is managed by payers responding to cost and satisfaction data which may compel them to choose one institution as more effective and efficient over another. Patient care costs are followed closely within the Shands system. Use of billable items such as x-rays, diagnostic laboratory tests, intensive care days, and O.R. time are tracked. Patient satisfaction is surveyed and comparison reports are shared among dozens of academic health centers similar to Shands.

The Clinical Resource Management office (395-0374) and the Clinical Resource Management Council, comprised of representative clinical attending faculty, support evaluation and ongoing improvement in patient care outcomes, costs, and value. Shands= Coordinated Care program, administered through the Department of Nursing and Patient Services, works with CRM to assist physicians in identifying clinical practice patterns which are efficient, effective, and satisfying for the patient as well as care provider.

During two years of concentrated effort, over 10% of Shands’ internal costs have been trimmed by residents and attendings making more judicious and appropriate decisions to utilize tests, exams, sites of care, and days of hospitalization. There remain, however, many opportunities to reduce clinical cost without negatively affecting care. It is the housestaff member’s particular daily challenge to identify these opportunities and act on them.

Costs to Patients and Their Payers

Examples of the 1996 price-to- the-patient for typical, high-volume diagnostic orders within Radiology and the Clinical Laboratory are found in the tables below. Shands must often discount these charges heavily to ensure continuing payment within the increasingly competitive marketplace. Even when discounted, payment by insurers and for those without insurance rarely meets total billings. Because we cannot rely on consistent levels of reimbursement, it is imperative that our internal costs be as lean as possible to afford providing the broadest array of clinical services and resident training. Further information about managed care is available through the CRM office. Specific charges to patients for other exams can be obtained by calling Radiology Administration at 395-0101, or the Clinical Laboratory at 395-0172.

High-Volume Radiology Exams (Annual Shands at UF Patients: Approx. 25,000)

Exam Patient Charger per Annual Quantity Annual Inpatient Exam Ordered Chargers Chest x-ray, 1 view $100 65,884 $6588,400 Chest s-ray, pa/lat (2 $115 6,692 $769,580 views) Portable Svc. Charge $0 72,000 $0 Abdomen, 1 view $105 2,830 $297,150 Abdominal Ultrasound $310 1,841 $570,630 CT-Abdomen w/ contrast $1,537 4,804 $7,382,460 MRI Brain $1,697 1,890 $3,208,090

Information for Vascular Neurology Fellows Attachment #3 Note: Housestaff are more likely to independently make decisions about use of less complex radiology exams such as abdominal and chest views than more expensive MRI and CT scans. Yet it can quickly be seen from the table that due to annual volume, resident decisions determine the greater overall financial impact of these top- volume radiology resources. Hypothetically, if all 600 residents participated equally in deciding to utilize chest and abdominal exams alone, each resident would have accounted for over $15,000 in cost-to-patient during the year for just these 2 resources.

High-Volume Laboratory Tests

Exam Patient Charge per Exam Annual Quantity Ordered Annual Inpatient Charges Electrolyte Battery $66 118 $7,762 Renal Disease Batt. $133 114 $15,198 Liver Battery $135 22,705 $3,075,952 UA $44 16,975 $743,206 CBC w/ Diff $114 57,109 $6,488,219 CBC $40 110,031 $4,386,428 PT/INR $48 55,524 $2,652,684 Blood Culture $111 29,748 $3,302,028 Urine Culture $56 13,969 $788,918 Sensitivity $44 11,942 $522,088

Again, it can be easily seen that during a single day (and night) on-service, a busy resident ordering multiple, serial lab batteries or common, single tests can impact his or her patient=s billings by thousands of dollars. In the intensive care areas, that figure can jump to thousands of dollars per day per patient.

Sensitivity and Specificity Criteria

The judicious use of diagnostic technology is a skill requirement for successful 21st century medical practice. This skill depends upon the clinician=s knowledge of a test=s sensitivity (the ability of the test to detect the disease), and it=s specificity (the ability of the test to exclude patients without the disease), and the prevalence of the disease in the population under consideration. The predictive value of an abnormal test result (how often the abnormal results will be due to the presence of the disease as opposed to a false positive) can be calculated from the sensitivity and specificity of the test and the prevalence of the disease. For example:

Clean catch urine cultures in women may illustrate the predictive value of a test. A single clean catch specimen, 5 organisms/mm, indicates a diagnosis of urinary tract infection with a sensitivity of 95% and a specificity of 84% (1). When women with complaint of both polyura and dysura are cultured, 60% will have true urinary tract infections (2). A positive urine culture will thus have a predictive value of 90% when compared to direct bladder puncture. When women complaining of dysura alone are cultured, only 33% will have infection, as b have vaginitis (3). A positive culture in this situation will be of less use, with a predictive value of about 75%. If women with no symptoms are studied, only 5% will have asymptomatic bacturia. In this situation, the predictive value of a positive culture indicating true infections is only 24%, much less than flipping a coin. Thus a laboratory test is most helpful in the context of strong clinical suspicion.

When to Order a Test?

For many patient groups, planned coordination of care will include specific pre-printed order sets to launch a patient into the clinical setting. Order sets will most often be used in conjunction with a clinical pathway, a time- and-event grid of the necessary care to ensure specific patient outcomes during hospitalization. The clinical pathway, developed by a multi-disciplinary team including attending faculty members, is used as a guide to optimizing the patient=s ongoing care and may include suggested intervals for standard diagnostic and 44

Information for Vascular Neurology Fellows Attachment #3 monitoring tests. Although structured across a time grid, the pathway is intended to be adjusted to each individual patient=s particular situation.

An adjunct to a pathway may be an algorithm, or mapped-out sequence of key decision points which assist the housestaff member in weighing treatment and diagnostic options. When applied to the care of a specific patient, algorithms and pathways both will involve the ongoing tracking of selected variances from intended outcomes. It is through the analysis of variance patterns that structured data emerges. The data are used to enhance revision of these tools, better supporting the clinician=s decision-making process.

Beyond the structured test-ordering patterns suggested in pathways and algorithms, housestaff should consult with their attendings and may order exams and tests to:

 confirm a clinical diagnosis based on reasonable expected prevalence  rule out treatable, life-threatening or serious disease  stage a disease for therapeutic or prognostic purposes  screen for asymptomatic disease only if evidence exists that finding the condition in an asymptomatic state can alter the long-term outcome of the patient  delineate risk factors for prognostic & counseling purposes  monitor drug therapy (pharmacy will provide guidelines 395-0418)  generate clinical research data among patients participating, with informed consent. (Cost of tests are absorbed by the institution and not applied to a patient=s bill)

The predictive value of laboratory tests and diagnostic procedures must be measured against the norm of the diagnostic power of a medical history and exam. Historically, the ability to solve clinical problems at the beside without the laboratory information approached 90% (4).d Today and in the future, the housestaff member’s skill in judging when and to what extent further diagnostic information clearly contributes to clinical decision- making and avoiding complications of care will be a critical factor in the success of that physician=s professional career.

References

1. Robbin, JA and AI Mushlin: Preoperative evaluation of the healthy patient. Med Clin N Am 1979; 63:1150

2. Stamm WE, KF Wagner, R Amsel, ER Alexander, et al: Causes of the acute urethral syndrome in women. N Eng J Med 1980; 303:409-415

3. Komaroff AL, TM Pass, JD McCue, F Frielund, and AM Cohen: Symptoms of urinary and vaginal infection in a primary care practice. Clin Res, 1978;26:328A

4. Hampton JR, MJG Harrison, JRA Mitchell, et al: Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical patients. Brit Med J 1975; 1:

Information for Vascular Neurology Fellows Attachment #4

ATTACHMENT 5: IMPAIRED PHYSICIANS POLICY

SUBJECT: Impaired Physician

INTENT: The sponsoring institution and each training program are responsible for monitoring residents for signs of impairment. Impairment is defined as the condition of being unable to perform one’s professional duties and responsibilities in a reasonable manner and consistent with professional standards. Cognitive function, judgment, reaction time, and ability to handle stress are increasingly affected. As impairment progresses the potential for compromised patient care increases. Impairment may result from dependence or use of mind or mood altering substances; distorted thought processes resulting from mental illness or physical condition; or disruptive social tendencies.

POLICY STATEMENT: The University of Florida College of Medicine will fully participate in the provisions of the Florida Medical Practice Act (F.S.458), the rules of the Board of Medicine, and Department of Professional Regulation. The College of Medicine supports the Florida Professional Resource Network (PRN). www.flprn.org

DESCRIPTION:

1. Faculty, staff, peers, family or other individuals who suspect that a member of the housestaff may be suffering from impairment are obligated to report such problems. Individuals suspecting such impairment can (a) discuss their concerns with the Program Director, (b) Department Chairman, (c) Associate Dean of Graduate Medical Education, or (d) report directly to the Florida Professional’s Resource Network (PRN)

2. It is the intent of the sponsoring institution that all appropriate rules that govern the practice of medicine be strictly enforced.

3. All referrals to the PRN are confidential. Individuals are required to undergo an independent evaluation by professionals of the PRN. Decisions about intervention, treatment and after care are determined by the PRN.

4. The PRN will authorize the participant’s ability to return to practice in consultations and with the recommendations from the approved treatment providers.

5. As Consultant to the Dept. of Health, Dept. of Business and Professional Regulation and Licensing Boards, PRN supports compliant participants and speaks in support of those in compliance.

6. Resumption of clinical activity and residency program will be contingent upon the continued successful participation in the PRN. Continuation of the resident in the program will be determined in consultation between the Residency Program Director, the Associate Dean of GME and the professionals at the PRN.

7. Information on the Florida Professional Resource Network (PRN) and its program can be obtained by calling 1-800-888- 8PRN, going online at www.flprn.org, or by writing to the PRN at P.O. Box 1020, Fernandina Beach, Florida 32035- 1020.

8. In addition, each Training Program will provide access to an educational program to their residents regarding substance abuse.

9. Compliance with the above will be monitored in the internal review process.

Last Review: Graduate Medical Education Committee December 11, 2008

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ATTACHMENT 6: SEXUAL HARRASSMENT

SUBJECT: Sexual Harassment

INTENT: The Accreditation Council for Graduate Medical Education Institutional Requirements requires the Sponsoring Institution to have written policies covering sexual and other forms of harassment.

POLICY STATEMENT: It is the policy of The University of Florida to provide an educational and working environment for its students, faculty and staff that is free from sex discrimination and sexual harassment. In accordance with federal and state law, the University prohibits discrimination on the basis of sex, including sexual harassment. Sex discrimination and sexual harassment will not be tolerated, and individuals who engage in such conduct will be subject to disciplinary action. The University encourages residents / fellows, students, faculty, staff and visitors to promptly report sex discrimination and sexual harassment.

DEFINITION: Sexual Harassment is a form of sex discrimination that can occur when:

The submission to unwelcome physical conduct of a sexual nature, or to unwelcome requests for sexual favors or other verbal conduct of a sexual nature, is made an implicit or explicit term or condition of employment or education; or

The submission or rejection to unwelcome physical conduct of a sexual nature, or to unwelcome requests for sexual favors or other verbal conduct of a sexual nature, is used as a basis for academic or employment decisions or evaluations; or

Unwelcome physical acts of a sexual nature, or unwelcome requests for sexual favors or other verbal conduct of a sexual nature, have the effect of creating an objectively hostile environment that interferes with employment or education on account of sex.

REPORTING: Confidential Discussion – No Reporting

Resident Reporting

If a resident / fellow would like to confidentially discuss this type of issue prior to reporting they may contact Shae Graham Kosch, Ph.D. - 392-4541 ext 228. This designated counselor does not have an obligation to report any incident that is brought to his/her attention.

Mandatory Action Required

A person who believes that he or she has been subjected to sex discrimination or sexual harassment may report the incident to any University official, administrator or supervisor. However, the Office of Human Resource Services, Larry Ellis, investigates all complaints. Incidents should be reported as soon as possible after the time of their occurrence.

Additional policy information should be reviewed and can be obtained at http://hr.ufl.edu/eeo

Any complaint or report of sexual harassment to any UF official MANDATES that individual to report it the Office of Human Resource Services.

Information for Vascular Neurology Fellows Attachment #5

Self Reporting – A resident / fellow can contact this person directly:

All Sexual Harassment complaints are investigated by the Office of Human Resource Services. The Complaint form is available is at http://www.hr.ufl.edu. All incidents should be reported as soon as possible to:

Larry T. Ellis, Director of Administration and Equal Employment Opportunity Human Resource Services P.O. Box 115010 Gainesville, FL 32611-5010 352-392-1075

Last review: Graduate Medical Education Committee December 11, 2008 Previous GMEC Review and Approval November 13, 2008 October 12, 2006

Information for Vascular Neurology Fellows Attachment #6

ATTACHMENT 7: INSTITUTIONAL OUTSIDE EMPLOYMENT POLICY

SUBJECT: Outside Employment (Moonlighting)

INTENT: The Accreditation Council for Graduate Medical Education Institutional Requirements require that the Sponsoring Institution have policies regarding professional activities outside the educational program.

POLICY STATEMENT: Housestaff must adhere to State University System Guidelines regarding outside activities/outside employment, conflict of interest, and additional compensation. Such outside activity includes private practice, private consultation, teaching, research, or other employment outside State government which is not part of assigned University duties and for which the University provides no compensation. Individual housestaff programs are accredited by their Residency Review Committee (RRC) and must adhere to RRC requirements regarding outside employment. Although RRC’s vary, the general theme is that any professional activities which are outside the established educational program must not interfere with the resident’s established educational process or the quality care of patients. Residents shall not be required to engage in professional activities outside the educational program.

DESCRIPTION

1. Each program must have a policy regarding outside and extracurricular employment which meets RRC requirements and University of Florida College of Medicine policy. There are two categories of such employment in University of Florida policy:

a. Programmatic: These activities are initiated by departments to provide clinical experiences in addition to the standard curriculum and which usually occur at non-campus health care affiliates. Supplemental salary income is provided by the University to housestaff who participate in programmatic activities.

b. Non-programmatic: These activities are initiated by the resident and do not involve any agreement between the College of Medicine and an outside employer. Residents must be licensed for unsupervised medical practice in the state where such activity occurs and attest to adequate professional liability coverage. In no circumstance is the resident to hold him or herself out as an employee of the University while engaged in such activities.

2. Each program’s rules regarding outside and extracurricular employment must be reviewed and approved by the GMEC during the periodic program reviews. The program director is ultimately responsible for assuring that outside activities do not interfere with the educational program and should monitor all outside activities of the residents in their program on an ongoing basis. Program Directors are required to prospectively approve any programmatic and nonprogrammatic activities, to include the number of hours per week such activities shall consume.

3. Programmatic & Non-Programmatic includes time spent in patient care, and consideration of patient and resident safety demand that these hours must be counted toward the residents’ 80 hour per week maximum, counted toward residents’ maximum continuous duty period and requirements for time free from patient care responsibilities. All Programmatic & Non-Programmatic must be completed at least 12 hours prior to residency duties unless given explicit permission by the resident’s program director.

4. A summary annual report of programmatic and nonprogrammatic professional employment of housestaff will be provided by the program director to the GMEC indicating that the program director is aware of the activities and approves. 49

Information for Vascular Neurology Fellows Attachment #6

5. All housestaff participating in nonprogrammatic outside professional employment must first complete a Non-Programmatic Professional Activity Form for approval and signature by their chairperson or program director and the Associate Dean, GME before undertaking such activity – Each episode of anticipated service must be included. Requests may be made for activities spanning up to one month, but in no circumstance will blanket approval for periods longer than one month be permitted.

6. Programs, departments and services will be responsible for enforcement of this policy. Violation by the resident may lead to immediate dismissal.

7. Housestaff training with a J-1 or H1-b visa is federally prohibited from participating in outside employment.

Last Reviewed: Graduate Medical Education Committee December 11, 2008

Information for Vascular Neurology Fellows Attachment #7

ATTACHMENT 8: GOALS AND OBJECTIVES FOR VASCULAR NEUROLOGY

University of Florida College of Medicine Department of Neurology

Vascular Neurology Fellowship Program

Division Policy/Procedures

Competency-Based Goals & Objectives for the Vascular Neurology Fellowship Program (By Rotation)

COMPETENCY-BASED GOALS & OBJECTIVES BY ROTATION

Overall Competency-based Program Goals:

Core Competencies:

Patient Care: Fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

Medical Knowledge: Fellows must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care.

Practice-Based Learning and Improvement: Interpersonal and Communication Skills: Fellows must demonstrate the ability to investigate and evaluate the care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self- evaluation and life-long learning. Fellows are expected to develop skills and habits to be able to meet the following goals:

9. Identify strengths, deficiencies, and limits in one’s knowledge and expertise 10. Set learning and improvement goals 11. Identify and perform appropriate learning activities 12. Systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement 13. Incorporate formative evaluation feedback into daily practice 14. Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems 15. Use information technology to optimize learning 16. Participate in the education of patients, families, students, residents and other health professionals

Information for Vascular Neurology Fellows Attachment #7 Interpersonal and Communication Skills: Fellows must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. Fellows are expected to:

6. Communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds 7. Communicate effectively with physicians, other health professionals, and health related agencies 8. Work effectively as a member or leader of a health care team or other professional group 9. Act in a consultative role to other physicians and health professionals 10. Maintain comprehensive, timely, and legible medical records

Professionalism: Fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Fellows are expected to demonstrate:

6. Compassion, integrity, and respect for others 7. Responsiveness to patient needs that supersedes self-interest 8. Respect for patient privacy and autonomy 9. Accountability to patients, society and the profession 10. Sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation

Systems-Based Practice: Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Fellows are expected to:

7. Work effectively in various health care delivery settings and systems relevant to their clinical specialty 8. Coordinate patient care within the health care system relevant to their clinical specialty 9. Incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate 10. Advocate for quality patient care and optimal patient care systems 11. Work in inter-professional teams to enhance patient safety and improve patient care quality 12. Participate in identifying system errors and implementing potential systems solutions

Overall Program Goals:

1. To prepare the physician for the independent practice of vascular neurology by providing training based on supervised clinical work with increasing responsibility for outpatients and inpatients. This training will be separate and distinct from the training required for certification in general and pediatric neurology. (Competencies Addressed: Patient Care, Medical Knowledge) 2. To provide a foundation for evidence-based medicine to facilitate the interpretation and implementation of clinical research in vascular neurology. (Competencies Addressed: Medical Knowledge, Practice Based Learning and Improvement) 3. To provide an opportunity to develop an investigative career in vascular neurology. (Competencies Addressed: Medical Knowledge) 4. To provide a basic understanding of ultrasonography and establish familiarity with performing and interpreting vascular imaging studies. (Competencies Addressed: Medical Knowledge) 5. To develop the many personal attributes necessary for becoming an effective physician, including honesty, compassion, reliability, and effective written and oral communication skills. (Competencies Addressed: Interpersonal and Communication Skills, Professionalism) 52

Information for Vascular Neurology Fellows Attachment #7 6. To gain teaching skills by educating and supervising residents and medical students rotating on the inpatient stroke service at Shands Hospital at the University of Florida. (Competencies Addressed: Practice Based Learning and Improvement, Interpersonal and Communication Skills, Systems Based Practice) 7. To participate in both clinical and educational activities (both hospital and community based) that relate to stroke and stroke prevention. (Competencies Addressed: Patient Care, Interpersonal and Communication Skills, Systems Based Practice)

Name of Rotation: Vascular Neurology Inpatient Care Supervisor: Michael F. Waters, MD, PhD Rotation Length: 6 months

Rotation Description: Vascular neurology inpatient care includes patients on the Neuro ICU, Neuro IMC, and Stroke Unit, as well as the emergency department and other service floors housing stroke patients with other comorbidities. The fellow will be responsible for inpatients on these services, and will follow patients from admission through treatment and discharge. The fellow will encounter a wide variety of cerebrovascular pathology and will interact with the multidisciplinary team including neuroradiologists, neurosurgeons, and Critical Care Medicine. The patient care experience will be supplemented with practical and didactic teaching sessions. The fellow will also take part in the monthly journal club which includes discussions on stroke topics. The resident will also take part in weekly Neurology Grand Rounds, weekly Neuroscience Seminar, weekly Neuroradiology/Neuropathology Case Conference, monthly Neurovascular Case Conference, monthly Stroke Lecture Series, and monthly journal club discussions of stroke topics.

Rotation Goals:

Perform detailed neurological histories and physical examinations of stroke patients. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Understand the indications and basic interpretation of diagnostic brain imaging for stroke. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Systems-Based Practice) Understand the clinical evaluation and treatment of acute stroke. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Understand the pathophysiology, diagnosis and management of common neurovascular disorders, including: ischemic stroke, hemorrhagic stroke, subarachnoid hemorrhage, and other cerebrovascular malformations. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Understand secondary stroke prevention measures. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement) Opportunity to observe neurointerventional cases and visit the OR. (Competencies Addressed: Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice)

Information for Vascular Neurology Fellows Attachment #7 Rotation Objectives:

Gain an understanding of the neuroanatomy and pathophysiology of acute cerebrovascular disease. (Competencies Addressed: Patient Care, Medical Knowledge) Develop clinical skills in recognizing acute stroke syndromes. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Learn basic strategies for management of stroke patients. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice)

Bibliography/Study List:

Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P. Antithrombotic and thrombolytic therapy for ischemic stroke: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126(3 Suppl): 483S-512S.

Adams H, Zoppo G, Alberts M, Bhatt D, Brass L, Furlan A, Grubb R, Higashida R, Jauch E, Kidwell C, Lyden P, Morgenstern L, Qureshi A, Rosenwasser R, Scott P, and Wijdicks E. Guidelines for the Early Management of Adults with Ischemic Stroke: A Guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007 May;38(5):1655-711. Epub 2007 Apr 12.

Goldstein L, Adams R, Alberts M, Appel L, Brass L, Bushnell C, Culebras A, DeGraba T, Gorelick P, Guyton J, Hart R, Howard G, Kelly-Hayes M, Nixon JV, Sacco R. AHA/ASA Guideline: Primary Prevention of Ischemic Stroke – A Guideline from the American Heart Association/American Stroke Association Stroke Council; Cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group. The American Academy of Neurology affirms the value of this guideline. (STROKE. 2006;37:1583.)

Patrono C, Coller B, FitzGerald G, Hirsh J, and Roth G. Platelet-Active Drugs: The Relationships Among Dose, Effectiveness, and Side Effects – The Seventh ACCP Conference on Antithrombotic and Throbolytic Therapy. Chest. 2001 Jan;119(1 Suppl):39S-63S.

Fisher, Marc. Approaches to Cerebrovascular Disease. Barcelona, Spain: Prous Science, 2006.

Name of Rotation: Vascular Neurology Outpatient Care Supervisor: Anna Khanna, M.D. Rotation Length: 4 ½-day clinics per month for 12 months

Rotation Description: The Neurovascular Outpatient Clinic provides follow-up care and initial evaluation for cerebrovascular patients, ongoing management of stroke risk factors, and evaluation and care of disabilities caused by prior strokes, including physical, cognitive and psychological problems. The goal of this rotation is to familiarize fellows with the spectrum of patient care challenges that arise in an outpatient setting. The fellow will independently evaluate patients, present their findings and

Information for Vascular Neurology Fellows Attachment #7 propose a management plan to an attending physician, see the patient with an attending to clarify salient history and examination features, and implement the final management plan jointly developed with the attending physician. It is encouraged that patients seen in the outpatient clinic be followed in the fellow’s continuity clinic. The fellow will order and follow-up on test results related to the management plan, and communicate these test results to the patient. Practical and didactic teaching sessions will supplement the patient care experience. The resident will also take part in weekly Neurology Grand Rounds, weekly Neuroscience Seminar, weekly Neuroradiology/Neuropathology Case Conference, monthly Neurovascular Case Conference, monthly Stroke Lecture Series, and monthly journal club discussions of stroke topics.

Rotation Goals:

Learn the neurologic significance of symptoms, signs, and test results for cerebrovascular disorders seen in outpatients. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement) Develop neurologic history and examination skills that facilitate eliciting pertinent clinical information in the time-limited fashion that is germane to the outpatient service. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Understand how to translate the medical significance of symptoms, signs, test results, diagnoses, and management plans into language that patients and families can understand. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism) Understand the anatomic localization of specific neurologic and cerebrovascular symptoms and signs. (Competencies Addressed: Medical Knowledge, Practice-Based Learning and Improvement) Learn the appropriate use of common pharmacologic and non-pharmacologic treatments for stroke prevention and treatment of disabilities caused by cerebrovascular events. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement) Seek to understand the impact of chronic disability caused by stroke on the daily lives of outpatients and their families. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems- Based Practice)

Rotation Objectives:

Learn to translate your understanding of the medical significance of symptoms, signs, test results, diagnoses, and management plans into language that patients and families can understand. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism) Learn how to dictate outpatient letters that reflect an understanding of the reason(s) for consultation and either answer the clinical question posed by the referring physician or clearly communicate how further evaluation or management by the referring physician should proceed. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism) Learn to elicit key aspects of the history and exam that enable initial management to proceed in a timely fashion required in an outpatient practice. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Learn the common pharmacologic and non-pharmacologic treatment options for management of common and treatable stroke risk factors and disabilities. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Systems-Based Practice)

Information for Vascular Neurology Fellows Attachment #7 Communicate test results and their significance to patients, and discuss test results of uncertain significance with attending staff. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism) Learn how to develop a neuroanatomic localization of patient-specific symptoms and signs, and an initial differential diagnosis to discuss with the supervising outpatient attending. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills)

Bibliography/Study List:

Stroke Rehabilitation: A Function-Based Approach by Glen Gillen EdD OTR FAOTA and Ann Burkhardt MA OTD OTR/L BCN FAOTA (April 27, 2004)

Stroke Recovery and Rehabilitation by Joel Stein (Dec 1, 2008)

Stroke (American Academy of Neurology) by Louis R. Caplan (Oct 1, 2005) by J. P. Mohr, Dennis Choi, James Grotta, and Philip Wolf

Acute Ischemic Stroke: An Evidence-based Approach by David M. Greer (Oct 5, 2007)

Stroke: A Practical Approach by James D Geyer and Camilo R Gomez (Sep 1, 2008)

Name of Rotation: Neurocritical Care Supervisor: Andrea Gabrielli, MD Rotation Length: 4 weeks (1 month)

Rotation Description: The Neurovascular ICU service will care for cerebrovascular patients in the adult neurocritical care unit. The Vascular Neurology fellow will be an integral part of the neurocritical care team. S/he will round on all inpatients in the critical care unit and be personally responsible for any acute stroke admissions. Patient care will also include the performance of Transcranial Doppler ultrasound if needed. The fellow will have responsibility for and follow patients from admission through treatment and discharge from the ICU. A wide variety of acute cerebrovascular problems will be encountered and the resident will interact with the multidisciplinary team including vascular neurosurgeons and neurointerventionalists. Practical and didactic teaching sessions will supplement the patient care experience.

Rotation Goals:

Perform a detailed neurological history and physical exam of critically ill patients. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism) Understand the indications and basic interpretation of monitoring and diagnostic testing in the ICU. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement) Understand and practice management of blood pressure in the NICU. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism) Understand the clinical evaluation and treatment of neurological emergencies in the ICE, i.e. coma, hypertensive crisis, malignant stroke, cerebral edema, etc. (Competencies Addressed: Patient Care, 56

Information for Vascular Neurology Fellows Attachment #7 Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Understand the pathophysiology, diagnosis and management of common neurovascular disorders, including: ischemic stroke, hemorrhagic stroke, subarachnoid hemorrhage, and other cerebrovascular malformations. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Understand patient management after neurosurgical and interventional procedures. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice)

Rotation Objectives:

Gain an introduction to the neuroanatomy and pathophysiology of acute cerebrovascular disease. (Competencies Addressed: Patient Care, Medical Knowledge) Develop clinical skills in managing neurological emergencies. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Learn basic strategies for management of blood pressure in the ICU. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement)

Bibliography/Study List:

Burchardi, H., Aims of Sedation/Anesthesia. Minerva Anetesiol 2004 70:137-43.

Gehlbach, B. K., and J. P. Kress, Sedation in the intensive care unit. Curren Opinion in Critical Care, 2001. 8:290-8.

Hogarth, D. K., and J. Hall, Management of sedation in mechanically ventilated patients. Current Opinon in Critical Care, 2004. 10:40-6.

Inouye, S. K., Delirium in older persons. New England Journal of Medicine, 2006. 354:1157-65.

Inouye, S. K., et al., A multicomponent intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine, 1999. 340:669-76.

Kistler, J. P., A. H. Ropper, and R. C. Heros, Therapy of ischemic cerebral vascular disease due to atherothrombosis. (1). New England Journal of Medicine, 1984. 311(1): p. 27-34.

Kistler, J. P., A. H. Ropper, and R. C. Heros, Therapy of ischemic cerebral vascular disease due to atherothrombosis. (2). New England Journal of Medicine, 1984. 311(2): p. 100-5.

Le Roux, P. D., et al., Predicting outcome in poor-grade patients with subarachnoid hemorrhage: a retrospective review of 159 aggressively managed cases. Journal of Neurosurgery, 1996. 85(1): p. 39-49.

Maybert, M.R., et al., Guidelines for the management of aneurismal subarachnoid hemorrhage. A statement for healthcare professionals from a special group of the Stroke Council, American Heart Association. Stroke, 1994. 25 (11): p. 2315-28.

Sloan, M. A., et al., Sensitivity and specificity of transcranial Doppler ultrasonography in the diagnosis of vasospasm following subarachnoid hemorrhage. Neurology, 1989. 39(11): P. 1514-8. 57

Information for Vascular Neurology Fellows Attachment #7 Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. New England Journal of Medicine, 1995. 333(24): p. 1581-7.

Name of Rotation: Neurorehabilitation Inpatient Care Supervisor: James Atchison, DO Rotation Length: 2 weeks ( ½ month)

Rotation Description: The neurorehabilitation inpatient care services, located at Shands Rehab Hospital, provides care for patients recovering from stroke. The fellow will study the application and benefits of various neurorehabilitation techniques and gain clinical experience managing patients in the acute recovery phase of recovery following stroke. The fellow will learn how to functionally assess patients post-stroke and prescribe a therapeutic program. S/he will also become familiar with the post-acute phase of recovery from neurologic injury, including community reentry, driving evaluations, vocational assessment and retraining. The fellow will become familiar with the use of neuroimaging techniques such as the head CT and MRI in neurorehabilitation. The fellow will learn about neuropsychological assessment of cognitive domains and the role of neuropsychological testing in rehabilitation practice. S/he will learn the principles of cognitive rehabilitation and behavioral management. The fellow will also learn neuropharmacologic management. The fellow will become proficient with the use of commonly use used functional assessment measures and gain experience with the prescription of assistive and adaptive equipment. Outcome predictors will be studied, along with follow-up care services for the neurologic patient. This rotation will be full time for a duration of 6 weeks. During this rotation the fellow will not take part in weekly Neurology Grand Rounds, weekly Neuroscience Seminar, weekly Neuroradiology/Neuropathology Case Conference, monthly Neurovascular Case Conference, monthly Stroke Lecture Series, however s/he will take part in the monthly journal club discussions of stroke topics.

Rotation Goals:

Develop skills in the diagnosis and management of common complications post stroke such as hemiplegia, hemiparesis, dysphagia, ataxia, paresthesia, neuropathic pain, aphasia, anosognisia, neglect, apraxia, and depression. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Understand the general principles of neurorehabilitation and neuroplasticity in the nervous system as it relates to patients with neurological disabilities and the roles of physical therapy, occupational therapy, and speech therapy in managing neurological problems. (Compentencies Addressed: Patient Care, Medical Knowledge, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Understand the principles of chronic pain management, including the management of neuropathic pain. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Understand approaches toward the evaluation and management of the aphasias and dysphagias. (Compentencies Addressed: Patient Care, Medical Knowledge, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Gain exposure to orthotics and adaptive/assistive equipment applications in the neurorehabilitative population. (Competencies Addressed: Patient Care, Medical Knowledge, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice)

Information for Vascular Neurology Fellows Attachment #7 Become familiar with the more commonly used functional assessment tools and predictors of functional outcome. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems- Based Practice)

Rotation Objectives:

Know the treatment options for neuropathic pain. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Systems-Based Practice) Know the neurorehabilitation assistive devices used to enhance mobility and ADL performance. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Participate in dysphagia evaluation, including the modified barium swallow. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Understand basic stroke rehabilitation. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Develop skills in therapeutic prescription writing and functional goal setting. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Understand when to refer for neuropsychological testing and what the results of the testing mean. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Learn approaches toward cognitive remediation. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Learn how to approach return to work and driving safety issues following stroke. (Competencies Addressed: Patient Care, Medical Knowledge, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice)

Bibliography/Study List:

AAN Continuums Series – American Academy of Neurology

Gordon et al. Physical Activity and Exercise Recommendations for Stroke Survivors. An American Heart Association Scientific Statement from the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Counsel on Nutrition, Physical Activity, and Metabolism; and the Stroke Council. Circulation 2004; 109:2031-41.

Stroke Rounds Series – Abrams, Stroke Rehabilitation 2004

Ward NS, Cohen LG. Mechanisms underlying recovery of motor function after stroke. Arch Neurol 2004: 1844-88.

Wolf et al. Effect of constraint induced movement therapy on upper extremity function 3 to 9 months after stroke. The EXCITE randomized clinical trial. JAMA 2006; 296:2095-2104.

Information for Vascular Neurology Fellows Attachment #7

Name of Rotation: Endovascular Neurosurgery Supervisor: Brian Hoh, MD Rotation Length: 1 month

Rotation Description: Vascular Neurology fellows will be able to spend a month (or more) on the Neurosurgery service, participating in both inpatient and outpatient settings. This elective is under the supervision of the Neurosurgery faculty.

In both the inpatient and outpatient settings, the vascular neurology fellow will be involved primarily in cerebrovascular disease within the specialty of Neurosurgery (e.g., intracerebral hemorrhage, subarachnoid hemorrhage, arterio-venous malformations).

Neurosurgery Inpatient:

The Vascular Neurology fellow will participate in the direct care of patients with neurosurgical diseases, under the supervision of the Neurosurgery attending. The Vascular Neurology fellow will assist members of the Neurosurgical team as appropriate. This elective will include care in the ED, ICU, and the operating room. The Fellow will be allowed to scrub and may participate in surgical procedures under the supervision of the Neurosurgery Chief Resident or Faculty.

Neurosurgery Outpatient:

The Vascular Neurology fellow will see outpatients under the supervision of the faculty and will participate in pre and post-operative neurosurgical evaluation.

Rotation Goals:

Perform an efficient initial assessment of patients with neurosurgical disease, including history and physical examination. (Competencies Addressed: Patient Care) Formulate a rational surgical intervention plan for patients with increased ICP, subarachnoid hemorrhage, unruptured aneurysm, ICH, sinus thrombosis, or AVM. (Competencies Addressed: Patient Care, Medical Knowledge) Assist in selected surgical procedures (e.g., ventriculostomies, VP shunt placement, simple craniotomies) under direct supervision of Neurosurgery Chief Resident or faculty. (Competencies Addressed: Patient Care) Demonstrate a solid foundation of knowledge of anatomy, physiology and pharmacology related to neurosurgery patients, particularly regarding common vascular neurology abnormalities. (Competencies Addressed: Medical Knowledge, Practice Based Learning and Improvement) Understand the pharmacokinetics, effects, and risks of the therapeutics commonly used in (Vascular) Neurosurgery. (Competencies Addressed: Medical Knowledge) Demonstrate a foundation for clinical neurosurgery problem-solving and decision-making. (Competencies Addressed: Medical Knowledge, Practice Based Learning and Improvement) Demonstrate familiarity with classic and current aspects of the (Vascular) Neurosurgical literature. (Competencies Addressed: Medical Knowledge)

Information for Vascular Neurology Fellows Attachment #7 Rotation Objectives:

Learn the indications for each of the surgical techniques available, the principles underlying each technique, and how they are applied to clinical problems, including ventriculostomies, VP shunt placement, simple craiotomies, etc. (Competencies Addressed: Patient Care, Medical Knowledge) Learn the anatomy, physiology and pharmacology related to neurosurgery patients, particularly regarding common vascular neurology abnormalities. (Competencies Addressed: Medical Knowledge) Develop the ability to formulate a rational surgical intervention plan for patients with increased ICP, subarachnoid hemorrhage, unruptured aneurysm, ICH, sinus thrombosis, or AVM. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Develop the ability to review their own practice to guide their learning. (Competencies Addressed: Practice-Based Learning) Develop an understanding of how Vascular Neurologists and Neurosurgeons collaborate for optimal patient care. (Competencies Addressed: Interpersonal and Communication Skills) Gain an understanding of cost, risks and benefits of surgical techniques for patients with increased ICP, subarachnoid hemorrhage, unruptured aneurysm, ICH, sinus thrombosis, or AVM . (Competencies Addressed: Systems-Based Practice) Develop attitudes that foster honesty, respectfulness towards patients and peers, dedication to patient care, and willingness to acknowledge mistakes. (Competencies Addressed: Professionalism)

Name of Rotation: Research Supervisor: Michael Waters, MD PhD Rotation Length: 1 month

Rotation Description: After acceptance into the fellowship program and prior to beginning the training year, each fellow will be assigned to one of the Stroke Service attending neurologists who is actively engaged in extramurally funded research. This assignment will be made after consultation with the fellow regarding his/her research interests. The faculty mentor will be responsible for ensuring that the fellow actively participates in an ongoing research project broadly related to the field of cerebrovascular disease either in that faculty member’s laboratory or by arrangement with another faculty member at the University of Florida School of Medicine. The fellow will also evaluate eligibility for, and enroll patients in, clinical research studies and clinical trials. S/he will collaborate with the principal investigators and research coordinators in the administrative and regulatory aspects of clinical projects. In addition, the faculty mentor will work with the fellow prior to and early in the training period to design and implement an independent research project. The scope of this project will vary based on the fellow’s interest and career goals and may range from a small project that can be completed in on month (such as a case report) to the initial development of larger scale projects to be completed during an optional non-accredited research-based fellowship year. The faculty mentor will use this endeavor as an opportunity to teach the principles of research design and statistical analysis. The fellow will be expected to present the results of these projects at Stroke Conference, submit abstracts to national meetings and prepare manuscripts for publication.

Rotation Goals:

When involved in clinical research, fellow demonstrates the ability to incorporate research, such as clinical trials, in the care of a cerebrovascular patient. (Competencies Addressed: Patient Care, Interpersonal and Communication Skills, Professionalism) 61

Information for Vascular Neurology Fellows Attachment #7 Fellow should demonstrate knowledge about good clinical practices and human subjects protection in the conduct of clinical research. (Competencies Addressed: Patient Care, Medical Knowledge, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Fellows should be able to use research to guide their own growth in Vascular Neurology. (Competencies Addressed: Practice-Based Learning and Improvement) Fellows should demonstrate the ability to communicate effectively and interact with research subjects and their families, clinic and research staff, referring physicians, and research collaborators. (Competencies Addressed: Interpersonal and Communication Skills, Professionalism) Fellows should develop and demonstrate attitudes that foster honesty, respectfulness towards research patients and their families, good work ethics and willingness to acknowledge mistakes. (Competencies Addressed: Patient Care, Interpersonal and Communication Skills, Professionalism) Fellows should demonstrate knowledge of how research can improve the delivery of care for patients and communities. (Competencies Addressed: Professionalism, Systems-Based Practice)

Rotation Objectives:

Demonstrate the conduct of clinical research in the most compassionate manner. (Competencies Addressed: Patient Care, Interpersonal and Communication Skills, Professionalism) Demonstrate an in-depth understanding of the research being conducted. (Competencies Addressed: Patient Care, Medical Knowledge, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice) Demonstrate the ability to use computerized and non-computerized information systems to facilitate research to instill the value of life-long learning. (Competencies Addressed: Practice- Based Learning and Improvement) Demonstrate ability in extracting information and salient features from the history and examination of patients, and their caregivers, upon which to base a differential diagnosis and management plan. (Competencies Addressed: Practice-Based Learning and Improvement) Demonstrate the ability to communicate effectively with research subjects and their families. (Competencies Addressed: Patient Care, Interpersonal and Communication Skills, Professionalism,) Demonstrate the ability to communicate effectively, interact and coordinate with clinic and research staff (schedulers, nurses, research coordinators), and with patients’ referring physicians. (Competencies Addressed: Patient Care, Interpersonal and Communication Skills, Professionalism) Demonstrate the ability to communicate and interact with your research mentor and other research collaborators. (Competencies Addressed: Interpersonal and Communication Skills, Professionalism) Demonstrate the ability to recognize and deal effectively with ethical issues that arise in the conduct of research. (Competencies Addressed: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism) Demonstrate the ability to meet all research goals and deadlines. (Competencies Addressed: Professionalism)

Information for Vascular Neurology Fellows Attachment #8

ATTACHMENT 9: THE ABPN VASCULAR NEUROLOGY CORE COMPETENCIES OUTLINE

(Coordinated with the American Board of Psychiatry and Neurology Core Competencies Outline, Version 4.1)

I. Vascular Neurology Patient Care Core Competencies A. Vascular neurologists shall demonstrate the following abilities: 1. To perform and document a relevant history and examination on culturally diverse 1 patients to include as appropriate: a. Chief complaint b. History of present illness c. Past medical history d. A comprehensive review of systems e. A biological family history 2 f. A sociocultural history g. A developmental history (especially for children) h. A situationally germane general and neurological examination 2. To delineate appropriate differential diagnoses 3. To evaluate, assess and recommend effective management of patients B. Based on a comprehensive neurological assessment, vascular neurologists shall demonstrate the following abilities: 1. To determine: a. If a patient’s symptoms are the result of a vascular disease affecting the central/vascular nervous system or are of another origin (e.g., of a systemic, psychiatric, or psychogenic illness) b. A formulation, differential diagnosis, laboratory investigation, and management plan 2. To develop and maintain the technical skills to: a. Perform lumbar puncture b. Identify and describe abnormalities seen in common vascular disorders on radiographic testing, including plain films, anteriography, CT, MRI, and TCD or carotid duplex studies c. Evaluate the application and relevance of investigative procedures and interpretation in the diagnosis of neurological disease, including the following: 1) Electroencephalogram and evoked potentials 2) Perimetry 3) Psychometry 4) CSF analysis 5) Vascular imaging (Duplex, transcranial Doppler) 6) Radiographic studies as outlined above d. Identify and describe gross and microscope specimens taken from the normal nervous system and from patients with vascular neurological disorders 3. To recognize and treat vascular neurological disorders in both adults and children 63

Information for Vascular Neurology Fellows Attachment #8

II. Vascular Neurology Medical Knowledge Core Competencies A. Vascular neurologists shall demonstrate the following: 1. Knowledge of major vascular diseases, including considerations relating to age, gender, race, and ethnicity, based on the literature and standards of practice. This knowledge shall include: a. The epidemiology of the disorder b. The etiology of the disorder, including medical, genetic, and sociocultural factors c. The phenomenology of the disorder d. An understanding of the impact of physical illness on the patient’s functioning e. The experience, meaning, and explanation of the illness for the patient and family, including the influence of cultural factors and culture-bound syndromes f. Effective treatment strategies g. Course and prognosis 2. Knowledge of healthcare delivery systems, including patient and family counseling 3. Knowledge of the application of ethical principles in delivering medical care 4. Ability to reference and utilize electronic systems to access medical, scientific, and patient information B. Vascular neurologists shall demonstrate knowledge of the following: 1. Basic science aspects of vascular neurology a. Vascular neuroanatomy b. Stroke pathophysiology 1) Cerebral blood flow 2) Blood-brain barrier in stroke 3) Coagulation cascade 4) Metabolic and cellular consequences of ischemia 5) Inflammation and stroke 6) Brain edema and increased intracranial pressure 7) Restoration and recovery following stroke 8) Secondary consequences from intracranial bleeding c. Neuropathology of stroke 1) Pathological-imaging-clinical correlations d. Pharmacology 1) Antiplatelet agents – prevention, acute treatment 2) Anticoagulants – prevention, acute treatment 3) Thrombolytic agents 4) Neuroprotective agents and other acute treatments 5) Cardioactive agents 6) Medications to prevent stroke by treating risk factors 7) Medications to treat auto-immune diseases and vasculitis 8) Medications to treat complications of stroke 9) Medications to improve or restore neurologic function or to augment rehabilitation 10) Medications to prevent rebleeding or vasospasm following hemorrhage

Information for Vascular Neurology Fellows Attachment #8 11) Anti-migraine medications 12) Vitamins 13) Interactions between medications 14) Drugs that cause stroke, including drugs of abuse 2. Patient evaluation and treatment selection, including: a. The nature of patients’ history and physical findings and the ability to correlate the findings with a likely localization for neurological dysfunction b. Likely diagnoses and differential diagnoses 1) In adults 2) In children c. Planning for evaluation and management d. Potential risks and benefits of potential therapies, including surgical procedures 3. Employment of principles of quality improvement in practice C. Prevention, risk factors and epidemiology 1. Populations at risk for stroke 2. Modifiable risk factors for stroke 3. Infections predisposing to stroke 4. Genetic factors predicting stoke 5. Stroke as a complication of other medical illnesses 6. Special populations at risk for stroke 7. Stroke educations programs and regional health services 8. Concepts of clinical research 9. Outcomes a. Prognosis b. Mortality and morbidity of subtypes of stroke D. Clinical features of cerebrovascular diseases 1. Neuro-otologic signs and symptoms 2. Neuro-ophthalmologic signs and symptoms 3. Transient ischemic attack 4. Ischemic stroke syndromes – cerebral hemispheres 5. Ischemic stroke syndromes – brain stem and cerebellum 6. Ischemic stroke syndromes of the spinal cord 7. Vascular dementia and vascular cognitive syndromes 8. Features differentiating hemorrhagic or ischemic stroke 9. Intracerebral hemorrhage 10. Subarachnoid hemorrhage/saccular aneurysms 11. Vascular malformations 12. Primary intraventricular hemorrhage 13. Subdural or epidural hematoma 14. Spinal cord hemorrhage or infarction 15. Carotid cavernous or dural fistulas 16. Pituitary apoplexy 17. Hypertensive encephalopathy and eclampsia 18. Clinical presentations of primary and multisystem vasculitides

Information for Vascular Neurology Fellows Attachment #8 19. Hypoxia – ischemia 20. Brain death 21. MELAS and metabolic disorders causing neurologic symptoms 22. Non-stroke presentations of vascular disease 23. Cardiovascular diseases 24. Vascular presentations of other diseases of central nervous systems 25. Infectious diseases and stroke 26. Migraine E. Evaluation of the patient with cerebrovascular disease 1. Evaluation of the brain and spinal cord a. Computed tomography of brain b. Computed tomography of spine and spinal cord c. Magnetic resonance imaging of brain d. PET and SPECT e. Electroencephalography and evoked potentials f. Examination of the CSF g. ICP monitoring 2. Evaluation of the vasculature – occlusive or non-occlusive a. Arteriography and venography b. Extracranial ultrasonography c. Intracranial ultrasonography d. CT angiography e. MR angiography 3. Evaluation of the heart and great vessels a. Electrocardiography b. Transthoracic echocardiography and transesophageal echocardiography c. Other chest imaging studies 4. Other diagnostic studies a. Hematologic studies b. Immunological studies c. Biochemical studies d. Urine tests e. Biopsies f. Evaluation of the complications of stroke g. Evaluation of the consequences of stroke h. Genetic testing F. Causes of stroke 1. Atherosclerosis – ischemic stroke 2. Non-atherosclerotic vasculopathies – ischemic stroke a. Non-inflammatory b. Infectious c. Inflammatory, non-infectious 3. Migraine 4. Other causes of ischemic stroke

Information for Vascular Neurology Fellows Attachment #8 5. Genetic and metabolic causes of stroke 6. Drug abuse and toxicities 7. Cerebral amyloid angiopathy – infarction or hemorrhage 8. Cardioembolic causes of stroke 9. Pro-thrombotic causes of stroke a. Inherited b. Acquired c. Autoimmune causes of thrombosis d. Iatrogenic/drugs, toxins 10. Bleeding diatheses a. Inherited b. Acquired c. Systemic diseases d. Iatrogenic/drugs/toxins 11. Aneurysms 12. Vascular malformations 13. Trauma and intracranial bleeding 14. Moyamoya disease and syndrome 15. Hypertensive hemorrhage 16. Other causes of hemorrhage 17. Genetic diseases causing hemorrhagic stroke 18. Complications of stroke a. Early neurologic complications b. Early medical complications c. Chronic neurologic sequelae d. Chronic medical sequelae G. Treatment of patients with stroke 1. Outpatient management 2. Medical therapies to prevent stroke 3. Hyperacute treatment of ischemic stroke a. Emergency department b. Hospitalization c. ICU d. Neurosurgical management 4. Chronic care 5. Prevention of recurrent stroke 6. Treatment of venous thrombosis 7. Treatment of spinal cord vascular disease 8. Treatment of pituitary apoplexy 9. Professionalism, ethics, systems based practice a. Palliative care b. End-of-life decisions c. Advanced directives, informed consent, regulations d. Other

Information for Vascular Neurology Fellows Attachment #8 H. Recovery, regenerative approaches and rehabilitation

III. Vascular Neurology Interpersonal and Communications Skills Core Competencies A. Vascular neurologists shall demonstrate the following abilities: 1. To listen to and understand patients and to attend to nonverbal communication 2. To communicate effectively with patients using verbal, nonverbal, and written skills as appropriate 3. To develop and maintain a therapeutic alliance with patients by instilling feelings of trust, honesty, openness, rapport, and comfort in the relationship with physicians 4. To partner with patients to develop an agreed upon healthcare management plan 5. To transmit information to patients in a clear and meaningful fashion 6. To understand the impact of physicians’ own feelings and behavior so that it does not interfere with appropriate treatment 7. To communicate effectively and work collaboratively with allied healthcare professionals and with other professionals involved in the lives of patients and families 8. To educate patients, their families, and professionals about medical, psychosocial, and behavioral issues B. Vascular neurologists shall demonstrate the ability to obtain, interpret, and evaluate consultations from other medical specialties. This shall include: 1. Knowing when to solicit consultation and having sensitivity to assess the need for consultation 2. Formulating and clearly communicating the consultation question 3. Discussing the consultation findings with the consultant 4. Discussing the consultation findings with patient and family C. Vascular neurologists shall serve as an effective consultant to other medical specialists, mental health professionals, and community agencies by demonstrating the abilities to: 1. Communicate effectively with the requesting party to refine the consultation question 2. Maintain the role of consultant 3. Communicate clear and specific recommendations 4. Respect the knowledge and expertise of the requesting professionals D. Vascular neurologists shall demonstrate the ability to communicate effectively with patients and their families by: 1. Gearing all communication to the educational and intellectual levels of patients and their families 2. Demonstrating sociocultural sensitivity to patients and their families 3. Providing explanations of psychiatric and neurological disorders and treatment that are jargon-free and geared to the educational/intellectual levels of patients and their families 4. Providing preventive education that is understandable and practical 5. Respecting the patients’ cultural, ethnic, religious, and economic backgrounds 6. Developing and enhancing rapport and a working alliance with patients and their families 7. Ensuring that the patient and/or family have understood the communication E. Vascular neurologists shall maintain up-to-date medical records and write legible prescriptions. These records must capture essential information while simultaneously respecting patient privacy, and they must be useful to health professionals outside psychiatry and neurology.

Information for Vascular Neurology Fellows Attachment #8 F. Vascular neurologists shall demonstrate the ability to effectively lead a multidisciplinary treatment team, including being able to: 1. Listen effectively 2. Elicit needed information from team members 3. Integrate information from different disciplines 4. Manage conflict 5. Clearly communicate an integrated treatment plan G. Vascular neurologists shall demonstrate the ability to communicate effectively with patients and their families while respecting confidentiality. Such communication may include: 1. The results of the assessment 2. Use of informed consent when considering investigative procedures 3. Genetic counseling and palliative care when appropriate 4. Consideration and compassion for the patient in providing accurate medical information and prognosis 5. The risks and benefits of the proposed treatment plan, including possible side-effects of medications and/or complications of nonpharmacologic treatments 6. Alternative (if any) to the proposed treatment plan 7. Appropriate education concerning the disorder, its prognosis, and prevention strategies

IV. Vascular Neurology Practice-Based Learning and Improvement Core Competencies A. Vascular neurologists shall recognize limitations in their own knowledge base and clinical skills, and understand and address the need for lifelong learning. B. Vascular neurologists shall demonstrate appropriate skills for obtaining and evaluating up-to-date information from scientific and practice literature and other sources to assist in the quality care of patients. This shall include, but not be limited to: 1. Use of medical libraries 2. Use of information technology, including Internet-based searches and literature databases (e.g., Medline) 3. Use of drug information databases 4. Active participation, as appropriate, in educational courses, conferences, and other organized educational activities both at the local and national levels. C. Vascular neurologists shall evaluate caseload and practice experience in a systematic manner. This may include: 1. Case-based learning 2. Use of best practices through practice guidelines or clinical pathways 3. The review of patient records 4. Obtaining evaluations from patients (e.g., outcomes and patient satisfaction) 5. Employment of principles of quality improvement in practice 6. Obtaining appropriate supervision and consultation 7. Maintaining a system for examining errors in practice and initiating improvements to eliminate or reduce errors D. Vascular neurologists shall demonstrate an ability to critically evaluate relevant medical literature. This ability may include:

Information for Vascular Neurology Fellows Attachment #8 1. Using knowledge of common methodologies employed in psychiatric and neurological research 2. Researching and summarizing a particular problem that derives from their own caseloads E. Vascular neurologists shall demonstrate the ability: 1. To review and critically assess scientific literature to determine how quality of care can be improved in relation to one’s practice (e.g., reliable and valid assessment techniques, treatment approaches with established effectiveness, practice parameter adherence). Within this aim, vascular neurologists shall be able to assess the generalizability or applicability of research finding to one’s patients in relation to their sociodemographic and clinical characteristics 2. To develop and pursue effective remediation strategies that are based on critical review of the scientific literature

V. Vascular Neurology Professionalism Core Competencies A. Vascular neurologists shall demonstrate responsibility for their patients’ care, including: 1. Responding to communication from patients and health professionals in a timely manner 2. Establishing and communicating back-up arrangements, including how to seek emergent and urgent care when necessary 3. Using medical records for appropriate documentation of the course of illness and its treatment 4. Providing coverage if unavailable, (for example, when out of town or on vacation) 5. Coordinating care with other members of the medical and/or multidisciplinary team 6. Providing for continuity of care, including appropriate consultation, transfer, or referral if necessary B. Vascular neurologists shall demonstrate ethical behavior, integrity, honesty, compassion, and confidentiality in the delivery of care, including matters of informed consent/assent, professional conduct, and conflict of interest. C. Vascular neurologists shall demonstrate respect for patients and their families, and their colleagues as persons, including their ages, cultures, disabilities, ethnicities, genders, socioeconomic backgrounds, religious beliefs, political leanings, and sexual orientations. D. Vascular neurologists shall demonstrate understanding of and sensitivity to end of life care and issues regarding provision of care. E. Vascular neurologists shall review their professional conduct and remediate when appropriate. F. Vascular neurologists shall participate in the review of the professional conduct of their colleagues. G. Vascular neurologists shall be aware of safety issues, including acknowledging and remediating medical errors, should they occur.

VI. Vascular Neurology Systems-Based Practice Core Competencies A. Vascular neurologists shall have a working knowledge of the diverse systems involved in treating patients of all ages, and understand how to use the systems as part of a comprehensive system of care in general and as part of a comprehensive, individualized treatment plan. This will include the: 1. Use of practice guidelines 2. Ability to access community, national, and allied health professional resources that may enhance the quality of life of patients with chronic psychiatric and neurological illnesses

Information for Vascular Neurology Fellows Attachment #8 3. Demonstration of the ability to lead and delegate authority to healthcare teams needed to provide comprehensive care for patients with psychiatric and neurological disease 4. Demonstration of skills of the practice of ambulatory medicine, including time management, clinical scheduling, and efficient communication with referring physicians 5. Use of appropriate consultation and referral mechanisms for the optimal clinical management of patients with complicated medical illness 6. Demonstration of awareness of the importance of adequate cross-coverage 7. Use of accurate medical data in the communication with and effective management of patients B. In the community system, vascular neurologists shall: 1. Recognize the limitation of healthcare resources and demonstrate the ability to act as an advocate for patients within their sociocultural and financial constraints 2. Demonstrate knowledge of the legal aspects of vascular neurological diseases as they impact patients and their families 3. Demonstrate an understanding of risk management C. Vascular neurologists shall demonstrate knowledge of and interact with managed health systems, including: 1. Participating in utilization review communications and, when appropriate, advocating for quality patient care 2. Educating patients concerning such systems of care D. Vascular neurologists shall demonstrate knowledge of community systems of care and assist patients to access appropriate care and other support services. This requires knowledge of treatment settings in the community, which include ambulatory, consulting, acute care, partial hospital, skilled care, rehabilitation, and substance abuse facilities; halfway houses; nursing homes and home care; and hospice organizations. Vascular neurologists shall demonstrate knowledge of the organization of care in each relevant delivery setting and the ability to integrate the care of patients across such settings.

1 Cultural diversity includes issues of race, gender, language, age, country of origin, sexual orientation, religious/spiritual beliefs, sociocultural class, educational/intellectual levels, and physical disability. Working with a culturally diverse population requires knowledge about cultural factors in the delivery of healthcare. For the purposes of this document, all patient and peer populations are to be considered culturally diverse.

2 Regarding sociocultural issues, for the purposes of this document, “family” is defined as those having a biological or otherwise meaningful relationship with the patient. Such “significant others” are to be defined from the patient’s point of view.

70904 Approved by the ABPN Core Competencies Committee 7/16/04

Information for Vascular Neurology Fellows Attachment #8

ATTACHMENT 10: PROGRAM RESPONSIBILITIES, PHYSICIAN RESPONSIBILITIES & FELLOW RESPONSIBILITIES

Program Responsibilities

1. An assessment of a Fellow’s competence shall serve as the basis for determining the minimum level of supervision required for different activities. Objective criteria shall be developed and consistently applied to evaluate a Fellow’s progressive ability to function independently. This assessment will include the evaluations of the Fellow’s communication skills, patient management, medical knowledge, and capacity to perform as required. The Program Director will communicate the assessment of the Fellows’ competence to the Fellow semi-annually and when significant progress or deficiencies are noted.

2. All patients seen by a Fellow, on an inpatient or outpatient basis, will be seen by, discussed with, and reviewed by the responsible Attending Physician.

3. A Vascular Neurology faculty attending will be available to the Vascular Neurology Fellows at all times (24 hours a day, 7 days a week) in person or by page. Vascular Neurology Attending Physicians are able to provide adequate supervision off site as long as their physical presence can be assured within a reasonable amount of time in case of need. The Program Director will assure that a schedule with the name and contact number of the responsible Attending Physician is available at all times to the fellows.

4. The program will continuously monitor and improve compliance with its competency assessments and supervision policies, using feedback provided by fellows and Attending Physicians.

5. The Program Director will ensure direct and adequate supervision of fellows at all times. Fellows will be provided with rapid, reliable systems for communicating directly with supervising faculty.

6. Faculty schedules are structured to provide fellows with adequate supervision and consultation.

7. Faculty and fellows will be educated to recognize the signs of fatigue and apply policies to prevent and counteract the potential negative effects of fatigue.

Attending Physicians Responsibilities

1. An Attending Physician is responsible for, and actively involved, in the care provided to each patient, both inpatient and outpatient.

2. An Attending Physician directs the care of each patient and provides the appropriate level of supervision for a Fellow based on the nature of the patient’s condition, the likelihood of major changes in the management plan, the complexity of care, and the level of education, ability, experience and judgment of the Fellow being supervised.

3. The Attending Physician will accord the Fellow progressive responsibility for the care of the patient based on the Fellow’s clinical experience, judgment, knowledge, skill, and capacity to function.

4. The Attending Physician will inform the Program Director if he/she believes a change in the level of the Fellow’s responsibility and supervision should be considered. The overriding consideration must be the safe and effective care of the patient that is the personal responsibility of the Attending Physician.

Information for Vascular Neurology Fellows Attachment #8 5. The Attending Physician fosters and environment that encourages questions and requests for support or supervision from the Fellow, and encourages the Fellow to call and/or inform the Attending Physician of significant or serious patient conditions or significant changes in patient condition.

Fellow Responsibilities

1. A Fellow’s responsibilities shall include patient care activities within the scope of his/her clinical privileges, attendance at clinical rounds and conferences, timely completion of medical records, teaching duties (including but not limited to organizing monthly teaching conferences and journal club for Neurology residents and students, and participating in the education of Neurology residents rotating on the Vascular Neurology service) and other responsibilities as assigned or as are required of all members of the Medical Staff.

2. Each Fellow will take action as necessary to remain knowledgeable of the clinical status of all patients assigned to him/her, and discuss any significant changes in clinical status with the attending as soon as possible.

3. In life-threatening emergencies, Fellows may initiate or modify major diagnostic and therapeutic actions consistent with their level of ability and training.

4. In case of emergency, the Fellow may ask another health care provider to immediately contact the Attending Physician while the Fellow initiates emergency interventions but must inform the Attending as soon as possible and receive additional instruction as indicated.

Fellow’s Duties

Each vascular Neurology fellow will spend a minimum of 6 months on the acute (6 months daytime hours and 6 months night call) and inpatient stroke service. The two fellows will alternate being on service. While on service, the fellow will participate in the daily rounds on the Neurology patients in the Neuro ICU and the inpatient stroke service. He/She is required to be familiar with all aspects of the individual patient’s care, but may delegate some case presentations to the Neurology residents. For non-acute inpatient consults and follow-up inpatient management, general Neurology residents will perform the initial detailed evaluation, write full notes, and write orders under the Vascular Neurology Fellow’s supervision. The Vascular Neurology fellow will, in turn, be supervised by the Attending Physician. Vascular Neurology Fellows are required to formulate a differential diagnosis, develop a diagnostic plan, and propose therapeutic interventions for every patient.

The fellow will respond to Stroke Pager calls during weekdays, nights and weekends, when on service, and provide 24-hour coverage for the acute stroke service, including urgent Emergency Department evaluations and inpatient consultations, with individual case review for each case by the attending. The fellow will be required to obtain history, perform physical and neurological examinations, review all diagnostic studies, and write a detailed note on all patients seen as “Stoke Alert”.

Each fellow, whether on or off service, attends six ½-day clinic sessions per month under the supervision of a stroke service attending. This is largely a Fellow-Attending precepting style clinic, with the majority of initial and follow-up evaluations performed by the fellow. Every visit has direct Attending Physician involvement in clinical evaluation, patient education, communication, and management decision making. The clinic will consist primarily of stroke patients (new and follow up from inpatient hospitalization). However, unoccupied slots may be given to general neurology patients. The clinic is a referral center for complex cerebrovascular disorders and second opinions. The Fellows are continuously guided through this process. The record keeping is entirely online, and all notes are co-signed by the Attending Physicians. Direct feedback is provided on all aspects of patient-physician interactions. Fellows will rate their learning experience in parallel, and bidirectional feedback will contribute to continuous improvement of quality of patient care and the fellowship experience.

Information for Vascular Neurology Fellows Attachment #8 The fellow will take part in ongoing clinical studies and participate in the informed consent and data collection processes, under the direction of the Attending Physician. The fellow is also required to enter patients’ data into our computerized stroke registry on a weekly basis, and is encouraged to maintain a log of patients evaluated throughout his/her training with regard to clinical diagnosis to assure that the diversity of cerebrovascular disorders cases has been seen and that an understanding of the condition has been achieved.

Fellow mandatory duties and responsibilities include:

1. Evaluation of acute stroke patients in the Emergency Department

2. Supervise acute care of stroke patients (on the inpatient stroke service) and critically ill neurological patients (in the Neuro ICU) in the inpatient setting

3. Have one outpatient clinic session per month

4. Learn and interpret diffusion- and perfusion-weighted MRI and MRA; and perfusion CT and CTA

5. Learn and perform, under supervision, transcranial Doppler studies

6. Organize monthly Neurovascular Case Conferences, the monthly Stroke Lecture Series, and the monthly Stroke Journal Club.

7. Attend all weekly and monthly Vascular Neurology Conferences (see below)

8. Alternate night and weekend call to provide 24/7 coverage for Stroke Alerts, on a weekly basis

9. Participate in ongoing clinical trials involving stroke patients

10. Obtain consent for and enter patients’ data into our computerized Stroke Database on a weekly basis

11. Create and maintain a Portfolio and Patient Log using New Innovations™

12. Complete all evaluations and other paperwork in a timely manner

13. Complete NIHSS and mRS training and certification during the first two weeks of training

14. Complete CITI training in human subjects protection and bioethics and HIPAA & Research Training tutorials and exams offered by the University of Florida College of Medicine during the first two weeks of training

15. Teach residents and medical students during daily rounds

16. Participate in the Longitudinal Resident as Teacher Program offered by the Faculty Development Office.

Information for Vascular Neurology Fellows Attachment #8

ATTACHMENT 11: POLICY/PROCEDURES FOR DUTY HOURS

In accordance with the GMEC’s policy on Duty Hours, duty hours will be assigned, monitored and reported in accordance with the ACGME’s Institutional and Common Program Requirements. House officers will collect raw data, and accurately report time worked via the New-Innovations Software. A tutorial with complete instructions for entering Duty Hours is available from the GMEC website at http://housestaff.medinfo.ufl.edu/. The GMEC will monitor compliance by the programs through the Internal Review policy, periodic resident surveys and interviews, and when needed, collection of time cards from residents.

In order to ensure program and institutional compliance, house officers in ACGME accredited training programs must participate in all anonymous surveys conducted by the ACGME upon their request.

Definition of Duty Hours

Duty hours are defined as all clinical and academic activities related to the residency program, i.e., patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences. Duty hours include all Programmatic and Non-programmatic (moonlighting) activities. All Non-programmatic activities must abide by the GMEC and Program Policies on Outside Employment (Moonlighting) and must be pre-approved by both the Program Director and the GME Associate Dean. Duty hours do not include reading and preparation time spent away from the duty site.

Duty Hour Limits

Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive all in-house call activities related to the training program and Non-programmatic activity authorized by the Program Director. In-house call must occur no more frequently than every third night, averaged over a four-week period. Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Fellows may remain on duty for up to 6 additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical care as defined by the ACGME in the Specialty and Subspecialty Program Requirements. No new patients, as defined in Specialty and Subspecialty Program Requirement, may be accepted after 24 hours of continuous duty. A new patient is defined as any patient for whom the Fellow has not previously provided care.

Adequate time for rest and personal activities must be provided. This must consist of a 10-hour time period provided between all daily duty periods and after in-house call. Fellows must be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period, inclusive of in-house call. One day is defined as one continuous 24-hour period free from all clinical, educational and administrative duties.

At-home Call (Pager Call)

All call for Vascular Neurology Fellows is At-home Call. At-home call is defined as call taken from outside the assigned institution. The frequency of at-home call is not subject to the every third night limitation. However, at-home call must not be so frequent as to preclude rest and reasonable personal time for each Fellow. Fellows are required to report the amount of time spent participating in patient care activities during at-home call to the Program Director on a daily basis. Scheduling adjustments will be made by the Program Director and faculty to mitigate sleep deprivation and/or fatigue resulting from excessive at-home call. Excessive at-home call is defined as patient care demands that require frequent interruption or significant deprivation of sleep. Excessive at-home call will be considered the equivalent of in-house call with regard to duty hours. Additionally, when Fellows are called into the hospital from home, the hours spent in-house are counted toward the 80-hour duty limit, as detailed above.

Information for Vascular Neurology Fellows Attachment #8 Fellows who spend 12 hours in patient care and program requirements followed by 12 hours of active call duty will be considered to have spent 24 hours on continuous duty. In such circumstances, the fellow may participate in limited activities, as defined above, for an additional 6 hours. This period of activity must be followed by a minimum of 10 hours of rest prior to returning to duty.

Fellows taking at-home call must be provided with 1 day in 7 completely free from all educational and clinical responsibilities, averaged over a 4-week period.

Vascular Neurology Fellows are on call every other week, with 5 nights (Monday through Friday) of weekday night coverage followed by 1 day (Saturday) of 24-hour coverage. One 24-hour period (Sunday) is free from all call duty each week.

Sleep Deprivation and Fatigue

Issues related to sleep deprivation and fatigue must be reported to the Program Director to allow for coverage.

Duty Hour Exceptions

In accordance with the GMEC’s Approved Specialty Specific Duty Hour Language, the Review Committee for Neurology will not consider requests for exceptions to the limit of 80 hours per week, averaged over a four week period. There will be no exceptions to the above stated Duty Hours Policy.

Information for Vascular Neurology Fellows Attachment #8

ATTACHMENT 12: HANDOFF COMMUNICATION POLICY

POLICY NUMBER: CP02.061

CATEGORY: Patient Care

TITLE: Handoff Communication

POLICY: Pertinent information regarding patient care needs is communicated to the next care provider prior to that provider assuming responsibility for the patient. This process shall include an opportunity to ask and answer questions.

PURPOSE: To ensure the smooth transition of patient care between providers by providing a structured process for communication of relevant information about a patient’s care or treatment when care is “handed- off” from one care provider to another.

APPROVED:

Timothy Flynn, M.D.

Chief Medical Officer

Timothy Goldfarb

Chief Executive Officer

DEFINITIONS

A. Transition to Another Provider - occurs any time a patient is transferring or transported for service to another setting, provider, or team of caregivers including, but not limited to the following care transitions:

1. Shift change in nursing units.

2. Assuming temporary responsibility for care when staff leave a unit for a short period of time (e.g. lunch breaks).

3. Transfer of patients between units, i.e. transferring a patient from one level of care to another, including admissions, from the Emergency Department, PACU, and Outpatient areas.

4. Transfer of patient between ancillary departments, (e.g., OT/PT) for tests/procedures or rehabilitation therapy.

Information for Vascular Neurology Fellows Attachment #8 5. Physicians transferring complete or on-call responsibility for a patient’s care to another physician.

6. Anesthesiologist’s report to the post-anesthesia recovery room nurse, or ICU nurse.

7. Transfer or transport of a patient from the Emergency Department or other hospital unit to another hospital or healthcare organization.

8. Discharges to home with Home Health, Hospice or other caregiver agency.

B. Provider - any direct care clinician, for example physician, resident, ARNP, PA, RN, LPN, therapists, technicians, transporters or an alternate level of healthcare (e.g. Home Care, Long Term Care, Rehabilitation).

C. Handoff Communication - For the purpose of this policy, a “hand-off” is defined as the provision of verbal and/or written information from one healthcare provider to another so that pertinent care, treatment, or service needs as well as the patient’s current condition and any recent or anticipated changes are accurately communicated; with an opportunity for questions to be asked and answered.

CORE PROCEDURE

I. Applicability - Handoff Communication applies to all hospital staff and physicians who take responsibility for inpatient or outpatient care or who discharge or send a patient to other sites for care. The primary objective of a hand-off is to provide accurate information about a patient’s care, treatment, and services, current condition, and any recent or anticipated changes. If a nurse or physician accompanies a patient to procedure area and continues to provide care for the patient during the procedure, a hand-off is not applicable.

II. Hand-off of patients between care providers will follow a standardized process and include an opportunity to ask and respond to questions.

A. Hand-offs will be structured to include standard minimum criteria (including up-to-date information regarding the patient’s condition, care, treatment, medications, services, and any recent or anticipated changes).

B. The patient’s hard copy medical record (“blue back”) shall accompany all patients transported to and from inpatient units and procedure departments or testing areas with the exception of those areas using the electronic health record (Epic).

C. Staff will access Epic for other needed information, e.g. Medication Administration Record, Plan of Care, trends, etc. Electronic medical record information will be available for review as needed by “receiving” care givers.

III. Required components of handoff communication: As appropriate, the communication between providers should include:

A. Patient name, medical record number or date of birth

B. Physician’s name

C. Diagnosis 78

Information for Vascular Neurology Fellows Attachment #8

D. Current condition and stability

E. Precautions (isolation, safety, etc)

F. Routine monitoring in use

G. Medications impacting current condition (e.g. analgesics, sedation, vasoactive)

H. Anticipated initial priorities for care

I. Name and contact information for questions

J. Pending diagnostic results, medications, procedures or requests for information, as appropriate (e.g., Home medications)

K. “Hand-off” communication may include:

1. Vital signs

2. Other assessment parameters during monitoring

3. Pertinent up-to-date information regarding treatment, care and services

4. Current condition and any recent or anticipated changes

5. Transfer notes summarizing details of report given to sending and receiving areas

6. Names of individual assuming care

IV. Communication of hand-off information shall follow an “SBAR” (Situation, Background, Assessment, Recommendations) format, which includes but is not limited to:

A. Situation:

1. Name and contact information for the sending care provider to allow the receiving care provider to call for any questions or clarification needed

2. Scheduled test /procedure destination(s), mode of transport, prep completed (y/n/na), etc.

3. Patient’s current reason for entry into health care setting

4. Patient’s response to procedure

5. Special post procedure care

B. Background:

1. Isolation precautions

2. Safety precautions

Information for Vascular Neurology Fellows Attachment #8 3. Language barrier(s), visual/hearing deficits

4. Routine monitoring in use: telemetry, pulse oximetry, etc

5. Other precautions/issues

C. Current Assessment / Condition and stability:

1. IV’s /Infusions/Drips

2. Restraints

3. NPO status

4. Oxygen

5. Mental Status

6. Medications impacting current status: e.g. pain level with medication and time given

7. Patient’s response to procedure

D. Recommendations

1. Anticipated priorities for this and next interval of care

a. Labs/lab monitoring b. Medications due (including antibiotics) c. Pain control plan d. Repositioning needs

2. Patient Mobility/assistance needed

3. Patient’s post procedure care needs

4. If a nurse or physician accompanies a patient to procedure area and remains with the patient during the procedure a hand-off communication is not applicable.

V. Hand-off communication will be provided using verbal and/or written communication using the following criteria:

A. Written communication without verbal report shall occur using standard criteria for “Ticket to Ride” (Form found in Epic) when a patient transporter is involved in moving the patient from one clinical area to another.

1. If patient is being transported to a procedure department and not accompanied by a nurse or physician:

a. The nurse caring for the patient will complete the hospital approved “Ticket to Ride” prior to transport to ensure appropriate clinical documentation is relayed to the next provider of care.

Information for Vascular Neurology Fellows Attachment #8 b. The Patient Transporter will notify the unit nurse prior to leaving the inpatient unit with a patient to ensure all documentation has been obtained and the “Ticket to Ride” has been signed off by the unit nurse.

c. The Patient Transporter will indicate the destination of the patient on the Navicare® screen or the Unit Transport log. The transporter will contact receiving unit/department staff immediately upon arrival for appropriate placement of a patient on isolation.

2. The procedure staff receiving patient shall review the ”Ticket to Ride” patient information for modifications to their intended plan for the patient, incorporating isolation and safety precautions and priorities for care. Those staff shall contact the sending staff with questions as needed.

3. If patient is being transported from a procedure department, the procedure staff will update the “Ticket to Ride”.

a. The procedure staff caring for the patient will complete the hospital approved “Ticket to Ride” prior to transport to ensure appropriate clinical documentation is relayed to the next provider of care.

b. The Patient Transporter will notify the procedure staff prior to leaving the procedure department and verify that the “Ticket to Ride” and medical record (including all documentation sent from the inpatient unit) are takedocumentation sent from the inpatient unit) are taken with the patient.

c. The Patient Transporter returning patient to nursing unit must have face to face exchange with a receiving nurse and indicate the patient return on the Navicare® Screen or the Unit Transport Log.

B. Verbal Communication

1. Verbal communication shall occur between care providers using SBAR format (Appendix A).

2. Verbal communication is required for:

a. Shift to shift report b. Operating room (anesthesia) to and from next level of care (PACU, ICU) c. Transfer between nursing units and procedure/testing departments with or without change in level of care. d. Emergency Room to OR, or patient care unit, and to, or from, procedure/testing departments.

3. Telephone contact to inform receiving area that the patient is coming will include information related to any immediate equipment or personnel needs upon arrival.

4. Telephone report is required from the current care provider to the next provider of care if transport to the receiving area will not be provided by the nurse or physician.

5. Provider to provider hand-off of care may include telephone report as well as direct report on arrival when transport is provided by the current provider of care.

Information for Vascular Neurology Fellows Attachment #8 C. Verbal and written communication shall be conducted on patients with high acuity and complex care needs and requires interactive/verbal communication. This will include, but not be limited to, the following patient situations:

1. Patients having invasive procedures

2. Person to person interactive/verbal communication between the procedure area nurse and the receiving unit nurse is needed for all patients undergoing invasive procedures.

3. Patients who have received sedation or anesthesia for any procedure or test: If the patient has received sedation or undergone an invasive procedure, procedure staff shall communicate:

a. Patient status at completion of procedure b. Medications given during procedure c. Priorities for care post procedure including post procedure monitoring

4. Patients being transferred to and from the ED, ICU or IMC

5. Patients being transferred to an ICU or IMC between nursing units

6. Patients with any acute change in condition when away from assigned nursing unit

7. Physician/ARNP/PA to physician/ARNP/PA communication will occur whenever the primary responsibility for patient care is being transferred to a different physician/ARNP/PA. Hand-off communication should include the information included in Appendix A and will be required for, but not limited to:

a. Transfer from one surgical or medical service to another service

b. Change/transfer in on-call physician responsibility

c. Acute change in patient condition resulting in escalation of care to ICU/IMC

d. Patients being discharged from an ICU where care was managed by a critical care service

e. Anesthesiologist report to post-anesthesia recovery room nurse or ICU nurse receiving patient following surgery

f. Transfer from Emergency Department to inpatient units, different hospitals, nursing homes and home health care

VI. Other requirements:

A. The patient’s medical record is a primary source of care communication and shall be present or accessible wherever the patient is located.

B. Interactive communication is expected between the care providers involved. There should be an opportunity for questions to be asked and answered.

C. Interruptions during the hand-off should be minimized. 82

Information for Vascular Neurology Fellows Attachment #8

D. As appropriate, information communicated during the hand-off should be repeated or read back from the recipient to the provider to ensure accuracy.

E. “Hand-offs” can be verbal and /or written. In cases where report or patient information is written, the receiving caregiver shall have the ability to contact the sending party by phone to provide opportunity for clarification or questions as needed.

F. The receiver of the information should have the opportunity to review relevant historical data on the patient, which may include previous care, treatment, or service.

VII. Shands Home Care, Shands Rehab and Shands Vista may establish guidelines addressing any specific documentation requirements or processesany specific documentation requirements or processes and the elements of Hand Off information to be provided to transport personnel.

HAND-OFF COMMUNICATION BETWEEN PHYSICIANS OR OTHER PERSONS RESPONSIBLE FOR THE PATIENT’S CARE

“SBAR” (Situation, Background, Assessment, Recommendations) format: ______SITUATION:

• Patient’s name, gender and age • Any planned / needed procedures / tests • Any pending diagnostic tests, e.g. labs, radiology ______BACKGROUND:

• Date of admission • Admission diagnosis • Pertinent medical hx related to current problem • Allergies • Brief synopsis of treatment to date ______CURRENT ASSESSMENT / CONDITION & STABILITY:

• Current / recent VS is pertinent • Systems review – pertinent issues • Current treatment goals / issues ______RECOMMENDATIONS:

• Medical priorities • Pending issues

Information for Vascular Neurology Fellows Attachment #8

ATTACHMENT 13: LINES OF SUPERVISION FOR VASCULAR NEUROLOGY RESIDENTS/FELLOWS

Supervision of Patient Care

Vascular Neurology residents will be supervised in all activities and at all times by the designated Stroke Attending Physician during their inpatient, outpatient and neurorehabilitation rotation. All patients seen by the fellows will be reviewed with an Attending Physician to confirm critical components of the patient history, examination, and discussion of the management plan, all notes will be co-signed, and all data/studies related to patient care will be reviewed by the Attending Physician. In all “relatively” non-urgent inpatient and emergency department evaluations and in the clinics, the Attending Physician will evaluate the patient after the fellow to confirm his/her findings and provide real time teaching at the end of the evaluation. This provides for a system that established the fellow as the patient’s physician while maintaining adequate supervision and provision of time for “teaching at the bedside”. Feedback will be provided directly and immediately to the fellow by the attending. In addition, fellows are encouraged to discuss their concerns, stresses, challenges and plans with any of the Attending Physicians at any time. The supervising medical staff members have current Full License issued by the Florida Board of Medicine, and are properly credentialed.

Medication Initiation and Refills

Initiation of any medications by the fellow should be after discussion with the Attending Physician. Continuation of medication (refills) in the outpatient setting for stable patients needs no further input.

Data/Tests Interpretation

All relevant laboratory and imaging data, including MRI/MRA, CT/CTA, and TCD will be initially reviewed by the fellow, then by the Attending Physician. The findings and interpretation will be discussed with the fellow to provide immediate feedback. For the TCD reports, the fellow will perform (initially under the Attending Physician’s supervision and independently once adequate skills are established), review, interpret the findings discussed, and write a preliminary report that will be sent for co-signature by an Attending Physician. The study and report will be reviewed by the Attending Physician and discussed with the fellow. Further changes may occur before final sing off.

Co-Signature

All notes (electronic and/or hand-written in chart) will be co-signed by the Attending Physician.

Out-of-Clinic Communications

Telephone contact should be discussed with the Attending Physician, documented in the Online Medical Records, and sent for co-signature by the Attending Physician. The Attending Physician may request more details before final sign off.

Progressive Responsibilities for Patient Management

The Vascular Neurology fellows will have graded responsibility. Initially, for at least the first 2 months the fellow will participate in morning and teaching rounds with the Stroke Service Attending Physician and resident staff. During the first months of training, the fellow will present each non-critical patient to the Attending Physician prior to executing any management plan and all critical clinical medical decisions will be made in conjunction with the Attending Physician.

As Vascular Neurology fellows progress through their training, they will serve as adjuncts to the attendings and are given progressively larger responsibility for direct line patient care with less intensive supervision, unless so 84

Information for Vascular Neurology Fellows Attachment #8 specified for individual fellows based on their performance (although all fellows will have direct and immediate access to an attending staff and all notes will still require co-signature). A Vascular Neurology faculty attending will be available to the Vascular Neurology fellow at all times by page for prompt communication and consultation when/if needed.

In the non-acute inpatient setting, the Vascular Neurology fellow will function as a senior resident, assisting the more junior resident staff in triaging and delegating the day’s workload. The Vascular Neurology fellow will also be in charge of organizing subspecialty education for the students and junior residents. These duties will be performed with support the Attending Physician.

In the acute inpatient setting, including the Emergency Department, the Vascular Neurology fellow will function as a primary resident provider, either alone or assisted by a General Neurology resident. Vascular Neurology fellows are expected to perform an appropriate history and physical, formulate a plan for diagnosis and management, and follow the patient over time with the support of their Attending Physician.

In the outpatient setting, fellows are given gradually greater responsibility for managing their outpatients by the Attending Physician as they show the aptitude and responsibility to assume that load. The Vascular Neurology fellow will be the primary resident provider in the outpatient clinic setting. Vascular Neurology fellows are expected to perform a detailed history and physical, formulate a plan for diagnosis and management, and follow the patient over time with supervision from their Attending Physician.

Neurorehabilitation Rotation

The Vascular Neurology fellow will serve as an adjunct to the Attending Physician with responsibilities delegated as the Attending Physician sees fit after observing and monitoring the Vascular Neurology fellow’s performance.

Supervision of Research

Each fellow will be assigned a faculty supervisor to guide the fellows through a mentored independent or joint research project.

Information for Vascular Neurology Fellows Attachment #8

ATTACHMENT 14: POLICY ON FELLOW WORK ENVIRONMENT

The Division of Vascular Neurology within the Department of Neurology supports the University of Florida Office of Graduate Medical Education and Shands Hospital at the University of Florida policy on resident/fellow work environment. The elements of this policy are listed below:

• The hospital(s) will provide services to assure that residents/fellows do not perform work extraneous to achieving educational goals and objectives. These include services such as peripheral IV access, phlebotomy services, laboratory services, messenger and transport services, and medical records systems. The department fully supports institution of the electronic medical record at all inpatient and outpatient sources.

• The hospital must provide an effective laboratory and radiologic information retrieval system accessibly by the resident/fellow 24 hours a day.

• The hospital must provide a medical records system that documents the course of each patient’s illness and care. This system must be available 24 hours a day and must be adequate to support the education of residents/fellows, quality-assurance activities, and provide a resource for scholarly activity.

• The hospital(s) must provide resources that ensure a healthy and safe work environment for residents/fellows, including access to food 24 hours a day; call rooms that are safe, quiet, and private; safe and secure parking facilities; on-call quarters; security access.

• The hospital(s) must provide residents/fellows with ready access to adequate communication resources, technology support, and specialty-specific reference material in print or electronic format. In particular, residents/fellows must have access to electronic medical literature databases with search capabilities.

Information for Vascular Neurology Fellows Attachment #8

ATTACHMENT 15: POLICY ON OUTSIDE EMPLOYMENT/MOONLIGHTING WITHIN THE FELLOWSHIP PROGRAM

Policy Statement

Housestaff must adhere to State University System Guidelines regarding outside activities/outside employment, conflict of interest, and additional compensation. Such outside activity includes private practice, private consultation, teaching, research, or other employment outside State government which is not part of assigned University duties and for which the University provides no compensation.

Additionally, the ACGME requires that all Non-Programmatic activity (moonlighting) by residents/fellows must be monitored and approved by the Program Director. Individual housestaff programs are accredited by their Residency Review Committee (RRC) and must adhere to RRC requirements regarding outside employment. In order to insure that moonlighting by fellows is not excessive and does not interfere with patient care responsibility as part of the training program, the Vascular Neurology Fellowship Program has adopted the following Non-Programmatic Activity/Moonlighting Policy:

The University of Florida Vascular Neurology Fellowship Program is a demanding, full-time undertaking that requires a great deal of time and effort from each fellow in the performance of clinical duties and the necessary independent reading, study and research. In order to maintain physical and mental health, it is important that each fellow have adequate free time for family, recreation, and rest. The fellowship is a hard, full-time job.

Moonlighting by fellows is not a requirement of the Vascular Neurology training program and must not interfere with the fellow’s responsibilities to his/her patients, colleagues or other responsibilities of his/her training program.

Both Programmatic and Non-Programmatic activities must be counted towards the fellow’s 80 hour per week maximum duty hours, counted toward fellow’s maximum daily continuous duty period, and requirements for free time from patient care responsibilities. All Programmatic and Non-Programmatic activities must be completed at least 12 hours prior to fellowship duties unless the fellow receives explicit permission from the fellow’s Program Director.

The Program Director is responsible for ensuring that outside activities do not interfere with the educational program and will monitor all outside activities of the fellows in the program on an ongoing basis. The Program Director must provide a summary annual report of Programmatic and Non-Programmatic professional employment of program housestaff to the GMEC verifying that the Program Director is aware of all Non- Programmatic activity and approves. Adverse effects on the performance of a fellow directly resulting from Non-Programmatic activities may lead to withdrawal of permission.

Fellows may not provide physician services to other healthcare institutions for remuneration outside the scope of their educational activities and regularly assigned duties of the training program unless prior and specific written notification detailing such activities is given to, and written consent for such activities is obtained from, the Program Director and the Associate Dean, GME. Housestaff training with a J-1 or H10b visa are federally prohibited from participating in outside employment.

Non-Programmatic Professional Activity Form

All housestaff who wish to participate in non-programmatic outside professional employment must first complete a Non-Programmatic Professional Activity Form, which can be found on the UF Housestaff website at http://housestaff.medinfo.ufl.edu/, under “Essential Information and Forms for Housestaff”. Each episode of anticipated non-programmatic service must be included on the form. Requests may be made for activities spanning up to one month, but in no circumstances will blanket approval for periods longer than one month be

Information for Vascular Neurology Fellows Attachment #8 permitted. The Non-Programmatic Professional Activity Form must be reviewed and signed by both the Department Chairman or Program Director and the Associate Dean, GME.

Non-Programmatic activities are activities initiated by the fellow and do not involve any agreement between the University of Florida College of Medicine and an outside employer. Fellows must be licensed for unsupervised medical practice in the state where such activity occurs and attest to adequate professional liability coverage. In no circumstance is the fellow to hold him/herself out as an employee of the University while engaged in such activities.

Information for Vascular Neurology Fellows Attachment #8

ATTACHMENT 16: POLICY ON PROMOTION & GRADUATION

Promotion

The Vascular Neurology Fellowship Program is a one year program and therefore does not offer a promotion during the training year.

Graduation

The Fellow must satisfactorily complete all required rotations and be able to independently assess and treat cerebrovascular diseases to graduate.

Graduates of this program are expected, after passing the ABPN Neurology Boards, to sit for the ABPN’s Examination for Special Qualification in Vascular Neurology.