CLINICAL CURRICULUM

Overview

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

Our fellowship rotations are one week in duration rotated at regular intervals throughout the year. Rotations consist of the Inpatient Rotation, the Telemedicine Rotation, and the Outpatient/Elective Rotation. These rotations are divided amongst our four fellows according to the following:

FellowRotation (one week each)
Fellow 1

Inpatient Rotation – Hillcrest/Mercy
UCSD Hillcrest Medical Center (wards and stroke codes)
Scripps Mercy Hospital (ED stroke codes only)

Fellow 2

Inpatient Rotation – La Jolla
UCSD Jacobs Medical Center (wards and stroke codes)
Veterans Administration Medical Center (stroke codes only)

Fellow 3Telemedicine Rotation
Fellow 4Outpatient Clinic or Elective Rotation

Fellows will spend a total of 24 weeks on the Inpatient Rotations (12 weeks Hillcrest/Mercy Rotation and 12 weeks La Jolla Rotation), 12 weeks on the Telemedicine Rotation, 6 weeks of dedicated Outpatient Clinic and 6 weeks of Elective Rotation. Fellows will also be provided 4 weeks of vacation time. In general, each of these rotations also accommodates adequate time for fellows to develop their research projects and manuscripts to provide the most well-rounded educational experience.

Each rotation also allows adequate time for fellows to develop their research projects and manuscripts to provide the most well-rounded educational experience.

Inpatient Rotation

Fellows will have the opportunity to rotate through various institutions that will provide clinical experience in both an academic (UCSD hospitals) and community setting (Scripps Mercy Hospital).

Fellows will be responsible for the management and oversight of stroke codes and the inpatient stroke census at UCSD Hillcrest Medical Center or at UCSD Jacobs Medical Center (depending on the designated inpatient rotation). Fellows will be encouraged to lead morning rounds and perform bedside neurological examination teaching and will supervise and guide the neurology residents in managing stroke codes, admissions, and inpatient consultations.

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

Ultimately, the role of the vascular neurology fellow is to be the junior faculty on the inpatient service. This role requires making important inpatient clinical decisions (with the supervision of the stroke faculty) and guiding the residents/stroke nurse practitioners through inpatient admissions/consults and stroke codes to the point where the fellow creates a productive learning environment for every team member on the inpatient rotations. Fellows are expected to obtain progressive autonomy in stroke clinical decision-making throughout the year to provide them the confidence in managing vascular neurology patients upon graduation.

When rotating on the Hillcrest/Mercy inpatient rotation, the role of the vascular neurology fellow at the Scripps Mercy Hospital facility is to manage stroke codes independently (with faculty supervision) and to understand stroke systems of care within a community setting. Fellows will only manage stroke codes activated by the Emergency Department. The fellow does not manage any stroke codes activated on inpatients admitted at Scripps Mercy Hospital and there is no daily inpatient ward responsibility at this facility.

When rotating on the La Jolla inpatient rotation, the role of the vascular neurology fellow at the San Diego Veterans Administration Medical Center facility is to manage Emergency Department and inpatient stroke codes only with the UCSD neurology resident. Note that there is no daily inpatient ward responsibility at this facility for stroke fellows.

Telemedicine Rotation

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

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

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

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

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

Outpatient Clinic

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

The outpatient clinics are scattered amongst the various inpatient rotations to supplement the knowledge gained from the wards (approximately 1-2 half day's of clinic per week). There is also a dedicated Outpatient Rotation where fellows will rotate through the clinics of all stroke faculty members (approximately 4 half days of clinic per week for 6 weeks) to understand the various approaches to outpatient stroke management.

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

  • UCSD Hillcrest – Medical Offices North
  • UCSD Sulpizio Cardiovascular Center
  • San Diego Veterans Administration Medical Center

Elective Rotation

Elective rotations are available to provide more subspecialty experience in vascular neurology and stroke care. Fellows will be able to rotate through dedicated Neurocritical Care and Endovascular Neurosurgery Electives based on the fellow's interests. There is also an opportunity for Research and Away Electives to facilitate accomplishing the fellow's research goals and to supplement any educational activity that may not be available within the fellowship program. 

On-Call

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