VASCULAR FELLOWSHIP PROGRAM
Competency-based goals and objectives for each assignment at each educational level
FIRST YEAR
During the first six months of the fellowship, the fellow will be working at the VA clinic on Thursdays. During the first two months of this period, the fellow will be learning non-invasive vascular laboratory testing at the vascular lab at the VA. Months 3-6 of this period, the fellow will be involved with endovascular therapy training and basic science research.
Months 1–6: Exposure to Patient care and preoperative planning
The vascular fellow will be actively involved in the Vascular outpatient clinic at the VA Hospital of Iowa City every Thursday throughout the months 1-6. During that clinic, under supervision of faculty, the fellow will evaluate the majority of the new consults and participate in the decision making of all patients who require an intervention.
Assessment of completion of these goals during 6 month rotation based on:
- Faculty observation during clinic.
- 360 degree evaluation that includes faculty, junior residents, senior residents, and nurses in the clinic as well as patient questionnaires.
Month 1 & 2: Non-invasive vascular lab training
These two months are based at the non Invasive Vascular Laboratory of the VA hospital of Iowa City.
Learn the basics of non invasive vascular lab testing.
- The fellow should become familiar with performing the most commonly used vascular lab testing such as duplex scanning of the carotid arteries, duplex scanning of the abdominal aorta and duplex scanning of the lower extremities including the venous and arterial system.
- The fellow is expected to perform approximately 50 vascular lab duplex tests and maintain a portfolio of all the diagnostic vascular lab tests he/she conducted, to be viewed by Program Director upon completion of this two month rotation.
- Didactic curriculum is based on the vascular lab didactic curriculum provided by the Association of Program Directors in Vascular Surgery. The list includes a CD that depicts the various testing which will be used as a guide while the residents are learning to perform and interpret the procedures.
Assessment of completion:
- A formal report from the vascular lab technologists at the VA who are also instructors for vascular lab technicians in the ultrasonography program at The University of Iowa.
- Fellow performance of each of the non invasive vascular tests, i.e. a duplex ultrasound of the carotids, an abdominal aortic ultrasound, and a venous duplex ultrasound, under the surveillance of the Program Director.
- Resident portfolio of vascular lab tests to be examined by Program Director.
Months 3–6: Endovascular therapy training/Basics of Scientific Research
The resident will be exposed and trained at performing percutaneous diagnostic and therapeutic interventions. This would include diagnostic aortograms and distal vessel runoff as well as diagnostic cerebrovascular testing.
1. Learn the basics of endovascular therapy
- Learn the various available catheters and wires including directional catheters and selective catheters.
- Learn the various differences between balloons and stents and the various aspects of balloon expandable and self expanding stents.
- Receive exposure to the performance of endovascular AAA as well as other forms of endovascular therapy such as vena caval filter placement, thrombolysis, and hypogastric embolization.
2. Learn the basics of scientific research
- Identify a clinical or basic science project whereby the fellow will evaluate available data and summarize the data and conclusions and write an abstract to be submitted at a national meeting which will ultimately result in a publication in a peer reviewed journal.
- Contribute as a co-author in book chapters or review articles.
Assessment of completion
- Observation and evaluation of fellow, by the program director, while performing endovascular procedures.
- Assessment by entire vascular faculty of the fellow’s performance and skills in endovascular techniques.
- Submission and presentation of academic projects at national meetings under the monitoring and guidance of program director or appointed faculty.
Specific patient care and medical knowledge goals for months 1-6:
- To understand radiation safety issues for the patient and operator.
- To understand arterial and venous radiographic anatomy.
- To develop proficiency with percutaneous arterial and venous cannulation of the upper and lower extremity.
- To become familiar with and be able to name all basic guidewires, catheters and other devices used for diagnostic and therapeutic interventional procedures.
- To perform under supervision diagnostic arteriography and venography of the abdomen and lower extremities.
- To learn the indications for, the performance of, and the interpretation of arterial physiologic testing and venous duplex scanning for DVT.
- To demonstrate expertise with percutaneous puncture and with diagnostic arteriography of the abdomen and lower extremity.
- To perform under supervision diagnostic arteriography of the renal and brachiocephalic arteries.
- To perform under supervision balloon angioplasty and stenting of the iliac and lower extremity arteries.
- To perform under supervision vena cava filter placement.
- To learn the indications for, the performance of, and the interpretation of peripheral arterial duplex scanning and duplex scanning for venous valvular incompetence.
- To learn the basic issues involved in the preoperative evaluation of patients undergoing open vascular surgery.
- To demonstrate effective patient evaluation techniques, including history, physical examination and noninvasive testing.
- To clearly present patient information on rounds and in conferences.
- To demonstrate appropriate initial evaluation of outpatients with the vascular disease including plans for initial diagnostic evaluation.
- To demonstrate expertise with the procedures learned during the general surgery residency.
- To acquire detailed knowledge concerning arterial occlusive and aneurysmal disease and venous thrombosis and insufficiency.
- To demonstrate appropriate OUTPATIENT evaluation of patients with vascular disease, including plans for diagnostic evaluation and initial therapeutic planning.
- To demonstrate proficiency in placing percutaneous arterial and venous monitoring catheters.
Assessment method:
- Faculty evaluation
- 360 degree evaluation
Specific practice based learning and improvement objectives, months 1-6:
- Participate in Vascular Journal Club
- Present at weekly Vascular conference
- Participate in clinical teaching
- Investigate and evaluate own patient care practices
Assessment method:
- Faculty evaluation
- Performance on presentation at conference
- Performance on presentation at journal club
Months 7–12: Clinical experience at UIHC
This part of the year is spent at the University of Iowa Hospitals and Clinics. During the 6 months, the fellow will be exposed to all aspects of vascular surgery including open and endovascular procedures. In addition the fellow will be actively involved in the preoperative, intra-operative and postoperative patient care. Participation in the outpatient clinic at least one day per week is essential for the fellow to learn the issues related to patient selection for intervention versus non operative management. It will also allow the fellow to be exposed to the issues related to follow and management of early and late complications of vascular interventions. During this period the fellow will also be actively involved in the interpretation of vascular laboratory testing performed on their patients.
Goals for patient care include learning to identify indications for interventions and indications for conservative management. The goals also include the ability to differentiate between the role of open interventions versus endovascular interventions. The fellow during these months will learn how to expose blood vessels and the various aspects of the body with assistance from the faculty in addition to constructing vascular anastomoses with assistance. The fellow will also learn to obtain angiographic access and to learn how to navigate the catheters over the aortic bifurcation and achieve third degree selection and cannulation. The fellow during these months will also learn to use 3-D imaging for pre-operative planning for endovascular aortic aneurysm replacement. Below is a selected list of goals to be achieved during this rotation.
- Identify indication for interventions
- Identify indications for conservative managements
- Identify roles for open versus endovascular interventions.
- Learn to expose blood vessels with assistance
- Construct vascular anastomoses with assistance
- Obtain angiographic access with minimal assistance
- Learn to navigate catheter over the aortic bifurcation and 3rd degree vessel selection
- Learn to use 3D imaging for preoperative planning of EVAR
- Provide inpatient care on the wards and participate in the care of vascular patients in intensive care unit.
- Learn to identify complications
The medical knowledge during these six months will be complimented by using departmental conferences, clinical teachings on rounds, and the utilization of the core curriculum provided by the Program Directors in Vascular Surgery. The medical knowledge will be assessed using direct faculty evaluation, and the participation in a written examination. At the end of the second 6 months of the training, the vascular fellow should be able:
- To demonstrate expertise with procedures learned during the previous rotation.
- To demonstrate thorough evaluation of outpatients with vascular disease, including diagnostic and therapeutic planning.
- To acquire basic knowledge concerning less common arterial, venous and lymphatic disease processes, including diagnosis and treatment options.
- To learn the indications for, the performance of, and the interpretation of carotid artery duplex, abdominal arterial duplex, and upper extremity venous duplex scanning.
- To perform under supervision of balloon angioplasty and stenting of renal and mesenteric arteries.
- To perform under supervision thrombin injection of femoral pseudoaneurysms.
- To become exposed to the use embolic protection devices during endovascular procedures.
- To become exposed to catheter directed thrombolysis procedures. To perform under supervision catheter directed thrombolysis procedures.
- To perform under supervision operations including lower extremity bypass, carotid endarterectomy, exposure of the abdominal aorta through trans-and retroperitoneal exposure, and endovascular aortic and iliac aneurysm repair.
- To demonstrate responsibility for the care of the vascular patients in the intensive care units.
- To perform under supervision inpatient consultations for other services.
Practice based learning and improvement: These will be implemented through departmental conferences and clinical teachings and journal club. The residents will be able to investigate and evaluate their own patient care practices. Complications will be discussed and best practices will be adopted based on peer reviewed literature and evidence based literature. Journal club will be used to identify and appraise new scientific evidence. The assessment tool will include faculty evaluations and performance on presentation at M & M and Journal Club.
Interpersonal and communication skill: The resident during those six months will be able to demonstrate interpersonal and communication skills that result in effective information exchange and collaboration with patients, their families, and other health professionals. This will be implemented through one on one clinical teachings in the clinics. The residents will have the opportunity to interview patients and to communicate with patients and their families. The residents will be able to pass on and communicate this information to the faculty in the clinic or through consultations at various hours of the day and communicate the information to their faculty members or other members of the team. The assessment tool will include faculty evaluations, evaluations from nursing staff and other residents, a 360 degree evaluation, as well as patient questionnaires.
Professionalism: The residents will demonstrate a commitment to carrying out professional responsibilities and adhere to ethical principles and sensitivity to a diverse population. This will be implemented through clinical teachings in the clinic. The faculty members will serve as role models and will communicate their interactions with family members and other colleagues and members of the theme. The didactic lectures and journal club will include a review of ethics papers presented in the Journal of Vascular Surgery. The assessment tool will include faculty evaluation as well as 360 degree evaluation and resident questionnaires.
Systems-based Practice: The resident will demonstrate an awareness and responsibility to the point of contacts and system of health care and the ability to effectively call on system resources to provide optimal care. This will be implemented through departmental conferences and clinical teaching. The M & M conferences will serve as a platform through which the residents will review adverse events and identify causes that can be due to a system problem. The residents will be able to outline changes in the system that will ultimately result in improvement of patient care. This will be assessed using faculty evaluation, 360 evaluations and the resident portfolio. The residents will learn how to coordinate the care between the various aspects of the disciplines within the hospital including referring physicians, various departments, various radiological departments and operating personnel and schedulers and families and insurance companies.
SECOND YEAR
Months 1–6: Clinical experience at the UIHC
During these six months, the clinical experience of the residents is expected to mature further. During the six months, the fellow will be exposed to all aspects of vascular surgery including open and endovascular procedures.
Selected goals for this 6 month rotation with respect to patient care and medical knowledge:
- Further refine skills and goals learned in the previous year
- Read noninvasive vascular laboratory studies and perform interpretations under faculty supervision.
- Become capable of obtaining angiographic access independently.
- Become capable of 3rd degree vessel selection independently
- Learn to use mechanical thrombolytic devices.
- Perform under supervision carotid artery stenting.
- Perform under supervision selective catheterization of branch arteries for coil embolization.
- Become capable of using 3D imaging for preoperative planning of EVAR independently
- Learn to expose blood vessels with little or no assistance
- Perform under supervision complex vascular operations, including thoracoabdominal aneurysm repair, excision and replacement of infected bypass grafts, redo carotid endarterectomy, carotid body tumor excision, renal and mesenteric artery bypass, and redo abdominal aortic surgery.
- Identify and learn to manage complications with minimal assistance.
- With respect to communication and professionalism, the resident should become capable of communicating information related to outcome of interventions in elderly patients to the elderly patients themselves and to their family members; develop the ability to discuss options such as risk of rupture of an aortic aneurysm, the risk of stroke of carotid disease, the risk of amputation following bypass, the ability to communicate such information to an elderly patient who may have limitation of cognitive functions or limitations in hearing or understanding. The same will apply to the ability of explaining and communicating such findings to the family member. The resident should become more comfortable of dealing with issues related to making the difficult decision to intervene or not intervene in a patient with a ruptured abdominal aortic aneurysm.
Assessment of Completion
Faculty evaluation
360 degree evaluation
Months 7-12
The last six months of the fellowship are spent at the VA Hospital of Iowa City. During the six months, the fellow will be exposed to all aspects of vascular surgery including open and endovascular procedures. During that time, the resident will serve in a capacity of a junior faculty though fully supervised by faculty members. The fellow is expected by then to have acquired the clinical judgment and technical skills necessary to be an independent practitioner of vascular surgery. The fellow should be able to serve as a teaching assistant to PGY4 and PGY1 residents at the VA. The fellow should be able to teach PGY4 exposures of blood vessels and teach them how to construct vascular anastomoses. He/she should be capable of exposing redos with little or no assistance and should be capable of managing complications.
The communication skills will be monitored through the interaction of the resident with the other faculty members and junior residents on the team. The interpersonal and communication skills will be assessed by 360 degree evaluations. They will be implemented by having the resident present at various departmental conferences and activities including the multidisciplinary conference and M&M.
The system based practice will be implemented by having the fellow learn how to interact with different system at the VA hospital of Iowa City with different support and constraints. Issues and the outcome will be used as a means of evaluating system problems and changes in practice and outcomes based on working in a different system environment.
Selected goals for this 6 month rotation:
- Demonstrate expertise with procedures learned during the previous rotations.
- Demonstrate detailed knowledge concerning all arterial, venous and lymphatic disease processes, including diagnosis and treatment options, using interventional, open and medical management techniques.
- Assume responsibilities for supervision of the entire vascular service at the VA hospital of Iowa City.
- Independently manage complex vascular patients minimal faculty supervision in both the outpatient and inpatient setting.
- Serve as teaching assistant for PGY4 and PGY1 residents at VA, Teach PGY4 and PGY1 exposure of blood vessels and construction of vascular anastomoses. To instruct a junior residents in basic diagnostic interventional procedures.
- Expose redos with little or no assistance.
- Become comfortable in managing complications
- Independently manage complex interventional procedures with minimal faculty supervision.
- Demonstrate appropriate rescue techniques for complications of interventional procedures.
- Have read sufficient noninvasive vascular laboratory studies and perform interpretations under faculty supervision to qualify for the (RPVI) Registered Physicians Vascular Interpretation Exam.
- Fellowship Introduction
- Overview of Training
- Goals and Objectives
- Self Study
- Facilities
- Faculty and Staff
- Past Vascular Fellows
- Summary