Program Overview
Goals and Objectives for Training
The Johns Hopkins Fellowship in Neurocritical Care is a two year program. A major goal of our program is to train critical care clinician-scientists. The research interests of our physicians are varied and there is adequate time provided for development in these areas. All fellows have the combined resources of major contributing departments at their disposal. Once an area of interest is identified, a formal mentorship is established. It is expected that fellows will take part in 12 months of research over the course of two years. The remaining 12 months of training consist of clinical patient care activities.
Clinical Component: Clinical rotations take place in the NCCU at The Johns Hopkins Hospital (22 beds) as well as the NCCU at The Johns Hopkins Bayview Medical Center (8 ICU beds + 6 step-down beds) in 1-2 week blocks. Other clinical rotations include a two week block in the surgical ICU, medical or cardiac ICU as “observers” (participation in rounds and all academic activities but not directly responsible for patient care) and a two week block in the operating rooms for exposure to intra-operative monitoring and elective intubations/airway management.
Research Component: Research endeavors may be comprised of clinical or laboratory-based research. Clinical research participation is mandatory for all fellows in training via participation in the numerous ongoing (institutionally-based or multi-center) clinical trials on a variety of themes such as brain resuscitation, stroke and ischemic neuroprotection. Laboratory-based research in the areas of epilepsy, cardiac arrest and stroke entails active participation under close supervision of the mentor and senior laboratory investigator.
Hours and Supervision: The program is designed to have close and direct supervision from attending staff during clinical rotations. Fellows spend 10-12 hours per day providing direct patient care. Typically, the NCCU team consists of an attending, three fellows, 3-4 residents and a nurse practitioner’s team. With this team approach, sleep deprivation and excessive hours rarely is an issue, but if it arises on occasion, the team approach allows for appropriate backup from attendings and co-fellows. For research activities, a mentorship program has been developed whereby each fellow identifies a faculty member in the division who functions as a mentor for all non-clinical research activities (laboratory-based and clinical) including writing and reviewing articles in peer-reviewed journals, formulating hypothesis-driven research protocols, grant writing etc.
Rounds: Rounds are structured toward active participation with distinct roles for each member of the team (attending, fellow, resident, nurses, pharmacist, and social worker). Detailed critical care rounds occur with a “systems-approach” to each patient and special emphasis is applied to bedside teaching as it pertains directly to patient care. Multiple goal-directed rounds occur through the course of the day (Combined neurosurgical rounds, critical care rounds, radiology rounds, and evening rounds) and the fellows lead these rounds. The first year as a junior fellow is spent developing patient care skills and teaching the ICU house-staff and nurses regarding the bedside care of patients.
Procedural Requirements: All procedures are closely supervised and countersigned by attending staff during clinical rotations. Procedural competence is an integral part of training. Procedures include arterial line and central line placement, Swan-Ganz catheter placement, thoracentesis, airway management including endotracheal intubations and bronchoscopy. Fellows are permitted to perform procedures independently only during emergencies and following approval from the NCCU director and co-director on enrollment into the advanced specialty training program (ASTP).
Didactic Components: Didactic teaching sessions occur daily for fellows and resident house staff. Topics include diseases that are seen commonly with special emphasis on fundamental principles, pathophysiology and critical aspects of patient management. A typical monthly lecture schedule is attached. In addition, over the first 1-2 month period at the start of fellowship training, there is an intensive didactic lecture series on topics that include cardiopulmonary aspects of critical care as it pertains to critically ill neurological and neurosurgical patients. An intensive one-week course in neurosonology (transcranial doppler) comprising of lectures and “hands-on” practice is mandatory for all fellows in the first six months of fellowship training. Intensive one-week courses for advanced cardiac life support (ACLS) and advanced trauma life support (ATLS) are also mandatory for all fellows toward obtaining certification.
Conferences: Conferecnes include a weekly divisional research conference (institutional CME-approved) where a broad spectrum of topics in basic science and clinical research are presented. Particular emphasis is paid to basic science research that has translational significance into clinical paradigms. Attendance at this conference is mandatory for all faculty and fellows in the Division. Updates on patient enrollment in ongoing clinical trials and alterations in existing protocols are also provided. Invited speakers include faculty from the NCCU division, other JHU faculty, other institutions, as well as pharmaceutical-based experts in the research field. Fellows and faculty are encouraged to attend weekly departmental grand rounds in the Departments of Neurology, Neurological Surgery and Anesthesiology/Critical Care Medicine. A journal club encompassing recent published research articles are presented by fellows and critically discussed once a month at these conferences.
Personal Enrichment Programs: Fellows are encouraged to attend courses given by the School of Public Health and the School of Medicine and other CME courses at the national meetings of the Academy of Neurology, American Neurological Association and the Society of Neuroimaging. Courses on medical ethics, biostatistics, and epidemiology are particularly encouraged.
Teaching Opportunities: Participation in bedside teaching as well as with didactic lectures is an integral part of fellowship training. Fellows are given specific topics and expected to give 1-2 lectures per week formally to resident house staff during their NCCU rotations. Other informal bedside teaching sessions to resident house staff are an integral part of the fellowship training. Participation as speakers at courses organized by the divisional faculty at national meetings (e.g. American Academy of Neurology, Society of Critical Care Medicine) is encouraged.
Quality Assurance: Fellows are charged with tracking of Morbidity and Mortality in the units and take turns presenting such cases formally at a divisional conference held every other month. Fellows are also designated to other task force committees for specific practice parameters as performance improvement tools such as incidence of unplanned or self-extubations in the NCCU, patient-family satisfaction surveys etc. Such focused work groups consist of selected nursing staff and are frequently headed by the designated fellow.
Progression in Responsibilities: Critical evaluation by the faculty at the end of first year as a junior fellow determines the fellow’s promotion to the second year as a senior fellow in the training program. Second year of training focuses on developing leadership and administrative skills in managing a busy critical care unit in addition to teaching and supervising junior fellows and house staff. Specially gifted fellows are enrolled in the institutional advanced specialized training program (ASTP) in their second year of training. Fellows are given remedial coaching in areas of weakness and, on occasion in the past, the fellowship program has utilized the faculty and staff assistance program (FASP) in cases that have special needs and face difficulties during their training period.
