Medical College of Wisconsin Neurology Fellowship Programs

The Neurocritical Care Fellowship Program at the Medical College of Wisconsin is accredited through the United Council of Neurological Subspecialties (UCNS). This training program is tailored to fulfill the educational curriculum and requirements as set forth by the UCNS and provides an opportunity to work with nationally and internationally recognized experts in the field of Neurointervention, Stroke, Neurosurgery and Neurocritical Care.

Learn about the Adult Neurocritical Care Fellowship Program

The Department of Neurology offers a fellowship in Clinical Neurophysiology which is accredited by the Accreditation Council for Graduate Medical Education (ACGME). Successful completion of this one-year program leads to eligibility to sit for the American Board of Psychiatry and Neurology (ABPN) examination in Clinical Neurophysiology.

Learn about the Clinical Neurophysiology Fellowship Program

The Department of Neurology offers a fellowship in Epilepsy which is accredited by the Accreditation Council for Graduate Medical Education (ACGME). Successful completion of this one-year program leads to eligibility to sit for the American Board of Psychiatry and Neurology (ABPN) examination in Epilepsy.

Learn about the Epilepsy Fellowship Program

The Department of Neurology offers a fellowship in Headache Medicine which is accredited by the United Council for Neurological Subspecialties (UCNS). Successful completion of this one-year program leads to eligibility to sit for the UCNS-board examination in Headache Medicine.

Learn about the Headache Medicine Fellowship Program

The Department of Neurology offers a fellowship in Movement Disorders which is a one- to two-year program that provides clinical training across the spectrum of movement disorders, including advanced therapies such as deep brain stimulation and botulinum toxin injections. Successful applicants to this program must have completed a Neurology residency in an ACGME-accredited program and should be board eligible or board certified in Neurology.

Learn about the Movement Disorders Fellowship Program

The Division of Neurointervention is dedicated to training highly-skilled neurointerventionalists who will be able to continue to expand care for patients with neurovascular disorders. For more information contact NEV_fellowship@mcw.edu.

Learn about the Neuroendovascular Surgery Fellowship Program

The Neuroimmunology and Multiple Sclerosis (MS) Fellowship is a one- to two-year program for neurologists who are looking for a career in patient care and clinical research in neuroimmunology.

Learn about the Neuroimmunology and MS Fellowship Program

The Division of Neuropsychology offers two-year postdoctoral fellowships in pediatric and adult neuropsychology. The purpose of the training program is to provide doctoral-level psychologists with sufficient clinical and research competencies to practice independently in the specialty of clinical neuropsychology. Our postdoctoral training program is a member of the Association of Postdoctoral Programs in Clinical Neuropsychology (APPCN; The Clinical Neuropsychologist, 1993, 7, 197-204) and adheres to the Houston Conference (HC) standards (Archives of Clinical Neuropsychology, 1998, 13, 160-166) for specialty training in clinical neuropsychology.  For more information contact MCW_Neuropsych_Postdoc@mcw.edu.

Learn about the Neuropsychology Fellowship Program

The Department of Neurology’s Child Neurology Division offers a fellowship in Pediatric Neurocritical Care, a quickly growing subspecialty within pediatric neurology. The program is 12 months of clinical training tailored to the fellow’s specific career goals. Successful applicants to this program must have completed a Child Neurology residency in an ACGME-accredited program and should be board-eligible or board certified in Child Neurology.

Learn about the Pediatric Neurocritical Care Fellowship Program

This is a one year, ACGME accredited program. The Vascular Program is dedicated to training highly-skilled vascular neurologists who will be able to continue to expand care for patients with neurovascular disorders.

Learn about the Vascular Fellowship Program

Dr. Pommy is focusing the majority of her effort during her fellowship on research projects related to dementia, particularly initiatives related to early diagnosis. Dr. Pommy has expertise in cognitive neuroimaging analysis, and her present work is aimed at assessing patients who are showing signs of mild cognitive impairment. If successful, this work will lead to earlier identification of neurodegenerative disorders and improve prediction of further decline due to Alzheimer’s disease or other causes. Diagnosing patients at this stage of disease progression is a critical priority for researchers and clinicians who are working to understand how Alzheimer’s disease develops and spreads in the brain.

In addition to undertaking her own research, she is working with mentors to apply for additional funding to support her research, publish and present at conferences, and receive higher-level training in advanced forms of statistical analysis.

About
Dr. Sam Hooshmand, a fellow in Multiple Sclerosis and Neuroimmunology, was awarded the Daniel M. Soref Fellowship for Clinical Neuroscience at the Medical College of Wisconsin for the 2020/2021 academic year in a competitive process. Clinical fellows from throughout Neurosciences are invited to submit research projects for consideration. Those projects are then judged by a group of researchers and leaders in Neurosciences. Dr. Hooshmand’s research entitled Creation of a Novel, Technology-Based, Multidimensional Tool for Multiple Sclerosis Disability with Integration of Patient-Reported Outcomes is being generously supported by the Daniel M. Soref Trust. Dr. Ahmed Obeidat, a specialist in Multiple Sclerosis and Neuroimmunology and also the Director of the MS/Neuroimmunology fellowship is serving as Dr. Hooshmand’s mentor.

Proposal
First developed in 1955, the Expanded Disability Status Scale (EDSS) continues to be the most widely used outcome measure in multiple sclerosis (MS) research1,2. Despite routine implementation in clinical trials, the EDSS is criticized for its time-consuming nature, a lack of inter/intra-reliability, limited sensitivity to changes in patient condition, bias towards changes in ambulation, and neglect of patient-reported symptoms3-7. The National Multiple Sclerosis Society (NMSS) recognized the EDSS shortcomings and the need for better measures of disability, which has led to development of the Multiple Sclerosis Functional Composite Scale (MSFCS) along with other less notable scales4. The MSFCS improves upon the EDSS by including measures of dexterities and cognitive functions; however, MSFCS cannot replace EDSS due to its lack of detailed assessments and difficulties with correlating standardized clinical scoring with z-scores8. A need clearly exists for a quantitative MS disability tool/scale that can provide comprehensive precise measures, which is easy to administer, and can incorporate patient-reported symptoms.

Our project aims to address the limitation of current assessment tools of disability in MS

1. To design a multi-dimensional novel battery of tests to assess MS disability progression by combining innovative, technology-based measures with classical objective assessments.
2. Pilot the tool on participants with clinically definitive MS longitudinally to establish the feasibility for repetitive testing and participant retention/adherence.
3. Obtain feedback from each participant concerning their overall experience with the tool with a focus on increasing study size.

References

1. Kurtzke, J. (2015). On the origin of EDSS. Multiple sclerosis and related disorders, Mar 31;4(2):95-103.
2. Obeidat, A. (2016). John F. Kurtzke, MD (1926-2015). Neuroepidemiology, Jan 20;46(2):118-9.
   van Munster, C., & Uitdehaag, B. (2017). Outcome Measures in Clinical Trials for Multiple Sclerosis. CNS Drugs, 217 - 236.
3. Whitaker, J., McFarland, H., Rudge, P., & Reingold, S. (1995). Outcomes assessment in multiple sclerosis clinical trials: a critical analysis. Multiple Sclerosis Journal, Apr;1(1):37-47.
4. Noseworthy, J. H., Vandervoort, M. K., Wong, C. J., & Ebers, G. C. (1990). Interrater variability with the Expanded Disability Status Scale (EDSS) and Functional
5. Systems (FS) in a multiple sclerosis clinical trial. Neurology, 40(6), 971-971.
6. Francis, D. A., Bain, P., Swan, A. V., & Hughes, R. A. (1991). An assessment of disability rating scales used in multiple sclerosis. Archives of neurology, 48(3), 299-301
7. Goodkin, D. E., Cookfair, D., Wende, K., Bourdette, D., Pullicino, P., Scherokman, B., & Whitham, R. (1992). Inter‐and intrarater scoring agreement using grades 1.0 to 3.5 of the Kurtzke Expanded Disability Status Scale (EDSS). Neurology, 42(4), 859-859.
8. Cutter, G., Baier, M., Rudick, R., Cookfair, D., Fischer, J., Petkau, J., Ellison, G. (1999). Development of a multiple sclerosis functional composite as a clinical trial outcome measure. Brain, May 1;122(5):871-8.

Significance and Potential of Impact
The proposed project will be the first to integrate technology-based, detailed measures into a multidimensional battery of tests to assess disability progression in MS. Additionally, it will be the first to integrate patient reported outcome measures into the scoring system of objective tests. Further, the concept of weighted scoring is novel for MS disability assessment tools. Consequently, this project will have the possibility of being a viable alternative to current MS disability measures such as EDSS, in addition to providing an innovated notion of weighted disability scoring in MS. Future directions of this project will aim to test the novel tool in a large population of MS patients, validate the tool against current MS measures (EDSS, MSFC, MSOAC), correlate the measurements with other biomarkers of disease activity (imaging and laboratory tests), and pursue studies to establish the potential for the novel tool as a primary clinical measure of disability in MS clinical trials.

About
Dr. Southwood, a fellow in Neuro-Critical Care, was awarded the Daniel M. Soref Fellowship for Clinical Neuroscience at the Medical College of Wisconsin for the 2019/2020 academic year in a competitive process. Clinical fellows from throughout Neurosciences are invited to submit research projects for consideration. Those projects are then judged by a group of researchers and leaders in Neurosciences. Dr. Southwood’s research on improving door-to-device times for acute ischemic stroke thrombectomy patients is being generously supported by the Daniel M. Soref Trust. Dr. Marc Lazzaro, a specialist in Vascular Neurology and Endovascular Surgical Neuroradiology and the Program Director of the Neurointervention fellowship program is serving as Dr. Southwood’s mentor.

Aims

• Hypothesis: Existing processes and workflows at Froedtert Hospital for patient management, care team activation, and transport in the Door-to-Device (DTD) phase of care contain inefficiencies leading to time delay, which can be improved with a systematic review, revision, and implementation of time-sensitive process updates.
• Aim 1: Perform a retrospective analysis of previously collected time intervals for all patients with acute ischemic stroke who underwent thrombectomy.
• Aim 2: Convene a multidisciplinary workgroup to review and compare time intervals with published data, identify areas for potential improvement, and propose a revised process for patient management in the DTD phase of care targeting a safe and meaningful reduction in time.
• Aim 3: Perform Plan-Do-Study-Act (PDSA) cycles to implement and assess effectiveness of change, specifically for a safe and meaningful reduction in time.

Methods
To accomplish these aims, I will work closely with my mentor to complete a retrospective analysis of time intervals for patients undergoing acute stroke thrombectomy. This project will entail multiple Plan-Do-Study-Act (PDSA) cycles to streamline our DTD process for endovascular therapy. Specifically, there will be an in-depth analysis of our current state and examining our practices, standards, and identifying the stakeholders in this process including representatives from emergency medicine, radiology, stroke neurology, neurointervention, anesthesia, nurses, interventional radiology technologists, the Access Center, operators, and patient transport staff. In order to improve our process, it will be imperative to understand the challenges encountered across our multidisciplinary treatment team. This will require establishing metrics to accurately assess our current state and understanding national standards and targets to set and reach our goals. Changes concepts will aim to eliminate waste, improve workflow, optimize inventory, improve the work environment, reduce variation, and avoid errors. Through multiple PDSA cycles, it will be important to reduce waste and inefficiencies across every team members’ roles to improve our metrics. Future directions include taking patients directly from the CT scanner to the angiography suite without delaying for image interpretation, improving patient transport times to eliminate waste, working with anesthesia in parallel to avoid waste, standardizing a “stroke cart” so the radiology technologists can very quickly reach for the tools needed for any stroke case. The IV tPA door-to-needle times at Froedtert Hospital have already improved by 34 minutes using similar efforts to improve processes and workflow. The environment, multidisciplinary collaboration, and resources exist to make this a successful project.

Proposal
Stroke is the fifth leading cause of death in the United States and recognized as a leading cause of disability¹. Treatment of acute ischemic stroke has undergone a revolution within the last half-decade with focuses on improving access to thrombolytic pharmacologic therapy and later overwhelming evidence supporting endovascular therapy (EVT). Treatment with pharmacological thrombolysis with alteplase (tPA) has also been refined to enhance access for more patients. Specifically, the American Heart Association/American Stroke Association has implemented a Target: Stroke initiative to streamline processes and efficiently deliver reperfusion therapy in a timely fashion. This initiative has successfully reduced Door-to-Needle times. Specifically, at Froedtert hospital we have been able to improve our door-to-needle times by 34 minutes over the last 5 years.

In 2015, EVT was firmly established within six hours to significantly improve functional recovery. Thrombectomy treatment for acute ischemic stroke has been further validated up to 24 hours, allowing for more stroke patients to attain functional independence. Now, the focus has turned to streamlining the endovascular therapy processes to improve efficiency and outcomes, deemed Door-to-Device (DTD) target times as has been supported by some of the thrombectomy trials^2,3. The ESCAPE trial emphasized efficient workflow to achieve fast vessel recanalization². As the Target: Stroke program enters phase III, the DTD will target 50% of patients in 90 minutes or less for patients entering Froedtert’s emergency room, and for DTD targeting less than 60 minutes for patients transferred from outside facilities⁴.

Significance and Potential Impact
Process and workflow inefficiencies may lead to unnecessary delays in delivering the critical and time-sensitive therapy of thrombectomy to acute ischemic stroke patients. Through improving the process of endovascular therapy for acute ischemic stroke, there is potential for significant impact for each patient treated around Wisconsin. The well-established mantra of “time in brain” remains true as the estimated rate of neuron death is 1.9 million for each minute in which stroke is untreated⁵. The aim to improve our metrics to meet the proposed goals in Target: Stroke phase III will undoubtedly improve each patients’ chances of recovery while reducing the burden of death and disability on our community. Similar projects are underway nationwide⁶, but it will be important to understand the unique challenges within the Froedtert health system to help patients in Wisconsin.