Neurovascular and Endovascular Academic Practice
Author: Christopher S. Ogilvy, MD
I am currently Professor of Neurosurgery, Harvard Medical School and the Director of Endovascular and Operative Neurovascular Surgery at the Beth Israel Deaconess Medical Center Brain Aneurysm Institute. My practice is highly specialized in the complete care of patients with neurovascular disease, which entails any blood vessel problem in the head neck or spine. A standard week of elective procedures involves two days a week in the operating room performing open neurosurgical procedures and two days a week in the endovascular suite performing endovascular diagnostic and therapeutic procedures. One day a week is spent in clinic.
I have been on every other or every third night call for the last six years. With acute stroke care and mechanical thrombectomy falling squarely in our neurovascular armamentarium, the type of call we take has changed dramatically in the last 8 to 10 years. We now have to be available within 15 to 20 minutes of being called to perform these procedures on a regular basis. As the indications for these procedures widen, the number of times an individual is called in has increased as well. This type of call burden is one of the main reasons why having partners you like and can have fun with is so critical to our area of neurosurgery. I feel blessed to work with Dr.Ajit J. Thomas and Dr. Justin Moore, who also help run our neurovascular practice at Beth Israel Deaconess Medical Center.
For younger individuals embarking on neurovascular surgery career, synergy with partners is essential for clinical and academic productivity. For those finishing fellowship, we often spend the better part of their final year carefully seeking out a work situation that fits. Careful evaluation takes time and energy for both the fellow and their mentors, collaborating and communicating with different potential work environments. The “best job” on paper may not be the right fit for every fellow finishing the training. Extensive energy spent on job procurement is often one of the keys to a happy and productive initiation of practice.
Though sub-specialization was well underway when I finished my training, it has become more refined over the years, to the benefit of neurosurgeons in training and our field. The earlier an individual can identify their passion within neurosurgery the better they are able to delve in to the intricacies of that sub-specialization from an academic and clinical standpoint.
Over the past 6 years, our institution has developed a combined endovascular and open neurovascular fellowship. My two partners and I perform both endovascular and open neurosurgical procedures on a regular basis. Our fellows typically spend two years during or after their neurosurgical training performing both endovascular and open surgical procedures throughout the fellowship. This is much more representative of what their practice will look like when they are on their own after training. In our current setting, we as practitioners and our fellows feel completely comfortable working in the operating room in the morning and in the endovascular suite in the afternoon. This type of arrangement obviously involves fellows who are mature and function as much like junior attendings as they do individuals in training.
Clinical fellow Dr. Alturki and former clinical fellow Dr. Griessenauer, Drs. Thomas and Ogilvy, and research fellow Dr. Ascanio and former research fellow Dr. Motiei-Langroudi.
Our residents and fellows become the face of neurosurgery to the hospital community and the community at large. This interface is critical in order for an individual to practice successfully within an institution. Regardless of whether individuals are in a private practice setting or an academic setting, they should embrace the concept of “citizenship,” which often involves being active in committee work within the hospital or the medical school and within regional and national neurosurgical organizations. While there is typically no formal compensation for this type of work, it can be incredibly rewarding and help to work out solutions to problems within the hospital and medical school.
Collaboration with industry is essential to bring neurovascular concepts from laboratory to bedside in short order. It can be difficult to balance the risks and true benefits of cutting edge technology. Lowest risk does not always mean least invasive. The neurosurgeon must stand ready to abandon techniques, if newer techniques offer truly lower risks with equal or better efficacy. Aneurysm management is a prime example, where the tremendous advances in catheter and device engineering have made endovascular techniques more “user- friendly,” compared to open surgical techniques with much steeper learning curves. Many ask how younger surgeons will gain the experience with open surgery some of us more experienced (i.e. older) surgeons have had treating several thousand aneurysms. One answer is they may not need all of the previously utilized open surgical techniques. However where these techniques or variations of them are needed, the concept of mentorship and fellowships becomes integral to the vitality of our subspecialty.