Goals and Expectations

Goals

The fellowship training program in pediatric interventional radiology (PIR) at Boston Children’s Hospital is designed to provide comprehensive, advanced academic training in interventional management of pediatric pathologies. At the completion of the fellowship the fellow is expected to be competent in performing IR procedures in children, with an understanding of the particular needs and demands of pediatric intervention. At the end of the training period, the fellows should be familiar with the full range of pediatric disorders and are expected to formulate and execute management and follow-up plans in a competent, organized and compassionate manner.

Curriculum

The fellowship program curriculum follows closely the requirements outlined by the ACGME. This includes clinical and didactic training that encompasses the entire field of vascular and interventional radiology. Examples of vascular and nonvascular procedures include, but are not limited to, the following:

1. Vascular diagnosis and intervention: arteriography; venography; embolization; sclerotherapy, lymphangiography, angioplasty; stent placement; thrombolysis; foreign body removal; selective venous sampling; dialysis access intervention; PICC and central venous catheter placement; caval filter placement and retrieval and transjugular liver biopsy, endoluminal and cutaneous laser applications.

2. Nonvascular intervention: percutaneous drainage procedures, biliary and renal interventions, enteric feeding tube placement and management, radiofrequency ablation, musculoskeletal steroid injections for pain, botox injection.

3. Diagnostic tasks: Performance and interpretation of dedicated ultrasound examinations, vascular Doppler studies, interpretation of MRI and CT angiograms.

The PIR fellow is expected to develop a wide variety of clinical, technical, and cognitive skills throughout the training period.

Expectations and Responsibilities

The PIR fellows are expected to participate in all the clinical and academic activities within the division of interventional radiology. In addition active participation is also expected in relevant departmental and hospital activities. Clinical duties related to patient’s care include, but are not limited to:

Discussion of the requests for procedures with the PIR staff and referring service, including indications, potential contraindication, urgency, consent and related logistic issues.
All fellows should have active PALS certification and should be credentialed to prescribe sedation, including Ketamine. All cases referred to IR should be assessed for the level of anesthesia required. If the procedure can be performed under sedation and meets sedation criteria, it should then be referred to the IR nurses for further assessment.
Pre-procedure workup: Review of clinical history, prior procedures and complications, available relevant imaging studies and sedation/anesthesia plan. Completion in writing or electronic format of a pre-procedure note pertaining to each procedure. Documentation of special instructions for patients such as premedications (e.g.: medications for contrast allergy, SBE prophylaxis, anticoagulation, prior history of post-procedure nausea, prior reaction to steroids, etc.) and response to prior treatment. Performance of a directed history and physical (H&P) examination if required.
Performance of the procedure: All procedures are done under the supervision of a PIR staff. Fellows will be given graded responsibilities and PIR staff supervision will gradually decrease as the fellowship progresses. Toward the end of the year, the PIR fellows will be able to function with a minimum of supervision to the extent that is allowed by safety of PIR practice.
Post-procedure assessment: Performance of a complete vascular physical examination (and Doppler US if needed) prior and immediately after all arterial procedures. Documentation of pulse presence and strength bilaterally for all the limbs studied.
Post-procedure orders and documentation:

i.     Completion of procedure note (please see guidelines on post-procedure notes).

                ii.     Entry of post-procedure orders and Brief Operative Note using PowerChart.

                iii.     Communication of these orders to the nurse practitioners, IR and PACU nurses and the scheduling coordinators.

                iv.     Notification of admitting/referring service with the outcome of the procedure, special instructions and plan.

The fellow is responsible for a verbal sign-out with the nurse practitioners following each procedure, except for the minor ones.
Dictation of the procedure report on the day of the procedure following discussion with the IR attending.
Daily rounds and notes on inpatients.

Completion of clinical follow-up visit, with documentation as per IR guidelines.

Membership of Professional Societies

Membership of the following societies is highly recommended for PIR fellows:

1. The Society for Pediatric Interventional Radiology (SPIR).

Apply for Members-in-Training Status. Send 1. CV, 2. letter of recommendation from an SPIR member, and 3. letter from your program director stating the program site, type of training, and anticipated date of completion to [email protected]. Fellows should also subscribe to the PIR list-serve by emailing [email protected]

2. New England Society of Interventional Radiology (NESIR)

Monthly angioclub on the second Tuesdays September-May. PIR fellows present a case or more every meeting (alternating between fellows). Free membership for fellows. nesir.org

3. Society of Interventional Radiology (SIR)

Submit form and letter of recommendation from Program Director. Form available at: http://www.sirweb.org/join-us/beMemPDF/SIR_Membership_Application.pdf

4. The International Society for the Study of Vascular Anomalies (ISSVA).

Trainees have no voting rights and pay annual dues. Membership as trainee is optional but highly recommended as a practicing attending. www.issva.org

Rotations

Currently, there are two full-time positions IR fellows who spend the entirety of the fellowship year at BCH. In addition, there are 8-10 pediatric radiology fellows who will spend a 2 week rotation in IR during their first year. Second year diagnostic fellows may also request an additional elective rotation in PIR. There are several rotating residents who may electively spend part of their rotation at BCH in PIR. Visitors may also spend some time in the angiosuite.

Call and Conference Coverage

It is the fellows' responsibility to ensure adequate coverage for call and conferences (including VAC and MAS). If there is a possibility of a fellow not being able to cover call, it is the fellow's responsibility to ensure that a co-fellow or IR resident provides back up. This should be coordinated with the chief fellow and communicated to the attendings. If a fellow is on call and covering conference, the pager should be covered by other fellow/resident for the duration of the meeting.

Elective Rotations

There is a potential to spend an elective rotation (limited to 2 weeks) outside IR or BCH. Special arrangements can be made with Interventional Cardiology (BCH) and IR (BWH, BID). This rotation is not part of the core curriculum and should be approved by the program director. Due to time required for credentialing and coordination with other services and hospitals, elective rotations should be requested and planned at least 3 months in advance and cannot be performed in the first or last months of the fellowship.

Evaluation

An online evaluation checklist should be completed by the fellows at the end of the first month and every quarter.

The same evaluation checklist will be completed by selected IR staff, and written feedback provided to the fellows.

Patient care documentation will be audited every 2 weeks for the first month and every 2 months thereafter. The audit will be performed using a sample of 5 procedure notes (simple and complex), 2 clinic notes, 2 US reports and 2 inpatients notes. Written feedback will be provided.

Fellows will be evaluated by the PIR staff on a quarterly basis with a formal one-on-one evaluation with the PIR Fellowship director or associate director.

These meetings are also an opportunity for the fellows to evaluate the training program and suggest areas for improvement. If the fellows have any clinical or professional concerns these should be discussed with the program director at the earliest opportunity.