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Graduate Medical Education (GME): Neuro-Oncology
National Cancer Institute
National Institute for Neurological Disorders and Stroke
National Institutes of Health
Teri Kreisl, MD, Program Director
Lilian Yang, Program Administrator
The Neuro-Oncology Branch (NOB) is a trans-institutional program of the National Cancer Institute (NCI) and National Institute of Neurological Disorders and Stroke (NINDS) at the National Institutes of Health (NIH). Since the NOB was first established in 2000, fellowship positions in neuro-oncology have been offered to qualified candidates who have completed training in the fields of neurology, neurosurgery, or medical oncology.
Trainees may participate in the program for one to three years, depending on the goals of the individual candidate. Candidates are anticipated to come from varied levels of clinical training and research backgrounds. Those interested primarily in acquiring subspecialty expertise in the clinical practice of neuro-oncology may participate in the Clinical Track, where competence in the field may be achieved in a minimum of one year with the ability to enrich their experience with up to a second year of training. The Research Track is a three year program where those interested in cultivating academic careers in neuro-oncology have additional training experience (both practical and didactic) in clinical and/or translational brain tumor research. Candidates must specify their intended track and duration of training at the time of application. Those who initially enter the program on the Clinical Track who later wish to complete a Research Track must notify the Program Director by the completion of year one for consideration of extending their tenure.
Prerequisite Training / Selection Criteria
Candidates must be physicians either board certified or board eligible in their respective specialty of medical oncology, neurosurgery, or neurology. They must hold or be able to hold an unrestricted license to practice medicine in the United States. The fellowship position is advertised on the NOB website, various online indexes of subspecialty training opportunities, and periodic specialty journal announcements. Interested candidates will submit applications on a rolling basis comprised of: curriculum vitae, cover letter with statement of career and research interests/goals, and three letters of recommendation. Highly qualified candidates will be invited for a formal one to two day interview process. Based on the supplied application materials and interview evaluations, candidates selected for the program will be offered a position with the NOB as a Clinical Fellow. The NIH is an equal opportunity employer.
Goals and Objectives for Training
1. To provide supervised training, with increasing responsibility, in the inpatient and outpatient practice of Neuro-Oncology. This training will include principles of diagnosis and management of primary and central and peripheral nervous system neoplasms, side effects of related treatments, and related supportive care measures.
2. To provide supervised training in aspects of clinical and/or basic research in Neuro-Oncology.
3. To develop independence and evidence of competence of the Neuro-Oncology trainees.
4. To provide training in the technical aspects and procedures related to Neuro-Oncology, including administration of chemotherapy, other anti-neoplastic therapy, and related specialized procedures.
5. To develop, in the trainee, skills and a familiarity with the process of clinical trial development and conduct; academic presentations and/or publications; federal and private grant submissions; and independent research.
6. To provide guidelines and counsel with regards to the transition to an independent career as a competent Neuro-oncologist. Upon completion of training, trainees will be able to participate in the academic life of their institution, and in the national and international communities of Neuro-oncologists.
Neuro-Oncology is by nature multidisciplinary and has been recognized as a subspecialty of both Medical Oncology and Neurology by the American Board of Internal Medicine and by the American Board of Psychiatry and Neurology. It is not an ACGME approved subspecialty fellowship in either primary discipline. Certification through the United Council for Neurologic Subspecialties (UCNS) is available for select candidates and programs. The NOB fellowship program is not UCNS accredited. The fellowship is NIH GMEC approved.
Acting Medical Director
Tenure Track Clinical Investigator
Teri N. Kreisl, MD
Dr. Kreisl is a board certified neurologist with subspecialty training in neuro-oncology and training program administrative experience in both residency and fellowship. She is dedicated to teaching and career mentorship in addition to her responsibilities as a clinical investigator. Research interests include adult therapeutics and molecular imaging of the blood brain barrier.
Joohee Sul, MD
Dr. Sul is a board certified neurologist with subspecialty training in neuro-oncology. Research interests include adult therapeutics and immunotherapy for gliomas.
Katharine A. McNeill, MD
Dr. McNeill is a board certified neurologist with subspecialty training in neuro-oncology. Research interests include adult therapeutics and molecular targeted agents in glioma.
The NOB fellowship program is entirely intramural and all clinical and research activities are conducted within the NIH campus. The NIH Clinical Center incorporates the Brain Tumor Clinic outpatient facility, outpatient chemotherapy unit, 18 bed intensive care unit, 12 bed neurology inpatient unit, 28 bed inpatient medical oncology unit, in addition to a variety of other clinical resources. Outside rotations that may contribute to a more comprehensive training experience may be considered. The NOB has a well developed infrastructure for patient care and research administration with a cadre of nurse practitioners, data managers, and patient care coordinators.
EDUCATIONAL PROGRAM – BASIC CURRICULUM
All fellows will participate in care of over 2000 primary brain tumor patients seen annually in the Brain Tumor Clinic conducted two full days a week. They will be responsible for taking full patient histories and perform physical/neurological exams. After independent review of the information and relevant neuroimaging, the fellow will formulate a preliminary assessment and plan and present a synopsis of the case to an attending. Fellows will work closely with research nurses and administrative staff to coordinate follow-up care for their patients and participate in communication with outside physicians. For clinical trial patients, they will be responsible for adverse event monitoring and reporting. The practice is primarily outpatient, without commitments to an active inpatient consult service. With supervision, fellows will be responsible for admitting and managing patients who may need acute inpatient care in the NIH Clinical Center.
Trainees will develop clinical expertise in the following areas critical to the practice of neuro-oncology:
a) knowledge of advanced principles of management of primary and nervous system tumors;
b) expertise in the treatment of primary central nervous system tumors including surgery, radiation, chemotherapy and other medical therapies, and an up-to-date knowledge of agents in clinical research as applicable to neuro-oncology;
c) expertise in the treatment of cancer-related neurologic complications, specifically as it applies to neuro-oncologic patients, including: toxic, nutritional or metabolic encephalopathy; CNS and systemic infections; cerebrovascular disease; seizures; increased intracranial pressure; deep venous thromboembolism; neutropenia, thrombocytopenia, and anemia; paraneoplastic syndromes;
d) expertise in the evaluation and provision of basic medical care for neuro-oncologic complications of cancer or medical disorders that may typically occur in neuro-oncology patients, including treatment of toxic effects of surgery, chemotherapy, radiotherapy or other neuro-oncologic therapeutic modalities; in the safe and approved use of blood products and growth factor support; and basic competency in supportive and end-of-life care and pain management of neuro-oncology patients;
e) skills involved in coordination of the overall management plan for neuro-oncology patients, including oversight of the interdisciplinary management of patients with neuro-oncologic disorders (e.g., appropriate indications for referral for consultation with or care by medical oncologists, neurosurgeons, radiation oncologists, neuroradiologists, neuropathologists, pain management specialists, rehabilitative personnel, and/or palliative care personnel).
Fellows participating in the three year Research Track will participate in research projects that include development, data analysis and manuscript preparation of clinical trial work conducted by the NOB. They will be required to initiate at least one thoughtful investigative question that may be turned into an independent study using the wealth of patient data available from the clinic population. They will also prepare at least one study for submission to a national scientific meeting and as a manuscript for publication in a peer reviewed journal. Fellows in the Research Track will be required to complete the Introduction to the Principles and Practice of Clinical Research (IPPCR), Writing Cancer Grant Applications (WCGA), and Statistical Analysis of Research Data (SARD) courses offered by the NIH Clinical Center and Center for Cancer Research (CCR). The goal by the end of their three year term is to be able to complete an application for a peer reviewed funding mechanism aimed towards supporting a career as an independent investigator in neuro-oncology.
Fellows who are designated as Clinical Track are encouraged but not required to participate in any of the above described research activities, with the exception of the IPPCR course which will be completed by all trainees in their first year as a fundamental introduction to the landscape of clinical research. Both Clinical Track and Research Track fellows will be offered opportunities to write invited manuscripts such as review articles or book chapters as a means of enriching their academic experience. Likewise, all fellows will be encouraged to attend and participate in national scientific meetings.
Participant's supervisory and patient care responsibilities
The Program Director, via direct observation and performance evaluations, will assess competence in the following areas:
1. Patient Care:
a. Neuro-Oncology trainees are expected to provide patient care that is compassionate, appropriate and effective for the promotion of health, prevention of illness, treatment of disease, and care at the end of life.
b. Trainees must be able to gather accurate, essential information from all sources, including medical interviews, physical examinations, medical records and diagnostic/therapeutic procedures.
c. Trainees must be able to make informed recommendations about preventive, diagnostic and therapeutic options and interventions that are based upon sound clinical judgment, scientific evidence, and patient preference.
d. Trainees must develop, negotiate and implement effective patient management plans and integrate patient care.
e. Trainees must be able to perform the diagnostic and therapeutic procedures considered essential to the practice of Neuro-Oncology with competency.
2. Medical Knowledge:
a. Neuro-Oncology trainees are expected to demonstrate knowledge of established and evolving biomedical and clinical sciences, and the application of their knowledge to patient care and the education of others. Trainees must:
b. Apply an open-minded, analytical approach to acquisition of new knowledge.
c. Access and critically evaluate current medical information and scientific evidence, including evidence-based practice guidelines pertaining to Neuro-Oncology
d. Develop a clinically applicable knowledge of the basic and clinical sciences that underlie the practice of Neuro-Oncology.
e. Apply this knowledge to clinical problem solving, clinical decision-making, and critical thinking.
3. Practice-Based Learning and Improvement:
Neuro-Oncology trainees are expected to be able to use scientific evidence and methods to investigate, evaluate and improve patient care practices. Trainees must be able to:
a. Identify areas for improvement and implement strategies to enhance knowledge, skills, attitudes and processes of care.
b. Analyze and evaluate practice experiences and implement strategies to continually improve the quality of patient practice.
c. Develop and maintain a willingness to learn from experience to improve the system or processes of care.
d. Use information technology or other available methodologies to access and manage information, support patient care decisions, and enhance both patient and physician education.
e. Gain information and experience from ongoing educational conferences, e.g. multidisciplinary patient conferences, neuropathology and neuroradiology conferences, and journal clubs.
4. Interpersonal and Communication Skills:
Neuro-Oncology trainees are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families, and other members of the health care team. Trainees must be able to:
a. Provide effective and professional consultation to other physicians and health care professionals, and sustain therapeutic and ethically sound professional relationships with patients, their families and colleagues.
b. Use effective listening, nonverbal, questioning, and narrative skills to communicate with patients and families.
c. Interact with consultants in a respectful, appropriate manner.
d. Maintain comprehensive, timely, and legible medical records.
Neuro-Oncology trainees are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice methods, an understanding and sensitivity to diversity and a responsible attitude toward their patients, their profession, and society.
a. Demonstrate respect, compassion, integrity and altruism in relationships with patients, families, and colleagues.
b. Demonstrate sensitivity and responsiveness to the gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities of patients and professional colleagues.
c. Adhere to principles of confidentiality, scientific/academic integrity, and informed consent.
d. Recognize and identify deficiencies in peer performance.
6. Systems-Based Practice:
Neuro-Oncology trainees are expected to demonstrate both an understanding of the contexts and systems in which neuro-oncologic care is provided, and the ability to apply this knowledge to improve and optimize patient care. Trainees must be able to:
a. Understand, access and utilize the resources, providers and systems necessary to provide optimal care.
b. Understand the limitations and opportunities inherent in various practice types and delivery systems, and develop strategies to optimize care for the individual patient.
c. Apply evidence-based, cost-conscious strategies to prevention, diagnosis and disease management.
d. Collaborate with other members of the health care team to assist patients in dealing effectively with complex systems and to improve systematic processes of care.
Throughout their years of participation, fellows will participate in a call system where they will cover urgent/emergent patient phone calls after hours and on weekends. The fellow on-service will be responsible for any inpatient care that may be required during the month, including rounding, placement of orders, and coordination of tests/procedures/consults. An attending physician will concurrently be on call for supervision and support.
Fellows may moonlight in the NINDS Neurology call pool if qualified and available, providing it does not interfere with their duties with the NOB. Qualified applicants will also receive NOB support for participation in the Intramural Loan Repayment Program.
There will be regular academic conferences specific to neuro-oncology that will include participation from neurosurgery, neuropathology, neuroradiology, and radiation oncology. Fellows will prepare presentations on select topics that require a detailed review of the literature. Areas to be covered by the lecture series include:
a) review of the major classes of chemotherapy, dosing and schedules, formulations, pharmacokinetics, toxicities and methods of administration as applicable to neuro-oncology;
b) diagnosis and medical treatment of adult gliomas, CNS lymphoma, meningioma and other primary CNS tumors;
c) diagnosis and medical treatment of the unique spectrum of primary brain tumors arising primarily but not exclusively in children, including optic pathway gliomas, diffuse brainstem gliomas, primitive neuroectodermal tumors, craniopharyngioma, ependymoma, and CNS germ cell tumors;
d) molecular targeted therapies, viral and immunotherapies, and novel therapeutics;
e) basic principles of neurosurgical therapy as it applies to neuro-oncology;
f) basic principles of radiation oncology as it applies to neuro-oncology;
g) diagnosis and treatment of metastatic cancer to the nervous system including brain, spinal cord, leptomeningeal, epidural, plexus, peripheral nerve, and skull metastases;
h) hematologic toxicity monitoring, administration of growth factors and blood products;
i) principles of corticosteroid use;
j) diagnosis and treatment of common medical complications in neuro-oncology patients, including seizures, raised intracranial pressure, vomiting, pain and headache, infections, venous thrombosis and pulmonary emboli, radiation toxicity, and other commonly associated conditions and toxicities; expertise in end-of-life care;
k) familiarity with the heredofamilial syndromes that predispose to CNS tumors.
In addition to the NIH Clinical Center and Center for Cancer Research courses described for fellows in the Research Track, all trainees will be encouraged to take advantage of the wealth of didactic lectures, courses and workshops offered on the NIH campus.
Brain Tumor Clinic
Academic Neuro-Oncology Conferences (required to prepare at least three presentations)
Formulation of original research project – optional for Clinical Track
Optional additional academic activities (i.e., invited manuscripts, additional NIH coursework/workshops)
Brain Tumor Clinic
Academic Neuro-Oncology Conferences (required to prepare at least two presentations)
Submission of original research study for presentation at national scientific meeting and/or publication – optional for Clinical Track
Writing Cancer Grant Applications (WCGA) - optional for Clinical Track
Statistical Analysis of Research Data (SARD) - optional for Clinical Track
Optional additional academic activities (e.g., invited manuscripts, additional CCR coursework/workshops)
Brain Tumor Clinic
Academic Neuro-Oncology Conferences (required to prepare at least two
Submission of original research study for presentation at national scientific
meeting and/or publication – optional for Clinical Track
Preparation and submission of application for grant funding mechanism -
optional for Clinical Track
Optional additional research activities (e.g., invited manuscripts, additional
A. Trainee Evaluation
1. Written evaluations of the trainee's performance will be provided by the program director and other teaching faculty. These evaluations will follow the standard format approved by the institution or in compliance with ACGME and/or Residency Review Committee recommendations for postdoctoral medical training, and be reviewed by both the faculty member and trainee.
2. A final written evaluation of performance will be provided by the program director at the conclusion of the training program, discussed by the trainee and program director and signed by both.
3. The educational experience will be documented in the trainee's file, including the curriculum present during the time of training, and a certificate or letter signed by the appropriate supervisor(s) (program director, Branch Chief, etc.) indicating: a) successful completion of the fellowship program, and b) competency regarding its content, which may be ascertained as desired by the program director (e.g., interview, examination).
4. The program director will meet on a regular basis (at least quarterly) with the trainee(s) to discuss performance, clinical practice, and quality assurance issues as applicable to the actual training experience and clinical practice of trainees, and produce written minutes reflecting the proceedings of such meetings that will be kept confidential and protected.
5. All evaluations described will remain confidential and will not be disclosed except in accordance with institutional and state policies. The program director is responsible for making reasonable efforts to ensure confidentiality and protected security of these records.
B. Faculty Evaluation
1. The trainee will provide feedback, preferably in the form of a written evaluation, of the faculty supervisors and of the training experience on a yearly basis. These evaluations will be kept in a secure and confidential place by the program director.
2. The Branch Chief will evaluate the faculty for suitability of participation in the training program on a yearly basis and make appropriate changes, additions or substitutions in the faculty as necessary.
C. Program Evaluation
1. On an annual basis, the trainees will provide a written evaluation of the program and training experience, including perceived strengths and weaknesses. These issues should be summarized by the program director and discussed with the trainees and with the faculty.
2. On an annual basis, the faculty involved in the training program should provide a written composite evaluation of the program. A summary of this evaluation should subsequently be provided to the training faculty.
3. The program director or the designated trainee advisor should meet at least quarterly with the trainee for an informal discussion of the program conduct, strengths and weakness, and preferably retain minutes of these discussions.
4. On an annual basis, the program director, in consultation with the training faculty and Branch Chief, should make any necessary changes in the program that would result in improvement or enhancement of the quality of the training program. Substantive changes in the curriculum or program should be documented annually in the form of minutes.
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