In this text, separate chapters are devoted to the various “practice models” that have been developed over time by various institutions for the efficient evaluation and management of neurovascular patients. We will describe the “departmental model.” In this model, physicians from several neurovascular specialties work together to evaluate, treat, and manage patients. However, each remains an employee of his or her department. We will review the structured framework for patient care and will note the financial implications of the departmental model. We will highlight some of the potential advantages and disadvantages of this structure.

The Evolution and Structure of the Departmental Model: The Massachusetts General Hospital Brain Aneurysm/AVM Neurovascular Center

Many of the currently existing tertiary care programs that offer care of complicated neurovascular problems have evolved over time and within institutions, depending on the preexisting arrangements of the various departments involved. This is certainly true for the situation at the Massachusetts General Hospital (Boston, MA). The Massachusetts General Hospital Brain AVM/Aneurysm Neurovascular Center was formally developed in conjunction with the hospital administration in 1991. The Center was proposed based on collaborations that were emerging between neuroradiology (specifically, the evolving section of interventional neuroradiology), vascular neurology, and vascular neurosurgery. This “Center of Excellence” was conceptualized as a distributed network of caregivers without the need for a specific physical location within the hospital. The Center was developed with partial support from each department involved, as well as a financial commitment from the hospital.

In the development of the Center, we agreed that physician members of the Center would remain employed by their respective department. The member is directly responsible to their respective chief of service. There is no “fee for service” remuneration for any members of the physician staff involved with the Center, and each member receives a salary. Figure 22-1 shows how the Center concept relates to the various members involved. As can be seen, the specialists from vascular neurology, neurointensive care, interventional neuroradiology, radiation oncology, and vascular neurosurgery all combine expertise to care for a patient with a neurovascular problem.

The Logistics of How the Center Operates in a Non-Emergency Situation

The offices of the Center physicians are dispersed throughout the hospital; therefore, an initial challenge was to find a time point every week for Center physicians to gather and efficiently discuss issues regarding the management of new patients. Thus, we scheduled a weekly morning neurovascular conference. The various Center physicians are free to place cases on the agenda. In some cases, one or another of the Center physicians has already met the patient. Physicians throughout the country send in other cases for review and recommendations.

FIGURE 22-1 The AVM/Aneurysm/Cerebrovascular Center unites physicians from the departments of neurosurgery, radiology, neurology, and radiation oncology. These physicians remain salaried employees of their respective departments but collaborate in the management of patients with cerebrovascular diseases.