Objective: To compare the times to evaluation and thrombolytic treatment of patients treated with a telemedicine-enabled mobile stroke treatment unit (MSTU) vs those among patients brought to the emergency department (ED) via a traditional ambulance. Methods: We implemented a MSTU with telemedicine at our institution starting July 18, 2014. A vascular neurologist evaluated each patient via telemedicine and a neuroradiologist and vascular neurologist remotely assessed images obtained by the MSTU CT. Data were entered in a prospective registry. The evaluation and treatment of the first 100 MSTU patients (July 18, 2014–November 1, 2014) was compared to a control group of 53 patients brought to the ED via a traditional ambulance in 2014. Times were expressed as medians with their interquartile ranges. Results: Patient and stroke severity characteristics were similar between 100 MSTU and 53 ED control patients (initial NIH Stroke Scale score 6 vs 7, p = 0.679). There was a significant reduction of median alarm-to-CT scan completion times (33 minutes MSTU vs 56 minutes controls, p < 0.0001), median alarm-to-thrombolysis times (55.5 minutes MSTU vs 94 minutes controls, p < 0.0001), median door-to-thrombolysis times (31.5 minutes MSTU vs 58 minutes controls, p = 0.0012), and symptom-onset-to-thrombolysis times (97 minutes MSTU vs 122.5 minutes controls, p = 0.0485). Sixteen patients evaluated on MSTU received thrombolysis, 25% of whom received it within 60 minutes of symptom onset. Conclusion: Compared with the traditional ambulance model, telemedicine-enabled ambulance-based thrombolysis resulted in significantly decreased time to imaging and treatment.

> To bring about destruction by overcrowding, mass starvation, anarchy, the destruction of our most cherished values—there is no need to do anything. We need only do nothing except what comes naturally—and breed. And how easy it is to do nothing. Isaac Asimov The purpose of any training program is to provide a supply of skilled workers to address an unmet demand for their services. With respect to medical training, new physicians are required either to take the place of retiring physicians or to address an unmet demand for patient care. Evolving data strongly suggest that the supply of neurointerventional (NI) physicians is not only sufficient, but has exceeded the present need for services. Despite this, we continue to train new neurointerventionists (NIs) in unprecedented and increasing numbers every year. These new NI physicians are finding it progressively more difficult to secure employment and, once hired, face considerable challenges in building a practice and developing/maintaining their skills. Fellowship training is ingrained into the fabric of our academic practices and currently seems to be perpetuated more by inertia than a dynamic evaluation of the present workforce needs. It is the position of the authors that, if we do not re-evaluate this process, we are potentially doing a tremendous disservice to the people we are training, to patients in need of treatment (and maybe more importantly to those patients with lesions who are not in need of treatment), and finally to ourselves. One of the more difficult aspects of evaluating the NI workforce is obtaining accurate data to characterize the status of current supply and demand—such as the number of practicing NI physicians, the number and growth rate of neuroendovascular cases and the number of new graduates entering the market each year. These statistics must be triangulated using several available sources, the most …