Pediatrics: Pulmonary and Sleep Medicine

Clinical Training

Clinical training in Pediatric Pulmonary Fellowship centers on a multidisciplinary approach to the care of patients with respiratory diseases at Children’s Hospital of Wisconsin. Children’s Hospital is an award-winning health care system dedicated solely to the health and well-being of children. Multidisciplinary teams of physicians, nurses, and many other health care professionals specializing in pediatrics are available to meet the full range of patient-care needs.

A variety of essential lectures and conferences are included in the fellows’ weekly schedule which include, but are not limited to: daily inpatient rounds with the attending, intensive care unit ward team and general ward team; weekly inpatient sign-out rounds with all members of the pulmonary section; fellows conference where a pulmonary topic is reviewed, and monthly radiology/pathology, journal club, and research conference. Additionally, all fellows are expected to attend the monthly Joint Fellowship Curriculum, which is overseen by the Department of Pediatrics, which reviews certain basic concepts, including development of research design, abstract and manuscript preparation, basic biostatistics, quality improvement, and professionalism and communication, among other topics.

Subspecialty Clinics

The Pulmonology division is involved in various multidisciplinary clinics that provide care to patients with disorders requiring a multidisciplinary approach.  The following clinics are currently active and will be included to enhance the fellows’ outpatient Pulmonology experience.

• Cystic Fibrosis                                     
• Trach/Vent
• Positive Airway Pressure Program
• Muscular Dystrophy
• Asthma Plus
• Aerodigestive

Clinical Rotations

During the 3-year training program, time is distributed to ensure that fellows develop clinical expertise. Clinical time will be split between outpatient clinics, inpatient service, procedures, and the corresponding service related conferences. Fellows will hold a one-half day per week of continuity clinic for the duration of their training.

Year 1:
The focus of the first year of the fellowship is to develop the clinical skills and abilities to provide optimal patient care for children with respiratory diseases. The program provides approximately 10 months of clinical experience, including both inpatient and outpatient care during the first year. During their inpatient rotation the fellow will be on first call from 7:30am-4:30pm and will also take two weekends per month and two nights per week on the assigned inpatient service. Continuity clinic will focus on pulmonary patients one-half day per week throughout the first year. During the first year, the fellow will devote his/her effort to the following rotations:

Pulmonary Service – The fellow will spend 5 months on the pulmonary service during the first year. At the end of the first year the fellow will have a diversity of experiences with children with respiratory diseases and develop the clinical skills needed to function as a clinician.

Responsibilities include:

• Graduated responsibility for the care of pulmonary inpatients with increasing responsibility as training progresses.
• Graduated responsibility completing pulmonary inpatient consultations on general floors and the PICU. The fellow will be responsible for the initial contact and evaluation, staffing with a faculty member, and appropriate documentation and communication with the primary team.
• Graduated responsibility for resident education on the pulmonary inpatient team for residents and medical students.
• Graduated responsibility in the care of inpatients with tracheostomies and home ventilators.

Anesthesiology Service – The fellow will spend ½ month on the anesthesiology service during the first year. The second ½ month will be assigned to respiratory physiology.

Objectives include:

• To learn airway anatomy including a particular focus on laryngeal structures and how this affects airway instrumentation.
• To gain an appreciation of anesthesia principle and how these pertain to pulmonary procedures such as bronchoscopy.
• To gain an appreciation of the pulmonary complications of general anesthesia and prevention in children with respiratory diseases.
• To gain familiarity with commonly used respiratory devises for airway clearance.
• To gain advance understanding of pulmonary physiology through interactions in the OR and self study.

Pediatric Intensive Care Unit (PICU) – The fellow will spend 1 month on the PICU service during the first year.

Responsibilities include:

• Daily inpatient rounds with the PICU team with one week in a cardiac ICU and 3 weeks in a general medical ICU.
• In house night call every fourth night with a critical care faculty member immediately available. (This is the only mandatory in-house call included in the pulmonary fellowship curriculum.)

Objectives include:

• To gain familiarity with the management of acute respiratory failure and common causes in pediatrics.
• To improve management of chronic respiratory failure in an inpatient setting.
• To gain an appreciation of respiratory disease and complications seen in congenital heart disease.

Cystic Fibrosis (CF) – The fellow will spend 1 month observing pediatric and adult Cystic Fibrosis clinics.

Responsibilities include:

• Attend weekly CF team meetings.
• Participating in CF multidisciplinary clinics.
• Independent study to gain familiarity with landmark CF research trials and scientific rationale behind current CF therapies.

Objectives include:

• Gain a thorough understanding of current CF practice guidelines.
• Gain an appreciation of the team approach to CF care, and available team members and tools such as Port CF.
• Gain an appreciation of the role of multi-center trials in CF research and advancement of care.
• Develop knowledge to identify and manage CF nutritional needs.
• Gain familiarity with standard medications and airway clearance techniques used in CF care.
• Master the criteria for CF admission for pulmonary exacerbation.

Research - The fellow will take one month during the first year to identify a research mentor and project with the guidance of the Scholarship Oversight Committee. This month will also give exposure to various potential basic and clinical research projects that are available within the Pulmonary Section, the Department of Pediatrics, and throughout the Medical College of Wisconsin.

Objective:

• Identify a research interest area and select a mentor.
• Develop a research question and build a research plan.
• Present a poster at the MCW Pediatric Fellows’ poster session in April with an overview of research plan

Years 2 and 3

The second and third years of the fellowship training provides ample protected time to pursue research endeavors while fostering improved clinical, administrative, and teaching skills.

Research – The fellow will spend 7-8 months during the second and third year implementing their research project. This will involve building new skill sets within the scope of their project, including specific knowledge within the field of study and more general skills such as IRB submission, grant writing, abstract writing and manuscript preparation.

Objectives:

• Present at local, regional, and national meetings beginning in the second year.
• A peer-review publication, an in-depth manuscript, a thesis or dissertation written in connection with the pursuit of an advanced degree, an extramural grant application that has either been accepted or favorably reviewed.
• Building a skill set and academic focus/research area that can be maintained throughout the fellow’s career.

Sleep Medicine – The fellow will spend 1 month attending sleep clinics during the second year.

During this rotation the fellow will:

• Attend all sleep clinics.
• Attend all Positive Airway Pressure clinics.
• Attend the Sleep Conference every Friday.
• Begin to learn to score and read sleep studies, gaining an appreciation for the information they contain.
• Learn the indications for sleep studies and additional sleep related testing.

Procedural Skills and Diagnostic Studies

Fellows in the program are expected to develop procedural skills which include but are not limited to, flexible bronchoscopy and bronchoalveolar lavage, transbronchial biopsies, intubation and airway management techniques. Each fellow will participate in a minimum of 100 flexible bronchoscopies his/her fellowship.

Fellows will become proficient in the interpretation of pulmonary function tests (PFTs), including methacholine challenges, cardiopulmonary exercise testing and infant PFTs. In addition, they will interpret overnight pulse oximetry studies and learn their indications and limitations. The fellowship also allows the fellows to become familiar with interpreting overnight polysomnographic studies.