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  • 1. 10/25/10 July 1, 2007 ACGME SLEEP FELLOWSHIP TRAINING PROGRAM Program Director: Ilene Rosen, M.D., M.S.C.E. Associate Program Director: Alex Mason, M.D., Ph.D. Fellowship Coordinator: Kim Battillo EDUCATIONAL MISSION STATEMENT The Division of Sleep Medicine is committed to excellence in sleep medicine. It conducts high quality clinical sleep medicine with a service to patients with the whole range of sleep disorders providing multidisciplinary care; it ensures that findings from our research and that of others is transferred into practice; it provides training for fellows, who come from different disciplines, in all aspects of sleep medicine. The Sleep Division Faculty is committed to advancing knowledge in sleep medicine by conducting the highest quality basic & clinical research. The program is multi-disciplinary, utilizing specialists in Pulmonary Medicine, Neurology, Psychiatry, Geriatrics, Pediatrics and Nursing. These specialists also work closely with colleagues in Otorhinolaryngology (Ear, Nose and Throat), Oral-maxillo-facial Surgery, and Weight Management in the treatment of obstructive sleep apnea. The Division of Sleep Medicine Fellowship Training Program reflects the multidisciplinary nature of sleep medicine at PENN.
  • 2. Table of Contents The Six ACGME Competencies 3 Program Goals and Objectives 5 Clinical Training 6 Sample Rotation Schedules 8 Inpatient Sleep Rotations 9 Rotation-Specific Learning Objectives HUP Outpatient 11 HUP Inpatient 17 CHOP Sleep Medicine Rotation 22 Philadelphia VAMC Sleep Medicine Rotation 28 CHOP Pediatric Otolaryngology Rotation 34 Educational Conferences 39 PSG Scoring and Interpretation 42 Supervision Policies and Evaluation Methods 43 Evaluation Tools 44 Sick Days/Vacation Policy 45 Research 46 Important Forms Outpatient Clinic Cancellation or Reduction Request Form 48 Mini-CEX Form 49 SAM_E Tool 51 Departmental Phone Lists 52 Chart Audit 56 2
  • 3. THE SIX COMPETENCIES Medical Knowledge Patient Care Practice Based Learning and Improvement Systems Based Practice Professionalism Interpersonal and Communication Skills MEDICAL KNOWLEDGE Fellows must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Fellows are expected to: 1. Demonstrate an investigatory and analytic thinking approach to clinical situations 2. Know and apply the basic and clinically supportive sciences which are appropriate to their discipline PATIENT CARE Fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Fellows are expected to: 1. Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families 2. Gather essential and accurate information about their patients 3. Make informed decisions about diagnostic and therapeutic interventions based on patient information, preferences, up-to-date scientific evidence, and clinical judgment 4. Develop and carry out patient management plans 5. Counsel and educate patients and their families 6. Use information technology to support patient care decisions and patient education 7. Perform competently all medical and invasive procedures considered essential for the area of practice 8. Provide health care services aimed at preventing health problems or maintaining health 9. Work with health care professionals, including those from other disciplines, to provide patient-focused care 3
  • 4. PRACTICE BASED LEARNING AND IMPROVEMENT Fellows must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Fellows are expected to: 1. Analyze practice experience and perform practice-based improvement activities using a systematic methodology 2. Obtain and use information about their own population of patients and the larger population from which their patients are drawn 3. Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems 4. Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness 5. Use information technology to manage information, access on-line medical information; and support their own education 6. Facilitate the learning of students and other health care professionals SYSTEMS BASED PRACTICE Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Fellows are expected to: 1. Know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources 2. Practice cost effective health care and resource allocation that do not compromise quality of care 3. Advocate for quality patient care and assist patients in dealing with system complexities 4. Partner with health care managers and health care providers to assess, coordinate PROFESSIONALISM Fellows must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Fellows are expected to: 1. Demonstrate respect, compassion and integrity 2. Demonstrate a commitment to ethical principles 3. Demonstrate sensitivity and responsiveness to patients’ culture, age, gender and disabilities INTERPERSONAL AND COMMUNICATION SKILLS Fellows must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients’ families, and professional associates. Fellows are expected to: 4
  • 5. 1. Create and sustain a therapeutic and ethically sound relationship with patients 2. Use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills 3. Work effectively with others as a member or leader of a health care team or other professional group 5
  • 6. PROGRAM GOALS AND OBJECTIVES 1. Patient Care a. Perform an adequate medical history and physical exam on patients in outpatient sleep clinic and inpatients seen on the inpatient consultation service b. Order appropriate diagnostic tests c. Interpret polysomnograms and other diagnostic sleep evaluation d. Form a clinical management plan e. Interact with other health care providers to implement patient-focused care 2. Medical Knowledge a. Demonstrate knowledge about established and evolving biomedical, clinical and cognate sciences during clinical encounters including discussions with patients, other health care providers (during office hours, in dictations to referring physicians, and in consultation notes in inpatient charts), weekly Clinical Case conferences, and Research conferences. b. Attend the didactic sleep conferences held throughout the year c. Application of medical knowledge to patient care 3. Practice-based Learning and Improvement a. Fellows’ presentations at Clinical Case Conference b. Fellows’ presentations at Sleep Journal Club 4. Interpersonal and Communication Skills a. Communication and interaction with other health care providers/support staff by participating in multidisciplinary practice meetings involving physicians, nurses, medical assistants, respiratory therapists and clinical support staff. b. Communication and interaction with patients and their families during outpatient and inpatient clinical encounters c. Fellows’ presentations at Clinical Case Conference d. Fellows’ presentations at Sleep Journal Club 5. Professionalism a. Intranet courses on patient privacy, good clinical practices, and patient safety b. Encourage sensitivity to patients of diverse backgrounds c. Carrying out professional responsibilities and adherence to ethical principles d. Completion of assigned responsibilities including chart documentation, dictations, and polysomnographic studies. e. Answer pages and patient phone calls in a timely fashion. f. Attend the minimum number of required conferences. 6. Systems-based Practice a. Participation in quality assurance/quality improvement project b. Participate in multidisciplinary practice meetings involving physicians, nurses, medical assistants, respiratory therapists and clinical support staff 6
  • 7. CLINICAL TRAINING Each fellow will be expected to evaluate 200 new patients in the adult sleep medicine outpatient practice. Each fellow will be expected to provide continuous care to 300 follow-up patients in the adult sleep medicine outpatient practice. Each fellow will be expected to evaluate at least 40 new patients in the pediatric sleep medicine outpatient practice. • Each fellow will be expected to provide continuous care to at least 40 follow-up patients in the pediatric sleep medicine outpatient practice. • Each fellow is expected to evaluate a minimum of 10 inpatients with sleep medicine complaints from representative demographic groups. • Each fellow will keep a log of his/her clinical activities that documents: the clinics attended, number of patients seen in clinic and their diagnoses, the number of PSG interpreted, and the number of PSG set-ups completed. This log will be used to document that the fellow has fulfilled the clinical requirements set by the ACGME. (Log form available upon request). These forms when completed must be turned into the Program Coordinator for placement in portfolios. OUTPATIENT SLEEP CLINICS ADULT SLEEP TRACK Continuity Clinic Each fellow will be assigned a ½ day per week adult continuity clinic. The fellow will attend this clinic throughout the year in order to learn about the chronic management of patients with sleep disorders. The fellow’s continuity clinic will be staffed by a faculty member of the Division of Sleep Medicine. • Continuity clinic is scheduled on a weekly basis throughout the year. • As per the policies of CPUP and the Department of Medicine, all absences/ cancellations must be scheduled 6 weeks in advance to be considered an excused absence except for illness, family emergencies, etc. • Any absence less than 6 weeks from the time of the scheduled office session will require an approval from the Program Director, the Faculty Advisor and the Division Chief. • Therefore, whenever possible, any cancellations must be made 6 weeks in advance IN WRITING to the program director, the program coordinator and the scheduling staff of the appropriate clinic. 7
  • 8. • Pertinent phone numbers, pager numbers and email addresses are provided at the end of the handbook. Pediatric Rotation (CHOP) – 4 months scheduled in 1 block, if possible. • Each fellow will be assigned 3 ½-day per week pediatric clinics. Adult Rotations (HUP/PVAMC) – 8 months total scheduled over the course of the year. • Each fellow will be assigned 5 ½-day per week adult clinics. PEDIATRIC SLEEP TRACK Continuity Clinic Each fellow will be assigned a ½ day per week adult continuity clinic and a ½ day per week pediatric continuity clinic. The fellow will attend this clinic throughout the year in order to learn about the chronic management of patients with sleep disorders. The fellow’s continuity clinic will be staffed by a faculty member of the Division of Sleep Medicine. • Continuity clinic is scheduled on a weekly basis throughout the year. • As per the policies of CPUP and the Department of Medicine, all absences/cancellations must be scheduled 6 weeks in advance to be considered an excused absence except for illness, family emergencies, etc. • Any absence less than 6 weeks from the time of the scheduled office session will require an approval from the Program Director, the Faculty Advisor and the Division Chief. • Therefore, whenever possible, any cancellations must be made 6 weeks in advance IN WRITING to the program director, the program coordinator and the scheduling staff of the appropriate clinic. • Pertinent phone numbers, pager numbers and email addresses are provided at the end of the handbook. Adult Rotations (HUP/PVAMC) – 5-6 months total scheduled in 1-month blocks. • Each fellow will be assigned 5 ½-day per week adult clinics. Pediatric Rotation (CHOP) – 6-7 months scheduled over the course of the year. • Each fellow will be assigned 3 -½ day per week pediatric clinics. 8
  • 9. SAMPLE ROTATION SCHEDULES Sample Rotation (HUP) 2007 Monday Tuesday Wednesday Thursday Friday Fellows Dr. 8:00 - 12:00 Dr. Kline Continuity Dr. Cantor Gooneratne Clinic 12:00 - 1:00 lunch provided Conference Conference 1:00 - 5:00 Dr. Gehrman Dr. Pien PSG Review Sample Rotation (PVAMC) 2007 Monday Tuesday Wednesday Thursday Friday Sleep Disorders CPAP CPAP FU Clinic/ Sleep Disorders Fellows 8:00 - Support Clinic/ Set-up Clinic/CPAP FU Continuity 12:00 Clinic AutoCPAP Clinic/CPAP FU Clinic Clinic (10am-12pm) set-up clinic Clinic 12:00 - 1:00 lunch Conference Conference provided OSA Sleep OSA Sleep Sleep Disorders Disorders Clinic/ Sleep Disorders Disorders AutoCPAP Clinic/Sleep CPAP FU Clinic/ Clinic/CPAP FU 1:00 - 5:00 Clinic/ set-up Study AutoCPAP set-up Clinic/AutoCPAP CPAP FU clinic Interpretations clinic set-up clinic Clinic Sample Rotation (CHOP) 2007 Monday Tuesday Wednesday Thursday Friday Patient Review PSG Review 8:00 - 12:00 PSG Review Ped Sleep Clinic Fellows Clinic CHOP Inpt CHOP Inpt 12:00 - 1:00 Conference - Conference – lunch provided MKT MKT Ped Sleep Clinic PSG Clinic/Ped 1:00 - 5:00 PSG Review PSG Review PSG Review CHOP Conf Sleep Clinic 9
  • 10. INPATIENT SLEEP ROTATIONS ADULT & PEDIATRIC SLEEP TRACKS • HUP Inpatient Consultations. Each fellow will be assigned 4-6 weeks of coverage of the inpatient sleep medicine consultation service at HUP. • This occurs in 2 week blocks. Sleep medicine fellows perform new consultations, present their cases to the Sleep Medicine Attending on the consult service, and then provide management advice and follow-up as needed. As soon as possible after receiving the request for consultation, the fellow interviews and examines the patient, gathers all necessary information from the chart and other sources as appropriate. S/he then presents the patient to the attending after which the fellow and attending see the patient together at the bedside. A plan of care is developed by fellow and attending together and then communicated by the fellow both verbally and in writing to the service requesting the consultation within 24 hours of the request for the consultation. Thereafter, the fellow rounds at least once daily on all active patients on the consult service and discusses them with the attending. All patients with active issues or whose status has changed are revisited with the attending later in the day. Of note, sleep medicine fellows will also be continuing their outpatient responsibilities during this time as the burden of consultations is quite low. • Additionally, all fellows will spend up to 4 weeks total on a combination of various subspecialty inpatient consultation services including the neurology, pulmonology, bariatric surgery and heart failure services at HUP. During these rotations, the supervising physician will be board certified in the subspecialty of the rotation as well as sleep medicine or have a specific interest in sleep medicine (e.g. sleep apnea and heart failure). These inpatient experiences will serve to illustrate how sleep disorders integrate into the differential diagnoses of various clinical questions posed to subspecialty consultation services. Sleep medicine fellows perform new consultations, present their cases to the attending on the consult service, and then provide management advice and follow-up as needed. As soon as possible after receiving the request for consultation, the fellow interviews and examines the patient, gathers all necessary information from the chart and other sources as appropriate. S/he then presents the patient to the attending after which the fellow and attending see the patient together at the bedside. A plan of care is developed by fellow and attending together and then communicated by the fellow both verbally and in writing to the service requesting the consultation. Thereafter, the fellow rounds at least once daily on all active patients on the consult service and discusses them with the attending. All patients with active issues or whose status has changed are revisited with the attending later in the day. Of note, sleep medicine fellows will have reduced outpatient responsibilities during this portion of their sleep inpatient rotation. • Pertinent phone numbers, pager numbers and email addresses are provided at the end of the handbook. • CHOP Inpatient Consultations. Each fellow will be expected to perform 4-5 inpatients consults per year on pediatric sleep medicine patients admitted to CHOP during their time on the CHOP rotation. • Inpatient consultations. The fellow will perform all inpatient consultations under the direct supervision of an ABMS-certified physician. The sleep medicine fellow, under the 10
  • 11. supervision of a sleep medicine attending, will review the patient’s medical chart and elicit a history, examine the patient, and discuss the goals of evaluation with the hospital team. A formal consultation note by the fellow/attending will become part of the medical record. If a polysomnogram is deemed appropriate, the results will be reviewed with the primary team, and the sleep fellow will offer management options accordingly. When possible, continuity of care will be promoted by scheduling follow-up appointments with the fellow in the outpatient sleep clinic. • Each fellow will keep a log of his/her clinical activities that documents: the inpatients seen at either HUP or CHOP and their diagnoses. This log will be used to document that the fellow has fulfilled the clinical requirements set by the ACGME. (Log form available upon request). These forms when completed must be turned into the Program Coordinator for placement in portfolios. 11
  • 12. ROTATION-SPECIFIC LEARNING OBJECTIVES  HUP Outpatient Rotation  HUP Inpatient Consultation  CHOP Sleep Medicine Rotation  PVAMC Sleep Medicine Rotation  Pediatric Otolaryngology Rotation (CHOP) Learning Objectives for HUP Outpatient Rotation: Sleep Medicine Ambulatory Experience Educational Rationale: Sleep Medicine Ambulatory Experience includes three components: direct patient care, didactic sessions and hands-on experience with sleep studies and associated tools. The approach to care in the faculty-fellow practice is multi-disciplinary. Each site (i.e. Market Street and Radnor) works with a practice nurse, who is available to conduct teaching visits and other focused visits such as mask fittings and response to medications and also as an initial phone contact for patient questions. Respiratory therapists and medical assistants work on site to facilitate the care of patients with sleep-disordered breathing. Disease Mix/Patient Characteristics: Patient population in the faculty-fellow practices is quite heterogeneous, including individuals from a wide range of socioeconomic and ethnic backgrounds. Additionally, because of the multi- disciplinary nature of the specialty as well as the multi-disciplinary nature of the Penn Sleep Centers faculty, the types of encounters range from snoring and complaints related to sleep-disordered breathing to restless legs and nocturnal seizures. Procedures: Fellows can expect to review and interpret polysomnographies, both diagnostic and therapeutic, multiple sleep latency tests, actigraphies and sleep logs on the patients they encounter in their office- based practices. Principal Teaching Methods/Learning Venues: A core curriculum in sleep medicine is presented in a multifaceted approach that includes the continuity practice experience, elective faculty specific block rotations as well as a series of didactic initiatives. The most important component is the Sleep Medicine Continuity Practice (SMCP). Each fellow is assigned to the Fellows’ Continuity Practice which is based at 3624 Market Street under the direction of two clinic directors. Each fellow has their own panel of patients within the practice that they keep throughout the clinical year of fellowship. Fellows attend their practices one half-day per week except during vacation. Related to their continuity based practices, trainees are also responsible for participating in a personal quality improvement project (PQIP). This project is designed to address practice based and systems based learning. Fellows utilize a diagnosis-specific abstraction tool developed by the faculty and review 5-10 of their own charts with the tool. The data is summarized and an 12
  • 13. intervention plan is implemented in conjunction with a faculty mentor who may be the PD, continuity clinic preceptors or member of the faculty advisory committee. When it is fully implemented the chart abstraction will occur in the second quarter of the clinical year and again in the spring In addition, ambulatory block rotations are designed to supplement the continuity practice experience to further develop skills in sleep medicine. For an additional 4 to 5 half days per week, each fellow will have the opportunity to experience a variety of different Faculty-Based Practices (FBP) in ambulatory settings as well. These include faculty with various backgrounds including internal medicine, pulmonary/critical care, neurology, psychiatry, emergency medicine and behavioral psychology. Furthermore, patient care is rounded out with an intensive experience in interpretations of sleep studies, including polysomnography, multiple sleep latency tests, maintenance of wakefulness tests, actigraphy and sleep logs. This occurs during a weekly PSG Review (PSGR) session which occurs with all the fellows and 2 dedicated faculty preceptors. As many as 15 studies of various types are reviewed in detail during these sessions. A pre-review session reviews the literature important to these interpretations including the basis for the scoring of sleep stages, respiratory events, arousals, periodic limb movements, etc. Additionally, fellows will participate in a Quality Assurance (QA) program within the sleep laboratory whereby fellows, along with the faculty and sleep laboratory technical staff, score a sleep study. The results are scored against a gold standard and feedback is provided to the individual fellow by the faculty coordinator of the program. The final component of the HUP sleep medicine educational program is the Sleep Medicine Conference Schedule (SMCS), which include two 1-hour didactic sessions per week and the Center for Sleep Seminar series which occurs 8-10 times per year. The twice weekly didactic sessions are either Clinical Case Conferences (CCC), Sleep Lecture Series (SLS), Sleep Medicine Journal Club (SMJC) or Sleep Medicine Research Conference (SMRC) The principal teaching/learning activity of the HUP outpatient rotation occurs through Direct Patient Care (DPC) activities. In all of the ambulatory settings mentioned above, fellows present their cases to the supervising faculty member and a discussion of evaluation and management ensues. Often, the fellow and faculty member return together to the examining room to expand on the history or physical examination and to teach about interviewing and examination techniques. The didactic programs described above complement direct patient care activities. Principal Educational Goals by Relevant Competency: In the tables below, the principal educational goals for the HUP outpatient rotation are listed for each of the six ACGME competencies. The second column of the table indicates the most relevant principal teaching/learning activity for each goal, using the legend below. * Legend for Learning Activities (See above for descriptions) SMCP -- Sleep Medicine Continuity Practice CCC -- Clinical Case Conferences FBP -- Faculty-Based Practices SLS -- Sleep Lecture Series QA-- Quality Assurance Program MJC -- Sleep Medicine Journal Club PQIP-- Personal Quality Improvement Project SMRC -- Sleep Medicine Research Conference PSGR -- Polysomnography Review session 13
  • 14. 1) Patient Care Principal Educational Goals Learning Activities* Effectively interview sleep medicine outpatients SMCP, FBP, PQIP Effectively examine sleep medicine inpatients SMCP, FBP, PQIP Maintain focus and timeliness in the evaluation and SMCP, FBP, PQIP management of sleep medicine problems Order appropriate diagnostic tests CCC, SLS, SMJC, PQIP, PSGR Interpret polysomnograms and other diagnostic sleep evaluation tools SMCP, FBP, PSGR, QA, CCC 2) Medical Knowledge Principal Educational Goals Learning Activities* Expand clinically applicable knowledge base of the biomedical, SMCP, FBP, CCC, SLS, SMJC, clinical and cognate sciences underlying the care of sleep SMRC, PSGR medicine patients Access and critically evaluate current medical information ALL and scientific evidence relevant to outpatient sleep medicine patient care Assess the validity of original research concerning clinical CCC, SLS, SMJC, SMRC, questions such as diagnosis, prognosis, treatment and prevention PSGR 3) Practice-Based Learning and Improvement Principal Educational Goals Learning Activities* Identify and acknowledge gaps in personal knowledge and SMCP, FBP, CCC, SMJC skills in the care of sleep medicine patients PQIP, QA Develop real-time strategies for filling knowledge gaps that SMCP, FBP, CCC, SMJC will benefit patients in a busy practice setting PQIP, QA 4) Interpersonal Skills and Communication Principal Educational Goals Learning Activities* Communicate effectively with patients and families across a SMCP, FBP broad range of socioeconomic and ethnic backgrounds Communicate effectively with physician colleagues and SMCP, FBP members of other health care professions to assure comprehensive patient care 5) Professionalism 14
  • 15. Principal Educational Goals Learning Activities* Behave professionally toward towards patients, families, ALL colleagues, and all members of the health care team 6) Systems-Based Practice Principal Educational Goals Learning Activities* Understand and utilize the multidisciplinary resources ALL necessary to care optimally for sleep medicine patients Collaborate with other members of the health care team to SMCP, FBP, PQIP, QA, assure comprehensive sleep medicine outpatient care CCC Use evidence-based, cost-conscious strategies in the care of ALL sleep medicine patients Begin to understand the business aspects of practice SMCP, FBP, CCC, SLS management in a variety of settings PQIP, PSGR Begin to develop efficient practice patterns so patient care SMCP, FBP, CCC, SLS, PQIP, proceeds at an acceptable rate PSGR, QA Principal Educational Goals In addition to the above goals by competency, after 12 months of training, the fellow should have achieved the following: • Function as an integral member of an outpatient multidisciplinary team • Evaluate 200 new adult sleep medicine patients • Provide continuous care to 300 adult sleep medicine patients • Attending a minimum number of the required departmental conferences, including clinical case conference, sleep lecture series and journal clubs • Enhance office based time management skills • Develop telephone management skills • Develop urgent care skills • Function as role models and mentors for younger trainees within the multidisciplinary fields that make up sleep medicine Recommended Resources UpToDate (available on-site in the practice) Ahrens, E.H. (1992). The Crisis in Clinical Research. New York: Oxford University Press. Bates, D.V. (1989). Respiratory Function in Disease (3rd edition). Philadelphia: W.B. Sanders Company. Berry, R.B. (2003). Sleep Medicine Pearls (2nd edition). Philadelphia: Hanley & Belfus, Inc. Carlson, R.W. & Geheb, M.A. (1993). Principles and Practices of Medical Critical Care. Philadelphia: W.B. Saunders Company. Chase, M.H. & Roth, T (eds.) (1990). Slow Wave Sleep. Los Angeles: Regents of the University of California. Chokroverty, S., Thomas, R.J., & Bhatt, M. (2005). Atlas of Sleep Medicine. Philadelphia: Elsevier, Inc. 15
  • 16. Fraser, R.G. (1988). Diagnosis of Diseases of the Chest: Volume 1. Philadelphia: W.B. Saunders Company. Fraser, R.G. (1988). Diagnosis of Diseases of the Chest: Volume 2. Philadelphia: W. B. Saunders Company. Fritz, R. (1993). Sleep Disorders: America’s Hidden Nightmare. Grawn: National Sleep Alert, Inc. George, R.B., Light, R.W., Matthay, M.A., & Matthay, R.A. (1990). Chest Medicine: Essentials of Pulmonary and Critical Care Medicine (2nd edition). Baltimore: Williams & Wilkins. Inlander, C.B. & Moran, C.K. (1995). 67 Ways to Good Sleep. New York: Walker Publishing Company, Inc. Johnson, T.S. & Halberstadt, J. (1993). Phantom of the Night. Cambridge: NTP, Inc. Kryger, M.H., Roth, T. & Dement, W.C. (1994). Principles and Practice of Sleep Medicine (2nd edition). Philadelphia: W.B. Saunders Company. Kryger, M.H., Roth, T. & Dement, W.C. (2000). Principles and Practice of Sleep Medicine (3rd edition). Philadelphia: W.B. Saunders Company. Kryger, M.H., Roth, T. & Dement, W.C. (2005). Principles and Practice of Sleep Medicine (4th edition). Philadelphia: Elsevier, Inc. Marklund, M. (2001). Treatment of Obstructive Sleep Apnea with a Mandibular Advancement Device. Umea: Umea University. Mazzoni, P., Pearson, T., & Rowland, L.P. (2006). Merritt’s Neurology Handbook (2nd edition). Lippincott Williams & Wilkins. Murray, J.F. & Nadel, J.A. (1988). Textbook of Respiratory Medicine: Volume 1 (1st edition). Philadelphia: W.B. Saunders Company. Murray, J.F. & Nadel J.A. (1988). Textbook of Respiratory Medicine: Volume 2 (1st edition). Philadelphia: W.B. Saunders Company. Murray, J.F. & Nadel, J.A. (1994). Textbook of Respiratory Medicine: Volume 1 (2nd edition). Philadelphia: W.B. Saunders Company. Murray, J.F. & Nadel, J.A. (1994). Textbook of Respiratory Medicine: Volume 2 (2nd edition). Philadelphia: W.B. Saunders Company. Ogden, T.E. (1991). Research Proposals: A Guide to Success. New York: Raven Press, Ltd. Pack, A.I. (2002). Sleep Apnea. New York: Marcel & Dekker, Inc. Parrillo, J.E. & Dellinger, R.P. (2001). Critical Care Medicine: Principles of Diagnosis and Management in the Adult (2nd edition). St. Louis: Mosby, Inc. Rechtschaffen, A. & Kales, A. (1968). A Manual of Standardized Terminology, Techniques and Scoring System for Sleep Stages of Human Subjects. Bethesda: U.S. Department of Health, Education, and Welfare. Richardson, G. (ed.) (2006). Update on the Science, Diagnosis, and Management of Insomnia. London: RSM Press, Ltd. Shoemaker, W.C., Ayres, S., Grenvik, A., Holbrook, D.R., & Thompson, W.L. (1989). Textbook of Critical Care (2nd edition). Philadelphia: W.B. Saunders Company. Spriggs, W.H. (2002). Principles of Polysomnography (1st edition). Salt Lake City: Sleep Ed, LLC. Evaluation Methods A competency-based evaluation matrix is available at the end of the curriculum. The evaluation methods that apply to these rotations include: • Web enabled competency-based evaluation forms that are completed by faculty at the end of each rotation • 360° evaluations completed quarterly by clinical support staff, nursing and sleep laboratory technical staff • Mini-CEXs are completed at least four times during the fellowship • Review of PQIPs are evaluated by faculty preceptors 16
  • 17. • Review of QA scoring are evaluated by faculty preceptors • Procedure logs/Portfolios • ABIM sleep board summative exam results Level of Supervision by Faculty All fellows are supervised by the attending of record according to the institutional policy on Attending supervision that is included in our departmental policies. Ratio of fellows to faculty in a given practice session is no more than 4:1; faculty usually do not see their own patients during sessions when they are precepting fellows in their continuity practice setting. When a fellow is rotating in a faculty-based practice the ratio of fellows to faculty will not exceed 2:1; faculty may see their own patients if the fellow to faculty ratio is 1:1. Regardless of the clinical scenario, every patient seen is reviewed with the faculty preceptor before being released. 17
  • 18. Learning Objectives for HUP Inpatient Consultation: Educational Rationale: Sleep Medicine Inpatient Consultation experience can encompass a broad range of sleep disorders depending on the practice setting. However, the extent and complexity of the role may be determined by the availability of neurological, psychiatric, otolaryngological, pediatric internal medicine and other specialists, including pediatric and internal medicine subspecialists such as pulmonologists and cardiologists. Since sleep medicine consultation is practiced at the interface of multiple specialties, it requires familiarity with those specialties, skill in synthesizing information and appropriate effective communication with attending and other consulting physicians, dentists, other health care workers, and families. These skills are acquired via a multidisciplinary approach to sleep medicine consultation. First of all, all clinical fellows spend up to 4-6 weeks covering the Sleep Medicine Inpatient Consultation (SMIC) Service at HUP. This occurs in 2 week blocks. Sleep medicine fellows perform new consultations, present their cases to the Sleep Medicine Attending on the consult service, and then provide management advice and follow-up as needed. As soon as possible after receiving the request for consultation, the fellow interviews and examines the patient, gathers all necessary information from the chart and other sources as appropriate. S/he then presents the patient to the attending after which the fellow and attending see the patient together at the bedside. A plan of care is developed by fellow and attending together and then communicated by the fellow both verbally and in writing to the service requesting the consultation within 24 hours of the request for the consultation.. Thereafter, the fellow rounds at least once daily on all active patients on the consult service and discusses them with the attending. All patients with active issues or whose status has changed are revisited with the attending later in the day. Of note, sleep medicine fellows will also be continuing their outpatient responsibilities during this time as the burden of consultations is quite low. Additionally, all fellows will spend up to 4 weeks total on a combination of various subspecialty inpatient consultation services including the neurology, pulmonology, bariatric surgery and heart failure services at HUP. During these rotations, the supervising physician will be board certified in the subspecialty of the rotation as well as sleep medicine or have a specific interest in sleep medicine (e.g. sleep apnea and heart failure). These inpatient experiences will serve to illustrate how sleep disorders integrate into the differential diagnoses of various clinical questions posed to subspecialty consultation services. Sleep medicine fellows perform new consultations, present their cases to the attending on the consult service, and then provide management advice and follow-up as needed. As soon as possible after receiving the request for consultation, the fellow interviews and examines the patient, gathers all necessary information from the chart and other sources as appropriate. S/he then presents the patient to the attending after which the fellow and attending see the patient together at the bedside. A plan of care is developed by fellow and attending together and then communicated by the fellow both verbally and in writing to the service requesting the consultation. Thereafter, the fellow rounds at least once daily on all active patients on the consult service and discusses them with the attending. All patients with active issues or whose status has changed are revisited with the attending later in the day. Of note, sleep medicine fellows will have reduced outpatient responsibilities during this portion of their sleep inpatient rotation. Disease Mix/ Patient Characteristics: 18
  • 19. The Hospital of the University of Pennsylvania is a 700-bed hospital serving a patient population with a variety of ethnic backgrounds and socioeconomic statuses. The opportunity to round on multiple subspecialty services in addition to interfacing with any clinical service that might call a sleep consult allows for exposure to a diverse disease mix. Principal Teaching Methods/Learning Venues: Direct Patient Care (DPC) – Daily bedside rounds with the sleep medicine attending on service seeing new consultations and follow-ups. Consult Attending Teaching Rounds (CATR) – As patients are seen, the attending on consult service provides focused teaching on common topics in Sleep Medicine Consultation. The final component of the HUP sleep medicine educational program is the Sleep Medicine Conference Schedule (SMCS), which include two 1-hour didactic sessions per week and the Center for Sleep Seminar series which occurs 8-10 times per year. The twice weekly didactic sessions are either Clinical Case Conferences (CCC), Sleep Lecture Series (SLS), Sleep Medicine Journal Club (SMJC) or Sleep Medicine Research Conference (SMRC). Principal Educational Goals by Relevant Competency In the tables below, the principal educational goals for the General Medicine Consultation Rotation are listed for each of the six ACGME competencies. The second column of the table indicates the most relevant principal teaching/learning activity for each goal, using the legend below. * Legend for Learning Activities (See above for descriptions) DPC – Direct Patient Care CATR – Consult Attending Teaching Rnds CCC -- Clinical Case Conferences SLS -- Sleep Lecture Series SMJC -- Sleep Medicine Journal Club SMRC -- Sleep Medicine Research Conference 1) Patient Care Principal Educational Goals Learning Activities* Effectively, efficiently, and sensitively interview and examine DPC, CATR patients hospitalized with complaints that suggest a possible sleep disorder Obtain all necessary medical information by chart review, DPC, CATR discussion with the service requesting the consultation, and through contact with the patient’s primary care internist and other important providers Adjust all recommendations as required by the patients DPC, CATR coexistent problem(s) which resulted in their admission to another service: impending or recent surgery, pregnancy or recent delivery, etc. 2) Medical Knowledge Principal Educational Goals Learning Activities* 19
  • 20. Expand clinically applicable knowledge base of the biomedical, DPC, CCC, SLS, SMJC, clinical and cognate sciences underlying the care of patients with CATR sleep related illness on non-dedicated sleep medicine services. Access and critically evaluate current medical information ALL and scientific evidence relevant to inpatient sleep medicine patient care Assess the validity of original research concerning clinical CCC, SLS, SMJC, SMRC, questions such as diagnosis, prognosis, treatment and prevention CATR 3) Practice-Based Learning and Improvement Principal Educational Goals Learning Activities* Identify and acknowledge gaps in personal knowledge and DPC, CATR skills in the care of patients with sleep-related illness on non-sleep medicine services Develop evidence-based, real-time strategies for filling gaps in DPC, CATR, personal knowledge and skills in the care of patients with CCC, SLS, SMJC sleep-related illness on non-sleep medicine services 4) Interpersonal Skills and Communication Principal Educational Goals Learning Activities* Communicate sensitively and effectively with patients with DPC, sleep-related illness on non-sleep medicine services and with their families Communicate effectively with residents, fellows and attending DPC, CATR physicians on the service requesting the consultation to be Verbally communicate findings and recommendations to the DPC, CATR requesting resident and/or attending physician clearly and concisely as soon as the consultation is completed and assure that all questions have been satisfactorily answered Complete a concise consultation note with clearly stated, DPC, CATR detailed recommendations Communicate effectively with the nursing staff and other DPC, CATR members of the health care team on the patient's primary service to assure that plan of medical care is clear 5) Professionalism Principal Educational Goals Learning Activities* 20
  • 21. Behave professionally toward towards patients, families, ALL colleagues, and all members of the health care team 6) Systems-Based Practice Principal Educational Goals Learning Activities* Work with the service requesting the consultation to assure DPC, CATR that care for the patient's medical needs is properly coordinated with care being delivered by the primary service Assist with scheduling of any tests or treatments necessary DPC, CATR to assure the patient's proper medical care Use evidence-based, cost-conscious strategies in the care of ALL patients with sleep-related illness on non-sleep medicine services and patients being assessed for pre-operative medical risk Recommended Resources All fellows are expected to read about their patients in an appropriate sleep medicine or subspecialty text (see below for examples). Because it is frequently updated, extensively referenced, and includes abstracts of referenced articles, the program highly recommends UpToDate as a primary resource. UpToDate is available at all sites on the UPHS network. The reference shelf from the Biomedical library is also available online. Additional educational resources include the didactic conference curriculum and primary review of laboratory and sleep studies in addition to radiology. Ahrens, E.H. (1992). The Crisis in Clinical Research. New York: Oxford University Press. Bates, D.V. (1989). Respiratory Function in Disease (3rd edition). Philadelphia: W.B. Sanders Company. Berry, R.B. (2003). Sleep Medicine Pearls (2nd edition). Philadelphia: Hanley & Belfus, Inc. Carlson, R.W. & Geheb, M.A. (1993). Principles and Practices of Medical Critical Care. Philadelphia: W.B. Saunders Company. Chase, M.H. & Roth, T (eds.) (1990). Slow Wave Sleep. Los Angeles: Regents of the University of California. Chokroverty, S., Thomas, R.J., & Bhatt, M. (2005). Atlas of Sleep Medicine. Philadelphia: Elsevier, Inc. Fraser, R.G. (1988). Diagnosis of Diseases of the Chest: Volume 1. Philadelphia: W.B. Saunders Company. Fraser, R.G. (1988). Diagnosis of Diseases of the Chest: Volume 2. Philadelphia: W. B. Saunders Company. Fritz, R. (1993). Sleep Disorders: America’s Hidden Nightmare. Grawn: National Sleep Alert, Inc. George, R.B., Light, R.W., Matthay, M.A., & Matthay, R.A. (1990). Chest Medicine: Essentials of Pulmonary and Critical Care Medicine (2nd edition). Baltimore: Williams & Wilkins. Inlander, C.B. & Moran, C.K. (1995). 67 Ways to Good Sleep. New York: Walker Publishing Company, Inc. Johnson, T.S. & Halberstadt, J. (1993). Phantom of the Night. Cambridge: NTP, Inc. Kryger, M.H., Roth, T. & Dement, W.C. (1994). Principles and Practice of Sleep Medicine (2nd edition). Philadelphia: W.B. Saunders Company. 21
  • 22. Kryger, M.H., Roth, T. & Dement, W.C. (2000). Principles and Practice of Sleep Medicine (3rd edition). Philadelphia: W.B. Saunders Company. Kryger, M.H., Roth, T. & Dement, W.C. (2005). Principles and Practice of Sleep Medicine (4th edition). Philadelphia: Elsevier, Inc. Marklund, M. (2001). Treatment of Obstructive Sleep Apnea with a Mandibular Advancement Device. Umea: Umea University. Mazzoni, P., Pearson, T., & Rowland, L.P. (2006). Merritt’s Neurology Handbook (2nd edition). Lippincott Williams & Wilkins. Murray, J.F. & Nadel, J.A. (1988). Textbook of Respiratory Medicine: Volume 1 (1st edition). Philadelphia: W.B. Saunders Company. Murray, J.F. & Nadel J.A. (1988). Textbook of Respiratory Medicine: Volume 2 (1st edition). Philadelphia: W.B. Saunders Company. Murray, J.F. & Nadel, J.A. (1994). Textbook of Respiratory Medicine: Volume 1 (2nd edition). Philadelphia: W.B. Saunders Company. Murray, J.F. & Nadel, J.A. (1994). Textbook of Respiratory Medicine: Volume 2 (2nd edition). Philadelphia: W.B. Saunders Company. Ogden, T.E. (1991). Research Proposals: A Guide to Success. New York: Raven Press, Ltd. Pack, A.I. (2002). Sleep Apnea. New York: Marcel & Dekker, Inc. Parrillo, J.E. & Dellinger, R.P. (2001). Critical Care Medicine: Principles of Diagnosis and Management in the Adult (2nd edition). St. Louis: Mosby, Inc. Rechtschaffen, A. & Kales, A. (1968). A Manual of Standardized Terminology, Techniques and Scoring System for Sleep Stages of Human Subjects. Bethesda: U.S. Department of Health, Education, and Welfare. Richardson, G. (ed.) (2006). Update on the Science, Diagnosis, and Management of Insomnia. London: RSM Press, Ltd. Shoemaker, W.C., Ayres, S., Grenvik, A., Holbrook, D.R., & Thompson, W.L. (1989). Textbook of Critical Care (2nd edition). Philadelphia: W.B. Saunders Company. Spriggs, W.H. (2002). Principles of Polysomnography (1st edition). Salt Lake City: Sleep Ed, LLC. Evaluation Methods A competency-based evaluation matrix is available at the end of the curriculum. The evaluation methods that apply to these rotations include: • Web enabled competency-based evaluation forms that are completed by faculty at the end of each rotation • 360° evaluations completed quarterly by clinical support staff, nursing and sleep laboratory technical staff • Mini-CEXs are completed at least four times during the fellowship • Review of PQIPs are evaluated by faculty preceptors • Review of QA scoring are evaluated by faculty preceptors • Procedure logs/Portfolios • ABIM sleep board summative exam results Level of Supervision by Faculty All fellows are supervised by the attending of record according to the institutional policy on attending supervision that is included in our departmental policies. 22
  • 23. Learning Objectives for CHOP Sleep Medicine Rotation: Educational Rationale: Sleep Medicine Ambulatory Experience at the Children’s Hospital of Philadelphia (CHOP) includes three components: direct patient care, didactic sessions and hands-on experience with sleep studies and associated tools. The approach to care is multi-disciplinary, with sleep medicine attendings from pediatric pulmonary and pediatric neurology, as well as other faculty from child psychology and dedicated pediatric sleep medicine nurses. Disease Mix/Patient Characteristics: The CHOP Sleep Clinic is a weekly, full day, multidisciplinary clinic that provides medical care for children (0-21 years of age) with any type of sleep complaint. Common conditions seen in the clinic include, but are not limited to, sleep-disordered breathing (including obstructive sleep apnea syndrome, central apnea and central hypoventilation syndromes, and children requiring noninvasive nocturnal positive pressure ventilation), narcolepsy, circadian rhythm disorders (particularly delayed sleep phase syndrome), behavioral sleep disorders, parasomnias, restless legs syndrome and periodic limb movement disorders, and sleep problems in children with complex medical conditions. The clinic attracts pediatric patients from all over the country with complex sleep problems. Founded in 1855, CHOP was the first children’s hospital established in the United States, and the second in the world. For the past four years, The Children’s Hospital of Philadelphia has been recognized in surveys by Child Magazine and U.S. News and World Report as the #1 children’s hospital in the nation. This phenomenal recognition reflects the commitment of the Hospital and its administration in providing unparalleled excellence of clinical care. CHOP is a large (373 beds), tertiary children’s hospital where all subspecialties are represented. It handles nearly 23,000 inpatient admissions annually, 75,000 emergency department visits, and 85,000 outpatient visits each year. The patient population draws from the greater Philadelphia tri-state region, as well as nationally and internationally. All racial and ethnic groups are represented in the patient mix. Procedures: Fellows will be trained in the evaluation and interpretation of overnight polysomnograms, both diagnostic and therapeutic, multiple sleep latency tests, actigrams and sleep logs on the children evaluated in the Sleep Center. Pediatric sleep studies are scheduled and performed through the CHOP sleep laboratory, a 6 bed facility accredited by the American Academy of Sleep Medicine and located on the 7th floor of CHOP’s Main Hospital. The CHOP sleep laboratory operates at capacity 7 nights per week. Principal Teaching Methods/Learning Venues: 1) Pediatric sleep clinics. During a typical rotation at CHOP, a fellow will attend at least three outpatient pediatric sleep clinics in CHOP’s Wood Center per week in addition to his/her adult continuity clinic. The sleep medicine fellow is expected to have the first contact with new patients, to complete a comprehensive history and physical exam, to formulate an assessment and plan, and then to discuss the case with the attending physician. The attending physician reviews the case with the patient and appropriate family members. There is a final discussion of the assessment and plan between the sleep fellow and attending, and then care is undertaken. It is expected that the fellow will serve as the sleep 23
  • 24. medicine care provider for that patient and family for the remainder of that rotation. The fellow will review all laboratory test results (e.g., sleep studies) and provide further management. Follow-up visits serve as an opportunity for the attending and sleep fellow to review the patient’s progress and any intervening care or advice given by the fellow. 2) Polysomnography scoring and interpretation. Under the direct supervision of an ABMS- certified attending specializing in pediatric sleep medicine, the fellow will review overnight polysomnograms and Multiple Sleep Latency Tests. The fellow will be responsible for formulating the interpretation of these data into concise clinical reports. The fellow will also discuss results with referring physicians as needed. The fellow will lead the weekly Multidisciplinary Patient Conference at CHOP, reviewing each patient’s medical history, sleep issues, prior polysomnographic studies (if any), and propose an individualized plan for monitoring. The fellow will be contacted by the sleep lab staff Monday through Thursday nights, when necessary, for questions regarding the patients being studied at CHOP; an attending physician will always be available for back-up support. 3) Inpatient consultations. The fellow will perform all inpatient consultations under the direct supervision of an ABMS-certified physician. The sleep medicine fellow, under the supervision of a sleep medicine attending, will review the patient’s medical chart and elicit a history, examine the patient, and discuss the goals of evaluation with the hospital team. A formal consultation note by the fellow/attending will become part of the medical record. If a polysomnogram is deemed appropriate, the results will be reviewed with the primary team, and the sleep fellow will offer management options accordingly. When possible, continuity of care will be promoted by scheduling follow-up appointments with the fellow in the outpatient sleep clinic. 4) Conferences. As noted above, the fellow will lead the lead the weekly Multidisciplinary Patient Conference. The fellow will also actively participate in the weekly CHOP sleep medicine lecture series, that covers a broad range of topics related to pediatric sleep medicine, both clinical care and clinical research. The fellow will also be required to attend the Sleep Center Administrative Meeting, where issues related to clinic and sleep laboratory organization, educational goals, health care delivery to sleep medicine patients and other topics will be discussed; this meeting will contribute to the fellow’s aptitude in resource management, and foster insight into the operation and management of a pediatric sleep center. The principal teaching/learning activity of the CHOP sleep medicine rotation occurs through Direct Patient Care (DPC) activities. The didactic programs described above complement direct patient care activities. Principal Educational Goals by Relevant Competency: In the tables below, the principal educational goals for the CHOP sleep medicine rotation are listed for each of the six ACGME competencies. The second column of the table indicates the most relevant principal teaching/learning activity for each goal, using the legend below. * Legend for Learning Activities (See above for descriptions) PSC—Pediatric Sleep Clinics PSI—Polysomnography Scoring and Interpretation IC—Inpatient Consultations CONF—Pediatric Sleep Medicine Conferences 1) Patient Care 24
  • 25. Principal Educational Goals Learning Activities* Effectively interview sleep medicine patients PSC, IC Effectively examine sleep medicine patients PSC, IC Maintain focus and timeliness in the evaluation and PSC, IC management of sleep medicine problems Order appropriate diagnostic tests PSC, PSI, IC, CONF Interpret polysomnograms and other diagnostic sleep evaluation tools PSC, PSI, IC, CONF 2) Medical Knowledge Principal Educational Goals Learning Activities* Expand clinically applicable knowledge base of the biomedical, PSC, IC, CONF clinical and cognate sciences underlying the care of sleep medicine patients Access and critically evaluate current medical information PSC, IC, CONF and scientific evidence relevant to sleep medicine patient care Assess the validity of original research concerning clinical PSC, IC, CONF questions such as diagnosis, prognosis, treatment and prevention 3) Practice-Based Learning and Improvement Principal Educational Goals Learning Activities* Identify and acknowledge gaps in personal knowledge and PSC, IC skills in the care of sleep medicine patients Develop real-time strategies for filling knowledge gaps that PSC, IC, CONF will benefit patients in a busy practice setting 4) Interpersonal Skills and Communication Principal Educational Goals Learning Activities* Communicate effectively with patients and families across a PSC, IC broad range of socioeconomic and ethnic backgrounds Communicate effectively with physician colleagues and PSC, PSI, IC, CONF members of other health care professions to assure 25
  • 26. comprehensive patient care 5) Professionalism Principal Educational Goals Learning Activities* Behave professionally toward towards patients, families, PSC, PSI, IC, CONF colleagues, and all members of the health care team 6) Systems-Based Practice Principal Educational Goals Learning Activities* Understand and utilize the multidisciplinary resources PSC, PSI, IC, CONF necessary to care optimally for sleep medicine patients Collaborate with other members of the health care team to PSC, PSI, IC, CONF assure comprehensive sleep medicine outpatient care Use evidence-based, cost-conscious strategies in the care of PSC, PSI, IC, CONF sleep medicine patients Begin to understand the business aspects of practice PSC, IC, CONF management in a variety of settings Begin to develop efficient practice patterns so patient care PSC, IC proceeds at an acceptable rate Principal Educational Goals In addition to the above goals by competency, after 12 months of training, the fellow should have achieved the following: • Function as an integral member of an outpatient multidisciplinary team • Evaluate at least 40 new pediatric sleep medicine outpatients • Evaluate and manage 4-5 pediatric sleep medicine inpatients • Provide continuous care to at least 40 pediatric sleep medicine outpatients • Attend pediatric sleep medicine conferences regularly • Enhance office based time management skills • Develop telephone management skills • Develop urgent care skills • Function as role models and mentors for younger trainees within the multidisciplinary fields that make up sleep medicine Specialty Tracks: Additional training is available to fellows who want a concentrated experience in pediatric sleep medicine. Fellows on the Pediatric Track will spend a total of 6 one month blocks at CHOP, in addition to maintaining an additional year-long sleep medicine continuity clinic at CHOP. Specifically, the Wednesday afternoon sleep clinic session will be maintained throughout the year to allow continuity in the care of pediatric sleep medicine patients. Trainees in this track will be expected to evaluate at least 60 new pediatric sleep medicine patients throughout the year. 26
  • 27. Recommended Resources UpToDate (available on-site in the practice) Ahrens, E.H. (1992). The Crisis in Clinical Research. New York: Oxford University Press. Bates, D.V. (1989). Respiratory Function in Disease (3rd edition). Philadelphia: W.B. Sanders Company. Berry, R.B. (2003). Sleep Medicine Pearls (2nd edition). Philadelphia: Hanley & Belfus, Inc. Carlson, R.W. & Geheb, M.A. (1993). Principles and Practices of Medical Critical Care. Philadelphia: W.B. Saunders Company. Chase, M.H. & Roth, T (eds.) (1990). Slow Wave Sleep. Los Angeles: Regents of the University of California. Chokroverty, S., Thomas, R.J., & Bhatt, M. (2005). Atlas of Sleep Medicine. Philadelphia: Elsevier, Inc. Fraser, R.G. (1988). Diagnosis of Diseases of the Chest: Volume 1. Philadelphia: W.B. Saunders Company. Fraser, R.G. (1988). Diagnosis of Diseases of the Chest: Volume 2. Philadelphia: W. B. Saunders Company. Fritz, R. (1993). Sleep Disorders: America’s Hidden Nightmare. Grawn: National Sleep Alert, Inc. George, R.B., Light, R.W., Matthay, M.A., & Matthay, R.A. (1990). Chest Medicine: Essentials of Pulmonary and Critical Care Medicine (2nd edition). Baltimore: Williams & Wilkins. Inlander, C.B. & Moran, C.K. (1995). 67 Ways to Good Sleep. New York: Walker Publishing Company, Inc. Johnson, T.S. & Halberstadt, J. (1993). Phantom of the Night. Cambridge: NTP, Inc. Kryger, M.H., Roth, T. & Dement, W.C. (1994). Principles and Practice of Sleep Medicine (2nd edition). Philadelphia: W.B. Saunders Company. Kryger, M.H., Roth, T. & Dement, W.C. (2000). Principles and Practice of Sleep Medicine (3rd edition). Philadelphia: W.B. Saunders Company. Kryger, M.H., Roth, T. & Dement, W.C. (2005). Principles and Practice of Sleep Medicine (4th edition). Philadelphia: Elsevier, Inc. Marcus, C.L., Carroll J.L., Loughlin G.M. (eds.) (2000). Sleep and breathing in children. New York: Dekker. Marklund, M. (2001). Treatment of Obstructive Sleep Apnea with a Mandibular Advancement Device. Umea: Umea University. Mazzoni, P., Pearson, T., & Rowland, L.P. (2006). Merritt’s Neurology Handbook (2nd edition). Lippincott Williams & Wilkins. Mindell, J.A. & Owens, J.A. (2003). A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems. Lippincott Williams & Wilkins. Murray, J.F. & Nadel, J.A. (1988). Textbook of Respiratory Medicine: Volume 1 (1st edition). Philadelphia: W.B. Saunders Company. Murray, J.F. & Nadel J.A. (1988). Textbook of Respiratory Medicine: Volume 2 (1st edition). Philadelphia: W.B. Saunders Company. Murray, J.F. & Nadel, J.A. (1994). Textbook of Respiratory Medicine: Volume 1 (2nd edition). Philadelphia: W.B. Saunders Company. Murray, J.F. & Nadel, J.A. (1994). Textbook of Respiratory Medicine: Volume 2 (2nd edition). Philadelphia: W.B. Saunders Company. Ogden, T.E. (1991). Research Proposals: A Guide to Success. New York: Raven Press, Ltd. Pack, A.I. (2002). Sleep Apnea. New York: Marcel & Dekker, Inc. Parrillo, J.E. & Dellinger, R.P. (2001). Critical Care Medicine: Principles of Diagnosis and Management in the Adult (2nd edition). St. Louis: Mosby, Inc. 27
  • 28. Rechtschaffen, A. & Kales, A. (1968). A Manual of Standardized Terminology, Techniques and Scoring System for Sleep Stages of Human Subjects. Bethesda: U.S. Department of Health, Education, and Welfare. Richardson, G. (ed.) (2006). Update on the Science, Diagnosis, and Management of Insomnia. London: RSM Press, Ltd. Sheldon, S.H., Kryger, M.H., Ferber, R. (2005). Principles and Practice of Pediatric Sleep Medicine. Philadelphia: W.B. Saunders Company. Shoemaker, W.C., Ayres, S., Grenvik, A., Holbrook, D.R., & Thompson, W.L. (1989). Textbook of Critical Care (2nd edition). Philadelphia: W.B. Saunders Company. Spriggs, W.H. (2002). Principles of Polysomnography (1st edition). Salt Lake City: Sleep Ed, LLC. Evaluation Methods A competency-based evaluation matrix is available at the end of the curriculum. The evaluation methods that apply to these rotations include: • Web enabled competency-based evaluation forms that are completed by faculty at least every 60 days • 360° evaluations completed quarterly by clinical support staff, nursing and sleep laboratory technical staff • Mini-CEXs are completed at least four times during the fellowship • Procedure logs/Portfolios • ABIM sleep board summative exam results Level of Supervision by Faculty All fellows are supervised by the attending of record according to the institutional policy on Attending supervision that is included in our departmental policies. Ratio of fellows to faculty in a given clinic session is no more than 2:1; faculty do not see their own patients while precepting fellows in pediatric sleep clinic. Every patient seen is reviewed with the faculty preceptor before being released. 28
  • 29. Learning Objectives for Philadelphia VAMC Sleep Medicine Rotation: Sleep Medicine Ambulatory Experience Educational Rationale: Sleep Medicine Ambulatory Experience includes three components: direct patient care, didactic sessions and hands-on experience with sleep studies and associated tools. The approach to care in the faculty-fellow practice is multi-disciplinary. The fellows work with two ABSM certified Sleep Medicine physicians, a Neurologist specializing in sleep medicine, a Nurse Practitioner, a Registered Nurse, two Respiratory Therapists, and a Clinic Clerk. The fellows participate in review and interpretation of sleep studies, new patient evaluations, follow-up clinic visits, positive airway pressure mask fittings, patient education, and patient set-up sessions for distribution of portable monitors for home unattended testing. Disease Mix/Patient Characteristics: The VISN 4 Eastern Regional Sleep Center is a full service facility accredited by the American Academy of Sleep Medicine. The patient population seen in the outpatient clinics is heterogeneous, including individuals from a wide range of socioeconomic and ethnic backgrounds. Approximately 45% of the patients enrolled at the Philadelphia VAMC are African American. The patients have a broad range of sleep disorders. Fellows have an opportunity to evaluate and manage veterans with a broach range of sleep disorders. Post traumatic stress disorder, and insomnia due to psychiatric disorders is particularly prevalent in the veterans seen in the sleep center. Procedures: Fellows can expect to review and interpret polysomnograms, both diagnostic and therapeutic, multiple sleep latency tests, home unattended sleep studies, home unattended autoCPAP titration studies, and sleep logs on the patients they encounter in the outpatient clinics. Principal Teaching Methods/Learning Venues: A core curriculum in sleep medicine is presented in a multifaceted approach that provides the fellow with the opportunity to work with Staff Physicians, a Nurse Practitioner, a Registered Nurse and two Respiratory Therapists. The Staff Physicians have a total of 4 half-day outpatient clinic sessions (FBP) during which they supervise fellows’ evaluations of new and follow-up patients. The Nurse Practitioner has 4 half-day outpatient clinic sessions (NPCS) during which fellows perform supervised evaluations of new patients referred to the sleep center for suspected sleep apnea. The Registered Nurse has several half-day outpatient clinic sessions (RNCS) throughout the week to provide follow-up evaluation and management of patients with sleep apnea on positive airway pressure. This includes a comprehensive CPAP adherence program to track treatment adherence and effectiveness. Two to four weeks following initiation of CPAP treatment, patients are seen in follow-up for education, downloads of media card technology to assess adherence and efficacy of treatment and mask interface adjustments. Patients who have no active problems are then scheduled for routine follow-up appointments every 6-12 months. Sleep Medicine fellows participate in the care of these patients in a multidisciplinary approach interacting with the registered nurse, respiratory therapists and medical assistants. The two Respiratory Therapists conduct mask fittings during each outpatient clinic session. In addition, they implement the home testing program by holding several clinic sessions (RTCS) during the week to set-up patients who are scheduled for home unattended sleep testing with Type 3 diagnostic monitor or autoCPAP. The 29
  • 30. fellows interact with the clinic clerk to schedule follow-up clinic visits, sleep studies and processing of sleep study interpretations. Under direct faculty supervision, the fellows interpret sleep studies, including polysomnography, multiple sleep latency tests, and home unattended sleep studies. On a weekly basis, the sleep center performs 8 polysomnograms, 6 home unattended diagnostic sleep studies, and 8 home unattended autoCPAP titration studies. One of the sleep specialty physicians meets with the fellow on a weekly basis for a Sleep Study Review (SSR) to discuss the scoring and analysis of the studies and finalize the interpretations. All outpatient sleep clinics are held in the sleep center. Fellows are encouraged to review any sleep studies that have been performed on patients they are evaluating in follow-up clinics. The principal teaching/learning activity of the PVAMC sleep center rotation occurs through direct patient care activities. In all of the ambulatory settings mentioned above, fellows present their cases to the supervising staff member and a discussion of evaluation and management ensues. During the physician staffed outpatient clinics, the fellow and staff physician may see the patient together. When the fellow sees the patient alone, he/she then presents the findings and proposed management plan to the supervising faculty member. The fellow and faculty member then return together to the examining room to expand on the history or physical examination and to teach about interviewing and examination techniques. The fellows use the VA electronic medical record to document their patient encounters. The VA computer network provides fellows access to the internet, UpToDate and the New England Journal of Medicine. A library of sleep medicine textbooks and sleep recording atlases are available in the sleep center for fellows to study. A copy of the AASM Practice Parameters is on file with the sleep center’s policies and procedures notebooks. During the rotation at PVAMC, fellows are required to attend their continuity clinic and conferences at the Penn Sleep Center. Principal Educational Goals by Relevant Competency: In the tables below, the principal educational goals for the PVAMC outpatient rotation are listed for each of the six ACGME competencies. The second column of the table indicates the most relevant principal teaching/learning activity for each goal, using the legend below. * Legend for Learning Activities (See above for descriptions) FBP – Faculty-Based Practices NPCS – Nurse Practitioner Clinic Sessions RNCS – Registered Nurse Clinic Sessions RTCS – Respiratory Therapist Clinic Sessions SSR – Sleep Study Review 1) Patient Care Principal Educational Goals Learning Activities* Effectively interview sleep medicine outpatients FBP, NPCS, RNCS Effectively examine sleep medicine outpatients FBP, NPCS, RNCS 30
  • 31. Maintain focus and timeliness in the evaluation and FBP, NPCS, RNCS management of sleep medicine problems Order appropriate diagnostic tests FBP, NPCS, RNCS Interpret polysomnograms and other diagnostic sleep evaluation tools SSR 2) Medical Knowledge Principal Educational Goals Learning Activities* Expand clinically applicable knowledge base of the biomedical, ALL clinical and cognate sciences underlying the care of sleep medicine patients Access and critically evaluate current medical information ALL and scientific evidence relevant to outpatient sleep medicine patient care Assess the validity of original research concerning clinical PCS, NPCS questions such as diagnosis, prognosis, treatment and prevention 3) Practice-Based Learning and Improvement Principal Educational Goals Learning Activities* Identify and acknowledge gaps in personal knowledge and ALL skills in the care of sleep medicine patients Develop real-time strategies for filling knowledge gaps that ALL will benefit patients in a busy practice setting 4) Interpersonal Skills and Communication Principal Educational Goals Learning Activities* Communicate effectively with patients and families across a ALL broad range of socioeconomic and ethnic backgrounds Communicate effectively with physician colleagues and ALL members of other health care professions to assure comprehensive patient care 5) Professionalism Principal Educational Goals Learning Activities* Behave professionally toward towards patients, families, ALL 31
  • 32. colleagues, and all members of the health care team 6) Systems-Based Practice Principal Educational Goals Learning Activities* Understand and utilize the multidisciplinary resources ALL necessary to care optimally for sleep medicine patients Collaborate with other members of the health care team to ALL assure comprehensive sleep medicine outpatient care Use evidence-based, cost-conscious strategies in the care of ALL sleep medicine patients Begin to understand the business aspects of practice ALL management in a variety of settings Begin to develop efficient practice patterns so patient care ALL proceeds at an acceptable rate Principal Educational Goals In addition to the above goals by competency, after 12 months of training, the fellow should have achieved the following in their rotation at PVAMC: • Function as an integral member of an outpatient multidisciplinary team • Provide care of 65 new and 100 follow-up adult sleep medicine patients • Attend the required number of departmental conferences at the University of Pennsylvania, including clinical case conference, sleep lecture series and journal clubs • Enhance office based time management skills • Develop telephone management skills • Develop urgent care skills • Function as role models and mentors for younger trainees within the multidisciplinary fields that make up sleep medicine Recommended Resources UpToDate (available on-site in the practice) Ahrens, E.H. (1992). The Crisis in Clinical Research. New York: Oxford University Press. Bates, D.V. (1989). Respiratory Function in Disease (3rd edition). Philadelphia: W.B. Sanders Company. Berry, R.B. (2003). Sleep Medicine Pearls (2nd edition). Philadelphia: Hanley & Belfus, Inc. Carlson, R.W. & Geheb, M.A. (1993). Principles and Practices of Medical Critical Care. Philadelphia: W.B. Saunders Company. Chase, M.H. & Roth, T (eds.) (1990). Slow Wave Sleep. Los Angeles: Regents of the University of California. Chokroverty, S., Thomas, R.J., & Bhatt, M. (2005). Atlas of Sleep Medicine. Philadelphia: Elsevier, Inc. Fraser, R.G. (1988). Diagnosis of Diseases of the Chest: Volume 1. Philadelphia: W.B. Saunders Company. Fraser, R.G. (1988). Diagnosis of Diseases of the Chest: Volume 2. Philadelphia: W. B. Saunders Company. 32
  • 33. Fritz, R. (1993). Sleep Disorders: America’s Hidden Nightmare. Grawn: National Sleep Alert, Inc. George, R.B., Light, R.W., Matthay, M.A., & Matthay, R.A. (1990). Chest Medicine: Essentials of Pulmonary and Critical Care Medicine (2nd edition). Baltimore: Williams & Wilkins. Inlander, C.B. & Moran, C.K. (1995). 67 Ways to Good Sleep. New York: Walker Publishing Company, Inc. Johnson, T.S. & Halberstadt, J. (1993). Phantom of the Night. Cambridge: NTP, Inc. Kryger, M.H., Roth, T. & Dement, W.C. (1994). Principles and Practice of Sleep Medicine (2nd edition). Philadelphia: W.B. Saunders Company. Kryger, M.H., Roth, T. & Dement, W.C. (2000). Principles and Practice of Sleep Medicine (3rd edition). Philadelphia: W.B. Saunders Company. Kryger, M.H., Roth, T. & Dement, W.C. (2005). Principles and Practice of Sleep Medicine (4th edition). Philadelphia: Elsevier, Inc. Marklund, M. (2001). Treatment of Obstructive Sleep Apnea with a Mandibular Advancement Device. Umea: Umea University. Mazzoni, P., Pearson, T., & Rowland, L.P. (2006). Merritt’s Neurology Handbook (2nd edition). Lippincott Williams & Wilkins. Murray, J.F. & Nadel, J.A. (1988). Textbook of Respiratory Medicine: Volume 1 (1st edition). Philadelphia: W.B. Saunders Company. Murray, J.F. & Nadel J.A. (1988). Textbook of Respiratory Medicine: Volume 2 (1st edition). Philadelphia: W.B. Saunders Company. Murray, J.F. & Nadel, J.A. (1994). Textbook of Respiratory Medicine: Volume 1 (2nd edition). Philadelphia: W.B. Saunders Company. Murray, J.F. & Nadel, J.A. (1994). Textbook of Respiratory Medicine: Volume 2 (2nd edition). Philadelphia: W.B. Saunders Company. Ogden, T.E. (1991). Research Proposals: A Guide to Success. New York: Raven Press, Ltd. Pack, A.I. (2002). Sleep Apnea. New York: Marcel & Dekker, Inc. Parrillo, J.E. & Dellinger, R.P. (2001). Critical Care Medicine: Principles of Diagnosis and Management in the Adult (2nd edition). St. Louis: Mosby, Inc. Rechtschaffen, A. & Kales, A. (1968). A Manual of Standardized Terminology, Techniques and Scoring System for Sleep Stages of Human Subjects. Bethesda: U.S. Department of Health, Education, and Welfare. Richardson, G. (ed.) (2006). Update on the Science, Diagnosis, and Management of Insomnia. London: RSM Press, Ltd. Shoemaker, W.C., Ayres, S., Grenvik, A., Holbrook, D.R., & Thompson, W.L. (1989). Textbook of Critical Care (2nd edition). Philadelphia: W.B. Saunders Company. Spriggs, W.H. (2002). Principles of Polysomnography (1st edition). Salt Lake City: Sleep Ed, LLC. Evaluation Methods A competency-based evaluation matrix is available at the end of the curriculum. The evaluation methods that apply to these rotations include: • Web enabled competency-based evaluation forms that are completed by faculty at the end of each rotation • 360° evaluations completed quarterly by clinical support staff, nursing and sleep laboratory technical staff • Mini-CEXs are completed at least four times during the fellowship • Procedure logs/Portfolios Level of Supervision by Faculty All fellows are supervised by the attending of record according to the institutional policy on Attending supervision that is included in our departmental policies. Ratio of fellows to faculty in a 33
  • 34. given practice session is usually 1:1 and never more than 2:1; faculty usually see their own patients during sessions when they are supervising fellows. Regardless of the clinical scenario, every patient evaluated by the fellow is seen and examined by the faculty preceptor before being released. 34
  • 35. Learning Objectives for CHOP Pediatric Otolaryngology Rotation: Educational Rationale: Pediatric Otolaryngology at the Children’s Hospital of Philadelphia (CHOP) includes components of direct patient care and frequent observation of specialized procedures. Because the approach to care is multi-disciplinary in pediatric sleep medicine, with sleep medicine attendings practicing very closely with pediatric otolaryngologists, it is especially important for pediatric sleep medicine trainees to understand the surgical approach to care of the pediatric patient with a sleep disorder. Disease Mix/Patient Characteristics: The CHOP Pediatric Otolaryngology Clinic is a daily clinic that provides medical and surgical care for children (0-21 years of age) with ear, nose, and throat disorders. Patients seen in clinic include those with obstructive sleep apnea secondary upper airway pathology: adenotonsillar hypertrophy, nasal septal deviation, palate and tongue abnormalities. Patients with tracheostomies are reviewed for possible decannulation. Other disorders seen include subglottic stenosis, vocal cord dysfunction, and chronic inflammation (otitis media, sinusitis). In addition, more than 10,000 pediatric otolaryngology surgical procedures are performed at CHOP each year. Common procedures performed include, but are not limited to, tonsillectomy, adenoidectomy, palatoplasties, tracheostomies, and diagnostic procedures such as direct laryngoscopies. Procedures: While not performing procedures directly, the sleep fellow will have the opportunity to monitor multiple surgical procedures. Principal Teaching Methods/Learning Venues: 5) Pediatric otolaryngology clinics. During a typical rotation with CHOP-based pediatric otolaryngologists, a fellow will attend at least four outpatient pediatric ENT sleep clinics in CHOP’s Wood Center per week. The fellow will learn the fundamentals of surgical management of the airway. The sleep medicine fellow will evaluate patients with an ENT attending present. Management plans will be finalized by the ENT attending. 6) Operating Room Exposure. The fellow will have several opportunities to observe surgical procedures firsthand in the operating room, while receiving further teaching from a CHOP ENT attending. 7) Conferences. A weekly surgical conference will be held in CHOP’s Main Hospital. The fellow will be encouraged to attend this conference when feasible. The principal teaching/learning activity of the CHOP pediatric otolaryngology rotation occurs through Direct Patient Care (DPC) activities. The didactic programs described above complement direct patient care activities. The fellow’s sleep medicine continuity clinics will continue throughout the rotation. Principal Educational Goals by Relevant Competency: In the tables below, the principal educational goals for the CHOP pediatric otolaryngology rotation are listed for each of the six ACGME competencies. The second column of the table indicates the most relevant principal teaching/learning activity for each goal, using the legend below. * Legend for Learning Activities (See above for descriptions) 35
  • 36. POC—Pediatric Otolaryngology Clinics OR—Operating Room Exposure CONF—CHOP Surgical Conference, Pediatric Sleep Medicine 1) Patient Care Principal Educational Goals Learning Activities* Effectively interview pediatric otolaryngology patients POC, OR, CONF Effectively examine pediatric otolaryngology patients POC, OR, CONF Maintain focus and timeliness in the evaluation and POC, CONF management of pediatric otolaryngology problems Order appropriate diagnostic tests POC, OR, CONF 2) Medical Knowledge Principal Educational Goals Learning Activities* Expand clinically applicable knowledge base of the biomedical, POC, OR, CONF clinical and cognate sciences underlying the care of pediatric otolaryngology patients Access and critically evaluate current medical information POC, OR, CONF and scientific evidence relevant to pediatric otolaryngology patient care Assess the validity of original research concerning clinical POC, OR, CONF questions such as diagnosis, prognosis, treatment and prevention 3) Practice-Based Learning and Improvement Principal Educational Goals Learning Activities* Identify and acknowledge gaps in personal knowledge and POC, OR, CONF skills in the care of pediatric otolaryngology patients Develop real-time strategies for filling knowledge gaps that POC, CONF will benefit patients in a busy practice setting 4) Interpersonal Skills and Communication Principal Educational Goals Learning Activities* Communicate effectively with patients and families across a POC, OR broad range of socioeconomic and ethnic backgrounds Communicate effectively with physician colleagues and POC, OR, CONF 36
  • 37. members of other health care professions to assure comprehensive patient care 5) Professionalism Principal Educational Goals Learning Activities* Behave professionally toward towards patients, families, POC, OR, CONF colleagues, and all members of the health care team 6) Systems-Based Practice Principal Educational Goals Learning Activities* Understand and utilize the multidisciplinary resources POC, OR, CONF necessary to care optimally for pediatric otolaryngology patients Collaborate with other members of the health care team to POC, OR, CONF assure comprehensive pediatric otolaryngology patients care Use evidence-based, cost-conscious strategies in the care of POC, OR, CONF pediatric otolaryngology patients Begin to understand the business aspects of practice POC, OR, CONF management in a variety of settings Begin to develop efficient practice patterns so patient care POC proceeds at an acceptable rate Principal Educational Goals In addition to the above goals by competency, after 12 months of training, the fellow should have achieved the following: • Function as an integral member of a multidisciplinary team • Understand the fundamentals of surgical management of the pediatric airway • Attend pediatric sleep medicine conferences regularly • Enhance office based time management skills • Function as role models and mentors for younger trainees within the multidisciplinary fields that make up sleep medicine Specialty Tracks: Additional training is available to fellows who want a concentrated experience in pediatric sleep medicine. Fellows on the Pediatric Track will be required to spend one month on the Pediatric Otolaryngology Rotation. Recommended Resources UpToDate (available on-site in the practice) Ahrens, E.H. (1992). The Crisis in Clinical Research. New York: Oxford University Press. 37
  • 38. Bates, D.V. (1989). Respiratory Function in Disease (3rd edition). Philadelphia: W.B. Sanders Company. Berry, R.B. (2003). Sleep Medicine Pearls (2nd edition). Philadelphia: Hanley & Belfus, Inc. Carlson, R.W. & Geheb, M.A. (1993). Principles and Practices of Medical Critical Care. Philadelphia: W.B. Saunders Company. Chase, M.H. & Roth, T (eds.) (1990). Slow Wave Sleep. Los Angeles: Regents of the University of California. Chokroverty, S., Thomas, R.J., & Bhatt, M. (2005). Atlas of Sleep Medicine. Philadelphia: Elsevier, Inc. Fraser, R.G. (1988). Diagnosis of Diseases of the Chest: Volume 1. Philadelphia: W.B. Saunders Company. Fraser, R.G. (1988). Diagnosis of Diseases of the Chest: Volume 2. Philadelphia: W. B. Saunders Company. Fritz, R. (1993). Sleep Disorders: America’s Hidden Nightmare. Grawn: National Sleep Alert, Inc. George, R.B., Light, R.W., Matthay, M.A., & Matthay, R.A. (1990). Chest Medicine: Essentials of Pulmonary and Critical Care Medicine (2nd edition). Baltimore: Williams & Wilkins. Inlander, C.B. & Moran, C.K. (1995). 67 Ways to Good Sleep. New York: Walker Publishing Company, Inc. Johnson, T.S. & Halberstadt, J. (1993). Phantom of the Night. Cambridge: NTP, Inc. Kryger, M.H., Roth, T. & Dement, W.C. (1994). Principles and Practice of Sleep Medicine (2nd edition). Philadelphia: W.B. Saunders Company. Kryger, M.H., Roth, T. & Dement, W.C. (2000). Principles and Practice of Sleep Medicine (3rd edition). Philadelphia: W.B. Saunders Company. Kryger, M.H., Roth, T. & Dement, W.C. (2005). Principles and Practice of Sleep Medicine (4th edition). Philadelphia: Elsevier, Inc. Marklund, M. (2001). Treatment of Obstructive Sleep Apnea with a Mandibular Advancement Device. Umea: Umea University. Marcus, C.L., Carroll J.L., Loughlin G.M. (eds.) (2000). Sleep and breathing in children. New York: Dekker. Mazzoni, P., Pearson, T., & Rowland, L.P. (2006). Merritt’s Neurology Handbook (2nd edition). Lippincott Williams & Wilkins. Mindell, J.A. & Owens, J.A. (2003). A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems. Lippincott Williams & Wilkins. Murray, J.F. & Nadel, J.A. (1988). Textbook of Respiratory Medicine: Volume 1 (1st edition). Philadelphia: W.B. Saunders Company. Murray, J.F. & Nadel J.A. (1988). Textbook of Respiratory Medicine: Volume 2 (1st edition). Philadelphia: W.B. Saunders Company. Murray, J.F. & Nadel, J.A. (1994). Textbook of Respiratory Medicine: Volume 1 (2nd edition). Philadelphia: W.B. Saunders Company. Murray, J.F. & Nadel, J.A. (1994). Textbook of Respiratory Medicine: Volume 2 (2nd edition). Philadelphia: W.B. Saunders Company. Ogden, T.E. (1991). Research Proposals: A Guide to Success. New York: Raven Press, Ltd. Pack, A.I. (2002). Sleep Apnea. New York: Marcel & Dekker, Inc. Parrillo, J.E. & Dellinger, R.P. (2001). Critical Care Medicine: Principles of Diagnosis and Management in the Adult (2nd edition). St. Louis: Mosby, Inc. Rechtschaffen, A. & Kales, A. (1968). A Manual of Standardized Terminology, Techniques and Scoring System for Sleep Stages of Human Subjects. Bethesda: U.S. Department of Health, Education, and Welfare.Richardson, G. (ed.) (2006). Update on the Science, Diagnosis, and Management of Insomnia. London: RSM Press, Ltd. 38
  • 39. Sheldon, S.H., Kryger, M.H., Ferber, R. (2005). Principles and Practice of Pediatric Sleep Medicine. Philadelphia: W.B. Saunders Company. Shoemaker, W.C., Ayres, S., Grenvik, A., Holbrook, D.R., & Thompson, W.L. (1989). Textbook of Critical Care (2nd edition). Philadelphia: W.B. Saunders Company. Spriggs, W.H. (2002). Principles of Polysomnography (1st edition). Salt Lake City: Sleep Ed, LLC. Level of Supervision by Faculty All fellows are directly supervised by an ENT attending through the rotation. Patients will be jointly evaluated with the ENT attending, who will be responsible for finalizing all treatment plans. 39
  • 40. EDUCATIONAL CONFERENCES ACGME certification guidelines require that the fellows’ attendance at conference be documented. Fellows must sign the attendance sheet at every conference. Fellows are expected to attend 60% of the CSRN/Sleep Division conferences per year. Compliance with this requirement will be determined by review of the attendance sign-in sheets. Fellows who do not meet a 60% attendance level will not be certified for the ABIM Sleep Medicine exam. The program coordinator should be notified preferably by email if a fellow is unable to attend a particular conference and needs to be excused. • The conferences are posted on the Sleep Center website and include: http://www.uphs.upenn.edu/sleepctr/conferences/conf_semin_200304.htm • Sleep Summer Lecture Series (July, August, and September) 3624 Market Street – Monday, Thursday, Friday 12pm-1pm. • Sleep Clinical Case Conference (September – June) 3624 Market Street – Monday, 12pm-1pm. • Sleep Grand Rounds (September – June) 3624 Market Street – Thursday 12pm-1pm. • Sleep Journal Club (September – June) 3624 Market Street – last Thursday of the month 12pm-1pm. • CSRN Invited Speakers Research Seminar – Location TBD. One Friday a month 12pm-1pm. • Fellows are expected to participate in weekly conferences as an essential part of their training. Fellows present cases and discuss topics at the following conferences: • Sleep Clinical Case Conference (September through June). These conferences will consist of clinical case presentations by fellows, followed by a focused discussion of relevant literature. Fellows are encouraged to select cases that they have directly encountered in their outpatient practices. These may include common presentations of unusual conditions, unusual presentations of a particular syndrome, a management dilemma, etc. For guidance on appropriate cases, fellows should contact Drs. Alex Mason or Charles Cantor one month prior to the conference. 40
  • 41. • Guidelines for Sleep Clinical Case Conference: 1. Try to present an interesting case. Pick cases that are interesting to you or have interesting twist to them. However, even run of the mill OSA or obesity-hypoventilation patients have many interesting comorbities or novel treatments associated with them. 2. Plan your talk for no longer than 45 minutes. By the time people arrive and you get started (plus people like to ask lots of questions during conference), the whole hour will pass by. A good rule of thumb is 1 slide = 1 minute. However, some slides, especially ones with lots of graphics can take longer so you need to take that into account. 3. Focus your presentation. Focus your clinical case conference on a specific topic. For example, if you are presenting a patient with narcolepsy with cataplexy, you may want to spend your conference talking about novel medications used for narcolepsy or the value of the MSLT in diagnosing narcolepsy, etc., rather than reviewing all of narcolepsy in 45 minutes. People walk out with more if you focus your discussion. 4. Make simple slides. Limit your slides to at most seven bullet points. Don’t type a paragraph out. Don’t put tables that are overly complicated or crammed. Use simple statements and relatively simple figures. Don’t put five figures from a paper onto 1 slide. Otherwise, you will lose your crowd. Also, color helps keep people’s attention. However, remember that many people are red/ green color blind so be wary of using these colors too often. 5. Use summary of history and physical during clinical case conference. You don’t need to include every detail, just the pertinent ones. Someone will ask you about a particular issue if they really want to know. 6. Try to use patient’s data such as PSG data, sleep logs, actigraphy, MSLT, etc. You don’t need to include the whole sleep study but some interesting epochs. It is a great chance for people to learn and discuss especially with faculty there. 7. Handouts are very useful. Your handout should include a good review paper on that topic or at least a copy of your slides. 41
  • 42. 8. Have fun! You really learn so much doing these conferences and the things you present will stick with you for a long time. Also, doing presentations will help polish your public speaking skill. 9. THE SHOW MUST GO ON! That is, you can't cancel...you need to find someone to cover you. • Sleep Journal Club. These conferences are held on the last Thursday of each month. Please see guidelines below: JOURNAL CLUB MISSION • To review influential papers in the field of sleep medicine. • To provide a forum for discussion of state of the art ideas. • To provide an opportunity for trainees to practice public speaking. Papers Chosen In general, every effort should be made to pick high impact papers. Preference should be given to papers published in high impact journals such as Nature, Neuron, Science, Sleep, The blue journal, etc. The impact factor of journals can be found at http://www.sciencegateway.org/impact/if03bc.htm and in most cases an impact factor of >5 is preferred. Papers should be current, preferably published within the last year. In occasional cases, older literature can be presented if, for example, it represents the current state of the art of a particular field. Papers chosen by fellows should be approved no less than 2 weeks in advance by a faculty mentor (see below) Only primary articles will be presented. No Review or opinion articles. Mentorship of Fellows A fellow will be responsible for choosing a faculty mentor to • Approve the paper for journal club • To help in journal club preparation • To come to the presentation and help generate discussion. For guidance on appropriate articles and/or choice of faculty mentor, fellows should contact Grace Pien or David Raizen one month prior to the conference. Presentation Format Because of the wide spectrum of expertise in the Penn sleep community, presentations should include a detailed background and rationale for the paper. 42
  • 43. Though the format should be informal to encourage discussion, PowerPoint presentations are preferred, in particular for trainees. 43
  • 44. PSG SCORING AND INTERPRETATION ADULT & PEDIATRIC SLEEP TRACK Fellows need to learn how to perform patient set-ups, and how to score and interpret the various sleep evaluations. They should be familiar with the PSG amplifiers/equipment used to collect and record the data. PSG practical sessions to review these concepts will be held every Thursday afternoon at 3624 Market Street and will run for 8 weeks beginning in July. • Subsequent to these Thursday afternoon sessions, scoring, review and interpretation of clinical studies including overnight PSGs, CPAP/BIPAP titrations, MSLTs/MWTs and actigraphy performed at HUP, Sheraton, Phoenixville and Doylestown will take place in a group setting under the direction of a faculty member. • Skills specific to interpretation of pediatric sleep studies have been incorporated into the summer PSG series. Real time PSG review and interpretation of pediatric clinical studies will occur in formalized settings at CHOP under the direction of a faculty member. • Rotations at the PVAMC will incorporate PSG interpretation, both laboratory and home based. 44
  • 45. SUPERVISION POLICIES AND PROCEDURES AT ALL CLINICAL SITES All Fellow notes must be co-signed by an attending. ALL FELLOW NOTES MUST CONTAIN EVIDENCE OF ATTENDING SUPERVISION. THIS IS A REQUIREMENT. Attendings must write an addendum or separate note on all initial visits and inpatient and outpatient consults EVALUATION METHODS A competency-based evaluation matrix is available at the end of the curriculum. The evaluation methods utilized during the various rotations include: • Web enabled competency-based evaluation forms that are completed by faculty at the end of each rotation • 360° evaluations completed at least semi-annually by clinical support staff, nursing and sleep laboratory technical staff • Mini-CEXs are completed at least four times during the fellowship • Review of PQIPs are evaluated by faculty preceptors • Review of QA scoring are evaluated by faculty preceptors • Procedure logs/Portfolios • ABIM sleep board summative exam results Each fellow will receive a mid-year review with an evaluative summary of evaluations thus far by the Program Director. An exit interview at the end of the clinical year will comprise of a more comprehensive evaluative summary based on a review of the various aspects of the evaluation matrix by the Program Director. 45
  • 46. EVALUATION TOOLS • SAM_E (Self-Assessment Mid-Rotation Evaluation) Tool: Fellows must complete one SAM_E in each half of the year, for a total of two for the fellowship. Mini-CEX: Fellows must complete 3 Mini-CEX in each block, for a total of at least 6 for the year. • PQIP/Chart Audit: 5 charts should be audited after November of the academic year. These will be reviewed and discussed at the mid-year evaluation. An action plan for improvement will be developed. A subsequent audit of 5 additional charts (such that 10 total chart audits will be performed over the course of the year) will occur prior to the end of the academic year. • QA Scoring: Fellows will participate in two QA scoring assessments along with sleep technicians. Direct feedback about personal performance and how it relates to the group will be given by the faculty supervisor for this initiative. 46
  • 47. SICK DAYS/VACATION POLICIES • Fellows are excused from their continuity clinic(s) and VA clinic on holidays and during the week of the APSS annual meeting. Fellows are also excused from their elective clinics when the attending is on vacation or has cancelled his/her clinic. • Fellows have 4 weeks of vacation time during their clinical year. Fellows must notify the Fellowship Director and Program Coordinator, in writing, of dates when they plan to take vacation or administrative leave. These requests should be submitted at least one month in advance. In addition, the scheduling/administrative staff of the participating clinic should be notified IN WRITING. If a fellow is absent from clinic for administrative leave or vacation, it is the fellow’s responsibility to notify the clinical staff and the supervising physician. If it is less than 6weeks from the date of the scheduled clinic, it is the fellow’s responsibility to find coverage for those hours and those patients. Patients are scheduled for these clinics with the understanding that a fellow will be attending these clinics; the Fellowship Program promotes good clinical practice, which includes keeping appointments and avoiding last-minute cancellations. • If a fellow is unable to attend a continuity clinic due to a sudden illness that does not allow arranging for a substitute, he/she should notify both the clinic attending and the Program Coordinator at his/her earliest convenience. These patients should then be rescheduled for an alternate time slot whenever possible. PLEASE NOTE THAT ONLY TWO SUCH EMERGENCIES WILL BE ALLOWED. SUBSEQUENT INFRACTIONS WILL RESULT IN AN EXTENSION OF TRAINING TO FULFILL CLINICAL COMMITMENTS. 47
  • 48. RESEARCH • While there is no formal research requirement during the ACGME clinical year, sleep fellows are encouraged to participate in scholarly activities which are ongoing in the Division. This may include oral or poster presentations at local and national meetings, community outreach/education and/or participation in various forms of patient-oriented research which is ongoing in the Division of Sleep Medicine and the Center for Sleep and Respiratory Neurobiology. • Fellows can start to meet with Researchers Investigators 6-8 months into their clinical year to determine which research program they might like to participate in after their clinical fellowship. 48
  • 49. Important Forms  Outpatient Clinic Reduction or Cancellation Request Form  Mini-CEX Form (Assessment Tool)  SAM_E Tool (Assessment Tool)  Departmental Phone Lists  Chart Audit (Assessment Tool) 49
  • 50. OUTPATIENT CLINIC CANCELLATION OR REDUCTION REQUEST FORM REQUEST MUST BE RECEIVED THIRTY DAYS PRIOR TO EFFECTIVE DATE Process for Requesting Cancellation or Reduction: 1. Sleep Fellow must first get approval from the Fellowship Director (Ilene Rosen, MD). 2. Once request has been approved, Sleep Fellow provides Practice Manager (Samantha Cartagena), Patient Service Representative (Tiffany Brown), their Primary Attending Physician, and the Fellowship Coordinator (Kim Battillo) this form for date of clinic cancellation or reduction. REQUEST MUST BE RECEIVED THIRTY DAYS PRIOR TO EFFECTIVE DATE Today’s Date: ____________ Effective Date of Change: _______________ Name of Clinic: _________________________________________________________ Name of Provider: _______________________________________________________ Type of Change Requested: Cancellation Reduction Justification for Change: _______________________________________________ ______________________________________________________________________ ______________________________________________________________________ “I certify that I have reviewed the IDX schedule and that the date for rescheduling of each patient is appropriate based on the condition of the individual patient.” __________________________________________ Sleep Fellow’s Signature Approve/Disapprove: ________________________________________________________________ Program Director Date 50
  • 51. UNIVERSITY OF Division of Sleep Medicine PENNSYLVANIA Sleep Fellowship Program HEALTH SYSTEM MINI-CEX FORM Evaluator: _______________________________ Date: __________________ Fellow: _______________________________ Patient Problem/Dx: ______________________________________________________ Settings: __ Ambulatory __ Inpatient __ ED __ Other Patient: Age: ____ Sex: ____ __ New __ Follow-up Complexity: __ Low __ Moderate __ High Focus: __ Data Gathering __ Diagnosis __ Therapy __ Counseling 1. Medical Interviewing Skills Unsatisfactory Satisfactory Superior Facilitates patient’s telling of story; N/A 1 2 3 4 5 6 7 8 9 Effective use of questions and Directions to obtain accurate, adequate information needed; responds appropriately to affect, non-verbal cues. 2. Physical Examination Skills Unsatisfactory Satisfactory Superior Follows an efficient, logical sequence; N/A 1 2 3 4 5 6 7 8 9 Appropriately selective balance of screening, diagnostic steps for problem; alerts patient of next moves, attends to patient’s comfort, modesty. 3. Counseling Skills Unsatisfactory Satisfactory Superior Explains rationale for test and treatment, N/A 1 2 3 4 5 6 7 8 9 obtains patient’s consent, educates/ counsels regarding management. 51
  • 52. 4. Clinical Judgement Unsatisfactory Satisfactory Superior Selectively orders or performs diagnostic N/A 1 2 3 4 5 6 7 8 9 studies appropriate to patient’s perspective with medical facts, costs, risks, benefits; informs patient of appropriate diagnostic possibilities. 5. Humanistic Qualities/Professionalism Unsatisfactory Satisfactory Superior Demonstrates respect, compassion, N/A 1 2 3 4 5 6 7 8 9 empathy, establishes trust; attends to patient’s needs for comfort, modesty, confidentiality, information, encouragement. 6. Overall Clinical Competence Unsatisfactory Satisfactory Superior Judgement, synthesis, caring, analysis, N/A 1 2 3 4 5 6 7 8 9 effectiveness, efficiency. Total time observing: _______ minutes Total time providing feedback: _______ minutes Evaluator Satisfaction with Mini-CEX Low High Fellow Satisfaction with Mini-CEX Low High Please forward completed form to Kim Battillo. 52
  • 53. Self-Assessment Mid-Rotation Evaluation (SAM_E) Tool (For discussion with the preceptor evaluating the fellow.) Specific Rotation Competencies Resident Attending Ways to keep improving. (Fellow and preceptor brainstorm (Learning expectations for rotation.) Rating.* Rating.* ways to keep improving in given area. Fellow progress to be (How I feel I (Preceptor rates reviewed during final evaluation with preceptor.) am doing.) how I’m doing.) 1. Perform an adequate medical history and physical exam on patients in outpatient sleep clinic 2. Interpret polysomnograms and other diagnostic sleep evaluation 3. Demonstrate knowledge about established and evolving biomedical, clinical, and cognate sciences for OSA 4. Demonstrate knowledge about established and evolving biomedical, clinical, and cognate sciences for narcolepsy 5. Application of medical knowledge to patient care for OSA 6. Application of medical knowledge to patient care for narcolepsy 7. Communication and interaction with other health care providers to get CPAP ordered 8. Communication and interaction with patients and their families 9. Sensitivity to patients of diverse backgrounds 10. Carrying out professional responsibilities and adherence to ethical principles 11. Knowledge of practice and delivery systems for treatment of OSA 12. Practice cost effective care 13. Use evidence from scientific studies 14. Facilitate learning of others *Score 1-3, 1=needs improvement; 2=appropriate for level of training; 3=competent at the level expected of graduating fellow. 53
  • 54. CENTER FOR SLEEP AND RESPIRATORY NEUROBIOLOGY And DIVISION OF SLEEP MEDICINE PHONE LIST (Includes faculty, staff and postdoctoral fellows) (Modified: June, 2007) NAME LOCATION PHONE NUMBER EMAIL PAGER ACCARDO, Jennifer, M.D. 3624 Market, Ste 205 590-9176 accardo@email.chop.edu 590-1000 x14791 AHMED, Murtuza, M.D. 3624 Market, Ste 205 615-4199 murtuza.ahmed@uphs 314-0475 AL-SHEHABI (McGee), Erica 3615 Chestnut, #236 615-0141 ericamcg@mail.med ANASTASI, Matthew, RPSGT 11 West Gates 615-1630 matthew.anastasi@uphs ANTONIOU, Maria, M.D. 3624 Market, Ste 201 615-4847 maria.antoniou@uphs 267-481-3385 (cell; no pts) ASHMORE, Lesley, Ph.D. 2130 TRL 746-4817 hickman@mail.med AYENE, Anou 971 Maloney 614-0080 ayene@mail.med BARRETT, Daniel C. 2119 TRL 746-4801 dbarrett@mail.med BATTILLO, Kimberley 3624 Market, Ste 205 615-0980 kim.battillo@uphs BECKETT, Barbara 3624 Market, Ste 205 662-3287 bbeckett@biomedstat.com BEOTHY, Elizabeth 3624 Market, Ste 205 615-4112 eabeothy@mail.med BERGMANN, Andrea, R.N. 3624 Market 662-6262 georenoa@uphs 961-5267 BLECKMAN, Inna 991 Maloney 662-3189 bleckman@mail.med BRENNICK, Michael, Ph.D. VA Med Ctr 823-5800 x6531 brennick@mail.med BROTHERS, Cynthia 972 Maloney 614-0082 cynthia.brothers@uphs BROWN, Tiffany 3624 Market, Ste.201 615-3693 tiffanyb@uphs CALAMARO, Christina, Ph.D. 316 NEB 898-0761 calamaro@nursing CANTOR, Charles, M.D. 3624 Market, Ste 201 615-4838 crcantor@pahosp.com 422-5361 CATER, Jacqueline, Ph.D. 3624 Market, Ste 205 662-3287 jcater@mail.med CHAKRAVORTY, Subhajit, M.D. 3624 Market, Ste 205 823-5800 x 3405 subhajit.chakravorty@uphs 265-0976 CHI, Luqi, M.D. 3624 Market, Ste 205 615-4197 luqi.chi@uphs 403-8452 CROWLEY, Colleen 11 Gates 615-1632 colleen.crowley@uphs FELDMAN, Andrew Ralston Penn Ctr 573-3429 afeldma4@mail.med FENIK, Polina 2111 TRL 746-4821 polina@mail.med 54
  • 55. NAME LOCATION PHONE NUMBER EMAIL PAGER FERBER, Megan 2111 TRL 746-4821 FERGUSON, Karimah 11 West Gates 615-1630 karimah.ferguson@uphs FRIEDMAN, Eliot, M.D. 3624 Market, Ste 205 615-0954 eliot.friedman@uphs 312-0162 GALANTE, Raymond J. 2118 TRL 746-4808 galante@mail.med GOOD, Virginia 2111 TRL 746-4823 vp@mail.med GOONERATNE, Nalaka, M.Sc., M.D. Ralston Penn Ctr 349-5938 ngoonera@mail.med 812-2411 GURUBHAGAVATULA, Indira, MD 3624 Market, Ste 205 662-3301 gurubhag@mail.med 961-1072 HACHADOORIAN, Robert 3624 Market, Ste 205 662-3287 hach@biomedstat.com HUGHES, John 3624 Market, Ste 205 HURLEY, Sharon 3624 Market, Ste 205 662-3287 hurley@mail.med JONES-PARKER, Mary, RRT, RPSGT 11 West Gates 615-1633 mfjones@mail.med KIM, Eugene 3624 Market, Ste 205 349-8980 keugene@sas KUNA, Samuel, M.D. VA Med Ctr 823-4400 skuna@mail.med 581-8041 LIAN, Jie 2131 TRL 746-4824 jielian@mail.med MACKIEWICZ, Miroslaw, Ph.D. 2124 TRL 746-4805 mirekmm@mail.med MAISLIN, Greg, M.S., M.A. 3624 Market, Ste 205 610/645-5708 gmaislin@biomedstat.com MARIE, Elisabeth 309 Ralston Penn 746-3098 felisa@mail.med MAYCOCK, Matthew 2131 TRL 746-4824 maycock@mail.med MONTOYA, Jennifer TRL 746-4802 jennifer.montoya@uphs NAIDOO, Nirinjini, Ph.D. 2116 TRL 746-4811 naidoo@mail.med NKWUO, J. Emeka, Ph.D. 3624 Market, Ste 205 615-4867 jnkwuo@mail.med OTTO, Cynthia, D.V.M., Ph.D. 2117 TRL 746-4810 cmotto@vet PACK, Allan I., M.D., Ph.D. 2120 TRL 746-4806 pack@mail.med PACK, Frances, R.N. 812 East Gates 614-1807 fmpack@mail.med 812-4103 PALMA, Jonathan 11 West Gates 615-1630 palmaj@mail.med PATEL, Nirav, MBBS 3624 Market, Ste 205 615-4198 nirav.patel@uphs 265-2741 PIEN, Grace, M.D. 3624 Market, Ste 205 614-0081 gpien@mail.med 314-0981 PLATT, Alec, M.D. 3624 Market, Ste 205 615-4868 alec.platt@uphs 308-4649 RAIZEN, David, M.D., Ph.D. 2122 TRL 746-4809 raizen@mail.med 838-5093 55
  • 56. NAME ROOM NO. PHONE NUMBER EMAIL PAGER ROBINSON, Mary 2111 TRL 746-4819 marobins@vet RODWAY, George, Ph.D. 224 NEB 898-0761 rodway@nursing ROGERS, Ann E., Ph.D., R.N. 429L NEB 573-7512 aerogers@nursing ROMER, Micah 2111 TRL 746-4821 mromer@mail.med ROSEN, Ilene, M.D. 3624 Market, Ste 205 615-4719 irosen@mail.med 812-3457 SANFILIPP-COHN, Benjamin 2111 TRL 746-4821 SCHARF, Matthew 2130 TRL 746-4816 mscharf@mail.med. SCHUTTE-RODIN, Sharon, M.D. 3624 Market, Ste. 201 615-4841 sharon.rodin@uphs 308-1268 SCHWAB, Richard, M.D. 3624 Market, Ste 205 349-5477 rschwab@mail.med 980-1934 STACHE, Stephen 11 West Gates 615-1630 stephen.stache@uphs STALEY, Beth, RPSGT 11 West Gates 615-1634 beth.staley@uphs VEASEY, Sigrid, M.D. 2115 TRL 746-4812 veasey@mail.med 401-8333 WEAVER, Terri, Ph.D., R.N. 406 NEB 898-2992 tew@nursing WIELAND, William 11 West Gates 615-1630 william.wieland@uphs WU, Mark, M.D., Ph.D. 3624 Market, Ste 205 615-4199 marknwu@mail.med 577-1130 ZHAN, Guan Xia, M.D. 2111 TRL 746-4821 guanz@mail.med ZHANG, Kathy VA Med Ctr 823-5800 kzhang3@mail.med ZHANG, Lin, M.D. 2111 TRL 746-4821 zhanglin@mail.med ZHU, Yan 2130 TRL 746-4818 zhuy@mail.med ZIMMERMAN, John, Ph.D. 2125 TRL 746-4804 johnez@mail.med All “uphs” and “mail.med” email addresses end with “.upenn.edu” PHONE FAX Sleep Lab, Market Street, Suite 201 662-7772 349-8038 Sleep Outpatient Practice – Market Street, Ste 201 615-3669 615-3671 Sleep Outpatient Practice – Radnor 610-902-5600 610-902-5609 Center for Sleep/Market Street, Ste 205 662-3305 662-7749 Center for Sleep/TRL 746-4813 746-4814 Clinical Research Center for Sleep - HUP 615-1630 615-1635 56
  • 57. CHOP SLEEP MEDICINE PHONE LIST Name Position Email Phone Pager Beck, Suzanne E., M.D. Attending becksu@email.chop.edu (215) 590-6918 18788 brooksl@email.chop.edu (856) 435-1300 (215) 819-6516 Brooks, Lee J., M.D. Attending (x. 31495) Brown, Larry M.D. Attending brownla@email.chop.edu (267) 426-5842 14829 267.426.5842 Cornaglia, Mary Anne Secretary, Sleep Center cornaglia@email.chop.edu (215) 590-3500 (fax) DiFeo, Natalie Nurse Practitioner difeo@email.chop.edu (267) 426-5842 19337 Elliott, Joanne Sleep Lab Manger elliott@email.chop.edu (215) 590-3703 Attending marcus@email.chop.edu Marcus, Carole L., M.B.B.Ch. (215) 590-4406 (215) 905-0325 Director, Sleep Center masont@email.chop.edu Mason, Alex, M.D., Ph.D. Attending (215) 590-0810 (215) 980-0495 Lisa Meltzer, Ph.D. Attending meltzerl@email.chop.edu (267) 426-5842 Associate Director, Mindell, Jodi , Ph.D. mindell@email.chop.edu (267) 426-5842 15411 Sleep Center Sleep Lab Technician Area (215) 590-9176 Sleep Lab tate@email.chop.edu (215) 590-3703 Tate, Mary Office Coordinator (215) 590-2632 (fax) VA SLEEP MEDICINE PHONE LIST Name VA Telephone Email Amy Sawyer 2574 asawyer@nursing.upenn.edu Khena Hin 4299 sakhena.hin@va.gov Les Gellis 3450 leslie.gellis2@va.gov Raj Gupta pending s0538655@monmouth.edu Jackie Ferguson 4435 or X2771 jacqueline.ferguson@med.va.gov Sam Kuna 4400 skuna@mail.med.upenn.edu 57