Loading…

Flash Player 9 (or above) is needed to view presentations.
We have detected that you do not have it on your computer. To install it, go here.

Like this document? Why not share!

Sleep Fellowship Training Program Guide.doc.doc.doc.doc

on

  • 806 views

 

Statistics

Views

Total Views
806
Views on SlideShare
806
Embed Views
0

Actions

Likes
0
Downloads
2
Comments
0

0 Embeds 0

No embeds

Accessibility

Upload Details

Uploaded via as Microsoft Word

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

Sleep Fellowship Training Program Guide.doc.doc.doc.doc Sleep Fellowship Training Program Guide.doc.doc.doc.doc Document Transcript

  • 10/25/10 2009-2010 ACGME SLEEP MEDICINE FELLOWSHIP TRAINING PROGRAM Program Director: Ilene Rosen, MD, MSCE Associate Program Director: Alex Mason, MD, PhD, MSCE Program Coordinator: Kimberley Halscheid 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 multidisciplinary, 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.
  • TABLE OF CONTENTS I. The Six ACGME Competencies 3-4 II. Duty Hours/Moonlighting 5 III. Program Goals and Objectives 6 IV. Clinical Training Requirements 7 V. Outpatient Sleep Clinics 8-9 VI. Dictation and Chart Maintenance 10-13 VII. Sample Rotation Schedules 14 VIII. Inpatient Sleep Rotations 15-16 IX. Rotation-Specific Learning Objectives 17-45 1. Adult Outpatient Rotation 17-28 1a. UPHS Sleep Medicine Ambulatory Experience 17-22 1b. PVAMC Sleep Medicine Ambulatory Experience 23-28 2. HUP PSG Interpretation and Inpatient Consultation Rotation 29-34 3. Pediatric Sleep Medicine Rotation (CHOP) 35-40 4. Pediatric Otolaryngology Rotation (CHOP) 41-45 X. Educational Conferences 46-48 XI. PSG Scoring and Interpretation 49 XII. Evaluation and Assessment 50 XIII. Sick Days/Vacation Policy 51 XIV. Research 52 XV. Important Forms 53 2
  • THE SIX ACGME 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 View slide
  • 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 View slide
  • 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
  • DUTY HOURS/MOONLIGHTING The Fellowship’s policies on duty hours and moonlighting mirror those of the health system. This information can be found on the GME Policy CD provided and will be sent to you electronically by the Program Coordinator. 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 c. Perform a chart audit looking at agreed upon minimum requirements of evaluation and management of patients with various sleep disorders d. Compare polysomnographic scoring abilities against a gold standard 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. Timely 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 (60%) 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 7
  • CLINICAL TRAINING REQUIREMENTS  Each fellow is expected to evaluate 200 new patients in the adult sleep medicine outpatient practice.  Each fellow is expected to provide continuous care to 300 follow-up patients in the adult sleep medicine outpatient practice.  Each fellow is expected to evaluate at least 40 new patients in the pediatric sleep medicine outpatient practice.  Each fellow is 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 is expected to review and interpret 200 polysomnographic studies, of which a minimum of 40 need to be pediatric-based.  Each fellow is expected to review and interpret 25 Multiple Sleep Latency Tests (MSLTs) and/or Maintenance of Wakefulness Tests (MWTs).  Each fellow is expected to score 25 polysomnograms, at least 5 of which must be in children.  Each fellow will keep a log of his/her clinical activities that documents: the date of visit; the supervising faculty member’s name; initials, MRN and DOB of patients seen in clinic and their diagnoses; date, PSGs interpreted, PSGs scored and MSLTs/MWTs interpreted. This log will be used to document that the fellow has fulfilled the clinical requirements set by the ACGME. These forms when completed must be turned into the Program Coordinator on a monthly basis for placement in portfolios. 8
  • 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 (Ilene Rosen, MD), the Medical Director (Charles Cantor, MD) and the Division Chief (Allan Pack, MB, ChB, PhD). Therefore, whenever possible, any cancellations must be made 6 weeks in advance in writing to the Program Director, Program Coordinator (Kim Halscheid) and the scheduling staff of the appropriate clinic (Tiffany Brown). Pediatric Rotation (CHOP) – 2 months  Each fellow will be assigned 9 ½-days per week at CHOP. Adult Rotations (HUP/PVAMC/PSG Consult) – 10 months total scheduled over the course of the year (including 4 weeks vacation). HUP Adult Rotation  Each fellow will be assigned a minimum of 5 ½-day per week adult clinics. The rest of the rotation is devoted to PSG review and administrative time. PVAMC Rotation  Each fellow will be assigned 9 ½-days per week at the PVAMC (this includes a minimum of 5 ½-day per week clinics, administrative time, and PSG interpretation). PSG/Consult Rotation  Each fellow will be assigned at most 2 ½-day clinics per week (weekly continuity clinic and one ½-day clinic per week at the PVAMC). The rest of the rotation is devoted to reading PSGs and completing consults. PEDIATRIC SLEEP TRACK Continuity Clinic  Each fellow will be assigned one full day per week continuity clinic (½ day per week adult continuity clinic and ½ day per week pediatric continuity clinic). The fellow will attend these clinics throughout the year in order to learn about the chronic management of patients with sleep disorders. Each continuity clinic will be staffed by a faculty member of the Sleep Medicine Division. 9
  •  Continuity clinic at HUP is scheduled on a monthly basis throughout the year (2 full days/month, for example).  As per the policies of CPUP and the Department of Medicine, all absences/cancellations must be scheduled in writing at least 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 Medical Director and the Division Chief. Therefore, whenever possible, any cancellations must be made 6 weeks in advance in writing to the Program Director (Dr. Ilene Rosen), the Program Coordinator (Kim Halscheid) and the scheduling staff of the appropriate clinic (Tiffany Brown).  Continuity clinic at CHOP is scheduled on a weekly basis throughout the year.  Absences/cancellations must be scheduled at least 6 weeks in advance to be considered an excused absence except for illness, family emergencies, etc.  Cancellations must be made 6 weeks in advance in writing to the Associate Program Director (Dr. Alex Mason), the Program Coordinator (Kim Halscheid) and the appropriate scheduling staff. Adult Rotations (HUP/PVAMC/PSG Consult) – 4 months total HUP Adult Rotation  Each fellow will be assigned a minimum of 5 ½-day per week adult clinics at HUP and one ½-day per week clinic at the PVAMC. The rest of the rotation will be devoted to PSG review and administrative time. PSG/Consult Rotation  Each fellow will be assigned only to their continuity clinics (adult and pediatric). The rest of the rotation is devoted to reading PSGs and completing consults. Pediatric Rotation (CHOP) – 8 months scheduled over the course of the year (including 4 weeks vacation).  Each fellow will be assigned 9 ½-days per week at CHOP (this includes clinic, administrative time, and PSG interpretation). 10
  • ADULT CONTINUITY CLINIC GENERAL CLINIC LAYOUT AND FLOW - The patients come into the waiting room and are greeted by one of the front desk staff. They sign in and the time they arrive is recorded. - The Medical Assistant (MA) triages the patient (takes their vitals) and records the time that this is done. - The chart is placed in the respective doctor’s bin, ideally in order of patient appointment time (you can double check with your schedule to be sure patients in the proper order). - Once you have seen the patient, they wait in their room for you to review with the Attending (which is done in the Control Room). - The Attending meets and examines the patient. - The Fellow finishes up any paperwork (for ex, ordering PSG, writing for F/U and mask clinic, filling out mask clinic form) and walks the patient to Check-out. - The charts must be given to the Attending at some point for them to do their documentations. - Once the Attending has documented, the chart is returned to the fellow for you to finish any notes and do dictations. - If there are CPAP/mask orders, the chart must be given to Christy Cellucci. - If there are no orders, the chart is returned to the file room. - Please remember to sign and date on every line! In order for the flow to be optimized and everyone’s frustrations minimized, our philosophy is for all the members of the team to be proactive: if you have a tough patient and are running behind, alert the attending and he or she can route your next patient to someone else if possible; if you see the MA is overwhelmed and cannot get to your patient, you can take the vitals in the room; if your patients no-show, check with the Attending if someone else is running behind, download a compliance card, etc., etc. CHART (please see also DICTATIONS AND CHART MAINTENANCE below) - A new patient chart will come with the patient questionnaire filled out; this is reviewed with the patient and you can expand on relevant issues. - The medication/allergy sheet is also filled out; if any medications are started, they need to be added to this sheet. - Once you have finished charting, there is a sheet on the inside front cover on which you should list all diagnoses. - New patient charts will occasionally have PSGs in them already (if PSG done before office visit). - Medview/EPIC can be used to look up previous laboratory testing; there is access to these systems from all the rooms. - For follow-up patients on CPAP, the MA (Michelle Durant or Christy Cellucci) will have downloaded the compliance data for you. The mask clinic rep can also do this, as can Andrea Bergmann, RN or Megin Myers, CRNP, if they are free. 11
  • MASK CLINIC - We have a mask clinic on all days. - This is a clinic run by Home Care companies who provide a service to us and our patients. They help with mask fitting and any other technical issues. Occasionally, they can set up a pt with CPAP on the same day (if pt severe, for example) but this MUST be cleared with Christy first. For all mask clinic visits, patients will sign in to the first-come-first-serve list, after they finish their appointment with you. It is important to explain to them that as this is not a scheduled visit, they may have another wait before being seen in the mask clinic. SUPPORT STAFF - Michelle Durant and Christy Cellucci are our MAs: they do vitals and CPAP compliance card downloads. Christy does all CPAP ordering. - Andrea Bergmann, RN and Megin Myers, CRNP are our excellent nurses; Andrea sees pts and has particular expertise in mask problems; Megin sees follow-up patients, either OSA or insomnia (so far she is not seeing other pt types). - Samantha Simonsen is the lab manager and can do just about anything! - Bob Warrell is the head technologist who is excellent and can help you with any PSG questions. - All support staff are extremely helpful. Please don’t forget to show your appreciation of their time and energy! MAILROOM - There is a Medical Record room in the back hallway where Sleep charts are kept. - Your Mailbox is in there. Please check on a daily basis. You may find pt calls, compliance card downloads to review, medications to renew, etc. If you need anything faxed/mailed, there are appropriate bins for this in the Front Desk area. Once you are done with any chart, please return to the “To be filed” bin in the mailroom. DICTATIONS AND CHART MAINTENANCE For patients you see in your adult fellows’ continuity practice, please dictate the follow- up notes as well as the consult letter. It is good structure for us as consultants to send letters to referring physicians, even if nothing much has apparently changed. It is good for them to know what is going on with the patient so that they can answer any patient- related questions better. Also, what seems to be “routine” to us with CPAP, may not be routine for a PCP. NOTE: Please double check with other attendings for what they would like for their follow-ups. 1. Please use both the patient’s DOB & MRN at the head of letter. 2. When seeing a new patient sent to us by another physician, please thank the physician for consulting you on their patient Mr./Mrs. XXX. Alternatively, you could state that Mr./Mrs.XXX was seen in consultation by us in the Penn Sleep Center Outpatient Practice. DO NOT USE the word “referral” in your initial 12
  • introductory paragraph. This will actually change the appropriate billing code and can lead to fraud. 3. Please use full sentences and not fragments in your dictations. Use “The patient denies any history of snoring” rather than “Denies snoring.” If you use abbreviations like ESS or MSLT, please say what it stands for at least once. “Mrs. Jones underwent a Multiple Sleep Latency Test (MSLT) to evaluate her sleepiness.” Also, please give parameters for these tests. (e.g. the Epworth was XX out of 24 and this is consistent with pathologic sleepiness vs normal, etc) 6. Please have a full Impression & Plan which includes a description of what you are diagnosing and why as well as your management plan. A problem list is ok provided you put a “comment” section where you expand on the important items in the list. Alternatively you can list each problem in association with a written discussion about your thoughts processes as you manage that particular problem. Particularly remember that if you are diagnosing something a bit more unusual, like DSPS or narcolepsy, etc., further details about that disorder are warranted. You can have the dictation service create macros for you if this would be helpful. 7. Don’t forget to always include one of the following statements: ”seen & examined by [name of attending] who performed a history and physical examination and agree with diagnosis & treatment plan as outlined above” or “This patient was seen and examined under the supervision of Dr. XXXX, who performed a history and physical examination and participated in the formulation of the treatment plan as outlined above” 8. Finally, review & correct your letters on the Protype website (justfordoctors.com) This includes filling in the PCP name & address as well as the MRN & DOB if you didn’t have it when you dictate it. If you do not have this information, Lorraine, Deidre or Tiffany in the front office can get it upon request. 9. When you are completing your handwritten notes in the chart, please be certain you sign and print your name. 10. In addition, be sure that when you sign your name anywhere in the chart you also enter the date and time you signed the note. 11. Before you are finished with the chart, please make sure all forms are completed and signed by you & filled out [i.e., Medication List, Patient Intake Questionnaire including the patient problem summary list, and the Epworth Sleepiness Scale]. 12. Finally, please make sure an attending has co-signed your note. ALL FELLOW NOTES MUST CONTAIN EVIDENCE OF ATTENDING SUPERVISION. The 13
  • attendings must write an addendum or separate note on all visits both in the inpatient and outpatient settings. If a patient is seen in the outpatient setting and for some reason does not see an attending physician (e.g. a patient has to leave to go to work and refuses to wait to see the supervising physician), document the reason clearly in the chart and circle “MED 999” on the patient encounter form the patient will bring to the front desk staff at check out. 14
  • SAMPLE ROTATION SCHEDULES Adult-Track HUP Adult Rotation 2009 Monday Tuesday Wednesday Thursday Friday UPHS Outpatient UPHS Outpatient UPHS Outpatient UPHS Fellows UPHS Outpatient 8am-12pm Clinic Clinic Clinic Continuity Clinic Clinic 12pm-1pm Conference Conference Conference Independent PSG UPHS Outpatient Independent PSG 1pm-5pm Administrative Time UPHS PSG Review Interpretation Clinic Interpretation Adult PSG/Consult Rotation 2009 Monday Tuesday Wednesday Thursday Friday UPHS Fellows 8am-12pm PSG Review PSG Review PSG Review PSG Review Continuity Clinic 12pm-1pm Conference Conference Conference 1pm-5pm Administrative Time PSG Review PVAMC Sleep Clinic UPHS PSG Review PSG Review Adult PVAMC Rotation 2009 Monday Tuesday Wednesday Thursday Friday PVAMC CPAP PVAMC Insomnia UPHS Fellows PVAMC Embletta 8am-12pm PVAMC Sleep Clinic Clinic Clinic Continuity Clinic Setup Clinic 12pm-1pm Conference Conference Conference PVAMC Insomnia PVAMC PSG/USS PVAMC PSG/USS 1pm-5pm Administrative Time PVAMC AutoCPAP Follow-up Clinic Reading Reading CHOP Pediatric Rotation 2009 Monday Tuesday Wednesday Thursday Friday Patient Review/ UPHS Continuity CHOP Pediatric PSG Review/CHOP 8am-12pm CHOP Inpatient CHOP PSG Review Clinic Outpatient Clinic Inpatient Consults 12pm-1pm Conference CHOP Conference Conference Conference UPHS PSG CHOP PSG 1pm-5pm CHOP PSG Review CHOP Sleep Clinic Clinic/Ped Sleep CHOP PSG Review Review Clinic Pediatric-Track HUP Adult Rotation 2009 Monday Tuesday Wednesday Thursday Friday UPHS Outpatient UPHS Outpatient UPHS Outpatient UPHS Fellows UPHS Outpatient 8am-12pm Clinic Clinic Clinic Continuity Clinic Clinic 12pm-1pm Conference Conference Conference Independent PSG Independent PSG 1pm-5pm Administrative Time PVAMC Sleep Clinic UPHS PSG Review Interpretation Interpretation Pediatric Rotation 2009 Monday Tuesday Wednesday Thursday Friday Patient Review/ CHOP Pediatric Administrative Time Adult Continuity 8am-12pm CHOP Inpatient CHOP PSG Review Outpatient Clinic Clinic Consults 12pm-1pm Conference CHOP Conference Conference Conference UPHS PSG CHOP PSG CHOP Continuity Adult Continuity 1pm-5pm CHOP PSG Review Clinic/Ped Sleep Review Clinic Clinic Clinic Adult PSG/Consult Rotation 2009 Monday Tuesday Wednesday Thursday Friday Adult Continuity 8am-12pm PSG Review PSG Review PSG Review PSG Review Clinic 12pm-1pm Conference CHOP Conference Conference Conference CHOP Continuity Adult Continuity 1pm-5pm Administrative Time PSG Review UPHS PSG Review Clinic Clinic 15
  • INPATIENT SLEEP ROTATIONS ADULT & PEDIATRIC SLEEP TRACKS  HUP Inpatient Consultations. Each fellow will be assigned a minimum of 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.  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 will review the 16
  • 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. These forms when completed must be turned into the Program Coordinator monthly for placement in portfolios. 17
  • ROTATION-SPECIFIC LEARNING OBJECTIVES  Adult Outpatient Rotation  UPHS Sleep Medicine Ambulatory Experience  PVAMC Sleep Medicine Ambulatory Experience  HUP Polysomnography Interpretation and Inpatient Consultation Rotation  Pediatric Sleep Medicine Rotation (CHOP)  Pediatric Otolaryngology Rotation (CHOP) Learning Objectives for Adult Outpatient Rotation: UPHS Sleep Medicine Ambulatory Experience Educational Rationale: Sleep Medicine Ambulatory Experience includes two major components: direct patient care and didactic sessions. In addition, there is one minor component, namely, hands-on experience with sleep studies and associated tools. The approach to care in the faculty-fellow practice is multi- disciplinary. The fellow has an opportunity to work 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. In addition, respiratory therapists, certified sleep technicians and medical assistants work on site to facilitate the care of patients with sleep disorders. 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 polysomnograms, 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 clinical practices experiences as well as a series of didactic initiatives. The most important component is the Sleep Medicine Continuity Practice (SMCP). Each fellow is assigned to a Continuity Practice based at one of three sites (3624 Market Street, Penn Medicine at Radnor, or Penn Sleep Medicine at Cherry Hill) under the direction of a faculty clinic director. 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. 18
  • 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 sleep medicine specific abstraction tool developed by the faculty and review 5-10 of their own charts with the tool. The data is summarized and an 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 5 to 6 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, and behavioral psychology. Furthermore, patient care is rounded out with exposure to the interpretations of sleep studies, including polysomnography, multiple sleep latency tests, maintenance of wakefulness tests, actigraphy and sleep logs. This occurs throughout the week independently and culminates in 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. 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 PQIP-- Personal Quality Improvement Project SMJC -- Sleep Medicine Journal Club PSGR -- Polysomnography Review SMRC -- Sleep Medicine Research Conference 1) Patient Care 19
  • 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 SMCP, FBP, PSGR, CCC tools 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, PSGR 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 SMCP, FBP, CCC, SMJC skills in the care of sleep medicine patients PQIP, Develop real-time strategies for filling knowledge gaps that SMCP, FBP, CCC, SMJC will benefit patients in a busy practice setting PQIP, 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, CCC, SMJC members of other health care professions to assure comprehensive patient care 20
  • 5) Professionalism 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, CCC 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 SMCP, FBP, CCC, SLS, PQIP, management in a variety of settings PSGR Begin to develop efficient practice patterns so patient care SMCP, FBP, CCC, SLS, PQIP, proceeds at an acceptable rate PSGR, 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 a minimum of 200 new adult sleep medicine patients • Provide continuous care to 300 adult sleep medicine patients • Attend 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 21
  • 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, including Harrison’s Textbook of Medicine. Ahrens, E.H. (1992). The Crisis in Clinical Research. New York: Oxford University Press. American Academy of Sleep Medicine. (2005). International Classification of Sleep Disorders (2nd Edition) Westchester, IL: American Academy of Sleep Medicine. American Academy of Sleep Medicine Clinical Practice Parameters. 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 & 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. (2005). Principles and Practice of Sleep Medicine (4th edition). Philadelphia: Elsevier, Inc. Libby, P., Bonow, R.O., Zipes, Mann, D.L. (2007). Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine: 2 Volume Set. (8th Edition) Philadelphia: W.B. Saunders Company. Marklund, M. (2001). Treatment of Obstructive Sleep Apnea with a Mandibular Advancement Device. Umea: Umea University. 22
  • Mazzoni, P., Pearson, T., & Rowland, L.P. (2006). Merritt’s Neurology Handbook (2nd edition). Lippincott Williams & Wilkins. Murray, J.F. & Nadel, J.A. (1994). Textbook of Respiratory Medicine: Volume 1 & 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. Spriggs, W.H. (2002). Principles of Polysomnography (1st edition). Salt Lake City: Sleep Ed, LLC. Additional educational resources include the didactic conference curriculum and primary review of laboratory and sleep studies in addition to radiology. Evaluation Methods The competency-based 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 • SAM-Es are completed at least twice 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 University of Pennsylvania 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 trainees 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. 23
  • PVAMC 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 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 Philadelphia VAMC (VISN 4 Eastern Regional Sleep Center) is a full service facility accredited by the American Academy of Sleep Medicine that provides health care for some 433,000 veterans living in the Philadelphia metropolitan area and surrounding seven counties. The medical center is affiliated with the University of Pennsylvania and is a 10 minute walking distance from the Hospital of the University of Pennsylvania and the Children’s Hospital of Philadelphia. The medical center’s sleep center receives referrals from two other VA medical centers and four surrounding regional VA outpatient clinic facilities. The sleep center conducts approximately 600 diagnostic polysomnograms (PSG) per year and 300 unattended home sleep studies. The patient population seen in the outpatient clinics is heterogeneous, including individuals from a wide range of socioeconomic and ethnic backgrounds. The medical center’s population consists of the following race/ethnic groups: (1) white, not of Hispanic origin, 47%; (2) black, not of Hispanic origin, 40%; (3) Hispanic, white, 2%; (4) Hispanic, black, <1%; (5) Asian or Pacific Islander, <1%; (6) American Indian or Alaskan native, <1%; unknown, 11% (Veterans Affairs Medical Center External Affairs Department). Fellows have an opportunity to evaluate and manage veterans with a broad range of sleep disorders. Post traumatic stress disorder (PTSD) and insomnia due to psychiatric disorders are 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 3 half-day outpatient clinic sessions (FBP) during which they supervise fellows’ evaluations of new and follow-up patients. 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 24
  • monitor or autoCPAP. The 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 home unattended sleep studies. On a weekly basis, the sleep center performs 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 these studies and finalize the interpretations. In addition, 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. The fellow and staff physician may see the patient together., or 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 at HUP (and CHOP, if applicable). The final component of the PVAMC sleep medicine educational program is the Sleep Medicine Conference Schedule, which includes 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 included a weekly clinical case conference, a sleep grand rounds lecture series, journal club and research conference. 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 RTCS – Respiratory Therapist Clinic Sessions SSR – Sleep Study Review SMCS – Sleep Medicine Conference Series 1) Patient Care Principal Educational Goals Learning Activities* 25
  • Effectively interview sleep medicine outpatients FBP Effectively examine sleep medicine outpatients FBP Maintain focus and timeliness in the evaluation and FBP management of sleep medicine problems Order appropriate diagnostic tests FBP Interpret portable monitoring studies and other diagnostic SSR, RTCS sleep evaluation tools 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 FBP, SMCS 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 26
  • 5) Professionalism 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 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 to a minimum of 100 new and 150 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 27
  • 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, including Harrison’s Textbook of Medicine. Ahrens, E.H. (1992). The Crisis in Clinical Research. New York: Oxford University Press. American Academy of Sleep Medicine. (2005). International Classification of Sleep Disorders (2nd Edition) Westchester, IL: American Academy of Sleep Medicine. American Academy of Sleep Medicine Clinical Practice Parameters. 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 & 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. (2005). Principles and Practice of Sleep Medicine (4th edition). Philadelphia: Elsevier, Inc. Libby, P., Bonow, R.O., Zipes, Mann, D.L. (2007). Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine: 2 Volume Set. (8th Edition) Philadelphia: W.B. Saunders Company. Marklund, M. (2001). Treatment of Obstructive Sleep Apnea with a Mandibular Advancement Device. Umea: Umea University. 28
  • Mazzoni, P., Pearson, T., & Rowland, L.P. (2006). Merritt’s Neurology Handbook (2nd edition). Lippincott Williams & Wilkins. Murray, J.F. & Nadel, J.A. (1994). Textbook of Respiratory Medicine: Volume 1 & 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. Spriggs, W.H. (2002). Principles of Polysomnography (1st edition). Salt Lake City: Sleep Ed, LLC. Additional educational resources include the didactic conference curriculum and primary review of laboratory and sleep studies in addition to radiology. Evaluation Methods The competency-based evaluation methods that apply to this rotation include: • Web enabled competency-based evaluation forms that are completed by faculty at the end of each rotation • 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 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. 29
  • Learning Objectives for HUP Polysomnography Interpretation and Inpatient Consultation Rotation: 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. Additionally, interpretation of sleep studies and associated tools is integral to the practice of Sleep Medicine. A system which provides hands-on approach leading to a mastery of scoring, interpretation and reporting is required. All clinical adult track fellows spend 4 months covering the Sleep Medicine Inpatient Consultation (SMIC) Service at HUP. This occurs in 2 to 4 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. Additionally, all fellows may 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 . 30
  • 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 throughout the week independently with supervised review of all studies occurring 2-3 times per week at dedicated times. The trainee will have primarily reviewed 10-15 studies per week in this fashion. Disease Mix/ Patient Characteristics: 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. The Penn Sleep Centers encompasses 4 sites in the greater Philadelphia area. There are studies performed 7 nights a week giving rise to a total of over 4000 studies per year. 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. PSG Review (PSGR) sessions which occurs multiple times per week with the PSG attending of the block as well as a once a week larger review session with all the fellows and 2 dedicated faculty preceptors. A core curriculum series reviews literature important to these interpretations including the basis for the scoring of sleep stages, respiratory events, arousals, periodic limb movements, etc. In addition to primary scoring, 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). 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 31
  • CCC -- Clinical Case Conferences PSGR – Polysomnography Review QA – Quality Assurance 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. Interpret polysomnograms and other diagnostic sleep evaluation tools PSGR, QA, CCC, SLS 2) Medical Knowledge Principal Educational Goals Learning Activities* 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, CCC, QA 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, QA 32
  • 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* 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 Collaborate with other members of the health care team to assure DPC, QA, CCC, CATR comprehensive sleep medicine outpatient care. 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 33
  • 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 inpatient/consultation team multidisciplinary team • Interpretation of 160 adult sleep interpretation. • Attend a minimum number of the required departmental conferences, including clinical case conference, sleep lecture series and journal clubs • Function as role models and mentors for younger trainees within the multidisciplinary fields that make up sleep medicine 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, including Harrison’s Textbook of Medicine. Ahrens, E.H. (1992). The Crisis in Clinical Research. New York: Oxford University Press. American Academy of Sleep Medicine. (2005). International Classification of Sleep Disorders (2nd Edition) Westchester, IL: American Academy of Sleep Medicine. American Academy of Sleep Medicine Clinical Practice Parameters. 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 & 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. 34
  • Johnson, T.S. & Halberstadt, J. (1993). Phantom of the Night. Cambridge: NTP, Inc. Kryger, M.H., Roth, T. & Dement, W.C. (2005). Principles and Practice of Sleep Medicine (4th edition). Philadelphia: Elsevier, Inc. Libby, P., Bonow, R.O., Zipes, Mann, D.L. (2007). Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine: 2 Volume Set. (8th Edition) Philadelphia: W.B. Saunders Company. 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. (1994). Textbook of Respiratory Medicine: Volume 1 & 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. Spriggs, W.H. (2002). Principles of Polysomnography (1st edition). Salt Lake City: Sleep Ed, LLC. Additional educational resources include the didactic conference curriculum and primary review of laboratory and sleep studies in addition to radiology. Evaluation Methods The competency-based evaluation methods that apply to this rotation include: • Web enabled competency-based evaluation forms that are completed by faculty at the end of each rotation • 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 University of Pennsylvania institutional policy on attending supervision that is included in our departmental policies. 35
  • Learning Objectives for Pediatric 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 multidisciplinary, 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 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 (441 beds), tertiary children’s hospital where all subspecialties are represented. It handles over 24,000 inpatient admissions annually. The hospital and the CHOP network has over 1.1 million 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 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 36
  • 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 appropriately 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 a supervising 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) Specific Pediatric 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. 5) The final component of the CHOP sleep medicine educational program is the Sleep Medicine Conference Schedule, which includes 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 included a weekly clinical case conference, a sleep grand rounds lecture series, journal club and research conference, all of which may be adult or pediatric in scope. The principal teaching/learning activity of the CHOP sleep medicine rotation occurs through Direct Patient Care 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 PEDCONF—Pediatric Sleep Medicine Conferences IC—Inpatient Consultations SMCS – Sleep Medicine Conference Schedule PSI—Polysomnography Scoring and Interpretation 37
  • 1) Patient Care 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 ALL Interpret polysomnograms and other diagnostic sleep evaluation tools ALL 2) Medical Knowledge Principal Educational Goals Learning Activities* Expand clinically applicable knowledge base of the biomedical, PSC, IC, PEDCONF, SMCS clinical and cognate sciences underlying the care of sleep medicine patients Access and critically evaluate current medical information PSC, IC, PEDCONF, SMCS and scientific evidence relevant to sleep medicine patient care Assess the validity of original research concerning clinical PSC, IC, PEDCONF, SMCS 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, PEDCONF, SMCS 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 ALL 38
  • 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 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 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 minimum 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. 39
  • 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, including Harrison’s Textbook of Medicine. Ahrens, E.H. (1992). The Crisis in Clinical Research. New York: Oxford University Press. American Academy of Sleep Medicine. (2005). International Classification of Sleep Disorders (2nd Edition) Westchester, IL: American Academy of Sleep Medicine. American Academy of Sleep Medicine. (2007). The AASM Manual for the Scoring of Sleep and Associated Events. Westchester, IL: American Academy of Sleep Medicine American Academy of Sleep Medicine Clinical Practice Parameters. 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., Hening, W.A., & Walters, A.S. (2003). Sleep and Movement Disorders. Philadelphia: Butterworth Heinemann. 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 & 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. (2005). Principles and Practice of Sleep Medicine (4th edition). Philadelphia: Elsevier, Inc. 40
  • Libby, P., Bonow, R.O., Zipes, Mann, D.L. (2007). Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine: 2 Volume Set. (8th Edition) Philadelphia: W.B. Saunders Company. Marcus, C.L., Carroll, J.L., Donnelly, D.F., & Loughlin, G.M. (2008). Sleep in Children (2nd edition). New York: Informa. 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. (1994). Textbook of Respiratory Medicine: Volume 1 & 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. Richardson, G. (ed.) (2006). Update on the Science, Diagnosis, and Management of Insomnia. London: RSM Press, Ltd. Spriggs, W.H. (2002). Principles of Polysomnography (1st edition). Salt Lake City: Sleep Ed, LLC. Additional educational resources include the didactic conference curriculum and primary review of laboratory and sleep studies in addition to radiology. 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 at least once a year by clinical support staff, nursing and sleep laboratory technical staff at CHOP • 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 University of Pennsylvania 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 4:1; 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. 41
  • 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: 1) 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. 2) 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. 3) Conferences. A weekly surgical conference will be held in CHOP’s Main Hospital. The fellow will be encouraged to attend this conference when feasible. 4) The final component of the CHOP pediatric otolaryngology educational program is the Sleep Medicine Conference Schedule, which includes 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 included a weekly clinical case conference, a sleep grand rounds lecture series, journal club and research conference, which may of adult or pediatric scope. 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. 42
  • 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) POC—Pediatric Otolaryngology Clinics OR—Operating Room Exposure SURGCONF—CHOP Surgical Conference, Pediatric Sleep Medicine SMCS – Sleep Medicine conference Schedule 1) Patient Care Principal Educational Goals Learning Activities* Effectively interview pediatric otolaryngology patients ALL Effectively examine pediatric otolaryngology patients ALL Maintain focus and timeliness in the evaluation and POC, SURGCONF, SMCS management of pediatric otolaryngology problems Order appropriate diagnostic tests ALL 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 pediatric otolaryngology patients Access and critically evaluate current medical information ALL and scientific evidence relevant to pediatric otolaryngology patient care Assess the validity of original research concerning clinical ALL 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 pediatric otolaryngology patients Develop real-time strategies for filling knowledge gaps that POC, SURGCONF, SMCS will benefit patients in a busy practice setting 43
  • 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 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 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 pediatric otolaryngology patients Collaborate with other members of the health care team to ALLassure comprehensive pediatric otolaryngology patients care Use evidence-based, cost-conscious strategies in the care of ALL pediatric otolaryngology 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 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 44
  • Specialty Tracks: Fellows on the Pediatric Track will be required to spend one month on the Pediatric Otolaryngology Rotation. Other trainees can take this month as an elective if desired. 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, including Harrison’s Textbook of Medicine. Ahrens, E.H. (1992). The Crisis in Clinical Research. New York: Oxford University Press. American Academy of Sleep Medicine. (2005). International Classification of Sleep Disorders (2nd Edition) Westchester, IL: American Academy of Sleep Medicine. American Academy of Sleep Medicine. (2007). The AASM Manual for the Scoring of Sleep and Associated Events. Westchester, IL: American Academy of Sleep Medicine American Academy of Sleep Medicine Clinical Practice Parameters. 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., Hening, W.A., & Walters, A.S. (2003). Sleep and Movement Disorders. Philadelphia: Butterworth Heinemann. 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 & 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. 45
  • Kryger, M.H., Roth, T. & Dement, W.C. (2005). Principles and Practice of Sleep Medicine (4th edition). Philadelphia: Elsevier, Inc. Libby, P., Bonow, R.O., Zipes, Mann, D.L. (2007). Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine: 2 Volume Set. (8th Edition) Philadelphia: W.B. Saunders Company. Marcus, C.L., Carroll, J.L., Donnelly, D.F., & Loughlin, G.M. (2008). Sleep in Children (2nd edition). New York: Informa. 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. (1994). Textbook of Respiratory Medicine: Volume 1 & 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. Richardson, G. (ed.) (2006). Update on the Science, Diagnosis, and Management of Insomnia. London: RSM Press, Ltd. Spriggs, W.H. (2002). Principles of Polysomnography (1st edition). Salt Lake City: Sleep Ed, LLC. Additional educational resources include the didactic conference curriculum and primary review of laboratory and sleep studies in addition to radiology. 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. 46
  • 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 Sleep Division conferences per year. Compliance with this requirement will be determined by review of the attendance 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.  The conferences are posted on the Sleep Center website and include: (http://www.med.upenn.edu/sleepctr/Conferences.shtml) Sleep Grand Rounds Summer Lecture Series (July - September) 3624 Market Street – Mondays, Thursdays, and Fridays 12pm-1pm. Sleep Clinical Case Conference (September – June) 3624 Market Street – Mondays, 12pm-1pm. Sleep Grand Rounds (September – June) 3624 Market Street – Thursdays, 12pm-1pm. Sleep Journal Club (September – June) 3624 Market Street – first Thursday of the month, 12pm-1pm. Sleep Research Conference (September – June) 3624 Market Street – Fridays, 12pm-1pm. CSRN Invited Speakers Research Seminar – Location TBA. Select Fridays throughout the year, 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. 47
  • Guidelines for Sleep Clinical Case Conference: Try to present an interesting case. Choose cases that are interesting to you or have an interesting twist to them. However, even OSA or obesity- hypoventilation patients have many interesting comorbidities or novel treatments associated with them. 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 per minute. However, some slides, especially ones with lots of graphics can take longer so you need to take that into account. 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 come away with more if you focus your discussion. Make simple slides. Limit your slides to 7 bullet points. Avoid typing a paragraph out. Don’t use tables that are overly complicated or crammed. Use simple statements and relatively simple figures. Don’t put 5 figures from a paper onto 1 slide. 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. 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. 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 would be good. It is a great chance for people to learn and discuss especially with faculty there. Handouts are very useful. Your handout should include a good review paper on that topic – let the Program Coordinator know if you have educational materials for distribution in addition to your slides. Have fun! You really learn so much doing these conferences and the things you present will stick with you for a long time. It will also help polish your public speaking skills. THE SHOW MUST GO ON! Let the Program Coordinator know immediately if you need to reschedule – someone must cover you. 48
  • Sleep Journal Club (September through June). 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. Though the format should be informal to encourage discussion, PowerPoint presentations are preferred, in particular for trainees. 49
  • PSG SCORING AND INTERPRETATION 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 during selected Thursday conferences at 3624 Market Street throughout the year. In addition, on Thursday afternoons from 1pm to 3pm , scoring, review and interpretation of adult clinical studies including overnight PSGs, CPAP/BIPAP titrations, MSLTs/MWTs and actigraphy will take place in an individual or group setting under the direction of a faculty member. Skills specific to interpretation of pediatric sleep studies have been incorporated into the summer lecture 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. While on an adult rotation, fellows training on the ADULT track should expect to interpret studies on patients they evaluate in all of their clinical encounters. In addition, ADULT track fellows on an adult rotation will be expected to read studies on patients referred to or cared by individuals in the fellows’ continuity practice, even if they are not their primary patient. While on a pediatric rotation, fellows training on the ADULT track will not be expected to review studies generated on their patients in the adult fellows’ continuity practice UNLESS they are specifically interested in the study results and/or upon review of their logs will be short on polysomnographic studies. In these latter cases, the ADULT track fellow would be expected to read no more than 1-2 studies per week while on a pediatric rotation. While on an adult rotation, fellows training on the PEDIATRIC track should expect to interpret studies on patients they evaluate in their clinical encounters in their CONTINUITY PRACTICE ONLY. In addition, PEDIATRIC track fellows on an adult rotation may be expected to read studies on patients referred to or cared by individuals in the fellows’ continuity practice. INSTRUCTIONS FOR SAVING PSGs IN HUP CONTINUITY CLINIC When saving PSGs, please save as Word document, with following format: Lastname, firstname- study type- YYMMDD-mrn- your initials attending initials Ex: A study on Jane Jones that was performed on July 16, 2009, read by Ann Fellow & Maria Antoniou, would look like: Jones, Jane- psg- 090716-12345678- AFMA Please save in your folder for your records and in attending folder. Please email the attending that study has been saved there. 50
  • 51
  • EVALUATION METHODS 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 quarterly by clinical support staff, nursing and technical staff • Mini-CEXs are completed at least four times during the fellowship • Review of one PQIP (Chart Audit) is evaluated by faculty preceptors • Review of quarterly QA scoring are evaluated by faculty preceptors • Procedure logs • Portfolios • SAM_E (Self-Assessment Mid-Rotation) tool twice a year • 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 be a summative review of the various aspects of the evaluation matrix by the Program Director. 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 4 Mini-CEXs each year (1 quarterly). 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 quarterly QA scoring assessments against a gold standard. Direct feedback about personal performance and how it relates to the group will be given by the faculty supervisor for this initiative. A 360-degree evaluation will be administered to clinical support staff, nursing and sleep laboratory technical staff by program leadership. The fellow will be given feedback regarding the quality of presentations and attendance at conference in their individual portfolios during their biannual meetings with the Program Directors. Fellows are able to view their portfolios and evaluations at any time. 52
  • SICK/VACATION POLICIES Fellows are excused from their continuity clinic(s) and PVAMC 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 must be submitted at least 6 weeks 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 Program Coordinator, clinical staff and the supervising physician. If it is less than 6 weeks 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. 53
  • RESEARCH 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. The program leadership will be happy to assist fellows in finding a mentor to guide them through this process. A meeting with the Division Chief should occur within the first 8 weeks to identify a mentor. Progress of scholarly activities will be reviewed in general terms at monthly fellowship meetings as well as during the biannual meetings with the Program Director. Fellows who are going on to complete a research fellowship can start to meet with investigators 6-8 months into their clinical year to determine which research program they might like to participate in after their clinical fellowship. 54
  • IMPORTANT DOCUMENTS The following forms will be sent to you in electronic format by the Program Coordinator:  Chart Audit form  Adult Patient Log  Pediatric Patient Log  PSG Log  Inpatient Log  Mini-CEX Form  SAM_E Tool  GME Policy on Duty Hours  GME Policy on Moonlighting  Sleep Medicine Division Phone List 55