Responsibilities and Requirements

Requirements for Applicants for Sleep Medicine Fellowship

As outlined by the American Board of Internal Medicine, by the time the fellowship training begins (July 1st of the training year), sleep fellows will have satisfactorily completed residency training in one of the sponsoring specialties. Completion of training must be confirmed in all cases. These specialties include: internal medicine, pediatrics, neurology, psychiatry, otolaryngology, anesthesiology, and pulmonary diseases. Sleep medicine is primarily an outpatient specialty, and the fellowship program is geared in this direction. As a result, there is no night or weekend call. Inpatient consults for sleep disorders at University of Maryland Medical Center and University Specialty Hospital will be handled by the fellows on the University of Maryland Adult Sleep Medicine Clinic Rotation, in conjunction with one of the attendings from that clinic. However, because there are relatively few calls, this is only considered a minor part of the training.

The sleep medicine fellowship at University of Maryland has two ACGME approved positions. The number of fellows actually taken in any one year will depend on the quality of the applicants, as well as the availability of funding for appropriate salary support.

Responsibility of Residents and Attendings

General Attending Physician Responsibilities

An attending physician is responsible for, and actively involved in, the care provided to each patient, both inpatient and outpatient.
An attending physician directs the care of each patient and provides the appropriate level of supervision for a resident based on the nature of the patient's condition, the likelihood of major changes in the management plan, the complexity of care, and level of education, ability, experience, and judgment of the resident being supervised.
The attending physician, in consultation with the program director, accords a resident progressive responsibility for the care of the patient based on the resident's clinical experience, judgment, knowledge, technical skill, and capacity to function.
The attending physician advises the program director if he/she believes a change in the level of the resident's responsibility and supervision should be considered. The overriding consideration must be the safe and effective care of the patient that is the personal responsibility of the attending physician.
The attending physician fosters an environment that encourages questions and requests for support or supervision from the resident, and encourages the resident to call or inform the attending physician of significant or serious patient conditions, or significant changes in patient condition.

Resident Responsibilities and Requirements

The resident must be aware of his/her level of training, his/her specific clinical experience, judgment, knowledge, technical skill, and any associated limitations. The resident must not independently perform procedures or treatments, or management plans that he/she is unauthorized to perform or lacks the skill and training to perform.
The resident is responsible for communicating to the attending physician any significant issues regarding patient care.

Clinical Skills

The expectation is that each resident entering the program will know how to perform a basic history and physical examination. Independent practice of this skill may be undertaken at the initiation of training with confirmation of findings by senior residents or fellows and attending physicians. Fellows may write all orders, outpatient prescriptions, referrals for sleep laboratory and other testing on patients they evaluate as part of the program. In the case of orders for polysomnographic evaluation, the attending must countersign these orders as specified by the policy of the sleep laboratory. "Do not resuscitate" and other advanced directives are not written as part of the Sleep Medicine Fellowship. However, all fellows and attendings are required to act in accordance with any advanced directives the patients may bring with them.

During the course of the fellowship, fellows learn a variety of clinical skills relevant to the field of sleep medicine. A representative, but not exhaustive, list of skills learned includes:

Specific aspects of the medical history relevant to sleep disorders
Taking a sleep history
Evaluation of sleep patterns from history, patient logs and actigraphy
Evaluation of patients with cardinal sleep symptoms: insomnia, excessive daytime sleepiness, sleep related behavioral disorders and movement disorders
Use of specific laboratory tests for evaluating sleep disorders including polysomnography, sleep latency testing, CPAP titration, oxygen titration, treatment of nocturnal hypoventilation
Use of non-specific clinical testing for evaluating patients with sleep disorders including radiology, neurologic testing, psychologic testing, pulmonary function testing, appropriate hematologic testing, appropriate endocrinologic testing
Scoring laboratory sleep studies according to the most recent scoring rules released by the American Academy of Sleep Medicine
Strategies for interpretation of sleep studies
Interfacing when appropriate with other specialties, including neurology, dentistry, otolaryngology, cardiology and pulmonology

Technical Skills

All residents need to maintain current certification in basic life support during the sleep fellowship.

While sleep fellows are expected to understand the technical aspects of sleep study recording, they are not required to be proficient in the technical skills required to perform these studies.

Outpatient Care

Sleep medicine is primarily an outpatient procedure. At continuity clinics in the University Health Center and VA Medical Center, fellows perform the initial and follow-up evaluations of patients assigned to them. Management plans are formulated, and fellows present their clinical findings and management plans to the attending supervising the clinic. The attending visits the patient with the fellow and reviews key parts of the history and physical with the patient. The attending also reviews, with the fellow, the results of all laboratory testing, including sleep – specific and non-specific – testing. Fellows see the same patients in follow-up; therefore, they gain a sense of the clinical course of the disease and the results of therapy. Fellows will write orders for all sleep specific and non-specific evaluation and management plans. They will also write follow-up orders for treatment, such as treatment with positive airway pressure, appropriate medications and behavioral therapy.

There is an active Cognitive Behavioral Therapy clinic with a sleep behavioralist and psychologist. This clinic is a resource and an integral part of the outpatient clinic program. Fellows participate in all aspects of behavioral treatment for insomnia, circadian rhythm disorders and poor sleep hygiene in collaboration with this clinic.

Inpatient Care

There are relatively few instances of inpatient consultation for specific sleep disorders. However, those inpatient consultations that arise will be handled by sleep medicine fellows under the supervision of attending sleep faculty. This supervision takes place in various forms: examination of patients by the attending to confirm physical findings, discussion of the patient's problems and appropriate diagnostic and therapeutic intervention with residents, and didactic rounds to educate the residents about the disease process in general. Inpatient consultation services will be available at both University of Maryland Medical Center and the Baltimore VA Medical Center.

Rotations

While most experience is obtained through the adult sleep medicine program, there are two months of rotation in the pediatric sleep clinic, which includes the interpretation of sleep studies from the pediatric division of the sleep lab and two months rotation at University Specialty Hospital, the site of the sleep laboratory. This rotation includes inpatient experience and extensive experience in scoring and interpreting sleep studies from the adult and pediatric divisions under the supervision of the lead scoring technologist and the attending on rotation as well. There is also an electrophysiology rotation early in the fellowship to familiarize fellows with the principles of electrophysiological recording. Lastly, there is also an elective rotation which may be used for clinical experience or completion of scholarly activity (below). During all rotations, however, attendance at the Sleep Medicine Clinic continues. Fellows are also required to spend 3 – 4 evenings in the sleep lab to observe patient acceptance procedures, education procedures and laboratory performance of sleep studies. They are invited to undergo sleep study themselves. Fellows are also required to spend 3 – 4 sessions in the ENT clinic to observe the evaluation of the upper airway.

Evening, Nights, Weekend Hours and Holidays

There is no "in-house" or night call for sleep fellows. Fellows are expected to observe the hook-up and performance of sleep studies in the sleep laboratory 3 – 4 times throughout the year. They are given the next day off following these nights.

The limitations for hours, including "moonlighting" meet the currently accepted ACGME guidelines and must be documented.

Outpatient Care

Sleep Medicine is primarily an outpatient specialty. Fellows will be integrated into all of the outpatient clinics as outlined above.

Communication

Communication with the attending physician is mandatory for all fellow patient encounters and laboratory testing. Attendings must personally examine each patient seen in the outpatient clinics and must approve of all plans for evaluation and management of patients seen by the fellow. In the case of the interpretation of polysomnographic recordings, fellows will evaluate and provide a preliminary interpretation of these recordings as they are assigned. These recordings and their interpretation must then be reviewed and approved by the attending physician who will sign the laboratory report.

Scholarly Activity

Each fellow is expected to complete at least one scholarly activity by the end of the fellowship. This may be a research project (or continuation of a previous project with relevance to sleep medicine), a review article or book chapter with one of the attendings, or a proposal for a research project containing a literature review, aims, and approach.

Didactic Training

In addition to supervised "hands-on" experience, there is an active didactic teaching program for fellows and others interested in sleep medicine. This program consists of:

Boot camp orientation for incoming sleep fellows. This is a very basic orientation to sleep medicine and polysomnography designed to familiarize incoming fellows with some of the terminology used in sleep medicine.
Weekly sleep study/clinical case conference. Polysomnographic results are reviewed with an emphasis on the clinical background, rules and strategies for scoring and interpretation, and technical evaluations of recordings. In addition to all physicians and faculty who attend this conference, the lead techs for the adult and pediatric branches of the laboratory also attend. This conference is a lively opportunity for feedback between the components of the laboratory testing portion of the sleep program.
Bi-weekly multidisciplinary conference. This conference includes a journal club, case presentations, lectures on important topics, and reviews of research protocols being carried out by members of the sleep disorders center.
Yearly sleep medicine course. This course is offered to all members of the Pulmonary Division and Departments of Psychiatry, Otolaryngology, and Neurology, as well as Internal Medicine. The course consist of 12 sessions pertaining to various aspects of sleep medicine, including classification of sleep disorders, neuro and respiratory biology of sleep, technical aspects of sleep recordings, approach to excessive sleepiness, specific sleep disorders, sleep disturbances in medical and psychiatric disease, a practicum on sleep recordings and more.
Sleep fellows are also invited to participate in the lecture series of the electrophysiology department and the basic pulmonary physiology series of the Division of Pulmonary and Critical Care.

Research Activities in the Sleep Disorders Center:

The faculty of the Sleep Disorders Center maintains a wide variety of research interests. Fellows are invited and encouraged to participate in these interests as suitable for a one-year program. These interests include, but are not limited to:

Sleep disturbances in COPD (Scharf)
Sleep quality in patients on chronic ventilatory therapy (Verceles, Diaz)
Sleep disturbances in patients with ALS (Diaz)
Sleep quality in traumatic brain injury
Sleep deprivation and neurocognitive decline in nurses working 12 hour shifts (Geiger-Brown, Scharf)
Neurocognitive effects of napping in preschoolers (Lam)
Effects of chronic intermittent hypoxia on cardiovascular function in rodents (Scharf, Chen)

Monitoring/Evaluation:

The goals and objectives, as well as the process of evaluation, for the training program are discussed at orientation. A syllabus is handed out to all fellows at the start of the rotation. The syllabus also contains a review of sleep medicine, some key papers, and the practice guidelines of the American Academy of Sleep Medicine. Rotation specific evaluations, which mirror the goals and objectives for a given rotation, have been developed and implemented. At the end of each rotation, a formal written evaluation is completed for each resident by the faculty supervisor, and fellows complete an evaluation of the rotation and the educational experience. These evaluations are completed every two months.

Assessment of resident performance will be based on multiple evaluation strategies and will include:

Direct observation of clinical and interpersonal skills
Case-based discussion
Completion of teaching modules
Review of medical records, chart stimulated review
Preparation and delivery of teaching sessions, including Journal Club
Participation in conferences
Review of patient and/or procedure logs
Feedback from patients and families
Feedback from allied health professionals
Feedback from supervising residents and attending physicians
Assigned projects such as a clinical research
Review of program improvement and practice-based modules

Non-compliance with responsibilities or performance problems are discovered and addressed in accordance with ACGME requirements and recommendations