02/13/16
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
1. Adult Outpatient Rotation
1a. UPHS Sleep Medicine Ambulatory Experience
1b. PVAMC Sleep Medicine Ambulatory Experience
2. HUP PSG Interpretation and Inpatient Consultation Rotation
3. Pediatric Sleep Medicine Rotation (CHOP)
4. Pediatric Otolaryngology Rotation (CHOP)
17-45
17-28
17-22
23-28
29-34
35-40
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
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:
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
4
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.
5
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
6
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.
7
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.
8






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).
9
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.
10
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 followup 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 patientrelated 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
11
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
12
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.
13
SAMPLE ROTATION SCHEDULES
Adult-Track
HUP Adult Rotation
2009
Monday
UPHS Outpatient
8am-12pm
Clinic
12pm-1pm
Conference
Tuesday
UPHS Outpatient
Clinic
Wednesday
UPHS Outpatient
Clinic
1pm-5pm
Independent PSG
Interpretation
UPHS Outpatient
Clinic
Adult PSG/Consult Rotation
2009
Monday
Tuesday
Wednesday
8am-12pm
PSG Review
PSG Review
PSG Review
PVAMC Sleep Clinic
Tuesday
Wednesday
PVAMC Insomnia
Clinic
Administrative Time
Thursday
UPHS Fellows
Continuity Clinic
Conference
UPHS PSG Review
Friday
UPHS Outpatient
Clinic
Conference
Independent PSG
Interpretation
Thursday
UPHS Fellows
Continuity Clinic
Conference
UPHS PSG Review
Friday
Thursday
UPHS Fellows
Continuity Clinic
Conference
PVAMC PSG/USS
Reading
Friday
PVAMC Embletta
Setup Clinic
Conference
PVAMC PSG/USS
Reading
Thursday
UPHS Continuity
Clinic
Friday
CHOP Conference
Conference
Conference
CHOP PSG Review
CHOP Sleep Clinic
UPHS PSG
Clinic/Ped Sleep
Clinic
CHOP PSG Review
HUP Adult Rotation
2009
Monday
UPHS Outpatient
8am-12pm
Clinic
12pm-1pm
Conference
Tuesday
UPHS Outpatient
Clinic
Wednesday
UPHS Outpatient
Clinic
Thursday
UPHS Fellows
Continuity Clinic
Conference
1pm-5pm
Independent PSG
Interpretation
PVAMC Sleep Clinic
UPHS PSG Review
Tuesday
Wednesday
Thursday
Friday
CHOP PSG Review
CHOP Pediatric
Outpatient Clinic
Administrative Time
Adult Continuity
Clinic
CHOP Conference
Conference
Conference
CHOP PSG Review
CHOP Continuity
Clinic
UPHS PSG
Clinic/Ped Sleep
Clinic
Adult Continuity
Clinic
Adult PSG/Consult Rotation
2009
Monday
Tuesday
Wednesday
Thursday
8am-12pm
PSG Review
PSG Review
PSG Review
PSG Review
12pm-1pm
Conference
Administrative Time
CHOP Conference
CHOP Continuity
Clinic
Conference
1pm-5pm
PSG Review
12pm-1pm
Conference
1pm-5pm
Administrative Time
Adult PVAMC Rotation
2009
Monday
PVAMC CPAP
8am-12pm
Clinic
12pm-1pm
Conference
1pm-5pm
Administrative Time
CHOP Pediatric Rotation
2009
Monday
Patient Review/
8am-12pm
CHOP Inpatient
Consults
12pm-1pm
Conference
1pm-5pm
CHOP PSG
Review
PVAMC Sleep Clinic
PVAMC AutoCPAP
PVAMC Insomnia
Follow-up Clinic
Tuesday
Wednesday
CHOP PSG Review
CHOP Pediatric
Outpatient Clinic
PSG Review
Conference
PSG Review
PSG Review/CHOP
Inpatient
Pediatric-Track
Pediatric Rotation
2009
8am-12pm
12pm-1pm
1pm-5pm
Administrative Time
Monday
Patient Review/
CHOP Inpatient
Consults
Conference
CHOP PSG
Review
PSG Review
UPHS PSG Review
Friday
UPHS Outpatient
Clinic
Conference
Independent PSG
Interpretation
Friday
Adult Continuity
Clinic
Conference
Adult Continuity
Clinic
14
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
15
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.
16
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 multidisciplinary. 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 multidisciplinary 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 officebased 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.
17
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
FBP -- Faculty-Based Practices
PQIP-- Personal Quality Improvement Project
PSGR -- Polysomnography Review
CCC -- Clinical Case Conferences
SLS -- Sleep Lecture Series
SMJC -- Sleep Medicine Journal Club
SMRC -- Sleep Medicine Research Conference
1) Patient Care
18
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
management of sleep medicine problems
SMCP, FBP, PQIP
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,
clinical and cognate sciences underlying the care of sleep
medicine patients
SMCP, FBP, CCC, SLS, SMJC,
SMRC, PSGR
Access and critically evaluate current medical information
and scientific evidence relevant to outpatient sleep medicine
patient care
ALL
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
skills in the care of sleep medicine patients
SMCP, FBP, CCC, SMJC
PQIP,
Develop real-time strategies for filling knowledge gaps that
will benefit patients in a busy practice setting
SMCP, FBP, CCC, SMJC
PQIP,
4) Interpersonal Skills and Communication
Principal Educational Goals Learning Activities*
Communicate effectively with patients and families across a
broad range of socioeconomic and ethnic backgrounds
SMCP, FBP
Communicate effectively with physician colleagues and
members of other health care professions to assure
comprehensive patient care
SMCP, FBP, CCC, SMJC
19
5) Professionalism
Principal Educational Goals Learning Activities*
Behave professionally toward towards patients, families,
colleagues, and all members of the health care team
ALL
6) Systems-Based Practice
Principal Educational Goals Learning Activities*
Understand and utilize the multidisciplinary resources
necessary to care optimally for sleep medicine patients
ALL
Collaborate with other members of the health care team to
assure comprehensive sleep medicine outpatient care
SMCP, FBP, PQIP, QA, CCC
Use evidence-based, cost-conscious strategies in the care of
sleep medicine patients
ALL
Begin to understand the business aspects of practice
management in a variety of settings
SMCP, FBP, CCC, SLS, PQIP,
PSGR
Begin to develop efficient practice patterns so patient care
proceeds at an acceptable rate
SMCP, FBP, CCC, SLS, PQIP,
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
20
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.
21
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.
22
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
23
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*
24
Effectively interview sleep medicine outpatients
FBP
Effectively examine sleep medicine outpatients
FBP
Maintain focus and timeliness in the evaluation and
management of sleep medicine problems
FBP
Order appropriate diagnostic tests
FBP
Interpret portable monitoring studies and other diagnostic
sleep evaluation tools
SSR, RTCS
2) Medical Knowledge
Principal Educational Goals Learning Activities*
Expand clinically applicable knowledge base of the biomedical,
clinical and cognate sciences underlying the care of sleep medicine
patients
ALL
Access and critically evaluate current medical information
and scientific evidence relevant to outpatient sleep medicine
patient care
ALL
Assess the validity of original research concerning clinical
questions such as diagnosis, prognosis, treatment and prevention
FBP, SMCS
3) Practice-Based Learning and Improvement
Principal Educational Goals Learning Activities*
Identify and acknowledge gaps in personal knowledge and
skills in the care of sleep medicine patients
ALL
Develop real-time strategies for filling knowledge gaps that
will benefit patients in a busy practice setting
ALL
4) Interpersonal Skills and Communication
Principal Educational Goals Learning Activities*
Communicate effectively with patients and families across a
broad range of socioeconomic and ethnic backgrounds
ALL
Communicate effectively with physician colleagues and
members of other health care professions to assure
comprehensive patient care
ALL
25
5) Professionalism
Principal Educational Goals Learning Activities*
Behave professionally toward towards patients, families,
colleagues, and all members of the health care team
ALL
6) Systems-Based Practice
Principal Educational Goals Learning Activities*
Understand and utilize the multidisciplinary resources
necessary to care optimally for sleep medicine patients
ALL
Collaborate with other members of the health care team to
assure comprehensive sleep medicine outpatient care
ALL
Use evidence-based, cost-conscious strategies in the care of
sleep medicine patients
ALL
Begin to understand the business aspects of practice
management in a variety of settings
ALL
Begin to develop efficient practice patterns so patient care
proceeds at an acceptable rate
ALL
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
26
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.
27
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.
28
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 .
29
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
30
CCC -- Clinical Case Conferences
QA – Quality Assurance
SMJC -- Sleep Medicine Journal Club
PSGR – Polysomnography Review
SLS -- Sleep Lecture Series
SMRC -- Sleep Medicine Research Conference
1) Patient Care
Principal Educational Goals Learning Activities*
Effectively, efficiently, and sensitively interview and examine
patients hospitalized with complaints that suggest a possible sleep disorder
DPC, CATR
Obtain all necessary medical information by chart review,
discussion with the service requesting the consultation, and
through contact with the patient’s primary care internist and
other important providers
DPC, CATR
Adjust all recommendations as required by the patients
coexistent problem(s) which resulted in their admission to
another service: impending or recent surgery, pregnancy or
recent delivery, etc.
DPC, CATR
Interpret polysomnograms and other diagnostic sleep evaluation tools
SLS
PSGR, QA, CCC,
2) Medical Knowledge
Principal Educational Goals Learning Activities*
Expand clinically applicable knowledge base of the biomedical,
clinical and cognate sciences underlying the care of patients with
sleep related illness on non-dedicated sleep medicine services.
DPC, CCC, SLS, SMJC,
CATR
Access and critically evaluate current medical information
and scientific evidence relevant to inpatient sleep medicine
patient care
ALL
Assess the validity of original research concerning clinical
questions such as diagnosis, prognosis, treatment and prevention
CCC, SLS, SMJC, SMRC,
CATR
3) Practice-Based Learning and Improvement
Principal Educational Goals Learning Activities*
Identify and acknowledge gaps in personal knowledge and
skills in the care of patients with sleep-related illness on non-sleep
medicine services
DPC, CATR, CCC, QA
Develop evidence-based, real-time strategies for filling gaps in
personal knowledge and skills in the care of patients with
DPC, CATR, QA
CCC, SLS, SMJC
31
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
sleep-related illness on non-sleep medicine services and with their
families
DPC
Communicate effectively with residents, fellows and attending
physicians on the service requesting the consultation to be
DPC, CATR
Verbally communicate findings and recommendations to the
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
DPC, CATR
Complete a concise consultation note with clearly stated,
detailed recommendations
DPC, CATR
Communicate effectively with the nursing staff and other
members of the health care team on the patient's primary
service to assure that plan of medical care is clear
DPC, CATR
5) Professionalism
Principal Educational Goals Learning Activities*
Behave professionally toward towards patients, families,
colleagues, and all members of the health care team
ALL
6) Systems-Based Practice
Principal Educational Goals Learning Activities*
Work with the service requesting the consultation to assure
that care for the patient's medical needs is properly
coordinated with care being delivered by the primary service
DPC, CATR
Collaborate with other members of the health care team to assure
comprehensive sleep medicine outpatient care.
DPC, QA, CCC, CATR
Assist with scheduling of any tests or treatments necessary
to assure the patient's proper medical care
DPC, CATR
Use evidence-based, cost-conscious strategies in the care of
patients with sleep-related illness on non-sleep medicine services
and patients being assessed for pre-operative medical risk
ALL
32
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.
Johnson, T.S. & Halberstadt, J. (1993). Phantom of the Night. Cambridge: NTP, Inc.
33
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.
34
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
35
2)
3)
4)
5)
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.
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.
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.
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.
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
36
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
management of sleep medicine problems
PSC, IC
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,
clinical and cognate sciences underlying the care of sleep medicine
patients
PSC, IC, PEDCONF, SMCS
Access and critically evaluate current medical information
and scientific evidence relevant to sleep medicine
patient care
PSC, IC, PEDCONF, SMCS
Assess the validity of original research concerning clinical
questions such as diagnosis, prognosis, treatment and prevention
PSC, IC, PEDCONF, SMCS
3) Practice-Based Learning and Improvement
Principal Educational Goals Learning Activities*
Identify and acknowledge gaps in personal knowledge and
skills in the care of sleep medicine patients
PSC, IC
Develop real-time strategies for filling knowledge gaps that
will benefit patients in a busy practice setting
PSC, IC, PEDCONF, SMCS
4) Interpersonal Skills and Communication
Principal Educational Goals Learning Activities*
Communicate effectively with patients and families across a
broad range of socioeconomic and ethnic backgrounds
PSC, IC
Communicate effectively with physician colleagues and
members of other health care professions to assure
ALL
37
comprehensive patient care
5) Professionalism
Principal Educational Goals Learning Activities*
Behave professionally toward towards patients, families,
colleagues, and all members of the health care team
ALL
6) Systems-Based Practice
Principal Educational Goals Learning Activities*
Understand and utilize the multidisciplinary resources
necessary to care optimally for sleep medicine patients
ALL
Collaborate with other members of the health care team to
assure comprehensive sleep medicine outpatient care
ALL
Use evidence-based, cost-conscious strategies in the care of
sleep medicine patients
ALL
Begin to understand the business aspects of practice
management in a variety of settings
ALL
Begin to develop efficient practice patterns so patient care
proceeds at an acceptable rate
PSC, IC
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.
38
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.
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.
39
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.
40
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.
41
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
management of pediatric otolaryngology problems
POC, SURGCONF, SMCS
Order appropriate diagnostic tests
ALL
2) Medical Knowledge
Principal Educational Goals Learning Activities*
Expand clinically applicable knowledge base of the biomedical,
clinical and cognate sciences underlying the care of pediatric
otolaryngology patients
ALL
Access and critically evaluate current medical information
and scientific evidence relevant to pediatric otolaryngology
patient care
ALL
Assess the validity of original research concerning clinical
questions such as diagnosis, prognosis, treatment and prevention
ALL
3) Practice-Based Learning and Improvement
Principal Educational Goals Learning Activities*
Identify and acknowledge gaps in personal knowledge and
skills in the care of pediatric otolaryngology patients
ALL
Develop real-time strategies for filling knowledge gaps that
will benefit patients in a busy practice setting
POC, SURGCONF, SMCS
42
4) Interpersonal Skills and Communication
Principal Educational Goals Learning Activities*
Communicate effectively with patients and families across a
broad range of socioeconomic and ethnic backgrounds
POC, OR
Communicate effectively with physician colleagues and
members of other health care professions to assure
comprehensive patient care
ALL
5) Professionalism
Principal Educational Goals Learning Activities*
Behave professionally toward towards patients, families,
colleagues, and all members of the health care team
ALL
6) Systems-Based Practice
Principal Educational Goals Learning Activities*
Understand and utilize the multidisciplinary resources
necessary to care optimally for pediatric otolaryngology patients
ALL
Collaborate with other members of the health care team to
comprehensive pediatric otolaryngology patients care
ALLassure
Use evidence-based, cost-conscious strategies in the care of
pediatric otolaryngology patients
ALL
Begin to understand the business aspects of practice
management in a variety of settings
ALL
Begin to develop efficient practice patterns so patient care
proceeds at an acceptable rate
POC
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
43
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.
44
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.
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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.
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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 obesityhypoventilation 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.
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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.
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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.
49
EVALUATION METHODS
The evaluation methods utilized during the various rotations include:






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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.
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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.
51
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.
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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
53