As outlined by the American Board of Internal Medicine, by the time the fellowship training begins (July 1st of the training year), sleep fellows will have satisfactorily completed residency training in one of the sponsoring specialties. Completion of training must be confirmed in all cases. These specialties include: internal medicine, pediatrics, neurology, psychiatry, otolaryngology and pulmonary diseases. Sleep medicine is primarily an outpatient specialty, and the fellowship program is geared in this direction. As a result, there is no night or weekend call. Inpatient consults for sleep disorders at University of Maryland Medical Center and University Specialty Hospital will be handled by the fellows on the University of Maryland Adult Sleep Medicine Clinic Rotation, in conjunction with one of the attendings from that clinic. However, because there are relatively few calls, this is only considered a minor part of the training.
The sleep medicine fellowship at University of Maryland has two ACGME approved positions. The number of fellows actually taken in any one year will depend on the quality of the applicants, as well as the availability of funding for appropriate salary support.
General Attending Physician Responsibilities
Resident Responsibilities and Requirements
The expectation is that each resident entering the program will know how to perform a basic history and physical examination. Independent practice of this skill may be undertaken at the initiation of training with confirmation of findings by senior residents or fellows and attending physicians. Fellows may write all orders, outpatient prescriptions, referrals for sleep laboratory and other testing on patients they evaluate as part of the program. In the case of orders for polysomnographic evaluation, the attending must countersign these orders as specified by the policy of the sleep laboratory. “Do not resuscitate” and other advanced directives are not written as part of the Sleep Medicine Fellowship. However, all fellows and attendings are required to act in accordance with any advanced directives the patients may bring with them.
During the course of the fellowship, fellows learn a variety of clinical skills relevant to the field of sleep medicine. A representative, but not exhaustive, list of skills learned includes:
All residents need to maintain current certification in basic life support during the sleep fellowship.
While sleep fellows are expected to understand the technical aspects of sleep study recording, they are not required to be proficient in the technical skills required to perform these studies.
Sleep medicine is primarily an outpatient procedure. At continuity clinics in the University Health Center and VA Medical Center, fellows perform the initial and follow-up evaluations of patients assigned to them. Management plans are formulated, and fellows present their clinical findings and management plans to the attending supervising the clinic. The attending visits the patient with the fellow and reviews key parts of the history and physical with the patient. The attending also reviews, with the fellow, the results of all laboratory testing, including sleep – specific and non-specific – testing. Fellows see the same patients in follow-up; therefore, they gain a sense of the clinical course of the disease and the results of therapy. Fellows will write orders for all sleep specific and non-specific evaluation and management plans. They will also write follow-up orders for treatment, such as treatment with positive airway pressure, appropriate medications and behavioral therapy.
There is an active Cognitive Behavioral Therapy clinic with a sleep behavioralist and psychologist. This clinic is a resource and an integral part of the outpatient clinic program. Fellows participate in all aspects of behavioral treatment for insomnia, circadian rhythm disorders and poor sleep hygiene in collaboration with this clinic.
There are relatively few instances of inpatient consultation for specific sleep disorders. However, those inpatient consultations that arise will be handled by sleep medicine fellows under the supervision of attending sleep faculty. This supervision takes place in various forms: examination of patients by the attending to confirm physical findings, discussion of the patient’s problems and appropriate diagnostic and therapeutic intervention with residents, and didactic rounds to educate the residents about the disease process in general. Inpatient consultation services will be available at both University of Maryland Medical Center and the Baltimore VA Medical Center.
While most experience is obtained through the adult sleep medicine program, there are two months of rotation in the pediatric sleep clinic, which includes the interpretation of sleep studies from the pediatric division of the sleep lab and two months rotation at University Specialty Hospital, the site of the sleep laboratory. This rotation includes inpatient experience and extensive experience in scoring and interpreting sleep studies from the adult and pediatric divisions under the supervision of the lead scoring technologist and the attending on rotation as well. There is also an electrophysiology rotation early in the fellowship to familiarize fellows with the principles of electrophysiological recording. Lastly, there is also an elective rotation which may be used for clinical experience or completion of scholarly activity (below). During all rotations, however, attendance at the Sleep Medicine Clinic continues. Fellows are also required to spend 3 – 4 evenings in the sleep lab to observe patient acceptance procedures, education procedures and laboratory performance of sleep studies. They are invited to undergo sleep study themselves. Fellows are also required to spend 3 – 4 sessions in the ENT clinic to observe the evaluation of the upper airway.
There is no “in-house” or night call for sleep fellows. Fellows are expected to observe the hook-up and performance of sleep studies in the sleep laboratory 3 – 4 times throughout the year. They are given the next day off following these nights.
The limitations for hours, including “moonlighting” meet the currently accepted ACGME guidelines and must be documented.
Sleep Medicine is primarily an outpatient specialty. Fellows will be integrated into all of the outpatient clinics as outlined above.
Communication with the attending physician is mandatory for all fellow patient encounters and laboratory testing. Attendings must personally examine each patient seen in the outpatient clinics and must approve of all plans for evaluation and management of patients seen by the fellow. In the case of the interpretation of polysomnographic recordings, fellows will evaluate and provide a preliminary interpretation of these recordings as they are assigned. These recordings and their interpretation must then be reviewed and approved by the attending physician who will sign the laboratory report.
Each fellow is expected to complete at least one scholarly activity by the end of the fellowship. This may be a research project (or continuation of a previous project with relevance to sleep medicine), a review article or book chapter with one of the attendings, or a proposal for a research project containing a literature review, aims, and approach.
In addition to supervised “hands-on” experience, there is an active didactic teaching program for fellows and others interested in sleep medicine. This program consists of:
The faculty of the Sleep Disorders Center maintains a wide variety of research interests. Fellows are invited and encouraged to participate in these interests as suitable for a one-year program. These interests include, but are not limited to:
The goals and objectives, as well as the process of evaluation, for the training program are discussed at orientation. A syllabus is handed out to all fellows at the start of the rotation. The syllabus also contains a review of sleep medicine, some key papers, and the practice guidelines of the American Academy of Sleep Medicine. Rotation specific evaluations, which mirror the goals and objectives for a given rotation, have been developed and implemented. At the end of each rotation, a formal written evaluation is completed for each resident by the faculty supervisor, and fellows complete an evaluation of the rotation and the educational experience. These evaluations are completed every two months.
Assessment of resident performance will be based on multiple evaluation strategies and will include:
Non-compliance with responsibilities or performance problems are discovered and addressed in accordance with ACGME requirements and recommendations