Good afternoon. We're going to go ahead and get started. I'm Eileen Rosen, and I am the fellowship director of the Sleep Medicine Fellowship at the University of Pennsylvania. And I have been asked, or we all, the panel, we have been asked to speak about adult and pediatric sleep medicine, how to balance it within fellowship programs. And we're each going to start off by giving an overview of, really, our philosophy and approach of how our programs handle having both adult and pediatric trainees in the program. And then I think the idea is to have the Q&A at the end. Somehow I got the short straw. I'm going first. Okay. So, these are the panel speakers. I'm going to talk about the University of Pennsylvania, Anita Shelkegar is going to talk about the University of Michigan, Kieran Maskey will talk about Boston Children's, and Kanika Bagai is going to talk about Vanderbilt University. Okay. So University of Pennsylvania. So the history of our program is that we initially applied, back in 2004 or 2005, as two separate programs because, although the Hospital of the University of Pennsylvania and Children's Hospital of Philadelphia, HUP and CHOP, are literally next door to each other and the faculty are both part of the University of Pennsylvania, the hospital entities are completely separate. So actually HUP has now grown into Penn Medicine, if you ever hear about Penn Medicine. And the pediatrics component is all done at CHOP, which is owned separately. So we initially applied separately, and at that time there was a rule about sharing resources, and they felt being next door was enough to say that we were sharing resources between two separate programs, and we had to reapply as a joint program. So we had the benefit of sitting down from the beginning and thinking about what we had already created we wanted to do and what the pediatric group thought their trainees needed, and we used that as a way, and we kind of merged it into two. So the program right now, the sponsoring institution is the Hospital of the University of Pennsylvania, but we are a combined program, if your trainees look us up, we have both names, and we from the outset have structured our program in two tracks. So if you have a pediatric background, you can be in the pediatric track, and if you're in the adult background, you can be in the adult track. The funding, the way we do it now, it was complicated, but what simplified it now is that all the funds flow through HUP, and so we are approved for five slots. There is one dedicated slot for pediatrics, one adult HUP GME slot, and then the VA will give us two to three more slots, or sometimes we get industry funding, and we can have all five fellows be pediatric trained if we would like to, if there was a need for that, but one slot at least, the only one that CHOP pays for, is pediatric. And our associate program director, he's really more of the, I would call the head of the pediatric sleep track, is also the site director at CHOP, and so the fellows that are pediatric trained really identify with both myself as the program director and with Alex Mason, who is our pediatric lead. So what do the tracks look like? So the adult track has one month of intensive pediatric training at CHOP. They have outpatient experiences during that one month. It's broken up into two two-week blocks. They're at the sleep center and do some pediatric ENT. They do PSGs, and then throughout the year, scheduled out, they have another 12 half-day sessions that are scheduled in full-day experiences at satellite rotations. And then they have 11 months, the remaining 11 months of adult-focused rotations. Obviously there's one month of vacation in there, and they do this at our other sites and have elective half-days mix in, and the adults get all their inpatient consultation at the Hospital of the University of Pennsylvania. In our pediatric track, we have three months of intensive adult training spread out at all our adult sites. They have elective half-days in adult sleep medicine mixed in. They get PSGs, MSLTs, reading, and they also do inpatient adult consultation, in part because of some logistics that changed on the CHOP side. But they do do some adult time, not a ton, in the consult service. And then they spend nine dedicated months of pediatric, which includes one month of pediatric ORL. They have elective half-days mixed in, and they do do some inpatient consults. I left that off the slide. I told you about the funding, and that ideally what we do with the additional, we very easily make three, funding for three, and then with that fourth and fifth slot, we really try to split it for another adult and another pediatric. Again, part of that has to do with just who the applicant pool is. Just because it's so complicated, I think, for people to get their head around when they're thinking about training in sleep medicine is that we actually decided that we needed to dedicate one interview day to pediatrics and really spend a lot of time explaining how the two experiences were different. So on that day, everyone comes together for an overview at 7.30 in the morning. In the morning interviews, the pediatric applicants go to CHOP and get a series of interviews there, and the adult applicants stay at HUP. Then everyone meets up for lunch with our fellows, and then in the afternoon, the pediatric applicants come to HUP and meet with the adult faculty, and then the adult applicants are able to leave. I should say that adult applicants will often meet with one or two pediatric faculty. Alex Mason, who I mentioned, he will do some of the interview days, but essentially, if you're a PEDS-trained applicant and going to spend nine months there, nine months over at CHOP, that faculty gets involved, and it's a much more involved full-day interview for the pediatric track applicants. We have actually, I think some of you have asked me about this in the recent years, we actually have two codes. So if you can see there, the number is the same except for what's after the F. So the pediatric code is F1. The quota, I list the quota as 1, and then I have it revert to an adult if it doesn't fill. So depending on my funding, if I'm going to take all five applicants and I'm willing to have all five be adult, if the pediatric one doesn't fill, I move it over. On the adult side, I tell all PEDS applicants, if they really want to come, to rank both. And then if we want to take two pediatric folks, for example, then we will rank our top one, two, or three choices on the pediatric track number, and then I will rank the top one or two pediatricians high enough on our list to match. And then, because this is confusing when they come for the interview day, even though I show them the slides, I send a reminder email in e-RAS I push out right before their rank list is due, reminding them of exactly what I have on this slide. So the overview of the year, this is sort of what I was showing in a different slide before. But if you can see on the adult track, a lot of the time is spent. So the consults come out of the HUP side. So it's 14 weeks at HUPs and 30 weeks at the VA. They go to CHOP for four weeks plus those additional blocks. And then on the pediatric side, you can see most of the weeks are spent at CHOP. We definitely want to have transparency, and I want them to all feel like one group. And so the master list and the monthly schedule that comes out has everybody's schedule on it. Everyone is eligible for any elective experience they want on the adult or pediatric side. And then everyone has a half-day of protected scholarship time weekly. Of course they all get four weeks of vacation, and I mentioned about the master schedule. So what about patient encounters? So I inform them from the beginning, even on the interview days about the mandatory minimums which you all know. And then we have done this now enough over the last 14 years that I have been doing this that I only have to worry does an adult fellow get enough pediatrics and does a PEDS-trained fellow get enough adult. And so rather than having these very cumbersome logs with 600 people that the Competency Committee had to look at every year, I now know based on the rotation allocations I just told you that our adult fellows will get between 80 and 100. Actually this year we had a change in one of our external sites, and that's been an issue for us, but we knew it because they were tracking their pediatric numbers. And the same is true for the PEDS on the adult side. I'm not sure if I mentioned it, but the, actually maybe it's in the next slide. How do we make it so that they, particularly the pediatric folks, are able to spend nine months at CHOP and still see close to 300 plus adults? And essentially it's because in the pediatric track they have two continuity clinic experiences. The first one is that they're pediatric, half day per week at CHOP Main, like everyone else a half day of clinic, but then they spend a half day a week or sometimes it's a full day every other week depending on the site that they're at, spread out in that year. And so because they have that regular continuity experience, which comes out of whatever rotation they're on, they more than get their numbers. We have combined conferences. We have a summer lecture series specifically geared towards new fellow, and we actually, we don't assume what anyone's background is. We teach everybody the same thing from the beginning. You probably all do that. We have Penn-based conferences, which occur on Monday and Thursday, and that's specifically to leave Wednesday open for the CHOP-based conferences, and all fellows are expected to go to both places and attendance is tracked, and I do discuss it with them when I meet with them throughout the year. So I would say we're one program with customized tracks. We've trained 44 ACGME fellows over the last 14 years. 14 of them have been pediatricians, although this current year I have two, and I'm having two come in next year, which we're really thrilled about because I think the interest from pediatrics into sleep has been really grown in the last few years, but we had one or two years where we didn't have anyone interested in pediatrics. 95% of the trainees have all gotten jobs in the sleep field, either all or in part, meaning they do some sleep and some something else, and of the pediatricians, of those 14, 100% of them are practicing sleep, and two of them are actually in practices where they include adult sleep, and what I've heard from all the fellows that have left are graduates that they feel like they've been adequately prepared. So that's all I have, and I'll let Anita go. Hi, my name's Anita Schellgeker. I'm at the University of Michigan, so I'll just give you a brief overview of our program. Here's where we are in Ann Arbor. So we're in southeastern Michigan, so there's us, there's Wayne State University in Detroit, and Henry Ford in Detroit, so there's three fellowship programs clustered within a relatively small geographic area. We have seven ACGME-approved positions. We have one track. Our fellows come from all over the country and from a number of different backgrounds, and as you know with the match, that mix changes from year to year, so last year we had no pediatric-trained fellows. This year we have two general pediatricians, a pediatric neurologist, and a med-peds fellow, so we have a really heavy pediatric representation this year, and next year we have two incoming pediatric pulmonologists. So it just changes year to year, which is part of the fun, as you know, but part of also the mental gymnastics for trying to balance these experiences. And then after graduation, our fellows go on to academic positions and private practice settings as well, and everyone, all of our graduates do practice sleep. Some of them choose to do 100 percent sleep or to do some of their primary discipline as well, and that just varies person to person. This is a list of our faculty. Just to emphasize the multidisciplinary nature of our faculty, and so our fellows, regardless of their background training, do rotate with all of these individuals over the course of the year, so they do get exposure to multiple aspects of the field. All right, so in terms of our training sites, we have the University of Michigan, which has four attended laboratories, and then the VA Health System, which also has an attended lab. Out of our seven spots, six are funded by the university and one is funded by the VA. And then there are comprehensive clinics, both adult and pediatric, that are located at the university, and we have an adult, obviously adult, clinic at the VA as well. And then we have multidisciplinary clinics on both the adult and pediatric side, so alternatives to CPAP clinic, refractory CPAP clinic for adult and pediatric patients, our multidisciplinary insomnia clinic, which is our behavioral sleep medicine clinic, and then a pediatric sleep and behavior clinic that's staffed by our pediatric sleep medicine faculty and by a developmental pediatrician. So these are experiences that all of our fellows rotate through over the year. We don't have them short of the VA. We have them as longitudinally integrated clinical experiences, so it's not one discrete month of pediatrics here or there. It's experiences that the fellows all rotate through throughout the year. And then we have research that they do as well. We don't require research. We require that they present a poster at a meeting, either the sleep meeting or one of our institutional meetings. We have a University of Michigan Neuroscience Day. We are obviously a multidisciplinary program, but institutionally our sleep medicine fellowship is housed in the Department of Neurology, so our fellows can participate in this Neuroscience Day along with the Department of Neurosurgery, so it just gives them another opportunity to share their work and to present their work with other people. And then we have an academic track that is an add-on to our clinical program. So we have the 12-month clinical program. And then if somebody designates, you know, in the first third or first half of their fellowship that they wanted to add dedicated research training, then we do have this opportunity. So this, you know, we go many years with no one wanting to do this, and this year we have two that are staying on for T32-funded research experiences. And so those are, again, open to fellows from any background. So one of the T32 grants is in neurology, but one of our internal medicine trained fellows is doing that for next year. So there is some flexibility there. And we do require that they complete their clinical training entirely before they start this research training. So it's not integrated over a three-year period. It's a discrete one-year period followed by two years of research. So one thing that we struggle with is this balanced exposure. Everybody goes to everything, right? But obviously if you're a pediatric pulmonologist versus an adult neurologist, your level of interest in attending pediatric clinics versus adult VA clinics may be different. And that's, I think, sometimes the struggle, especially with year-to-year, we have a different number of pediatric trained candidates coming through. So the good is that we have many committed multidisciplinary faculty. I think that allows us to pivot a little bit. It certainly allows our fellows to explore their clinical interests, their academic interests, and to have that mentorship throughout the course of the 12 months of training. The way our schedule is built, all of our fellows get clinic experience and PSG experience with patients of all ages. So they're reading pediatric studies throughout the year, reading adult studies throughout the year. And there is some flexibility available in the second half of the fellowship. We experimented with electives. And again, kind of depending on the fellow and depending on what they chose, they kind of got bored after two days. Like, OK, I've seen enough inpatient EEG. I don't really need to do this for two weeks' time. So we do allow them to have that opportunity to explore things as needed. And even, again, when our balance of pediatric to adult trained is maybe not so heavy as it is this year, then sometimes they will swap out clinics and be like, can I trade your VA for your PEDs because I've gotten my quota, I've checked my boxes in terms of volume for pediatric patients. Sometimes that works. That's a little harder this year when we have so many people vying for similar experiences. The challenges, again, as Eileen already described, the requirements are the same in terms of basic minimums, right? So there are some things that we can't change regardless of the fellow's interest in career goals, even though sometimes we may like to. And again, there's this variability from one fellow to the next and even from one fellow class to the next, which, again, requires a little bit of creativity on our end to make sure that we provide meaningful experiences to everyone who comes through the program. And then the opportunity is that these differences in the background, I think, really do force us and inspire us to seek curricular innovation, right? So we don't stagnate from year to year. It's like, OK, how can we do this better? How can we think about other opportunities to provide people with the experiences that are meaningful to them, that are useful to them, not only in the short term for their fellowship training and board prep, but even for the long haul? And then that broadened exposure during a fellowship does sometimes open new career pathways. So we've had alum who came in as internal medicine trained fellows or residents, and because they were required to do pediatrics, said, oh, I actually really love this. And then that's the focus of their career 10 years later. So I think that making sure that all of our fellows do get sufficient exposure to both pediatric and adult sleep medicine, regardless of their background, can be helpful in that regard as well. So that's my email address. And I will turn it over to Kieran. Thank you. All right, so my name is Kieran Maskey. I head the clerkship for the Boston Children's Hospital Sleep Fellowship, and this is within Beth Israel Deaconess Medical Center. So we had a unique experience where we actually did have our own pediatric sleep fellowship from 2009 to 2012 and had two sleep fellows per year. We combined in 2013 to have two to three adult fellows per year and one pediatric sleep fellow, and that was primarily for funding reasons. We had just less buy-in from the pediatric side, and so we combined forces with the adult side in terms of fellowship. Now just in terms of funding, we have a single department within Boston Children's funding the pediatric track. So currently we have the adult sleep fellowship structure is to have a half-day clinic, and that's a continuity clinic through their 12-month rotation. And they rotate with attendings from sleep neurology, sleep behavior developmental medicine, sleep pulmonary, and our cognitive behavior clinic is an observational experience at Boston Children's Hospital. And they're assigned two pediatric sleep studies a week. In terms of their stats, the adult fellows read about 60 to 65 pediatric PSGs per year, which is a little over the requirement per year. The adult fellows see about 60 to 80 new pediatric patients and 44 to 60 follow-up patients. And in terms of the feedback that we've gotten from the pediatric experience, the adult fellows seem to enjoy the teaching experience and the pace of clinic, but it was interesting that they actually wanted to see more variety of pediatric patients, and that's why we created this rotational experience of rotating through the various neurology versus pulmonary-type clinic style. Sometimes they found working with parents or children challenging as adult providers. Some are excellent at it and some really struggle. So we sort of have learned that attendings do have to play a role in terms of the continuity and the communication to avoid frustrations on both ends. And interestingly, they wanted to read more complex pediatric PSG studies and specifically wanted to read infant studies, complex sleep apnea, or even MSLTs. And that can be a challenge, frankly, because of their busy schedules, and we have a turnaround time of three days with some of these types of studies that's not always feasible. In terms of the Pediatric Sleep Fellowship training structure, our Pediatric Sleep Fellow spends about 75% of the time at Boston Children's, so they have three half-day clinics at Boston Children's with those different clinics I mentioned. They spend one and a half days at Beth Israel, and we used to have this as just a single half day, and because we were not meeting the numbers for the adult requirements, added this every other week, adult clinic. So the way that this works is they have a continuity pulmonary clinic with a sleep attending at Beth Israel, and then every other week they rotate through a subspecialty sleep clinic. There's a circadian clinic at Beth Israel and a complex sleep apnea clinic there. And they're reading about three to five pediatric PSGs per week and reading about two to three adult PSGs per week. And in terms of their numbers, if it's important, they saw more than a sufficient number of patients, news about 135s, follow-ups 138, and they read 131 PSGs, and they meet the adult criteria. So in terms of challenges overall, I think funding sources is something that we've worked out over time. Initially Beth Israel and Beth Children's were splitting the cost of the fellow. Currently a single department now has committed funding for the fellow. I think recruitment challenges, as Eileen had mentioned, we had the issue of not having that NRMP dedicated code, and that's a problem if you have not encountered this. So one year we did not fill, even though we had plenty of candidates, because we didn't have a specific code for pediatric sleep. So I think that's really important. I think a central place to list pediatric sleep fellowships is important, whether that's on the ASM website. It's not always apparent from just looking at ARIS which group has a pediatric track and which doesn't. And then I think overall, I mean, something to discuss, just the pipeline of candidates has gotten, I think, has gotten less over time. So we're doing things like trying to increase sleep exposure in various pediatric subspecialties, such as neurology or epilepsy, developmental medicine or general pediatrics, and including psychiatry. And then in terms of, I think, other challenges, just knowing what adults need to learn in pediatric sleep and vice versa would be a helpful discussion. We really don't have data on what graduates do after graduation in terms of if adult fellows are seeing pediatrics or if pediatric fellows are seeing adults. But certainly, we've had the experience that's been shared by my colleagues up here that there's a lot of cross needs in the group and, I think, the advantage of an integrated program. So I think having more clear learning objectives, especially for pediatric sleep medicine, would be important. And then the benefits, I think, are just the collaborative nature of the program. So the teaching conferences are joint. We have a clinical grand sleep rounds, sleep grand rounds that's more basic science. There's a weekly sleep fellowship lecture, and the pediatric sleep lectures are monthly or bimonthly. And it certainly increases the breadth of mentorship we have and research opportunities. I think we produce well-rounded graduates who are competent to manage sleep problems and really confident seeing both adult and pediatric patients. So in terms of our program, we have had 13 pediatric candidates. Only one is not practicing sleep, and that was primarily due to a visa issue. And we have one pediatric trainee who actually only sees adult patients now. So I think, again, it's hard to always project what's going to happen down the road. But felt, obviously, well-trained to manage. Thank you. Last but not the least, I'll give you our experience from the Vanderbilt University Medical Center. So Beth Nall is sitting here. She was our program director for the initial few years when I was a fellow under her, and then I took over maybe about 10 years back now. Our fellowship came in – the ACGME accredited fellowship came into existence in 2005, and it is housed under the Department of Neurology. Every year we train two fellows, so even though this is an adult neurology department, we do not have a separate pediatric track. Both pediatric and adult exposure is provided through an integrated one-year fellowship, and we've had success in it over the years. So our goal is basically to give them not just clinical and didactic exposures to the various sleep disorders, but also provide them that experience across the lifespan. So we've, over the last several years, trained people from a lot of disciplines – medicine, neurology, pediatrics, pediatric pulmonary, adult pulmonary and critical care, family medicine. The only people we haven't trained as yet are ENT doctors. I don't think they like coming to our program. They probably seek out the surgical sleep programs more. And like any of you might be doing, it's based on looking at the letters of recommendation and formal interview process, and then we go through – put both our spots through the NRMP match. We have a really unique thing that the night before they come for interviews, we arrange for a dinner with the fellows, which is an informal dinner. They also tour the sleep lab, which over the years, they've given us feedback. They really like the one-on-one with the fellows without the faculty there so that they can ask all the questions and get their questions answered. And then the next day, we have formal interviews as well as a lecture with lunch for them. We have our rotations pretty much set in terms of the sleep continuity clinics, which are throughout the year, the sleep study review sessions throughout the year, and then interspersed are these inpatient exposures, exposure to the ENT clinics, psychiatry clinic, as well as pulmonary clinic. So I'll go into details with each of those. So the fellows, irrespective of their background, attend one half day of pediatric clinic throughout the year, and then two half days of adult clinic throughout the year for the longitudinal care of their patients. And these clinics on Tuesdays or Friday morning and afternoon are with specific attendings. I think the reason why we are able to do this is that our faculty is very flexible. A lot of us see both pediatric and adult patients, even though we are adult neurologists. So I think that's made it simple for us. We just cross-train whoever comes in. We train them, and they're happy to see pediatric patients as well. We also have a refractory pediatric OSA clinic, which the fellows go to once a month to get experience regarding management of the complex patients, pediatric patients with refractory OSA. So in addition to the sleep clinics, the fellows rotate through specific rotations, which I enlisted as adult or pediatric ENT, adult or pediatric pulmonary, and then the outpatient psychology or psychiatry clinic with the emphasis on CBTI. So this is the flexibility that we give them. So there might be a pediatric pulmonary fellow who wants to go to a pediatric ENT clinic. And on the reverse, there might be an adult, an adult medicine fellow who wants to go to an adult ENT clinic. So we give them that flexibility. They can choose and reach out to the attending and then set up a time, because they have enough flexibility in their schedule week to week to be able to attend one half-day session for a month. And they do that for pulmonary as well as well as the psychiatry exposure. We do make them go through two weeks of inpatient EEG, and also they do sleep inpatient consults during that time. We find this very, very useful, because often the non-neurology candidates come back feeling that they've learned so much, and they're finding spikes on these pediatric studies, which we would have missed, and then we can report them, and it's really nice to see them learn. And the learning curve is really steep for them. So the sleep study review sessions are held three half-days per week. They spend the mornings preparing the studies, and in the afternoon, we go over them. And it's just whatever's available in terms of, are there more pediatric studies to read that day versus adult studies? They just interchange. They read both of them. All the attendings read both the studies. So I think, as compared to the previous speakers, my role is much, much easier, and I think Beth made it easy by keeping our sleep lab integrated, where we do both adult and sleep studies in our two labs together, and they all come in under one pool. So at the end of it, we have a candidate who is like a wholesome, truly multidisciplinary trained fellow who can go out and read both adult and pediatric studies. We've had adult pulmonary critical care fellows who choose to read pediatric studies because they find them easy, and that's another thing they can add to the program where they're going to. So it's been really nice. We evaluate them. I meet with them every quarter to go over their evaluations. They're evaluated by the attendings every month, and based on what they are saying, they need more experience, and we might fine-tune their exposure because we do have that flexibility on Mondays when they have either didactics or working on their Q&Is that they can go to additional clinics if they want to. On Monday mornings, we have our lecture series, including book chapter review. We go over the Krieger textbook. We take chapters from the Krieger textbook and go over them month by month, so it's like three, four chapters, 100 pages of reading, and then that weekend, they really have to study hard. Journal clubs and difficult case conferences. We have quarterly sleep CME conferences. We have sleep MNIs. There's thankfully no morbidity, but MNIs we call them. They attend the sleep division meetings to learn about quality improvement topics within the program, and then we have the technical education series, and I have a few slides to show you some of the things that we do in our technical education series. So this is the example from last year. So there are so many other things in sleep that we cannot send them for a rotation for a month. For example, learning on how to do actigraphy or learning titration protocols for ASV titrations or going to the oral maxillofacial clinic to see how an oral appliance is made or how the patient is evaluated. So this is where they're, you know, these are senior fellows. They can take it upon themselves. We tell them who the attendings are or who is the expert who can give them that training, and they set up a time with that person and do one-on-one sessions. We also require that they go to the sleep lab at least twice a month so that they can work with the techs and learn about artifacts and stuff like that. So this is the second half of this year. You can see some of the things that they're doing. CBTI, ASV, EKG interpretation, artifact review, and then this month they're coming to the sleep meeting. Okay. So I just put this. This is the last slide. You can see the variability in terms of the candidates that we've trained. Last year, family medicine, critical care. This year we have internal medicine and pediatrics. And they've gone on to, I would say, 50 percent end up doing academics and 50 percent going to private practice. That's it. Thank you. open it up for questions, you can go to the mic. The one thing I'll just say that I didn't mention, we also have a T32 at our program that we advertise during the interview, but we don't make anyone commit until the first three to six months that they're in the program, and it is open to whatever background you are. So this year, only one of our fellows is staying to do the T32, and she's a pediatric neurologist. Thank you all for sharing your experiences. My interest in coming to the session today was not so much to start a pediatric tract just because we don't have the pediatric staff to support a tract, but one of the trends I've been noticing with just having adult slots is that instead of pulling from pulmonary and neurology in the specialty areas, we're getting more interest from med-peds, internal medicine, and family practice. So they're going to encounter potentially more pediatric patients than us who have been trained first in a subspecialty. So it is important to me that they get the appropriate pediatric exposure, but we have one person within our university who is doing ped-sleep, and that person's also neurology-based and does a lot with epilepsy. So that person wears a lot of different hats. Sleep is just a part of that. And so I can get the clinic, I can get the follow-up, or the follow-up and the consults that we need to see, or the new patient experiences, but I can't get didactics. I can't get them to commit to any lecture on any single patient. And I just feel that that is a necessary part of a curriculum, and I'm just wondering if anyone here has any ideas about how to incorporate more pediatric into the lecture and series. I mean, I've obviously had some pediatric training through my sleep fellowship program, but I do mostly adults, and I just don't feel I'm, I just don't feel experientially, that's a word, qualified enough to be able to really speak to those subjects. Yeah, I mean, that's something that, our pediatric sleep medicine faculty, none of them are 100% sleep. They all have clinical responsibilities in their primary discipline, which we're able to accommodate the clinical volume, but I know that that's sometimes a challenge, right? Because that reality is what it is. I think that's when maybe, to your point about needing more resources for didactics, I mean, I think that's when we should hopefully, and can hopefully look to each other and rely on each other. I mean, there is the webinar series that the SMFDC puts on, and the old ones are archived on to sleep.org, and there are some pediatric ones there for sure, that are, all the webinars in that series are fantastic. So definitely the ones that are archived, I think are still relevant as well. And I think maybe this is an opportunity for us to share resources that we have, or maybe try to use screen sharing or other platforms to share lectures in real time from one institution to the other as well. Yeah. And the only thing I would add to that is that, I'm not sure where you're located, but in Philadelphia there are multiple sleep programs and even multiple non-sleep folks who want some training. And over the years, I have had people ask if they can either, they actually will send their fellows over to sit in, particularly our summer lecture series sessions, which do include core pediatrics, not some of the upper level stuff. But if you have any neighboring programs, I would ask them if you can share resources in the short run, I agree that we as a group should be doing that. Hi, thank you all for your presentation. My name's Sue Beck. I work at CHOP as a pediatric pulmonologist and a sleep doctor there. And I just wanted your guys' thoughts on this. So most of pediatric sleep positions are offered within the context of a subspecialist, subspecialty division under general pediatrics. For example, our sleep centers in the division of pulmonary medicine. So I wanted your thoughts on how well-trained is a pediatric, straight out of pediatrics does one year of sleep. How marketable are they after that one year in the context of joining a subspecialty division? And is that a problem when they finish the one year fellowship? Because I've talked to my colleagues who are in similar position to me. How do we hire someone that's just done one year of a sleep fellowship and no other fellowship into a subspecialty practice? And the Department of Pediatrics, you know, we're doing it, but we have to make a lot of concessions for night call, for weekend call, and, you know, equitability and all that kind of stuff. So I just wanted your thoughts on that or anyone else's thoughts too. Yeah, I would say for us too, it's something that has evolved. Our leadership in pediatrics has changed over the years. So the prior chair, I think it was almost just a hard and fast no if someone wasn't subspecialty trained in addition to being sleep trained for pediatrics. Now they will offer, you know, an opportunity with the hospitalist division or the general pediatrics division. So again, not an opportunity to do 100% pediatric sleep, but if, you know, someone is willing to do general outpatient pediatrics or pediatric hospitalist, then they will work with them to split that time. I feel the same. I think things are changing and both in the adult world and pediatric world people are realizing that sleep is really a full-time job and you know a lot of us who were doing a lot of inpatient service time, the hospitals are hiring hospitalists, neurologists and so we are doing more more and more sleep study in reading as well as clinic stuff so they're recognizing that sleep can be just as important and you don't need to have other specialties, subspecialties to be trained in. I mean I think in pediatric sleep in reading studies the majority are straightforward but it's when you get that last 15 to 20 percent where they're you know complex pulmonary patients it's really hard to have someone trained I think in a year to do that and also in pediatric sleep in the clinic our clinic is very interdisciplinary I think it's hard to do pediatric sleep outside of that context and hopefully that's recognized during the course of their training I think at Penn definitely it is right because they come over but you know behavioral insomnia childhood and CPAP adherence is totally different than adult medicine. So just to give you an example one of our adult trained fellows who came back to Vanderbilt is doing 100% PEDS under pediatrics. She's hired by the pediatrics department under pediatric pulmonary and yes she has some very complicated patients because we are a tertiary care center but she brings those cases to the difficult case conference where everybody is sitting there and then reaches out to the patient with with a common consensus so I think you learn as you go because even the pediatric pulmonary trained sleep fellows may not have that kind of experience some patients are just that complicated. Thank you all. Thank you for the session. My name is Hisham Hamdan. I'm a pediatric pulmonologist and a pediatric sleep medicine physician. I recently graduated fellowship so I was interested in sharing the experience of a few points from a recent graduate perspective. The program where I did my sleep fellowship gave me the option of doing 60% PEDS 40% adult as opposed to the opposite which is the standard so I think that was very helpful for me so I did three days of pediatric sleep and two in the adult per week. With the aim of that I will be doing only sleep medicine in pediatrics when I graduate. Having said that I do appreciate that I had substantial adult exposure because there are a lot of common pathology in sleep between adults and pediatrics and in the adult world the pathology usually is clearer and easier to read from sorry easier to learn from and it occurs more common. The example I think of most of the time is Restless Leg Syndrome where during my adult exposure I saw a lot of cases of Restless Leg Syndrome and it was very clear and I went through probably the entire spectrum of treatments and saw a lot of side effects of the treatments as opposed if in the pediatric exposure there were very few cases and they weren't very clear so my understanding of the of the disease itself or the condition was much clearer because I had good adult exposure and that made me a better sleep medicine physician in the pediatrics world. In addition to that there's a lot of central like apneas and complex sleep disorder breathing issues that occur more common in adults but you can also extrapolate to pediatrics so I think even for people who are going to do pediatric sleep good exposure to adult is I think fundamental. The other point from an aspect of what I kind of benefited from was I chose to do a lot of pediatric sleep psychology also we had a pediatric psychologist in our center and I chose to do a lot of sessions with him and I think that came very helpful for me in my future and in my practice currently because that's a good chunk of what I do. The fourth point that I found that was helpful but I wish I could would have done more was getting involved more with the issues that relate to the technicalities and the hardware because I mean if you're gonna end up practicing in a tertiary care center that's probably may not be an issue because the other supporting staff are well trained and they've been there for a while but you never know if you end up somewhere where the technologists are not all of them are not at the same level then you can end up getting calls at night about technology issues and instruments and hardware so I think that point is also important to be emphasized in sleep medicine training.

balance

adult sleep medicine

pediatric sleep medicine

fellowship programs

University of Pennsylvania

University of Michigan

Boston Children's Hospital

Vanderbilt University