University of Toronto

Pediatric Sleep Medicine Training Program

(Please Note: This program is not accredited through the Royal College of Physician and Surgeons of Canada)

  1. General Training Objectives
  1. The Trainee will develop special competency in the clinical practice of Pediatric SleepMedicine.
  2. The Trainee will develop the knowledge and managerial skills necessary toindependently operate a pediatric sleep laboratory.
  3. The Trainee will develop experience in sleep-related research (basic scientific,clinical, or epidemiological) or in education, with a view to a career in academicSleep Medicine.
  1. Core Competencies

Medical Expert

The Trainee will

  1. Understand the physiology of normal human sleep, including basic mechanisms ofsleep-wake states, sleep-promoting mechanisms, and REM sleep.
  2. Understand alterations in cardiovascular, respiratory, endocrine, and gastrointestinalphysiology during sleep, as well as the impact of sleep on host defenses andthermoregulation.
  3. Understand the normal ultradian distribution of human sleep and recognize thechanges which occur with normal aging.
  4. Understand the basis for mammalian circadian systems, sleep homeostasis, andmodels of sleep regulation.
  5. Understand the pharmacology of hypnotic and wake-promoting medications, and becognizant of the effects of other medications on sleep.
  6. Have an approach to the history and physical examination of a patient presentingwith disordered sleep.
  7. Be familiar with the classification of sleep disorders, including the InternationalClassification of Sleep Disorders 3ed edition.
  8. Have knowledge of the epidemiology, prevention, pathogenesis, clinicalmanifestations, laboratory testing, treatment, prognosis, and complications of:
  1. Sleep Disordered Breathing in adults and children. This includes snoring, and upper airways resistance,obstructive sleep apnea, central sleep apnea, sleep hypoventilation, andneuromuscular disorders. In particular, the Trainee will have detailed understandingof the cardiovascular consequences of sleep breathing disorders.
  2. Various treatment options for Pediatric Sleep Disordered Breathing including medications, oxygen, non-invasive and invasive ventilation.
  3. Insomnia. The Trainee will be familiar with the causes of insomnia, and bothpsychological/behavioural and pharmacologic therapies.
  4. Disorders of Chronobiology, including jet lag, shift work, delayed and advancedsleep phase syndrome.
  5. Hypersomnias of Central Origin, including narcolepsy and idiopathichypersomnia.
  6. Sleep Related Movement Disorders, including restless legs syndrome, periodicleg movement disorder, sleep related leg cramps, bruxism, and rhythmic movementdisorder.
  7. Parasomnias, including disorders of arousal from NREM sleep and parasomniasusually associated with REM sleep.
  8. Sleep related eating disorders.
  9. Other sleep related disorders including bedtime resistance, sleep onset, maintenance association problems.
  1. Understand the sleep-related effects of:
  1. Daytime school and behavior.
  2. Mood, anxiety, and psychotic disorders.
  3. Chronic pain, including fibromyalgia.
  4. Pregnancy and menopause.
  5. Seizure disorders.
  1. Be familiar with the technical aspects of polysomnography, including:
  1. Lead placement and procedures for Level 1 polysomnography.
  2. Procedures and protocols for performing Level 1 diagnostic polysomnography andpositive pressure titration (including CPAP, BiPAP, and adaptive servo-ventilation).
  3. Scoring of a Level 1 polysomnogram, including sleep staging, respiratory events,EKG interpretation, leg movements, and abnormal movements such as bruxism.
  4. Identification of sources of artifact and the proper steps towards correction.
  1. Be proficient at the interpretation of polysomnography data and at synthesizing theelements of a polysomnogram into a physician’s report.
  2. Be proficient at the interpretation of multiple sleep latency testing and maintenanceof wakefulness testing.
  3. Be familiar with the use of sleep diaries, and actigraphy.
  4. Be proficient at the interpretation of Positive airway pressure adherence downloads and familiar of management strategies to improve compliance.

Communicator

The Trainee will

  1. Be comfortable explaining etiologies, consequences, and treatment options topatients with sleep disorders and their families.
  2. Be proficient at providing a clear, concise and complete consultation letter toreferring physicians, and be available to discuss cases with other health careprofessionals and consultants.

Collaborator

The Trainee will

  1. Work with technical staff and learn to implement quality assessment andimprovement strategies.
  2. Work with other health professionals in a multi-disciplinary approach to patient care.For example, the Trainee may collaborate with dieticians, pharmacists, psychologists,and nursing staff or consult other specialist physicians.

Manager

The Trainee will

  1. Gain understanding of the process of appropriately triaging referrals made to a sleepclinic or laboratory.
  2. Understand the role of a Quality Assurance director of a sleep laboratory.
  3. Gain insight into the issues of hiring and managing technical staff of a sleeplaboratory.
  4. Be cognizant of the essential equipment required to operate a sleep laboratory.

Health Advocate

The Trainee will

  1. Understand the societal implications of sleep disorders, including the impact on apatient’s ability to operate a motor vehicle.
  2. Be aware of preventative measures that can be taken to reduce the impact of sleepdisorders on society.
  3. Provide documentation for patients requiring medical information for the purposes oftraveling or reimbursement from government programs and insurance plans.

Scholar

The Trainee will

  1. Understand the epidemiologic and physiological principles behind core literature inthe field of Sleep Medicine.
  2. Recognize the importance of continuing education in the rapidly advancing field ofSleep Medicine.

Professional

The Trainee will

  1. Demonstrate a commitment to patients, profession, and society through the ethicalpractice of Sleep Medicine.
  2. Exhibit appropriate professional behaviors in practice and recognize and manageconflicts of interest.
  1. Training Program Structure

The Trainee will undertake minimum of one year(range 12-24 months) of full-time clinical training in Sleep Medicine. This willusually begin with the academic year on July 1st and end on June 30 of the followingyear or the year after depending on the duration of the training. The Fellow will be permitted to take 4 weeks of vacation time per year, excluding statutoryholidays.

Technical Skills

A minimum of one month of the program (early on in the training) will be spent concentrating onlearning the techniques for acquisition, scoring, and interpretation of polysomnographicdata. This will take place in the sleep laboratories at The Hospital for Sick Children,St. Michael’s Hospital and at theToronto Rehabilitation Institute, with guidance from registered polysomnographytechnologists. During this time, the Trainee will have minimal clinical duties and will beexpected to complete a minimum of:

  1. The set up of a minimum of 5 Level 1 polysomnograms.
  2. Overnight observation of a diagnostic polysomnogram and NIPPVand trach/vent titration studies.
  3. Observation of a multiple sleep latency test.
  4. The scoring of a minimum of 25 complete records and 2 multiple sleep latency tests, which will becompared with technician scoring for accuracy.

Resources will include the American Academy of Sleep Medicine Scoring Manual(2012), Retschaffen and Kales, and Sheppard’s Atlas of Polysomnography.

Polysomnogram Interpretation

Over the course of the program, the Trainee will be expected to interpret a minimum of200 baseline polysomnograms. This will be in addition to at least 60 NIPPV titration studies , 25 Multiple Sleep Latency Tests, and 10 Maintenance of WakefulnessTests.

The Trainee will attend weekly Polysomnogram Interpretation sessions with Dr. Narang, Dr. Amin and/or Dr. Al-Saleh. The Trainee will be expected to prepare for these sessions byviewing the polysomnograms on the Monday prior to the sessions.

Clinical Activities-Adults

During 1-2 months adult rotation, the Trainee will attend a minimum of 4ambulatory clinics per week to gain exposure to Sleep Medicine from the viewpoints ofSleep Medicine specialists from different backgrounds (Respirology, Neurology, Psychiatry). This will take place in Toronto General Hospital, St Michael Hospital and Sunnybrooks Hospital. The Trainee will perform both initial and follow up assessmentsin these clinics. This will be under supervision of the attending staffs in the clinics.

Clinical Activities-Complex Respiratory Care

During 1-2 months complex respiratory care rotation, the Trainee will attend a minimum of 3 ambulatory clinics per week to gain exposure to complex respiratory care from the viewpoints ofspecialists from different backgrounds (Pediatrics, Adults, Developmental, neurology). This will take place in The Hospital for Sick Children, West park and Bloorview rehab centres). The Trainee will perform both initial and follow up assessmentsin these clinics. This will be under supervision of the attending staffs in the clinics.

Clinical Activities-Pediatrics

Over the remaining period of the program, the Trainee will attend a minimum of 2ambulatory clinics per week to gain exposure to Pediatric Sleep Medicine from the viewpoints ofSleep Medicine specialists from different backgrounds (Respirology, home ventilation, Neurology,Psychiatry, Developmental Pediatrics). The Trainee will perform both initial and follow up assessmentsin these clinics. This will be under supervision of the attending staffs in the clinics.

Scholarly Activity

The Trainee will engage in the following educational activities:

  1. University of Toronto Centre for Sleep Medicine and Circadian Biology Rounds (2ndFriday of each month, September to June). The Trainee will attend these rounds on amonthly basis and will be expected to present once on a topic of his/her choiceduring the program year.
  2. The Hospital for Sick Children Laboratory Rounds. These rounds take place at The Hospital for Sick Childrenat 5 PM, on oneTuesday of each month. Rounds are attendedby staff sleep physicians (Dr. Narang, Dr. Amin and Dr. Al-Saleh), as well as rotating Pediatric Respirologyresidents and polysomnography technologists. The Trainee is encouraged to bringinteresting cases and/or polysomnograms for discussion.
  3. The Traineewill be encouraged to attend Dr. Richard Horner’s course on Advanced Sleep Physiology.This is a weekly course from January to April.
  4. The Trainee will be encouraged to attend Sleep courses and conferences.
  5. The Trainee will be encouraged to participate in either a research or educationalproject in Sleep Medicine. In the case of a research project, this will need to bediscussed with Dr. Narang, Dr. Amin and/or Dr. Al-Saleh.
  6. The Trainee will critically appraise and discuss one article per month at a JournalClub which will be held at 9 AM of the first Friday of each month September to June.
  7. Trainee will present a case or topic at pediatric sleep medicine round which will be held at 9 AM of the last Friday of each month September to June.
  8. Division of Respiratory Medicine chest round that occur every Tuesday at 4 PM which is a Trainee presentation of various respiratory and sleep topics.

Evaluation

The Trainee will receive formative feedback upon completion of the third and sixthmonths of training. Feedback will be solicited from the various staff physicians whohave supervised the Trainee in clinics and summarized by the Program Director, who willmeet with the Trainee to discuss strengths and strategies for improvement. The Traineewill be given an opportunity to provide feedback to the Program Director on the trainingprogram. Following the twelfth month of training, the Program Director will again meetwith the Trainee to provide summative feedback, again with input from the varioussupervising staff physicians.

1

University of Toronto

Pediatric Sleep Medicine Program Training Program

OBJECTIVES – ROTATION SPECIFIC

  1. Sleep Medicine-Pediatrics
  2. Complex Respiratory care
  3. Sleep Medicine-Adults
  4. Sleep Lab- Overnight studies and scoring
  5. Research

Electives

  1. To be added

1

UNIVERSITY OF TORONTO, DEPARTMENT OF PEDIATRICS

DIVISION OF RESPIRATORY MEDICINE

SLEEP MEDICINE- Pediatrics

CanMEDS Criteria

A. Medical Expert

1.Basic science knowledge

2.Clinical knowledge

3.Data-gathering (e.g. history & physical)

4.Choice & use of ancillary tests (e.g. laboratory tests)

5.Soundness of judgment & clinical decisions

6.Self-assessment ability (insight)

B. Communicator

1.Establishes therapeutic relationships with patients/families

2.Delivers understandable information to patients/families

3.Provides effective counseling to patients/families

4.Maintains professional relationships with other health care providers

5.Provides clear and complete records & reports (including oral reports

C. Collaborator

1.Works effectively in a team environment

2.Consults effectively with other physicians and health care providers

D. Manager

1.Manages time effectively

2.Allocates health care resources effectively

3.Utilizes information technology effectively

4.Works effectively in a health care organization

5.Practices evidence based medicine

E. Health Advocate

1.Is attentive to preventive measures

2.Is attentive to issues of public policy for health

3.Recognizes important determinants of health

4.Demonstrates concern that patients have access to appropriate information and services

5.Advocates on behalf of patients

F. Scholar

1.Attends and contributes to rounds, seminars and other learning events

2.Accepts and acts on constructive feedback

3.Takes an evidence-based approach to management problems

4.Contributes to the education of patients, house staff/students, and other health professionals

5.Contributes to the development of new knowledge

G. Professional

1.Recognizes limitations and seeks advice and consultation when needed

2.Exercises initiative within limits of knowledge and training

3.Discharges duties and assignments responsibly and in a timely and ethical manner

4.shows respect of diversity of race, age, gender, sexual orientation, disability, intelligence and socio-economic status

5.Reports facts accurately, including own errors

6.Maintains appropriate boundaries in work and learning situations

7.Shows respect of diversity of race, age, gender, sexual orientation, disability, intelligence and socio-economic status

H. Rotation Specific

Medical Expert

The Trainee will

  1. Have an approach to the history and physical examination of apediatric patient presentingwith disordered sleep.
  2. Have knowledge of the epidemiology, prevention, pathogenesis, clinicalmanifestations, laboratory testing, treatment, prognosis, and complications ofvarious sleep related disorders in children includingSleep Breathing Disorders,Insomnia,Disorders of Chronobiology,Hypersomnias of Central Origin,Sleep Related Movement Disorders,Parasomnias andOther sleep related disorders including bedtime resistance, sleep onset, maintenance association problems.
  3. Understand the sleep-related effects of:
  4. Daytime school and behavior.
  5. Mood, anxiety, and psychotic disorders.
  6. Chronic pain.
  7. Seizure disorders.
  8. Be proficient at the interpretation of pediatric polysomnography data and multiple sleep latency testing and at synthesizing theelements of a polysomnogram into a physician’s report.
  9. Be familiar with the use of sleep diaries, questionnaires, and actigraphy.

Communicator

The Trainee will

  1. Be comfortable explaining etiologies, consequences, and treatment options topatients with sleep disorders and their families.
  2. Be proficient at providing a clear, concise and complete consultation letter toreferring physicians, and be available to discuss cases with other health careprofessionals and consultants.

Collaborator

The Trainee will

  1. Work with clinic and sleep staff and learn to implement quality assessment andimprovement strategies.
  2. Work with other health professionals in a multi-disciplinary approach to patient care.For example, the Trainee may collaborate with dieticians, pharmacists, psychologists,and nursing staff or consult other specialist physicians.

Manager

The Trainee will

  1. Gain understanding of the process of appropriately triaging referrals made to a sleepclinic or laboratory.

Health Advocate

The Trainee will

  1. Understand the societal implications of sleep disorders, including the impact on apatient’s ability to operate a motor vehicle, school and work performance.
  2. Be aware of preventative measures that can be taken to reduce the impact of sleepdisorders on individuals and society.
  3. Provide documentation for patients requiring medical information for the purposes oftraveling or reimbursement from government programs and insurance plans.

Scholar

The Trainee will

  1. Understand the epidemiologic and physiological principles behind core literature inthe field of Sleep Medicine.
  2. Recognize the importance of continuing education in the rapidly advancing field ofSleep Medicine.

Professional

The Trainee will

  1. Demonstrate a commitment to patients, profession, and society through the ethicalpractice of Sleep Medicine.
  2. Exhibit appropriate professional behaviors in practice and recognize and manage conflicts of interest.

1

UNIVERSITY OF TORONTO, DEPARTMENT OF PEDIATRICS

DIVISION OF RESPIRATORY MEDICINE

Complex Respiratory Care

CanMEDS Criteria

A. Medical Expert

1.Basic science knowledge

2.Clinical knowledge

3.Data-gathering (e.g. history & physical)

4.Choice & use of ancillary tests (e.g. laboratory tests)

5.Soundness of judgment & clinical decisions

6.Self-assessment ability (insight)

B. Communicator

1.Establishes therapeutic relationships with patients/families

2.Delivers understandable information to patients/families

3.Provides effective counseling to patients/families

4.Maintains professional relationships with other health care providers

5.Provides clear and complete records & reports (including oral reports

C. Collaborator

1.Works effectively in a team environment

2.Consults effectively with other physicians and health care providers

D. Manager

1.Manages time effectively

2.Allocates health care resources effectively

3.Utilizes information technology effectively

4.Works effectively in a health care organization

5.Practices evidence based medicine

E. Health Advocate

1.Is attentive to preventive measures

2.Is attentive to issues of public policy for health

3.Recognizes important determinants of health

4.Demonstrates concern that patients have access to appropriate information and services

5.Advocates on behalf of patients

F. Scholar

1.Attends and contributes to rounds, seminars and other learning events

2.Accepts and acts on constructive feedback

3.Takes an evidence-based approach to management problems

4.Contributes to the education of patients, house staff/students, and other health professionals

5.Contributes to the development of new knowledge

G. Professional

1.Recognizes limitations and seeks advice and consultation when needed

2.Exercises initiative within limits of knowledge and training

3.Discharges duties and assignments responsibly and in a timely and ethical manner

4.shows respect of diversity of race, age, gender, sexual orientation, disability, intelligence and socio-economic status

5.Reports facts accurately, including own errors

6.Maintains appropriate boundaries in work and learning situations

7.Shows respect of diversity of race, age, gender, sexual orientation, disability, intelligence and socio-economic status

H. Rotation Specific

Medical Expert

The Trainee will

  1. Have an approach to the history and physical examination of a pediatric patient presenting with disordered sleep.
  2. Have knowledge of the epidemiology, prevention, pathogenesis, clinical manifestations, laboratory testing, treatment, prognosis, and complications of various sleep related disorders in children including Sleep Breathing Disorders, Insomnia, Disorders of Chronobiology, Hypersomnias of Central Origin, Sleep Related Movement Disorders, Parasomnias and Other sleep related disorders including bedtime resistance, sleep onset, maintenance association problems.
  3. Understand the sleep-related effects of:
  4. Daytime school and behavior.
  5. Mood, anxiety, and psychotic disorders.
  6. Chronic pain.
  7. Seizure disorders.
  8. Be proficient at the interpretation of pediatric polysomnography data and multiple sleep latency testing and at synthesizing the elements of a polysomnogram into a physician’s report.
  9. Be familiar with the use of sleep diaries, questionnaires, and actigraphy.

Communicator