INTRODUCTION
The Department of Pediatrics of the University of Alberta offers a two-year fellowship training program in Neonatal-Perinatal Medicine to individuals who have completed their pediatric residency training. A third year of neonatal-perinatal training, predominantly research, may be available for selected trainees at the discretion of the program director and residency program committee. The training program is based at the two tertiary neonatal units of the Royal Alexandra Hospital (RAH) and University of Alberta Hospital (UAH), and the two intermediate care nurseries at the Grey Nuns (GNH) and Misericordia (MIS) hospitals. All four units are university affiliated and the UAH and RAH are part of the Stollery Children’s Hospital.
The northern Alberta region has approximately 29,000 deliveries per year with 18,000 of those deliveries in the Edmonton area. Edmonton has four neonatal units which provide regionalized care with approximately 3500 admissions/year. The RAH, a combined level 3A and 2 unit, has 69 beds with approximately 1300 admissions/year and the UAH, a surgical/cardiac level 3C unit with 18 beds has approximately 500 admissions/year. The Grey Nuns hospital, a level 2C unit, has 28 beds and approximately 1300 admissions/year admitting ≥30 weeks gestational age and the Misericordia is a level 2B unit with 15 beds. The combined number of admissions and broad range of clinical problems encountered offers very comprehensive clinical training in Neonatology. At the RAH, where high-risk Perinatology is located, there is a particular interest in the clinical management of refractory respiratory failure, including the use of nitric oxide and high frequency oscillatory ventilation. All premature infants less than 30 weeks in northern Alberta are admitted to this unit. The UAH provides a nurse‑clinician based transport program and has a very active general surgery and cardiosurgical service for neonates. All neonates requiring cardiac surgery from Manitoba, Saskatchewan and Alberta are admitted there. It also provides other specialized services such as neurosurgery, neonatal general surgery, ENT, and all pediatric subspecialties. All units function as one program.
There are thirty two neonatologists in the Program. There is also a full complement of subspecialists in areas relevant to neonatology including general surgery, plastic surgery, urology, orthopedics, cardiovascular surgery, neurosurgery, cardiology, endocrinology, hematology, immunology, gastroenterology, ophthalmology, infectious diseases, nephrology, metabolic disorders, clinical genetics, developmental pediatrics, and perinatology.
Both hospitals have complete diagnostic services including pathology, microbiology, biochemistry, radiology, ultrasonography, MRI, histopathology, and nuclear medicine.
The Northern Alberta Neonatal Services is also associated with a neonatal and infant neurodevelopmental follow-up clinic that follows at risk infants including prematurity, neonatal surgeries and intercardiac surgery.
NEONATAL SUBSPECIALTY RESIDENT TRAINING PROGRAM STRUCTURE
The neonatal program is structured to give wide exposure to clinical care early on with gradually increasing responsibility during the Program. The following is a brief outline of the Program structure and can be adjusted depending on previous experience of the neonatal subspecialty trainee and/or future needs.
For specific CanMEDS objectives for individual rotations please refer the specific objectives for each rotation.
First Year - Clinical - 10 blocks; divided between the UAH and the RAH
The year includes clinical service during which the neonatal trainee assumes progressive responsibilities including being involved in daily NICU rounds; the general function of the neonatal unit; clinical procedures; supervision of residents; teaching of interns, residents, and neonatal nurses; and responsibility for patient care under the supervision of the attending neonatologist. Towards the later half of the year, the trainee will assume a junior neonatologist staff role at a Level 2B or2C NICU. One block is dedicated to planning and development of research projects according to his/her own area of interest with the support and supervision of a staff neonatologist and/or associated scientist. A rotation in the Neonatal and Infant Follow‑up Clinic could be undertaken, or this could be deferred to the second year. Opportunities will be provided to accompany the neonatal transport team on high risk transports.
The night call will be a maximum of 6 call/block, consisting of 4 weekdays (Monday-Friday) and 2 weekend days (Saturday, Sunday).
Second Year
In the standard second year, 4-6 blocks are assigned to research. The second year curriculum for an international trainee suggests a maximum of 6 blocks of research. The RCPSC track trainee may have, but is not guaranteed, up to 12 months of research. The neonatal trainee is expected to become actively involved with the ongoing research activities of the NICU’s and to implement his/her own research project with the support and supervision of a staff neonatologist and/or other scientist.
During the second year, the neonatal trainee has at least 2 blocks of dedicated level III clinical service at a staff neonatologist level. Neonatal trainees who have progressed satisfactorily in their training assume increasing teaching, organization, and administrative responsibilities culminating with the complete running of the neonatal unit at the staff level under the supervision of a neonatologist. Additional junior staff service in a Level 2B may also be done if in line with the trainees learning objectives and career goals.
To complete the second year of training, one block is dedicated to an off‑service rotation in Perinatology/Genetics related to Perinatology. One additional block can be allocated to an optional, but recommended, rotation affiliated with neonatology (cardiology, radiology, genetics/metabolics, palliative care, PICU, etc). One block of transport will be done in which the trainee accompany and assists the transport team. A rotation in the Neonatal and Infant Follow-up Clinic will be undertaken if not completed in the first year. In discussion with the program director, there is an option to do an additional elective month. The second year trainee will also buddy teach and supervise first year trainees in the role of a mentor and professional.
The neonatal trainee is expected to submit his/her scholarly project data in the form of abstracts to Scientific Meetings such as SPR, WHCRI, WPRM CPS, etc. The neonatal trainee is also encouraged to submit research data for publication to peer-reviewed journals.
The night call will be a maximum of 5 call/block consisting of 3 weekdays (Monday-Friday) and 2 weekend days (Saturday, Sunday).
Third Year - Research
In order to offer further depth of training in teaching, research, and administration, an optional third year may be offered to individual trainees. These trainees must establish and become involved in significant research projects during the second year and intend to pursue further research. Such individuals shall be expected to attain an excellent academic standard and be planning a career in tertiary care academic Neonatology. Other clinical rotations may be recommended by RPC to ensure that clinical acumen is maintained during the third year. There is no dedicated funding to provide a third year and is granted on an individual basis.
Off-service Rotations
To broaden and complement the neonatal trainee’s knowledge, the following off‑service rotations have been established in areas closely related to neonatology.
1. Neonatal and Infant Follow-up Clinic at the Glenrose Hospital (first or second year)
3 months’ duration on Mondays, plus 2-4 half days - mandatory
The Neonatal and Infant Follow-up Clinic follows those infants discharged from the two tertiary neonatal intensive care units at the Royal Alexandra Hospital and the University of Alberta Hospital who are at the highest risk for disabling conditions. The Follow-up Clinic is located at the Glenrose Rehabilitation Hospital and is closely related to a network of multidisciplinary diagnostic and rehabilitation clinics. The Follow-up Program carries out both audit and research functions with the two NICUs.
Resources:
- the Neonatal and Infant Follow-up Clinic is under the direction of Dr. A. Shafey
- Other specialists include; developmental pediatrician, Dr. G. Andrew, neonatologist, Drs. M. Hicks, M. Qureshi, A. Reichert
J. Tyebkhan; pediatric neurologist, Dr. L. Richer; pediatric physiatrist, Dr. M.J. Watt and Dr. J. Anderson
- During this rotation, in addition to being involved with the Neonatal and Infant Follow-up Clinic, the trainee will be involved with some of the following clinics and programs:
o Audiology Department
o Neuromuscular Disorder Clinic
o Spina Bifida Clinic
o Feeding Team
o FIRST, a parent group for parents of young disabled children
Specific objectives to be achieved by the NPM Trainees through this rotation:
a. To be aware of the long-term sequelae of intensive care of critically ill newborn infants and of the sequelae of complications arising prenatally, at the time of birth, and postnatally.
b. To be familiar with diagnostic rehabilitation and intervention plans for disabled infants including visual, auditory, mental and motor development, behavioral-adaptive and social needs.
c. To be able to perform a follow-up neurological assessment and psychomotor developmental assessment.
The NPM Trainee is expected to participate in the Neonatal and Infant Follow‑up Clinic on Mondays, being actively involved in the physical, neurological, psychomotor, auditory, and visual assessment of the infants and to participate in the summary conference at the end of each clinic day.
Maternal-Fetal Medicine (second year)
One block duration - mandatory
Specific objectives to be achieved by the NPM Trainee through this rotation:
a. To acquire a basic knowledge of fetal physiology, growth and development.
b. To learn to recognize and to categorize high-risk pregnancies and be familiar with the clinical implications of perinatal risk.
c. To learn the clinical and investigative aspects of prenatal assessment such as ultrasound, biophysical profile, amniocentesis, cordocentesis, etc.
d. To learn the principles of management of the different types of high-risk pregnancy (by participation in clinics, prenatal consults, etc.).
e. To learn the principles of management of labor and the complications of the high-risk patient.
f. To be exposed to the genetic clinic including participation in prenatal and postnatal consultations and counseling for families with fetuses or newborns affected with genetic problems such as chromosomal anomalies, congenital anomalies, and inborn errors of metabolism.
Resources: Dr. Trina Stryker
Transport Rotation (second year)
Specific objectives to be achieved by the NPM Trainee through this rotation:
a. to learn the functioning of a centralized perinatal care model
b. to learn the limitations of rural hospitals in caring for sick newborns
c. to gain experience in stabilization of sick newborns in hospitals with limited facilities
d. to become an effective communicator as a transporting physician (phone and at site)
Resources: Chantal Balash, Transport Team Leader; Dr. Dianna Wang, Physician Leader
Cardiology (second year elective)
One block duration - optional but recommended
Specific objectives to be achieved by the neonatal trainee through this rotation:
a. To have a general understanding of anatomy, physiology, and clinical characteristics resulting from the most common cardiac lesions.
b. To learn the basis and application of neonatal electrocardiography (EKG).
c. To have an understanding of fetal and neonatal echocardiography, including anatomical/echocardiographic correlations and echocardiographic parameters of cardiac function.
d. To acquire knowledge about the clinical management of infants with congenital heart disease and other pediatric cardiology problems.
e. To observe cardiac catheterization and be familiar with the principles of invasive cardiac monitoring.
f. To acquire knowledge of the perioperative management of the infant with congenital heart disease including decision-making for surgery; observation of closed and open heart surgical procedures; intra- and post-operative management; surgical problems such as bleeding, shock, arrhythmias, pacemakers, etc.
During this rotation, the trainee will be expected to:
1. Read routine pediatric EKG's at SCH and review with staff cardiologist.
2. Attend at the Echocardiography Lab and bedside echocardiography to learn the basic concepts of echocardiography.
3. Attend at the Pediatric Cardiology Clinic, pediatric cardiology rounds, and case reviews.
4. Attend at least once at the Cardiac Catheterization Laboratory.
5. Attendance at surgical heart procedures in the operating room.
PICU (second year elective)
One block duration – optional
An elective in PICU will be considered for individual fellows, depending on their stage of training upon entering the Program and their clinical progress during the first fellowship year.
Resources: Dr. Allan De Caen, PICU at the Stollery Children's Hospital
Radiology/Ultrasound (second year elective)
Two weeks’ duration - optional
To be exposed to the basic concepts and clinical application of ultrasound and other imaging techniques.
Resources: Drs. Bhargava, Noga and Kanigan of Pediatric Radiology at the Stollery Children’s Hospital.
Palliative Care (selective year elective)
One half or one block duration – optional
An elective in palliative care will be considered for individual trainees, depending on their stage of training upon entering the Program and their clinical progress during the first fellowship year
Exposure to the palliative care team and the services they provide. Training to aid in supporting families with dying babies/children. Exposure to different methods of pain control and sedation.
Opportunity to develop and refine communication and collaboration skills. Understand the logistics and resources for an “at home” death.
Resources: ASSIST team of the Stollery Children’s Hospital.
Metabolics and Genetics (second year elective)
One half or one block duration - optional
To be exposed to the approach, work up and follow up of metabolic and genetic conditions. Time will also be spent in the metabolics lab to develop an understanding of the provincial metabolic screen process as well as the cytogenetics lab to appreciate the lab technique and time required to perform genetic testing. Will work with the multidisciplinary team of metabolic nutritionist, genetic counselors and physicians at these clinics.
Resources: Dr. Shailly Jain
ROTATION SCHEDULE :
i) Mandatory Content of Training
First Year
Second Year
A. c) Elective Content of Training
Second or Third Year
EDUCATIONAL OBJECTIVES / COMPETENCIES
The main objective of the Neonatal-Perinatal Subspecialty Training Program is to train future neonatologists with the knowledge, skills, and attitudes necessary for the provision of state-of-the-art neonatal care.
1. Medical Expert
B. Knowledge
i) Basic Science
At the completion of two years of training, the neonatal subspecialty trainee is expected to have acquired a good knowledge of the physiology of a normal pregnancy; the influences of maternal pathology and pharmacology on the fetus, fetal growth, nutrition, and development; physiology and pathophysiology of the placenta, antepartum and intrapartum fetal assessment and monitoring; the process of neonatal adaptation at birth, normal physiology and biochemistry of the fetus and neonate.
ii) The Pathophysiology, Biochemistry, and Pharmacology of Neonatal Illness
With particular emphasis on prematurity, respiratory diseases, cardiovascular disorders, asphyxia, sepsis, and jaundice. The neonatal subspecialty trainee should have an understanding of growth and nutrition in the neonate.
iii) Clinical
The neonatal subspecialty trainee is expected to understand the system of regionalized perinatal health care. The neonatal trainee is expected to learn the clinical aspects of the broad range of neonatal medical and surgical illness, including diagnosis, investigation, and treatment. An extensive clinical knowledge and experience is expected of serious acute neonatal illness, of chronic conditions, the effects on the family, and the sequelae on infant psychomotor development. In addition, the neonatal trainee is expected to acquire a reasonable knowledge of epidemiology and biostatistics, and be able to critically review the literature in the neonatal‑perinatal and follow-up fields. The neonatal trainee is expected to have an understanding of the ethical issues in perinatal medicine and acquire an ability to deal with these issues in practice. The neonatal trainee is expected to acquire a working knowledge on the use of all basic equipment within the neonatal unit including incubators and warmers, monitors, conventional ventilators and circuits, high-frequency ventilators, infusion pumps. The neonatal trainee is expected to be familiar with all equipment used in neonatal transport.
C. Skills
The neonatal subspecialty trainee is expected to be able to obtain a history and perform a complete neonatal examination and to be competent in neonatal cardiopulmonary resuscitation and stabilization; endotracheal intubation; umbilical vein/artery catheterization; percutaneous insertion or cutdown of peripheral arterial lines and peripheral/central venous lines; lumbar taps and ventricular reservoir taps; insertion of chest, pericardial, and abdominal drains; exchange transfusions; bladder taps. The neonatal trainee should be able to deal with emergency transport calls and perform competently in a transport situation. The neonatal trainee is expected to be able to trouble-shoot problems with ventilators, monitors, and incubators/warmers. The neonatal trainee should observe the technical performance of ultrasound studies, especially of the brain, heart, and fetal assessment studies, and be able to evaluate cranial ultrasounds and CT scans. The neonatal trainee is expected to be competent in the interpretation of chest, abdominal, cranial, and long bone radiology and in CT/MR imaging of the brain of the newborn. The neonatal trainee should be competent in the interpretation of basic laboratory tests and be familiar with the basis of neonatal EKG’s and neonatal EEG’s.
2. Communicator
The neonatal subspecialty trainee is expected to be able to establish appropriate communication with the parents of sick infants; to understand the issues involved in communicating bad news to families; to be able to explain complicated medical issues in simple terms to families; to develop the ability to communicate with families and the medical team in tense situations or crises; to resolve conflict between families and members of the health care team during times of stress or crisis.
Because this Program is the Prairie Cardiovascular Referral Center for Western Canada, the neonatal trainee will be expected to be knowledgeable in this highly specialized area. The neonatal trainee is involved directly in pre- and post-operative management of infants with complex congenital heart disease.
3. Collaborator
The neonatal subspecialty trainee should develop the skills to provide prenatal and neonatal consultations and for discharge planning and coordination of multidisciplinary follow-up; to communicate effectively and in a timely manner with consulting services; to communicate care plans clearly and precisely to all members of the allied health teams; to manage differing opinions from all members of the health care team and to work in a collaborative manner with fellow learners.
4. Manager
The neonatal subspecialty trainee should effectively balance time between patient care, learning and stress management; manage fatigue and recognize when they are unsafe and effectively prioritize a heavy workload; learn the practical skills necessary to effectively run an NICU and be the final person in the decision making ladder. Finally, the neonatal trainee should understand the basic principles and develop a proactive role in regard to risk management and the triage beds according to severity of illness and resource allocation.
5. Health Advocate
The neonatal subspecialty trainee should be aware of the relative costs of different diagnostic and treatment modalities, demonstrate proficiency with obtaining informed consent and counsel parents and families accordingly when patients face a terminal illness or very poor prognosis. The neonatal subspecialty trainee should have an understanding of the attachment process of the parents and newborn infant, the sequelae of separation of the sick newborn from the parents, and the grieving process. Finally, neonatal trainee should be aware of measures available for care of premature and /or chronically debilitated infants after discharge from the Neonatal ICU.
6. Scholar
The neonatal subspecialty trainee will be actively involved in teaching and supervision of medical students, interns, neonatal nurses, neonatal nurse practitioner, respiratory therapists, and pediatric and other specialty residents. In addition, the neonatal trainee should develop the knowledge and skills for providing comprehensive regional outreach education. Finally, the neonatal trainee should demonstrate a basic understanding of biostatistics, study design, grant and manuscript preparation.
7. Professional
The neonatal subspecialty trainee will ensure detailed and complete follow-up and handover of all patients under the resident’s care; understand the responsibility and the liability involved with the transfer of a patient from one institution to another; ensure that there is continuity of care and that all details of the patient’s care have been attended to prior to transfer to another attending.
RESOURCES TO ACHIEVE COMPETENCIES
i) Personnel
There are eighteen neonatologists in the Neonatal Program, and a full complement of pediatric and surgical specialists and subspecialists. Areas of special interest/expertise of the staff neonatologists are broad and include nutrition and energy metabolism; ethics; nitric oxide, surfactant replacement, high frequency ventilation, apnea, hypoxic-ischemic encephalopathy, extracorporeal membrane oxygenation; noninvasive measurements of cardiac output and hemodynamics, and congenital heart disease; control of breathing and diaphragmatic development; developmental care, infant behaviour, neurodevelopmental outcome; evidence-based reviews; quality improvement and quality research; database development and management; multi-centre trial development and management and leadership and business management. There is an active research group with extensive peer-reviewed, government and industry funding.
The nursing staff functions in an advanced role with various levels of nurse practitioners skilled in clinical assessment, diagnosis, and treatment plans; the insertion of umbilical and peripheral lines; resuscitation; endotracheal intubation; and transport. Each unit has full-time respiratory therapists skilled in neonatal ventilatory support and noninvasive monitoring. Both tertiary units have modern radiology and diagnostic ultrasound facilities, with experienced fetal and pediatric radiologists and ultrasonographers.
At the RAH, there is a Neonatal Research Office which employs research nurses experienced in human and animal research. Several multichannel and computerized recording systems are available for research projects. Animal research facilities are available at the Surgical Medical Research Institute (SMRI) where our group has a well-equipped laboratory.
Career planning is discussed with the neonatal subspecialty trainee, particularly towards the end of the second year of subspecialty training. Seminars in stress management, ethics, counseling, and management of grief response are available. Mentors are assigned to the residents and support in the form of the Learner Advocacy and Wellness Office is available for residents in academic difficulty or undue stress.
ii) Equipment
Both tertiary NICUs have a full range of standard equipment including provision for bedside monitoring of heart rate, blood pressure, respiration, TcPO2, TcPCO2, pulse oximetry, and end-tidal CO2. Breath-by-breath respiratory mechanics can be measured by a computerized system.
Conventional mechanical ventilators include the Draeger Babylog, Evita 2 and 4. Oscillators include the SensorMedics Oscillator and the Babylog. CPAP is administered by the Arabella with SiPAP delivered by Viasys equipment. Monitoring for nitric oxide administration include the chemiluminescence analyzer model 42H (Thermo Environmental) and the electrochemical analyzer, Pulmonox II. The tertiary units perform arterial blood gas estimates either within or immediately adjacent to the neonatal units. Bedside real time ultrasound with Doppler measurements and portable radiology are available as well as portable EEG and brainstem evoked potentials systems.
There is an extensive collection of textbooks and journals at the University of Alberta Medical School Library and the smaller library at the Royal Alexandra Hospital, plus the personal libraries and files of the neonatologists. There are small fellow libraries with essential textbooks at the RAH and UAH. An online collection of informative instructional journal articles as well as influential articles in neonatology are accessible 24 hours a day from a hospital computer on the NICU shared drive. In addition, Medline and Internet searches are available 24 hours a day.
Finally there are several computers at both the RAH, UAH, GNH for literature searches, word processing, and for evaluation of research data.
FORMAL TEACHING
Other formal learning opportunities with Mandatory ore Highly Recommended Attendance (Protected Time)
NRP Course - Mandatory Component of Orientation Cycle – offered every Tuesday at RAH site, multi-disciplinary (am and pm courses)
NRP Instructor Course - Offered once/year to incoming trainees – mandatory (full day)
Resuscitation Stabilization Caseroom Course and Simulation Program - Mandatory for all first year trainees, second year trainees may participate or instruct, second year fellows participate in simulations (2/year for 1-2 days per session)
In Situ (NICU or Caseroom) Multidisciplinary Acute Care Scenario Simulation - All residents participate – every 2 months (1-2 hr)
PALS - Offered to all first year fellows in Spring of first year, 2 day course – highly recommended attendance (cost reimbursed)
Physician Leadership Course - 25 hour course over 6 days in a 6 month longitudinal course. Mandatory.
Conflict Resolution/Communication Course – 16 hours in 4 days over 2 years. Mandatory.
Neonatal and Infant Feeding Course - 3-4 hours/course, to be taken at least once during training program
Trainee Research Methodology Course - On line Course – 1 month timeline for completion. Mandatory for first year residents
Women’s and Children’s Health Research Day and Symposium – 1 day symposium to present research and attend symposiums on research development, research mentorship, data collection, etc – mandatory all residents
Ethics Lecture Series – 5 lunch hour sessions/year put on by the John Dosseter Center for Health Ethics Attendance Encouraged
Lunch and Learn or Knowledge and Nourishment - Lunch Hour Session- once/week at the UAH and/or RAH site on various NICU topics given by members of multidisciplinary team including the residents
EVALUATIONS
During the two-year program, the neonatal subspecialty trainee is continuously evaluated by staff neonatologists at all neonatal units. The neonatal trainee is evaluated by direct clinical observation and interactions with multiple instruments.
In-Training Evaluation Report (ITER) and Final In Training Evaluation (FITER)
A specially developed, very detailed ITER with a 4-point scale which evaluates the neonatal trainee’s basic skills, application of knowledge, and professional attitudes. In addition, the form also evaluates the trainee as a teacher. This evaluation is completed by neonatologists at the end of each clinical service dyad. For off‑service rotations, the staff supervisor of that rotation completes the evaluation. This evaluation is discussed by the Neonatal-Perinatal Medicine Residency Program Director with the neonatal trainee and recommendations are made. The FITER is filled out by the Program Director and approved by RPC at the end of the training and encompasses evaluation of all CanMEDS roles on a 5 point scale.
Objectives Structured Clinical Examination (OSCE)
The neonatal subspecialty training program holds its own OSCE every year and also will send its fellows to the National OSCE exam during in each of the first and second years of training.
360 Multi-source Feedback Tool
The NPM Resident is evaluated in their collaborator, communicator role by members of the allied health team in the NICU. There is representation from Neonatal Nurse Practitioners, Respiratory Therapists, and Charge Nurses. Social workers, pharmacists and dieticians are encouraged to participate if they have had significant interaction with the resident in the time preceding the evaluation.
American Board of Pediatrics In Training Exam
The NPM Resident will write the ABP SITE every year with results sent to the trainee and the PD. Results will be reviewed to identify areas of strength and for development.
Royal College of Physicians and Surgeons of Canada
The NPM Resident is required by the RCPSC to write the subspecialty exam at the end of the training. This is a fall exam.
In addition, the program director will evaluate written notes (admit or progress) twice a year, formal consults will be read by attending physicians with feedback, rounds given by residents (NICU Grand Rounds) are evaluated by attendees, and teaching sessions (medical school, NRP, half days) are evaluated by the attendees. All evaluations are fed back and stored in their progress binder.