Thomas G. Keens, M.D.
Director, Pediatric Pulmonology Fellowship Training Program
Childrens Hospital Los Angeles
Los Angeles, California

Why go into Pediatric Pulmonology?

Pediatric Pulmonology is the ultimate subspecialty, because it is intellectually exciting, has a variety of practice options, permits accommodation to desired lifestyle, and has ample employment opportunities in both academic and private practice settings. Why choose anything else? Consider the following facts about Pediatric Pulmonology:

• Respiratory disorders are the leading cause of hospital admission in children. You will always be in demand.
• Unlike other organ systems, the lungs are directly exposed to the environment, leaving them susceptible to a variety of diseases, including infections, toxins, allergens, extreme temperatures, etc. You will deal with a whole different arena of disorders than other subspecialists.
• The lungs are rapidly developing. The respiratory system of a premature infant is dramatically different from that of the adolescent or young adult. Thus, disease processes in the infant have very different manifestations than the same disease processes in older children.
• Lung damage occurring early in life leaves affects subsequent lung growth and development, predisposing patients to lung disease in adult life. What you do, or don't do, for a young child as a Pediatric Pulmonologist affects her for the rest of her life. $ Almost every systemic disorder affects the lungs. Thus, you will see all of the interesting patients in a medical center, and you will be able to help them.
• Most general pediatricians have seen a lot of children with lung disease, but they rarely understand it. Therefore, you will be frequently consulted, and you will have ample opportunity for teaching.
• Respiratory physiology guides the diagnosis and management of respiratory disorders in children. The physiologic principles you learn in Fellowship will guide your practice of Pediatric Pulmonology for your entire career.
• Even if you can't cure a lung disease, your knowledge of respiratory physiology will permit you to improve or relieve symptoms, activity limitation, or distress in nearly every patient you see.
• Pediatric Pulmonology encompasses a wide variety of practice options C from acute respiratory failure in the neonatal or pediatric intensive care unit to long-term care of patients with chronic respiratory disorders. You can focus on procedures, such as flexible fiberoptic bronchoscopy, or on the pulmonary physiology laboratory. Sleep profoundly affects breathing, and increasing numbers of Pediatric Pulmonologists include sleep medicine as an important part of their practice.
• For some patients, you will provide continuity of care from infancy through young adult life. For some children, they would not have survived without your skill and dedication. For many more, they could not have achieved what they did without your expert medical care.
• There is a critical shortage of Pediatric Pulmonologists. Therefore, there are abundant employment opportunities for Pediatric Pulmonologists in both academic medicine and private practice settings.

Intellectual Content of the Subspecialty:

Pediatric respiratory disorders are the most frequent cause of hospitalization in children The Pediatric Pulmonologist provides clinical care for infants through adolescents with a variety of respiratory disorders, including acute and chronic lung diseases, ventilatory muscle weakness, and disorders of neurologic control of breathing. Ventilatory muscle power, neurologic control of breathing, and lung function change dramatically from infancy through adolescence. These changes profoundly affect the way respiratory disorders look. Further, most systemic disorders also affect the lungs. Therefore, the Pediatric Pulmonologist is involved in the care of many patients with both common and exotic disorders. Although general pediatricians may have seen a lot of children with lung disease, they rarely understand the physiology and pathophysiology involved. Therefore, as a Pediatric Pulmonologist, you will be frequently consulted, and you will likely be a teacher in great demand. Similarly, even if you can not cure a child's respiratory disorder, you can nearly always improve or relieve symptoms, activity limitation, or distress.

Variety of Practice Opportunities:

The practice of pediatric pulmonology can be tailored to accommodate the lifestyle and interests of the physician. Pediatric pulmonologists care for infants, children, and adolescents with acute respiratory disorders and respiratory failure. Consultations are frequently requested by neonatologists and intensivists. Thus, the practice of this subspecialty can be directed toward critical care medicine. Pediatric pulmonologists care for infants, children, and adolescents with chronic lung diseases, ventilatory muscle weakness, and disorders of neurologic control of breathing. This includes treatment with supplemental oxygen, home mechanical ventilation, non-invasive ventilation, etc. The pediatric pulmonologists frequently cares for the same child from infancy through young adult life; providing the opportunity for continuity of care and watching his or her patients grow and thrive. I have practiced Pediatric Pulmonology at Childrens Hospital Los Angeles for over 25-years. I still see several patients entering college who I have cared for since the first few months of life. The emotional rewards of helping to arrange for medications, oxygen, or a home ventilator, for a young person going to college, whom you have cared for since infancy, defy description. Thus, the practice of this subspecialty can be directed toward chronic care, including the challenge of using technology in the home.

Pediatric pulmonologists perform a variety of procedures, including flexible fiberoptic bronchoscopy. Thus, the practice of this subspecialty includes procedures unique to the diagnosis and management of lung diseases. Pediatric pulmonologists perform and interpret pulmonary function tests. These include routine pulmonary function tests, exercise stress tests, sleep studies, tests of ventilatory muscle strength, tests of ventilatory control, and infant pulmonary function tests. The pediatric pulmonologist is further challenged by designing physiologic tests applicable to children of varying ages and abilities to cooperate with testing. Thus, th practice of this subspecialty involves the use of physiologic testing to assist in diagnosis and management of children. Sleep has a profound effect on breathing, and this effect is greater in infants and young children than in adults. Therefore, many Pediatric Pulmonologists include sleep medicine as an important part o their practice. All Pediatric Pulmonologists must be concerned about the effects of sleep on the respiratory disorders of their patients. The Pediatric Pulmonologist can tailor his or her practice to suit the type of medicine he or she would like to practice.

Employment Opportunities:

There are fewer than 1,000 board certified Pediatric Pulmonologists in the United States. Therefore, there is a tremendous shortage of subspecialists in both academic medicine and in private practice. Thus, employment opportunities abound for the Pediatric Pulmonologist. Most Fellows graduating from accredited programs in the U.S. have an option of choosing between several academic and/or private practice jobs. Many U.S. medical schools still have no Pediatric Pulmonologist. Those medical schools and private practices who have Pediatric Pulmonologists want more. Therefore, it is likely that there will be more demand than available subspecialists for several years to come.

Pediatric Pulmonology: Why choose anything else?

Pediatric Pulmonology Fellowship Training.

General:

Fellowship training programs in Pediatric Pulmonology are designed to train physicians capable of assuming a leadership role in the development of the subspecialty. In addition to excellence in clinical care, Fellowships provide training in academic activities, such as research and teaching. In order to qualify for American Board of Pediatrics eligibility in Pediatric Pulmonology, fellows must successfully complete a 3-year ACGME accredited fellowship training program. In general, fellowship training programs are small. There will usually be only one or two fellows per year for a three-year program. Some fellowship programs will have fourth year fellows, usually involved in research. Thus, training occurs on an apprenticeship basis with your faculty. You will get to know your faculty and fellow colleagues quite well, and they will be your teachers.

Clinical Training:

An important role of Fellowship Training is to provide comprehensive training in the diagnosis and management of infants, children, and adolescents with respiratory disorders. This includes both inpatient and outpatient experience. In general, training is physiologically based.

Use of the pulmonary physiology and sleep laboratories are important adjuncts of diagnosis and management. Fellows are also expected to master procedures required for subspecialists, notably flexible fiberoptic bronchoscopy. In general, fellows are required to gain experience in asthma, bronchopulmonary dysplasia, cystic fibrosis, pulmonary infections, respiratory disorders in systemic diseases and in immunocompromised hosts, neuromuscular diseases, disorders of ventilatory control, interstitial lung diseases, congenital malformations of the respiratory system, etc.; and the use of supplemental oxygen, home mechanical ventilation, non-invasive mask ventilation, and other technologies. Fellows generally function at a junior consultant level, providing consultation, guidance, and education to Pediatric house officers. Fellows are also required to have a continuity clinic over their entire 3-years, where they follow a select number of patients with a variety of disorders to learn the long-term management of pediatric respiratory disorders.

An important part of the Pediatric Pulmonology Fellowship training is an understanding of respiratory physiology and the use of the physiology laboratory in the diagnosis and management of patients. Thus, fellowship training provides extensive exposure to the performance and interpretation of routine pulmonary function tests, sleep studies, infant pulmonary function tests, exercise stress tests, tests of ventilatory muscle strength, and tests of ventilatory control. A challenge of this subspecialty is the adaptation of these physiologic tests to children of different ages, sizes, and abilities to cooperate.

Although there is no fixed standard, most Fellows spend 12-18 months of their three-year training program learning clinical care.

Academic Training:

A goal of fellowship training is to produce academic leaders in the subspecialty. The traditional route for most fellows is to engage in either basic or clinical research. Fellowship training programs provide training in biostatistics, research design, and the ethics of research. Fellows will usually initiate, conduct, and publish the results of one or more research studies performed during fellowship. The faculty of the training program serve as the research mentors for fellows, and research training is usually learned by an apprenticeship system. In many programs, additional research mentors, outside the faculty of the program, perform basic and/or clinical research mentoring for fellows. Increasingly, there is also a need for experts in outcomes and epidemiologic research. Additional training, such as obtaining an M.P.H. or advanced epidemiology or biostatistics degree, may be offered in some training programs.

Not all fellows are destined for a career focusing on research. There is a need for excellent clinician-teachers. When fellows choose to improve their teaching abilities, instead of focusing on research, some fellowships offer formal teaching in medical education, perhaps leading to a M.Ed. or similar advanced degree.

Board Certification:

Pediatric Pulmonologists can be certified in the subspecialty by the American Board of Pediatrics after passing a written Board examination. In order to be eligible for the written Subboard examination, fellows must successfully complete a 3-year ACGME accredited program. In order to be Board Certified in Pediatric Pulmonology, one must first be certified in Pediatrics. This means that fellows need to complete three years of accredited Pediatric residency prior to fellowship training. Those certified in Pediatric Pulmonology must be recertified every 7-years. Although international medical graduates without U.S. or Canadian Pediatric residency can not be Board Certified in Pediatric Pulmonology, they are welcome additions to many training programs.

Combined certification:

In general, the American Board of Pediatrics permits fellows to qualify for only one subspecialty for each 3-year fellowship program. There are some exceptions. However, all combined training programs must be approved by the American Board of Pediatrics before the fellow begins training. Individuals may be certified in Pediatric Pulmonology and Pediatric Critical Care Medicine after a four year combined fellowship training program. Similarly, fellows may be certified in Pediatric Pulmonology and Neonatal-Perinatal Medicine after a five year combined training program. Both fellowships at the institution must be ACGME accredited, and the research must be applicable to both subspecialties.

Applying for Pediatric Pulmonology Fellowship:

How do I find out about Pediatric Pulmonology Fellowship Training Programs?

ACGME accredited fellowships in Pediatric Pulmonology are published by the American Thoracic Society and the American Academy of Pediatrics. If you have a Pediatric Pulmonology program at your institution, ask the faculty of that Division for their recommendations. If there are Pediatric Pulmonology fellows at your institution, ask them about the programs they considered and why. Write to programs and ask for application materials and information. Often, fellows pick a specific program because they are interested in working with a specific faculty member, group, or researcher.

Applying for Fellowship:

Each program must be applied to separately. Thus, each program's application and requirement for letters of reference may differ. In general, letters of reference are the most important objective information about an applicant which the fellowship training program has to consider. Ask your faculty who know you best to write your letters. There are generally no fees required for applying to a fellowship program.

Interview:

Fellowship programs will want to interview all applicants whom they are seriously considering. The fellow must pay the costs of traveling to the interview. The interview is a time when the fellowship program learns about you, the applicant. But, as important, it is a time for you to learn about the program. Be sure to speak with a number of faculty. If you are interested in a program because of a specific faculty member, be sure to speak with that person. This should be requested ahead of time, so your interview is not inadvertently scheduled when the faculty member is out of town. Be sure to speak with current fellows away from faculty. They are likely to tell you what the program is really like. Be sure to ask specific questions about clinical training, physiology training, bronchoscopy training, learning how to teach, learning research methods, and research opportunities. Also aks questions that are important to you about lifestyle issues, such as the on-call schedule. Most Pediatric Pulmonology fellowships involve pager call on nights and week-ends, but you should check to be sure. While applicants are always anxious to make a good impression, most fellowship programs are most impressed by applicants who ask important questions about the program. Use your interview to get the information you need. The fellowship faculty will ask you what they need to know.

Time Line:

Since there is no match program or centralized application process for Pediatric Pulmonology, the time line for applications is somewhat flexible. However, in general, applicants will obtain information about fellowship programs in the summer or fall 18-24 months before beginning fellowship. Applications are generally submitted in the fall and winter 15-21 months before beginning fellowship. Interviews are generally conducted in the winter and spring 14-18 months before fellowship begins. Fellowship programs have usually selected their incoming class 12-15 months before fellowship begins. This means that second year Pediatric residents should be applying for fellowships.

Deciding which program is right for you:

After interviewing at the fellowships that interest you, you need to ask yourself what direction you would like your career in Pediatric Pulmonology to go. Consider the positives and negatives of the programs you have seen. Try to match your interests with the program who has a similar emphasis. Consider intangibles, like location, the people you met in your interview, what the fellows said, etc. Your Pediatric Pulmonology fellowship will be your academic home for three-years. Be as sure as you can that you can thrive in the environment and enjoy the experience.

Pediatric Pulmonology: Why choose anything else?

Last reviewed: February 2015