As part of a world-renowned institution, the Pediatric Pulmonary, Allergy, Sleep and Cystic Fibrosis Unit at Massachusetts General Hospital provides sophisticated, evidence-based diagnostic and therapeutic care to a diverse population of patients, and receives referrals from throughout the region and around the country. The division includes a very active cystic fibrosis center, a well-developed pediatric sleep program, a multi-specialty airway, voice and swallowing center, and an allergy and immunology program. These services are supported by a fully-equipped pulmonary function laboratory, bronchoscopy service and pediatric sleep laboratory. The Mass General Pediatric Pulmonary, Allergy, Sleep and Cystic Fibrosis center includes five full-time and two part-time pulmonary faculty members who are actively involved in patient care, basic and clinical research, and teaching. It therefore follows that the Pediatric Pulmonary Fellowship at Mass General offers fellows a rich training environment in which to hone their clinical and research interests and skills.
The primary goal of the first year of the fellowship is to become proficient in the clinical care of pediatric patients with pulmonary conditions in both the inpatient and outpatient setting. During their first year of training, each fellow participates actively in the clinical activities of the Pediatric Pulmonary Unit at Mass General, including the provision of clinical care in both the inpatient and outpatient settings. The year includes a month of transplant medicine and year-long longitudinal clinical experiences in outpatient pediatric pulmonology, sleep medicine, chest radiology, respiratory care and bronchoscopy. Fellows also attend multiple conferences, which are outlined in greater detail in the curriculum tab.
The goal of the second year of fellowship is to become proficient at reviewing the biomedical literature, developing an appropriate research question, and generating effective research plans and methods. During this time, fellows begin performing research under the close mentorship of an independent investigator. Fellows are also expected to continue to develop and strengthen their clinical skills — especially with respect to outpatient care and inpatient cross-coverage — by continuing to attend outpatient clinics and educational conferences during this time.
During the third year, fellows continue to build their research skills with the goal of becoming proficient at implementing research methods and techniques, collecting and analyzing data, interpreting results and presenting research findings in oral and written formats. As with the second year, third-year fellows are also expected to continue to develop and strengthen their clinical skills— especially with respect to outpatient care and inpatient cross-coverage — by continuing to attend outpatient clinics and educational conferences during this time.
Applicants to the Program Must Be Graduates of:
- Medical schools in the United States and Canada accredited by the Liaison Committee on Medical Education (LCME), OR
- Colleges of osteopathic medicine in the United States accredited by the American Osteopathic Association (AOA), OR
- Medical schools outside the United States and Canada and who have:
3.1. Received a currently valid certificate from the Educational Commission for Foreign Medical Graduates prior to appointment, OR
3.2. A full and unrestricted license to practice medicine in a U.S. licensing jurisdiction in which they are in training, OR
- Medical schools outside the United States who have completed a Fifth Pathway* program provided by an LCME-accredited medical school
USMLE Completion Requirements:
- Documentation of successful completion of USMLE Step II and USMLE Step III is required for initial appointment as a clinical fellow at Massachusetts General Hospital
- Program Directors/Chiefs, in consultation with the Director or Associate Director of GME, may grant individual exceptions to the above provision for one year at a time
- Canadian physicians and Doctors of Osteopathy who are eligible for licensure may substitute documentation of successful completion of LMCC/MCCQE and COMLEX examinations, respectively, in lieu of USMLE examinations
Foreign Nationals/International Medical Graduates Must Have:
- A valid visa appropriate to the level of training
- A valid ECFMG certificate (if applicable)
- Passing scores on USMLE steps 1 and 2, or equivalent
Visa Options for Clinical Trainees:
- F-1: Students ("plus one year" GME). Foreign nationals holding an F-1 visa who have graduated from a U.S. medical school are eligible for one year of practical training on the F-1 visa. Such employment must be an extension of their academic studies. Students obtain an employment authorization document (EAD) identification card with the dates of validity inscribed. A change of visa status will be needed to continue employment (i.e., residency/fellowship training) beyond the expiration date on the EAD
- J-1: Exchange Visitors (Clinical). The Educational Commission for Foreign Medical Graduates (ECFMG) is authorized by the United States Department of State (DoS) to sponsor foreign national physicians as exchange visitors in accredited programs of graduate medical education or training. ECFMG is the sole sponsor of J-1 physicians in clinical training programs in the United States. Foreign national physicians applying for ECFMG sponsorship must meet the following requirements:
- Hold a valid ECFMG Certificate (NB: graduates of LCME-accredited U.S. and Canadian medical schools are not required to be ECFMG-certified, but must submit a certified, translated copy of their medical school diploma.)
- Hold a contract or an official letter of offer for a position in an accredited training program that is affiliated with a medical school
- Provide a statement of need from the Ministry of Health of the country of nationality or last legal permanent residence. This statement must provide written assurance that the country needs specialists in the area in which the exchange visitor will receive training and that s/he will return to the country upon completion of training.
- J-2: Dependent. The J-2 visa permits a spouse accompanying a J-1 visa holder to work in the U.S. after obtaining an employment authorization document (EAD). A J-2 visa holder is not limited in the type of employment s/he may seek. Employment authorization is issued in one-year increments and must be renewed prior to expiration to avoid employment interruption. J-2 visa holders may not remain in the U.S. beyond the stay of the spouse on the J-1.
- H-1B: Professionals in Specialty Occupations. The H-1B is a temporary nonimmigrant visa defined as a “specialty occupation” visa, which permits professionals to work in the U.S. for a total of six years. The Immigration Act of 1990 opened the door for foreign physicians to perform clinical work via the H-1B visa. Eligibility relies upon successful completion of the following:
a. Graduates of International Medical Schools:
i. USMLE, I-III OR
ii. FLEX, I and II AND a Massachusetts medical license (limited or full) AND a valid ECFMG Certificate (Canadian medical school graduates are exempt)
b. Graduates of U.S. Medical Schools:
i. Proof of graduation AND a Massachusetts medical license (limited or full)
The H-1B application is a two step process involving both the U.S. Department of Labor and the Immigration and Naturalization Service. The Partners Office for International Staff, Scholars and Students (PIO) prepares all visa applications and will work with the applicants and program directors to obtain the necessary documentation.
- O-1: Alien of Extraordinary Ability. An O-1 visa is reserved for those who can demonstrate that they have risen to the top of their field; therefore, extensive documentation must be submitted in support of an O-1 petition. Such documentation includes awards, publications, media mention and very strong letters of recommendation from persons prominent in the field.
In addition to the clinical and research components of the program (which are described in detail in their respective sections), the program curriculum includes a comprehensive collection of conferences, individual learning plans and a quality improvement project, each of which is reviewed in detail here.
The program-specific conferences include each of the following:
- Physiology Tutorial: Each week, there is a one-on-one physiology tutorial for the first-year fellow led by the program director. Through this one-hour session, fellows gain a clear understanding of fundamental pulmonary physiology and how this physiology is altered by both disease states and therapeutic interventions
- Core Fellow Lecture Series: The weekly core lecture series provides fellows with a comprehensive knowledge base in the field of pediatric pulmonology. The curriculum for these lectures is based on the ACGME Program Requirements for Graduate Medical Education in Pediatric Pulmonology and the Pediatric Pulmonology Content Outline provided by the American Board of Pediatrics. These lectures are attended by both fellows (who are freed from all clinical and research duties during this time) and by faculty
The core fellows’ conferences span a period of three years in order to ensure that each fellow attends all lectures. The topics include, but are not limited to, the following:
- Essential background
a. Lung growth and development
b. Structure of the lung and chest wall
c. Cell biology of the lung
d. Lung defenses
e. Pulmonary pathology/cytology
c. ICU management
a. Relationship to asthma
b. Allergic rhinosinusitis
c. Allergy testing
- Cystic Fibrosis
b. Pulmonary manifestations
c. Non-pulmonary manifestions
d. Care of the CF patient
e. Hot research topics
- Congenital abnormalities of the upper airway
a. Laryngeal web
b. Paradoxical vocal cord motion
c. Subglottic stenosis
e. Tracheoesophageal fistula
- Congenital abnormalities of the lower airway
b. Congenital diaphragmatic hernia
c. Pulmonary sequestration
- Infectious disorders of the upper airway
c. Pharyngeal abscess
- Infectious disorders of the lower airway
f. Mycobacterial: TB and Atypical mycobacterial organisms
- Aspiration/chemical pneumonia
a. Aspiration “from above” – neuromuscular weakness, cleft, etc.
b. Gastroesophageal reflux
d. Near drowning
e. Smoke inhalation
- Disorders of the chest wall
a. Asphyxiating thoracic dystrophy
d. Diaphragmatic paralysis
- Neonatal disorders
c. Meconium aspiration
- Pulmonary vascular diseases
a. Cor pulmonale
b. Pulmonary edema
c. Pulmonary emboli/infarction
d. Pulmonary hypertension
e. Pulmonary hemorrhage
f. Pulmonary vascular malformations
- Pulmonary manifestations of immunosuppression (infectious and non-infectious)
c. Solid organ transplant
- Control of breathing disorders
- Acute/Critical care
a. Foreign body aspiration
c. Pneumothorax (primary, secondary)
d. Pleural effusion
- Extrapulmonary conditions with respiratory implications
a. Gastroesophageal reflux
b. Sinusitis (allergic and bacterial)
c. Mediastinal masses/tumors
- Conditions with pulmonary and extra-pulmonary involvement
a. Ciliary dysmotility
c. Alpha-1-antitrypsin deficiency
e. Immune deficiencies (CGD, SCID, IgG subclass deficiencies, CVID)
- Pulmonary conditions
a. Hypersensitivity pneumonitis
b. Eosinophilic pulmonary diseases
c. Pulmonary alveolar proteinosis
d. Interstitial lung disease
e. Surfactant protein deficiencies
- Lung transplantation
- Respiratory therapies/devices
b. Flutter valve
e. Tracheostomies and their care
a. Pulmonary function testing
b. Chest radiology (radiographs, CT, etc.)
c. Sleep studies
a. Pediatric bronchoscopy
b. Sweat testing
c. Allergy testing
- Teaching-related topics:
a. Giving an effective oral presentation
b. Bedside teaching skills
- Psychosocial aspects of care
b. Cultural diversity
- Principles of research
a. Critical literature review
b. Principles of evidence-based medicine
c. Clinical and Laboratory research methods/study design
d. Fundamental statistics and epidemiology
e. Ethical principles related to clinical research
f. Grant preparation
g. Preparation of protocols for IRB
- Health care delivery
a. Economics of healthcare
b. Quality Improvement
c. Practice management
d. Clinical outcomes
- Essential background
- Pediatric Pulmonary Consortium Conference: Each week, the pediatric pulmonary staff from the Massachusetts General Hospital, New England Medical Center, Boston City Hospital, Children’s Hospital, University of Massachusetts, Worcester, meet to discuss interesting, challenging and educational cases. The overarching goal of the consortium is to train fellows to approach cases in a deliberate, critical, comprehensive and collaborative manner with other specialists in the field of pediatric pulmonary medicine. Fellows are expected to improve their skills in practice-based learning and improvement, while also honing their interpersonal and communication skills in a team-based environment.
Fellows attend this conference throughout each of their three years of fellowship. Each first-year fellow is responsible for presenting one or two patients at this conference approximately every five weeks. In preparing their presentations, fellows are expected to search the literature for references pertinent to their cases. Relevant articles are frequently distributed at these conferences.
- Pediatric Pulmonary Journal Club: The division of Pediatric Pulmonary, Allergy, Sleep and Cystic Fibrosis Unit meets every other week for a journal club. The overarching goal of the journal club is provide fellows with the skills necessary to navigate, understand and apply the literature related to both scientific understanding and clinical practice of pediatric pulmonology.
During this conference, faculty members bring to the group’s attention any new and relevant articles that are published, and fellows take turns leading a more detailed discussion of one or two manuscripts. The articles for discussion are chosen based on the relevance of the data and conclusions to clinical practice and to the basic understanding of the pathophysiology of disease.
Fellows participate in the journal club during each of their three years in training. Topics covered include those relevant to general pediatrics, pediatric pulmonary, cystic fibrosis, sleep disorders and physiology. The core concepts and skills addressed during the journal club include:
- Critical literature review
- Principles of evidence-based medicine
- Clinical and basic research study design and methods
- Fundamental concepts in statistics and epidemiology
- Ethical principles related to clinical research
- Teaching/presentation skills
- Patient Care and Quality Assurance: The division of Pediatric Pulmonary, Allergy and Sleep Disorders meets weekly for clinical case conference immediately preceding the weekly fellows’ lecture. Fellows attend these conferences throughout each of the three years of their training. Faculty attendance at these conferences is also expected.
These conferences afford an opportunity for trainees and attending physicians to bring challenging diagnostic and management issues to the table for group discussion and input, thereby allowing members of the division to learn from each others’ collective knowledge and experience. Priority is given to cases in which care may have not been optimal or in which a systematic error may have occurred. Examples include discussion of appropriateness of direct admission to the hospital, equipment failures, lab errors or problems in communication. Evidence-based management, awareness of practice guidelines, and multidisciplinary approaches are continually emphasized.
Additional conferences attended by fellows in the Mass General Pediatric Pulmonary Fellowship Program:
- MassGeneral Hospital for Children Grand Rounds: Pediatric Grand Rounds is held every week except during the months of July and August. The chairman of the Department of Pediatrics and the pediatric chief residents determine the topics and speakers selected for this conference. The overall goal of Pediatric Grand Rounds is to keep all faculty members and housestaff in the Department of Pediatrics appraised of critical new developments within the field of pediatrics.
- Introduction to Pulmonology and Critical Care: This is a weekly conference series held during the months of July and August in order to provide pulmonary and critical care fellows with the core knowledge base required to function effectively as trainees within their field of practice.
- Pulmonary Arterial Hypertension
- Pre-Op Assessment
- Ventilator-Associated Pneumonia
- Infiltrate in the Immunocompromised Host
- Lung Transplantation
- Pulmonary Pathology
- Anatomy of the Ventilator
- Monitoring Mechanics during Mechanical Ventilation
- Community-Acquired Pneumonia
- Solitary Pulmonary Nodule
- Idiopathic Interstitial Pneumonitis
- Cardiopulmonary Exercise Testing
- Cystic Fibrosis
- Pleural Effusion
- Chronic Cough
- Pulmonary Embolism
- Introductory Course for Allergy Fellows: Due to the overlap between pulmonary, allergic, and immunologic conditions, each first-year fellow attends an introductory course for allergy fellows held at the Brigham and Women’s Hospital. The overarching goal of this course is to provide fellows with a core knowledge of allergic and immunologic conditions that will inform their understanding of pediatric pulmonology. The course takes place over four days and includes lectures on the following general topics.
- Types of immune cells
a. T Cells: Th1, Th2, Th17, T reg
b. B Cells
c. NK and NKT Cells
d. Dendritic Cells
e. Mast cells
- Products of immune cells
a. Inhibitory Receptors of the Immune System
b. Toll-like Receptors in Immunity
- Specific conditions
a. Rhinitis and Sinusitis
b. Ocular Allergies
d. Drug Allergy
e. Food Allergies
f. Allergic Skin Diseases
g. Atopic Dermatitis
iv. Adult Asthma Therapy
v. Pediatric Asthma
l. Eosinophilic GI Disorders
i. B Cells
ii. T Cells
- Evaluation of allergic/immune function
a. In Vivo Testing for Hypersensitivity
b. In Vitro Testing for Hypersensitivity
- Therapies for allergic and immunologic conditions
a. Principles of Bone Marrow and Stem Cell Transplantation
c. Desensitizations for Drug HSR
- Intro to Statistics
- Introduction to Biostatistics and Study Design: The primary goal of the Introduction to Biostatistics and Study Design is to provide fellows with the core knowledge of biostatistics and study design required to review, interpret and perform research. The program consists of a series of four lectures given by Brian Healy, MD, a biostatistician on staff at Mass General.
- Research Group Meetings/Journal Clubs: Each laboratory in which fellows perform research has its own set of conferences, including laboratory meetings and journal clubs, which the fellow working there is expected to attend. In most cases, laboratory meetings are held at least weekly. Journal clubs are typically weekly, but every other week in some cases. The primary goals of the research group meetings and journal clubs are to teach fellows how to function as active members of a research group, how to think critically about research projects, papers and presentations, and how to deliver effective presentations in this setting.
- Massachusetts General Hospital Institutional Orientation: On the first day of their fellowship, each trainee attends the MGH Institutional orientation. The primary goal of the institutional orientation is to provide fellows with the core institutional knowledge and skills required to function effectively as trainees at Mass General. The program consists of a full day of lectures on a variety of topics that are essential for all trainees at Mass General to be familiar with.
- Partners Clinical Fellows Retreat: The Graduate Medical Education Office of the Partners HealthCare System invites all clinical fellows at all levels of training and across all specialties to participate in an annual Fellows Retreat. The primary goal of the fellows’ retreat is to provide clinical fellows with educational content which is important for clinical training and professional development but which may be difficult for fellowship program directors to provide for their trainees. A secondary goal of the retreat is to provide fellows with valuable networking opportunities to meet their peers across Partners hospitals.
- National subspecialty conferences: Attendance at annual academic conferences is encouraged but not required. These include the Cystic Fibrosis research meetings where the activities of the cystic fibrosis therapeutic development network are discussed, as well as the annual meeting of the American Thoracic Society (ATS). Fellows are also encouraged to attend the fellows’ course immediately prior to ATS, as well as other conferences of specific interest to them.
Inpatient Pediatric Pulmonary Service:The primary goal of the inpatient component of the program is to prepare fellows to provide high-quality, evidence-based care of patients with pulmonary conditions in the inpatient setting. When he or she is not participating in other required and elective activities, the first year pulmonary fellow spends weekdays and every 4th or 5th weekend on the general pediatric pulmonary service. In this role, the fellow responds to all requests for consultations on patients admitted to the inpatient service, in the pediatric and neonatal intensive care units, and in the emergency department. The fellow also initiates the management of children admitted to the pulmonary service, designs and implements inpatient management plans, follows the daily progress of each patient, and performs outpatient discharge planning. These activities are all performed under the direction of our attending physicians.
Outpatient Pulmonary Clinical Component:The overarching goal of the outpatient component of the fellowship is to prepare fellow to provide high-quality, evidence-based care to pediatric pulmonary patients in the outpatient setting. Throughout all three years of program, fellows see patients in the outpatient setting on a weekly basis. The first-year fellow sees patients on Wednesday mornings under the mentorship of Drs. Shannon Fracchia (general pulmonary and CF), Dr. Allen Lapey (general pulmonary, cystic fibrosis and allergy), and Dr. Shuba Iyengar (allergy, immunology). The second- and third-year fellows see patients on Tuesdays under the mentorship of Dr. Bernard Kinane (general pulmonary), Dr. Jolan Walter (allergy, immunology), and Dr. Craig Canapari (general pulmonary, neuromuscular disorders, sleep disorders). Whenever possible, patients are scheduled in the fellow’s name in order to promote continuity of care. During their first year of training, fellows also provide phone coverage for off-hours calls from outpatients and from referring physicians on weekdays and every 4th or 5th weekend.
Cystic Fibrosis (CF) Care:Throughout their training, fellows care for patients with CF, both in the outpatient setting and the inpatient setting. Throughout the first year, the fellow is the key member of the multidisciplinary cystic fibrosis care team, which includes physicians, physical therapists, nutritionists, social workers, and psychiatrists. During the entirety of the first year, the fellow provides care to patients with cystic fibrosis in both the outpatient and inpatient setting, and meets weekly with the cystic fibrosis care team to review the care provided to all patients with cystic fibrosis seen at Mass General and meets with the inpatient team making management decisions under the direction of the attending. Fellows are also involved in genetic counseling of parents of infants who have positive screens for cystic fibrosis on the state newborn screening of Massachusetts. The fellow is also encouraged to attend the CF national conference and funding is usually available for this.
Pediatric Sleep Disorders Component:The overall goal of the sleep component of the Pediatric Pulmonology Fellowship is to provide fellows with the training required to provide high-quality pulmonary care to patients with sleep-disordered breathing. Each first-year fellow spends one month with the Sleep Disorders Service, participating in the following activities:
- Seeing patients with sleep disorders in the Mass General Pediatric Pulmonary, Allergy, Sleep and Cystic Fibrosis Clinic
- Assisting clinical staff in the review of patients referred for polysomnography and determination of appropriate testing variation (e.g. placement of extra EEG leads, determining the need for various types of PAP therapy)
- Participating in New England Pulmonary Consortium: As of part of a new initiative, every eighth conference will be dedicated to review of sleep cases. Fellows familiar with the patient discussed will be expected to participate in case presentation and discussion
Lung Transplantation Component:The transplant rotation is a month-long clinical experience for fellows during their first year of training. The overarching goal of this rotation is to prepare the fellow to be responsible for the evaluation and care of patients requiring lung transplantation. During this time, fellows admit and follow patients both before and after single or double lung transplantation. They are carefully supervised by the Lung Transplantation Medical Director and the transplant surgeons. Trainees also perform consultations on patients who have received heart, liver, bone marrow and other solid organ transplantation.
Pulmonary Function Testing:First-year fellows participate in the interpretation of all pulmonary function tests performed in the pediatric pulmonary function laboratory. The goal of this component of the fellowship is to prepare fellows for independent utilization and interpretation of PFTs. Fellows are also expected to gain a general understanding of how laboratories function, including principles of quality control, validity and reliability of tests. Early in the year, general principles are stressed; later in the year, the focus shifts to more complex issues in PFT interpretation. They are mentored in this process by the program director or a designee.
Bronchoscopy Component:During the first year of the fellowship, trainees perform bronchoscopies on Monday mornings at the Massachusetts Eye and Ear Infirmary. The primary goal of this experience is to provide fellows with the knowledge and skills required to perform and interpret flexible bronchoscopy on pediatric patients. As part of this experience, fellows are expected to learn airway anatomy and recognize common anomalies and disorders.
Pediatric Respiratory Care:During the first year of the fellowship, trainees spend one Thursday afternoon every month with the respiratory therapy service, participating in the care of patients in the Pediatric Intensive Care Unit and the Neonatal Intensive Care Unit. The primary goal of this experience is to provide fellows with the knowledge and skills required to manage patients requiring various methods of respiratory care and support.
Pediatric Radiology:During the first year of the fellowship, trainees spend one Thursday afternoon every month with the pediatric radiology service, reviewing imaging studies and attending all radiology rounds and teaching conferences. The primary goal of this experience is to provide fellows with the knowledge and skills required to select and interpret imaging studies pertinent to pediatric patients with respiratory diseases.
The overarching goal of the research component of the fellowship is to provide trainees with the fundamental skills required to perform original research in fields related to pediatric pulmonology. Fellows are also expected to obtain sufficient experience and skills to become competitive for research grants that will support them in their future careers.
To this end, each fellow performs research in a laboratory of their choosing during the second and third years of training. The process of selecting a research topic begins early in the first year, and the intent is to match each fellow’s interests with those of one of the many accomplished faculty available throughout out Harvard. Collaboration is available with the Adult Pulmonary Unit at Massachusetts General Hospital, the Channing Laboratory, the Harvard School of Public Health and affiliated clinical and research facilities throughout the region.
With the guidance of their research mentors, fellows are expected to generate a research question, develop the appropriate study design, collect and interpret data, and present the data in the form of an original publication. Fellows participate as active members of the research team, attending and participating in laboratory meetings and journal clubs. In order to ensure a successful research experience, each fellow is assigned a Research Oversight Committee which meets with the fellow annually in order to assess the fellow’s progress and provide feedback. The program director also meets with fellows and mentors individually on a biannual basis to monitor and facilitate their progress.
Thank you for your interest in the Pediatric Pulmonology Fellowship at MassGeneral Hospital for Children. We accept applications online electronically through theElectronic Residency Application Service.
Applications should include the following documents:
- ERAS Common Application Form
- Curriculum vitae
- Personal statement
- 3 letters of recommendation
- Official medical school transcript
- USMLE transcript
- ECFMG status report (international medical graduates only)
ERAS opens for applications on July 15, 2016. Trainees are encouraged to complete submissions by August 15th, which affords ample time for the program to review all applications and schedule personal interviews for competitive applicants. Interviews are held in September and October.
If you have any questions regarding our program or the application process, please feel free to contact Elena Donovan, Fellowship Coordinator at 617-726-7613 or email@example.com.
MGHfC Pulmonary Fellowship Program
Program Director: T. Bernard Kinane, MD
Assistant Director: Ben A. Nelson MD
Program Coordinator: Elena Donovan