During the first year of fellowship, each fellow at Duke is exposed to delivery room resuscitation, ventilatory management, and intensive care of sick neonates, as well as the convalescent care of recovering infants. In addition, the fellow jointly manages neonatal surgical patients and patients referred to Duke from outside pediatricians, perinatologists and obstetricians. These skills are enhanced as the fellow becomes more independent during the second and third years.
Excellent clinical care depends on a broad knowledge of the underlying physiology, pathophysiology, and clinical literature. Weekly lectures, journal clubs, clinical conferences, core readings, and discussions help build a broad based fund of knowledge in neonatal medicine. During clinical training, the fellow learns the leadership skills needed to supervise a busy intensive care unit with house staff, neonatal nurse practitioners, and respiratory care specialists. In addition, the fellow participates in unit administration which includes problem identification and solutions. There is a weekly Neonatal Medical Ethics Case presentation run by the Head of Medical Ethics of Duke.
There is a broad range of lectures & seminar series available to more than meet Board and ACGME Core Curriculum requirements including Curriculum Design, Teaching Skills, Comprehensive Introduction to Clinical Research, Molecular Biology Techniques, Introduction to Evidence-Based Medicine, Grant Writing Seminar, and Medical Ethics. Master's-level programs are available to our fellows and include the Clinical Research & Medical Genomics Training Programs, and master's program in Biomedical Engineering.
The new Intensive Care Nursery at Duke provides care for babies who are admitted with a wide variety of illnesses and congenital abnormalities. There are 38 intensive care beds at Duke and 54 transitional beds spread between Duke and its affiliates Durham Regional Hospital (18) and Alamance Regional Medical Center.
All pediatric medical and surgical subspecialties are available at Duke. During the clinical rotations, fellows provide leadership and oversight of the bedside care team under the direct guidance of a faculty member. The fellows assist in the training of more junior residents and interns during their ICN rotations, and provide consultations for prenatal visits arranged with obstetrical colleagues.
All fellows participate in the administrative activities of the division. As fellows become more senior in training, they are given more clinical leadership responsibilities. The first and second year fellows coordinate joint conferences and lead discussions at patient care conferences. The senior fellows attend the weekly executive administrative meeting in the Unit and actively participate in the development of health care plans and problem solving activities. One or two months of the senior year are spent as "junior attending" on resident team. During that time, the fellow rounds with the team and later a faculty member.
Neurodevelopmental Follow-Up and Outcomes
Fellows attend the multidisciplinary neonatal follow-up clinic (Special Infant Care Clinic) during their fellowship. During this clinical experience, fellows become familiar with the expected outcomes of various groups of high risk infants. In addition, they learn to determine whether a child's neurologic and/or developmental outcome is consistent with his/her neonatal course and whether further evaluations are indicated (i.e. neuroimaging studies, neurology consultations, genetics and metabolism consultations, etc.). Each fellow learns to perform a detailed neurologic examination of an infant through two years of age, including the careful evaluation of muscle tone and primitive reflexes. One of the goals of the training experience is learning to distinguish transient neurologic abnormalities seen commonly in premature and sick full term infants from the early precursors of cerebral palsy. Fellows are taught how to discuss the diagnosis of cerebral palsy and developmental disabilities with families. They also become familiar with various types of intervention services and their indications. Board certified physical therapists, occupational therapists, speech therapists and psychologists work hand in hand with physicians and assist in determining the need for interventional services as well as provide parent education.
Early in training, and throughout the fellowship, trainees are given the opportunity to identify infants in the NICU who they would like to follow in clinic. The distribution of patients should include extremely low birthweight infants, infants with known intracranial injury and full term infants with respiratory failure.
For fellows interested in more extensive training in neurodevelopmental follow-up and outcome research, a specialized clinical research track is available. This track of the training program includes electives in neuroimaging, pulmonary, neurology, rehabilitation, PT/OT, speech/feeding and fetal maternal medicine. It also includes the opportunity to participate in ongoing outcome research and original follow-up studies in the Special Infant Care Clinic. For more information, read about the Neurodevelopmental Follow-up and Outcomes Research Track.
Cardiac Intensive Care and ECMO
The neonatology fellows also have a rotation in the Cardiac Intensive Care Unit. This rotation is primarily to provide the experience and oversight of the care of postoperative cardiac surgery and ECMO patients. There are over three hundred pediatric cardiac operations performed per year at Duke. During this rotation, the fellow supervises and manages care of pediatric intensive care patients under the direction of senior Cardiac/PICU faculty. Fellows further their central vascular access skills and ventilatory management of neonates with cardiac disorders.
There is a strong relationship between Pediatric Cardiology & Neonatology, and a full cardiology experience for neonatology fellows is available. This includes a seminar series & postoperative cardiac surgery experience with joint management of cardiology patients admitted to the ICN pre and postoperatively.
Neonatal fellows participate in National ECMO certification course given at the National Children's Hospital in Washington, D.C.
During the fellowship years, there is a rotation within the Division of Maternal-Fetal Medicine in order to gain expertise in prenatal diagnosis, diagnostic ultrasound, prenatal genetic counseling, and multi-disciplinary consultations for complex cases. There is a weekly case conference held between Neonatal Medicine, Maternal-Fetal Medicine, and Obstetric Anesthesiology to discuss upcoming cases and management. In addition, fellows attend a monthly fetal board case review and are responsible for perinatal counseling under the direction of the neonatal and obstetric faculty.
This three-year fellowship track is designed to provide excellent clinical training in the acute and convalescent care of premature and sick full term infants as well as the medical and neurodevelopmental follow-up care required for these infants post-discharge. The fellow will receive comprehensive training in the methods for conducting neurodevelopmental follow-up, and other outcome research. The requirements of this fellowship track will include:
Twelve months of clinical service in the ICN (standard fellowship requirement) with additional clinical service time in our transitional care nurseries.
Weekly participation in the Special Infant Care Clinic including following a designated cohort of infants (both extremely low birth weight and critically ill full term infants) over 2-3 years. Skills to be learned in clinic will include:
- To be able to perform a detailed neurologic assessment of an infant and young child.
- To be able to manage ongoing medical problems of high risk infants (e.g. chronic lung disease, gastroesophageal reflux, growth and feeding problems).
- To gain familiarity with the expected neurodevelopmental outcome of various neonatal problems.
- To be able to determine whether the neurologic and developmental abnormalities of an infant are consistent with the neonatal course, and if not, what further diagnostic evaluations or referrals are indicated.
- To be able to distinguish the transient neurologic abnormalities of premature and sick full-term infants from the early precursors of cerebral palsy.
- To understand the indications and interpretation of the various developmental assessment tools used by members of the developmental team.
- To gain familiarity with the various intervention services available for infants and young children with developmental disabilities and how to help families access these services.
- To develop experience in discussing unfavorable prognosis and outcome with parents in a supportive and compassionate way.
Weekly participation in Developmental Rounds in the ICN and biweekly rounds at DRH.
Participation in providing medical care of infants rehospitalized soon after discharge with exaccerbation of neonatal problems.
- Elective months in the following areas:
- Neuroimaging (indications and interpretation)
- Neonatal neurology
- Rehabilitation/CP clinic
- Physical/occupational therapy
- Speech/feeding disorders
- Fetal-maternal medicine
- Master's degree in Clinical Research from the Duke Center for Clinical Research (optional). This program includes training in epidemiology and biostatistics as well as design of clinical trials.
- Participation in ongoing neurodevelopmental follow-up studies.
- Design one or more projects involving outcome research to be completed by the end of fellowship.