Fellows learn procedural competence in both didactic and experiential settings. All incoming first year fellows, regardless of current certification, participate in a Neonatal Resuscitation Protocol (NRP) course during orientation and are expected to maintain certification. Because of the high proportion of older or term infants in the surgical service of Children's Hospital, the Program also pays for fellows to obtain Pediatric Advanced Life Support (PALS) certification. Several lectures in orientation and during the three year core curriculum series also deal with procedural competence, including ECMO, transport medicine and a two-part ventilatory management workshop presented by NICU respiratory therapists. Didactic training is complemented by procedural training during simulation exercises. In addition to this didactic content, all fellows learn procedures such as endotracheal intubation, thoracentesis and thoracostomy tube placement, and venous and arterial access, at the bedside from expert NICU staff, including attendings, nurse practitioners, and respiratory therapists. These are under direct supervision by an attending physician or his or her delegate until the fellow has attained a set number of successful procedures, at which point they are credentialed in the procedure log system to perform the procedure independently. All procedures, whether successful or not, are documented in a procedure log system that is part of the New Innovations software suite provided by Children's Hospital GME program. When entering the procedure, the fellow identifies a supervising attending, who is then notified to confirm the result. Tallies of procedures are maintained and reviewed with the fellow at each Career Planning Conference with then Program Director. Procedural competence is also part of the trainee's rotation evaluation completed by the attending at the conclusion of each monthly rotation. The latter are reviewed at the CPC with the fellow and each month by the Fellowship Committee.