Pulmonary and Respiratory Diseases
Pediatric Pulmonary Fellowship at Children’s Hospital, Boston
The following is designed as an introduction to the Pediatric Pulmonary Fellow Training Program. Debra M. Boyer, M.D. directs the training program.
Applications for the Fellowship Program consist of a personal statement, curriculum vitae, and three letters of reference and should be submitted via ERAS. Questions should be directed to Donna Giromini, Division of Respiratory Diseases, Children’s Hospital, Boston, 300 Longwood Avenue, Boston, MA 02115. Ms. Giromini may be contacted at (617) 355-6105.
Pulmonary Division Overview
The Division of Respiratory Diseases at Children’s Hospital, Boston, carries out a range of activities in basic science and clinical research, provides outstanding clinical care, and maintains an active fellowship training program.
Members of the Division staff provide clinical care for infants, children, and young adults with a variety of chronic and acute respiratory disorders. The Division’s Cystic Fibrosis Center cares for approximately 579 patients, half of whom are adults. The clinical service accounts for 7,500-8,000 inpatient days and 3,500-4,000 outpatient visits each year. There are greater than 400 bronchoscopy procedures performed each year including bronchoalveolar lavage and transbronchial biopsies. Additional procedures performed with the aid of bronchoscopy include whole lung lavage, airway dilation, airway stent placement, and removal and/or biopsy of airway lesions. The Lung Transplant service cares for patients both pre-, peri- and post-operatively.
The Pulmonary Function Laboratory performs 7,000 tests each year, including arterial blood gas drawing , exercise studies, and lung function studies. Some of the lung function studies performed include spirometry, measurements of total lung capacity and its subdivisions by body plethysmography and helium dilution, diffusing capacity, airway challenge studies, infant pulmonary function studies, assessment of respiratory strength, and graded cardiopulmonary exercise testing. Seventy-five percent of these studies are carried out on outpatients. The Division’s Sweat Test Laboratory performs 1,200 studies each year.
The Division is actively engaged in training physicians and medical researchers about the manifestations and mechanisms of pediatric pulmonary diseases. Members of the Division teach several courses at Harvard Medical School. The Pulmonary Service at Children’s Hospital is a core rotation for pediatric house officers in the Boston Combined Residency Program.
The Fellowship program in Pediatric Pulmonology is a three-year program designed to provide a balanced clinical and research experience. In addition, the fellowship is designed to insure that all fellows meet criteria for certification in Pediatric Pulmonology by the American Board of Pediatrics at the end of their fellowship. Dual fellowships performed in conjunction with other pediatric subspecialties may be arranged. In general, three new fellows are accepted into the program each year. The first year of training is dominated by clinical experience on the inpatient hospital services and in the outpatient Pulmonary/Cystic Fibrosis Program while the second and third years have their focus on research activities.
The inpatient hospital services of the Division are divided between the Pulmonary Inpatient Service, the Pulmonary Consult Service and the Bronchoscopy service. The Inpatient Service serves as the admitting service for patients with acute and chronic respiratory diseases including asthma, Cystic Fibrosis, BPD, pneumonia, pleural effusions, pneumothoraces, congenital malformations and many others. The Inpatient Service is generally composed of an attending physician, a pulmonary fellow, a nurse practitioner and three junior pediatric residents. The fellow is responsible for supervisory duties under the direction of the attending. The Inpatient Service averages 562 pulmonary discharges per year with an average length of stay of 8 days. The Pulmonary Consult Service provides consultative services to all programs and services within Children's Hospital, Boston as well as to the Neonatal Intensive Care Units at Brigham & Women's Hospital and Beth Israel Deaconess Hospital. The Pulmonary Consult Service consists of an attending and a pulmonary fellow. The Division’s consultation service is asked to advise on the care of approximately 400-500 patients per year.
As mentioned, the Bronchoscopy Service performs greater than 400 bronchoscopic procedures each year. While on the Bronchoscopy service, the fellows will also be responsible for interpreting pulmonary function tests performed in our laboratory under the direction of an attending physician. When not on one of the three services described above, the first year fellow will choose among a variety of electives as well as take one month of vacation. Night call for the Pulmonary Service from Monday through Thursday is directed to one of the fellows on Service and is taken from home. Weekend coverage is rotated among all of the fellows.
Fellows follow their own template of ambulatory patients in the Pulmonary/Cystic Fibrosis Clinic under the supervision of an attending physician. All fellows attend clinic longitudinally throughout their three years of training. The Pulmonary/Cystic Fibrosis Program conducts multidisciplinary clinic sessions where nutritional, physical and respiratory therapy, social service, nursing, and physician services are provided. There are approximately 11,000 outpatient visits to the Pulmonary and Cystic Fibrosis Clinics per year. Interesting and/or difficult patients are reviewed during the weekly clinical conference. In addition to their continuity clinic, second and third year fellows rotate through our sub-sub-specialty clinics to gain further clinical exposure to these patients. These clinics include; BPD, sleep, CDH, Transplant, Exercise evaluation and Aerodigestive Clinic.
During the initial period of clinical experience, the fellows also familiarize themselves with various research opportunities. Fellows in Pediatric Pulmonology pursue a research project during the second and third years of their training. This project can be in either clinical or bench research. Selection of a project is guided by consultation with the Fellowship Director, the Division Chief, and other members of the Division. The research progress of the fellow during the latter years of fellowship is monitored and facilitated through biannual presentations before a Scholarship Oversight Committee.
Near the end of the first year, the emphasis shifts to research, and this focus continues throughout the second and third years of training. While the majority of their time is spent pursuing their research projects, second and third year fellows will spend approximately 6-8 weeks on a combination of the Inpatient, Consult and Bronchoscopy services.
The fellowship director has developed a Pediatric Pulmonary Fellowship Boot Camp that all fellows in the program will participate in. This occurs longitudinally during their training and will entail simulation activities to allow exposure to a variety of clinical situations.
Members of the Division are engaged in laboratory and clinical research projects in a wide variety of areas. Craig J. Gerard, M.D., PhD leads the bench research efforts of the Division. He along with Norma Gerard, Ph.D., and coworkers in the Ina Sue Perlmutter Cystic Fibrosis Research Laboratory investigate mechanisms of inflammation and in particular focus upon the family of G protein coupled receptors, which serve by way of chemokine binding to direct the migration of leukocytes. Mouse genetic models and in vitro transfection and expression analyses are used to understand the complex balance between the defense against infection and the excessive inflammation characteristic of Cystic Fibrosis. The laboratory is now focusing upon the development of biofilms to answer several questions, including whether proteins in such films are host or bacterially derived, how and when G protein receptors are activated, and what the relationships of CFTR may be to biofilm development. Other members of the Division have participated or are currently participating in bench research in laboratories located elsewhere in the immediate area, including the Pulmonary Division at Brigham & Women’s Hospital, the Channing Laboratory at Brigham & Women’s Hospital, the Respiratory Physiology Program of the Harvard School of Public Health, Harvard University, and the Whitehead Institute at the Massachusetts Institute of Technology.
Our basic science investigations also include:
- Studying roles of innate immune components, including the programmed death receptor, complement receptors and eosinophils on the pulmonary responses to respiratory viral infections
- Exploring novel strategies to prolong lung allograft survival by modifying the immune response in preventing T cell activation and promoting tolerance
- Molecular mechanisms of leukocyte trafficking in inflammation and injury using MMP deficient mice
- Understanding the role of systemic inflammation and disease by studying the pro-inflammatory condition of obesity and diabetes
- Studying how extracellular matrix components modulate the pathogenesis of infectious and non-infectious inflammatory diseases
- Analyzing the genomic make-up of hundreds of organisms in the sputum of patients with CF, potentially to lead to the identification of new drug targets
- Investigating the potential use of cell-based therapies (ex. stem cells) to potentially restore lung function.
The division has a number of investigators involved in a wide variety of clinical research projects as well, including:
- Pulmonary outcomes of prematurity
- Quality improvement in cystic fibrosis
- Prevention of acute rejection in lung transplant patients
- Assessing healthy children for signs of OSA
- Analyzing home based sleep studies
- Improving triage and diagnosis of OSA in children with Down syndrome
- Pulmonary Exercise Physiology
- Development of a Pediatric Pulmonary Fellowship Boot Camp
- Examining the Balance of Education and Service in Pediatric Training
- Studying urinary biomarkers as a predictor of renal dysfunction in CF
- Salivary diagnostics of markers of inflammation in CF
- Identified as a Therapeutics Development Center of the Cystic Fibrosis Foundation and is currently engaged in a variety of early clinical trials involving novel therapeutics for Cystic Fibrosis
- Vertex Potentiator trials in Cystic Fibrosis
- Inhaled Levofloxacin in Cystic Fibrosis
- Studying the clinical implication of Primary Ciliary Dyskinesia
- Clinical manifestations of pulmonary hypertension
- Developing a National Database for Pediatric Interstitial Lung Disease
- Environmental risk factors for asthma morbidity in children
Our fellows choose a research project based on their own interests after careful consultation with the program leadership. These projects may be bench research, clinical/epidemiological and/or translational.
Collaborative research arrangements within the Harvard Medical area are extensive and include the Divisions of Newborn Medicine, Immunology, Allergy, Gastroenterology and others within Children's Hospital, Boston; the Respiratory Division of Brigham & Women's Hospital; the Physiology Department of the Harvard School of Public Health; and the Channing Laboratories at Brigham and Women’s Hospital. The research progress of the fellow is monitored and facilitated through biannual presentations before the fellow’s Scholarship Oversight Committee. In addition to selecting a research project, several fellows in the Division have completed additional courses of study during their fellowship years, including a Masters Program in Public Health offered by the Harvard School of Public Health.
In addition to their clinical duties and hands-on research experience, fellows participate in several conferences each week. The Division sponsors a weekly clinical and research conference series; a weekly fellowship curriculum conference, which covers a two-year curriculum in Pediatric Pulmonology; and a weekly clinical case conference, which alternates with a journal club and Morbidity and Mortality conferences. Clinical case conferences are also held weekly at the New England Pediatric Pulmonary Consortium, which has a typical attendance of 15-25 pediatric pulmonologists from the region. All trainees and staff members in the Division are encouraged to attend these conferences. Finally, there are a wide variety of conferences held within the Longwood Medical Area, centered on Harvard Medical School, which are of interest.
Sample Weekly Conference/Clinic Schedule
12:00-1:00 PM Pulmonary Division Clinical and Research Conference
1:00-5:00PM Fellow’s Continuity Clinic
11:00AM-12:00PM Fellow’s Seminar
12:00- 1:00PM Case Conference/Journal Club/M+M
7:30-9:00 AM New England Pediatric Pulmonary Conference
12:00-1:00 PM Pediatric Grand Rounds
12:00-1:00 PM Firm Rounds (clinical conference)
Faculty of the Pulmonary Division, 2011-2012
Craig Gerard, MD, PhD, Division Chief and Director, Ina Sue Perlmutter Laboratory
Henry Dorkin, Associate Chief and Director, Cystic Fibrosis Center
Gary Visner, DO, Medical Director, Lung Transplant Program
Debra Boyer, MD, Director Fellowship Training Program
Ahmet Uluer, DO, Adult CF Center Director
Martha Fishman, Medical Director Ambulatory Program
Thomas Martin, MD, Director, Pulmonary Function Lab
Kenan Haver, MD, Director, Bronchoscopy Services
Gregory Sawicki, MD, Associate Director, Cystic Fibrosis Center
Dennis Rosen, MD, Associate Medical Director, Sleep Disorders Program
LawrenceRhein, MD, Director, Center for Healthy Infant Lung Development
Craig Gerard, MD, PhD
Norma Gerard, PhD
Henry Dorkin, MD
Hyeryun Choe, PhD
Gary Visner, DO
Thomas Martin, MD
Debra Boyer, MD
Martha Fishman, MD
Kenan Haver, MD
Virginia Kharasch, MD
Catherine Sheils, MD
Christopher Hug, MD, PhD
Richard Parad, MD
Edward Lee, MD, MPH, Pediatric Radiologist
Gregory Sawicki, MD
Meera Subramaniam, MD
Assistant Clinical Professors
David A. Waltz, MD
Alicia Casey, MD
Carolyn Donovan, MD
Dawn Ericson, MD
Jonathan Gaffin, MD
Dennis Rosen, MD
Ahmet Uluer, DO
Claudia Ordonez, MD
John McLaughlin, MD
M. Lawrence Reiner, MD
First Year: Evan Bailey, MD
Rizwana Popatia, MD
Ruby Wang, MD
Second Year: Tregony Simoneau, MD
Lianne Kopel, MD
Phuong Vo, MD
Third Year: Kara May Palm, MD
Devika Rao, MD
Rafael Aquino, PhD
Monali Bera, DVM
Kazutaka Hayashida, PhD
Khadije Iken, PhD
Stephanie Jemielity, PhD
Kaifeng Liu, MD, PhD
Akiko Ohno, PhD
Yvonne Teng, PhD
Deborah Yoder-Himes, PhD