NEONATAL-PERINATAL MEDICINE

INTRODUCTION:Neonatal-perinatal medicine is concerned with the maintenance of health and long-term development of the newborn and young infant, and with special knowledge and skills in the prevention, diagnosis and treatment of disorders of the fetus, newborn and young infant.

A university wishing to have an accredited program in neonatal-perinatal medicine must also sponsor accredited programs in pediatrics and obstetrics & gynecology. The purpose of this document is to provide program directors, surveyors and residents with an interpretation of the general standards of accreditation as they relate to the accreditation of programs in neonatal-perinatal medicine.

GOALS AND OBJECTIVES:There must be a clearly worded statement outlining the goals of the residency program and the educational objectives of the residents. The following terminal objectives have been outlined by the Specialty Committee in Neonatal-Perinatal Medicine. Accredited programs are expected to develop enabling, rotation-specific objectives for the program based on these terminal objectives.

General Objectives

1. Knowledge

At the completion of training, the resident will have acquired:

1. Knowledge of the basic sciences applicable to the full range of the practice of neonatal-perinatal medicine including
   • maternal physiological, biochemical and pharmacological influences on the fetus;
   • fetal physiology;
   • fetal development and nutrition;
   • placental function (placental circulation, gas exchange and growth);
   • physiological and biochemical adaptation to birth;
   • physiology, biochemistry, pharmacology and pathology relevant to the diseases of the newborn;
   • psychology of pregnancy and maternal/infant interaction;
   • growth and nutrition;
   • genetics;
   • psychomotor development and outcome;
   • epidemiology and biostatistics of perinatal care; and
   • appropriate understanding of the technical devices used in the care of the newborn.
2. In-depth knowledge of growth, development and nutritional requirements of the normal fetus and newborn and of clinical disorders affecting all their body systems. This should include methods of monitoring the fetus and the newborn for potential as well as diagnosed clinical problems, as well as the long term follow-up of disorders related to the antepartum and new born period.
3. Knowledge of criteria for critical appraisal of studies which seek to establish causation, determine natural history and prognosis, assess accuracy of diagnostic tests or evaluate therapy of fetal and neonatal disease.
4. An adequate understanding of the complex ethical issues relating to perinatology and the ability to use this understanding in facilitating appropriate patient care.
5. An understanding of the principles of quality assurance and administration relevant to perinatal care.
6. An understanding of how to plan, carry out and evaluate a research project and how to summarize the results and prepare a report for presentation and publication.
1. Clinical and Technical Skills

At the completion of training, the resident will have acquired:

1. Special competence in clinical assessment and direction of the management of critically ill newborn infants including techniques of resuscitation, vascular access, ventilatory support, continuous monitoring, temperature control, diagnostic techniques, general principles of critical care including maternal/fetal and neonatal transport, and assessment and management of pain and distress in newborn infants including those on assisted ventilation, those requiring frequent or potentially painful procedures and those in the postoperative phase.
2. The ability to function as an effective consultant and to appropriately request consultation of others when required.
3. The ability to communicate effectively and offer psychological support to parents and members of the health care team.
4. Demonstrated leadership in clinical care and as an advocate for further improvements in outcome for the fetus and newborn.
5. The ability to teach, supervise and evaluate junior trainees and students.
2. Attitudes

At the completion of training, the resident will have acquired:

1. A compassionate interest and overall understanding of the patient as a person, and sympathetic support to all members of the family.
2. Recognition of the need to function as a member of the health care team.
3. An acceptance of the obligation for continuing self-education, the teaching of others and an appreciation of the need for critical analysis of current scientific developments related to more effective patient care in neonatal-perinatal medicine.
4. An understanding of the importance of principles of cost effectiveness and continuous quality assurance/improvement.

All residents must demonstrate the knowledge, skills and attitudes relating to gender, culture, and ethnicity pertinent to neonatal-perinatal medicine.

CONTENT AND ORGANIZATION OF THE RESIDENCY PROGRAM

There must be an organized program of rotations and other educational experiences, both mandatory and elective, designed to provide each resident with the opportunity to fulfill the educational requirements and achieve competence in the specialty.

The following are the minimum educational requirements in the subspecialty of neonatal-perinatal medicine. Additional experience may be required by the program director.

1. Pre-requisite

Three years of pediatrics which must be completed prior to entry into the neonatal-perinatal medicine program.

2. Program requirements

Two years of neonatal-perinatal medicine, one year of which may be undertaken during the final year of pediatrics with the joint approval of the program director in pediatrics and the program director in neonatal-perinatal medicine.

This period:

1. clinical neonatal-perinatal medicine during which involvement with clinical investigation is strongly recommended. Must provide adequate clinical experience in a university-affiliated tertiary obstetric high risk centre with an integrated neonatal care unit;
2. residency which may include the following:
   1. clinical neonatal-perinatal medicine, or
   2. clinical and/or laboratory research relevant to perinatal pediatrics, six months of which may include maternal-fetal medicine or,
   3. research or other academic activity related to neonatal-perinatal medicine and acceptable to the program committee. If the research training is in basic science, allowance must be made for concurrent maintenance of special aspects of clinical expertise.

Residents must be provided with increasing individual professional responsibility, under appropriate supervision, according to their level of training, ability, and experience, for the evaluation and management of neonatal patients and their families.

For satisfactory completion of the College requirements in neonatal-perinatal medicine a resident must:

1. have successfully completed a program in neonatal-perinatal medicine in an accredited program in which the resident.
2. have attained certification in pediatrics.

RESOURCES:There must be sufficient resources including teaching faculty, the number and variety of patients, physical and technical resources, as well as the supporting facilities and services necessary to provide the opportunity for all residents to complete the program and achieve the educational objectives in neonatal-perinatal medicine.

In those cases where a university has sufficient resources to provide most of the training in neonatal-perinatal medicine but lacks one or more essential elements, the program may still be accredited provided that formal arrangements have been made to send residents to another accredited residency program for periods of appropriate prescribed training.

1. Teaching Faculty

There must be a minimum of three full-time equivalent qualified neonatal-perinatal specialists to ensure continuous availability of supervision of clinical training of residents.

2. Number and Variety of Patients

Clinical training must be based on adequate facilities and resources to ensure full training for each resident in all aspects of neonatal-perinatal medicine. To ensure the availability of these resources, there should be adequate numbers of births annually in the region served by the university to provide the full spectrum of patients in neonatal-perinatal medicine.

Adequate numbers of patients and qualified specialty and subspecialty staff must be available for the teaching of residents in specialized areas relevant to the practice of neonatal-perinatal medicine including all of the following related areas: cardiology, clinical genetics, endocrinology, general surgery, hematology, immunology, infectious diseases, neurology, neurosurgery, pharmacology, and respirology. There must be a follow-up program in which the resident participates to learn the multidisciplinary aspects of assessments for both patient care and quality assurance/improvement.

3. Clinical Services Specific to Neonatal-Perinatal Medicine
   1. In-Patient

The participating institutions must comprise the regional tertiary perinatal facility and, as such must be the centre for the regional program in perinatal medicine.

Nursery design and perinatal facilities should be in accordance with federal government standards for perinatal intensive care services and should be in a desirable physical relationship with other hospital areas including the obstetrical and post-partum wards and laboratories.

The programs in maternal-fetal medicine and neonatal-perinatal medicine should be so structured as to ensure case review by the combined staff and combined obstetric-pediatric decision-making in complex high-risk mothers and their fetuses. Training in neonatal care should be under the supervision of appropriately trained staff and responsibility should be graded according to the level of experience and expertise, with availability of more senior staff when required for clinical care and/or supervision.

2. Intensive Care

The neonatal intensive care unit must be under the direction of a qualified full-time neonatal-perinatal specialist.

There must be an integrated perinatal intensive care unit in which tertiary obstetric and tertiary neonatal intensive care facilities are closely associated.

3. Resources for Community Learning Experiences

The program must provide experience in neonatal transport. Opportunities should be available to participate in educational programs for personnel of regional and/or community hospitals.

4. Supporting Services — Clinical, Diagnostic, Technical
   1. Liaison with Other Specialties and Subspecialties

There must be appropriate liaison with teaching services in maternal-fetal medicine.

2. Diagnostic Services

Diagnostic services should include an active pathology service, preferably incorporating a subdivision of perinatal pathology, a microbiochemical service, a microbiology service, a full range of radiological and ultrasound services and specialized staff and facilities for laboratory assessment of endocrine-metabolic, hematologic, cardiologic, respiratory, neurologic and cytogenetic disorders.

ACADEMIC AND SCHOLARLY ASPECTS OF THE PROGRAM:

The academic and scholarly aspects of the program must be commensurate with the concept of a university postgraduate education. The quality of scholarship in the program will in part, be demonstrated by a spirit of enquiry during clinical discussions, rounds, and conferences. Scholarship implies an in-depth understanding of basic mechanisms of normal and abnormal states and the application of current knowledge to practice.

1. Organized Scholarly Activities

Organized scholarly activities such as journal clubs, research conferences and seminars must be a regular part of the program. Service demands must not seriously interfere with the ability of the residents to follow the academic program.

2. Basic and Clinical Sciences Relevant to Neonatal-Perinatal Medicine

The program should include definitive learning in the relevant basic sciences and in the advanced clinical and scientific knowledge essential to the understanding of those areas of the discipline outlined in previous sections.

3. Biomedical Ethics

The program must ensure that residents learn the relevant aspects of ethics related to perinatal and neonatal care and to participate in their implementation. There should be access to expertise in biomedical ethics in regard to neonatal-perinatal medicine.

4. Communication Skills

The program must ensure that residents learn effective communication skills for interacting with, parents, colleagues, co-workers from other disciplines and students. Clearly defined educational objectives for teaching these skills and mechanisms of formal assessment should be in place.

5. Patient Care Team

Residents must be given opportunities to develop effective skills in collaborating with all members of the patient care team. There must be opportunity to learn the relevant aspects of multidisciplinary communication and administration, especially those pertaining to high intensity work environments.

6. Teaching Skills

Residents must be given opportunities to develop effective teaching skills by teaching junior colleagues and students, and other health care professionals, including those in community hospitals, as well as through conference presentations, clinical and scientific reports, and patient education.

7. Management Skills

Residents must be given opportunities to develop skills in management as applied to neonatal-perinatal medicine such as efficient practice and records management and the ethical use of health care resources. Residents should also be prepared for their role as a health care advocate.

8. Quality Assurance/Improvement

The program must provide residents with opportunities to gain an understanding of the principles and practice of quality assurance/improvement. Opportunities should be provided for residents to participate actively in such programs in their hospital departments.

The resident must gain experience in perinatal epidemiology, specifically in collection and evaluation of fetal and neonatal mortality and morbidity statistics.

9. Research Opportunities for Residents

The academic program must provide the opportunity for residents to learn biostatistics and the critical appraisal of research methodology and medical literature. All residents must demonstrate an ability to incorporate gender, cultural and ethnic perspectives in research methodology, data presentation and analysis.

A research program in which the resident may spend up to one of the two years is essential with supervision by a scientist or neonatal-perinatal specialist of university rank. The role of the resident in the research program should be clearly defined. There should be adequate resources and opportunity for involvement in clinical research.

Recognizing that it is difficult to provide training for a career in research within the two year program in neonatal-perinatal medicine, programs should have the opportunity to offer a third (or additional) year in an educational program primarily devoted to research.

10. Faculty Research

A satisfactory level of research and scholarly activity must be maintained among the faculty identified with the program.

11. Life-Long Learning

All programs must promote development of skills in self-assessment and self-directed life-long learning. To promote this end, the program should provide opportunities for residents to attend conferences outside their own university.

PROGRAMS (WITH TRAINING REQUIREMENTS):

Diplomas(Dip):

Six months of approved residency training.

Doctor of Medicine(M.D):

Eighteen months of approved residency training.

Doctor of Philosophy(Ph.D):

Forty eight months(four years)of approved residency training.