Thank you for taking an interest in our Neonatal-Perinatal Medicine Fellowship program. Our fellowship program is located at UT Health San Antonio. The primary clinical site is University Hospital. The ACGME granted accreditation to our neonatology fellowship program in 1998. Graduating fellows have all had success in practicing neonatology throughout the country with approximately forty percent of our graduated doctors entering academia. The Neonatal Fellowship Program at UT Health San Antonio has a well-established research program, a structured educational program, and a strong clinical program.

In addition, the goal of our fellowship program is to provide trainees with the background to gain expertise in the field of neonatology. We aim for fellows to graduate from our program not only to be well rounded clinicians, but also to have the ability to continue to contribute to the field of neonatology through research, education, and scholarly activity. We strive to find fellows who have a strong passion and desire to pursue life-long learning.

I have been the neonatology fellowship program director since 2009. In this time period, it has been my mission to enable our fellows to have the best clinical and research training. Through my passion for hands-on training, I am the director of our highly interactive Neonatal Fellow Simulation Program which has led to the production of national and international presentations as well as fellow-led publications. Also, I’m heavily involved in the National Neonatology Curriculum Committee and have helped develop a neonatal physiology curriculum for neonatal fellows nationwide through the use of the flipped classroom (NeoFlip). I enjoy looking for new ways to teach trainees and to keep up with my own continued education.

I am an advocate for trainee and faculty wellness. As a wife and mother of two children, I believe in having a strong home and work life balance. In my spare time, I enjoy spending time with my family and attending my children’s many sporting events. This is important in our fellowship program as well. Our fellowship has fellow wellness chiefs. These fellows help to coordinate quarterly wellness activities as well as coordinating our annual fellows’ wellness retreat. As the program director, I look forward to continuing to share these and other exciting developments with our outstanding fellows and future trainees.

Please look through our website to learn more about our Neonatal-Perinatal Medicine Fellowship Program. You may contact me with any questions or you may contact the Neonatology Program Coordinator, Kelly Gallegos.

Sincerely,

Margarita M. Vasquez, MD
Professor of Pediatrics
Fellowship Director, Neonatal-Perinatal Medicine

University Hospital

University Hospital is one of the nation’s leading teaching hospitals and South Texas’ premier Level I trauma center and Level IV Neonatal Intensive Care Unit. University Hospital offers the most technically advanced care available anywhere, in an inviting and comfortable setting.

PREMIEre Program

The PREMIEre Program is a specialized follow-up program to ensure our infants with complex medical conditions and developmental challenges due to prematurity, catastrophic illnesses at birth, or environmental factors are evaluated for growth, neurological, and developmental abnormalities in an intense care-coordinated program.

Pediatric & Congenital Cardiac Care Unit

Our Pediatric & Congenital Cardiac Care Unit (PCCU) is the only dedicated comprehensive inpatient and outpatient pediatric cardiac center in South Texas. Our South Texas Pediatric & Congenital Heart Center is one of just 19 programs in the nation designated as a Center of Excellence by Optum, Aetna and Superior Health Plan Insurance Entities, and one of only three in Texas.

Our patient outcomes are among the best in the nation. We are the only program in the region who publicly reports its outcomes data through the Society of Thoracic Surgeons Database.

New Women’s & Children’s Hospital

The Women’s & Children’s Hospital at University Hospital is expected to open in 2023. The new hospital will be a 14 story, 300-bed hospital for women, babies and children with additional shell space for future growth.

Brooke Army Medical Center (BAMC)

Our Neonatology fellows rotate one month at the BAMC NICU. The NICU provides newborn health care and neonatal intensive care services to Department of Defense beneficiaries in a 26 bed Level III NICU.

Various conferences occur at regular intervals throughout the entire Neonatal Fellowship training. Fellows are required to attend all conferences unless they are on vacation, postcall or if the conferences would put them in violation of their duty hours.

Faculty are to cover clinical and patient care so fellows may attend the conferences.

Morning Report

All available staff, NNPs and fellows attend this report. The fellow on service will be primarily responsible for presenting patients.

The fellow is expected to present:

• New level III admissions since the last morning report
• High-interest patients with ongoing diagnostic or therapeutic issues in the NICU
• Unresolved topics of interest discussed at the prior morning report

The on-service fellow and staff will decide the main focus of patient/issue discussion prior to the morning report. Fellows will be evaluated based on ability to:

• Present complex patients efficiently, completely and accurately
• Focus and expand on pertinent issues involving diagnosis (diagnostic tests and differentials) and therapy (standard and experimental)
• Discuss current literature

All fellows are required to participate in discussions and provide ideas, questions, interpretations and recommendations. The goal is for fellows to develop a strong sense of teamwork in medicine. Additionally, topics discussed will include ethical, psychosocial and medical-economic aspects of care. Staff is encouraged to provide clarifying and guiding questions, but to allow fellows to work out questions and issues before providing input.

Combined Morning Report

This conference is attended by all available SAMMC and University Health Faculty as well as by all fellows from both programs. Fellows on service at University Health, SAMMC and Santa Rosa will present interesting patients for review and discussion among the entire group. This conference allows fellows to see the various management styles at the different institutions and provides forum for discussion of cases.

Perinatal Conference

This conference is designed to enhance communication between obstetrics (OB) and pediatrics. The OB residents under supervision of the maternal-fetal medicine (MFM) staff will present all inpatient OB patients. Aside from simple information sharing, discussions will focus on diagnosis and therapy, as well as anticipated complications.

Fellows are encouraged to ask questions of the MFM staff and to target reading based on anticipated upcoming admissions. The on-service fellow will then be expected to provide a brief update of those NICU patients delivered at University Hospital of interest to the OB team.

Morbidity Case Conference

All fellows and available neonatologists attend this conference. In addition, the pediatric residents on the NICU and Newborn service as well as the medical students attend this conference.

The assigned Neonatal Fellow presents an interesting case and provides additional teaching in the form of lecture and power point on the selected topic. Fellows are expected to review current literature and incorporate this into their talk. The presentation will then lead to a discussion among the group.

The presenting fellow is encouraged to invite appropriate subspecialists to highlight discussion. Fellows will be evaluated based on presentation efficiency and accuracy and the ability to target the discussion.

Mortality Conference

Patient deaths for the previous month will be discussed at this conference. OB residents will discuss the mom’s history and delivery and the Neonatal fellow will discuss the infant history.

A pathologist will review with the group any pertinent pathological information. If an autopsy is done, the pathologist will review the pictures and slides of the autopsy.

Cases and cause of death will be discussed among the OB, pathology and NICU staff and fellows.

Journal Club

All available neonatal staff and fellows from SAMMC, UT Health San Antonio and affiliated SRCH faculty will attend this combined activity. One fellow and one staff will be responsible for selecting appropriate articles and disseminating them to the groups at all teaching hospitals in sufficient time before the journal club.

The goal is to teach fellows the methodology of reviewing individual articles and evaluating them based on scientific method, validity and appropriateness, as well as the context and potential impact on practice. Presentations will be evaluated based on thoroughness and depth of analysis.

Fellow Didactic Lectures

These lectures will be given by neonatal staff at UT Health San Antonio as well as invited guests presenting topics of perinatal interest. In addition, all fellows will be responsible for giving one didactic lecture per year. Topics are based on the content specifications outlined by the ABP.

During the first three months of the academic year, essential lectures will be given (ventilator management, fluid management, etc.) annually with remaining material being covered on a rotating three-year schedule. The goal of the core lecture series is to cover basic pathophysiology and clinical material pertinent to the Perinatal-Neonatal subspecialty board exam, as well as to touch on state-of-the-art clinical practice and ongoing research for selected topics.

Fellow lectures will be evaluated based on clarity and content of material, as well as the ability to effectively present to the target audience.

Research Update

Fellow research updates will be given to the division in the fall and spring of each year, to coincide with upcoming presentations to be given at regional and national meetings. The purpose is to allow for staff and fellow input and guidance, as well as ensure steady progress and setting of realistic goals and objectives. Additional meetings will be arranged for fellows to practice their upcoming presentations at meetings, to include combined research conferences with UT Health San Antonio- and SRCH-affiliated faculty.

Fellows will be evaluated based on ability to meet the individual goals set out by the fellow and research mentor, to present a hypothesis and present their plans and, when available, supporting data and interpretations.

Discharge Planning

This weekly meeting is attended by the on-service fellow and staff, social work, CPS caseworker, PT/OT/ST, Premiere clinic coordinator and continuity care coordinator.

During this meeting each patient in the NICU will be discussed in terms of family support needs, psychosocial needs and discharge planning needs.

Board Review

There are two board review conferences. The first is at SAMMC. This is a fellow-driven conference, currently based on the NeoReviews and the questions from NeoReviews Plus. The second board review is at University Hospital. This board review is based off readings from Fanaroff and Martin.

Neonatal attendings rotate leading these reviews. Fellows are expected to do the readings and be involved in the discussions on the topic. Fellows also answer board type questions to further their education and prepare for the board exam.

Prenatal Diagnosis Multidisciplinary Conference

This is a combined conference with MFM fellows and faculty. All Neonatal fellows and faculty attend. MFM and Neonatal fellows are required to present a case. The respective fellows discuss maternal, fetal and neonatal aspects in the case presentations.

Following 30 minutes of case presentation, MFM and Neonatal faculty and fellows hold discussions on the topic. The goal of this conference is to keep open communication between MFM and neonatology as well as for fellows to get a better understanding of maternal and fetal care.

Pediatric Surgeons Conference

Neonatal faculty and fellows as well as one to two pediatric surgeons attend this conference. The neonatal fellow presents a surgical case and discussion of surgical management ensues with the pediatric surgeon.

The goal of this conference is to obtain a better understanding of surgical management pre- and postoperatively, as well as to maintain good communication with our pediatric surgeons.

Thematic Journal Update

The presenter of this conference (fellow or faculty) chooses a topic of interest. They review all current literature on the topic of choice and select 10 to 15 articles to review. All fellows and faculty in attendance chooses one of the articles to present to the group in approximately five minutes. This conference allows continual review and practice of evidence-based medicine.

Neonatal-Perinatal Research Conference at Alamo City

UT Health San Antonio’s Division of Neonatology holds an annual Neonatal-Perinatal Research Conference intended for Neonatal-Perinatal Fellows and Pediatric Residents with an interest in Neonatology who want to share their research with leaders in neonatal nutrition in a relaxed but scientific environment. 

Trainees submit an abstract and application. Up to 30 fellows and five residents from across the country are selected to attend this meeting. Scholars are invited to present their research in a 10-minute platform presentation. Information pertaining to our upcoming conference can be found here.

National Board Review Conferences

There are currently two national Neonatology Board Review courses offered every two years in alignment with the years of the American Board of Pediatrics Neonatal-Perinatal Medicine board certification. Each of our Neonatal Fellows are given the opportunity to attend one of the two courses in the years they are offered.

Duty Hours

The Perinatal-Neonatal Fellowship program maintains in compliance with the duty hour regulations set forth by the ACGME. In order to regulate duty hours, fellows enter duty hours into New Innovations and the hours are monitored by the Program Director. Institutional Duty hour surveys are conducted twice yearly and ACGME resident surveys are conducted annually.

Clinical Call Schedule

University Hospital (UH-NICU)

The call schedule for fellows varies throughout the year. During the block of primary UH-NICU, the fellow is on-call in the hospital on average of two nights per week. These calls are all in-house to back up the pediatric residents or NNPs and increase their patient contact experience.

During this period, the fellow’s daily or weekly hours do not exceed the ACGME guidelines and the fellow is off every Saturday. The Neonatal Attending Faculty takes two to three nights of in-house call per week in place of the fellows to allow for time off. For the remaining blocks (research or clinical electives), the fellow takes an average of no more than one call per week. In addition, during these blocks the fellow gets one to two full weekend days off every week. There is no formal home call schedule. However, in the event of a difficult neonatal transport, fellows may volunteer for transport duty to gain additional patient care experience (provided that hours do no exceed the ACGME guidelines).

Fellows have private sleep facilities in the hospital and are required to go home postcall for a period of rest as per the ACGME guidelines. First-year fellows will have either a faculty neonatologist or NNP in house with them until the faculty deem the fellow competent to stay in house with faculty neonatologist backup from home and the fellow feels comfortable with remote rather than in house backup (typically the first four to six months).

San Antonio Military Medical Center (SAMMC NICU)

Fellows rotate at SAMMC NICU once (four weeks) during their fellowship. During this rotation, fellows do not take in-house call and are off one day in seven. Duty hours and time off are in accordance with the ACGME guidelines.

CHRISTUS Santa Rosa Children’s Hospital PICU & University Hospital Maternal-Fetal Medicine Electives

Neonatal fellows are not required to take in-house call in the PICU or MFM units. They are still required to take one night of in-house call per week in the University Health NICU during these rotations.

Vacation

Fellows are permitted up to 15 days of vacation per year. Vacation requests are made in advance to the program director and cannot be carried over to the following year.

Sick Leave

A maximum of 15 working sick days are allowed and can be carried over to subsequent years. Combined absences/leave in excess of three months during the three years of training, whether for vacation, parental leave, illness, etc., must be made up. If the program director believes that combined absences/leave that exceeds three months is justified, a letter of explanation is sent by the director for review by the Credentialing Committee.

We are wholly committed to educating our trainees to become exemplary neonatologists who can provide outstanding neonatal-perinatal clinical care for premature babies and newborns exhibiting all levels of illness. Several of our graduating fellows wish to embark upon an academic career; many are inspired to become innovative physician scientists or passionate educators.

To support our Neonatal-Perinatal Fellows in finding their area of expertise, we encourage them to choose from one of three tracks individualized to fit their primary interests. Each of these tracks have been carefully designed by our experienced faculty in the Division of Neonatology so that fellows can develop the skills to become experts in their chosen professional careers.

• Research Fellowship Track
• Medical Educator Fellowship Track
• Clinical/QI Fellowship Track

Goals

The goals of this fellowship program are to provide trainees with the background to understand the physiology and altered structure and function of the fetus and the neonate, and to diagnose and manage problems of the neonate using both basic and advanced techniques.

The Perinatal-Neonatal Fellowship program takes seriously the mandate to systematically and comprehensively integrate competency-based educational processes into the curriculum.

Objectives

1. Develop a sound foundation in the clinical practice of neonatal medicine including diagnosis and management of a full array of medical, surgical and psychosocial disorders which will allow the trainee to be qualified to assume a clinical position in any setting.
2. Develop and demonstrate consultative skills in the management of high-risk pregnancies and recognized the psychological implications of disorders of the fetus, neonate and young infant, as well as in the family dynamics surrounding the birth and care of a sick neonate.
3. Demonstrate skill, knowledge and judgment in performing aero medical and ground transports of critically ill patients of a variety of sizes and conditions.
4. Acquire clinical and laboratory research experience in order to be qualified to assume a position in any academic and clinical setting and carry on scholarly efforts in Perinatal-Neonatal medicine, including critical evaluation of the literature.
5. Develop and demonstrate administrative skills for setting up and managing a nursery with Level I, II, IIIA or IIIB care. This will include, but not be limited to, economics of medicine; operating instruction development and review; quality improvement activities; managing space, personnel, and equipment; interactions with certifying and accreditation activities; and function of health systems.
6. Become fully qualified for sub-board certification in Perinatal-Neonatal Medicine as established by the ACGME Residency Review Committee for Perinatal-Neonatal Medicine and the American Board of Pediatrics, sub-board of Perinatal-Neonatal Medicine.

Application Requirements

The Perinatal-Neonatal Fellowship program requires a degree of Doctor of Medicine or Osteopathy and successful completion of three years of general pediatric training in an ACGME-accredited program.

Application Process

Applicants need to apply through Association of American Medical College's Electronic Residency Application Service (ERAS®) website. Electronic Residency Application Service (ERAS®) is a service that transmits the MyERAS application and supporting documentation from applicants and their Designated Dean's Office to program directors. ERAS consist of MyERAS, Dean's Office Workstation (DWS), Program Director's Workstation (PDWS) and ERAS post office.

MyERAS website opens to fellowship applicants in mid-June for applicants to begin working on their applications. The ERAS post office opens on December 1 for programs to begin downloading applications. Applicants are required to complete their application packet in ERAS prior to receiving an offer for an interview. This consists of:

• A completed application form with personal statement
• Medical school transcripts
• USMLE (or COMLEX) transcript
• Three letters of reference

Selection Procedures

Fellowship positions are selected through the National Residency Matching Program (NRMP). Details regarding registration for the match and important deadlines can be found on the NRMP website.

Competitive applicants will be invited for an interview consisting of a meeting with the program director, a tour of the facility, lunch with one to two current fellows and interviews by selected faculty and staff. Each interviewer completes an evaluation and rates the individual relative to previous applicants. No applicant will be considered for the program without an interview.

Rank List

Upon completion of the interview process for all viable candidates, a rank list is generated and submitted to the NRMP. This list is generated by the faculty members of the Division of Perinatal-Neonatal Medicine in a formal meeting prior to the submission deadline. Only the faculty and fellows of the division participate in this process.

The order of the rank list is based upon those candidates who are considered to have the strongest potential with regard to:

• Clinical skills
• Ability to develop into a competitive, independent investigator or clinical educator
• Personal attributes that promote leadership, teamwork, responsibility, sensitivity and compassion for others

Once the results of the match are known, the selected fellows are contacted and offered a contract for the corresponding academic year. Orientation materials are supplied in the spring prior to the beginning of the first year of appointment.

Additional Requirements

The Joint Commission has clarified HR Standard 1.20 to provide that hospitals are now required to screen trainees in the same manner as staff employed by the hospital if the trainees work in the same capacity as staff that provides care, treatment and services.

In order to meet this standard and continue to provide safe, quality patient care and excellent educational opportunities, the GME has implemented additional screening requirements for trainees. These additional requirements are consistent with the requirements imposed on other employed staff. House staff paid by University Hospital or UT Health San Antonio is required to successfully pass all screening requirements including a criminal background check prior to beginning their training at this institution.

Further Information

For further information, please contact:

Simulation

UT Health’s Neonatology Fellowship Simulation Program is a simulation-based training program. The program’s primary objectives are:

• Quarterly interprofessional team training with UT Neonatology Fellows, University Hospital NICU nurses and respiratory therapists
• Drill scenario and learning objectives dealing not only with cognitive and technical knowledge review and affirmation but to emphasize behavioral knowledge practice

The program’s focus on acute crisis management is in the form of efficient teamwork actions, acknowledged communication and vital leadership skills in accordance with the goals of the team training program TeamSTEPPS™. These acquired behavioral knowledge skills benefit from practice in simulated clinical scenarios.

The program also emphasizes a professional business-like approach to post-event debriefing and how team performance is affected by individual actions, which in turn ultimately affects patient care.

The program has evaluated the need for a delivery room checklist by neonatology fellow-led delivery room teams for Extremely Low Birth Weight (ELBW) infant births. The data has been presented at an international pediatric simulation conference and will soon be submitted for publication.

Our future goals include incorporating Rapid Cycle Deliberate Practice simulation methodology into the program as well as expand the role and participation of ancillary providers.

Flipped Classroom

Dr. Vasquez is a member of the Organization of Neonatal Training Program Directors (ONTPD) National Neonatology Curriculum (NNC) executive committee. The committee is working on pooling resources to develop a shared standardized, high quality, peer reviewed national physiology curriculum for Neonatal-Perinatal Medicine fellows using online videos for knowledge acquisition paired with flipped classrooms. 

Content is based on the American Board of Pediatrics (ABP) content specifications for Neonatal-Perinatal Medicine board certification. The Neonatal-Perinatal “NeoFlip” curriculum can be found here.

The Department of Pediatrics at UT Health San Antonio has developed a didactic lecture series to cover the required core curriculum materials. Topics covered in the lecture series include:

• Teaching skills
• Delivering difficult news
• Professionalism
• Medical ethics
• Sleep and fatigue
• Cultural diversity
• Quality improvement
• Clinical research
• Statistics
• Personal statement
• CV writing workshops

The lectures are required for all Pediatric subspecialty fellows and are given throughout the three years of the fellowship.

PGMEC Training Seminars for First Year Fellows

All first year fellows are required to attend the Fellow Orientation Lectures provided by UT Health San Antonio, usually scheduled during the first week in September. Fellows will be excused from clinical duties to attend these lectures.

The goal of this orientation week is to provide a forum for all of the fellows in the Department of Pediatrics to receive uniform information about the scholarly oversight process and participate in a core set of didactics required by the ACGME.

Topics Covered in the Orientation Week

• American Board of Pediatrics maintenance of certification
• Orientation to scholarly activity
• Career development
• Overview of laboratory research and finding a mentor
• Teaching skills
• Evidence-based medicine
• Delivering difficult news
• Professionalism and medical ethics

Online Learning

In the first six months of training, fellows are required to complete Sleep and Fatigue Module on Blackboard as well as Cultural Diversity: Cross Cultural Healthcare — Case Studies online. The program coordinator tracks completion of these modules.

Introduction to Clinical Investigation (ICI) Course

In the spring, first year fellows are also required to attend the ICI Course sponsored by UT Health San Antonio, unless enrolled in the MSCI course. First year fellows will be excused from clinical activities to attend the course, which is usually held the first two weeks in February.

• Mentoring
• Clinical research design
• Statistical methods in clinical research
• Institutional review board/human subjects research
• Informed consent
• Literature reviews
• Searching the medical literature
• Writing skills
• Data collection
• Management

Continuous Quality Improvement Lecture

Second-year fellows participate in a two-hour didactic on continuous quality improvement, usually offered in mid-September. The didactic provides fellows with a foundation in understanding CQI to aid in the development of their own quality improvement projects.

Health care Economics & Practice Management

During the spring of second year, a one-day seminar is given introducing fellows to healthcare economics and practice management. The topics in this seminar are:

• Practice management
• Contracts
• Financial planning
• Billing and coding
• Health care economics and management

The first year Perinatal-Neonatal Medicine fellow completes four to five rotations (four-week blocks) in the NICU at University Hospital. Clinical training and acquisition of specialty-specific skills are the main objectives of the first year of training.

The fellow is assigned to a team of pediatric residents. They learn pathophysiology of common newborn lung diseases and how to manage modes of respiratory support including synchronized intermittent mandatory ventilation and high frequency ventilation. To learn advanced resuscitation skills, they are certified as an instructor for the American Academy of Pediatrics Neonatal Resuscitation Program.

Each fellow selects a mentor, begins meeting with the Scholarly Oversight Committee to review proposal for a scholarly activity and begins the approved project. Fellows in the first year attend the PGMEC Training Seminars for First Year Fellows and complete the online learning modules for Sleep and Fatigue and Cultural Diversity. In February of the first year, the fellows also attend an Introduction to Clinical Investigation Course.

Each of the three years of fellowship is divided into thirteen 4-week blocks. On average during the three years of fellowship, there are 17.5 blocks of clinical training, (including clinical electives, call and follow-up clinic) 19.25 blocks of research and 2.25 blocks of vacation.

First Year NICU Blocks

University Hospital NICU (PGY4)

University Hospital is the program’s primary facility for fellowship training. The main objective of the first year of fellowship is to solidify clinical skills and provide the fellow with the foundation to competently care for the majority of neonatal problems in a tertiary care NICU setting.

During the first months of fellowship, fellows will be directly involved in primary care of NICU patients. They also will supervise student and resident members of the NICU team. This opportunity allows the program director and other neonatal staff to become acquainted with the skills and knowledge level of the trainee, allows the trainee to become familiar with the nuances of patient care in our facility and provides time and experience for the trainee in the management of special techniques such as high-frequency ventilation and inhaled nitric oxide.

In all rotations, the fellow will be directly in charge of overseeing all care provided by residents, nurse practitioners and medical students on the intensive care service.

Fellows will make daily work rounds with the NICU team and attending. Fellows will assist the attending staff in providing teaching and patient care discussions. Fellows will attend all surgical procedures performed in the NICU or operating room. Fellows will participate in the transport process to include taking initial calls, organizing the team and leading the transport team.

Fellows will assist in the management of all ongoing clinical research studies in the NICU. As experience and skill levels improve, the fellow will be given increasing responsibility and autonomy, including supervising rounds once to twice weekly.

Regardless of level of autonomy, staff should be notified as quickly as possible of all level III admissions, transports and significant changes in status for infants currently admitted to the NICU service. Staff is to be notified of all nonurgent level II admissions within eight to 12 hours.

Fellows are responsible for writing fellow admission notes, transport notes and on-call notes for significant clinical events. Fellows are additionally responsible for arranging family meetings and assuring appropriate follow-up care for high-risk patients.

Educational conferences (morning report, didactic lectures, journal clubs, board review conferences, discharge planning meetings) take priority over all but urgent patient care and unique training opportunities, and staff coverage will be arranged.

Competency with the following skills, but not limited to these, are expected in the PGY4 year of subspecialty training:

• Techniques of neonatal resuscitation
• Venous and arterial access
• Endotracheal intubation
• Preoperative and postoperative care of surgical patients
• Preparation for transport
• Ventilator support
• Use of inhaled nitric oxide therapy
• Continuous cardiorespiratory monitoring
• Intravenous/enteral nutritional support

PREMIEre Clinic (PGY4)

Fellows attend approximately 28 to 32 high-risk follow up clinics each year. The goal of this twice-weekly clinic is to provide health care management and maintenance to parents and their infants who were cared for at the NICU and were born with a birth weight of less than 1,500 grams and/or have a high risk for long-term neurodevelopmental disability.

The clinic provides patients with neurodevelopmental assessments using Bayley Scales of Infant Development as well as evaluation by a neonatologist and fellows for growth and neurodevelopment. The clinic follows patients from the time of discharge until they are 3 years old. Infants found to be at high risk for developmental delays are also referred to Early Childhood Intervention programs.

The NICU fellow assigned to the clinic and supervised by a staff neonatologist will see patients. All management decisions and follow-up plans will be communicated with the patient’s primary care physician.

Electives Available During the Fellowship

• NICU rotations at an outside Level III or IV hospital
• Maternal-fetal medicine
• Pediatric cardiology
• Clinical statistics
• Newborn nursery/neonatal nurse practitioner service

During the second year, fellows are expected to develop an advanced understanding of complex clinical problems and to be able to independently formulate an appropriate differential diagnosis, diagnostic evaluations and initial treatment of ill newborns. They are scheduled to complete four clinical rotations (three blocks in the NICU at University Hospital, one block in the NICU at SAMMC and one block on maternal-fetal medicine).

They are expected to assume a more managerial role in the care of the patients, supervision of team members and interactions with other consultants. They have the remainder of the year to conduct their approved scholarly activity and present their work in progress to their scholarship oversight committee. In the second year of fellowship, fellows participate in a Continuous Quality Improvement Lecture as well as a workshop on preparing CV and writing a personal statement.

Each of the three years of fellowship is divided into thirteen 4-week blocks. On average during the three years of fellowship, there are 17.5 blocks of clinical training, (including clinical electives, call and follow-up clinic) 19.25 blocks of research and 2.25 blocks of vacation.

Second Year NICU Blocks

University Hospital NICU (PGY5)

University Hospital is the program’s primary facility for fellowship training. The main objective of the first year of fellowship is to solidify clinical skills and provide the fellow with the foundation to competently care for the majority of neonatal problems in a tertiary care NICU setting. During the first months of fellowship, fellows will be directly involved in primary care of NICU patients. They also will supervise student and resident members of the NICU team. This opportunity allows the program director and other neonatal staff to become acquainted with the skills and knowledge level of the trainee, allows the trainee to become familiar with the nuances of patient care in our facility and provides time and experience for the trainee in the management of special techniques such as high-frequency ventilation and inhaled nitric oxide.

In all rotations, the fellow will be directly in charge of overseeing all care provided by residents, nurse practitioners and medical students on the intensive care service. Fellows will make daily work rounds with the NICU team and attending. Fellows will assist the attending staff in providing teaching and patient care discussions. Fellows will attend all surgical procedures performed in the NICU or operating room. Fellows will participate in the transport process, to include taking initial calls, organizing the team and leading the transport team.

Fellows will assist in the management of all ongoing clinical research studies in the NICU. As experience and skill levels improve, the fellow will be given increasing responsibility and autonomy, including supervising rounds once to twice weekly.

Regardless of level of autonomy, staff should be notified as quickly as possible of all level III admissions, transports and significant changes in status for infants currently admitted to the NICU service. Staff is to be notified of all nonurgent level II admissions within eight to 12 hours.

Fellows are responsible for writing fellow admission notes, transport notes and on-call notes for significant clinical events. Fellows are additionally responsible for arranging family meetings and assuring appropriate follow-up care for high-risk patients. Educational conferences (morning report, didactic lectures, journal clubs, board review conferences, discharge planning meetings) take priority over all but urgent patient care and unique training opportunities, and staff coverage will be arranged.

PGY5 fellows will advance and refine the skills they acquired in the PGY4 year while increasing their research activity.

SAMMC NICU (PGY5)

San Antonio Military Medical Center is the military medical facility in San Antonio. The NICU is staffed by both Air Force and Army neonatologists and is the training site for military Neonatal fellows.

Fellows will rotate through SAMMC in one 4-week block in the PGY-5 year. Fellows will participate in all NICU care when on service at the SAMMC in a similar manner to that described for the University Hospital NICU, and the goals and objectives are similar for this rotation. However, this rotation offers the fellow exposure to a less indigent patient population with a higher compliance rate for their prenatal care.

While at SAMMC, fellows will participate in all departmental conferences at SAMMC but also continue to attend core didactic lectures at University Hospital. Fellows also will be required during this rotation to present admissions and discuss clinical care issues at AM report three times a week. Fellows will organize and participate in all didactic and family conferences involving patients on their service, at which time they will become familiar with multidisciplinary military discharge planning.

Fellows participate in transport of high-risk newborns to SAMMC and in the care of all ECMO patients admitted to the NICU service.

PREMIEre Clinic (PGY5)

Fellows attend approximately 28 to 32 high-risk follow up clinics each year. The goal of this twice-weekly clinic is to provide health care management and maintenance to parents and their infants who were cared for at the NICU and were born with a birth weight of less than 1,500 grams and/or have a high risk for long-term neurodevelopmental disability.

The clinic provides patients with neurodevelopmental assessments using Bayley Scales of Infant Development as well as evaluation by a neonatologist and fellows for growth and neurodevelopment. The clinic follows patients from the time of discharge until they are 3 years old. Infants found to be at high risk for developmental delays are also referred to Early Childhood Intervention programs.

Patients will be seen by the NICU fellow assigned to the clinic and supervised by a staff neonatologist. All management decisions and follow-up plans will be communicated with the patient’s primary care physician.

Electives Available During the Fellowship

• NICU rotations at an outside Level III or IV hospital
• Maternal-fetal medicine
• Pediatric cardiology
• Clinical statistics
• Newborn nursery/neonatal nurse practitioner service

During the third year, the fellow is expected to develop skills to practice neonatology competently and independently. They complete three blocks in the NICU, with one block as a “junior attending” supervising a NICU team. They also complete one block in the cardiac care unit to learn the management of post-operative cardiac care.

They assume responsibility for organizing conferences and call schedules. They are expected to complete the core curriculum and produce a “work product” to summarize their completed scholarly activity.

Each of the three years of fellowship is divided into thirteen 4-week blocks. On average during the three years of fellowship, there are 17.5 blocks of clinical training, (including clinical electives, call, and follow-up clinic) 19.25 blocks of research and 2.25 blocks of vacation.

Third Year NICU Blocks

University Hospital NICU (PGY6)

This rotation, several months into the last academic year, will allow the fellow maximum autonomy as the acting attending. They will demonstrate not only clinical skills but will be responsible for training and evaluating the residents as well. Staff backup and oversight will always be present and available. However, interference with fellow management plans will be kept to a minimum.

The primary goal is to ensure that the fellow is a competent independent practitioner at the completion of their PGY6 year. Senior fellows continue to organize and run AM report with more autonomy than per PGY 4 and 5 years.

CSRCH PICU (PGY6)

Christus Santa Rosa Children’s Hospital houses the largest pediatric cardiothoracic center in South Texas. Fellows will do one 4-week block in the cardiac intensive care unit during their PGY6 year. The main purpose of this rotation is for senior fellows to further their understanding of both the diagnosis and management of congenital heart disease (CHD) in neonates.

Fellows will be directly supervised by the pediatric critical care staff and have multidisciplinary interaction with pediatric cardiology, cardiothoracic surgery and anesthesia staff. Fellows will primarily follow and make decisions on all neonatal and infant patients with CHD admitted to the unit for surgical repair of their disease.

Didactic teaching will be given during daily rounds with the pediatric critical care and cardiology staff as well as weekly grand rounds with pediatric cardiothoracic surgery.

Fellows will participate in any procedures required for their patients both pre- and postoperatively while in the PICU, and will directly observe operative management by CT surgery and anesthesia in the operating room. Fellows also will participate in diagnostic management of patients with cardiology to include involvement with preoperative echocardiograms and cardiac catheterizations, as well as through attendance of a weekly cardiac care conference.

PREMIEre Clinic (PGY6)

Fellows attend approximately 28 to 32 high-risk follow up clinics each year. The goal of this twice-weekly clinic is to provide healthcare management and maintenance to parents and their infants who were cared for at the NICU and were born with a birth weight of less than 1,500 grams and/or have a high risk for long-term neurodevelopmental disability.

The clinic provides patients with neurodevelopmental assessments using Bayley Scales of Infant Development as well as evaluation by a neonatologist and fellows for growth and neurodevelopment. The clinic follows patients from the time of discharge until they are 3 years old. Infants found to be at high risk for developmental delays also are referred to Early Childhood Intervention programs.

Patients will be seen by the NICU fellow assigned to the clinic and supervised by a staff neonatologist. All management decisions and follow-up plans will be communicated with the patient’s primary care physician.

Electives Available During the Fellowship

• NICU rotations at an outside Level III or IV hospital
• Maternal-fetal medicine
• Pediatric cardiology
• Clinical statistics
• Newborn nursery/neonatal nurse practitioner service

Fellow Scholarly Activities: Mentored Research Projects

Fellows can choose from a variety of basic, translational science, or clinical research projects depending on their preferred interests and chosen tracks. We try to focus these research activities to fit the long-term career goals of each individual fellow. Our program is designed to ensure that fellows have sufficient protected time for the successful completion of their scholarly projects within the scope of their chosen educational track. Research faculty within the Division of Neonatology will be responsible for individualized mentorship.

Within the first three months of starting, it is recommended that the fellows choose a mentor and a research project. Mentors are not confined to the Division, but preferably remain within the University. Several past and present fellows have undertaken both a basic and clinical research project. Together with their mentors, all fellows propose and plan a comprehensive scholarly project. This usually begins with a detailed project proposal, followed by methods for data collection and analysis, and a final outline for a peer-reviewed publication.

All fellow research activities are reviewed quarterly (September, January and May) by a designated Neonatal Scholarship Oversight Committee (NSOC). The main focus of the NSOC is oversight and approval of the scholarly work product as defined by the American Board of Pediatrics (ABP). The committee consists of 2-3 faculty members of the Division of Neonatology and an ad hoc member within the Department of Pediatrics. Fellows are expected to give a brief update on the progress of their projects, future plans, and an appropriate timeline for work product completion. All fellows present their projects at regional and national conferences.