New Application: Adolescent Medicine

New Application: Adolescent Medicine

Review Committee for Pediatrics

ACGME

COMMON SUBSPECIALTY SECTION

Institutions

Using the table below, provide a summary of the program’s leadership and support staff, including the name and percent FTE protected time. 1.0 FTE is greater than or equal to 40 hours per week. Add rows as needed.[PR I.A.2.-3.]

Adolescent Medicine Updated 4/2016

Program Leadership / Name / % FTE Protected Time for the Administration of the Program (excluding Scholarly Activity)
Program Director / Name / #%
Associate Program Director(s) / Name / #%
Title / Name / #%
Title / Name / #%
Title / Name / #%
Title / Name / #%
Title / Name / #%
Administrative/Support Personnel / Number of Administrative Personnel / % FTE in This Fellowship Program for Each
e.g., Fellowship Coordinator / 1 / 100%
e.g., Administrative Assistant / 1.5 / 100%/50%
Title / # / #%
Title / # / #%
Title / # / #%
Title / # / #%
Title / # / #%

Adolescent Medicine Updated 4/2016

Faculty Research

Complete the table below regarding the involvement of faculty members in research. Add rows as needed. [PR II.B.5-5.b).(3); II.B.5.f)-f).(2)]

Adolescent Medicine Updated 4/2016

Name / # of Current IRB-Approved Research Projects / Total # of Current Funded Research Projects / # of Current Research Projects with Peer-Review Funding (Subset of Total # in Previous Column) / # of Presentations at National Scientific Meetings in Last 5 Years / # of Publications in Peer-Review Journals in Last 5 Years
Program Director:
Name / # / # / # / # / #
Physician Faculty Members within the Program Subspecialty (e.g., for a Pediatric Gastroenterology Program, Only List the Pediatric Gastroenterology Faculty Members):
Name / # / # / # / # / #
Name / # / # / # / # / #
Name / # / # / # / # / #
Name / # / # / # / # / #
Name / # / # / # / # / #
Non-Physician Research Mentors or Physician Faculty Members from Other Subspecialties:
Name / # / # / # / # / #
Name / # / # / # / # / #
Name / # / # / # / # / #
Name / # / # / # / # / #
Name / # / # / # / # / #

Adolescent Medicine Updated 4/2016

2.List active research projects in the subspecialty. Add rows as needed. [PR II.B.5.-5.b).(3); II.B.5.f).(1)-(2)]

Adolescent Medicine Updated 4/2016

Project Title / Funding Source / Place An "X" if Funding Awarded by PeerReview Process / Years of Funding (Dates) / Faculty Investigator and Role in Grant (i.e., PI, Co-PI, Co-Investigator)
Project title / Funding source / ☐ / Years of funding / Faculty investigator/role in grant /
Project title / Funding source / ☐ / Years of funding / Faculty investigator/role in grant /
Project title / Funding source / ☐ / Years of funding / Faculty investigator/role in grant /
Project title / Funding source / ☐ / Years of funding / Faculty investigator/role in grant /
Project title / Funding source / ☐ / Years of funding / Faculty investigator/role in grant /
Project title / Funding source / ☐ / Years of funding / Faculty investigator/role in grant /
Project title / Funding source / ☐ / Years of funding / Faculty investigator/role in grant /

Adolescent Medicine Updated 4/2016

Research Resources

1.Does the program provide research laboratory space and equipment?...... ☐ YES ☐ NO

2.Does the program provide financial support for research?...... ☐ YES ☐ NO

3.Does the program provide computer and statistical consultation services?...... ☐ YES ☐ NO

Program Curriculum

Goals and Objectives

Are there goals and objectives for all training experiences?[PR IV.A.2.] / ☐ YES ☐ NO
Are these rotation- and level-specific?[PR IV.A.2.] / ☐ YES ☐ NO
How are they distributed? [PR IV.A.2.] / ☐ Hard copy ☐ Electronic or web-based
If not web-based, when are they distributed to fellows?[PR IV.A.2.] / ☐ Prior to each rotation☐ Annually
☐ Once in handbook☐ Other
If not web-based, when are they distributed to faculty members?[PR IV.A.2.] / ☐ Prior to each rotation
☐ Annually
☐ Other
If web-based, are reminders sent to access them?[PR IV.A.2.] / ☐ YES ☐ NO
If YES, when are the reminders sent?[PR IV.A.2.] / Click here to enter text. /

Collaboration among Programs

Are there meetings among the core program director and subspecialty program directors? [PR II.A.4.s)] / ☐ YES ☐ NO
How often do these meetings occur? [PR II.A.4.s).(1)] / Click here to enter text. /
Who typically participates in these meetings? (check all that apply) [PR II.A.4.s)] / ☐ Core program director
☐ Subspecialty program director for this specialty
☐ Program directors from other subspecialties

General Subspecialty Curriculum

Topic / Where Taught in Curriculum (Name Should Match Name in Conference List) / Number of Structured Teaching Hours Dedicated to Topic Area / Participants (Place An "X" in the Appropriate Column)
Fellows in this Discipline Attend / All Subspecialty Fellows Attend / Residents and Subspecialty Fellows Attend
e.g., Biostatistics / Research Course / 14 / X
Basic science as related to the application in clinical subspecialty practice [PR IV.A.6.a).(3)] / Click here to enter text. / # / ☐ / ☐ / ☐
Clinical subspecialty content [PR IV.A.6.a).(3)] / Click here to enter text. / # / ☐ / ☐ / ☐
For the topics below, if the topic is not appropriate for the discipline (e.g., lab research for fellows in developmental behavioral pediatrics), enter N/A in Column 2 (Where Taught…).
Biostatistics [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Lab research methodology (if appropriate) [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Clinical research methodology [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Study design [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Grant preparation [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Preparation of protocols for Institutional Review Board [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Principles of evidence-based medicine/critical literature review [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Quality improvement [PR IV.A.6.a).(6)] / Click here to enter text. / # / ☐ / ☐ / ☐
Teaching skills [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Professionalism/ethics [PR IV.A.5.e] / Click here to enter text. / # / ☐ / ☐ / ☐
Cultural diversity [PR IV.A.5.e).(5)] / Click here to enter text. / # / ☐ / ☐ / ☐
Systems-based practice (economics of healthcare, practice management, clinical outcomes, etc.) [PR IV.A.5.f)] / Click here to enter text. / # / ☐ / ☐ / ☐

Conferences

1.List regular subspecialty and interdepartmental conferences, rounds, etc. that are a part of the program. Identify the "Site" by using the corresponding number as it appears in the Accreditation Data System (ADS) portion of the application. Indicate the frequency (e.g., weekly, monthly) and whether conference attendance is required (R) or optional (O). List the planned role of the fellow in this activity (e.g., conducts conference, presents case and participates in discussion, case presentation only, participation limited to Q&A component). Add rows as needed.[PR IV.A.6.a).(2)-(4)]

Adolescent Medicine Updated 4/2016

Conference / Site # / Frequency / Attendance Required (R) or Optional (O) / Role of the Fellow
Conference / Site # / Frequency / ☐R
☐O / Role of fellow /
Conference / Site # / Frequency / ☐R
☐O / Role of fellow /
Conference / Site # / Frequency / ☐R
☐O / Role of fellow /
Conference / Site # / Frequency / ☐R
☐O / Role of fellow /
Conference / Site # / Frequency / ☐R
☐O / Role of fellow /
Conference / Site # / Frequency / ☐R
☐O / Role of fellow /

Adolescent Medicine Updated 4/2016

2.Describe the mechanism that will be used to ensure fellow attendance at required conferences. State the degree to which faculty member attendance is expected, and how this will be monitored.[PR IV.A.6.a).(2)]

(Limit response to 50 words)

Click here to enter text. /

Scholarship Oversight Committee

1.Will there be a Scholarship Oversight Committee for every fellow? [PR IV.B.2.b)]...... ☐YES ☐ NO

2.If YES, how often will the committee meet with the fellow? [PR IV.B.2.b)]...... # times per year

Fellow Research Activities

1.Describe how the program will ensure a meaningful supervised research experience for fellows beginning in their first year and extending throughout their training.[PR IV.B.2.a)]

Click here to enter text. /

2.Identify any research mentors outside the division that will be actively involved in mentoring fellows, and describe how liaisons will be used between these mentors and the fellows to allow for meaningful accomplishment of research. [PRIV.B.2.c)]

Click here to enter text. /

The Learning and Working Environment

Night Float/Night Shift

If the program requires night experiences, indicate the frequency of these experiences each year, and describe how they are structured to ensure educational value to fellows. [PR VI.F.6.a)]

(Limit response to 200 words)

Click here to enter text. /

Adolescent Medicine Updated 4/2016

SPECIALTY-SPECIFIC SECTION

Other Professional Personnel

Indicate with a check mark the personnel who will interact regularly with fellows at each participating site. [PR Int.A.3.]

Adolescent Medicine Updated 4/2016

Team Members / Site #1 / Site #2 / Site #3 / Site #4
Psychology / ☐ / ☐ / ☐ / ☐ /
Social Work / ☐ / ☐ / ☐ / ☐ /
School Systems/ Education / ☐ / ☐ / ☐ / ☐ /
Public Health / ☐ / ☐ / ☐ / ☐ /
Chemical Dependency / ☐ / ☐ / ☐ / ☐ /
Nutrition / ☐ / ☐ / ☐ / ☐ /
Pharmacology Toxicology / ☐ / ☐ / ☐ / ☐ /

Adolescent Medicine Updated 4/2016

For categories of personnel that are unavailable, describe how that function will be addressed in the program.

Click here to enter text. /

Program Personnel and Resources

Faculty Disciplines for Pediatric Subspecialties

In the table below, indicate the number of faculty that are present in each of the required disciplines [PR: II.B.2.e); VII.A.2.a)-VII.A.2.g)]:

Adolescent Medicine Updated 4/2016

Discipline / Number of Essential Faculty
Site #1 / Site #2 / Site #3 / Site #4
PEDIATRIC SUBSPECIALTIES
Pediatric cardiology / # / # / # / # /
Pediatric critical care medicine / # / # / # / # /
Pediatric emergency medicine / # / # / # / # /
Pediatric endocrinology / # / # / # / # /
Pediatric gastroenterology / # / # / # / # /
Pediatric hematology/oncology / # / # / # / # /
Pediatric infectious diseases / # / # / # / # /
Neonatal-perinatal medicine / # / # / # / # /
Pediatric nephrology / # / # / # / # /
Pediatric pulmonology / # / # / # / # /
Pediatric rheumatology / # / # / # / # /
SPECIFIC TO ADOLESCENT MEDICINE
Anesthesiology / # / # / # / # /
Child and adolescent psychiatry / # / # / # / # /
Dermatology / # / # / # / # /
Diagnostic radiology / # / # / # / # /
Medical genetics / # / # / # / # /
Neurology with specialty qualification in child neurology / # / # / # / # /
Obstetrics and gynecology / # / # / # / # /
Orthopaedic surgery / # / # / # / # /
Pathology-anatomic and clinical / # / # / # / # /
Pediatric sports medicine / # / # / # / # /
Pediatric surgery / # / # / # / # /
Surgery / # / # / # / # /

Adolescent Medicine Updated 4/2016

Inpatient Data[PR VII.C.3.]

Provide the following information for the most recent 12-month period.Note the same timeframe should be used throughout the forms.

Inclusive Dates: / From: Click here to enter a date. / To: Click here to enter a date.

Regardless of whether there is a separate adolescent medicine service, in #1 and #2 below, separate out those admissions for whom the fellows have primary care responsibility from those being seen only in consultation.

Adolescent Medicine Updated 4/2016

Inpatient / Site #1 / Site #2 / Site #3 / Site #4
1.Total number of admissions for which the adolescent medicine service assumed primary responsibility / # / # / # / # /
2.Total number of consultations by adolescent medicine specialists on other inpatient services / # / # / # / # /
Total Number of Admissions & Consultations (Total of line 1 and 2) / # / # / # / # /
3.Number of admissions (from the row above) requiring follow-up care as outpatients by adolescent medicine service / # / # / # / # /

Adolescent Medicine Updated 4/2016

Identify the type of inpatient settings in which fellows will participate in addressing the needs of hospitalized adolescents by placing an X in the box under the appropriate participating site.For inpatient services indicate the number of available beds.

Adolescent Medicine Updated 4/2016

Inpatient / Site #1 / Site #2 / Site #3 / Site #4
General Pediatric Unit / ☐ / ☐ / ☐ / ☐ /
Intensive Care Units / ☐ / ☐ / ☐ / ☐ /
Separate Adolescent Medicine Unit / ☐ / ☐ / ☐ / ☐ /
Psychiatric Unit / ☐ / ☐ / ☐ / ☐ /
Detoxification Unit or Substance Abuse Facility / ☐ / ☐ / ☐ / ☐ /
Inpatient Services / # / # / # / # /
Other: Click here to enter text. / ☐ / ☐ / ☐ / ☐ /
Other: Click here to enter text. / ☐ / ☐ / ☐ / ☐ /

Adolescent Medicine Updated 4/2016

List 50 consecutive admissions and/or consultations in which the adolescent medicine service participated. Identify the time period during which these admissions/consultations occurred. The date range should occur within the same 12-month period used in previous sections. The dates must begin on the date the first patient on the list was admitted and end with the date the 50th patient was admitted, (e.g., July 1, 2014 through October 20, 2014). Submit a separate list for each site that provides required rotations. Use additional tables as necessary.

Site Name: / Click here to enter text.
Inclusive Dates: / From: / mm/dd/yy / To: / mm/dd/yy

Adolescent Medicine Updated 4/2016

Patient ID / Primary Diagnosis / Secondary Diagnosis
Adolescent Issues
Number / Age
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text
# / Age / Click here to enter text / Click here to enter text

Adolescent Medicine Updated 4/2016

List of Continuity Experience Diagnoses

List 50 CONSECUTIVE patient visits to a representative setting used for fellows’ continuity experience. (This list can be consecutive patient visits from one fellow’s log or consecutive patient visits to one site.) The date range should occur within the same 12-month period used in previous sections. The dates must begin on the date the first patient on the list was admitted and end with the date the 50th patient was admitted, (e.g., July 1, 2014 through October 20, 2014). Use additional tables as necessary.

Clinical Site: / Click here to enter text.
Inclusive Dates: / From: / mm/dd/yy / To: / mm/dd/yy

Adolescent Medicine Updated 4/2016

Ambulatory Adolescent Medicine Training Sites

List the name of setting used to address core knowledge areas for each participating site listed in ADS as well as all sites for fellows’ continuity experience. Designate continuity clinic sites with an asterisk (*). Also list the duration of experience, number of sessions, annual number of patient visits, and role of fellow in care of patients – designate as: primary provider (PP), consultant (C), observer (O), multidisciplinary care team member (T), and counselor (CS). Add rows as necessary.

Adolescent Medicine Updated 4/2016

Name of Setting Used to Address Core Knowledge Areas / Duration of Experience(in weeks/year) / Number of Sessions Per Week Per Fellow / Annual number of patient visits (State N/A if non-medical sites) / Role of Fellow in Care of Patients
Click here to enter text. / Duration / # / # / Click here to enter text.
Click here to enter text. / Duration / # / # / Click here to enter text.
Click here to enter text. / Duration / # / # / Click here to enter text.
Click here to enter text. / Duration / # / # / Click here to enter text.
Click here to enter text. / Duration / # / # / Click here to enter text.
Click here to enter text. / Duration / # / # / Click here to enter text.
Click here to enter text. / Duration / # / # / Click here to enter text.
Click here to enter text. / Duration / # / # / Click here to enter text.
Click here to enter text. / Duration / # / # / Click here to enter text.
Click here to enter text. / Duration / # / # / Click here to enter text.

Adolescent Medicine Updated 4/2016