Didactic Curriculum
| Journal Club once per month | Hypersomnia Board once per month | Pharmacology of Sleep |
| Genetics of Sleep Disorders | PSG Monitoring, Methodology, and Troubleshooting | HSAT; Flow Based on PAT Technology |
| AASM Scoring Rules - Pediatrics | AASM Scoring Rules - Adult | Writing a Sleep Report |
| Neonatal Sleep | Behavioral Insomnia of Childhood | Introduction of OSA in both adult and pediatric |
| Control of Breathing, Sleep, and Respiratory Physiology | Neuroanatomy of Sleep | Actigraphy, MSLT, and MWT |
| Sleep in Autism and ADHD | Introduction to PAP | Introduction to CSA |
| Introduction to Hypersomnia | Introduction to Narcolepsy | Circadian Rhythm Disorders |
| Sleep in Women and Pregnancy | MSLT Workshop | Medico-legal Aspect of Sleep Medicine |
| Upper Airway Anatomy | Upper Airway Resistance Syndrome | Parasomnias |
| Billing in the Sleep World | Sleep Related Movement Disorders | REM Sleep Disorders in Adults and Pediatrics |
| Obstructive Sleep Apnea Overview and PAP Troubleshooting | Surgical Treatment for OSA | Bariatric Surgery and Care in Sleep Disorders |
| Obesity Hypoventilation Syndrome | Insomnia in Adults | Pharmacology and CBTi for Insomnia |
| Sleep Disorders in PTSD | Complementary and Integrative Approaches for Sleep | Approach to a DISE |
| New Surgical Interventions (including hyoid suspension and combination therapy) | Implantable Devices for Sleep Apnea | MAD and TAP-PAP |
| Epilepsy and Sleep | How to Review an Article | Jobs Interviews and Updating CV |
| Rett's Syndrome and Sleep | HGNS Therapy in Children with Down Syndrome | How to Run a Sleep Lab and Business of Sleep Medicine |
Clinical Rotations
The Sleep Medicine Fellowship training program consists of a two-week intensive "boot camp" in Sleep Medicine followed by extensive clinical experiences in both outpatient and inpatient settings for the rest of the one-year program. Fellows are eligible for sleep medicine board after completion of the one-year program. Each fellow is required to perform an established number of procedures to be eligible to graduate.
Clinical rotations at each setting provide experience with various patient populations to acquaint the trainee with different approaches to the care of patients by a number of different sleep medicine specialists.
In expanding the clinical competence in the subspecialty area, our training program encourages the development of sound clinical judgment. This includes teaching integration of medical knowledge with clinical data, weighing alternatives, understanding the limitations of knowledge, recognizing complications of disease and side effects of treatment, instituting prompt measures to deal with serious or life-threatening clinical complications, incorporating the considerations of risks and benefits to the patient and developing a logical plan for the evaluation of both immediate and long-term management of patients. Good clinical judgment is synonymous with a physician’s ability to be able to adapt to current scientific and technological developments.
An integral part of the clinical experience will be enhancing their ability to gather information through problem–specific history–taking, physical examination and review of laboratory data. These skills include performing medical interviews that are precise, thorough and reliable; conducting expert, focused physical examinations that elicit subtle findings and are directed toward the patient’s problems; and demonstrating understanding and proficiency while minimizing risk and discomfort to patients in the performance of certain diagnostic and therapeutic procedures. Fellows are given the opportunity to develop skills in the procedures specific to Sleep Disorders Medicine, as listed in the core curriculum.
We believe that our clinical practice should include a humanistic element that focuses on integrity, respect and compassion demonstrated in the care of patients and their families. We also believe that an integral component of the practice includes involvement and responsiveness to patients’ wishes, respect of patients’ need for information, establishment of patients’ trust, provision for empathy and maintaining credibility and rapport with patients and their families. Finally, we foster a pleasant, collegial relationship with each fellow as they develop into a subspecialist, a relationship we intend to continue far after the fellow leaves the training program. These philosophies will be practiced as an ongoing part of patient care.
Michael E DeBakey Veterans Affairs Medical Center Sleep Center
The Michael E DeBakey Veterans Affairs Medical Center Sleep Center—including a sleep laboratory and sleep medicine clinic—serves as a hub of one of the largest sleep medicine clinical care centers in the United States. Fellows attend weekly clinics at this facility.
The VA Hospital serves as a key training site for fellows specializing in sleep medicine for adult patients.
During the first week of the sleep fellowship, our fellows spend a day learning the essential components of conducting sleep studies, including the patient hookup for polysomnography (PSG) and PAP titration studies.
From Monday to Friday, fellows dedicate half of each day to reviewing sleep studies conducted in our eight-bed sleep lab. This includes a diverse range of studies, such as baseline polysomnography (PSGs), split-night studies, positive airway pressure (PAP) titrations, and multiple sleep latency tests (MSLTs). Occasionally, we also conduct maintenance of wakefulness tests (MWTs).
Additionally, the fellows participate in a weekly actiwatch clinic, where they analyze 10 to 15 actigraphs/month. Each Friday morning, fellows meet with their assigned attending physician to discuss the week's sleep studies and review the corresponding reports. Throughout the day, fellows have direct access to their attending physicians for guidance on any questions that arise while interpreting the sleep studies.
During the other half of the day, the fellows participate in various clinics.
EEG: During the first three months of their fellowship, our fellows attend the Neurology EEG unit twice a month on Wednesday mornings. Here, they receive in-depth education about EEGs from a neurologist's perspective.
CBTi Clinic: We work closely with our mental health team, which includes a psychologist integrated into our sleep clinic. The psychologist helps conduct Cognitive Behavioral Therapy for Insomnia (CBTi) in both group and individual sessions. Based on the fellows’ interest in learning CBTi, in addition to routine lectures, we arrange rotations in this clinic for fellows to observe and conduct CBTi sessions alongside the psychologist.
Routine sleep clinic: Routine clinic sessions are held once a week for the entire day, during which the fellow encounters a range of sleep disorders, including simple obstructive sleep apnea (OSA), PAP follow-ups, insomnia, and excessive daytime sleepiness. This structure enables fellows to effectively manage a wide array of sleep disorders.
PAP clinic: AVAPS/ASV: In the PAP clinic, patients come in for PAP downloads, which include CPAP, BPAP, APAP, as well as ASV and AVAPS. Fellows learn not only how to operate and troubleshoot these devices but also how to correct elevated AHI and ensure patient comfort.
REMEDE clinic: The REMEDE clinic was established a couple of years ago to accommodate patients with central sleep apnea and Cheyne-Stokes respiration, providing alternative treatment options for those who have failed BPAP therapy and where better CHF management has not resolved the CSA. Fellows gain a better understanding of the various causes of central sleep apnea (CSA) and how to manage them based on their primary etiology.
Currently, we have 15 follow-up patients, along with occasional new patients for REMEDE evaluation. Fellows can observe and conduct REMEDE activations and routine follow-ups. The Electrophysiology service places the device, allowing fellows to observe the procedure as well.
Sleep Endoscopy: While patients can be evaluated for alternative treatments for sleep apnea in any sleep clinic, the sleep endoscopy clinic offers fellows the opportunity to discuss hypoglossal nerve stimulation therapy, what a sleep endoscopy entails and what to expect post-implant.
Parasomnia Clinic: One notable clinic is the parasomnia clinic, where they spend half a day assessing a range of disorders, including REM Behavior Disorder, Exploding Head Syndrome, and sexsomnia, along with several other cases encountered this past month.
Mild sleep apnea clinic: During the time of the PAP recall, this clinic was established to explore alternative treatments for mild obstructive sleep apnea (OSA) beyond PAP therapy. The fellows encounter various types of mandibular advancement devices fabricated by the dental sleep physician. They are involved in troubleshooting these devices, evaluating side effects, and monitoring patient tolerance during follow-up visits.
Additionally, fellows consider other alternatives such as nasal EPAP, positional therapy for OSA, and the potential use of auto-adjusting positive airway pressure (APAP) for symptomatic patients with significant comorbidities, where PAP therapy may be beneficial.
Hypoglossal Nerve Stimulation Clinic
This clinic is conducted both virtually and in person. Here, fellows encounter patients who have been implanted with the hypoglossal nerve stimulation (HGNS) device. During the pre-activation visit, they assess patients to rule out neuropraxia and other factors that may delay activation. Following activation, a two-week follow-up is scheduled to ensure that the up titration is progressing as recommended.
Face-to-face visits are conducted to activate the device and for routine follow-ups. These visits ensure adequate device usage, troubleshoot any issues, facilitate download of the remote and allow for planning a repeat sleep study if appropriate.
Hypersomnia Clinic: The hypersomnia clinic sees patients with narcolepsy, idiopathic hypersomnia, and Traumatic brain injury-related hypersomnia. This virtual clinic enables fellows to utilize telehealth while gaining insights into effective treatments for these conditions and addressing daytime sleepiness. Under the supervision of their attending, fellows dispense controlled medications by completing specialty pharmacy forms, while also discussing potential results and side effects.
DISE: Once a month, we conduct a drug-induced sleep endoscopy on approximately 8 to 10 patients. Fellows observe their attending perform these procedures, and those whose primary specialty is pulmonary are encouraged to participate as well.
Otolaryngology clinic: For a few HGNS patients with unsatisfactory results, an awake endoscopy is conducted by the ENT service. Fellows are encouraged to observe these procedures to learn about the different electrode configurations and the associated movements of the tongue.
Sleep Consult in-patient setting: In addition to the outpatient clinic and procedure exposure with DISE, our fellows also see patients admitted for other reasons who have co-morbid OSA and/or CSA. By integrating outpatient clinic exposure with inpatient consultations, fellows gain a comprehensive understanding of sleep disorders in various contexts. They typical see 3-6 consults/week.The variability in consult numbers keeps the experience dynamic, ensuring that fellows remain engaged and adaptable in their training.
| Monday | Tuesday | Wednesday | Thursday | Friday | |
| AM | Parasomnia Clinic | Mild sleep apnea clinic and Dental Clinic Noon: Pediatric case conference/week 1 p.m.: Journal Club/month | Sleep study reading | VA Fellows Clinic and Endoscopy Clinic | Review sleep studies w/ Attending Remede Clinic/Once a month |
| PM | Sleep study reading | Sleep study reading Hypoglossal Nerve stimulation clinic | Virtual Narcolepsy/ Hypersomnia Clinic 3 pm/month: Hypersomnia Conference | Didactics Conferences/Board review |
5-10 in-patient consults per week
A Drug Induced Sleep Endoscopy (DISE) procedure is conducted one Friday per month. Up to ten patients undergo the procedure. Depending on the fellow's specialty, he or she may observe and or perform the DISE.
Texas Children’s Sleep Center
The Texas Children’s Sleep Center is one of the largest pediatric sleep medicine clinical care centers in the United States, with a total of 18 pediatric sleep laboratory beds and a home sleep testing system. Behavioral sleep medicine and otolaryngology services are part of the clinical experience. Fellows attend weekly clinics apart from their home base rotations.
The Texas Children’s Sleep Center is one of the largest pediatric sleep medicine clinical care centers in the United States, featuring 23 pediatric sleep laboratory beds and a home sleep testing system. It is one of the few centers in the country that has earned accreditation from the American Board of Sleep Medicine. The sleep center includes both sleep clinics, and a sleep lab located within the hospital.
It is a tertiary referral center for medically complex children.
The physician team includes Neurology, Pulmonary, Behavioral sleep medicine and otolaryngology.
Our fellows spend 4-5 months at the sleep center during their fellowship. From Monday to Friday, they dedicate half a day to reviewing sleep studies for patients ranging from 1 week to 18 years of age. They assist in managing sleep issues in complex cases, including:
- Congenital heart disease
- Craniofacial abnormalities
- Neuromuscular disorders
- Prader-Willi Syndrome
- Genetic syndromes
- Beckwith-Wiedemann Syndrome
- Achondroplasia
- Obesity hypoventilation
- Pulmonary hypertension
In addition to their home base rotations, fellows participate in weekly clinics. The clinical experience encompasses:
- Behavioral Sleep Medicine: Helping patients and their families successfully complete PSG, improve adherence to PAP therapy, and address behavioral insomnia and circadian rhythm disorders.
- Otolaryngology Services
- Neuromuscular Clinic
- Bariatric Multidisciplinary Clinic
- Multidisciplinary OSA Clinic (MOSA): The MOSA team includes surgeons, sleep medicine specialists, pulmonologists, social workers, dietitians, and psychologists.
Fellows have the opportunity to review the DISE conducted by the ENT service and manage HGNS therapy in patients with Down Syndrome. Since the sleep center is located within the hospital, our fellows see up to five inpatient consultations per week and follow up with a PSG and titration study if required.
| Monday | Tuesday | Wednesday | Thursday | Friday | |
| AM | Sleep study reading | Sleep clinic (In-person) | Sleep study reading | Review sleep studies with Attending | |
| Noon | Pediatric Case Conference/week | VA Fellows Clinic | |||
| PM | Sleep clinic | Sleep study reading | Behavioral Sleep Clinic (Virtual) | Didactics Conferences/Board review |
- Up to 5 in-patient consults per week.
- Rotating home call for the 6 fellows and their supervising attending in Pediatric Sleep Medicine each night.
Harris Health Sleep Medicine Clinic
The Harris Health System Sleep Medicine clinic is located at Smith Clinic, a large multi-specialty and primary care clinic. Fellows attend weekly clinics apart from their home base rotations.
Baylor Medicine Sleep Medicine Clinic and Sleep Center at Baylor St. Luke's Medical Center
Multi-specialty sleep medicine clinics, including behavioral sleep medicine, otolaryngology and neuromuscular disease, are part of the clinical experience.
Clinical Competency
Fellows will acquire new medical knowledge defined as the specialized, currently accepted, and up-to-date knowledge and information required to function as a subspecialist in the evaluation and management of patients with suspected sleep disorders. The level of responsibility will rise and the supervision of other physicians will rise as fellows progress in the fellowship training. Fellows supervise residents, medical students and respiratory therapy and sleep technology students throughout their training.
Clinical competence is viewed as demonstrated by consistent application of high-quality care—appropriate and responsive to patients’ needs and wishes, demonstration of cultural awareness and competency in interfacing with a wide variety of cultures and the use of therapeutic modalities, laboratory tests, consultations and diagnostic procedures efficiently, effectively and in patients’ best interests. Additionally, we provide experiences to develop skills in effective communication, acceptance of responsibility, and writing comprehensive notes in a timely, effective and legible manner. Good interpersonal and communication skills are emphasized to work with paramedical personnel, particularly nurses, sleep technologists and respiratory therapists.
Research
Our training program includes a research component. Faculty in the program are involved in different aspects of sleep disorders research, including insomnia and sleep-related breathing disorders. The faculty has published regularly in peer-reviewed journals and is involved in sleep-related national and international organizations.
Quality Improvement
The program requires the implementation and completion of a quality improvement project.