Ten Commandments for Neonatal-Perinatal Medicine Fellows

Abstract

The transformation of a general pediatrician into a neonatologist requires rigorous training in a diverse range of core skills during neonatal-perinatal medicine fellowship. This training includes the care of high-risk newborn infants, as well as interdisciplinary communication with care team members and families in the neonatal intensive care unit. In addition, neonatal-perinatal medicine fellows need to acquire competency in key procedurals skills, including neonatal resuscitation techniques, to be able to safely practice neonatology without direct supervision on graduation. Although there is much general advice available to help residents and fellows navigate training, there is little specific advice or guidance for neonatal fellows. In this Perspective, we present 10 commandments for neonatal fellows. The commandments include (1) cherish your patients and their families, (2) know your limits and seek help when needed, (3) understand competency-based medical education, (4) remember the 6 core competencies, (5) review your specialty milestones, (6) have an individualized learning plan, (7) seek out feedback, (8) honor your attendings and nurses, (9) appreciate the importance of teamwork, and (10) do not take thyself in vain. These commandments were developed based on the experience of the authors, working closely with neonatal fellows over several decades. The commandments are present not as unbreakable rules, but rather as words of advice from 2 neonatologists who, having completed their neonatal fellowship, want to help guide others do the same. We believe that this resource will be useful to fellowship programs and neonatal-perinatal fellows.

Introduction

During neonatal-perinatal medicine fellowship training, a general pediatrician transforms into a subspecialty pediatrician charged with the care of fragile newborns and their families. Neonatal-perinatal medicine fellowship is incredibly demanding as trainees need to acquire the knowledge to independently deliver care to high-risk infants and the procedural skills specific to fragile premature babies including resuscitation techniques. The complex environment of the neonatal intensive care unit (NICU) with fragile high-risk babies makes neonatal fellowship unique due to the prognostic uncertainty and the complex balancing between curative and palliative care. Although there is much general advice available to help pediatric residents and fellows navigate training, there is little specific advice or guidance for neonatal fellows.

In this Perspective, we present 10 commandments for neonatal fellows. These commandments were developed based on our experience working closely with neonatal fellows. We present them here not as unbreakable rules set down from above, but rather as words of advice from 2 neonatologists who, having completed their neonatal fellowship, want to help guide others do the same. We believe that this resource will be useful to other fellowship programs and benefit future neonatal-perinatal fellows.

The 10 Commandments of Neonatal-Perinatal Medicine Fellowship

Cherish your patients and their families

Neonatal-perinatal medicine fellowship training is experiential. The essential learning activity is interaction with patients and families including interdisciplinary communication skills such as provision of anticipatory prenatal counseling, discussion of daily goals and plan of care, communication about prognosis and discussions regarding end-of-life care. For these interactions to be meaningful, neonatal fellows must assume personal responsibility for the infants they care for. They must make informed decisions with the infant’s best interest in mind. To help make these decisions, fellows should develop a relationship with the infant’s parents/caregivers and be inclusive during decision making. Neonatology fellows often face unique challenges giving difficult news to families and they should learn the art of effective communication while being forthright and honest with families. They should also be empathetic and understanding. Having a sick baby in the NICU is probably the hardest thing any parent will go through and families need a lot of compassion.

Know your limits and seek help when needed

As neonatal fellows gain experience, and their ability to care for patients improves, they are allowed to practice with less supervision and more independence. As the amount of supervision decreases, fellows must be acutely aware of their personal limits. When needed, fellows should request additional help and supervision to provide safe and effective care. This includes both when making diagnostic and treatment decisions and during neonatal procedures such as newborn resuscitation, umbilical catheter placement, neonatal intubation, and chest tube placement.

Understand competency-based medical education

Competency-based medical education (CBME)^1,2 is a system that promotes progressive development and allows for longitudinal assessment of performance toward a specified level of competency. Features of CBME include individualized learning, feedback, emphasis on the exit criteria, modularized training, a systematic approach, and accountability by both the learner and the program. The CBME requires identification of the competencies, the establishment of performance levels (eg, milestones), and ongoing competency-based evaluation. Neonatal-perinatal medicine fellows should work to understand the competencies that define their unique specialty and the performance levels that are used to evaluate them.

Remember the 6 Core Competencies

In 2002, the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) established 6 Core Competencies for graduate medical education in the United States. The 6 ACGME Core Competencies^3,4 are as follows: (1) Patient Care and Procedural Skills, (2) Medical Knowledge, (3) Practice-Based Learning and Improvement, (4) Interpersonal and Communication Skills, (5) Systems-Based Practice, and (6) Professionalism. Each of the 6 Core Competency includes one, or more, subcompetency. Pediatric subspecialty fellowship training, including neonatal-perinatal medicine, involves 21 subcompetencies.⁵ Each subcompetency has a series of discrete milestones that neonatal fellows progress through during their training.

Review your specialty milestones

A milestone is a significant point along a continuum of development. Milestones in graduate medical education describe performance levels in a subcompetency of 1 of the 6 Core Competencies.⁶ Each milestone includes a narrative description of the behaviors and attributes associated with it. The milestones provide a framework for competency-based assessment. Unique milestones have been created for each of the 21 subcompetencies of neonatal-perinatal medicine fellowship training.⁵ The use of milestones as an assessment method was designed to allow fellows and programs to monitor a fellow’s professional development from year to year. Milestones are now the primary formative component in graduate medical education. Neonatal fellows should review these milestones and make an individualized learning plan (ILP) to assess their own progress through the milestones during training.

Have an individualized learning plan

Learning in a CBME system of graduate medical education is individualized. Each neonatal fellow will progress at different rates through the various milestones. Likewise, each fellow will have specific subcompetencies that he or she needs to work on. An ILP⁷ provides a method by which fellows can track and guide their own trajectory through training. The ILP should address each of the 6 Core Competencies and include milestone progression. For each of the 21 pediatric subspecialty fellow subcompetencies, the fellow should identify the current state, plans for the future, and presence of barriers. The ILP should be reviewed at least twice a year as part of the semi-annual review process. At that meeting, the barriers can be discussed and program assistance can be provided, as needed.

Seek out feedback

In a CBME system, assessments are used both for giving feedback (formative assessment) and for making decisions about progression to the next level of training (summative assessment). Receiving formative feedback on performance is critical for the professional development of neonatal fellows. This feedback is the primary method by which fellows can self-assess their current performance and develop an ILP. Unfortunately, during a busy NICU rotation, feedback is often not given due to the tiring shifts. To ensure that adequate feedback is provided, fellows should actively seek it out by setting aside specific time and ask for feedback on a regular basis.

Honor your attendings and nurses

During neonatal fellowship, patient care and family interactions are provided under the guidance and supervision of neonatal attendings. The attending gives context, value, and meaning to those interactions, often serving as a role model for fellows to emulate. They also provide support, mentorship, and education. Do not take them for granted. Likewise, experienced NICU nurses have a wealth of clinical knowledge and experience as they care for high-risk neonates and premature babies. They also have unique insights into the psychosocial context of parents and the families they work with. Neonatal fellows should listen to—and acknowledge—nursing questions, concerns, and suggestions when making clinical care decisions.

Appreciate the importance of teamwork

Medicine is a team sport. This is especially true in the NICU. A diverse team of medical professionals including doctors, nurses, respiratory therapists, pharmacists, nutritionists, and others are engaged in the care of every infant. Each member of the team has unique attitudes, knowledge, skills, and valuable insights into the care of the high-risk infant and fragile premature babies. Neonatal fellows need to learn how to be a team player and leverage this collective expertise to provide optimal patient care. Neonatal fellows need to be respectful and develop good working relationships with all the care team members in the NICU to be successful in the workplace.

Do not take thyself in vain

Neonatal fellowship is intellectually, emotionally, and physically demanding. Making hard clinical decisions, working with emotionally stressed-out parents, and trying to navigate a complex medical system with multiple team members—all on limited sleep—can be exhausting. While caring for patients is critical, neonatal fellows should not forget to care for themselves as well (put your own oxygen mask first!).

Fellows need to practice self-care to sustain a high level of performance during training and avoid burnout. They should work on improving self-awareness of personal stressors (knowing what triggers your stress and how to identify and manage them is critical!). They need to learn to practice mindfulness and seek to develop resilience. Having a support system, especially peer support, is critical to their own well-being. Some of the methods of fostering peer support with regular check-in at the workplace include having a buddy system, Mentoring system, Balint groups (doctor groups to discuss difficult patient cases in a safe/supportive environment), and Coffee groups/Lunch groups.

In addition, fellows should also work to find other people for support including friends, peers, other specialty fellows, mentors, staff, and family. Being present in mind and body can improve well-being and enhance their sense of satisfaction and fulfillment.

Conclusions

In this Perspective, we presented 10 commandments which will serve as a framework for training neonatal fellows. Although they were developed specifically for neonatal-perinatal medicine, many of the commandments apply to any graduate medical education training program. We believe that abiding by these commandments will help neonatal fellows successfully navigate training and help shape their future to become successful physicians.

Author Contributions

All authors participated in the design, execution, and analysis of this paper and have seen and approved the final version.