Division of Pulmonary and Respiratory Diseases Fellowship Program

Division of Pulmonary and Respiratory Diseases Fellowship Program

The following is designed as an introduction to the Pediatric Pulmonary Fellow Training Program. Debra M. Boyer, M.D, MHPE. directs the training program.

Applications for the Fellowship Program consist of a personal statement, curriculum vitae, and three letters of reference and should be submitted via ERAS. Questions should be directed to Hillary Dearborn, Division of Respiratory Diseases, Boston Children’s Hospital, 300 Longwood Avenue, BCH 3121 Boston, MA 02115. Ms. Dearborn may be contacted at (617) 355-5926.

Pulmonary Division Overview

The Division of Respiratory Diseases at Boston Children’s Hospital, carries out a range of activities in basic science and clinical research, provides outstanding clinical care, and maintains an active fellowship training program.

Members of the Division staff provide clinical care for infants, children, and young adults with a variety of chronic and acute respiratory disorders. The Division’s Cystic Fibrosis Center cares for approximately 720 patients, half of whom are adults. The clinical service accounts for about 8000 inpatient days and more than 15,000 outpatient visits each year. There are greater than 700 bronchoscopy procedures performed each year including bronchoalveolar lavage and transbronchial biopsies. Additional procedures performed with the aid of bronchoscopy include whole lung lavage, airway dilation, airway stent placement, and removal and/or biopsy of airway lesions. The Lung Transplant service cares for patients both pre-, peri- and post-operatively.

The Pulmonary Function Laboratory performs more than 15,000 tests each year, including arterial blood gas drawing , exercise studies, and lung function studies. Some of the lung function studies performed include spirometry, measurements of total lung capacity and its subdivisions by body plethysmography and helium dilution, diffusing capacity, airway challenge studies, infant pulmonary function studies, assessment of respiratory strength, and graded cardiopulmonary exercise testing. Seventy-five percent of these studies are carried out on outpatients. The Division’s Sweat Test Laboratory performs over 800 studies each year.

Fellowship Program

The Fellowship program in Pediatric Pulmonology is a three-year program designed to provide a balanced clinical and research experience. In addition, the fellowship is designed to insure that all fellows meet criteria for certification in Pediatric Pulmonology by the American Board of Pediatrics at the end of their fellowship. Dual fellowships performed in conjunction with other pediatric subspecialties may be arranged. In general, three new fellows are accepted into the program each year. The first year of training is dominated by clinical experience on the inpatient hospital services and in the outpatient Pulmonary/Cystic Fibrosis Program while the second and third years have their focus on research activities.

The inpatient hospital services of the Division are divided between the Pulmonary Inpatient Service, the Pulmonary Consult Service and the Bronchoscopy service. The Inpatient Service serves as the admitting service for patients with acute and chronic respiratory diseases including asthma, Cystic Fibrosis, BPD, pneumonia, pleural effusions, pneumothoraces, congenital malformations and many others. The Inpatient Service is generally composed of an attending physician, a pulmonary fellow, a nurse practitioner and three junior pediatric residents. The fellow is responsible for supervisory duties under the direction of the attending. The Pulmonary Consult Service provides consultative services to all programs and services within Boston Children's Hospital, as well as to the Neonatal Intensive Care Units at Brigham & Women's Hospital and Beth Israel Deaconess Hospital. The Pulmonary Consult Service consists of an attending and a pulmonary fellow.

As mentioned, the Bronchoscopy Service performs greater than 700 bronchoscopic procedures each year. While on the Bronchoscopy service, the fellows will also be responsible for interpreting pulmonary function tests performed in our laboratory under the direction of an attending physician. When not on one of the three services described above, the first year fellow will choose among a variety of electives as well as take one month of vacation. Night call for the Pulmonary Service from Monday through Thursday is directed to one of the fellows on Service and is taken from home. Weekend coverage is rotated among all of the fellows.

Fellows follow their own template of ambulatory patients in the Pulmonary/Cystic Fibrosis Clinic under the supervision of an attending physician. All fellows attend clinic longitudinally throughout their three years of training. The Pulmonary/Cystic Fibrosis Program conducts multidisciplinary clinic sessions where nutritional, physical and respiratory therapy, social service, nursing, and physician services are provided. Interesting and/or difficult patients are reviewed during the weekly clinical conference. In addition to their continuity clinic, second and third year fellows rotate through our sub-sub-specialty clinics to gain further clinical exposure to these patients. These clinics include; Asthma, Pulmonary Hypertension, BPD, sleep, CDH, Transplant, Exercise evaluation and Aerodigestive Clinic.

During the initial period of clinical experience, the fellows also familiarize themselves with various research opportunities. Fellows in Pediatric Pulmonology pursue a research project during the second and third years of their training. This project can be in either clinical or bench research. Selection of a project is guided by consultation with the Fellowship Director, the Division Chief, and other members of the Division. The research progress of the fellow during the latter years of fellowship is monitored and facilitated through biannual presentations before a Scholarship Oversight Committee.

Near the end of the first year, the emphasis shifts to research, and this focus continues throughout the second and third years of training. While the majority of their time is spent pursuing their research projects, second and third year fellows will spend approximately 6-8 weeks on a combination of the Inpatient, Consult and Bronchoscopy services.

The fellowship director has developed a Pediatric Pulmonary Fellowship Boot Camp that all fellows in the program will participate in. This occurs longitudinally during their training and will entail simulation activities to allow exposure to a variety of clinical situations. 

Research Activities:

The Pulmonary Division remains actively engaged in a wide range of research initiatives in both the basic and clinical sciences. The faculty have published in leading biomedical and subspecialty journals including the New England Journal of Medicine, Pediatrics, Circulation, the American Journal of Respiratory and Critical Care Medicine, and the Journal of Allergy and Clinical Immunology. 

Dr. Pyong Park and his team described new roles for syndecans and other proteoglycans, demonstrating their modulation of innate immune responses that affect the progression and outcome of drug-induced liver injury and polymicrobial sepsis, and may potentiate the efficacy of mesenchymal stem cells (MSCs) in attenuating acute lung injury. These findings prompted the awarding this year of two new NIH grants to define the underlying mechanisms at both the molecular and cellular level.

Dr. Norma Gerard continues her studies designed to determine the mechanism of action of Staphylococcus aureus – derived Panton Valentine Leckocidin (PVL) and its exquisite selectivity for human neutrophils. These studies established a co-receptor function for human protein tyrosine phosphatase receptor type C (PTPRC/CD45) in addition to the C5a receptor for this selectivity.

Dr. Ruobing Wang continues to make progress in advancing the use of induced pluripotent stem cells (iPSC) and CRISPR-cas9 gene-editing tools to model disease-relevant immune-epithelial interactions in Cystic Fibrosis (CF). Using samples obtained from CF patients with extreme phenotypes of lung function decline, Dr. Wang has derived 19 viable iPSC lines, has CRISPR-corrected the mutant CFTR gene in 5, and has successfully developed a cell-based model based on in vitro differentiation of patient derived iPSCs to functional putative macrophages. This project supported the awarding of a NICHD K12 and the CF Foundation Harry Shwachman Clinical Investigator Award.

Other members of the Division have participated or are currently participating in bench research in laboratories located elsewhere in the immediate area, including the Pulmonary Division at Brigham & Women’s Hospital, the Channing Laboratory at Brigham & Women’s Hospital, the Respiratory Physiology Program of the Harvard School of Public Health, Harvard University, and the Whitehead Institute at the Massachusetts Institute of Technology.

Our pulmonary clinical research team remains among the most active pediatric clinical trials group in the country, continuing to enroll large numbers of subjects across a diverse set of clinical trials, and continue to serve the northeastern United States and all of New England as a primary referral center for clinical trials in pediatric pulmonary disease. The greatest proportion of studies has been in cystic fibrosis. In the past year, we have participated in numerous high-profile Phase III clinical trials examining the efficacy and safety of triple combination CFTR-modulating agents developed by Vertex Pharmaceuticals. We also participated in other studies of CFTR modulators developed by Celtaxsys Inc., Corbus Pharmaceuticals, Savara Pharmaceuticals, and Proteostasis Therapeutics. Through all these efforts, of the 89 Clinical Research Centers in the Cystic Fibrosis Therapeutic Development Network (CFF-TDN), Boston Children’s Hospital was ranked #1 in weighted clinical enrollment.

We continue to diversify our disease portfolio, completing our enrollment in the Parion-sponsored CLEAN-PCD study (the first randomized controlled trial in Primary Ciliary Dyskinesia) and a pharmacokinetic study in asthma. The team is also supporting multiple Division-based translational research efforts, providing personnel, informatics, and regulatory oversight to facilitate patient enrollment, sample collection and processing, and data management. These include the CHILD Bronchopulmonary Dysplasia (BPD) registry (led by Dr. Lystra Hayden); a severe asthma clinical cohort (Dr. Jonathan Gaffin); gene mapping efforts in Childhood Interstitial Lung Disease (Dr. Alicia Casey and Dr. Martha Fishman); and sleep disordered breathing syndromes and idiopathic bronchiectasis (Dr. Katwa). Dr. Gaffin’s ongoing work examining the environmental determinants of impaired lung function in children resulted in the demonstration that greater degrees of airflow obstruction were observed among children in classrooms with elevated indoor levels of NO2 - a potentially modifiable risk factor. Dr. Hayden continues to make progress on her studies of the early life determinants of obstructive pulmonary disease: a 5-years follow-up of 4,915 adults from the COPDGene study, she found that smokers with a history of asthma early in life experienced COPD exacerbations with greater frequency and severity as compared to those without childhood asthma. She was awarded a K23 grant from the NHLBI to further her career development in the field of genomic epidemiology.

Our fellows choose a research project based on their own interests after careful consultation with the program leadership. These projects may be bench research, clinical/epidemiological and/or translational.

Collaborative research arrangements within the Harvard Medical area are extensive and include the Divisions of Newborn Medicine, Immunology, Allergy, Gastroenterology and others within Boston Children's Hospital; the Respiratory Division of Brigham & Women's Hospital; the Physiology Department of the Harvard School of Public Health; and the Channing Laboratories at Brigham and Women’s Hospital. The research progress of the fellow is monitored and facilitated through biannual presentations before the fellow’s Scholarship Oversight Committee. In addition to selecting a research project, several fellows in the Division have completed additional courses of study during their fellowship years, including a Master’s Program in Public Health offered by the Harvard School of Public Health.

Educational Activities

In addition to their clinical duties and hands-on research experience, fellows participate in several conferences each week. The Division sponsors a weekly clinical and research conference series; a weekly fellowship curriculum conference, which covers a two-year curriculum in Pediatric Pulmonology; and a weekly clinical case conference, which alternates with a journal club and Morbidity and Mortality conferences. Clinical case conferences are also held weekly at the New England Pediatric Pulmonary Consortium, which has a typical attendance of 15-25 pediatric pulmonologists from the region. All trainees and staff members in the Division are encouraged to attend these conferences. Finally, there are a wide variety of conferences held within the Longwood Medical Area, centered on Harvard Medical School, which are of interest.

Sample Weekly Conference/Clinic Schedule

Monday

12:00-1:00 PM Pulmonary Division Clinical and Research Conference

 Tuesday

11:00AM-12:00PM Fellow’s Seminar

12:00- 1:00PM Case Conference/Journal Club/M+M

Wednesday

 7:30-9:00 AM New England Pediatric Pulmonary Conference

12:00-1:00 PM Pediatric Grand Rounds

Faculty

Debra Boyer, MD, MHPE, Director, Fellowship Training Program

Alicia Casey, MD, Associate Director, Fellowship Training Program

Emily Barsky, MD

Manuela Cernadas, MD

Carolyn Donovan, MD

Dawn Ericson, MD

Martha Fishman, Medical Director Ambulatory Program

Jonathan Gaffin, MD, MMSc

Kenan Haver, MD, Director, Bronchoscopy Services

Lystra Hayden, MD, MMSc

Eliot Katz, MD

Umakanth Katwa, MD

Virginia Kharasch, MD

Thomas Martin, MD, Director, Pulmonary Function Lab

Kara May, MD

Levent Midyat, MD

Dennis Rosen, MD, Associate Medical Director, Sleep Disorders Program

Gregory Sawicki, MD, MPH, Associate Director, Cystic Fibrosis Center

Catherine Sheils, Director, Center for Infant Lung Development

Meera Subramaniam, MD

Ahmet Uluer, DO, Adult CF Center Director

Gary Visner, DO, Medical Director, Lung Transplant Program

Ruobing Wang, MD