Return from the darkside--Sleep Medicine fellowship training: past, present and future.

At the time this editorial comes to press, I will be nearing completion of my 6½ years of service on the Internal Medicine Residency Review Committee (IMRRC) of the Accreditation Council of Graduate Medical Education (ACGME). Six and a half years is a long time to serve on any committee, and the IMRRC is no exception. I will not miss the hours of hard work, time away from home or the sometimes heated debate, but I always will cherish the camaraderie among fellow educators and the privilege of representing the sleep medicine community on this important body. The IMRRC a frequently misunderstood committee. I have been told by some that serving on the IMRRC is analogous “going over to the dark side,” and that the IMRRC and the ACGME are the “enemy.” This cannot be further from the truth. Although the IMRRC does sanction Sleep Medicine and other training programs that are non compliant with its requirements, the IMRRC in virtually every instance tries to improve the medical educational experience at the programs it accredits. With respect to Sleep Medicine, it is not commonly appreciated that accredited training and American Board of Medical Specialties (ABMS) board certification would not be possible today without the action taken by the ACGME. For years, organized Sleep Medicine had petitioned the ABMS for a certification examination, but had been consistently rebuffed. However, the ACGME, under the leadership of the late Dr. Marvin Dunn, agreed that Sleep Medicine was an emergent medical specialty and ACGME accredited Sleep Medicine training was born.1 Because the ABMS generally does not wish to have accredited training without a parallel examination process, ABMS board certification in Sleep Medicine became possible. Thus, during my service on the IMRRC, I have witnessed and participated in the development of the training requirements for Sleep Medicine fellowships and observed the accreditation of 71 Sleep Medicine fellowships.2 These events would not have been possible without the understanding and assistance of the IMRRC which solicited input from our community in the developing policy and program requirements. What then is the immediate future for Sleep Medicine training? In July 2012, in parallel with implementation of new program requirements for Internal Medicine subspecialties, there will be new program requirements for Sleep Medicine. Although the format of the program requirements will be different and will include the new ACGME common requirements with their focus on duty hours, core educational content related to Sleep Medicine will not be markedly different. There will be greater flexibility for training programs that emphasize pediatrics and a requirement for all key clinical faculty including the program director to be certified in Sleep Medicine by an ABMS member board. It also is likely that a provision to allow residents trained in Anesthesiology to enter Sleep Medicine training will be added to be consistent with their eligibility to take the ABMS certification exam. Moreover, the IMRRC will continue review all Sleep Medicine programs irrespective of their sponsoring specialty. However, the greatest changes will occur in assessment of fellows' meeting the six ACGME competencies: Medical Knowledge, Patient Care, Practice-based Learning, Communications, Professionalism and Systems-Based Practice. Evaluation methods will now require direct observation of these skills, solicitation of opinions from patients and staff and objective assessment tools. In general, the leadership of the ACGME is attempting to move to a less proscriptive and more outcomes-based accreditation process with longer accreditation cycles for programs in good standing. In the long-term, Sleep Medicine training will reflect the practice of Sleep Medicine. The IMRRC never makes changes in training program requirements without input from its constituent specialty communities. Thus, as the practice of Sleep Medicine evolves more toward ambulatory testing, and emphasizing the cognitive value of a Sleep Medicine specialist in the evaluation and treatment of all sleep disorders, not just sleep disordered breathing, fellowship training will need to mirror these changes in practice. It will be important for Sleep Medicine educators to provide input to the IMRRC for these changes to occur. Finally, as I return unscathed from the dark side, remember, the IMRRC is not your enemy, and in most cases it wants to be your friend.