Wanted: Specialists in Pulmonary Care
Fellowship programs tackle shortage of pulmonary, allergy, and critical care experts

BY LISA TREI

FALL 2006 -- Joseph DiCarlo, MD, remembers that when he was a medical resident in the mid-1980s, children with cystic fibrosis (CF) lived only into their early 20s. Today, depending on where patients with the disease receive treatment, they can live twice as long, says the critical care specialist at Lucile Packard Children's Hospital.

As more medical discoveries are translated into lifesaving treatments, children are surviving diseases such as CF that would have led to early death less than a generation ago. But these survivors require specialists to treat their conditions. Alongside this growing demand, rates of pediatric asthma are soaring nationwide—it is now the number-one chronic childhood illness. Despite such trends, pediatricians skilled in treating these illnesses are in short supply.

"In the early 90s, there was a feeling that we were not training enough generalists, so training programs were redesigned to push primary care," says Richard Moss, MD, professor and chief of pediatric pulmonary medicine. "Now there is a general recognition that we're failing to train adequate numbers of subspecialists, especially in pediatrics." For example, fewer than 1,000 pulmonologists nationwide are trained to treat children, compared with more than 50,000 adult pulmonologists, Moss says.

That's where Packard Hospital is taking the lead. The hospital's Center for Pulmonary Biology is already well regarded for its subspecialty fellowships in pediatric critical care, which DiCarlo heads, and in allergy, asthma and immunology, which Moss runs. To address a growing need, Packard plans to launch a new fellowship next year in pediatric pulmonary medicine to be directed by John Mark, MD, who directed the University of Arizona's pediatric pulmonary fellowship program until Stanford recruited him last year.

Similar to critical care and allergy/immunology, there is a nationwide labor shortage in pediatric pulmonology. "Over the last 20 years it has become clear that there is a big need for pulmonary physicians to take care of patients with interrelated diseases like CF, asthma, chronic lung disease in newborns, chronic cough and recurrent pneumonia," Mark says. The fellowship will train specialists to treat these chronic issues and work in critical care and neonatology, he says.

A Responsibility to Train

Packard's plan is to bring the three programs under one administrative umbrella and establish a "fellowship college" within the Pulmonary Care and Cystic Fibrosis Center headed by director David Cornfield, MD. The goal is to train highly skilled pediatric clinicians, educators and researchers who will help catalyze research, push the discovery of new therapies and instruct the next generation of specialists.

"My view is that as a leading educational institution, if we don't provide people who will be leaders in each of these fields, who will?" Moss says. "It is really part of our mission, our responsibility."

In the field of immunology, Moss explains, scientific advances have "just exploded" over the last generation. "We're just now getting to the point where those scientific discoveries are being translated into treatments," he says. "The holy grail for allergists is to find that predictive factor that could prevent the onset of allergies. We haven't got there yet, but we're getting closer."

Kari Nadeau, MD, PhD, an instructor in allergy/immunology, says bringing fellows in pulmonary- related diseases and critical care under one umbrella will encourage cross-fertilization of ideas.

Pulmonologist John Mark, MD, with relief nurse Tammy Mendez, RN, in the pulmonary clinic. Mark is developing a fellowship in pediatric pulmonary medicine at Packard.

According to Moss, "translational" medicine is the new benchmark for researchers. "What it means to us in the subspecialties is support for taking things from the laboratory to the patient, from bench to bedside," he says. "It has special meaning in pediatrics. You ask different questions when you deal with children: 'Is it safe for a 2-year-old and a 20-year-old?' This age-sensitive translational medicine is really the focus of the fellowship program."

Lorry Frankel, MD, division chief of pediatric critical care, says former fellows have become medical leaders in California and on the East Coast. But those who pursue academic medicine take a financial hit. "It's hard to keep fellows," he says. "When residents finish they have tremendous debt incurred during medical school, from about $150,000 to $200,000. To do more training after residency is costly."

A Sense of Purpose

Jennifer Yoo, first-year fellow, gives two-year-old Lucas a check up at Packard's Allergy Clinic.

Despite such obstacles, new fellows arrive on campus with a sense of purpose. Jennifer Yoo, who just completed her first year in allergy/immunology, selected Stanford because she knew it would best support her clinical research interests. Her interest in asthma began when she worked with obese inner-city kids as a medical school student in Chicago, one of several U.S. cities experiencing rising mortality rates from asthma. Some experts attribute the surge to a "hygiene hypothesis," she explains, which contends that American kids are being raised in ultra-clean environments and are not exposed to germs that would train their immune system to dampen allergic reactions. According to the hypothesis, if such stimulation is removed during the first six months of life, the immune system can overreact and allow allergies and asthma to develop.

Yoo's research focuses on how giving probiotics (friendly bacteria normally found in the body) to infants and pregnant mothers might decrease the onset of asthma. "It's really important for us to have support and funding for research," she says. "Allergic diseases are definitely increasing. That's a fact."

Lorry Frankel, MD, division chief of pediatric critical care, sits in on a teaching session with fellows and residents.

Critical care fellow Josh Cisco says he has been struck by the fragility of very ill children. "Despite all this technology, when it comes down to it, our ability to assess what's going on is relatively crude," he says. "You have to make big decisions with imperfect data. You learn a lot from people who have been doing it for years. You can't learn that from books. Kids just don't follow the books a lot of the time."

These pediatric Packard fellowships give doctors an experience that will enable them to make a lasting contribution to society, Nadeau says. "Whether they're in critical care, allergy/immunology or pulmonology, we're really giving a gift to the future," she says.

Meet the Patients

Nathan Parks, age 18

Jenny Hoyland, age 11

Jonah Fong, age 4

Rachel Herrera, age 12