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Competency Training Requirements for the Area of Focused Competence in Sleep Disorder Medicine

January 2018

VERSION 1.0

DEFINITION

Sleep Disorder Medicine is that area of enhanced competence within medicine concerned with the study of the investigation, diagnosis and management of sleep disorders.

ELIGIBILITY REQUIREMENTS

The Area of Focused Competence (AFC) trainee must have Royal College certification, or equivalent acceptable to the Royal College, in Developmental Pediatrics, General Internal Medicine, Neurology (adult or pediatric), Otolaryngology-Head and Neck Surgery, Psychiatry, or Respirology (adult or pediatric), or must be enrolled in a Royal College accredited residency program in one of these areas (see requirements for these qualifications). These disciplines share a common set of competencies related to the management of sleep disorders, which each discipline applies to its distinct patient population.

All trainees must be certified in their primary specialty in order to be eligible to submit a Royal College competency portfolio in Sleep Disorder Medicine (SDM).

MAJOR TASKS OF SLEEP DISORDER MEDICINE

The discipline of Sleep Disorder Medicine includes responsibility for:

• Assessment of patients with sleep-wake complaints;
• Management of patients with sleep disorders;
• Management of patients with sleep-related breathing disorder in the perioperative period;
• Interpretation of sleep investigations;
• Management of a sleep laboratory; and
• Advancement of the discipline of Sleep Disorder Medicine.

At the completion of training, the resident will have acquired the following competencies and will function effectively as a:

Medical Expert

Definition:

As Medical Experts, physicians integrate all of the CanMEDS Roles, applying medical knowledge, clinical skills, and professional values in their provision of high-quality and safe patient-centred care. Medical Expert is the central physician Role in the CanMEDS Framework and defines the physician’s clinical scope of practice.

Key and Enabling Competencies: Sleep Disorder Medicine diplomates are able to…

1. Practise medicine within their defined scope of practice and expertise
   1. Demonstrate a commitment to high-quality care of their patients
   2. Integrate the CanMEDS Intrinsic Roles into their practice of medicine
   3. Apply knowledge of the clinical and biomedical sciences relevant to SDM
      1. Sleep mechanisms and phylogeny
      2. Age and gender related normal patterns of sleep architecture, the developmental changes in sleep across the lifespan, and cultural influences on sleep
      3. Chronobiology
      4. Physiology of sleep
      5. Neurophysiology of sleep and circadian rhythm disorders
      6. Genetics of sleep and sleep disorders
      7. Psychobiology and dreaming
      8. Behavioural psychology as it relates to patient counselling
      9. Epidemiology, classification, etiology, pathophysiology and treatment of sleep disorders across the lifespan
         1. Insomnia
         2. Sleep-related breathing disorders
         3. Central disorders of hypersomnolence
         4. Circadian rhythm sleep-wake disorders
         5. Parasomnias
         6. Sleep-related movement disorders
      10. Disturbances in sleep architecture and chronobiology due to underlying medical or psychiatric conditions
      11. Clinical consequences of acute and chronic sleep deprivation
      12. Impact of sleep disorders on other medical or psychiatric conditions
      13. Impact of sleep disordered breathing on perioperative morbidity and mortality
          1. Pre-operative assessment
          2. Perioperative management
      14. Pharmacology, with emphasis on pharmacological effects on sleep-related breathing disorders and movement disorders
          1. Sleep supporting medications and supplements
          2. Wake promoting medications and supplements
          3. Off-label therapies
          4. Medications and substances that disturb sleep and wakefulness, including narcotics and psychoactive agents
          5. Medications used for other sleep disorders, including sleep-related movement disorders and narcolepsy
      15. Sequelae associated with sleep disorders, including cardiometabolic, neurocognitive, and mental health
      16. Principles of occupational health, as relevant to SDM (adult only)
          1. Ergonomic and occupational risks
          2. Fatigue risk management strategies, including shift scheduling and design
          3. Health surveillance of individuals with sleep disorders in high safety risk occupations
      17. Impact of sleep disorders on patients performing critical safety activities
      18. Principles of sleep laboratory investigations, including polysomnograms (PSG), multiple sleep latency tests (MSLT), maintenance of wakefulness tests (MWT) as well as home sleep monitoring
          1. Indications and contraindications for testing
          2. Physical and developmental requirements for patient suitability for testing
          3. Strengths and limitations of testing
          4. Technical components, including equipment and protocols
   4. Perform appropriately timed clinical assessments with recommendations that are presented in an organized manner
   5. Carry out professional duties in the face of multiple, competing demands
   6. Recognize and respond to the complexity, uncertainty, and ambiguity inherent in medical practice
2. Perform a patient-centred clinical assessment and establish a management plan
   1. Prioritize issues to be addressed in a patient encounter
      1. Identify patients in critical occupations whose sleep disorder is an issue of individual and/or public safety (adult only)
      2. Identify patients whose sleep disorder is critically affecting development, or educational and/or psychosocial well-being
   2. Elicit a history, perform a physical exam, select appropriate investigations, and interpret the results for the purpose of diagnosis and management, disease prevention, and health promotion
      1. Elicit a sleep and circadian pattern history
      2. Obtain an occupational history, as relevant
      3. Perform a mental health assessment
      4. Administer and interpret relevant sleep questionnaires
      5. Perform a relevant physical exam, with focus on the
         1. Upper airway
         2. Cardiorespiratory system
         3. Central and peripheral nervous system
      6. Integrate data from the following sources into the clinical assessment
         1. Sleep diary
         2. Condition-specific questionnaires
         3. Collateral history from a sleep witness (e.g., bed partner, caregiver, sleep lab technologist)
         4. Wearable technology (e.g., smartwatch)
         5. Adherence records
         6. Technological information downloaded from positive pressure equipment
      7. Select investigations appropriately and interpret the results
         1. Genetic testing
         2. Diagnostic imaging
         3. Pulmonary function testing, including arterial blood gases
         4. Echocardiography
         5. Electroencephalography (EEG) for possible seizure disorder
         6. Sleep studies
            1. Polysomnography
            2. MSLT
            3. MWT
            4. Overnight oximetry
            5. Portable sleep studies
            6. Actigraphy
      8. Synthesize clinical information to determine:
         1. Patient candidacy and physical and intellectual suitability to undergo sleep laboratory testing
         2. Diagnosis and prognosis
         3. Suitability for ventilator support
         4. Response to treatment and/or treatment toxicity
   3. Establish goals of care in collaboration with patients and their families1, which may include slowing disease progression, treating symptoms, achieving cure and improving function
   4. Establish a patient-centred management plan for
      1. Insomnia
      2. Sleep-related breathing disorder
      3. Central disorder of hypersomnolence
      4. Circadian rhythm sleep-wake disorder
      5. Parasomnia
      6. Sleep-related movement disorder
      7. Coexisting sleep disorders
      8. Sleep disorders and coexisting medical or psychiatric conditions
3. Plan and perform procedures and therapies for the purpose of assessment and/ or management
   1. Determine the most appropriate procedures or therapies
      1. Lifestyle interventions
      2. Weight loss
      3. Positional therapy
      4. Smoking, alcohol, and/or substance use cessation
      5. Behavioural therapies
      6. Non-pharmacologic therapies, including phototherapy
      7. Pharmacologic therapies
         1. Sleep supporting medications
         2. Wake-promoting medications
         3. Medications used for other sleep disorders, including sleep-related movement disorders and narcolepsy
         4. Discontinuation or tapering of medications that disturb sleep and wakefulness, including narcotics and psychoactive agents
      8. Positive airway pressure therapies, including adherence monitoring data surgical intervention
      9. Surgical intervention
   2. Obtain and document informed consent, explaining the risks and benefits of, and the rationale for, a proposed procedure or therapy
      1. Demonstrate knowledge of the use of off-label therapies, and the added implications for informed consent
      2. Ensure patients are fully informed of the risks and benefits when initiating therapy with powerful sedative medications (e.g., sodium oxybate)
   3. Prioritize a procedure or therapy, taking into account clinical urgency and available resources
      1. Prioritize access to sleep laboratory investigations based on patient safety, occupation, and/or co-morbidities
      2. Modify plans for investigation based on availability of alternative testing such as home sleep monitoring
   4. Plan, supervise, and interpret tests and therapies in a skilful and safe manner for the purposes of assessment and/or management, adapting to unanticipated findings or changing clinical circumstances
      1. Diagnostic polysomnograms
      2. Therapeutic polysomnograms
         1. Continuous positive airway pressure (CPAP)
         2. Dental/oral appliances
         3. Oxygen titration
         4. Bi-level therapy and Adaptive Servo-Ventilation (ASV)
      3. MSLT
      4. MWT
      5. Overnight oximetry
      6. Home sleep monitoring
      7. Actigraphy
   5. Prescribe, monitor, and adjust positive airway pressure therapy
4. Establish plans for ongoing care and, when appropriate, timely consultation
   1. Implement a patient-centred care plan that supports ongoing care, follow-up on investigations, response to treatment, and further consultation
      1. Establish plans for monitoring adherence, treatment efficacy, and patient response
      2. Identify the necessity and timing of consultation with other health care professionals
         1. Provide referral for further management, including surgical intervention or cognitive behavioural therapy
5. Actively contribute, as an individual and as a member of a team providing care, to the continuous improvement of health care quality and patient safety
   1. Recognize and respond to harm from health care delivery, including patient safety incidents
      1. Differentiate adverse effects of therapy from other causes of adverse patient outcomes
      2. Recognize and respond to harm from the effects of therapy and/or the interactions between therapy and the underlying condition(s)
   2. Adopt strategies that promote patient safety and address human and system factors

Communicator

Definition:

As Communicators, physicians form relationships with patients and their families that facilitate the gathering and sharing of essential information for effective health care.

Key and Enabling Competencies: Sleep Disorder Medicine diplomates are able to…

1. Establish professional therapeutic relationships with patients and their families
   1. Communicate using a patient-centred approach that encourages patient trust and autonomy and is characterized by empathy, respect, and compassion
      1. Demonstrate awareness of the psychological, occupational, and social consequences of sleep disorders
   2. Optimize the physical environment for patient comfort, dignity, privacy, engagement, and safety
      1. Optimize patient comfort in the sleep laboratory
   3. Recognize when the perspectives, values, or biases of patients, physicians, or other health care professionals may have an impact on the quality of care, and modify the approach to the patient accordingly
      1. Demonstrate an appreciation of cultural influences on sleep patterns and behaviours
   4. Respond to a patient’s non-verbal behaviours to enhance communication
   5. Manage disagreements and emotionally charged conversations
      1. Respond to the emotional distress of patients whose activities of daily living or vocational/occupational status is at risk due to the impact of their sleep disorder
   6. Adapt to the unique needs and preferences of each patient and to his or her clinical condition and circumstances
      1. Demonstrate awareness of the communication needs of children and adults with intellectual disabilities
2. Elicit and synthesize accurate and relevant information, incorporating the perspectives of patients and their families
   1. Use patient-centred interviewing skills to effectively gather relevant biomedical and psychosocial information
   2. Provide a clear structure for and manage the flow of an entire patient encounter
   3. Seek and synthesize relevant information from other sources, including the patient’s family, with the patient’s consent
      1. Elicit a collateral history from a sleep witness (e.g., bed partner, care-giver)
3. Share health care information and plans with patients and their families
   1. Share information and explanations that are clear, accurate, and timely, while checking for patient and family understanding
      1. Provide information to prepare patients for the sleep laboratory experience
      2. Provide information to the patient and family about principles of sleep, sleep hygiene, and circadian rhythms
      3. Engage patients in conversations that promote adherence to therapy
   2. Disclose harmful patient safety incidents to patients and their families accurately and appropriately
4. Engage patients and their families in developing plans that reflect the patient’s health care needs and goals
   1. Facilitate discussions with patients and their families in a way that is respectful, non-judgmental, and culturally safe
   2. Assist patients and their families to identify, access, and make use of information and communication technologies to support their care and manage their health
   3. Use communication skills and strategies that help patients and their families make informed decisions regarding their health
      1. Use communication skills to assess and enhance a patient’s evaluation of treatment options
5. Document and share written and electronic information about the medical encounter to optimize clinical decision-making, patient safety, confidentiality, and privacy
   1. Document clinical encounters in an accurate, complete, timely, and accessible manner, in compliance with regulatory and legal requirements
      1. Provide reports of diagnostic and therapeutic studies that integrate age specific normative data; pharmacologic effects of medication taken during the course of the investigation; and the variety, severity, and interaction of known mental and physical conditions on sleep, with recommendations where appropriate
      2. Communicate reports of critical diagnoses in an expedited manner
   2. Communicate effectively using a written health record, electronic medical record, or other digital technology
   3. Share information with patients and others in a manner that respects patient privacy and confidentiality and enhances understanding
      1. Share information with other parties, such as employers and school systems, with the patient’s consent, in a manner that advocates for the patient’s best interest, while respecting privacy and confidentiality

Collaborator

Definition:

As Collaborators, physicians work effectively with other health care professionals to provide safe, high-quality, patient-centred care.

Key and Enabling Competencies: Sleep Disorder Medicine diplomates are able to…

1. Work effectively with physicians and other colleagues in the health care professions
   1. Establish and maintain positive relationships with physicians and other colleagues in the health care professions to support relationship-centred collaborative care
   2. Negotiate overlapping and shared responsibilities with physicians and other colleagues in the health care professions in episodic and ongoing care
      1. Supervise technologists in the use of supplemental oxygen, the use and titration of different positive pressure devices, and the decision to terminate an investigation
      2. Respond appropriately to input from technologists and home positive airway pressure (PAP) providers
   3. Engage in respectful shared decision-making with physicians and other colleagues in the health care professions
      1. Consult with colleagues in relevant specialties or subspecialties to optimize sleep, daytime functioning, and ventilation for patients with underlying medical or psychiatric conditions
      2. Engage the patient, technologist, respiratory therapist, sleep educator, caregiver, and/or home care company in the adjustment of the therapeutic plan
2. Work with physicians and other colleagues in the health care professions to promote understanding, manage differences, and resolve conflicts
   1. Show respect toward collaborators
   2. Implement strategies to promote understanding, manage differences, and resolve conflicts in a manner that supports a collaborative culture
      1. Apply strategies to nurture and support the functioning of the sleep laboratory team
3. Hand over the care of a patient to another health care professional to facilitate continuity of safe patient care
   1. Determine when care should be transferred to another physician or health care professional
      1. Determine the appropriateness and timing of patient transition to their primary care provider for ongoing care
   2. Demonstrate safe handover of care, using both oral and written communication, during a patient transition to a different health care professional, setting, or stage of care
      1. Ensure continuity of care in transitions from hospital to community based programs
      2. Provide clear summaries of a patient’s condition, status, and ongoing treatment at times of transition of care
      3. Provide clear instructions regarding management or re-consultation, anticipating changes in patient status or therapeutic needs

Leader

Definition:

As Leaders, physicians engage with others to contribute to a vision of a high-quality health care system and take responsibility for the delivery of excellent patient care through their activities as clinicians, administrators, scholars, or teachers.

Key and Enabling Competencies: Sleep Disorder Medicine diplomates are able to…

1. Contribute to the improvement of health care delivery in teams, organizations, and systems
   1. Apply the science of quality improvement to contribute to improving systems of patient care
      1. Demonstrate knowledge of the relevant standards for data acquisition, scoring, and storage
      2. Participate in quality assurance programs for sleep test scoring and interpretation
      3. Participate in the quality assurance program of the sleep laboratory
   2. Contribute to a culture that promotes patient safety
   3. Analyze patient safety incidents to enhance systems of care
   4. Use health informatics to improve the quality of patient care and optimize patient safety
2. Engage in the stewardship of health care resources
   1. Allocate health care resources for optimal patient care
      1. Triage requests for sleep studies
      2. Advise other health care providers regarding the selection of the appropriate sleep study and/or alternative investigations
      3. Apply knowledge of health care resources in the local setting to optimize patient care
   2. Apply evidence and management processes to achieve cost-appropriate care
3. Demonstrate leadership in professional practice
   1. Demonstrate leadership skills to enhance health care
      1. Demonstrate knowledge of the operations of sleep laboratories including budgeting, equipment selection and maintenance, and human resources/staffing
      2. Develop and monitor protocols for sleep technologists’ scope of practice
      3. Share sleep medicine disorder expertise with provincial governing agencies for the purposes of sleep laboratory accreditation
   2. Facilitate change in health care to enhance services and outcomes
      1. Contribute to quality improvements in sleep laboratory practices
4. Manage career planning, finances, and health human resources in a practice
   1. Set priorities and manage time to integrate practice and personal life
      1. Balance the demands of practice and continuing professional development in the entry discipline and in SDM
   2. Manage a career and a practice
   3. Implement processes to ensure personal practice improvement

Health Advocate

Definition:

As Health Advocates, physicians contribute their expertise and influence as they work with communities or patient populations to improve health. They work with those they serve to determine and understand needs, speak on behalf of others when required, and support the mobilization of resources to effect change.

Key and Enabling Competencies: Sleep Disorder Medicine diplomates are able to…

1. Respond to an individual patient’s health needs by advocating with the patient within and beyond the clinical environment
   1. Work with patients to address determinants of health that affect them and their access to needed health services, resources, or vocational or educational accommodation
      1. Facilitate patient access to therapy and resources, such as positive airway pressure therapy
      2. Work with patients to identify and implement strategies for vocational or educational accommodation (e.g., modification of work or school schedules)
   2. Work with patients and their families to increase opportunities to adopt healthy behaviours
      1. Apply motivational interviewing skills to promote adherence to prescribed therapy
      2. Apply the principles of behavioural change during conversations with patients about adopting healthy behaviours, including
         1. Weight loss
         2. Exercise
         3. Reduction and/or cessation of smoking, alcohol, and substance use
      3. Counsel patients regarding positional therapy programs
   3. Incorporate disease prevention, health promotion, and health surveillance into interactions with individual patients
      1. Identify indications for family screening for sleep disorders
2. Respond to the needs of the communities or populations they serve by advocating with them for system-level change in a socially accountable manner
   1. Work with a community or population to identify the determinants of health that affect them
      1. Identify populations at risk of poor sleep and/or sleep deprivation
      2. Promote access to sleep laboratory testing
   2. Improve clinical practice by applying a process of continuous quality improvement to disease prevention, health promotion, and health surveillance activities
   3. Contribute to a process to improve health in the community or population they serve
      1. Promote healthy sleep patterns/sleep hygiene across the lifespan to improve health and reduce the burden of illness in the general public
      2. Promote awareness of disorders of sleep and chronobiology in the education system and/or workplace
      3. Promote improvements in work shifts in accordance with principles of circadian physiology to improve productivity and safety in the workforce
      4. Promote awareness of occupational fatigue management
      5. Work with advocacy groups and/or other agencies to improve access to sleep expertise, testing and therapeutics

Scholar

Definition:

As Scholars, physicians demonstrate a lifelong commitment to excellence in practice through continuous learning and by teaching others, evaluating evidence, and contributing to scholarship.

Key and Enabling Competencies: Sleep Disorder Medicine diplomates are able to…

1. Engage in the continuous enhancement of their professional activities through ongoing learning
   1. Develop, implement, monitor, and revise a personal learning plan to enhance professional practice
   2. Identify opportunities for learning and improvement by regularly reflecting on and assessing their performance using various internal and external data sources
      1. Seek out and apply information on personal performance
   3. Engage in collaborative learning to continuously improve personal practice and contribute to collective improvements in practice
2. Teach students, residents, the public, and other health care professionals
   1. Recognize the influence of role-modelling and the impact of the formal, informal, and hidden curriculum on learners
   2. Promote a safe learning environment
   3. Ensure patient safety is maintained when learners are involved
   4. Plan and deliver learning activities
      1. Deliver learning activities for members of the sleep laboratory team
      2. Provide information about sleep and sleep medicine to non-medical audiences such as the general public, members of the educational system, and government or other regulatory agencies
   5. Provide feedback to enhance learning and performance
   6. Assess and evaluate learners, teachers, and programs in an educationally appropriate manner
3. Integrate best available evidence into practice
   1. Recognize practice uncertainty and knowledge gaps in clinical and other professional encounters and generate focused questions that address them
   2. Identify, select, and navigate pre-appraised resources
   3. Critically evaluate the integrity, reliability, and applicability of health-related research and literature
   4. Integrate evidence into decision-making in their practice
4. Contribute to the creation and dissemination of knowledge and practices applicable to health
   1. Demonstrate an understanding of the scientific principles of research and scholarly inquiry and the role of research evidence in health care
   2. Identify ethical principles for research and incorporate them into obtaining informed consent, considering potential harms and benefits, and considering vulnerable populations
   3. Contribute to the work of a research program
   4. Pose questions amenable to scholarly inquiry and select appropriate methods to address them
   5. Summarize and communicate to professional and lay audiences, including patients and their families, the findings of relevant research and scholarly inquiry

Professional

Definition:

As Professionals, physicians are committed to the health and well-being of individual patients and society through ethical practice, high personal standards of behaviour, accountability to the profession and society, physician-led regulation, and maintenance of personal health.

Key and Enabling Competencies: Sleep Disorder Medicine diplomates are able to…

1. Demonstrate a commitment to patients by applying best practices and adhering to high ethical standards
   1. Exhibit appropriate professional behaviours and relationships in all aspects of practice, demonstrating honesty, integrity, humility, commitment, compassion, respect, altruism, respect for diversity, and maintenance of confidentiality
   2. Demonstrate a commitment to excellence in all aspects of practice
   3. Recognize and respond to ethical issues encountered in practice
      1. Vocational/educational restrictions due to the impact of sleep disorders
   4. Recognize and manage conflicts of interest
      1. Disclose and mitigate the risk of conflict of interest associated with their own financial association with sleep testing and/or therapies
   5. Exhibit professional behaviours in the use of technology-enabled communication
2. Demonstrate a commitment to society by recognizing and responding to societal expectations in health care
   1. Demonstrate accountability to patients, society, and the profession by responding to societal expectations of physicians
   2. Demonstrate a commitment to patient safety and quality improvement
3. Demonstrate a commitment to the profession by adhering to standards and participating in physician-led regulation
   1. Fulfil and adhere to professional and ethical codes, standards of practice, and laws governing practice
      1. Apply provincial driving regulations and mandatory reporting requirements
      2. Adhere to the accreditation standards for diagnostic reporting
   2. Recognize and respond to unprofessional and unethical behaviours in physicians and other colleagues in the health care professions
   3. Participate in peer assessment and standard-setting
4. Demonstrate a commitment to physician health and well-being to foster optimal patient care
   1. Exhibit self-awareness and manage influences on personal well-being and professional performance
   2. Manage personal and professional demands for a sustainable practice throughout the physician life cycle
   3. Promote a culture that recognizes, supports, and responds effectively to colleagues in need

REQUIRED TRAINING EXPERIENCES

1. Participation in clinics providing experience in the breadth of patient presentations in Sleep Disorder Medicine (SDM) (insomnia, sleep-related breathing disorders, central disorders of hypersomnolence, circadian rhythm sleep-wake disorders, parasomnias, sleep-related movement disorders) at all phases of patient assessment, monitoring, and follow-up. This clinical experience must include pediatric and adult patient populations (minimum of 5-10 % in each age group)
2. Participation in dental and otolaryngological assessments for sleep disorders
3. Participation in clinics providing experience with neuromuscular and neurodegenerative disease
4. Performance of perioperative consultations for patients with sleep disordered breathing (SDB)
5. Participation in positive airway pressure (PAP) orientation and follow-up, including managing side effects, and challenges with adherence, and experience with advanced PAP therapies (BiPAP, ASV)
6. Observation of individual and/or group cognitive behavioural therapy for insomnia
7. Completion of the American Academy of Sleep Medicine (AASM) module
8. Preparation of a patient and the equipment for a polysomnogram (PSG)
9. Observation of a diagnostic and a PAP titration study for both adult and pediatric populations
10. Observation of a multiple sleep latency test (MSLT) and a maintenance of wakefulness test (MWT)
11. Scoring of ten PSGs and two MSLTs, with comparison to technologist
12. Supervision of PSGs, MSLT and MWT studies
13. Interpretation for both adult and pediatric populations
    1. 200 PSGs
    2. 25 MSLTs (may be teaching file for pediatrics)
    3. 25 home sleep monitoring reports (may be teaching file for pediatrics)
    4. Ten actigraphy reports (may be teaching file for pediatrics)
14. Completion or significant participation in a scholarly project in an area relevant to any aspect of SDM
15. Participation in provision of educational activities for peers, learners, continuing professional development audiences (physicians and/or other health care professionals), and/or non-medical audiences

RECOMMENDED TRAINING EXPERIENCES

1. Participation in clinical assessments in oral maxillofacial surgery clinics
2. Experience a polysomnogram
3. Participation, with a neurologist, in the interpretation of EEGs
4. Training in motivational interviewing (MITI)

This document is to be reviewed by the AFC Committee in Sleep Disorder Medicine by December 2019.

• Approved – Specialty Standards Review Committee – December 2017

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