NASPGHAN Guidelines for Training in Pediatric Gastroenterology

1. OVERVIEW The field of pediatric gastroenterology, hepatology, and nutrition (referred to subsequently as pediatric gastroenterology) continues to expand and evolve and is far different from 1999, when the previous guidelines on fellowship training in this field were published (1). Although still a relatively young field, this subspecialty is increasingly recognized and accepted throughout the world (2), albeit with varying degrees of medical resources and access to care. Tremendous medical advances, especially in the fields of genetics, infectious disease, pharmacology, and immunology, have changed our fundamental understanding of pathophysiology, and along with technological innovations, such as wireless imaging technology and intraesophageal impedance monitoring, have affected the way we diagnose and manage disease. At the same time, economic factors have become increasingly important in discussions of health care and graduate medical education (3). With rapidly escalating health care costs, care must be demonstrated to be not only high in quality but also cost-effective. Moreover, in response to pressure from the public to ensure practitioners are competent, accrediting agencies are imposing new and increasingly complex constructs for assessing the competency of our trainees. These factors demand that the training of pediatric gastroenterology fellows be continuously revised and reevaluated. It is not sufficient to focus exclusively on the clinical aspects of training, however. Although the primary mission of fellowship programs is to create competent clinicians, ensuring the health of future generations requires a broader training mission that recognizes that some of our trainees will choose careers as researchers and medical educators. Fellowship training, therefore, must provide individuals with the opportunity to pursue other essential career pathways. The necessity of providing this more inclusive training must be reconciled with evolving lifestyle expectations of trainees (4) and duty hour restrictions (5). In response to these enumerated factors, the Executive Council of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) charged its Training Committee with the task of updating the 1999 fellowship training guidelines. The goals outlined by the Steering Committee were to consider existing guidelines and seek consistency where possible; specifically incorporate the Accreditation Council for Graduate Medical Education (ACGME) competencies; create a framework that would permit consistent updating; reflect the unique aspects of pediatric gastroenterology, including the breadth of the field and unique nature of the patients, especially the changing presentation of disease as children develop; and respond to the practical needs of pediatric gastroenterology program directors. In addition to the original NASGPHAN guidelines, other existing guidelines were reviewed in the preparation of this document. Table 1 provides a list of the primary guidelines and the means to access them. ACGME's Residency Review Committee issues standards for fellowship training in pediatric gastroenterology and updates them every 5 years, with the most recent update in 2009 (6,7). ACGME establishes detailed training program requirements that are not included in these NASPGHAN guidelines. Requirements for training as a pediatric gastroenterologist in Canada are enumerated by the Royal College of Physicians and Surgeons in Canada (RCPSC) (8,9). The European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) reviewed training issues and developed a curriculum for fellows in 2002 (2). The task force also reviewed the gastroenterology core curriculum generated by 4 adult gastroenterology societies that was updated in 2007 (10) and the recent guidelines for fellowship training in pediatric cardiology, a subspecialty with similar training issues, including procedure training and advanced training opportunities (11).TABLE 1: Guide to existing guidelinesUnique Characteristics of a Pediatric Gastroenterologist A pediatric gastroenterologist is expected to be an expert in the anatomy and physiology of a large segment of the human body that includes the esophagus, stomach, intestines, liver, biliary tree, and pancreas, as well as the diverse array of acute, subacute, and chronic illnesses that may affect these organs. Trainees must have the ability to analyze and integrate the clinical data, instead of limiting their thought processes to a particular organ or segment of the gastrointestinal (GI) tract. In pediatric gastroenterology, an assessment of growth and nutrition is an especially integral part of any patient's evaluation and care. Diseases of the digestive system can negatively affect the nutritional status of the child; conversely, the nutritional status of the child can profoundly affect the diagnostic evaluation of the patient. In addition, the practitioner must possess exemplary interpersonal and communication skills, because the field of pediatric gastroenterology is truly multidisciplinary and requires routine consultations and collaborations with myriad allied providers, including endoscopy suite and operating room personnel, nurses, dietitians, pharmacists, social workers, surgeons, intensivists, radiologists, pathologists, psychologists, and psychiatrists. Many of the diseases encountered by a pediatric gastroenterologist also are of relevance to other subspecialties, including endocrinology, rheumatology, pulmonology, and metabolism/genetics, necessitating collaborative relationships with these experts. A pediatric gastroenterologist, unlike an adult gastroenterologist, interacts extensively with both the patient and the patient's care provider(s). As such, it is imperative that the care not only be evidence-based and cost-effective but also be delivered in a compassionate manner that respects patients’ families and their cultures. The fiscal aspects of health care, especially in the United States, are undergoing seismic modifications and it is anticipated that events in the next 5 years will be characterized by vastly different reimbursement models and accountability in medicine. A pediatric gastroenterologist will need to be adept at demonstrating added value to health care dollars and strive for continuous quality enhancement of care. Knowledge of the dollar footprint of care will be imperative, especially as the subspecialist will have increasing access to an ever-expanding array of technological tools and diagnostic modalities, including medical genetic and pharmacogenetic testing. Furthermore, it is likely that as medical homes are established, pediatric subspecialists will need to develop new relationships with primary care providers. The other trend affecting fellowship programs is the juxtaposition of personal lifestyle choices and career choices. A subset of pediatric gastroenterologists works part-time for a variety of reasons, including needs for childcare, personal (or family) health issues, or other personal obligations or pursuits. Because these needs affect the training years, programs have increasingly adapted to trainee lifestyle requests. In the early years of this subspecialty, the majority of practitioners entered academic institutions, and this later expanded to private practice options. Presently, graduating trainees also consider hybrid practices in which they have an academic appointment with some role in trainee education, but otherwise maintain an independent practice. In summary, the field of pediatric gastroenterology is undergoing rapid transformation and these updated guidelines aim to address the changes occurring in the training of this subspecialty during the last decade and, more important, to prepare us for the future. Competencies ACGME was established in 1981 with a goal of developing a uniform set of guidelines that could be applied to ensure and improve the quality of resident and fellow education. As part of its Outcome Project, 6 core competencies that could serve as focal points in the development of residency and fellowship training program curricula were identified in 1999 and became part of program requirements in 2002 (12). Similarly, the RCPSC developed a set of core competencies that are an integral part of fellowship training program curricula (Canadian Medical Education Directives for Specialists, or CanMEDS competencies) (13). Although the CanMEDS competencies are not identical to those of the ACGME, their goals are similar (Table 2). Application of these core competencies and implementation of assessment tools by program directors of pediatric gastroenterology fellowship training are required for program certification by the ACGME and the RCPSC. Table 3 indicates how the ACGME competencies are presented in this guideline document.TABLE 2: ACGME and CanMEDS core competenciesTABLE 3: Mapping ACGME competencies to guidelinesThe competency of medical knowledge (CanMEDS Medical Expert and Scholar) requires that fellows demonstrate knowledge of relevant biomedical, clinical, epidemiological, and sociobehavioral sciences and their application to patient care. Areas that are particularly applicable to understanding the clinical manifestations and treatment of GI disease include developmental biology, pharmacology, host/microbial interactions, immunology, and genetics. Fellows should develop an understanding of the pathophysiology underlying the disorders that are encountered in ambulatory and inpatient settings. Medical knowledge should be obtained through didactic conferences, self-directed learning, and in the course of supervised clinical care. Concepts important for training in pediatric gastroenterology are included in the individual content areas. The competency of patient care (CanMEDS Medical Expert and Manager) is directed at ensuring that fellows are able to provide competent and compassionate care to their patients. They must be able to gather appropriate information via the performance of a complete clinical history and comprehensive physical examination, review of medical records, and appraisal of up-to-date scientific evidence. They must be able to develop and implement patient management plans, taking into consideration patient/family preferences. They must be able to interpret diagnostic and therapeutic interventions and develop the clinical judgment necessary to make informed decisions. Fellows also are expected to develop technical competency in the performance of GI procedures that are considered essential for the practice of pediatric gastroenterology and should understand the indications, benefits, risks, and limitations of all procedures commonly used in the evaluation of children with GI disorders. Enumeration of the patient care experiences required for training in pediatric gastroenterology is included in the individual patient content areas of this document. Recommendations for procedural training are reviewed in a separate section of this overview and in more detail in the final section of these guidelines. The competency of practice-based learning and improvement (CanMEDS Scholar) emphasizes lifelong learning. Instruction in this competency should help fellows to develop a set of skills that will empower them to serially assess and reflect upon their perceived strengths and weaknesses as clinicians, and to develop strategies and realistic goals to improve their clinical practice. This includes the ability to incorporate constructive feedback provided by supervisors, colleagues, other health care providers, administrative staff, and patients. In addition, this process of continuous improvement requires the ability to use information technology to support their education and an understanding of the principles and application of evidence-based medicine. Fellows must perform practice-based improvement, which involves obtaining information about their own population of patients, instituting a change, and assessing the effect using a systematic methodology. This competency also includes the development of specific teaching skills that will permit fellows to effectively educate patients and families, students, residents, other fellows, and consulting physicians. The competency of interpersonal and communication skills (CanMEDS Communicator) encompasses more than the performance of specific tasks or behaviors. Fellows should demonstrate interpersonal skills such as the ability to be present in the moment; awareness of the importance of the relationships among physician, patient, and family members; respect for others and treating others as one would like to be treated; and the capacity to adjust interpersonal skills based on the needs of different patients and families (14). Fellows must be able to create and sustain therapeutic and ethically sound relationships with patients, use effective listening skills to facilitate relationships, and work effectively with others as a member or leader of a health care team. Physician providers must be able to communicate across cultural and socioeconomic boundaries. In addition, fellows should begin to learn the skills necessary to communicate their findings and experiences with colleagues and other health care providers, both orally and in the form of written reports, manuscripts, and case series. Such skills are critical in practicing medicine effectively in a multidisciplinary setting. The competency of professionalism (CanMEDS Professional) includes training to ensure that fellows will be able to provide compassionate care to their patients in a manner that is sensitive to language, age, culture, sex/sexual orientation, religious persuasion, and disabilities. Professionalism is realized through partnership between a patient and doctor, based on mutual respect, individual responsibility, and appropriate accountability. It should include such areas as honesty and integrity, self-awareness and knowledge of limits, reliability, respect for others, compassion, altruism and advocacy, continuous self-improvement, collaboration, and working in partnership with members of the health care team (15). Moral reasoning and judgment also are essential components of professional behavior. Fellows should receive formal training in bioethics to equip them in addressing complex problems, such as parental or to provide care for their The content areas of this include of the specific application of this competency to disorders encountered in the course of pediatric gastroenterology practice. The competency of practice (CanMEDS and fellows to their clinical in a manner that is of high and cost-effective. This requires that fellows understand different of medical practice and Fellows must learn skills that will them to for their patients and to from throughout the health care of training, the fellow should be able to demonstrate or understanding of the of members of a multidisciplinary team and how to a multidisciplinary that management of complex such as disease or The content areas of this also include of the specific application of this competency to disorders encountered in the course of pediatric gastroenterology practice. A of can be used to fellow and specific competencies may be through the application of different Medical knowledge may be with tools such as written or competencies are using a variety of including patient clinical patient and Although the particular of evaluation may from to it is essential that all pediatric gastroenterology fellowship training programs develop a process that the of and of constructive feedback to fellows in a manner that is and most likely to to their personal and career development is to the of these and to an effective feedback At are expert in these areas A fundamental in assessing trainees based on the ACGME competencies is that are to this the of clinical care and knowledge of the development of trainees A to this is the of professional to and are part of the essential professional must and to recognized of professional be and be and in its process and of a in pediatric gastroenterology is the medical management of the patient. provide a clinical in which to a in of the 6 areas by In this competency in practice could be in or ability to work on a multidisciplinary team and the competency in communication in or ability to provide compassionate and to the patient and and that one could create a specific on 1 and the ACGME competencies that could to the on training, would the of a set by all of the relevant program directors in the application of ACGME the content areas of this include the development of that in specific to appropriate In the guidelines for training in pediatric gastroenterology may be based on a of ACGME and the American of a to the competencies and improve the assessment of The and a of developmental for Application of the to subspecialty training must and Training ACGME requirements for subspecialty training in pediatric gastroenterology that the training program should be 3 years in and ensure trainee as by their 6 competencies in the treatment of and with diseases of the GI the pancreas, the and RCPSC guidelines only years of fellowship for certification in pediatric gastroenterology all of the enumerated for a training in Canada could an of fellowship or training their the increasing of pediatric gastroenterology practice and the ACGME we that at should be to clinical training in inpatient and ambulatory (Table This of clinical training would still permit the fellow to be by training that clinical a clinical the majority of fellowship training in the inpatient that clinical pediatric gastroenterology is an consideration should be to providing a of training in the ambulatory setting. A care opportunity of at should be provided during the 3 years of the training duty should to the guidelines by ACGME and be of training fellow should increasing for clinical care and demonstrate increasing both in the inpatient and ambulatory during the course of the Fellows also should demonstrate increasing in the performance of routine diagnostic and therapeutic GI Fellows have career goals that may affect their The of training should trainees with specific to clinical training, including training in such as and therapeutic or liver, and the required of clinical a fellow to formal in areas such as or management of training, to during the could be to this such training could of the pediatric gastroenterology as a separate or in a clinical practice. Such training should not with of the work on the also should permit fellows are in academic careers to pursue advanced such as a in public health or clinical Trainees in a career in or would receive training during their fellows and programs should that the to as an commonly requires that at 4 to 5 years of training is to equip a fellow to work as an in or of this career is included as an 1 to years as a trainee or as on and of to support training, and the individual needs of trainees. Table 5 of training for pediatric gastroenterologists different career training for different career and are an integral part of the practice of pediatric gastroenterology, and trainees are expected to demonstrate competency in the performance of a array of and such as and are in a of as a of technological in changes in other diagnostic and in the health care it important to guidelines for pediatric gastroenterology training programs that trainees are to in the most core principles of procedure training will important of the of specific Trainees must understand the appropriate indications, risks, benefits, and of both diagnostic and therapeutic program must have formal for and development of skills in the performance of procedure on a trainees should maintain a procedures and This will facilitate the feedback that must be to trainees throughout their training as to their of and they are expectations for their of Trainees are not expected goals should be constructive in how to the necessary of for their of training and the of procedures to competency for procedure are in the endoscopy and procedure guideline for training that trainee not have to in all of the procedures but it is important that trainee become with every procedure and understand its and competency is recognized as a As such, it is recognized that some trainees will procedural competency at a of procedures because of and other factors that procedural others will more or to the same of Although that procedural competency than is the more appropriate review of the published for of that should be procedures Trainees are expected to in the procedures that they to perform of At of training, trainees have not procedural in a procedure that they to perform will by an such as procedural competency an essential of all training programs is to ensure that trainee is to relevant which include diagnostic and therapeutic GI diagnostic and therapeutic of the endoscopy and and impedance monitoring, and the of the 1999 North American Society for Pediatric and Nutrition training guidelines the 2009 ACGME update procedures from the list to the the including and This was by the that some of the procedures are increasingly by These will to affect the training of pediatric gastroenterologists and certification As a guidelines for procedure training will to the of the care of children with and nutritional disorders is the of disease and the development of new diagnostic and therapeutic In addition, a understanding of the and processes the development and of the GI liver, and is essential to in disease and health during The of these requires the of individuals with training in clinical, and medical education, health and health in the subspecialty of pediatric gastroenterology must understand the of the field and be to assess the of new information on clinical care and practice evidence-based medicine. with ACGME and guidelines subspecialty training in pediatric gastroenterology must fellows must receive formal training in and in clinical, or or The of of other than recognizes the importance of all for the of the field of pediatric in this can be as 4 of academic The of encompasses the in original and clinical The of education involves the development of and assessment tools for the communication of knowledge to and the The of is with among diverse such as the use of communication technology in in or in patient care. The of application involves the use of knowledge to of individuals and The of work by this include clinical and Many are included the of and Trainees need to knowledge in all aspects of through a of and in a with appropriate The must begin during the and throughout the of The requirements for the nature of the and its but it not the of that must be to this the goals established by the at of fellowship training should be to some such as a a at some of will be for of the these of the should be to Trainees must in a formal core curriculum in The curriculum should be presented in a that learning through the use of diverse modalities, including and The curriculum should provide trainees with the opportunity to an understanding of clinical and critical of data, collaborative in social responsibility, human and application of to clinical and evidence-based medicine. The curriculum also should include principles of teaching and adult learning, curriculum and assessment of Trainees should the necessary skills to information in and written prepare for and of clinical and and complete and for Furthermore, the trainees should develop as effective of individuals and of in clinical and requirements all fellows are to complete a supervised This must be to the field of pediatric gastroenterology, hepatology, or with the to prepare trainees to become effective subspecialists and to to the of in the in the should to the development of skills to analyze the work of gather and analyze new and and from a body of from and into written and The may include clinical, and medical education, health and health include clinical, and or systematic review of the critical of health or and curriculum The must be or have and requires and of information or Trainees must and comprehensive knowledge of all aspects of their Trainees should practice during the performance of the by about the the of others, and to The is to to a work for which trainees are for a of its of an work are a a formal extensively a or complex a and a Fellowship training in is to be in a and Trainees must have the opportunity to and analyze present their work in conferences, and with other trainees and in a variety of provide an appropriate of the program must include with established skills in in different areas of clinical health health and education. Trainees should a member to provide during their The is fundamental to the training process and must to support trainees during the of their The should have an established of in have in a field to pediatric gastroenterology, and be of the opportunities for trainees to for in conferences, and with others in the subspecialty of pediatric The must ensure that the and required for the of the specific are to the fellow and must or and provide trainee is to have a by written guidelines The in with the and program is for the of trainees through the of the and for the assessment of a specific and the of that the guidelines for The as by the is to at 3 individuals the with 1 member from the subspecialty of pediatric The program can serve as a and in but or is not a member of the The is to on a during the of training, at The is to trainees in the development of a course of to knowledge and skills those provided by the core curriculum to ensure of the The will in the specific of the and of the of the at its The will the program on during the training and the was and to the program and guidelines. Training the of knowledge and some pediatric gastroenterologists have their practices to clinical areas. to practice in these areas may training to develop the medical knowledge and clinical and technological skills necessary to At the field of pediatric includes areas of and guidelines for training in of these were published in As the of pediatric gastroenterology it is likely that new will develop and others will The goal of advanced training in pediatric gastroenterology is to provide clinical for subspecialty trainees would be expected in a fellowship training of areas in which advanced training can be appropriate include but are not to pediatric hepatology, and therapeutic and and Such training could be obtained in 1 of 3 the of a all of the requirements for clinical training and are during an of fellowship or in the course of practice. The only for obtaining advanced training in pediatric gastroenterology is that which for pediatric a of added in this subspecialty requires the of an of fellowship training in pediatric and a examination, by the and the American of Although the original NASPGHAN guidelines requirements for advanced training in other areas of subspecialty pediatric gastroenterology for advanced fellowship training not and, therefore, for this training were not included in this document. Furthermore, it is that the will be able to the expected of that NASPGHAN consider the requirements for programs that may advanced training in areas other than pediatric and for fellowship training in these areas. of the Areas to the medical knowledge and clinical skills that trainees must develop to a field have in and detailed of specific In such have by program directors and of practical The Steering Committee established a of principles for the development of content areas. the that to be the of the content areas should be by and than In the of medical of all relevant is and learning, on a is an essential part of practice and should be goal was to create a that could be updated in response to changes in medical knowledge and practice. a to the ACGME competencies for content was thought to be important to help all aspects of trainee development that are necessary to both professional and of practice. The Steering Committee identified areas of content that the breadth of pediatric gastroenterology in disease, of the GI GI GI and and GI nutritional and of these content were to task and they in to serve on these task The of content the role of the competencies in fellowship The of the content areas and the of the to the competencies are in Table The last section of Table 6 emphasizes the importance of the developmental in understanding the field of pediatric of the content The the role of the and especially the task force and members for their work in the content areas. and in the document. and the NASPGHAN with The also the NASPGHAN members reviewed the and provided critical

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