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 They must be able to develop and patient They must be able to diagnostic and and develop the clinical to Fellows also are expected to develop competency in the performance of GI that are essential for the practice of pediatric gastroenterology and should the and of in the evaluation of children with GI of the patient care required for training in pediatric gastroenterology is included in the individual patient content of this document. for training are reviewed in a of this and in more in the of these guidelines. The competency of and (CanMEDS Scholar) in this competency should fellows to develop a set of that will them to and reflect their and as clinicians, and to develop and goals to improve their clinical practice. includes the ability to incorporate by other health care providers, and patients. In addition, this of continuous requires the ability to information technology to their education and an understanding of the and application of evidence-based medicine. Fellows must which information their of patients, a and assessing the a competency also includes the development of that will permit fellows to and other and The competency of interpersonal and communication (CanMEDS more the performance of or Fellows should demonstrate interpersonal such as the ability to be in the of the of the relationships and for and as would to be and the to interpersonal on the needs of different and families Fellows must be able to create and and relationships with patients, to and with as a or of a health care must be able to and In addition, fellows should to the to their and with and other health care providers, both and in the of and are in in a multidisciplinary The competency of (CanMEDS includes training to ensure that fellows will be able to provide compassionate care to their in a manner that is to and is through a patient and on individual and appropriate It should include such as and and knowledge of for and continuous and in with of the health care and also are essential of Fellows should training in to them in complex such as or to provide care for their The content of this include of the 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. requires that fellows different of medical practice and Fellows must that will them to for their and to from throughout the health care of training, the fellow should be able to demonstrate or understanding of the of of a multidisciplinary and how to a multidisciplinary that of complex such as disease or The content of this also include of the application of this competency to disorders encountered in the course of pediatric gastroenterology practice. A of can be to fellow and competencies may be through the application of different Medical knowledge may be with tools such as or competencies are a variety of including patient clinical patient and Although the particular of evaluation may from to it is essential that pediatric gastroenterology fellowship training programs develop a that the of and of 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 At are expert in these A fundamental in assessing trainees 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 to and are part of the essential must and to recognized of be and be and in its and of a in pediatric gastroenterology is the medical of the patient. provide a clinical in which to a in of the 6 by In this competency in practice could be in or ability to on a multidisciplinary and the competency in communication in or ability to provide compassionate and to the patient and and that could create a on 1 and the ACGME competencies that could to the on training, would the of a set by of the relevant program directors in the application of ACGME the content of this include the development of that in to appropriate In the guidelines for training in pediatric gastroenterology may be 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 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 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 should be to providing a of training in the ambulatory A care opportunity of at should be 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 GI Fellows have career goals that may affect their The of training should trainees with to clinical training, including training in such as and or liver, and the required of clinical a fellow to in such as or of training, to during the could be to this such training could of the pediatric gastroenterology as a or in a clinical practice. training should not with of the 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 training during their fellows and programs should that the to as an requires that at 4 to 5 years of training is to a fellow to as an in or of this career is included as an 1 to years as a trainee or as on and of to 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 of procedure training will important of the of Trainees must the appropriate and of both diagnostic and program must have for and development of in the performance of procedure on a trainees should maintain a and will the 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 in how to the of for their of training and the of to competency for procedure are in the endoscopy and procedure guideline for training that trainee not have to in of the but it is important that trainee become with every procedure and its and competency is recognized as a As such, it is recognized that some trainees will competency at a of because of and other factors that will more or to the same of Although that competency is the more appropriate review of the published for of that should be Trainees are expected to in the that they to of At of training, trainees have not in a procedure that they to will by an such as competency an essential of training programs is to ensure that trainee is to relevant which include diagnostic and GI diagnostic and 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 from the list to the the including and was by the that some of the 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 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 the of the field and be to the of new information on clinical care and practice evidence-based medicine. with ACGME and guidelines subspecialty training in pediatric gastroenterology must fellows must training in and in clinical, or or The of of other recognizes the of for the of the field of pediatric in this can be as 4 of academic The of the in original and clinical The of education the development of and assessment tools for the communication of knowledge to and the The of is with diverse such as the of communication technology in in or in patient care. 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The only for 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 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 other pediatric and for fellowship training in these areas. of the Areas to the medical knowledge and clinical that trainees must develop to a field have in and detailed of In such have by program directors and of practical The Steering Committee established a of for the development of content areas. the that to be the of the content should be by and In the of medical of 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 aspects of trainee development that are to both and of practice. The Steering Committee identified 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 and the of the to the competencies are in Table The last of Table 6 the of the developmental in understanding the field of pediatric of the content The the role of the and especially the task force and for their in the content areas. and in the document. and the NASPGHAN with The also the NASPGHAN reviewed the and

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