TRAINING IN PEDIATRIC GASTROENTEROLOGY, HEPATOLOGY, AND NUTRITION IN EUROPE—A FORWARD TO THE EUROPEAN TRAINING SYLLABUS
Pediatric gastroenterology developed rapidly in the late 1960s and 1970s. As a consequence, the European Society of Pediatric Gastroenterology (ESPG) was founded in 1968 by a group of individuals actively engaged in gastroenterologic research. In the mid-1970s, with the development of pediatric nutrition, the society became the European Society of Pediatric Gastroenterology and Nutrition (ESPGAN), and in the 1990s it became ESPGHAN to reflect the growth in hepatology. The drive and interest of ESPGHAN has largely focused on scientific research. However, during the 1990s, ESPGHAN began an educational initiative with the development of Summer Schools in Gastroenterology, Nutrition and Hepatology, traveling summer courses, and with the Millennium Eastern Summer Schools in Eastern Europe. Study days throughout Europe have been features of this initiative. Interaction with our colleagues who work with adults has developed through the United European Gastroenterology Federation (UEGF), of which ESPGHAN is one of the founding seven sisters. In 1996, the first UEGF postgraduate course in pediatric gastroenterology and hepatology was held.
Despite these European-wide scientific training initiatives, formal training in pediatric gastroenterology, hepatology, and nutrition is not standardized across Europe, and, despite the preeminent standing of ESPGHAN in the world of pediatric gastroenterology, pediatric gastrology, hepatology, and nutrition, is not recognized in Europe as a board-certified pediatric subspecialty, as it is in Australia and in North America.
Pediatric gastroenterology, hepatology, and nutrition must be recognized as a pediatric subspecialty. With the introduction of standardized general pediatric training in Europe, an opportunity exists to develop further training in pediatric gastroenterology, hepatology, and nutrition and to introduce uniform standards through Europe. In 1995, the Confederation Europeenne des Specialistes en Pediatrie (CESP) set up a European Board of Paediatrics (EBP) to standardize all aspects of pediatrics across European. As the predominant body for pediatric gastroenterology, hepatology, and nutrition in Europe, ESPGHAN has set standards in training approved by CESP and EBP.
These standards are contained in the training syllabus published in this issue of the journal.
A pediatric gastroenterologist and hepatologist is a trained pediatrician who specializes in the investigation and treatment of children with gastrointestinal, liver, and nutritional disorders (pediatric gastroenterology, hepatology, and nutrition). Most pediatric gastroenterologists and hepatologists practice within a tertiary care setting, which offers a full range of diagnostic procedures and the facilities for treating intestinal, liver, or nutritional failure.
The aims of this training syllabus are 1) to harmonize training in pediatric gastroenterology, hepatology, and nutrition among the various European countries; 2) to establish clearly defined standards of knowledge and skill for tertiary pediatric gastroenterology, hepatology, and nutrition care; 3) to foster the development of a European network of competent tertiary care centers in pediatric gastroenterology, hepatology, and nutrition; and 4) to further enhance the European contribution to international scientific progress in pediatric gastroenterology, hepatology, and nutrition.
AIMS OF TRAINING
The trainee in pediatric gastroenterology, hepatology, and nutrition should, before beginning the specialty training described in this document, have completed training in basic pediatrics. At the end of pediatric gastroenterology, hepatology, and nutrition training, the trainee should be suitable for appointment as a specialist in pediatric gastroenterology, hepatology, and nutrition at a tertiary center. Duration of training in the specialty should be a minimum of 2 years. A period of full-time research, preferably leading to a higher degree, is desirable. An opportunity also should be available to vary the gastroenterologic, hepatologic, and nutritional training components depending on the trainee's requirements.
During the period of training the trainee should have received:
- a broad range of clinical experience in gastrointestinal and hepatologic diseases of children, together with their associated nutritional problems;
- broad experience with the nutritional disorders of children;
- specific training in diagnostic techniques and their interpretation;
- experience in basic or clinical research;
- contact with adult gastroenterology/hepatology;
- knowledge of the administrative and organizational aspects of care for chronic pediatric gastroenterology and hepatology diseases; and
- experience functioning as part of a multidisciplinary team that includes addressing psychosocial aspects of care.
The trainee will gain experience with and understanding of the following:
- Epidemiology of the principal diseases encountered in pediatric gastroenterology and hepatology in childhood
- Diagnostic and therapeutic procedures required for examination of the gastrointestinal tract and liver:
- upper gastrointestinal endoscopy
- endoscopic procedures (e.g., polypectomy, removal of foreign bodies, sclerotherapy)
- endoscopic retrograde cholangiopancreatoscopy where appropriate
- small intestinal and rectal biopsy
- liver biopsy
- motility studies (e.g., pH monitoring, transit studies, and a knowledge of manometry)
- pancreatic function tests (e.g., screening tests, fecal elastase, and knowledge of intubation tests)
- Nutritional skills that include knowledge of the following:
- assessing nutritional status
- dietary requirements of children
- pathophysiology of malnutrition
- theory and techniques of enteral and parenteral nutritional support
- role of nutrition support teams and special therapeutic diets
- Skills in cooperation with other specialists (surgeons, pathologists, radiologists, laboratory scientists, adult specialists)
- Skills in relevant aspects of organization and management
- Experience in clinical audit
- Skills in teaching
- Research in pediatric gastrology, hepatology, and nutrition
Current general professional training in pediatrics is not adequate for the tertiary specialist in pediatric gastroenterology, hepatology, and nutrition. The boundaries must be defined between the skills and competence of general pediatricians and those of the specialist. The content of this syllabus details the additional training required for a specialist in pediatric gastroenterology, hepatology, and nutrition and thus also defines the boundaries between general pediatricians and pediatric gastroenterology, hepatology, and nutrition specialist pediatricians.
Training requirements for tertiary specialists include 1) basic knowledge; 2) clinical, technical, and management skills and competencies; 3) attitudes; and 4) the ability to diagnose and treat particular disorders.
Basic knowledge in gastroenterology will include understanding of the following:
- The association of abnormal embryogenesis with clinical disorders (e.g., diaphragmatic hernia, malrotation, atresias, biliary atresia)
- Physiology of the gastrointestinal tract including liver and pancreas: e.g., causes of malabsorption, steatorrhea, and protein-losing enteropathy
- Fluid-balance disturbances and causes and treatment of dehydration
- Recognition and interpretation of common symptoms including failure to thrive in infancy, chronic diarrhea, recurrent abdominal pain, and vomiting
- Presentation, investigation, and treatment of major gastrointestinal disorders (e.g., celiac disease, gastroesophageal reflux, chronic inflammatory bowel disease, etc.)
- Basic knowledge of mucosal immunology
- Causes and management of acute gastroenteritis: which children need admission?
Basic knowledge of hepatology will include understanding of the presentation, investigation, and treatment of the following:
- Neonatal liver disease
- Acute liver disorders and infections
- Chronic liver disease
- Liver failure
- Mechanisms of disease and disorders leading to cholestasis
- Role of nutritional support particular to liver disease
- Metabolic liver disorders
- Indications for liver transplantation
Basic knowledge in nutrition will include understanding of the following:
- Basis of normal infant/childhood feeding
- Assessing feeding ability and nutritional status
- Recognition and management of feeding disorders, including anorexia nervosa and bulimia
- Mechanisms of malnutrition in gastrointestinal and liver disease
- Methods of nutritional support and their use
- Dietary requirements of children
- Short- and long-term effects of malnutrition in the infant, child, and adolescent
Basic investigative knowledge include understanding of the following:
- The basis for tests of malabsorption, liver dysfunction, breath tests, esophageal pH monitoring, and manometric studies
- Indications and usefulness of relevant imaging and endoscopic techniques
Clinical skills will include the following:
- Assessing nutritional status of infants and children, including auxometry of height and weight
- Assessing dehydration, and planning fluid therapy
- Interpretation of plain radiographs and of contrast and other imaging studies
- Managing enteral and parenteral nutrition
- Prescribing elimination diets
- Knowledge of techniques for measuring dynamic nutritional parameters (e.g., resting energy expenditure)
Technical skills will include the following:
- Small intestinal biopsy
- Upper gastrointestinal endoscopy, diagnostic/therapeutic
- Pancreatic function tests
- Esophageal pH and motility studies (e.g., transit studies and knowledge of manometry)
- Liver biopsies
- Endoscopic retrograde cholangiopancreatoscopy
- Sclerosis of esophageal varices and other vascular malformations
- Placement of endoscopic gastrostomy when appropriate
- Removal of foreign bodies
Management skills include the following:
- Conducting a clinical audit
- Managing admission policies, endoscopy lists, etc.
- Understanding contracting and purchasing when appropriate
- Organizing a postgraduate teaching program
Research skills include the following:
- Designing clinical trials using medical statistics
- Organizing and presenting data
- Computer literacy including the ability to conduct a literature database search
- Understanding the need for a multidisciplinary approach
- Understanding that investigations may be unpleasant, painful, or frightening and that child and parents must be counseled in advance
- Developing communication skills with the child and parents to ensure their full understanding of and willing participation in the care process
- Understanding the need to deliver compassionate care
The trainee will gain the ability to recognize and initiate diagnostic tests, and outline management of the following:
- Pyloric stenosis
- Hirschsprung disease
- Peptic ulceration and Helicobacter pylori infection
- Recurrent or protracted diarrhea
- Acute and recurrent abdominal pain
- Persistent jaundice in the young infant
- Intestinal bleeding
- Intestinal obstruction
- Differentiation of abdominal masses
- Acute liver failure
- Short gut syndrome
- Chronic inflammatory bowel disease
- Small intestinal failure and intractable diarrhea syndrome
- Infections of gastrointestinal tract and liver
- Gastroenterologic problems with acquired immune deficiency syndrome (AIDS)
- Gastrointestinal food allergy
- Acute diarrhea including use of oral rehydration therapy
- Outbreak of hospital-acquired diarrhea
- Chronic liver disease and metabolic liver disease
- Management before and after liver transplantation
- Intestinal motility problems
- Gastrointestinal problems in handicapped children
- Chronic undernutrition/failure to thrive
- Feeding disorders, including self-starvation
- Specific nutrient deficiencies iron, folate, vitamins (B12, D, E, and K, thiamine, riboflavin, ascorbic acid), zinc, copper, selenium, and essential fatty acids
Structure of the Program
The syllabus is arranged as a series of modules that can be completed in one or several different training centers. The training should be performed at no more than four centers. Each module contains training in a specific area, expertise, or skill. Most trainees should complete all modules. However, if an individual will practice only hepatology, the program can be varied to include more hepatology and less gastroenterology, without the necessity for learning inappropriate technical skills.
Trainees in pediatric gastroenterology, hepatology, and nutrition will complete all modules.
Trainees in gastroenterology will complete the following modules: basic gastroenterology knowledge, basic hepatology knowledge 1 through 5, basic nutritional knowledge, clinical skills, technical skills (excluding skills 6:6), attitudes, and particular disorders.
Trainees in hepatology only will complete the following modules: basic gastroenterology knowledge 1 through 5, basic hepatology knowledge, basic nutritional knowledge, clinical skills, technical skills (excluding skills 1, 3–5, and 9–11), attitudes, and particular disorders 5, 9, 10, 13, 18, 21, 23, and 27.
Each trainee's progress is monitored by the trainee and an assigned tutor.
The trainee will maintain a personal logbook, in which he or she will document relevant training experiences, and will complete a self-assessment for each module / topic. The logbook and the trainee's progress will be discussed with the tutor at 3-month intervals.
Successful completion of a training module/topic will be certified by the tutor in the trainee's logbook.
A suggested scheme of self-assessment for gastroenterology, hepatology, and nutrition is given herein, with notes for trainers and trainees. Principles for assessing research and content of the logbook also is suggested.
Assessing meaningful accomplishment in research
Because research experience is an essential part of training in pediatric gastroenterology, hepatology, and nutrition, each trainee must meet the following objectives:
- Certification requires evidence of productive research participation.
- Evidence of meaningful accomplishment in research must be submitted. Acceptable evidence could include one of the following:
- First author of a research paper accepted for publication in an appropriate peer-reviewed journal
- Submission of research grant proposal that has been approved by peer review
- A postgraduate degree in a field relevant to pediatric gastroenterology, hepatology, and nutrition
- A research progress report (signed by both the applicant and supervisor), no more than five pages in length, to include the following:
- A statement of hypothesis
- A description of methodology
- Results and analysis
- Significance of the research
- Any other evidence considered appropriate
The trainee's supervisor is responsible for ensuring appropriateness of the research activity and will be involved in research planning.
Self-assessment by the pediatric gastroenterology, hepatology, and nutrition trainee
- 1 = I do not feel knowledgeable or competent in this topic.
- 2 = I have reasonable knowledge but no “hands-on” experience.
- 3 = I have dealt with one or a few cases of this condition/problem.
- 4 = I feel I am reasonably competent to manage and explain this condition or problem.
- 5 = I feel able to assume complete responsibility for this condition or problem.
- 1 = I have never seen or performed this.
- 2 = I have observed but not performed this.
- 3 = I have performed one or a few but I do not feel competent.
- 4 = I can undertake this but still want support to be available.
- 5 = I feel able to undertake this on my own.
Note to Trainee: This self-assessment is designed to help you and your supervisor review your training and experience, and to identify any gaps. To assess your knowledge and understanding, ask yourself, “Could I explain this condition/treatment/procedure clearly, logically, and persuasively to a consultant colleague in another specialty who may seek advice about a child?”
During training, a trainee may expect to encounter the conditions chosen in this exercise. Therefore, these experiences act as a marker of the breadth of training opportunities available to them in their post.
Please fill in the following assessment, in pencil initially so that you can change it if necessary, and discuss it with your local tutor or mentor before your annual review.
Note to supervisor: Please go through this with the trainee and discuss whether you agree with his or her self-ratings. If you do not agree, discuss the reasons for your assessment.
RECOGNITION OF SPECIALISTS IN PEDIATRIC GASTROENTEROLOGY, HEPATOLOGY, AND NUTRITION
Recognition as a European Specialist in pediatric gastroenterology, hepatology, and nutrition at either secondary or tertiary level will require satisfactory completion of a recognized, certified training program.
NATIONAL TRAINING PROGRAM
Where national training programs in pediatric gastroenterology, hepatology, and nutrition already exist or are at an advanced state of development, they should be considered compatible with this European program if they have a comparable syllabus, a similar duration, and a means of assessing the trainee.
Where no training program exists, national professional training bodies should be encouraged to adopt a national training program in PG&H that is closely compatible with this European program. Until such a program exists, individuals who have undergone a period of documented training compatible with this program could obtain European recognition by voluntarily taking and passing a board examination in a European country as laid down by the European Board of Paediatrics.
Certification as a European specialist in pediatric gastroenterology, hepatology, and nutrition could be obtained as above.