The 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 unwillingness or inability to provide lifesaving care for their child. The content areas of this document include examples of the specific application of this competency to disorders encountered in the course of pediatric gastroenterology practice.
The competency of systems-based practice (CanMEDS Health Advocate, Manager, and Collaborator) challenges fellows to conduct their clinical efforts in a manner that is medically sound, of high quality, and cost-effective. This requires that fellows understand different types of medical practice and delivery systems. Fellows must learn skills that will enable them to advocate for their patients and to coordinate services drawn from throughout the health care system. Upon completion of training, the fellow should be able to demonstrate his or her understanding of the roles of members of a multidisciplinary team and how to lead a multidisciplinary group that ensures optimal management of complex conditions, such as inflammatory bowel disease (IBD) or intestinal failure. The content areas of this document also include examples of the specific application of this competency to disorders encountered in the course of pediatric gastroenterology practice.
A number of metrics can be used to evaluate fellow performance, and specific competencies may be best addressed through the application of different methodologies (16,17). Medical knowledge may be best assessed with traditional tools such as written examinations or standardized oral examinations. Other competencies are better assessed using a variety of tools, including record review, chart-stimulated recall, checklists, logs/portfolios, standardized patient examinations, objective structured clinical examinations, simulations, patient surveys, and 360o global ratings. Although the particular choice of evaluation metrics may vary from institution to institution, it is essential that all pediatric gastroenterology fellowship training programs develop a process that facilitates the longitudinal collection of information/data and provision of constructive feedback to fellows in a manner that is timely, respectful, and most likely to positively contribute to their long-term personal and career development. Faculty development is key to the establishment of these metrics and to an effective feedback process. At present, few faculty are expert in these areas (18).
A fundamental difficulty in assessing trainees based on the ACGME competencies is that supervising physicians often are asked to do this outside the environment of clinical care and without knowledge of the longitudinal development of trainees (19). A proposed solution to this dilemma is the creation of entrustable professional activities (EPAs) (20,21). According to ten Cate and Scheele, EPAs are part of the essential professional work; must require adequate knowledge, skill, and attitude; lead to recognized output of professional labor; be independently executable; and be observable and measureable in its process and outcome. An example of a possible EPA in pediatric gastroenterology is the medical management of the postoperative liver transplant patient. EPAs provide a clinical context in which to judge a trainee's competence in >1 of the 6 areas defined by ACGME. In this example, trainees’ competency in systems-based practice could be assessed in his or her ability to work on a multidisciplinary team and the competency in communication assessed in his or her ability to provide compassionate and respectful anticipatory guidance to the transplant patient and family. ten Cate and Scheele suggest that one could create a matrix listing specific EPAs on 1 axis and the ACGME general competencies that could pertain to the EPAs on another. Successful training, then, would require reaching the entrustable level of each EPA within a set time period by satisfying all of the relevant competencies. To assist program directors in conceptualizing the application of ACGME competencies, the content areas of this document include the development of tables that relate possible EPAs in each specific area to appropriate competencies. In the future, guidelines for training in pediatric gastroenterology may be based on a series of carefully defined EPAs.
ACGME and the American Board of Pediatrics (ABP) initiated a pediatrics milestones project to better define the competencies and improve the assessment of outcomes (22,23). The project specifies 52 subcompetencies and proposes a series of developmental levels for assessment. Application of the milestones to subspecialty training must await further study and validation.
Clinical Training Guidelines
ACGME requirements for subspecialty training in pediatric gastroenterology specify that the training program should be 3 years in length and ensure trainee competence as defined by their 6 competencies in the treatment of infants, children, and adolescents with diseases of the GI tract, the pancreas, the hepatobiliary tract, and nutrition. Current RCPSC guidelines require only 2 years of fellowship for certification in pediatric gastroenterology (8). To meet all of the recommendations enumerated below for a 3-year fellowship, candidates training in Canada could arrange an additional year of fellowship or obtain equivalent training after completing their fellowship.
Acknowledging the increasing complexity of pediatric gastroenterology practice and the ACGME requirements, we recommend that at least 15 months should be devoted to clinical training in inpatient and ambulatory settings (Table 4). This length of clinical training would still permit the fellow to be supported by research training grants that restrict clinical activities after a first clinical year. Traditionally, the majority of fellowship training has occurred in the inpatient setting; however, given that clinical pediatric gastroenterology is predominantly an outpatient practice, consideration should be given to providing a significant component of training in the ambulatory setting. A continuity care outpatient opportunity of at least ½ day/week should be provided during the entire 3 years of fellowship. Throughout the training period, duty hours should conform to the guidelines issued by ACGME and be monitored closely (5).
The fellow should assume progressively increasing responsibility for clinical care and demonstrate increasing competence, both in the inpatient and ambulatory settings, during the course of the fellowship. Fellows also should demonstrate increasing competence in the performance of routine diagnostic and therapeutic GI procedures.
Fellows have differing career goals that may affect their training. The current flexibility of training should allow trainees with specific interests to obtain additional clinical training, including training in selected areas, such as neurogastroenterology and motility, nutrition, intestinal failure, IBD, therapeutic endoscopy, hepatology or liver, small bowel, and multivisceral transplantation after the required 15 months of clinical training. For example, if a fellow seeks to obtain expertise (without formal certification) in areas such as motility or management of intestinal failure, additional training, up to 9 months during the 3-year fellowship, could be devoted to this special interest. Alternatively, such specialized training could occur after completion of the pediatric gastroenterology fellowship, as a separate fourth year or in a mentored clinical practice. Such training should not interfere with completion of the scholarly work product. Depending on local institutional resources, the flexibility also should permit fellows who are interested in academic careers to pursue advanced degrees, such as a master's degree in public health or clinical science.
Trainees interested in a career in investigation (basic, translational, or clinical) would receive research training during their fellowship; however, fellows and programs should recognize that the path to independence as an investigator commonly requires that at least 4 to 5 years of training is needed to equip a fellow to work independently as an investigator in his or her area of interest. Whether this career path is included as an extra 1 to 2 years as a trainee or as junior faculty depends on local institutional resources, availability and type of funding to support further research training, and the individual needs of trainees. Table 5 suggests lengths of total training for pediatric gastroenterologists seeking different career pathways.
Endoscopy and Other Procedures
Procedures are an integral part of the practice of pediatric gastroenterology, and trainees are expected to demonstrate competency in the performance of a wide array of procedures. Endoscopy and related procedures, such as liver biopsy and motility procedures, are in a continual state of evolution as a result of technological advances in equipment, changes in other diagnostic disciplines (eg, radiology), and shifts in the health care delivery system. Nevertheless, it remains important to establish guidelines for pediatric gastroenterology training programs so that trainees are up to date in the most current techniques available. Certain core principles of procedure training will remain important regardless of the details of specific procedures. Trainees must understand the appropriate indications, risks, benefits, and alternatives of both diagnostic and therapeutic procedures. Each program must have formal mechanisms for monitoring and documenting trainees’ development of skills in the performance of each procedure on a regular basis. Ideally, trainees should maintain a log detailing procedures performed and problems encountered. This will facilitate the regular feedback that must be given to trainees throughout their training as to their level of skill acquisition and whether they are meeting expectations for their level of experience. Trainees who are not achieving expected goals should be given constructive guidance in how to achieve the necessary level of endoscopic competence for their level of training. Adequate training and the minimal threshold number of procedures recommended to achieve competency for each procedure are defined in the endoscopy and procedure guideline for training that follows. Each trainee does not necessarily have to attain competence in all of the procedures outlined, but it is important that each trainee become familiar with every procedure and understand its application, interpretation, and limitations.
Endoscopic competency is recognized as a continuum. As such, it is recognized that some trainees will achieve procedural competency at a lower number of procedures because of superior hand–eye coordination and other factors that determine procedural success, whereas others will require more instruction or experience to achieve the same level of proficiency. Although emphasizing that true procedural competency rather than volume is the more appropriate goal, careful review of the published literature allows for estimation of minimal numbers that should be achieved before performing procedures independently. Trainees are expected to achieve competence in the procedures that they intend to perform without supervision after completion of training. At completion of training, trainees who have not achieved adequate procedural competence in a procedure that they wish to perform will require mentoring by an experienced proceduralist until such time as procedural competency has been met.
Therefore, an essential aspect of all training programs is to ensure that each trainee is adequately exposed to relevant procedures, which include diagnostic and therapeutic upper GI endoscopy, percutaneous endoscopic gastrostomy tube placement, diagnostic and therapeutic colonoscopy, endoscopic examination of the small intestine (capsule endoscopy and/or small bowel enteroscopy), endoscopic retrograde cholangiopancreatography, percutaneous liver biopsy, rectal biopsy, manometry (esophageal, antroduodenal, colonic and anorectal), esophageal pH and impedance monitoring, and breath test analysis. Since the publication of the 1999 North American Society for Pediatric Gastroenterology and Nutrition training guidelines (1), the 2009 ACGME update has moved several procedures from the “demonstrate competence” list to the “understand the principles” list, including paracentesis and percutaneous liver biopsy (7). This change was driven by the recognition that some of the procedures are being increasingly performed by interventional radiologists. These trends will continue to affect the training of pediatric gastroenterologists and certification requirements. As a result, guidelines for procedure training will require regular updates.
Integral to the advancement of the care of children with GI, hepatobiliary, pancreatic, and nutritional disorders is the elucidation of basic disease mechanisms and the development of new diagnostic and therapeutic strategies. In addition, a greater understanding of the genetic, molecular, and cellular processes controlling the development and function of the GI tract, liver, and related organs is essential to progress in disease prevention and health maintenance during childhood. The continuation of these advances requires the availability of individuals with training in basic, clinical, and translational sciences, medical education, health services, and health policy. All clinicians in the subspecialty of pediatric gastroenterology must understand the foundations of the field and be prepared to assess the impact of new information on clinical care and thus practice evidence-based medicine.
Congruent with ACGME and ABP guidelines (7,24), subspecialty training in pediatric gastroenterology must emphasize scholarship. All fellows must receive formal training in scholarly pursuits and participate in basic, clinical, or translational research, or another scholarly activity. The inclusion of forms of scholarship other than research recognizes the importance of all contributions vital for the continued advancement of the field of pediatric gastroenterology.
Scholarship, in this context, can be conceived as 4 interrelated domains of academic activity (25). The scholarship of discovery encompasses the activities involved in original basic science and clinical research. The scholarship of education involves the development of educational strategies, curricula, and assessment tools for the communication of knowledge to students and the public. The scholarship of integration is concerned with making connections among diverse disciplines such as the use of communication technology in telemedicine, engineering methods in genomics research, or ethics in patient care. The scholarship of application involves the use of knowledge to solve problems of individuals and society. The types of scholarly work described by this domain include clinical trials and epidemiologic studies. Many translational biomedical activities are included within the domains of integration and application.
Trainees need to acquire knowledge in all aspects of scholarship through a combination of didactics and direct participation in a meaningful scholarly project with appropriate mentorship. The experience must begin during the first year and continue throughout the period of training. The ABP sets requirements for the nature of the scholarly project and its output, but it does not stipulate the amount of time that must be devoted to this activity. To meet the goals established by the ABP, at least 12 months of fellowship training should be committed to scholarship activities, although some activities, such as a basic science project, clearly require a longer time commitment. Ideally, at least some contiguous blocks of time will be designated for completion of the scholarly activity. During these designated periods, 80% of the trainees’ time should be committed to scholarly work.
Trainees must participate in a formal core curriculum in scholarship. The curriculum should be presented in a format that stimulates learning behavior through the use of diverse educational modalities, including lectures, group discussions, journal clubs, and research conferences. The curriculum should provide trainees with the opportunity to achieve an in-depth understanding of biostatistics, epidemiology, clinical and laboratory research methodology, study design, critical literature review, ethical norms governing scholarly activities (presentation of data, collaborative activities, confidentiality in peer review, authorship designation, social responsibility, human rights, and animal welfare), application of research to clinical practice, and evidence-based medicine. The curriculum also should include principles of teaching and adult learning, curriculum development, and assessment of educational outcomes. Trainees should acquire the necessary skills to deliver information in oral and written forms, prepare applications for approval and potential funding of clinical and research protocols, and complete abstracts and manuscripts for publication. Furthermore, the trainees should develop as effective teachers of individuals and groups of learners in clinical settings, classrooms, and seminars.
Per ABP requirements (24), all fellows are to complete a supervised scholarly activity. This activity must be directly related to the field of pediatric gastroenterology, hepatology, or nutrition, with the objective to prepare trainees to become effective subspecialists and to contribute to the advancement of scholarship in the field. Participation in the scholarly activity should lead to the development of skills to critically analyze the work of others; gather and analyze data; assimilate new knowledge, concepts, and techniques; formulate clear and testable questions from a body of data; derive conclusions from available data; and translate ideas into written and oral forms. The scholarly activity may include basic, clinical, and translational sciences, medical education, health services, and health policy. Acceptable projects include basic, clinical, and translational research; meta-analysis or systematic review of the literature; critical analysis of health services or policies; and curriculum development. The project must be hypothesis driven or have clearly stated objectives, and requires in-depth integration and analysis of information or data. Trainees must actively participate and acquire comprehensive knowledge of all aspects of their scholarly activity. Trainees should practice reflective critique during the performance of the scholarly activity by thinking about the work, seeking the opinion of others, and responding positively to criticism. The scholarly activity is to lead to a work product for which trainees are responsible for a significant portion of its completion. Examples of an acceptable work product are a peer-reviewed publication, a formal report extensively describing a completed or complex ongoing activity, a peer-reviewed extramural grant application, and a thesis.
Fellowship training in scholarship is to be performed in a supportive, stimulating, and inquisitive environment. Trainees must have the opportunity to discuss and critically analyze current literature, present their work in conferences, and interact with other trainees and faculty in a wide variety of disciplines. To provide an appropriate scholarly environment, faculty of the program must include people with established skills in scholarship, preferably in different areas of basic science, clinical science, health services, health policy, and education.
Trainees should designate a faculty member to provide mentorship during their scholarly activity. The mentor is fundamental to the training process and must commit to support trainees during the extent of their scholarly activity. The mentor should have an established record of productivity in scholarship, have attained excellence in a field related to pediatric gastroenterology, and be aware of the opportunities for trainees to apply for grant support, participate in national conferences, and collaborate with others in the subspecialty of pediatric gastroenterology. The mentor must ensure that the support, facilities, and equipment required for the completion of the specific scholarly activity are available to the fellow and must monitor his or her progress and provide ongoing feedback.
Each trainee is to have a scholarship oversight committee (SOC), governed by written guidelines (24). The SOC, in conjunction with the designated mentor and program director, is responsible for the guidance of trainees through the completion of the scholarly activity and for the assessment of whether a specific activity and the product of that activity meets the current ABP guidelines for certification. The SOC, as stipulated by the ABP, is to comprise at least 3 individuals (including the mentor), with 1 member from outside the subspecialty of pediatric gastroenterology. The program director can serve as a mentor and participate in committee activities, but he or she is not formally a member of the SOC. The committee is to meet on a regular basis during the period of training, at least twice per year. The committee is to assist trainees in the development of a course of study to acquire knowledge and skills beyond those provided by the core curriculum to ensure successful completion of the scholarly activity. The SOC will evaluate each fellow's progress, involvement in the specific scholarly activity, product of the scholarly activity, and defense of the product of the scholarly activity at its completion. The SOC will advise the program director on each fellow's progress during the training period and determine whether the scholarly activity was performed and completed according to the local program and ABP guidelines.
Given the explosion of knowledge and technology, some pediatric gastroenterologists have restricted their practices to certain highly specialized clinical areas. Preparation to practice in these areas may require further training to develop the medical knowledge and clinical and technological skills necessary to achieve competency. At present, the field of pediatric cardiology includes multiple areas of subspecialization, and guidelines for training in each of these were published in 2006 (11). As the discipline of pediatric gastroenterology develops further, it is likely that new subspecialties will develop and others will change.
The goal of advanced training in pediatric gastroenterology is to provide specialized clinical instruction for subspecialty trainees exceeding what would be expected in a traditional 3-year fellowship training program. Examples of areas in which advanced training can be appropriate include but are not limited to pediatric transplant hepatology, neurogastroenterology and motility, therapeutic endoscopy, IBD, intestinal rehabilitation and small bowel/multivisceral transplantation, and nutrition. Such training could be obtained in 1 of 3 ways: within the context of a standard 3-year fellowship, assuming all of the basic requirements for clinical training and scholarship are met; during an additional, dedicated fourth year of fellowship training; or postfellowship in the course of mentored, specialized practice.
The only current official mechanism for obtaining advanced training in pediatric gastroenterology is that which exists for pediatric transplant hepatology (26). Obtaining a certificate of added qualification in this subspecialty requires the completion of an additional year of fellowship training in pediatric transplant hepatology and passing a certifying examination, offered jointly by the ABP and the American Board of Internal Medicine (27).
Although the original NASPGHAN guidelines specified requirements for advanced training in other areas of subspecialty within pediatric gastroenterology (1), clear pathways for advanced fellowship training do not exist and, therefore, specifications for achieving this training were not included in this document. Furthermore, it is unlikely that the ABP will be able to offer certifying examinations, given the expected small numbers of applicants. We do, however, recommend that NASPGHAN consider defining the requirements for programs that may offer advanced training in areas other than pediatric transplant hepatology and for fellowship training in these areas.
Format of the Content Areas
Traditional approaches to enumerating the medical knowledge and clinical skills that trainees must develop to master a specialty field have resulted in lengthy and detailed lists of specific items. In practice, such lists have been rarely accessed by program directors and therefore been of little practical benefit. The Guidelines Steering Committee established a number of guiding principles for the development of content areas. First, the committee believes that to be effective, the format of the content areas should be simplified by avoiding repetitious language and emphasizing concepts rather than details. In the current era of expanding medical knowledge, retention of all relevant facts is impossible and problem-based learning, often on a Web-based platform, is becoming an essential part of practice and should be encouraged. Another goal was to create a format that could be updated easily periodically in response to changes in medical knowledge and practice. Finally, a link to the ACGME competencies for each content area was thought to be important to help embrace all aspects of trainee development that are necessary to meet both professional and lay concepts of acceptable practice.
The Steering Committee identified 11 areas of content that best encompassed the breadth of pediatric gastroenterology without resulting in needless complexity: acid-peptic disease, congenital anomalies of the GI tract, GI bleeding, GI infections, hepatobiliary disorders, IBDs, malignancies and premalignant conditions, motility and functional GI disorders, nutritional disorders, pancreatic disorders, and intestinal failure. For each of these content areas, acknowledged experts were drafted to lead task forces, and they in turn invited additional experts to serve on these task forces.
The format of each content area acknowledges the key role of the competencies in fellowship training. The outline of the content areas and the relation of the format to the general AGCME competencies are shown in Table 6. The last section of Table 6 emphasizes the importance of the developmental context in understanding the field of pediatric gastroenterology.
The authors acknowledge the role of the advisory group and especially the task force leaders and members for their work in creating the content areas. Mary Ruff and Rebecca Millson assisted in editing the document. Margaret Stallings and the NASPGHAN staff helped with logistical arrangements. The authors also thank the many NASPGHAN members who reviewed the document and provided critical feedback.
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