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  • 1. 1 Program Requirements for Fellowship Education in Pediatric Gastroenterology 2 3 Introduction 4 A. Scope of Training 5 1. Pediatric gastroenterology programs must provide the fellow in 6 gastroenterology with the background and experience to diagnose and 7 manage patients with acute and chronic diseases of the digestive system 8 (esophagus, stomach, intestines, hepatobiliary system, and pancreas) and 9 with nutritional disorders, including those that are life-threatening, and to10 conduct research in this specialized field. The fellow must be guided in11 developing clinical judgment and skills as well as in acquiring medical12 knowledge, humanistic qualities, and professional attitudes and behaviors13 that are appropriate for the pediatric gastroenterologist.14 2. An accredited program in pediatric gastroenterology must provide 3 years15 of progressive educational experience that includes the development of16 procedural skills, responsibility for patient care, and participation in17 research.18 VIII Program Personnel and Resources19 A. Faculty20 1. Pediatric Gastroenterology Specialists21 There must be at least three pediatric gastroenterologists on the teaching22 staff.23 2. Other Teaching and Consultant Faculty24 Consultant and collaborative faculty in the following related pediatric25 disciplines must be readily available to the program: In addition to the full26 range of pediatric subspecialists, the following physician faculty from27 other disciplines must be available: Allergy/Immunology, Child and28 Adolescent Psychiatry and/or Psychology, Medical Genetics, Pediatric29 Surgery and Nuclear Medicine30 B. Resources31 1. The following must be available to the program:32 a. Space in an ambulatory setting for optimal evaluation and care of33 outpatients.34 b. An inpatient area staffed by pediatric residents and faculty with a full35 array of pediatric and related services. including pediatric surgery and Pediatric Gastroenterology 1
  • 2. 36 child and adolescent psychiatry, and/or psychology.37 c. Full support services, including Physical/Occupational Therapy, Social38 Services, Nutrition, and Feeding Therapy.39 d. Pediatric intensive care unit.40 e. Neonatal intensive care unit.41 f. Access to a laboratory that can either perform or assess measures of42 intestinal absorptive and pancreatic function; nutritional parameters;43 and specialized serological, parasitological, immunological, metabolic,44 and toxicological studies applicable to gastrointestinal and45 hepatobiliary disorders.46 g. Fully equipped and staffed procedure facilities that include diagnostic47 and therapeutic endoscopic instruments. Access to a procedure facility48 for measuring gastrointestinal motility. The staff must be skilled in the49 care of pediatric patients. There must be appropriate equipment for50 patients ranging in age from the neonate to the young adult.51 2. Patient population52 The patient population available to the program must have sufficiently53 varied and complex diseases and be of a volume sufficient to ensure that54 the fellows have the opportunity to become clinically competent in the55 management of common as well as uncommon gastrointestinal,56 hepatobiliary, and pancreatic diseases and nutritional disorders in patients57 ranging from infancy through young adulthood.5859 IX. Educational Program60 A. Patient Care61 1. The educational program must be organized and conducted in a way that62 ensures an appropriate environment for the well-being and care of the63 patients and their families.64 2. To develop the fellows competence in clinical diagnosis, medical65 management of patients, and the correlation of pathophysiology with66 clinical disorders, the program must emphasize developmental67 gastrointestinal physiology in infants, children, adolescents, and young68 adults.69 3. There must be training in the selection, performance, and evaluation of70 procedures for morphological, physiological, immunological,71 microbiological, and psychosocial assessment of gastrointestinal and Pediatric Gastroenterology 2
  • 3. 72 hepatobiliary diseases and nutritional disorders. 73 4. Fellows must demonstrate competence in utilizing have experience in a 74 variety of diagnostic tests and therapeutic procedures, e.g., the use of 75 imaging techniques, tests of digestive system function, histological 76 interpretation of biopsy specimens, and assessment of nutritional status 77 and pancreatic function. 78 5. The program must stress the role of the subspecialist as a consultant and 79 promote skills necessary to communicate effectively with the referring 80 physician.81 6. In recognition of the importance of outpatient medicine to the practice of82 pediatric gastroenterology and nutrition, all fellows must spend at least ½83 day per week for the entire period of training in an ambulatory care clinic84 in which both new and established patients are seen. A subset of these85 patients must be part of a longitudinal continuity experience in which the86 fellows follow patients that they have cared for as an inpatient and/or over87 time in the outpatient setting.88 7. Fellows must have ongoing responsibility for the continuing care of89 patients with chronic gastrointestinal problems and must have sufficient90 opportunities to provide consultation on a wide variety of patients to91 become familiar with the gastrointestinal manifestations of a broad92 spectrum of pediatric illnesses. 93 8. Fellows’ clinical experience must involve the management of patients 94 with gastrointestinal and nutritional diseases and disorders, including but 95 not limited to those listed below in IV .B.2. As well as Fellows must 96 demonstrate knowledge of the methods of initial evaluation and criteria for 97 referral familiarity with the principles of evaluation and follow-up care of 98 the patient requiring liver transplantation and those with intestinal 99 failure/requiring small bowel transplantation.100 9. Diseases/Disorders101 a. Growth failure and malnutrition including an understanding of102 nutritional assessment and parenteral and enteral nutrition support.103 b. Malabsorption (celiac disease, cystic fibrosis, pancreatic104 insufficiency, etc)105 c. Gastrointestinal allergy106 d. Peptic ulcer disease107 e. Jaundice Pediatric Gastroenterology 3
  • 4. 108 f. Hepatobiliary disease (biliary atresia, fatty liver, intrahepatic109 cholestasis, autoimmune liver disease, viral hepatitis, acute liver110 failure, and metabolic liver diseases).111 g. Digestive tract anomalies112 h. Chronic Inflammatory bowel disease113 i. Functional bowel disorders114 j. Pancreatitis (acute and chronic)115 k. Other gastrointestinal disorders, such as gastrointestinal infections;116 gastrointestinal problems in the immune-compromised host,117 including graft versus-host (GVH) disease; motility disorders;118 infectious and metabolic liver diseases; and pancreatitis119 l. Gastrointestinal complications of eating disorders, such as, obesity,120 bulimia, and anorexia.121 10. Procedures122 Fellows must receive training in the following engage in formal123 instruction as well as, clinical experience in order to demonstrate124 competence in the performance of the following procedures:125126 a. Diagnostic colonoscopy (including biopsy) and therapeutic127 colonoscopy with snare polypectomy128 b. Diagnostic upper gastrointestinal endoscopy (including biopsy)129 and therapeutic upper gastrointestinal endoscopy130 c. Diagnostic upper gastrointestinal endoscopy (including biopsy)131 d. Esophageal pH monitoring132 e. Diagnostic and therapeutic flexible sigmoidoscopy133 f. Paracentesis134 g. Percutaneous liver biopsy135 h. Rectal biopsy136 i. Removal of foreign bodies from the gastrointestinal tract137 j. Small bowel biopsy138 In addition, residents should have training in the following:139 k. Anorectal manometry Pediatric Gastroenterology 4
  • 5. 140 l. Breath hydrogen analysis141 m. Dilatation of esophagus142 n. Therapeutic upper panendoscopy (sclerosis of esophageal varices)143 o. Esophageal manometry144 p. Pancreatic stimulation test145 q. Placement of percutaneous gastrostomy146 r. Endoscopic placement of feeding tubes147148 11. Fellows must understand the principles, indications, contraindications, and149 risks, and interpretation of results of procedures used to manage:150 a. gastrointestinal manometry151 b. rectal suction biopsy152 c. paracentesis153 d. esophageal impedance/pH testing154 e. pancreatic function testing155 f. breath hydrogen analysis156 g. endoscopic placement of feeding tubes (including percutaneous157 endoscopic gastrostomy placement)158 h. videocapsule endoscopy159 i. endoscopic retrograde cholangiopancreatography (ERCP)160 j. gastrointestinal foreign bodies161 k. variceal and nonvariceal gastrointestinal bleeding162 l. percutaneous liver biopsy163164 A skilled preceptor must be available to teach and supervise the fellows in165 the performance of these procedures, which must be documented in each166 fellow’s record, giving indications, outcomes, diagnoses, and167 supervisor(s). Assessment of procedural competence should not be based168 solely on a minimum number of procedures performed, but on a formal169 evaluation process. These evaluations should include objective170 performance criteria.171172 12. Knowledge may be achieved through direct patient care as well as through173 a variety of other learning activities. Learning activities, which may not174 involve direct contact with the patient, in which fellows engage to gain a175 solid understanding of these procedures and tests should be well176 documented.177 Pediatric Gastroenterology 5
  • 6. 178 13. Fellows must should also be familiar with the basic principles, indications,179 contraindications and risks of advanced endoscopic procedures,180 endoscopic ultrasonography, endoscopic laser therapy, esophageal181 endoscopic stent placement, and endoscopic esophageal fundoplication.182 14. Fellow evaluations must document an The fellows’ understanding of the183 indications, contraindications, risks, and benefits of diagnostic and184 therapeutic procedures, as well as development of skills in their185 performance must be documented and included in the regular fellow186 evaluations.187 B. Medical Knowledge188 1. The program must have a well-developed formally structured curriculum,189 including courses, workshops, seminars, and laboratory experience, that190 provides an appropriate background for fellows in the basic and191 fundamental disciplines related to the digestive system, such as192 embryology, physiology, pharmacology, nutrition, pathology,193 biochemistry, molecular biology, immunopathology, and genetics.194 Training in the evaluation of the psychosocial aspects of chronic195 gastrointestinal disease as they affect the child and competence in196 counseling chronically ill patients and their families including preventive197 measures for digestive disease should be components of the training198 program. Health education biomedical ethics, and also should be199 emphasized.200 2. Structured and scheduled interdisciplinary conferences with pediatric201 radiology, pediatric pathology, and pediatric surgery must be included in202 the didactic curriculum. Pediatric Gastroenterology 6