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  1. 1. 9/03 PEDIATRIC ENDOCRINOLOGY RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS 515 N. State St., Suite 2000 Chicago, IL 60610 INSTRUCTIONS FOR COMPLETING PROGRAM INFORMATION FORMS FOR PROGRAMS IN PEDIATRIC ENDOCRINOLOGY The same program information form (PIF) is used for those making initial application and those undergoing periodic re-review. This program information form is to be used in conjunction with the Program Requirements for Residency Education in Pediatric Endocrinology, effective July 1, 2000. Applications: The RRC will evaluate an application for a new program without a prior site visit. Contact the RRC office for deadlines. Note that a subspecialty program must function in conjunction with a fully accredited program in pediatrics that is in good standing. Title: The title of a subspecialty program should correspond to the title of the core pediatrics program to facilitate cross referencing. The official name of the core program and ID number may be obtained from the institution or from the director of the core pediatrics program. Refer to Program Requirements in the Subspecialties of Pediatrics II.A. Sponsor: Identify as the SPONSORING INSTITUTION that entity which has final administrative responsibility for the program, as evidenced by the fact that it monitors the quality of the education and coordinates the accreditation activity. This must be the same sponsor as for the core pediatrics residency. If the SPONSORING INSTITUTION and the PRIMARY HOSPITAL are one and the same, the hospital's name should be entered in both sections. Before work is begun on this form, the Program Requirements for Subspecialties of Pediatrics and the Program Requirements for Residency Education in Pediatric Endocrinology should be thoroughly reviewed. Copies of these documents may be obtained from the ACGME website ( If more than one hospital participates in the program, information on each hospital should be given as requested. The program director is responsible for gathering the requested data from the participating institutions and consolidating the information on one form. The total length of time subspecialty residents are assigned to each participating hospital should be filled in as requested on Pages 1 and 2. If the subspecialty residents in your program rotate for a period of time to another accredited Pediatric Endocrinology program, please refer to Institutional Requirement I.C. regarding letters of agreement.
  2. 2. -2- It is important that the original pagination remain the same. If necessary, paginate the forms by hand in the upper right corner. See note below. All sections of the form must be completed. If any requested information is not available, an explanation should be given in the appropriate place on the form. The completed form should be prepared as a single document with all added pages numbered in sequence as requested. INCLUDE ONLY THE REQUESTED INFORMATION. INCOMPLETE APPLICATIONS WILL BE RETURNED, WHICH COULD DELAY THE DECISION MAKING PROCESS. The program director is responsible for the accuracy of the information supplied in this form and must sign it. It must also be signed by the Department Chair/Chief of Service and the Chief Executive Officer of the sponsoring institution. ALL PAGES INCLUDED IN THE FORM SHOULD BE 8 2" BY 11". DO NOT USE UNDERSIZED OR OVERSIZED SHEETS. Each copy of the completed form may be secured with a rubber band, a clip, or it may be loosely enclosed in protective materials. DO NOT punch holes in the form. Remove all staples within the form, e.g., from the CV's. DO NOT use any kind of process to bind the form or attach it to anything. DO NOT insert section dividers. The number of copies to be submitted will vary as follows: New application: Send four complete copies to the Executive Director of the Residency Review Committee for Pediatrics at the above address. Resurvey: See letter announcing the site visit. Resident : Resident and subspe cialty resident are used interchangeably in this document . . Pediatric residents are referred to as such. If you have questions about the form, contact the Accreditation Administrator (Phone: 312-755-5044). For word processing questions/problems, contact the ACGME Help Desk (Phone: 312-755-7464). For questions regarding a site visit, contact the writer of the letter announcing the survey. NOTE THAT THE DOCUMENT IS SET FOR AUTOMATIC PAGE NUMBERING. IF THIS PRESENTS A PROBLEM, GO TO THE TOP OF THE FIRST NUMBERED PAGE 1, TURN PAGE NUMBERING OFF BY CLICKING ON FORMAT, PAGE, AND THEN NUMBERING. IF YOU TURN THIS FEATURE OFF, HAND NUMBER ALL PAGES SEQUENTIALLY IN ACCORDANCE WITH THE INSTRUCTIONS. ped s-endo. pif.rev (9/03)
  3. 3. THE RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS Pediatric Endocrinology PROGRAM INFORMATION FORM CHECKLIST Use this checklist before submitting the forms to the RRC office. The RRC considers it the responsibility of the program director to ensure that the application materials are complete. The signature of the program director on the forms indicates his/her approval of the content. A review of the instructions provided at the beginning of the form and on individual pages is suggested. Have the appropriate person(s) signed page 1 of the forms where requested? _______ Has Appendix A, the program director=s CV, been attached? _______ Has Appendix B, the one-page CV of each essential faculty member, been included according to the instructions? Is the form free of unrequested schedules, printouts, reprints, catalogs, brochures, etc.? Are all requested official letters of agreement/affiliation appended as requested on pages 1 and 2? Has the final copy been carefully proofread, and has it been checked to see that every question has been answered, every chart completed, etc.? Once the preparer is satisfied that the form has been completed and assembled correctly, make the appropriate number of copies. After the copies have been made, review the individual sets to be sure that all of the copied pages are legible and that each set of forms contains all of the pages in the original. ALL PAGES INCLUDEDIN THE FORMSHOULDBE 8- 1/2" by 11". DO NOT USE UNDERSIZEDOR OVERSIZED SHEETS. The completedcopiesof the formmaybe securedwithonelargestableor enclosedin a folder. DO NOT STAPLE INDIVIDUAL SECTIONS; use only one staple for the entire packet . Holesshould not be punchedin the formand it shouldnot be attachedto the folder. DO NOT INCLUDE THIS PAGE IN PROGRAM INFORMATION FORMS.
  4. 4. 1 9/03 RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS 515 North State Street, Suite 2000, Chicago, Illinois 60610 PROGRAM INFORMATION FORM PEDIATRIC ENDOCRINOLOGY MEDICINE Date: New Program Application: Yes No TITLE OF SUBSPECIALTY PROGRAM: (Use first line of program listing on the ACGME Website for core Pediatrics program to which this program is attached.) 10-digit ACGME Subspecialty Program ID# Title of Core Pediatrics Program: 10-digit ACGME Core Program ID# Accreditation Status of Core Pediatrics Program: Name and mailing address of Pediatric Endocrinology Program Director: Name: Full Time: YES NO Title: Address: E-mail Address: Telephone: Fax: The signatures of the director of the program and the chief of the department attest to the completeness and accuracy of the information provided on these forms. Pediatric Endocrinology Program Director Name (typed): Chief of Pediatrics/Department Chair Name (typed): Signature: Signature: Program Requirements for Subspecialties of Pediatrics II.A. SPONSORING INSTITUTION: (Name the entity, i.e., the university, hospital, or foundation that has administrative responsibility for this program. Must be the same as the sponsor of the core pediatrics program.) Name of Sponsor: Address: Name of Designated Institutional Official (Typed): Signature: Is there an affiliation with a medical school? If so, name: Yes No Program Requirements for Subspecialties of Pediatrics II.B. PRIMARY HOSPITAL (Hospital 1)
  5. 5. 2 Name: Address: Total number of months Pediatric Endocrinology subspecialty Year 1: Year 2: Year 3: resident is assigned to this institution in each year of training: Chief/Chair, Department of Pediatrics: For each participating institution provide letters of agreement specifying the administrative and organizational relationships which bear upon the educational program. Attach as Appendix C. OTHER PARTICIPATING INSTITUTION (Hospital 2) Name: Address: Total number of months Pediatric Endocrinology subspecialty Year 1: Year 2: Year 3: resident is assigned to this institution in each year of training: Distance between 2 and 1 in: Miles: Minutes: Is this hospital used for: (Please X appropriate box) Required Elective Both? rotations? rotations? OTHER PARTICIPATING INSTITUTION (Hospital 3) Name: Address: Total number of months Pediatric Endocrinology subspecialty Year 1 Year 2 Year 3 resident is assigned to this institution in each year of training: Distance between 3 and 1 in: Miles: Minutes: Is this hospital used for: (check appropriate box) Required Elective Both? rotations? rotations? Using the hospital designated as Primary Hospital 1, provide the following information: Primary Hospital 1 only Number of Beds Inpatient Pediatrics exclusive of ICU PICU NICU BACKGROUND INFORMATION Provide a response for each of the points below. If a category is not applicable, list it and indicate N/A.
  6. 6. 3 1. PREVIOUS CITATIONS AND/OR CONCERNS: List each of the citations and/or concerns, if any, from the notification letter that was sent following the last survey and review of the program and briefly and concisely describe the steps that have been taken to correct the problem. If such correction is documented in the program information form you prepare for this review, provide page references. (Insert text in box.) 2. CHANGES: Briefly describe major changes, other than those included in the response to previous citations and/or concerns (above), that have been implemented since the last survey and review. Include changes in sponsoring organization, participating hospitals, required rotations, program director, essential faculty, resident complement, etc. (Insert text in box)
  7. 7. SUBSPECIALTY RESIDENTS Programs making initial application should provide ONLY THE INFORMATION marked by an asterisk (*) in the top section of the page. Program Requirements for Subspecialties of Pediatrics II.C. *Number of positions offered: Year 1 Year 2 Year 3 *Number of positions filled: Year 1 Year 2 Year 3 *Source of salary support for subspecialty % from NIH: % from % from hospital: residents: Add the salaries of all other non- residents and indicate what percent of the federal total is supplied by each of the following programs: services: % from other federal % from % from other: programs: practice- generated income: *Does the program have a funded training YES NO grant? *If yes, supply the following: *Grant: *Amount *Project Director: CURRENT SUBSPECIALTY RESIDENTS (Refer to the Program Requirements for Subspecialties of Pediatrics II.C.) Provide the following information regarding the current residents in the program: Name of ACGME- accredited pediatric Date of residency program completion Date of ABP Date began Name completed* of residency Certifi.* endocrinology program Example: John Doe State Univ. School of 1997 1997 July 1, 1997 Med. Example: Mary Smith Foreign Country Med. 1993 N/A July 1, 1997 School *Explain exceptions (Insert text in box and limit your response to this page) Example: Mary Smith completed a pediatrics training program in a foreign country and was judged suitable for participation in subspecialty training. She will not be eligible to sit for the sub-board certifying examination.
  8. 8. SUBSPECIALTY RESIDENTS (continued) Provide the following information regarding those who have completed the program in the last seven years. Use additional pages as necessary. A program will be judged deficient if, over a period of 5-10 years, fewer than 75% of those completing the program have taken the certifying examination. Program Requirements in the Subspecialties of Pediatrics VIII. Total number of graduates who have completed the program in the last seven years: Number of graduates who have taken the sub board certifying # Graduates # Takers # Passed examination. Of this number, indicate how many have passed. Total_____ Total___ Total___ List residents in sequence by year of completion of endocrinology program. Name of ACGME accredited Took & Passed Failed pediatric subspecialty subspecialty residency Date of Date completed certification certification program completion Date of endocrinology exam and date exam and completed or of ABP List Graduates of Last 7 Years program date other* residency Certifi.* Example: John Doe July 1, 2000 Yes State Univ. 1997 1997 8/13/2000 School of Med. Example: Mary Smith July 1, 1997 N/A N/A Foreign Med. 1992 N/A School* *Explain exceptions (Insert text in this box and limit your response to this page) Example: Mary Smith completed a pediatrics training program in a foreign country and was, therefore, ineligible to sit for the sub- board certifying examination.
  9. 9. PROGRAM FACULTY Program Requirements for Subspecialties of Pediatrics, IV Program Requirements Pediatric Endocrinology, II A. PROGRAM DIRECTOR (Program Requirements for the Subspecialties of Pediatrics IV.A.) Explain on a page numbered 6a how the program director meets the Program Requirements with regard to: a) Board and Sub-board certification (If not certified by the American Board of Pediatrics' Sub-board of Pediatric Endocrinology Medicine, provide evidence of appropriate educational qualifications); b) Competence as a teacher and researcher; c) Adequate administrative experience to direct the program; and d) list other professional responsibilities; such as, division chief, department chair, private practice, and amount of time devoted to each. Attach as Appendix A the program director's full curriculum vitae and complete bibliography of articles in peer-reviewed journals. B. FACULTY (Program Requirements for Endocrinology II.A.) Identify the essential faculty members who are direct contributors to the program (Refer to Section II of Program Requirements for Endocrinology Medicine), including the program director. List the Pediatric Endocrinology subspecialists. Also include and identify any research mentors who participate in training in addition to the pediatric endocrinology subspecialists. 1. Provide details of each individual's role in this training program. If not certified in Pediatric Endocrinology, provide evidence of appropriate educational qualifications. Specify the type of contact with the residents, e.g., lectures, group discussions, ward rounds, laboratory supervision, patient care activities, consultations. Indicate clearly how the reported time is distributed. Include research mentors. Use additional pages as needed. 2. Attach curriculum vitae using the CV format contained on the page identified as Appendix B at the end of this form and follow its instructions. Do not include the CV for the program director as part of Appendix B. Time contributed to subspecialty Certification Name Primary specialty program Location Primary Recertif Sub- Sub- State primary role in / Board & y& year Boar Board Hours Weeks program Hospital year d& Recertify per per 1, 2, 3 year year week year 6
  10. 10. 7 PROGRAM FACULTY (continued) 3.OTHER PHYSICIAN TEACHING AND CONSULTANT FACULTY (working with Pediatric Endocrinology) at participating hospitals: Complete the following chart identifying the main person involved. It is understood that certification is not available in all of the disciplines listed below. List most recent certification or recertification, name of Board, and date. (If adult specialists cover pediatric subspecialties, enclose name or number in parentheses.) DO NOT include CVs. If any of the above are not housed predominantly in the primary hospital, provide specific details of their availability to the program. Include on a separate page inserted behind this page. Hospital 1, Certification/ Discipline Name 2, or 3 Sub-certification/ Recertification Name of Board/Sub- Year of board cert./ recert. SPECIFIC TO ENDOCRINOLOGY SPECIALTY Genetics Adult Endocrinology Internal Medicine Pediatric Nephrology Child Neurology Pediatric Neurosurgery Nuclear Medicine Obstetrics/Gynecology Pediatric Ophthalmology Pediatrics Child and Adolescent Psychiatry Pediatric Radiology Pediatric Surgery Pediatric Urology Other (specify)
  11. 11. 8 Hospital 1, Certification/ Name 2, or 3 Sub-certification/ Recertification Discipline Name of Board/Sub- Year of board cert./ recert. PEDIATRIC SUBSPECIALTIES Adolescent Medicine Cardiology Critical Care Emergency Medicine Gastroenterology Hematology/Oncology Infectious Diseases Neonatal-Perinatal Pulmonology Rheumatology SURGICAL SPECIALTIES Pediatric Orthopaedics Pediatric Otolaryngology OTHER DISCIPLINES Anesthesia Pathology Other:
  12. 12. 9 PROGRAM FACULTY (continued) D. OTHER PROFESSIONAL PERSONNEL List only the numbers of those who work in the Pediatric Endocrinology training program: Hospital 1 Hospital 2 Hospital 3 Staff trained in Psycho-Social support Staff trained and/or certified in Diabetes Education Other (specify) Describe the involvement of the staff in each of these categories in the Pediatric Endocrinology program. (Insert text in box):
  13. 13. FACILITIES AND SERVICES Indicate the availability of the following (Add additional pages as needed): Program Requirements for the Subspecialties of Pediatrics V.B.&D. Program Requirements for Pediatric Endocrinology III. Hospital 1 Hospital 2 Hospital 3 Facility/Service Yes No Yes No Yes No Space in an ambulatory setting for optimal evaluation and care of patients An inpatient area with full pediatric and related services (including surgery and psychiatry) staffed by pediatric residents and faculty Full support services including radiology, laboratory, nuclear medicine, pathology, nutrition, and social services Diagnostic Laboratories: 1. Radiommunoassay Facility 2. Chemistry Laboratory 3. Tissue Culture Facility (specify) 4. Diagnostic Radiology (CT, Isotope Scans, MRI, Others) Adequate library facilities with 24-hour availability to the residents. Computerized literature search facilities available? (Moved from narrative) Facility Number of Beds Inpatient Area If NO is indicated for any facilities and/or services across all hospitals, provide an explanation below. (Insert text in box.) Explain how the resident receives training in the performance of RIA or other immunoradiometric techniques, including assessment and interpretation of results. Also describe training in the use and interpretation of diagnostic steroid studies, hormone receptor assays (including HPLC) and other non-immunoradiometric tests such as chemiluminescent assays. (Insert
  14. 14. text in box.)
  15. 15. PATIENT DATA Provide the following information for the most recent 12-month period or academic year and use that same timeframe for all patient and procedural data provide n subsequent pages. Specify inclusive dates from month/date year to month/date/year. Note the same timeframe should be used throughout the forms. Program Requirements for the Subspecialties of Pediatrics V.C. Program Requirements for Pediatric Endocrinology IV. Inclusive dates: From (MM/DD/YY): To(MM/DD/YY): A. INPATIENT Hospital 1 Hospital 2 Hospital 3 1. Total number of admissions for whom the pediatric endocrinology service assumed major clinical responsibility a. Average daily census of patients on the pediatric endocrinology service (including diabetes) b. Number of new patients admitted each year (Anew@ refers to those who are seen by members of the endocrinology service for the first time.) Include Diabetes. c. Number of Pediatric patients admitted last year with diabetes mellitus: d. Average length of stay of patients on the Pediatric Endocrinology service (including diabetes): 2. Number of consultations by pediatric endocrinologists on other inpatients a. Are consultations provided to the NICU? Yes or No If yes, how many? b. Are consultations provided to the PICU? Yes or No If yes, how many? B. AMBULATORY VISITS Hospital 1 Hospital 2 Hospital 3 1. Is there a separate endocrinology clinic? Yes or No 2. If not, where are the ambulatory pediatric endocrinology patients seen (e.g. offices, clinics, location)? 3. Number of pediatric endocrinology ambulatory visits per year available to residents. 4. Of this number, how many are new patients? (Anew@ refers to those who are being seen by members of the endocrinology service for the first time.): 5. Number of Pediatric Endocrinology clinic sessions per week: 6. Number of pediatric patients with Diabetes Mellitus who are followed by the program: 7. Estimate the number of pediatric 1st Year 2nd Year 3rd Year endocrinology clinics a resident attends per year in the program.
  16. 16. PATIENT DATA 8. If the experience is in a private office remote from the primary or affiliated institutions, provide full details, including name and credentials of supervisor, numbers and types of patients, degree of resident responsibility for their care, frequency of attendance at office, how experience and resident performance are monitored 9. Explain how the residents have the opportunity to provide outpatient care for patients whom they treated on the inpatient service.
  17. 17. LIST OF DIAGNOSES List 150 consecutive inpatient admissions (A) and consultations (C) by the Pediatric Endocrinology service during the same 12- month period as used on previous pages. Use additional pages as necessary. Submit a separate list for each hospital that provides required rotations. Name of Hospital: Give inclusive dates during which these From (mo/day/yr): To (mo/day/yr): admissions/consultations occurred: Patient ID Number Major Procedure of days in or Tests A or C Number Age hospital Endocrinology Diagnosis Performed Outcome
  18. 18. 12-MONTH SUMMARY - OUTPATIENT/INPATIENT SERVICE Summarize how many pediatric patients with the following endocrinology problems were seen in the ambulatory setting and how many were admitted to or consulted on by the endocrinology service at the primary hospital. This should cover the same 12-month period used on the previous pages. Extract the information from the list of diagnoses on page 13 of this form. FOR NEW APPLICATIONS ONLY FILL IN THE FIRST COLUMN UNDER OUTPATIENTS AND THE FIRST TWO COLUMNS UNDER INPATIENTS. Name of Hospital: Inclusive Dates: From (mo/day/yr): To (mo/day/yr): Program Requirements for Pediatric Endocrinology IV. Outpatients Inpatients Number of patients Number seen by residents Number on Number on Number of Number seen endocrinology Number seen in endocrinology Number of Endocrine Disorders patients by residents service consultation service consultations 1. Short Stature (including constitutional delay) 2. Anterior Pituitary Hormone Physiology (including growth hormone deficiency) 3. Posterior Pituitary Hormone Physiology (including diabetes insipidus) 4. Hypothalamic Hormone Regulation 5. Thyroid Hormone Physiology (including secretion and synthesis) 6. Thyroid Nodules and Neoplasms 7. Adrenal Gland Physiology (including secretion and metabolism) 8. Sexual Differentiation and Development (including androgen and estrogen metabolism disorders) 9. Calcium, Phosphorous and Vitamin D Metabolism (including parathyroid gland physiology) 10. Carbohydrate Metabolism (including Diabetes Mellitus and Hypoglycemia) 11. Fluid and electrolyte balance 12. Nutrition, including eating disorders 13. Other Chronic Endocrine Disorders (please specify using additional sheet numbered 14 a if necessary) CURRICULUM
  19. 19. 1.In each block indicate the periods of time (1 month or one 4-week block) and percentages (100% clinical 50%, research, etc.) that represent the program. Designate clinical (C), research (R), elective (E), call from home (H), in-house called required (IH). Include vacation. 2.If one month is both clinical and research, indicate both in the block with percentages. 3.Identify the site in which each occurs (i.e., Hospital 1, Hospital 2, Site A, B, etc.) as designated on pages 1- 3 of this form. Asterisk the rotations that are call free. Program Requirements for the Subspecialties of Pediatrics VI.D. Program Requirements for Pediatric Endocrinology IV. Example Month/4wk 1 2 3 4 5 6 7 8 9 10 11 Endo Internal End Medicin Medicine Path* o Endo Endo Endo Endo Path* e (C)* (C)* (C& R) (C) (C) (C) (C) (C) (R) Endo Researc Experience or 100% 1 100% 1 50%/50 100 100 100% 100% 100% 100%1 (C) h* (R) rotations IH IH %1 %1 %1 1 1 1 H H 100% 2 100% 1 Asterisk the rotations that are call free FIRST YEAR BLOCK DIAGRAM Month/4wk 1 2 3 4 5 6 7 8 9 10 Experience or rotations SECOND YEAR BLOCK DIAGRAM Month/4wk 1 2 3 4 5 6 7 8 9 10 Experience or rotations THIRD YEAR BLOCK DIAGRAM Month/4wk 1 2 3 4 5 6 7 8 9 10 Experience or rotations Total number of months clinical_____________. Total number of months research___________. CURRICULUM (continued) If there are any exceptions to the training program as outlined on the previous page for any of the current residents, describe these exceptions below (Insert text in box.): SERVICE DUTIES (Program Requirements for Subspecialties of Pediatrics, VI.F.) Describe the call schedule and specify whether it is on-site or from home. Demonstrate how the schedule allows the subspecialty residents a monthly average of one day in seven away from program duties.
  20. 20. Describe the night call responsibilities during all rotations, including research, and whether call is done in-house or from home.
  21. 21. CONFERENCES List regular subspecialty and interdepartmental conferences, rounds, etc., that are a part of the Pediatric Endocrinology training program. Identify the "INSTITUTION" by using the corresponding number as appears on the first and second pages of this form. Indicate the frequency, e.g., weekly, monthly, etc., and whether conference attendance is required (R) or optional (0). HAVE CONFERENCE SCHEDULE AVAILABLE FOR REVIEW BY SITE VISITOR. DO NOT APPEND CONFERENCE SCHEDULE. Program Requirements for the Subspecialties of Pediatrics VI.E. Program Requirements in Pediatric Endocrinology IV.C. Person(s) responsible for Hospital Conference R/O Frequency conducting conference 1, 2, 3 Describe how residents participate in these activities (Insert text in box): Describe the mechanisms that are used to assure subspecialty resident attendance at required conferences. State to what degree faculty attendance is expected and how it is monitored. (Insert text in box.)
  22. 22. 19 NARRATIVE DESCRIPTION Provide a narrative description of this subspecialty program. The points listed below should be covered in the narrative. Insert text in boxes throughout this section. Note that the boxes will expand as text is entered and page s will automatically number. If page numbering become s a problem , turn off the page numbering function, and number pages sequentially by hand. See page 2 of the instructions for further information . A. PROGRAM GOALS AND OBJECTIVES (Program Requirements for Subspecialties of Pediatrics IV.A.2.) 1. Describe how the written statement outlining the educational goals of the program for each level of training with respect to knowledge, skills, and other attributes, and for each major rotation or other program assignment are distributed to subspecialty residents and members of the teaching staff. The written statement outlining the educational goals as required in IVA2 must be made available to the site visitor. Do not include them with the program information form. 2. Describe how goals and objectives are reviewed and revised. Describe the role of the subspecialty resident and faculty in this process. 3. Describehowthe writtenguidelinesdescribingsupervisorylinesof responsibilityfor the careof patientsarecommunicated to all membersof the programstaff. B. RELATIONSHIP TO OTHER PROGRAMS (Program Requirements for the Subspecialties of Pediatrics I. & VI.E.) 1. Describe the differences in responsibilities for the subspecialty residents at each level of training from those of the pediatric residents. 2. Describe how patients are assigned or apportioned between the pediatric residents and those in this subspecialty program. 3. Describe how those in this subspecialty program are involved with other pediatric subspecialty residents, other clinics, departments and accredited residency programs. C. SPECIALTY EXPERIENCES (Program Requirements for the Subspecialties of Pediatrics VI.B. and Program Requirements
  23. 23. 20 for Pediatric Endocrinology IV.) 1. Provide a general description of each year of training. 2.Inpatient experiences a. Describe the responsibilities that the subspecialty residents have for inpatients when assigned to inpatient services. b. Describe how and by whom the subspecialty residents are supervised. 3.Describe how the written statement outlining the educational goals of the program with respect to knowledge, skills, and other attributes of the subspecialty residents t each level of training, and for each major rotation or other program assignment are distributed to subspecialty residents and members of the teaching staff. d. State how many hours per week they participate in rounds with faculty. Describe this experience. 3. Outpatient experiences (if applicable) a. Describe the degree of responsibility the subspecialty residents have for required outpatient care. b. Describe how and by whom the subspecialty residents are supervised in the outpatient setting. c. State how many hours per week they participate in rounds with faculty. Describe this experience. . 4.Describe any additional outpatient facilities where residents gain ambulatory experience, e.g. emergency department and other clinics. Include the nature of the experience, location, supervision and the educational rationale for each. 4. Core Curriculum a. Describe any special sessions/coursework/special laboratory experiences in which the residents participate.
  24. 24. 21 b. Describehowthe programprovidesinstructionin relatedclinical andbasicsciencesrelatedto endocrinephysiology, pathology,andbiochemistry;embryologyof endocrineand relatedsystemswithemphasison sexualdifferentiation; genetics,includinglaboratorymethods,cytogenetics,andenzymology;andaspectsof immunologypertinentto understandingendocrinediseaseandthe useof immunoassays. c. Describehowthe programprovidesappropriatebackgroundin the pathophysiologyof disease,reviewsof recent advancesin clinical medicineandbiomedicalresearch,conferencesdealingwithcomplicationsanddeath,as well as instructionin the scientific,ethical, andlegal implicationsof confidentialityandof informedconsent. d. Describehowthe programprovidesinstructionin socioculturalfactorsthataffectpatientsandtheir families. e. Describehowthe programprovidesappropriatebackgroundin bioethics,biostatistics,epidemiologyandpopulation medicine,outcomeanalysis, andthe economicsof healthcare. D. TEACHING AND ADMINISTRATIVE EXPERIENCE (Program Requirements for the Subspecialties of Pediatrics VI.E. 1. Describethe residents'instructionandexperiencein the administrationof a PediatricEndocrinologyfacility. 2.Describe how these teaching experiences correlate basic biomedical knowledge with the clinical aspects of the subspecialty. 3. Describe how the program provides instruction in curriculum design and in the development of teaching material for the subspecialty residents. 4.Describe how the subspecialty residents are involved in the education of more junior trainees; such as, medical students, and pediatric residents. E. FACULTY RESEARCH (Program Requirements for Subspecialties of Pediatrics, VI.G.) 1. Describe how the program director is directly involved in a research program. 2. Describe participation of other faculty in this subspecialty who are actively engaged in research.
  25. 25. 22 6.RESIDENT RESEARCH PROGRAM 1. Describe how the program ensures a meaningful supervised research experience for the residents, beginning in their first year and extending throughout their training. Include a description of how they learn experimental design, data collection and analysis, and laboratory techniques used in this subspecialty research. Include the plans for frequency and duration of these sessions and the year of training in which they occur. Identify the teacher/supervisor in each case, and specify call- free research time. 2. If faculty outside the division are actively involved in (research) mentoring the residents, list and provide details. 3. Describe the support and guidance the subspecialty residents receive in the preparation of manuscripts, presentations, and in the process of grant application. 4. Describe research facilities, space and equipment directly related to this subspecialty program and the residents' research activity. 5. List active research projects in this subspecialty. Include the title of the project, the principal investigator(s), and the amount, dates and source(s) of financial support. RESEARCH PROJECTS Title of Project Principal Amount of Financial Dates of Financial Source(s) of Financial Investigator(s) Support Support Support 6. To enable the Committee to assess the scholarly environment that has occurred in the program, provide a list of scholarly publications and presentations at regional, national and international meetings by faculty and residents within the program for the last five years only. Do not duplicate citations. Underline the names of subspecialty residents. List journal articles, presentations and abstracts separately under those headings. G. EVALUATION (Program Requirements for Subspecialties of Pediatrics, VII) Do not attach evaluation forms but have them available for inspection by the site visitor. Demonstrate to the site visitor that the pediatric core= s evaluation mechanisms were adopted. 1. Evaluation of subspecialty residents a. Describe the frequency and by whom the residents in this program are formally evaluated.
  26. 26. 23 b. Describe the formal mechanisms for monitoring each resident=s acquisition of skills utilized in this subspecialty. Describe what part this process plays in the evaluation of subspecialty residents. 3.Describehowthe programdemonstratesthat it has an effectiveplan for assessingresidentperformancethroughoutthe programandfor utilizingassessmentresultsto improveresidentperformance. d. Explain the process, frequency and by whom these written evaluations are discussed with the residents and whether they have the opportunity to read and respond to their evaluations. e. Describe the information that is in the final written evaluation for each subspecialty resident who completes the program and where the evaluation is kept. 2. Evaluation of faculty a. Describe the mechanism, frequency and by whom faculty are evaluated on their teaching ability, clinical knowledge and scholarly activity. b. Describe how the subspecialty residents in this training program participate confidentially in the process. 3. Evaluation of program by staff and residents a. Describe the mechanisms for periodic evaluation of the training program by the staff and the residents. b. Explain how often these evaluations are used in program planning and development. c. Describe the mechanism by which the subspecialty residents participate confidentially in program evaluation.
  27. 27. Appendix B CURRICULUM VITAE CV should be condensed to fit this page. Do not add additional pages except as directed below. . Name: Position: Address: Professional Education (including dates and degrees obtained): Hospital Training (including dates of internships, residencies, fellowships, etc.): Current professional appointments: Primary certification* (including name & Subspecialty certification* (including Recertification (including date): date): date:) Professional activities/committees: Provide a brief description of your teaching role in this subspecialty program: (Insert text in box.) Include a bibliography for the past FIVE YEARS ONLY, limited to articles published or in press and abstracts presented. *If not Board Certified, provide evidence of appropriate educational credentials.
  28. 28. CONTENTS PROGRAM NAME: PROGRAM #: Once you have completed the form, number each page sequentially in the upper right hand corner. Report this pagination on this page. Place this table of contents at the front of the form. SECTION IN PROGRAM INFORMATION FORM Page Number(s) 1. Training Sites Sponsoring Institution Participating Institutions 2. Background Information Previous Citations and/or Concerns Changes 3. Pediatric Endocrinology Residents 4. Program Faculty A. Program Director B. Faculty C. Other Physician Teaching & Consultant Faculty D. Other Professional Personnel 5. Facilities and Services 6. Patient Data 7. List of Diagnoses 8. 12 Month Summary: Outpatient/Inpatient Services 9. Curriculum Block Diagram Service Duties 10. Conferences 11. Narrative Description of the Pediatric Endocrinology Program A. Program Goals and Objectives B. Relationship to Other Programs C. Specialty Experiences D. Teaching and Administrative Experience E. Faculty Research F. Resident Research Program G. Evaluation 12. Appendices Appendix A (Program Director’s Full CV) Appendix B (Teaching Staff CV’s) Appendix C (Letters of Agreement)