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NASPGHAN Guidelines for T...
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that includes the esophag...
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The competency of medical...
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clinical examinations, si...
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competency in the perform...
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During these designated p...
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within pediatric gastroen...
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16. Toolbox of Assessment...
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2. CONTENT AREAS
Organizi...
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omphalocele) and of conge...
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Functional GI and Motilit...
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medications (indications ...
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GI Bleeding
Task Force Me...
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bowel enteroscopy, and ra...
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Examples of Relevant Comp...
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pathogenicity of other ag...
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Trainees should understan...
Naspghan guidelines for_training_in_pediatric.1
Naspghan guidelines for_training_in_pediatric.1
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Naspghan guidelines for_training_in_pediatric.1

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  • 1. Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. NASPGHAN Guidelines for Training in Pediatric Gastroenterology Alan M. Leichtner, Lynette A. Gillis, Sandeep Gupta, James Heubi, Marsha Kay, Michael R. Narkewicz, Elizabeth A. Rider, Paul A. Rufo, Thomas J. Sferra, Jonathan Teitelbaum, and the NASPGHAN Training Committee 1. OVERVIEW The field of pediatric gastroenterology, hepatology, and nutri- tion (referred to subsequently as pediatric gastroenterology) continues to expand and evolve and is far different from 1999, when the previous guidelines on fellowship training in this field were published (1). Although still a relatively young field, this subspeci- alty is increasingly recognized and accepted throughout the world (2), albeit with varying degrees of medical resources and access to care. Tremendous medical advances, especially in the fields of genetics, infectious disease, pharmacology, and immunology, have changed our fundamental understanding of pathophysiology, and along with technological innovations, such as wireless imaging technology and intraesophageal impedance monitoring, have affected the way we diagnose and manage disease. At the same time, economic factors have become increasingly important in discussions of health care and graduate medical education (3). With rapidly escalating health care costs, care must be demon- strated to be not only high in quality but also cost-effective. Moreover, in response to pressure from the public to ensure practitioners are competent, accrediting agencies are imposing new and increasingly complex constructs for assessing the competency of our trainees. These factors demand that the training of pediatric gastroenterology fellows be continuously revised and reevaluated. It is not sufficient to focus exclusively on the clinical aspects of training, however. Although the primary mission of fellowship programs is to create competent clinicians, ensuring the health of future generations requires a broader training mission that recog- nizes that some of our trainees will choose careers as researchers and medical educators. Fellowship training, therefore, must provide individuals with the opportunity to pursue other essential career pathways. The necessity of providing this more inclusive training must be reconciled with evolving lifestyle expectations of trainees (4) and duty hour restrictions (5). In response to these enumerated factors, the Executive Council of the North American Society for Pediatric Gastroenter- ology, Hepatology, and Nutrition (NASPGHAN) charged its Train- ing Committee with the task of updating the 1999 fellowship training guidelines. The goals outlined by the Steering Committee were to consider existing guidelines and seek consistency where possible; specifically incorporate the Accreditation Council for Graduate Medical Education (ACGME) competencies; create a framework that would permit consistent updating; reflect the unique aspects of pediatric gastroenterology, including the breadth of the field and unique nature of the patients, especially the changing presentation of disease as children develop; and respond to the practical needs of pediatric gastroenterology program direc- tors. In addition to the original NASGPHAN guidelines, other existing guidelines were reviewed in the preparation of this document. Table 1 provides a list of the primary guidelines and the means to access them. ACGME’s Residency Review Committee issues standards for fellowship training in pediatric gastroenterology and updates them every 5 years, with the most recent update in 2009 (6,7). ACGME establishes detailed training program requirements that are not included in these NASPGHAN guidelines. Requirements for training as a pediatric gastroentero- logist in Canada are enumerated by the Royal College of Physicians and Surgeons in Canada (RCPSC) (8,9). The European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESP- GHAN) reviewed training issues and developed a curriculum for fellows in 2002 (2). The task force also reviewed the gastroenter- ology core curriculum generated by 4 adult gastroenterology societies that was updated in 2007 (10) and the recent guidelines for fellowship training in pediatric cardiology, a subspecialty with similar training issues, including procedure training and advanced training opportunities (11). Unique Characteristics of a Pediatric Gastroenterologist A pediatric gastroenterologist is expected to be an expert in the anatomy and physiology of a large segment of the human body G.G.C. has received compensation from the National Institutes of Health; M.C. has served on the speakers’ bureau and consulted for Nestle and served on the board of directors of the American Society for Parenteral and Enteral Nutrition; S.H.E. has consulted for Prometheus Labs; J.F. or her institution has received compensation from the Improve Care Now collaborative and Providence Health System; C.A.F. has received com- pensation from Children’s Mercy Hospital and the Driskill Law Firm; L.A.G. has received compensation from Vanderbilt University; S.G. has received compensation from numerous entities for consultancies, employment, expert testimony, grants, lectures/speakers’ bureaus, and stocks/stock options; J.H. has served on the board of Asklepion Pharm LLC, consulted to Nordmark and the Cystic Fibrosis Foundation, has received or has grants pending with Asklepion Pharma LLC, the National Institutes of Health, the Cystic Fibrosis Foundation, and Nordmark, and holds equity interest in Asklepion Pharma LLC; M.R.N. or his institution has received compensation from Vertex Pharmaceuticals and the Cystic Fibrosis Foundation; M.D.P.’s institution has grants/grants pending with Abbott Laboratories, AstraZeneca, Centocor, the Crohn’s and Colitis Foundation, the National Institute of Diabetes and Digestive and Kidney Diseases/National Institutes of Health, Nestle, and Optimer Pharmaceu- ticals; E.A.R. has received compensation from the Institute for Profes- sionalism & Ethical Practice, Boston Children’s Hospital; P.A.R.’s institution has received compensation from TechLab Inc; T.J.S. serves as the medical editor for the NASPGHAN Web site; L.J.S.’s institution has received compensation from Merck Pharmaceuticals and Vertex Pharmaceuticals, and L.J.S. has received compensation from Abbott Nutrition; J.T. has received compensation from the American Board of Pediatrics, Prometheus Labs, and Up to Date. The other authors report no conflicts of interest. Copyright # 2012 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition DOI: 10.1097/MPG.0b013e31827a78d6 JPGN Volume 56, Supplement 1, January 2013 S1
  • 2. Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. that includes the esophagus, stomach, intestines, liver, biliary tree, and pancreas, as well as the diverse array of acute, subacute, and chronic illnesses that may affect these organs. Trainees must have the ability to analyze and integrate the clinical data, instead of limiting their thought processes to a particular organ or segment of the gastrointestinal (GI) tract. In pediatric gastroenterology, an assessment of growth and nutrition is an especially integral part of any patient’s evaluation and care. Diseases of the digestive system can negatively affect the nutritional status of the child; conversely, the nutritional status of the child can profoundly affect the diagnostic evaluation of the patient. In addition, the practitioner must possess exemplary inter- personal and communication skills, because the field of pediatric gastroenterology is truly multidisciplinary and requires routine consultations and collaborations with myriad allied providers, including endoscopy suite and operating room personnel, nurses, dietitians, pharmacists, social workers, surgeons, intensivists, radi- ologists, pathologists, psychologists, and psychiatrists. Many of the diseases encountered by a pediatric gastroenterologist also are of relevance to other subspecialties, including endocrinology, rheu- matology, pulmonology, and metabolism/genetics, necessitating collaborative relationships with these experts. A pediatric gastroenterologist, unlike an adult gastroenter- ologist, interacts extensively with both the patient and the patient’s care provider(s). As such, it is imperative that the care not only be evidence-based and cost-effective but also be delivered in a com- passionate manner that respects patients’ families and their cultures. The fiscal aspects of health care, especially in the United States, are undergoing seismic modifications and it is anticipated that events in the next 5 years will be characterized by vastly different reimburse- ment models and accountability in medicine. A pediatric gastro- enterologist will need to be adept at demonstrating added value to health care dollars and strive for continuous quality enhancement of care. Knowledge of the dollar footprint of care will be imperative, especially as the subspecialist will have increasing access to an ever-expanding array of technological tools and diagnostic modalities, including medical genetic and pharmacogenetic testing. Furthermore, it is likely that as medical homes are established, pediatric subspecialists will need to develop new relationships with primary care providers. The other trend affecting fellowship programs is the juxta- position of personal lifestyle choices and career choices. A subset of pediatric gastroenterologists works part-time for a variety of reasons, including needs for childcare, personal (or family) health issues, or other personal obligations or pursuits. Because these needs affect the training years, programs have increasingly adapted to trainee lifestyle requests. In the early years of this subspecialty, the majority of practitioners entered academic institutions, and this later expanded to private practice options. Presently, graduating trainees also consider hybrid practices in which they have an academic appointment with some role in trainee education, but otherwise maintain an independent practice. In summary, the field of pediatric gastroenterology is under- going rapid transformation and these updated guidelines aim to address the changes occurring in the training of this subspecialty during the last decade and, more important, to prepare us for the future. Competencies ACGME was established in 1981 with a goal of developing a uniform set of guidelines that could be applied to ensure and improve the quality of resident and fellow education. As part of its Outcome Project, 6 core competencies that could serve as focal points in the development of residency and fellowship training program curricula were identified in 1999 and became part of program requirements in 2002 (12). Similarly, the RCPSC devel- oped a set of core competencies that are an integral part of fellow- ship training program curricula (Canadian Medical Education Directives for Specialists, or CanMEDS competencies) (13). Although the CanMEDS competencies are not identical to those of the ACGME, their goals are similar (Table 2). Application of these core competencies and implementation of assessment tools by program directors of pediatric gastroenterology fellowship training are required for program certification by the ACGME and the RCPSC. Table 3 indicates how the ACGME competencies are presented in this guideline document. TABLE 1. Guide to existing guidelines Organization Specification Location (ref) ACGME Program requirements Web site (6) Clinical training requirements Web site (7) Duty hours Web site (5) ABP Specifications for scholarly work Web site (24) RCPSC Program requirements Web site (9) Clinical training requirements Web site (8) AASLD, ACG, AGA, ASGE Internal medicine training requirements in gastroenterology Journal article (10) ESPGHAN Pediatric gastroenterology training requirements Journal article (2) AASLD, American Association for the Study of Liver Diseases; ABP, American Board of Pediatrics; ACG, American College of Gastroenterology; ACGME, Accreditation Council for Graduate Medical Education; AGA, American Gastroenterological Association; ASGE, American Society for Gastrointestinal Endoscopy; ESPGHAN, European Society for Pediatric Gastroenterology, Hepatology, and Nutrition; RCPSC, Royal College of Physicians and Surgeons in Canada. TABLE 2. ACGME and CanMEDS core competencies ACGME CanMEDS Medical knowledge Medical expert Interpersonal and communication skills Scholar Patient care Communicator Systems-based practice Collaborator Practice-based learning and improvement Manager Professionalism Health advocate Professional ACGME, Accreditation Council for Graduate Medical Education; CanMEDS, Canadian Medical Education Directives for Specialists. Leichtner et al JPGN Volume 56, Supplement 1, January 2013 S2 www.jpgn.org
  • 3. Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. The competency of medical knowledge (CanMEDS Medical Expert and Scholar) requires that fellows demonstrate knowledge of relevant biomedical, clinical, epidemiological, and socio- behavioral sciences and their application to patient care. Areas that are particularly applicable to understanding the clinical mani- festations and treatment of GI disease include developmental biology, pharmacology, host/microbial interactions, immunology, and genetics. Fellows should develop an understanding of the patho- physiology underlying the disorders that are encountered in ambu- latory and inpatient settings. Medical knowledge should be obtained through didacticconferences,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 pro- cedures 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 gastro- enterology 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 improve- ment (CanMEDS Scholar) emphasizes lifelong learning. Instruc- tion 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 under- standing 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 perform- ance 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 phys- ician, 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 thera- peutic and ethically sound relationships with patients, use effec- tive 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 socio- economic boundaries. In addition, fellows should begin to learn the skills necessary to communicate their findings and experi- ences 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 Pro- fessional) 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, collabor- ation, and working in partnership with members of the health care team (15). Moral reasoning and judgment also are essential com- ponents of professional behavior. Fellows should receive formal training in bioethics to equip them in addressing complex pro- blems, such as parental unwillingness or inability to provide life- saving 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 deliv- ery 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 per- formance, 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 TABLE 3. Mapping ACGME competencies to guidelines Competency Guideline section Medical knowledge Overview, Content Area text Patient care Overview, Content Area text Communication Overview Problem-based learning Overview Professionalism Overview, Content Area tables Systems-based practice Overview, Content Area tables ACGME, Accreditation Council for Graduate Medical Education. JPGN Volume 56, Supplement 1, January 2013 Guidelines for Training in Pediatric Gastroenterology www.jpgn.org S3
  • 4. Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. clinical examinations, simulations, patient surveys, and 360o glo- bal 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 devel- opment 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 con- tent areas of this document include the development of tables that relate possible EPAs in each specific area to appropriate competen- cies. In the future, guidelines for training in pediatric gastroenterol- ogy 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 com- petencies 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 gas- troenterology practice and the ACGME requirements, we recom- mend 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 1/2 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 respon- sibility 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 com- petence 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, includ- ing 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, trans- lational, 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 herarea 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 TABLE 4. Apportionment of training time Category Months of training à Clinical 15–24 Scholarly project 12–21y à Vacation time should be distributed proportionally between time devoted to clinical training and the scholarly project. y The nature of the scholarly project must be considered in the apportion- ment of time. Some projects will require longer time investment to achieve acceptable quality goals. Leichtner et al JPGN Volume 56, Supplement 1, January 2013 S4 www.jpgn.org
  • 5. Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. 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 facili- tate 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 appro- priate 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 pro- cedures, which include diagnostic and therapeutic upper GI endo- scopy, 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 impe- dance 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 certifica- tion requirements. As a result, guidelines for procedure training will require regular updates. Scholarship Integral to the advancement of the care of children with GI, hepatobiliary, pancreatic, and nutritional disorders is the elucida- tion of basic disease mechanisms and the development of new diagnostic and therapeutic strategies. In addition, a greater under- standing of the genetic, molecular, and cellular processes control- ling 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 ser- vices, 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), sub- specialty 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 inter- related 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 assess- ment 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 com- munication 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 scholar- ship 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. TABLE 5. Overall training for different career pathways Intended career pathway Length of training, y à Clinical practice 3 Clinical practice with subspecialization 3–4 Medical education 3 Independent research At least 4–5 à The estimates assume 3 years for standard pediatric gastroenterology fellowship. JPGN Volume 56, Supplement 1, January 2013 Guidelines for Training in Pediatric Gastroenterology www.jpgn.org S5
  • 6. Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. 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 biostatis- tics, 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. Further- more, the trainees should develop as effective teachers of individ- uals 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 subspe- cialists 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 hypoth- esis 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 reflec- tive 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 funda- mental 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 conjunc- tion 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 activi- ties, 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. Advanced Training Given the explosion of knowledge and technology, some pediatric gastroenterologists have restricted their practices to cer- tain 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 trai- nees 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, thera- peutic 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 Leichtner et al JPGN Volume 56, Supplement 1, January 2013 S6 www.jpgn.org
  • 7. Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. 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. Further- more, 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 train- ing in these areas. Format of the Content Areas Traditional approaches to enumerating the medical know- ledge 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 Guide- lines Steering Committee established a number of guiding prin- ciples 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 pro- blem-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, hepato- biliary disorders, IBDs, malignancies and premalignant con- ditions, 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 under- standing the field of pediatric gastroenterology. Acknowledgments: 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. REFERENCES 1. Rudolph CD, Winter HS, NASPGN Executive Council, et al. NASPGN guidelines for training in pediatric gastroenterology. J Pediatr Gastro- enterol Nutr 1999; 29:S1–26. 2. Milla P. The European training syllabus in pediatric gastroenterology, hepatology, and nutrition. J Pediatr Gastroenterol Nutr 2002;34:111–5. 3. Iglehart JK. Health reform, primary care, and graduate medical educa- tion. N Engl J Med 2010;363:584–90. 4. Worley LL, Cooper GJ, Fiser DH. Generational evolution and the future of pediatrics. J Pediatr 2004;145:143–4. 5. Duty hours: ACGME standards. www.acgme.org/acgmeweb/tabid/271/ GraduateMedicalEducation/DutyHours.aspx. Accessed November 19, 2012. 6. ACGME Program Requirements for Graduate Medical Education in Pediatrics. www.acgme.org/acgmeweb/Portals/0/PDFs/archive/320_ pediatrics_PRs_RC.pdf. Published 2007. Accessed November 19, 2012. 7. ACGME Program Requirements for Graduate Medical Education in Pediatric Gastroenterology. www.acgme.org/acgmeweb/Portals/0/ PFAssets/2013-PR-FAQ-PIF/332_gastroenterology_peds_07012013.pdf. Published 2009. Accessed November 19, 2012. 8. Gastroenterology: specialty training requirements. http://rcpsc.medical. org/residency/certification/training/gastroenterology_e.pdf. Published 2011. Accessed July 27, 2012. 9. Gastroenterology: specific standards of accreditation requirements for residency programs (pediatric). http://rcpsc.medical.org/residency/ accreditation/ssas/gastropeds_e.pdf. Published 2011. Accessed July 27, 2012. 10. American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Associa- tion (AGA) Institute, American Society for Gastrointestinal Endoscopy. The gastroenterology core curriculum, third edition. Gastroenterology 2007; 132:2012–8. 11. Allen HD, Bricker JT, Freed MD, et al. ACC/AHA/AAP recommenda- tions for training in pediatric cardiology. Pediatrics 2005;116:1574–96. 12. ACGME. Common program requirements: general competencies. www.acgme.org/.../InstitutionalReview/ProgramDirectorGuidetothe CommonProgramRequi.aspx Published 2007. Accessed November 19, 2012. 13. CanMEDS 2005 Framework. http://www.royalcollege.ca/portal/page/ portal/rc/canmeds/framework. Accessed November 19, 2012. 14. Rider EA. Interpersonal and communication skills. In: Rider EA, Nawotniak RH, eds. A Practical Guide to Teaching and Assessing the ACGME Core Competencies. 2nd ed. Marblehead, MA: HCPro Inc; 2010: 1–47. 15. Committee on Bioethics, American Academy of Pediatrics. Policy statement—professionalism in pediatrics: statement of principles. Pediatrics 2007; 120:895–7. TABLE 6. Format of the content areas Section Description Importance of area Statement of the significance of the content area within pediatric gastroenterology Medical knowledge Enumeration of the concepts necessary for competent clinical care Patient care Enumeration of the skills and patient experiences necessary for competent clinical care: history-taking and physical examination, use and interpretation of diagnostic tests, participation in multidisciplinary care and longitudinal follow-up Professionalism Table relating to EPA(s) Systems-based practice Table relating to EPA(s) Developmental context Examples of emphasizing different disease presentations at different ages JPGN Volume 56, Supplement 1, January 2013 Guidelines for Training in Pediatric Gastroenterology www.jpgn.org S7
  • 8. Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. 16. Toolbox of Assessment Methods. 2000. (Accessed August 29, 2011, at http://www.acgme.org/outcome/assess/toolbox.asp.) 17. Rider EA, Nawotniak, RH. In: A Practical Guide to Teaching and Assessing the ACGME Core Competencies. 2nd ed. Marblehead, MA: HCPro Inc; 2010. 18. Green ML, Holmboe E. Perspective: the ACGME toolbox: half empty or half full? Acad Med 2010;85:787–90. 19. Jones MD Jr, Rosenberg AA, Gilhooly JT, et al. Perspective: compe- tencies, outcomes, and controversy—linking professional activities to competencies to improve resident education and practice. Acad Med 2011;86:161–5. 20. ten Cate O, Scheele F. Competency-based postgraduate training: can we bridge the gap between theory and clinical practice? Acad Med 2007;82:542–7. 21. ten Cate O. Entrustability of professional activities and competency- based training. Med Educ 2005;39:1176–7. 22. Hicks PJ, Schumacher DJ, Benson BJ, et al. The pediatrics milestones: conceptual framework, guiding principles, and approach to develop- ment. J Grad Med Educ 2010;2:410–8. 23. ACGME/ABP. The pediatrics milestone project. http://www.acgme.org/ acgmeweb/tabid/143/ProgramandInstitutionalGuidelines/MedicalAccr editation/Pediatrics.aspx. Published 2010. Accessed November 19, 2012. 24. American Board of Pediatrics. Principles regarding the assessment of scholarly activity. https://www.abp.org/ABPWebStatic/?anticache= 0.19046151501638908-murl=%2FABPWebStatic%2FresidentFellow Training.html%26surl=%2Fabpwebsite%2Fcertinfo%2Fsubspec%2 Fscholary.htm. Published 2008. Accessed August 30, 2011. 25. Boyer EL. Scholarship Reconsidered: Priorities of the Professiorate. San Francisco: Jossey-Bass; 1990. 26. American Board of Pediatrics. Eligibility criteria for certification in pediatric transplant hepatology. https://www.abp.org/ABPWebStatic/ indexSearch.html?url=/abpwebsite/becomecert/subspecialties/subspec ialtycertifications/pediatrictransplanthepatology.htm. Published 2010. Accessed November 19, 2012. 27. American Board of Internal Medicine. Taking the transplant hepatology exam. http://www.abim.org/exam/certification/transplant-hepatology. aspx. Published 2010. Accessed September 3, 2011. Leichtner et al JPGN Volume 56, Supplement 1, January 2013 S8 www.jpgn.org
  • 9. Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. 2. CONTENT AREAS Organizing the essential knowledge and skills that fellows should acquire by the end of fellowship training into an easily readable document is a daunting task. Although the 11 content areas were chosen to reflect the major themes in pediatric gastro- enterology, some specific topics do not clearly fit into any area and others overlap !2 areas. Readers seeking a truly comprehensive list should also consult the ABP Content Outline for Pediatric Gastroenterology (1). Trainees in pediatric gastroenterology should understand the diagnostic and therapeutic approach to important GI problems in children that are not included in any single content area, such as the following: Vomiting Diarrhea Abdominal pain Abdominal mass lesions Conditions associated with protein-losing enteropathy Abdominal trauma Rectal prolapse In addition, trainees should be familiar with the diagnosis and management of conditions that frequently are managed primarily by pediatric surgeons and other pediatric subspecialists, including the following: Acute appendicitis Pyloric stenosis Intussusception Other causes of obstruction of the GI tract Foreign bodies Necrotizing enterocolitis of the newborn REFERENCE 1. American Board of Pediatrics. Content outline. Pediatric gastroenterology. Subspecialty in-training, certification, and maintenance of certification examinations.https://www.abp.org/abpwebsite/takeexam/subspecialtycer- tifyingexam/contentpdfs/gast2011.pdf. Published 2009. Accessed July 30, 2012. Congenital Anomalies Task Force Members Jacqueline Fridge, Chair Michael D. Bates William J. Byrne Sanjeev Dutta Importance of Area Because many children with congenital anomalies present initially to a pediatric gastroenterologist and usually continue their posttreatment long-term care with a pediatric gastroenter- ologist, trainees should be familiar with these anomalies and the diagnosis, treatment options, and long-term prognosis for these patients. Medical Knowledge Trainees in pediatric gastroenterology should understand the embryologic origins, normal histology, and vascular supply of the entire digestive system and have a detailed understanding of fundamental developmental processes, including intestinal rotation and fixation. They should know the incidence, presentation, and natural history of congenital anomalies, both treated and untreated. For anomalies having a known genetic basis, they should under- stand the pattern of inheritance and implications for the family. Trainees should be familiar with the differential diagnosis of the various anomalies and the various treatment approaches, even though many therapy options fall outside the role of a pediatric gastroenterologist. When surgical treatment is needed, trainees should understand the general techniques and potential compli- cations. Trainees should understand the malformations that can directly affect feeding: Pierre Robin sequence Cleft lip and palate Treacher Collins syndrome Anomalies of and around the esophagus (eg, atresia, web, tracheoesophageal fistula [TEF], and vascular ring) Trainees should thoroughly understand the advantages and disadvantages of feeding methods, how feeding choices can be individualized for each child’s needs, and that feeding choices in infancy can have significant consequences for future feeding abilities. Trainees should be familiar with anatomic anomalies of the foregut (including the liver, biliary system, and pancreas). Trainees should understand the presentation and complications of anatomic variants of hepatic and pancreatic anatomy and vascular supply, including congenital biliary atresia, choledochal cyst, annular pancreas, and pancreas divisum. They should know the strengths and pitfalls of various diagnostic methods (eg, ultrasonography, computerized tomography [CT], magnetic resonance cholangio- pancreatography [MRCP], and endoscopic retrograde cholangio- pancreatography [ERCP]) in assessing the pancreas and biliary tract. Trainees should be aware of other foregut anomalies, including anomalies of the stomach and duodenum (eg, web, duplication, atresia), which may present with upper GI tract obstruction. Trainees should be aware of important congenital anomalies of the midgut, including anomalies of the small intestine (eg, web, duplication, atresia, Meckel diverticulum). They should compre- hend abnormalities of rotation and fixation, including malrotation and volvulus. Trainees should know that the differential diagnosis of a small bowel obstruction in the newborn also includes meco- nium ileus from cystic fibrosis. Trainees should be familiar with anomalies of the hindgut, including abnormalities of fixation, atresias, and anorectal malformations. Trainees should understand the wide age range of presen- tation of these and other associated anomalies, and they should be familiar with methods of diagnosing these anomalies and indica- tions for surgery. They should also know diagnostic and therapeutic approaches to upper GI (UGI) and lower GI (LGI) obstruction and be able to recognize the symptoms and signs of bacterial over- growth that may accompany obstruction or blind loops. Trainees also should be familiar with the treatment and consequences of abdominal wall defects (eg, gastroschisis, JPGN Volume 56, Supplement 1, January 2013 Guidelines for Training in Pediatric Gastroenterology www.jpgn.org S9
  • 10. Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. omphalocele) and of congenital diaphragmatic hernias. Trainees should recognize that abdominal wall and diaphragm defects are typically associated with anomalies of intestinal rotation, but that in most cases these are clinically inconsequential. Trainees should be aware of syndromes and associations that frequently include congenital anomalies of the GI tract (eg, Down syndrome, VACTERL association [a combination of at least 3 of the following defects: vertebral defects, anal atresia, cardiac defects, TEF, renal anomalies, and limb abnormalities]). Trainees should understand congenital anomalies that can cause disorders of defecation (eg, spina bifida, tethered cord, Hirsch- sprung disease), and they should be familiar with syndromic conditions that have hepatobiliary associations (eg, Alagille syndrome). Trainees should be familiar with the presentation, differential diagnosis, evaluation, and long-term treatment of these disorders. Trainees should appreciate that many of these congenital anomalies of the intestinal tract have long-term motility con- sequences because of disordered fetal GI development, and they should become proficient in treatment approaches for the feeding- intolerant child. Required Patient Care Experiences/Skills Trainees should develop the necessary skills and experience in history taking and physical examination of neonates and children of all ages with regard to potential congenital anomalies. They should learn to exercise clinical judgment about which children require further investigation and which tests are most appropriate based on the anomaly being considered and the age of the patient (eg, barium enema, rectal suction biopsy, anorectal manometry to evaluate for Hirschsprung disease). Trainees’ experience should include time evaluating neo- nates in a high-risk newborn nursery. They should be able to counsel families about prognosis and management of congenital anomalies in the neonatal period; for example, they should be able to present the prognosis for an infant with omphalocele or gastroschisis, and the factors that predict a favorable outcome. Trainees should participate in inpatient and outpatient man- agement of the preoperative and postoperative care of patients with anomalies requiring surgery in the neonatal period (eg, esophageal atresia). Trainees should be able to determine the appropriate uses of various feeding devices and should develop skills in handling commonly used equipment and solving potential com- plications. This experience should include placement, care, and troubleshooting gastrostomy and jejunostomy tubes and other feeding devices. Trainees should develop skills in the procedures used to assess and/or manage children with congenital anomalies (eg, percutaneous gastrostomy tube placement in the neonate with Pierre Robin sequence who cannot feed orally). Trainees should be able to perform rectal suction biopsies to evaluate for Hirschsprung disease and interpret the histopathologic findings. They should understand the implications of congenital malformations and their prior surgical repair when considering endoscopic evaluation. They should be familiar with the indications, technique, and complications of dilata- tions (eg, of an esophageal stricture following repair of esophageal atresia). Trainees should develop skills in interpreting the results of investigations used to assess for congenital anomalies, including diagnostic imaging techniques: Ultrasonography Fluoroscopy CT Magnetic resonance imaging (MRI) Trainees should be able to participate with competence in multidisciplinary teams, including working closely with pediatric surgeons, geneticists, neonatologists, dietitians, and feeding thera- pists. They should be skilled in communicating effectively with nursing staff and familiar with the home supply needs of children with feeding or continence issues, and how to provide for those needs. They also should be familiar with specific enteral and parenteral nutrition options for maintaining appropriate nutrition in these patients. Trainees should have the opportunity to maintain continuity with their patients during the course of their training and to experience the long-term care of patients with congenital anomalies and how these will or will not affect the patients’ ability to achieve developmental milestones (eg, ability to achieve continence of stool for a child born with imperforate anus). Examples of Relevant Competencies—Congenital Anomalies Competency Relevant area Recommended experience Suggested means of assessment Professionalism Discussion of new diagnosis of TEF and esophageal atresia Participation in family meetings to counsel families regarding surgical and feeding issues and prognosis Patient survey; 3608 evaluation; chart-stimulated recall; OSCE; direct observation by faculty followed by feedback; portfolios used for self-reflection Discussion of new diagnosis of Meckel diverticulum Participation in family meetings to counsel family regarding a life-threatening GI event Patient survey; 3608 evaluation; chart-stimulated recall; OSCE; direct observation by faculty followed by feedback; portfolios used for self-reflection Systems-based practice Participation in the multidisciplinary care of patients with complex congenital lesions (eg, diaphragmatic hernia, gastroschisis) Participation in multidisciplinary care team, including surgical, medical, and behavioral providers 3608 evaluation, including providers of consulting services; chart- stimulated recall; portfolios (continued ) Leichtner et al JPGN Volume 56, Supplement 1, January 2013 S10 www.jpgn.org
  • 11. Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. Functional GI and Motility Disorders Task Force Members Gisela G. Chelimsky, Chair Carlo DiLorenzo Samuel Nurko Manu Raj Sood Importance of Area Because functional GI disorders (FGID) and motility dis- orders are common in children, trainees in pediatric gastroenterol- ogy require comprehensive exposure to the diagnosis and treatment of these disorders and their complications, as well as a thorough understanding of their pathophysiology. Medical Knowledge Because of the wide range of disorders in this category, the discussion of medical knowledge is divided into 2 sections: FGID and disorders of transit. FGID: Trainees in pediatric gastroenterology should understand the types and current classification of FGID by the Rome III criteria, including the disorders in the 2 main groups: neonates and infants and children and adolescents (Table 1). They should be familiar with the epidemiology of FGID, including the following: Prevalence in different geographic areas Age-related vulnerability Sex predominance of certain disorders Natural history Trainees should thoroughly comprehend the biopsychosocial model of illness and the concept of the brain–gut axis in the evaluation and treatment of FGID. They also should be cognizant of fictitious disorder by proxy and how it may mimic organic or functional disease. For each FGID syndrome (Table 1), trainees should know the following: The diagnostic criteria The alarm signs that should prompt further evaluation The role of different diagnostic tests (including indications and limitations of manometry testing in FGID) The indications and adverse effects of the available medi- cations The role of psychological evaluation and behavioral modifications as part of the multidisciplinary approach to children with FGID Disorders of Transit: Trainees should comprehend the swallowing mechanism, including the role of the central nervous system in swallowing. They should be familiar with the indications and technique of performing tests to evaluate swallowing disorders in children. Trainees should know the anatomy and innervation of the different portions of the esophagus and understand the most common causes of esophageal dysmotility, including those occurring in eosinophilic esophagitis and other kinds of esopha- gitis and in achalasia. They should have sufficient exposure to children with a history of TEF to recognize the dysmotility associated with this entity and be able to manage symptomatic children with TEF. Trainees should be familiar with the pathophysiology and modes of presentation of gastroesophageal reflux disease (GERD) and how it is distinguished from physiologic gastroesophageal reflux. They should understand the differential diagnosis of GERD, its evaluation (including pH monitoring, esophageal impe- dance monitoring, and endoscopy with biopsies), and treatment options (including lifestyle changes, pharmacologic therapy, and fundoplication). Trainees should know the causes and presentation of gastro- paresis and be familiar with the indications and limitations of the tests available for the diagnosis of gastroparesis. More specifically, they should know how to interpret nuclear medicine gastric emptying studies and how to integrate information about gastric emptying in the evaluation and treatment of the child with nausea, vomiting, and other dyspeptic symptoms. They should know the treatments available for gastroparesis including lifestyle changes, Competency Relevant area Recommended experience Suggested means of assessment Developmental context Understanding the implications of esophageal atresia and other foregut anomalies upon the development of feeding skills and the long-term consequences of interruption of this process Lecture, seminar, or case-based discussion on acquisition of feeding skills, management of feedings in patient with repaired TEF and esophageal atresia Exam MCQ; chart-stimulated recall; use of case vignettes to assess knowledge Understanding the different presentations of choledochal cysts in different age groups Lecture, seminar, or case-based discussion of choledochal cysts Exam MCQ; chart-stimulated recall GI, gastrointestinal; MCQ: multiple-choice questions; OSCE, Objective Structured Clinical Examination; TEF, tracheoesophageal fistula. TABLE 1. Rome III classification of FGID Neonates and infants Children and adolescents Infant regurgitation Vomiting and aerophagia Infant rumination syndrome Adolescent rumination syndrome Cyclic vomiting syndrome Cyclic vomiting syndrome Infant colic Aerophagia Functional diarrhea Abdominal pain-related FGID Infant dyschezia Functional dyspepsia Functional constipation Irritable bowel syndrome Abdominal migraine Childhood functional abdominal pain/childhood functional abdominal pain syndrome Constipation and incontinence Functional constipation Nonretentive fecal incontinence FGID, functional gastrointestinal disorders. Examples of Relevant Competencies—Congenital Anomalies (Continued) JPGN Volume 56, Supplement 1, January 2013 Guidelines for Training in Pediatric Gastroenterology www.jpgn.org S11
  • 12. Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. medications (indications and adverse effects), and the role of surgery. Trainees also should be familiar with the causes of pseu- doobstruction, its presentation, and the available tests to diagnose pseudoobstruction. In addition, they should understand the preva- lence and role of small bowel bacterial overgrowth in motility disorders. Trainees in pediatric gastroenterology should be able to recognize normal and abnormal defecation patterns in children, from newborns to adolescents. Trainees should understand the causes of chronic constipation and fecal incontinence and know when diagnostic studies are indicated. They should understand the approach to treatment, including lifestyle changes, diet, and medi- cations. Trainees should be familiar with Hirschsprung disease, including the following: Pathophysiology Epidemiology Diagnostic approach – barium enema, anorectal manometry, and suction and full-thickness rectal biopsy (including how to recognize ganglion cells on histological sections) Surgical approach and complications Trainees should understand manometry procedures and their application to disorders of transit, as follows: Indications Technique of performing Risks and shortcomings How to recognize tracings consistent with achalasia and Hirschsprung disease (including identification of the recto- anal inhibitory reflex) Trainees should be aware of the effect of systemic endocri- nopathies on GI motility and possible contribution to disorders of transit. Patient Care Experiences/Skills Trainees should be proficient in performing complete histories and physical examinations of patients with FGID or suspected motility problems. They should be able to identify and evaluate GI symptoms, nutritional issues, psychosocial concerns, and other relevant findings. Trainees should participate in the care of a sufficient number of children with swallowing problems, feeding difficulties, FGID, GERD, constipation, and motility disturbances to be exposed to a wide array of presentations, complications, and therapeutic inter- ventions. They should have the opportunity to participate in the evaluation of children with Hirschsprung disease and collaborate with colleagues in radiology and surgery in diagnosis and manage- ment. They should also participate in the care of children with pseudoobstruction. Trainees should be able to apply and synthesize appropriate evaluation plans, including the following: Laboratory studies Radiologic imaging Endoscopy and colonoscopy Motility studies Mucosal biopsies Trainees should understand the complexity of caring for children with FGID and motility disorders and recognize the importance of a multidisciplinary approach to the problem. Trainees should participate in patient care with teams including but not limited to social workers, psychologists, nutritionists, neurologists, surgeons, pathologists, nurses, and motility specialists. Trainees also should play an active role in the nutritional management of children with pseudoobstruction or motility disorders that require enteral nutrition via tubes or parenteral nutrition. Trainees should participate in the long-term care of children with FGID and motility disorders, including continued consultation with other medical specialists as required. Competency Relevant area Recommended experience Suggested means of assessment Professionalism Understanding the social impact of fecal incontinence Directly participate in the care of patients with fecal incontinence, including the psychosocial aspects, interaction with social workers and psychologists, as necessary Patient survey; 3608 evaluation; chart-stimulated recall; OSCE; portfolios for reflection Systems-based practice Management of patient with constipation and/or fecal incontinence in the setting of congenital problems such as myelomeningocoles Discussion and collaboration with other disciplines, including neurology, neurosurgery, urology, nursing, social work, and psychology in patient evaluation and management, participation in team meetings 3608 evaluation; including providers from other disciplines; Chart- stimulated recall; portfolios Developmental context Understanding the developmental aspects of fecal continence Lectures, seminars, and case-based discussions, management of children of different ages with a focus on normal and abnormal defecation Exam MCQ; chart-stimulated recall; use of case vignettes to assess knowledge MCQ, multiple-choice questions; OSCE, Objective Structured Clinical Examination. Examples of Relevant Competencies—Functional GI and Motility Disorders Leichtner et al JPGN Volume 56, Supplement 1, January 2013 S12 www.jpgn.org
  • 13. Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. GI Bleeding Task Force Members Marsha Kay, Chair Bradley Barth Mark A. Gilger Michael Nowicki David A. Piccoli Importance of Area GI bleeding occurs not uncommonly in children, is often worrisome, and is occasionally life threatening. Understanding the different etiologies by patient age, the importance of assessing the severity of bleeding, and methods for accurately determining the cause and site of bleeding are critical in the proper management of this condition. Individuals caring for patients with GI bleeding must be able to identify and respond to signs of hypovolemic shock and impending decompensation to prevent ongoing blood loss and avoid a medical emergency. Medical Knowledge Trainees in pediatric gastroenterology should comprehend the differential diagnosis of, diagnostic techniques for, and treat- ment of GI bleeding, as well as have a thorough understanding of the pathophysiology. The potential sources of UGI and LGI bleed- ing are listed by age group in Tables 1 and 2. With regard to acute GI bleeding, trainees in pediatric gastroenterology should understand the following: The initial and subsequent assessment of a patient with acute GI bleeding, including the signs of impeding decompensation or shock The requirements for fluid resuscitation and medical treatment of hemorrhagic shock The need to focus on the location and severity of the bleeding The components of the preendoscopic evaluation and understand the need for the patient to be hemodynamically stable before endoscopic evaluation The elements of postprocedure care, including prevention and assessment of ongoing blood loss Trainees in pediatric gastroenterology should be familiar with the differential diagnosis and diagnostic approach to the pediatric patient with subacute, intermittent, or chronic GI bleeding from either an upper or lower tract source, including the appropriate use of upper endoscopy and/or colonoscopy as both a diagnostic and therapeutic tool. In the evaluation of bleeding of obscure origin, trainees should comprehend the appropriate use of techniques such as capsule endoscopy, small TABLE 1. Differential diagnosis of acute UGI bleeding in pediatric patients Newborn Infant Child Adolescent Swallowed maternal blood Stress gastritis or ulcer Mallory-Weiss tear Mallory-Weiss tear Vitamin K deficiency Esophagitis Gastritis or peptic ulcer Esophagitis Stress gastritis or ulcer Mallory-Weiss tear Esophagitis Esophageal ulcer (pill, caustic, or infectious etiology)Esophagitis Esophageal/gastric or duodenal duplication Varices Gastritis or ulcerVascular malformations (hemangioma, telangiectasia, arteriovenous malformation) Caustic ingestion Portal hypertensive gastropathy Varices Anatomic lesions (gastric polyp, duplication) Vascular malformations (hemangioma, telangiectasia, arteriovenous malformation) Caustic ingestion Portal hypertensive gastropathy Gastric heterotopia Henoch-Scho¨nlein purpura Vascular malformations (hemangioma, telangiectasia, arteriovenous malformation) Vascular malformations (hemangioma, telangiectasia, arteriovenous malformation) Varices Henoch-Scho¨nlein purpura Crohn disease Foreign body Tumor Dieulafoy ulcer Tumor Foreign body HemobiliaAnatomic lesions (polyp, duplication) Anatomic lesions (polyp, duplication) Crohn disease TABLE 2. Differential diagnosis of acute LGI bleeding in pediatric patients Infant à Child and adolescent Necrotizing enterocolitis Anal fissure Infectious colitis Infectious colitis Allergic colitis Polyp Hirschsprung enterocolitis Lymphonodular hyperplasia Ischemic colitis Meckel diverticulum Inflammatory bowel disease Intussusception Inflammatory bowel disease Hemorrhoid Solitary rectal ulcer Hemolytic uremic syndrome Mu¨nchausen syndrome by proxy Ischemic colitis Vascular malformations and angiomata Malignancy à In addition to all causes of UGI bleeding outlined in Table 1. JPGN Volume 56, Supplement 1, January 2013 Guidelines for Training in Pediatric Gastroenterology www.jpgn.org S13
  • 14. Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. bowel enteroscopy, and radiologic imaging (eg, nuclear medi- cine, angiography). Trainees should understand the appropriate endoscopic assessment and treatment of GI bleeding and that esophagogas- troduodenoscopy (EGD) is usually indicated for assessment of acute UGI bleeding requiring transfusion or unexplained recur- rent bleeding and can determine the source of the bleeding in most cases from an upper tract source. Trainees must recognize that because UGI bleeding in children frequently stops spon- taneously, emergency endoscopy is indicated only when the findings will influence a clinical decision, such as the need for medical or surgical therapy, or if endoscopic therapy can be performed that will stop the ongoing bleeding or prevent rebleed- ing. Trainees should comprehend the distinction between lesions amenable to endoscopic therapy (eg, polyps, ulceration, angio- mata) and bleeding lesions likely to require surgical therapy to terminate the bleeding episode (eg, Meckel diverticulum, malig- nancies). Trainees should understand the risks, benefits, appli- cations, and limitations of these techniques, including electrocoagulation (eg, heater probe, monopolar probe, multipolar electrocoagulation probe), argon plasma coagulation, injection of hemostatic agents, band ligation, and mechanical clipping. Trai- nees should understand that because there is little published experience with these techniques in children, the best technique for each type of bleeding has not been established. Trainees should be aware that the combination of injection (using hemostatic agents such as epinephrine) and thermocoagulation or other mechanical techniques appears to be the most effective endoscopic treatment of UGI bleeding resulting from gastric or duodenal ulcers in children. Trainees should understand that endoscopic treatment of esophageal varices includes injection sclerotherapy, variceal banding, or a combination of these techniques, and they should know the efficacy and complications of each technique. This should include knowledge that complications of injection scler- otherapy comprise strictures, recurrence of the varices, and recurrent bleeding and that band ligation is becoming the pre- ferred method in both pediatric patients and in adults, is better tolerated in children than sclerotherapy, and has fewer compli- cations (eg, retrosternal pain, fever). Trainees must understand that banding equipment has not yet been adapted for use in infants and small children. In the setting of acute GI bleeding, trainees must understand the potential benefits and risks of medical therapy, including the following: Administration of selective vasoconstrictors (eg, somatostatin analogues), including dosing and duration of therapy The role of H2-receptor antagonists and proton pump inhibitors Appropriate use of antibiotics in patients with acute bleeding, especially those with cirrhosis, underlying cardiac disease, and other conditions that are associated with an increased risk of infections during a bleeding episode Trainees should comprehend the value of the various surgical treatment options, including the following: Exploratory laparotomy, which is generally reserved for uncontrollable bleeding Procedures for bleeding originating from a posterior duodenal ulcer with arterial bleeding, bowel perforation with bleeding, gastroesophageal variceal bleeding, or GI bleeding originat- ing from malignancy Portosystemic shunting procedures (mesocaval, distal sple- norenal, or central portocaval shunt) Esophageal transection, in which the distal esophagus is transected and then stapled back together after varices have been ligated, or devascularization of the gastroesophageal junction (Sugiura procedure), a rare but potentially lifesaving surgery for bleeding esophageal varices Significant advances in the field of interventional radiology for GI bleeding for both pediatric patients and adults allow for both rapid diagnosis and therapy of many types of bleeding lesions. Trainees should be familiar with the risks, benefits, applications, and limitations of angiographic and other imaging/interventional methods for the diagnosis and therapy of GI bleeding in pediatric patients, particularly when bleeding is obscure in origin or refractory to endoscopic therapy. Trainees should understand the indications, contra- indications, diagnostic yield, and relative merits of the follow- ing procedures: Meckel’s scan Nuclear medicine bleeding scan (tagged red blood cell scan) CT angiography Diagnostic and therapeutic angiography (including emboli- zation and coiling, and the radiologic transjugular intrahe- patic portosystemic shunt insertion) Patient Care Experiences/Skills Trainees should understand how to obtain a history directed at assessing the rate, severity, and location of the bleeding, and how to identify possible etiologies of GI bleeding. They also should be able to perform a physical examination to evaluate the hemody- namic status of the patient and identify mucocutaneous, abdominal, or other physical examination findings that may suggest the etiol- ogy of the bleeding. Trainees should be competent at performing upper endo- scopy and colonoscopy and selected therapeutic procedures. They should be able to identify endoscopic lesions that may result in blood loss. Although the number of therapeutic pro- cedures may be insufficient to obtain competency, opportunities for learning these procedures can take place at hands-on courses. Detailed competencies in terms of procedure skills including methods of assessment are outlined separately in this document (See ‘‘Training in Endoscopy and Related Pro- cedures’’). Trainees should participate in the management of patients of different ages with GI bleeding and be able to integrate endoscopic findings, including results of capsule endoscopy and small bowel enteroscopy, as well as those from radiologic procedures, into a management plan for diagnosis and therapy. Trainees should understand the team approach to the diagnosis and management of GI bleeding and participate in clinical decision making with radiologists, surgeons, and intensi- vists. Trainees should have the opportunity to do a follow-up evaluation of patients with a history of GI bleeding and provide counseling regarding possible recurrent bleeding. Leichtner et al JPGN Volume 56, Supplement 1, January 2013 S14 www.jpgn.org
  • 15. Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. Examples of Relevant Competencies—GI Bleeding GI Infections Task Force Members Nicola L. Jones, Chair Alessio Fasano David R. Mack Phillip I. Tarr Eytan Wine Importance of Area Infections of the GI tract are an important subset of GI disorders to which the pediatric patient is particularly predisposed. Infections also can mimic other GI disorders, such as IBD, and vice versa. Trainees in pediatric gastroenterology, therefore, require comprehensive exposure to the diagnosis and treatment of bacterial, viral, and parasitic infections and their complications. Medical Knowledge Trainees in pediatric gastroenterology should understand the basic pathophysiology, including host defense mechanisms against enteric infections and factors that determine microbial virulence. Trainees should comprehend how congenital or acquired immuno- deficiencies can alter the host response to GI infections. Trainees in pediatric gastroenterology should have an under- standing of the epidemiology, natural history, and complications associated with Helicobacter pylori infection and a thorough knowledge of the indications and current recommendations for the testing and treatment of H pylori infection. Trainees should understand the clinical manifestations, including extraintestinal manifestations, and the complications, diagnosis, and treatment of bacterial infections that cause diarrhea, including the following: Campylobacter Salmonella Shigella Yersinia Escherichia coli (enterotoxigenic, enteroadherent, enteroin- vasive, enteroaggregative, adherent invasive, and Shiga toxin producing) Clostridium difficile (including an approach to antibiotic- associated diarrhea) Vibrio Listeria Trainees should be familiar with the signs and symptoms of small bowel bacterial overgrowth, as well as its predisposing factors, the available diagnostic tests, and currently recommended therapies. The pediatric gastroenterology trainee should be aware of potential emerging pathogens and should be able to recognize illnesses related to toxin exposure (eg, staphylococcal food poison- ing). They should comprehend the pathophysiology of bacterial- mediated diarrhea and know how to develop a management plan, including the rationale for the use or avoidance of antibiotics, physiologic basis and use of oral/intravenous rehydration solutions, and the advantages and disadvantages of adjunctive therapy (eg, probiotics). Trainees also should be aware of the public health issues related to infections from these organisms. Trainees also should be able to identify and diagnose infections that can resemble Crohn disease (CD). Trainees should be familiar with the epidemiology, clinical manifestations, prevention, and therapy of viral enteric pathogens (eg, rotavirus; caliciviruses, including noroviruses, adenoviruses, and astroviruses). Trainees also should be familiar with cytome- galovirus colitis and the manifestations, diagnosis, and treatment of Epstein-Barr virus–related complications, particularly in the immunocompromised patient. Trainees should be familiar with the clinical manifestations, diagnosis, and treatment options for common parasitic infections, including giardiasis, Entamoeba histolytica, and cryptosporidium. They should comprehend the controversies surrounding the Competency Relevant area Recommended experience Suggested means of evaluation Professionalism Discussion of acute life-threatening event with family Participation in family meetings under supervision of attending physician Patient survey; direct observation by faculty followed by feedback; 3608 evaluation; portfolios used for self-reflection; chart-stimulated recall; OSCE Obtaining informed consent for diagnostic and therapeutic endoscopic procedures Lecture or seminar on informed consent; experience obtaining consent, initially under attending supervision Record review of completed forms; checklist; direct observation by faculty followed by feedback Systems-based practice Participating in multidisciplinary care of patient with severe GI bleeding Discussion with consulting physicians, and participation in team meetings 3608 evaluation including consulting providers; chart stimulated recall Developmental context Understanding the change in differential diagnosis of bleeding and diagnostic approach with increasing patient age; understanding age-dependent response to blood loss Lecture; experience managing patients with GI bleeding at different ages Simulation; OSCE; exam MCQ; direct observation; use of case vignettes to assess knowledge GI, gastrointestinal; MCQ: multiple-choice questions; OSCE: Objective Structured Clinical Examination. JPGN Volume 56, Supplement 1, January 2013 Guidelines for Training in Pediatric Gastroenterology www.jpgn.org S15
  • 16. Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. pathogenicity of other agents (eg, Dientamoeba fragilis, Blastocys- tis hominis). Trainees should understand the primary and secondary immunodeficiencies with GI manifestations and the pathogens, including fungal agents, such as Candida albicans, encountered under these circumstances. Trainees should be familiar with the sexually transmitted diseases that can affect the GI tract. Patient Care Experiences/Skills Trainees should develop expertise in performing a history and physical examination aimed at identifying potential enteric infections or immunodeficiencies with GI manifestations. This expertise can be achieved by working with patients with GI infections in both inpatient and outpatient settings. Where specific enteric infections or immunodeficiencies are rare and unlikely to be encountered, case-based teaching, multidisciplin- ary case conferences, simulations, and learner-directed reading can be used to ensure that adequate medical knowledge is achieved. Trainees should become experienced in performing diag- nostic testing in patients and should understand the indications and limitations of testing for enteric infections, including being able to use procedures to exclude infections. Trainees should be able to interpret laboratory, radiological, endoscopic, and histological findings. Pediatric gastroenterology trainees should participate in pathology and radiology joint management con- ferences when possible to enhance knowledge development. Because of the varied clinical manifestations and need for specialized testing, the management of patients with GI infections often requires multidisciplinary interactions with pathologists, microbiologists, infectious disease specialists, and immunologists. Trainees should be involved in coordinating these multidisciplinary consultations for patients when indicated (eg, suspected immuno- deficiency presenting with enteric infection). Trainees also should participate in the treatment of chil- dren with acute and chronic enteric infections to develop the necessary skills to initiate and implement the appropriate treat- ment. Examples of Relevant Competencies—GI Infections Hepatology Task Force Members Michael R. Narkewicz, Chair Regino P. Gonzalez-Peralta M. James Lopez Elizabeth Rand Importance of Area Because diseases of the liver and biliary tract have a sig- nificant impact on children, trainees in pediatric gastroenterology should have comprehensive exposure to the diagnosis and treatment of these disorders and their complications, as well as a thorough understanding of their pathophysiology. Medical Knowledge Trainees in pediatric gastroenterology should understand the normal structure and function of the liver and biliary tree, and the prevalence, natural history, age-appropriate differential diagnoses, and genetic and other risk factors of hepatobiliary disorders. Caring for children with hepatobiliary disease requires a thorough under- standing of both common and rare causes, including infectious, metabolic, genetic, anatomic, immunologic, and toxic (Table 1). Trainees should understand the varying clinical manifes- tations of these disorders, especially the issues that are unique to pediatric hepatobiliary disorders (eg, effects on growth, nutrition, puberty, psychosocial functioning). Trainees also should have a complete understanding of the diagnostic criteria that distinguish liver and biliary diseases with common patterns of presentation (eg, cholestasis, neonatal choles- tasis, elevated aminotransferases, hepatomegaly, hepatosplenome- galy, acute liver failure, direct or indirect hyperbilirubinemia, ascites), including differences in the following: Affected populations Results of laboratory evaluations Histopathology Radiologic studies Disease course Competency Relevant area Recommended experience Suggested means of assessment Professionalism Approach to patients with possible sexually transmitted diseases Care of patients with such infections with participation in discussions with patients and/or families as appropriate Patient survey; direct observation followed by feedback; 3608 evaluation; chart-stimulated recall; OSCE Systems-based practice Participating in multidisciplinary care Observation of, and discussion with, providers of consulting services (eg, radiology, microbiology, infectious disease, immunology) 3608 evaluation, including providers of consulting services; chart- stimulated recall; portfolios Understanding public health implications of community- acquired enteric infections Reading of relevant materials; reporting infections to relevant agencies as indicated Exam MCQ; chart-stimulated recall; use of case vignettes to assess knowledge Developmental context Trainees will recognize how developmental context can affect the susceptibility to and clinical manifestations of enteric infections (eg, rotavirus) Directed and independent reading; care of patients with GI infections at various ages and demographics Exam MCQ; chart-stimulated recall examination; use of case vignettes to assess knowledge GI, gastrointestinal; MCQ, multiple-choice questions; OSCE, Objective Structured Clinical Examination. Leichtner et al JPGN Volume 56, Supplement 1, January 2013 S16 www.jpgn.org
  • 17. Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. Trainees should understand the comprehensive evaluation of patients suspected to have hepatobiliary diseases, as well as the appropriately targeted evaluation of patients with known liver disease who may be experiencing an exacerbation or complication or who require routine monitoring (eg, recommendations for labora- tory and radiologic surveillance for cancer). They should under- stand both the indications for and potential complications of the various tests that may be required. Knowledge of the indications for performance and interpretation of liver biopsy, percutaneous trans- hepatic cholangiography and ERCP is a key component of the evaluation of hepatobiliary disease. Trainees should know an approach to liver histopathology and be able to recognize the findings in the common pediatric liver diseases, such as biliary atresia, Alagille syndrome, idiopathic neonatal cholestasis, auto- immune hepatitis, sclerosing cholangitis, chronic viral hepatitis B and C, nonalcoholic fatty liver disease, Wilson disease, metabolic liver diseases (eg, glycogen storage disease, mitochondrial dis- orders, disorders of fatty acid metabolism), a-1-antitrypsin deficiency, cystic fibrosis, hemochromatosis, and hemosiderosis. Imaging studies (eg, abdominal ultrasound [US], CT scan, MRI, MRCP, and radionuclide cholescintigraphy) also are key com- ponents of this evaluation. They also should understand the indica- tions and complications for radiologic intervention, such as hepatic abscess drainage, percutaneous transhepatic cholangiography, and transjugular intrahepatic portosystemic shunt. Trainees should understand the inheritance patterns of the common genetic disorders of the liver (eg, a-1-antitrypsin deficiency, glycogen storage disease type 1A, Wilson disease, Alagille syndrome), use of genetic testing for diagnoses (eg, in Alagille syndrome, hemochromatosis, Gilbert syndrome, a-1-anti- trypsin deficiency, Wilson disease, progressive familial intrahepatic cholestasis disorders), and recommendations for screening of family members (eg, in Wilson disease, in hemochromatosis). Trainees should understand the management of various acute and chronic liver and biliary diseases and their complications. They should fully comprehend the indications for specific medical inter- ventions in the following diseases/disorders: Chronic viral hepatitis Autoimmune hepatitis Biliary atresia and other biliary anomalies Cholestasis from other etiologies Alagille syndrome a-1-antitrypsin deficiency Wilson disease Nonalcoholic fatty liver disease Primary sclerosing cholangitis Gallstone disease and other disorders of the gallbladder Other metabolic liver diseases Trainees should understand the indications for specific treat- ments of in both newly diagnosed and existing hepatobiliary diseases, including the use of the following: Enteral and parenteral nutritional therapy Fat-soluble vitamins Antibiotics Chelation therapies Corticosteroids Immunomodulators Antiviral agents Antipruritics Trainees must understand the efficacy, dosing, adverse effects (eg, growth effects of steroids, renal toxicity of calcineurin inhibitors, common interactions of calcineurin inhibitors with other medications, increased infection risk from Epstein-Barr virus and cytomegalovirus with immunomodulators, hypertension with steroids and calcineurin inhibitors, bone marrow suppression with azathioprine, and posttransplant lymphoproliferative disease), and necessary monitoring when using these medications, particularly regarding the use of immunosuppressant and chelation therapies. Trainees should be familiar with the complications of acute liver failure and their management, including coagulopathy, ence- phalopathy, renal and metabolic impairment, and increased risk of infection. Trainees should know the complications of chronic liver disease and their management, including fat-soluble vitamin deficiency and pruritus in cholestasis, coagulopathy, sequelae of portal hypertension (ascites, variceal hemorrhage, and encephalo- pathy), hepatorenal syndrome, hepatopulmonary syndrome, nutri- tional complications, and risk and indications of screening for hepatocellular carcinoma. Although not all trainees will be directly involved in the care of children who are awaiting or have undergone liver transplan- tation, they should know the indications, approach to the evaluation, outcomes, and acute complications of liver transplantation, TABLE 1. Categories of hepatobiliary disorders Categories Disorders Viral hepatitis Hepatitis A, B, C, D, and E, EBV, HSV, CMV, and enterovirus Metabolic liver diseases Wilson disease, hemochromatosis, galactosemia, fructosemia, glycogen storage diseases, disorders of fatty acid oxidation (MCAD, LCAD, LCHAD), mitochondrial disorders, tyrosinemia Genetic disorders a-1-antitrypsin deficiency, Alagille syndrome, PFIC disorders, cystic fibrosis, bile acid synthetic disorders, mitochondrial disorders Cholestatic conditions Biliary atresia, idiopathic neonatal hepatitis, choledochal cyst, other biliary anomalies Immunologic disorders Autoimmune hepatitis, PSC Other liver disorders Acute liver failure, gallstones, NAFLD, drug-induced liver disease, liver tumors, histiocytosis Secondary hepatobiliary diseases Veno-occlusive disease of the liver, secondary PSC, granulomatous hepatitides, drug toxicities, sickle cell hepatopathy, and others CMV, cytomegalovirus; EBV, Epstein-Barr virus; HSV, herpes simplex virus; LCAD, long-chain acyl-CoA dehydrogenase deficiency; LCHAD, long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency; MCAD, medium-chain 3-hydroxyacyl-CoA dehydrogenase deficiency; NAFLD, nonalcoholic fatty liver disease; PFIC, progressive familial intrahepatic cholestasis; PSC, primary sclerosing cholangitis. JPGN Volume 56, Supplement 1, January 2013 Guidelines for Training in Pediatric Gastroenterology www.jpgn.org S17

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