Training in Procedures

Pediatric gastrointestinal endoscopy is a fundamental tool for the diagnosis and management of pediatric patients with gastrointestinal disorders. All trainees should achieve competence in the diagnostic and therapeutic endoscopy in pediatric patients in order to be able to provide comprehensive care. Our training program will incorporate endoscopic teaching materials (e.g., books, atlases, videotapes, simulation programs) into the training program and periodically review and update training methods and the quality of training in the endoscopy unit.

Diagnostic competence is defined as the ability to recognize abnormalities and to understand the pathologic features of the lesions that can occur. Therapeutic competence is the ability to recognize whether a therapeutic procedure is indicated in a given patient and the ability to perform that procedure safely and successfully in pediatric patients.

Evaluation of trainees involves direct observation of performance, evaluation to promote improvement and avoid errors, and documentation of clinical and procedural skills. Feedback will be immediate and direct, with constructive and informative discussion between attending physician and fellow. Attending physicians will share their objective assessment of each fellow’s procedural proficiency with the program director, who in turn, will conduct regular performance reviews with each fellow throughout the year.

Certification of competence requires satisfactory performance in a minimum number of cases of each procedure under direct supervision and independent performance of these procedures. Certification also requires proficiency in all aspects of use and maintenance of endoscopy equipment and in pediatric patient preparation and sedation.

• Trainees will understand the appropriate indications, risks, and benefits of diagnostic and therapeutic procedures
• Know how to determine placement of a pH probe by using an established formula and reviewing x-rays, and analyze pH probe results
• Know how to interpret Breath Hydrogen tests
• Know how to perform an anorectal manometry
• Demonstrate proficiency in the following procedures:
  • rectal biopsy
  • percutaneous liver biopsy
  • straight forward diagnostic upper endoscopy, including endoscopy with pancreatic stimulation
• Demonstrate the ability to perform the following with some assistance from the supervising Attending:
  • endoscopic foreign body removal
  • endoscopic variceal banding/sclerotherapy
  endoscopic electrocautery to control bleeding
  • endoscopic dilatation of esophageal strictures
  • percutaneous gastrostomy tube placement
  • completion of a colonoscopy including intubation of the ileocecal valve
  • polypectomy

A fully trained pediatric gastroenterologist must be competent in the procedures outlined below.

Minimum numbers required to achieve competency in endoscopic procedures in pediatric patients:

Study type	aThreshold # for competence
Upper endoscopy - Diagnostic (including biopsy)	100b
Therapeutic upper endoscopy with foreign body removal	5
Lower endoscopy -flexible sigmoidoscopy	10c
Colonoscopy (including biopsy)	100d
Therapeutic lower endoscopy with snare polypectomy	20

^aThese numbers represent threshold numbers of procedures that must be performed before competency can be assessed and are adapted from recommendations of the NASPGN Training and Education Com¬mittee, ASGE Task Force on Gastrointestinal Endoscopy and Gastro¬intestinal Bleeding, ASGE Publication No. 1001, 1986, and Methods of Granting Hospital Privileges to Perform Gastrointestinal Endoscopy, ASGE Publication No. 1012, Revised 1992.

^bAt least 25 must be performed in patients >12 years old.

^cFlexible sigmoidoscopy skills are most likely assured if adequate colonoscopy experience has been obtained. However, all trainees must perform at least 10 flexible sigmoidoscopies or colonoscopies in pa¬tients less than 2 years old to assure competence in this age group.

^dAt least 25 must be performed in patients <12 years old.

After completion of a training program in pediatric gastroenterology, trainees will be able to:

• Recommend endoscopic procedures on the basis of personal consultation and consideration of specific indications, contraindications, and diagnostic and therapeutic alternatives
• Counsel the pediatric patient and family on bowel preparation and other supportive methods as indicated
• Select and apply appropriate sedation and/or anesthesia as indicated
• Identify age- and problem-appropriate endoscopy equipment
• Perform each indicated procedure safely, completely, independently, and expeditiously
• Interpret and describe endoscopic findings accurately
• Integrate endoscopic findings and/or therapy into the management plan
• Understand the inherent risks of endoscopic procedures and be able to recognize and manage complications
• Recognize personal and procedural (including equipment) limits and know when to request assistance
• Clean and maintain endoscopic equipment and be familiar with Joint Commission of American Hospital Organization (JCAHO) standards for quality improvement, infection control, sedation, and monitoring