Care of children and adolescents with Inflammatory Bowel Disease
1. Description of Activity
Practicing subspecialists must be trained to care for children and adolescents with IBD which represents one of the major chronic diseases managed by gastroenterologists. Pediatric gastroenterologists need to be familiar with classic understanding of disease processes but also differences in children compared to adults. Additionally, subspecialists should be able to manage acute issues as well as long-term chronic management including the transition of care. This requires a multitude of competencies within each domain of competence.
The functions required of this activity include:
1. Understand the epidemiology, pathogenesis and natural history, of Crohn’s disease (CD) and ulcerative colitis (UC)
2. Understand the clinical implications of basic/translational research in IBD
3. Diagnose and recognize children with suspected IBD in a variety of clinical presentations
4. Manage children and adolescents with IBD
5. Educate parents and children on IBD cause, treatment, and clinical course.
6. Lead and direct care for children/adolescents with IBD in the medical system including coordinating care
2. Domains of Competence (Judicious Mapping)
__X__Patient Care
__X__Medical Knowledge and Diagnostic Skills Required
__X__Practice Based Learning
__X__Interpersonal Skills
__X__Professionalism
__X__System-based Practice
_____Personal and Professional Development
3. Competencies within each domain critical to entrustment decision (From Pediatric Milestones Document)
PC 6,7,9,10
MK 1-2
PBLI 10
ICS 3, 4
SBP 5
4. Curriculum - List Specific Knowledge, skills and attitudes needed to execute EPA
Medical Knowledge
1. Understand clinical science of IBD including epidemiology, natural history, clinical presentation and features including similarities and differences between CD and UC.
2. Understand the pathogenesis, genetics, microbiome, and mucosal immunology of IBD including similarities and differences between CD and UC.
3. Understand the mechanism of action, side effects, and other complications of medications and treatments for IBD including steroids, immunomodulators, biologics, nutrition therapy and other medications.
4. Understand and identify red flags for systemic auto-immune and immune deficiency syndromes which may have similar manifestations and findings as IBD and can co-exist with IBD
Patient Care
1. Perform an appropriate history and physical examination in a child with suspected IBD
2. Perform an appropriate initial workup and appropriate use of diagnostic labs, serology and other studies for a child with suspected IBD (laboratory, serology, endoscopy, histological interpretation, imaging, video capsule endoscopy)
3. Develop an initial diagnosis and treatment strategy focused on inducing remission
4. Recognize a disease flare and perform appropriate tests to differentiate a disease flare from symptoms of other etiology
5. Develop a treatment plan for disease flares and maintenance therapy
6. Perform standard endoscopy for the diagnosis of CD and UC
7. Understand imaging modalities for small and large bowel evaluation in IBD including but not limited to abdominal radiography, UGI with SBFT, ultrasonography, CT or MR enterography, and video capsule endoscopy
8. Understand the use of treatment modalities for CD and UC including:
Steroids
Immunomodulators – including TPMT and use of metabolites to optimize dose
Biologics including use of levels and antibodies
Oral, enteral and parenteral nutrition
Other medications and supplements (probiotics, fish oil etc.)
Surgical treatment
Non-conventional therapies: fecal transplant, alternative medicine
Evolving Therapies / New Treatment Modalities
Apply and understand disease activity indices and phenotypic classifications for CD and UC.
9. Recognize extra-intestinal manifestations of IBD (PSC, joints, etc)
10. Interpret endoscopy and pathology findings including knowing differences between CD and UC
11. Diagnose and treat penetrating or fistulizing Crohn’s disease including perianal disease, intra-abdominal abscess, fistulizing disease, and stricturing disease.
12. Understand health care maintenance and vaccinations in children with IBD
13. Recognize and manage relevant problems associated with IBD such as malnutrition, anemia, osteopenia and psychosocial concerns
Practice Based Learning
Understand quality measures as they have been applied to IBD (for example Improve Care Now)
Apply quality measures to improve care of children with IBD
Educate parents and children on cause, treatment, and other aspects of IBD including maintenance health checks and cancer surveillance
Participate in lifelong learning as it relates to care of children with IBD
Interpersonal and Communication Skills
Effectively communicate disease information, treatment plan, and outcome to parents and children
Effectively communicate with other medical professionals involved in the care of IBD patients
Professionalism
Demonstrate compassion, integrity, respect and sensitivity to diversity in treating IBD, a complex chronic disease
Protect patient privacy
System-based Practice
Coordinate care of children with IBD including PCPs, surgeons, psychologists/social workers, nutritionists, radiologists, and other medical professionals
Transition care in children with IBD to adult gastroenterologists
Personal and Professional Development
Thoughtfully analyze practice style, self-confidence and seek advice for management of complex patients
Develop effective bedside manner and maturity through interactions with patients and families
5. Assessment Procedure (from ACGME Assessment Toolbox – see below):
Checklist
Chart stimulated recall / Chart audits
Direct observations