New Application: Pediatric Gastroenterology
Review Committee for Pediatrics
ACGME
515 North State Street, Suite 2000, Chicago, Illinois 60654  312.755.5000  www.acgme.org
COMMON SUBSPECIALTY SECTION
FACULTY RESEARCH
1. Complete the table below regarding the involvement of faculty in research. Add rows as necessary.
[PR II.B.5.b)]
# of current
IRB approved
research
Name
projects
Program Director:
Total # of
current
funded
research
projects
# of current
research
projects with
peer review
funding
(subset of
total # in
previous
column)
#
presentations
at national
scientific
# publications
meetings in in peer review
the last 5
journals in the
years
last 5 years
Key Faculty:
Research Mentors Who Are Not Key Faculty:
2. List active research projects in the subspecialty. Add additional rows as necessary.
Project title
Funding
source
Put an “X” for
funding
awarded by
peer review
process
Pediatric Gastroenterology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Years of
funding
(dates)
Faculty investigator and
role in grant (i.e. PI, Co-PI,
Co-investigator)
Updated 4/2015
Page 1 of 12
RESEARCH RESOURCES
1. Does the program provide research laboratory space and equipment? (if appropriate) [PR II.D.]
.................................................................................................................................... ☐ YES ☐ NO
2. Does the program provide financial support for research? ........................................... ☐ YES ☐ NO
3. Does the program provide computer and statistical consultation services? .................. ☐ YES ☐ NO
PROGRAM CURRICULUM
Goals and Objectives
Place an ‘X” in the box before the applicable response. [PR IV.A.2.]
Are there goals and objectives for all training
☐ YES ☐ NO
experiences?
Are they rotation and level specific?
☐ YES ☐ NO
How are they distributed?
☐ Hard Copy ☐ Electronic or web-based
If not web-based, when are they distributed to
☐ Prior to Each Rotation
☐ Annually
fellows?
☐ Once in Handbook
☐ Other
If not web-based, when are they distributed to
☐ Prior to Each Rotation
faculty?
☐ Annually
☐ Other
If web-based, do you send out reminders to access ☐ YES ☐ NO
them?
If yes, when do you send them?
Click here to enter text.
Collaboration between Programs
Are there meetings among the core Program
Director and subspecialty Program Directors?
How often do these meetings occur?
Who is typically involved in these meetings?
(check all that apply)
☐ YES ☐ NO
Click here to enter text.
☐ Core program director
☐ Subspecialty program director for this specialty
☐ Program directors from other subspecialties
General Subspecialty Curriculum
Topic
e.g., Biostatistics
Basic science as
related to the
Participants (place and X in the
appropriate column)
Where Taught in
Number of
Fellows in
Curriculum?
Structured
this
All
Residents &
(Name should Teaching Hours Discipline Subspecialty Subspecialty
match name in
Dedicated to
Will
Fellows
Fellows
conference list)
Topic Area?
Attend
Attend
Attend
Research
Course
14
X
Click here to
#
☐
☐
☐
enter text.
Pediatric Gastroenterology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 2 of 12
Participants (place and X in the
appropriate column)
Where Taught in
Number of
Fellows in
Curriculum?
Structured
this
All
Residents &
(Name should Teaching Hours Discipline Subspecialty Subspecialty
match name in
Dedicated to
Will
Fellows
Fellows
conference list)
Topic Area?
Attend
Attend
Attend
Topic
application in clinical
subspecialty practice
Clinical subspecialty
Click here to
#
☐
☐
☐
content
enter text.
For the topics below, if the topic is not appropriate for your discipline (i.e., lab research for
fellows in developmental and behavioral pediatrics), enter N/A into column 1.
Biostatistics
Click here to
#
☐
☐
☐
enter text.
Lab research
Click here to
#
☐
☐
☐
methodology (if
enter text.
appropriate)
Clinical research
Click here to
#
☐
☐
☐
methodology
enter text.
Study design
Click here to
#
☐
☐
☐
enter text.
Grant preparation
Click here to
#
☐
☐
☐
enter text.
Preparation of
Click here to
#
☐
☐
☐
protocols for
enter text.
institutional review
board
Principles of evidenceClick here to
#
☐
☐
☐
based medicine/
enter text.
Critical literature
review
Quality Improvement
Click here to
#
☐
☐
☐
enter text.
Teaching skills
Click here to
#
☐
☐
☐
enter text.
Professionalism/Ethics
Click here to
#
☐
☐
☐
enter text.
Cultural Diversity
Click here to
#
☐
☐
☐
enter text.
Systems-based
Click here to
#
☐
☐
☐
practice (economics of
enter text.
healthcare, practice
management, clinical
outcomes, etc.)
Conferences
1. List regular subspecialty and interdepartmental conferences, rounds, etc., that are a part of the
subspecialty training program. Identify the "SITE" by using the corresponding number as appears
Pediatric Gastroenterology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 3 of 12
on the first and second pages of this form. Indicate the frequency, e.g., weekly, monthly, etc., and
whether conference attendance is required (R) or optional (0). List the planned role of the fellow in
this activity (e.g., conducts conference, presents case and participates in discussion, case
presentation only, participation limited to Q&A component, etc.). Add rows as necessary.
Conference
Site #
Frequency
R/O
Role of the Fellow
2. Describe the mechanism that will be used to ensure fellow attendance at required conferences.
State the degree to which faculty attendance is expected, and how this will be monitored.
Limit the response to 50 words
Click here to enter text.
Scholarship Oversight Committee
1. Will there be a scholarship oversight committee for every fellow? ................................ ☐ YES ☐ NO
2. How often will the committee meet with the fellow? ................................................... # times per year
Fellow Research Activities
1. Describe how the program will ensure a meaningful supervised research experience for the fellows,
beginning in their first year and extending throughout their training.
Click here to enter text.
2. If faculty outside the division will be actively involved in mentoring the fellows, identify the mentors
and describe how liaisons will be created between these mentors and the fellows that allows for
meaningful accomplishment of research.
Click here to enter text.
Pediatric Gastroenterology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 4 of 12
SPECIALTY-SPECIFIC SECTION
PROGRAM PERSONNEL AND RESOURCES
Other Professional Personnel
1. Indicate with a check mark the personnel who will interact regularly with fellows at each
participating site. [PR VII.B.1.c)]
Team Members
Physical Therapy
Occupational Therapy
Social Work
Nutrition
Feeding Therapy
Site #1
☐
☐
☐
☐
☐
Site #2
☐
☐
☐
☐
☐
Site #3
☐
☐
☐
☐
☐
2. For categories of personnel that are unavailable, describe how that function will be addressed in the
program.
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Outpatient and Inpatient [PR VII.B]
1. Indicate the availability of the following:
Facility/Service
Space in an ambulatory setting for optimal
evaluation and care of patients [PR VII.B.1.a)]
An inpatient area with pediatric and related
services staffed by pediatric residents and
faculty [PR VII.B.1.b)]
Support services including:
 radiology
 nuclear medicine
 pathology
PICU (indicate total number of beds) [PR
VII.B.1.d)]
NICU (indicate total number of beds) [PR
VII.B.1.e)]
Endoscopy facilities [PR VII.B.1.g)]
Procedure facility for measuring gastrointestinal
motility
Site #1
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Site #3
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2. For every facility/service that is not available at any of the sites, provide an explanation below.
Explain how the service is provided for patients.
Click here to enter text.
Pediatric Gastroenterology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
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3. In a bulleted format explain how fellows, in caring for patients, will have access to a laboratory that
can either perform or assess measures of intestinal absorptive and pancreatic function; nutritional
parameters; and specialized serological, parasitological, immunological, metabolic, and
toxicological studies applicable to gastrointestinal and hepatobiliary disorders. [PR VII.B.1.f)]
 Click here to enter text.
Patient Data [PR VII.B.2)
1. Provide the following information for the most recent 12-month academic or calendar year. Note
the same timeframe should be used throughout the forms.
Inclusive dates:
FROM: Click here to enter a date.
Total number of admissions to the Pediatric
Gastroenterology service
Number of new patients admitted each year
(“new” refers to those who are seen by members
of the Gastroenterology service for the first time.)
Average length of stay of patients on the
pediatric Gastroenterology service
Total number of consultations by pediatric
Gastroenterologists on other inpatients
Number of consultations provided to the
NICU
Number of consultations provided to the
PICU
Average daily census of patients on the Pediatric
Gastroenterology service, including
consultations
Number of patients requiring follow-up care by
Gastroenterology service as outpatients during
12-month period reported
TO: Click here to enter a date.
Site #1
Site #2
Site #3
#
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2. If the ADC on the pediatric gastroenterology service is less than six, explain how fellows have an
adequate exposure to inpatients.
Click here to enter text.
3. Provide the following information for the most recent 12-month academic or calendar year for each
site used to provide a specific required experience, such as transplant, cardiology, intensive care,
etc. Duplicate this table as necessary. Note the same timeframe should be used throughout the
forms.
Inclusive dates:
FROM: Click here to enter a date.
TO: Click here to enter a date.
Site #1
Site #2
Site #3
Name of service:
Pediatric Gastroenterology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 6 of 12
Total number of fellows and residents on the
service
Total number of admissions to the service
Number of new patients admitted each year
(“new” refers to those who are seen by members
of the service for the first time.)
Average length of stay of patients on the service
Average daily census of patients on the service,
including consultations
EDUCATIONAL PROGRAM [PR VIII.]
Ambulatory Pediatric Gastroenterology Experience for All Years of Training
Add rows as necessary.
Name of Experience
Site/Other Setting Identifier
Planned
Number of
Duration of Sessions
Experience Per Week
(in wks/yr) Per Fellow
Estimated
Number of
New
Patients
Per Fellow
Per
Session
Estimated
Planned
Number of
Average
Return
Number
Patients
Teaching
Per Fellow Attendings
Per
Per
Session
Session
If the experience is in a private office, provide full details, including name and credentials of supervisor,
numbers and types of patients, degree of fellow responsibility for their care, frequency of attendance at
office, how director will monitor the experience and fellow performance.
Click here to enter text.
Pediatric Gastroenterology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
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12-Month Summary: Outpatient Clinics/Inpatient Services
1. During the same 12-month period as used in previous sections, how many pediatric patients with
the following gastroenterology problems were: a) seen in the ambulatory settings; b) were admitted
to and/or consulted on by the pediatric gastroenterologists at the primary site?
Inclusive dates:
FROM: Click here to enter a date.
TO: Click here to enter a date.
Outpatients
Gastroenterology Diagnosis/Disorder
Growth failure and malnutrition [PR VIII.A.8.a)]
Malabsorption/maldigestion [PR VIII.A.8.b)]:
 celiac disease
 cystic fibrosis
 pancreatic insufficiency
Gastrointestinal allergy [PR VIII.A.8.c)]
Peptic ulcer disease [PR VIII.A.8.d)]
Hepatobiliary Disease [PR VIII.A.8.e)]:
 biliary atresia
 diseases of the gallbladder
 fatty liver
 intrahepatic cholestasis
 autoimmune liver disease
 viral hepatitis
 metabolic liver diseases
Liver failure (including evaluation and follow-up
care of patient requiring liver transplantation) [PR
VIII.A.8.e)]
Congenital Digestive tract anomalies (including
Hirschsprung’s disease) [PR VIII.A.8.f)]
Inflammatory bowel disease [PR VIII.A.8.g)]
Functional bowel disorders [PR VIII.A.8.h)]
 Vomiting (including gastroesophageal reflux)
 Acute and chronic abdominal pain
 Acute and chronic diarrhea
 Constipation
 Gastrointestinal bleeding
 Motility disorders
Pancreatitis (acute & chronic) [PR VIII.A.8.i)]
Gastrointestinal problems in the immunecompromised host [PR VIII.A.8.k)]
Transplantation [PR VIII.A.9]
 Liver
Total # of
patients
#
Pediatric Gastroenterology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Inpatients
Total # of
patients on
gastro service
Total # of
# on gastro
patients seen
service
in consultation
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Outpatients
Gastroenterology Diagnosis/Disorder
 Small Bowel
Total # of
patients
#
Inpatients
Total # of
patients on
gastro service
Total # of
# on gastro
patients seen
service
in consultation
#
#
2. Describe how fellows will gain knowledge of the methods of initial evaluation and criteria for referral
and follow-up care of the patient requiring liver transplantation and those with intestinal
failure/requiring small bowel transplantation. [PR VIII.A.9]
Click here to enter text.
List of Diagnoses
List 150 CONSECUTIVE admissions and/or consultations to the gastroenterology service. Identify the
time period during which these admissions/consultations occurred. The date range should occur within
the same 12-month period used in previous sections. The dates must begin on the date the first patient
on the list was admitted and end with the date the 150th patient was admitted (e.g., July 1, 2014
through October 20, 2014). Submit a separate list for each site that provides required rotations. Add
additional tables as necessary.
Site Name:
Give inclusive dates during
which these admissions/
consultations occurred:
Patient ID
Number Age
FROM: Click here to enter a date. TO: Click here to enter a date.
Number of days in hospital
Gastroenterologic diagnosis
(may include secondary diagnosis if relevant)
Skill Objectives
Pediatric Gastroenterology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 9 of 12
1. Indicate whether or not the program provides experience in each of the following procedures. Use
the same 12-month period as indicated on the previous sections. For procedures not performed at
any of the participating sites, provide an explanation.
Give inclusive dates during
which these
admissions/consultations
occurred:
FROM: Click here to enter a
date.
# performed on service(s)
Diagnostic & Therapeutic Colonoscopy (including
biopsy) [PR VIII.A.10.a).(1).(a)]
Diagnostic upper endoscopy (including biopsy)
[PR VIII.A.10.a).(1).(b)]
TO: Click here to enter a date.
Site #1
#
Site #2
#
Site #3
#
#
#
#
2. Provide a description of the method by which fellows will acquire skills and how their
competence is ensured for the required procedures listed above
Click here to enter text.
Core Curriculum
Identify the learning activities (clinical experience, conference series, journal club, etc.) and training
sites (Site #) which will be used to address the required core knowledge area.
Core Knowledge Area
Gastrointestinal manometry
[PR VIII.A.11.a)]
Rectal suction biopsy
[PR VIII.A.11.b)]
Paracentesis
[PR VIII.A.11.c)]
Esophageal impedance/pH
testing
[PR VIII.A.11.d)]
Pancreatic function testing
[PR VIII.A.11.e)]
Breath hydrogen analysis
[PR VIII.A.11.f)]
Endoscopic placement of feeding
tubes (including percutaneous
endoscopic gastrostomy
placement)
[PR VIII.A.11.g)]
Videocapsule endoscopy
[PR VIII.A.11.h)]
Endoscopic retrograde
List the Corresponding
List the Learning Activities Setting in Which These
Used to Address the Core Learning Activities Take Year(s) of
Knowledge/Skills Area
Place
Training
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Pediatric Gastroenterology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 10 of 12
Core Knowledge Area
cholangiopancreatography
(ERCP)
[PR VIII.A.11.i)]
Management of gastrointestinal
foreign bodies
[PR VIII.A.11.j)]
Hemostatic techniques for
variceal and nonvariceal
gastrointestinal bleeding
[PR VIII.A.11.k)]
Percutaneous liver biopsy
[PR VIII.A.11.l)]
Training in the evaluation of the
psychosocial aspects of chronic
gastrointestinal disease as they
affect the child
[PR VIII.B.1.b)]
Competence in counseling
chronically ill patients and their
families including preventive
measures for digestive disease
[PR VIII.B.1.b)]
List the Corresponding
List the Learning Activities Setting in Which These
Used to Address the Core Learning Activities Take Year(s) of
Knowledge/Skills Area
Place
Training
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Inpatient Experiences
What responsibilities will the fellows have for inpatients and how and by whom will they be
supervised when assigned to inpatient services?
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Outpatient Experiences
1. Describe the responsibilities that fellows will have for outpatients and how and by whom
fellows will be supervised.
Click here to enter text.
2. Describe the continuity of care experience fellows will receive during their period of
assignment to the outpatient clinic. To what extent will fellows have the opportunity to provide
outpatient care for patients whom they treated on the inpatient service? [PR VIII.A.7]
Click here to enter text.
IF THERE ARE ANY UNIQUE SCENARIOS OCCURRING IN THE PROGRAM THAT DO NOT FIT WITHIN THE CONFINES
OF THIS FORM, PLEASE EXPLAIN.
Click here to enter text.
Pediatric Gastroenterology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
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Pediatric Gastroenterology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
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