Pediatric Gastroenterology, Hepatology and Nutrition Fellowship Program

During the first year of the Pediatric Gastroenterology, Hepatology and Nutrition Fellowship Program, fellows focus primarily on clinical training. Patient care takes place in inpatient and outpatient settings.

A vital part of clinical training is outpatient service. Fellows are required to attend a continuity clinic for one half day each week. They see gastroenterology patients that they can follow through the entire three years of training. Patient continuity is stressed as part of each fellow’s education. Faculty members of the Emory University Division of Pediatric Gastroenterology and Nutrition provide oversight at this clinic as attending physicians.

While on clinical inpatient service, fellows perform daily rounds with attending physicians. Fellows function in the role of attending physician when relating to house staff by providing:

• Relevant articles about interesting cases.
• Supervision in developing differential diagnoses, problem-oriented lists and care plans.
• Education regarding typical GI, liver and nutrition problems.

Fellows on inpatient service have the responsibility to organize and develop treatment plans and diagnostic evaluation plans for pediatric patients with a variety of GI, hepatologic and nutritional problems. Attending physicians directly observe and review fellows’ notes on individual patient charts.

Fellows and attending physicians perform daily consults. Residents and house staff on the GI rotation have the option of rounding on consult patients. Fellows are responsible for assessing consults first, and then they present a prepared differential diagnosis and treatment plan to the attending physician on service.

Our inpatient clinical service is distributed so the primary group of patients with GI, hepatologic and nutritional problems are located at Egleston Hospital. Inpatient consults referred by other subspecialty services and general pediatrics are also seen at Egleston Hospital by the fellow and attending physician on inpatient service.

Occasional consults are also seen at Children's Hughes Spalding Hospital, while neonatal consults are seen at Grady Memorial Hospital and Emory University Hospital Midtown in the neonatal intensive care unit (NICU).

The second and third years of training are primarily research oriented. The half day each week in the outpatient clinic continues throughout training. Fellows provide weekend coverage once a month and brief coverage for vacations. Fellows also have one to two months of elective or on-service time during each of the second and third years of fellowship training.

During the first month of the fellowship program, fellows participate in a department-wide didactic course addressing many areas critical for careers in academic medicine, including:

• Critical literature review.
• Computer use.
• Statistical epidemiology.
• Research design.
• Grant or proposal writing.

A research project will be designed well in advance of starting the research portion of the fellowship. The project will be designed along with a research oversight committee in keeping with the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Pediatrics (ABP) requirements. The oversight committee will consist of a primary mentor from within the department, or a mentor from within the basic or epidemiological sciences, or a funded established researcher(s) from the Emory University Department of Pediatrics. Training can encompass basic or clinical projects.

Once data is generated, fellows analyze it with standard computer programs under the supervision of a mentor. Then, fellows compile the data in the format of a manuscript and submit it to an appropriate journal for publication.

The goal is to have a project that provides enough data to generate a:

• First-author, peer-reviewed manuscript.
• Presentation on original research for national and international meetings.
• “Niche” and a set of tools that can be further developed and applied to a successful career in academic medicine.

Fellows maintain a role in teaching house officers, medical students and other allied health professionals primarily with:

• Activities in ward round.
• Patient evaluation on the wards.
• Gastroenterology clinics.
• Didactic lectures (at least once each year).

While on inpatient service, fellows perform all of the diagnostic and therapeutic procedures on patients in the gastroenterology or hepatology inpatient service and those patients for which consultation has been rendered under the direction of a board-certified pediatric gastroenterologist.

Our program teaches pediatric nutrition using a combination of formal didactic exercises and informal bedside teaching. Problem-based, integrative case studies will constitute an important aspect of the didactic process.

Fellows gain direct experience by responding to pediatric nutrition consults, rounding with specialty dieticians, and observing both the outpatient obesity clinic and the nutrition rehabilitation program at Egleston Hospital.

The goals and objectives of the nutrition elective program are for fellows to:

• Know how to assess nutritional status using anthropometrics, balance studies, body composition analysis and measurement of energy expenditure.
• Recognize the clinical and biochemical manifestations of nutrient deficiencies and nutrient excess.
• Understand the special nutritional needs of patients with inflammatory bowel disease (IBD), short bowel syndrome, cholestatic liver disease, end-stage liver disease, renal disease, neoplasia and immunodeficiency states.
Become competent in nutritionally rehabilitating patients who are undernourished.
• Recognize metabolic syndromes, as well as other obesity-related manifestations.
• Know how to implement better health programs.

During the program’s didactic exercises, fellows will:

• Discuss integrated case studies (nutritional assessment, nutrient biochemistry, macronutrient deficiency, micronutrient deficiency, short gut, IBD, liver disease, renal failure and immunodeficiency) weekly.
• Prepare and present a nutrition-related topic (journal article, case report or review) at the nutrition conference on the fourth Tuesday of each month.
• Attend nutrition conferences at Egleston.
• Obtain and evaluate:
• 24-hour dietary recall from a patient or test individual.
• 24-hour or three-day diet diary from a patient or test individual.
• New parenteral nutrition orders (this will be done in order to identify the pros and cons of obtaining these as measures of dietary assessment in pediatrics).

Weekdays, during the early morning, fellows conduct a round with a subspecialty dietician.

The schedule will be:

• First week: GI (Monday, Tuesday), hematology/oncology (Thursday) and renal (Friday)
• Second week: hepatology and transplant (Monday, Tuesday), hematology/oncology (Thursday) and renal (Friday)
• Third and fourth weeks: rotate with metabolic team at Egleston Hospital
• Every Wednesday: attend neonatology and short bowel nutrition rounds:
• Answer nutrition consultations precepted by the dietitian, and follow those patients during the rotation under the direction of the subspecialty dietitian
• Attend specialty clinics when available (Eating Disorders Clinic, Obesity Clinic, and the Adult and Pediatric Nutritional Rehabilitation clinics)

During rotations, it is expected that fellows will review literature and textbooks. It is optional to write a case report if an interesting patient or problem is encountered during rotations.

Recommended texts include:

• “Nutrition in Pediatrics: Basic Science and Clinical Applications,” 3^rd Edition, Walker, Watkins and Duggan eds.
• “Pediatric Nutrition Handbook,” 5^th Edition, AAP