NMC Issues Guidelines For Competency-Based Training Programme For MCh Pediatric Surgery

New Delhi: The National Medical Commission (NMC) has released the guidelines for Competency-Based Postgraduate Training Programme For MCh In Pediatric Surgery.

1. Preamble

The goals and objectives of M.Ch. training should be to educate candidates in the surgical sciences and to develop their aptitude for providing care for newborns and young children as well as their knowledge, skills, and attitudes in the field of paediatric surgery.

The training should enable him or her to work safely as a paediatric surgeon, a freelance clinical consultant, a medical educator, and a researcher.

2. Subject Specific Objectives

The objective of the programme is to create paediatric surgeons who can lead by example and exhibit corresponding levels of expertise in their field. The training should be designed to help the candidate acquire a thoughtful mixture of the three learning domains that will be used in ethical practice.

Cognitive (knowledge),
Psychomotor (practice) and
Affective (communication).

2.1 Cognitive domain (Knowledge)

Be familiar with the fundamental sciences (embryology, anatomy, physiology, biochemistry, pharmacotherapeutics, etc.) and paediatric surgical practice principles.
Know the embryology, aetiology, pathophysiology, diagnosis, and treatment of common paediatric and neonatal surgical issues, whether they are elective or urgent.
Group approach: Recognize the importance of a multidisciplinary and interdisciplinary approach in treating different paediatric surgical disorders so that, when needed, you can get the opinion of the right specialist.
Research Technique: Familiarity with and participation in clinical and experimental research investigations; knowledge of basic research methodology and biostatistics; involvement in scientific presentation and publication.
Appreciate the role that a child's family, society, and sociocultural environment play in their recovery.

2.2 Psychomotor domain(Practical)

Thoroughly assess a patient (history, clinical examination), order pertinent investigations, and analyse the results to arrive at a diagnosis and management strategy.
Independently plan and carry out uncomplicated investigations/procedures (at the bedside, in the lab, or in the radiology suite).
Offer basic and advanced life support services, such as NALS and PALS, in an emergency.
Become familiar with surgical newborns and infants and offer critical care including airway support, breathing, central venous access, etc.
Set up a patient for an emergency or elective surgery and offer specialised post-operative care.
Offer primary caregivers and the patient counselling to ensure that medical treatment is administered efficiently.
Develop expertise in standard ward procedures (e.g. bladder catheterization, wound dressings, peripheral vascular access, child restraint etc.).
Become proficient in performing minor and major surgical procedures as directed, first with help and then on your own.
Keep an eye on the post-operative patient in the intensive care unit, high dependency unit, and regular post-op ward.
At the time of release, provide the patient and family precise, pertinent information regarding adequate at-home care, hospital reporting in an emergency, and routine follow-up.

2.3 Affective domain (Communication)

Work on and practice your communication abilities.
Interact professionally and, where necessary, seek the advice of specialists or additional services.
Establish a paediatric surgical unit and maintain teamwork while instructing others in a clinical care unit.
Establish clear lines of communication with the patient's caregivers, especially about counselling and end-of-life care.
Medical ethics and human values: The student will instil ethical concepts (professional honesty and integrity, humility, moderation, informed consent, counselling, understanding of patients' rights and privileges, etc.) in all areas of paediatric surgical practice and research.

3. Subject Specific Competencies

3.1 Cognitive (Knowledge) Domain

3.1.1 Competencies to be Acquired in the Cognitive Domain (knowledge)

History and Physical

- Build a rapport with the child and the parent/guardian who is fully familiar with the child and collect a thorough history;

- Conduct a thorough physical inspection of pertinent systems based on history,

- Should be familiar with systemic examinations in children.

- Compile the findings from the physical examination and history to form a tentative diagnosis, along with other possible differential diagnoses, and share this information with the other team members.

Evaluation and Management

- List out and organise the necessary investigations in order to reach a final diagnosis or reduce the range of differential diagnoses. Give emergency and routine investigations top priority.

- Should be able to confirm a valid diagnosis and interpret the findings of the specified investigations, including any permissible normal variations.

- Management of the plan in accordance with the final diagnostic made,

- Effectively communicate to the parents or caregivers the diagnosis, treatment strategy, and potential consequences.

- Explain to the team in detail the findings of the investigation and the management plan that supports them.

- Be able to identify unusual findings and reports and give priority to those that need an immediate response.

- mentor and train the younger team members.

Documentation

- Must be able to thoroughly record case history, exam results, and a management plan based on clinical examination and investigations.

- Use the electronic record when available to update the team on progress.

- A flowchart of management with clear and intelligible directives for subordinates,

- Be able to draught proper cross-departmental referrals,

- Must be able to write concise discharge summaries that clearly outline the hospital stay, including admission, evaluation, management, and post-operative care, as well as follow-up care and prescription recommendations.

Communication

- Clearly explains the diagnosis and treatment plan to the parents or legal guardians,

- Explains the treatment strategy to junior healthcare professionals orally and in writing,

- Uses appropriate communication when handing off to continue patient care,

- Obtain parental consent for procedures and surgery after outlining all available options to them.

Team work.

- Should participate actively in professional teamwork;

- Should accept and effectively carry out responsibilities;

- Should ask team members for assistance when necessary and should be eager to do so; - Should be actively involved in patient care and follow-up.

Others.

- Have compassion for patients and their guardians/parents.

- Adheres to all four medical ethics tenets and does so consistently;

- Is aware of medical practise regulations, such as those governing patient confidentiality,

- Develops research concepts and executes studies utilising Good Clinical Practices,

- Teach relevant paediatric surgical concepts to medical students, junior coworkers, nursing personnel, and paramedics.

- Recognize the risk factors for hospital infections and take the necessary general precautions to avoid them.

- Should be knowledgeable about how the department and ward are run administratively, including the staffing needs, purchasing, and upkeep of electro-medical equipment.

3.1.2 Competencies to be acquired in basic sciences applicable to Pediatric Surgery:

a) Genetic basis of disease
b) Molecular biology applicable to congenital anomalies
c) Fetus as a patient

Antenatal diagnostic tools
Antenatal prognosticators
Fetal interventions

d) Normal and anomalous embryogenesis of all systems:

Gastrointestinal tract
Hepatobiliary and pancreas
Respiratory system including diaphragm and related Cardiovascular system
Genito-urinary tract, including descent of testes, sexual differentiation
Lymphatic system
Face and neck including lip, palate, branchial and thyroglossal apparatus
Abdominal wall, umbilicus and inguinal canal
Central nervous system and spine

e) Surgical anatomy of all above mentioned systems
f) Physiology and biochemistry

Physiology of fetus and newborn including transition from former to latter
Gastrointestinal physiology including deglutition, esophageal motility, antireflux mechanism, intestinal motility & defecation and neuroenteric regulation
Altered biochemistry in intestinal obstruction
Hepatic function including bilirubin metabolism.
Physiology of micturition and neurogenic regulation of same
Biochemical changes in obstructive uropathy and renal failure.
Cardiovascular physiology including fetal & neonatal cardiac function
Pulmonary physiology and basis of mechanical ventilation
Fluid and electrolyte balance.
Hemolytic disorders
Nutritional requirements in health and disease including parenteral nutrition.
Sexual differentiation including biochemical aspects in anomalous conditions
Physiological changes during pre-operative and post-operative period and changes during different types of anesthesia and laparoscopic surgery

g) Microbiological principles governing:

Pathophysiology of sepsis in neonates, infants and children, and inflammatory response,
Maintenance of asepsis, sterility in newborn nursery, ward and operation theatre,
Sterilization of surgical instruments including endoscopes & ventilators,
Common surgical infections, including osteomyelitis and septic arthritis,
Surgical tuberculosis including atypical mycobacterial infection,
AIDS/HIV in Pediatric Surgery,
Parasitic surgical conditions,
Elements of immunology including its importance in organ transplantation & immunosuppression,
Immunization and vaccination.

3.1.3 Competencies to be acquired in general patient care applicable to Pediatric Surgery

Basic and Advanced life support in Neonates and Pediatrics
Basics of mechanical ventilation, different types of ventilatory support
Different types of venous access, arterial access - monitoring
Principles and types of physiological monitoring
Transport and restraint of the sick child

3.1.4. Trauma

General principles of trauma

Upon completion of this, the trainee should be able to describe & discuss:

Epidemiology of Pediatric trauma
Different types of trauma, presentation
Acute care of trauma patients including immediate assessment, triaging, evaluation tools to be used, scoring systems and prognostications

Systemic trauma

Upon completion of this, the trainee should be

able to describe & discuss the different types of trauma pertaining to, their management, indications for surgery, outcomes of :

Head injury
Thoracic injuries including airway,chest wall and mediastinum
Abdominal injuries including blunt and penetrating, solid and hollow viscera, retroperitoneum
Genitourinary trauma including kidney, ureter, bladder, urethra and genital organs
Musculoskeletal and spine trauma
Burns
Child abuse
Soft tissue and envenomation

3.1. 5 Pediatric Oncology

General principles

Upon completion of this, the trainee should be able to describe & discuss:

Genetic basis of tumours
Tumour markers
Principles and application of chemotherapy including toxicities of routinely used chemotherapeutic drugs
Principles and application of radiotherapy including toxicities of routinely used radiotherapy
Immuno-therapy
Gene therapy and newer modalities of treatment
Various evaluation modalities in Oncology

Systemic oncology

Upon completion of this, the trainee should be able to describe & discuss in detail the presentations, staging, prognostication, various treatment systems applicable to specific tumours:

Wilms' tumour
Neuroblastoma
Liver tumours
Rhabdomyosarcomas
Germ Cell - tumours

Upon completion of this, the trainee should be able to describe & discuss an outline of the presentation and management of the following tumours:

Common lymphomas and leukemias
Common bone tumours
Central nervous system tumours

3.1.6 Evaluation methods in Pediatric Surgery

Radiology

Upon completion of this, the trainee should be able to describe & discuss the principles of, applications, pitfalls, modifications in specific situations, how to carry out various investigations and interpret:

X rays
Ultrasonography including Doppler
CT scan
Voiding Cystourethrography
Contrast upper and lower GI series
Intravenous pyelography
MRI
PET - CT scan

Nuclear Medicine

Renal Dynamic Diuretic Radionuclide scintigraphy with various isotopes like EC, MAG3, DTPA
Static Cortical renogram - DMSA
Direct Radionuclide Cystography (DRCG)
Hepatobiliary scintigraphy
MIBG scan
Lymphatic scintigraphy
Thyroid scintigraphy
Gastro-esophageal reflux scintigraphy
RBC blood pool scan
Technitium Meckel's scan
PET scan
Liver-Spleen scan
Bone scan

Urodynamics

Uroflowmetry
Cystometrogram
Video urodynamics

Others

24 hour pH monitoring
Esophageal and anorectal manometry
3. Intracranial pressure monitoring
4. Basics of pathological biopsies, examination including frozen section immunohistochemistry

3.1.7 Transplantation

Upon completion of this, the trainee should be able to describe & discuss:

Principles of transplantation including immunology and selection of recipients
Organ procurement and preservation
Outcomes including complications of transplantation
Immuno-suppression and its toxicities
Indications, preparation of recipient, techniques and post transplantation management and outcomes of the following:
- a. Kidney transplantation and liver transplantation in detail
- b. An outline of pancreatic transplantation, intestinal transplantation, bone marrow transplantation, heart & heart-lung transplantation

3.1.8 Regional and Special Pediatric Surgery

At the end of the training, the student should be able to describe, discuss, analyse and present pathogenesis, clinical presentations, differential diagnosis, diagnostic approach, roles of specific diagnostic tools, interpretation of the test results, management options (both non-operative and surgical), indications for surgery, preparation for surgery, peri- and post-operative management, surgical steps, complications and their management, outcomes (short and long - term) of the various congenital and acquired pathologies in each system as below (elaborated in detailed in the syllabus sections):

A: Head and Neck:

B: Thorax:

C: Abdomen:

D: Genitourinary Tract

Special Pediatric Surgery

3.1.9 Recent Advances

Upon completion of this, the trainee should be able to describe & discuss the advanced technology, its applications in diagnosis and treatment, complication and research options related to the fields outlined above. In addition, he must be conversant with:

Minimal Access surgery of all areas including laparoscopy, thoracoscopy, ventriculoscopy, stealth and endoscopic surgeries, gastrointestinal endoscopy including ERCP (endoscopic retrograde cholangio- pancreatography), Bronchoscopy and Endourology.
Robotics in Pediatric Surgery
Use of newer energy sources in surgery including LASER, harmonic scalpel etc.
Use of various types of staplers: Intestinal, Vascular, Endo GI etc.

3.2 Affective Domain (Attitudes & Values)

The post graduate student should imbibe the following:

Group /Team approach: function as a part of a team, cooperate with colleagues, and interact with the patient to provide the optimal medical care.
Ethical practice: Abide by ethical principles in medical practice, maintain proper etiquette in dealings with patients, caretakers and other health personnel including due attention to the patient's right to information, consent and second opinion. Maintain professional integrity while dealing with patients, colleagues, seniors, pharmaceutical companies and equipment manufacturers.
Skills: Preparation of oral presentation, medical documents, professional opinion in interaction with patients, caretakers, peers and paramedical staff – both for clinical care and medical teaching. Effective communication with the patient/caretakers regarding the nature and extent of disease, treatment options available and realistic outcome following optimal management is essential.
During the course of three years the postgraduate student is expected to attend instructive courses that facilitate proficiency relevant to this domain, eg., communication skills, biomedical ethics, patient counseling etc.

3.3 Psychomotor Domain (Skills)

The trainee pursuing MCh. in Pediatric Surgery course must acquire the following evaluations and skills - procedural and non-procedural skills - in the management of surgical diseases of children -

3.3.1. Clinical examination, outpatient and inpatient evaluation

Upon completion of the course, the post graduate student should be able to perform the following:

Assess the child patient with surgical problems by:

Eliciting pertinent history.
Performing correct physical examination.
Making a working diagnosis.
Determining the type of care that is appropriate – outpatient/ inpatient/daycare.
Initiate and institute life-saving emergency care, including CPR.
Requesting appropriate investigations and interpretation of their result.
Identify pre-operative and post-operative complications promptly and deal with them safely.
Document and maintain a record of patients systematically.
Seek professional help from other colleagues where needed.
Treat patients and their relatives with respect and empathy.
Able to counsel caretakers and the family of patients and obtain requisite consent for care.

3.3.2 Radiological procedures

Upon completion of the course, the post graduate student should be able to perform the following:

Apply knowledge of imaging modality (USG,CT,MR) to investigate surgical diseases of childhood,
Interpret the radiological images to correctly identify normal structures, abnormalities and pathology,
Familiarity with conduct and interpretation of intra-operative imaging – radiography and ultrasonography,
The postgraduate student should be able to perform certain investigative and therapeutic procedures in the radiology suite with due precautions -

Esophageal swallow
Upper GI contrast study
Contrast enema
Therapeutic contrast enemas in meconium ileus
Reduction of select idiopathic intussusception with radiological (air/contrast enema) or ultrasonography (hydrostatic)
Voiding cystourethrogram
Retrograde urethrogram
Antegrade studies through drainage tubes
Percutaneous drainage, biopsy

3.3.3 Physiological studies:

The post graduate student should be able to perform a uroflowmetry and cytometry with standard precautions and interpret the results real time.

3.3.4 Operative procedures:

This includes elective, semi-emergency and emergency procedures.

Minor surgery
Major surgery
Endoscopic procedures
Minimally invasive surgery

The actual numbers performed may vary according to the patient load of the training unit and related departments.

At the end of his training period, the candidate must be able to Perform the following procedures independently

General:

Peripheral and central venous access, chemoport and Hickman catheter placement
Arterial line placement
Wound debridement and suturing
Incision and drainage of abscess
Excision of superficial lesions of skin / subcutaneous planes
Limb amputation
Percutaneous/open tumor, viscera (e.g. liver ) and lymph node biopsy
Skin grafting
Fasciotomy
Contracture release
Muscle biopsy
Nerve biopsy
Umbilical vein cannulation
Peritoneal dialysis catheter insertion
Restraint of the sick child

Head and Neck:

Repair of cleft lip
Repair of cleft palate
Salivary duct / orifice dilatation
Ranula - marsupialization
Release of ankyloglossia
Sistrunk's procedure
Excision of branchial remnants
Excision of superficial head and neck masses
Sternomastoid muscle release
Diagnostic laryngoscopy
Esophagostomy
Cricothyroidotomy
Injection sclerotherapy of accessible vascular lesions
Tracheostomy

Thorax:

Mastectomy
Bronchoscopy - diagnostic, lavage
Esophagoscopy - diagnostic
Diagnostic thoracoscopy
ICTD insertion
Repair of eventration diaphragm
Decortication
Primary repair of TEF
Diversion for TEF – esophagostomy, gastrostomy

Abdomen:

Exploratory laparotomy for acute abdomen
Laparoscopy - diagnostic, therapeutic minor
Gastrostomy,
Fundoplication
Pyloromyotomy
Ladd's procedure
Repair of cong. diaphragmatic hernia

Bochdalek, Morgagni

Repair of eventration diaphragm
Per op cholangiogram
Cholecystectomy, cholecystostomy
Cystogastrostomy, cystojejunostomy
Surgery for Vitello-intestinal duct remnants
Feeding tube jejunostomy
Ileostomy, colostomy
Surgery for meconium ileus
Mesenteric cyst excision
Appendectomy
Appendicular abscess – drainage
Bowel resection, anastomosis
Secondary suturing (burst abdomen)
Surgery for inguinal hernias and hydrocele, Umbilical hernia, Femoral hernia
Rectal biopsy
Anoplasty for low anorectal malformation
Splenectomy

Genitourinary

Cystoscopy - Diagnostic, stent removal
Nephrostomy
Suprapubic cystostomy
Vesicostomy
Urolithiasis- pyelolithotomy, cystolithotomy
Meatotomy/meatoplasty
Distal hypospadias repair
Urethral fistula repair
Urethral calibration / dilatation
Circumcision, preputioplasty and dorsal slit, reduction of paraphimosis
Orchidopexy- open
Fowler Stephen Stage 1 (open, laparoscopic ) orchidopexy
Exploration for torsion testes, orchidectomy

Neurosurgery

Ventriculoperitoneal stunts.
External ventricular drainage
Repair of spina bifida

At the end of his training period, the post graduate student must be able to perform the following procedures under senior supervision:

General

Vascular anastomosis
HD catheter insertion

Trauma:

Laparotomy for trauma
Thoracotomy for trauma

Head and Neck:

Salivary gland excision
Excision of lymphatic malformations/ neck masses
Thyroidectomy
Repair of H-type TEF

Thorax:

Bronchoscopy - foreign body extraction
Esophagoscopy - foreign body extraction , dilatation
Repair of Pectus Excavatum
Repair of Pectum Carinatum
Thoracoscopic procedures, VATS for empyema
Mediastinal mass excisions
Pulmonary resection
Esophageal replacement.

Abdomen:

Abdominal wall defects - Silo construction
Surgery for varicocele
Orchidopexy- lap assisted
Duodeno-duodenostomy
Neonatal small bowel atresia – resection, anastomosis
Laparoscopy - therapeutic, major
Pull through for Hirschsprung disease
Excision of duplication cyst
Operations for necrotizing enterocolitis
Anorectal myectomy
Surgery for high anorectal malformation: PSARP, ASARP, AP Pull through etc.
Colonic resections
Kasai's portoenterostomy
Operations for choledochal cyst
Liver abscess drainage
Operation for liver hydatid
Hepatic resection
Operation for portal hypertension
Operation for pancreatic pseudocysts
Pancreatic resection
Pancreatico-enteric anastomosis
Adrenalectomy

Genitourinary

Nephrectomy Nephroureterectomy
Partial nephrectomy
Cystoscopy, fulguration of PUV
Pyeloplasty
Ureterocele incision
Ureterostomy
Ureteric reimplantation
Urolithiasis - nephrolithotomy, ureterolithotomy
Exstrophy repair (turn in)
Bladder augmentation
Mitrofanoff procedure
Bladder neck repair
Ureterosigmoidostomy
Epispadias repair
Colonic conduit
Urethroplasty for Hypospadias
Operation for intersex disorder
Correction of penoscrotal transposition

Oncosurgery

Pediatric solid tumour surgery for Wilms' tumour, Neuroblastoma, Hepatoblastoma, Sacrococcygeal teratoma, Germ cell tumours, Thoracic tumours, Head & Neck tumours, Genitourinary tumours, Soft tissue tumours,

Common bone tumours, Lymphomas Neurosurgery

Repair of encephalocele
Repair of occult spinal dysraphism

In addition to the above procedures, the student must be familiar with, prepared a patient for and should have witnessed procedures like:

UGI endoscopy and variceal sclerotherapy / banding,
Colonoscopy,
Extracorporeal shock wave lithotripsy, Percutaneous nephrolithotomy.

4. Syllabus

Course contents:

Cognitive domain

The following is a broad outline of the syllabus:

Basic sciences as applied to Pediatric Surgery

Medical genetics and gene therapy.
Antenatal diagnosis and fetal intervention
Developmental and transitional physiology of the respiratory, cardiovascular and renal systems
Neonatal physiology and assessment of the surgical neonate.
Neonatal sepsis
Nutrition – enteral, parenteral
Vascular access
Principles of imaging (radiodiagnosis, nuclear) in Pediatric practice
Pharmacology and use of common drugs , antibiotics and policy
Pediatric analgesia and anaesthesia , critical care , mechanical ventilation
General principles of Endoscopy and Minimal Access Surgery – fetoscopy, genitourinary endoscopy, tracheo-bronchoscopy, laparoscopy, thoracoscopy, robotic surgery
Biomedical ethics and legal issues in Pediatric surgical practice.
The organisation of a Pediatric Surgical unit
HIV/AIDS in children
National health policy-programs pertinent to Pediatric practice
Telemedicine and telesurgery - principles , practice and limitations

Trauma

Birth trauma
Pediatric trauma – general principles.
Thoracic, abdominal, genitourinary, central nervous system trauma
Soft tissue and envenomation injuries
Musculoskeletal and vascular trauma
Burns
Child abuse.

Pediatric Oncology

General principles of oncology, radiotherapy and chemotherapy
Wilms' tumor
Neuroblastoma
Liver tumours
Rhabdomyosarcoma
Germ cell tumours
Other tumor of childhood (outline)-Leukemias, Lymphomas, Bone tumours, CNS tumours,
Retinoblastoma

Transplantation

General principles
Kidney and liver transplantation
Outline of other solid organ and bone marrow transplantation

Head and Neck Disorders

Craniofacial anomalies
Cleft lip and palate
Disorders of the upper airway and oral cavity.
Salivary glands
Disorders of lymph nodes.
Thyroid and parathyroid gland
Cysts and sinuses of the neck
Torticollis

Thoracic Disorders

Congenital chest wall deformities.
Disorders of the breast.
Diaphragmatic hernia and eventration
Mediastinal mass lesions.
Endoscopy of the upper aerodigestive tract.
Congenital tracheal and Bronchopulmonary/ foregut malformations
Infective pleuro-pulmonary condition.
Congenital oesophagal anomalies
Oesophagal motility disorders ,achalasia cardia , gastro-esophageal reflux
Oesophageal rupture, injury, stricture, perforation.
Oesophagal replacement.

Abdominal Disorders

Umbilical disorders and abdominal wall defects.
Inguinal hernias and hydroceles
Testicular maldescent, torsion
Hypertrophic pyloric stenosis.
Duodenal atresia, annular pancreas.
Jejunoileal atresia and stenosis
Meconium ileus
Meckel's diverticulum
Intussusception.
Disorder of midgut rotation.
Short bowel syndrome
Gastrointestinal endoscopy and laparoscopy.
Gastrointestinal bleeding
Gastrointestinal duplications.
Mesenteric and omental cysts
Ascites
Polypoid disease of the GIT
Necrotising enterocolitis.
Intestinal stomas
Primary peritonitis.
Inflammatory bowel disease in children.
Colonic atresia and functional obstruction.
Appendicitis
Hirschsprung disease, neuromuscular disorders of intestines
Anorectal malformations.
Congenital short colon /pouch colon
Colonic and rectal tumours
Neonatal/Infantile obstructive cholangiopathy
Congenital biliary dilatation.
Infective and inflammatory hepatobiliary disorders
Benign liver tumours
Portal hypertension
Disorders of the pancreas
Splenectomy and post-splenectomy sepsis.
Adrenal gland.

Genitourinary and related disorders

Renal agenesis, dysplasia, cystic disease, ectopia
Pelvic ureteral junction obstruction
Vesicoureteric reflux
Infective and inflammatory renal disorder.
Pediatric urolithiasis
Congenital ureteric anomalies.
Prune belly syndrome
Urinary diversion and undiversion, bladder augmentation
Disorders of bladder function.
Structural bladder disorders
Exstrophy – epispadias complex
Hypospadias.
Anomalies of the external genitalia
Disorders of Sex Differentiation
Abnormalities of the female genital tract.

Miscellaneous Pediatric Surgical Disorders

Spina bifida
Hydrocephalus
Congenital heart disease
Congenital orthopaedic deformities
Amputation, bone and joint infections
Conjoined twins
Hemangiomas & vascular malformations.

5. Teaching And Learning Methods

Teaching programs will need to be held on all working days (at least one hour per day)

Activities
Journal Club
Didactic lectures
Seminars/ Webinars
Hospital (Grand Rounds/Clinical meeting/Audit meet)
Clinical Case Presentation/ presentation to multidisciplinary tumour boards

5.1 Teaching And Learning Methods

General principles - Acquisition of practical competencies being the cornerstone of post graduate medical education, PG training should be skills oriented. Learning in PG programmes should be essentially self-directed and primarily emanating from clinical and academic work.

The formal sessions are merely meant to supplement this core effort. The post graduate student should be given the responsibility of managing and caring for patients in a gradual manner under supervision.

Formal teaching sessions: This should include regular bedside case presentations and demonstrations, didactic lectures, seminars/Webinars, journal clubs, clinical meetings, and combined conferences with allied departments, Audit meet, clinical case presentation etc. as per sample schedule given below:

Didactic Lectures by faculty: In addition, lectures covering recent advances in all aspects of pediatric surgical conditions would be taken by faculty. All post graduate students will be required to attend these lectures.

Short term courses on the following basic and clinical aspects must be included:

Research methodology and bio-statistics
Laboratory medicine techniques/courses relevant to Pediatric Surgery
Use of computers/ data science management in medicine,
Bioethics, ethical issues involved in pediatric surgery
Hospital waste management,
Health economics.

5.1. The M.Ch. Pediatric Surgery training program will include two main arms:

5.1.1. Formal training and learning

5.1.2. Experiential learning

5.1.1. Formal training and learning will include the topics listed in the syllabus:

The modalities for formal training will be as follows:

Seminars/Webinars: To be held once a week and presented by the trainee under supervision of the teaching faculty.

Journal Review: To be held once a week under supervision of the teaching faculty. It should include discussion on recent articles, which relate to various topics in Pediatric Surgery and allied disciplines.

Clinical Case presentation: Representative clinical cases shall be presented and discussed in detail in presence of faculty.

Operative procedures: This session, recommended once a month, aims at discussing common operative procedures and practical details.

Treatment Planning: The trainee must discuss the planning of a given patient who is being worked up for surgery. The idea of this academic exercise is to familiarize the trainee with the objectives of planning in a given patient through group discussion/ multidisciplinary tumour boards based on evidence-based medicine.

Pediatric Radiology/Nuclear Medicine conferences should be held once a week in which the radiological and nuclear medicine investigations of various cases are discussed in consultation with the faculty of Radiology and Nuclear Medicine.

Clinical grand rounds: A clinical grand round, involving presentation of unusual and difficult cases, is to be done by a post graduate student, once a week, in the presence of all the clinical staff belonging to the department of Pediatric surgery. The exercise is to develop the clinical acumen of the trainee.

Clinico-pathological conference: Special emphasis is made on the surgical pathology, histology review and autopsy discussions.

Lecture/discussion: Lectures on newer topics by faculty, in place of seminar, is to be arranged as per need.

Teaching and training responsibilities (Pedagogy skills): A final year M.Ch. trainee should be entrusted with the responsibilities of teaching post graduate students of General Surgery and allied disciplines.

Training in research methodology: The purpose of the exercise is to impart proficiency in research methodology to the trainee. This would be a mandatory component of training. All M.Ch. trainees must complete research projects as per requirement of concerned Universities, under the supervision of a principal supervisor and appropriate number of co-supervisors which would enable the trainee to attain proficiency in collecting clinical / experimental data and analyze them in a scientific way using appropriate statistical methods.

Attendance and presentation at academic meets: The student must attend accredited scientific meetings (CME, symposia, and conferences) once or twice a year. He should present at least one poster or read one paper at a national/state conference in Pediatric Surgery or subspecialty (Pediatric Urology, Pediatric Surgical Oncology etc.) during the second and third year of the training period.

Research Publication (Research skills): A student has to present one paper which is published/accepted for publication/sent for publication during the period of his postgraduate studies so as to make him eligible to appear at the postgraduate degree examination.

The research has to be done under the direct supervision of the supervisor or his associate(s). Through this exercise, the trainee would learn how to collect and analyze data, make observations in a scientific manner, and use appropriate statistical methodology.

The trainee would learn the art of putting the outcome of observations and results in an appropriate format of a scientific paper that is relevant to a particular journal.

Use of Skills lab stations: The skills lab must facilitate training and acquisition of both common (e.g. endotracheal intubation, ICT drainage, Central line insertion) skills in real life situations and uncommon skills (laparoscopic suturing, cricothyroidotomy etc.) that the student may not encounter often.

Mortality and morbidity (Audit) meetings: Departmental and interdepartmental/ institutional

5.1.2. Experiential learning

Apart from routine postings in ward, OPD, operation theatre and speciality clinics, the M,Ch (Pediatric Surgery) trainee will be posted in the following allied specialties. The total duration of these postings shall not exceed three months.

There is no specified compulsory posting in Emergency Medicine/Casualty; however, the student will attend the emergency cases pertaining to/referred to their department at the Emergency/ Casualty in the course of the routine clinical duties.

Pediatric Intensive Care Unit: Duration- 2-4 weeks. This is intended to familiarize the student to the principles of pediatric medical intensive care and its applications to pediatric surgical care.
Neonatology Intensive Care Unit: Duration- 2-4 weeks. During this posting, the candidate will receive training on care of the sick neonates, particularly premature and small for date.
Optional External Posting: Other postings may be scheduled as deemed necessary for the fulfilment of curricular demands, e.g. Pediatric Oncology, etc. in the third year, in the same or in another tertiary teaching Centre/Institute. The posting in another institute may be for a special training that is currently not available at the home institute. It may be for 4-8 weeks with the prior approval of the Head of the Institution. Prescribed institutional regulations will be adhered to for such an external posting.
Administrative experience: The final year post graduate student should be entrusted with administrative responsibilities including preparation of academic programme, patient management, functioning of the ward and outpatient department. These may include:

Admission of patients,
Preparing the operation theatre lists,
Improving the functioning in the ward through the supervisor,
Preparing list of topics for teaching of junior trainees posted in the department,
Organizing the posting of trainees in various work stations of the department as per the demand of the situation.

5. Log Book

The trainees must maintain a log book of the work carried out by them and the training program undergone during the period of training including details of the surgical operations assisted or done independently. The log book should be checked and assessed periodically by the faculty members imparting the training.

During the training programme, patient safety is of paramount importance; therefore, skills are to be learnt initially on the models, later to be performed under supervision followed by performing independently. For this purpose, provision of skills laboratories in medical colleges is mandatory.

6. Assessment

Formative Assessment during the training includes:

Personal attributes Ongoing after each clinical posting
Clinical skills and performance -do-
Academic activities -do-
Theory assessment End of 1-, 2- and at 2 years 9 months
Practical assessment -do-

Clinical skills and performance, academic performance and personal attributes shall be graded on a scale of 1 to 5 (5 being the highest). The academic presentations shall be graded at the time of presentation by the faculty in-charge. Evaluation on clinical skills and personal attributes etc. shall be done by the unit/department in-charge at the end of every semester. The student to be assessed periodically as per categories listed in post graduate student appraisal form (Annexure I).

Summative Assessment at the end of the training will be as follows:

The M.Ch. examination shall be in two parts:

Theory: There shall be four theory papers as follows:

Paper I: Basic Sciences in Pediatric Surgery, Trauma, Transplantation
Paper II: Regional Pediatric Surgery (Head and Neck, Thorax),
Pediatric Oncosurgery
Paper III: Regional Pediatric Surgery (Abdomen, Genitourinary)
Paper IV: Recent advances in Pediatric surgery

The theory examination shall be held in advance before the clinical and practical examination, so that the answer books can be assessed and evaluated before the commencement of the clinical/practical/oral examination. The post graduate students for M.Ch in Pediatric surgery will be examined also in surgical procedures.

Practical: The practical examination should consist of the following and should be spread over two days, if the number of candidates appearing is more than one:
Four cases from various sections of Pediatric surgery/subspecialities: History taking, physical examination, interpretation of clinical findings, differential diagnosis, investigations, prognosis and management.
Ward rounds comprising of discussion of practical problems in the management of pediatric patients undergoing surgery.
Viva-voce examination