NMC Guidelines for Competency-Based Training Programme For MD Paediatrics

The National Medical Commission (NMC) has released the Guidelines For Competency Based Postgraduate Training Programme For MD In Paediatrics

The purpose of PG education is to create specialists who would provide high quality health care and advance the cause of science through research & training.

A post graduate student after undergoing the required training should be able to deal effectively with the needs of the community and should be competent to handle the problems related to his specialty including recent advances. S/He should also acquire skills in teaching of medical/para- medical students.

The purpose of this document is to provide teachers and learners illustrative guidelines to achieve defined outcomes through learning and assessment. This document was prepared by various subject-content specialists. The Reconciliation Board of the Academic Committee has attempted to render uniformity without compromise to purpose and content of the document. Compromise in purity of syntax has been made in order to preserve the purpose and content. This has necessitated retention of "domains of learning" under the heading "competencies".

SUBJECT SPECIFIC OBJECTIVES

The objectives of MD Course in Paediatrics are to produce a competent pediatrician who:

• Recognizes the health needs of infants, children and adolescents and carries out professional obligations in keeping with principles of the National Health Policy and professional ethics

• Has acquired the competencies pertaining to Paediatrics that are required to be practiced in the community and at all levels of health system

• Has acquired skills in effectively communicating with the child, family and the community

• Is aware of contemporary advances and developments in medical sciences as related to child health

• Is oriented to principles of research methodology

• Has acquired skills in educating medical and paramedical professionals

• Is able to recognize mental conditions and collaborate with Psychiatrists/Child Psychologists for the treatment of such patients

SUBJECT SPECIFIC COMPETENCIES

A. Cognitive domain

At the end of the MD course in Paediatrics, the students should be able to:

1. Recognize the key importance of child health in the context of the health priority of country

2. Practice the specialty of Paediatrics in keeping with the principles of professional ethics

3. Identify social, economic, environmental, biological and emotional determinants of child and adolescent health, and institute diagnostic, therapeutic, rehabilitative, preventive and promotive measures to provide holistic care to children

4. Recognize the importance of growth and development as the foundation of Paediatrics and help each child realize her/his optimal potential in this regard

5. Take detailed history; perform full physical examination including neuro- development and behavioral assessment and anthropometric measurements in the child and make clinical diagnosis.

6. Perform relevant investigative and therapeutic procedures for the paediatric patient

7. Interpret important imaging and laboratory results

8. Diagnose illness based on the analysis of history, physical examination and investigations

9. Plan and deliver comprehensive treatment for illness using principles of rational drug therapy

10. Plan and advice measures for the prevention of childhood disease and disability

11. Plan rehabilitation of children with chronic illness and handicap and those with special needs

12. Manage childhood emergencies efficiently

13. Provide comprehensive care to normal, 'at risk' and sick neonates

14. Demonstrate skills in documentation of case details, and of morbidity and mortality data relevant to the assigned situation

15. Recognize the emotional and behavioral characteristics of children, and keep these fundamental attributes in focus while dealing with them

16. Demonstrate empathy and humane approach towards patients and their families and keep their sensibilities in high esteem

17. Demonstrate communication skills of a high order in explaining management and prognosis, providing counseling and giving health education messages to patients, families and communities

18. Develop skills as a self-directed learner. Recognize continuing educational needs; use appropriate learning resources and critically analyze published literature in order to practice evidence-based Paediatrics

19. Demonstrate competence in basic concepts of research methodology and epidemiology

20. Facilitate learning of medical/nursing students, practicing physicians, paramedical health workers and other providers as a teacher-trainer

21. Implement National Health Programs, effectively and responsibly

22. Organize and supervise the desired managerial and leadership skills

23. Function as a productive member of a team engaged in health car, research and education.

24. Recognize mental conditions, characterized by self absorption, reduced ability to respond, abnormal functioning in social interaction with or without repetitive behavior, poor communication (autism) and collaborate with Psychiatrists/Child Psychologists for the treatment of such patients.

All PG students joining the course should have an orientation session to acquaint them with the requirements and other details. A plan for orientation session has been given at Annexure 1.

B. Affective Domain:

1. Should be able to function as a part of a team, develop an attitude of cooperation with colleagues, and interact with the patient and the clinician or other colleagues to provide the best possible diagnosis or opinion.

2. Always adopt ethical principles and maintain proper etiquette in dealings with patients, relatives and other health personnel and to respect the rights of the patient including the right to information and second opinion.

3. Develop communication skills to word reports and professional opinion as well as to interact with patients, relatives, peers and paramedical staff, and for effective teaching.

C. Psychomotor domain

At the end of the course, the student should have acquired following skills:

I. History and Examination

The student must gain proficiency in eliciting, processing and systemically presenting Paediatrics history and examination with due emphasis of the important and minimization of less important facts. The following skills must be achieved:

i) Recognition and demonstration of physical findings

ii) Recording of height, weight, head circumference and mid arm circumference and interpretation of these parameters using growth reference standard assessment of nutritional status and growth

iii) Assessment of pubertal growth

iv) Complete development assessment by history and physical examination, and recognizing developmental disabilities, including autism

v) Systematic examination

vi) Neonatal examination including gestation assessment by physical neurological criteria

vii) Examination of the fundus and the ear-drum

viii) Skills related to IMNCI and IYCF

II. Monitoring Skills

Non-invasive monitoring of blood pressure, pulse and respiratory rates, saturation; ECG

III. Investigative Procedures

i) Venous, capillary and arterial blood sampling using appropriate precautions

ii) Pleural, peritoneal, pericardial aspiration; subdural, ventricular and lumbar puncture

iii) Tuberculin test

iv) Biopsy of liver and kidney

v) Urethral catheterization and suprapubic tap

vi) Gastric content aspiration

IV. Therapeutic Skills

i) Breast feeding assessment and counseling; management of common problems

ii) Establishment of central and peripheral vascular access; CVP monitoring

iii) Administration of injections using safe injection practices

iv) Determination of volume and composition of intravenous fluids and heir administration

v) Neonatal and Pediatric basic and advanced life support

vi) Oxygen administration, CPAP and nebulization therapy

vii) Blood and blood component therapy

viii) Intraosseous fluid administration

ix) Phototherapy, umbilical artery and venous catheterization and exchange transfusion

x) Nasogastric feeding

xi) Common dressings and abscess drainage; intercostal tube insertion

xii) Basic principles of rehabilitation

xiii) Peritoneal dialysis

xiv) Mechanical ventilation

V. Bed side investigations, including

i) Complete blood counts, micro ESR, peripheral smear

ii) Urinalysis

iii) Stool microscopy and hanging drop

iv) Examination of CSF and other body fluids

v) Blood sugar

vi) Shake test on gastric aspirate

vii) Gram stain, ZN stain

VI. Patient Management Skills

i) Proficiency in management of pediatric emergencies, including emergency triaging

ii) Drawing and executing patient management plan and long term care

iii) Documenting patient records on day to day basis and problem oriented medical record

iv) Care of a normal and sick newborn, management of neonatal disorders hypothermia, sepsis, convulsions, jaundice, metabolic problems

v) Identifying need for timely referral to appropriate departments/health facility and pre-transport stabilization of the sick child

VII. Communication Skills; Attitudes; Professionalism

i) Communicating with parents/child about nature of illness and management plan prognostication, breaking bad news

ii) Counseling parents on breast feeding, nutrition, immunization, disease prevention, promoting healthy life style

iii) Genetic counseling

iv) Communication and relationship with colleagues, nurses and paramedical workers

v) Appropriate relation with pharmaceutical industry

vi) Health economics

vii) Professional and research ethics

VIII. Interpretation of Investigations

i. Plan x-ray chest, abdomen, skeletal system

ii. Contrast radiological studies: Barium swallow, barium meal, barium enema, MCU

iii. Ultrasound skull and abdomen

iv. Histopathological, biochemical and microbiological investigations

v. CT Scan and MRI (skull, abdomen, chest)

vi. Electrocardiogram, electroencephalogram

vii. Arterial and venous blood gases

viii. Desirable: Interpretation of radio-isotope studies, audiogram, neurophysiological studies, (BERA, VER, Electromyography [EMG], Nerve Conduction Velocity [NCV]), lung function tests

IX. Academic Skills

i. Familiarity with basic research methodology, basic IT skills. Planning the protocol of the thesis, its execution and final report

ii. Review of literature

iii. Conducing clinical sessions for undergraduates medical students

iv. Desirable: writing and presenting a paper. Teaching sessions for nurses and medical workers

Syllabus

Course contents: Guidelines

During the training period, effort must be made that adequate time is spent in discussing child health problems of public health importance in the country or particular region.

Basic Sciences

• Principles of inheritance, chromosomal disorders, single gene disorders, multifactorial / polygenic disorders, genetic diagnosis and prenatal diagnosis, pedigree drawing.

• Embryogenesis of different organ systems especially heart, genitourinary system, gastro-intestinal tract. Applied anatomy and functions of different organ systems.

• Physiology of micturition and defecation; placental physiology; fetal and neonatal circulation; regulation of temperature, blood pressure, acid base balance, fluid electrolyte balance and calcium metabolism.

• Vitamins and their functions.

• Hematopoiesis, hemostasis, bilirubin metabolism.

• Growth and development at different ages, growth charts; puberty and its regulation.

• Nutrition: requirements and sources of various nutrients.

• Pharmacokinetics of common drugs, microbial agents and their epidemiology.

• Basic immunology, biostatistics, clinical epidemiology, ethical and medico-legal issues.

• Teaching methodology and managerial skills.

Understanding the definition, epidemiology, aetiopathogenesis, presentation, complications, differential diagnosis and treatment of the following, but not limited to:

Growth and development

• principles of growth and development • normal growth and development,

• normal growth and development • sexual maturation and its disturbances

• failure to thrive and short stature • Autism (as mentioned in objective 24)

Neonatology

• perinatal care • low birth weight

• care in the labor room and resuscitation • newborn feeding

• prematurity • respiratory distress

• common transient phenomena • apnea

• infections • anemia and bleeding disorders

• jaundice • gastrointestinal disorders

• neurologic disorders • malformations

• renal disorders • understanding of perinatal medicine

• thermoregulation and its disorders

Nutrition

• maternal nutritional disorders; • nutrition for the low birth weight impact on fetal outcome • breast feeding

• infant feeding including • vitamin and mineral deficiencies complementary feeding

• protein energy malnutrition • obesity

• adolescent nutrition • parenteral and enteral nutrition

• nutritional management of systemic illness (GI, hepatic, renal illness)

Cardiovascular

• congenital heart diseases • rheumatic fever and rheumatic heart

(cyanotic and acyanotic) disease

• infective endocarditis • arrhythmia

• disease of myocardium • diseases of pericardium (cardiomyopathy, myocarditis) • systemic hypertension

• hyperlipidemia in children

Respiratory

• congenital and acquired disorders of nose • infections of upper respiratory tract tonsils and adenoids • obstructive sleep apnea

• congenital anomalies of lower respiratory tract • acute upper airway obstruction

• foreign body in larynx trachea and bronchus • trauma to larynx

• subglottic stenosis (acute, chronic) • neoplasm of larynx and trachea

• bronchial asthma • bronchiolitis

• acute pneumonia, bronchiolitis • aspiration pneumonia, GER

• recurrent, interstitial pneumonia • suppurative lung disease

• atelectasis • lung cysts, mediastinal mass

• pleural effusion

Gastrointestinal and liver disease

• disease of oral cavity • disorders of deglutition and esophagus

• peptic ulcer disease • congenital pyloric stenosis

• intestinal obstruction • acute and chronic pancreatic disorders

• malabsorption syndrome • acute and chronic diarrhea

• irritable bowel syndrome • inflammatory bowel disease

• Hirschsprung disease • anorectal malformations

• hepatitis • hepatic failure

• chronic liver disease • Budd-Chiari syndrome

• metabolic diseases of liver • cirrhosis and portal hypertension

Nephrologic and Urologic disorders

• acute and chronic glomerulonephritis • xanthema syndrome

• hemolytic uremic syndrome • urinary tract infection

• VUR and renal scarring • involvement in systemic diseases

• renal tubular disorders • neurogenic bladder, voiding dysfunction

• congenital and hereditary renal disorders • renal and bladder stones

• posterior urethral valves • hydronephrosis

• undescended testis, hernia, hydrocoele • Wilms tumor

Neurologic disorders

• seizure and non-seizure paroxysmal events • epilepsy, epileptic syndromes

• meningitis, encephalitis • brain abscess

• febrile encephalopathies • Guillain-Barre syndrome

• neurocysticercosis and other neuroinfestations • HIV encephalopathy

• SSPE • cerebral palsy

• neurometabolic disorders • neurodegenerative disorders

• neuromuscular disorders • mental retardation

• learning disabilities • muscular dystrophies

• acute flaccid paralysis and AFP surveillance • malformations

• movement disorders • Tumors

Hematology and Oncology

• deficiency anemias • hemolytic anemias

• aplastic anemia • pancytopenia

• thrombocytopenia • disorders of hemostasis

• blood component therapy • transfusion related infections

• bone marrow transplant/stem cell transplant • acute and chronic leukemia

• myelodysplastic syndrome • Lymphoma

• neuroblastoma • hypercoagulable states

Endocrinology

• hypopituitarism/hyperpituitarism • diabetes insipidus

• pubertal disorders • hypo – and hyper-thyroidism

• adrenal insufficiency • Cushing's syndrome

• adrenogenital syndromes • diabetes mellitus

• hypoglycemia • short stature

• gonadal dysfunction and intersexuality • obesity

Infections

• bacterial (including tuberculosis) • viral (including HIV)

• fungal • parasitic

• rickettssial • mycoplasma

• protozoal and parasitic • nosocomial infections

• control of epidemics and infection prevention • safe disposal of infective material

Emergency and Critical Care

• emergency care of shock • cardio-respiratory arrest

• respiratory failure • acute renal failure

• status epilepticus • acute severe asthma

• fluid and electrolyte disturbances • acid-base disturbances

• poisoning • accidents

• scorpion and snake bites

Immunology and Rheumatology

• arthritis (acute and chronic) • vasculitides

• immunodeficiency syndromes • systemic lupus erythematosus

ENT

• acute and chronic otitis media • hearing loss

• post-diphtheritic palatal palsy • acute/chronic tonsillitis/adenoids

• allergic rhinitis/sinusitis • foreign body

Skin Diseases

• exanthematous illnesses • vascular lesions

• pigment disorders • vesicobullous disorders

• infections • Steven-Johnson syndrome

• atopic, seborrheic dermatitis • drug rash

• alopecia • icthyosis

Eye problems

• refraction and accommodation • partial/total loss of vision

• cataract • night blindness

• strabismus • conjunctival and corneal disorders

• disorders of retina, including tumors

Behavioral and Developmental disorders

• rumination, pica • enuresis, encopresis

• sleep disorders • habit disorders

• breath holding spells • anxiety disorders

• mood disorders • temper tantrums

• attention deficit hyperactivity disorders • autism (as mentioned in objective 24)

Social/Community Paediatrics

• national health programs related to child health • IMNCI

• Vaccines: constituents, efficacy, storage, contraindications and adverse reactions

• rationale and methodology of pulse polio immunization

• child labor, abuse, neglect • adoption

• disability and rehabilitation • rights of the child

• National policy of child health and population • juvenile delinquency

• Principles of prevention, control of infections (food, water, soil, vector borne)

• Investigation of an epidemic

Orthopaedics

• major congenital orthopedic deformities • bone and joint infections

• common bone tumors

Approach to clinical problems Growth and development

• precocious and delayed puberty • developmental delay

• impaired learning

Neonatology

• low birth weight newborn • sick newborn

Nutrition

• lactation management and complementary • protein energy malnutrition feeding (underweight, wasting, stunting)

• failure to thrive and micronutrient deficiencies

Cardiovascular

• Murmur • cyanosis

• congestive heart failure • systemic hypertension

• arrhythmia • shock

GIT and Liver

• Acute diarrhea • persistent and chronic diarrhea

• abdominal pain and distension • ascites

• vomiting • constipation

• gastrointestinal bleeding • jaundice

• hepatosplenomegaly • hepatic failure and encephalopathy

Respiratory

• Cough/chronic cough • hemoptysis

• wheezy child • respiratory distress

Infections

• acute onset pyrexia • prolonged pyrexia with and

• recurrent infections without localizing signs

• nosocomial infections • fever with xanthema

Renal

• Hematuria/dysuria • bladder/bowel incontinence

• voiding dysfunctions • renal failure (acute and chronic)

• hypertension

Hematology and Oncology

• anemia • bleeding

Neurology

• limping child • convulsions

• paraplegia, quadriplegia • cerebral palsy

• macrocephaly and microcephaly • floppy infant

• acute flaccid paralysis • headache

Endocrine

• thyroid swelling • ambiguous genitalia

• obesity • short stature

Miscellaneous

• skin rash • lymphadenopathy

• epistaxis • proptosis

• arthralgia, arthritis

TEACHING AND LEARNING METHODS

Postgraduate teaching programme General principles

Acquisition of practical competencies being the keystone of PG medical education, PG training should be skills oriented. Learning in PG program should be essentially self- directed and primarily emanating from clinical and academic work. The formal sessions are merely meant to supplement this core effort.

Teaching methodology

This should include regular bedside case presentations and demonstrations, didactic lectures, seminars, journal clubs, clinical meetings, and combined conferences with allied departments. The post graduate student should be given the responsibility of managing and caring for patients in a gradual manner under supervision. Department should encourage e-learning activities.

Formal teaching sessions

In addition to bedside teaching rounds, at least 5-hr of formal teaching per week are necessary. The departments may select a mix of the following sessions:

• Journal club t Once a week

• Seminar Once a fortnight

• Case discussions

• Interdepartmental case or seminar [Cardiology, Pediatric Surgery] once a month Once a month

• Attend accredited scientific meetings (CME, symposia, and conferences).

• Additional sessions on resuscitation, basic sciences, biostatistics, research methodology, teaching methodology, hospital waste management, health economics, medical ethics and legal issues related to pediatric practice are suggested.

• There should be a training program on Research methodology for existing faculty to build capacity to guide research.

• The postgraduate students shall be required to participate in the teaching and training programme of undergraduate students and interns.

• A postgraduate student of a postgraduate degree course in broad specialities/super specialities would be required to present one poster presentation, to read one paper at a national/state conference and to present one research paper which should be 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.

• Log book: During the training period, the post graduate student should maintain a Log Book indicating the duration of the postings/work done in Pediatric Wards, OPDs and Casualty. This should indicate the procedures assisted and performed, and the teaching sessions attended. The purpose of the Log Book is to:

a) Help maintain a record of the work done during training,

b) Enable Consultants to have direct information about the work; intervene if necessary,

c) Use it to assess the experience gained periodically.

The log book shall be used to aid the internal evaluation of the student. The Log books shall be checked and assessed periodically by the faculty members imparting the training.

Rotations

The postgraduate student should rotate through all the clinical units in the department. In addition, following special rotations should be undertaken:

Mandatory

Neonatology, perinatology Intensive care, emergency Desirable

Posting in Out Patient Services of the following specialties is recommended Skin

Pediatric Surgery

Physical Medicine and Rehabilitation Community

Note: Additionally, the PG students may be sent to allied specialties (Cardiology, Neurology, nephrology etc.) depending on facilities available. It should be ensured that the training conforms to the curriculum.

• Thesis Objectives

By carrying out a research project and presenting his work in the form of thesis, the student shall be able to:

• identify a relevant research question

• conduct a critical review of literature

• formulate a hypothesis

• determine the most suitable study design

• state the objectives of the study

• prepare a study protocol

• undertake a study according to the protocol

• analyze and interpret research data, and draw conclusions

• write a research paper

Guidelines

While selecting the topic, following should be kept in mind:

• the scope of study is limited to enable its conduct within the resources and time available

• the study must be ethically appropriate

• the emphasis should be on the process of research rather than the results

• the protocol, interim progress and final presentation is made formally to the department

• only one student per teacher/thesis guide

There should be periodic department review of the thesis work, as per following schedule:

End of 6 months Submission of protocol

During 2nd yr Mid-term presentation 6 months prior to examination Final presentation; submission

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.

ASSESSMENT

FORMATIVE ASSESSMENT, ie., assessment to improve learning

Formative assessment should be continual and should assess medical knowledge, patient care, procedural & academic skills, interpersonal skills, professionalism, self directed learning and ability to practice in the system.

General Principles

Internal Assessment should be frequent, cover all domains of learning and used to provide feedback to improve learning; it should also cover professionalism and communication skills. The Internal Assessment should be conducted in theory and practical/clinical examination.

Quarterly assessment during the MD training should be based on:

1. Journal based / recent advances learning

2. Patient based /Laboratory or Skill based learning

3. Self directed learning and teaching

4. Departmental and interdepartmental learning activity

5. External and Outreach Activities / CMEs

The student to be assessed periodically as per categories listed in postgraduate student appraisal form (Annexure I).

SUMMATIVE ASSESSMENT, ie., assessment at the end of training

The summative examination would be carried out as per the Rules given in POSTGRADUATE MEDICAL EDUCATION REGULATIONS, 2000.

The postgraduate examination shall be in three parts:

1. Thesis

Thesis shall be submitted at least six months before the Theory and Clinical / Practical examination. The thesis shall be examined by a minimum of three examiners; one internal and two external examiners, who shall not be the examiners for Theory and Clinical examination. A post graduate student shall be allowed to appear for the Theory and Practical/Clinical examination only after the acceptance of the Thesis by the examiners.

2. Theory examination

The examinations shall be organized on the basis of 'Grading'or 'Marking system' to evaluate and to certify post graduate student's level of knowledge, skill and competence at the end of the training. Obtaining a minimum of 50% marks in 'Theory' as well as 'Practical' separately shall be mandatory for passing examination as a whole. The examination for M.D./ MS shall be held at the end of 3rd academic year. An academic term shall mean six month's training period.

There shall be four theory papers. Each paper should have 10 short essay questions (SEQ).

Paper I: Basic sciences as applied to Paediatrics

Paper II: Neonatology and community Paediatrics

Paper III: General Paediatrics including advances in Paediatrics relating to Cluster I specialties

Paper IV: Paediatric Medicine including advances in Paediatrics relating to Cluster II specialties

Cluster I: Nutrition, Growth and Development, Immunization, Infectious disease, Genetics, Immunology, Rheumatology, Psychiatry and Behavioral Sciences, Skin, Eye, ENT, Adolescent Health, Critical Care, Accidents and Poisoning

Cluster II: Neurology and Disabilities, Nephrology, Hematology and Oncology, Endocrinology, Gastroenterology and Hematology, Respiratory and Cardiovascular disorders

3. Practical/clinical and Oral/viva voce examination Practical examination

Case I

Case II (Newborn) Case III

OSCE may be used.

Oral/Viva voce examination on defined areas by each examiner separately. Oral examination shall be comprehensive enough to test the post graduate student's overall knowledge of the subject.

Recommended Reading:

Books (latest edition)

1. Nelson's Textbook of Pediatrics, Kliegman et al (Editors)

2. Manual of Neonatal care, Cloherty

03-05 international Journals and 02 national (all indexed) journals

Annexure I Orientation sessions for PG students joining MD in Paediatrics

This could be spread over 4-5 sessions once or twice a week depending on departmental routine and feasibility.

For all PG students

Orientation to the Hospital: Various Departments and facilities available

• Communication skills: Patients and colleagues

• Literature search

• Basic research methodology

• Protocol writing and thesis

Pediatric PGs

Introduction to Residency in Paediatrics

• Universal precautions and appropriate disposal of hospital waste

• Management of shock

• Congestive cardiac failure

• Normal fluid and electrolyte requirement and their disorders

• Interpretation and management of disorders of acid-base balance

• Evaluation of a sick newborn

• Management of seizures, hypothermia and hypoglycemia in the newborn

• Management of seizures and status epilepticus

• Management of comatose patients

• Hospital management of severe PEM

• Acute kidney injury

• Fulminant hepatic failure

• Management of respiratory distress

• Management of acute diarrhea

• Approach to a bleeding child and its management

• Rational antibiotic therapy