ABSTRACT
Background: NASPGHAN guidelines for fellowship training in pediatric gastroenterology (GI) highlight the importance of multidisciplinary treatment across GI conditions. Specific required medical knowledge for pediatric GI fellows includes (1) understanding of the biopsychosocial model and brain-gut axis involvement in functional GI disorders (FGIDs) and (2) familiarity with the role of psychological evaluation and interventions within the multidisciplinary management of FGIDs. Pediatric psychologists are well-suited to provide this training as education of interdisciplinary professionals is a defining competency in pediatric psychology. While pediatric GI psychologists may be informally involved in the training of GI fellows through shared multidisciplinary patient care, we sought to develop a didactic series to formalize a GI Psychology curriculum consistent with clinical training guidelines and the expressed interests of fellows at our institution. Method(s): GI psychologists and GI chief fellows at Children's Hospital of Philadelphia (CHOP) developed an 8-lecture didactic series to be incorporated into an existing weekly didactic meeting for all GI fellows. GI psychologists presented a topic quarterly over the course of 2 training years (FY20-FY21). Topics for the inaugural 2-year series were: Introduction to GI Psychology, Giving the Positive Functional Diagnosis, Cognitive Behavioral Therapy for Functional Abdominal Pain Disorders, Behavioral Interventions for Constipation and Encopresis, Psychosocial Adjustment in Inflammatory Bowel Disease, Behavioral Treatment of Rumination Syndrome, Somatic Symptom Disorders, and Treatment Adherence. In summer 2020, GI psychologists also presented an unplanned didactic session related to coping with secondary traumatic stress during the COVID-19 pandemic. For the next iteration of the 2-year series (FY22-FY23), GI psychologists selected a new topic of Feeding and Eating Difficulties: Role of GI Psychology to replace Introduction to GI Psychology. Introduction to GI Psychology was moved to a fellow orientation session. Fellows participated in the first three years of the program which spanned the inaugural 2-year series and 1 year of a second series (n = 12, 11, 11). Attendance at specific didactic sessions was not recorded. At the end of each training year, fellows completed an anonymous program evaluation survey via REDCap for ongoing quality improvement. Fellows rated 5 items assessing the impact of the didactics on their knowledge of the biopsychosocial approach, delivery of clinical impressions and recommendations, confidence with description of psychological goals and strategies, and recommendations for continuation of the GI Psychology didactics. Items were scored on a 5-point Likert scale ranging from Strongly Agree to Strongly Disagree. During the inaugural 2-year series, the survey also included items rating the value of each didactic topic. Each year the survey allowed for open-ended suggestions for additional topics. Result(s): The GI Psychology didactic series for GI fellows has been implemented successfully at CHOP for an inaugural 2-year series (FY20-FY21) with a second series currently in progress (FY22-FY23). Although survey response rate was low (33% FY20;9% FY21;45% FY22), 100% of the fellows completing the survey Agree/Strongly Agree the didactic series increased their knowledge of the biopsychosocial approach to managing GI conditions, informed how they deliver clinical impressions and treatment recommendations for patients/families, recommended continued GI Psychology involvement in GI fellow didactics and recommended other institutions consider Psychology involvement in GI fellow didactic education. Additionally, 80% of the fellows Agree/Strongly Agree the didactic series increased their confidence to describe common goals and strategies within psychological treatment for patients with GI conditions. Conclusion(s): We describe development of a novel GI Psychology curriculum for GI fellows at CHOP focused on core topics to enhance competency in the biopsychosocial approach across GI conditions, which was favorably evaluated by GI fellows. Fellowship training programs in pediatric GI may wish to consider a similar approach to incorporating didactic training from pediatric psychologists. Doing so may increase relevant medical knowledge and facilitate experience with and use of a multidisciplinary approach to evaluation and management across GI conditions, consistent with NASPGHAN clinical training guidelines and calls for best practice to incorporate integrated psychological care across GI conditions.
ABSTRACT
Background: Behavioral interventions for functional constipation (FC) are demonstrated to improve success rates and soiling frequency relative to medical treatment alone. Group treatments serving multiple patient-families (PFs) enhance social support and access to behavioral interventions. Intervention for Soiling, fecal Incontinence, and reToileting (I-SIT) is a group treatment for patients diagnosed with FC, with or without fecal incontinence, and their caregivers, implemented at Children's Hospital of Philadelphia. Sessions are facilitated by licensed psychologists and billed as health and behavior group intervention. Satisfaction with the I-SIT program is extremely high (100% of PFs would highly recommend I-SIT to another family) but enrollment has been consistently lower than capacity. Low enrollment has been attributed to logistical barriers (scheduling, distance). Given staffing requirements for in-person I-SIT, low enrollment results in patient:staff ratios that limit access to behavioral interventions. To address enrollment barriers, I-SIT was adapted to a virtual telehealth platform which was able to be implemented during the COVID-19 pandemic. The goal of this quality improvement (QI) project was to increase enrollment to I-SIT by adapting to a telehealth platform while maintaining high PF satisfaction. Method: Gastroenterologists referred patients (ages 5-10) to GI Psychologists for assessment and eligible patients were referred to I-SIT. All enrolled patients had a diagnosis of FC (with or without fecal incontinence). Exclusion criteria included need for individualized intervention due to psychiatric or developmental comorbidity or use of interpreter. Nine families participated in I-SIT across three cohorts during FY2017-2018. In person I-SIT was delivered by two psychologists across 4 weekly, 1 hour sessions with separate child and caregiver groups. Eleven families participated in virtual I-SIT across three cohorts during FY2020-2021. Virtual I-SIT was delivered by one psychologist via family sessions (child and caregiver together). Virtual I-SIT Cohorts 1 and 2 were delivered using the same schedule as in person I-SIT. Virtual I-SIT Cohort 3 was delivered across 3 biweekly, 90 minute sessions due to provider schedule, with caregiver only portions of each session in response to Cohorts 1 and 2 feedback. Content was identical across delivery platforms and included FC education, goal-setting, behavioral strategies for medication adherence and structured toilet sitting, collaborating with schools, and coping with social concerns. Following completion of I-SIT and virtual I-SIT, caregivers completed a 7-item satisfaction survey including quantitative and qualitative items. Completers of virtual I-SIT completed an additional 5 item telehealth survey regarding session duration, frequency, and format to inform QI efforts. Results: Primary outcome of enrollment increased with virtual I-SIT (11 telehealth patients in 3 cohorts compared to 9 in-person patients in 3 cohorts). Given decreased staffing requirements for telehealth format and increased enrollment, access to behavioral interventions for FC is improved with virtual I-SIT (3.67 telehealth patients per psychologist;1.5 in-person patients per psychologist). Engagement is also improved with virtual I-SIT (81% virtual group completers;67% in person group completers). Acceptability of virtual I-SIT was also high for group completers (1 PF prefers in-person;4 PFs prefer virtual;4 PFs unsure). Our balancing metric of patient satisfaction did show signs of decreased satisfaction with Cohort 3 of virtual I-SIT. All group completers from in-person Cohorts 1-3 and virtual Cohorts 1 and 2 would “highly recommend” I-SIT or virtual I-SIT while two PFs in virtual Cohort 3 indicated they would recommend virtual I-SIT and one reported feeling neutral. Duration, frequency, and number of sessions differed for virtual Cohort 3, and one PF was enrolled after brief screening rather than full assessment. Cohort 3 feedback indicated preference for former duration and umber of sessions (60 minutes or less, 4+ sessions) which may explain the decline in satisfaction. Conclusion: Enrollment to a group intervention and access to behavioral interventions for pediatric patients with FC and their families was increased with conversion to a telehealth format while maintaining satisfaction and increasing engagement. Family feedback suggests telehealth group format should include caregiver-only portions and shorter group sessions. To continue our quality improvement effort to increase enrollment, our next intervention will focus on improved advertising and consideration of primary care referrals. Future directions also include inclusion of FC outcome measures and digital adaptation of educational materials (e.g., videos, mobile phone applications).