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
Introduction: The biopsychosocial model has been used to describe the complex pathophysiology of functional gastrointestinal disorders (FGIDs), and the literature is clear that conventional medical treatment alone is often inadequate and should be supplemented with behavioral and/or dietary treatment. We hypothesized that the implementation of a multidisciplinary clinic for children with FGIDs would lead to decreased healthcare utilization. Our objective was to compare healthcare utilization before and after the initial visit in a pediatric multidisciplinary FGID clinic. Methods: We performed a retrospective review of children seen in the FGID clinic at our institution for their initial visit from March 2018-November 2019 (to avoid any impact of the COVID-19 pandemic). Our FGID clinic sees patients referred from other gastroenterologists. The initial visit is a 60-minute visit with a pediatric gastroenterologist, psychologist, and at times a dietitian. We recorded baseline characteristics and clinic visit information. To evaluate impact on healthcare utilization, we compared phone calls, electronic messages, additional outpatient GI visits, emergency department (ED) or urgent care (UC) visits, and hospitalizations for GI symptoms three months before and after a patient's initial FGID clinic visit. Results: We included 49 patients (76% female, median age 16 years, range 5-19). Primary FGID diagnoses were functional abdominal pain (45%), irritable bowel syndrome (22%), functional dyspepsia (20%), rumination syndrome (6%), functional constipation (4%), and abdominal migraine (2%). Other diagnoses included anxiety (73%), depression (33%), and inflammatory bowel disease (2%). Prior testing included blood tests (86%), imaging (82%), esophagogastroduodenoscopy (78%), colonoscopy (35%), and manometry testing (31%). At the initial visit, 71% were on a medication for their GI symptoms, 76% were on a supplement or probiotic, and 35% were on a psychiatric medication. During their initial visit, 96% met with a psychologist and 18% met with a dietitian. Recommendations at the initial visit included new medications (76%), follow up with a GI psychologist (45%), dietary treatment (22%), imaging studies (16%), manometry testing (10%), psychiatry referral (10%), blood tests (8%), esophagogastroduodenoscopy (4%), and colonoscopy (2%). As shown in Table 1, total phone calls, electronic messages, and ED/UC visits for GI symptoms decreased after the FGID clinic visit (p<0.001, p<0.001, and p=0.02 respectively). Conclusion: Healthcare utilization decreased significantly after children with FGIDs were seen in a multidisciplinary FGID clinic. Our findings imply that establishing a multidisciplinary FGID clinic improves the care of children with these disorders and may also reduce the time and financial costs of caring for these disorders.(Table Presented)