Pediatric Surgery Competencies

2021 VERSION 1.0

Effective for residents who enter training on or after July 1, 2021.

DEFINITION

Pediatric Surgery is the branch of surgery concerned with the investigation, diagnosis, and operative and non-operative management of patients ranging in age from the fetal period through to late adolescence.

PEDIATRIC SURGERY PRACTICE

Pediatric surgeons provide surgical care for neonates, infants, children, and adolescents with a broad range of conditions affecting the gastrointestinal, hepatobiliary, genitourinary, gynecologic, and vascular systems, and the head and neck, pancreas, spleen, and skin and soft tissues. This includes conditions due to congenital malformations, infectious and inflammatory diseases, benign and malignant neoplasms, and traumatic injury.

Pediatric surgeons provide consultation for urgent and non-urgent clinical presentations, perform diagnostic procedures, and provide acute and long-term operative and non- operative management, including pre- and post-operative care, long-term follow-up, and active surveillance. Pediatric surgeons use percutaneous, endoscopic, open, and minimally invasive approaches to diagnostic and therapeutic interventions. They have a leadership role in directing trauma resuscitation and in the definitive management of patients with injuries, as well as in the management of trauma and complex post-operative care in the intensive care unit.

The resource requirements of Pediatric Surgery, together with the complex needs of this patient population, delineate the practice location of pediatric surgeons, requiring that they practise in a pediatric hospital or a centre with pediatric medical and surgical clinical services. This includes professionals with expertise in medical imaging, pathology, anesthesia, and neonatal and pediatric intensive care.

Pediatric surgeons work in inter- and intra-professional teams with other health care providers to facilitate the delivery of family1 and patient-centred management plans, including the transition to appropriate adult care.

1 Throughout this document, references to the patient’s family are intended to include all those who are personally significant to the patient and are concerned with his or her care, including, according to the patient’s circumstances, family members, partners, caregivers, legal guardians, and substitute decision-makers.

© 2020 The Royal College of Physicians and Surgeons of Canada. All rights reserved. This document may be reproduced for educational purposes only provided that the following phrase is included in all related materials: Copyright © 2020 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission. Please forward a copy of the final product to the Office of Specialty Education, attn: Associate Director, Specialties. Written permission from the Royal College is required for all other uses. For further information regarding intellectual property, please contact: [email protected]. For questions regarding the use of this document, please contact: [email protected].

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ELIGIBILITY REQUIREMENTS TO BEGIN TRAINING

Royal College certification in General Surgery.

Eligibility for the Royal College certification examination in General Surgery (See requirements for these qualifications).

ELIGIBILITY REQUIREMENTS FOR EXAMINATION2

All candidates must be Royal College certified in General Surgery in order to be eligible for the Royal College examination in Pediatric Surgery.

PEDIATRIC SURGERY COMPETENCIES

Medical Expert

Definition:

As Medical Experts, pediatric surgeons integrate all of the CanMEDS Roles, applying medical knowledge, clinical skills, and professional values in their provision of high-quality and safe patient-centred care. Medical Expert is the central physician Role in the CanMEDS Framework and defines the physician’s clinical scope of practice.

Key and Enabling Competencies: Pediatric surgeons are able to…

1. Practise medicine within their defined scope of practice and expertise 1.1. Demonstrate a commitment to high-quality care of their patients 1.2. Integrate the CanMEDS Intrinsic Roles into their practice of Pediatric Surgery 1.3. Apply knowledge of the clinical and biomedical sciences relevant to Pediatric Surgery 1.3.1. Anatomy, physiology, embryology, and pathology of the following: 1.3.1.1. Head and neck 1.3.1.1.1. Branchial arches and clefts and their remnants 1.3.1.1.2. Salivary glands 1.3.1.1.3. Lymph nodes 1.3.1.1.4. Thyroid gland 1.3.1.1.5. Parathyroid glands 1.3.1.1.6. Blood vessels and lymphatics

2 These eligibility requirements do not apply to Subspecialty Examination Affiliate Program (SEAP) candidates. Please contact the Royal College for information about SEAP.

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1.3.1.2. Thorax 1.3.1.2.1. Major airways 1.3.1.2.2. Lungs 1.3.1.2.3. Pleura 1.3.1.2.4. Chest wall and diaphragm 1.3.1.2.5. Mediastinum

1.3.1.3. Gastrointestinal (GI) tract 1.3.1.3.1. Esophagus 1.3.1.3.2. Stomach 1.3.1.3.3. Duodenum 1.3.1.3.4. Small bowel 1.3.1.3.5. Colon and appendix 1.3.1.3.6. Anorectum 1.3.1.3.7. Liver 1.3.1.3.8. Biliary tract 1.3.1.3.9. Exocrine pancreas

1.3.1.4. Spleen 1.3.1.5. Genitourinary and gynecologic systems 1.3.1.5.1. Kidneys and ureters 1.3.1.5.2. Bladder 1.3.1.5.3. Penis 1.3.1.5.4. Testes 1.3.1.5.5. Ovaries and fallopian tubes 1.3.1.5.6. Uterus 1.3.1.5.7. Vagina

1.3.1.6. Skin and soft tissue 1.3.1.7. Musculoskeletal system 1.3.1.8. Breast 1.3.1.9. Endocrine organs 1.3.1.9.1. Endocrine pancreas 1.3.1.9.2. Adrenal glands

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1.3.2. Principles of the assessment, investigation, and management of conditions affecting the following: 1.3.2.1. Head and neck 1.3.2.2. Thorax 1.3.2.3. GI tract, including hepatobiliary system 1.3.2.4. Pancreas 1.3.2.5. Spleen 1.3.2.6. Genitourinary and gynecologic systems 1.3.2.7. Skin and soft tissue 1.3.2.8. Musculoskeletal system 1.3.2.9. Breast 1.3.2.10. Endocrine organs

1.3.3. Principles related to traumatic and thermal injury 1.3.3.1. Epidemiology and demographics 1.3.3.2. Mechanisms and patterns of injury, including signs of non- accidental trauma 1.3.3.3. Pathophysiology

1.3.4. Principles of oncology 1.3.4.1. Molecular biology of cancer 1.3.4.2. Cytogenetics and tumour markers 1.3.4.3. Genetic predisposition to pediatric malignancies 1.3.4.4. Paraneoplastic syndromes 1.3.4.5. Diagnostic evaluation, including role of medical imaging, biopsy, and other investigations 1.3.4.6. Risk stratification and staging 1.3.4.7. Cancer therapy, including chemotherapy, surgery, radiation therapy, and immunotherapy 1.3.4.8. Role of multi-institutional clinical trials in pediatric oncology 1.3.4.9. Short- and long-term complications of cancer treatment

1.3.5. Principles of nutritional assessment and support 1.3.5.1. Normal nutritional requirements, including calories, carbohydrate, fat, protein, minerals, vitamins, and trace elements 1.3.5.2. Nutritional assessment 1.3.5.3. Enteral and parenteral nutrition

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1.3.5.4. Disorders of nutrition, including short bowel syndrome and refeeding syndrome 1.3.5.5. Principles of bariatric surgery, including assessment, planning, and optimization of nutrition

1.3.6. Principles of antenatal and neonatal care 1.3.6.1. Antenatally diagnosed conditions relevant to pediatric surgery 1.3.6.2. Normal newborn physiology and postnatal adaptations, including 1.3.6.2.1. Thermoregulation 1.3.6.2.2. Cardiorespiratory, hepatic, and renal function 1.3.6.2.3. Metabolic and endocrine control, including glucose and electrolytes

1.3.6.3. Neonatal host defenses and infections 1.3.6.4. Pathophysiologic changes in newborns, including premature, small- for-gestational-age, and large-for-gestational-age neonates

1.3.7. Principles of perioperative and critical care 1.3.7.1. Principles of airway management, including surgical airway 1.3.7.2. Principles of mechanical ventilation 1.3.7.3. Principles of hemodynamic and respiratory monitoring 1.3.7.4. Indications, techniques, and complications of central venous access and arterial access 1.3.7.5. Cardiopulmonary support, including extracorporeal life support (ECLS) indications, contraindications, and complications and techniques of cannulation and monitoring 1.3.7.6. Indications and complications of the placement of hemodialysis and peritoneal dialysis catheters 1.3.7.7. Fluid and electrolyte management 1.3.7.7.1. Maintenance requirements 1.3.7.7.2. Management of dehydration 1.3.7.7.3. Principles of third space loss 1.3.7.7.4. Physiology and pathophysiology of acid-base equilibrium 1.3.7.7.5. Correction of perioperative electrolyte disturbances

1.3.7.8. Thermoregulation 1.3.7.8.1. Physiologic effects and management of hypothermia and hyperthermia

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1.3.7.9. Shock 1.3.7.9.1. Clinical features and management of different types of shock, including hypovolemic, cardiogenic, distributive, and neurogenic 1.3.7.9.2. Principles of hemodynamic monitoring 1.3.7.9.3. Resuscitation, including use of fluid resuscitation, antibiotics, and inotropic agents

1.3.7.10. Cardiac 1.3.7.10.1. Congenital heart disease and transitional circulation, and their effects on other organ systems

1.3.7.11. Pulmonary 1.3.7.11.1. Lung function and volumes relevant to the patient’s age and development 1.3.7.11.2. Invasive and non-invasive ventilation techniques 1.3.7.11.3. Etiology, clinical features, and management of 1.3.7.11.3.1. Pulmonary hypertension 1.3.7.11.3.2. Acute respiratory distress syndrome (ARDS)

1.3.7.12. Anesthesia 1.3.7.12.1. Pharmacology and pharmacokinetics of commonly used anesthetic and analgesic agents 1.3.7.12.2. Clinical features and management of malignant hyperthermia 1.3.7.12.3. Management of post-operative pain, including responsible use of opioids

1.3.7.13. Transfusion therapy and coagulation 1.3.7.13.1. Principles of massive transfusion 1.3.7.13.2. Management of coagulation disorders, including 1.3.7.13.2.1. Hemophilia 1.3.7.13.2.2. von Willebrand disease 1.3.7.13.2.3. Diffuse intravascular and consumptive coagulopathy 1.3.7.13.2.4. Fibrinolysis 1.3.7.13.2.5. Idiopathic thrombocytopenic purpura 1.3.7.13.2.6. Thrombosis

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1.3.7.13.3. Indications for, and pharmacology and pharmacokinetics of, heparin, anti-platelet agents, and thrombolytics

1.3.7.14. Transplantation 1.3.7.14.1. Principles of solid organ transplantation and immunosuppression

1.3.7.15. Criteria for brain death and organ donation

1.4. Perform appropriately timed clinical assessments with recommendations that are presented in an organized manner 1.5. Carry out professional duties in the face of multiple competing demands 1.6. Recognize and respond to the complexity, uncertainty, and ambiguity inherent in Pediatric Surgery practice

2. Perform a patient-centred clinical assessment and establish a management plan 2.1. Prioritize issues to be addressed in a patient encounter 2.1.1. Concurrently diagnose and manage life-threatening emergencies 2.1.2. Apply the principles of trauma life support to establish and respond to priorities of resuscitation

2.2. Elicit a history, perform a physical exam, select appropriate investigations, and interpret their results for the purpose of diagnosis and management, disease prevention, and health promotion 2.2.1. Gather a clinical history, including maternal, perinatal, neonatal, and family history, as relevant 2.2.2. Identify and interpret clinically significant findings in a physical examination 2.2.3. Adapt the clinical assessment to the patient’s age and development 2.2.4. Perform the initial evaluation of patients with traumatic and thermal injury 2.2.4.1. Assess neurological status, including the use of the Glasgow Coma Scale 2.2.4.2. Identify cases suspicious for non-accidental trauma and perform the appropriate diagnostic evaluation

2.2.5. Select investigations, considering the limitations of blood volume on laboratory testing and the challenges and risks of performing medical imaging in children 2.2.6. Select and interpret the clinical relevance of 2.2.6.1. Histologic findings of tissue biopsies

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2.2.6.2. Medical imaging findings, including 2.2.6.2.1. Radiography 2.2.6.2.2. Ultrasonography 2.2.6.2.3. Computed tomography (CT) 2.2.6.2.4. Magnetic resonance imaging (MRI) 2.2.6.2.5. Positron emission tomography (PET) 2.2.6.2.6. Nuclear imaging

2.2.7. Order and interpret diagnostic evaluations for patients with tumours 2.2.7.1. Tumours arising in the following anatomic sites: 2.2.7.1.1. Head (extra-cranial) and neck 2.2.7.1.2. Lung, pleura, chest wall, and mediastinum 2.2.7.1.3. GI tract 2.2.7.1.4. Liver 2.2.7.1.5. Pancreas: exocrine and endocrine tumours 2.2.7.1.6. Kidney 2.2.7.1.7. Adrenal gland 2.2.7.1.8. Testicle 2.2.7.1.9. Ovary 2.2.7.1.10. Skin and soft tissue

2.2.7.2. Other specific tumour types: 2.2.7.2.1. Neuroblastomas 2.2.7.2.2. Teratomas 2.2.7.2.3. Sarcomas, including primitive neuroectodermal tumours and desmoplastic small round cell tumours 2.2.7.2.4. Hodgkin’s and non-Hodgkin’s lymphoma 2.2.7.2.5. Hepatic and pulmonary metastases 2.2.7.2.6. Multiple endocrine neoplasia syndromes 2.2.7.2.7. Conditions associated with an increased risk of tumour development, including Beckwith-Wiedemann syndrome and von Hippel-Lindau syndrome

2.2.8. Assess perioperative risk 2.2.9. Determine the indications for, and benefits and risks of, surgical intervention for the clinical presentation

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2.3. Establish goals of care in collaboration with patients and their families, which may include slowing disease progression, treating symptoms, achieving cure, improving function, and palliation 2.4. Establish a patient-centred management plan 2.4.1. Recommend an operative or non-operative approach, as appropriate 2.4.1.1. Apply knowledge of operative and non-operative treatment options, including their indications, contraindications, and potential complications 2.4.1.2. Recognize that operative treatment may involve procedures beyond one’s skill set, and arrange transfer to an appropriate surgeon as necessary

2.4.2. Develop plans for perioperative care 2.4.3. Provide post-operative management on the inpatient ward 2.4.3.1. Provide optimal post-operative analgesia

2.4.4. Provide plans for post-operative management in the critical care setting 2.4.4.1. Manage the care of critically ill children and adolescents in collaboration with other health care professionals

2.4.5. Direct the resuscitation and care of children sustaining major and minor trauma 2.4.6. Provide follow-up care, including surveillance 2.4.7. Develop plans for the transition of adolescents to the adult care setting

3. Plan and perform procedures and therapies for the purpose of assessment and/or management 3.1. Determine the most appropriate procedures or therapies 3.1.1. Select an open or minimally invasive surgery approach based on relevant patient and operating environment factors

3.2. Obtain and document informed consent, explaining the risks and benefits of, and the rationale for, a proposed procedure or therapy 3.2.1. Apply the concepts of consent and assent when engaging children in the process of informed consent 3.2.2. Recognize and respond to challenges arising in obtaining consent in emergency situations

3.3. Prioritize procedures or therapies, taking into account clinical urgency and available resources

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3.4. Perform procedures in a skilful and safe manner, adapting to unanticipated findings or changing clinical circumstances

Endoscopy 3.4.1. Direct laryngoscopy 3.4.2. Laryngoscopy and bronchoscopy: flexible and rigid 3.4.3. Upper GI endoscopy: flexible and rigid 3.4.4. Colonoscopy 3.4.5. Proctosigmoidoscopy: flexible and rigid

Skills of minimally invasive surgery (MIS) 3.4.6. Patient positioning to optimize patient safety and to facilitate access during MIS procedures 3.4.7. Safe access to the peritoneal and thoracic cavities using open and closed techniques 3.4.8. Port site selection, placement, and closure 3.4.9. Safe and appropriate use of minimally invasive surgical instruments 3.4.10. Laparoscopic placement of sutures 3.4.11. Hemostasis

Surgical procedures 3.4.12. Placement of vascular access appropriate for long-term use 3.4.13. Enteral feeding access, both gastric and postpyloric 3.4.14. Procedures to manage the following: 3.4.14.1. Head and neck 3.4.14.1.1. Branchial cleft cyst, sinus, and other remnants 3.4.14.1.2. Dermoid cysts 3.4.14.1.3. Lymphadenopathy 3.4.14.1.4. Pre-auricular sinus and tags 3.4.14.1.5. Thyroglossal duct anomalies

3.4.14.2. Thorax 3.4.14.2.1. Airway, lung, and pleura 3.4.14.2.1.1. Congenital 3.4.14.2.1.1.1. Congenital pulmonary airway malformations (CPAM)

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3.4.14.2.1.1.2. Lobar emphysema 3.4.14.2.1.1.3. Sequestration

3.4.14.2.1.2. Acquired 3.4.14.2.1.2.1. Abscess and pneumatocele 3.4.14.2.1.2.2. Blebs and spontaneous pneumothorax 3.4.14.2.1.2.3. Chylothorax 3.4.14.2.1.2.4. Empyema 3.4.14.2.1.2.5. Foreign bodies 3.4.14.2.1.2.6. Infiltrates in immunosuppressed patients 3.4.14.2.1.2.7. Lung complications in cystic fibrosis 3.4.14.2.1.2.8. Pulmonary metastastic disease

3.4.14.2.2. Diaphragm 3.4.14.2.2.1. Congenital diaphragmatic hernia, including Bochdalek and Morgagni 3.4.14.2.2.2. Diaphragmatic eventration

3.4.14.2.3. Chest wall 3.4.14.2.3.1. Pectus excavatum and carinatum

3.4.14.2.4. Mediastinal lesions 3.4.14.2.5. Congenital and acquired cysts and masses

3.4.14.3. GI tract, including hepatobiliary system 3.4.14.3.1. Esophagus 3.4.14.3.1.1. Achalasia 3.4.14.3.1.2. Barrett esophagus 3.4.14.3.1.3. Caustic ingestion 3.4.14.3.1.4. Esophageal atresia and tracheoesophageal fistulae of all types 3.4.14.3.1.5. Foreign bodies 3.4.14.3.1.6. Gastroesophageal (GE) reflux 3.4.14.3.1.7. Hiatal hernia 3.4.14.3.1.8. Perforation 3.4.14.3.1.9. Stricture 3.4.14.3.1.10. Web

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3.4.14.3.2. Stomach 3.4.14.3.2.1. Antral web 3.4.14.3.2.2. Complications of acid-peptic disease, including stress ulcer, gastritis, perforation, and bleeding 3.4.14.3.2.3. Foreign bodies 3.4.14.3.2.4. Pyloric stenosis 3.4.14.3.2.5. Pyloric atresia 3.4.14.3.2.6. Spontaneous perforation

3.4.14.3.3. Duodenum 3.4.14.3.3.1. Atresia 3.4.14.3.3.2. Duplication 3.4.14.3.3.3. Stenosis 3.4.14.3.3.4. Web, including windsock variant

3.4.14.3.4. Small intestine 3.4.14.3.4.1. Bowel obstruction 3.4.14.3.4.2. Congenital bands 3.4.14.3.4.3. Duplication 3.4.14.3.4.4. Foreign bodies 3.4.14.3.4.5. Inflammatory bowel disease 3.4.14.3.4.6. Intussusception 3.4.14.3.4.7. Jejunoileal atresia and stenosis 3.4.14.3.4.8. Meckel diverticulum and related vitelline duct anomalies 3.4.14.3.4.9. Meconium ileus and equivalent 3.4.14.3.4.10. Mesenteric cysts 3.4.14.3.4.11. Mesenteric defects 3.4.14.3.4.12. Necrotizing enterocolitis (NEC) 3.4.14.3.4.13. Rotation anomalies

3.4.14.3.5. Colon 3.4.14.3.5.1. Appendicitis 3.4.14.3.5.2. Colonic atresia 3.4.14.3.5.3. Hirschsprung disease

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3.4.14.3.5.4. Inflammatory bowel disease 3.4.14.3.5.5. Intestinal pseudo-obstruction 3.4.14.3.5.6. Meconium plug syndrome 3.4.14.3.5.7. Neutropenic enteropathy 3.4.14.3.5.8. Polyps, including juvenile, familial, and adenomatous

3.4.14.3.6. Anorectum 3.4.14.3.6.1. Abscess 3.4.14.3.6.2. Anorectal malformation 3.4.14.3.6.3. Condylomata 3.4.14.3.6.4. Constipation 3.4.14.3.6.5. Fecal incontinence 3.4.14.3.6.6. Fissure 3.4.14.3.6.7. Fistula 3.4.14.3.6.8. Rectal prolapse

3.4.14.3.7. Liver 3.4.14.3.7.1. Congenital and acquired liver cysts 3.4.14.3.7.2. Liver abscess 3.4.14.3.7.3. Tumours: benign and malignant

3.4.14.3.8. Biliary tract 3.4.14.3.8.1. Bile duct perforation 3.4.14.3.8.2. Biliary atresia 3.4.14.3.8.3. Choledochal cyst 3.4.14.3.8.4. Gallstones

3.4.14.4. Pancreatic conditions 3.4.14.5. Splenic conditions 3.4.14.6. Genitourinary and gynecologic systems 3.4.14.6.1. Acute scrotum 3.4.14.6.2. Balanitis 3.4.14.6.3. Cryptorchidism 3.4.14.6.4. Hydrocele 3.4.14.6.5. Phimosis and paraphimosis

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3.4.14.6.6. Urachal anomalies 3.4.14.6.7. Non-malignant ovarian conditions

3.4.14.7. Abdominal wall 3.4.14.7.1. Gastroschisis 3.4.14.7.2. Hernias, including umbilical, inguinal, epigastric, and femoral 3.4.14.7.3. Omphalocele and variants

3.4.14.8. Skin and soft tissue 3.4.14.8.1. Benign skin and soft tissue lesions 3.4.14.8.2. Ingrown toenails and paronychia 3.4.14.8.3. Lymphatic and vascular malformations 3.4.14.8.4. Necrotizing soft tissue infections 3.4.14.8.5. Pilonidal disease

3.4.14.9. Breast 3.4.14.9.1. Benign breast conditions requiring biopsy or lumpectomy 3.4.14.9.2. Malignant breast disease

3.4.14.10. Surgical oncology, including biopsy and/or resection of the following tumours: 3.4.14.10.1. Adrenal gland 3.4.14.10.2. Gastrointestinal tract, including carcinoid and desmoid tumours, adenocarcinoma, and gastrointestinal stromal tumour (GIST) 3.4.14.10.3. Kidney 3.4.14.10.4. Liver and biliary tract 3.4.14.10.5. Lung 3.4.14.10.6. Lymphoma 3.4.14.10.7. Neuroblastoma 3.4.14.10.8. Ovary 3.4.14.10.9. Soft tissue, including rhabdomyosarcoma 3.4.14.10.10. Teratomas, including gonadal, mediastinal, and sacrococcygeal 3.4.14.10.11. Testicle

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3.5. Provide non-operative and operative management of major and minor trauma 3.5.1. Provide airway management, including surgical airway 3.5.2. Provide emergency management of cranial trauma, including determining indications for intracranial pressure monitoring 3.5.3. Manage patients with thermal injury 3.5.3.1. Provide initial and maintenance fluid resuscitation 3.5.3.2. Manage inhalation injury 3.5.3.3. Identify indications for escharotomy

3.5.4. Provide initial stabilization and comprehensive operative and non-operative management for patients with abdominal trauma, including hollow viscus injury and solid organ injury 3.5.5. Provide initial stabilization and emergency management for patients with 3.5.5.1. Injuries to the esophagus, trachea, and cervical blood vessels 3.5.5.2. Cardiac, pulmonary, and mediastinal trauma 3.5.5.3. Kidney, ureter, bladder, and urethral trauma 3.5.5.4. Gynecological trauma, including vaginal laceration 3.5.5.5. Pelvic trauma and fracture 3.5.5.6. Cervical and thoracolumbar spine fractures 3.5.5.7. Spine and spinal cord trauma

4. Establish plans for ongoing care and, when appropriate, timely consultation 4.1. Implement a patient-centred care plan that supports ongoing care, follow-up on investigations, response to treatment, and further consultation 4.1.1. Recognize and manage intra-operative and post-operative complications 4.1.2. Provide follow-up on results of investigations and response to treatment 4.1.3. Assess the family’s ability to access services in the health and social systems, and address needs for support 4.1.4. Develop and implement follow-up plans, considering geographic and economic factors 4.1.5. Determine the need for and timing of referral to another health care professional

5. Actively contribute, as an individual and as a member of a team providing care, to the continuous improvement of health care quality and patient safety 5.1. Recognize and respond to harm from health care delivery, including patient safety incidents

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5.2. Adopt strategies that promote patient safety and address human and system factors 5.2.1. Participate in or lead pre-operative safety checklists

Communicator

Definition:

As Communicators, pediatric surgeons form relationships with patients and their families that facilitate the gathering and sharing of essential information for effective health care.

Key and Enabling Competencies: Pediatric surgeons are able to…

1. Establish professional therapeutic relationships with patients and their families 1.1. Communicate using a patient-centred approach that encourages patient and family trust and autonomy and is characterized by empathy, respect, and compassion 1.2. Optimize the physical environment for patient and family comfort, dignity, privacy, engagement, and safety 1.3. Recognize when the perspectives, values, or biases of patients, patients’ families, physicians, or other health care professionals may have an impact on the quality of care, and modify the approach to the patient accordingly 1.4. Respond to a patient’s or family’s non-verbal behaviours to enhance communication 1.5. Manage disagreements and emotionally charged conversations 1.6. Adapt to the unique needs and preferences of each patient and family and to the clinical condition and circumstances

2. Elicit and synthesize accurate and relevant information, incorporating the perspectives of patients and their families 2.1. Use patient-centred interviewing skills to effectively gather relevant biomedical and psychosocial information 2.2. Provide a clear structure for and manage the flow of an entire patient encounter 2.3. Seek and synthesize relevant information from other sources, including the patient’s family, with the patient’s consent

3. Share health care information and plans with patients and their families 3.1. Share information and explanations that are clear, accurate, and timely, while assessing for patient and family understanding 3.1.1. Use language and images that facilitate understanding and decision-making

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3.2. Disclose harmful patient safety incidents to patients and their families

4. Engage patients and their families in developing plans that reflect the patient’s health care needs and goals 4.1. Facilitate discussions with patients and their families in a way that is respectful, non-judgmental, and culturally safe 4.2. Assist patients and their families to identify, access, and make use of information and communication technologies to support their care and manage their health 4.3. Use communication skills and strategies that help patients and their families make informed decisions regarding their health

5. Document and share written and electronic information about the medical encounter to optimize clinical decision-making, patient safety, confidentiality, and privacy 5.1. Document clinical encounters in an accurate, complete, timely, and accessible manner, in compliance with regulatory and legal requirements 5.2. Communicate effectively using a written health record, electronic medical record, or other digital technology 5.3. Share information with patients, families, and others in a manner that enhances understanding and that respects patient privacy and confidentiality

Collaborator

Definition:

As Collaborators, pediatric surgeons work effectively with other health care professionals to provide safe, high-quality, patient-centred care.

Key and Enabling Competencies: Pediatric surgeons are able to…

1. Work effectively with physicians and other colleagues in the health care professions 1.1. Establish and maintain positive relationships with physicians and other colleagues in the health care professions to support relationship-centred collaborative care 1.2. Negotiate overlapping and shared responsibilities with physicians and other colleagues in the health care professions in episodic and ongoing care 1.2.1. Provide relevant information outlining the clinical assessment and treatment plans to family physicians, pediatricians, and other health care professionals to facilitate their participation in the care of the patient 1.2.2. Utilize interprofessional expertise and community resources to facilitate appropriate and effective patient discharge

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1.3. Engage in respectful shared decision-making with physicians and other colleagues in the health care professions 1.3.1. Engage with anesthesiologists regarding pre-operative patient assessment and optimization, and post-operative care, including pain management 1.3.2. Use clear audible communication with the anesthesiologist and other team members in the operating room to optimize patient care 1.3.3. Request and provide timely intra-operative consultations 1.3.4. Participate in multidisciplinary patient conferences, such as tumour board, to plan treatment strategies

2. Work with physicians and other colleagues in the health care professions to promote understanding, manage differences, and resolve conflicts 2.1. Show respect toward collaborators 2.2. Implement strategies to promote understanding, manage differences, and resolve conflict in a manner that supports a collaborative culture

3. Hand over the care of a patient to another health care professional to facilitate continuity of safe patient care 3.1. Determine when care should be transferred to another physician or health care professional 3.2. Demonstrate safe handover of care, using both oral and written communication, during a patient transition to a different health care professional, setting, or stage of care 3.2.1. Provide safe handover of care of the post-operative patient to the post- anesthetic care unit, the pediatric intensive care unit, and the neonatal intensive care unit 3.2.2. Facilitate transfer of care to a primary care physician or specialist, or from the pediatric to adult health care setting

Leader

Definition:

As Leaders, pediatric surgeons engage with others to contribute to a vision of a high-quality health care system and take responsibility for the delivery of excellent patient care through their activities as clinicians, administrators, scholars, or teachers.

Key and Enabling Competencies: Pediatric surgeons are able to…

1. Contribute to the improvement of health care delivery in teams, organizations, and systems 1.1. Apply the science of quality improvement to systems of patient care

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1.2. Contribute to a culture that promotes patient safety 1.2.1. Participate in operating room safety procedures 1.2.2. Participate in reviews of operative complications and other aspects of quality improvement

1.3. Analyze patient safety incidents to enhance systems of care 1.4. Use health informatics to improve the quality of patient care and optimize patient safety

2. Engage in the stewardship of health care resources 2.1. Allocate health care resources for optimal patient care 2.2. Apply evidence and management processes to achieve cost-appropriate care

3. Demonstrate leadership in health care systems 3.1. Demonstrate leadership skills to enhance health care 3.2. Facilitate change in health care to enhance services and outcomes

4. Manage career planning, finances, and health human resources in personal practice(s) 4.1. Set priorities and manage time to integrate practice and personal life 4.2. Manage personal professional practice(s) and career 4.2.1. Apply leadership skills to optimize patient care in the operating room 4.2.2. Assume a leadership role in the management of complex cases

4.3. Implement processes to ensure personal practice improvement

Health Advocate

Definition:

As Health Advocates, pediatric surgeons contribute their expertise and influence as they work with communities or patient populations to improve health. They work with those they serve to determine and understand needs, speak on behalf of others when required, and support the mobilization of resources to effect change.

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Key and Enabling Competencies: Pediatric surgeons are able to…

1. Respond to an individual patient’s health needs by advocating with the patient within and beyond the clinical environment 1.1. Work with patients and their families to address determinants of health that affect them and their access to needed health services or resources 1.1.1. Facilitate timely patient access to services and resources

1.2. Work with patients and their families to increase opportunities to adopt healthy behaviours 1.2.1. Counsel patients and families regarding preventive strategies for trauma and head injury, including helmet use and use of seat belts and child restraints

1.3. Incorporate disease prevention, health promotion, and health surveillance into interactions with individual patients 1.3.1. Identify patients at increased risk of developing cancer, and provide counselling and surveillance 1.3.2. Recommend screening for relatives of patients with identified genetic associations

2. Respond to the needs of the communities or populations they serve by advocating with them for system-level change in a socially accountable manner 2.1. Work with a community or population to identify the determinants of health that affect them 2.2. Improve clinical practice by applying a process of continuous quality improvement to disease prevention, health promotion, and health surveillance activities 2.3. Contribute to a process to improve health in the community or population they serve

Scholar

Definition:

As Scholars, pediatric surgeons demonstrate a lifelong commitment to excellence in practice through continuous learning, and by teaching others, evaluating evidence, and contributing to scholarship.

Key and Enabling Competencies: Pediatric surgeons are able to…

1. Engage in the continuous enhancement of their professional activities through ongoing learning 1.1. Develop, implement, monitor, and revise a personal learning plan to enhance

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professional practice 1.2. Identify opportunities for learning and improvement by regularly reflecting on and assessing their performance using various internal and external data sources 1.3. Engage in collaborative learning to continuously improve personal practice and contribute to collective improvements in practice

2. Teach students, residents, the public, and other health care professionals 2.1. Recognize the influence of role-modelling and the impact of the formal, informal, and hidden curriculum on learners 2.2. Promote a safe and respectful learning environment 2.3. Ensure patient safety is maintained when learners are involved 2.3.1. Provide appropriate graded responsibility to junior learners in the operating room to optimize educational opportunities without compromising patient care

2.4. Plan and deliver learning activities 2.5. Provide feedback to enhance learning and performance 2.6. Assess and evaluate learners, teachers, and programs in an educationally appropriate manner

3. Integrate best available evidence into practice 3.1. Recognize practice uncertainty and knowledge gaps in clinical and other professional encounters and generate focused questions that can address them 3.2. Identify, select, and navigate pre-appraised resources 3.3. Critically evaluate the integrity, reliability, and applicability of health-related research and literature 3.4. Integrate evidence into decision-making in their practice

4. Contribute to the creation and dissemination of knowledge and practices applicable to health 4.1. Demonstrate an understanding of the scientific principles of research and scholarly inquiry and the role of research evidence in health care 4.2. Identify ethical principles for research and incorporate them into obtaining informed consent, considering potential harms and benefits, and vulnerable populations 4.3. Contribute to the work of a research program 4.4. Pose questions amenable to scholarly investigation and select appropriate methods to address them

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4.5. Summarize and communicate to professional and lay audiences, including patients and their families, the findings of relevant research and scholarly inquiry

Professional

Definition:

As Professionals, pediatric surgeons are committed to the health and well-being of individual patients and society through ethical practice, high personal standards of behaviour, accountability to the profession and society, physician-led regulation, and maintenance of personal health.

Key and Enabling Competencies: Pediatric surgeons are able to…

1. Demonstrate a commitment to patients by applying best practices and adhering to high ethical standards 1.1. Exhibit appropriate professional behaviours and relationships in all aspects of practice, demonstrating honesty, integrity, humility, commitment, compassion, respect, altruism, respect for diversity, and maintenance of confidentiality 1.2. Demonstrate a commitment to excellence in all aspects of practice 1.3. Recognize and respond to ethical issues encountered in practice 1.4. Recognize and manage conflicts of interest 1.5. Exhibit professional behaviours in the use of technology-enabled communication

2. Demonstrate a commitment to society by recognizing and responding to societal expectations in health care 2.1. Demonstrate accountability to patients, society, and the profession by responding to societal expectations of physicians 2.2. Demonstrate a commitment to patient safety and quality improvement

3. Demonstrate a commitment to the profession by adhering to standards and participating in physician-led regulation 3.1. Fulfil and adhere to professional and ethical codes, standards of practice, and laws governing practice 3.1.1. Adhere to requirements for mandatory reporting of cases suspicious for non-accidental injury 3.1.2. Adhere to jurisdictional guidelines for substitute decision-making

3.2. Recognize and respond to unprofessional and unethical behaviours in physicians and other colleagues in the health care professions 3.3. Participate in peer assessment and standard setting

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4. Demonstrate a commitment to physician health and well-being to foster optimal patient care 4.1. Exhibit self-awareness and manage influences on personal well-being and professional performance 4.1.1. Demonstrate self-awareness of professional limitations 4.1.2. Recognize and manage occupational health risks from disease transmission, substance abuse, fatigue, and overwork 4.1.3. Prevent, recognize, and manage personal health impairments that may affect surgical competence 4.1.4. Recognize and manage stress from caring for sick or dying patients

4.2. Manage personal and professional demands for a sustainable practice throughout the physician life cycle 4.3. Promote a culture that recognizes, supports, and responds effectively to colleagues in need

This document is to be reviewed by the Specialty Committee in Pediatric Surgery by December 2021.

APPROVED – Specialty Standards Review Committee – July 2019 REVISED CBD LAUNCH DATE – Specialty Committee in Pediatric Surgery – May 2020

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