Gastroenterology, Hepatology & Nutrition

Overview

The University of Toronto Training Program in Paediatric Gastroenterology, Hepatology and Nutrition is based at The Hospital for Sick Children (SickKids) and maintains a strong tradition of training clinicians from all over the world for academic careers encompassing research, education and clinical care. The training program is the largest in Canada and comparably sized to the premier training programs in this subspecialty in the United States.

The training program is fully accredited in Canada by the Royal College of Physicians and Surgeons. Training in Toronto is also fully recognized by the American Board of Paediatrics in the USA, and the Royal Australasian College of Physicians in Australia and New Zealand.

The core fellowship program follows a three-year structure with one clinical year followed by two research-focused years. Previous trainees who have completed the three-year fellowship program have been extremely successful in obtaining high caliber academic and leadership positions in Canada, the United States, and around the world. Graduates of the program typically continue research activities and hold extramural grants to support their research programs.

We also offer one-year clinical training fellowships and subspecialty fellowship programs for advanced trainees who have completed the majority of their core training in Gastroenterology, Hepatology and Nutrition elsewhere.

Objectives

To produce world-class academic physicians. The program strives for excellence in three key areas – clinical training, research training, and the provision of career development opportunities – and encompasses the Competence by Design (CBD) and CanMEDS framework of physician competency.

The goals that we strive to achieve within our Training Program are entirely aligned with the Mission of SickKids. This alignment translates into unrivalled support to learn about and provide excellent clinical care, to learn about research and undertake ground-breaking studies.

Training Sites

North York General Hospital (NYGH) During this rotation, you will attend adult gastroenterology clinics and procedure lists. This is an excellent opportunity to improve your colonoscopy skills and have exposure to adult GI pathologies.

Program Content

Core Fellowship Training

The program is accredited and/or fully recognized by:

  • The Royal College of Physicians and Surgeons of Canada (RCPSC)
  • The American Board of Pediatrics (USA)
  • The Royal Australasian College of Physicians (Australia & New Zealand)

The Core Fellowship Training program is a three-year program and is divided into:

  • One year of clinical training
  • Two years of research-focused training

Clinical Training

During the first year of training, trainees are exposed to a large variety of clinical cases and to all aspects of ambulatory and inpatient paediatric gastroenterology, hepatology & nutrition (GHN). Trainees have a unique opportunity to engage in cutting edge medicine and state of the art clinical care. Clinical care is provided in an academic environment using an evidence-based approach under ongoing staff support and supervision.

During the first clinical year trainees will rotate through the following services:

  • General GHN inpatient service
    • general GI, IBD, non-transplant liver disease, feeding disorders, motility disorders and pancreatic disorders (usual census 6-12 patients).
  • Transplant service
    • liver and intestine transplantation, acute liver failure and end-stage liver disease (30-35 liver transplants annually; usual census 5-10 patients).
  • Consult service
    • consultation services to the hospital in-patient wards and to community-based practitioners
  • GIFT service
    • intestinal failure training (usual census 5-8 patients).
  • Adult gastroenterology
    • one month of adult gastroenterology and endoscopy training.
  • Outpatient clinics
    • general GI and specialized clinics in IBD, hepatology, nutrition, motility disorders, celiac, intestinal failure, liver transplantation, pancreatic diseases and others.
  • Paediatric procedures
    • upper and lower endoscopies, variceal band ligation, polypectomy, foreign body removals. Each trainee performs 150-200 paediatric procedures during the first year of training.

On-call service

Overnight and weekend on-call coverage for patients admitted to the GHN and transplant inpatient services are provided by core fellowship trainees during their three years of training.  Trainees provide calls from home and provide support for general paediatrics residents who remain in hospital overnight.  Trainees may need to come to the hospital during their call. Call frequency is roughly one night each week and one weekend each month.

Funding

Salary support is available on a competitive basis from either the Ontario Ministry of Health and Long-Term Care (for Canadian trainees) or SickKids (for international trainees for the first two years of training). Third-year funding is obtained on a competitive basis through supervisor, divisional, hospital or extra-mural sources. Traditionally all of our research trainees successfully obtain salary support from these sources for their last year of research training.

Advanced Subspecialty Fellowship Training Programs

The GI training program at SickKids provides opportunities for advanced clinical and research training in specific domains of paediatric gastroenterology. The advanced subspecialty fellowship training programs include inflammatory bowel disease, hepatology /liver transplantation and intestinal failure. See below for additional details.

Inflammatory Bowel Disease - (IBD)

A one-year advanced IBD clinical and research training fellowship is available for interested trainees and is supported through the SickKids IBD Centre.

Canada has among the highest incidence rates for IBD worldwide.  Ontario health administrative data suggest that the incidence is continuing to increase, particularly in children. IBD care is centralized within the Gastroenterology, Hepatology and Nutrition (GHN) Division, such that three IBD specialists provide ambulatory care in six “half-day” IBD clinics weekly with over 2000 patient visits annually. IBD patients also account for the majority of inpatient days on the “GHN” ward. Ten to twelve patients are newly diagnosed each month and remain under follow-up care until the time of transfer to adult care by age 18 years. The SickKids IBD Program is hence responsible at any given time for the care of 900 children and adolescents with Crohn’s disease and ulcerative colitis, making it one of the largest paediatric IBD programs worldwide.

The IBD ambulatory program includes three specialty clinics. Dr. Alex Muise, co-lead of the international NEOPICS consortium, which has been very successful in identifying monogenic forms of IBD, runs a very-early onset IBD clinic. There is an alternate weekly “anti-TNF” therapy clinic exclusively for patients being treated with biologics, and a periodic joint clinic with Drs Ling and Kamath, for the care and study of patients with PSC-IBD. 

All fellows in the GI/Hepatology/Nutrition training program are given multiple opportunities for small group learning including new patient IBD rounds, challenging IBD patient rounds, IBD teaching rounds for fellows, and Magnetic Resonance Imaging rounds, all held once in every two weeks.

The IBD program aspires always to integrate state of the art clinical care with meaningful patient-based and translational research.   The program has had remarkable opportunities to train the next generation of paediatric IBD specialists, and in networking internationally to advance IBD research and clinical care. The Canadian Children IBD Network: a joint partnership of CIHR and the CH.I.L.D. Foundation is led by the SickKids IBD program.

Group for Improvement of Intestinal Function and Treatment - (GIFT)

Advanced training in intestinal failure and rehabilitation is provided by the SickKids intestinal rehabilitation program (GIFT – Group for Improvement of Intestinal Function and Treatment). The GIFT program is the largest of its kind in Canada and one of the leading intestinal rehabilitation programs in the world with 20 to 25 new patients every year. The program follows a large variety of patients with intestinal failure ranging from short bowel syndrome to severe motility disorders and congenital diarrheas in an inpatient and outpatient setting. The inpatient service is an independent service with a daily census of 5 to 10 patients/day. A multi-disciplinary team of paediatric gastroenterologists, paediatric surgeons, nurses, dieticians, physiotherapists, oral therapists, social workers and others provide comprehensive daily care. Clinical, translational and basic research is an integral part of the program activities and multiple opportunities exist for interested trainees under the supervision of Dr. Paul Wales, general surgery, and Dr. Yaron Avitzur, paediatric gastroenterology.

Intestinal failure training is focused on clinical and research training in the field of intestinal failure and rehabilitation. Training is offered for a one year period for fully trained general gastroenterologists or general surgeons and is recognized by the University of Toronto. Funding is provided on a competitive basis through SickKids Transplant Centre.

Hepatology and Liver Transplant

Advanced training in paediatric hepatology and liver transplantation is provided by the Division of Paediatric Gastroenterology, Hepatology and Nutrition and the Liver Transplant Program at SickKids*. 

Our one-year program provides flexible training to meet the needs of each individual fellow, whether their focus is advanced hepatology training, training in liver transplantation, or research training.  Our overall aim is to train future leaders in this field across the world.  SickKids currently performs between 25 and 40 paediatric liver transplants per year and has completed more than 500 paediatric orthotopic liver transplants, including over 150 from live donors, since the first SickKids paediatric liver transplant in 1986.  Our clinical service includes four paediatric hepatology clinics, a liver transplant clinic each week and a busy inpatient liver transplant service.  We work closely with our partners at the University of Toronto Transplant Institute and Toronto Liver Centre.

During this year of training, the Hepatology and Liver Transplant Fellow will gain clinical mastery in a wide range of general acute and chronic liver conditions, including care of patients with neonatal cholestasis, abnormal liver tests, end-stage liver failure, fulminant liver failure, hepatic neoplasms, metabolic liver conditions, portal hypertension, viral hepatitis, biliary diseases, vascular malformations of the liver; diagnosis of immune-mediated liver diseases and cholestasis syndromes; assessment of the candidacy of patients for liver transplantation;  management of paediatric patients pre- and post-liver transplantation; and long-term post-liver transplantation care. Fellows will interact closely with subspecialists in other divisions, including critical care medicine, interventional radiology, pathology, metabolic genetics, and transplant surgery. Fellows will develop diagnostic and therapeutic expertise in areas of hepatology and nutritional disorders and develop proficiency in the performance of diagnostic and therapeutic procedures (ie. endoscopic variceal band ligation); observation of procedures (including liver transplantation, percutaneous cholangiography), and non-transplant hepatobiliary surgeries (including Kasai portoenterostomy, partial external biliary diversion, shunt surgery); interpretation of liver histopathology; organizational structure and administration of a liver transplant program. 

Clinical, translational and basic research is an integral part of the program activities and multiple opportunities exist for interested trainees under the supervision of faculty hepatologists within the Division of Paediatric Gastroenterology, Hepatology, Nutrition and Liver Transplantation to complete a mentored concise clinical or translational research project.

* Note to US Citizens:  This one-year training program is not yet RCPSC or ACGME-accredited and training, therefore, may not be accepted towards the Certificate of Added Qualification (CAQ) from the American Board of Pediatrics.

Research Experience

The second and third years of the Core Fellowship Program are primarily focused on research training. There are a vast number of opportunities for high caliber clinical, translational or basic science research within the division, within the SickKids Research Institute and at the University of Toronto. The Research Institute (RI) is the largest hospital-based research program in Canada and is among the largest paediatric research programs in the world. The multidisciplinary structure of the RI encourages collaborative research, as does its new home in the Peter Gilgen Centre for Research and Learning. Areas for research training are chosen by a discussion between the trainee and potential supervisors, according to the interest of the trainee and the interests and expertise within our division and the RI.

Specific areas of research within the division include basic science, clinical and translational science, epidemiology and education. For specific research themes within the division please refer to staff research activities through the Research Institute.

Evaluation

Entrustable Professional Activity (EPA)

These evaluations will be completed by supervising staff online on the Elantra software. Multiple evaluations are required as per specific EPA requirements. Details on those requirements will appear at the beginning of each on-line EPA. It is the resident primary responsibility to complete the evaluations in a timely manner, to ensure progression to the next stage of CBD training. Each trainee receives an individual learner’s schedule that outlines the needed EPA’s to be completed in each rotation.

In Training Evaluation Reports (ITARs)

Using the University of Toronto “POWER” system. These reports will be completed online by supervising staff at each of the rotations during the clinical year and the research years.  You must sign off on each of these evaluations online. Printed copies of ITARs for each rotation must be included in your portfolio.

Online Course Completion Documentation

This will include research ethics training documentation, iLearn modules, and any other on-line evaluations of completed learning modules, such as those provided by “PGCorEd”.

Scholarship Oversight Committee (SOC) Reports

Completed 6-monthly during research training.  May include reports of supervisory committees for those residents and fellows enrolled in Master’s or PhD programs.

Teaching Evaluations

Documentation summarizing the evaluations provided by learners during sessions provided by the fellow/resident (including Physiology rounds, research seminars, evaluations by residents).

Teaching Rounds Presentations

A summary document providing an overview of presentations at Divisional teaching rounds (e.g. title and references reviewed).

Procedure Log

List of all relevant procedures performed during training (REDCap template provided).

Motility Training

Document your attendance at least one esophageal and one ano-rectal manometry study, and your involvement in reading at least three of each of these studies and three PH metry / impedance studies.

Ambulatory Clinic Log

This will include details of all clinics attended and the diagnoses of patients seen (template provided).

American Board of Paediatrics Subspecialty In-Training Examination (SITE)

All fellows are expected to write this examination each year.  It is provided annually by the ABP in March, registration is required, and you must schedule a time to go to a central office in Toronto to write the exam.  The Division will cover the registration cost.  Your grade is provided to you and the Program Director, with the average scores also available for trainees in the same year of training across North America.

GI Objective Structured Clinical Examination (OSCE)

All fellows are expected to do this exam each year. The exam is provided annually by the GI division. The training program director will provide you with your final score and score for each station as well as the average for each year.

Ways To Get Involved

  • Residency Program Committee
  • Chief Fellow

Applying To The Program

Interested applicants should send an updated CV to Mrs. Sherry Joy, Education Administrative Coordinator, for pre-application screening starting March 2nd in the year before the intended start date. CVs will be screened on a rolling basis during the period March 2nd – July 1st only. Selected candidates will be invited to complete a full application.  The deadline to submit completed applications is July 15th . Earlier submission of your application is recommended. If your application is successful you will be invited for interviews with faculty and trainees.  Interviews are projected to occur during the month of September.

Decisions are made approximately 6-8 months prior to the start of training which is on July 1st in any given year.

International applicants interested in applying for the 3-year training program or the 1-year clinical training program should be certified paediatricians in their home country.

Applicants interested in advanced subspecialty fellowship training program should be either a certified Paediatric Gastroenterologist, completed successfully paediatric gastroenterology training in an accredited training program or are considered Paediatric Gastroenterologist in countries with no formal accreditation or certification process.

Applicants who have applied to the U.S match through the National Residency Matching Program (NRMP), please be advised that the University of Toronto is a participating institution and adheres to the match policy. The policy states that "Applicants who have matched to a program or have accepted a position during the Supplemental Offer and Acceptance Program (SOAP), shall not apply for, discuss, interview for, or accept a concurrent year position in another program prior to the NRMP granting the requested waiver." More information is accessible at http://www.nrmp.org/wp-content/uploads/2017/06/2018-MPA-Specialities-Matching-Service.pdf.

Canadian residents are requested to submit their application through the CaRMS website.

Information for international applicants seeking to apply can be found via the University of Toronto. 

Elective Opportunities

Canadian Resident Electives

If you are eligible and interested in pursuing an elective with Division of Gastroenterology, Hepatology and Nutrition, please send your requested start and end dates to determine availability to the solomon.sualim@sickkids.ca.

International Resident Electives

If you are eligible and interested in pursuing an elective with Division of Gastroenterology, Hepatology and Nutrition, please send your requested start and end dates to determine availability to solomon.sualim@sickkids.ca.

Observership Opportunities

We provide observership opportunities for all trainees currently enrolled in an academic program in medicine (postgraduate, fellowship).

If you are an international applicant, please contact Mrs. Haya Al Husseini who is the Program Coordinator for the International Office at the Learning Institute: haya.al-husseini@sickkids.ca

For more information please contact us directly at: solomon.sualim@sickkids.ca

Extra-curricular Activities

We plan several social activities for fellows in the program. Despite busy work schedules, fellows find time to socialize and enjoy Toronto!
Scheduled social activities include:

  • Divisional Holiday Party (annually in December) – this is a formal event attended by close to 100 Divisional members, faculty, fellows, nurses, allied health professionals and administrative assistants. An excellent example of how the Division comes together for fun, food and dancing!
  • End of Year Rounds – an annual event when the fellows sing, dance and act their way through a fun-filled poke at the faculty and Division.
  • Divisional summer get-together – a divisional event for fellows and faculty during the summer months to welcome the first-year fellows.

Contact

Training Program Director

Binita Kamath, MD, MBBChir, MRCP
Phone: 416-813-6176

Fax: 416-813-4972
Email: binita.kamath@sickkids.ca

Education Administrative Coordinator

Sherry Joy

Phone: 416-813-6176
Fax: 416-813-4972
Email address: sherry.joy@sickkids.ca