GASTROENTEROLOGY CURRICULUM

Division of Gastroenterology and Liver DiseasesThe George Washington University

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TABLE OF CONTENTS

I. Faculty 2

II. Introduction 3

III. Mission 4

IV. Program Requirements 5

V. Curriculum Overview 6

VI. Curriculum Requirements 7

VII. Clinical Competencies 10

VIII. Methods of Teaching 13

IX. Methods of Evaluation 14

X. Performance Criteria for GI Endoscopy 15

XI. Principle Learning Activities and Conferences 20

XII. Principle Educational Goals by Competency 21

XIII. Evaluation of Program and Faculty 33

XIV. Salaries and Benefits 34

XV. AGA Task Force Overview 38

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FACULTY

Marie L. Borum, MD, EdD, MPHProfessor of MedicineDirector, Division of Gastroenterology and Liver Diseases

M. Ali Aamir, MDAssistant Professor of Medicine

Showkat Bashir, MDAssistant Professor of Medicine

Paul Chang, MDClinical Professor of Medicine

Leonard Ehrlich, MDClinical Associate Professor

Allen Ginsberg, MDProfessor of Medicine

Sands Irani, MDClinical Professor of Medicine

Patricia Latham, MD (Hepatology)Associate Professor of Medicine and Pathology

Ephraim Nsien, MDAssistant Professor of Medicine

Zobair Younossi, MD (Hepatology)Professor of Medicine (appointment pending)

Adjunct FacultyMichael Albert, MDClinical Professor of Medicine

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INTRODUCTION

This curriculum is developed for the use of gastroenterology fellows at The George Washington University. It is designed to outline the curricular goals and expectations for the gastroenterology fellows. This curriculum is structured around the six Accreditation Council of Graduate Medical Education (ACGME) core competencies. There is also information about the institution, faculty, evaluation processes, schedules and conferences.

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MISSION

The Gastroenterology fellowship at the George Washington University is designed to set the highest standard for excellence in training. The purpose of the gastroenterology training program is to ensure that trainees have the appropriate breadth and depth of training in the field of gastroenterology and hepatology. The fellows who complete this program will:

1. be competent to act as consultants in the field of gastroenterology / hepatology2. be capable of pursuing careers in academic medicine or clinical practice3. possess habits of life-long learning that will continue to enhance their knowledge,

skills and professionalism.

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PROGRAM REQUIREMENTS

EDUCATIONAL PROGRAM1. 18 months of clinical gastroenterology with 5 months of hepatology2. Formal instruction, clinical experience and competence in 26 content areas3. Formal instruction, experience and competence in technical procedures4. Formal instruction in 8 related topic areas

FACULTY The key clinical faculty and the program director are board-certified

The gastroenterology program presently consists of 4 fellows with the intention of program expansion to 6 fellows (2 per training year). There are 9 institutionally-based key clinical faculty and 2 adjunct faculty. In addition, a minimum of 3 faculty members and the program director have >10 hours / week devoted to the fellowship. Three of the clinical faculty members have a hepatology focus. Two of the key clinical faculty must have advanced endoscopy focus.

PROCEDURAL REQUIREMENTSThe newly proposed procedure requirements are documented in the Curriculum Requirement Section.

FACILITIES AND RESOURCES

GI PROCEDURE LABORATORYThe GI procedure laboratory has an up-to-date array of diagnostic and therapeutic endoscopic instruments and accessories.

SUPPORT SERVICESThe Division of Gastroenterology has access to support services that include pathology, radiology, surgery, oncology and parasitology.

FACILITIESThe Division of Gastroenterology has access to Intensive Care Units and the ability to have close interaction with subspecialties, including surgery, oncology, pediatrics, radiology and pathology.

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CURRICULUM OVERVIEW

The content of the gastroenterology curriculum is based upon an assessment of the knowledge and skills desired at the completion of fellowship training, review of the ACGME requirements and the Tasks Force recommendations from the American Gastroenterological Association and American Society of Gastrointestinal Endoscopy. The Task Force recommendations are the results of the efforts of major gastroenterology / hepatology societies. This curriculum is written in effort to set the highest standard for excellence in training.

The gastroenterology training at George Washington University consists of 3 years of training. The core clinical curriculum requires a minimum of 18 months of clinical activity and consists of traditional inpatient and outpatient consultation experience supplemented by conferences and didactic sessions. A longitudinal outpatient experience is required during their 3 years of training. Training in the basic endoscopic skills are supported by the curriculum. Training in advanced procedures (i.e. ERCP, endoscopic ultrasound) is reserved for selected trainees who have demonstrated endoscopic skill and desire procedural experience for advanced interventional endoscopy. Programmatic requirements for specific content areas and endoscopic expectations are outlined. In addition there is a requirement for substantive research experience of not less than 6 months.

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CURRICULUM REQUIREMENTS

Gastroenterology fellows have formal instruction, clinical experience and opportunities to acquire expertise in the evaluation and management of the following disorders

1. Esophageal diseases2. Acid peptic disorders3. Motility disorders4. Irritable bowel syndrome5. Nutrient assimilation disorders6. Inflammatory bowel disease7. Vascular disorders of the gastrointestinal tract 8. Gallstones and cholecystitis9. Biliary and pancreatic disorders10. Acute and chronic hepatitis11. Chronic liver disease12. Drug-induced hepatic injury13. Alcoholic liver disease14. Cholestatic syndromes15. Infections of the gastrointestinal tract (including bacterial, retroviral, mycotic, and

parasitic)16. Gastrointestinal diseases with an immune basis17. Gastrointestinal manifestations of HIV infections18. Gastrointestinal and pancreatic neoplasms19. Hepatobiliary neoplasms

Gastroenterology fellows have formal instruction, clinical experience and opportunities to acquire expertise in the evaluation and management of patients with the following clinical problems

1. Dysphagia2. Abdominal pain3. Acute abdomen4. Nausea and vomiting5. Diarrhea6. Constipation7. Gastrointestinal bleeding8. Jaundice9. Cirrhosis and portal hypertension10. Malnutrition11. Genetic / inherited disorders12. Depression, neurosis and somatization syndromes13. Surgical care of gastrointestinal disorders

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The program provides instruction in the indications, contraindications, complications, limitations and (as appropriate) interpretation of the following diagnostic and therapeutic techniques and procedures

A. Imaging of the digestive system, including1. ultrasound2. computed tomography3. magnetic resonance imaging4. vascular radiography5. nuclear medicine

B. Percutaneous cholangiographyC. Percutaneous endoscopic gastrostomyD. Gastric, pancreatic and biliary secretory testsE. Diagnostic and therapeutic procedures utilizing enteral intubation and bougienageF. Enteral and parenteral alimentationG. Liver transplantationH. Pancreatic needle biopsyI. ERCP, including papillotomy and biliary stent placement

Opportunities are provided for the gastroenterology fellow to gain competence in the performance of the following procedures. If the ACGME or the gastroenterology societies suggest a minimum number of procedures, it is noted. A skilled preceptor is available to teach and to supervise the procedures. Each gastroenterology fellow documents the procedures performed in a procedure log. The fellow’s log includes the procedure performed, the indication and outcomes of the procedure, the patient’s diagnoses and the supervising physician(s).

A. Esophagogastroduodenoscopy (EGD) - 130B. Esophageal dilatation - 20C. ProctoscopyD. Flexible sigmoidoscopy - 30E. Colonoscopy - 140F. Colonoscopy with polypectomy - 30G. Percutaneous liver biopsy - 20H. Percutaneous endoscopic gastrostomy (PEG) - 15I. Biopsy of the esophagus, stomach, small bowel and colonJ. Gastrointestinal motility disordersK. Nonvariceal hemostasis (upper and lower) - 25

(10 active bleeders)L. Variceal hemostasis - 20

(5 active bleeders)M. Enteral and parenteral alimentation

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The program provides instruction and emphasis on the pathogenesis, manifestations and complications of gastrointestinal disorders, including the behavioral adjustments of patients to their problems. The impact of various modes of therapy and the appropriate utilization of laboratory tests and procedures is also stressed.

The program also has formal instruction (lectures, conferences, seminars) on specific content areas that include the following.

A. Anatomy, physiology, pharmacology and pathology related to the gastrointestinal system, including the liver

B. The natural history of digestive diseasesC. Factors involved in nutrition and malnutritionD. Surgical procedures employed in relation to digestive system disorders and their

complicationsE. Prudent, cost-effective and judicious use of special instruments, tests, and therapy

in the diagnosis and management of gastroenterologic disordersF. Liver transplantationG. Sedation and sedative pharmacologyH. Interpretation of abnormal liver chemistries

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CLINICAL COMPETENCIES

The Accreditation Council of Graduate Medical Education (ACGME) Core Competencies introduced six defined areas of competency which residents must obtain over the course of their training. The core competencies, established in July 2001, are outlined below.

1. PATIENT CARE

Residents are expected to delivery patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.a. Residents are expected to provide patient care that is compassionate, appropriate

and effective for the promotion of health, prevention of illness, treatment of disease and care at the end of life.

b. Gather accurate, essential information from all sources, including medical interviews, physical examination, records, and diagnostic/therapeutic procedures.

c. Make informed recommendations about preventive, diagnostic, and therapeutic options and interventions that are based on clinical judgement, scientific evidence, and patient preferences.

d. Develop, negotiate and implement patient management plans.e. Perform competently the diagnostic procedures considered essential to the

practice of gastroenterology and hepatology

2. MEDICAL KNOWLEDGE

Residents are expected to demonstrate knowledge about established and evolving biomedical, clinical and cognate (e.g. epidemiological and social-behavioral) sciences and the application of the knowledge in patient care.a. Residents are expected to demonstrate knowledge of established and evolving

biomedical, clinical and social sciences, and demonstrate the application of their knowledge to patient care and education of others.

b. Apply an open-minded and analytical approach to acquiring new knowledgec. Develop clinically applicable knowledge of the basic and clinical sciences that

underlie the practice of gastroenterology and hepatologyd. Apply this knowledge in developing critical thinking, clinical problem solving

and clinical decision-making skills.e. Access and critically evaluate current medical information and scientific evidence

and modify knowledge base accordingly.

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3. PRACTICE-BASED LEARNING AND IMPROVEMENT

Residents are expected to demonstrate practice-based learning and improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care.a. Residents are expected to be able to use scientific methods and evidence to

investigate, evaluate, and improve their patient care practices.b. Identify areas for improvement and implement strategies to improve their

knowledge, skills, attitudes and processes of carec. Analyze and evaluate their practice experiences and implement strategies to

continually improve their quality of patient practiced. Develop and maintain a willingness to learn from errors and use errors to improve

the system or processes of caree. Use information technology or other available methodologies to access and

manage information and support patient care decisions and their own education

4. INTERPERSONAL AND COMMUNICATION SKILLS

Residents are expected to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their families and other health professionals.a. Residents are expected to demonstrate interpersonal and communication skills

that enable them to establish and maintain professional relationships with patients, families and other members of health care teams.

b. Residents are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with members of the health care teams.

c. Provide effective and professional consultation to other physicians and health care professionals and sustain therapeutic and ethically sound professional relationships with patients, their families, and colleagues.

d. Use effective listening, nonverbal questioning and narrative skills to communicate with patients and families

e. Interact with consultants in a respectful and appropriate fashionf. Maintain comprehensive, timely and legible medical records

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5. PROFESSIONALISM

Residents are expected to demonstrate professionalism as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.a. Residents are expected to demonstrate behaviors that reflect a commitment to

continuous professional development and ethical practice.b. Residents are expected to demonstrate an understanding and sensitivity to

diversity and responsible attitude toward their patients, their profession and society.

c. Demonstrate respect, compassion, integrity, and altruism in their relationships with patients, families and colleagues.

d. Demonstrate sensitivity and responsiveness to patients and colleagues, including gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities

e. Adhere to principles of confidentiality, scientific/academic integrity, and informed consent

f. Recognize and identify deficiencies in peer performance

6. SYSTEMS-BASED PRACTICE

Residents are expected to demonstrate systems-based practice as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.a. Residents are expected to demonstrate and understanding of the contexts and

systems in which health care is provided and demonstrate the ability to apply this knowledge to improve and optimize health care

b. Understand access, and utilize the resources and providers necessary to provide optimal care

c. Understand the limitations and opportunities inherent in various practice types and delivery systems, and develop strategies to optimize care for the individual patient.

d. Apply evidence-based, cost-conscious strategies to prevention, diagnosis and disease management.

e. Collaborate with other members of the health care team to assist patients in dealing effectively with complex systems and to improve systematic processes of care.

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METHODS OF TEACHING

In order to achieve the goals and objectives for the fellowship program, the following experiences have been established for the purpose of teaching gastroenterology fellows. These methods include: (1) the inpatient gastroenterology experience, (2) the outpatient gastroenterology experience, (3) interaction with other clinical specialties, (4) conferences, (5) research experience, and (6) continuing medical education and society participation.

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METHODS OF EVALUATION

In order for the gastroenterology training program to assess its ability to achieve the goals and objectives, an evaluation process that includes global assessments, observation, standardized patients and written examinations has been developed.

1. GLOBAL ASSESSMENTSThese assessments are conducted twice yearly by gastroenterology attendings and are included in the permanent record. Twice annually the faculty reviews the performance of the fellows in written evaluation. These are compiled on standard forms that assess medical knowledge, clinical skills, clinical judgement, humanistic qualities, professional attitudes and commitment to scholarship. Evaluations of the fellows are also solicited from residents, staff and patients (360o evaluation). The program director receives all of the written evaluations, which are kept in the fellow’s master file. Fellows may request a meeting at any time to personally review their files.

Semi-annually, fellows meet individually with the program director to formally review their evaluations. The meeting is to provide feedback to the fellow on their performance and to identify areas for professional enhancement. The program director reviews the log of each fellow’s procedures, consults and conference attendance. A written summary of this session is placed in the fellow’s permanent record.

2. OBSERVATIONFocused, personal observation assessments will be completed using the Mini-cex format by the gastroenterology attendings.

3. STANDARDIZED PATIENTS Examinations using standardized patients will be videotaped in the George Washington University Hospital education resource center that is specifically designed for such training activities.

4. WRITTEN EXAMINATION The residents participate in the annual standardized examination that is offered by the American Gastroenterological Association. The results are reviewed and an individualized program of instruction and learning is developed based upon the residents’ performance.

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Guidelines for Endoscopic Training Parameters of Competency

1. reviews records, x-rays, identified risk factors

2. understands and discusses appropriate alternative procedures

3. correctly identified indication, knows how the endoscopic procedure may influence management

4. obtains appropriate informed consent

5. demonstrates proper use of premedication and noninvasive patient monitoring devices

6. inserts the endoscope using proper technique

7. performs procedure with attention to patient comfort and safety

8. correctly identified landmarks

9. conducts thorough examination of the entire organ

10. detects and identifies all significant pathology

11. completes examination within a reasonable time

12. prepares an accurate report

13. plans correct management and disposition

14. discusses findings with patient and other physicians

15. conducts proper follow-up, review of pathology, case outcome

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PERFORMANCE CRITERIA FOR EVALUATION OF DIAGNOSTIC GASTROINTESTINAL ENDOSCOPYProcedure Performance Criteria

Esophagogastroduodenoscopy (EGD) Esophageal intubation

Pyloric intubation

Colonoscopy Navigation through sigmoid colon

Intubation of splenic flexure

Intubation of the hepatic flexure

Intubation of cecum

Intubation of terminal ileum (desirable skill)

Retroflexion in the rectum

Sigmoidoscopy Navigation through the sigmoid colon

Visualization of the splenic flexure

Retroflexion in the rectum

Endoscopic retrograde cholangiopancreatography(ERCP)

Cannulation of the desired duct

Opacification of the desired duct

Sphincterotomy

Stent placement

Stone extraction

Endoscopic ultrasonography Intubation of esophagus

Intubation of pylorus

Imaging of desired organ and/or lesion

Successful lesion biopsy

Tumor staging in agreement with the

surgical findings and similar to that

reported in the literature

All procedures Accurate recognition of normal and

abnormal findings

Development of appropriate endoscopic/medical treatment in response to these findings

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ASSESSMENT SCHEME FOR CORE CLINICAL COMPETENCIES

Outlined is an assessment scheme developed for the six ACGME Core Clinical Competencies with identification of the skill(s) being evaluated.

1. PATIENT CARE (Health Promotion Skills)a. Direct observation (minimum of 5 attending evaluations per year)

Skill: information gathering and communicating

b. Procedure log signed for a required procedures Skill: assessing competence in medical procedures

c. Completion of a minimum of 30 supervised hospital consultations Skill: assessing clinical judgement

d. Global evaluations from attendings Skill: assessing effective management of patient illness

2. MEDICAL KNOWLEDGE (Scientific Understanding)a. Written examination

Skill: assessing knowledge acquisition

b. Attendance at one major gastroenterology or hepatology conference per year Skill: demonstrating self-improvement and acquisition of life-long learning skills

c. Attendance at gastroenterology conferences Skill: development of the ability to interpret and apply evidence-based medicine

d. Review of core curriculum checklist and required readingSkill: ability to locate useful sources of information to enhance medical knowledge

e. Managed care tutorial available on-line at the School of Medicine Himmelfarb LibrarySkill: assessing knowledge acquisition, evidence-based clinical-decision making

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3. EVIDENCE-BASED LEARNING AND IMPROVEMENT (Assimilation of Scientific Information)a. Presentation at a minimum of 10 conferences

Skill: assessing ability to locate, interpret and distill relevant science

b. Completion of NIH on-line course on The Protection of Human Study Subjects with placement of a copy of the certificate on file Skill: assessing ethical implementation of study design.

c. Participation in a mentored research project Skill: assessing the completion of scholarly activity and apply biostatistical techniques

d. Attendance at monthly Inter-city Gastroenterology Grand Rounds Skill: developing the skill to analyze practice experience and facilitate the learning of other health care professionals

e. Attendance at monthly Gastroenterology-Surgery-Radiology conferenceSkill: developing the skill to analyze practice experience and facilitate the learning of other health care professionals

f. Attendance at monthly Inflammatory Bowel Disease conferenceSkill: developing the skill to analyze practice experience and facilitate the learning of other health care professionals

g. Attendance at monthly Complicated Case conferenceSkill: developing the skill to analyze practice experience and facilitate the learning of other health care professionals

h. Attendance at monthly Hepatitis C management conferenceSkill: developing the skill to analyze practice experience and facilitate the learning of other health care professionals

i. Attendance at monthly Morbidity and Mortality conferenceSkill: developing the skill to analyze practice experience and facilitate the learning of other health care professionals

j. Attendance at weekly Endoscopy Case conferenceSkill: developing the skill to analyze practice experience and facilitate the learning of other health care professionals

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4. INTERPERSONAL COMMUNICATION (Effective and Empathetic Interpersonal Exchange)a. Direct observation

Skill: effective nonverbal assessment technique

b. Standardized patients (direct observation)Skill: effective verbal assessment techniques

c. Attendance at Fellows’ Core Curriculum lecture seriesSkill: medical records management, effective communication, and understanding business and legal practice as it relates to gastroenterology and liver disease.

5. PROFESSIONALISM (Ethics and Cultural Sensitivity)a. Direct Observation

Skill: demonstrates respect, compassion, integrity and altruism

b. Standardized patient examinations (direct observation)Skill: demonstrates respect, compassion, and integrity

c. Completion of NIH on-line course on The Protection of Human Study Subjects with placement of a copy of the certificate on file.Skill: recognizes ethical dilemmas and maintains confidentiality.

d. Attend Fellows’ Core Curriculum lecture seriesSkill: recognizes impact of disability and cultural issues

6. SYSTEMS-BASED PRACTICE (Advocacy, partnering and cost-effectiveness in health care delivery)a. Direct observation

Skill: functions effectively as part of a health care team

b. Attend Fellows’ Core Curriculum lecture seriesSkill: familiarity with coding, documentation and reimbursement

c. Letters of completion of radiology, pathology and nutrition rotationsSkill: able to collaborate with ancillary care services

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PRINCIPAL LEARNING ACTIVITIES AND CONFERENCES

Attendance at all conferences is required by the Gastroenterology Fellows when they are fulfilling their duties at George Washington University. Gastroenterology faculty members are expected to attend scheduled conferences.

PRINCIPAL PATIENT CARE ACTIVITIES

Continuity ClinicEach fellow is assigned to 2-3 continuity clinics throughout their gastroenterology fellowship. Each fellow is assigned to a physician for general gastroenterology care. In addition, specialty clinics to which they are assigned at varying portions of their training include inflammatory bowel disease, motility disorders, liver disease and pancreatico-biliary diseases.

Hospital Attending RoundsFive mornings each week (Monday through Friday) the GI fellows, internal medicine residents and students on the gastroenterology elective meet with the attending physician assigned to the inpatient services. All of the patients who are hospitalized are discussed. There is a review of the pathophysiology of the medical condition supplemented with literature pertinent to the clinical circumstances resulting. Evidence-based clinical decision-making is performed. Written consultations are reviewed. Each patient is seen and examined at the bedside.

Procedure TeachingAll procedures performed on patients (inpatient or outpatient) by gastroenterology fellows are directly supervised by an attending physician. These procedures include fiberoptic endoscopy with or without diagnostic procedures (i.e. upper endoscopy, small bowel enteroscopy, flexible sigmoidoscopy, colonoscopy) advanced endoscopic procedures (i.e. endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography), esophageal manometry and pH studies, liver biopsy and capsule endoscopy. The fellows are required to maintain a log of the procedures that the have performed. They are monitored on a yearly basis for completeness and accuracy.

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ACADEMIC CONFERENCES

Board ReviewConference meets monthly. All fellows and coordinating faculty members are expected to attend. Cases and questions are discussed to prepare for gastroenterology specialty board examination.

City-wide Gastroenterology Grand RoundsConference meets once a month. Participants include all of the fellows and faculty members of gastroenterology divisions in the Washington, D.C.-area. Institutions that participate include George Washington University, Georgetown University, Howard University, Washington Hospital Center, National Institutes of Health and Walter Reed Medical Center. The fellows are required to present a case and discuss findings and management using evidence-based medical information

Complicated Case and Quality Review ConferenceConference meets once a month. Fellows and faculty present difficult management cases, complemented by pertinent literature. Systems and judgement errors are reviewed in a constructive fashion in an effort to continually improve clinical decision-making. Plans are developed to implement new procedures and policies to avoid similar errors / complications in the future. Individual judgement errors are addressed as necessary by the faculty and director of gastroenterology fellowship.

Didactic LecturesConference meets three times a month. Faculty members of the Division of Gastroenterology and Departments of Surgery, Radiology and Pathology offer didactic session that review pertinent issues important in the gastroenterology and hepatology fellowship training. These include conferences focussed upon pathophysiology and disease entities.

Endoscopy Case ConferenceConference meets monthly. Participants include faculty, fellows and nursing staff involved in procedures. The fellows are expected to review a case involving endoscopy and present a video of the endoscopic procedure with discussion of the literature that addresses issues related to management and the endoscopic intervention.

Gastroenterology – Surgery – Radiology ConferenceConference meets once a month. Participants in the conference include residents, fellows and faculty members of the Division of Gastroenterology, Department of Surgery and Department of Radiology. Medical residents and faculty members of other specialties (i.e. Oncology, Pathology) are invited to attend when there are cases when there is overlapping specialty interests. Gastroenterology fellows are required to present case and provide a review of appropriate literature pertinent for the discussion.

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Graduate Medical Education Core Lecture SeriesConference meets monthly. All internal medicine subspecialty fellows are required to attend the lecture series. The lectures has been developed to address professionalism through discussions with experts in areas of: (1) principled negotiation, (2) risk management, (3) law and medicine, (4) medical errors, (5) medical ethics, (6) ethics committee, (7) quality assurance.

Inflammatory Bowel Disease ConferenceConference meets once a month. The conference includes a review of cases and discussion of the literature that addresses issues related to emerging therapies and management.

Internal Medicine Grand RoundsConference meets weekly and is the only conference in which all of the internal medicine residents, subspecialty fellows and Department of Medicine faculty attend. Local, national and internationally recognized faculty are invited to address the Department of Medicine. The subjects are varied and the invited speakers are chosen from a variety of disciplines. Following the Grand Round presentations, the speaker will often interact with resident physicians or subspecialty fellows in a lecture format or on rounds. The Division of Gastroenterology is expected to have faculty members give at least one Grand Round presentation annually.

Journal ClubConference meets twice a month. Fellows are required to select a manuscript from an approved, peer-reviewed journal. Each fellow reviews one article at the conference. The fellows are expected to discuss the findings providing a critical review of the study design and application for clinical practice (if appropriate).

Liver ConferenceConference meets quarterly. Fellows and faculty members from George Washington University and other institutions meet to discuss liver disease cases. Fellows are expected to discuss the case and provide a review of the pertinent literature.

Morbidity and Mortality ConferenceConference meets monthly. Participants include the faculty, fellows and nursing staff involved in procedures. The faculty and fellows are expected to present the clinical outcome and complications of hospitalized patients. Systems and judgement errors are reviewed in a constructive fashion in an effort to continually improve clinical decision-making. Plans are developed to implement new procedures and policies to avoid similar errors / complications in the future. Individual judgement errors are addressed as necessary by the faculty and director of gastroenterology fellowship.

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Pathology ConferenceConference meets twice a month. Fellows and faculty members of the Division of Gastroenterology and Department of Pathology present the cases of individuals who have pathology specimens for review. Fellows are expected to discuss the case and provide a review of the pertinent literature.

Research ConferencesConference meets monthly. The conference reviews research concepts, protocol design and statistical review. Fellows and faculty members are also responsible for presenting updates on on-going research, presentations and publications. These research projects are critically appraised by participants in the conference.

All fellows are expected to design and complete a research project. Individual research meetings occur with the fellows and Director of the Division reviewing their research investigations.

The Division director also has research meetings with students and internal medicine residents who are conducting research in gastroenterology. Fellows are invited to attend these conferences and are frequently involved in the conduction of these ongoing projects.

Viral Hepatitis Management ConferenceConference meets 2-4 times a month. Participants include fellows, physician assistants and faculty involved in the care of chronic hepatitis C. The conference is focused upon the discussion of patients who are actively receiving therapy, have complicated management issues or are involved or being considered for clinical trials. Review of pertinent literature is offered. Research trials and study design for patients with chronic viral hepatitis C are also discussed during this conference.

Visiting Scholars, Professors and Investigators ConferenceConferences in which visiting scholars, professors and investigators are held to support the stimulation of new thoughts and ideas among fellows and faculty.

Additional Conferences

American Society of Gastrointestinal Endoscopy (ASGE) First-Year Fellow Endoscopy CourseThe first year fellows are given the opportunity to participate in the Endoscopy Course that is offered by the ASGE. The course offers an overview of endoscopy and hands-on experience in endoscopic procedures. (The agenda for the course is in the appendix.)

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William B. Steinberg Board Review CourseThis 3-day course meets annually in the Washington, D.C. area. Two fellows are given the opportunity to participate in the course. Additional fellows are given the opportunity to attend based upon funding sources.

Walter Reed Gastroenterology CourseThis 3-day course meets every other year. Two fellows are given the opportunity to participate in the course. Additional fellows are given the opportunity to attend based upon funding sources.

Annenberg Inflammatory Bowel Disease CourseThis is a 3-day course that meets annually. Application is made annually to offer one fellow the opportunity to participate in the course.

Society and Educational MeetingsEach fellow attends a minimum of one approved conference annually. The conference can be an international or national society meeting or educational course approved by the director. In addition, the fellow may also attend conferences in which they are presenting research.

Examples of society meetings in which GI fellows have participated include:American Gastroenterological Association (AGA)American College of Gastroenterology (ACG)American Society of Gastroenterology Endoscopy (ASGE)American Association of the Society of Liver Diseases (AASLD)Digestive Disease Week

Examples of educational meetings in which GI fellows have participated include:William B. Steinberg Board Review CoursesWalter Reed Gastroenterology ReviewInternational Conference on Capsule EndoscopyAmerican Gastroenterological Association (AGA) Educational SymposiumsAmerican Gastroenterological Association (AGA) Review CourseAnnenberg Inflammatory Bowel Disease Course

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DIVISION OF GASTROENTEROLOGY AND LIVER DISEASECONFERENCE SCHEDULE

MondayDidactic Sessions / Academic Lectures noon 2nd

Research Conference noon 1st

City-wide Grand Rounds 5 pm 2nd

TuesdayInflammatory Bowel Disease Conference noon 1st

Journal Club noon 2nd, 4th

Complicated Case Conference noon 3rd

GI-Surgery-Radiology Conference 5 pm 1st

Liver Conference 5 pm 3rd

WednesdayDidactic Sessions / Academic Lectures 8 am 1st, 3rd

Staff Conference noon 1st, 3rd

ThursdayInternal Medicine Grand Rounds noon 1st, 2nd, 3rd, 4th

Chronic hepatitis management 4 pm 1st, 2nd, 3rd, 4th

FridayMorbidity and Mortality 8 am 1st

Endoscopy Case Conference 8 am 1st, 2nd, 3rd, 4th

Pathology Conference noon 1st, 3rd

Board Review Conference noon 2nd

Fellow Meeting noon 4th

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PRINCIPLE EDUCATIONAL GOALS BY RELEVANT COMPETENCY

Legend for Learning Activities

Direct Patient CareContinuity Clinics (CC)Hospital Attending Rounds (HR)Procedure Teaching (PT)

Educational Conferences and MeetingsBoard Review Seminar (BR)Complicated Case and Quality Review Conference (CCQR)Didactic Lectures (DL)Endoscopy Case conference (EC)Gastroenterology – Surgery – Radiology Conference (GSR)Graduate Medical Education Core Lectures Series (GME)Grand Rounds (GR)Viral Hepatitis Management Conference (HC)Inflammatory Bowel Disease Conference (IBD)Inter-City Gastroenterology Grand Rounds (ICGR)Journal Club (JC)Liver Conference (LC)Morbidity and Mortality Conference (MM)Pathology Conference (PC)Research Conferences (RC)Society and Educational Meetings (EM)

Legend for Evaluation Methods

Attending Evaluations (AE)Directly Supervised Procedures (DSP)Program Director’s Review (PDR)Peer Review (PR)Semi-Annual Exam (SE)Standardized Patient Evaluation (SPE)

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PATIENT CARE

Principal Education Goals Learning Activities Evaluation MethodsPerform a complete medical history

CC, HR AE, PDR, SPE

Perform a comprehensive examination

CC, HR, PT AE, DSP, PDR, SPE

Formulate comprehensive and accurate problem lists

CC, HR, PT, CCQR, DL. GSR, HC, IBD, LC, MM

AE, PDR, SE, SPE

Generate and prioritize differential diagnosis

CC, HR, PT, CCQR, DL, EC, GSR, HC, IBD, LC, MM

AE, PDR, SE, SPE

Develop rational, evidence-based management strategies

CC, HR, CCQR, DL, EC, GSR, HC, IBD, LC, MM

AE, PDR, SE, SPE

Develop concise, accurate, rational, informative consultation

CC, HR, PT AE, DSP, PDR, SPE

Ability to recognize major abnormalities on radiologic studies

CC, HR, PT, GSR AE, PDR, SE

Ability to determine and perform appropriate diagnostic and therapeutic procedures

CC, EC, HR, PT AE, DSP, PDR

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MEDICAL KNOWLEDGE

Principal Education Goals Learning Activities Evaluation MethodsDemonstrate knowledge of basic and clinical sciences underlying patient care

BR, CC, HR, PT, CCQR, DL, GSR, HC, IBD, ICGR, LC, MM, PC

AE, PDR, SE, SPE

Demonstrate an analytical approach to acquiring new knowledge

BR, CC, HR, PT, CCQR, DL, GSR, HC, IBD, ICGR, JC, LC, MM, PC, RC

AE, PDR, SE

Demonstrate continued advancement of knowledge

BR, CC, HR, PT, CCQR, DL, EC, GSR, HC, IBD, ICGR, JC, LC, MM, PC, RC

AE, DSP, PDR, SE, SPE

Apply knowledge in the development of critical thinking, problem-solving and decision-making

BR, CC, HR, PT, CCQR, DL, EC, GSR, HC, IBD, ICGR, LC, MM, RC

AE, PDR, SE, SPE

Assess and critically evaluate current medical information and scientific evidence and modify knowledge base accordingly

BR, CCQR, DL, GSR, HC, IBD, ICGR, JC, LC, MM, PC, RC

AE, PDR, SE, SPE

Demonstrate the knowledge of the indications for, principles, complications and interpretations of specialized tests and procedures

BR, CC, HR, PT, CCQR, EC, GSR, HC, IBD, ICGR, LC, MM

AE, DSP, PDR, SE, SPE

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EVIDENCE-BASED LEARNING AND IMPROVEMENT

Principal Education Goals Learning Activities Evaluation MethodsUse scientific methods and evidence to investigate, evaluate and improve patient care

CC, HR, CCQR, DL, GSR, HC, IBD, ICGR, MM

AE, PDR, SE

Identify areas of improvement and implement strategies to improve knowledge, skills, attitudes and care processes

CC, HR, CCQR, DL, GSR, HC, IBD, ICGR, MM

AE, PDR, SE

Analyze and evaluate practice experiences and continually improve quality of patient practice

CC, HR, PT, CCQR, GSR, HC, IBD, ICGR, LC, MM, PC

AE, PDR, SE

Maintain a desire to learn from errors and improve the system or processes of care

CC, HR, PT, CCQR, GSR, GME, HC, LC, MM, PC,

AE, PDR, SE

Use information technology and other methodologies to assess and manage information

CC, HR, PT, CCQR, GSR, HC, JC, LC, MM, PC

AE, PDR, SE

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INTERPERSONAL SKILLS AND COMMUNICATION

Principal Education Goals Learning Activities Evaluation MethodsDemonstrate interpersonal skills that establish and maintain professional relationships with patients, families, and members of health care teams

CC, HR, PT AE, PDR, PR, SPE

Demonstrate interpersonal skills that establish and maintain professional relationships with members of health care teams

CC, HR AE, PDR, PR, SPE

Provide effective and professional consultations

CC, HR, PT, CCQR, HC, IBD, ICGR, LC, MM

AE, DSP, PDR

Demonstrate effective listening, nonverbal questioning and narrative skills to communicate with patients

CC, HR, PT AE, PDR, PR, SPE

Demonstrate respectful and appropriate interactions with consultants

CC, HR, PT AE, PDR, PR

Maintain comprehensive, timely and legible medical records

CC, HR, PT AE, PDR

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PROFESSIONALISM

Principal Education Goals Learning Activities Evaluation MethodsDemonstrate a commitment to professional development and ethical practice

CC, HR, PT, CCQR, DL, GSR, GME, GR, HC, IBD, ICGR, JC, LC, MM, PC, RS, EM

AE, DSP, PDR, PR

Demonstrate and understanding and sensitivity to diversity and responsible attitude toward patients, profession and society

CC, HR, PT, CCQR, DL, GME, HC, IBD, LC, MM, EM

AE, PDR, PR, SPE

Demonstrate respect, compassion, integrity and altruism in relationships with patients, families and colleagues

CC, HR, PT, CCQR, GME, HC, IBD, LC, MM

AE, DSP, PDE, PR, SPE

Demonstrate sensitivity and responsiveness to patients and colleagues, including gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities

CC, HR, PT, CCQR, GSR, GME, HC, IBD, ICGR, LC, MM

AE, PDR, PR, SPE

Adhere to principals of confidentiality, scientific/academic integrity and informed consent

CC, HR, PT, CCQR, GSR, GME, HC, IBD, ICGR, LC, MM, PC

AE, DSP, PDR

Recognize and identify deficiencies in peer performance

CC, HR, PT, CCQR, GSR, HC, IBD, ICGR, LC, MM, PC, RC, EM

AE, PDR, PR

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SYSTEMS-BASED PRACTICE

Principal Education Goals Learning Activities Evaluation MethodsDemonstrate and understanding of the contexts and systems in which health care is provided and demonstrate the ability to apply this knowledge to improve and optimize health care

CC, HR, PT, CCQR, GSR, HC, IBD, ICGR, LC, MM, PC

AE, PDR

Understand, access, and utilize the resources and providers necessary to provide optimal care

CC, HR, PT, CCQR, EC, GSR, HC, IBD, ICGR, LC, MM, PC

AE, DSP, PDR

Understand the limitations and opportunities inherent in various practice types and delivery systems, and develop strategies to optimize care for the individual patient.

CC, HR, PT, CCQR, GSR, HC, IBD, ICGR, LC, MM

AE, DSP, PDR

Apply evidence-based, cost-conscious strategies to prevention, diagnosis and disease management.

CC, HR, PT, CCQR, GSR, HC, IBD, ICGR, JC, LC, MM, PC, EM

AE, DSP, PDR

Collaborate with other members of the health care team to assist patients in dealing effectively with complex systems and to improve systematic processes of care.

CC, HR, PT, CCQR, GSR, HC, IBD, ICGR, LC, MM, PC, EM

AE, DSP, PDR, PR

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EVALUATION OF THE PROGRAM AND FACULTY

The program director specifically inquires about the strengths and weaknesses of the program at regular meetings with the fellows together and separately. At times, programmatic adjustments are made on the basis of this feedback. Midway through the fellowship, evaluation forms will be provided to the fellows and are completed and submitted to a Fellowship Oversight Committee (which does not include any faculty or staff member from the Division of Gastroenterology and Liver Diseases). A summary of the evaluations is given to the program director for review.

Upon completion of the fellowship, individuals are contacted for a formal evaluation of the program. This is reviewed by the program director with a focus on the perceived deficiencies. The findings are discussed with faculty so that programmatic alterations can be made as necessary.

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SALARIES AND BENEFITS

SALARIES

Salaries for the 2004-2005 academic years are as follows:

PGY 4 $45,905.93PGY 5 $47,686.58PGY 6 $49,098.07

BENEFITS

The following benefits are available to all George Washington University Fellows. All benefits are subject to change without advance notice.

LICENSURE AND MEDICAL LIABILITY COVERAGE

Drug Enforcement Administration (DEA) registration fees for eligible fellowsThe DEA registration fee is paid for fellows who are required to obtain a DC medical license because they graduated from a U.S. medical school at least 3 years ago or are international medical graduates entering the 4th year of post-graduate training. The federal DEA registration fee is reimbursed at the rate of 1/3 the total cost for each year the fellow remains at GW.

Medical Licensure feesFellows are required by law to be licensed in the District of Columbia beginning their 4th year of post-graduate training. They will be reimbursed by the GME office for the cost of the license.

The DC Board of Medicine requires any fellow who has obtained a non-restricted license in another state to apply for licensure in DC. Fellows must comply with this requirement and submit proof of licensure to the GME office; however, this cost is not reimbursed unless the fellow meets appropriate criteria as outlined above. Costs for the GME office pays for temporary licenses required for training in Maryland or Virginia.

Liability InsuranceProfessional liability insurance is provided for those activities and services within the scope of duties as defined by the program director. Liability insurance is not provided for activities outside the course and scope of duties within the fellowship training (i.e. moonlighting)

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HEALTH, DISABILITY, LIFE AND RETIREMENT INSURANCE

Health InsuranceFellows are eligible to participate in several plans, including Care First BC/BS PPO, CIGNA HMO and CIGNA PPOs and Care First Blue Choice HMO. The cost to the fellow depends on the options selected.

Flexible Spending AccountsThis program allows fellows to set aside tax-free dollars in special accounts to pay our of pocket medical and/or dependent care expenses

Voluntary Dental PlanFellows are eligible to participate in the Guardian Life Insurance dental plan. Discounted dental services are available through dentists associated with the Care First Blue Choice HMO.

Short term Disability Income PlanFellows are eligible to purchase this coverage through the Benefits Office. Provident Life Insurance is the providers.

Long-Term Disability InsuranceFor the first year of training, an individual policy is paid by the Medical Center which provides $2000 / month after 180 days of total disability, with provisions for partial claims. This coverage can be continued by the fellow on an individual basis at a discounted rate after the first year. After the first year of training, fellows are enrolled in the University Long-Term Disability Insurance plan.

Life InsuranceBasic life and Accidental Death and dismemberment coverage equal to the base annualized salary is provided at no cost. Optional terms and universal insurance is available at an additional charge.

Retirement BenefitsFellows must be at least 21 years of age and have completed two years of service to participate. GW contributes 4% of the annualized regular salary to the plan. Fellows who contribute a portion of their salary to the plan are eligible to receive matching contributions equal to 1.5 times the employee contribution, up to a maximum of 6%.

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LEAVE POLICY

Fellows are eligible for the following leave according to University Policy

1. Vacation, holiday leave and sick leave. (Determined by each program / department)

2. Family and medical leave3. Temporary disability leave4. Maternity leave5. Leave of absence6. Bereavement leave7. Leave for jury duty8. Leave for court appearances9. Military duty leave

EDUCATION BENEFITSTuition BenefitsTuition benefits cover a maximum of six credit hours in the fall and spring semesters and nine credit hours in the summer sessions for courses taken in degree programs. Some exclusions apply. Benefits for spouses and dependent children vary depending on years of service to the university.

Tuition Exchange ProgramThe university is a member of the Tuition Exchange, Inc., which provides a limited number of tuition remission scholarships for employees of member colleges and universities. The Benefits Office determines the eligibility.

MISCELLANEOUSLab CoatsOne personalized white lab coat is provided to each fellow on an annual basis

ParkingParking is provided free if assigned to University garages and parking lots.

Student Loan DefermentThe GME office will assist in the processing of student loan deferments.

Health and Wellness CenterThe Health and Wellness Center is located at 2301 G Street. The annual membership fee is @395.00 and can be paid through payroll deduction.

Employee Assistance ProgramConfidential problem assessment, counseling and referral services are provided.

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OVERVIEW OF TASK FORCE RECOMMENDATIONS BYAMERICAN GASTROENTEROLOGICAL ASSOCIATION

CLINICAL TASK FORCESMotility, Diverticular Disease and Functional IllnessAcid-Peptic DiseaseBiliary Tract Diseases and Pancreatic DisordersGastrointestinal Inflammation, Enteric and Infectious DiseasesGastrointestinal MalignancyHepatologyGastrointestinal EndoscopyNutritionPediatric GastroenterologyGastrointestinal and Hepatic PathologyGastrointestinal RadiologySurgeryGeriatric GastroenterologyWomen’s Health Issues in Digestive Diseases

OTHER TASK FORCESOverview of Training in Gastroenterology ResearchGastrointestinal Cellular and Molecular Physiology

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TASK FOR ON MOTILITY, DIVERTICULAR DISEASE AND FUNCTIONAL BOWEL ILLNESS

MOTILITY AND FUNCTIONAL BOWEL ILLNESS

Knowledge Areas for Motility and Functional Bowel Illnesses1. Understanding the management of patients with motility and functional bowel

disorders2. Understanding the physiology of gastrointestinal motility3. Understanding the brain-gut axis and visceral sensation4. Understanding the nuances of functional bowel disorders5. Understanding the importance of psychosocial aspects of functional bowel

disorders6. Understand the usefulness of, indications for and limitations of motility studies

Goals of TrainingIncludes the understanding of the pathophysiology of the disorders, exposure to management of adequate numbers of patients under the supervision of experienced clinicians and understanding the rationale for, usefulness of, and potential pitfalls of various motility tests that are available. This level of training is expected for all trainees.

1. Clear understanding of the indications and contraindications of the performance of motility studies

2. Understanding the limitations of interpretation of esophageal manometry, esophageal pH studies, esophageal motility with provocative agents, radionuclide gastric emptying studies, small bowel motility, colonic transit measurements, anal sphincter manometry and anal sphincter biofeedback training.

3. Recognize the manometric features of major motor disorders of the esophagus and anal sphincter, including esophageal achalasia, scleroderma, internal anal sphincter weakness, external anal sphincter weakness and absence of rectoanal inhibitory reflex

4. Understand the features of pH testing which indicates reflux and significance of a symptom score index

5. Understand the physiology of motility of different areas of the gut, the brain-gut axis and the physiology of visceral sensation

6. Develop a theoretical framework of the role of main neurotransmitters involved in sensory and motor functions

7. Familiar with the health care-seeking behavior and the associated psychosocial factors that appear to be important in patients with functional bowel disorders

8. Develop an understanding of the use of psychopharmaceuticals in the treatment of functional bowel disorders

9. Understand when and how to refer patients refractory to therapy for psychiatric evaluation and management.

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Training Process

1. Provide an appropriate clinical outpatient experience that provides an opportunity to evaluate and manage patients with possible motility disorders

2. Development of skills in interview techniques and integration of psychological information into clinical reasoning and decision-making

3. Development of decision-making that incorporates appropriate testing, interpretation of test results and treatment the patient under the guidance of appropriate staff

4. Teach the roles of motility, and sensation, in functional bowel disorders5. Provide information and instruction in the performance of motility studies,

including 24-hour pH studies6. Offer specific literature and didactic teaching to develop an understanding of the

pathophysiology of motility disorders7. Review motility tracings to enhance interpretation of studies

Assessment of Competence1. Appropriately trained preceptors are identified by program director 2. Preceptors will formally review fellows techniques in evaluating and managing

patients with motility and functional bowel disorders3. Appropriately trained preceptors will formally review fellows skills in conducting

motility studies4. Certification of competence by program director

DIVERTICULOSIS AND DIVERTICULAR DISEASE

The management of diverticular disease should be encountered by all trainees in an active clinical program. The clinical program will offer an understanding of presentations of diverticular diseases and the management of the complications. Therefore, no specific curriculum was offered by the Task Force.

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TASK FORCE ON ACID PEPTIC DISORDERS

Knowledge Areas1. Obtain knowledge of acid peptic disorders, including duodenal and gastric ulcers,

gastroesophageal reflux, gastritides/gastropathies, Zollinger-Ellison syndrome and other hypersecretory states and duodenitis.

2. Obtain an understanding of the prevalence, potential for complications, economic consequences of the disorders

3. Obtain knowledge of the technology and appropriate skills in the performance of diagnostic and therapeutic imaging techniques and understanding the surgical approaches to the disease

Goals of TrainingThe fellow is expected to gain knowledge and understanding of 1. the anatomy, physiology and pathophysiology of the esophagus, stomach and

duodenum2. the gastric secretion and indications for gastric analysis3. the indications for serum gastrin measurement and secretin testing and

consequences of hypergastrinemia in both hypersecretory and achlorhydric states 4. the natural history, epidemiology and complications of acid-peptic disorders,

including recognition of premalignant conditions (i.e. Barrett'’ esophagus)5. the role of H. pylori and NSAIDs in acid-peptic diseases6. the pharmacology, adverse reactions, efficacy and NSAID-appropriate use of

drugs for acid-peptic disorders; these include antacids and histamine-2 receptor antagonists, proton pump inhibitors, mucosal protective agents, prostaglandin analogues, prokinetic agents and antibiotics

7. the endoscopic and surgical treatments of acid-peptic disorders, including cost-effectiveness, complications and side effects, both short-term and long-term

The fellows are expected to develop competence in1. the performance of a thorough gastrointestinal-directed history of physical

examination2. the performance diagnostic and therapeutic upper gastrointestinal endoscopy3. the performance and interpretation of esophageal pH probe tests and esophageal

motility studies4. the interpretation of plain films of the abdomen, barium examinations of the upper

gastrointestinal tract, ultrasonography, abdominal computed tomographic scans and magnetic resonance imaging

5. the understanding invasive and noninvasive techniques for diagnosing H. pylori infection

6. the understanding the role of prostaglandins in mucosal protection, the importance of prostaglandin inhibitors (NSAIDs, aspirin) in causing ulcers and the effects of selective cyclooxygenase-2 inhibitors on the upper gastrointestinal tract

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Training Process

Care and ManagementFellows must acquire a thorough knowledge of appropriate history-taking, an ability to perform a comprehensive and accurate examination, develop appropriate differential diagnosis and outline a logical plan for specific and targeted investigations and a treatment plan

Proficiency in Endoscopic and Ancillary InvestigationsObtain experience under direct supervision to become competent in performing and interpreting all procedures and diagnostic tests that are used in the evaluation and treatment of patients with acid-peptic disorders. This would include the indications, limitations, technical aspects and complications of the following procedures. Fellows must also understand the benefits and dangers of conscious sedation.

1. Upper intestinal endoscopy, both elective and emergent. This would include the various modalities for the treatment of upper gastrointestinal bleeding, biopsy and polypectomy

2. Dilatation of benign and malignant esophageal strictures3. Performance and interpretation of esophageal motility studies, 24-hour pH

monitoring and the interpretation of gastric secretory studies4. Interpretation of radiological studies of the upper gastrointestinal tract, including

contrast gastrointestinal examinations, ultrasonography, computed tomographic scans and magnetic resonance imaging.

5. Indications and interpretation of studies for specific entities, such as hypersecretory states, H. pylori, and other infections of the upper gastrointestinal tract, particularly acquired immunodeficiency syndrome (AIDS)-related disorders

6. Develop a working knowledge of upper gastrointestinal tract pathology, such as mucosal biopsies for gastritis, Barrett’s esophagus and malignant conditions

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TASK FORCE ON TRAINING IN BILIARY DISEASES AND PANCREATIC DISORDERS

A major goal in training in biliary tract diseases should be to develop highly skilled consultants who can provide state-of-the-art care of patients with complex biliary disease. These physicians should be aware of the advantages and disadvantages of available options involving the diagnosis and therapy of biliary diseases and of potential complications. If complications occur, the specialists should be in a position to manage them.

Goals of Training for Biliary Disease1. Become acquainted with varied presentations of biliary tract disease and have

detailed knowledge about all aspects of biliary disease2. Acquire competency in the decision-making process involving the appropriate

choice of diagnostic procedures, their timing and their sequence3. Establish proficiency in diagnostic and therapeutic procedures involving biliary

tract disease and acquire the ability to perform them safely, successfully and expeditiously

4. Appreciate the advantages and disadvantages of radiological and endoscopic procedures and be able to balance the risks and benefits of these procedures for patients

5. Understand the importance of teamwork which involves close collaboration with radiologist, surgeons and hepatologists

Goals of Training for Pancreatic DisordersTrainees should attain knowledge and understanding of 1. The embryological development and anatomy of the pancreas and pancreatic duct

system2. The regulation of pancreatic growth and differentiation3. The physiological processes involved in pancreatic exocrine secretion of digestive

enzymes, water and electrolytes4. The regulation of exocrine secretory processes5. The types of digestive enzymes secreted by the pancreas and their roles in the

digestive system6. The mechanisms by which pancreatic enzymes secreted as zymogens are

activated in the small intestine7. The factors that protect the pancreas from autodigestion8. The physiological interactions between exocrine and endocrine pancreas9. The epidemiology, pathophysiology and natural history of acute pancreatitis,

chronic pancreatitis and pancreatic cancer

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Goals for Training for Acute Pancreatitis

In caring for acute pancreatitis, trainees must be able to 1. establish diagnosis and assess severity2. determine the etiology3. direct initial volume resuscitation4. monitor for and treat extra pancreatic complications (i.e. Pulmonary and renal failure)5. diagnosis and treat expeditiously infected necrosis or pancreatic abscess and other

septic complications6. diagnosis and manage pancreatic pseudocysts, 7. pancreatic ascites8. hemorrhage9. determine the need for and timing and type of nutritional support10. evaluate patients for possible treatable occult causes of otherwise ‘idiopathic’ acute

pancreatitis

Goals for Training for Chronic Pancreatitis

In caring for individuals with chronic pancreatitis, trainees must be able to1. establish the diagnosis (particularly in the presentation of occult disease)2. develop the differential diagnosis between chronic pancreatitis and pancreatic

cancer3. determine the etiology4. manage abdominal pain, pancreatic exocrine and endocrine insufficiency and

biliary obstruction5. diagnosis and manage pancreatic pseudocysts, ascites, pleural effusion and

vascular complications (i.e.. splenic vein thrombosis, pseudoaneurysm)

Goals for Training for Pancreatic Cancer

Trainees must be able to1. use diagnosis tests in a rational and cost-effective manner2. assess operability3. manage pain, biliary and intestinal obstructions, pancreatic insufficiency and

splenic vein thrombosis

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Additional Goals

Trainees must be able to1. recognize and diagnosis cystic fibrosis and manage pancreatic insufficiency in

that setting2. diagnosis and treat annular pancreas3. assess the importance of pancreas divisum in the etiology of pancreatic disease4. understand the indications for and the interpretation of diagnostic tests results in

the diagnosis and management of disease of the pancreas, including serum amylase and lipase determination, serum tumor markers, indirect tests of pancreatic secretory function, direct tests of secretory function, duodenal drainage with analysis for biliary crystals and fine needle aspiration of pancreatic masses and analysis of cytology in endoscopic aspirates of pancreatic juice

5. Understand the role of other disciplines in the management of pancreatic disorders, including therapeutic endoscopy, surgery, interventional radiology, anatomic pathology and cytopathology, nutritional support, pan management, medical oncology and radiation oncology.

Training Process

Basic science training (physiology and pathophysiology). The fundamental core of information for all trainees should include1. detailed knowledge of hepatobiliary and pancreatic anatomy, including

developmental anomalies2. physiology of bile and factors regulating bile flow3. physiological function of bile components (bile acids, phospholipid, cholesterol

and protein)4. gallbladder function, mechanism of bile concentration an regulation of gallbladder

contraction5. regulation of bile duct motility and sphincter of Oddi function (contraction /

relaxation)6. pathophysiology of cholestasis and the mechanisms responsible for alteration of

bile flow7. pathophysiology of gallstone formation (cholesterol, pigment stone)8. pathogenesis of motility disorders of the biliary tract9. pathophysiology and scientific rationale for therapy of major biliary tract

disorders and complications of liver transplantation as well as other hepatobiliary surgical procedures

10. basic familiarity with techniques of molecular biology, principles of cell biology and physical chemistry

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Clinical Aspects of biliary diseases

1. understanding of the epidemiology, manifestations, differential diagnosis and natural history of major biliary tract disorders

2. familiarity with specific biliary tract disease, including benign and malignant strictures, primary and secondary neoplasms, choledocholithiasis, cholecystitis, sclerosing cholangitis, congenital abnormalities of the pancreaticobiliary tract (i.e. biliary atresia, choledochal cysts), hemobilia, motility disorders of biliary tract, post-operative complications of the biliary tree and post-liver transplant biliary problems, acute and chronic pancreatitis and pancreatic neoplasms.

3. Senior trainees should obtain more detailed exposure to biliary disease through active participation in the medical care of patients with biliary tract diseases through inpatient and outpatient consultations

Procedures

1. knowledge of the advantages and disadvantages of the different diagnostic and therapeutic procedures used in the diagnosis and treatment of biliary tract disease and pancreatic disease, including potential risks, limitations and costs in the evaluation and management of biliary tract and pancreatic diseases

2. understand the role of endoscopic techniques and alternative diagnostic and therapeutic modalities (medical, surgical and radiological) in the management of biliary and pancreatic disease

3. Understand the role of ERCP as the primary tool for accessing the biliary tree and pancreatic ductal system and as a major route for therapeutic intervention. Appreciate the indications, contraindications, limitations, complications and interpretation.

4. Understand the role of percutaneous transhepatic cholangiography. Appreciate the indications, contraindications, limitations, complications and interpretation.

5. Understand and have a basic understanding (indications, advantages and disadvantages) and how to interpret the following imaging procedures, including: plain abdominal film, cholecystogram, ultrasound, computed tomography, magnetic resonance imaging and scintigraphy

6. Exposed to the performance and interpretation of endoscopic ultrasound7. Exposed to surgical biliary and pancreatic procedures

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TASK FORCE ON TRAINING IN GASTROINTESTINAL INFLAMMATION, ENTERIC AND INFECTIOUS DISEASES

Goals of training

Trainees must master a basic body of knowledge, including an understanding of1. mechanism of inflammation2. elements of mucosal defense systems (including the mucosal immune system and

the components of intestinal barrier function)3. composition and function of normal enteric flora (including protection again

pathogens, colonization resistance, role in the metabolism and effects of antibiotics on flora

4. prevalence, clinical presentation and virulence factors of gastrointestinal pathogens (viral, bacterial, fungal, protozoa)

5. pathophysiology of diarrheal disease6. indications and contraindications of antimicrobial therapy, mechanisms of

microbial drug resistance and risk of infections from altering normal flora

Clinical Skills

Familiarity with the following diagnostic and histopathologic studies1. stool examination, fecal leukocytes and ova and parasites2. cultures of stool, intestinal fluid and biopsy (specimen collection, handling,

special stains, media)3. mucosal biopsy interpretation4. antigen detection (enzyme immunoassay, fluorescent antibody) in stool and fluid

and stool toxin testing5. rapid diagnostic tests (DNA probes or polymerase chain reaction), disinfection

and antibiotic prophylaxis6. liver biopsy and interpretation

Familiarity with the following1. selection and use of antibiotic therapy and methods for preventing infection

during endoscopy (disinfection and antibiotic prophylaxis)2. gastrointestinal infection, including the diagnosis and management of patients

with common infectious presentations, including esophagitis, (fungal, viral , bacterial), ulcer disease and gastritis (emphasis on H. pylori and appropriate antibiotic therapy),

3. acute, chronic, hemorrhagic and traveler's diarrhea4. bacterial overgrowth5. infections in immunocompromised hosts (transplantation patients)6. hepatic inflammation (liver abscesses, hepatitis, cholangitis07. role of liver biopsy

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8. concepts of preventive medicine, indications for vaccination, routes of infection, dietary an hygienic practice for travelers, appropriate recommendations for prophylactic antibiotic therapy

Training process

1. participation in the evaluation and management of outpatients and inpatients with presentation and diagnoses

2. exposure to appropriate use of diagnostic tests, indications and complications of therapy

3. additional exposure to related sciences (immunology, microbiology and molecular biology) and related fields of medicine (infectious disease, and laboratory, anatomic an surgical pathology

4. conferences, seminars and literature reviews

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HIV-RELATED GASTROINTESTINAL DISORDERS

Goals of training

1. AIDS-related from AIDS-unrelated conditions2. management of esophageal disorders , including infectious esophagitis3. assess AIDS gastropathy and other infectious and neoplastic gastric disorders4. assess disorders of the small intestine, including causes of diarrhea and HIV-

infected5. interpretation of endoscopic, barium and computed tomographic and ultrasound

examination 6. treat bacterial,, fungal, viral and protozol infections in patients with AIDS7. recognize cause of colorectal disorders, including proctitis, proctocolitis and

AIDS-related malignancy8. familiar with the indications for and interpretation of flexible sigmoidoscopic,

colonoscopic and radiographic studies

Biliary system1. evaluate causes of hepatomegaly, abnormal liver test results (infectious,

neoplasia, drugs) and interaction of hepatitis virus and HIV2. distinguish AIDS cholangiopathy and cholecystitis 3. assess indications of liver biopsy

Pancreatic disorders1. causes of pancreatitis (infectious, neoplastic, toxic)2. implications of hyperamylasemia3. nutritional evaluation of pancreatic disorders4. assessment of nutritional status and development and implementation of

nutritional therapies (enteral and parenteral)5. determine the cause of and prescribe a rational treatment plan for common

opportunistic and neoplastic conditions in a cost-effective and humanitarian fashion.

Training Process

1. inpatient and outpatient consultative evaluations2. exposure to patients with AIDS with dysphagia/odynophagia, diarrhea, rectal

bleeding, abnormal liver enzymes/hepatomegaly, abdominal pain and hyperamylasemia

3. interaction between trainees and specialists in laboratory medicine, diagnostic and interventional radiology and infectious disease and immunology

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INFLAMMATORY BOWEL DISEASE

Goals of Training

1. recognize clinical and laboratory features of intestinal inflammation and to distinguish them from signs of secretory and osmotic diarrhea and from symptom of irritable bowel syndrome

2. differentiate chronic idiopathic IBD from other specific entities, including acute self-limited ileitis and colitis, drug- or radiation-induced colitis and diverticulitis by history and interpretation of radiological, endoscopic, histological and microbiological studies

3. understand indications for and interpretation of colonoscopy, barium enema, upper gastrointestinal and small bowel series, enteroclysis and computed tomographic scan

4. understand the cost-benefit and risk-benefit of procedures5. familiarity with different presentations of IBD, including the pediatric

manifestations, anorectal complications, and inflammatory vs. fistulizing vs. fibrostenotic patterns of Crohn’s disease

6. recognize various presentations of IBD with history-taking, physical examinations7. capable of evaluating intestinal (i.e. hemorrhage, obstruction), extraintestinal (i.e.

ocular, dermatologic, musculoskeletal, hepatobiliary) and nutritional complications of ulcerative colitis and Crohn’s disease.

8. Familiarity with the influence of IBD on pregnancy and of pregnancy on IBD and be capable of addressing issues pertaining to family history and genetic counseling.

9. Awareness of long-term cancer risks in ulcerative colitis and Crohn’s disease and be able to implement appropriate cost-effective surveillance programs

10. Sensitivity to psychosocial influences and consequences of IBD on the individuals and on family dynamics

11. Developing a therapeutic plan according to the extent and severity of specific disease patterns and to understand the indications, contraindications, and pharmacology of nonspecific therapies, including new biologic therapies, anticholinergic agents, antidiarrheals and bile salt sequestrants, oral and topical aminosalicylates, parenteral, enteral and rectal corticosteroids, immunosuppressants and antibiotics used in relevant clinical situations

12. Understand the indications for enteral and parenteral alimentation and be able to implement nutritional therapies

13. Capable of diagnosing and differentiating other inflammatory disorders, including collagenous colitis, microscopic colitis, NSAID enterocolopathies, diverticulitis (including medical and surgical complications), radiation enteritis and colitis, Whipple’s disease, celiac sprue, diversion colitis, and the solitary rectal ulcer

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Training Process

1. able to assume responsibility, encompassing diagnoses, acute and chronic therapies, long-term follow-up and counseling of the families and/or significant others

2. exposure to hospitalized as well as ambulatory patients, including the initial assessment and longitudinal management of patients with IBD

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TASK FORCE ON TRAINING IN GASTROINTESTINAL MALIGNANCY

Goals of training

1. develop a thorough familiarity with the literature on cancer epidemiology, primary prevention and screening for colorectal cancer with fecal occult blood tests and well as endoscopic and radiological approaches

2. become knowledgeable about the recommended guidelines for screening for gastrointestinal neoplasia and the literature supporting these recommendations

3. develop ability to read and interpret literature about the merging technologies and able to evaluate novel technologies and approaches

4. develop a working knowledge of clinical genetics and understand the approaches to the genetic diagnosis of FAP, HNPCC and other rarer polyposis syndromes

5. recognize the clinical characteristics of diseases, the distinctions among the familial forms of cancer, the specific diagnostic and screening tests for each and the rational approaches to their treatment

6. learn the principles of neoplastic growth as they relate to therapy, including endoscopic treatment as well as traditional surgical approaches

7. develop a complete understanding of the management of premalignant conditions8. familiarity with the pathological interpretation of tissue biopsies (endoscopic and

percutaneous)9. develop a thorough working knowledge of management of dysplastic lesions10. understand the distinctions among the varieties of colorectal polyps and their

management11. learn the principles of chemotherapy for gastrointestinal cancer and radiation

treatment of early and advanced tumors12. understand the initial management of patients in whom the diagnosis of

gastrointestinal cancer has been made13. understand how to counsel patients who have had gastrointestinal neoplasia and

how to manage patients who have positive family histories of gastrointestinal cancer

14. understand the principles and importance of genetic counseling as it pertains to genetic testing and the management of inherited gastrointestinal diseases

15. familiarity with the prognoses associated with different types of gastrointestinal cancer

16. familiarity with the technical considerations in the therapy of colorectal adenomas and carcinomas

17. become thoroughly experienced in colonoscopic polypectomy of pedunculated and sessile polyps and ablative therapies for sessile lesions

18. understand the capabilities and limitations of endoscopic mucosectomy for early gastrointestinal cancer

19. familiarity with the appropriate surveillance and surveillance interval for patients at high risk for developing cancer and those in whom premalignant epithelium has already been detected

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20. selected individuals should obtain experience in placement of endoscopic stents, laser ablation, photodynamic therapy, endoscopic ultrasound, fine needle aspiration of tumors, endoscopic mucosectomy and endoscopic celiac ganglion block for patients with pancreatic cancer.

Training Process

Throughout the training process, trainees should participate in the screening, diagnosis and management of all types of gastrointestinal malignancies. Lectures in molecular and cellular biology as well as clinical oncology and screening, treatment and palliation of gastrointestinal cancer should be included in the core curriculum. Lectures are sought from interventional endoscopists, oncological surgeons, medical oncologists, radiation oncologists and a medical geneticists.

Lectures are provided in the following:

1. changes in screening and surveillance recommendations2. the evolution of genetic testing and counseling for FAP, HNPCC and other

familial forms of gastrointestinal cancer3. novel approaches to the diagnosis of gastrointestinal cancer, including endoscopic

approaches, radiological approaches, nuclear medicine, ultrasound/endoscopic ultrasound and new genetic techniques

4. staging of gastrointestinal cancer, management options and prognostication5. techniques used in the basic science investigation of gastrointestinal cancer,

including flow cytometry, polymerase chain reaction assays, mutation analysis, DNA sequencing and linkage analysis

Endoscopic training in the diagnosis and management of gastrointestinal cancer is required. Recommendations for the duration and frequency of procedures are noted in the section on procedures. Areas that are relevant to gastrointestinal malignancy that require specific attention include:1. endoscopic management of Barrett’s esophagus2. familiarity and at least limited experience with the indications techniques, and

management implication of laser therapy and stents for palliating esophageal cancers

3. the management of upper gastrointestinal neoplasia in FAP, including the management of gastric, duodenal and periampullary lesions

4. the endoscopic management of gastric remnants following Billroth I and II surgery

5. recognition of neoplasia in the pancreaticobiliary tree6. familiarity and at least limited experience with the indications, techniques and

management implications of therapeutic endoscopic retrograde cholangiopancreatography for pancreatic and biliary cancers

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7. proper technique for polypectomy for pedunculated and sessile polyps, including saline injection

8. management of the diminutive adenomatous polyp9. surveillance of the colon in IBD, including considerations for normal-appearing

mucosa and abnormal-appearing mucosa10. recognition of anal cancer lesions with the use of the anoscope

Gastroenterology trainees should become familiar with the appearance of cancer by using the following diagnostic techniques

Radiological1. gastrointestinal cancer on barium upper gastrointestinal series2. gastrointestinal cancer on barium enema3. pancreatic and hepatic cancers on computed tomographic scans and magnetic

resonance imaging4. pancreaticobiliary cancer on endoscopic retrograde cholangiopancreatography

Pathological1. identification of adenoma, adenocarcinoma and hyperplastic and other

nonneoplastic polyps2. recognition of the depth of invasion of cancer in the polyp or into the wall of the

colon and its significance3. recognition of dysplasia vs. reactive changes in IBD4. recognition of Barrett’s epithelium and dysplastic change in Barrett’s mucosa5. recognition of intestinal metaplasia and atrophy in the stomach6. recognition of neuroendocrine and stromal cell tumors of the gastrointestinal tract

Certain trainees may elect to receive additional training in advanced endoscopic procedures. These procedures will be reserved for those who wish to spend the time to master these techniques. These procedures include the following:1. endoscopic ultrasound of the esophagus, stomach, duodenum and rectum2. dilating, stenting and tissue sampling of the esophagus and biliary and pancreatic

tree3. ablative therapy of neoplasms using laser4. photodynamic treatment of epithelial neoplasia in Barrett’s esophagus5. fine-needle aspiration of masses in the liver and pancreas

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TASK FORCE ON TRAINING IN HEPATOLOGY

The faculty should have at least one individual recognized to posses advanced expertise in liver disease, including continued productivity in clinical or basic research related to hepatology. Hepatology training should be an integral component of the subspecialty fellowship with approximately 30% of the 18 clinical months dedicated to hepatology training. This training should be divided between the management of inpatients with a variety of hepatic disorders and the treatment of outpatients with liver disease. The trainees should have experience in the evaluation of patients for liver transplantation. There should be opportunities for trainees to become familiar with the referral and management of liver transplant patients. Opportunities should be available for clinical and/or laboratory research in liver diseases. There should be regularly scheduled conferences that include didactic lectures, literature reviews, and research seminars.

Goals of training

All training programs must provide trainees with a broad knowledge of the physiology of the liver and a thorough knowledge of the management of patient with hepatobiliary diseases. This program requires that the trainee provides the following:

1. significant fund of knowledge about genetic markers of liver disease, immunology, virology, and other pathophysiological mechanism of liver injury; the basic biology and pathobiology of the liver and biliary systems as well as a thorough understanding of the diagnostic and treatment of a broad range of hepatobiliary disorders

2. skill in the performance of a limited number of diagnostic and therapeutic procedures

3. an appreciation of the indications and use of a number of diagnostic and therapeutic procedures that are needed to manage hepatobiliary disorders

Comprehensive teaching of the following subjects occurs1. biology and pathobiology of the liver 2. diagnosis and management of patients with the wide variety of disease of the liver

and biliary tract systems, includinga. acute hepatitis: viral, drug, toxicb. fulminant hepatic failure, including the management of cerebral edema,

coagulopathy and other complications associated with acute hepatic failurec. recognition and diagnosis of chronic hepatitis and cirrhosis,; chemical,

biochemical, serological, and histopathologic diagnosis of chronic viral hepatitis

d. complications of liver disease; ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, hepatorenal syndrome, prevention and treatment of bleeding esophageal varices and gastropathy, diagnosis and treatment of hepatocellular carcinoma

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e. diagnosis and treatment of nonviral causes of chronic liver disease, such as alcohol, nonalcoholic fatty liver disease (including nonalcoholic steatohepatitis), Wilson’s disease, primary biliary cirrhosis, autoimmune hepatitis, hemochromatosis and a-1-antitrypsin deficiency

f. gallstone disease, including the appropriate use of medical and surgical therapies

g. hepatobiliary disorders associated the pregnancyh. preoperative evaluation and postoperative management of patient with

defined diseases of the liver or evidence of hepatobiliary dysfunction

3. use of antiviral and immunosuppressive agents in the treatment of liver disease4. selection and care of patients awaiting and following liver transplantation,

including the assessment of patients with alcoholic liver disease for transplantation, recognition of alcohol dependence and an understanding of the use of immunosuppressive agents; diagnosis and management of rejection and recognition of other complications of transplantation, such as certain infections and biliary tract and vascular problems.

5. Management of the nutritional problems associated with chronic liver disease.6. An understanding of the principle of experimental design, clinical biostatistics

and epidemiology sufficient to critically interpret the medical literature7. Pediatric and congenital hepatobiliary disorders8. Liver pathology, including histological interpretation and specific pathological

techniques9. Liver imaging modalities including interpretation of computed tomography,

magnetic resonance-based techniques (magnetic resonance imaging, magnetic resonance angiography, magnetic resonance cholangiography), hepatic angiography and ultrasound (including Doppler evaluation of hepatic vasculature). The limitation of each modality should be understood.

Procedural skills

Trainees must acquire competence in the performance of 1. percutaneous liver biopsy (minimum 20)2. diagnostic and therapeutic paracentesis (minimum 20)

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TASK FORCE ON TRAINING IN GASTROINTESTINAL ENDOSCOPY

Goals of Training

Trainees will have achieved:1. the ability to recommend endoscopic procedures based on findings from personal

consultations and in consideration of specific indications, contraindications, and diagnostic/therapeutic alternatives

2. the ability to perform a specific procedures safely, completely and expeditiously3. the ability to interpret most endoscopic findings correctly4. the ability to integrate endoscopic findings or therapy into patient management

plan5. the ability to understand the risk factors attendant to endoscopic procedures and to

be able to recognize and manage complication6. the ability to recognize personal and procedural limits and to know when to

request assistance

Procedures goalsOutlined in the Curriculum Requirement section.

Training process

All trainees should 1. have an understanding of indications, limitations, complications and medical and

surgical implications of the findings of medical and surgical implications of the findings of gastrointestinal endoscopy

2. have an understanding of the underlying pathophysiology of gastrointestinal disease and the ability to interpret the endoscopic findings

3. participate in the performance of endoscopic procedures as part of the continuing care of patients.

4. Participate in the performance of endoscopic procedures with staff gastroenterologists or surgeons knowledgeable in the indication for and the technique of performing the procedures as well as the method of recording the results of the procedures and clinical significance of the findings.

5. Develop an understanding of the essential components of patient safety during endoscopic procedures, including the intravenous administration of medications that produce sedation and analgesia and the application and interpretation of noninvasive patient monitoring devices.

6. Become familiar with the care, cleaning and proper maintenance of endoscopy equipment.

7. Develop the capability of independently performing routine endoscopic procedures including specific therapeutic maneuvers (i.e. polypectomy, hemostasis) when indicated.

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PERFORMANCE CRITERIA FOR EVALUATION OF DIAGNOSTIC GASTROINTESTINAL ENDOSCOPYProcedure Performance Criteria

Esophagogastroduodenoscopy (EGD) Esophageal intubation

Pyloric intubationColonoscopy Navigation through sigmoid colon

Intubation of splenic flexure

Intubation of the hepatic flexure

Intubation of cecum

Intubation of terminal ileum (desirable

skill)

Retroflexion in the rectumSigmoidoscopy Navigation through the sigmoid colon

Visualization of the splenic flexure

Retroflexion in the rectumEndoscopic retrograde cholangiopancreatography(ERCP)

Cannulation of the desired duct

Opacification of the desired duct

Sphincterotomy

Stent placement

Stone extractionEndoscopic ultrasonography Intubation of esophagus

Intubation of pylorus

Imaging of desired organ and/or lesion

Successful lesion biopsy

Tumor staging in agreement with the surgical findings and similar to that reported in the literature

All procedures Accurate recognition of normal and abnormal findings

Development of appropriate endoscopic/medical treatment in response to these findings

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Guidelines for Endoscopic Training: Parameters of Competency

16. reviews records, x-rays, identified risk factors17. understands and discusses appropriate alternative procedures18. correctly identified indication, knows how the endoscopic procedure may

influence management19. obtains appropriate informed consent20. demonstrates proper use of premedication and noninvasive patient monitoring

devices21. inserts the endoscope using proper technique22. performs procedure with attention to patient comfort and safety23. correctly identified landmarks24. conducts thorough examination of the entire organ25. detects and identifies all significant pathology26. completes examination within a reasonable time27. prepares an accurate report28. plans correct management and disposition29. discusses findings with patient and other physicians30. conducts proper follow-up, review of pathology, case outcome

Assessment of Competence

Objective criteria based upon parameters developed to assess competency should be used. Judgment as well as interpretive and technical skills must be evaluated. Regular ongoing feedback is essential. All trainees should be observed regularly by supervisors. Faculty members should substantiate the trainees’ competence. The program director should document the competency of all gastroenterology trainees. A logbook of procedures should be maintained by all trainees.

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TASK FORCE ON TRAINING IN NUTRITION

Goals of training

It is important for the trainees to understand:1. basic principles of nutrient requirements, ingestion, digestion, absorption and

metabolism in health and gastrointestinal diseases2. assessment of nutritional status, including specific nutrient deficiencies and

excesses, protein-energy malnutrition and obesity3. metabolic response to starvation and the pathophysiological effects of

undernutrition4. metabolic response to illness and injury and nutrient requirements during stress

states5. indications for nutritional support6. implementation and management of nutritional therapy including modified diets,

enteral tube feeding and parenteral nutrition7. pathophysiology and clinical management of obesity8. ethical and legal issues involved in providing and withdrawing nutritional support

Training process

1. didactic lectures, case conferences, selected readings, clinical experience 2. involved in providing enteral and parenteral nutrition support to hospitalized patients,

including those in intensive care units and nutritional management of outpatients3. clinical experience can include rotation on an inpatient nutrition support service,

experience on other inpatient services and participation in an outpatient clinic that involves nutritional counseling

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TASK FORCE ON TRAINING IN PEDIATRIC GASTROENTEROLOGY

Goals of Training

Trainees in adult gastroenterology should 1. appreciate the unique aspects of the field with an increased awareness of the

clinical problems of pediatric gastroenterology. (The goal is not to develop competence because pediatric gastroenterology is a recognized field of pediatrics.)

2. be prepared to participate in limited scope of care when in underserved areas in which pediatric gastroenterology consultative services are not available.

Curriculum will include1. age-related physiological and psychological variables of children and adults2. unique aspects of the disease in pediatric vs. adult patients 3. manifestation of commonly encountered entities (i.e. abdominal pain,

constipation, gastrointestinal bleeding, diarrhea, cystic fibrosis)

Training process1. clinical conference in which a pediatric cases are discussed2. potential for limited experience with pediatric gastroenterology service 3. visiting professorship of a pediatric gastroenterologist

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TASK FORCE ON TRAINING IN GASTROINTESTINAL AND HEPATIC PATHOLOGY

Goals of Training

Trainees should:1. appreciate the spectrum of normal histology2. learn to recognize patterns of histopathologic change in gastrointestinal and

hepatic disorders3. learn optimal biopsy technique and submit adequate samples4. learn to describe endoscopic findings and clinical information to aid the

pathologist interpretation of biopsy specimens5. be able to recognize when a biopsy can or cannot help in investigation or

management6. be familiar with the clinical implications of the pathological findings in biopsy

and in surgical specimens7. know the value and limitation of exfoliative and aspiration cytology 8. understand the mechanism and the usefulness of new techniques, such as flow

cytometry, immunohistochemistry and tests based on molecular biology (i.e. PCR, in situ hybridization)

9. have an overview of special techniques and special stains as diagnostic aids in gastrointestinal and hepatic pathology (in situ hybridization, immunohistochemistry, etc.)

10. be familiar with recognition of unusual pediatric liver diseases, recognition of opportunistic infections with HIV, graft-vs.-host disease and the submission of biliary biopsy specimens for detection of cholangiocarcinoma or other bile duct changes

11. recognize the usefulness and limitations of endoscopic biopsy in distinguishing different forms of microscopic colitis

12. understand the approaches to, timing of, flaws, and risks and benefits of dysplasia surveillance in chronic inflammatory diseases of the gastrointestinal tract

13. recognize when gastric biopsy is appropriate in management of upper gastrointestinal disorders, the appropriate sites for biopsy and when pursuing endoscopic biopsies is indicated.

Training Process

1. multidisciplinary conferences with gastroenterologists and pathologist weekly or biweekly o review specimens

2. rotation with pathologist for developing an understanding of handling and interpretation of gastrointestinal, endoscopic and liver biopsy specimens

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TASK FORCE ON TRAINING IN GASTROINTESTINAL RADIOLOGY

Goals of Training

Trainees should be able to:1. recognize normal anatomy of the alimentary tract and related organs2. achieve a basic knowledge of gastrointestinal pathology as demonstrated by plain

film radiography, barium studies, computed tomography, ultrasound, magnetic resonance imaging, gastrointestinal vascular and interventional studies, scintigraphy and positron emission transaxial tomography (PET)

3. develop and understanding of the logical sequence of using these techniques in the evaluation of gastrointestinal problems

4. have an appreciation for and understanding of the costs for different radiological studies

5. have an understanding of the indications and contraindications for radiological interventional studies.

Training Process

1. participation in work rounds on individual patients which is integral to routine patient care

2. exposure at weekly conference that include a review of radiographic imaging studies in relating to gastrointestinal disease

3. self-instruction programs in gastrointestinal radiology4. defined rotations on a radiology service

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TASK FORCE IN TRAINING IN SURGERY

Trainees in gastroenterology must learn about the indications and contraindications for surgical treatment and the general principles of the surgical procedures that may be used. Trainees should learn about the expected outcomes of operations that are likely to be performed on their patients and be prepared to care for patients post-operatively as appropriate.

Goals of Training

Trainees should:1. learn the way that surgical procedures are conducted2. should be thoroughly knowledgeable about the postoperative care of patients after

major and minor surgical procedures3. should learn the indications and contraindications for a variety of common operations

for gastrointestinal disorders4. be able to judge whether surgery is necessary and what kind of operation is indicated

and when it should be performed5. be familiar with common complications and their management6. be familiar with long-term consequences of surgical treatment of gastrointestinal

diseases7. be knowledgeable about esophageal procedures, surgery of the gastrointestinal tract

and liver malignancies8. be knowledgeable about surgical vs. endoscopic vs. interventional radiology

procedure and when to pursue specific techniques

Specific procedures with which the trainees should be familiar include1. antireflux procedures2. ulcer operations3. hepatobiliary operations4. portosystemic shunts5. hepatic transplantation6. pancreatic procedures for benign and malignant disease7. surgery for BID of the small and large bowel8. colonic procedures for diverticular disease or cancer9. various anorectal operations10. laparoscopic vs. open procedures

Training Process

Lectures constitute a convenient method of conveying knowledge about surgical procedures and a systematic series of lectures organized by organ or disease process ensures comprehensive coverage. Participation by trainees in joint medical-surgical conferences to discuss specific patients is mandatory. Personal learning through literature searches is an essential element in this effort.

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Trainees are encouraged to go to the operating room when their patients are undergoing surgical procedures. Observation of gross pathological abnormalities will help trainees correlate preoperative information with operative findings. Trainees also will gain an appreciation of the conduct of operations, the factors entering into surgical judgment and the recognition and management of postoperative complications. Rotation with the gastrointestinal surgical team can aid in advancing knowledge about gastrointestinal surgery.

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TASK FORCE ON TRAINING IN GASTROINTESTINAL CELLULAR AND MOLECULAR PHYSIOLOGY

The field of gastroenterology requires and understanding of cellular, molecular and genetic mechanisms underlying normal physiology, including proliferation, differentiation and programmed cell death (apoptosis). The importance of the multiple specialized tissues that encompass gastrointestinal function, ranging from the musculature to the gut brain, the splanchnic circulation, the endocrine system, the gut immune system, and the epithelia should be emphasized.

Goals of training

Trainees will 1. Gain exposure to a variety of disciplines, including immunology, genetics,

physiology, pharmacology, biochemistry and pathology. 2. Develop an operational understanding of technology as well as information on

cellular and subcellular structure and function. 3. Develop the capacity to understand and interpret the relevant literature as well as to

comprehend and study future developments4. Be able to search and critically analyze fundamental scientific information from

appropriate national and international scientific organizations.

General concepts

Molecular biology

The trainees should understand1. the function of the gene and chromosome and their location, composition, and the

mechanisms regulating their replication2. genomic organization, including the function of the promotor region, introns, exons

and untranslated regions, and mechanisms regulating the expression of this information, including transcription, messenger RNA synthesis, translation, and protein synthesis

3. the importance of genetic variability, including single nucleotide polymorphisms and other chromosomal aberrations, particularly as they apply to diagnostics and therapeutics

4. the molecular processes responsible for maintaining genetic fidelity, such as proofreading and repair enzymes, and the consequences of their failure, including malignant degeneration

5. the basic cellular mechanisms regulating cell proliferation and differentiation and cellular demise, including those of apoptosis and necrosis

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Genetics

The trainees should understand1. genetic polymorphisms, genetic defects, the genetic basis of gastrointestinal diseases

such as hemochromatosis, familial pancreatitis, MEN-1, and colon cancer; the gene mutations involved; and the nature of human gene mutation

2. oncogenes, tumor suppressor genes, microsatellite instability, genomic imprinting, chromosomal rearrangements, gene amplification, and their roles in altered cell growth

3. the genetics of colon cancer so that information can be used to identify individual patients at risk, guide diagnostic and therapeutic interventions in specific patients and their families, and provide guidance, counseling, and answers to questions from patients and their families

Cell biology

The trainees should understand1. the basic subcellular constituents of the cell such as the nuclear, mitochondria, golgi,

endoplasmic reticulum and lysosomes, along with their normal functions and alterations in disease.

2. The normal control of the cell cycle and processes leading to its disruption3. The fundamental properties of cell types specific to and crucial to the operation of the

gastrointestinal tract. This includes an understanding of the turnover of the gastrointestinal epithelium and the need for continuous differentiation from stem cells located within each specific tissue and/or organs comprising the gastrointestinal tract as well as the processes regulating normal tissue differentiation and organogenesis

4. The epithelial layer as a modulator of vectorial transport and as critical barrier against toxins and pathogens

5. The functional organization of the enteric nervous system, the network of neurons embedded within the gastrointestinal wall controlling gastrointestinal function, and the extrinsic neurons (afferent and efferent) that contribute to the modulation of digestive functions. Segmental differences down the cephalocaudal axis critical to function as well as specialized regulatory cells such as the interstitial cells of Cajal also must be understood.

Pharmacology and cellular signaling

Trainees should recognize1. basic receptor pharmacology, including regulation, trafficking, and signaling as well

as receptor transport mechanisms, cellular transduction and cell-to-cell signaling2. the existence of different superfamilies of receptors including ion-channel gated G

protein coupled, and tyrosine kinase-activating receptors, along with the different mechanisms by which second messengers are activated to induce a functional response

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3. the rapidly growing field of cellular signal transduction as a mechanism underpinning critical regulatory processes in health and disease. These include cell-matrix communication, important in host defense; cell-cell communication, important in tissue responses; and intracellular pathways critical for cell homeostasis that, when disturbed, can cause unregulated growth or premature cell death

4. the existence of numerous transmitters and modulators synthesized and released by neurons innervating the digestive system, including classical transmitters such as acetylcholine and noradrenaline as well as slow transmitters/modulators such as peptides.

5. The existence and importance of the endocrine system that is scattered throughout the digestive tract and that are often expresses the same chemical messengers as neurons

6. The disparate mechanism by which different chemical messengers are released and reach their sites of action, including endocrine, neuroendocrine, and paracrine mechanisms of action. Trainees should develop a basic understanding of hormones and of neurotransmitters and their specific receptors as they relate to the gastrointestinal tract.

7. The roles of nitric oxide and NO synthase in cellular physiological events and their implications related to gastrointestinal physiology and pathophysiology as well as the NO pathway in inflammation and splanchnic circulation

Host-environment interactions

Trainees should have an understanding of1. the factors permitting the existence of commensal organisms and their contribution to

maintaining host health as well as the processes whereby pathogenic organisms are recognized and by which they induce a host response

2. the cellular and molecular biology underlying important infections, including H. pylori

3. basic virology so that current infections, including the many cases of hepatitis, as well as future disorders can be appreciated.

Immunology

Trainees should have an understanding of1. the gut-associated immune system, its distinct differences from systemic

immunology, and the implications of this in understanding gastrointestinal physiology and pathophysiology. This includes an understanding of the roles of a variety of mediators and modifiers of the inflammatory process, including cytokines and chemokines and other related molecular species

2. autoimmune disease and the markers for immune-mediated gastrointestinal diseases3. basic transplantation biology, including the processes leading to and permitting the

development of critical disorders such as graft-versus-host disease

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Technologies

Technical advances have played a critical role in allowing bench-to-bedside transfer of technology. A basic understanding of many critical technologies should be included in the educational curriculum. These technologies should include

1. Genetic screening techniques: A fundamental understanding of genetics required to apply genetic screening techniques effectively

2. Principles of polymerase chain reaction: Understanding the technology as well as its utility, limitations, applications, and diagnostic and information acquisition potential

3. Microarray technology: Understanding the methodology, present and projected applications, and limitations

4. Recombinant technology: Understanding the techniques and applications of development of recombinant human proteins and peptides for their therapeutic and diagnostic applications

5. Antibody methodology: Understanding techniques involved in creation of hybridomas and the potential application of monoclonal antibodies obtained using this technique. Also, an understanding of the theory and practical use of humanized chimeric monoclonal antibodies because of their present and future applications for diagnosis and management of patients.

6. Cell sorting technology / flow cytometry: Understanding the basis of these techniques and their potential applications to distinguish among specific cell types.

7. Detection of cell markers: Understanding methodologies ranging from microscopic, nucleic acid hybridization, immunodetection methods to enzymatic assays, used to identify cell markers. Application of such technologies to distinguish the various populations of cells involved in inflammatory and neoplastic processes. The limitations of these immunological and biochemical detection methods in sorting out information regarding specific disease processes.

8. New technologies. An understanding of rapidly developing technologies, including phage display technology, filamentous phage biology, and applications form the nascent fields of genomics and protenomics.

9. Information acquisition: Understanding the acquisition of information in molecular biology or as it pertains to gastroenterology, both now and in the future, via the Internet.

Training Process

The experience, training and acquisition of information for trainees can be provided in a variety of ways, which are not mutually exclusive. The methods of training can include:

1. Specific lectures dedicated to conveying information regarding the topics2. Appropriate readings and instructional materials with discussion seminars (i.e. journal

club)3. Conferences and lectures at local or national meetings

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4. Seminar-type courses that focus on the cellular and molecular basis of gastrointestinal physiology

5. Personal instruction and questioning of trainees during the diagnosis and management of patients

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TASK FORCE ON TRAINING IN GERIATRIC GASTROENTEROLOGY

Geriatric training in gastroenterology can be divided into 2 broad categories1. General geriatric issues that need to be addressed include the impact of age on patient

communication, family and social support, and presentation of disease2. Geriatric gastroenterology deals with the impact of age on presentation, diagnosis and

treatment of common and important gastrointestinal conditions in the elderly. An important feature of this training is the ability to recognize the effect of age on pathophysiology and response to treatment

General Geriatric Issues

1. Pathophysiology of aging: Obtain an overview of the current concepts and models of aging, with particular emphasis on the gastrointestinal tract.

2. Demographics and epidemiology of aging: An understanding of the impact of aging on the epidemiology of gastrointestinal disease, health care delivery and the issues of costs and resources

3. Impact of common geriatric disorders on gastroenterology: Develop an understanding of the impact of common diseases, such as depression and dementia, on the presentation and evaluation of gastrointestinal disease. Able to assess the patients’ ability to follow a treatment plan, with emphasis on the effect of cognitive impairment on management of gastrointestinal problems

4. Social and ethical issues in aging: Able to asses the patients’ levels of dependence on external psychosocial support from family, friends and organizations as part of the treatment plan and should be aware of the importance of appropriate communication with the patients’ families (or equivalent). Trainees should be aware of common signs and symptoms of abuse and have a basic knowledge of community resources available for intervention in cases of abuse, neglect, and caregiver stress. Trainees should develop an understanding of the special needs of frail older individuals, including ethical issues concerning the risk-to-benefit ratio of the investigation and treatment of disease as well as end-of-life issues.

Geriatric Gastroenterology

1. Changes in gastrointestinal function with aging: Trainees should be aware of the normal or expected changes in the physiology of the gut, pancreas, and liver that occur with aging. These include swallowing disorders due to a variety of aging-associated changes in oropharyngeal and esophageal motility, impaired gastric motility and acid secretion, changes in hepatic metabolism, slowing of colonic motility and rectal dysfunction. There should be a familiarity with the normal range of laboratory data in the elderly.

2. Changes in drug metabolism with aging: Trainees must have an appreciation of the changes in drug metabolism, particularly in the liver, which occur with aging. Trainees should be able to identify and anticipate side effects and interactions of

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medications used for the management of gastrointestinal disorders in the geriatric population

3. Gastrointestinal effects of drugs: Trainees should have an appreciation for the presentation and differential diagnosis of gastrointestinal side effects of commonly prescribed drugs in older individuals. These include drugs with significant symptoms or effects on gastrointestinal motility, including neuroleptics, antihistamines, antidepressants, antiarrhythmic agents, and antihypertensive agents (i.e. calcium channel antagonists).

4. Effects of aging on nutrition: Trainees should be able to discover malnutrition in the geriatric age group with an awareness of the common disorders resulting from inadequate intake of nutrients (including vitamin deficiencies). There should be a recognition that adaptation of food intake to illness or abrupt changes in physiology is impaired or delayed in older individuals. Trainees should be taught age-appropriate strategies for fluid and nutritional replacement in inpatient and outpatient settings. There should be an appreciation of the presentation of anorexia, obesity and eating disorders in older individuals. The ethical and treatment issues of feeding tube placement should be covered with particular emphasis on risks and benefits in frail and demented patients.

5. Common gastrointestinal conditions in the elderly: Trainees should be familiar with the presentation and pathophysiology of common gastrointestinal diseases in the elderly, including dysmotility syndromes affecting oropharynx, stomach and colon. Trainees should also be aware of malabsorption, gastrointestinal bleeding, and oncologic diseases in older patients and they should be aware of the prevalence, diagnosis and treatment. Appropriate management of common disorders in the elderly should be reviewed, as it may be different in the elderly patient. There should also be an understanding of the diagnosis and management of common gastrointestinal problems in institutionalized and bedridden geriatric individuals.

6. Effective strategies for inpatient and outpatient management. Trainees should be able to assess the severity and emergent natures o f gastrointestinal complaints in the elderly in inpatient and outpatient settings. Appropriate strategies for fluid/volume assessment and management in the elderly should be appreciated. There should also be an understanding of the subtle and misleadingly benign presentation of acute abdominal conditions in frail older patients and an understanding of the need for early surgical referral if appropriate.

Training Process

Trainees knowledge should be obtained through a variety of experiences1. Didactic lectures (including CD-ROM and Internet-based programs), case

presentations, group discussions and seminars, clinical bedside teaching and individualized teaching

2. Clinical experience provided primarily by interaction with consultants in both gastroenterology and geriatric medicine.

3. Clinical exposure should include both outpatient and inpatient geriatric settings

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TASK FORCE ON TRAINING IN WOMEN’S HEALTH ISSUES IN DIGESTIVE DISEASES

Women’s health issues and awareness of gender differences should be incorporated into the overall gastroenterology fellowship. The patient population cared for by trainees should include a minimum of 25% women. There are three broad categories of women’s health that should be included in the curriculum. These categories are general women’s health issues, specific digestive diseases and women’s health issues, and pregnancy and childbearing issues.

Goals of training

General Women’s Health Issues

1. Doctor-patient relationship: Development of an understanding of gender differences as they pertain to the doctor-patient relationship

2. Cultural and religious issues: The cultural and religious difference between men and women and the manner in which health care is both perceived and sought and with which recommendations or complied should be appreciated.

3. Psychosocial issues: Trainees should understand psychosocial issues both as initiating factors in certain disease states in women and as their contribution to ongoing clinical symptoms and pathology and their impact on evaluation and treatment. Patient should be able to elicit information about abuse and understand their consequences upon gastrointestinal issues. Trainees should be able to develop empathy for the special needs of women.

4. Laboratory values and diagnostic tests: Trainees should recognize that there are gender differences as well as changes during pregnancy in normal laboratory values, including liver tests, hematocrit, and creatinine values. They should recognize anatomic gender differences on diagnostic tests and changes in women with age and pregnancy.

5. Disease presentation and physician visits: Trainees should recognize gender differences in disease presentation as well as different thresholds between women and men in seeking medical care. In addition, there are differences in thresholds for pain perception in difference disease states as well as among individual patients.

6. Complementary and alternative medicine: Trainees should be able to elicit a history of the use of complementary and alternative medicine during the routine examination and be aware of the potential impact upon health and disease, as well as the potential complications of some herbal remedies.

Specific Digestive Diseases and Women’s Health Issues

1. Health and disease states in women: Trainees should understand the presentation and pathophysiology of all gastrointestinal and hepatic disease in both women and men. There should be an awareness of gender differences in demographics and

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epidemiology and pathophysiology of many gastrointestinal and hepatic diseases. There should be an awareness of gender differences in demographics, epidemiology and pathophysiology of many gastrointestinal tract and liver disorders. Trainees should understand the psychosocial impact on many of the gastrointestinal disorders as well as the effect that chronic disease has on a women’s daily life and that an effective treatment plan often includes a multidisciplinary approach.

2. The effect of the menstrual cycle and menopause on digestive disease function in health and disease: Trainees should understand the effect of the menstrual cycle and menopause on gastrointestinal tract and liver function in both health and disease. This includes and understanding of estrogen and progesterone and the role of these and other hormones have on gastrointestinal tract and liver function.

3. Gender differences in the pharmacokinetics of medications: Trainees should recognize and understand gender differences in medication pharmacokinetics, differences in the prolongation of QT intervals, differences in metabolism of certain medications and differences in the therapeutic response. There should be an appreciation of potential side effects, complications and interactions of medications that are used for the management of gastrointestinal and liver disease in women.

Pregnancy and childbearing issues

1. Fertility and infertility: Trainees should be cognizant of the issues regarding fertility and pregnancy and be able to appropriately advise women with gastrointestinal and liver disorders who desire pregnancy. There should be a basic knowledge of genetics as it pertains to the gastrointestinal tract and liver disorders and the risk to the women’s unborn infants.

2. Pregnancy: Trainees should become knowledgeable about the following:a. Gastrointestinal and liver changes and disorders in normal pregnancyb. Effect of preexisting gastrointestinal and liver disorders on pregnancyc. The initial clinical presentation during pregnancy of a gastrointestinal or liver

disorderd. Gastrointestinal and liver disorders that are unique to pregnancy, including acute

fatty liver of pregnancy and HELLP syndromee. The impact of gastrointestinal and liver disorders on a woman’s ability to carry a

healthy baby to term as well as the impact of her pregnancy on her gastrointestinal liver disorder

f. The risk of maternal-fetal transmission of infectious agents, such as hepatitis B and hepatitis C, and the appropriate treatment of both the mother and the newborn infant

g. The different pharmacokinetics and interaction of medications during pregnancy and breast feeding

h. The potential harm to the fetus of medications, sedation, endoscopic procedures, and diagnostic tests, including radiographic tests, and the appropriate use of these during pregnancy

i. Good nutrition, including increased vitamin and mineral requirements during pregnancy

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3. Postpartum issues: Trainees should understand that there are gastrointestinal disorders that are caused or affected by delivery and that manifest themselves immediately in the postpartum period or years afterward that the trainees should be able to recognize (i.e. rectal prolapse, urinary and/or fecal incontinence, hemorrhoids).

Training Process

Trainees knowledge should be obtained through a variety of experiences, including didactic lectures (which can include CD-ROM and Internet-based programs), case conferences, self-directed learning, selected readings and clinical experiences.

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APPENDIXContents

ASGE first year Endoscopy CourseBoard Review CourseWalter Reed Gastroenterology CourseGME fellow seminar scheduleOrientation agenda

NeedEvaluation formsOrientation manualDiscussion with prior fellowsLiver curriculum

Meeting with FairfaxFellows application for Fairfax rotation

Fellow Rotation scheduleFaculty lecture scheduleClinic scheduleCall schedule

Check document for GI resident vs. fellow (consistency in citing throughout document)

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FELLOW CLINIC SCHEDULE

CLINIC SCHEDULEMonday Tuesday Wednesday Thursday Friday

Inflammatory Bowel DiseaseBorum

Liver DiseaseBorum

General GIEhrlich

General GIBorum

Inflammatory Bowel DiseaseGinsberg

Biliary Disease / MotilityNsien

General GI / Biliary DiseaseBashir

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