10-07.doc

GI FELLOW CURRICULUM:

Rotation Goals and Responsibilities

GI Hospital ServiceCurriculum for Year I, II & III Fellows

Educational Purpose:The GI Hospital Service introduces the fellow to inpatient hospital management of patients with gastrointestinal diseases. During this period, the fellow will have the opportunity to assess a wide variety of acute and chronic gastrointestinal conditions. The fellow will participate in increasing levels of management/ treatment involvement with patient needs and procedures, depending on the fellow’s level of experience. The fellow will be expected to formulate the differential diagnosis, institute diagnostic studies and recommend therapy. The amount of learning obtained from this rotation is directly proportional to the amount of time spent in the evaluation of the patients.

Objectives:Fellows will learn all aspects of inpatient gastrointestinal care and will display all general competencies during this experience. Minimum levels of achievement in each competency are expected during each of the three years of fellowship training. Those meeting competency will receive a score of 5 in the program’s evaluation system. Fellows performing at a level better than expected for that competency receive a score of 6 or 7 in the evaluation system, those at a level better than most fellows at that PGY receive an 8, and those performing at a level deemed to be “one of the best fellows ever observed” will receive a score of 9. Fellows receiving a score of 4 or below are deemed deficient in that competency; this will be brought to the attention of the program director immediately, and, if necessary, remediation will be implemented.

The following are the goals and objectives for each competency at each level of training for the GI Hospital Service:

Year I Fellow:

Goal: A Year I fellow should be able to assess new patient problems, formulate and execute a treatment plan with guidance and teach basic gastroenterology skills to medical students and other trainees. Year I fellows should begin to develop basic procedural competencies in diagnostic upper endoscopy and colonoscopy.

Patient Care Objectives: Perform an accurate physical examination and present information concisely with an initial assessment plan.

Follow the patient’s disease course during the patient’s hospital stay. With attending consultation, formulate and execute an impression and a list of recommendations for the primary service. When indicated, consent patients for procedures and order appropriate diagnostic tests (e.g., endoscopy, radiologic tests, etc.) in conjunction with the primary/referring service.

Perform with supervision the following basic gastroenterology procedures (see practicum):o Colonoscopy

By completion of Year I a fellow should be able to perform a diagnostic colonoscopy to the cecum with limited assistance.

o EsophagoGastroDuodenoscopy (EGD or Upper Endoscopy) By completion of Year I a fellow should be able to perform a diagnostic endoscopy to the

second portion of the duodenum. Develop expertise in the diagnosis and management of acute and chronic inpatient gastrointestinal diseases

including:o Upper & lower GI bleedingo Peptic ulcer diseaseo GI infectionso Ischemic colitis.

Learn to provide inpatient care that is safe and compassionate and to develop the ability to thoroughly and clearly educate the inpatient in the relevant areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.

Medical Knowledge Objectives: Attend core conferences and teaching rounds to learn the pathophysiology, epidemiology, disease management

and procedure and medicine management skills for common and uncommon inpatient gastrointestinal diseases including:

o Upper & lower GI bleedingo Peptic ulcer diseaseo GI infections

o Ischemic colitis. Accumulate and begin to solve the issues that he/she encounters from other trainees, attendings and related

medical professionals. Teach medical students the basics of gastroenterology and hepatology care. Achieve an average percentile score of at least 61.18on the “General” section of the in-service Gastroenterology

Training Examination (GTE) exam. This score is the national average on this exam for Year I fellows. By end of Year I, pass the Internal Medicine Board Examination.

Practice-Based Learning Objectives: Become familiar with the concepts of quality improvement. Participate in conferences such as M&M, geared to the programmatic review of adverse events. Begin to review, analyze and utilize scientific evidence from the gastrointestinal literature for the management of

GI patients. Learn the best practice patterns to facilitate gastroenterology care through clinic operating procedures and patient

interactions.

Interpersonal Communication Skill Objectives: Interview patients and family members accurately, patiently and compassionately and present information in an

understandable and compassionate manner. Convey bad news compassionately and honestly. Learn to communicate effectively with staff, peers, attending gastroenterologists, referring physicians and other

consultants.

Professionalism Objectives: Learn to understand and demonstrate professional behavior in daily activities. Participate in professionalism-based learning activities through conferences. Learn to interact collegially with his/her peer group and other healthcare professionals. Learn to practice ethical principles with relation to patient care and confidentiality. Learn to practice appropriate interactions with pharmaceutical representatives and be unbiased in prescribing

habits. Learn to be sensitive to cultural, age, gender and disability issues. Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to

responsible colleagues. Participate in program planning, including annual Faculty Meeting attendance, Fellow Curriculum Committee

participation and Program Director meetings when requested.

Systems-Based Practice Objectives: Attend conferences concerning healthcare system patient management and components of systems of

healthcare. Achieve basic understanding of healthcare systems related to gastroenterology care and overall system activities. Learn proper documentation and billing skills to practice cost-effective care. Develop and become familiar with the e-portfolio system for personal documentation management,

communication with mentors and other collaborators and related fellowship program documentation. Utilize an appropriate range of healthcare professionals to care for patients, working closely with socials services

to maximize patient care and understanding the role of hospice, referring appropriately when needed. Begin involvement to understand the standard operating procedures and quality improvement initiatives within the

hospital. Attend national gastroenterology conferences (e.g., ACG and endoscopy training courses).

Year II Fellow:

Goal: A Year II fellow should learn to assess and care for a larger volume of patients and learn and teach basic textbook and evidence-based medicine to medical students and other trainees. Year II fellows should independently perform diagnostic upper endoscopy and colonoscopy and begin to perform therapeutic maneuvers.

Patient Care Objectives: Complete a time-efficient history and physical examination. Critique the work and orders of Year I fellows. Direct the Year I fellows successfully with the appropriate level of intervention for each trainee’s skills. Complete competency-level performance of the following basic gastroenterology procedures (see practicum

checklist):

o Colonoscopy By completion of Year II, master all Year I colonoscopic skill requirements. Additionally,

perform endoscopic maneuvers, including snare polypectomy and begin to develop competency in control of GI bleeding: sclerotherapy and thermal coagulopathy of bleeding vessels.

o Upper Endoscopy By completion of Year II, master all Year I upper endoscopic skill requirements.

Additionally, begin to develop competency in performing therapeutic maneuvers: banding and sclerosing of varices, and sclerotherapy and thermal coagulopathy of bleeding vessels.

Develop clear expertise in the diagnosis and management of acute and chronic inpatient gastrointestinal diseases including:

o Neuroendocrine diagnosiso Intestinal/colonic pseudobstructiono Secretory diarrheal stateso Idiopathic abdominal paino Upper & lower GI bleedingo Peptic ulcer diseaseo Inflammatory bowel diseaseo GI infectionso Pancreatitiso Ischemic colitis

Present cases succinctly in a direct manner. Know the GI Hospital Service’s patients at a management level. Handle consult calls respectfully and appropriately. Teach good symptom management skills to medical students and other trainees. Provide inpatient care that is safe and compassionate and develop the ability to thoroughly and clearly educate

the inpatient in the relevant areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.

Medical Knowledge Objectives: Begin to take a leadership role at core conferences and teaching rounds regarding the pathophysiology,

epidemiology, disease management and procedures and medicine management skills for common and uncommon inpatient gastrointestinal diseases including:


Organize the team’s performance at teaching rounds. Read textbook and pertinent literature materials concerning problems encountered. Teach medical students and other trainees about GI disease states and patient management. Achieve an average percentile score of at least 62.98 on the “General” section of the in-service Gastroenterology

Training Examination (GTE) exam. This score is the national average on this exam for Year II fellows.

Practice-Based Learning Objectives: Participate in project groups, committees and hospital groups when requested. Participate in programmatic reviews and conferences studying adverse events. Give usable feedback to medical students and other trainees based on observation of their performance and

assess improvement. Participate in problem-based quality improvement projects. Review, analyze and utilize scientific evidence from the gastrointestinal literature for the management of GI

patients.

Know the best practice patterns to facilitate gastroenterology care through clinic operating procedures and patient interactions.


understandable manner. Convey bad news compassionately and honestly. Plan patient and family conferences. Counsel patients about transitioning to palliative care, when needed. Address or refer patients related to spiritual or existential issues. Communicate effectively with staff, peers, attending gastroenterologists, referring physicians and other

consultants. Present cases succinctly, in a problem-based, direct manner. Learn to become a teacher of gastroenterology to junior trainees, medical students and other healthcare

professionals.

Professionalism Objectives: Begin to mentor medical students, other trainees and Year I fellows in professional conduct. Understand and demonstrate professional behavior in daily activities. Participate in professionalism-based learning activities through conferences. Interact collegially with his/her peer group and other healthcare professionals, including acting responsibly in the

larger context of pursuing programmatic successes. Practice ethical principles with relation to patient care and confidentiality. Practice interactions with pharmaceutical representatives and be unbiased in prescribing habits. Practice sensitivity to cultural, age, gender and disability issues. Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to


participation and Program Director meetings, when requested.


healthcare. Understand and be able to work effectively related to hospital functions within UPMC and UPP. Understand and practice proper documentation and billing skills to practice cost-effective care. Use the program’s e-portfolio system for personal documentation management, communication with mentors and

other collaborators and related fellowship program documentation. Assist other trainees in the utilization of appropriate healthcare resources for the best care of the GI Hospital

Service’s patients. Model appropriate interactions in multidisciplinary planning, including standard operating procedures and quality

improvement initiatives. Attend national gastroenterology or hepatology conferences (e.g., DDW or AASLD).

Year III Fellows:

Goal: The senior-level, Year III fellow should demonstrate rapid assessment and planning skills and near-attending level care planning and management, while teaching medical students and other trainees at near to or exceeding attending level teaching. Year III fellows should be able to perform diagnostic and therapeutic upper endoscopy and colonoscopy procedures independently.

Patient Care Objectives: Master the Year II fellow objectives. Demonstrate efficient organization of the GI Hospital Service and a working knowledge of all patients. Demonstrate near-attending level capacity for program assessment and care planning. Attain trainer level proficiency in the following gastroenterology procedures pertinent to his/her career choices:

o Colonoscopy By completion of Year III, master all Year II colonoscopic skill requirements. Additionally,

be able to independently intubate the terminal ileum and begin to develop independent mastery of more advanced maneuvers, e.g., removal of large or complex polyps by saline assisted polypectomy or piecemeal resection and control of bleeding using clips or argon plasma laser coagulation.

o Upper Endoscopy By completion of Year III, master all Year II endoscopic skill requirements. Additionally,

be able to pass a side viewing scope to identify the papilla or lesions difficult to observe with forward viewing scope and perform advanced maneuvers, such as placing clips on bleeding vessels or argon plasma laser coagulopathy.

Secure expertise in the diagnosis and management of acute and chronic inpatient gastrointestinal diseases including:


Provide inpatient care that is safe and compassionate with the leadership ability to thoroughly and clearly educate the inpatient and all other trainees regarding relevant areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.

Medical Knowledge Objectives: Access and critique the medical literature regarding gastroenterology and hepatology problems encountered. Assume the trainee leadership role at core conferences and teaching rounds regarding the pathophysiology,

epidemiology, disease management, procedures and medicine management skills for common and uncommon inpatient gastrointestinal diseases including


Teach medical students, other trainees and Year I & II fellows at near-attending level. Prepare for the ABIM certifying exam throughout the year. Organize team activities in a smooth and authoritative fashion. Assist Year II fellows’ development directly at teaching conferences and indirectly at work sites. Achieve an average percentile score of at least 64.07 on the “General” section of the in-service Gastroenterology

Training Examination (GTE) exam. This score is the national average on this exam for Year III fellows.

Practice-Based Learning Objectives: Demonstrate mastery of Year II fellow skills and encourage participation of colleagues. Review, analyze and utilize scientific evidence from the gastrointestinal literature for the management of GI

patients, taking a leadership role in guiding Year I & II fellows and sharing relevant literature reviews with them. Know and be able to succinctly communicate the best practice patterns to facilitate gastroenterology care through

clinic operating procedures and patient interactions.


understandable manner. Convey bad news compassionately and honestly. Supervise Year I & II fellows’ work related to planning patient/family conferences and patient

communications/counseling. Communicate effectively as a consultant with staff, peers, attending gastroenterologists, referring physicians and

other consultants and lead other trainees related to appropriate fellow-to-medical-professional communications. Present cases succinctly, in a problem-based, direct manner.

Assume the role of a teacher of gastroenterology to junior trainees, medical students and other healthcare professionals.

Professionalism Objectives: Demonstrate proficiency in Year II objectives. Mentor medical students, other trainees and Year I fellows in professional conduct. Assist in formal teaching exercises as requested. Assert leadership in program planning, including fellow participation in the annual Faculty/Fellow Meeting, Fellow

Curriculum Committee and Conference Planning Committees.


healthcare. Assist and mentor other trainees in utilization of appropriate UPMC/UPP healthcare resources for the best care of

the GI Hospital Service’s patients, including proper documentation and billing skills. Use and train others on the program’s e-portfolio system for personal documentation management,

communication with mentors and other collaborators and related fellowship program documentation. Model appropriate interactions in multidisciplinary planning, including improvements related to standard operating

procedures and quality improvement initiatives. Participate in hospital and national medical association committees and multidisciplinary planning groups when

requested. Attend national conferences directed at career goals. Demonstrate near-attending level utilization of overall systems of care.

Teaching Methods:Gastroenterology fellows participate in the GI Hospital Service during all three fellowship years. Two fellows are assigned to the GI Hospital Service during all rotations. Teaching of medical students, residents and other trainees as well as appropriate interactions with other healthcare providers are important aspects of this rotation. Participating in all required conferences is mandatory, and rounding is an integral part of this experience. As fellows gain experience throughout their training, skills of organization and efficiency as well as team leadership become increasingly important.

The GI Hospital Service experience will prepare the fellow to evaluate and manage acute and chronic gastrointestinal illnesses that will be encountered in the fellow’s future practice. This rotation will expose the fellow to a wide variety of acute abdominal inflammatory processes, major gastrointestinal hemorrhages, oncological emergencies and a wide variety of gastrointestinal problems.

Fellows assigned to this service will evaluate all new consults at UPMC Presbyterian and Montefiore Hospitals and will be assigned to a continuity clinic one-half day per week. They will present new consults to the attending by the following day for routine consults and as soon as possible for emergencies. Fellows will evaluate each patient and will make initial recommendations regarding diagnostic tests and treatments. They will make arrangements for studies such as endoscopy, motility tests, biopsies, etc. They will review the appropriateness of the procedure with the attending before making final scheduling plans. The fellow will follow each patient under active consultation on a regular basis, will make further recommendations as indicated and will keep the attending informed of the patient’s status. Fellows must also communicate with the procedure fellow for all diagnostic studies.

Disease Mix:Fellows see a complete mix of gastrointestinal diseases and conditions at the GI Hospital Service’s teaching hospitals. UPMC Presbyterian and UPMC Montefiore have a substantial primary care basis, which provides the entire spectrum of internal medicine diagnoses and gastrointestinal care.

Diagnoses range from pancreatitis, inflammatory bowel disease, and functional GI motility and pain disorders to primary and secondary gastrointestinal malignancies, and there is an appropriate concentration of common gastrointestinal diseases such as peptic ulcer disease, gastroesophageal reflux disease and gastrointestinal infections. In particular, UPMC Presbyterian is a tri-state and international referral center, and there is outstanding diversity of unusual diagnoses in the teaching services.

Patient Characteristics:UPMC Presbyterian and UPMC Montefiore offer a diverse mixes of socioeconomic and gender status. Teaching faculty provide an abundant supply of upper- and middle-class patients, and our contracts with medical assistance and

pro bono care efforts ensure access to lower-income patients. Due to a primary care base simultaneous with the hospitals’ constantly active referrals (complete with helicopter and fixed-wing transport 24/7), patients are seen in both acute status and in diagnostic dilemma status, with both common and uncommon disorders.

Types of Clinical Encounters – Attending Supervision:Encounters are inpatient in nature during the GI Hospital Service. Fellows provide 24/7 consultative care under the supervision of an attending within duty hour limits and with faculty back up for situations of overload. Daily attending supervision is available at both UPMC Presbyterian and UPMC Montefiore seven days per week, and in-house supervision is available all night as well. The attending has ultimate responsibility for patients.

Procedures:During the GI Hospital Service, emergency procedures (e.g. for gastrointestinal bleeding) are performed 24/7 within duty hour limits by the fellow with the attending. Non-emergent procedures are performed during daytime hours in the GI lab by the fellow under the direct supervision of the attending. Procedure based evaluation is performed twice per year by a supervising attending (see procedure practicum: direct observation).

Evaluation:Fellows are evaluated during all GI Hospital Service rotations and are expected to participate in the evaluation of other fellows as well. This occurs in the following forms: Detailed, automated evaluations using the myevaluations.com system are submitted for each rotation. These

evaluations are reflective of the program’s curriculum requirements. Attendings evaluate fellows, and the fellows evaluate the attending as well. Evaluations include:

o 360-degree (attending, nurse, nurse practitioner, staff/clerical, etc.);o Direct observation (Procedure Practicum);o Peer-reviewed; ando Patient.

Evaluation summaries become part of the fellows’ and attendings’ promotional documents. Fellows self-evaluate through their e-portfolio participation/communication with mentors and colleagues and

through document maintenance. The fellow also evaluates the Gastroenterology Fellowship Program annually through a confidential basis. Attendings evaluate the Gastroenterology Fellowship Program annually. A Curriculum Committee oversees major changes to the curriculum. Representative program personnel (i.e.,

program director, representative faculty and at least one fellow) must be organized to review program goals and objectives and the effectiveness with which they are achieved. This group must conduct a formal documented meeting at least annually for this purpose. In the evaluation process, the group must take into consideration written comments from the faculty, the most recent report of the GMEC of the sponsoring institution and the residents’ confidential written evaluations. If deficiencies are found, the group will prepare an explicit plan of action, which should be approved by the faculty and documented in the minutes of the meeting.

The Program Director meets with all fellows individually twice per year. An in-service GTE exam is given to all fellows annually.

Bibliography: Resource Documents

o Up-To-Dateo PubMedo Textbook of Gastroenterology – Yamada, et.al.o Gastrointestinal Diasese: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.o Major Gastroenterology journals online and in the program’s fellow library including

Gastroenterology, American Journal of Gastroenterolgy, Gut, and other major publications.o Required reading for IBD interests:

Xavier RJ, Podolsky DK. Unravelling the pathogenesis of inflammatory bowel disease. Nature 2007;448:427-434

Clark M, Colombel JF, Feagan BC, Fedorak RN, Hanauer SB, Kamm MA, Mayer L, Regueiro C, Rutgeerts P, Sandborn WJ, Sands BE, Schreiber S, Targan S, Travis S, Vermeire S. American gastroenterological association consensus development conference on the use of biologics in the treatment of inflammatory bowel disease, June 21-23, 2006. Gastroenterology. 2007 Jul;133(1):312-39.

Curricular Design o ACGME Outcome Project documentation (from www.acgme.org).

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Vermeire%20S%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Travis%20S%22%5BAuthor%5D&itool=EntrezSystem2.PEntre%0D%0Az.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Targan%20S%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Schreiber%20S%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Sands%20BE%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Rutgeerts%20P%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Regueiro%20C%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Mayer%20L%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Kamm%20MA%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Hanauer%20SB%22%5BAuthor%5D&am%0D%0Ap;itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Fedorak%20RN%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Feagan%20BC%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Colombel%20JF%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Clark%20M%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

o Graduate Education in Internal Medicine: A Resource Guide to Curriculum Developmento The report of the Federated Council for Internal Medicine Task Force on the Internal Medicine

Residency Curriculum, 1997. Pertinent Teaching References:

o Textbook of Gastroenterology – Yamada, et.al.o Gastrointestinal Diasese: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.

Competencies-at-a-GlanceGI Hospital Service

COMPETENCY LEARNING OPPORTUNITY EVALUATIONPatient Care Work Rounds

Teaching Rounds Conferences

360-global evaluations GTE in-service exam Direct Observation

Medical Knowledge Work Rounds Teaching Rounds Conferences

360-global evaluations GTE in-service exam

Practice-Based Learning Quarterly M&M Conference Work Rounds

360-global evaluations E-portfolio procedure

documentation Direct Observation

Interpersonal Skills Work Rounds 360-global evaluationsProfessionalism Work Rounds

Conferences 360-global evaluations E-portfolio self-

documentation

Systems-Based Practice Committee Participation Grand Rounds (GI & Medical) Conferences

360-global evaluations E-portfolio collaboration

documentation

The GI Hospital Service is the core fellow rotation related to the teaching and evaluation of all six competencies. Day-to-day patient care, related teaching and the curriculum conferences during the rotation are the greatest elements that teach the competencies, and the global evaluation (provided for each rotation) is the most important single measurement device. In addition to didactic learning, medical center committee participation is encouraged to bolster system-wide knowledge and practice management understanding.

Updated:December 2005June 2006February 2007

Hepatology Consultative ServiceCurriculum for Year I, II & III Fellows

Educational Purpose:The Hepatology Consultative Service introduces the fellow to inpatient management of patients with liver diseases. During this period, the fellow will have the opportunity to assess a wide variety of acute and chronic hepatology conditions. The fellow will participate in increasing levels of management/ treatment involvement with patient needs and procedures depending on the fellow’s level of experience. The fellow will be expected to formulate the differential diagnosis, institute diagnostic studies and recommend therapy. The amount of learning obtained from this rotation is directly proportional to the amount of time spent in the evaluation of the patients.

Objectives:Fellows will learn all aspects of inpatient liver disease care and will display all general competencies during this experience. Minimum levels of achievement in each competency are expected during each of the three years of fellowship training. Those meeting competency will receive a score of 5 in the program’s evaluation system. Fellows performing at a level better than expected for that competency receive a score of 6 or 7 in the evaluation system, those at a level better than most fellows at that PGY receive an 8, and those performing at a level deemed to be “one of the best fellows ever observed” will receive a score of 9. Fellows receiving a score of 4 or below are deemed deficient in that competency; this will be brought to the attention of the program director immediately, and, if necessary, remediation will be implemented.

The following are the goals and objectives for each competency at each level of training for the Hepatology Consultative Service:

Year I Fellow:

Goal: A Year I fellow should be able to assess new patient problems, formulate and execute a treatment plan with guidance and teach basic hepatology and gastroenterology skills to medical students and other trainees. Year I fellows should begin to develop basic procedural competencies in diagnostic upper endoscopy and colonoscopy.



Perform with supervision the following basic procedures (see practicum):o Colonoscopy



second portion of the duodenum.o Liver Biopsies:

Fellows must have formal instruction and clinical expertise and must demonstrate competence in the performance of percutaneous liver biopsies.

o Abdominal Paracentesis: Fellows must have formal instruction and clinical expertise, and must demonstrate

competence in the performance of diagnostic and therapeutic paracentesis Fellows must have formal instruction and clinical experience and demonstrate competence in:

o The prevention of acute and chronic endstage liver disease o The evaluation and management of inpatients with acute and chronic endstage liver disease o The management of fulminant liver failureo The psychosocial evaluation of all candidates, in particular those with a history of substance abuse o Drug hepatotoxicity and the interaction of drugs with the livero Diagnosis and mangement of autoimmune hepatitiso Diagnosis and management of cholestatic liver diseases – primary biliary cirrhosis (PBC) and

primary sclerosing cholangitis (PSC)

Learn to provide inpatient care that is safe and compassionate and to develop the ability to thoroughly and clearly educate the inpatient in the relevant areas of disease prevention, detection, progression and therapy to promote liver health.

Medical Knowledge Objectives: Attend core conferences and teaching rounds --- especially the Monday and Wednesday Hepatology Conferences

--- to learn the pathophysiology, epidemiology, disease management and procedure and medicine management skills for common and uncommon inpatient liver diseases including:

o The prevention of acute and chronic endstage liver disease o The evaluation and management of inpatients with acute and chronic endstage liver disease o The management of fulminant liver failureo The psychosocial evaluation of all candidates, in particular those with a history of substance abuse o Drug hepatotoxicity and the interaction of drugs with the livero Diagnosis and mangement of autoimmune hepatitiso Diagnosis and management of cholestatic liver diseases – primary biliary cirrhosis (PBC) and

primary sclerosing cholangitis (PSC) Accumulate and begin to solve the issues that he/she encounters from other trainees, attendings and related

medical professionals. Teach medical students the basics of gastroenterology and hepatology care. Achieve an average percentile score of at least 59.8 on the liver section of the in-service Gastroenterology

Training Examination (GTE) exam. This score is the national average for the liver section for Year I fellows. By end of Year I, pass the Internal Medicine Board Examination.

Practice-Based Learning Objectives: Become familiar with the concepts of quality improvement. Participate in conferences such as M&M, geared to the programmatic review of adverse events. Begin to review, analyze and utilize scientific evidence from the hepatology literature for the management of liver

disease patients. Learn the best practice patterns to facilitate liver disease care through clinic operating procedures and patient

interactions.


understandable and compassionate manner. Convey bad news compassionately and honestly. Learn to communicate effectively with staff, peers, attending gastroenterologists/hepatologists, referring

physicians and other consultants.



responsible colleagues. Participate in program planning.


healthcare. Achieve basic understanding of healthcare systems related to hepatology care and overall system activities. Learn proper documentation and billing skills to practice cost-effective care. Develop and become familiar with the e-portfolio system for personal documentation management,

communication with mentors and other collaborators and related fellowship program documentation. Utilize an appropriate range of healthcare professionals to care for patients, working closely with social services to

maximize patient care and understanding the role of hospice, referring appropriately when needed.

Begin involvement to understand the standard operating procedures and quality improvement initiatives within the hospital.

Attend national gastroenterology conferences (e.g., ACG and endoscopy training courses).

Year II Fellow:


Patient Care Objectives: Complete a time-efficient history and physical examination. Critique the work and orders of Year I fellows. Direct the Year I fellows successfully with the appropriate level of intervention for each trainee’s skills. Complete competency-level performance of the following basic gastroenterology/hepatology procedures (see

practicum checklist):o Colonoscopy

By completion of Year II, master all Year I colonoscopic skill requirements. Additionally, perform endoscopic maneuvers, including snare polypectomy and begin to develop competency in control of GI bleeding: sclerotherapy and thermal coagulopathy of bleeding vessels.



o Liver Biopsies: Fellows must have formal instruction and clinical expertise, and must demonstrate

competence in the performance of percutaneous liver biopsies.o Abdominal Paracentesis:

Fellows must have formal instruction and clinical expertise, and must demonstrate competence in the performance of diagnostic and therapeutic paracentesis.

Fellows must have formal instruction and clinical experience and demonstrate competence in:o The comprehensive management of patients who are high on the transplant list in the intensive

care setting with complications of end-stage liver disease including: refractory ascites, hepatic hydrothorax; hepatorenal syndrome, hepatopulmonary and portal pulmonary syndromes, and refractory portal hypertensive bleeding

o The management of chronic viral hepatitis in the pre-transplantation, peri-transplantation, and post-transplantation settings

o Nutritional support of patients with chronic liver diseaseo The use of interventional radiology in the diagnosis and management of portal hypertension, as

well as biliary and vascular complications Present cases succinctly in a direct manner. Know the Hepatology Consultative Service’s patients at a management level. Handle consult calls respectfully and appropriately. Teach good symptom management skills to medical students and other trainees. Provide inpatient care that is safe and compassionate and develop the ability to thoroughly and clearly educate



epidemiology, disease management and procedures and medicine management skills for common and uncommon inpatient liver diseases including:

o The comprehensive management of patients who are high on the transplant list in the intensive care setting with complications of end-stage liver disease including: refractory ascites, hepatic hydrothorax; hepatorenal syndrome, hepatopulmonary and portal pulmonary syndromes, and refractory portal hypertensive bleeding



well as biliary and vascular complications Organize the team’s performance at teaching rounds. Read textbook and pertinent literature materials concerning problems encountered. Teach medical students and other trainees about liver disease states and patient management. Achieve an average percentile score of at least 65.7 on the liver section of the in-service Gastroenterology

Training Examination (GTE) exam. This score is the national exam average for liver diseases for Year II fellows.


assess improvement. Participate in problem-based quality improvement projects. Review, analyze and utilize scientific evidence from the hepatology literature for the management of liver disease

patients. Know the best practice patterns to facilitate hepatology care through clinic operating procedures and patient

interactions.


understandable manner. Convey bad news compassionately and honestly. Plan patient and family conferences. Counsel patients about transitioning to palliative care, when needed. Address or refer patients related to spiritual or existential issues. Communicate effectively with staff, peers, attending hepatologists/gastroenterologists, referring physicians and

other consultants. Present cases succinctly, in a problem-based, direct manner. Learn to become a teacher of hepatology to junior trainees, medical students and other healthcare professionals.






other collaborators and related fellowship program documentation. Assist other trainees in the utilization of appropriate healthcare resources for the best care of the Hepatology

Consultative Service’s patients. Model appropriate interactions in multidisciplinary planning, including standard operating procedures and quality


Year III Fellows:


Patient Care Objectives: Master the Year II fellow objectives. Demonstrate efficient organization of the Hepatology Consultative Service and a working knowledge of all

patients. Demonstrate near-attending level capacity for program assessment and care planning. Attain trainer level proficiency in the following procedures pertinent to his/her career choices:





o Liver Biopsies Fellows must have formal instruction and clinical expertise and must demonstrate

competence in the performance of percutaneous liver biopsies.o Abdominal Paracentesis

Fellows must have formal instruction and clinical expertise and must demonstrate competence in the performance of diagnostic and therapeutic paracentesis.

Fellows must have formal instruction and clinical experience and demonstrate competence in:o The diagnosis and management of hepatocellular carcinoma and cholangiocarcinoma including

transplantation, non-transplantation, and non-surgical approaches o Transplant immunology including blood group matching, histocompatibility, tissue typing, and

infectious and malignant complications of immunosuppression o Ethical considerations relating to liver transplant donors, including questions related to living

donors, non-heart beating donors, criteria for brain death, and appropriate recipients o Acquiring a current working knowledge of the organizational and logistic aspects of liver

transplantation including the the role of nurse coordinators and other support staff (e.g., social work), organ procurement, and UNOS policies including those regarding organ allocation.

Provide inpatient care that is safe and compassionate with the leadership ability to thoroughly and clearly educate the inpatient and all other trainees regarding relevant areas of disease prevention, detection, progression and therapy to promote liver health.

Medical Knowledge Objectives: Access and critique the medical literature regarding hepatology and gastroenterology problems encountered. Assume the trainee leadership role at core conferences and teaching rounds regarding the pathophysiology,

epidemiology, disease management, procedures and medicine management skills for common and uncommon inpatient liver diseases including

Fellows must have formal instruction and clinical experience and demonstrate competence in:o The diagnosis and management of hepatocellular carcinoma and cholangiocarcinoma including



donors, non-heart beating donors, criteria for brain death, and appropriate recipients o Acquiring a current working knowledge of the organizational and logistic aspects of liver

transplantation including the the role of nurse coordinators and other support staff (e.g., social work), organ procurement, and UNOS policies including those regarding organ allocation.

Teach medical students, other trainees and Year I & II fellows at near-attending level.

Prepare for the ABIM certifying exam throughout the year. Organize team activities in a smooth and authoritative fashion. Assist Year II fellows’ development directly at teaching conferences and indirectly at work sites. Achieve an average percentile score of at least 70.6 on the liver section of the in-service Gastroenterology

Training Examination (GTE) exam. This score is the national exam average for the liver section for Year III fellows.

Practice-Based Learning Objectives: Demonstrate mastery of Year II fellow skills and encourage participation of colleagues. Review, analyze and utilize scientific evidence from the hepatology literature for the management of liver disease

patients, taking a leadership role in guiding Year I & II fellows and sharing relevant literature reviews with them. Know and be able to succinctly communicate the best practice patterns to facilitate liver disease care through





other consultants and lead other trainees related to appropriate fellow-to-medical-professional communications. Present cases succinctly, in a problem-based, direct manner. Assume the role of a teacher of hepatology to junior trainees, medical students and other healthcare

professionals.

Professionalism Objectives: Demonstrate proficiency in Year II objectives. Mentor medical students, other trainees and fellows in professional conduct. Assist in formal teaching exercises as requested. Assert leadership in program planning.







Teaching Methods:Gastroenterology fellows participate in the Hepatology Consultative Service during all three fellowship years. Two fellows are assigned to the Hepatology Consultative Service during all rotations.Teaching of medical students, residents and other trainees as well as appropriate interactions with other healthcare providers are important aspects of this rotation. Participating in all required conferences is mandatory, and rounding is an integral part of this experience. As fellows gain experience throughout their training, skills of organization and efficiency as well as team leadership become increasingly important.

The Hepatology Consultative Service experience will prepare the fellow to evaluate and manage acute and chronic liver diseases that will be encountered in the fellow’s future practice. This rotation will expose the fellow to a wide variety of acute and chronic liver diseases. Fellows will learn to incorporate and interact with a multidisciplinary team approach with the Liver Transplant Program at the Starzl Transplant Institute, Montefiore University Hospital. Fellows will learn the appropriate use of interventional radiology facilities capable of performing Transjugular Intrahepatic Portal Systemic Shunts (TIPS) and balloon angioplasty and will learn to share patient co-management responsibilities with

transplant surgeons from the preoperative phase to the outpatient period as well as learn to interact with an experienced liver transplant pathologist.

Fellows assigned to this service will evaluate all new consults at UPMC Presbyterian, Montefiore and Magee Womens Hospitals and will be assigned to a continuity clinic one-half day per week. They will present new consults to the attending by the following day for routine consults and as soon as possible for emergencies. Fellows will evaluate each patient and will make initial recommendations regarding diagnostic tests and treatments. They will make arrangements for studies such as GI endoscopic procedures, liver biopsies (percutaneous and transjugular), abdominal paracenteses and thoracenteses, percutaneous transhepatic cholangiograms (PTC), etc. They will review the appropriateness of the procedure with the attending before making final scheduling plans. The fellow will follow each patient under active consultation on a regular basis, will make further recommendations as indicated and will keep the attending informed of the patient’s status. Fellows must also communicate with the procedure fellow for all diagnostic studies.

Disease Mix:Fellows see a complete mix of liver diseases and conditions at the Hepatology Consultative Service’s teaching hospitals. UPMC Presbyterian and UPMC Montefiore and the Starzl Transplant Institute have a substantial primary care basis, which provides the entire spectrum of internal medicine diagnoses and gastroenterology/hepatology care.

Diagnoses range from acute viral hepatitis (A/B), drug induced liver injury,fulminant liver failure, chronic viral hepatitis post transplantation, complicated hepatocellular carcinoma and cholangiocarcinoma. There is also an appropriate concentration of common liver diseases such as evaluation of abnormal liver function tests, management of ascites including refractory ascites, hepatic hydrothorax, hepatorenal syndrome, and portal hypertensive bleeding, diagnosis and management of autoimmune liver diseases and cholestatic liver diseases (PBC and PSC), metabolic liver diseases (Non-Alcoholic Fatty Liver Disease [NAFLD]), Inherited Liver Diseases such as Genetic Hemochromatosis; Wilson’s Disease and Alpha One Antitrypsin Deficiency. In particular, UPMC Presbyterian/UPMC Montefiore and the Starzl Transplant Institute comprise a tri-state and international referral center, and there is outstanding diversity of unusual diagnoses in the teaching services.

Patient Characteristics:UPMC Presbyterian and UPMC Montefiore offer a diverse mix of socioeconomic and gender status. Teaching faculty provide an abundant supply of upper- and middle-class patients, and our contracts with medical assistance and pro bono care efforts ensure access to lower-income patients. Due to a primary care base simultaneous with the hospitals’ constantly active referrals (complete with helicopter and fixed-wing transport 24/7), patients are seen in both acute status and in diagnostic dilemma status, with both common and uncommon disorders.

Types of Clinical Encounters – Attending Supervision:Encounters are inpatient in nature during the Hepatology Consultative Service. Fellows provide 24/7 consultative care under the supervision of an attending within duty hour limits and with faculty back up for situations of overload. Daily attending supervision is available at both UPMC Presbyterian and UPMC Montefiore seven days per week, and in-house supervision is available all night as well. The attending has ultimate responsibility for patients.

Procedures:During the Hepatology Consultative Service, emergency procedures (e.g. for acute gastrointestinal bleeding) are performed 24/7 within duty hour limits by the fellow with the attending. Non-emergent procedures are performed during daytime hours in the GI lab by the fellow under the direct supervision of the attending. Procedure based evaluation is performed twice per year by a supervising attending (see procedure practicum: direct observation).

Evaluation:Fellows are evaluated during all Hepatology Consultative Service rotations and are expected to participate in the evaluation of other fellows as well. This occurs in the following forms: Detailed, automated evaluations using the myevaluations.com system are submitted for each rotation. These

evaluations are reflective of the program’s curriculum requirements. Attendings evaluate fellows, and the fellows evaluate the attendings as well. Evaluations include:

o 360-degree (attending, nurse, nurse practitioner, staff/clerical, etc.);o Direct observation;o Peer-reviewed; ando Patient.

Evaluation summaries become part of the fellows’ and attendings’ promotional documents.

Fellows self-evaluate through their e-portfolio participation/communication with mentors and colleagues and through document maintenance.

The fellow also evaluates the Gastroenterology Fellowship Program annually through a confidential basis. Attendings evaluate the Gastroenterology Fellowship Program annually. A Curriculum Committee oversees major changes to the curriculum. Representative program personnel (i.e.,

program director, representative faculty and at least one fellow) are organized to review program goals and objectives and the effectiveness with which they are achieved. This group conducts a formal documented meeting at least annually for this purpose. In the evaluation process, the group must take into consideration written comments from the faculty, the most recent report of the GMEC of the sponsoring institution and the residents’ confidential written evaluations. If deficiencies are found, the group will prepare an explicit plan of action, which should be approved by the faculty and documented in the minutes of the meeting.



o Up-To-Dateo PubMedo Textbook of Gastroenterology – Yamada, et.al.o Gastrointestinal Disease: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.o Diseases of the Liver - Leon Schiff and Eugene Schiffo Zakim and Boyer’s Hepatology: A Textbook of Liver Diseaseo Major Gastroenterology/Hepatology/Transplantation journals online and in the program’s fellow

library including Gastroenterology, American Journal of Gastroenterolgy, Gut, Hepatology, Liver Transplantation, Journal of Hepatology and other major publications.

o Recommended reading and landmark articles are available on the Division of Gastroenterology, Hepatology and Nutrition’s shared-access drive. This information includes:

Practice Guidelines from the American Association for the Study of Liver Diseases (AASLD) [may also be accessed via www.aasld.org].

Transplant Hepatology CAQTo access the Division’s shared-access drive, go to >

“H:” drive Click on “GI” Click on “Public” Click on the “Chopra” file.

Curricular Design o ACGME Outcome Project documentation (from www.acgme.org).o Graduate Education in Internal Medicine: A Resource Guide to Curriculum Developmento The report of the Federated Council for Internal Medicine Task Force on the Internal Medicine


o Textbook of Gastroenterology – Yamada, et.al.o Gastrointestinal Diasese: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.o Diseases of the Liver - Leon Schiff and Eugene Schiff

Competencies-at-a-GlanceHepatology Consultative Service








documentation

http://www.aasld.org/

Direct Observation


Conferences 360-global evaluations E-portfolio self-documentation



documentation

The Hepatology Consultative Service reflects appropriate teaching and evaluation related to all six core competencies. Day-to-day patient care, related teaching and the curriculum conferences during the rotation are the greatest elements that teach the competencies, and the global evaluation is the most important single measurement device. In addition to didactic learning, medical center committee participation is encouraged to bolster system-wide knowledge and practice management understanding.

Updated:December 2005June 2006September 2007

Hepatology Outpatient ServiceCurriculum for Year I, II & III Fellows

Educational Purpose:The Hepatology Outpatient Service introduces the fellow to outpatient management of patients with liver diseases. During this period, the fellow will have the opportunity to assess a wide variety of acute and chronic liver conditions. The fellow will participate in increasing levels of management/treatment involvement with patient needs depending on the fellow’s level of experience. The fellow will be expected to formulate the differential diagnosis, institute diagnostic studies and recommend therapy. The amount of learning obtained from this rotation is directly proportional to the amount of time spent in the evaluation of the patients.

Objectives:Fellows will learn all aspects of outpatient liver disease care and will display all general competencies during this experience. Fellows will develop familiarity with standard treatments for common complications such as ascites, portal hypertension or hepatic encephalopathy and will build familiarity with standard treatments of chronic liver diseases such as viral hepatitis, autoimmune liver diseases, metabolic liver diseases, drug-induced liver disease, fatty liver disease and liver tumors. Fellows will obtain exposure to the liver transplantation selection process and will receive experience in the timing of referring patients for liver transplantation. Minimum levels of achievement in each competency are expected during each of the three years of fellowship training. Those meeting competency will receive a score of 5 in the program’s evaluation system. Fellows performing at a level better than expected for that competency receive a score of 6 or 7 in the evaluation system, those at a level better than most fellows at that PGY receive an 8, and those performing at a level deemed to be “one of the best fellows ever observed” will receive a score of 9. Fellows receiving a score of 4 or below are deemed deficient in that competency; this will be brought to the attention of the program director immediately, and, if necessary, remediation will be implemented.

The following are the goals and objectives for each competency at each level of training for the Hepatology Outpatient Service:

Year I Fellow:

Goal: A Year I fellow should be able to assess new patient problems, formulate and execute a treatment plan with guidance and teach basic hepatology and gastroenterology skills to medical students and other trainees. Year I fellows should begin to develop basic procedural competencies.


Follow the patient’s disease course from visit to visit with possible.. With attending consultation, formulate and execute an impression and a list of recommendations. When indicated, consent patients for procedures and order appropriate diagnostic tests (e.g., endoscopy, radiologic tests, etc.) in conjunction with the primary/referring service.

Perform with supervision the following basic procedures (see practicum):o Colonoscopy



second portion of the duodenum.o Liver Biopsies:

Fellows must have formal instruction and clinical expertise and must demonstrate competence in the performance of percutaneous liver biopsies.

o Abdominal Paracentesis: Fellows must have formal instruction and clinical expertise, and must demonstrate

competence in the performance of diagnostic and therapeutic paracentesis

Fellows will have formal instruction and clinical experience and will demonstrate competence in:o The prevention of acute and chronic endstage liver disease o The evaluation and management of inpatients with acute and chronic endstage liver disease o The management of fulminant liver failureo The psychosocial evaluation of all candidates, in particular those with a history of substance abuse

o Drug hepatotoxicity and the interaction of drugs with the livero Diagnosis and management of autoimmune hepatitiso Diagnosis and management of cholestatic liver diseases – primary biliary cirrhosis (PBC) and

primary sclerosing cholangitis (PSC) Learn to provide outpatient care that is safe and compassionate and to develop the ability to thoroughly and

clearly educate the patient in the relevant areas of disease prevention, detection, progression and therapy to promote liver health.

Medical Knowledge Objectives: Attend core conferences and teaching rounds --- especially the mandatory Wednesday Hepatology Conference ---

to learn the pathophysiology, epidemiology, disease management and procedures and medicine management skills for common and uncommon liver diseases including:

o The prevention of acute and chronic endstage liver disease o The evaluation and management of inpatients with acute and chronic endstage liver disease o The management of fulminant liver failureo The psychosocial evaluation of all candidates, in particular those with a history of substance abuse o Drug hepatotoxicity and the interaction of drugs with the livero Diagnosis and amangement of autoimmune hepatitiso Diagnosis and management of cholestatic liver diseases – primary biliary cirrhosis (PBC) and

primary sclerosing cholangitis (PSC) Accumulate and begin to solve the issues that he/she encounters from other trainees, attendings and related

medical professionals. Teach medical students the basics of gastroenterology and hepatology care. Achieve an average percentile score of at least 59.8on the liver section of the in-service Gastroenterology

Training Examination (GTE) exam. This score is the national average for the liver section for Year I fellows. By end of Year I, pass the Internal Medicine Board Examination.

Practice-Based Learning Objectives: Become familiar with the concepts of quality improvement. Participate in conferences such as M&M, geared to the programmatic review of adverse events. Begin to review, analyze and utilize scientific evidence from the hepatology literature for the management of liver

disease patients. Learn the best practice patterns to facilitate liver disease care through clinic operating procedures and patient

interactions.








healthcare. Achieve basic understanding of healthcare systems related to hepatology care and overall system activities. Learn proper documentation and billing skills to practice cost-effective care.

Develop and become familiar with the e-portfolio system for personal documentation management, communication with mentors and other collaborators and related fellowship program documentation.

Utilize an appropriate range of healthcare professionals to care for patients, working closely with social services to maximize patient care and understanding the role of hospice, referring appropriately when needed.

Begin involvement to understand the standard operating procedures and quality improvement initiatives within the hospital.

Attend national gastroenterology conferences (e.g., ACG and endoscopy training courses).

Year II Fellow:


Patient Care Objectives: Complete a time-efficient history and physical examination. Critique the work and orders of Year I fellows. Direct the Year I fellows successfully with the appropriate level of intervention for each trainee’s skills. Complete competency-level performance of the following basic procedures (see practicum checklist):

o Colonoscopy By completion of Year II, master all Year I colonoscopic skill requirements. Additionally,

perform endoscopic maneuvers, including snare polypectomy and begin to develop competency in control of GI bleeding: sclerotherapy and thermal coagulopathy of bleeding vessels.



o Liver Biopsies: Fellows must have formal instruction and clinical expertise and must demonstrate


Fellows must have formal instruction and clinical expertise, and must demonstrate competence in the performance of diagnostic and therapeutic paracentesis

Fellows will have formal instruction and clinical experience and demonstrate competence in:o The comprehensive management of patients who are high on the transplant list in the intensive

care setting with complications of end-stage liver disease including: refractory ascites, hepatic hydrothorax; hepatorenal syndrome, hepatopulmonary and portal pulmonary syndromes, and refractory portal hypertensive bleeding



well as biliary and vascular complications Present cases succinctly in a direct manner. Know the Hepatology Outpatient Service’s patients at a management level. Handle consult calls respectfully and appropriately. Teach good symptom management skills to medical students and other trainees. Provide outpatient care that is safe and compassionate and develop the ability to thoroughly and clearly educate

the patient in the relevant areas of disease prevention, detection, progression and therapy to promote liver health.


epidemiology, disease management and procedures and medicine management skills for common and uncommon outpatient liver diseases including:

o The comprehensive management of patients who are high on the transplant list in the intensive care setting with complications of end-stage liver disease including: refractory ascites, hepatic

hydrothorax; hepatorenal syndrome, hepatopulmonary and portal pulmonary syndromes, and refractory portal hypertensive bleeding.



well as biliary and vascular complications Organize the team’s performance at teaching rounds. Read textbook and pertinent literature materials concerning problems encountered. Teach medical students and other trainees about liver disease states and patient management. Achieve an average percentile score of at least 65.7 on the liver section of the in-service Gastroenterology

Training Examination (GTE) exam. This score is the national exam average for liver diseases for Year II fellows.


assess improvement. Participate in problem-based quality improvement projects. Review, analyze and utilize scientific evidence from the hepatology literature for the management of liver disease

patients. Know the best practice patterns to facilitate hepatology care through clinic operating procedures and patient

interactions.



other consultants. Present cases succinctly, in a problem-based, direct manner. Learn to become a teacher of hepatology to junior trainees, medical students and other healthcare professionals.






other collaborators and related fellowship program documentation. Assist other trainees in the utilization of appropriate healthcare resources for the best care of the Hepatology

Consultative Service’s patients. Model appropriate interactions in multidisciplinary planning, including standard operating procedures and quality


Year III Fellows:

Goal: The senior-level, Year III fellow should demonstrate rapid assessment and planning skills and near-attending level care planning and management, while teaching medical students and other trainees at near to or exceeding attending level teaching. Year III fellows should be able to perform diagnostic and therapeutic upper endoscopy and colonoscopy procedures independently

Patient Care Objectives: Master the Year II fellow objectives. Demonstrate efficient organization of the Hepatology Outpatient Service and a working knowledge of all patients. Demonstrate near-attending level capacity for program assessment and care planning. Attain trainer level proficiency in the following procedures pertinent to his/her career choices:





o Liver Biopsies: Fellows must have formal instruction and clinical expertise and must demonstrate


Fellows must have formal instruction and clinical expertise, and must demonstrate competence in the performance of diagnostic and therapeutic paracentesis

Fellows will have formal instruction and clinical experience and demonstrate competence in:o The diagnosis and management of hepatocellular carcinoma and cholangiocarcinoma including



donors, non-heart beating donors, criteria for brain death, and appropriate recipientso Acquiring a current working knowledge of the organizational and logistic aspects of liver

transplantation including the the role of nurse coordinators and other support staff (e.g., social work), organ procurement, and UNOS policies including those regarding organ allocation

Provide outpatient care that is safe and compassionate with the leadership ability to thoroughly and clearly educate the patient and all other trainees regarding relevant areas of disease prevention, detection, progression and therapy to promote liver health.


epidemiology, disease management, procedures and medicine management skills for common and uncommon inpatient liver diseases including

o The diagnosis and management of hepatocellular carcinoma and cholangiocarcinoma including transplantation, non-transplantation, and non-surgical approaches

o Transplant immunology including blood group matching, histocompatibility, tissue typing, and infectious and malignant complications of immunosuppression

o Ethical considerations relating to liver transplant donors, including questions related to living donors, non-heart beating donors, criteria for brain death, and appropriate recipients

o Acquiring a current working knowledge of the organizational and logistic aspects of liver transplantation including the the role of nurse coordinators and other support staff (e.g., social work), organ procurement, and UNOS policies including those regarding organ allocation

Teach medical students, other trainees and Year I & II fellows at near-attending level. Prepare for the ABIM certifying exam throughout the year. Organize team activities in a smooth and authoritative fashion. Assist Year II fellows’ development directly at teaching conferences and indirectly at work sites. Achieve an average percentile score of at least 70.6 on the liver section of the in-service Gastroenterology

Training Examination (GTE) exam. This score is the national exam average for the liver section for Year III fellows.







other consultants and lead other trainees related to appropriate fellow-to-medical-professional communications. Present cases succinctly, in a problem-based, direct manner. Assume the role of a teacher of hepatology to junior trainees, medical students and other healthcare

professionals.








Teaching Methods:Gastroenterology fellows participate in the Hepatology Outpatient Service during all three fellowship years. Two fellows are assigned to the Hepatology Outpatient Service during all rotations. Teaching of medical students, residents and other trainees as well as appropriate interactions with other healthcare providers are important aspects of this rotation. Participating in all required conferences is mandatory, and rounding is an integral part of this experience. As fellows gain experience throughout their training, skills of organization and efficiency as well as team leadership become increasingly important.

The Hepatology Outpatient Service experience will prepare the fellow to evaluate and manage acute and chronic liver diseases that will be encountered in the fellow’s future practice. This rotation will expose the fellow to a wide variety of acute and chronic liver diseases. Fellows will learn to incorporate and interact with a multidisciplinary team approach with the Liver Transplant Program at the Starzl Transplant Institute. Fellows will learn the appropriate use of interventional radiology facilities capable of performing Transjugular Intrahepatic Portal Systemic Shunts (TIPS) and

balloon angioplasty and will learn to share patient co-management responsibilities with transplant surgeons from the preoperative phase to the outpatient period and will learn to interact with an experienced liver transplant pathologist.

Fellows assigned to this service will rotate through various outpatient Hepatology Clinics (General Hepatology and Pre- and Post-Transplantation Clinics) at the Center for Liver Diseases and the Starzl Transplant Institute. Fellows will evaluate each patient and will make initial recommendations regarding diagnostic tests and treatments. They will make arrangements for studies such as GI endoscopic procedures, liver biopsies (percutaneous and transjugular), abdominal paracenteses and thoracenteses, percutaneosu transhepatic cholangiograms (PTC), etc. They will review the appropriateness of the procedure with the attending before making final scheduling plans. The fellow will follow each patient under active consultation on a regular basis, will make further recommendations as indicated and will keep the attending informed of the patient’s status. Fellows must also communicate with the procedure fellow for all diagnostic studies.

Disease Mix:Fellows see a complete mix of liver diseases and conditions at the Center for Liver Diseases (CLD), which is the primary outpatient liver clinic. A diverse spectrum of internal medicine diagnoses and gastroenterology/hepatology care is provided at the CLD

Diagnoses range from acute viral hepatitis (A/B), drug induced liver injury, fulminant liver failure, chronic viral hepatitis post transplantation, complicated hepatocellular carcinoma and cholangiocarcinoma. There is an appropriate concentration of common liver diseases related to evalaution of abnormal liver function tests, management of ascites including refractory ascites, hepatic hydrothorax, hepatorenal syndrome and portal hypertensive bleeding. diagnosis and management of autoimmune liver diseases and cholestatic liver diseases (PBC; PSC), metabolic liver diseases (Non-Alcoholic Fatty Liver Disease [NAFLD]), Inherited Liver Diseases such as Genetic Hemochromatosis, Wilson’s Disease and Alpha One Antitrypsin Deficiency. Due to collaborations with UPMC Presbyterian Hospital --- a tri-state and international referral center --- and the institution’s Starzl Transplantation Institute, there is outstanding diversity of unusual diagnoses in the teaching services.

Patient Characteristics:The Center for Liver Diseases offers a diverse mix of socioeconomic and gender status. Teaching faculty provide an abundant supply of upper- and middle-class patients, and our contracts with medical assistance and pro bono care efforts ensure access to lower-income patients.

Types of Clinical Encounters – Attending Supervision:Fellows provide consultative care under the supervision of an attending within duty hour limits and with faculty back up for situations of overload. Daily attending supervision is available seven days per week. The attending has ultimate responsibility for patients.

Procedures:During the Hepatology Outpatient Service, emergency procedures are performed 24/7 within duty hour limits by the fellow with the attending. Non-emergent procedures are performed during daytime hours in the GI lab by the fellow under the direct supervision of the attending. Procedure based evaluation is performed twice per year by a supervising attending (see procedure practicum: direct observation).

Evaluation:Fellows are evaluated during all Hepatology Outpatient Service rotations and are expected to participate in the evaluation of other fellows as well. This occurs in the following forms: Detailed, automated evaluations using the myevaluations.com system are submitted for each rotation. These

evaluations are reflective of the program’s curriculum requirements. Attendings evaluate fellows, and the fellows evaluate the attendings as well. Quarterly evaluations include:

o 360-degree (attending, nurse, nurse practitioner, staff/clerical, etc.);o Peer-reviewed; ando Patient.



program director, representative faculty and at least one fellow) are organized to review program goals and

objectives and the effectiveness with which they are achieved. This group conducts a formal documented meeting at least annually for this purpose. In the evaluation process, the group must take into consideration written comments from the faculty, the most recent report of the GMEC of the sponsoring institution and the residents’ confidential written evaluations. If deficiencies are found, the group will prepare an explicit plan of action, which should be approved by the faculty and documented in the minutes of the meeting.



o Up-To-Dateo PubMedo Textbook of Gastroenterology – Yamada, et.al.o Gastrointestinal Diasese: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.o Diseases of the Liver - Leon Schiff and Eugene Schiffo Zakim and Boyer’s Hepatology: A Textbook of Liver Diseaseo Major Gastroenterology journals online and in the program’s fellow library including

Gastroenterology, American Journal of Gastroenterolgy, Gut, Hepatology, Liver Transplantation, Journal of Hepatology and other major publications.

o Website of the American Association for the Study of Liver Disease (AASLD) with related linkso Recommended reading and landmark articles are available on the Division of Gastroenterology,

Hepatology and Nutrition’s shared-access drive. This information includes: Practice Guidelines from the American Association for the Study of Liver Diseases

(AASLD) [may also be accessed via www.aasld.org]. Transplant Hepatology CAQ

To access the Division’s shared-access drive, go to > “H:” drive Click on “GI” Click on “Public” Click on the “Chopra” file.



o Textbook of Gastroenterology – Yamada, et.al.o Gastrointestinal Diasese: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.o Diseases of the Liver - Leon Schiff and Eugene Schiffo Zakim and Boyer’s Hepatology: A Textbook of Liver Disease

http://www.aasld.org/

Competencies-at-a-GlanceHepatology Outpatient Service













documentation

The Hepatology Outpatient Service reflects appropriate teaching and evaluation related to all six core competencies. Patient care, teaching and the curriculum conferences during the rotation are the greatest elements that teach the competencies, and the global evaluation is the most important single measurement device. In addition to didactic learning, medical center committee participation is encouraged to bolster system-wide knowledge and practice management understanding.


Pancreaticobiliary ServiceCurriculum for Year II & III Fellows

Educational Purpose:The Pancreaticobiliary Service introduces the fellow to inpatient management of patients with pancreas and biliary diseases. During this period, the fellow will have the opportunity to assess a wide variety of acute and chronic pancreaticobiliary conditions. As such, there will be an introduction to ERCP, but, for advanced training, fellows will require a fourth year. Additionally, a faculty committee will decide if certain fellows merit more intensive ERCP training during the three year fellowship. These fellows will be selected by the faculty. Pancreaticobiliary Service fellows will participate in increasing levels of management/ treatment involvement with patient needs and procedures, depending on the fellow’s level of experience. The fellow will be expected to formulate the differential diagnosis, institute diagnostic studies and recommend therapy. The amount of learning obtained from this rotation is directly proportional to the amount of time spent in the evaluation of the patients.

Objectives:Fellows will learn all aspects of pancreas and biliary disease care and will display all general competencies during this experience. Minimum levels of achievement in each competency are expected during Years II and III of training, when fellows may participate in the Pancreaticobiliary Service. Those meeting competency will receive a score of 5 in the program’s evaluation system. Fellows performing at a level better than expected for that competency receive a score of 6 or 7 in the evaluation system, those at a level better than most fellows at that PGY receive an 8, and those performing at a level deemed to be “one of the best fellows ever observed” will receive a score of 9. Fellows receiving a score of 4 or below are deemed deficient in that competency; this will be brought to the attention of the program director immediately, and, if necessary, remediation will be implemented.

The following are the goals and objectives for each competency at each level of training for the Pancreaticobiliary Service:

Year II Fellow:

Goal: A Year II fellow should be able to assess and care for a large volume of patients and learn and teach basic textbook and evidence-based medicine to medical students and other trainees. Year II fellows should independently perform upper endoscopy procedures with a side viewing scope. Year II fellows should understand the indications for ERCP and EUS as well as risks and benefits of such procedures.

Patient Care Objectives: Complete a time-efficient history and physical examination. Direct medical students successfully with the appropriate level of intervention for each trainees’ skills. Complete competency-level performance of the following pancreaticobiliary procedures (see practicum checklist):

o Upper Endoscopy o Passage of side viewing endoscope and visualization of the ampulla of vater.o Begin to perform cannulation of the bile duct.

Develop clear expertise in the diagnosis and management of acute and chronic pancreaticobiliary diseases including:

o Acute Pancreatitiso Chronic Pancreatitiso Pancreatis Cancero Bile Duct Stoneso Liver Cancero Biliary Cancero Post-Operative Injuries to the Liver, Bile Ducts & Pancreas

Present cases succinctly in a direct manner. Know the Pancreaticobiliary Service’s patients at a management level. Handle consult calls respectfully and appropriately. Teach good symptom management skills to medical students and other trainees. Provide inpatient care that is safe and compassionate and develop the ability to thoroughly and clearly educate



epidemiology, disease management and procedures and medicine management skills for common and uncommon pancreaticobiliary diseases including:

o Acute Pancreatitiso Chronic Pancreatitiso Pancreatis Cancero Bile Duct Stoneso Liver Cancero Biliary Cancero Post-Operative Injuries to the Liver, Bile Ducts & Pancreas

Organize the team’s performance at teaching rounds. Read textbook and pertinent literature materials concerning problems encountered. Teach medical students and other trainees about pancreas and biliary disease states and patient management. Achieve an average percentile score of at least 73.90 on the Biliary Tract section and 48.36 on the Pancreas

section of the in-service Gastroenterology Training Examination (GTE) exam. These scores are the national exam averages for pancreatiobiliary diseases for Year II fellows.


assess improvement. Participate in problem-based quality improvement projects. Review, analyze and utilize scientific evidence from pancreaticobiliary literature related to patient management. Know the best practice patterns to facilitate pancreaticobiliary care through clinic operating procedures and patient

interactions.



consultants. Present cases succinctly, in a problem-based, direct manner. Learn to become a teacher of pancreas and biliary diseases to junior trainees, medical students and other

healthcare professionals.

Professionalism Objectives: Begin to mentor medical students and other trainees in professional conduct. Understand and demonstrate professional behavior in daily activities. Participate in professionalism-based learning activities through conferences. Interact collegially with his/her peer group and other healthcare professionals, including acting responsibly in the




healthcare. Understand and be able to work effectively related to hospital functions within UPMC and UPP. Understand and practice proper documentation and billing skills to practice cost-effective care.

Use the program’s e-portfolio system for personal documentation management, communication with mentors and other collaborators and related fellowship program documentation.

Assist other trainees in the utilization of appropriate healthcare resources for the best care of Pancreaticobiliary Service patients.

Model appropriate interactions in multidisciplinary planning, including standard operating procedures and quality improvement initiatives.

Attend national gastroenterology conferences (e.g., DDW, ACG or APA).

Year III Fellows:

Goal: The senior-level, Year III fellow should demonstrate rapid assessment and planning skills and near-attending level care planning and management, while teaching medical students and other trainees at near to or exceeding attending level teaching. Year III fellows should be able to perform diagnostic and therapeutic upper endoscopy procedures independently, as well as passage of the side viewing scope.

Patient Care Objectives: Master the Year II fellow objectives. Demonstrate efficient organization of the Pancreaticobiliary Service and a working knowledge of all patients. Demonstrate near-attending level capacity for program assessment and care planning. Attain trainer level proficiency in the following procedures pertinent to his/her career choices: Complete competency-level performance of the following pancreaticobiliary procedures reflecting Year III

responsibilities (see practicum checklist):o Upper Endoscopy o ERCPo Cannulation of bile duct and perform sphincterotomy and placement of bile duct stents

Secure expertise in the diagnosis and management of acute and chronic inpatient pancreaticobiliary diseases including:

o Acute Pancreatitiso Chronic Pancreatitiso Pancreatic Cancero Pancreatic divisumo Congenital biliary abnormalitieso Biliary strictures and primary sclerosing cholangitiso Pancreatic necrosiso Management of bile duct injuries related to traumao Bile Duct Stoneso Liver Cancero Biliary Cancero Post-Operative Injuries to the Liver, Bile Ducts & Pancreas

Provide inpatient care that is safe and compassionate with the leadership ability to thoroughly and clearly educate the inpatient and all other trainees regarding relevant areas of disease prevention, detection, progression and therapy to promote pancreas and biliary health.

Medical Knowledge Objectives: Access and critique the medical literature regarding pancreas and biliary problems encountered. Assume the trainee leadership role at core conferences and teaching rounds regarding the pathophysiology,

epidemiology, disease management, procedures and medicine management skills for common and uncommon inpatient pancreaticobiliary diseases including

o Acute Pancreatitiso Chronic Pancreatitiso Pancreatic Cancero Pancreatic divisumo Congenital biliary abnormalitieso Biliary strictures and primary sclerosing cholangitiso Pancreatic necrosiso Management of bile duct injuries related to traumao Bile Duct Stoneso Liver Cancer

o Biliary Cancero Post-Operative Injuries to the Liver, Bile Ducts & Pancreas

Teach medical students, other trainees and Year I & II fellows at near-attending level. Prepare for the ABIM certifying exam throughout the year. Organize team activities in a smooth and authoritative fashion. Assist Year II fellows’ development directly at teaching conferences and indirectly at work sites. Achieve an average percentile score of at least 79.02 on the Biliary Tract section and 54.44 on the Pancreas

section of the in-service Gastroenterology Training Examination (GTE) exam. These scores are the national exam averages for pancreatiobiliary diseases for Year III fellows.







other consultants and lead other trainees related to appropriate fellow-to-medical-professional communications. Present cases succinctly, in a problem-based, direct manner. Assume the role of a teacher of pancreas and biliary diseases to junior trainees, medical students and other









Teaching Methods:Gastroenterology fellows participate in the Pancreaticobiliary Service during Years II and III of fellowship training. One fellow is assigned to the Pancreaticobiliary Service during all rotations. Teaching of medical students, residents and other trainees as well as appropriate interactions with other healthcare providers are important aspects of this rotation. Participating in all required conferences is mandatory, and rounding is an integral part of this experience. As fellows gain experience throughout their training, skills of organization and efficiency as well as team leadership become increasingly important.

The Pancreaticobiliary Service experience is rigorous and will prepare the fellow to evaluate and manage acute and chronic pancreas and biliary diseases that will be encountered in the fellow’s future practice. This rotation will expose the fellow to a wide variety of pancreas and biliary disease diseases and problems.

Fellows assigned to this service will evaluate all new consults at UPMC Presbyterian and Montefiore Hospitals and will be assigned to a continuity clinic one-half day per week. They will present new consults to the attending by the following day for routine consults and as soon as possible for emergencies. Fellows will evaluate each patient and will make initial recommendations regarding diagnostic tests and treatments. They will make arrangements for studies such as upper endoscopy, ERCP, MRCP etc. They will review the appropriateness of the procedure with the attending before making final scheduling plans. The fellow will follow each patient under active consultation on a regular basis, will make further recommendations as indicated and will keep the attending informed of the patient’s status. Fellows must also communicate with the procedure fellow for all diagnostic studies.

Disease Mix:Fellows see a complete mix of liver diseases and conditions within the Pancreaticobiliary Service’s teaching hospitals. UPMC Presbyterian, UPMC Montefiore, and UPMC Shadyside have a substantial primary care basis, which provides the entire spectrum of internal medicine diagnoses and gastroenterology care.

Diagnoses range from acute pancreatitis to pancreatic cancer, and there is an appropriate concentration of common pancreas and biliary diseases such as Cholangitis, cholelithiasis, biliary strictures. Importantly, UPMC Presbyterian is a tri-state and international referral center, and there is outstanding diversity of unusual diagnoses in the teaching services.

Patient Characteristics:UPMC Presbyterian and UPMC Montefiore and Shadyside offer a diverse mix of socioeconomic and gender status. Teaching faculty provide an abundant supply of upper- and middle-class patients, and our contracts with medical assistance and pro bono care efforts ensure access to lower income patients. Due to a primary care base simultaneous with the hospitals’ constantly active referrals (complete with helicopter and fixed-wing transport 24/7), patients are seen in both acute status and in diagnostic dilemma status, with both common and uncommon disorders.

Types of Clinical Encounters – Attending Supervision:Encounters are inpatient in nature during the Hepatology Consultative Service. Fellows provide 24/7 consultative care under the supervision of an attending within duty hour limits and with faculty back up for situations of overload. Daily attending supervision is available at both UPMC Presbyterian and UPMC Montefiore seven days per week, and in-house supervision is available all night as well. The attending has ultimate responsibility for patients.

Procedures:During the Pancreaticobiliary Service, emergency procedures are performed 24/7 within duty hour limits by the fellow with the attending. Non-emergent procedures are performed during daytime hours in the GI lab by the fellow under the direct supervision of the attending. Procedure based evaluation is performed twice per year by a supervising attending (see procedure practicum: direct observation).

Evaluation:Fellows are evaluated during all Pancreaticobiliary Service rotations and are expected to participate in the evaluation of other fellows as well. This occurs in the following forms: Detailed, automated evaluations using the myevaluations.com system are submitted for each rotation. These






The Program Director meets with all fellows individually twice per year.

An in-service GTE exam is given to all fellows annually.

Additional Instructions for Fellows Participating in the Pancreaticobiliary Service:

I. Patient Care1. Consultations/inpatient admissions : Consultations and inpatient admissions are evaluated by the

pancreaticobiliary fellow on service on the day they are called in. They are to be written up and presented to the attending on service. Additionally, the attending should be notified of any urgent consultations or admissions as soon as possible, particularly if a same-day procedure is anticipated.

2. Pre-procedure evaluation : The fellow is expected to pre-round on inpatients in the morning prior to beginning the day's procedures. If issues arise, the attending on service should be contacted as soon as possible. A pre-review of all outpatients slated for procedures that day should similarly be completed. This may be done by a MARS search, DDC/hospital chart review and, if appropriate, a phone call to the patient to introduce yourself and gather any further information that may be applicable. A thorough patient history, physical exam, and a review of the laboratory and radiologic data should be performed prior to ERCP. The history should be obtained sufficiently in advance to permit procedural changes as warranted (e.g., general anesthesia, correction of coagulation factors, set-up of sphincter of Oddi manometry, enrollment in an ongoing protocol, etc.). The fellow is responsible for entering all pertinent patient data into the ERCP database/report generator prior to and following the procedure. The attending physician and the fellow are expected to discuss the case in detail prior to proceeding, so that both are in agreement regarding the procedure. All inpatients should be seen daily, and a note should be written prior to attending rounds. Attending rounds will be performed daily after all procedures have been completed. All admissions and consultations will be seen on the day they are called, with rare exceptions as approved by the attending on service.

3. Intraoperative : The fellow will assist the attending in performance of the ERCP procedure. The goals for the fellow are to build a solid foundation in patient assessment, approach to the procedure, endoscopic technique, and familiarity with accessories (such as wires, catheters, stents, etc.) as well as the workings of the ERCP team. The number of "successful cannulations, papillotomies, guide wire placements, etc." performed should not, by any means, be considered the ultimate measure of success. These come with time, as skills mature. Since the risks of therapeutic ERCP are equal to those of many surgical procedures, factors such as patient care and safety must remain paramount. Certain cases (high risk, difficult/prior failed procedure, pediatric, etc.) may be considered attending-only cases insofar as the actual performance of the procedure is concerned, and limitation of the fellow’s participation in the case will be at the discretion of the attending. However, the observant fellow will learn a great deal in assisting the attending and watching vigilantly. Such non-hands-on participation is important to the learning process.

4. Postoperative :a. Inpatients : Postop orders are to be written immediately after the procedure is completed.

Pertinent postop data must be entered into the database and a preliminary report generated, signed, and placed on the chart before the patient leaves the GI lab. The attending will be responsible for dictating the procedure note. All inpatients who undergo a procedure must be seen on evening rounds, and a post-procedure check must be documented on the chart. The pancreatico-biliary service will be responsible for ALL aspects of the immediate postoperative management, as occurs on a surgical service. The pancreatico-biliary fellow on service will keep their pagers on, and will be immediately accessible within pager range, 24 hours a day, six days per week, respectively while on service, with no exceptions. On Saturdays, the fellow on-service will round with the GI attending on service. On Sunday, the fellow will sign out to the GI team. On Monday am, the pancreaticobiliary fellow will take report from the GI team for Sunday’s events/admissions. The pancreaticobiliary attending will leave their beepers on 24Hr/7Day to serve as a back-up for the fellow and GI team on weekends for complex cases and for call-ins for emergency procedures.

b. Outpatients : Outpatient post-procedure follow-up mirrors the inpatient model. The fellow will evaluate each patient in the MPU to assess for post-ERCP complications. The fellow will also contact the nurse coordinator for the service who calls each patient following the procedure.

If the fellow has personal business which would interfere with his/her responsibilities while on service, special coverage arrangements must be made in advance with the attending. Fellow cross coverage is acceptable only if the cross-covering fellow has had prior experience with ERCP and has been adequately familiarized with the patients on the service. The service fellow will remain responsible for assuring that cross-coverage proceeds smoothly.

II. ERCP Database

The ERCP database/report generator exists to assist in patient care follow-up and efficient pre-procedure patient review, to aid in research activities and to provide the fellow with an automatic, detailed, and running logbook of procedures performed. The database is divided into three parts: preop assessment, procedure report and follow-up. The database will generate the preliminary ERCP report, keep the fellow’s ERCP procedure log updated and will provide detailed, tabulated information for any ERCP study and/or protocol. Dr. Slivka or assigned Division faculty will inservice all fellows on the use of the database/report generator prior to beginning the pancreaticobiliary rotation. Fellows are responsible for correctly entering patient information and maintaining follow-up on patients they have seen.

III. Research ProtocolsFellows are encouraged to become familiar with existing research protocols, while they are on the pancreaticobiliary service. Fellows are expected to participate in patient enrollment and in carrying out the steps involved in any procedure-related protocols which apply to procedures they perform. Any fellow wishing to design studies is encouraged to discuss such ideas with the attendings. Fellows with a particular interest in pancreaticobiliary gastroenterology are encouraged to discuss the research opportunities available in the pancreatico-biliary section with the attendings, so that they can develop projects early in the fellowship.


o Up-To-Dateo PubMedo Textbook of Gastroenterology – Yamada, et.al.o Gastrointestinal Disease: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.o Major Gastroenterology journals online and in the program’s fellow library including

Gastroenterology, American Journal of Gastroenterology, Gut, and other major publications.o Gastrointestinal Endoscopy: the Journal of the American Society for Gastrointestinal Endoscopy,

the endoscopy journal with the widest circulation throughout the world (monthly).o Endoscopy: the Journal of the European Society for Gastrointestinal Endoscopy (monthly).o Pancreas: the Journal of the American Pancreatic Association.o Gastrointestinal Endoscopy Clinics of North America (quarterly).o Annual of Gastrointestinal Endoscopy (annual review of therapeutic endoscopy literature

worldwide).o Practical Gastrointestinal Endoscopy, by Peter Cotton and Christopher Williams, the classic

“beginner’s guide to endoscopy” and a perennial favorite of GI fellows. Curricular Design

o ACGME Outcome Project documentation (from www.acgme.org).o Graduate Education in Internal Medicine: A Resource Guide to Curriculum Developmento The report of the Federated Council for Internal Medicine Task Force on the Internal Medicine


o Textbook of Gastroenterology – Yamada, et.al.o Gastrointestinal Disease: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.

Competencies-at-a-GlancePancreaticobiliary Service











documentation



documentation

The Pancreaticobiliary Service reflects appropriate teaching and evaluation related to all six core competencies. Day-to-day patient care, related teaching and the curriculum conferences during the rotation are the greatest elements that teach the competencies, and the global evaluation is the most important single measurement device. In addition to didactic learning, medical center committee participation is encouraged to bolster system-wide knowledge and practice management understanding.


VAMC GI ServiceCurriculum for Year I, II & III Fellows

Educational Purpose:The VAMC Service introduces the fellow to inpatient hospital management of patients with gastrointestinal diseases in the veterans population. During this period, the fellow will have the opportunity to assess a wide variety of acute and chronic gastrointestinal and liver conditions and will participate in procedures. The fellow will participate in increasing levels of management/treatment involvement with patient needs and procedures, depending on the fellow’s level of experience. The fellow will be expected to formulate the differential diagnosis, institute diagnostic studies and recommend therapy. The amount of learning obtained from this rotation is directly proportional to the amount of time spent in the evaluation of the patients.

Objectives:Fellows will learn all aspects of inpatient and outpatient gastrointestinal care and will display all general competencies during this experience. Minimum levels of achievement in each competency are expected during each of the three years of fellowship training. Those meeting competency will receive a score of 5 in the program’s evaluation system. Fellows performing at a level better than expected for that competency receive a score of 6 or 7 in the evaluation system, those at a level better than most fellows at that PGY receive an 8, and those performing at a level deemed to be “one of the best fellows ever observed” will receive a score of 9. Fellows receiving a score of 4 or below are deemed deficient in that competency; this will be brought to the attention of the program director immediately, and, if necessary, remediation will be implemented.

The following are the goals and objectives for each competency at each level of training for the VAMC GI Service:

Year I Fellow:







second portion of the duodenum. Develop expertise in the diagnosis and management of acute and chronic inpatient gastrointestinal and hepatic

diseases including:o Upper & lower GI bleedingo Peptic ulcer diseaseo GI infectionso Ischemic colitis.o Cirrhosiso Pancreaticobiliary diseases

Learn to provide inpatient care that is safe and compassionate and to develop the ability to thoroughly and clearly educate the inpatient in the relevant areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.


and procedure and medicine management skills for common and uncommon inpatient gastrointestinal diseases including:

o Upper & lower GI bleedingo Peptic ulcer diseaseo GI infectionso Ischemic colitis.o Cirrhosiso Pancreaticobiliary diseases

Accumulate and begin to solve the issues that he/she encounters from other trainees, attendings and related medical professionals.

Teach medical students the basics of gastroenterology and hepatology care. Achieve an average percentile score of at least 61.18 on the “General” section of the in-service Gastroenterology


Practice-Based Learning Objectives: Become familiar with the concepts of quality improvement. Participate in conferences such as M&M and the VAMC Tumor Board, geared to the programmatic review of

adverse events. Begin to review, analyze and utilize scientific evidence from the gastrointestinal literature for the management of


interactions.



consultants.










Year II Fellow:



checklist):o Colonoscopy




Develop clear expertise in the diagnosis and management of acute and chronic inpatient gastrointestinal and liver diseases including:


Present cases succinctly in a direct manner. Know the VAMC GI Service’s patients at a management level. Handle consult calls respectfully and appropriately. Teach good symptom management skills to medical students and other trainees. Provide inpatient care that is safe and compassionate and develop the ability to thoroughly and clearly educate





Organize the team’s performance at teaching rounds. Read textbook and pertinent literature materials concerning problems encountered. Teach medical students and other trainees about GI disease states and patient management. Achieve an average percentile score of at least 62.98 on the “General” section of the in-service Gastroenterology


Practice-Based Learning Objectives:

Participate in project groups, committees and hospital groups when requested. Participate in programmatic reviews and conferences studying adverse events. Give usable feedback to medical students and other trainees based on observation of their performance and


patients. Know the best practice patterns to facilitate gastroenterology care through clinic operating procedures and patient

interactions.




professionals.








Service’s patients. Model appropriate interactions in multidisciplinary planning, including standard operating procedures and quality


Year III Fellows:


Patient Care Objectives: Master the Year II fellow objectives. Demonstrate efficient organization of the VAMC GI Service and a working knowledge of all patients. Demonstrate near-attending level capacity for program assessment and care planning.

Attain trainer level proficiency in the following gastroenterology procedures pertinent to his/her career choices:o Colonoscopy

By completion of Year III, master all Year II colonoscopic skill requirements. Additionally, be able to independently intubate the terminal ileum and begin to develop independent mastery of more advanced maneuvers, e.g., removal of large or complex polyps by saline assisted polypectomy or piecemeal resection and control of bleeding using clips or argon plasma laser coagulation.














Interpersonal Communication Skill Objectives:

Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner. Convey bad news compassionately and honestly.

Supervise Year I & II fellows’ work related to planning patient/family conferences and patient communications/counseling.

Communicate effectively as a consultant with staff, peers, attending gastroenterologists, referring physicians and other consultants and lead other trainees related to appropriate fellow-to-medical-professional communications.

Present cases succinctly, in a problem-based, direct manner. Assume the role of a teacher of gastroenterology to junior trainees, medical students and other healthcare

professionals.









Teaching Methods:Gastroenterology fellows participate in the VAMC GI Service during all three fellowship years. Two fellows are assigned to the VAMC GI Service during all rotations. Teaching of medical students, residents and other trainees as well as appropriate interactions with other healthcare providers are important aspects of this rotation. Participating in all required conferences is mandatory, and rounding is an integral part of this experience. As fellows gain experience throughout their training, skills of organization and efficiency as well as team leadership become increasingly important.

The VAMC GI Service experience will prepare the fellow to evaluate and manage acute and chronic gastrointestinal illnesses that will be encountered in the fellow’s future practice. This rotation will expose the fellow to a wide variety of acute abdominal inflammatory processes, major gastrointestinal hemorrhages, oncological emergencies and a wide variety of gastrointestinal problems. The development of endoscopic skills, particularly therapeutic colonoscopy, will be emphasized.

Fellows assigned to this service will evaluate all new consults at the VAMC University Drive Hospital and will be assigned to a continuity clinic one-half day per week. They will present new consults to the attending by the following day for routine consults and as soon as possible for emergencies. Fellows will evaluate each patient and will make initial recommendations regarding diagnostic tests and treatments. They will make arrangements for studies such as endoscopy, motility tests, biopsies, etc. They will review the appropriateness of the procedure with the attending before making final scheduling plans. The fellow will follow each patient under active consultation on a regular basis, will make further recommendations as indicated and will keep the attending informed of the patient’s status.

Disease Mix:Fellows see a complete mix of gastrointestinal diseases and conditions at VAMC University Drive, encompassing the entire spectrum of internal medicine diagnoses and gastrointestinal care.

Diagnoses range from pancreatitis, inflammatory bowel disease, and functional GI motility and pain disorders to primary and secondary gastrointestinal malignancies, and there is an appropriate concentration of common gastrointestinal diseases such as peptic ulcer disease, gastroesophageal reflux disease and gastrointestinal infections.

There are also a number of patients with hepatologic disorders. This patient population allows for education of fellows in the diagnosis and management of patients with acute and chronic liver diseases. Patients requiring liver transplantation are transferred to UPMC PUH-MUH. The VAMC University Drive is a tri-state and international referral center, and there is outstanding diversity of unusual diagnoses in the teaching services.

Patient Characteristics:The VAMC University Drive offers a diverse mixes of socioeconomic status. While the major of patients are male, both male and female patients are treated at this facility. Due to a primary care base simultaneous with the hospital’s constantly active referrals (complete with helicopter and fixed-wing transport 24/7), patients are seen in both acute status and in diagnostic dilemma status, with both common and uncommon disorders.

Types of Clinical Encounters – Attending Supervision:Encounters are inpatient in nature during the VAMC GI Service. Fellows provide 24/7 consultative care under the supervision of an attending within duty hour limits and with faculty back up for situations of overload. Daily attending supervision is available at the VAMC University Drive seven days per week, and in-house supervision is available all night as well. The attending has ultimate responsibility for patients.

Procedures:During the VAMC GI Service, emergency procedures (e.g. for gastrointestinal bleeding) are performed 24/7 within duty hour limits by the fellow with the attending. Non-emergent procedures are performed during daytime hours in the GI lab by the fellow under the direct supervision of the attending. Procedure based evaluation is performed twice per year by a supervising attending (see procedure practicum: direct observation).

Evaluation:Fellows are evaluated during all VAMC GI Service rotations and are expected to participate in the evaluation of other fellows as well. This occurs in the following forms: Detailed, automated evaluations using the myevaluations.com system are submitted for each rotation. These

evaluations are reflective of the program’s curriculum requirements. Attendings evaluate fellows, and the fellows evaluate the attending as well. Quarterly evaluations include:








Gastroenterology, American Journal of Gastroenterolgy, Gut, and other major publications. Curricular Design

o ACGME Outcome Project documentation (from www.acgme.org).o Graduate Education in Internal Medicine: A Resource Guide to Curriculum Development

o The report of the Federated Council for Internal Medicine Task Force on the Internal Medicine Residency Curriculum, 1997.

Pertinent Teaching References:o Textbook of Gastroenterology – Yamada, et.al.o Gastrointestinal Diasese: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.

Competencies-at-a-GlanceVAMC GI Service











documentation



documentation

The VAMC GI Service is a core fellow rotation related to the teaching and evaluation of all six competencies. Day-to-day patient care, related teaching and the curriculum conferences during the rotation are the greatest elements that teach the competencies, and the global evaluation (provided for each rotation) is the most important single measurement device. In addition to didactic learning, medical center committee participation is encouraged to bolster system-wide knowledge and practice management understanding.

SPECIAL VAMC INFORMATION:

TelephonesAll phone numbers with the extension beginning with 6 can be dialed directly from outside of the VAMC. When calling extensions beginning with 4 or 5 from outside of the VAMC, dial 688-6000, then dial 8 and then enter the extension or dial 0 (operator) for the desired extension.

VAMC GI Lab Area Policies1. The privacy and dignity of the GI patients is our highest priority. This policy must be maintained at all times.2. Discussion of patients must be done away from other patients and their families.

Special VAMC Procedures Communication Center - The communication center is located on the first floor near clinic area 1A241. The

purpose of the communication center is to provide a single contact point for referring physicians, patients, and families, and to facilitate transfers to and from the OVAMC. Phone # 5075/6682

What to do when contacted by physicians outside the Oakland VAMC? Document telephone contact (report of contact) VA form 10-01141, or a progress form can be used. This contact should include date, patient name and social security number, and a brief description of the complaint.

Medical transfers must be arranged through the Medical service office, phone 688-6146 and accepted by a medical attending prior to transfer. GI can not be the accepting service and the GI attending cannot be the accepting physician. The transferring physician must contact the accepting physician by telephone with report of reason for transfer and patient status before transporting.

The Communication Center 688-6682/5075/5077 must also be notified of pending transfer and this is the transferring physician’s responsibility.

In-house transfer of unstable or ICU patients. All ICU and CCU patients must be accompanied by a house officer to the unit. Monitors are required for all coronary care admissions. All IV lines should be in place before transporting patients to the unit.

VAMC GI Lab ProceduresAll patients require a pre-procedure assessment which should be completed in CPRSAll patients should sign a consent form. For patients unable to give informed consent a family member or power of attorney should provide consent. Complete procedure report (procedure notes) Label and print pictures Complete QA information

VAMC Emergency Cart ProcedureThe fellow is responsible for setting up the cart for out of hours procedures. Procedures can only be performed in the ICU/CCU. Otherwise hemodynamically stable patients (eg. Food impaction) requiring a procedure out of hours should be moved to the ICU/CCU. The emergency cart is kept in room 3 in the GI lab. Return the cart after the procedure. The report can be dictated or typed into CPRS under the heading gastrointestinal procedure, or alternatively the report generator can be used.

Care of VAMC Emergency EndoscopesAfter procedures out of hours scopes should be wiped down and left in the scope cleaning room in the GI lab. Do not attempt to clean the scope yourself

CONSULTATION GUIDELINES: GI Patients

Outpatients consults are reviewed by the multi-specialty nurse, and appointments are scheduled appropriately. When seeing a patient in the clinic, dictate a concise history and physical and management plan after discussing the case with an attending. A progress note should be dictated or typed for follow-up patients after appropriate perception.

For in-patients consults, the resident/fellow is paged by the appropriate party. The consult should be seen as soon as possible, but always within 24 hours. A concise history and physical should be dictated or typed. The attending will add an addendum. A daily progress note should be typed for follow-up patients using the SOAP format. The junior fellow should triage the consults and allocate them to the team members as appropriate. Emergency consults should be seen immediately and should then be discussed with the attending prior to any emergent procedure.

Liver Transplant Patients Liver transplant candidates must be coordinated through Dr. Asif Khalid (pager: #4915; email:

[email protected]). Kathy Downey CRNP (pager 2224) is the liver transplant coordinator. She can provide instructions on how to

complete the pre-transplant work-up for inpatients. Referral form must be completed by attending physician. There must be a referral letter from the attending physician summarizing the patient’s current situation and

complete clinical history and suitability for transplant.

Telephone Dictation Instructions: Call medical service (688-6146) to obtain an electronic signature code. (This is needed when reviewing/editing

and signing off on past dictated reports). Call x 688-4030 or 688-5666 with your name and SS# to be activated into the dictation system. To access dial 688-6970Enter Physician ID followed by # keyEnter work type followed by # key1. Transfer summary (stat)2. History and Physical3. Discharge and death summery

mailto:[email protected]

4. Miscellaneous5. C & P exam6. GI lab report7. Operative report8. Consults9. Progress notes10. Outpatient consult- follow the instructions about entering the consult ID number11. Outpatient progress noteEnter patient’s full ss# follow by #key Press * if a mistake is made and re-enter number

Dictation Instructions: To record - press 2 and being speaking To Pause - press 2 (soft beep-pause) Press 2 to begin recording again To edit - press 3 - skip back

press 2 - stop rewindingpress 2- record over unwanted material

To review press 3 to skip backpress 77 back to start

To forward press 44 to end of report Next report press 8

enter work type, then # Enters patient ss# number, the #. Dictation complete press 5* ( if you forgot to press 5 or get stuck call 688-5669

Dictation FormatProgress notes Your name Your clinic (GI) Type of report and patient’s name “This is Dr. ____ from GI Service dictation a progress note on John Doe”.Dictate report press 8 at end of report press 5 to disconnect. Editing - can be done prior to affixing electronic signature.Consults NotesFor both outpatient and inpatient consult notes, use the appropriate code and then follow the instructions about entering the consult ID number.


Nutrition ServiceCurriculum for Year I, II & III Fellows

Educational Purpose:The Nutrition Service introduces the fellow to inpatient management of patients needing nutrition advice and the implementation of enteral and paraenteral feeding throughout the hospital and at home. Special nutrition support attention is directed to the needs of patients receiving intestinal or visceral transplants. During this period, the fellow will have the opportunity to assess a wide variety of acute and chronic conditions. The fellow will participate in increasing levels of management/ treatment involvement with patient needs and procedures, depending on the fellow’s level of experience. The fellow will be expected to formulate the differential diagnosis, institute diagnostic studies and recommend therapy. The amount of learning obtained from this rotation is directly proportional to the amount of time spent in the evaluation of the patients.

Objectives:Fellows will learn all aspects of nutrition support care and will display all general competencies during this experience. Minimum levels of achievement in each competency are expected during each of the three years of fellowship training. Those meeting competency will receive a score of 5 in the program’s evaluation system. Fellows performing at a level better than expected for that competency receive a score of 6 or 7 in the evaluation system, those at a level better than most fellows at that PGY receive an 8, and those performing at a level deemed to be “one of the best fellows ever observed” will receive a score of 9. Fellows receiving a score of 4 or below are deemed deficient in that competency; this will be brought to the attention of the program director immediately, and, if necessary, remediation will be implemented.

The following are the goals and objectives for each competency at each level of training for the Nutrition Service:

Year I Fellow:

Goal: A Year I fellow should be able to assess new patient problems, formulate and execute a treatment plan with guidance and teach basic gastroenterology nutrition skills to medical students and other trainees. Year I fellows should begin to develop basic procedural competencies inpercutaneous endoscopic gastrotomy tube placement.

Patient Care Objectives: Perform an accurate physical examination, sometimes on acutely ill patients, and present information concisely

with an initial assessment plan. Follow the patient’s disease course during the patient’s hospital stay. With attending consultation, formulate and execute an impression and a list of recommendations for the primary service. When indicated, consent patients for procedures and order appropriate diagnostic tests (e.g., endoscopy, radiologic tests, etc.) in conjunction with the primary/referring service. Know when to use EN and PN.

Perform with supervision the following basic procedures (see practicum):o By the completion of Year I, a fellow should be able to perform an EGD with percutaneous

endoscopic gastrotomy tube placement. o Additionally the fellow should begin to understand the techniques required to place nasoduodenal

and nasojejunal tubes. Develop expertise in the diagnosis and management of acute and chronic nutrition related diseases including:

o Marasmuso Kwashiorkoro Intestinal failureo Protein losing enteropathy

Learn to provide inpatient care that is safe and compassionate and to develop the ability to thoroughly and clearly educate the inpatient in the relevant areas of disease prevention, detection, progression and therapy to promote liver health.

Medical Knowledge Objectives: Attend core conferences and teaching rounds --- especially the nutrition conferences --- to learn the

pathophysiology, epidemiology, disease management and procedure and medicine management skills for common and uncommon nutrition related diseases including:

o Marasmuso Kwashiorkoro Intestinal failureo Protein losing enteropathy


Teach medical students the basics of gastroenterology and hepatology care. By end of Year I, pass the Internal Medicine Board Examination.

Practice-Based Learning Objectives: Become familiar with the concepts of quality improvement. Participate in conferences such as M&M, geared to the programmatic review of adverse events. Begin to review, analyze and utilize scientific evidence from medical literature for the management of nutrition

support patients. Learn the best practice patterns to facilitate nutrition support care through clinic operating procedures and patient

interactions.









communication with mentors and other collaborators and related fellowship program documentation. Utilize an appropriate range of healthcare professionals to care for patients, working closely with social services to

maximize patient care and understanding the role of hospice, referring appropriately when needed. Begin involvement to understand the standard operating procedures and quality improvement initiatives within the


Year II Fellow:

Goal: A Year II fellow should learn to assess and care for a larger volume of nutrition support patients and learn and teach basic textbook and evidence-based medicine to medical students and other trainees. Patient Care Objectives: Complete a time-efficient history and physical examination. Critique the work and orders of Year I fellows. Direct the Year I fellows successfully with the appropriate level of intervention for each trainee’s skills. Complete competency-level performance of the following basic nutrition support procedures:

o EGDBy completion of Year II, master all Year I skill requirements. o Additionally, perform endoscopic placement of nasoduodenal and nasojejunal tubes.

Develop clear expertise in the diagnosis and management of acute and chronic nutrition support needs including:o Pancreatic insufficiencyo Nutrition in acute pancreatitiso Appropriate use of total parenteral nutrition

Present cases succinctly in a direct manner.

Know the Nutrition Service’s patients at a management level. Handle consult calls respectfully and appropriately. Teach good symptom management skills to medical students and other trainees. Provide inpatient care that is safe and compassionate and develop the ability to thoroughly and clearly educate



epidemiology, disease management and procedures and medicine management skills for common and uncommon inpatient nutrition diseases including:

o Pancreatic insufficiencyo Nutrition in acute pancreatitiso Appropriate use of total parenteral nutrition

Organize the team’s performance at teaching rounds. Read textbook and pertinent literature materials concerning problems encountered. Teach medical students and other trainees about nutrition disease states and patient management.


assess improvement. Participate in problem-based quality improvement projects. Review, analyze and utilize scientific evidence from nutrition support literature for patient management. Know the best practice patterns to facilitate nutrition support care through clinic operating procedures and patient

interactions.



other consultants. Present cases succinctly, in a problem-based, direct manner. Learn to become a teacher of nutrition support to junior trainees, medical students and other healthcare

professionals.






other collaborators and related fellowship program documentation.

Assist other trainees in the utilization of appropriate healthcare resources for the best care of the Nutrition Service’s patients.


Attend national gastroenterology or hepatology conferences (e.g., DDW or AASLD).

Year III Fellows:

Goal: The senior-level, Year III fellow should demonstrate rapid assessment and planning skills and near-attending level care planning and management, while teaching medical students and other trainees at near to or exceeding attending level teaching. Year III fellows should be able to perform diagnostic and therapeutic procedures independently, including placement of PEG, PEJ, nasoduodenal and nasojejunal tubes.

Patient Care Objectives: Master the Year II fellow objectives. Demonstrate efficient organization of the Nutrition Service and a working knowledge of all patients. Demonstrate near-attending level capacity for program assessment and care planning. Attain trainer level proficiency in the following procedures pertinent to his/her career choices:

o Procedure Name By completion of Year III, master all Year II skill requirements. Additionally, be able to

independently place PEG, PEJ, and naso-duodenal and naso-jejunal tubes. Secure expertise in the diagnosis and management of acute and chronic inpatient nutrition related diseases

including:o Intestinal failure and intestinal transplanto Feeding of patients with rejection of the intestinal grafts.o Risks and benefits of total parenteral nutrition

Provide inpatient care that is safe and compassionate with the leadership ability to thoroughly and clearly educate the inpatient and all other trainees regarding relevant areas of disease prevention, detection, progression and therapy to promote nutrition health.


epidemiology, disease management, procedures and medicine management skills for common and uncommon inpatient nutrition diseases including

o Intestinal failure and intestinal transplanto Feeding of patients with rejection of the intestinal grafts.o Risks and benefits of total parenteral nutrition

Teach medical students, other trainees and Year I & II fellows at near-attending level. Prepare for the ABIM certifying exam throughout the year. Organize team activities in a smooth and authoritative fashion. Assist Year II fellows’ development directly at teaching conferences and indirectly at work sites.

Practice-Based Learning Objectives: Demonstrate mastery of Year II fellow skills and encourage participation of colleagues. Review, analyze and utilize scientific evidence from the literature for the management of nutrition support disease

patients, taking a leadership role in guiding Year I & II fellows and sharing relevant literature reviews with them. Know and be able to succinctly communicate the best practice patterns to facilitate nutrition support care through





other consultants and lead other trainees related to appropriate fellow-to-medical-professional communications. Present cases succinctly, in a problem-based, direct manner.

Assume the role of a teacher of nutrition support to junior trainees, medical students and other healthcare professionals.




the Nutrition Service’s patients, including proper documentation and billing skills. Use and train others on the program’s e-portfolio system for personal documentation management,




Teaching Methods:Gastroenterology fellows participate in the Nutrition Service during all three fellowship years. One fellow is assigned to the Nutrition Service during all rotations. Teaching of medical students, residents and other trainees as well as appropriate interactions with other healthcare providers are important aspects of this rotation. Participating in all required conferences is mandatory, and rounding is an integral part of this experience. As fellows gain experience throughout their training, skills of organization and efficiency as well as team leadership become increasingly important.

The Nutrition Service experience will prepare the fellow to evaluate and manage nutrition support for acute and chronic diseases that will be encountered in the fellow’s future practice. This rotation will expose the fellow to a wide variety of disease problems associated with malnutrition, intestinal failure, and malabsorption.

Fellows assigned to this service will evaluate all new consults at UPMC Presbyterian and Montefiore Hospitals and will be assigned to a continuity clinic one-half day per week. They will present new consults to the attending by the following day for routine consults and as soon as possible for emergencies. Fellows will evaluate each patient and will make initial recommendations regarding diagnostic tests and treatments. They will review the appropriateness of the procedure with the attending before making final scheduling plans. The fellow will follow each patient under active consultation on a regular basis, will make further recommendations as indicated and will keep the attending informed of the patient’s status. Fellows must also communicate with the procedure fellow for all diagnostic studies.

Disease Mix:Fellows see a complete mix of diseases and conditions at the Nutrition Service’s teaching hospitals. UPMC Presbyterian and UPMC Montefiore have a substantial primary care basis, which provides the entire spectrum of internal medicine diagnoses and gastroenterology/hepatology care.

Diagnoses range from acute pancreatitis to intestinal rehabilitation and transplantation, and there is an appropriate concentration of common diseases such as celiac sprue, protein losing enteropathy and malnutrition due to poor enteral feeding. In particular, UPMC Presbyterian is a tri-state and international referral center, and there is outstanding diversity of unusual diagnoses in the teaching services.


Types of Clinical Encounters – Attending Supervision:Care for both inpatients and outpatients is conducted during the Nutrition Service. Fellows provide 24/7 consultative care under the supervision of an attending within duty hour limits and with faculty back up for situations of overload. Daily attending supervision is available at both UPMC Presbyterian and UPMC Montefiore seven days per week, and in-house supervision is available all night as well. The attending has ultimate responsibility for patients.

Procedures:During the Nutrition Service procedures are performed during daytime hours in the GI lab by the fellow under the direct supervision of the attending. Procedure based evaluation is performed twice per year by a supervising attending (see procedure practicum: direct observation).

Evaluation:Fellows are evaluated during all Nutrition Service rotations and are expected to participate in the evaluation of other fellows as well. This occurs in the following forms: Detailed, automated evaluations using the myevaluations.com system are submitted for each rotation. These







The computer terminal in the fellows’ portion of the M2 conference room has resources for use including: Textbook: The Science and Practice of Nutrition Support: A Case-Based Care Curriculum.

o Icon: Gastrobooks Computer-based Calculation for TPN

o Icon: TPN Calculation



Gastroenterology, American Journal of Gastroenterolgy, Gut, and other major publications.o The Science and Practice of Nutrition Support: A Case-Based Care Curriculum.o Clinical nutrition texts and a syllabus of collated research articles on clinical nutrition principles and

nutrition support practices are available in Dr. Graham’s academic office. These are available for review by fellows rotating on the Nutrition Support Service. Individual references may be copied as needed, however, the sheer volume of material exceeds that which can be duplicated en masse. In addition, each of the attendings on the Nutrition Support Service has in his/her personal file, primary papers relevant to specialized nutrition and the “science” of nutrition which he/she will share with fellows as the case material requires.

o The computer terminal in the fellows’ portion of the M2 conference room has resources for use including:

Textbook: The Science and Practice of Nutrition Support: A Case-Based Care Curriculum.

Icon: Gastrobooks Computer-based Calculation for TPN

Icon: TPN Calculation Curricular Design




Competencies-at-a-GlanceNutrition Service



360-global evaluations Direct Observation


360-global evaluations






documentation



documentation

The Nutrition Service reflects appropriate teaching and evaluation related to all six core competencies. Day-to-day patient care, related teaching and the curriculum conferences during the rotation are the greatest elements that teach the competencies, and the global evaluation is the most important single measurement device. In addition to didactic learning, medical center committee participation is encouraged to bolster system-wide knowledge and practice management understanding.


Shadyside Hospital ServiceCurriculum for Year I, II & III Fellows

Educational Purpose:The Shadyside Service introduces the fellow to both outpatient and inpatient hospital management of patients with gastrointestinal diseases. During this four-week rotation, fellows will work directly with Division faculty and community-based gastroenterologists for both clinic and inpatient work. During this period, the fellow will have the opportunity to assess a wide variety of acute and chronic gastrointestinal conditions and will receive specialized exposure to gastrointestinal oncology; given that Shadyside hospital serves patients from the UPMC Hillman Cancer Center, there is an emphasis on oncologic diseases. The fellow will participate in increasing levels of management/ treatment involvement with patient needs and procedures, depending on the fellow’s level of experience. The fellow will be expected to formulate the differential diagnosis, institute diagnostic studies and recommend therapy. The amount of learning obtained from this rotation is directly proportional to the amount of time spent in the evaluation of the patients.

Objectives:Fellows will learn all aspects of inpatient and outpatient gastrointestinal care and will display all general competencies during this experience. Minimum levels of achievement in each competency are expected during each of the three years of fellowship training. Those meeting competency will receive a score of 5 in the program’s evaluation system. Fellows performing at a level better than expected for that competency receive a score of 6 or 7 in the evaluation system, those at a level better than most fellows at that PGY receive an 8, and those performing at a level deemed to be “one of the best fellows ever observed” will receive a score of 9. Fellows receiving a score of 4 or below are deemed deficient in that competency; this will be brought to the attention of the program director immediately, and, if necessary, remediation will be implemented.

The following are the goals and objectives for each competency at each level of training for the Shadyside Hospital Service:

Year I Fellow:







second portion of the duodenum. Develop expertise in the diagnosis and management of acute and chronic inpatient gastrointestinal diseases

including:o Upper & lower GI bleedingo Peptic ulcer diseaseo GI infectionso Ischemic colitis.o Colon cancero GERD

Learn to provide inpatient and outpatient care that is safe and compassionate and to develop the ability to thoroughly and clearly educate the inpatient in the relevant areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.

Medical Knowledge Objectives:

Attend core conferences and teaching rounds to learn the pathophysiology, epidemiology, disease management and procedure and medicine management skills for common and uncommon inpatient gastrointestinal diseases including:

o Upper & lower GI bleedingo Peptic ulcer diseaseo GI infectionso Ischemic colitiso Colon cancero GERD


Teach medical students the basics of gastroenterology and hepatology care. Achieve an average percentile score of at least 61.18 on the “General” section of the in-service Gastroenterology


Practice-Based Learning Objectives: Become familiar with the concepts of quality improvement. Participate in conferences such as M&M, geared to the programmatic review of adverse events. Begin to review, analyze and utilize scientific evidence from the gastrointestinal literature for the management of


interactions, particularly in the community gastroenterologist setting.



consultants.










Year II Fellow:







Develop clear expertise in the diagnosis and management of acute and chronic inpatient gastrointestinal diseases including:

o Neuroendocrine diagnosiso Intestinal/colonic pseudobstructiono Secretory diarrheal stateso Idiopathic abdominal paino Upper & lower GI bleedingo Peptic ulcer diseaseo Inflammatory bowel diseaseo GI infectionso Pancreatitiso Ischemic colitiso GI oncologic emergencieso Graft verses host diseaseo GI opportunistic infections related to chemotherapyo Barrett’s Esophagus

Present cases succinctly in a direct manner. Know the ShadysideService’s patients at a management level. Handle consult calls respectfully and appropriately. Teach good symptom management skills to medical students and other trainees. Provide inpatient care that is safe and compassionate and develop the ability to thoroughly and clearly educate





o Colon cancero GI oncologic emergencieso Graft verses host diseaseo GI opportunistic infections related to chemotherapyo Barrett’s Esophagus

Organize the team’s performance at teaching rounds. Read textbook and pertinent literature materials concerning problems encountered, especially related to GI

cancers Teach medical students and other trainees about GI disease states and patient management. Achieve an average percentile score of at least 62.98 on the “General” section of the in-service Gastroenterology




patients. Know the best practice patterns to facilitate gastroenterology care through clinic operating procedures and patient

interactions.




professionals.








Service’s patients.



Year III Fellows:


Patient Care Objectives: Master the Year II fellow objectives. Demonstrate efficient organization of the Shadyside Service and a working knowledge of all patients. Demonstrate near-attending level capacity for program assessment and care planning. Attain trainer level proficiency in the following gastroenterology procedures pertinent to his/her career choices:






o Neuroendocrine diagnosiso Intestinal/colonic pseudobstructiono Secretory diarrheal stateso Idiopathic abdominal paino Upper & lower GI bleedingo Peptic ulcer diseaseo Inflammatory bowel diseaseo GI infectionso Pancreatitiso Ischemic colitiso Colon cancero Barrett’s Esophaguso Pancreatic Cancero GI oncologic emergencies



epidemiology, cancer screening, disease management, procedures and medicine management skills for common and uncommon inpatient gastrointestinal diseases including

o Neuroendocrine diagnosiso Intestinal/colonic pseudobstructiono Secretory diarrheal stateso Idiopathic abdominal paino Upper & lower GI bleedingo Peptic ulcer disease

o Inflammatory bowel diseaseo GI infectionso Pancreatitiso Ischemic colitiso Colon cancero Barrett’s Esophaguso Pancreatic Cancero GI oncologic emergencies





clinic operating procedures and patient interactions. Attend to the special requirements of a gastroenterologist in a community practice setting.




other consultants and lead other trainees related to appropriate fellow-to-medical-professional communications. Present cases succinctly, in a problem-based, direct manner. Assume the role of a teacher of gastroenterology to junior trainees, medical students and other healthcare

professionals.









Teaching Methods:Gastroenterology fellows participate in the Shadyside Hospital Service during all three fellowship years. One fellow is assigned to this service during all rotations. Teaching of medical students, residents and other trainees as well as appropriate interactions with other healthcare providers are important aspects of this rotation. Participating in all

required conferences is mandatory, and rounding is an integral part of this experience. As fellows gain experience throughout their training, skills of organization and efficiency as well as team leadership become increasingly important.

The Shadyside Service experience will prepare the fellow to evaluate and manage acute and chronic gastrointestinal illnesses that will be encountered in the fellow’s future practice. Inpatient rounding, clinic responsibilities and exposure to gastroenterology in a community practice setting will be part of this roation. The Shadyside Service will expose the fellow to a wide variety of acute abdominal inflammatory processes, major gastrointestinal hemorrhages, oncological emergencies and a wide variety of gastrointestinal problems.

Fellows assigned to this service will evaluate all new consults at UPMC Shadyside Hospital and will be assigned to a continuity clinic one-half day per week. They will present new consults to the attending by the following day for routine consults and as soon as possible for emergencies. Fellows will evaluate each patient and will make initial recommendations regarding diagnostic tests and treatments. They will make arrangements for studies such as endoscopy, motility tests, biopsies, etc. They will review the appropriateness of the procedure with the attending before making final scheduling plans. The fellow will follow each patient under active consultation on a regular basis, will make further recommendations as indicated and will keep the attending informed of the patient’s status. Fellows must also communicate with the procedure fellow for all diagnostic studies.

Disease Mix:Fellows see a complete mix of gastrointestinal diseases including gastrointestinal cancers at the UPMC Shadyside Hospital. UPMC Shadyside has a substantial primary care basis, which provides the entire spectrum of internal medicine diagnoses and gastrointestinal care.

Diagnoses range from pancreatitis, inflammatory bowel disease, and functional GI motility and pain disorders to primary and secondary gastrointestinal malignancies, and there is an appropriate concentration of common gastrointestinal diseases such as peptic ulcer disease, gastroesophageal reflux disease and gastrointestinal infections. In particular, UPMC Shadyside is a tri-state and international referral center, and there is outstanding diversity of unusual diagnoses in the teaching services.

Patient Characteristics:The UPMC Shadyside Service experience offers a diverse mix of socioeconomic and gender status. Teaching faculty provide an abundant supply of upper- and middle-class patients, and our contracts with medical assistance and pro bono care efforts ensure access to lower-income patients. Due to a primary care base simultaneous with the hospitals’ constantly active referrals, patients are seen in both acute status and in diagnostic dilemma status, with both common and uncommon disorders.

Types of Clinical Encounters – Attending Supervision:Encounters are inpatient in nature during the Shadyside Service. Fellows provide 24/7 consultative care under the supervision of an attending within duty hour limits and with faculty back up for situations of overload. Daily attending supervision is available at both UPMC Shadyside Hospital seven days per week, and in-house supervision is available all night as well. The attending has ultimate responsibility for patients.

Procedures:During the Shadyside Service, procedures are performed during daytime hours in the GI lab by the fellow under the direct supervision of the attending.

Evaluation:Fellows are evaluated during all Shadyside Service rotations and are expected to participate in the evaluation of other fellows as well. This occurs in the following forms: Detailed, automated evaluations using the myevaluations.com system are submitted for each rotation. These




through document maintenance. The fellow also evaluates the Gastroenterology Fellowship Program annually through a confidential basis.

Attendings evaluate the Gastroenterology Fellowship Program annually. A Curriculum Committee oversees major changes to the curriculum. Representative program personnel (i.e.,



Contact:Howard Dubner, MD is the coordinating physician for the Shadyside Rotation and may be reached at [email protected].



Gastroenterology, American Journal of Gastroenterolgy, Gut, and other major publications. Curricular Design




Competencies-at-a-GlanceShadyside Service











documentation

Systems-Based Practice Committee Participation Grand Rounds (GI & Medical)


mailto:[email protected]

Conferences documentation

The Shadyside Service provides primary fellow exposure to gastrointestinal oncologic patients and career-related experiences in a community gastroenterology practice setting. All Service responsibilities reflect the teaching and evaluation of all six competencies. Day-to-day patient care, related teaching and the curriculum conferences during the rotation are the greatest elements that teach the competencies, and the global evaluation (provided for each rotation) is the most important single measurement device. In addition to didactic learning, medical center committee participation is encouraged to bolster system-wide knowledge and practice management understanding.

Updated:December 2005June 2006January 2007September 2007

Motility ServiceCurriculum for Year II & III Fellows

Educational Purpose:The Motility Service introduces the fellow to inpatient management needs of patients suffering from functional gastroenterology disorders. Fellows will learn the appropriateness of various motility procedures and techniques as well as the physiology of gastrointestinal motility and the pathophysiology of GI motility disorders. During this period, the fellow will have the opportunity to assess a wide variety of acute and chronic conditions. The fellow will participate in increasing levels of management/ treatment involvement with patient needs and procedures, depending on the fellow’s level of experience. The fellow will be expected to formulate the differential diagnosis, institute diagnostic studies and recommend therapy. The amount of learning obtained from this rotation is directly proportional to the amount of time spent in the evaluation of the patients.

Objectives:Fellows will learn all aspects of GI motility care and will display all general competencies during this experience. Minimum levels of achievement in each competency are expected during each of the three years of fellowship training. Those meeting competency will receive a score of 5 in the program’s evaluation system. Fellows performing at a level better than expected for that competency receive a score of 6 or 7 in the evaluation system, those at a level better than most fellows at that PGY receive an 8, and those performing at a level deemed to be “one of the best fellows ever observed” will receive a score of 9. Fellows receiving a score of 4 or below are deemed deficient in that competency; this will be brought to the attention of the program director immediately, and, if necessary, remediation will be implemented.

The following are the goals and objectives for each competency at each level of training for the Motility Service:

Year II Fellow:

Goal: A Year II fellow should learn to assess and care for a large volume of motility patients and learn and learn basic textbook and evidence-based medicine related to motility disorders. Year II fellows should independently perform patient assessment in the ambulatory care setting, propose appropriate diagnostic strategies and evaluate test results.

Patient Care Objectives: Complete a time-efficient history and physical examination. Critique the work and orders of other trainees. Complete competency-level performance of the following basic motility procedures:

o Esophageal manometryo Ambulatory pH testing of the esophaguso Hydrogen breath testing

By completion of Year II, perform anorectal manometry. Develop clear expertise in the diagnosis and management of acute and chronic functional bowel support needs

including:o Achalasiao Distal esophageal spasmo Gastroesophageal reflux diseaseo Gastrointestinal manifestations of systemic sclerosiso Fecal incontinenceo Constipation

Present cases succinctly in a direct manner. Know the Motility Service’s patients at a management level. Handle consult calls respectfully and appropriately. Teach good symptom management skills to medical students and other trainees. Provide inpatient care that is safe and compassionate and develop the ability to thoroughly and clearly educate



epidemiology, disease management and procedures and medicine management skills for common and uncommon inpatient motility diseases including:

o Achalasiao Irritable bowel syndromeo Postprandial distress syndromeo Gastroparesiso Acute colonic pseudoobstructiono Chronic intestinal pseudoobstruction

Organize the team’s performance at teaching rounds. Read textbook and pertinent literature materials concerning problems encountered. Teach medical students and other trainees about motility disease states and patient management.


assess improvement. Participate in problem-based quality improvement projects. Review, analyze and utilize scientific evidence from nutrition support literature for patient management. Know the best practice patterns to facilitate nutrition support care through clinic operating procedures and patient

interactions.



other consultants. Present cases succinctly, in a problem-based, direct manner. Learn to become a teacher of GI motility to junior trainees, medical students and other healthcare professionals.






other collaborators and related fellowship program documentation. Assist other trainees in the utilization of appropriate healthcare resources for the best care of the Motility Service’s

patients. Model appropriate interactions in multidisciplinary planning, including standard operating procedures and quality

improvement initiatives. Attend national gastroenterology conferences (e.g., DDW or AASLD).

Year III Fellows:

Goal: The senior-level, Year III fellow should demonstrate rapid assessment and planning skills and near-attending level care planning and management, while teaching medical students and other trainees at near to or exceeding attending level teaching. Year III fellows should be able to perform diagnostic procedures independently. In addition, they are expected to participate in therapeutic interventions for rare esophageal motility disorders such as botulinum toxin injection, pneumatic dilation.

Patient Care Objectives: Master the Year II fellow objectives. Demonstrate efficient organization of the Motility Service and a working knowledge of all patients. Demonstrate near-attending level capacity for program assessment and care planning. Attain trainer level proficiency in the following procedures pertinent to his/her career choices:

o By completion of Year III, master all Year II skill requirements detailed in the Year II section of this Motility Service curriculum.

o Additionally, be able to independently perform and interpret anorectal manometries, interpret imaging studies of the pelvic floor and impedance studies of the esophagus.

Secure expertise in the diagnosis and management of acute and chronic inpatient motility related diseases including those listed in the Year II section of this curriculum and:

o Chronic gastroparesiso Chronic intestinal pseudoobstructiono Cyclic vomiting syndrome.

Provide inpatient care that is safe and compassionate with the leadership ability to thoroughly and clearly educate the inpatient and all other trainees regarding relevant areas of disease prevention, detection, progression and therapy to promote functional gastrointestinal health.

Medical Knowledge Objectives: Access and critique the medical literature regarding gastroenterology problems encountered. Assume the trainee leadership role at core conferences and teaching rounds regarding the pathophysiology,

epidemiology, disease management, procedures and medicine management skills for common and uncommon inpatient motility diseases including

o Achalasiao Irritable bowel syndromeo Postprandial distress syndromeo Gastroparesiso Acute colonic pseudoobstructiono Chronic intestinal pseudoobstruction

Teach medical students, other trainees and Year I & II fellows at near-attending level. Prepare for the ABIM certifying exam throughout the year. Organize team activities in a smooth and authoritative fashion. Assist Year II fellows’ development directly at teaching conferences and indirectly at work sites.

Practice-Based Learning Objectives: Demonstrate mastery of Year II fellow skills and encourage participation of colleagues. Review, analyze and utilize scientific evidence from the literature for the management of motility disease patients,

taking a leadership role in guiding Year I & II fellows and sharing relevant literature reviews with them. Know and be able to succinctly communicate the best practice patterns to facilitate GI motility care through clinic

operating procedures and patient interactions.




other consultants and lead other trainees related to appropriate fellow-to-medical-professional communications. Present cases succinctly, in a problem-based, direct manner. Assume the role of a teacher of GI motility to junior trainees, medical students and other healthcare professionals.

Professionalism Objectives: Demonstrate proficiency in Year II objectives.

Mentor medical students, other trainees and fellows in professional conduct. Assist in formal teaching exercises as requested. Assert leadership in program planning.



the Nutrition Service’s patients, including proper documentation and billing skills. Use and train others on the program’s e-portfolio system for personal documentation management,




Teaching Methods:Gastroenterology fellows may participate in the Motility Service during Years II and III of fellowship. One fellow is assigned to the Motility Service during most rotations. Teaching of medical students, residents and other trainees as well as appropriate interactions with other healthcare providers are important aspects of this rotation. Participating in all required conferences is mandatory, and rounding is an integral part of this experience. As fellows gain experience throughout their training, skills of organization and efficiency as well as team leadership become increasingly important.

The Motility Service experience will prepare the fellow to evaluate and manage gastrointestinal motility for acute and chronic diseases that will be encountered in the fellow’s future practice. This rotation will expose the fellow to a wide variety of patients and procedures and a wide variety of disease problems associated with altered gastrointestinal function. Fellows will learn the indications, usefulness and shortcomings of esophageal, anorectal motility studies, ambulatory pH studies,colonic transit studies, pelvic floor imaging studies and hydrogen breath tests.

Fellows may be assigned to a continuity clinic one-half day per week. They will present new patients to the attending by the following day for routine consults and as soon as possible for emergencies. Fellows will evaluate each patient and will make initial recommendations regarding diagnostic tests and treatments. They will review the appropriateness of the procedure with the attending before making final scheduling plans.

Disease Mix:Fellows see a complete mix of diseases and conditions at the Motility Service’s teaching hospitals. UPMC Presbyterian and UPMC Montefiore have a substantial primary and specialty care basis, which provides the entire spectrum of internal medicine diagnoses and gastroenterology/hepatology care.

Diagnoses range from achalasia to chronic intestinal pseudo-obstruction and there is an appropriate concentration of common diseases such as gastroesophageal reflux disease and defecation disorders (constipation and incontinence). Importantly, UPMC Presbyterian is a tri-state and international referral center, and there is outstanding diversity of unusual diagnoses in the teaching services.


Types of Clinical Encounters – Attending Supervision:Care for both inpatients and outpatients is conducted during the Motility Service. Fellows provide 24/7 consultative care under the supervision of an attending within duty hour limits and with faculty back up for situations of overload. Daily attending supervision is available at both UPMC Presbyterian and UPMC Montefiore seven days per week, and in-house supervision is available all night as well. The attending has ultimate responsibility for patients.

Procedures:All motility procedures are performed during daytime hours in the GI lab by the fellow under the direct supervision of the attending. Procedure based evaluation is performed twice per year by a supervising attending (see procedure practicum: direct observation). Emergency coverage for potential complications and/or questions is provided 24/7 within duty hour limits by the fellow with the attending.

Evaluation:Fellows are evaluated during all Motility Service rotations and are expected to participate in the evaluation of other fellows as well. This occurs in the following forms: Detailed, automated evaluations using the myevaluations.com system are submitted for each rotation. These









Gastroenterology, American Journal of Gastroenterolgy, Gut, and other major publications.o The Science and Practice of Nutrition Support: A Case-Based Care Curriculum.




Landmark Motility Publications:o Murray JA, Clouse RE, Conklin JL: Components of the standard oesophageal manometry.

Neurogastroenterology & Motility: 15: 591-606;2003o Pandolfino JE, Richter JE, Ours T, Guardino JM, Chapman J, Kahrilas PJ: Ambulatory esophageal

pH monitoring using a wireless system. The American Journal of Gastroenterology: 98(4): 740-749;2003

o Drossman DA, Camilleri M, Mayer E, Whitehead WE. AGA technical review on irritable bowel syndrome. Gastroenterology. 2002;123:2108-2131

o Talley NJ, Vakil NB, Moayyedi P. American Gastroenterological Association Technical Review on the Evaluation of Dyspepsia. Gastroenterology 2005; 129: 1756-1780

o Pandolfino JE, Kahrilas PJ: AGA technical review on the clinical use of esophageal manometry. Gastroenterology 2005; 128: 209-224

o Parkman HP, Hasler WL, Fisher RS: American Gastroenterological Association technical review on the diagnosis and treatment of gastroparesis. Gastroenterology 2004; 127: 1592-1622

o Quigley EMM, Hasler WL, Parkman HP: AGA technical review on nausea and vomiting. Gastroenterology 2001: 120: 263-286

o Locke GR, Pemberton JH, Phillips SF: AGA technical review on constipation. Gastroenterology 2000; 119: 1766-1778

o Spechler SJ: AGA technical review on treatment of patients with dysphagia caused by benign disorders of the distal esophagus. Gastroenterology 1999; 117: 233-254

o Diamant NE, Kamm MA, Wald A, Whitehead WE: AGA technical review on anorectal testing techniques. Gastroenterology 1999; 116: 735-760

Competencies-at-a-GlanceMOTILITY Service



360-global evaluations Direct Observation










documentation

The GI Motility Service reflects appropriate teaching and evaluation related to all six core competencies. Day-to-day patient care, related teaching and the curriculum conferences during the rotation are the greatest elements that teach the competencies, and the global evaluation is the most important single measurement device. In addition to didactic learning, medical center committee participation is encouraged to bolster system-wide knowledge and practice management understanding.

Updated:December 2005June 2006August 2007

GI Procedure ServiceCurriculum for Year II & III Fellows

Educational Purpose:The Procedure Service introduces the fellow to inpatient and outpatient gastroenterology and hepatology procedures and management of patients in need of these procedures. During this period, the fellow will have the opportunity to perform a wide variety of GI procedures with appropriate supervision. The fellow will participate in increasing levels of procedure activities, depending on the fellow’s level of experience. The fellow will be expected to conduct appropriate patient communications, perform the procedure, make post-procedure recommendations and document the procedure. The amount of learning obtained from this rotation is directly proportional to the amount of time spent conducting procedures and conferring with supervising attendings.

Objectives:Fellows will learn all aspects of procedure performance and will display all general competencies during this experience. Minimum levels of achievement in each competency are expected during each of the three years of fellowship training. Those meeting competency will receive a score of 5 in the program’s evaluation system. Fellows performing at a level better than expected for that competency receive a score of 6 or 7 in the evaluation system, those at a level better than most fellows at that PGY receive an 8, and those performing at a level deemed to be “one of the best fellows ever observed” will receive a score of 9. Fellows receiving a score of 4 or below are deemed deficient in that competency; this will be brought to the attention of the program director immediately, and, if necessary, remediation will be implemented.

The following are the goals and objectives for each competency at each level of training for the GI Procedure Service:

Year II Fellow:

Goal: A Year II fellow should learn to assess and care for a large volume of patients. Year II fellows should independently perform diagnostic upper endoscopy and colonoscopy and begin to perform therapeutic maneuvers.






Present cases succinctly in a direct manner. Know Procedure Service patients at a management level. Handle consult calls respectfully and appropriately. Teach good procedure and symptom management skills to medical students and other trainees. Provide GI procedure care that is safe and compassionate and develop the ability to thoroughly and clearly

educate the patient in the relevant areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.



o Neuroendocrine diagnosiso Intestinal/colonic pseudobstruction

o Secretory diarrheal stateso Idiopathic abdominal paino Upper & lower GI bleedingo Peptic ulcer diseaseo Inflammatory bowel diseaseo GI infectionso Pancreatitiso Ischemic colitis

Organize the team’s performance during procedure rounds. Read textbook and pertinent literature materials concerning procedure problems encountered. Teach medical students and other trainees about GI procedures and patient management.

Practice-Based Learning Objectives: Participate in project groups, committees and hospital groups when requested. Participate in programmatic reviews and conferences studying adverse procedure events. Give usable feedback to medical students and other trainees based on observation of their performance and


patients and the utilization of GI procedures. Know the best practice patterns to facilitate gastroenterology procedure care through GI la operating procedures

and patient interactions.



consultants. Present cases succinctly, in a problem-based, direct manner. Learn to become a teacher of gastroenterology procedures to junior trainees, medical students and other



larger context of pursuing programmatic successes. Practice ethical principles with relation to patient care and confidentiality. Practice interactions with pharmaceutical and medical equipment representatives and be unbiased in prescribing

and procedure habits. Practice sensitivity to cultural, age, gender and disability issues. Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to






Service’s patients.



Year III Fellows:


Patient Care Objectives: Master the Year II fellow objectives. Demonstrate efficient organization of the Procedure Service and a working knowledge of all patients. Demonstrate near-attending level capacity for program assessment and care planning. Attain trainer level proficiency in the following gastroenterology procedures pertinent to his/her career choices:





Provide gastroenterology procedure care that is safe and compassionate with the leadership ability to thoroughly and clearly educate the inpatient and all other trainees regarding relevant areas of disease prevention, detection, progression, procedure activities and therapy to promote gastrointestinal health.

Medical Knowledge Objectives: Access and critique the medical literature regarding gastroenterology and hepatology procedure problems

encountered. Assume the trainee leadership role at core conferences and teaching rounds regarding the pathophysiology,



Teach medical students, other trainees and Year I & II fellows at near-attending level. Prepare for the ABIM certifying exam throughout the year. Organize procedure team activities in a smooth and authoritative fashion. Assist Year II fellows’ development directly at teaching conferences and indirectly at work sites.

Practice-Based Learning Objectives: Demonstrate mastery of Year II fellow skills and encourage participation of colleagues. Review, analyze and utilize scientific evidence from the gastrointestinal literature for the procedure management

of GI patients, taking a leadership role in guiding Year I & II fellows and sharing relevant literature reviews with them.

Know and be able to succinctly communicate the best practice patterns to facilitate gastroenterology procedure care through GI lab operating procedures and patient interactions.




other consultants and lead other trainees related to appropriate fellow-to-medical-professional communications. Present procedure cases succinctly, in a problem-based, direct manner. Assume the role of a teacher of gastroenterology procedures to junior trainees, medical students and other


Professionalism Objectives: Demonstrate proficiency in Year II objectives. Mentor medical students, other trainees and Year I fellows in professional GI procedure conduct. Assist in formal teaching exercises as requested. Assert leadership in program planning, including fellow participation in the annual Faculty/Fellow Meeting, Fellow




the GI Procedure Service’s patients, including proper documentation and billing skills. Use and train others on the program’s e-portfolio system for personal documentation management,




Teaching Methods:Each fellow will have at least one procedure block during the three years of fellowship. Only one fellow is assigned to the GI Procedure Service. The Procedure Service experience will prepare the fellow to diagnosis and manage acute and chronic gastrointestinal illnesses that will be encountered in the fellow’s future practice. This rotation will expose the fellow to a wide variety of acute abdominal inflammatory processes, major gastrointestinal hemorrhages, oncological emergencies and a wide variety of gastrointestinal problems.

Since endoscopic procedures are integral to the gastroenterology profession, this month should serve as a time to hone skills and work on specific procedures that may be difficult to master during the inpatient months (e.g., polypectomy, esophageal dilation, etc.). The procedure month should be viewed as supplemental to the inpatient endoscopies and outpatient procedures performed with the fellow’s clinic attending.

Participating in all required conferences is mandatory. As fellows gain experience throughout their training, skills or organization and efficiency as well as team leadership become increasingly important.

During the procedure block the fellow should make an effort to work with as many different attendings as possible. Although the majority of procedures will be done at PUH GI lab, the fellow may elect to work with an attending at one of the other sites (e.g., Magee, Shadyside or VAMC). The fellow should keep a log of procedures performed during the month and should have the procedure practicum completed by a faculty member during the month.

The fellow will evaluate each patient and will make initial recommendations regarding diagnostic tests and treatments. He/she will make arrangements for studies such as endoscopy, motility tests, biopsies, etc. The fellow will review the appropriateness of the procedure with the attending before making final procedure plans. The fellow should gain experience with upper endoscopy and colonoscopy with biopsies, polypectomy and esophageal dilations during the procedure rotation.

Disease Mix:

Fellows see a complete mix of gastrointestinal diseases and conditions at the Procedure Service’s teaching hospitals. UPMC Presbyterian operates with a substantial primary care basis, which provides the entire spectrum of internal medicine diagnoses and gastrointestinal care.

Diagnoses range from pancreatitis, inflammatory bowel disease, and functional GI motility and pain disorders to primary and secondary gastrointestinal malignancies, and there is an appropriate concentration of common gastrointestinal diseases such as peptic ulcer disease, gastroesophageal reflux disease and gastrointestinal infections. In particular, UPMC Presbyterian is a tri-state and international referral center, and there is outstanding diversity of unusual diagnoses in the teaching services.

Patient Characteristics:UPMC Presbyterian offers a diverse mixes of socioeconomic and gender status. Teaching faculty provide an abundant supply of upper- and middle-class patients, and our contracts with medical assistance and pro bono care efforts ensure access to lower-income patients. Due to a primary care base simultaneous with the hospitals’ constantly active referrals (complete with helicopter and fixed-wing transport 24/7), patients are seen in both acute status and in diagnostic dilemma status, with both common and uncommon disorders.

Types of Clinical Encounters – Attending Supervision:Encounters are both inpatient and outpatient in nature during the Procedure Service. Fellows provide 24/7 consultative care under the supervision of an attending within duty hour limits and with faculty back up for situations of overload. Daily attending supervision is available seven days per week, and in-house supervision is available all night as well. The attending has ultimate responsibility for patients.

Procedures:During the Procedure Service, emergency procedures (e.g. for gastrointestinal bleeding) are performed 24/7 within duty hour limits by the fellow with the attending. Non-emergent procedures are performed during daytime hours in the GI lab by the fellow under the direct supervision of the attending. Procedure based evaluation is performed twice per year by a supervising attending (see procedure practicum: direct observation).

Evaluation:Fellows are evaluated during all Procedure Service rotations and are expected to participate in the evaluation of other fellows as well. This occurs in the following forms: Detailed, automated evaluations using the myevaluations.com system are submitted for each rotation. These








o Appropriate use of Gastrointestinal Endoscopy in Gastrointestinal Endoscopy. 52(6), 2000.o Complications of colonoscopy in Gastrointestinal Endoscopy. 57(4), 2003.o Complications of Upper GI Endoscopy in Gastrointestinal Endoscopy. 55(7), 2002.

o Visit the Practice Guidelines section of the ASGE website > http://www.asge.org/PublicationsProductsindex.aspx?id=352




Competencies-at-a-GlanceGI Hospital Service











documentation



documentation

Procedure care, related teaching and the curriculum conferences during the rotation are the greatest elements that teach the competencies, and the global evaluation (provided for each rotation) is the most important single measurement device. In addition to didactic learning, medical center committee participation is encouraged to bolster system-wide knowledge and practice management understanding.

Updated:December 2005June 2006January 2007September 2007

http://www.asge.org/PublicationsProductsindex.aspx?id=352

Research ServiceCurriculum for Year I, II & III Fellows

Educational Purpose:The Research Service introduces the fellow to the field of gastroenterology and hepatology research. While Year I fellows discuss and plan for future research, the Research Service is primarily designed for Year II and Year III fellows and allows time for research planning, work and post-research outcomes. The Division of Gastroenterology, Hepatology and Nutrition has a large faculty with diverse clinical and academic interests, ensuring that fellows have complete opportunities to investigate the gastroenterology or hepatology research project of their choice generally designed and conducted in close interaction with their mentor . The fellow will participate in increasing levels of research activities, depending on the fellow’s level of experience. The amount of learning obtained from this rotation is directly proportional to the amount of time dedicated to research.

The Division of Gastroenterology, Hepatology and Nutrition is the recipient of a T-32 training grant (Institutional Ruth L. Kirschstein NRSA Training Grant) from the National Institutes of Health. All GI fellows committed to a research career are eligible for participation in this T-32 grant, when T-32 slots are available and when all research study components are mutually agreed upon. The goal of the University of Pittsburgh’s gastroenterology research training grant is to prepare physicians and pre-/post-doctoral trainees for biomedical research careers in digestive diseases by providing concentrated, structured and well-mentored research training. Some fellows, especially T-32 trainees, may begin research activities in Year I and/or may have greater research concentrations during Years II and III.

Objectives:Fellows will follow a complete course of research study during this rotation including research ethics, project exploration, planning, actual research activity, analysis, written outcomes and, ideally, presentation of their project at a national GI or hepatology meeting or in a peer-reviewed journal. Fellows will display the following ACGME core competencies during this rotation: medical knowledge, practice-based learning, professionalism and systems-based practice. Minimum levels of achievement in each competency are expected during each of the three years of fellowship training. Those meeting competency will receive a score of 5 in the program’s evaluation system. Fellows performing at a level better than expected for that competency receive a score of 6 or 7 in the evaluation system, those at a level better than most fellows at that PGY receive an 8, and those performing at a level deemed to be “one of the best fellows ever observed” will receive a score of 9. Fellows receiving a score of 4 or below are deemed deficient in that competency; this will be brought to the attention of the program director immediately, and, if necessary, remediation will be implemented.

The following are the goals and objectives for each competency at each level of training for the GI Research Service:

Year I Fellow:

Goal: Most Year I fellows will not participate in a dedicated research rotation, although this option is open to Year I fellows in special circumstances. The first training year is a time for fellows to attend conferences, explore research project ideas, and meet with current fellows and potential faculty mentors to discuss research ideas and feasibility. Year I fellows are expected to meet with one and preferably all of the following faculty leaders related to research goals: fellowship program director, fellowship associate director (and research leader) and division chief. Fellows are not expected to begin their research project during their first year, but they are expected to select their research project and mentor before the end of their first year. Year I fellows are expected to attend the GI Research Rounds conference sessions at which Year II and III fellows present their research plans and outcomes.


and procedure and medicine management skills for common and uncommon inpatient gastrointestinal diseases and related basic science, translational and clinical research.

Accumulate and begin to solve the issues that he/she encounters from other trainees, attendings and related medical professionals. Begin to apply problem solving skills to research project analysis.

Develop a commitment to inquisitiveness and novel thinking related to research investigations. While this objective is arguably innate and can be least affected by training, it is critical for success in independent investigations.

By end of Year I, pass the Internal Medicine Board Examination.

Practice-Based Learning Objectives:

Become familiar with the concepts of quality improvement. Participate in conferences such as the GI Research conference or the Tuesday Morning Educational Program,

geared to the programmatic review of journal articles, research and related investigations. Begin to review, analyze and utilize scientific evidence from the gastrointestinal literature related to the fellow’s

research explorations and actual project.

Professionalism Objectives: Learn to understand and demonstrate professional behavior in daily activities. Participate in professionalism-based learning activities through conferences. Learn to interact collegially with his/her peer group and other healthcare professionals. Learn about and begin to practice appropriate research organizational skills including background study,

hypothesis formulation, study design, statistics, data management and data interpretation. Learn to practice ethical principles with relation to medical research. Important ethical issues include

confidentiality, informed consent, data safety, ownership and responsibility, reporting honestly, and authorship fairness.

Learn to practice appropriate interactions with pharmaceutical representatives. Learn to be sensitive to cultural, age, gender and disability issues. Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to



Systems-Based Practice Objectives: Attend conferences concerning internal system research practices, research practices elsewhere, Internal Review

Board (IRB) policies, and similar programs. Achieve basic understanding of healthcare systems related to gastroenterology and hepatology research, related

translational gastroenterology care and overall system activities. Learn proper documentation skills to practice cost-effective research activities. Develop and become familiar with the e-portfolio system for personal documentation management,

communication with research mentors and other collaborators and related fellowship program documentation. Utilize an appropriate range of healthcare professionals to explore research opportunities. Begin involvement to understand the standard operating procedures and quality improvement initiatives within the

hospital. Attend national gastroenterology conferences (e.g., ACG).

Year II Fellow:

Goal: The primary research rotation blocks occur in Year II, and fellows average five consecutive research rotations. The fellow will formulate a testable hypothesis, propose a study design and complete most of his/her investigations during Year II, and will concentrating on data acquisition and management. An understanding of statistical analysis should be achieved. Prior to their research rotation, Year II fellows will meet with the associate fellowship program director (and research leader) to ensure reasonable research goals, and Year II fellows are also expected to present their research plans at the GI Research Rounds conference. The fellow will work closely with his/her research mentor to ensure appropriate research ethics including patient privacy, complete actual research activities and begin abstract or publication materials.

Medical Knowledge Objectives: Begin to take a leadership role at core conferences and teaching rounds regarding the research investigations

and critiques, pathophysiology, epidemiology, disease management and procedures and medicine management skills for common and uncommon inpatient gastrointestinal diseases.

Organize the team’s performance in the research environment. Read textbook and pertinent literature materials concerning problems encountered. Continue to develop inquisitiveness and novel thinking attributes and apply these character traits to active

laboratory investigations.

Practice-Based Learning Objectives: Participate in project groups, committees and hospital groups when requested. Participate in programmatic reviews and conferences studying adverse events. Give usable feedback to research technicians, medical students and other trainees based on observation of their

performance and assess improvement.

Participate in problem-based quality improvement projects. Review, analyze and utilize scientific evidence from the gastrointestinal and hepatology literature to enhance

research productivity and outcomes. Know the best practice patterns to facilitate quality research projects based on research laboratory procedures

and organization.

Interpersonal Communication Skill Objectives (if patient or human subject interactions are needed for Year II research project): Interview patients and family members accurately, patiently and compassionately and present information in an

understandable manner. Practice appropriate informed consent procedures. Ensure appropriate patient confidentiality measures. Plan patient and family conferences as needed. Communicate effectively with research mentor, research staff, administrative staff, peers, attending

gastroenterologists, referring physicians and other consultants as needed. Ensure reporting honesty and authorship fairness throughout research activities.

Learn to become a teacher of gastroenterology research to junior trainees, medical students and other healthcare professionals.


larger context of pursuing programmatic and research successes. Practice appropriate research organizational skills including background study, hypothesis formulation, study

design, statistics, data management and data interpretation. Present research plans and to-date research outcomes to peers through presentations and, as relevant, in publications.

Continue to attend to the ethical principles activities and commitment achieved in Year I. Important ethical issues include confidentiality, informed consent, data safety, ownership and responsibility, reporting honestly, and authorship fairness.

Practice interactions with pharmaceutical representatives and be unbiased in research investigations. Interact appropriately and present all needed document to the system’s Internal Review Board (IRB). Practice sensitivity to cultural, age, gender and disability issues. Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to



Systems-Based Practice Objectives: Attend conferences concerning all aspects of research investigation and discovery as well as healthcare system

patient management and components of systems of healthcare. Understand and be able to work effectively related to research functions within UPMC and UPP. Understand and practice proper research organization and documentation. Use the program’s e-portfolio system for personal documentation management, communication with research

mentors and other collaborators and related fellowship program documentation. Assist other trainees in the utilization of appropriate research resources. Model appropriate interactions in multidisciplinary planning, including standard operating procedures and quality


Year III Fellows:

Goal: The senior-level, Year III fellow should demonstrate comprehensive understanding of their area of study, study design, data acquisition and analysis . In addition, they are expected to prepare a manuscript based on their work for publication in a peer-reviewed journal. Year III fellows typically dedicate an average of three rotations to finalizing their research projects and writing about their research outcomes. The development of abstract and/or publication submissions of the fellows’ research project should occur early during Year III. In cases where the Year III fellow has established themselves in research and has made strides toward a career as an independent researcher, this fellow could mentor a Year I fellow in conjunction with a faculty researcher. Fellows are required to present or publish their

research before graduation. Year III fellows are expected to present their research outcomes and plans for project outcome submissions in national publications at the GI Research Rounds conference.

Medical Knowledge Objectives: Access and critique the research literature regarding gastroenterology and hepatology problems encountered. Assume the trainee leadership role at core conferences and teaching rounds regarding the research

investigations and reviews, pathophysiology, epidemiology, disease management, procedures and medicine management skills for common and uncommon inpatient gastrointestinal diseases.

Prepare for the ABIM certifying exam throughout the year. Organize team activities in a smooth and authoritative fashion. Assist Year II fellows’ development directly at teaching conferences and indirectly at laboratory sites.

Practice-Based Learning Objectives: Demonstrate mastery of Year II fellow skills and encourage participation of colleagues related to research

successes. Review, analyze and utilize scientific evidence from the gastrointestinal literature related to the critical review of

research publications, translational research/clinical care management of GI patients, and taking a leadership role in guiding Year I & II fellows and sharing relevant literature reviews with them.

Know and be able to succinctly communicate the best practice patterns to facilitate gastroenterology care through research investigations.

Achieve acceptance of research outcome submissions in at least one of the following publication/presentation formats:

o Publication of original research;o Review article;o Editorial in a peer-reviewed (indexed) journal;o Funded peer-reviewed grant;o Book chapter in a medical textbook;o Abstracts published; and/or o Abstracts presented at a national gastroenterology or hepatology meeting.

Professionalism Objectives: Demonstrate proficiency in Year II objectives. Mentor medical students, other trainees and Year I fellows in professional research conduct. Make a commitment to finalize the research project early in Year III, so that appropriate writing and application

submissions may be made for research publications and national gastroenterology and hepatology meetings. Write about research project outcomes and work with research mentor to submit project documentation, abstracts

and/or articles to national meeting and peer-reviewed journal reviewers. Consider the multidisciplinary implications of the fellow’s research project. Learn appropriate grant writing skills. If appropriate, work with research mentor to apply for grants. Assist in formal research-related teaching exercises as requested. Assert leadership in program planning, including fellow participation in the annual Faculty/Fellow Meeting, Fellow


Systems-Based Practice Objectives: Attend conferences concerning all aspects of research investigations, healthcare system patient management and

components of systems of healthcare. Assist and mentor other trainees in utilization of appropriate UPMC/UPP healthcare resources for the best

research approaches and outcomes, including proper documentation. Use and train others on the program’s e-portfolio system for personal documentation management,

communication with research mentors and other collaborators and related fellowship program documentation. Model appropriate interactions in multidisciplinary planning, including improvements related to standard operating



Teaching Methods:

Principles of gastroenterology and hepatology research are part of the trainees’ entire fellowship experience. Fellows review other peer-reviewed research during Year I, select their own research mentor and begin planning of their own research projects during this time. Active research lab work and/or clinical investigations occur during Year II. Year III fellows finalize their research projects and prepare all outcome documentations for abstract submissions, presentations and/or publications. Fellows will have adequate clinical, laboratory and equipment resources to complete conduct and complete their research projects. Teaching of medical students, residents and other trainees as well as appropriate interactions with other research and healthcare providers are important aspects of this rotation. Participation in all required conferences is mandatory. As fellows gain experience throughout their training, skills of organization and efficiency as well as team leadership become increasingly important.

The GI Research Service experience will prepare the fellow to evaluate and manage gastroenterology and hepatology research and will prepare the fellow to work on and publish outcomes related to his/her own research projects. Fellows will be prepared for a career in academic gastroenterology/hepatology and will have the opportunity to write grants for continued research when appropriate. Fellows must communicate with his/her research mentor and with all relevant research staff and collaborators related to all investigative studies.

Research Format and Expectations:The Gastroenterology Fellowship Program is committed to a rigorous, challenging and rewarding research experience for its fellows. While most research skills may be taught and/or mentored, some critical components of research investigations related to investigator eagerness, commitment and novel thinking are instinctive and may only be encouraged and mentored via high quality teaching. Research faculty, therefore, maintain strong and valuable commitments to fellow research productivity and are committed to developing fellows’ career goals related to a research/academic career.

The GI Research Rotation incorporates the following targeting research training goals A commitment to research ethics including issues related to confidentiality, informed consent, data safety,

ownership and responsibility, reporting honestly and authorship fairness. A commitment to the thorough and thoughtful review of relevant gastroenterology and hepatology literature,

including identifying, reading and understanding this literature. A commitment to appropriate data acquisition and management both in the lab and among potential subjects. A commitment to inquisitiveness and novel thinking. This is an innate ability perhaps least affected by training but

critical for success in becoming an independent investigator. A commitment to research organizational skills including background study, hypothesis formulations, study

design, statistics, data acquisition and charting, data management and interpretation, presentations to peers and colleagues, and attention to national presentations and publications. For fellows pursuing a career in academic gastroenterology, exposure to and understanding of descriptive and analytical statistics is important.

A commitment to the basic principles of grant writing and grant writing encouragement and instruction for those fellows following a career in academic medicine.

A commitment to the identification of unique and talented researchers early on and the development of research mentoring skills in these young researchers.

Patient Characteristics:To the degree that patients or subjects are needed for the fellow’s research project, UPMC Presbyterian and UPMC Montefiore offer a diverse mixes of socioeconomic and gender status. Teaching faculty provide an abundant supply of upper- and middle-class patients, and our contracts with medical assistance and pro bono care efforts ensure access to lower-income patients. Due to a primary care base simultaneous with the hospitals’ constantly active referrals (complete with helicopter and fixed-wing transport 24/7), patients are seen in both acute status and in diagnostic dilemma status, with both common and uncommon disorders.

Evaluation:Fellows are evaluated during the GI Research Rotation and are expected to participate in the evaluation of other fellows as well. This occurs in the following forms: Detailed, automated evaluations using the myevaluations.com system are submitted for each rotation. These



Evaluation summaries become part of the fellows’ and attendings’ promotional documents.

Fellows self-evaluate through their e-portfolio participation/communication with mentors and colleagues and through document maintenance.

The fellow also evaluates the Gastroenterology Fellowship Program annually through a confidential basis. Attendings evaluate the Gastroenterology Fellowship Program annually. A Curriculum Committee oversees major changes to the curriculum. Representative program personnel (i.e.,




o Up-To-Dateo PubMedo Textbook of Gastroenterology – Yamada, et.al.o Gastrointestinal Disease: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.o Major Gastroenterology journals online and in the program’s fellow library including

Gastroenterology, American Journal of Gastroenterology, Gut, and other major publications. Curricular Design

o ACGME Outcome Project documentation (from www.acgme.org).o Graduate Education in Internal Medicine: A Resource Guide to Curriculum Development

The report of the Federated Council for Internal Medicine Task Force on the Internal Medicine Residency Curriculum, 1997. Pertinent Teaching References:

o Textbook of Gastroenterology – Yamada, et.al.o Gastrointestinal Disease: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.o Fellow participation in the University of Pittsburgh’s Clinical Research Training Program is also

available to interested trainees. Eligibility for this course will be at the discretion of the fellowship research committee.

Fellow are expected to complete the following form with Year I of their training experience:

Division of Gastroenterology, Hepatology and NutritionUniversity of Pittsburgh

GASTROENTEROLOGY FELLOWSHIP PROGRAM

Fellowship Research Blocks

The fellow’s research experience within the University of Pittsburgh Gastroenterology Fellowship Program is an important part of training. Typically, fellows average nine months of research during Year II and III of fellowship training. Fellows on a research track may be selected for the Division of Gastroenterology, Hepatology and Nutrition’s NIH T32 grant and receive up to 18 months of research training.

In order to provide the necessary research time, the fellow must complete this document.

_____________________________(Name of fellow) proposed to participate in research with _________________________________(name of faculty research mentor). The title of the project is _______________________________________________________ (title of research project) and my role in the project will be to _____________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________(include brief description of research project and your role in the project)

I have met with my research mentor and anticipate that I will require ________________(complete amount of time required, i.e., 6 months, 9 months, 1 year, etc) to complete this project. Given my mentor’s schedule and the time it will take to receive IRB approval, I request that my research block begin on _____________________(insert date) and end on ______________________(insert date).

As part of the research block I will present a brief 10 to 15 minute overview of the proposed project. At project completion, I will present my data and provide a brief written review (i.e., one side of a page) and oral presentation. These presentations will occur during the Friday GI Research Rounds conference and will be coordinated by Dr. Klaus Bielefeldt.

____________________________________ ________________________Fellow Signature Date

____________________________________ _________________________Research Mentor Signature Date

____________________________________ _________________________Program Director Date

Competencies-at-a-GlanceGI Research Rotation

COMPETENCY LEARNING OPPORTUNITY EVALUATIONPatient Care Research Activities

Conferences 360-global evaluations

Medical Knowledge Research Activities Conferences


Practice-Based Learning Quarterly M&M Conference Research Conference Journal Club Conferences Work Rounds


documentation

Interpersonal Skills Research Activities Subject Interactions


Professionalism Research Activites Conferences

360-global evaluations E-portfolio self-

documentation



documentation

Updated:August 2007