Gastroenterology

Gastroenterology Competency-Based Curriculum

Rational and Overview

It is estimated that more than 60 million Americans are affected by digestive diseases, with an annual mortality of about 190,000. Six million people in the US undergo GI procedures each year, accounting for 14% of the total procedures done. New advances in the pathophysiology, diagnostic procedures and treatments have been constantly made, and care for patients with gastrointestinal disorders is a dynamic challenge.

Internists are having increasing responsibilities caring for patients with primary or secondary complaints of digestive disorders, either in their office or in the hospital setting. It is crucial for the medical residents to recognize and manager common gastrointestinal disorders during their training.

The goal of this gastroenterology rotation for our internal medicine residents is to acquire sufficient scientific knowledge, clinical skills and professional attitude to care for these patients.

Goals

A. Knowledge:

Upon completion of training, we expect our residents to:

  1. Understand the basic mechanisms of normal GI function, understand the etiology and pathogenesis of common digestive disorders.
  2. Master the clinical presentation, natural history, diagnosis and management strategies of common digestive diseases.
  3. Properly and effectively use the laboratory, radiologic, endoscopic and physiologic diagnostic studies in GI disease, and correctly interpret the results.
  4. Manage patients with common GI complaints: diarrhea, constipation, abdominal pain, non cardiac chest pain, N/V, jaundice, ascites, and abnormal liver function tests.
  5. Properly evaluate and manage immunocompromised patients presented with GI problems.
  6. Manage GI emergencies: massive upper and/or lower GI bleed, complications of fulminant or severe hepatic failure, and cholangitis.
  7. Identify situations where appropriate GI or surgery referral is indicated for optimal patient care.
  8. Keep up with the new technology and development in GI and liver diseases including but not limited to capsule endoscopy, diagnosis and management of H. Pylori, etiology and treatment for IBS, evolving treatments for IBD, and antiviral therapy for viral hepatitis.
  9. Be familiar with the indications and contraindications of GI endoscopy (EGD, ERCP, and colonoscopy), be familiar with the complications of these procedures and their management.

B. Skills

Upon completion of the GI elective, the resident will be able to:

  1. Develop the ability to accurately assess clinical situations, obtain a problem focused comprehensive gastrointestinal history and perform a complete gastrointestinal physical examination, including rectal examination and fecal occult blood testing.
  2. Synthesize a thorough assessment for a specific gastrointestinal illness and create a rational plan of clinical management.
  3. Be able to function as part of a team providing care for a patient with gastrointestinal problem(s).
  4. Observe and assist in esophagogastroduodenoscopy, colonoscopy and endoscopic retrograde chlolangiopancreatography to be able to identify the appearance of common diseases like peptic ulcer disease, various esophagitis, vascular malformations, polyps and cancerous lesions.
  5. Know indications and contraindications for paracentesis.
  6. Assist in and perform paracentesis.
  7. Be able to correctly interpret diagnostic imaging and laboratory studies.
  8. Know indications, contraindications and complications of liver biopsy.
  9. Observe and assist in liver biopsy and recognize histopathology of common diseases entities.

C. Attitudes:

Upon completion of training, we expect our residents to appreciate those attitudes valued and nurtured by gastroenterologists, including:

  1. Viewing medicine as humane science.
  2. Balancing art with science.
  3. Recognizing the limitations of technology and the value of clinical insight.
  4. Making difficult judgments when certainty is elusive.
  5. Understanding that testing, no matter how advanced or sophisticated, rarely substitutes for thorough, thoughtful evaluation by an informed clinician.
  6. Balancing intervention with patience.
  7. Recognizing limitations of our interventions.
  8. Appreciating the unique circumstances of caring for patients with chronic, usually incurable diseases.
  9. Learning the importance of functional considerations.

Experiences

In order to achieve the goals and objectives for the residency program the following experiences have been established for the purpose of teaching Gastroenterology to residents.

1. The Inpatient Experience (IP)

The residents assigned to this rotation will be responsible for supervising evaluation of inpatient consultations and patients admitted to the gastroenterology service as well as the continued follow up of these patients during their hospitalization. Essential in this role is the development and refinement of clinical evaluation skills of patients with digestive diseases. These skills include the development of appropriate differential diagnosis, assessing the need for hospitalization, diagnostic evaluation strategies and treatment plans. Essential in this rotation will be developing skills in providing consultation services, to include communicating with the referring physicians and ensuring support for continuing care of the patients' gastroenterologic condition. A resident will be called upon to perform literature research on topics appropriate to the case at hand. They will participate actively in the teaching activities of the consultation team. Through this experience the resident will also develop a comprehensive understanding of the indications, contraindications, techniques, complication of paracentesis as well as the interpretation of results from this procedure. The resident will acquire the knowledge of and skill in educating patients about the procedure and in obtaining informed consent. Faculty supervision is required in developing these skills.

2. The Ambulatory Experience (AM)

All residents will participate in gastroenterology outpatient activities appropriately supervised by dedicated attending faculty members. The goals of this experience will be for the residents to gain expertise in the outpatient evaluation and management of digestive problems. The experience provides an opportunity to develop an understanding for the natural history of these conditions over an extended period of time.

3. Didactic Conferences (DC)

Numerous monthly conferences are held for the residents throughout the month. They cover a variety of topics in all the major medical subspecialties. Residents will be required to attend each of the conferences that do not conflict with their clinical duties.

Evaluations

Assessment Methods (of Resident)

The evaluation methods that apply to these rotations include some or all of the following:

  • Evaluation of resident competence by faculty attendings (AE)- Formal formative evaluations should occur at the completion of the specific rotation. It is to be based on direct observation on rounds, at conferences, and at the bedside. All faculty members are encouraged to complete the form prior to the completion of the rotation and review their impressions directly with the resident. All completed evaluation forms are returned to the Program Director for review and placed in the resident's permanent file.
  • Mini CEXs may be used when warranted, particularly in the beginning of the academic year.
  • Self-evaluation by In-service training examination scores
  • MKSAP study plan (MKSAP)
  • Participation and presentations at didactic conferences (DC)
  • Multi Source evaluations by patients and staff (MS)

Assessment Method (of Program)

Residents have the ability to evaluate teaching faculty and experience at the end of each rotation. They are encouraged to use this opportunity to give constructive feedback.

Residents are encouraged to maintain a high level of communication with the Program Director and faculty. These informal meetings can be used to disseminate information, receive timely feedback, and for other purposes.

Annually, all residents are required to complete and return an evaluation form of the faculty and the program. Evaluations are collected in a fashion to assure the anonymity of the resident. The feedback received during informal meetings, formal meetings, and the semi-annual evaluation form will be used to make programmatic change.

Competency Based Goals & Objectives:

1) Medical Knowledge

Goals and Objectives-PGY1 Learning Activities* Assessment
Describe the epidemiology, genetics, natural history, clinical expression of the GI illness encountered in the inpatient setting. IP, AM, DC AE, DC, MKSAP
Summarize an approach to the evaluation of the common presentations of GI illness (GI bleed, diarrhea, jaundice / transaminitis, etc) IP, AM, DC AE, DC, MKSAP
Describe structure and function of GI tract, liver and biliary systems IP, AM, DC AE, DC, MKSAP
Generate and prioritize differential diagnoses for patients with digestive disease IP, AM, DC AE, DC, MKSAP
Develop rational, evidence-based management strategies for patients with digestive disease IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Summarize an approach to the evaluation of common GI presentations IP, AM, DC AE, DC, MKSAP
Distinguish patients with functional bowel disorders from those with other "organic" bowel diseases IP, AM, DC AE, DC, MKSAP
Interpret diagnostic tests used in the evaluation of outpatients with suspected GI Illness IP, AM, DC AE, DC, MKSAP
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation of outpatients and inpatients with GI disorders. IP, AM, DC AE, DC, MKSAP

2) Patient Care

Goals and Objectives-PGY1 Learning Activities* Assessment
Effectively perform a comprehensive history and complete physical examination in patients with GI/biliary symptoms IP, AM, DC AE, DC, MKSAP
Appropriately select and interpret laboratory, imaging, and pathologic studies used in the evaluation of GI/biliary disorders IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Construct a comprehensive treatment plan and assess response to therapy. IP, AM, DC AE, DC, MKSAP
Counsel patients concerning their diagnosis, planned diagnostic testing and recommended therapies. IP, AM, DC AE, DC, MKSAP
Utilize validated instruments in the assessment of function and quality of life to monitor and adjust therapy. IP, AM, DC AE, DC, MKSAP

3) Practice-Based Learning and Improvement

Goals and Objectives-PGY1 Learning Activities* Assessment
Identify and acknowledge gaps in personal knowledge and skills in the care of hospitalized and ambulatory patients with related diseases IP, AM, DC AE, DC, MKSAP
Develop and implement strategies for filling gaps in knowledge and skills of patients related diseases IP, AM, DC AE, DC, MKSAP
Integrate and apply knowledge obtained from multiple sources to the care of inpatients and outpatients IP, AM, DC AE, DC, MKSAP
Demonstrate ability to critically assess the scientific literature IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Effectively use technology to manage information, support patient care decisions, and enhance both patient and physician education. IP, AM, DC AE, DC, MKSAP
Demonstrate ability to critically assess the scientific literature IP, AM, DC AE, DC, MKSAP
Set and assess individualized learning goals IP, AM, DC AE, DC, MKSAP
Analyze clinical experience and employ a systematic methodology for improvement IP, AM, DC AE, DC, MKSAP
Develop and maintain a willingness to learn from errors, and use errors to improve the system or processes of care IP, AM, DC AE, DC, MKSAP

4) Interpersonal Skills and Communication

Goals and Objectives-PGY1 Learning Activities* Assessment
Apply empathy in all patient encounters IP, AM, DC AE, DC, MKSAP
Demonstrate effective skills of listening and speaking with patients, families and other members of the health care team IP, AM, DC AE, DC, MKSAP
Present patient information concisely and clearly, verbally and in writing IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Reliably and accurately communicate the patient's and his/her family's views and concerns to the attending IP, AM, DC AE, DC, MKSAP
Compose clear and timely admission and progress notes and consultations IP, AM, DC AE, DC, MKSAP
Counsel patients, families and colleagues regarding side effects and appropriate use of specific medications, providing written documentation when appropriate IP, AM, DC AE, DC, MKSAP
Teach colleagues effectively IP, AM, DC AE, DC, MKSAP

5) Professionalism

Goals and Objectives-PGY1 Learning Activities* Assessment
Be prompt and prepared for all clinical duties IP, AM, DC AE, DC, MKSAP
Recognize the importance of patient primacy, patient privacy, patient autonomy, informed consent, and equitable respect and care to all IP, AM, DC AE, DC, MKSAP
Respect patients and their families, staff and colleagues IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Model ethical behavior by reporting back to the attending and referring providers any key clinical findings IP, AM, DC AE, DC, MKSAP
Demonstrate integrity IP, AM, DC AE, DC, MKSAP
Respond to phone calls and pages promptly IP, AM, DC AE, DC, MKSAP

6) Systems-Based Practice

Goals and Objectives-PGY1 Learning Activities* Assessment
Demonstrate effective collaboration with other health care providers, including nursing staff, ancillary staff, therapists, primary care physicians, and consultants in the care of patients with cardiac diseases IP, AM, DC AE, DC, MKSAP
Develop an understanding of the hospital resources available to the evaluation and management of patients with problems encountered by the subspecialty. IP, AM, DC AE, DC, MKSAP
Demonstrate a knowledge of and commitment to the rules governing confidentiality of patient information. IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Discuss how the health care system affects the management of inpatients with endocrine diseases. IP, AM, DC AE, DC, MKSAP
Determine cost-effectiveness of alternative proposed interventions. IP, AM, DC AE, DC, MKSAP
Design cost-effective plans based on knowledge of best practices IP, AM, DC AE, DC, MKSAP
Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the health care system, cost of the procedure, insurance coverage, and resources utilized IP, AM, DC AE, DC, MKSAP

Teaching Methods

All residents participate in patient care duties, didactic conferences and independent reading. They will learn at the bedside from attendings, nurses and physician extenders, pharmacists, social workers, case managers, peers, and patients.

Level of Supervision

Interns are supervised in their care of patients by more senior medical house staff (PGY- 2/3 and Chief Residents) and faculty. PGY2/3 residents have direct and indirect supervision by Chief Resident and Faculty

References

Tadataka Yamada (Editor), David H. Alpers (Editor), Loren Laine (Editor): Textbook of Gastroenterology, Lippincott Williams & Wilkins Publishers.

Mark Feldman, Lawrence S. Friedman, Marvin H. Sleisenger, Bruce F. Scharschmidt: Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/ Management (2 Volume Set), W B Saunders.

Sheila Sherlock, James Dooley: Disease of the Liver and Biliary System, Blackwell Scientific Inc.

Eugene R. Schiff (Editor), Michael F. Sorrell (Editor), Willis C. Maddrey (Editor): Schiff's Diseases of the Liver, Lippincott Williams & Wilkins Publishers

Michael V. Sivak (Editor): Gastroenterologic Endoscopy (2 Volume Set), W B Saunders

Recommended Journals:

  • Gastroenterology
  • Hepatology
  • Gut
  • Digestive Disease and Sciences
  • American Journal of Gastroenterology
  • Journal of Hepatology
  • Gastrointestinal Endoscopy

Faculty

Askin, Matthew, M.D., Educational Coordinator
Franzese, John N., M.D.
Green, Jon, M.D., Co Chief
Mogan, Glen R., M.D.
Ramasamy, Dhanasekaran, M.D.
Rosenthal, Laerence, M.D.
Ruffini, Robert A., M.D.
Schrader, Zalman R., M.D.
Schuman, Robert W., M.D.
Sloan, William C., M.D.