The continuity clinic experience is designed to develop a continuous healing relationship between the gastroenterology fellow and the patients to whom they provide ambulatory care. This provides the opportunity for gastroenterology fellows to observe and learn the course of gastrointestinal disease, develop communication skills, improve their outpatient care practice including preventative care, develop an understanding and commitment to professionalism, learn cost effective ambulatory health care, and learn how to partner with other health care providers in an ambulatory setting. Specific competency based goals and objectives are listed below:
- Detailed knowledge of the pathophysiology of gastrointestinal disorders.
- Knowledge of the utility of diagnostic tests in specific conditions.
- Knowledge of the indications for, contraindications to, complications of, and alternatives to diagnostic and therapeutic gastrointestinal endoscopy.
- Knowledge of the utility and adverse effects of medical therapy for gastrointestinal disease.
- A knowledge of the indications for, and contraindications and alternatives to surgical treatment of gastrointestinal disorders.
- A knowledge of preventative care in patients with gastrointestinal disorders including but not limited to colon cancer and polyp screening, polyp surveillance, Barrett’s screening and surveillance, adult immunizations, screening for hepatitis B and C, and screening for hepatoma.
- Demonstration of an acceptance of a personal accountability for patient care.
- Ability to obtain an accurate and thorough history from the patient, and to perform a complete and accurate physical examination.
- Ability to generate a differential diagnosis and a working hypothesis based upon the patient evaluation.
- Ability to effectively and efficiently develop a diagnostic and therapeutic plan.
- Ability to educate and counsel patients and their families.
- Ability to initiate a preventive health care plan for patients with gastrointestinal disorders.
Practice Based Learning and Improvement
- Develops the ability to teach other fellows, residents and students.
- Participates in quality assurance and improvement projects.
- Incorporates QA guidelines into practice.
- Utilizes online and other resources to educate himself/herself, and incorporates information gathered from these resources into ongoing patient care.
- Arrives for clinic sessions on time.
- Notifies clinic personnel and patients when patient emergencies will cause delays in providing services.
- Interacts with patients and other health care personnel in a respectful and courteous manner.
- Demonstrates appropriate sensitivity to patients’ cultural, gender, age, and disability status.
- Dresses appropriately.
- Provides cost-conscious care.
- Considers a patients health care coverage when developing a treatment plan.
- Determines the need for system or community support.
- Utilizes all resourses to provide care including dietary, social services, support groups, and others.
- Serves as a patient advocate.
- Participates in development of system improvements to improve delivery of care and patient outcome.
Specific knowledge, skills and attitudes to be attained for each year of fellowship are outlined below.
First year gastroenterology fellows will acquire the following knowledge, skills and attitudes through their continuity clinic experience in conjunction with other rotations, and clinical and didactic conferences:
1. The ability to take a complete and accurate gastrointestinal history.
2. The ability to diagnose and treat common gastrointestinal disorders.
3. The ability to communicate effectively with patients and their families.
4. The ability to make use of information technology to help manage patients, obtain online medical information, and support their own learning.
5. The ability to function as a member of an outpatient care team.
6. The ability to communicate with primary care providers and other specialists.
7. The ability to effectively utilize the electronic medical record.
8. The ability to behave professionally at all times.
Second year gastroenterology fellows will acquire the following knowledge and skills through their continuity clinic experience in conjunction with other rotations, and clinical and didactic conferences:
1. A knowledge and understanding of proper billing and coding practices.
2. A knowledge of medical systems and the ways in which they impact outpatient medical care.
3.The ability to diagnose and treat less common gastrointestinal and liver disorders.
4. The ability to utilize outside resources to assist with outpatient management.
5. The ability to counsel outpatients with chronic or life threatening illnesses.
6. A knowledge of and ability to utilize preventative measures such as vaccinations and screening to optimize care of outpatients with gastrointestinal disease.
Third year gastroenterology fellows will acquire the following knowledge and skills through their continuity clinic experience in conjunction with other rotations, and clinical and didactic conferences:
1. Competency to assume complete care of patients with gastrointestinal or liver disease.
2. The ability to function in an organized and efficient fashion in the outpatient setting.
3. The ability to lead an outpatient healthcare team.
4. The ability to communicate with referring physicians and other health care providers as a gastrointestinal consultant and educator.
5. The ability to teach students and junior residents the principles of gastroenterology.
6. The ability to serve as a patient advocate.
7. The ability to use a systematic approach to reduce errors and to improve patient care.
8. A recognition of the necessity to participate in a lifelong learning process.
Instructional Environment and Teaching Methods
All continuity clinics will be held at the USF Morsani Center for Advanced Health Care. The patients at this facility are approximately 50% male, and 50% female. They have a wide variety of gastrointestinal and liver disorders representing the full spectrum of gastrointestinal and hepatobiliary disease. The patient population will include both return patients for follow up care, and new patients either referred for consultation or self referred for gastrointestinal or liver problems. The Center has an electronic medical record that can be accessed over the internet. Computers are available in every room to facilitate access to records, and information technology.
The gastroenterology fellow will work with one gastroenterology attending, who will be a faculty member in the Division of Digestive Diseases and Nutrition, for 18 months. The fellow will then rotate with a second faculty member for the final 18 months of the fellowship. Continuity clinic will be held one half day per week. The fellow is excused from all other clinical and research responsibilities to attend this clinic. Four to eight patients will be seen by the fellow per half day session with no more than three new patients, and no more than 6 return patients seen per clinic. The fellow sees each patient independently, formulates a differential diagnosis, evlauation and treatment plan. The fellow then presents the patient to the gastroenterology attending who sees the patient and verifies key parts of the history and physical findings, and approves the diagnostic and treatment plan. This provides an opportunity for teaching, as well as ensuring high quality patient care. Fellows order diagnostic testing and write all orders and prescriptions on their patients. They then follow these patients on subsequent visits. The fellows will be notified if their patient is hospitalized, and will also be notified of the results of any outpatient testing that they are not directly involved in (eg. endoscopic procedures).
Fellows interact with the nursing staff, schedulers, and financial counselors in the clinic; and the healthcare personnel at infusion centers, and at home healthcare agencies. They communicate and work with primary care providers and subspecialists referring patients. They work closely with gastrointestinal surgeons to whom they refer patients and from whom they receive consults.
Gastroenterology fellows have an opportunity and responsibility to teach patients, referring physicians and other healthcare providers about gastrointestinal disease. They are responsible for informing patients about their problems and the care of these problems, as well as appropriate preventative and health maintenance measures. They periodically will have the opportunity to teach medical residents and medical students rotating through a gastroenterology outpatient experience.
Assessment of Performance
The gastroenterology fellow will get feedback on performance from the attending gastroenterologist after each clinic session. A written core competency evaluation will be given to the fellow every six months by the attending physician. A mini-CEX evaluation will be conducted every six months. Finally, patient evaluations of the fellow will be obtained from at least two patients every six months. At the end of the fellowship, the fellow will be competent to practice outpatient gastroenterology without supervision.