VAMC 

A.        Training Goals and Objectives

I. Year One

 

The training program in DD&N is designed to instruct subspecialty residents who have completed internal medicine training in the following:

 

            a)         Basic scientific principles, pathophysiology, clinical laboratory methods and cognitive skills necessary to diagnose and treat patients with gastrointestinal and liver diseases.

 

                        This is linked to the core competencies of Patient Care and Medical Knowledge.

 

b)          Basic principles of nutrition support, including management of parenteral and enteral feeding.

 

           This is linked to the core competencies of Patient Care and Medical Knowledge.

 

c)         Exposure to techniques of basic GI endoscopic procedures including but not limited to

                       diagnostic EGD, flexible sigmoidoscopy, esophageal dilation (with and without fluoroscopic

                       guidance), mucosal biopsy, PEG, liver biopsy, paracentesis.

Colonoscopy including polypectomy during the second half of the academic year after proficiency in flexible sigmoidoscopy.

Conscious sedation is stressed as an integral part of the procedure.

 

This is linked to the core competencies of Patient Care and Practice Based Learning and Improvement.

 

            d)         Experience in the pre-transplant evaluation of liver transplant candidates including endoscopic screening and surveillance.

 

                        This is linked to the core competencies of Patient Care, Medical Knowledge and Systems-Based Practice.

 

            e)         Experience in participating in the pre- and post-transplant care of liver transplant patients.

                       

                        This is linked to the core competencies of Patient Care, Medical Knowledge and Systems-Based Practice.

 

            f)          Experience in participating in the pre-transplant GI evaluation of cardiac and renal transplant patients and GI problems unique to the transplant setting and to immunosuppressed patients.

 

                        This is linked to the core competencies of Patient Care, Medical Knowledge and Systems-Based Practice.

 

            g)         Design and conduct clinical research projects.

 

                        This is linked to the core competency of Medical Knowledge.

 

            h)         Planning and presentation of conferences.

 

                        This is linked to the core competency of Interpersonal Communication Skills

 

            i)          Teaching of medical students, residents in medicine and other disciplines.

 

                        This is linked to the core competency of Interpersonal Communication Skills

 

k)          Experience in the care of post-colonoscopy patients, including using guidelines to schedule

            follow up procedures and appointments.  Patients’ special needs, i.e. GI cancer

            and inflammatory bowel disease, are addressed.

 

                        This is linked to the core competencies of Patient Care, Medical Knowledge and Systems-Based Practice.

 

 

            Objective a) through k) are all linked to the core competency of Professionalism at all levels.

 

 

II.         Year Two

 

Year two builds on the foundation of cognitive and procedural skills obtained during year one (outlined under A. I. a - h).

           

            In addition, the following objectives are to be achieved:

 

            a)         Refinement of endoscopic techniques (A. I. b), with a major emphasis on colonoscopy and polypectomy techniques, including snare polypectomy and saline lift injections.

 

                        This is linked to the core competency of Patient Care.

 

            b)         Technique of hemostasis (variceal and non-variceal) including injection therapy, coaptive coagulation, band ligation, contact and non-contact coagulation of mucosal hemorrhage, endoclip placement.

 

                        This is linked to the core competency of Patient Care.

 

            c)         Exposure to diagnostic and therapeutic ERCP.

 

                        This is linked to the core competency of Patient Care.

 

d)          Exposure to the treatment of achalasia including botulinum toxin injection and pneumatic

            dilatation.

           

                        This is linked to the core competency of Patient Care.

 

            e)         Experience in esophageal function studies including manometry and 24 hour pH probe, with interpretation of results.

 

                        This is linked to the core competency of Patient Care.

 

            f)          Exposure to evaluation of stool incontinence and anorectal dysfunction through transanal ultrasound.

 

                        This is linked to the core competency of Patient Care.

 

            g)         Experience in capsule endoscopy. 

                        This is linked to the core competency of Patient Care.

 

            Objectives a) through g) are also linked to core competencies of Medical Knowledge, Practice

            Based Learning and Improvement and Professionalism at all levels.

           

 

III.        Year Three

 

The core curriculum as outlined in the General Training Goals and Objectives of the division is covered in a twenty month period in years one and two with two months each year in protected time for research.

 

The third is designed to be flexible in an attempt to further develop individual’s special interests.  The division offers additional training in:

 

            1.)        Hepatobiliary and pancreatic diseases, including exposure to diagnostic and therapeutic EUS.

 

                        This is linked to the core competencies of Patient Care, Medical Knowledge and involves Practice-Based Learning and Improvement, and System-Based Practice.

 

2.)   Exposure to pre- and post- liver transplant patient care supervised by board certified transplant hepatologist.

 

                        This is linked to the core competencies of Patient Care, Medical Knowledge and involves Practice-Based Learning and Improvement, and System-Based Practice.

                                                           

3.)        Advanced endoscopic procedures including esophageal mucosal ablation therapy, placement of prostheses (esophageal, gastric, biliary, pancreatic, colorectal), endoscopic mucosal resection, submucosal dissection, enteroscopy (push and single-balloon).

 

                        This is linked to the core competencies of Patient Care, Medical Knowledge and involves Practice-Based Learning and Improvement, and System-Based Practice.

 

 

            4.)        Teaching:  Increased emphasis is placed on teaching during the third year.  Senior gastroenterology subspecialty residents will teach internal medicine and other specialty residents, as well as students about the pathophysiology of GI diseases as it relates to their individual patients.  This includes but is not limited to discussion of proper utilization of diagnostic and therapeutic procedures, nutritional support and other therapeutic modalities.  The same applies to the teaching of junior gastroenterology residents (those in years one and two).

 

 

            This is linked to the core competencies of Interpersonal Communication Skills.

 

            Objectives 1 though 4 are all linked to Professionalism at all levels.

 

 

 

 

 

B.        Instructional Environment and Teaching Methods

 

            The clinical instructional environment consists of four components:

           

            1.)        The Inpatient Consultation Service.

            2.)        The Endoscopy Suite.

            3.)        The Sub-Specialty Outpatient Center, including general GI, IBD, hepatology, and liver transplant clinics.

            4.)       The weekly Sub-Specialty Conference.

           

 

1.)        The Inpatient Service covers all consult requests from Medical, Surgical, ER and other specialty services.  The resident evaluates the patient, reviews medical records, laboratory, imaging and other studies and prepares an initial patient assessment including differential diagnoses and plan for further follow-up and therapy for presentation to the attending gastroenterologist during teaching rounds five days a week.  After hours and weekend consultations are regulated through a special on call schedule of GE residents and attending physicians.

 

Consultations are presented to the attending physician during rounds for further instruction, critique and correction. 

 

 

2.)        The fellow performs endoscopic procedures on in-and out-patients under a mentoring preceptorship designed to improve safety, accuracy, diagnostic and therapeutic yield and time management.  The integration of endoscopic findings into the overall cognitive training is stressed. 

 

3.)         Patients are seen and evaluated by the fellows, who discuss their own management plan with

           the supervising physician.  This clinic setting provides one-on-one teaching and allows for

           exposure to innumerable GI diagnoses.

 

4.)         Each week a GI case presentation or topic review is formally presented by either faculty

           members or fellows.  A multi-disciplinary approach is often used, integrating pathology,

           radiology, and surgery for discussion.   

                       

 

 

C.   Assessment of Cognitive and Procedural Skills

 

            Subspecialty residents are evaluated monthly in writing by the GI attending.  Evaluations are based on direct observation of the resident during rounds, procedures and conferences.  Feedback of cognitive and procedural skills is provided on an informal daily basis through mentoring and preceptorship, with more formal evaluations at the rotation mid point and web-based, typed evaluation with discussion at the end of the month. 

 

Additional evaluations are based on a yearly written national, computer based Self Assessment. Evaluation and a Consultation Evaluation Exercise.

 

The experience goals for procedure competence are listed in the Division Training Goals and Objectives and the Curriculum (see 6).

 

            The following objectives will have to be met before the resident will advance to the next level:

 

            a.)        EGD - Successful esophageal intubation, passage of the pylorus and intubation of the second portion of the duodenum, retroflexion in the gastric fundus.

 

                        Accurate target biopsy:

 

                        Correct recognition of common inflammatory, ulceration and neoplastic lesions with appropriate photo-and written documentation of findings.

 

A threshold level of 80% of the above criteria will be considered for advancement to therapeutic upper GI procedures, (hemostasis, dilation, PEG, combined endoscopic laparoscopic techniques).

 

            b)         Flexible sigmoidoscopy:  Passage of the rectosigmoid junction, intubation of the sigmoid colon to at least 45cm and retroflexion in the rectal ampulla. Accurate target biopsy.

                       

                        A threshold level of 80% of the above criteria will be considered for advancement to colonoscopy and polypectomy.

 

            c)         Colonoscopy:  Intubation of the cecum in 85 - 95% of cases, as well as intubation of the terminal ileum will be considered for competence.

 

            d)         ERCP:  Cannulation of the desired duct in 80% of the cases will be considered a criterium for minimal competency.

 

e)         See also Curriculum - Guidelines for Technical Skills Training (6) for threshold numbers for Level 1 and Level 2 procedures.

 

 

D.        Clinical Experience:

 

            Residents will have formal instructions, clinical experience or opportunities to

acquire expertise in the evaluation and management of gastrointestinal disorders as outlined in the Division’s Curriculum (see 7. clinical experience)

 

 

E.         ACGME Core Competencies

 

The above outlined three year curriculum assures that fellows obtain competencies in the six ones listed below to the level of a new practitioner:

                                                                                                                                                           

a.            Patient Care that is compassionate, appropriate and effective for the treatment of health problems and promotion of health.

 

b.            Medical Knowledge

 

c.            Practice Based Learning and Improvement

 

d.            Interpersonal and Communication Skills

 

e.            Professionalism

 

f.             Systems-Based Practice