I. Year One
The training program in DD&N is designed to instruct advanced 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) Techniques of basic GI endoscopic procedures including but not limited to diagnostic EGD, flexible sigmoidoscopy, esophageal dilation techniques, mucosal biopsy techniques, PEG, liver biopsy, gastric secretory studies.Colonoscopy including polypectomy during the second half of the academic year after proficiency in flexible sigmoidoscopy.This is linked to the core competencies of Patient Care and Practice Based Learning and Improvement.c) Experience with combined endoscopic - laparoscopic techniques in the operating room (during laparoscopic Heller myotomy) after proficiency in diagnostic EGD.This is linked to the core competencies of Patient Care, Medical Knowledge and Systems-Based Practice.d) Experience in the pretransplant 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.g) Experience in the multidisciplinary patient care and research in Digestive Diseases in the Digestive Disorders Center (Surgery, Gastroenterology, GI Radiology, GI Pathology, Nutrition, Ostomy Care, Social Services).This is linked to the core competencies of Interpersonal Communication Skills and Patient Care.h) Design and conduct clinical research projects.This is linked to the core competency of Medical Knowledge.i) Planning and presentation of CME conferences.This is linked to the core competency of Interpersonal Communication Skillsj) Teaching of medical students, residents in medicine and other disciplines.This is linked to the core competency of Interpersonal Communication SkillsObjective a) through j) 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 - j).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.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.This is linked to the core competency of Patient Care.c) Exposure to diagnostic and therapeutic ERCP including SO manometry.This is linked to the core competency of Patient Care.d) Exposure to the treatment of achalasia including pneumatic dilation and botulinum toxin injection.This is linked to the core competency of Patient Care.e) Experience in esophageal function studies including manometry and 24/48 pH-metry. Placement of “Bravo” capsule and interpretation of results.This is linked to the core competency of Patient Care.f) Exposure to experience in the evaluation of anorectal and pelvic floor dysfunction through defecography and anorectal manometry and transanal ultrasound.This is linked to the core competency of Patient Care.g) Experience in capsule endoscopy under the supervision of an experienced faculty member. A vast library of cases with extensive pathology is available for self study.This is linked to the core competency of Patient Care.Objectives a) through g) are also linked to core competencies of Medical Knowledge, PracticeBased Learning and Improvement and Professionalism at all levels.
III. Year ThreeThe 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 year content builds on the completion of the core curriculum and the program’s strengths in an attempt to be responsive to the resident’s special interests. It is designed to be flexible. The division offers additional training in:1) Hepatobiliary and pancreatic diseases.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 transplant hepatology through joint programs with LifeLink Transplant Institute.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 (level 2) procedures including ERCP, manometry (esophageal, SO, anorectal), ELT, mucosal ablation therapy, placement of prostheses (esophageal, gastric, biliary, pancreatic, colorectal), capsule endoscopy, enteroscopy (push and 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) Experience in the treatment of achalasia (see A. II. d.).5) Teaching: Increased emphasis is placed on teaching during the third year with the following increased responsibilities.This is linked to the core competencies of Interpersonal Communication Skills.Objectives 1 though 5 are all linked to Professionalism at all levels.a) Informal teaching: 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. GI residents will teach other residents and students assigned to the Gastroenterology Consultation Service. The same applies to the teaching of junior gastroenterology residents (those in years one and two).
b) Formal teaching: The residents assume an increasing responsibility for organization and conduction of the various TGH teaching conferences (Clinical, Pathology, Liver, GI-Surgical-X-Ray-Multidisciplinary). This includes case selection, coordination with preceptors, presentation and review of the literature.
The clinical instructional environment consists of five components:1) The Inpatient Consultation Service.2) The Gastroenterology Center (Endoscopy Service).3) The TGH Specialty Outpatient Clinic.4) The multidisciplinary Digestive Disorders Center.5) The Liver Transplant Service.
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.The teaching environment is enhanced through the fact that TGH is a tertiary referral center, the only Level I Trauma Center on the west coast of Florida, and has other facilities like a multilevel ER and Transfer Center supplemented by four aeromed ambulances, MICU, SICU, CSU, CCU, Burn Center, Pediatric ICU, Neuro ICU and Rehabilitation Center, as well as a multidisciplinary Digestive Disorders Center.2) The new Endoscopy Center consists of ten procedure rooms, four of which are dedicated to ERCP/Fluoroscopy with support facilities and is supported by state of the art Olympus video endoscopic equipment including NBI and high definition imaging. ERBE computerized electrosurgical generators, ERBE argon plasma coagulator, automated OEC fluoroscopy unit, manometry and 24/48 hr pH-metry equipment (Bravo Capsule.) Approximately 6000 endoscopic procedures are performed per year. 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. Anesthesia support for sedation and anesthesia is available by unit based anesthesiologists.3) County health plan patients are seen in consultation and in follow-up at the TGH Specialty Clinic. In addition, this clinic provides an opportunity to appreciate and address the special social problems and needs that many of these patients present with, including substance and alcohol abuse and HIV infection.4) The multidisciplinary Digestive Disorders Center is designed to provide state of the art care for digestive disorders capitalizing on the special interest, skills and research of the faculty in the Department of Surgery, Division of Digestive Diseases and Nutrition, Department of Radiology, Department of Pathology, Dietary Services and Social Services. Many faculty hold joint appointments. Patients are cared for on one designated hospital floor with joint teaching conferences and research protocols. Residents participate in this service and are taught the techniques and advantages of multidisciplinary patient care.5) Liver Transplant Service: Residents have an opportunity to participate in the pre-operative and post-operative care of patients with complex and advanced hepatic disorders and their complications including pre-peri and post-transplant endoscopies.During the third year opportunities are provided to round with the transplant team. This service has been expanded with the retention of a transplant hepatologist to include a liver and transplant clinic rotations.
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 written evaluation with discussion and copy to the resident at the end of the month. Evaluations are forwarded to the Division Director.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.
Residents will have formal instructions, clinical experience or opportunities toacquire 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 Knowledgec. Practice Based Learning and Improvementd. Interpersonal and Communication Skillse. Professionalism
f. Systems-Based Practice