VACATION PREFERENCE:.doc.doc

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Division of Gastroenterology, Hepatology & Nutrition ----- University of Pittsburgh School of Medicine TRAINING MANUAL for GASTROENTEROLOGY FELLOWS 2007 - 2008 Miguel D. Regueiro, MD Associate Professor of Medicine Associate Chief for Education Co-Director & Clinical Head, Inflammatory Bowel Disease Center Program Director, Gastroenterology Fellowship Program Klaus Bielefeldt, MD PhD Associate Professor of Medicine Director, GI Motility Center Associate Program Director, Gastroenterology Fellowship Program Kapil B. Chopra, MD Associate Professor of Medicine Medical Director, Comprehensive Liver program – UPMC Liver Pancreas Institute Program Director, Hepatology Fellowship Program David C. Whitcomb MD, PhD Giant Eagle Foundation Professor of Cancer Genetics Professor of Medicine, Cell Biology & Physiology and Human Genetics Chief, Division of Gastroenterology, Hepatology and Nutrition 1

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Division of Gastroenterology, Hepatology & Nutrition-----

University of Pittsburgh School of Medicine

TRAINING MANUALfor

GASTROENTEROLOGY FELLOWS

2007 - 2008

Miguel D. Regueiro, MDAssociate Professor of Medicine

Associate Chief for EducationCo-Director & Clinical Head, Inflammatory Bowel Disease Center

Program Director, Gastroenterology Fellowship Program

Klaus Bielefeldt, MD PhDAssociate Professor of Medicine

Director, GI Motility CenterAssociate Program Director, Gastroenterology Fellowship Program

Kapil B. Chopra, MDAssociate Professor of Medicine

Medical Director, Comprehensive Liver program – UPMC Liver Pancreas InstituteProgram Director, Hepatology Fellowship Program

David C. Whitcomb MD, PhDGiant Eagle Foundation Professor of Cancer Genetics

Professor of Medicine, Cell Biology & Physiology and Human GeneticsChief, Division of Gastroenterology, Hepatology and Nutrition

Division of Gastroenterology, Hepatology and NutritionUniversity of Pittsburgh School of Medicine

PUH – Mezz. 2 – C Wing200 Lothrop Street

Pittsburgh, PA 15213Phone: 412-648-9115

Fax: 412-648-9378http://dom.pitt.edu/gi

Revised 10/07

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Division of Gastroenterology, Hepatology and Nutrition University of Pittsburgh

GASTROENTEROLOGY FELLOWSHIP PROGRAM

TABLE OF CONTENTS

PAGE NUMBER DOCUMENT4 Introduction5 Faculty Roster6 Fellow Roster7 Primary Division Contact Information8 GI Fellowship Tracks:

Physician Scientist Clinical Investigation/Research Informatics and Clinical Educator

10 Specialized Training: Endoscopic Ultrasound (EUS) Transplant Hepatology Pancreaticobiliary T-32 Research Opportunities

11 POLICIES, RESPONSIBILTIES AND RELATED INFORMATION12 Orientation13 Duty Hours, On Call, Scheduling and Time Off Policies

Duty Hour Information Directions for Using the UPMC ROCS System GI On Call Hours GI and Hepatology Fellow On Call Pager Numbers Scheduling Research Blocks Vacation Requests Maternity and Paternity Leave Policies Vacation Request Form

15 Clinical Activities and Lines of Responsibility Resident Responsibilities Related to Clinical Activities Routine Fellow Responsibilities Continuity Clinic Policy to Obtain Informed Consent

16 Research: Fellow Research Block Preference Form

17 Required Conferences18 Evaluation

Procedure Practicum Information and Form21 External Meeting Attendance Policy22 Procedure Log Requirements to Complete GI Fellowship Training23 Policy for Inpatient Procedures in the GI Lab24 Magee Womens Hospital Off-Hour and Weekend Emergency Procedures25 Services to address stress, Fatigue and Related GI Fellow Needs26 Curriculum Vitae (CV) Directions29 Adherence to ACGME Core Competencies30 GI FELLOW CURRICULUM31 GI Hospital Service38 Hepatology Consultative Service46 Hepatology Outpatient Service54 Pancreaticobiliary Service61 VAMC GI Service70 Nutrition Service77 Shadyside Hospital Service85 Motility Service91 GI Procedure Service97 Research Rotation

104 Institutional & Department Policies & Procedures

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Division of Gastroenterology, Hepatology and NutritionUniversity of Pittsburgh

GI FELLOWSHIP PROGRAM

INTRODUCTION

Welcome to the University of Pittsburgh Division of Gastroenterology, Hepatology and Nutrition and the GI Fellowship Program. The GI Fellowship program seeks to select, develop and mentor young physicians in a thoughtful and scholarly manner, and we are pleased that you will join us for the next three years.

This training manual for gastroenterology fellows will provide a basic overview of this program as well as reviews of fellow service responsibilities. Additional regulatory information and documentation from recent University memos and publications is also provided.

The GI Training Program at the University of Pittsburgh is becoming more selective and, consequently, more respected every year. Our Division has a strong commitment to monitoring and evaluating the Training Program. Your comments and suggestions will be welcomed at every opportunity.

Miguel D. Regueiro, MDAssociate Professor of MedicineAssociate Chief for EducationDirector, GI Fellowship ProgramCo-Director & Clinical Head, Inflammatory Bowel Disease Center

Klaus Bielefeldt, MD PhDAssociate Professor of MedicineAssociate Program Director, GI Fellowship ProgramDirector, GI Motility Center

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Division of Gastroenterology, Hepatology & NutritionUniversity of Pittsburgh School of Medicine

FACULTY (* = SECONDARY APPOINTMENT):Steven Abo, MDAssistant Professor of Medicine - Director, GI Services at Magee Womens Hospital - GIJawad Ahmad, MDAssistant Professor of Medicine - HepatologyKathryn Albers, PhDAssociate Professor of Medicine - ResearchLeonard Baidoo, MDInstructor of Medicine - GIAnthony Bauer, PhDProfessor of Medicine - ResearchJaideep Behari, MD PhDAssistant Professor of Medicine – Hepatology & ResearchKlaus Bielefeldt, MD PhDAssociate Professor of Medicine - Director, GI Motility Lab – GI & ResearchRandall Brand, MDAssociate Professor of Medicine – GIRhonda Brand, PhD* ResearchBrian Davis, PhDAssociate Professor of Medicine - ResearchHoward Dubner, MDUPMC Shadyside - GIRichard Duerr, MDAssociate Professor of Medicine - Co-Director & Genetics Head, IBD Center – GI & ResearchMichael Dunn, MDProfessor of Medicine – Director, Medical Records TechnologyPatricia Eagon, PhDAssociate Professor of Medicine - Director, Medical Student Course in Gastroenterology, Hepatology and Nutrition - ResearchKenneth Fasanella, MDInstructor of Medicine - GIGerald Gebhart, PhD*ResearchToby O. Graham, MDAssociate Professor of Medicine – GI & NutritionJulia Greer, MD PhDAssistant Professor of Medicine - ResearchChristine Lee Gulati, MDInternal Medicine at Digestive Disorders CenterJanet Harrison, MDAssistant Professor of Medicine – Magee - GIRefaat Hegazi, MD PhDAssistant Professor of Medicine – Nutrition Farhad Ismail-Beigi, MDUPMC Shadyside - GI Hosssam Kandil, MD PhDAssociate Professor of Medicine – Hepatology & NutritionAsif Khalid, MDAssistant Professor of Medicine - Chief of GI Services, VAMC – GI & ResearchBarry Kisloff, MDClinical Assistant Professor of Medicine - Director, Clinical Services & the Digestive Disorders Center – GI

Christianna Kreiss, MDAssistant Professor of Medicine – VAMC - GISteven Lasky, MDAssistant Professor of Medicine – VAMC - GISacha Malin, PhDResearchMitchell Max, MDResearchJames B. McGee, MDAssociate Professor of Medicine - Assistant Dean for Medical Education Technology/School of Medicine - GIIan McGowan, MD PhDAssociate Professor of Medicine –Magee – GI & ResearchKevin McGrath, MDAssistant Professor of Medicine - Director, GI Lab - Director, EUS Program - GISatdarshan Monga, MD*ResearchStephen O’Keefe, MD, MScProfessor of Medicine - Director, Center for Intestinal Health & Nutrition – Nutrition & ResearchGeorgios Papachristou, MDAssistant Professor of Medicine - GIMichael Pezzone, MD, PhDAssistant Professor of Medicine – GI & ResearchMordechai Rabinovitz, MDAssociate Profesor of Medicine - HepatologyAmit Raina, MDInstructor of Medicine - GIMiguel Reguiero, MDAssociate Profesor of Medicine - Associate Chief for Education - Co-Director & Clinical Head, IBD Center - Director, GI Fellowship Program - GIMichael Sanders, MD Assistant Professor of Medicine - GIRobert Schoen, MD, MPHProfessor of Medicine - Director, Gastrointestinal Cancer Prevention & Treatment Center – GI & ResearchObaid Shakil Shaikh, MDAssociate Professor of Medicine - Director, Center for Liver Diseases - HepatologyAdam Slivka, MD, PhDProfessor of Medicine - Associate Chief for Clinical Services - GIErnest Sutton, MDClinical Professor of Medicine - GIDavid Whitcomb, MD, PhDGiant Eagle Foundation Professor of Cancer Genetics – Professor of Medicine, Cell Biology & Physiology and Human Genetics - Chief, Div. of Gastroenterology, Hepatology & Nutrition - Director, Pancreas & Biliary Center – GI & ResearchLee Weinberg, MDUPMC Shadyside – GIDhiraj Yadav, MDAssistant Professor of Medicine – GI

Division of Gastroenterology, Hepatology & NutritionUniversity of Pittsburgh School of Medicine

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GASTROENTEROLOGY FELLOWS: 2007-2008

Year IIIScott Cooper, MDMark Lazarev, MDJohn Lyons, MD – Chief Gastroenterology FellowJames Park, MD

Year IIArthur “Tripp” Barrie, MD PhDKaren Collinson, MDCarmen Meier, MDBrian Ng, MD

Year IElie Aoun, MDSandra El-Hachem, MDDavid Lo, MDShahid Malik, MDJoseph Rodemann, MDVinay Sundaram, MD

HEPATOLOGY FELLOW: 2006-2007Anastasios Mavarkis, MD

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Primary Division Contact Information:

Division of Gastroenterology, Hepatology and NutritionUniversity of PittsburghPUH – Mezz. 2 – C Wing200 Lothrop StreetPittsburgh, PA 15213

Location: Phone:

Fellowship Program Director TEL: 412-648-2344 (Elaine New, scheduling secr.)Miguel D. Regueiro, MD TEL: 412-648-3372 (direct)

PAGER: short range: 2276; long range: 565-0996

Director, Digestive Health Programs TEL: 412-648-3232Joy Jenko Merusi, MA [email protected]

Fellowship Program Coordinator TEL: 412-648-9241Helen Gibson [email protected]

Academic Main Number (M2) TEL: 412-648-9115Marlaine Moore, receptionist FAX: 412-648-9378

Digestive Disorders Center (DDC) @ PUH TEL: 412-647-8666 or 1-866-4-GASTRO (1-866-442-7876)

FAX: 412-647-6446

GI Lab @ PUH TEL: 412-647-3780FAX: 412-647-1017

Center for Liver Diseases TEL: 412-647-1770 or1-800-447-1651

FAX: 412-647-9268

GI Services @ Magee Womens Hospital TEL: 412-641-2096FAX: 412-641-2085

GI Lab @ VAMC TEL : 412-688-6177FAX : 412-688-6959 or 412-688-6942

Pager 412-647-PAGE (7243)

Referral Communications 412-647-7000

UPMC Medical Media 412-647-5050

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GI FELLOWSHIP TRACKS

Introduction: The purpose of incorporating career tracks into the fellowship include: 1) Defining long-term career goals at the beginning of the fellowship. 2) Providing a structured three-year training experience to allow each fellow to achieve their career goals. 3) Advancing interested fellows into a third-tier, specialized training programs.

The three career tracks are: physician scientist, clinical investigator/research and clinician educator/informatics. Additional masters-level courses may be taken as part of the training program (e.g., courses in public health, business administration and education). By the completion of the three-year fellowship, ALL fellows must submit at least one manuscript to a peer reviewed journal. Additionally, all fellows must give an abstract presentation at a national meeting or have a related publication or presentation opportunity approved by the fellowship program director.

At the beginning of the fellowship the program director and faculty will introduce the career tracks. Within the first six months, each fellow will meet with the program director to identify career interests. By the end of the first year, each fellow will have a structured template for the second and third years.

Physician Scientist:

Career Goals: To establish a career as a physician scientist in a university/academic center and become an independent principal investigator. Fellowship objectives: Under the supervision of a faculty mentor the fellow will be provided 18 months for bench research and 18 months of clinical training.

Faculty responsibilities: To serve as research mentor for the fellow choosing a career as a physician scientist.

Expectations at end of three year fellowship: To continue research as a post-doctoral fellow or junior faculty in an academic institution and establish independent funding as a career scientist.

Note: Although this career track is geared toward fellows with prior research experience and interest, there will be ample opportunity for fellows with little research background to enter this track. It is anticipated that fellows on this track will be supported by the (T32) Digestive Diseases Research Training Grant. Example: A fellow enters the program with extensive research experience (e.g. MD-PhD or MD with research background) and identifies a faculty mentor. By the end of the first clinical year there is a defined research project and mentor. Eighteen months of the second and third years are spent in the lab under the supervision of the faculty mentor. Fellows entering this track are encouraged to apply for grant support in the third year and to continue their research as junior faculty. Clinical Investigation/Research:

Career Goals: To establish a career as a clinical investigator in an academic medical center.

Fellowship objectives: To define a niche specialty within gastroenterology, hepatology, or nutrition and identify an area of research that would continue as a faculty member in an academic medical center.

Faculty responsibilities: In the first six months of fellowship, selected faculty will present an overview of their research. These presentations will serve as an introduction of ongoing research within the division and identify potential faculty mentors for fellows.

Expectations at the end of three-year fellowship: To join a clinical academic faculty and continue clinical research within the chosen clinical subspecialty.

Note: By the end of the first clinical year, there is a defined clinical research project and mentor. During the summer of the second or third years, there will be an opportunity to participate in didactic course work that is directed by the division of general internal medicine. The second and third years will be spent completing the clinical research project and identifying a subspecialty niche. For example, a fellow with an interest in GI oncology will participate in a research project in GI oncology and devote clinical time to this area.

Informatics and Clinician Educator:

Career Goals: To establish a career as a clinician educator with expertise in the field of medical informatics. Clinical experience in an academic-affiliated hospital will be emphasized.

Fellowship objectives: To learn how to become an effective clinician educator with an emphasis on learning informatics as an educational tool.

Faculty responsibilities: At the beginning of fellowship, introduce the field of medical informatics and its role in clinician education.

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Expectations at the end of three-year fellowship: To join an academic medical center as clinical faculty dedicated to clinical education and informatics, or to be able to incorporate education and continuing medical education into a GI practice setting.

Note: At the completion of the first year, there are identified projects within the field of medical informatics. Fellows choosing this path may have the opportunity to supplement these experiences with didactic courses through the School of Public Health or School of Medicine. In the second and third years, the fellow would define an education/informatics project that would be integrated with a subspecialty niche. For example, a fellow with a clinical interest in hepatology may design an informatics project that focused on clinician education of Hepatitis C.

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SPECIALIZED TRAINING

Introduction: The specific disciplines within gastroenterology, hepatology and nutrition support services at UPMC are available through specialized training include:

Endoscopic Ultrasound; Transplant Hepatology; and Pancreaticobiliary.

In the Division of Gastroenterology, Hepatology, and Nutrition, there are unique opportunities for fellows to gain exposure to these disciplines within the three-year core training program and/or as a separate third tier (fourth) year. (See specialized training outlines for specific career objectives.) UPMC fellows with an interest and qualifications will be given preference for selection as a third tier fellow. If an internal candidate is not identified, the position will be offered to an external candidate. Fellows entering third tier training must be board admissible or certified in gastroenterology and will be hired as a clinical instructor within the Division of Gastroenterology, Hepatology, and Nutrition.

Endoscopic Ultrasound (EUS): All fellows within the three-year core fellowship will have the opportunity for exposure to EUS through didactic conferences. Fellows with a specific interest in pursuing a career in EUS will begin EUS research in the second and third years and will complete their training as a fourth-year, third tier fellow. All of the technical, "hands-on" training will take place during the fourth year. At the end of the third tier year, fellows will have the academic and technical skills to direct an EUS program.

Transplant Hepatology: All fellows within the three-year core fellowship will have exposure to at least six months of inpatient and outpatient hepatology. Fellows with a specific interest in transplant hepatology and achieving UNOS certification will be considered for a third tier (fourth) year. Fellows interested in the third tier year will begin hepatology research in the second and third years. The third tier year will be designed as an intensive transplant hepatology experience. Fellows chosen internally will continue research projects in this third tier year. At the end of the third tier year, fellows will be UNOS certified and will have the skills to participate in a liver transplant program.

Pancreaticobiliary: Fellows interested in pancreatobiliary disease will follow a three-year core fellowship with anticipation of applying for a third-tier (fourth year) training position to become an expert in ERCP and to become familiar with EUS of the pancreas. This rotation(s) within the three-year fellowship will provide exposure and training in pancreaticobiliary disorders. 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.

Fellows in the pancreaticobiliary track will train in the basics of pancreatic and biliary physiology, pathophysiology, genetics, pancreatic function testing, pancreatobiliary radiology and surgery, as well as diagnostic and therapeutic procedures. Opportunities are also available for basic research in genetics, cell biology, molecular biology, electrophysiology, and GI oncology. In addition, fellows are encouraged to take graduate courses in clinical research and study design. A Masters in Clinical Research, Public Health, or Public Health Genetics represents several of the special graduate programs that can be completed through this program.

Within the three-year core fellowship, all fellows will have clinical rotations on the pancreaticobiliary service (e.g. fellows may continue to elect to spend 1-3 months on the pancreaticobiliary service). All fellows will have at least one month of pancreaticobiliary clinical service time during their three years. Fellows interested in the third tier year will begin pancreaticobiliary research in the second and third years. The third tier year will be designed as an intensive and technically demanding pancreaticobiliary experience.

T-32 Grant: Fellows interested in obtaining protected time for basic science research are eligible to participate in the University of Pittsburgh Division of Gastroenterology, Hepatology and Nutrition’s T-32 research grant. Fellows will be required to identify a research mentor for this program.

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Gastroenterology Division Policies, Responsibilities and Related Information

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ORIENTATION

A half-day resident orientation will be held by the Graduate Medical Education (GME) office each June and July, and Year I fellows are required to attend one half-day session. Topics discussed at this general orientation will include: Ethics, autopsy and trainee fatigue.

An additional half-day new gastroenterology fellow orientation program will be held in either June or July each year (typically during the afternoon following the GME office’s morning orientation session), and all Year I fellows and the chief fellow will be required to attend.

Orientation topics include but are not limited to: Overview of GI fellowship program Introductions of select faculty and returning fellows Tours of key Division clinical and research areas Review of rotation schedules Financial allowance information Conference information Clinical rotation information Distribution of keys and pagers Instructions for photo ID’s and related information.

Note that Year I gastroenterology fellows will be required to attend both the resident GME orientation as well as the Division’s gastroenterology fellow orientation.

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DUTY HOURS, ON CALL, SCHEDULING AND TIME OFF POLICIES

Duty Hour Information:All fellows are responsible for duty hour tracking through the UPMC ROCS (Resident Online Coordination System). Appropriate duty hour compliance is mandatory for the University of Pittsburgh Gastroenterology Fellowship Program. Gastroenterology fellows are expected to adhere to the following duty hours and on call regulations. Fellow hours will not exceed 80 hours per week. Fellows will have a minimum of 10 hours off of clinical duties between work shifts. Fellows will have at least one day out of seven per week with no work-related activities. No fellow will work more than 30 continuous hours.Any fellow duty hour violations will be noted on the GME ROCS system duty hour evaluation report. If a fellow has a violation, the program director will contact the fellow to inquire about the reason for the violation and to implement corrective action.

Directions for using the UPMC ROCS (Resident Online Coordination System): The website for viewing and approving timesheets is available through UPMC MedTrak > http://providertrak.upmc.com. Log in

using UPMC Log In and Password. Once logged into MedTrak, click the left menu link for GME ROCS. The timesheets must be approved each week between 8:00 am Friday and 12:00 midnight on Saturday. If a fellow does not sign his/her time sheet by 12:00 midnight on Saturday, a paycheck will not be issued.

If a fellow cannot sign off, notify Helen Gibson by e-mail > [email protected], and she can approve the timesheet. If Helen is not e-mailed, the time sheet will not be approved, and the fellow will not receive his/her paycheck.

The system will permit only a few changes to the schedule. For now, all other changes must be made by Helen, or the fellow will need to type the changes in the comment box (i.e., and Helen will then input the new schedule information).

Fellows may change the start and/or end times of their shifts. Helen has only listed the Tuesday morning and Medical Grand Rounds conferences for now. If a fellow does not

attend one of these conferences, the fellow must inform her. For now, Helen has entered “day off” information. Needed corrections should be reported to Helen.

Moonlighting needs to be documented through the ROCS system as well. All moonlighting work must be reported to Helen in writing via e-mail.

GI On Call Hours: GI on call weekday hours are 5:00 pm to 8:00 am. A minimum of two fellows will be on call over the weekend:

o Weekends are split, so that each fellow will be on call for 24 hours from 8:00am on Saturday to 8:00am on Sunday with the same for Sunday.

o Each fellow will cover either GI or Liver/VA. On Sunday, the GI fellow will also cover the pancreaticobiliary service.o Fellows staying past 10:00pm on weeknights will leave at 1:00pm the following day.

GI and Hepatology Fellow On Call Pager Numbers: GI = 3227 Hepatology = 3299 Nutrition = 6629

Scheduling Research Blocks:Fellows must notify the chief fellow of their research time requests, when the yearly schedule is determined. Once the schedule is set, there will be no changes. If a fellow needs to make a change, he/she must find coverage for the change, and then all involved fellows must propose their change plan to the chief fellow. The program director will have the final say regarding any conflicts.

Vacation Requests: A vacation request form (see next page of this manual for a form sample) is distributed at the beginning of the fellowship year. Time

off requests are considered when the fellow rotation master schedule is made. If these original time off requests change, fellows are to inform Helen Gibson and the chief fellow, in writing, at least one month before the change.

Additional time off requests for vacation, conferences, etc. are to be made in writing no later than one month before the intended time off period. These requests are to be submitted to Helen Gibson and the chief fellow and are subject to approval by Dr. Regueiro.

For any time off period, it is the obligation of the fellow to arrange for appropriate and approved coverage. The following fellowship program rotations permit vacation: Research, VAMC, Shadyside, Motility, Liver Outpatient and GI

Procedures.

Maternity & Paternity Leave Policies: Female fellows will receive six weeks off for maternity leave. Male fellows will receive one week off for paternity leave.

The following is a copy of the fellow vacation form that must be completed and given to the program coordinator per the instructions on the previous page of this manual.

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FELLOW VACATION PREFERENCES FOR 2006-07 SCHEDULE

FELLOW NAME: ________________________________________________

DECEMBER HOLIDAY:

HOLIDAY: CHRISTMAS NEW YEARSCHOICE:

VACATION PREFERENCE:(One week blocks)

OMIT October 29 to November 3, 2006 (ACG); October 27 to 31, 2006 (AASLD);Mid-November to End December 22, 2006 (Second Year Medical Student Course); and May 20-25, 2006 (AGA-DDW)

FIRST SECOND THIRD FOURTHCHOICE:

LIFE EVENTS:(Weddings, Births, Religious Holidays)

DATE, DAYS DESCRIPTION

ARE YOU TAKING INTERNAL MEDICINE BOARDS? YES______ NO_____

COMMENTS:________________________________________________________________________________________

Please return to ASAP:Helen Gibson ([email protected] of Gastroenterology and HepatologyPUH, Mezzanine Level, C-Wing200 Lothrop StreetPittsburgh, PA 15213FAX: 412 383 7580Phone: 412 648 9241

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CLINICAL ACTIVITIES AND LINES OF RESPONSIBILITY

Resident responsibilities Related to Clinical Activities: Patient Care: Fellows’ clinical education will be emphasized over service. Rotation learning objectives describe levels of patient

care for all three fellowship years, and this information may be found in the rotation curriculum sections of this manual. Level of Responsibility for Patient Management: Fellows will experience increasing levels of responsibility for patient management,

as the progress successfully through the training program. Levels of responsibility for each rotation and each year level of training may be found in the curriculum sections of this manual.

How Supervised and By Whom: All fellow patient care actions and responsibilities are supervised by assigned attending faculty and/or the program director through direct observation, signing off on all procedures, fellow evaluations and direct supervision for all activities. Additional information about fellow supervision may be found in the curriculum sections of this manual.

Routine Fellow Responsibilities:Gastroenterology fellows do not routinely perform ancillary services such as routine blood draws, prepping patients, starting IV’s, transporting patients, etc. If a fellow finds him/herself conducting these duties, he/she should report these activities to the program director for corrective action.

Continuity Clinic:Fellows will participate in a continuity clinical one-half day per week during the entire 36 months of training. Fellows will work within the same clinic during their first year. Based on interest, the fellow may rotate through other specialty clinics in six-month internals during the remaining two years of their training.

Policy to Obtain Informed Consent:All physicians are reminded that a very detailed policy and procedure technique has been approved by the Board of the University of Pittsburgh Medical Center and its affiliated hospitals on the mechanism by which an informed consent must be obtained. You are reminded that a patient may bring legal action against any physician who performs a procedure without obtaining Informed Consent in an approved manner. Such physician can be convicted of battery if Informed Consent is not obtained in the approved fashion regardless of the outcome of the procedure. It is therefore imperative that all physicians have a clear understanding of the mechanism by which Informed Consent is obtained and to make sure that for each and every patient who has a procedure Informed Consent has been obtained including a full explanation of the risks involved, benefits and alternatives. Each dictation of procedures and each procedure note must specifically state that the patient understood all important risks and that the patient was fully capable of providing an Informed Consent to the procedure. A detailed explanation of the hospitals consent policy is on file in Dr Wald’s office. Several aspects of this procedure are worth reviewing. 1. The definition of an Informed Consent approved by the health care services malpractice Act, Act III is defined as THE PHYSICIAN

HAS INFORMED THE PATIENT.2. Informed consent must in every case include a full discussion of alternatives by the physician with the patient. 3. When verbal consent is obtained, either by the telephone or direct discussion with the patient, at least two individuals must witness

this consent and at least one of whom must be a nurse.4. The means of obtaining telephone or telegraph consent are quite specific as follows

a. If the patient is unable to consent and the person legally responsible for providing consent for the patient (minor, mental incompetent, other) is unable to come to the Hospital to sign the consent form, telephone consent is permissible.

b. This consent must be witnessed by two individuals on extensions of the same line who must sign the witness section of the consent form.

c. The means of obtaining the consent (telephone number and the time obtained) should be noted on the consent form.5. Physicians are urged to use caution on the judgment of the patients capacity to provide informed consent, particularly in any

situation which is clearly not an emergency. The specific wording used to describe the indications for obtaining consent from the patient’s family or legal guardian includes the very vague and broad concept that the patient may not be competent whenever “a physician or nurse has CAUSED TO DOUBT the medical capacity of the patient to consent” or to “understand the nature of the proposed treatment or procedure”. Note that this is a very broad definition where any doubt as to the patient’s capacities to fully understand the nature of the procedure or treatment requires additional consultation with the patient’s family or legal guardian. This is particularly true of patients who may show signs of encephalopathy.

6. The specific responsibilities for the physician in obtaining an informed consent are rather significant. These are:a. The physician/surgeon must explain to the patient the material aspects of the nature of the proposed procedure or treatment,

the risks involved, and the alternative to treatment or diagnosis.i. The physician should use layman’s terms during the explanation.ii. If a language barrier exists, a foreign language bank is available to obtain an interpreter.

b. The physician will enter on the order sheet the exact wording of the procedure(s) or treatment(s) planned and the physician who will perform the procedure.

c. The physician’s procedure note must reflect that the physician has discussed the proposed procedure/treatment, the risks involved, and the alternatives to treatment with the patient.

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RESEARCH

Fellows are expected to dedicate a block of time during Year II of fellowship to their research project. Fellows will be supervised by research faculty during their research blocks. Fellows are expected to maintain their continuity clinic during the research block experience. Before the end of training, fellows must demonstrate evidence of recent research productivity through one or more of the following: Publications (manuscripts or abstracts) in peer reviewed journals; and/or Abstracts presented at national subspecialty meetings.

Fellows are expected to complete and submit the following form towards the end of Year I (deadline date will be assigned). This form provides information to the Chief Fellow and fellow leadership that will be needed to assign fellow schedules for the following year.

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

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REQUIRED CONFERENCES:

Fellows are required to attend the following conferences:Mandatory for

FellowsConference Name PIF # Description Day Time Frequency

Yes State-of-the-Art Lecture Series: Summer Core Curri-culum Conference

13001 Core curriculum Tues. & Thurs.

7:30 – 8:30 am

8/mo. in summer for a total of 16 summer programs

Yes Medical Grand Rounds

13001 Core curriculum Fri. 11:00 – 12:00 n

4/mo.

Yes GI Grand Rounds 13001 Core curriculum Wed. 5:00 – 6:15 pm

4/mo. Sept. thru June

Yes Tuesday Morning Educational Conference: Patho-physiology/Clinical (incl. Endoscopy Conference)

13001 Core curriculum Tues. 7:30 – 8:30 am

1/mo. (endoscopy confr. = 1/quarter)

Yes Tuesday Morning Educational Confr.: Pathophysiology/Basic Science

13004 Basic science Tues. 7:30 – 8:30 am

1/mo. or more

Yes Tuesday Morning Educational Confer-ence: Journal Club

13010 Journal club Tues. 7:30 – 8:30 am

2/mo.

Yes Tuesday Morning Educational Confe-rence: Morbidity & Mortality (M&M)

13013 M&M Tues. 7:30 – 8:30 am

1/quarter

Yes GI Pathology Conference

13016 Multidisciplinary clinical confr.

Wed. 7:30 – 8:30 am

1/mo.

Yes GI Research Rounds 13007 Research Fri. 12:00 – 1:00 pm

2/mo.

Yes GI Motility/IBD Rounds

13016 Multidisciplinary clinical confr.

Fri. 12:00 – 1:00 pm

2/mo.

Yes Hepatology Conference

13016 & 13010

Clinical confer-ence, journal club & liver pathology

Wed. 7:30 – 8:30 am

4/mo.

Fellows are required to attend the core conference series outlined on this page.

The UPMC Health System offers many more conferences, and fellows are invited to any/all of these programs. Some additional non-required conferences which GI fellows regularly attend include: Hepatology Administrative & Research Meeting; Transplant Immuno-Pathology Conference, Pancreaticobiliary Conference, VMAC Liver Transplant Morbidity & Mortality Conference; Nutrition Grand Rounds; VAMC Tumor Board; and the Esophageal Disorders Conference.

Additional education concerning Palliative Medicine may be found at http://www.aahpm.org/cgi-bin/wkcgi/search?fastfact=1&search=1.

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EVALUATION

The Gastroenterology Fellowship Program uses an online evaluation system for most program evaluations. Fellows will be registered for access to www.myevaluations.com when starting the program, and fellows will be expected to complete all evaluation submission deadlines throughout their fellowship experience. Faculty attendings also use the myevaluations.com for fellow reviews. Automatic reminders are e-mailed to any reviewer who does not meet the submission deadlines, and these reminders continue to be sent until the evaluator completes his/her evaluations. If a reviewer ranks a comment poorly, the program director is automatically informed of this ranking, so that he may take immediate and appropriate action to improve the issue.

Evaluations to be completed through the myevaluations.com program include: Fellow evaluation of faculty – completed for each rotation. Faculty evaluation of fellows – completed for each rotation. Fellow global evaluations of peers – completed semi-annually. Other medical professional and staff global evaluations of fellows – completed semi-annually.

Evaluations to be complete via hardcopy forms include: Fellow evaluation of program and faculty – completed annually (June). (This is a confidential evaluation, and only aggregate scores

and comments are shared with reviewing leadership. If a fellows asks for a comment to not be shared, this comment will not be shared.)

Faculty evaluation of program and fellows – completed annually (June). Patient evaluations of fellows – completed annually (Spring). Procedure Practicum evaluation (i.e., direct observation) – completed semi-annually. Please see the following page for a sample of

the Procedure Practicum.

Fellows also take the AGA Gastroenterology Training Examination (GTE) annually (April). All fellows receive copies of their scores directly with comparisons to internal and national scores of the fellows’ peers. GTE results may be used by the fellow to identify areas of strength and to attend to and improve lower score areas. Likewise, aggregate GTE results are used by the program director and program leadership to improve fellow education opportunities, conference topics and other areas based on any lower fellow GTE scores.

Promotion Policy:Promotion of fellows from one year to the next is based on adequately fulfilling the goals and objectives set forth for Years I, II and III of the University of Pittsburgh GI Fellowship Program. All fellows must complete core competency requirements and meet the program goals as stated in the GI Fellowship Program Training Manual. Determination of promotion will be confirmed by the Program Director at the year-end (June) review meeting.

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EVALUATION

Procedure Practicum: Direct Observation of Fellow by Supervising Attending

Twice per year (November/December and April/May), Year I and III fellows will receive a focused direct observation evaluation of procedural competency by a supervising attending. This evaluation will be performed on one upper endoscopy and one colonoscopy twice per year. Ideally, the evaluating attending is the fellow’s continuity clinic attending, and this practicum should take place as part of a routine half day of procedures with that attending. However, the attending evaluator may be the inpatient attending or other faculty.

Given that competency develops over the three fellowship years, and certain aspects of procedural skills are learned with time, the task being evaluated is followed by parentheses with an expectation for each year. Related to the colonoscopy procedure, for example, insertion of scope into rectum should be achieved by all three years, whereas intubation of terminal ileum is expected only of Year III fellows.

At the completion of the evaluation, the attending will provide written and verbal feedback. For any areas “not competent,” the attending will discuss area(s) requiring remediation with the fellow and will repeat the evaluation at a later date after additional training has occurred (no more than eight weeks from original evaluation). If the fellow remains “not competent” in a certain area, further remediation and training will be provided by the program.

Year III fellows are only required evaluation once (November/December). If deficiencies are identified at that time, additional training will be administered by the program, and re-evaluation will occur in April.

A copy of this direct observation evaluation, the Procedure Practicum, may be found on the following page.

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The following is a sample of the Gastroenterology Fellowship Program’s direct observation evaluation form. See a reference and description of this form on the previous page of this manual.

PROCEDURE PRACTICUM CHECKLIST

Fellow Name: _____________________________________ Year #: _____________Attending Evaluator: _____________________________________ Date: _____________

GENERAL TO ALL PROCEDURES:Procedure Activity Competent Not Competent Not Applicable

Consents the patient for the procedure appropriately, explaining risks, benefits and alternatives of procedure (Years I, II & III)Understands the safe and proper administration of sedation (Years I, II & III)Appropriate communication and orders given to nursing and technical staff (Year I, II & III)Generation of procedure report with appropriate recommendations (Year I, II & III)Post-procedure review of findings and plan with patient and family/friend (Year I, II & III)Appropriate recognition of normal landmarks (e.g., esophageal squamocolumar junction, appendiceal orifice) (Year II & III)Appropriate recognition of abnormal findings and action taken based on finding (Year II & III)When indicated, proper biopsy technique (Year II & III)Master scoping and patient manipulations to the degree that patient comfort is acceptable at the level of a beginning independent gastroenterologist (Year II & III)When indicated, proper snare polypectomy (Year III)

UPPER ENDOSCOPYProcedure Activity Competent Not Competent Not Applicable

Successful and safe intubation of the esophagus (Year I, II & III)Evaluation of esophagus and recognition of GE junction (Year I, II & III)Evaluation of stomach to the pylorus (Year I, II & III)Evaluation of duodenum to second portion (Year I, II & III)Appropriate retrieval of scope (Year I, II & III)Retroflexion of scope in stomach (Year II & III)Intubation of pylorus (Year II & III)

COLONOSCOPYProcedure Activity Competent Not Competent Not Applicable

Digital rectal exam and insertion of scope into rectum (Year I, II & III)Passage of scope to the splenic flexure (Year I, II & III)Appropriate retrieval of scope and inspection of colon (Year I, II & III)Passage of scope to the hepatic flexure (Year II & III)Passage of scope to the cecum (Year II & III)Appropriate maneuvers utilized to reach cecum, (i.e., pressure on abdomen, rolling patient, etc.) (Year II & III)Retroflexion of scope in rectum (Year II & III)Passage of scope to the ileum (Year III)

COMMENTS:

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EXTERNAL MEETING ATTENDANCE POLICY

Attendance at national conferences is an important part of fellow career development. These meetings provide the opportunity to present research, establish academic collaborations and meet thought leaders from other institutions. These meetings often include Division faculty as course directors, moderators or presenters and provide unique experiences for fellows.

Attendance at these meetings is a privilege. Fellows not adhering to the Division’s professional and academic standards may lose meeting privileges.

The following external meeting schedule is recommended for fellows:Year I Fellows May attend one ASGE-sponsored (weekend) endoscopy course.

May attend either the ACG or AASLD meeting.Year II Fellows May attend DDW or AASLD.

The program recommends DDW as the preferred meeting for Year II fellows.Year III Fellows May attend one national conference.

May attend the autumn William Steinberg GI Board Review course.

The program director, Dr. Regueiro, must approve requests for meeting attendance preferences different from those described above. While attending any meetings, fellows are responsible for arranging their own coverage, and this coverage plan must be approved by the chief fellow. Acceptable reasons for attending more than one meeting per year include: Presentation of research (oral presentation takes priority over poster presentation); Fellow’s research mentor indicates importance of the additional meeting for the fellow’s career, and the faculty mentor discusses this

with the program director; and A fellow elects to go to more than one conference using his/her vacation time.

Funding Support for Meeting Attendance: Fellow annual discretionary fund. This should be the primary funding source for GI fellow conference expenses. Fellow travel awards or grants. Fellow is responsible for his/her own award application. Research mentor funds. At the discretion of the fellow’s mentor. Program director fellowship funds or corporate grants. These allocations will be distributed at the discretion of the program director

and should not be viewed as the primary funding source for fellow meeting expenses.

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PROCEDURE LOG REQUIREMENTS TO COMPLETE GI FELLOWSHIP TRAINING

The ACGME requires fellows to complete the following number of procedures during the three training years. If there is no number provided in the following chart, this indicates that the ACGME does not require a specific number of these procedures; however, the University of Pittsburgh GI Fellowship still requires fellows to conduct these procedures.

Procedures Required for the Univ. of Pittsburgh GI Fellowship Program ACGME Procedure RequirementEsophagogastroduodenoscopy 130Esophageal Dilation 20Flexible Sigmoidoscopy 25Colonoscopy 140Colonoscopy with Polypectomy 30Percutaneous Liver Biopsy 20Percutaneous Endoscopic Gastrostomy 20Biopsy of the Mucosa of Esophagus, Stomach, Small Bowel & ColonGastrointestinal Motility Studies & 24-hr. pH MonitoringNonvariceal Hemostasis (upper & lower) 25 cases, including 10 active bleedersVariceal Hemostasis 20 cases, including 5 active bleedersOther Diagnostic & Therapeutic Procedures Utilizing Enteral Intubation (Enteroscopy, Ileoscopy)Moderate & Conscious SedationERCPEUS

Fellows are strongly encouraged to keep track of their procedures daily or weekly on their Eportfolio page. Or, the program offers an Excel program through which the fellows may track their procedures. If needed, fellows can complete hardcopy forms and may obtain these forms from Helen Gibson, program coordinator. Please note that hardcopy procedures tracking is being phased out of the fellowship program and is not encouraged.

Fellows are required to submit procedure log forms three times per year to Helen Gibson. During each of these procedure log submissions, fellows are required to submit: All procedures submitted since the last procedure log submission (i.e., the previous third of the year); and All procedures submitted since the start of their fellowship with a numerical total of each type of procedure.

o As part of the tallied total procedure numbers, fellows are required to identify the “active bleeding” experiences for the variceal hemostatsis and nonvariceal hemostasis procedures.

Dr. Regueiro, program director, will sign off on all procedure logs.

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POLICY FOR INPATIENT PROCEDURES IN THE GI LAB

Attending Expectations: Start all inpatient procedures at 7:30 am WITHOUT the fellow (who will be at educational conferences). Each night, communicate the order in which the first two to three patients should be called down and whether MAC is required with the GI lab nurse. MAC is NOT mandatory for every inpatient; this is at the discretion of the inpatient attending.

Fellow Expectations: Fellows must consent the patient the night before and must write orders on the first two to three patients to ensure that they are in the GI lab at the prespecified time (beginning at 7:30am) with working IV. Fellows must ensure that the prep is adequate and that blood products are administered (when indicated). Prior to leaving the hospital, a complete list of patients must be written on the GI lab sheet in order of priority (first two or three patients should match those already communicated by the attending to the GI lab).

GI Lab Expectations: The GI lab nurse will page the attending on GI/Liver the night before to discuss the first two to three patients of the day. The GI lab nurse will also page the Nutrition attending the night before to find out which cases will be done and will require MAC (these will likely not start at 7:30am unless there is lab availability). The GI lab nurse will work with transport to ensure that patients are ready and are in the room for the attending at 7:30am. The GI lab nurse will communicate with anesthesia about which patients are scheduled for MAC. The GI lab will not page the fellow between 7:30am and 8:30am Mon. through Fri. and will work directly with the inpatient attending.

There will be exceptions to this policy such as emergencies coming in overnight which alter the schedule or personal emergencies that do not allow a start time of 7:30am, etc. In general, however, these guidelines should be followed.

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MAGEE WOMENS HOSPITAL OFF-HOUR and WEEKEND EMERGENCY PROCEDURES

Two potential situations during which a consult would result in a procedure include:1. Procedure on demand (e.g., guaiac positive stool) or consult that requires non-emergent procedure: notify the Director, Dr. Abo,

Monday-Friday AM 572-2253 or covering physician 641-2135.2. Consult that requires emergency procedure (see below).

If procedure needs to be done emergently then:1. Move patient to ICU if not already there.2. If MAC needed and patient not intubated, contact Anesthesia for possible OR case (unlikely to be needed).3. Call Clinician on duty (this is the head nurse in the hospital who will call the GI nurse/tech to come in) either through operator 412-

641-1000 or cell 412-641-2792.4. Tell Clinician on duty or nurse/tech what procedure is needed and what scopes are to be brought by the team.

Contact Attending Physician:1. If attending has privileges then proceed.2. If attending does not have privileges, call the clinician on duty to obtain emergency privileges. Clinician on duty will obtain

emergency privileges from the Administrator on duty.

Consent for procedure must be co-signed by attending.

After procedure1. Procedure notes.2. Dictate procedure into MARS.

Notify Director, Dr. Abo, in AM of the procedure.

Fellows may park in the Magee driveway circle or in the garage and have their tickets validated.

The GI service is purely consultative at Magee, and patients are admitted to the CCM/hospitalist service.

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SERVICES TO ADDRESS STRESS, FATIGUE AND RELATED GI FELLOW NEEDS

If day-to-day patient care is unusually difficult or prolonged, or if a related emergency occurs, a fellow should inform the chief fellow and/or the GI fellowship program director immediately. A fellow on a research rotation may be pulled to cover the emergency situation. If no fellows are available, a Division faculty member will provide coverage.

If a fellow is unable to perform work due to stress, the program director may remove the fellow for extended rest and, if necessary, counseling. The fellow may be referred to the Resident Fellow Assistance Program (RFAP). RFAP’s phone # is (412) 647-3669.

Additional information to help fellows to manage stress, fatigue and life/career issues may be found at > http://www.lifecurriculum.info

Fellow Mentoring:Mentoring is important to ensure successful assimilation in the training program and enjoyment with the experience. Successful assimilation will decrease stress and related negative factors that could inhibit graduation success.

Selected Year II and Year III fellows will mentor Year I fellows for the first six months (i.e., July thru Dec.). Fellow mentors will be chosen at the discretion of the chief fellow. Fellow mentoring activities will be informal and flexible, depending on new fellows’ needs. Faculty mentors will be matched to new fellows as well. At the end of Year I, fellows will also receive additional faculty research mentors.

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CURRICULUM VITAE (CV) Fellows are required to update CV’s three times per year and submit them to Helen Gibson, program coordinator. A CV preparation guideline for fellows follows:

University of Pittsburgh School of MedicineDivision of Gastroenterology, Hepatology and Nutrition

Gastroenterology Fellow Curriculum Vitae Format Guidelines List your last revision date on the front page of the CV (see page bottom).

BIOGRAPHICAL

Name: Birth Date:

Home Address: Birth Place:

Home Phone: Citizenship:

Business Address: E-mail Address:

Business Phone: Business Fax:

Spouse Name:

EDUCATION and TRAININGList entries in each section chronologically

with the oldest information first and the newest information last.

UNDERGRADUATE:

Dates Attended Name & Location Degree Received Major Subjectof Institution & Year

GRADUATE:

Dates Attended Name & Location Degree Received Major Advisorof Institution & Year & Discipline

POSTGRADUATE:Include internships, residencies, fellowships and/or any other professional training experiences.

Dates Attended Name & Location Name of Program Directorof Institution & Discipline

ACADEMIC:

Years Inclusive Name & Location of Rank/TitleInstitution or Organization *Visiting prefix must be used if faculty

member has been appointed pendingcommittee review or position approval.

NON-ACADEMIC:Include military or other government service

Years Inclusive Name & Location of Rank/Title or PositionInstitution or Organization

Revised: _____________

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CERTIFICATION and LICENSURE

SPECIALITY CERTIFICATION:

Certifying Board Year

MEDICAL or OTHER PROFESSIONAL LICENSURE:

Licensing Board/State Year

MEMBERSHIPS in PROFESSIONAL and SCIENTIFIC SOCIETIES

Organization Year

HONORS

Title of Award Year

PUBLICATIONSList the following categories separately and use the approved citation format.

List entries in each section chronologically with the oldest information first and the newest information last.

Refereed Articles Refereed articles must be listed separately Do not list articles submitted or in preparation Publications must be numbered Bold face your name when there are multiple authors Use Index Medicus citation format. List all authors. Do not use “et al” Letters to the Editor should be included under “Other Publications”

Reviews, Invited Published Papers, Proceedings of Conference and Symposia, Monographs, Books and Book Chapters Published Abstracts Other Publications

Sample Refereed Listings:1. Smith PJ, Jones WJ, Jackson AN. Name of article here with only first letter capitalized. American Journal of Gastroenterology

1993;341(1):244-5.2. Jackson AN, Samuels RR. Identification of nuclear matrix proteins. Gastroenterology 2003;256:14-27.

PROFESSIONAL ACTIVITIES

TEACHING:Provide a summary of courses and tutorials taught and include numbers and types of students taught, contact hours, number of lectures, etc. Provide other lectures and seminars too.

Include ALL teaching and educational presentations, including Journal Club, GI Grand Rounds, Pathology Conference, web case writing/development, etc. Also include any presentations at any outside program (e.g., Division CME programs, nonprofit medical presentations (CCFA, NPF, etc.) and teaching medical school trainees. Please also include a list of exams taken.

See the following examples for educational listings:

2002, November Crohn’s and Colitis Foundation of America, Patient and Family IBD Educational Conference. Clinical Trials for the IBD patient. Sheraton Station Square, Pittsburgh.

2002, December CME Symposium. University of Pittsburgh, Department of Gastroenterology, Hepatology and Nutrition GI Course, The Cutting Edge in Gastroenterology;

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Update in IBD Therapy. Pittsburgh, PA.

2003, January Journal Club. University of Pittsburgh, Department of Gastroenteroology, Hepatology and Nutrition The Secrets of Pain. Pittsburgh, PA

RESEARCH:When listing funding, it is advisable to include the total dollar amount (direct plus indirect costs).

Grant Role in Project & Years Source &Percentage of Effort Inclusive $ Amount

Current Grant Support:

Seminars and Invited Lectureships Related to Your Research:

Fellows: The research information outlined above mostly pertains to Division faculty. Please consider the following when preparing the research section of your current CV:

Project Mentor Dates Publications Resulting Awards Resultingfrom Project from Project

LIST OF CURRENT RESEARCH INTERESTS:This can be a bullet-point list.

SERVICE:

University and Medical SchoolInclude committee service and chairmanships, administrative appointments and assignments.

Community Activities

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ADHERENCE TO ACGME CORE COMPENTENCIES

All University of Pittsburgh’s Gastroenterology Fellowship Program clinical rotations integrate the following core competencies into all educational offerings. Gastroenterology fellows are required to obtain competence in the six areas listed below to the level expected of a new practitioner. The University of Pittsburgh defines the specific knowledge, skills, behaviors, and attitudes required, and provides educational experiences as needed in order for gastroenterology fellows to demonstrate the following:

1. Patient care that is compassionate, appropriate, and effective for the treatment of health programs and the promotion of health;

2. Medical knowledge about established and evolving biomedical, clinical, and cognate sciences, as well as the application of this knowledge to patient care;

3. Practice-based learning and improvement that involves the investigation and evaluation of care for their patients, and the appraisal and assimilation of scientific evidence, and improvements in patient care;

4. Interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and other health professionals;

5. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to patients of diverse backgrounds; and

6. Systems-based practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

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GI FELLOW CURRICULUM:

Rotation Goals and Responsibilities

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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 infectionso 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.

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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.

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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:

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

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.

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. 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 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. 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).

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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: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

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

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

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.

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Know and be able to succinctly communicate 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

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.

Systems-Based Practice Objectives: Attend conferences concerning 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 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.

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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).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

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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

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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.

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 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.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 failure

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o 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.

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/hepatologists, 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.

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 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:

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/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 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.

o Liver Biopsies:

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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 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 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

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 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.

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 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.

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. 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.

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.

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Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues.

Participate in program planning.

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

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 transplantation, non-transplantation, and non-surgical approaches

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

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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.

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 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

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 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.

Systems-Based Practice Objectives: Attend conferences concerning 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 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 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

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(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.

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-Date

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o 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 Residency Curriculum,

1997. Pertinent Teaching References:

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

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 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

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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.

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

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.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:

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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.

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/hepatologists, 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.

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 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:

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 procedures (see practicum checklist):

o Colonoscopy

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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.

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 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 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.

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 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.

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 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.

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 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.

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. 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.

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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 responsible

colleagues. Participate in program planning.

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

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 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 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.

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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 includingo 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 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

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 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

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 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.

Systems-Based Practice Objectives: Attend conferences concerning 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 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 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

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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.

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.

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

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Bibliography: Resource Documents

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.

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 Residency Curriculum,

1997. Pertinent Teaching References:

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

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Competencies-at-a-GlanceHepatology Outpatient 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 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.

Updated:December 2005June 2006September 2007

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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 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 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

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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.

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 pancreaticobiliary literature related to patient management. Know the best practice patterns to facilitate pancreaticobiliary 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

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 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 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 responsible

colleagues. Participate in program planning.

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

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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 Cancero 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.

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 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

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 pancreas and biliary diseases 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.

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Systems-Based Practice Objectives: Attend conferences concerning 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 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 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 evaluations are

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

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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.

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.

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II. ERCP DatabaseThe 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.

Bibliography: Resource Documents

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 Residency Curriculum,

1997. Pertinent Teaching References:

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

Competencies-at-a-GlancePancreaticobiliary 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 360-global evaluations58

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Grand Rounds (GI & Medical) Conferences

E-portfolio collaboration 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.

Updated:December 2005June 2006September 2007

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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:

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 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.

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 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 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.

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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 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 and liver 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 Pancreatitis

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o Ischemic colitis 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 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:

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

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.

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. 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 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. 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.

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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 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.

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: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

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

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

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

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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.

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.

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.

Systems-Based Practice Objectives: Attend conferences concerning 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 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 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.

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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:

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

COMPETENCY LEARNING OPPORTUNITY EVALUATIONPatient Care Work Rounds 360-global evaluations

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Teaching Rounds Conferences

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 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 Procedure

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The 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 summery4. 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

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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.

Updated:December 2005June 2006September 2007

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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

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. 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.

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Learn the best practice patterns to facilitate nutrition support 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/hepatologists, 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.

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 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:

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 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 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.

Practice-Based Learning Objectives: Participate in project groups, committees and hospital groups when requested. Participate in programmatic reviews and conferences studying adverse events.

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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 nutrition support literature for patient management. Know the best practice patterns to facilitate nutrition support 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

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 nutrition support 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 responsible

colleagues. Participate in program planning.

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

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 nutrition diseases including

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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 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

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 nutrition support 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.

Systems-Based Practice Objectives: Attend conferences concerning 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 care of 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, 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 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.

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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.

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: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 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.

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.

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

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

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 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

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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

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 Residency Curriculum,

1997. Pertinent Teaching References:

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

Competencies-at-a-GlanceNutrition Service

COMPETENCY LEARNING OPPORTUNITY EVALUATIONPatient Care Work Rounds

Teaching Rounds Conferences

360-global evaluations Direct Observation

Medical Knowledge Work Rounds Teaching Rounds Conferences

360-global evaluations

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 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.

Updated:December 2005June 2006September 2007

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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:

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.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

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.

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Achieve an average percentile score of at least 61.18 on 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,

particularly in the community gastroenterologist setting.

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 disease

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o 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 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:

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 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 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.

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. 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

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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 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. 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 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 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: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

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, cancer

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

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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

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. Attend to the special requirements of a gastroenterologist in a community practice setting.

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.

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.

Systems-Based Practice Objectives: Attend conferences concerning 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 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 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.

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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 evaluations are

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

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

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

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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. 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 Residency Curriculum,

1997. Pertinent Teaching References:

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

Competencies-at-a-GlanceShadyside 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 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

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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 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 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.

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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 nutrition support literature for patient management. Know the best practice patterns to facilitate nutrition support 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

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 GI motility 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 responsible

colleagues. Participate in program planning.

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

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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 includingo 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.

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 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.

Systems-Based Practice Objectives: Attend conferences concerning 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 care of 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, 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 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.

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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.

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: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 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.

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.

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

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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 Residency Curriculum,

1997. Pertinent Teaching References:

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

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;2003o Drossman DA, Camilleri M, Mayer E, Whitehead WE. AGA technical review on irritable bowel syndrome.

Gastroenterology. 2002;123:2108-2131o Talley NJ, Vakil NB, Moayyedi P. American Gastroenterological Association Technical Review on the Evaluation of

Dyspepsia. Gastroenterology 2005; 129: 1756-1780o Pandolfino JE, Kahrilas PJ: AGA technical review on the clinical use of esophageal manometry. Gastroenterology

2005; 128: 209-224o Parkman HP, Hasler WL, Fisher RS: American Gastroenterological Association technical review on the diagnosis

and treatment of gastroparesis. Gastroenterology 2004; 127: 1592-1622o Quigley EMM, Hasler WL, Parkman HP: AGA technical review on nausea and vomiting. Gastroenterology 2001: 120:

263-286o Locke GR, Pemberton JH, Phillips SF: AGA technical review on constipation. Gastroenterology 2000; 119: 1766-

1778o Spechler SJ: AGA technical review on treatment of patients with dysphagia caused by benign disorders of the distal

esophagus. Gastroenterology 1999; 117: 233-254o 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

COMPETENCY LEARNING OPPORTUNITY EVALUATIONPatient Care Work Rounds

Teaching Rounds Conferences

360-global evaluations Direct Observation

Medical Knowledge Work Rounds Teaching Rounds Conferences

360-global evaluations

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 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

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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.

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.

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.

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:

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

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.

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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 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 and the

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

interactions.

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. 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 procedures 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 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 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. 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 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:

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

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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.

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, epidemiology, 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 diseaseo Inflammatory bowel diseaseo GI infectionso Pancreatitiso Ischemic colitis

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.

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 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 healthcare

professionals.

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 Curriculum

Committee and Conference Planning Committees.

Systems-Based Practice Objectives: Attend conferences concerning 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 care of 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, 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.

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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 evaluations are

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

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

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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 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 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 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

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

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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.

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 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.

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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 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 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.

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 and research successes.

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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 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 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 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 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.

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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 Curriculum

Committee and Conference Planning Committees.

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 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: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

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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 evaluations are

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

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

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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

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Competencies-at-a-GlanceGI Research Rotation

COMPETENCY LEARNING OPPORTUNITY EVALUATIONPatient Care Research Activities

Conferences 360-global evaluations

Medical Knowledge Research Activities Conferences

360-global evaluations

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

360-global evaluations E-portfolio procedure

documentation

Interpersonal Skills Research Activities Subject Interactions

360-global evaluations

Professionalism Research Activites 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

Updated:August 2007

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APPENDIX

Policies & Procedures: Division of Gastroenterology, Hepatology and Nutrition

Policies & Procedurs: Graduate Medical Education Office / Univ. of Pittsburgh

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