Gastroenterology

I. BACKGROUND

The GI elective is offered at Moses campus to PGY 1- 3's as a 2 or 4 week elective

On your first day please arrive at Moses and page the GI fellow for further instructions.

The elective includes participation in a very active in-patient gastroenterology and liver diseases consultation service with daily combined management and teaching rounds, involvement in weekly out-patient gastroenterology clinic sessions, observation of a substantial number of endoscopic procedures, both elective and emergent, as well as participation in the numerous weekly conferences of the Division of Gastroenterology and Liver Diseases.

Patients are very diverse ethnically and socioeconomically, and are representative of the neighboring Montefiore communities.

The Gastroenterology rotation/elective consists of one block of two or four weeks, with 24/7 coverage by the Gastroenterology Fellows and Attendings. Internal Medicine Residents are on the service five days per week without night or weekend responsibilities for the gastroenterology and liver diseases service. The Gastroenterology rotation/elective is available to all Internal Medicine PGY1s, PGY2s and PGY3s.

Residents work in teams under the supervision of the Gastroenterology Fellow and the Gastroenterology Attending. The Attending physician is responsible for supervision of all patient care.

II. GOALS

The program of the Gastroenterology elective is designed to provide the house officer with the knowledge and skills needed to diagnose and treat a wide range of common diseases of the gastrointestinal tract and the liver, including both acute and chronic disorders. The house officer will learn to recognize and manage a variety of commonly encountered conditions in gastroenterology and hepatology.

B. Level based Rotation Objectives:

PGY1:

- Patient Care: Recognize the daily patient workload and prioritize; recognize the significance of a patient’s gastroenterologic conditions; differentiate the acuity level of illness, to establish patient focused care.

Trainees at the PGY 1 level are involved intensively in the daily management of all patients on the consult service. They will become very familiar with patients with GI bleeding, abdominal pain, diarrhea, a variety of liver diseases and pancreatitis. Trainees are expected to provide patient care that is compassionate, appropriate, and effective for the promotion of health, prevention of illness, treatment of disease, and care at the end of life.

Trainees at the PGY 1 level will gather accurate, essential information from all sources, including medical interviews, physical examination, records, and diagnostic procedures. They will make informed recommendations about preventive, diagnostic and therapeutic options and interventions that are based on clinical judgment, scientific evidence, and patient preferences. They will learn to interact appropriately with patients, families, and consultants to determine the most appropriate course of action tailored to the individual patient, and then implement that plan.

Trainees at the PGY 1 level will be expected to recognize common historical, physical and laboratory abnormalities associated with gastrointestinal diseases.

Trainees at the PGY 1 level will be expected to formulate an initial assessment incorporating the patient’s history, physical exam and incorporation the PGY1s’ understanding of the patient’s underlying pathophysiology.

- Medical Knowledge: Use discussions during daily rounds; use literature and reference sources to increase knowledge base, to learn guidelines and apply them for patient management; acquire basic knowledge in the areas of underlying pathophysiology and the clinical aspects of disease states in gastroenterology.

Trainees are expected to acquire in-depth knowledge of the medical conditions managed on the consult service. They are expected to be current on the established and evolving biomedical, clinical, and social sciences, and to have good clinical judgment in the application of this information to the care of acutely ill patients. It is also expected that the trainee will take an active role in teaching the other members of the consult team concerning these medical issues.

Diagnosis and management of the following conditions in considered an essential foundation for the management of patients by a PGY1 trainee on the consult service:

1. Esophageal disorders

2. Ulcer disease

3. Gastric cancer

4. Inflammatory bowel disease

5. Pancreatitis

6. Gallbladder disease

7. Abnormal liver tests

8. GI bleeding

9. Colon polyps and colorectal cancer

Essential to the understanding of these disorders is an understanding of the appropriate selection and timing of diagnostic procedures such as endoscopy, colonoscopy, ERCP, EUS and capsule endoscopy.

Trainees at the PGY1 level are also expected to gain understanding in optimal timing and nature of interactions with surgical and radiologic colleagues to help in the management of patients.

- Professionalism: Learn to establish trust with critically ill gastroenterology patients and family; to participate in teamwork. Exhibit honesty, reliability, and responsibility in patient care; demonstrate respect for patients and staff; attend conferences.

- Interpersonal and Communication Skills: Write understandable and timely notes; listen to patients and staff and communicate appropriately; work effectively as a member of the health care team.

- Practice Based Learning and Improvement: Recognize limitations of knowledge; use literature to improve your practice patterns; accept feedback and change behavior; ask for help when needed; learn from the outcomes of gastroenterology patients to improve outcomes in the future.

- System Based Practice: Be an advocate for patients with gastroenterological diseases; try to apply necessary devised guidelines; develop an understanding about various health care systems/structure and how they relate to patients requiring procedures in gastroenterology.

PGY2:

- Patient Care: Prioritize the daily tasks; recognize the relative significance of a given gastroenterology patient’s list of gastroenterology conditions; increase accurate recognition of the acuity levels of illness; recall the indications, contraindications and risks of procedures in gastroenterology; work with all providers to provide patient focused care.

In addition to the PGY 1 level expectations, trainees at the PGY2 level will be expected to recognize additional historical and physical examination abnormalities associated with GI disease and participate in management of patients with more complicated GI diseases such as extensive or longstanding inflammatory bowel disease and end stage liver disease.

Trainees at the PGY 2 level will be expected to formulate an assessment and initial plan incorporating the patient’s history, physical exam and incorporation the PGY2s’ understanding of the patient’s underlying pathophysiology.

- Medical Knowledge: Use literature and reference sources to increase knowledge base in gastroenterology; demonstrate basic knowledge in the areas of underlying pathophysiology and the clinical aspects of disease states in gastroenterology; apply knowledge in the treatment of patients.

In addition to the PGY 1 level expectations, diagnosis and management of the following additional conditions in considered an essential foundation for the management of patients on the consult service for the PGY 2:

Active GI bleeding requiring ICU care

Acute liver failure

Colonic obstruction, ileus and pseudoobstruction

Jaundice

Complicated biliary tract disease

Essential to the understanding of these disorders is an understanding of the appropriate selection and timing of diagnostic procedures such endoscopy, colonoscopy, ERCP, EUS and capsule endoscopy.

The trainee is also expected to gain understanding in optimal timing and nature of interactions with surgical and radiologic colleagues to help in the management of patients.

- Professionalism: Establish trust with patients and staff; exhibit honesty, reliability and responsibility in patient care; demonstrate respect for patients and staff; work to fulfill the needs of patients; accept assignments graciously; attend conferences.

- Interpersonal and Communication Skills: Write understandable and timely notes and consultation reports; actively listen to patients and staff and communicate verbally and nonverbally in a productive manner; work effectively as a member of the health care team.

- Practice Based Learning and Improvement: Recognize limitations of knowledge; use references and literature to improve practice patterns; accept feedback and change behavior; ask for help when needed.

- System Based Practice: Advocate for gastroenterology patients; apply necessary devised guidelines; develop understanding about health care systems/structures and how they relate to patients requiring procedures in gastroenterology.

PGY3:

- Patient Care: Prioritize the daily work load of patients with gastroenterological diseases and work with the junior house staff appropriately; recognize the relative significance of a given patients list of gastroenterology conditions; recognize the acuity levels of illness; fully understand the indications, contraindications and risks of common and uncommon procedures in gastroenterology; discuss risks/benefits of plans related to a specific patient with other specialists.

In addition to the PGY 1 and 2 level expectations, trainees at the PGY 3 level will be expected to recognize additional manifestations of complicated GI diseases, including choledocholithiasis, pancreatic masses, cysts and their management, esophageal motility disorders, and obscure GI bleeding.

Trainees at the PGY 3 level will be expected to formulate an assessment and detailed plan incorporating the patient’s history, physical exam and incorporation the PGY3s’ understanding of the patient’s underlying pathophysiology.

- Medical Knowledge: Use literature and reference sources to increase knowledge base and share knowledge with junior house staff; demonstrate sophisticated knowledge in the areas of underlying pathophysiology and the clinical aspects of simple and complicated disease states in gastroenterology; apply knowledge in the treatment of patients with gastroenterologic disorders.

In addition to the PGY 1 and 2 level expectations, diagnosis and management of the following additional conditions in considered an essential foundation for the management of patients on the consult service for the PGY 3:

Biliary tract stones and management algorithms,

Pancreatic masses, cysts and their management via ERCP, EUS and surgery

Achalasia and other esophageal motility disorders and the use of manometry and pH testing

Obscure GI bleeding and the utility of capsule testing

Essential to the understanding of these disorders is an understanding of the appropriate selection and timing of diagnostic procedures such as endoscopy, colonoscopy, ERCP, EUS and capsule endoscopy.

The trainee is also expected to gain understanding in optimal timing and nature of interactions with surgical and radiologic colleagues to help in the management of patients.

- Professionalism: Establish trust with patients and staff; exhibit honesty, reliability and responsibility in patient care; demonstrate respect for patients and staff and junior house staff; work with team to fulfill the needs of patients; lead health care team in patient care; understand limitations and ask supervisors for help when indicated; accept assignments graciously; attend conferences.

- Interpersonal and Communication Skills: Write understandable and timely notes and consultation reports; actively listen to patients and staff and communicate verbally and nonverbally in a productive manner; work effectively as a member of the health care team, and be an example for junior house officers.

- Practice Based Learning and Improvement: Recognize limitations of knowledge; use references and literature to improve practice patterns; accept feedback and change behavior; ask for help when needed; learn from the outcomes of other patients with gastroenterological disease under your care and alter practice patterns to improve outcomes in the future; aid junior house staff in evaluating their practice patterns

- System Based Practice: Advocate for patients; develop a sophisticated understanding about the health care system/structure and develop mechanisms to utilize ancillary services to benefit patients.

III. AREAS COVERED DURING GASTROENTEROLOGY ROTATION/ELECTIVE

1. Principles, Physiology and Basic Sciences

Develop an understanding of:

a) Anatomy and Physiology of the GI tract

b) Swallowing and its disorders

c) Digestion, absorption and their disorders

d) Gastrointestinal hormones, neurotransmitters and their action

e) Immunology and inflammation of the GI tract

f) Bile, including its production, action and reabsorption

g) Diarrhea

h) Defecation

i) Nutrition

j) Gastrointestinal motility

k) Pancreatic physiology and secretion

2. Practice Skills Unique to Gastroenterology

a) History and physical examination: with attention to systemic disorders with GI manifestations, abdominal exam with attention to liver disease and ascites, assessment of rectum and surrounding tissues

b) Specific tests and procedures: use and interpretation: blood tests and serologic markers, sonography, CT/MRI, nuclear scans, endoscopy, colonoscopy, sigmoidoscopy, ERCP (endoscopic retrograde cholangiopancreatography, EUS (endoscopic ultrasound) (with FNA), capsule endoscopy, manometry

c) Preventive care: colorectal cancer screening and prevention, Barrett’s esophagus

d) Patient education: diet, especially as it relates to common disorders such as GERD, obesity, and celiac disease

e) Attitudes/values: understand the psychosocial issues surrounding chronic illness, particularly inflammatory bowel disease and celiac disease

3. Approach to Presenting Complaints/Problems in Gastroenterology

a) Dysphagia

b) Odynophagia

c) Heartburn

d) Regurgitation

e) Abdominal pain

f) Constipation

g) Diarrhea

h) Fecal incontinence

i) Jaundice

j) Steatorrhea

k) GI bleeding

l) Acute emergencies

4. SPECIFIC DIAGNOSES IN GASTROENTEROLOGY

a) GERD

b) Motor Disorders of the Esophagus

c) Oropharyngeal dysphagia

d) Esophageal infections

e) Systemic diseases of the esophagus

f) Esophageal malignancy

g) Abdominal Pain

h) Nausea and vomiting

i) Dyspepsia

j) Gastroduodenal motility disorders and gastroparesis

k) Peptic ulcer disease

l) Gastritis

m) Upper GI bleeding

n) Gastric malignancy

o) Gastric infections

p) Gastric surgery

q) Maldigestion

r) Malabsorption

s) Intestinal obstruction and pseudoobstruction

t) Protein losing enteropathy

u) Sprue (celiac and tropical)

v) small bowel malignancy

w) Short bowel syndrome

x) Whipple’s Disease

y) Infectious diarrhea

z) Eosinophilic gastroenteritis

aa) Small bowel parasites

bb) Acute and chronic mesenteric ischemia

cc) Irritable bowel syndrome

dd) Volvulus and intussusception

ee) Secretory diarrhea

ff) Fecal incontinence

gg) Gas

hh) Lower GI bleeding

ii) Infectious colitis

jj) Inflammatory colitis

kk) Ischemic colitis

ll) Crohn’s Disease

mm) Diverticular disease

nn) Colon tumors

oo) Anorectal disorders

pp) Viral hepatitis (acute and chronic)

qq) Alcoholic liver injury

rr) Medication related liver injury

ss) Autoimmune liver disease

tt) Granulomatous liver disease

uu) Liver tumors

vv) Liver abscesses

ww) Cholestatic liver disease

xx) Wilson’s disease

yy) Hemochromatosis

zz) Porphyria

aaa) Liver disease and pregnancy

bbb) Liver in AIDS

ccc) Portal hypertension

ddd) Ascites

eee) Hepatorenal syndrome

fff) Hepatic encephalopathy

ggg) Fulminant hepatic failure

hhh) Liver transplantation

5. Treatment Modalities/Technical Skills

Familiarity with indications, contraindications, alternatives and limitations of:

a. Upper Endoscopy

b. Colonoscopy

c. Sigmoidoscopy

d. ERCP

e. EUS

f. Capsule endoscopy

g. Manometry

6. Emergencies/Therapeutic Interventions

a) Gastrointestinal Bleeding

b) Intestinal Obstruction

c) Foreign body ingestion

d) Cholangitis

e) Acute hepatic failure

IV. SCHEDULE OF ACTIVITIES

1) Morning rounds by a specific gastroenterology or hepatology attending. These rounds include a variety of sessions including case discussions, radiology and pathology of the GI tract, interdisciplinary meetings and tumor boards. There is frequent distribution of literature prior to these sessions.

2) Daily consultation rounds by gastroenterology attendings

3) Division Grand Rounds – Thursday afternoons

4) Medical Grand Rounds – Thursday mornings and noontime; various sites

V. REFERENCES

Feldman M, Friedman LS, Brandt LJ, eds: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 9th ed.; 2010

Cotton PB, Williams CB, Hawes RH, et al. Practical Gastrointestinal Endoscopy: The Fundamentals; Edition 6, 2008

Brandt LJ, Daum F. Clinical Practice of Gastroenterology, Volume 2, 1999

VI. METHODS OF TEACHING COMPETENCY ASSESSMENT

The Internal Medicine residents are evaluated continuously during their gastroenterology rotation. Importantly, there is continuous feedback to the house officers. The final evaluation is done through www.new-innov.com and the results are discussed in a meeting with the house officers. They are evaluated in terms of their overall clinical competence with the following categories: patient care, medical knowledge, clinical skills, humanistic qualities, professionalism, medical care and communication skills.