GI Fellow Rotation

The GI Fellow Rotation at Highland Hospital is designed to provide California Pacific Medical Center (CPMC) GI fellows with a clinical GI/Liver experience in a county, safety-net setting.  Although a focus of this rotation is to develop a foundational education in GI endoscopy, GI fellows will also have experiences in both the outpatient GI clinic and inpatient GI consult setting. 

During their time here, GI fellows will learn and perform the component elements (i.e. Pre-Op H&Ps, procedure performance, technical support) related to GI endoscopy under the supervision of the GI Attending and the Endoscopy Staff. They are also required to participate in 1 half day of outpatient GI clinic experience per week, they will interface with the GI Consult  Service, and they will attend related educational conferences. 

Fellows are required to give up to four 15-minute GI/Liver talks during their Highland rotation. Fellows are also required to give a GI noon conference to the Highland Hospital Internal Medicine Residency Program once a year. 

Each of the 7 CPMC GI fellows will rotate at Highland on outpatient endoscopy for 2 blocks per year. 2nd and 3rd years will rotate on inpatient GI Consult Service for 1 block per year. Each rotation is 4 weeks long.

If you have been APPROVED and SCHEDULED to rotate on the GI Fellow Rotation, please fill out the "GI Trainee Intake Form" using this link: https://goo.gl/forms/qLFqVfTz27npPVux1

• Attending Faculty: Our five full-time faculty (Drs. Benny Liu, Christina Chou, Jennifer Lai, Aaron Lee and Ayesha Zahiruddin) and eleven of our part-time faculty staff this rotation. Their general role is to provide daily teaching, clinical oversight, and mentorship to the trainees on this rotation. Our full-time faculty staff  full day endoscopies on Tuesdays, Wednesdays, and Thursdays. Our part-time faculty staff full day endoscopies on Mondays and Fridays. Our five full-time faculty rotate through inpatient GI consults each week.

• CPMC GI Fellows

  • CPMC GI Fellows each rotate on outpatient endoscopy for 2 blocks per year. Their general role is to learn the fundamentals of gastrointestinal endoscopy and to facilitate the flow of the outpatient endoscopy unit. 

  • While at Highland Hospital, the GI Fellow will also do a half day of outpatient GI clinic, to satisfy their outpatient GI continuity clinic requirement.

  • 2nd and 3rd year CPMC GI Fellows each rotate on the inpatient GI Consult Service for 1 block per year. Their general role is to learn to lead a team consisting of residents and medical students, triage patients accordingly, facilitate inpatient procedures, and to provide teaching and guidance to the residents and medical students. 

• Endoscopy Staff: Our nurses, GI techs, and registration staff are the core engine behind the Highland Endoscopy Unit. On this rotation, the GI Fellow will interface with them on a minute to minute basis.

Preparation prior to your Highland Rotation

• •  6-8 weeks prior to the start of your scheduled rotation dates, please email Nathan "Nate" Calloway (Highland GME/CME Liaison), Ana Olive (CPMC Administrative Coordinator), and Dr. Christina Chou (Highland Site Director) and attach the necessary paperwork for the rotation. It is the Fellow's responsibility to email and submit all paperwork ahead of time, in order to start the rotation on time. 

  • Please fill out this form a few days prior to the start of the rotation, and list 2-3 of your goals and plans for the rotation. We will go over this at the beginning and at the end of your rotation.

Outpatient Endoscopy (7.30 AM to 5.00PM)

• • Our first patient is scheduled for 7.30AM. Please arrive at 7.30AM to place pre-op orders and obtain H&Ps and consents for the outpatients. 

    • The Fellow is required to place pre-op orders, obtain H&Ps, obtain consents, and place discharge orders for the patients. We understand that there can be variability between attendings. Please discuss expectations with the endoscopy attending of the day. 

  • If outpatient endoscopy ends early, the Fellow should stay to round with the inpatient team and participate in inpatient GI procedures.

  • Fellows are required to give up to four 15-minute GI/Liver talks during their Highland rotation. 

  • Fellows are required to give a GI noon conference to the Internal Medicine Residency Program once a year.

Outpatient GI clinic (8.15AM to 12.00PM, 1.00PM to 5.30PM)

• • Fellows are expected to participate in half day outpatient GI clinic on Mondays, either Monday AM or Monday PM, while on outpatient endoscopy rotation. Fellows will participate in half day GI clinic on Friday AM while on the inpatient GI consult rotation.  If Monday is a holiday, we will try to arrange for makeup outpatient GI clinic for the Fellow, either on Tuesday AM or Friday AM.

  • Please touch base with the GI Attending to discuss which patients you will see, prior to the start of outpatient GI clinic.

  • First year Fellows should see up to 4 patients per half day of clinic, by the end of their first year.

  • Second year Fellows should see anywhere from 4-6 patients per half day of clinic.

  • Third year Fellows should see anywhere from 6-8 patients per half day of clinic.

  • If there is an internal medicine resident rotating through GI clinic, the resident will staff the patient with the Fellow. The Fellow will staff the patients with the GI Attending.

  • Fellows should participate in morning endoscopy procedures before PM GI clinic.

  • Fellows should participate in afternoon endoscopy procedures after AM GI clinic. 

Inpatient GI Consult Service (7.00 AM to 5.00PM)

• • Know and regularly review the "Core Expectations of All Trainees". These are outlined on the Medical Education landing page. Read the "Expectations" outlines for all members of the team, so you will have a better understanding of everyone's role.

    • We understand that there can be variability between attendings. Please discuss expectations with the inpatient attending of the week.

  • Learn and practice the principles of effective medical consultation. Strive to be a great consultant. Read this as a start.

  • Know the consult patients you are overseeing! Actively maintain and review the consult list with the team throughout the day. As we say, "Start the day thinking about the list, spend the day thinking about the list, and end the day thinking about the list."

  • Ensure that initial inpatient consultations notes are written on the day the patient is seen. Ensure that daily progress notes are written on patients that are being actively followed by our service.

  • Ensure that procedure consent is obtained appropriately before procedures. Medical students are not allowed to consent patients.

  • Pre-round with your team before attending rounds. This is the best time to identify potential pitfalls before the attending arrives. Know what you and your team are going to say to the attending before they (you) say it.

  • Make a deliberate effort to develop teaching and mentoring skills for the residents and medical students on our team. Help to develop your resident and medical students.

  • Be a good leader. Use this rotation to refine the skills of appropriate oversight, delegation, constructive feedback, and developing your team (i.e. residents/students). Remember: When the team looks good, you look good!

  • Perform therapeutic paracenteses under appropriate supervision. 

  • Additional daily expectations:

    • Read at least one (1) article from PubMed, that answers your clinical question of the day.

    • Watch at least one (1) video from the Education Resources page.

  • There will be verbal and written feedback given at the end of each week. Please fill out this form prior to your last feedback session for the rotation. 

Absences

• • We certainly understand that people get sick and have needs for excused absences, or if you need to leave early. If this is the case for you, please notify the Site Director and your Program Director using both email and a personal discussion (where possible). For each day missed, the trainee will need to complete one journal article summary assignment. Here are the guidelines for that. 

Fellows are strongly encouraged to review the resources provided on Entrustable Professional Activities (EPA) and the Competencies and Subcompetencies outlined by the ACGME. A complementary list of objectives and topics for review are also provided below as a learning tool.

Rotation Core Entrustable Professional Activities (EPA) (Specific knowledge and skill requirements outlined in materials provided):

Outpatient Endoscopy: 1,2,6,10,11,12

Outpatient Clinics - IBD: 2,10,11,13

Inpatient Service – 2,3,4,5,6,7,8,9,10,11,12 

General Knowledge

Given that the Highland Hospital experience provides the opportunity to engage in outpatient endoscopy, outpatient clinic, and inpatient consultations, a complementary list of knowledge and skills objectives (beyond those listed in the EPA) is impractical.  A major focus of the Highland Hospital experience will be outpatient endoscopy, and thus specific objectives for this are listed below.  In addition, high yield topics specific to the outpatient endoscopy experience are listed below.  Fellows are encouraged to refer to the EPA references regularly throughout the rotation to choose additional topics pertinent to their patients for further study. It is not expected that all aspects of each EPA will be covered during the course of a single rotation. 

·         Describe the operation and features of the diagnostic and therapeutic upper endoscopes, colonoscopes and pediatric scopes

·         Basic understanding of endoscope processing before and after procedures

·         Fellow is able to connect the endoscope to the processor to ensure its safe and proper use.

·         Describe the risks, benefits, and alternatives of upper endoscopy and colonoscopy

·         Describe the proper indications for upper endoscopy and colonoscopy

·         Describe the mechanism of action and risks of commonly administered sedatives for endoscopic procedures

·         Accurately assess the patient’s ASA class and monitor the patient’s level of consciousness throughout the procedure to maintain a safe and effective level of sedation

·         Administer reversal agents for sedatives when appropriate

·         Understand the proper billing and coding for routine screening and diagnostic endoscopic procedures

·         Understanding appropriate documentation to meet endoscopy quality measures and to support proper procedural billing

·         Know and apply the quality measures being applied to endoscopic practices

Upper Endoscopy

·         Safely and routinely intubate the esophagus

·         Perform a controlled and thorough evaluation of the body and antrum of the stomach

·         Perform a complete evaluation of the cardia, fundus and incisura of the stomach under retroflexion

·         Intubate the duodenum routinely

·         Completely evaluate the duodenum to the 2nd and 3rd portions

·         Describe the indications for biopsy on upper endoscopy

·         Complete targeted biopsies on upper endoscopy

·         Safely and effectively dilate the esophagus when indicated

·         Use dye, narrow band imaging and other advanced imaging tools when appropriate to aid in diagnosis and clinical decision making

·         Describe endoscopic findings to patients and prescribe proper follow up, including appropriate actions based on biopsy results

Colonoscopy

·         Perform a complete digital rectal exam and safely insert the colonoscope into the rectum

·         Skillfully remove liquid contents from the colon in order to ensure proper mucosal visualization

·         Intubate the sigmoid colon routinely

·         Intubate the descending colon routinely

·         Intubate the transverse colon routinely

·         Intubate the ascending colon routinely

·         Intubate the cecum routinely

·         Intubate the cecum in a timely fashion (8-12 min)

·         Intubate the terminal ileum when appropriate

·         Examine the rectum under retroflexion

·         Know the indications for colon biopsies

·         Recognize the endoscopic features of hyperplastic and adenomatous polyps

·         Perform snare polypectomy safely and effectively - includes proper equipment choice and management of the endoscopic team required for independent practice

·         Describe the rate of post polypectomy bleeding and its management

·         Perform saline lift prior to polypectomy when indicated

·         Perform submucosal injection for tattoo/marking when indicated

·         Apply endoclip effectively when indicated for post polypectomy bleeding prophylaxis or treatment

·         Describe colonoscopic findings to patients and prescribe proper follow up, including appropriate actions based on biopsy results

Topics for Review 

1) GERD

2) Barretts Esophagus

3) Dysphagia

4) Eosinophilic Esophagitis

5) H. pylori

6) Peptic Ulcer Disease

7) Atrophic Gastritis/Intestinal Metaplasia

8) Gastric Cancer

9) Functional Dyspepsia

10) PPI and PCAB usage/complications, 

11) Gastric Polyps

12) Celiac Disease

13) Colorectal Cancer Screening

14) Colorectal Cancer Surveillance

15) Chronic Diarrhea

16) Microscopic Colitis

17) Ulcerative Colitis

18) Crohn’s Disease

19) Polyposis Syndromes

20) Serrated Adenomas

21) Rectal Bleeding

22) Hemorrhoids/Anal Fissure

23) Procedural Complications

24) Colonoscopy Quality Improvement

25) Liver Lesions

26) Cirrhosis and its complications

27) Pancreatic diseases and lesions

28) Biliary diseases

29) Functional GI disorders

30) GI Motility disorders

31) Checkpoint Inhibitor related complications

Fellows are expected to keep a running procedure log throughout the rotation.  Supervising faculty will be asked to evaluate the fellow’s endoscopic and cognitive skills using the Endoscopy and Colonoscopy evaluation forms and clinical evaluation forms provided.  A written evaluation to assess the fellows fund of knowledge will be administered at the end of the rotation. Evaluation from the nursing and support staff will be solicited. Fellows will be given the opportunity to formally evaluate the faculty.  Informal evaluation and feedback on a day to day basis is an expected part of the program culture. Evaluations will be rooted in the core competencies and sub-competencies outlined by the ACGME.

There will be verbal and written feedback given at the end of the rotation. Please fill out this form prior to your last feedback session for the rotation.

The main goal of independent study should be to learn and reinforce the basic and core fundamental knowledge required to effectively apply endoscopy and colonoscopy in clinical practice. Therefore, review of the above topics using textbooks (ie. Sleisenger and Fordtran, Cotton’s Practical Endoscopy) and online resources such as topic reviews and guidelines published by the AGA, ACG, AASLD, and ASGE is expected.  Recent clinical trials and pertinent studies from GI/Hepatology journals should be reviewed to address patient management questions. Fellows are encouraged to actively seek out primary literature to supplement their clinical experience and to enhance their clinical knowledge and management skills.

Additional Resources

AGA – GI SAM Self-Assessment Modules (free to trainee members)

ACG – ACG Education Universe: Online modules, presentations available to ACG members

AASLD – Liver Learning: Online presentations, podcasts, available to AASLD members or recent attendees of AASLD annual liver meeting

ASGE – Online Learning Center: selected free presentations on endoscopic techniques