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  • 1. January, 2008 Gastroenterology Fellowship University of Oklahoma Health Sciences Center Objectives and CurriculumThe University of Oklahoma, College of Medicine sponsors the Gastroenterology Fellowship atthe University of Oklahoma. The institution’s participating and supporting the Fellowshipincludes OU Medical Center (OUMC) and the Oklahoma City VA Medical Center (VAMC).The Fellowship is a daughter program of the Internal Medicine Residency Program. TheFellowship is structured in three consecutive years of training. All trainees entering the programmust complete a three year accredited residency program in Internal Medicine. Fellowshipcandidates are selected to enter the fellowship approximately one and a half years beforebeginning the fellowship in a competitive interview process and that follows all the policies andprocedures set forth by the University.The curriculum for the Fellowship Program is essentially derived from the GI core curriculumestablished by the Gastroenterology Leadership Counsel and published in the journalGastroenterology in April 2003 (updated draft for 2006 in press used as of 2006-07 academicyear). Fellows completing this training program are expected to be expert in all areas outline inthat curriculum document with the broad topics outlined below. The trainee will achievecompetence when, in the judgment of the Program Director and the Key Faculty, the trainee hasestablished a knowledge base, procedural skills, communications skills, and the ability tomaximize patient care through self-learning and recruitment of all necessary health careresources necessary to serve as a consultant in Gastroenterology. The following documentsummarizes the content of the curriculum and the objectives of the Fellowship Program as wellas the means of supervision and documentation of competency among the trainees. Thecurriculum will be reviewed at least annually by the Curriculum Committee of the Section ofDigestive Diseases and adjustments made based on outcome measures such as performance onBoard Exams and Inservice Exams and feedback from graduating trainees. Changes will also bedictated by new technologies and the need to incorporate new scientific discoveries.Responsibility for Resident Education & SupervisionThe Program assumes full academic and administrative responsibility for the planning andexecution of the educational program, including, but not limited to, selection and appointment toresidency positions, advancement or promotion of residents, final determination of residents’satisfactory completion of training requirements, programming, curriculum content, and facultyappointments. The individual responsible for resident education and supervision in this Programis William M. Tierney, the residency Program Director. William M. Tierney, M.D. Associate Professor of Medicine Department of Medicine 920 SL Young Blvd. WP 1360 1
  • 2. Oklahoma City, OK 73104 Telephone Number: (405) 271-5428 FAX Number: (405) 271-5803Dr. Tierney works with colleagues on the faculty to determine the educational goals andobjectives, the period of assignments, teaching, supervision, and evaluation of residents, anddevelops policies and procedures for residents.Educational Goals and ObjectivesEducational Goals: The ultimate goal of this three-year training experience is to haveindividuals leave our program who are skilled and respected gastroenterology consultants. Atthe completion of their residency, our trainees will:• Possess a broad knowledge base,• Become skilled in patient care and be able to generate a relevant differential diagnosis based on accurate history and physical examination, and review of relevant clinical data,• Be able to communicate effectively with other health care providers and demonstrate compassion and benevolence in all patient interactions including the capacity to communicate effectively with patients and their families,• Understand the indications and contraindications for diagnostic and therapeutic procedures,• Be skilled at performing these procedures,• Be able to think critically, and participate in a scholarly research project,• Demonstrate commitment to professionalism and possess an appreciation of the humanistic and ethical aspects of medicine.• Be able to achieve practice-based learning (improving practice thru the care of patients and their educational activities).• Appreciate the entire scope of health care system and call upon resources in the system to optimize patient care and outcomesProfessionalism in medicine, personal integrity and the ability to communicate effectively withreferring physicians, colleagues and support personnel will be stressed at each level of training.Educational Objectives: The program director, faculty and participating hospitals will providethe supervision, facilities and resources for trainees to have didactic experience and ongoingdirect patient contact in both an inpatient and outpatient setting to gain a core knowledge base,expertise and skill in the diagnosis and management of the following disorders or disciplines asoutlined in the Gastroenterology Core Curriculum (Gastroenterology, 2003; updated draft from2006 in press used as of 2006-07):• cellular and molecular physiology• gastrointestinal pathology• motility, diverticular disease and functional bowel diseases• acid-peptic diseases• pancreatic disorders, gastrointestinal hormone and diarrheal diseases 2
  • 3. • gastrointestinal inflammation to include inflammatory bowel diseases, gastrointestinal infections (non-HIV related) and gastrointestinal infections (HIV related)• gastrointestinal malignancies• hepatology• biliary tract diseases• gastrointestinal endoscopy and gastrointestinal bleeding• nutrition• gastrointestinal and hepatic pathology• gastrointestinal radiology• medical ethics and economics• women’s gastrointestinal health issues• common pediatric digestive disorders• digestive function and disease associated with agingThe thirty-six month fellowship will be structured so that approximately thirty months will bedevoted to clinical activities and at least six months to research and scholarly activity. Theinitial eighteen months of clinical experience (level 1) will be directed toward achieving theabove educational goals. The final twelve months of clinical training (level 2) will continue theprogression of clinical training in the inpatient and outpatient setting. Increasing responsibilitywill be given to higher level trainees so that they will continue to develop skills in diagnosis andmanagement of gastrointestinal hepatic diseases (approximately 30% of overall clinicalexperience). Inpatient and outpatient encounters will represent a broad range of clinicalproblems from acute and chronically ill individuals. As trainees advance into the second andthird year of training they will be given more independence and encouraged to become moredirective teachers of general internal medicine trainees. At all times, however, supervision ofpatient care by attending faculty will be direct and expedient.All trainees will be educated on the indications, contraindications, technical skills, interpretation,and decision making process for upper and lower endoscopic procedures as well as percutaneousliver biopsy. This includes esophagogastroduodenoscopy, flexible sigmoidoscopy, colonoscopy,and percutaneous gastrostomy placement. Therapeutic maneuvers for both upper and lowerendoscopy including biopsy, polypectomy, dilation, and control of variceal and nonvaricealhemorrhage will be incorporated in the educational experience once trainees have mastereddiagnostic endoscopy. Percutaneous liver biopsy and paracentesis will also be an integral part ofthe procedural training. Having achieved an adequate number of routine endoscopic proceduresthat exceed the minimum standards set forth the trainee will be allowed participate more fully inconsultations and advanced endoscopic procedures including management of gastrointestinalbleeding, endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound(EUS). While all trainees will be educated on the indications, contraindications, and limitationsof advanced procedures, the program will not train all trainees to be competent in ERCP andEUS. Select fellows may be assessed for competence if they perform >200 procedures. Allfellows will be given basic introduction to esophageal motility and 24 hour pH monitoring andvideo capsule endoscopy. In those individuals desiring advanced training in gastrointestinalmotility procedures or capsule endoscopy, these experiences will be available. During the entirethree-year training period, trainees will attend outpatient clinics two ½ days per week (½ dayVA, ½ day OUMC). In all of these clinical encounters the trainee will have the opportunity toenhance their practice based learning through review of state of the art literature; navigate their 3
  • 4. patients through the entire health care delivery system; enhance their commitment toprofessionalism; and maturation of their interpersonal skills. These competency based goals andobjectives are further outlined in specific learning assignments below. Guidelines for Endoscopic Training in Routine Procedures: Threshold for Assessing Competence Procedure Required number1 Esophagogastroduodenoscopy 130 Including treatment of upper and lower nonvariceal hemorrhage 25 (10 actively bleeding) Including treatment of variceal hemorrhage 20 (5 actively bleeding) Esophageal dilation 20 Flexible sigmoidoscopy 25 Colonoscopy 140 Including snare polypectomy 30 Percutaneous endoscopic gastrostomy placement 15 Percutaneous liver biopsy 201 Required number represents the threshold number of procedures that must be performed beforecompetency can be assessed. The number represents a minimum, and it is understood that mosttrainees will require more (never less) than the stated number. The information expressed in thetable represents the current recommendations of the ASGE and the ACGME programrequirements.Educational Rotations: PRESBYTERIAN TOWER CONSULTATION SERVICEAssignment: One fellow per month.Description: The Presbyterian Hospital Consultation Fellow will serve as the primary contactand coordinating physician for all inpatient consultations requested by all services atPresbyterian Hospital.Objectives: Develop skill of performing specialty-based consultations on inpatients. Establishteaching skills with instruction of residents and students rotating on the consult service. Usingliterature and reference material review to improve knowledge of digestive diseases through casebased learning and practice based improvement. Improve and apply knowledge of all aspects ofdigestive diseases, as outlined in the GI Core Curriculum. Understand the role of inpatient 4
  • 5. services and the importance of continuity in transitioning from inpatient to outpatientmanagement in caring for patients acutely ill with digestive diseases.Educational Resources: Yamada’s Textbook of Gastroenterology; Schiff’s Hepatology Text,other gastroenterology textbooks and atlases, online resources including the OUHSC library’ssubscription to Up-to-Date, and OVID for literature searching for primary references.Expectation and Responsibilities: Consult Fellow will maintain his pager and be availablefrom 7:00 AM to 5:00 PM. Monday through Friday for all consultations requested on inpatientsat Presbyterian Hospital. This includes consults requested from the emergency room from thesehospitals during assigned hours. The fellow will then directly evaluate and perform anassessment and develop a diagnostic and management plan for all consultations. This willinclude review of all relevant clinical data including radiographic studies, pathology, laboratorydata, and endoscopic findings, in addition to performing a specialty based comprehensive historyand physical exam. This fellow is also charged with delegating some consults to medicalstudents and internal medicine trainees who are rotating on the GI Consultation Service. It isexpected that the fellow will also directly evaluate patients who are seen by these other traineeson the initial consultation. Subsequent follow up visits on these consultations may be performedsolely by the other trainees, however, the majority of patients delegated to Internal MedicineResidents and medical students should also be continuously evaluated by the fellow in training.The consult fellow is responsible for notifying the attending physician of any emergentconsultations that require immediate input from the attending physician. All consultations willbe reviewed and evaluated by the consult attending within 24 hours of their request. The fellowis responsible for communicating with the physician requesting the consultation. There will beno more than 10 new patients evaluated by the consult fellow in any 24-hour period. Alladditional consults will be evaluated by the attending. The Consult Fellow is also responsible for assisting in the education of medical studentsand Internal Medicine trainees on the consult service through informal lectures and literaturesearches. The fellow should demonstrate practice based learning by identifying appropriateliterature relative to patient’s digestive disorders and disseminate that material to the generalmedicine house officers and students on the team requesting consultation. While there are no assigned endoscopic responsibilities during the consultation month,urgent or emergent endoscopy, will often be performed directly by the Consult Fellow under thesupervision of the attending for the consult service. The Presbyterian Consult fellow will be expected to attend their weekly OU MedicalCenter continuity clinic.Evaluation: The fellow will be evaluated on their evaluation and management skills as well astheir teaching efforts, communication skills, knowledge acquisition, systems-based learning, andpractice-based learning throughout the month by the supervising attending on the consultservice. Systems based learning will be evaluated based on the ability of the trainee to mobilizeappropriate medical, social, and home-based resources for their patients especially at the time ofdischarge. As with all rotations, quarterly evaluations will be completed by all faculty and selectnurses to contribute to the 360-degree evaluation of their overall performance including theircontinuity clinics.Goals (Year 1) • Improve knowledge base of digestive diseases 5
  • 6. • Improve communication and interpersonal skills • Learn to navigate health care delivery system involving many specialties • Learn to provide consultative services in the specialty of gastroenterology • Enhance practice-based learning skills • Learn to lead a team of specialists • Improve teaching skills • Enhance an internist’s level history and exam skills to the level of a digestive disease specialist.(Years 2 and 3) In addition to above: • Develop expert (faculty level) knowledge base of digestive diseases • Graduate to more independent level of complex decision making in digestive disease management • Further enhance practice-based learning skills and familiarity with systems of careObjectives (Year 1) • Have dedicated experience in evaluation and management of inpatient digestive diseases • This includes performing comprehensive history and examination with emphasis on digestive processes. • In the process of diagnostic or therapeutic management recommendations, make decisions on appropriateness of gastrointestinal endoscopy and communicate risks and benefits to patient while obtaining informed consent • Work with several internal medicine residents and/or students to coordinate care delivery provided by consult team • Communicate consult findings and recommendations to requesting physician(s) • Communicate recommendations and findings of diagnostic studies directed towards digestive diseases to patients and family as appropriate. • Review literature on disease processes encountered in patients and utilize this literature and new knowledge to optimize patient care • Teach basic digestive diseases to earlier level trainees and internal medicine trainees requesting consultations. • Work with other health care providers including social workers, case managers, gastroenterology nursing staff, pharmacists, and other allied health professionals to optimize resources available to patients.(Years 2 and 3) In addition to above: • Have further experience in evaluation and management of inpatient digestive diseases with more independence in decision making • Maturation of communication skills as process of training advances with background expectation of practicing as competent gastroenterologist without the need for supervision. • Make complex management decisions with supervising faculty serving as learning resource and providing guidance • Further experience reviewing literature and using evidenced based medicine to optimize care 6
  • 7. • Perform more extensive teaching of residents and lower level trainees and even Internal Medicine faculty on the nature and pathophysiology of digestive diseases PRESBYTERIAN ENDOSCOPY FELLOWAssignment: One fellow per month. (Second or Third Year Fellow)Description: Presbyterian Endoscopy Fellow will be directly responsible for performing allendoscopy procedures in Presbyterian Endoscopy Lab including outpatients and inpatients. Thisfellow will also serve as the advanced endoscopy fellow responsible for ERCP both atPresbyterian Hospital and at the VA Medical Center.Objectives: Learn techniques, interpretation, and appropriate indications of basic upper andlower endoscopy including but not limited to therapeutic maneuvers such as polypectomy,dilation, gastrostomy tube placement, control of variceal and non-variceal bleeding. Learn skillof endoscopic report generation and communication with referring physicians. Learnappropriate surveillance practices for patients at risk for gastrointestinal neoplasia. Learntechniques and appropriate indications of percutaneous liver biopsy. Develop an exposure toERCP techniques and be able to understand the indications, contraindications, and limitations ofERCP. Improve and apply knowledge of all aspects of digestive diseases, as outlined in the GICore Curriculum, in the care of patients undergoing gastrointestinal endoscopy.Educational Resources: Yamada’s Textbook of Gastroenterology; Schiff’s Hepatology Text,other gastroenterology textbooks and atlases, online resources including the OUHSC library’ssubscription to Up-to-Date, and OVID for literature searching for primary references.Expectation and Responsibilities: The fellow assigned will be responsible for performing apreprocedural assessment, including determining appropriateness of the indications for theprocedure and obtaining informed consent from the patient prior to initiation of any procedures.The fellow is responsible for discussing the appropriateness and indications with the attendingphysician assigned to the endoscopy lab prior to proceeding with the procedure. The fellow willbe directly responsible for performing the procedure with the direct supervision of the attendingphysician. All findings and impressions will be discussed with the attending physician prior tothe generation of the report. The fellow is responsible for generating a written report includingdocumentation of the preprocedural assessment, medications used during moderate sedation ifappropriate, findings, impressions and recommendations. This report is to be generated andincluded into the patient’s OU Medical Center Medical Records. Fellows are expected to followup all pathology specimens and communicate results to the patient and referring physician. In addition to performing standard procedures at the VA Endoscopy Lab, thePresbyterian Endoscopy Fellow is also responsible for scheduling and coordinating all ERCP atPresbyterian Hospital and at the VA Medical Center. This includes the identification of theappropriateness of the procedure, the preprocedural evaluation, and informed consent prior toproceeding with the procedure. As with standard endoscopy, the case will be discussed with theattending physician responsible for supervising the fellow for the procedure. Also, as with thestandard endoscopic procedures, the fellow will be responsible for performing the procedureunder the direct supervision of the attending and then generating a report under the same 7
  • 8. guidelines as the general endoscopy procedure protocol. Fellows are expected to demonstratepractice-based learning through reading of primary literature relevant to disease statesencountered during their procedure encounters. While on this rotation the fellow will spend one day per week reviewing all esophagealmotility studies performed at both OU medical center and the VA medical center with thefaculty member responsible for reviewing esophageal motility studies. At times the Presbyterian Endoscopy Fellow will be called upon to assist with theconsultative services at Presbyterian Hospital and will work directly with the PresbyterianConsult Fellow in coordinating care for consults requested. During the month of the rotation thefellow will also attend their outpatient continuity clinics at OU Medical Center and at the VAMedical Center.Evaluation: The fellow on the Presbyterian Endoscopy Rotation will be evaluated by theattending physicians supervising him/her for procedures on at least a quarterly basis and therewill be at least monthly written evaluations of individual procedures performed in the mannersimilar to a mini-CEX. This is designed to show the acquisition of procedural skills towards thegoal of competency. Systems based learning will be evaluated based on the ability of the traineeto mobilize appropriate medical, social, and home-based resources for their patients.Goals (Year 2 and 3 only) • Expand experience with appropriate pre-procedural preparation recommendations based on evidenced based guidelines • Enhance understanding of informed consent process and optimal practice of providing patient education on the risks and benefits of GI endoscopy • Expand experience with basic endoscopic techniques with emphasis on esophagogastroduodenoscopy and colonoscopy with relevant therapeutics. Other techniques such as percutaneous liver biopsy and paracentesis will be learned • Enhance level of expertise in endoscopic interpretation • Learn more complex decision making based on real time endoscopic findings • Learn more advanced procedures (i.e. complex polypectomy, ERCP, small bowel endoscopy) • Achieve skills to independently perform all basic endoscopic techniques and apply therapeutic appropriately • Make complex decisions during and after endoscopic procedures with increased independence in year 3 • Learn complications of endoscopic procedures and appropriate management • Improve knowledge base of digestive diseases • Improve communication and interpersonal skills • Learn to navigate health care delivery system involving many specialties • Enhance practice-based learning skillsObjectives (Year 2 and 3 only) • Evaluate patients presenting for GI endoscopy with emphasis on the appropriateness and or contraindication to proceeding with scheduled procedure • Evaluate patients with more complex digestive diseases requiring gastrointestinal endoscopy 8
  • 9. • Counsel patients on the risks and benefits of advanced endoscopic procedures and obtain informed consent • Perform more complex procedures such as small bowel enteroscopy, endoscopic stent placement, endoscopic ablation of vascular malformations, gastrointestinal hemorrhage in the critically ill, complex polypectomy and endoscopic mucosal resection. • Evaluate all patients being considered for ERCP • Perform ERCP with a goal of becoming familiar with but not procedurally competent with therapeutic biliary endoscopy • Perform history and physical prior to all endoscopic procedures • Further experience in counseling patients and family on risks, benefits, and alternatives to relevant procedures and obtaining informed consent prior to endoscopic procedures, liver biopsy, or paracentesis • Work as part of a team in performing endoscopic procedures • Perform moderate sedation with focus on optimizing patient comfort and safety • Perform basic diagnostic endoscopy including esophagogastroduodenoscopy and colonoscopy with basic therapeutic maneuver including forceps biopsy, polypectomy, stricture dilation, control of gastrointestinal hemorrhage, and percutaneous gastrostomy • Perform percutaneous liver biopsy and paracentesis • Generate comprehensive procedure report indicating personnel involved, indication, detailed description of procedure, findings, pathology specimens, overall impression, and recommendation • Formulate management plan for digestive disease based on endoscopic findings or therapy applied. • Communicate findings to patient and/or family • Follow-up all pathology specimens and communicate findings and change in management plans based on pathologic findings to patients and referring physicians. • Read relative source material and literature to optimize patient management • Assist with coordination of patient follow-up in outpatient clinics or referral to other specialties based on endoscopic findings • Coordinate other specialty resources such as unusual pharmacy or device needs to optimize therapy (e.g. obtaining non-formulary drugs). VA HOSPITAL CONSULTATION SERVICEAssignment: One fellow per month.Description: The Consultation Fellow will serve as the primary contact and coordinatingphysician for all inpatient consultations requested by all services at the VA Medical Center.Objectives: Develop skill of performing specialty-based consultations on inpatients. Establishteaching skills with instruction of residents and students rotating on the consult service. Usingliterature and reference material review to improve knowledge of digestive diseases through casebased learning and practice based improvement. Improve and apply knowledge of all aspects ofdigestive diseases, as outlined in the GI Core Curriculum. Understand the role of inpatient 9
  • 10. services and the importance of continuity in transitioning from inpatient to outpatientmanagement in caring for patients acutely ill with digestive diseases.Educational Resources: Yamada’s Textbook of Gastroenterology; Schiff’s Hepatology Text,other gastroenterology textbooks and atlases, online resources including the OUHSC library’ssubscription to Up-to-Date, and OVID for literature searching for primary referencesExpectation and Responsibilities: Consult Fellow will maintain his pager and be availablefrom 7:00 AM to 5:00 PM. Monday through Friday for all consultations requested on inpatientsat the VA Hospital and consults requested at the OU Women’s and Children’s Hospital. Thisincludes consults requested from the emergency room from these hospitals during assignedhours. The fellow will then directly evaluate and perform an assessment and develop adiagnostic and management plan for all consultations. This will include review of all relevantclinical data including radiographic studies, pathology, laboratory data, and endoscopic findings,in addition to performing a specialty based comprehensive history and physical exam. Thisfellow may also be charged with delegating some consults to medical students and internalmedicine trainees who are rotating on the GI Consultation Service. It is expected that the fellowwill also directly evaluate patients who are seen by these other trainees on the initialconsultation. Subsequent follow up visits on these consultations may be performed solely by theother trainees, however, the majority of patients delegated to Internal Medicine Residents andmedical students should also be continuously evaluated by the fellow in training. The consultfellow is responsible for notifying the attending physician of any emergent consultations thatrequire immediate input from the attending physician. All consultations will be reviewed andevaluated by the consult attending within 24 hours of their request. The fellow is responsible forcommunicating with the physician requesting the consultation. There will be no more than 10new patients evaluated by the consult fellow in any 24-hour period. All additional consults willbe evaluated by the attending. The Consult Fellow is also responsible for assisting in the education of medical studentsand Internal Medicine trainees on the consult service through informal lectures and literaturesearches. The fellow should demonstrate practice based learning by identifying appropriateliterature relative to patient’s digestive disorders and disseminate that material to the generalmedicine house officers and students on the team requesting consultation. The VA Consultation Fellow will be expected to attend their weekly continuity clinic atthe VA Medical Center. The VA Consultation Fellow will also be directly involved in the performance ofendoscopies on both ambulatory patients and inpatients in the endoscopy suite at the VAMedical Center.Evaluation: The fellow will be evaluated on their evaluation and management skills as well astheir teaching efforts, communication skills, knowledge acquisition, systems-based learning, andpractice-based learning throughout the month by the supervising attending on the consultservice. Systems based learning will be evaluated based on the ability of the trainee to mobilizeappropriate medical, social, and home-based resources for their patients especially at the time ofdischarge. As with all rotations, quarterly evaluations will be completed by all faculty and selectnurses to contribute to the 360-degree evaluation of their overall performance including theircontinuity clinics.Goals (Year 1) 10
  • 11. • Improve knowledge base of digestive diseases • Improve communication and interpersonal skills • Learn to navigate health care delivery system involving many specialties • Learn to provide consultative services in the specialty of gastroenterology • Enhance practice-based learning skills • Learn to lead a team of specialists • Enhance an internist’s level history and exam skills to the level of a digestive disease specialist.(Years 2 and 3) In addition to above: • Develop expert (faculty level) knowledge base of digestive diseases • Graduate to more independent level of complex decision making in digestive disease management • Further enhance practice-based learning skills and familiarity with systems of careObjectives (Year 1) • Have dedicated experience in evaluation and management of inpatient digestive diseases • This includes performing comprehensive history and examination with emphasis on digestive processes. • In the process of diagnostic or therapeutic management recommendations, make decisions on appropriateness of gastrointestinal endoscopy and communicate risks and benefits to patient while obtaining informed consent • Work with several internal medicine residents and/or students to coordinate care delivery provided by consult team • Communicate consult findings and recommendations to requesting physician(s) • Communicate recommendations and findings of diagnostic studies directed towards digestive diseases to patients and family as appropriate. • Review literature on disease processes encountered in patients and utilize this literature and new knowledge to optimize patient care • Teach basic digestive diseases to earlier level trainees and internal medicine trainees requesting consultations. • Work with other health care providers including social workers, case managers, gastroenterology nursing staff, pharmacists, and other allied health professionals to optimize resources available to patients.(Years 2 and 3) In addition to above: • Have further experience in evaluation and management of inpatient digestive diseases with more independence in decision making • Maturation of communication skills as process of training advances with background expectation of practicing as competent gastroenterologist without the need for supervision. • Make complex management decisions with supervising faculty serving as learning resource and providing guidance • Further experience reviewing literature and using evidenced based medicine to optimize care 11
  • 12. • Perform more extensive teaching of residents and lower level trainees and even Internal Medicine faculty on the nature and pathophysiology of digestive diseases VA HOSPITAL ENDOSCOPY FELLOWAssignment: Two or three fellows per month.Description: Trainees assigned to the VA Endoscopy Service will be responsible forperforming a full array of endoscopic services on outpatients and inpatients at the VA MedicalCenter under the direct supervision of the attending physician assigned to the VA EndoscopyLab.Objectives: Learn techniques, interpretation, and appropriate indications of basic upper andlower endoscopy including but not limited to therapeutic maneuvers such as polypectomy,dilation, gastrostomy tube placement, control of variceal and non-variceal bleeding. Learn skillof endoscopic report generation and communication with referring physicians. Learnappropriate surveillance practices for patients at risk for gastrointestinal neoplasia. Learntechniques and appropriate indications of percutaneous liver biopsy. Improve skills of radiologyinterpretation. Improve and apply knowledge of all aspects of digestive diseases, as outlined inthe GI Core Curriculum, in the care of patients undergoing gastrointestinal endoscopy.Educational Resources: Yamada’s Textbook of Gastroenterology; Schiff’s Hepatology Text,other gastroenterology textbooks and atlases, online resources including the OUHSC library’ssubscription to Up-to-Date, and OVID for literature searching for primary referencesExpectation and Responsibilities: Endoscopy Fellows will be responsible for performing apreprocedure evaluation, including obtaining informed consent for all procedures performed atthe VA Medical Center. The fellow is responsible for discussing the appropriateness andindications with the attending physician assigned to the endoscopy lab prior to proceeding withthe procedure. The fellow will be directly responsible for performing the procedure with thedirect supervision of the attending physician. All findings and impressions will be discussedwith the attending physician prior to the generation of the report. The fellow is responsible forgenerating a written report including documentation of the preprocedural assessment,medications used during moderate sedation if appropriate, findings, impressions andrecommendations. This report is to be directly entered into the VA Medical Records. Whenprocedures are performed on inpatients, the fellow is responsible for directly communicatingwith both the consulting fellow and the inpatient primary service regarding the findings andrecommendations of the procedure. Fellows are expected to follow up all pathology specimensand communicate results to the patient and referring physician. Fellows are expected todemonstrate practice-based learning through reading of primary literature relevant to diseasestates encountered during their procedure encounters. Fellows assigned to the VA Endoscopy Rotation will also be expected to attend theirambulatory continuity clinics at the OU Medical Center, VA hospital, and the VA hepatitisclinic. One day per week the fellows will review radiographic studies with attendingradiologists at OU Medical Center as a means to solidify experience in computed tomography,ultrasonography, and plain film interpretation. 12
  • 13. Evaluation: The fellows on the VA Endoscopy Rotation will be evaluated, by faculty membersassigned on a daily basis to the endoscopy lab, on procedural skills including the appropriatenessof preprocedural evaluations and post-procedure counseling. There will be at least one monthlyformal written evaluations of procedural skills observed during an individual patient encountersimilar to a mini-CEX evaluation. This instrument is used to assess procedural competency aswell as patient communication, report generation, and ability to establish plan of care. Systemsbased learning will be evaluated based on the ability of the trainee to mobilize appropriatemedical, social, and home based resources for their patients. As with all rotations, quarterlyevaluations will be completed by all faculty and select nurses to contribute to the 360-degreeevaluation of their overall performance including their continuity clinics. Goals (Year 1) • Learn indications and contraindications of endoscopic procedures • Learn appropriate techniques of moderate sedation and requisite monitoring practices • Learn appropriate preprocedural preparation recommendations based on evidenced based guidelines • Learn basic endoscopic techniques with emphasis on esophagogastroduodenoscopy and colonoscopy with relevant therapeutics. Other techniques such as percutaneous liver biopsy and paracentesis will be learned • Learn basic interpretation of endoscopic findings • Learn complications of endoscopic procedures and appropriate management • Enhance understanding of informed consent process and optimal practice of providing patient education on the risks and benefits of GI endoscopy • Learn basic decision making based on real time endoscopic findings • Improve knowledge base of digestive diseases • Improve communication and interpersonal skills • Learn to navigate health care delivery system involving many specialties • Enhance practice-based learning skills • Learn radiology interpretation with focus on gastrointestinal radiology(Years 2 and 3)In addition to all above: • Learn more advanced procedures (i.e. complex polypectomy, ERCP, small bowel endoscopy) • Achieve skills to independently perform all basic endoscopic techniques and apply therapeutic appropriately • Enhance level of expertise in endoscopic interpretation • Make complex decisions during and after endoscopic procedures with increased independence in year 3Objectives (Year 1) • Evaluate patients presenting for GI endoscopy with emphasis on the appropriateness and or contraindication to proceeding with scheduled procedure • Perform history and physical prior to all endoscopic procedures • Experience in counseling patients and family on risks, benefits, and alternatives to relevant procedures and obtaining informed consent prior to endoscopic procedures, liver biopsy, or paracentesis 13
  • 14. • Work as part of a team in performing endoscopic procedures • Perform moderate sedation with focus on optimizing patient comfort and safety • Perform basic diagnostic endoscopy including esophagogastroduodenoscopy and colonoscopy with basic therapeutic maneuver including forceps biopsy, polypectomy, stricture dilation, control of gastrointestinal hemorrhage, and percutaneous gastrostomy • Perform percutaneous liver biopsy and paracentesis • Generate comprehensive procedure report indicating personnel involved, indication, detailed description of procedure, findings, pathology specimens, overall impression, and recommendation • Formulate management plan for digestive disease based on endoscopic findings or therapy applied. • Communicate findings to patient and/or family • Follow-up all pathology specimens and communicate findings and change in management plans based on pathologic findings to patients and referring physicians. • Read relative source material and literature to optimize patient management • Assist with coordination of patient follow-up in outpatient clinics or referral to other specialties based on endoscopic findings • Coordinate other specialty resources such as unusual pharmacy or device needs to optimize therapy (e.g. obtaining non-formulary drugs). • Spend one- half day per week reviewing gastrointestinal x-rays with faculty radiologists.(Year 2 and 3) In addition to above: • Evaluate patients with more complex digestive diseases requiring gastrointestinal endoscopy • Counsel patients on the risks and benefits of advanced endoscopic procedures and obtain informed consent • Perform more complex procedures such as small bowel enteroscopy, endoscopic stent placement, endoscopic ablation of vascular malformations, gastrointestinal hemorrhage in the critically ill, complex polypectomy and endoscopic mucosal resection. • Evaluate patients being considered for ERCP when the Presbyterian Endoscopy Fellow is unavailable. • Perform ERCP with a goal of becoming familiar with but not procedurally competent with therapeutic biliary endoscopy OU Physicians ENDOSCOPY FELLOWAssignment: Up to one fellow per month.(Third Year Fellow)Description:Senior Fellow will work directly with one attending each day of the week in performingstandard and advanced endoscopy (EUS) at the ambulatory endoscopy center at the OUPhysicians building. (Note: Facility is administered by OU Medical Center, and hence is ahospital endoscopy center but all patients are outpatients). 14
  • 15. Objectives: Learn techniques, interpretation, and appropriate indications of basic upper andlower endoscopy including but not limited to therapeutic maneuvers such as polypectomy,dilation. Obtain exposure to endoscopic ultrasound and understand its indications, limitationsand role in managing digestive diseases. Learn skill of endoscopic report generation andcommunication with referring physicians. Learn appropriate surveillance practices for patientsat risk for gastrointestinal neoclassic. Improve and apply knowledge of all aspects of digestivediseases, as outlined in the GI Core Curriculum, in the care of patients undergoinggastrointestinal endoscopy. Rotation designed to provide experience similar to communitybased endoscopy center with less acutely ill patients relative to the inpatient endoscopy lab butmore similar to ambulatory private practice.Educational Resources: Yamada’s Textbook of Gastroenterology; Schiff’s Hepatology Text,other gastroenterology textbooks and atlases, online resources including the OUHSC library’ssubscription to Up-to-Date, and OVID for literature searching for primary referencesExpectation and Responsibilities: The fellow assigned will be responsible for performing apreprocedural assessment, including determining appropriateness of the indications for theprocedure and obtaining informed consent from the patient prior to initiation of any procedures.The fellow is responsible for discussing the appropriateness and indications with the attendingphysician assigned to the endoscopy lab prior to proceeding with the procedure. The fellow willbe directly responsible for performing the procedure with the direct supervision of the attendingphysician. All findings and impressions will be discussed with the attending physician prior tothe generation of the report. The fellow is responsible for generating a written report includingdocumentation of the preprocedural assessment, medications used during moderate sedation ifappropriate, findings, impressions and recommendations. This report is to be generated andincluded into the patient’s OU Medical Center medical records. The experience is intended tobroaden the exposure to ambulatory patients, similar to the population seen in communitypractice. Furthermore, trainees will be directly involved in performing EUS. Fellows assignedto this rotation will be expected to develop a knowledge base of the rationale, limitations,indications and appropriateness of EUS but not necessarily develop full competence. Assignedreading will be provided. Fellows are expected to demonstrate practice-based learning throughreading of primary literature relevant to disease states encountered during their procedureencounters. .Evaluation: The fellow on the OUPB Endoscopy Rotation will be evaluated by the attendingphysicians supervising him/her for procedures on at least a quarterly basis and there will beperiodic written evaluations of individual procedures performed in the manner similar to a mini-CEX. This instrument is used to assess procedural competency as well as patientcommunication, report generation, and ability to establish plan of care. As with all rotationsquarterly evaluations will be completed by all faculty and select nurses to contribute to the 360-degree evaluation of their overall performance including their continuity clinics.Goals (Year 3 only) • Solidify experience in evaluation of patients referred for gastrointestinal endoscopy with focus on ambulatory patients similar to community gastroenterology practice • Enhance understanding of informed consent process and optimal practice of providing patient education on the risks and benefits of GI endoscopy with focus on ambulatory patients presenting for elective procedures 15
  • 16. • Improve decision making based on real time endoscopic findings with focus on ambulatory patients • Learn indications, contraindications, and complications of endoscopic ultrasound (EUS) with or without fine needle aspiration or other EUS guided therapies • Learn science of ultrasound imaging • Learn basic technique of EUS and EUS-guided FNA and ultrasound interpretation to level of familiarity with procedure but not competence • Learn GI cancer staging and complex decision making related to stage specific therapies in patients presenting for EUS staging of gastrointestinal malignancies • Improve knowledge base of digestive diseases • Improve communication and interpersonal skills necessary for successful ambulatory community based practice • Learn to navigate health care delivery system involving many specialties including numerous disciplines involved in care of patients with GI malignancy • Enhance practice-based learning skillsObjectives (Year 3 only) • Evaluate patients presenting for GI endoscopy with emphasis on the appropriateness and or contraindication to proceeding with scheduled procedure • Evaluate patients with more complex digestive diseases requiring gastrointestinal endoscopy • Counsel patients on the risks and benefits of advanced endoscopic procedures and obtain informed consent • Perform history and physical prior to all endoscopic procedures • Further experience in counseling patients and family on risks, benefits, and alternatives to relevant procedures and obtaining informed consent prior to endoscopic procedures. • Work as part of a team in performing endoscopic procedures in an ambulatory procedure area vs hospital based endoscopy areas in earlier training experiences • Perform moderate sedation with focus on optimizing patient comfort and safety • Perform basic diagnostic endoscopy including esophagogastroduodenoscopy and colonoscopy with basic therapeutic maneuver including forceps biopsy, polypectomy, and stricture dilation. • Perform basic EUS and assist with EUS-FNA with goal of being exposed to this advanced endoscopic procedure. • Generate comprehensive procedure report indicating personnel involved, indication, detailed description of procedure, findings, pathology specimens, overall impression, and recommendation • Acting with more independence formulate management plan for digestive disease based on endoscopic findings or therapy applied. • Communicate findings to patient and/or family • Follow-up all pathology specimens and communicate findings and change in management plans based on pathologic findings to patients and referring physicians. • Read relative source material and literature to optimize patient management • Read syllabus of EUS literature covering science of ultrasound, the role of EUS in evaluating patients with GI disease, and technical information unique to instruments used in EUS. 16
  • 17. • Assist with coordination of patient follow-up in outpatient clinics or referral to other specialties based on endoscopic findings.RESEARCH FELLOWAssignment: One or two fellows per month.Description: When assigned to the Research Rotation, the fellow will generally have sixcontiguous months dedicated solely to research activity. The fellow will not be assigned toconsultative or endoscopy services with the exception of the rare need to cover for the absenceof other fellows due to limited availability of personnel, such as when national meetings occur.Objective: Establish expertise in a focused basic or clinical area within gastroenterology.Understand the regulatory requirements for research involving human subjects. Producescholarly writings in gastroenterology.Educational Resources: Yamada’s Textbook of Gastroenterology; Schiff’s Hepatology Text,other gastroenterology textbooks and atlases, online resources including the OUHSC library’ssubscription to Up-to-Date, and OVID for literature searching for primary references.Expectation and Responsibilities: The fellow is expected to work directly with a facultymentor or mentors to develop research projects. This includes the development of anInstitutional Review Board proposal identifying the hypothesis, methodology and statisticalanalysis planned for the particular protocol. The fellow should be directly involved with thescientific review required to adequately prepare the protocol. Once the IRB protocol isapproved, the fellow will be directly responsible and involved in the data collection, subsequentdata analysis, development of abstracts, presentations at national meetings, and finally thewriting and completion of a publishable manuscript. During the course of the fellowship, it isrequired that the fellow achieve and experience during the six months of research training thatresults in a manuscript publishable in a peer-review or non-peer-review journal. During theresearch time the fellow will continue to have his ambulatory continuity clinics at the VAMedical Center and at OU Medical Center.Evaluation: The fellow will be evaluated, by all faculty members, at least on a quarterly basisbut particularly by the research mentors as to the commitment and successful completion of theresponsibilities as outlined above. As with all rotations quarterly evaluations will be completedby all faculty and select nurses to contribute to the 360 degree evaluation of their overallperformance including their continuity clinics.Goals (Year 2 only) The following is all under the guidance of research project mentor • Gain experience, with guidance of faculty member, in development of specific research (clinical or basic) question • Expand knowledge base of focused area relevant to research question • Learn to design research protocol to answer question • Become familiar with regulatory requirements for patient oriented research 17
  • 18. • Learn to communicate research findings in public forum either with poster or oral presentation • Learn to communicate research or scholarly work through publicationObjective (Year 2 only) The following is all under the guidance of research project mentor • Write a summary or research project proposal(s) prior to initiating research rotation • Read background literature for research project(s) • Submit IRB proposal if human subjects involved • Spend at least 6 months carrying out protocol • Submit results to local and/or national meeting for presentation (oral or poster) • Submit at least one manuscript of original research or other scholarly work to a peer- reviewed journal.Continuity Clinics OU Medical Center Continuity ClinicAssignment: All active fellows throughout their period of trainingDescription:All fellows will attend a one half-day outpatient clinic at OU Medical Center. The trainee willfollow a cohort of patients throughout their training with supervision provided by dedicatedclinic faculty. All patients will be directly scheduled with the trainee and patients will identifythe trainee as their gastroenterologist.Objectives: Establish experience and learn the diagnosis and management of ambulatorydigestive disorder including but not limited to: acid-peptic disease, inflammatory bowel disease,diarrheal diseases, gallbladder and biliary diseases, pancreatic diseases, viral and non-viral liverdiseases, functional bowel diseases, gastrointestinal malignancies, nutritional disorders andtherapy, motility disorders, and disorders specific to women and geriatric populations. Fellowswill also learn the role of preventive services including screening for gastrointestinal neoplasia,vaccination, nutritional therapy, and substance abuse treatment and counseling. Improve andapply knowledge of all aspects of digestive diseases, as outlined in the GI Core Curriculum, inthe care of patients undergoing gastrointestinal endoscopy. Develop skill with educating patientsand families in outpatient disorders and shepherding them through other aspects of the healthcare system including the need for consultation with other specialists such as gastrointestinalsurgeons, transplant services, and other medical and surgical subspecialties.Educational Resources: Yamada’s Textbook of Gastroenterology; Schiff’s Hepatology Text,other gastroenterology textbooks and atlases, online resources including the OUHSC library’ssubscription to Up-to-Date, and OVID for literature searching for primary referencesExpectation and Responsibilities: The Fellow will be assigned approximately 1-3 new patientsand 4-6 return visits for each half day encounter. Fellows will be excused from clinic only whenthey are assigned to the consult service at the alternative training site (VA Medical Center) or onvacation leave. They will never be absent for more than one continuous month. (Note: fellowswill participate in their continuity clinic at the VA medical center during their absence while on 18
  • 19. assignment at the VA consult service). At each visit fellows will perform a complete history andphysical exam, review relevant laboratory, endoscopy, radiology, and pathology findings anddevelop and independent assessment of the patients digestive disorder including a differentialdiagnosis when appropriate. The fellow will then formulate a diagnostic and therapeutic planindividualized for the patient’s condition. The entire findings of their evaluation andmanagement plan will be reviewed with the supervising attending and a consensus plan will beestablished and the fellow will document the entire findings and plan in a well organizedprogress note in the patient’s medical records. The attending will then review this record entryfor accuracy and organizational content before documenting his or her approval. At eachencounter fellows are expected to communicate their plans to the patient or the patient’srepresentative. The fellow is expected to follow-up any diagnostic testing and arrangeappropriate follow-up visits to review these findings and/or therapeutic responses with thepatient. Given the office hours only occur one half-day per week; fellows will be responsible forcommunicating with patients outside of usual clinic office hours in order to foster a strongpatient-physician relationship over time. Likewise, fellows will be expected to advocate fortheir patients when attempting to Sheppard them through the health care system. Fellows areexpected to demonstrate practice-based learning through reading of primary literature relevant todisease states encountered during their clinic encounters. .Evaluation: As with all rotations quarterly evaluations will be completed by all faculty andselect nurses to contribute to the 360-degree evaluation of their overall performance in theircontinuity clinics. Fellows will also provide select continuity patients with an evaluation formassessing the fellow’s performance as their subspecialty physician.Goals (All three years) • Learn to evaluate ambulatory patients with digestive diseases • Learn to serve as a digestive disease consultant for ambulatory patients • Expand history and exam skills beyond general internist level to level capable of more completely evaluating digestive complaints or detecting digestive disorders • Learn diagnostic and therapeutic decision making with increasing complexity as graduate to later years of training • Learn to communicate with patients and family members • Learn importance of commitment to continuity of care with emphasis on ensuring continuous availability, prompt follow-up of tests, and provision of superior care • Practice patient advocacy • Expand knowledge base of digestive disease with emphasis on practice based learningObjectives (All three years) • Participate in weekly half-day clinic consisting of panel of patients (one average 1-3 new patients; 4-6 return patients) identified as trainee’s patients. • Perform detailed history and physical on all patients • Review all laboratory, pathology, imaging data for individual patients • Independently formulate diagnostic and therapeutic plan • All patients reviewed with digestive disease faculty member to ensure supervised care and enhance instruction • Communicate recommendations in considerate fashion to both patient and referring physicians 19
  • 20. • In the process of communication appreciate cultural and gender specific concerns • Follow-up, in timely fashion, all tests ordered at time of encounter • Utilize other specialties and allied health services to optimize patient care • Shepard patients through health care system when other specialty services or referrals are needed • Read up to date literature on disease states encountered in patients for purpose of expanding knowledge and optimizing patient care VA Medical Center Continuity ClinicAssignment: All active fellows throughout their period of trainingDescription:All fellows will attend a one half-day outpatient clinic at the VA Medical Center. The traineewill follow a cohort of patients throughout their training with supervision provided by dedicatedclinic faculty. All patients will be directly scheduled with the trainee and patients will identifythe trainee as their gastroenterologist.Objectives: Establish experience and learn the diagnosis and management of ambulatorydigestive disorder including but not limited to: acid-peptic disease, inflammatory bowel disease,diarrheal diseases, gallbladder and biliary diseases, pancreatic diseases, viral and non-viral liverdiseases, functional bowel diseases, gastrointestinal malignancies, nutritional disorders andtherapy, motility disorders, and disorders specific to geriatric populations. Fellows will alsolearn the role of preventive services including screening for gastrointestinal neoplasia,vaccination, nutritional therapy, and substance abuse treatment and counseling. Improve andapply knowledge of all aspects of digestive diseases, as outlined in the GI Core Curriculum, inthe care of patients undergoing gastrointestinal endoscopy. Develop skill with educating patientsand families in outpatient disorders and shepherding them through other aspects of the healthcare system including the need for consultation with other specialists such as gastrointestinalsurgeons, transplant services, and other medical and surgical subspecialties.Educational Resources: Yamada’s Textbook of Gastroenterology; Schiff’s Hepatology Text,other gastroenterology textbooks and atlases, online resources including the OUHSC library’ssubscription to Up-to-Date, and OVID for literature searching for primary referencesExpectation and Responsibilities: The Fellow will be assigned approximately 1-3 new patientsand 4-6 return visits for each half-day encounter. Fellows will be excused from clinic only whenthey are assigned to the consult service at the alternative training site (OU Medical Center) or onvacation leave. They will never be absent for more than one continuous month. (Note: fellowswill participate in their continuity clinic at the OU medical center during their absence while onassignment at the OU consult service). At each visit fellows will perform a complete history andphysical exam, review relevant laboratory, endoscopy, radiology, and pathology findings anddevelop and independent assessment of the patients digestive disorder including a differentialdiagnosis when appropriate. The fellow will then formulate a diagnostic and therapeutic planindividualized for the patient’s condition. The entire findings of their evaluation andmanagement plan will be reviewed with the supervising attending and a consensus plan will beestablished and the fellow will document the entire findings and plan in a well organized 20
  • 21. progress note in the patient’s medical records. The attending will then review this record entryfor accuracy and organizational content before documenting his or her approval. At eachencounter fellows are expected to communicate their plans to the patient or the patient’srepresentative. The fellow is expected to follow-up any diagnostic testing and arrangeappropriate follow-up visits to review these findings and/or therapeutic responses with thepatient. Given the office hours only occur one half-day per week; fellows will be responsible forcommunicating with patients outside of usual clinic office hours in order to foster a strongpatient-physician relationship over time. Likewise, fellows will be expected to advocate fortheir patients when attempting to shepard them through the health care system. Fellows areexpected to demonstrate practice-based learning through reading of primary literature relevant todisease states encountered during their clinic encounters. .Evaluation: As with all rotations quarterly evaluations will be completed by all faculty andselect nurses to contribute to the 360-degree evaluation of their overall performance in theircontinuity clinics. Fellows will also provide select continuity patients with an evaluation formassessing the fellow’s performance as their subspecialty physician.Goals (All three years) • Learn to evaluate ambulatory patients with digestive diseases • Learn to serve as a digestive disease consultant for ambulatory patients • Expand history and exam skills beyond general internist level to level capable of more completely evaluating digestive complaints or detecting digestive disorders • Learn diagnostic and therapeutic decision making with increasing complexity as graduate to later years of training • Learn to communicate with patients and family members • Learn importance of commitment to continuity of care with emphasis on ensuring continuous availability, prompt follow-up of tests, and provision of superior care • Practice patient advocacy • Expand knowledge base of digestive disease with emphasis on practice based learningObjectives (All three years) • Participate in weekly half-day clinic consisting of panel of patients (one average 1-3 new patients; 4-6 return patients) identified as trainee’s patients. • Perform detailed history and physical on all patients • Review all laboratory, pathology, imaging data for individual patients • Independently formulate diagnostic and therapeutic plan • All patients reviewed with digestive disease faculty member to ensure supervised care and enhance instruction • Communicate recommendations in considerate fashion to both patient and referring physicians • In the process of communication appreciate cultural and gender specific concerns • Follow-up, in timely fashion, all tests ordered at time of encounter • Utilize other specialties and allied health services to optimize patient care • Shepard patients through a confined VA health care system when other specialty services or referrals are needed 21
  • 22. • Read up to date literature on disease states encountered in patients for purpose of expanding knowledge and optimizing patient care VA Medical Center Hepatology ClinicAssignment: Two fellows per monthDescription: Fellows assigned to the VA will spend one half-day per week in the HepatologyClinic. This specialty clinic evaluates and treats patients with chronic viral hepatitis, andpatients with advanced liver disease being considered for transplantation or status posttransplantation. These last patients are also co-managed in the transplant clinic operated by theDepartment of Surgery.Objectives: Establish experience in the evaluation and management of patients with liverdisorders. While there is ongoing continuity of care for patients with liver disorders in thegeneral continuity clinic, the VA Hepatology Clinic provides a focused experience dedicated tothe initial evaluation of patients with liver diseases. While the majority of patients have chronichepatitis C, patients with all forms of chronic liver disease leading to cirrhosis are managed inthis clinic. Indeed the experience emphasizes the diagnostic evaluation of new patientspresenting with signs, symptoms, or laboratory evidence of liver disease. This is also theopportunity to work in a multidisciplinary clinic with pharmacologists, psychologists, and nursepractitioners, fostering the notion of utilizing other health care professionals to optimize patientcare. These disciplines are integrated into the clinic specifically to streamline and optimize thecare for patients being treated for chronic hepatitis C. This experience builds upon and solidifiesthe knowledge of interferon-based therapies with particular emphasis on appropriate selection ofcandidates and monitoring of therapy response and side effects. Fellows also receive anexposure to pre-transplant evaluation and the process of referral to a transplant center whenpatients are deemed suitable candidates. A limited exposure to post-transplant care is providedas the clinic manages patients well after the immediate post-transplant period.Expectation and Responsibilities: Since the focus of the experience is initial evaluation ofpatients with liver diseases, the Fellow will be assigned approximately 3-4 new patients and 0-2return visits for each half-day encounter. At each visit fellows will perform a complete historyand physical exam, review relevant laboratory, endoscopy, radiology, and pathology findingsand develop and independent assessment of the patients digestive disorder including adifferential diagnosis when appropriate. The fellow will then formulate a diagnostic andtherapeutic plan individualized for the patient’s condition. The entire findings of theirevaluation and management plan will be reviewed with the supervising attending and aconsensus plan will be established and the fellow will document the entire findings and plan in awell organized progress note in the patient’s medical records. The attending will then reviewthis record entry for accuracy and organizational content before documenting his or herapproval. At each encounter fellows are expected to communicate their plans to the patient orthe patient’s representative. The fellow is expected to follow-up any diagnostic testing andarrange appropriate follow-up visits to review these findings and/or therapeutic responses withthe patient. Fellows are expected to demonstrate practice-based learning through reading ofprimary literature relevant to disease states encountered during their clinic encounters. 22
  • 23. Evaluation: As with all rotations quarterly evaluations will be completed by all faculty andselect nurses to contribute to the 360-degree evaluation of their overall performance in theircontinuity clinics.Goals (All three years) • Learn to evaluate ambulatory patients with liver disease • Expand history and exam skills to include skills specific to liver disease • Understand the complexities of viral hepatitis therapy including indications, contraindications of various regimens • Learn to communicate with patients and family members • Learn importance of commitment to continuity of care with emphasis on ensuring continuous availability, prompt follow-up of tests, and provision of superior care • Learn to work as part of a multidisciplinary team • Expand knowledge base of liver diseases with emphasis on practice based learning and preventive careObjectives (All three years) • Evaluate new patients presenting to the clinic • Formulate diagnostic plan including serologic evaluation, imaging studies, and possibly liver biopsy • Review results of diagnostic studies and decide on appropriateness of antiviral therapy • Review all patients with hepatology faculty member for instruction and supervision • Screen appropriate patients for liver cancer • Vaccinate appropriate patients based on guidelines to prevent viral hepatitis • Communicate to patients diagnostic findings, therapeutic plans, side effect profiles of drugs, and importance of compliance and follow-up monitoring/care • Work directly with allied health professionals (pharmacist, nurse practitioner, and psychologist) in a multidisciplinary clinic • Read relevant literature on liver diseases to optimize patient care and expand knowledgeTraining through conferences and other non-patient care activities: The GastroenterologySection has scheduled regular recurring conferences that are outlined below:1. GI Core Clinical Conference; weekly. Presentations of core lecture series by fellows, faculty, and visiting faculty. Topics rotated annually and assigned by Program Director to ensure broad representation of digestive diseases based on the GI Core Curriculum and state of the art gastroenterology as well as topics important for professionalism in medicine. Topics include review of biostatistic methods and study design and other topics required for broad based education (topics available from prior assignment schedules). Lectures throughout the 3 year training experience will address specifically or have incorporated in them the required fields of medical genetics, ethics, palliative care, pain management, risk management, physician impairment, substance abuse, quality improvement, and medical coding and billing. 23
  • 24. 2. Systems of Care Improvement (Complications Conference); monthly. Cases presented and discussed by fellow or staff. Quality Improvement initiatives planned and implemented at least yearly.3. Advanced Endoscopy Conference; Monthly. Cases presented by fellow, radiographs reviewed by fellows and faculty and issues of case management discussed in open forum.4. Consult Service Clinical Case Conference; monthly. At least one challenging case from both consult services presented and brief presentation of teaching points with literature references to promote practice based learning.5. Pathology conference; biweekly. Fellows present cases and slides reviewed with staff pathologist. GI staff members are in attendance.6. Journal Club; monthly to biweekly. Two fellows and one staff review pertinent articles from the recent literature.7. Pathophysiology discussion; biweekly. Fellows are expected to read pertinent chapters in current reference textbooks. Staff preceptor reviews these readings with fellows and discusses basic science principles in addition to organ specific physiology and disease specific pathophysiology. Principles of disease specific epidemiology, therapeutics, and prevention are also reviewed. During the course of three years two years dedicated to covering comprehensive gastroenterology textbook (prior to 2007 Yamada; Schleisenger and Fortran as of 2007); and one year dedicated to covering comprehensive hepatology textbook (Schiff). Program improvement for 2007- each session is accompanied by review of 5-6 board review questions based on topics in the reading. Faculty responsible for directing the conference are responsible for identifying or creating appropriate questions to consolidate knowledge reviewed. Database of all questions reviewed maintained by Program Coordinator8. Research Conference; monthly. Research (both Basic and Clinical Sciences) in progress presented by staff, fellows and visitors.9. Professor Rounds- monthly. Fellows present interesting case with included radiographs and discuss diagnostic possibilities and therapeutic options with affiliated faculty member, Dr. Phil Miner.10. Multidisciplinary GI Tumor Board; weekly. Fellows and faculty attend clinical case discussion in collaboration with trainees and faculty of Departments of Surgery, Pathology, Radiology, Radiation Oncology and Section of Oncology.11. Central Oklahoma Gut Club; biannually. Attended by fellows and staff. Speaker, usually, nationally known figure. Often this individual will serve as visiting professor and will have direct contact with fellows.12. National annual meeting of the AGA, ACG and AASLD will be available for residents to attend. Fellows will be encouraged to attend at least one meeting per year and funding provided for travel to one meeting annually.13. Evidenced Based Medicine and Teaching Skills Workshop- All faculty and fellows encouraged to attend (senior fellows required to attend). Administered annually by College of Medicine. Teaches practice based learning skills and tools to promote effective teacher to learner communication.14. Practice of Medicine Seminar- Sponsored annually by College of Medicine and the Southern Medical Society. (All senior fellows required to attend) Incorporates broad introduction to health care systems including legal, ethical, and fiscal topics important for practice of medicine.15. Completion of LIFE curriculum: Program improvement for 2007- Computer based video modules with completion questionnaire. The modules focus on resident fatigue, physician 24
  • 25. impairment, patient relationship boundaries, interpersonal skills, and other areas focused on professionalism.16. Completion of Digestive Disease Self –Evaluation Modules version 5.0. Program improvement for 2007- AGA sponsored self-directed learning computer based modules designed to systematically add to trainee’s knowledge base. All trainees required to log time spent reviewing modules with goal of completing entire CD based program in 12-24 months. Designed to improve knowledge and promote practice based learning and life long habit of self-learning.Research activity/practice based learning: Trainees will be expected to participate in practicebased learning throughout their training experience. This will include participation in formaldidactic sessions outlined above including Journal Club, Research Conference, and Systems ofCare Improvement Conference. In addition, they will be expected to have self-motivatedlearning with extending their medical knowledge based on their experience in the clinicalservices and this skill will be assessed by the faculty during clinical supervision of inpatient andoutpatient encounters.Scholarly activity and, in particular, research projects employing valid scientific methods will berequired of all trainees. Each trainee will be guaranteed; at least, six months of protected time toparticipate in a designed and institutional review board approval process for a clinical or basicscience research project. The trainee is expected to carry out this project and the resultspublished at an annual national or international meeting. In addition, the trainee will beencouraged to publish the results in a peer reviewed journal and to present their project in athesis based format at the sections research conference. All trainees are required to have amanuscript submitted to a peer-reviewed journal before completion of the Fellowship. This maybe the above project or other scholarly activity such as review article, several case series orreports. Several resources on campus will be utilized to support this mission including statisticalresources within the Department of Epidemiology and Biostatistics and basic laboratory facilitiesin other sections within the Department of Internal Medicine and the Departments of Surgery,Physiology, and Cell Biology. About six months of protected time will be provided for thetrainee to dedicate work to this project, ongoing participation in their project during their clinicaltraining will also be encouraged and more prolonged protected time available to trainees wishingto pursue research as a career similar to a “research tract” fellowship.Evaluation of trainee competence: Trainees are evaluated by individual staff members on aquarterly basis. Individual residents have their written evaluations reviewed with the ProgramDirector. Deficiencies are noted and a plan of remediation outlined with expectations clearlydelineated. Bi-annual written report is provided to individual fellows noting their progress,areas that need addition work and constructive criticism.For trainees to be deemed competent they should demonstrate the following:1. An understanding and commitment to all elements of professionalism including but not limited to participation in national societies, commitment to self-education, commitment to professional growth as demonstrated in maintenance of a comprehensive professional portfolio, dedication to superior patient care and quality improvement.2. A thorough knowledge of history taking and the ability to perform a comprehensive and accurate physical examination. 25
  • 26. 3. The ability to arrive at an appropriate differential diagnosis, to outline the logical plan for specific and targeted investigations pertaining to the patient’s complaints, and to formulate a plan for management and follow up treatment of the patient.4. The ability to communicate, effectively, the results of a consultation orally and in writing and to defend the clinical assessment, differential diagnosis, and diagnostic and management plan. This includes the ability to discuss findings with referring physicians, educate lower level trainees, and communicate with patients and their families. The last trait requires the trainee to be sensitive to the cultural and educational background of individual patients.5. A core fund of knowledge in gastroenterology and hepatic physiology, pathophysiology and clinical pharmacology. All areas of the GI core curriculum should be mastered to a level to pass the ABIM certifying exam for gastroenterology.6. An understanding of procedure indications, contraindications, and limitations.7. Proficient technical skills to permit independent, safe and thorough completion of standard gastrointestinal procedures (outlined above) as indicated by direct evaluation of individual procedure encounters.8. An ability to appropriately interpret endoscopic findings and independently apply them in complex decision making for individual patients9. Practice-based learning with continual efforts towards experience based improvement in delivery of clinical care.10. System based learning with appreciation of resources available for patient care. Guidelines for Endoscopic Training: Parameters of Competency Reviews records, x-rays, identifies risk factors Understands and discusses appropriate alternative procedures Correctly identifies indication, knows how study will influence management Obtains appropriate informed consent Demonstrates proper use of premedication and noninvasive patient monitoring devices Inserts the endoscope using proper technique Performs procedure with attention to patient comfort and safety Correctly identifies landmarks Conducts thorough examination of the entire organ Detects and identifies all significant pathology Completes examination within a reasonable time Prepare accurate report Plans correct management and disposition Discusses findings with patient and other physician Conducts proper follow up, review of pathology, case outcomeThe following methods will be used to evaluate trainees’ competence:1. Observation during rounds, conferences and review of written consultations.2. Formal evaluation forms evaluating each of the six core competencies completed each faculty member who comes in contact with the trainee (quarterly). 26
  • 27. 3. Monthly evaluations of the six core competencies at completion of all consult service months with evaluation completed and reviewed with trainee by the faculty member assigned to the monthly rotation (monthly).4. Observations during procedures to determine competence in individual components of the endoscopic procedure (at least once monthly when assigned to endoscopy rotations).5. 360-degree evaluations completed by nursing staff and patients (in addition to faculty and self evaluations) on annually basis with forms designed to assess six core competencies.6. Maintenance of a professional portfolio by the trainee outlining professional accomplishments and growth. Biannual review by the Program Director.7. Self-evaluations by the trainee.8. Annual In service ExaminationEach Core Competency will be assessed with specific tools as outlined: 1. Patient Care- History and Exam skills and medical decision making skills will be assessed in monthly consult service evaluations, quarterly faculty evaluations, other 360 degree evaluations (nurses and patients), endoscopy evaluations (similar to mini CEX). Procedure competency will be based on procedure logs and evaluations of specific encounters using a specific endoscopy evaluation form (mini CEX). 2. Medical Knowledge- Will be assessed with observation and evaluation from monthly consult evaluations, quarterly evaluations (based on presentation by the trainee during core clinical conferences, journal clubs, pathophysiology discussions, review of clinical cases during endoscopy rotations, discussions in pathology conference), In service examination results 3. Interpersonal and Communication Skills- Will be assessed by 360-degree evaluations including evaluations completed by nurses and patients. Faculty will also evaluate the trainee based on observation during consult months, endoscopy evaluations (mini CEX), and quarterly evaluations based on encounters in continuity clinics. Unsolicited feedback (both negative and positive) from other departments will also be maintained in the trainee’s folder for consideration. Presentation skills during conferences will be assessed during quarterly evaluations 4. Professionalism- Will be assessed by 360-degree evaluations including observations from faculty and nurses commenting on the ability of the trainee to act ethically and compassionately with an understanding of the cultural, educational, and psychosocial needs of individual patients. Review of the trainee maintained portfolio will document engagement in professional societies and the maintenance of the portfolio itself will establish commitment to professional growth. Success and commitment to scholarly activity will be assessed with quarterly evaluations and documented publications in portfolio. 5. Practice-Based Improvement- Will be assessed through quarterly evaluations with specific attention to performance in journal clubs, and systems of care improvement conference (complications conference). Monthly consult evaluations, quarterly evaluations will also grade the trainee based on using self-education to provide optimal care for patients in inpatient consult services and outpatient continuity clinics. Self- evaluations will be assessed for insight into needed areas for self-improvement. Attendance at national and regional meetings will also serve as a measure of self- education. Portfolios will also be assessed for national conference attendance, journal club participation, and overall commitment to education. 27
  • 28. 6. Systems-Based Practice-Will be assessed with 360-degree evaluations, with feedback by nurses and patients used to assess awareness of trainee of resources in health care system. Faculty will also evaluate trainee in monthly consult rotation evaluations, and quarterly evaluations based on ability of trainee to mobilize resources needed by their patients (i.e. social services, pharmaceutical assistance, referral to specialty services including transplantation centers, mental health services). Specific notation of these skills will be made by the Program Director. Participation in the College of Medicine sponsored seminar on Health Care Systems will be documented by a certificate of attendance.Outcomes Assessment As a means to continually improve the education content and outcome of the fellowship program the Program Director will monitor several parameters and based on this feedback design improvements in the curriculum. Outcomes currently monitored include results of the Gastroenterology In Training Examination. All fellows will participate in the examination typically given in April of the academic year. The program will receive individual trainee results as well as program results in specific organ sites with comparisons to nationwide averages. This allows the Program Director to design the Core Conference topic assignment for the following academic year with emphasis placed on organ sites or disease states that trainees systematically achieved lower scores. In addition, performance on ABIM certifying exam will be used to assess the success of the curriculum. In the future the program will use feedback from the graduates and colleagues of the graduates on the success of the trainees transitioning into the successful practice of gastroenterology and their ability to continue a life long practice of self- improvement and self-education for the purpose of enhancing patient care.Period of Assignment of ResidentsThe Program Director shall assign residents to the two hospitals on a rotating basis to meet theeducational needs of the Program. The specific rotations and their duration shall be determinedby the Program Director as outlined above. The residents will be assigned on a monthly basiswith one resident providing consultative services at OU Medical Center and another resident willbe assigned to provide consultative services at the VAMC . One resident will be assigned to theoutpatient/inpatient endoscopy center at Presbyterian Tower OUMC and based on the number ofresidents assigned to research; another resident may be assigned to the separate outpatientendoscopy center at OU Physicians Building (facility part of OUMC). Two residents will beassigned to the endoscopy center at the VA Medical center. At least one resident will beassigned to a research rotation on a monthly basis with a minimum of six continuous months.The goals, objectives, responsibilities, and evaluation process for each rotation is described indetail in a separate section (above). The number of resident physicians to be assigned shall be inconformance with the Annual Supplemental Agreement for Graduate Medical Educationbetween the College of Medicine and the Hospital.Work HoursAll trainees will be prohibited from working beyond the work hour restriction established by theACGME. This includes prohibition of working more than 24 hours consecutively. Also traineeswill have at least four 24-hour periods off averaged over 4 weeks and will have at least 10 hoursoff between in house duties. Work hours are monitored by the University’s TOAD reportingsystem on a monthly basis. On call responsibilities will be from home and generally assigned 28
  • 29. one week at a time. In the event that a trainee is called in to the hospital for an emergency thiswill be recorded as work hours, and if there is extenuating circumstance that keeps the trainee inthe hospital for a large portion of an overnight period the trainee will be excused from duty thefollowing day and the person assigned call the following week will assume at home call for thenext 24 hour period. Moonlighting will only occur with the expressed written consent of theProgram Director and any moonlighting at OUMC or the VA medical center will be tabulated inTOAD reporting. All other off campus moonlighting will be reported to the ProgramCoordinator to ensure the activity does not, in conjunction with usual reported work hours, leadto total hours beyond the above restrictions.Institutional Responsibility for Teaching, Supervision and Evaluation of ResidentsThe University Of Oklahoma College Of Medicine performs certain responsibilities as thesponsoring institution of the graduate medical education program as described in the “Essentialsof Accredited Residencies” published by the ACGME. This includes establishment andmaintenance of a Graduate Medical Education Committee whose membership includes programdirectors, residents, and representatives of the major affiliated institutions.The individual residency program and Program Director are responsible for teaching,supervision, and evaluation of residents in the Program as established by ACGME general andprogram specific requirements and College of Medicine requirements. This responsibilityincludes determination of advancement or promotion of residents and determination of resident’ssatisfactory completion of training requirements. An Internal Institutional Review conducted bythe Graduate Medical Education Committee of the College of Medicine assesses these functionsperiodically. They are also assessed during residency program accreditation site visitsperformed by the ACGME and its residency review committees.Policies and Procedures That Govern ResidentsThe University Of Oklahoma College Of Medicine has established policies and procedures togovern the graduate medical education programs of the College in compliance with ACGMEstandards. These policies are disseminated to residents, program directors, and hospitals in theform of a Resident Handbook, which is revised periodically. The Resident Handbook isincorporated as part of the Residency Agreement executed with each resident. The handbookincludes specific procedures for grievances. 29
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