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INTRODUCTION
 

INTRODUCTION

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    INTRODUCTION INTRODUCTION Document Transcript

    • GASTROENTEROLOGY CURRICULUMDivision of Gastroenterology and Liver Diseases The George Washington University 1
    • TABLE OF CONTENTSI. Faculty 2II. Introduction 3III. Mission 4IV. Program Requirements 5V. Curriculum Overview 6VI. Curriculum Requirements 7VII. Clinical Competencies 10VIII. Methods of Teaching 13IX. Methods of Evaluation 14X. Performance Criteria for GI Endoscopy 15XI. Principle Learning Activities and Conferences 20XII. Principle Educational Goals by Competency 21XIII. Evaluation of Program and Faculty 33XIV. Salaries and Benefits 34XV. AGA Task Force Overview 38 2
    • FACULTYMarie L. Borum, MD, EdD, MPHProfessor of MedicineDirector, Division of Gastroenterology and Liver DiseasesM. Ali Aamir, MDAssistant Professor of MedicineShowkat Bashir, MDAssistant Professor of MedicinePaul Chang, MDClinical Professor of MedicineLeonard Ehrlich, MDClinical Associate ProfessorAllen Ginsberg, MDProfessor of MedicineSands Irani, MDClinical Professor of MedicinePatricia Latham, MD (Hepatology)Associate Professor of Medicine and PathologyEphraim Nsien, MDAssistant Professor of MedicineZobair Younossi, MD (Hepatology)Professor of Medicine (appointment pending)Adjunct FacultyMichael Albert, MDClinical Professor of Medicine 3
    • INTRODUCTIONThis curriculum is developed for the use of gastroenterology fellows at The GeorgeWashington University. It is designed to outline the curricular goals and expectations forthe gastroenterology fellows. This curriculum is structured around the six AccreditationCouncil of Graduate Medical Education (ACGME) core competencies. There is alsoinformation about the institution, faculty, evaluation processes, schedules andconferences. 4
    • MISSIONThe Gastroenterology fellowship at the George Washington University is designed to setthe highest standard for excellence in training. The purpose of the gastroenterologytraining program is to ensure that trainees have the appropriate breadth and depth oftraining in the field of gastroenterology and hepatology. The fellows who complete thisprogram will:1. be competent to act as consultants in the field of gastroenterology / hepatology2. be capable of pursuing careers in academic medicine or clinical practice3. possess habits of life-long learning that will continue to enhance their knowledge, skills and professionalism. 5
    • PROGRAM REQUIREMENTSEDUCATIONAL PROGRAM1. 18 months of clinical gastroenterology with 5 months of hepatology2. Formal instruction, clinical experience and competence in 26 content areas3. Formal instruction, experience and competence in technical procedures4. Formal instruction in 8 related topic areasFACULTYThe key clinical faculty and the program director are board-certifiedThe gastroenterology program presently consists of 4 fellows with the intention ofprogram expansion to 6 fellows (2 per training year). There are 9 institutionally-basedkey clinical faculty and 2 adjunct faculty. In addition, a minimum of 3 faculty membersand the program director have >10 hours / week devoted to the fellowship. Three of theclinical faculty members have a hepatology focus. Two of the key clinical faculty musthave advanced endoscopy focus.PROCEDURAL REQUIREMENTSThe newly proposed procedure requirements are documented in the CurriculumRequirement Section. FACILITIES AND RESOURCESGI PROCEDURE LABORATORYThe GI procedure laboratory has an up-to-date array of diagnostic and therapeuticendoscopic instruments and accessories.SUPPORT SERVICESThe Division of Gastroenterology has access to support services that include pathology,radiology, surgery, oncology and parasitology.FACILITIESThe Division of Gastroenterology has access to Intensive Care Units and the ability tohave close interaction with subspecialties, including surgery, oncology, pediatrics,radiology and pathology. 6
    • CURRICULUM OVERVIEWThe content of the gastroenterology curriculum is based upon an assessment of theknowledge and skills desired at the completion of fellowship training, review of theACGME requirements and the Tasks Force recommendations from the AmericanGastroenterological Association and American Society of Gastrointestinal Endoscopy.The Task Force recommendations are the results of the efforts of majorgastroenterology / hepatology societies. This curriculum is written in effort to set thehighest standard for excellence in training.The gastroenterology training at George Washington University consists of 3 years oftraining. The core clinical curriculum requires a minimum of 18 months of clinicalactivity and consists of traditional inpatient and outpatient consultation experiencesupplemented by conferences and didactic sessions. A longitudinal outpatient experienceis required during their 3 years of training. Training in the basic endoscopic skills aresupported by the curriculum. Training in advanced procedures (i.e. ERCP, endoscopicultrasound) is reserved for selected trainees who have demonstrated endoscopic skill anddesire procedural experience for advanced interventional endoscopy. Programmaticrequirements for specific content areas and endoscopic expectations are outlined. Inaddition there is a requirement for substantive research experience of not less than 6months. 7
    • CURRICULUM REQUIREMENTSGastroenterology fellows have formal instruction, clinical experience and opportunities toacquire expertise in the evaluation and management of the following disorders1. Esophageal diseases2. Acid peptic disorders3. Motility disorders4. Irritable bowel syndrome5. Nutrient assimilation disorders6. Inflammatory bowel disease7. Vascular disorders of the gastrointestinal tract8. Gallstones and cholecystitis9. Biliary and pancreatic disorders10. Acute and chronic hepatitis11. Chronic liver disease12. Drug-induced hepatic injury13. Alcoholic liver disease14. Cholestatic syndromes15. Infections of the gastrointestinal tract (including bacterial, retroviral, mycotic, and parasitic)16. Gastrointestinal diseases with an immune basis17. Gastrointestinal manifestations of HIV infections18. Gastrointestinal and pancreatic neoplasms19. Hepatobiliary neoplasmsGastroenterology fellows have formal instruction, clinical experience and opportunities toacquire expertise in the evaluation and management of patients with the followingclinical problems1. Dysphagia2. Abdominal pain3. Acute abdomen4. Nausea and vomiting5. Diarrhea6. Constipation7. Gastrointestinal bleeding8. Jaundice9. Cirrhosis and portal hypertension10. Malnutrition11. Genetic / inherited disorders12. Depression, neurosis and somatization syndromes13. Surgical care of gastrointestinal disorders 8
    • The program provides instruction in the indications, contraindications, complications,limitations and (as appropriate) interpretation of the following diagnostic and therapeutictechniques and proceduresA. Imaging of the digestive system, including 1. ultrasound 2. computed tomography 3. magnetic resonance imaging 4. vascular radiography 5. nuclear medicineB. Percutaneous cholangiographyC. Percutaneous endoscopic gastrostomyD. Gastric, pancreatic and biliary secretory testsE. Diagnostic and therapeutic procedures utilizing enteral intubation and bougienageF. Enteral and parenteral alimentationG. Liver transplantationH. Pancreatic needle biopsyI. ERCP, including papillotomy and biliary stent placementOpportunities are provided for the gastroenterology fellow to gain competence in theperformance of the following procedures. If the ACGME or the gastroenterologysocieties suggest a minimum number of procedures, it is noted. A skilled preceptor isavailable to teach and to supervise the procedures. Each gastroenterology fellowdocuments the procedures performed in a procedure log. The fellow’s log includes theprocedure performed, the indication and outcomes of the procedure, the patient’sdiagnoses and the supervising physician(s).A. Esophagogastroduodenoscopy (EGD) - 130B. Esophageal dilatation - 20C. ProctoscopyD. Flexible sigmoidoscopy - 30E. Colonoscopy - 140F. Colonoscopy with polypectomy - 30G. Percutaneous liver biopsy - 20H. Percutaneous endoscopic gastrostomy (PEG) - 15I. Biopsy of the esophagus, stomach, small bowel and colonJ. Gastrointestinal motility disordersK. Nonvariceal hemostasis (upper and lower) - 25 (10 active bleeders)L. Variceal hemostasis - 20 (5 active bleeders)M. Enteral and parenteral alimentation 9
    • The program provides instruction and emphasis on the pathogenesis, manifestations andcomplications of gastrointestinal disorders, including the behavioral adjustments ofpatients to their problems. The impact of various modes of therapy and the appropriateutilization of laboratory tests and procedures is also stressed.The program also has formal instruction (lectures, conferences, seminars) on specificcontent areas that include the following.A. Anatomy, physiology, pharmacology and pathology related to the gastrointestinal system, including the liverB. The natural history of digestive diseasesC. Factors involved in nutrition and malnutritionD. Surgical procedures employed in relation to digestive system disorders and their complicationsE. Prudent, cost-effective and judicious use of special instruments, tests, and therapy in the diagnosis and management of gastroenterologic disordersF. Liver transplantationG. Sedation and sedative pharmacologyH. Interpretation of abnormal liver chemistries 10
    • CLINICAL COMPETENCIESThe Accreditation Council of Graduate Medical Education (ACGME) CoreCompetencies introduced six defined areas of competency which residents must obtainover the course of their training. The core competencies, established in July 2001, areoutlined below.1. PATIENT CAREResidents are expected to delivery patient care that is compassionate, appropriate,and effective for the treatment of health problems and the promotion of health.a. Residents are expected to provide patient care that is compassionate, appropriate and effective for the promotion of health, prevention of illness, treatment of disease and care at the end of life.b. Gather accurate, essential information from all sources, including medical interviews, physical examination, records, and diagnostic/therapeutic procedures.c. Make informed recommendations about preventive, diagnostic, and therapeutic options and interventions that are based on clinical judgement, scientific evidence, and patient preferences.d. Develop, negotiate and implement patient management plans.e. Perform competently the diagnostic procedures considered essential to the practice of gastroenterology and hepatology2. MEDICAL KNOWLEDGEResidents are expected to demonstrate knowledge about established and evolvingbiomedical, clinical and cognate (e.g. epidemiological and social-behavioral) sciencesand the application of the knowledge in patient care.a. Residents are expected to demonstrate knowledge of established and evolving biomedical, clinical and social sciences, and demonstrate the application of their knowledge to patient care and education of others.b. Apply an open-minded and analytical approach to acquiring new knowledgec. Develop clinically applicable knowledge of the basic and clinical sciences that underlie the practice of gastroenterology and hepatologyd. Apply this knowledge in developing critical thinking, clinical problem solving and clinical decision-making skills.e. Access and critically evaluate current medical information and scientific evidence and modify knowledge base accordingly. 11
    • 3. PRACTICE-BASED LEARNING AND IMPROVEMENTResidents are expected to demonstrate practice-based learning and improvementthat involves investigation and evaluation of their own patient care, appraisal andassimilation of scientific evidence, and improvements in patient care.a. Residents are expected to be able to use scientific methods and evidence to investigate, evaluate, and improve their patient care practices.b. Identify areas for improvement and implement strategies to improve their knowledge, skills, attitudes and processes of carec. Analyze and evaluate their practice experiences and implement strategies to continually improve their quality of patient practiced. Develop and maintain a willingness to learn from errors and use errors to improve the system or processes of caree. Use information technology or other available methodologies to access and manage information and support patient care decisions and their own education4. INTERPERSONAL AND COMMUNICATION SKILLSResidents are expected to demonstrate interpersonal and communication skills thatresult in effective information exchange and teaming with patients, their familiesand other health professionals.a. Residents are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families and other members of health care teams.b. Residents are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with members of the health care teams.c. Provide effective and professional consultation to other physicians and health care professionals and sustain therapeutic and ethically sound professional relationships with patients, their families, and colleagues.d. Use effective listening, nonverbal questioning and narrative skills to communicate with patients and familiese. Interact with consultants in a respectful and appropriate fashionf. Maintain comprehensive, timely and legible medical records 12
    • 5. PROFESSIONALISMResidents are expected to demonstrate professionalism as manifested through acommitment to carrying out professional responsibilities, adherence to ethicalprinciples, and sensitivity to a diverse patient population.a. Residents are expected to demonstrate behaviors that reflect a commitment to continuous professional development and ethical practice.b. Residents are expected to demonstrate an understanding and sensitivity to diversity and responsible attitude toward their patients, their profession and society.c. Demonstrate respect, compassion, integrity, and altruism in their relationships with patients, families and colleagues.d. Demonstrate sensitivity and responsiveness to patients and colleagues, including gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilitiese. Adhere to principles of confidentiality, scientific/academic integrity, and informed consentf. Recognize and identify deficiencies in peer performance6. SYSTEMS-BASED PRACTICEResidents are expected to demonstrate systems-based practice as manifested byactions that demonstrate an awareness of and responsiveness to the larger contextand system of health care and the ability to effectively call on system resources toprovide care that is of optimal value.a. Residents are expected to demonstrate and understanding of the contexts and systems in which health care is provided and demonstrate the ability to apply this knowledge to improve and optimize health careb. Understand access, and utilize the resources and providers necessary to provide optimal carec. Understand the limitations and opportunities inherent in various practice types and delivery systems, and develop strategies to optimize care for the individual patient.d. Apply evidence-based, cost-conscious strategies to prevention, diagnosis and disease management.e. Collaborate with other members of the health care team to assist patients in dealing effectively with complex systems and to improve systematic processes of care. 13
    • METHODS OF TEACHINGIn order to achieve the goals and objectives for the fellowship program, the followingexperiences have been established for the purpose of teaching gastroenterology fellows.These methods include: (1) the inpatient gastroenterology experience, (2) the outpatientgastroenterology experience, (3) interaction with other clinical specialties, (4)conferences, (5) research experience, and (6) continuing medical education and societyparticipation. 14
    • METHODS OF EVALUATIONIn order for the gastroenterology training program to assess its ability to achieve the goalsand objectives, an evaluation process that includes global assessments, observation,standardized patients and written examinations has been developed.1. GLOBAL ASSESSMENTSThese assessments are conducted twice yearly by gastroenterology attendings and areincluded in the permanent record. Twice annually the faculty reviews the performance ofthe fellows in written evaluation. These are compiled on standard forms that assessmedical knowledge, clinical skills, clinical judgement, humanistic qualities, professionalattitudes and commitment to scholarship. Evaluations of the fellows are also solicitedfrom residents, staff and patients (360o evaluation). The program director receives all ofthe written evaluations, which are kept in the fellow’s master file. Fellows may request ameeting at any time to personally review their files.Semi-annually, fellows meet individually with the program director to formally reviewtheir evaluations. The meeting is to provide feedback to the fellow on their performanceand to identify areas for professional enhancement. The program director reviews the logof each fellow’s procedures, consults and conference attendance. A written summary ofthis session is placed in the fellow’s permanent record.2. OBSERVATIONFocused, personal observation assessments will be completed using the Mini-cex formatby the gastroenterology attendings.3. STANDARDIZED PATIENTSExaminations using standardized patients will be videotaped in the George WashingtonUniversity Hospital education resource center that is specifically designed for suchtraining activities.4. WRITTEN EXAMINATIONThe residents participate in the annual standardized examination that is offered by theAmerican Gastroenterological Association. The results are reviewed and anindividualized program of instruction and learning is developed based upon the residents’performance. 15
    • Guidelines for Endoscopic Training Parameters of Competency1. reviews records, x-rays, identified risk factors2. understands and discusses appropriate alternative procedures3. correctly identified indication, knows how the endoscopic procedure may influence management4. obtains appropriate informed consent5. demonstrates proper use of premedication and noninvasive patient monitoring devices6. inserts the endoscope using proper technique7. performs procedure with attention to patient comfort and safety8. correctly identified landmarks9. conducts thorough examination of the entire organ10. detects and identifies all significant pathology11. completes examination within a reasonable time12. prepares an accurate report13. plans correct management and disposition14. discusses findings with patient and other physicians15. conducts proper follow-up, review of pathology, case outcome 16
    • PERFORMANCE CRITERIA FOR EVALUATION OF DIAGNOSTIC GASTROINTESTINAL ENDOSCOPY Procedure Performance CriteriaEsophagogastroduodenoscopy (EGD) Esophageal intubation Pyloric intubationColonoscopy Navigation through sigmoid colon Intubation of splenic flexure Intubation of the hepatic flexure Intubation of cecum Intubation of terminal ileum (desirable skill) Retroflexion in the rectumSigmoidoscopy Navigation through the sigmoid colon Visualization of the splenic flexure Retroflexion in the rectumEndoscopic retrograde Cannulation of the desired ductcholangiopancreatography Opacification of the desired duct(ERCP) Sphincterotomy Stent placement Stone extractionEndoscopic ultrasonography Intubation of esophagus Intubation of pylorus Imaging of desired organ and/or lesion Successful lesion biopsy Tumor staging in agreement with the surgical findings and similar to that reported in the literatureAll procedures Accurate recognition of normal and abnormal findings Development of appropriate endoscopic/medical treatment in response to these findings 17
    • ASSESSMENT SCHEME FOR CORE CLINICAL COMPETENCIESOutlined is an assessment scheme developed for the six ACGME Core ClinicalCompetencies with identification of the skill(s) being evaluated.1. PATIENT CARE (Health Promotion Skills) a. Direct observation (minimum of 5 attending evaluations per year) Skill: information gathering and communicating b. Procedure log signed for a required procedures Skill: assessing competence in medical procedures c. Completion of a minimum of 30 supervised hospital consultations Skill: assessing clinical judgement d. Global evaluations from attendings Skill: assessing effective management of patient illness2. MEDICAL KNOWLEDGE (Scientific Understanding) a. Written examination Skill: assessing knowledge acquisition b. Attendance at one major gastroenterology or hepatology conference per year Skill: demonstrating self-improvement and acquisition of life-long learning skills c. Attendance at gastroenterology conferences Skill: development of the ability to interpret and apply evidence-based medicine d. Review of core curriculum checklist and required reading Skill: ability to locate useful sources of information to enhance medical knowledge e. Managed care tutorial available on-line at the School of Medicine Himmelfarb Library Skill: assessing knowledge acquisition, evidence-based clinical-decision making 18
    • 3. EVIDENCE-BASED LEARNING AND IMPROVEMENT (Assimilation of Scientific Information) a. Presentation at a minimum of 10 conferences Skill: assessing ability to locate, interpret and distill relevant science b. Completion of NIH on-line course on The Protection of Human Study Subjects with placement of a copy of the certificate on file Skill: assessing ethical implementation of study design. c. Participation in a mentored research project Skill: assessing the completion of scholarly activity and apply biostatistical techniques d. Attendance at monthly Inter-city Gastroenterology Grand Rounds Skill: developing the skill to analyze practice experience and facilitate the learning of other health care professionals e. Attendance at monthly Gastroenterology-Surgery-Radiology conference Skill: developing the skill to analyze practice experience and facilitate the learning of other health care professionals f. Attendance at monthly Inflammatory Bowel Disease conference Skill: developing the skill to analyze practice experience and facilitate the learning of other health care professionals g. Attendance at monthly Complicated Case conference Skill: developing the skill to analyze practice experience and facilitate the learning of other health care professionals h. Attendance at monthly Hepatitis C management conference Skill: developing the skill to analyze practice experience and facilitate the learning of other health care professionals i. Attendance at monthly Morbidity and Mortality conference Skill: developing the skill to analyze practice experience and facilitate the learning of other health care professionals j. Attendance at weekly Endoscopy Case conference Skill: developing the skill to analyze practice experience and facilitate the learning of other health care professionals 19
    • 4. INTERPERSONAL COMMUNICATION (Effective and Empathetic Interpersonal Exchange) a. Direct observation Skill: effective nonverbal assessment technique b. Standardized patients (direct observation) Skill: effective verbal assessment techniques c. Attendance at Fellows’ Core Curriculum lecture series Skill: medical records management, effective communication, and understanding business and legal practice as it relates to gastroenterology and liver disease.5. PROFESSIONALISM (Ethics and Cultural Sensitivity) a. Direct Observation Skill: demonstrates respect, compassion, integrity and altruism b. Standardized patient examinations (direct observation) Skill: demonstrates respect, compassion, and integrity c. Completion of NIH on-line course on The Protection of Human Study Subjects with placement of a copy of the certificate on file. Skill: recognizes ethical dilemmas and maintains confidentiality. d. Attend Fellows’ Core Curriculum lecture series Skill: recognizes impact of disability and cultural issues6. SYSTEMS-BASED PRACTICE (Advocacy, partnering and cost- effectiveness in health care delivery) a. Direct observation Skill: functions effectively as part of a health care team b. Attend Fellows’ Core Curriculum lecture series Skill: familiarity with coding, documentation and reimbursement c. Letters of completion of radiology, pathology and nutrition rotations Skill: able to collaborate with ancillary care services 20
    • PRINCIPAL LEARNING ACTIVITIES AND CONFERENCESAttendance at all conferences is required by the Gastroenterology Fellows when they arefulfilling their duties at George Washington University. Gastroenterology facultymembers are expected to attend scheduled conferences.PRINCIPAL PATIENT CARE ACTIVITIESContinuity ClinicEach fellow is assigned to 2-3 continuity clinics throughout their gastroenterologyfellowship. Each fellow is assigned to a physician for general gastroenterology care. Inaddition, specialty clinics to which they are assigned at varying portions of their traininginclude inflammatory bowel disease, motility disorders, liver disease and pancreatico-biliary diseases.Hospital Attending RoundsFive mornings each week (Monday through Friday) the GI fellows, internal medicineresidents and students on the gastroenterology elective meet with the attending physicianassigned to the inpatient services. All of the patients who are hospitalized are discussed.There is a review of the pathophysiology of the medical condition supplemented withliterature pertinent to the clinical circumstances resulting. Evidence-based clinicaldecision-making is performed. Written consultations are reviewed. Each patient is seenand examined at the bedside.Procedure TeachingAll procedures performed on patients (inpatient or outpatient) by gastroenterologyfellows are directly supervised by an attending physician. These procedures includefiberoptic endoscopy with or without diagnostic procedures (i.e. upper endoscopy, smallbowel enteroscopy, flexible sigmoidoscopy, colonoscopy) advanced endoscopicprocedures (i.e. endoscopic retrograde cholangiopancreatography, endoscopicultrasonography), esophageal manometry and pH studies, liver biopsy and capsuleendoscopy. The fellows are required to maintain a log of the procedures that the haveperformed. They are monitored on a yearly basis for completeness and accuracy. 21
    • ACADEMIC CONFERENCESBoard ReviewConference meets monthly. All fellows and coordinating faculty members are expected toattend. Cases and questions are discussed to prepare for gastroenterology specialty boardexamination.City-wide Gastroenterology Grand RoundsConference meets once a month. Participants include all of the fellows and facultymembers of gastroenterology divisions in the Washington, D.C.-area. Institutions thatparticipate include George Washington University, Georgetown University, HowardUniversity, Washington Hospital Center, National Institutes of Health and Walter ReedMedical Center. The fellows are required to present a case and discuss findings andmanagement using evidence-based medical informationComplicated Case and Quality Review ConferenceConference meets once a month. Fellows and faculty present difficult management cases,complemented by pertinent literature. Systems and judgement errors are reviewed in aconstructive fashion in an effort to continually improve clinical decision-making. Plansare developed to implement new procedures and policies to avoid similar errors /complications in the future. Individual judgement errors are addressed as necessary bythe faculty and director of gastroenterology fellowship.Didactic LecturesConference meets three times a month. Faculty members of the Division ofGastroenterology and Departments of Surgery, Radiology and Pathology offer didacticsession that review pertinent issues important in the gastroenterology and hepatologyfellowship training. These include conferences focussed upon pathophysiology anddisease entities.Endoscopy Case ConferenceConference meets monthly. Participants include faculty, fellows and nursing staffinvolved in procedures. The fellows are expected to review a case involving endoscopyand present a video of the endoscopic procedure with discussion of the literature thataddresses issues related to management and the endoscopic intervention.Gastroenterology – Surgery – Radiology ConferenceConference meets once a month. Participants in the conference include residents, fellowsand faculty members of the Division of Gastroenterology, Department of Surgery andDepartment of Radiology. Medical residents and faculty members of other specialties(i.e. Oncology, Pathology) are invited to attend when there are cases when there isoverlapping specialty interests. Gastroenterology fellows are required to present case andprovide a review of appropriate literature pertinent for the discussion. 22
    • Graduate Medical Education Core Lecture SeriesConference meets monthly. All internal medicine subspecialty fellows are required toattend the lecture series. The lectures has been developed to address professionalismthrough discussions with experts in areas of: (1) principled negotiation, (2) riskmanagement, (3) law and medicine, (4) medical errors, (5) medical ethics, (6) ethicscommittee, (7) quality assurance.Inflammatory Bowel Disease ConferenceConference meets once a month. The conference includes a review of cases anddiscussion of the literature that addresses issues related to emerging therapies andmanagement.Internal Medicine Grand RoundsConference meets weekly and is the only conference in which all of the internal medicineresidents, subspecialty fellows and Department of Medicine faculty attend. Local,national and internationally recognized faculty are invited to address the Department ofMedicine. The subjects are varied and the invited speakers are chosen from a variety ofdisciplines. Following the Grand Round presentations, the speaker will often interact withresident physicians or subspecialty fellows in a lecture format or on rounds. The Divisionof Gastroenterology is expected to have faculty members give at least one Grand Roundpresentation annually.Journal ClubConference meets twice a month. Fellows are required to select a manuscript from anapproved, peer-reviewed journal. Each fellow reviews one article at the conference. Thefellows are expected to discuss the findings providing a critical review of the studydesign and application for clinical practice (if appropriate).Liver ConferenceConference meets quarterly. Fellows and faculty members from George WashingtonUniversity and other institutions meet to discuss liver disease cases. Fellows are expectedto discuss the case and provide a review of the pertinent literature.Morbidity and Mortality ConferenceConference meets monthly. Participants include the faculty, fellows and nursing staffinvolved in procedures. The faculty and fellows are expected to present the clinicaloutcome and complications of hospitalized patients. Systems and judgement errors arereviewed in a constructive fashion in an effort to continually improve clinical decision-making. Plans are developed to implement new procedures and policies to avoid similarerrors / complications in the future. Individual judgement errors are addressed asnecessary by the faculty and director of gastroenterology fellowship. 23
    • Pathology ConferenceConference meets twice a month. Fellows and faculty members of the Division ofGastroenterology and Department of Pathology present the cases of individuals who havepathology specimens for review. Fellows are expected to discuss the case and provide areview of the pertinent literature.Research ConferencesConference meets monthly. The conference reviews research concepts, protocol designand statistical review. Fellows and faculty members are also responsible for presentingupdates on on-going research, presentations and publications. These research projects arecritically appraised by participants in the conference.All fellows are expected to design and complete a research project. Individual researchmeetings occur with the fellows and Director of the Division reviewing their researchinvestigations.The Division director also has research meetings with students and internal medicineresidents who are conducting research in gastroenterology. Fellows are invited to attendthese conferences and are frequently involved in the conduction of these ongoingprojects.Viral Hepatitis Management ConferenceConference meets 2-4 times a month. Participants include fellows, physician assistantsand faculty involved in the care of chronic hepatitis C. The conference is focused uponthe discussion of patients who are actively receiving therapy, have complicatedmanagement issues or are involved or being considered for clinical trials. Review ofpertinent literature is offered. Research trials and study design for patients with chronicviral hepatitis C are also discussed during this conference.Visiting Scholars, Professors and Investigators ConferenceConferences in which visiting scholars, professors and investigators are held to supportthe stimulation of new thoughts and ideas among fellows and faculty. Additional ConferencesAmerican Society of Gastrointestinal Endoscopy (ASGE) First-Year FellowEndoscopy CourseThe first year fellows are given the opportunity to participate in the Endoscopy Coursethat is offered by the ASGE. The course offers an overview of endoscopy and hands-onexperience in endoscopic procedures. (The agenda for the course is in the appendix.) 24
    • William B. Steinberg Board Review CourseThis 3-day course meets annually in the Washington, D.C. area. Two fellows are giventhe opportunity to participate in the course. Additional fellows are given the opportunityto attend based upon funding sources.Walter Reed Gastroenterology CourseThis 3-day course meets every other year. Two fellows are given the opportunity toparticipate in the course. Additional fellows are given the opportunity to attend basedupon funding sources.Annenberg Inflammatory Bowel Disease CourseThis is a 3-day course that meets annually. Application is made annually to offer onefellow the opportunity to participate in the course.Society and Educational MeetingsEach fellow attends a minimum of one approved conference annually. The conferencecan be an international or national society meeting or educational course approved by thedirector. In addition, the fellow may also attend conferences in which they are presentingresearch.Examples of society meetings in which GI fellows have participated include: American Gastroenterological Association (AGA) American College of Gastroenterology (ACG) American Society of Gastroenterology Endoscopy (ASGE) American Association of the Society of Liver Diseases (AASLD) Digestive Disease WeekExamples of educational meetings in which GI fellows have participated include: William B. Steinberg Board Review Courses Walter Reed Gastroenterology Review International Conference on Capsule Endoscopy American Gastroenterological Association (AGA) Educational Symposiums American Gastroenterological Association (AGA) Review Course Annenberg Inflammatory Bowel Disease Course 25
    • DIVISION OF GASTROENTEROLOGY AND LIVER DISEASE CONFERENCE SCHEDULEMondayDidactic Sessions / Academic Lectures noon 2ndResearch Conference noon 1stCity-wide Grand Rounds 5 pm 2ndTuesdayInflammatory Bowel Disease Conference noon 1stJournal Club noon 2nd, 4thComplicated Case Conference noon 3rdGI-Surgery-Radiology Conference 5 pm 1stLiver Conference 5 pm 3rdWednesdayDidactic Sessions / Academic Lectures 8 am 1st, 3rdStaff Conference noon 1st, 3rdThursdayInternal Medicine Grand Rounds noon 1st, 2nd, 3rd, 4thChronic hepatitis management 4 pm 1st, 2nd, 3rd, 4thFridayMorbidity and Mortality 8 am 1stEndoscopy Case Conference 8 am 1st, 2nd, 3rd, 4thPathology Conference noon 1st, 3rdBoard Review Conference noon 2ndFellow Meeting noon 4th 26
    • PRINCIPLE EDUCATIONAL GOALS BY RELEVANT COMPETENCYLegend for Learning ActivitiesDirect Patient CareContinuity Clinics (CC)Hospital Attending Rounds (HR)Procedure Teaching (PT)Educational Conferences and MeetingsBoard Review Seminar (BR)Complicated Case and Quality Review Conference (CCQR)Didactic Lectures (DL)Endoscopy Case conference (EC)Gastroenterology – Surgery – Radiology Conference (GSR)Graduate Medical Education Core Lectures Series (GME)Grand Rounds (GR)Viral Hepatitis Management Conference (HC)Inflammatory Bowel Disease Conference (IBD)Inter-City Gastroenterology Grand Rounds (ICGR)Journal Club (JC)Liver Conference (LC)Morbidity and Mortality Conference (MM)Pathology Conference (PC)Research Conferences (RC)Society and Educational Meetings (EM)Legend for Evaluation MethodsAttending Evaluations (AE)Directly Supervised Procedures (DSP)Program Director’s Review (PDR)Peer Review (PR)Semi-Annual Exam (SE)Standardized Patient Evaluation (SPE) 27
    • PATIENT CAREPrincipal Education Goals Learning Activities Evaluation MethodsPerform a complete medical CC, HR AE, PDR, SPEhistoryPerform a comprehensive CC, HR, PT AE, DSP, PDR, SPEexaminationFormulate comprehensive CC, HR, PT, CCQR, DL. AE, PDR, SE, SPEand accurate problem lists GSR, HC, IBD, LC, MMGenerate and prioritize CC, HR, PT, CCQR, DL, AE, PDR, SE, SPEdifferential diagnosis EC, GSR, HC, IBD, LC, MMDevelop rational, evidence- CC, HR, CCQR, DL, EC, AE, PDR, SE, SPEbased management GSR, HC, IBD, LC, MMstrategiesDevelop concise, accurate, CC, HR, PT AE, DSP, PDR, SPErational, informativeconsultationAbility to recognize major CC, HR, PT, GSR AE, PDR, SEabnormalities on radiologicstudiesAbility to determine and CC, EC, HR, PT AE, DSP, PDRperform appropriatediagnostic and therapeuticprocedures 28
    • MEDICAL KNOWLEDGEPrincipal Education Goals Learning Activities Evaluation MethodsDemonstrate knowledge of BR, CC, HR, PT, CCQR, AE, PDR, SE, SPEbasic and clinical sciences DL, GSR, HC, IBD, ICGR,underlying patient care LC, MM, PCDemonstrate an analytical BR, CC, HR, PT, CCQR, AE, PDR, SEapproach to acquiring new DL, GSR, HC, IBD, ICGR,knowledge JC, LC, MM, PC, RCDemonstrate continued BR, CC, HR, PT, CCQR, AE, DSP, PDR, SE, SPEadvancement of knowledge DL, EC, GSR, HC, IBD, ICGR, JC, LC, MM, PC, RCApply knowledge in the BR, CC, HR, PT, CCQR, AE, PDR, SE, SPEdevelopment of critical DL, EC, GSR, HC, IBD,thinking, problem-solving ICGR, LC, MM, RCand decision-makingAssess and critically BR, CCQR, DL, GSR, HC, AE, PDR, SE, SPEevaluate current medical IBD, ICGR, JC, LC, MM,information and scientific PC, RCevidence and modifyknowledge base accordinglyDemonstrate the knowledge BR, CC, HR, PT, CCQR, AE, DSP, PDR, SE, SPEof the indications for, EC, GSR, HC, IBD, ICGR,principles, complications LC, MMand interpretations ofspecialized tests andprocedures 29
    • EVIDENCE-BASED LEARNING AND IMPROVEMENTPrincipal Education Goals Learning Activities Evaluation MethodsUse scientific methods and CC, HR, CCQR, DL, GSR, AE, PDR, SEevidence to investigate, HC, IBD, ICGR, MMevaluate and improvepatient careIdentify areas of CC, HR, CCQR, DL, GSR, AE, PDR, SEimprovement and HC, IBD, ICGR, MMimplement strategies toimprove knowledge, skills,attitudes and care processesAnalyze and evaluate CC, HR, PT, CCQR, GSR, AE, PDR, SEpractice experiences and HC, IBD, ICGR, LC, MM,continually improve quality PCof patient practiceMaintain a desire to learn CC, HR, PT, CCQR, GSR, AE, PDR, SEfrom errors and improve the GME, HC, LC, MM, PC,system or processes of careUse information technology CC, HR, PT, CCQR, GSR, AE, PDR, SEand other methodologies to HC, JC, LC, MM, PCassess and manageinformation 30
    • INTERPERSONAL SKILLS AND COMMUNICATIONPrincipal Education Goals Learning Activities Evaluation MethodsDemonstrate interpersonal CC, HR, PT AE, PDR, PR, SPEskills that establish andmaintain professionalrelationships with patients,families, and members ofhealth care teamsDemonstrate interpersonal CC, HR AE, PDR, PR, SPEskills that establish andmaintain professionalrelationships with membersof health care teamsProvide effective and CC, HR, PT, CCQR, HC, AE, DSP, PDRprofessional consultations IBD, ICGR, LC, MMDemonstrate effective CC, HR, PT AE, PDR, PR, SPElistening, nonverbalquestioning and narrativeskills to communicate withpatientsDemonstrate respectful and CC, HR, PT AE, PDR, PRappropriate interactionswith consultantsMaintain comprehensive, CC, HR, PT AE, PDRtimely and legible medicalrecords 31
    • PROFESSIONALISMPrincipal Education Goals Learning Activities Evaluation MethodsDemonstrate a commitment CC, HR, PT, CCQR, DL, AE, DSP, PDR, PRto professional development GSR, GME, GR, HC, IBD,and ethical practice ICGR, JC, LC, MM, PC, RS, EMDemonstrate and CC, HR, PT, CCQR, DL, AE, PDR, PR, SPEunderstanding and GME, HC, IBD, LC, MM,sensitivity to diversity and EMresponsible attitude towardpatients, profession andsocietyDemonstrate respect, CC, HR, PT, CCQR, GME, AE, DSP, PDE, PR, SPEcompassion, integrity and HC, IBD, LC, MMaltruism in relationshipswith patients, families andcolleaguesDemonstrate sensitivity and CC, HR, PT, CCQR, GSR, AE, PDR, PR, SPEresponsiveness to patients GME, HC, IBD, ICGR, LC,and colleagues, including MMgender, age, culture,religion, sexual preference,socioeconomic status,beliefs, behaviors anddisabilitiesAdhere to principals of CC, HR, PT, CCQR, GSR, AE, DSP, PDRconfidentiality, GME, HC, IBD, ICGR, LC,scientific/academic integrity MM, PCand informed consentRecognize and identify CC, HR, PT, CCQR, GSR, AE, PDR, PRdeficiencies in peer HC, IBD, ICGR, LC, MM,performance PC, RC, EM 32
    • SYSTEMS-BASED PRACTICEPrincipal Education Goals Learning Activities Evaluation MethodsDemonstrate and CC, HR, PT, CCQR, GSR, AE, PDRunderstanding of the HC, IBD, ICGR, LC, MM,contexts and systems in PCwhich health care isprovided and demonstratethe ability to apply thisknowledge to improve andoptimize health careUnderstand, access, and CC, HR, PT, CCQR, EC, AE, DSP, PDRutilize the resources and GSR, HC, IBD, ICGR, LC,providers necessary to MM, PCprovide optimal careUnderstand the limitations CC, HR, PT, CCQR, GSR, AE, DSP, PDRand opportunities inherent HC, IBD, ICGR, LC, MMin various practice typesand delivery systems, anddevelop strategies tooptimize care for theindividual patient.Apply evidence-based, cost- CC, HR, PT, CCQR, GSR, AE, DSP, PDRconscious strategies to HC, IBD, ICGR, JC, LC,prevention, diagnosis and MM, PC, EMdisease management.Collaborate with other CC, HR, PT, CCQR, GSR, AE, DSP, PDR, PRmembers of the health care HC, IBD, ICGR, LC, MM,team to assist patients in PC, EMdealing effectively withcomplex systems and toimprove systematicprocesses of care. 33
    • EVALUATION OF THE PROGRAM AND FACULTYThe program director specifically inquires about the strengths and weaknesses of theprogram at regular meetings with the fellows together and separately. At times,programmatic adjustments are made on the basis of this feedback. Midway through thefellowship, evaluation forms will be provided to the fellows and are completed andsubmitted to a Fellowship Oversight Committee (which does not include any faculty orstaff member from the Division of Gastroenterology and Liver Diseases). A summary ofthe evaluations is given to the program director for review.Upon completion of the fellowship, individuals are contacted for a formal evaluation ofthe program. This is reviewed by the program director with a focus on the perceiveddeficiencies. The findings are discussed with faculty so that programmatic alterations canbe made as necessary. 34
    • SALARIES AND BENEFITS SALARIESSalaries for the 2004-2005 academic years are as follows:PGY 4 $45,905.93PGY 5 $47,686.58PGY 6 $49,098.07 BENEFITSThe following benefits are available to all George Washington University Fellows. Allbenefits are subject to change without advance notice. LICENSURE AND MEDICAL LIABILITY COVERAGEDrug Enforcement Administration (DEA) registration fees for eligible fellowsThe DEA registration fee is paid for fellows who are required to obtain a DC medicallicense because they graduated from a U.S. medical school at least 3 years ago or areinternational medical graduates entering the 4th year of post-graduate training. The federalDEA registration fee is reimbursed at the rate of 1/3 the total cost for each year the fellowremains at GW.Medical Licensure feesFellows are required by law to be licensed in the District of Columbia beginning their 4thyear of post-graduate training. They will be reimbursed by the GME office for the cost ofthe license.The DC Board of Medicine requires any fellow who has obtained a non-restricted licensein another state to apply for licensure in DC. Fellows must comply with this requirementand submit proof of licensure to the GME office; however, this cost is not reimbursedunless the fellow meets appropriate criteria as outlined above. Costs for the GME officepays for temporary licenses required for training in Maryland or Virginia.Liability InsuranceProfessional liability insurance is provided for those activities and services within thescope of duties as defined by the program director. Liability insurance is not provided foractivities outside the course and scope of duties within the fellowship training (i.e.moonlighting) 35
    • HEALTH, DISABILITY, LIFE AND RETIREMENT INSURANCEHealth InsuranceFellows are eligible to participate in several plans, including Care First BC/BS PPO,CIGNA HMO and CIGNA PPOs and Care First Blue Choice HMO. The cost to thefellow depends on the options selected.Flexible Spending AccountsThis program allows fellows to set aside tax-free dollars in special accounts to pay our ofpocket medical and/or dependent care expensesVoluntary Dental PlanFellows are eligible to participate in the Guardian Life Insurance dental plan. Discounteddental services are available through dentists associated with the Care First Blue ChoiceHMO.Short term Disability Income PlanFellows are eligible to purchase this coverage through the Benefits Office. Provident LifeInsurance is the providers.Long-Term Disability InsuranceFor the first year of training, an individual policy is paid by the Medical Center whichprovides $2000 / month after 180 days of total disability, with provisions for partialclaims. This coverage can be continued by the fellow on an individual basis at adiscounted rate after the first year. After the first year of training, fellows are enrolled inthe University Long-Term Disability Insurance plan.Life InsuranceBasic life and Accidental Death and dismemberment coverage equal to the baseannualized salary is provided at no cost. Optional terms and universal insurance isavailable at an additional charge.Retirement BenefitsFellows must be at least 21 years of age and have completed two years of service toparticipate. GW contributes 4% of the annualized regular salary to the plan. Fellows whocontribute a portion of their salary to the plan are eligible to receive matchingcontributions equal to 1.5 times the employee contribution, up to a maximum of 6%. 36
    • LEAVE POLICYFellows are eligible for the following leave according to University Policy1. Vacation, holiday leave and sick leave. (Determined by each program / department)2. Family and medical leave3. Temporary disability leave4. Maternity leave5. Leave of absence6. Bereavement leave7. Leave for jury duty8. Leave for court appearances9. Military duty leave EDUCATION BENEFITSTuition BenefitsTuition benefits cover a maximum of six credit hours in the fall and spring semesters andnine credit hours in the summer sessions for courses taken in degree programs. Someexclusions apply. Benefits for spouses and dependent children vary depending on yearsof service to the university.Tuition Exchange ProgramThe university is a member of the Tuition Exchange, Inc., which provides a limitednumber of tuition remission scholarships for employees of member colleges anduniversities. The Benefits Office determines the eligibility. MISCELLANEOUSLab CoatsOne personalized white lab coat is provided to each fellow on an annual basisParkingParking is provided free if assigned to University garages and parking lots.Student Loan DefermentThe GME office will assist in the processing of student loan deferments.Health and Wellness CenterThe Health and Wellness Center is located at 2301 G Street. The annual membership feeis @395.00 and can be paid through payroll deduction.Employee Assistance ProgramConfidential problem assessment, counseling and referral services are provided. 37
    • OVERVIEW OF TASK FORCE RECOMMENDATIONS BY AMERICAN GASTROENTEROLOGICAL ASSOCIATIONCLINICAL TASK FORCESMotility, Diverticular Disease and Functional IllnessAcid-Peptic DiseaseBiliary Tract Diseases and Pancreatic DisordersGastrointestinal Inflammation, Enteric and Infectious DiseasesGastrointestinal MalignancyHepatologyGastrointestinal EndoscopyNutritionPediatric GastroenterologyGastrointestinal and Hepatic PathologyGastrointestinal RadiologySurgeryGeriatric GastroenterologyWomen’s Health Issues in Digestive DiseasesOTHER TASK FORCESOverview of Training in Gastroenterology ResearchGastrointestinal Cellular and Molecular Physiology 38
    • TASK FOR ON MOTILITY, DIVERTICULAR DISEASE AND FUNCTIONAL BOWEL ILLNESS MOTILITY AND FUNCTIONAL BOWEL ILLNESSKnowledge Areas for Motility and Functional Bowel Illnesses1. Understanding the management of patients with motility and functional bowel disorders2. Understanding the physiology of gastrointestinal motility3. Understanding the brain-gut axis and visceral sensation4. Understanding the nuances of functional bowel disorders5. Understanding the importance of psychosocial aspects of functional bowel disorders6. Understand the usefulness of, indications for and limitations of motility studiesGoals of TrainingIncludes the understanding of the pathophysiology of the disorders, exposure tomanagement of adequate numbers of patients under the supervision of experiencedclinicians and understanding the rationale for, usefulness of, and potential pitfalls ofvarious motility tests that are available. This level of training is expected for all trainees.1. Clear understanding of the indications and contraindications of the performance of motility studies2. Understanding the limitations of interpretation of esophageal manometry, esophageal pH studies, esophageal motility with provocative agents, radionuclide gastric emptying studies, small bowel motility, colonic transit measurements, anal sphincter manometry and anal sphincter biofeedback training.3. Recognize the manometric features of major motor disorders of the esophagus and anal sphincter, including esophageal achalasia, scleroderma, internal anal sphincter weakness, external anal sphincter weakness and absence of rectoanal inhibitory reflex4. Understand the features of pH testing which indicates reflux and significance of a symptom score index5. Understand the physiology of motility of different areas of the gut, the brain-gut axis and the physiology of visceral sensation6. Develop a theoretical framework of the role of main neurotransmitters involved in sensory and motor functions7. Familiar with the health care-seeking behavior and the associated psychosocial factors that appear to be important in patients with functional bowel disorders8. Develop an understanding of the use of psychopharmaceuticals in the treatment of functional bowel disorders9. Understand when and how to refer patients refractory to therapy for psychiatric evaluation and management. 39
    • Training Process1. Provide an appropriate clinical outpatient experience that provides an opportunity to evaluate and manage patients with possible motility disorders2. Development of skills in interview techniques and integration of psychological information into clinical reasoning and decision-making3. Development of decision-making that incorporates appropriate testing, interpretation of test results and treatment the patient under the guidance of appropriate staff4. Teach the roles of motility, and sensation, in functional bowel disorders5. Provide information and instruction in the performance of motility studies, including 24-hour pH studies6. Offer specific literature and didactic teaching to develop an understanding of the pathophysiology of motility disorders7. Review motility tracings to enhance interpretation of studiesAssessment of Competence1. Appropriately trained preceptors are identified by program director2. Preceptors will formally review fellows techniques in evaluating and managing patients with motility and functional bowel disorders3. Appropriately trained preceptors will formally review fellows skills in conducting motility studies4. Certification of competence by program director DIVERTICULOSIS AND DIVERTICULAR DISEASEThe management of diverticular disease should be encountered by all trainees in an activeclinical program. The clinical program will offer an understanding of presentations ofdiverticular diseases and the management of the complications. Therefore, no specificcurriculum was offered by the Task Force. 40
    • TASK FORCE ON ACID PEPTIC DISORDERSKnowledge Areas1. Obtain knowledge of acid peptic disorders, including duodenal and gastric ulcers, gastroesophageal reflux, gastritides/gastropathies, Zollinger-Ellison syndrome and other hypersecretory states and duodenitis.2. Obtain an understanding of the prevalence, potential for complications, economic consequences of the disorders3. Obtain knowledge of the technology and appropriate skills in the performance of diagnostic and therapeutic imaging techniques and understanding the surgical approaches to the diseaseGoals of TrainingThe fellow is expected to gain knowledge and understanding of1. the anatomy, physiology and pathophysiology of the esophagus, stomach and duodenum2. the gastric secretion and indications for gastric analysis3. the indications for serum gastrin measurement and secretin testing and consequences of hypergastrinemia in both hypersecretory and achlorhydric states4. the natural history, epidemiology and complications of acid-peptic disorders, including recognition of premalignant conditions (i.e. Barrett’ esophagus)5. the role of H. pylori and NSAIDs in acid-peptic diseases6. the pharmacology, adverse reactions, efficacy and NSAID-appropriate use of drugs for acid-peptic disorders; these include antacids and histamine-2 receptor antagonists, proton pump inhibitors, mucosal protective agents, prostaglandin analogues, prokinetic agents and antibiotics7. the endoscopic and surgical treatments of acid-peptic disorders, including cost- effectiveness, complications and side effects, both short-term and long-termThe fellows are expected to develop competence in1. the performance of a thorough gastrointestinal-directed history of physical examination2. the performance diagnostic and therapeutic upper gastrointestinal endoscopy3. the performance and interpretation of esophageal pH probe tests and esophageal motility studies4. the interpretation of plain films of the abdomen, barium examinations of the upper gastrointestinal tract, ultrasonography, abdominal computed tomographic scans and magnetic resonance imaging5. the understanding invasive and noninvasive techniques for diagnosing H. pylori infection6. the understanding the role of prostaglandins in mucosal protection, the importance of prostaglandin inhibitors (NSAIDs, aspirin) in causing ulcers and the effects of selective cyclooxygenase-2 inhibitors on the upper gastrointestinal tract 41
    • Training ProcessCare and ManagementFellows must acquire a thorough knowledge of appropriate history-taking, an ability toperform a comprehensive and accurate examination, develop appropriate differentialdiagnosis and outline a logical plan for specific and targeted investigations and atreatment planProficiency in Endoscopic and Ancillary InvestigationsObtain experience under direct supervision to become competent in performing andinterpreting all procedures and diagnostic tests that are used in the evaluation andtreatment of patients with acid-peptic disorders. This would include the indications,limitations, technical aspects and complications of the following procedures. Fellowsmust also understand the benefits and dangers of conscious sedation.1. Upper intestinal endoscopy, both elective and emergent. This would include the various modalities for the treatment of upper gastrointestinal bleeding, biopsy and polypectomy2. Dilatation of benign and malignant esophageal strictures3. Performance and interpretation of esophageal motility studies, 24-hour pH monitoring and the interpretation of gastric secretory studies4. Interpretation of radiological studies of the upper gastrointestinal tract, including contrast gastrointestinal examinations, ultrasonography, computed tomographic scans and magnetic resonance imaging.5. Indications and interpretation of studies for specific entities, such as hypersecretory states, H. pylori, and other infections of the upper gastrointestinal tract, particularly acquired immunodeficiency syndrome (AIDS)-related disorders6. Develop a working knowledge of upper gastrointestinal tract pathology, such as mucosal biopsies for gastritis, Barrett’s esophagus and malignant conditions 42
    • TASK FORCE ON TRAINING IN BILIARY DISEASES AND PANCREATIC DISORDERSA major goal in training in biliary tract diseases should be to develop highly skilledconsultants who can provide state-of-the-art care of patients with complex biliary disease.These physicians should be aware of the advantages and disadvantages of availableoptions involving the diagnosis and therapy of biliary diseases and of potentialcomplications. If complications occur, the specialists should be in a position to managethem.Goals of Training for Biliary Disease1. Become acquainted with varied presentations of biliary tract disease and have detailed knowledge about all aspects of biliary disease2. Acquire competency in the decision-making process involving the appropriate choice of diagnostic procedures, their timing and their sequence3. Establish proficiency in diagnostic and therapeutic procedures involving biliary tract disease and acquire the ability to perform them safely, successfully and expeditiously4. Appreciate the advantages and disadvantages of radiological and endoscopic procedures and be able to balance the risks and benefits of these procedures for patients5. Understand the importance of teamwork which involves close collaboration with radiologist, surgeons and hepatologistsGoals of Training for Pancreatic DisordersTrainees should attain knowledge and understanding of1. The embryological development and anatomy of the pancreas and pancreatic duct system2. The regulation of pancreatic growth and differentiation3. The physiological processes involved in pancreatic exocrine secretion of digestive enzymes, water and electrolytes4. The regulation of exocrine secretory processes5. The types of digestive enzymes secreted by the pancreas and their roles in the digestive system6. The mechanisms by which pancreatic enzymes secreted as zymogens are activated in the small intestine7. The factors that protect the pancreas from autodigestion8. The physiological interactions between exocrine and endocrine pancreas9. The epidemiology, pathophysiology and natural history of acute pancreatitis, chronic pancreatitis and pancreatic cancer 43
    • Goals for Training for Acute PancreatitisIn caring for acute pancreatitis, trainees must be able to1. establish diagnosis and assess severity2. determine the etiology3. direct initial volume resuscitation4. monitor for and treat extra pancreatic complications (i.e. Pulmonary and renal failure)5. diagnosis and treat expeditiously infected necrosis or pancreatic abscess and other septic complications6. diagnosis and manage pancreatic pseudocysts,7. pancreatic ascites8. hemorrhage9. determine the need for and timing and type of nutritional support10. evaluate patients for possible treatable occult causes of otherwise ‘idiopathic’ acute pancreatitisGoals for Training for Chronic PancreatitisIn caring for individuals with chronic pancreatitis, trainees must be able to1. establish the diagnosis (particularly in the presentation of occult disease)2. develop the differential diagnosis between chronic pancreatitis and pancreatic cancer3. determine the etiology4. manage abdominal pain, pancreatic exocrine and endocrine insufficiency and biliary obstruction5. diagnosis and manage pancreatic pseudocysts, ascites, pleural effusion and vascular complications (i.e.. splenic vein thrombosis, pseudoaneurysm)Goals for Training for Pancreatic CancerTrainees must be able to1. use diagnosis tests in a rational and cost-effective manner2. assess operability3. manage pain, biliary and intestinal obstructions, pancreatic insufficiency and splenic vein thrombosis 44
    • Additional GoalsTrainees must be able to1. recognize and diagnosis cystic fibrosis and manage pancreatic insufficiency in that setting2. diagnosis and treat annular pancreas3. assess the importance of pancreas divisum in the etiology of pancreatic disease4. understand the indications for and the interpretation of diagnostic tests results in the diagnosis and management of disease of the pancreas, including serum amylase and lipase determination, serum tumor markers, indirect tests of pancreatic secretory function, direct tests of secretory function, duodenal drainage with analysis for biliary crystals and fine needle aspiration of pancreatic masses and analysis of cytology in endoscopic aspirates of pancreatic juice5. Understand the role of other disciplines in the management of pancreatic disorders, including therapeutic endoscopy, surgery, interventional radiology, anatomic pathology and cytopathology, nutritional support, pan management, medical oncology and radiation oncology.Training ProcessBasic science training (physiology and pathophysiology). The fundamental core ofinformation for all trainees should include1. detailed knowledge of hepatobiliary and pancreatic anatomy, including developmental anomalies2. physiology of bile and factors regulating bile flow3. physiological function of bile components (bile acids, phospholipid, cholesterol and protein)4. gallbladder function, mechanism of bile concentration an regulation of gallbladder contraction5. regulation of bile duct motility and sphincter of Oddi function (contraction / relaxation)6. pathophysiology of cholestasis and the mechanisms responsible for alteration of bile flow7. pathophysiology of gallstone formation (cholesterol, pigment stone)8. pathogenesis of motility disorders of the biliary tract9. pathophysiology and scientific rationale for therapy of major biliary tract disorders and complications of liver transplantation as well as other hepatobiliary surgical procedures10. basic familiarity with techniques of molecular biology, principles of cell biology and physical chemistry 45
    • Clinical Aspects of biliary diseases1. understanding of the epidemiology, manifestations, differential diagnosis and natural history of major biliary tract disorders2. familiarity with specific biliary tract disease, including benign and malignant strictures, primary and secondary neoplasms, choledocholithiasis, cholecystitis, sclerosing cholangitis, congenital abnormalities of the pancreaticobiliary tract (i.e. biliary atresia, choledochal cysts), hemobilia, motility disorders of biliary tract, post- operative complications of the biliary tree and post-liver transplant biliary problems, acute and chronic pancreatitis and pancreatic neoplasms.3. Senior trainees should obtain more detailed exposure to biliary disease through active participation in the medical care of patients with biliary tract diseases through inpatient and outpatient consultationsProcedures1. knowledge of the advantages and disadvantages of the different diagnostic and therapeutic procedures used in the diagnosis and treatment of biliary tract disease and pancreatic disease, including potential risks, limitations and costs in the evaluation and management of biliary tract and pancreatic diseases2. understand the role of endoscopic techniques and alternative diagnostic and therapeutic modalities (medical, surgical and radiological) in the management of biliary and pancreatic disease3. Understand the role of ERCP as the primary tool for accessing the biliary tree and pancreatic ductal system and as a major route for therapeutic intervention. Appreciate the indications, contraindications, limitations, complications and interpretation.4. Understand the role of percutaneous transhepatic cholangiography. Appreciate the indications, contraindications, limitations, complications and interpretation.5. Understand and have a basic understanding (indications, advantages and disadvantages) and how to interpret the following imaging procedures, including: plain abdominal film, cholecystogram, ultrasound, computed tomography, magnetic resonance imaging and scintigraphy6. Exposed to the performance and interpretation of endoscopic ultrasound7. Exposed to surgical biliary and pancreatic procedures 46
    • TASK FORCE ON TRAINING IN GASTROINTESTINAL INFLAMMATION, ENTERIC AND INFECTIOUS DISEASESGoals of trainingTrainees must master a basic body of knowledge, including an understanding of1. mechanism of inflammation2. elements of mucosal defense systems (including the mucosal immune system and the components of intestinal barrier function)3. composition and function of normal enteric flora (including protection again pathogens, colonization resistance, role in the metabolism and effects of antibiotics on flora4. prevalence, clinical presentation and virulence factors of gastrointestinal pathogens (viral, bacterial, fungal, protozoa)5. pathophysiology of diarrheal disease6. indications and contraindications of antimicrobial therapy, mechanisms of microbial drug resistance and risk of infections from altering normal floraClinical SkillsFamiliarity with the following diagnostic and histopathologic studies1. stool examination, fecal leukocytes and ova and parasites2. cultures of stool, intestinal fluid and biopsy (specimen collection, handling, special stains, media)3. mucosal biopsy interpretation4. antigen detection (enzyme immunoassay, fluorescent antibody) in stool and fluid and stool toxin testing5. rapid diagnostic tests (DNA probes or polymerase chain reaction), disinfection and antibiotic prophylaxis6. liver biopsy and interpretationFamiliarity with the following1. selection and use of antibiotic therapy and methods for preventing infection during endoscopy (disinfection and antibiotic prophylaxis)2. gastrointestinal infection, including the diagnosis and management of patients with common infectious presentations, including esophagitis, (fungal, viral , bacterial), ulcer disease and gastritis (emphasis on H. pylori and appropriate antibiotic therapy),3. acute, chronic, hemorrhagic and travelers diarrhea4. bacterial overgrowth5. infections in immunocompromised hosts (transplantation patients)6. hepatic inflammation (liver abscesses, hepatitis, cholangitis07. role of liver biopsy 47
    • 8. concepts of preventive medicine, indications for vaccination, routes of infection, dietary an hygienic practice for travelers, appropriate recommendations for prophylactic antibiotic therapyTraining process1. participation in the evaluation and management of outpatients and inpatients with presentation and diagnoses2. exposure to appropriate use of diagnostic tests, indications and complications of therapy3. additional exposure to related sciences (immunology, microbiology and molecular biology) and related fields of medicine (infectious disease, and laboratory, anatomic an surgical pathology4. conferences, seminars and literature reviews 48
    • HIV-RELATED GASTROINTESTINAL DISORDERSGoals of training1. AIDS-related from AIDS-unrelated conditions2. management of esophageal disorders , including infectious esophagitis3. assess AIDS gastropathy and other infectious and neoplastic gastric disorders4. assess disorders of the small intestine, including causes of diarrhea and HIV- infected5. interpretation of endoscopic, barium and computed tomographic and ultrasound examination6. treat bacterial,, fungal, viral and protozol infections in patients with AIDS7. recognize cause of colorectal disorders, including proctitis, proctocolitis and AIDS-related malignancy8. familiar with the indications for and interpretation of flexible sigmoidoscopic, colonoscopic and radiographic studiesBiliary system1. evaluate causes of hepatomegaly, abnormal liver test results (infectious, neoplasia, drugs) and interaction of hepatitis virus and HIV2. distinguish AIDS cholangiopathy and cholecystitis3. assess indications of liver biopsyPancreatic disorders1. causes of pancreatitis (infectious, neoplastic, toxic)2. implications of hyperamylasemia3. nutritional evaluation of pancreatic disorders4. assessment of nutritional status and development and implementation of nutritional therapies (enteral and parenteral)5. determine the cause of and prescribe a rational treatment plan for common opportunistic and neoplastic conditions in a cost-effective and humanitarian fashion.Training Process1. inpatient and outpatient consultative evaluations2. exposure to patients with AIDS with dysphagia/odynophagia, diarrhea, rectal bleeding, abnormal liver enzymes/hepatomegaly, abdominal pain and hyperamylasemia3. interaction between trainees and specialists in laboratory medicine, diagnostic and interventional radiology and infectious disease and immunology 49
    • INFLAMMATORY BOWEL DISEASEGoals of Training1. recognize clinical and laboratory features of intestinal inflammation and to distinguish them from signs of secretory and osmotic diarrhea and from symptom of irritable bowel syndrome2. differentiate chronic idiopathic IBD from other specific entities, including acute self-limited ileitis and colitis, drug- or radiation-induced colitis and diverticulitis by history and interpretation of radiological, endoscopic, histological and microbiological studies3. understand indications for and interpretation of colonoscopy, barium enema, upper gastrointestinal and small bowel series, enteroclysis and computed tomographic scan4. understand the cost-benefit and risk-benefit of procedures5. familiarity with different presentations of IBD, including the pediatric manifestations, anorectal complications, and inflammatory vs. fistulizing vs. fibrostenotic patterns of Crohn’s disease6. recognize various presentations of IBD with history-taking, physical examinations7. capable of evaluating intestinal (i.e. hemorrhage, obstruction), extraintestinal (i.e. ocular, dermatologic, musculoskeletal, hepatobiliary) and nutritional complications of ulcerative colitis and Crohn’s disease.8. Familiarity with the influence of IBD on pregnancy and of pregnancy on IBD and be capable of addressing issues pertaining to family history and genetic counseling.9. Awareness of long-term cancer risks in ulcerative colitis and Crohn’s disease and be able to implement appropriate cost-effective surveillance programs10. Sensitivity to psychosocial influences and consequences of IBD on the individuals and on family dynamics11. Developing a therapeutic plan according to the extent and severity of specific disease patterns and to understand the indications, contraindications, and pharmacology of nonspecific therapies, including new biologic therapies, anticholinergic agents, antidiarrheals and bile salt sequestrants, oral and topical aminosalicylates, parenteral, enteral and rectal corticosteroids, immunosuppressants and antibiotics used in relevant clinical situations12. Understand the indications for enteral and parenteral alimentation and be able to implement nutritional therapies13. Capable of diagnosing and differentiating other inflammatory disorders, including collagenous colitis, microscopic colitis, NSAID enterocolopathies, diverticulitis (including medical and surgical complications), radiation enteritis and colitis, Whipple’s disease, celiac sprue, diversion colitis, and the solitary rectal ulcer 50
    • Training Process1. able to assume responsibility, encompassing diagnoses, acute and chronic therapies, long-term follow-up and counseling of the families and/or significant others2. exposure to hospitalized as well as ambulatory patients, including the initial assessment and longitudinal management of patients with IBD 51
    • TASK FORCE ON TRAINING IN GASTROINTESTINAL MALIGNANCYGoals of training1. develop a thorough familiarity with the literature on cancer epidemiology, primary prevention and screening for colorectal cancer with fecal occult blood tests and well as endoscopic and radiological approaches2. become knowledgeable about the recommended guidelines for screening for gastrointestinal neoplasia and the literature supporting these recommendations3. develop ability to read and interpret literature about the merging technologies and able to evaluate novel technologies and approaches4. develop a working knowledge of clinical genetics and understand the approaches to the genetic diagnosis of FAP, HNPCC and other rarer polyposis syndromes5. recognize the clinical characteristics of diseases, the distinctions among the familial forms of cancer, the specific diagnostic and screening tests for each and the rational approaches to their treatment6. learn the principles of neoplastic growth as they relate to therapy, including endoscopic treatment as well as traditional surgical approaches7. develop a complete understanding of the management of premalignant conditions8. familiarity with the pathological interpretation of tissue biopsies (endoscopic and percutaneous)9. develop a thorough working knowledge of management of dysplastic lesions10. understand the distinctions among the varieties of colorectal polyps and their management11. learn the principles of chemotherapy for gastrointestinal cancer and radiation treatment of early and advanced tumors12. understand the initial management of patients in whom the diagnosis of gastrointestinal cancer has been made13. understand how to counsel patients who have had gastrointestinal neoplasia and how to manage patients who have positive family histories of gastrointestinal cancer14. understand the principles and importance of genetic counseling as it pertains to genetic testing and the management of inherited gastrointestinal diseases15. familiarity with the prognoses associated with different types of gastrointestinal cancer16. familiarity with the technical considerations in the therapy of colorectal adenomas and carcinomas17. become thoroughly experienced in colonoscopic polypectomy of pedunculated and sessile polyps and ablative therapies for sessile lesions18. understand the capabilities and limitations of endoscopic mucosectomy for early gastrointestinal cancer19. familiarity with the appropriate surveillance and surveillance interval for patients at high risk for developing cancer and those in whom premalignant epithelium has already been detected 52
    • 20. selected individuals should obtain experience in placement of endoscopic stents, laser ablation, photodynamic therapy, endoscopic ultrasound, fine needle aspiration of tumors, endoscopic mucosectomy and endoscopic celiac ganglion block for patients with pancreatic cancer.Training ProcessThroughout the training process, trainees should participate in the screening, diagnosisand management of all types of gastrointestinal malignancies. Lectures in molecular andcellular biology as well as clinical oncology and screening, treatment and palliation ofgastrointestinal cancer should be included in the core curriculum. Lectures are soughtfrom interventional endoscopists, oncological surgeons, medical oncologists, radiationoncologists and a medical geneticists.Lectures are provided in the following:1. changes in screening and surveillance recommendations2. the evolution of genetic testing and counseling for FAP, HNPCC and other familial forms of gastrointestinal cancer3. novel approaches to the diagnosis of gastrointestinal cancer, including endoscopic approaches, radiological approaches, nuclear medicine, ultrasound/endoscopic ultrasound and new genetic techniques4. staging of gastrointestinal cancer, management options and prognostication5. techniques used in the basic science investigation of gastrointestinal cancer, including flow cytometry, polymerase chain reaction assays, mutation analysis, DNA sequencing and linkage analysisEndoscopic training in the diagnosis and management of gastrointestinal cancer isrequired. Recommendations for the duration and frequency of procedures are noted in thesection on procedures. Areas that are relevant to gastrointestinal malignancy that requirespecific attention include:1. endoscopic management of Barrett’s esophagus2. familiarity and at least limited experience with the indications techniques, and management implication of laser therapy and stents for palliating esophageal cancers3. the management of upper gastrointestinal neoplasia in FAP, including the management of gastric, duodenal and periampullary lesions4. the endoscopic management of gastric remnants following Billroth I and II surgery5. recognition of neoplasia in the pancreaticobiliary tree6. familiarity and at least limited experience with the indications, techniques and management implications of therapeutic endoscopic retrograde cholangiopancreatography for pancreatic and biliary cancers 53
    • 7. proper technique for polypectomy for pedunculated and sessile polyps, including saline injection8. management of the diminutive adenomatous polyp9. surveillance of the colon in IBD, including considerations for normal-appearing mucosa and abnormal-appearing mucosa10. recognition of anal cancer lesions with the use of the anoscopeGastroenterology trainees should become familiar with the appearance of cancer by usingthe following diagnostic techniquesRadiological1. gastrointestinal cancer on barium upper gastrointestinal series2. gastrointestinal cancer on barium enema3. pancreatic and hepatic cancers on computed tomographic scans and magnetic resonance imaging4. pancreaticobiliary cancer on endoscopic retrograde cholangiopancreatographyPathological1. identification of adenoma, adenocarcinoma and hyperplastic and other nonneoplastic polyps2. recognition of the depth of invasion of cancer in the polyp or into the wall of the colon and its significance3. recognition of dysplasia vs. reactive changes in IBD4. recognition of Barrett’s epithelium and dysplastic change in Barrett’s mucosa5. recognition of intestinal metaplasia and atrophy in the stomach6. recognition of neuroendocrine and stromal cell tumors of the gastrointestinal tractCertain trainees may elect to receive additional training in advanced endoscopicprocedures. These procedures will be reserved for those who wish to spend the time tomaster these techniques. These procedures include the following:1. endoscopic ultrasound of the esophagus, stomach, duodenum and rectum2. dilating, stenting and tissue sampling of the esophagus and biliary and pancreatic tree3. ablative therapy of neoplasms using laser4. photodynamic treatment of epithelial neoplasia in Barrett’s esophagus5. fine-needle aspiration of masses in the liver and pancreas 54
    • TASK FORCE ON TRAINING IN HEPATOLOGYThe faculty should have at least one individual recognized to posses advanced expertisein liver disease, including continued productivity in clinical or basic research related tohepatology. Hepatology training should be an integral component of the subspecialtyfellowship with approximately 30% of the 18 clinical months dedicated to hepatologytraining. This training should be divided between the management of inpatients with avariety of hepatic disorders and the treatment of outpatients with liver disease. Thetrainees should have experience in the evaluation of patients for liver transplantation.There should be opportunities for trainees to become familiar with the referral andmanagement of liver transplant patients. Opportunities should be available for clinicaland/or laboratory research in liver diseases. There should be regularly scheduledconferences that include didactic lectures, literature reviews, and research seminars.Goals of trainingAll training programs must provide trainees with a broad knowledge of the physiology ofthe liver and a thorough knowledge of the management of patient with hepatobiliarydiseases. This program requires that the trainee provides the following:1. significant fund of knowledge about genetic markers of liver disease, immunology, virology, and other pathophysiological mechanism of liver injury; the basic biology and pathobiology of the liver and biliary systems as well as a thorough understanding of the diagnostic and treatment of a broad range of hepatobiliary disorders2. skill in the performance of a limited number of diagnostic and therapeutic procedures3. an appreciation of the indications and use of a number of diagnostic and therapeutic procedures that are needed to manage hepatobiliary disordersComprehensive teaching of the following subjects occurs1. biology and pathobiology of the liver2. diagnosis and management of patients with the wide variety of disease of the liver and biliary tract systems, including a. acute hepatitis: viral, drug, toxic b. fulminant hepatic failure, including the management of cerebral edema, coagulopathy and other complications associated with acute hepatic failure c. recognition and diagnosis of chronic hepatitis and cirrhosis,; chemical, biochemical, serological, and histopathologic diagnosis of chronic viral hepatitis d. complications of liver disease; ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, hepatorenal syndrome, prevention and treatment of bleeding esophageal varices and gastropathy, diagnosis and treatment of hepatocellular carcinoma 55
    • e. diagnosis and treatment of nonviral causes of chronic liver disease, such as alcohol, nonalcoholic fatty liver disease (including nonalcoholic steatohepatitis), Wilson’s disease, primary biliary cirrhosis, autoimmune hepatitis, hemochromatosis and a-1-antitrypsin deficiency f. gallstone disease, including the appropriate use of medical and surgical therapies g. hepatobiliary disorders associated the pregnancy h. preoperative evaluation and postoperative management of patient with defined diseases of the liver or evidence of hepatobiliary dysfunction3. use of antiviral and immunosuppressive agents in the treatment of liver disease4. selection and care of patients awaiting and following liver transplantation, including the assessment of patients with alcoholic liver disease for transplantation, recognition of alcohol dependence and an understanding of the use of immunosuppressive agents; diagnosis and management of rejection and recognition of other complications of transplantation, such as certain infections and biliary tract and vascular problems.5. Management of the nutritional problems associated with chronic liver disease.6. An understanding of the principle of experimental design, clinical biostatistics and epidemiology sufficient to critically interpret the medical literature7. Pediatric and congenital hepatobiliary disorders8. Liver pathology, including histological interpretation and specific pathological techniques9. Liver imaging modalities including interpretation of computed tomography, magnetic resonance-based techniques (magnetic resonance imaging, magnetic resonance angiography, magnetic resonance cholangiography), hepatic angiography and ultrasound (including Doppler evaluation of hepatic vasculature). The limitation of each modality should be understood.Procedural skillsTrainees must acquire competence in the performance of1. percutaneous liver biopsy (minimum 20)2. diagnostic and therapeutic paracentesis (minimum 20) 56
    • TASK FORCE ON TRAINING IN GASTROINTESTINAL ENDOSCOPYGoals of TrainingTrainees will have achieved:1. the ability to recommend endoscopic procedures based on findings from personal consultations and in consideration of specific indications, contraindications, and diagnostic/therapeutic alternatives2. the ability to perform a specific procedures safely, completely and expeditiously3. the ability to interpret most endoscopic findings correctly4. the ability to integrate endoscopic findings or therapy into patient management plan5. the ability to understand the risk factors attendant to endoscopic procedures and to be able to recognize and manage complication6. the ability to recognize personal and procedural limits and to know when to request assistanceProcedures goalsOutlined in the Curriculum Requirement section.Training processAll trainees should1. have an understanding of indications, limitations, complications and medical and surgical implications of the findings of medical and surgical implications of the findings of gastrointestinal endoscopy2. have an understanding of the underlying pathophysiology of gastrointestinal disease and the ability to interpret the endoscopic findings3. participate in the performance of endoscopic procedures as part of the continuing care of patients.4. Participate in the performance of endoscopic procedures with staff gastroenterologists or surgeons knowledgeable in the indication for and the technique of performing the procedures as well as the method of recording the results of the procedures and clinical significance of the findings.5. Develop an understanding of the essential components of patient safety during endoscopic procedures, including the intravenous administration of medications that produce sedation and analgesia and the application and interpretation of noninvasive patient monitoring devices.6. Become familiar with the care, cleaning and proper maintenance of endoscopy equipment.7. Develop the capability of independently performing routine endoscopic procedures including specific therapeutic maneuvers (i.e. polypectomy, hemostasis) when indicated. 57
    • PERFORMANCE CRITERIA FOR EVALUATION OF DIAGNOSTIC GASTROINTESTINAL ENDOSCOPY Procedure Performance CriteriaEsophagogastroduodenoscopy (EGD) Esophageal intubation Pyloric intubationColonoscopy Navigation through sigmoid colon Intubation of splenic flexure Intubation of the hepatic flexure Intubation of cecum Intubation of terminal ileum (desirable skill) Retroflexion in the rectumSigmoidoscopy Navigation through the sigmoid colon Visualization of the splenic flexure Retroflexion in the rectumEndoscopic retrograde Cannulation of the desired ductcholangiopancreatography Opacification of the desired duct(ERCP) Sphincterotomy Stent placement Stone extractionEndoscopic ultrasonography Intubation of esophagus Intubation of pylorus Imaging of desired organ and/or lesion Successful lesion biopsy Tumor staging in agreement with the surgical findings and similar to that reported in the literatureAll procedures Accurate recognition of normal and abnormal findings Development of appropriate endoscopic/medical treatment in response to these findings 58
    • Guidelines for Endoscopic Training: Parameters of Competency16. reviews records, x-rays, identified risk factors17. understands and discusses appropriate alternative procedures18. correctly identified indication, knows how the endoscopic procedure may influence management19. obtains appropriate informed consent20. demonstrates proper use of premedication and noninvasive patient monitoring devices21. inserts the endoscope using proper technique22. performs procedure with attention to patient comfort and safety23. correctly identified landmarks24. conducts thorough examination of the entire organ25. detects and identifies all significant pathology26. completes examination within a reasonable time27. prepares an accurate report28. plans correct management and disposition29. discusses findings with patient and other physicians30. conducts proper follow-up, review of pathology, case outcomeAssessment of CompetenceObjective criteria based upon parameters developed to assess competency should be used.Judgment as well as interpretive and technical skills must be evaluated. Regular ongoingfeedback is essential. All trainees should be observed regularly by supervisors. Facultymembers should substantiate the trainees’ competence. The program director shoulddocument the competency of all gastroenterology trainees. A logbook of proceduresshould be maintained by all trainees. 59
    • TASK FORCE ON TRAINING IN NUTRITIONGoals of trainingIt is important for the trainees to understand:1. basic principles of nutrient requirements, ingestion, digestion, absorption and metabolism in health and gastrointestinal diseases2. assessment of nutritional status, including specific nutrient deficiencies and excesses, protein-energy malnutrition and obesity3. metabolic response to starvation and the pathophysiological effects of undernutrition4. metabolic response to illness and injury and nutrient requirements during stress states5. indications for nutritional support6. implementation and management of nutritional therapy including modified diets, enteral tube feeding and parenteral nutrition7. pathophysiology and clinical management of obesity8. ethical and legal issues involved in providing and withdrawing nutritional supportTraining process1. didactic lectures, case conferences, selected readings, clinical experience2. involved in providing enteral and parenteral nutrition support to hospitalized patients, including those in intensive care units and nutritional management of outpatients3. clinical experience can include rotation on an inpatient nutrition support service, experience on other inpatient services and participation in an outpatient clinic that involves nutritional counseling 60
    • TASK FORCE ON TRAINING IN PEDIATRIC GASTROENTEROLOGYGoals of TrainingTrainees in adult gastroenterology should1. appreciate the unique aspects of the field with an increased awareness of the clinical problems of pediatric gastroenterology. (The goal is not to develop competence because pediatric gastroenterology is a recognized field of pediatrics.)2. be prepared to participate in limited scope of care when in underserved areas in which pediatric gastroenterology consultative services are not available.Curriculum will include1. age-related physiological and psychological variables of children and adults2. unique aspects of the disease in pediatric vs. adult patients3. manifestation of commonly encountered entities (i.e. abdominal pain, constipation, gastrointestinal bleeding, diarrhea, cystic fibrosis)Training process1. clinical conference in which a pediatric cases are discussed2. potential for limited experience with pediatric gastroenterology service3. visiting professorship of a pediatric gastroenterologist 61
    • TASK FORCE ON TRAINING IN GASTROINTESTINAL AND HEPATIC PATHOLOGYGoals of TrainingTrainees should:1. appreciate the spectrum of normal histology2. learn to recognize patterns of histopathologic change in gastrointestinal and hepatic disorders3. learn optimal biopsy technique and submit adequate samples4. learn to describe endoscopic findings and clinical information to aid the pathologist interpretation of biopsy specimens5. be able to recognize when a biopsy can or cannot help in investigation or management6. be familiar with the clinical implications of the pathological findings in biopsy and in surgical specimens7. know the value and limitation of exfoliative and aspiration cytology8. understand the mechanism and the usefulness of new techniques, such as flow cytometry, immunohistochemistry and tests based on molecular biology (i.e. PCR, in situ hybridization)9. have an overview of special techniques and special stains as diagnostic aids in gastrointestinal and hepatic pathology (in situ hybridization, immunohistochemistry, etc.)10. be familiar with recognition of unusual pediatric liver diseases, recognition of opportunistic infections with HIV, graft-vs.-host disease and the submission of biliary biopsy specimens for detection of cholangiocarcinoma or other bile duct changes11. recognize the usefulness and limitations of endoscopic biopsy in distinguishing different forms of microscopic colitis12. understand the approaches to, timing of, flaws, and risks and benefits of dysplasia surveillance in chronic inflammatory diseases of the gastrointestinal tract13. recognize when gastric biopsy is appropriate in management of upper gastrointestinal disorders, the appropriate sites for biopsy and when pursuing endoscopic biopsies is indicated.Training Process1. multidisciplinary conferences with gastroenterologists and pathologist weekly or biweekly o review specimens2. rotation with pathologist for developing an understanding of handling and interpretation of gastrointestinal, endoscopic and liver biopsy specimens 62
    • TASK FORCE ON TRAINING IN GASTROINTESTINAL RADIOLOGYGoals of TrainingTrainees should be able to:1. recognize normal anatomy of the alimentary tract and related organs2. achieve a basic knowledge of gastrointestinal pathology as demonstrated by plain film radiography, barium studies, computed tomography, ultrasound, magnetic resonance imaging, gastrointestinal vascular and interventional studies, scintigraphy and positron emission transaxial tomography (PET)3. develop and understanding of the logical sequence of using these techniques in the evaluation of gastrointestinal problems4. have an appreciation for and understanding of the costs for different radiological studies5. have an understanding of the indications and contraindications for radiological interventional studies.Training Process1. participation in work rounds on individual patients which is integral to routine patient care2. exposure at weekly conference that include a review of radiographic imaging studies in relating to gastrointestinal disease3. self-instruction programs in gastrointestinal radiology4. defined rotations on a radiology service 63
    • TASK FORCE IN TRAINING IN SURGERYTrainees in gastroenterology must learn about the indications and contraindications forsurgical treatment and the general principles of the surgical procedures that may be used.Trainees should learn about the expected outcomes of operations that are likely to beperformed on their patients and be prepared to care for patients post-operatively asappropriate.Goals of TrainingTrainees should:1. learn the way that surgical procedures are conducted2. should be thoroughly knowledgeable about the postoperative care of patients after major and minor surgical procedures3. should learn the indications and contraindications for a variety of common operations for gastrointestinal disorders4. be able to judge whether surgery is necessary and what kind of operation is indicated and when it should be performed5. be familiar with common complications and their management6. be familiar with long-term consequences of surgical treatment of gastrointestinal diseases7. be knowledgeable about esophageal procedures, surgery of the gastrointestinal tract and liver malignancies8. be knowledgeable about surgical vs. endoscopic vs. interventional radiology procedure and when to pursue specific techniquesSpecific procedures with which the trainees should be familiar include1. antireflux procedures2. ulcer operations3. hepatobiliary operations4. portosystemic shunts5. hepatic transplantation6. pancreatic procedures for benign and malignant disease7. surgery for BID of the small and large bowel8. colonic procedures for diverticular disease or cancer9. various anorectal operations10. laparoscopic vs. open proceduresTraining ProcessLectures constitute a convenient method of conveying knowledge about surgicalprocedures and a systematic series of lectures organized by organ or disease processensures comprehensive coverage. Participation by trainees in joint medical-surgicalconferences to discuss specific patients is mandatory. Personal learning through literaturesearches is an essential element in this effort. 64
    • Trainees are encouraged to go to the operating room when their patients are undergoingsurgical procedures. Observation of gross pathological abnormalities will help traineescorrelate preoperative information with operative findings. Trainees also will gain anappreciation of the conduct of operations, the factors entering into surgical judgment andthe recognition and management of postoperative complications. Rotation with thegastrointestinal surgical team can aid in advancing knowledge about gastrointestinalsurgery. 65
    • TASK FORCE ON TRAINING IN GASTROINTESTINAL CELLULAR AND MOLECULAR PHYSIOLOGYThe field of gastroenterology requires and understanding of cellular, molecular andgenetic mechanisms underlying normal physiology, including proliferation,differentiation and programmed cell death (apoptosis). The importance of the multiplespecialized tissues that encompass gastrointestinal function, ranging from themusculature to the gut brain, the splanchnic circulation, the endocrine system, the gutimmune system, and the epithelia should be emphasized.Goals of trainingTrainees will1. Gain exposure to a variety of disciplines, including immunology, genetics, physiology, pharmacology, biochemistry and pathology.2. Develop an operational understanding of technology as well as information on cellular and subcellular structure and function.3. Develop the capacity to understand and interpret the relevant literature as well as to comprehend and study future developments4. Be able to search and critically analyze fundamental scientific information from appropriate national and international scientific organizations. General conceptsMolecular biologyThe trainees should understand1. the function of the gene and chromosome and their location, composition, and the mechanisms regulating their replication2. genomic organization, including the function of the promotor region, introns, exons and untranslated regions, and mechanisms regulating the expression of this information, including transcription, messenger RNA synthesis, translation, and protein synthesis3. the importance of genetic variability, including single nucleotide polymorphisms and other chromosomal aberrations, particularly as they apply to diagnostics and therapeutics4. the molecular processes responsible for maintaining genetic fidelity, such as proofreading and repair enzymes, and the consequences of their failure, including malignant degeneration5. the basic cellular mechanisms regulating cell proliferation and differentiation and cellular demise, including those of apoptosis and necrosis 66
    • GeneticsThe trainees should understand1. genetic polymorphisms, genetic defects, the genetic basis of gastrointestinal diseases such as hemochromatosis, familial pancreatitis, MEN-1, and colon cancer; the gene mutations involved; and the nature of human gene mutation2. oncogenes, tumor suppressor genes, microsatellite instability, genomic imprinting, chromosomal rearrangements, gene amplification, and their roles in altered cell growth3. the genetics of colon cancer so that information can be used to identify individual patients at risk, guide diagnostic and therapeutic interventions in specific patients and their families, and provide guidance, counseling, and answers to questions from patients and their familiesCell biologyThe trainees should understand1. the basic subcellular constituents of the cell such as the nuclear, mitochondria, golgi, endoplasmic reticulum and lysosomes, along with their normal functions and alterations in disease.2. The normal control of the cell cycle and processes leading to its disruption3. The fundamental properties of cell types specific to and crucial to the operation of the gastrointestinal tract. This includes an understanding of the turnover of the gastrointestinal epithelium and the need for continuous differentiation from stem cells located within each specific tissue and/or organs comprising the gastrointestinal tract as well as the processes regulating normal tissue differentiation and organogenesis4. The epithelial layer as a modulator of vectorial transport and as critical barrier against toxins and pathogens5. The functional organization of the enteric nervous system, the network of neurons embedded within the gastrointestinal wall controlling gastrointestinal function, and the extrinsic neurons (afferent and efferent) that contribute to the modulation of digestive functions. Segmental differences down the cephalocaudal axis critical to function as well as specialized regulatory cells such as the interstitial cells of Cajal also must be understood.Pharmacology and cellular signalingTrainees should recognize1. basic receptor pharmacology, including regulation, trafficking, and signaling as well as receptor transport mechanisms, cellular transduction and cell-to-cell signaling2. the existence of different superfamilies of receptors including ion-channel gated G protein coupled, and tyrosine kinase-activating receptors, along with the different mechanisms by which second messengers are activated to induce a functional response 67
    • 3. the rapidly growing field of cellular signal transduction as a mechanism underpinning critical regulatory processes in health and disease. These include cell-matrix communication, important in host defense; cell-cell communication, important in tissue responses; and intracellular pathways critical for cell homeostasis that, when disturbed, can cause unregulated growth or premature cell death4. the existence of numerous transmitters and modulators synthesized and released by neurons innervating the digestive system, including classical transmitters such as acetylcholine and noradrenaline as well as slow transmitters/modulators such as peptides.5. The existence and importance of the endocrine system that is scattered throughout the digestive tract and that are often expresses the same chemical messengers as neurons6. The disparate mechanism by which different chemical messengers are released and reach their sites of action, including endocrine, neuroendocrine, and paracrine mechanisms of action. Trainees should develop a basic understanding of hormones and of neurotransmitters and their specific receptors as they relate to the gastrointestinal tract.7. The roles of nitric oxide and NO synthase in cellular physiological events and their implications related to gastrointestinal physiology and pathophysiology as well as the NO pathway in inflammation and splanchnic circulationHost-environment interactionsTrainees should have an understanding of1. the factors permitting the existence of commensal organisms and their contribution to maintaining host health as well as the processes whereby pathogenic organisms are recognized and by which they induce a host response2. the cellular and molecular biology underlying important infections, including H. pylori3. basic virology so that current infections, including the many cases of hepatitis, as well as future disorders can be appreciated.ImmunologyTrainees should have an understanding of1. the gut-associated immune system, its distinct differences from systemic immunology, and the implications of this in understanding gastrointestinal physiology and pathophysiology. This includes an understanding of the roles of a variety of mediators and modifiers of the inflammatory process, including cytokines and chemokines and other related molecular species2. autoimmune disease and the markers for immune-mediated gastrointestinal diseases3. basic transplantation biology, including the processes leading to and permitting the development of critical disorders such as graft-versus-host disease 68
    • TechnologiesTechnical advances have played a critical role in allowing bench-to-bedside transfer oftechnology. A basic understanding of many critical technologies should be included inthe educational curriculum. These technologies should include1. Genetic screening techniques: A fundamental understanding of genetics required to apply genetic screening techniques effectively2. Principles of polymerase chain reaction: Understanding the technology as well as its utility, limitations, applications, and diagnostic and information acquisition potential3. Microarray technology: Understanding the methodology, present and projected applications, and limitations4. Recombinant technology: Understanding the techniques and applications of development of recombinant human proteins and peptides for their therapeutic and diagnostic applications5. Antibody methodology: Understanding techniques involved in creation of hybridomas and the potential application of monoclonal antibodies obtained using this technique. Also, an understanding of the theory and practical use of humanized chimeric monoclonal antibodies because of their present and future applications for diagnosis and management of patients.6. Cell sorting technology / flow cytometry: Understanding the basis of these techniques and their potential applications to distinguish among specific cell types.7. Detection of cell markers: Understanding methodologies ranging from microscopic, nucleic acid hybridization, immunodetection methods to enzymatic assays, used to identify cell markers. Application of such technologies to distinguish the various populations of cells involved in inflammatory and neoplastic processes. The limitations of these immunological and biochemical detection methods in sorting out information regarding specific disease processes.8. New technologies. An understanding of rapidly developing technologies, including phage display technology, filamentous phage biology, and applications form the nascent fields of genomics and protenomics.9. Information acquisition: Understanding the acquisition of information in molecular biology or as it pertains to gastroenterology, both now and in the future, via the Internet.Training ProcessThe experience, training and acquisition of information for trainees can be provided in avariety of ways, which are not mutually exclusive. The methods of training can include:1. Specific lectures dedicated to conveying information regarding the topics2. Appropriate readings and instructional materials with discussion seminars (i.e. journal club)3. Conferences and lectures at local or national meetings 69
    • 4. Seminar-type courses that focus on the cellular and molecular basis of gastrointestinal physiology5. Personal instruction and questioning of trainees during the diagnosis and management of patients 70
    • TASK FORCE ON TRAINING IN GERIATRIC GASTROENTEROLOGYGeriatric training in gastroenterology can be divided into 2 broad categories1. General geriatric issues that need to be addressed include the impact of age on patient communication, family and social support, and presentation of disease2. Geriatric gastroenterology deals with the impact of age on presentation, diagnosis and treatment of common and important gastrointestinal conditions in the elderly. An important feature of this training is the ability to recognize the effect of age on pathophysiology and response to treatmentGeneral Geriatric Issues1. Pathophysiology of aging: Obtain an overview of the current concepts and models of aging, with particular emphasis on the gastrointestinal tract.2. Demographics and epidemiology of aging: An understanding of the impact of aging on the epidemiology of gastrointestinal disease, health care delivery and the issues of costs and resources3. Impact of common geriatric disorders on gastroenterology: Develop an understanding of the impact of common diseases, such as depression and dementia, on the presentation and evaluation of gastrointestinal disease. Able to assess the patients’ ability to follow a treatment plan, with emphasis on the effect of cognitive impairment on management of gastrointestinal problems4. Social and ethical issues in aging: Able to asses the patients’ levels of dependence on external psychosocial support from family, friends and organizations as part of the treatment plan and should be aware of the importance of appropriate communication with the patients’ families (or equivalent). Trainees should be aware of common signs and symptoms of abuse and have a basic knowledge of community resources available for intervention in cases of abuse, neglect, and caregiver stress. Trainees should develop an understanding of the special needs of frail older individuals, including ethical issues concerning the risk-to-benefit ratio of the investigation and treatment of disease as well as end-of-life issues.Geriatric Gastroenterology1. Changes in gastrointestinal function with aging: Trainees should be aware of the normal or expected changes in the physiology of the gut, pancreas, and liver that occur with aging. These include swallowing disorders due to a variety of aging- associated changes in oropharyngeal and esophageal motility, impaired gastric motility and acid secretion, changes in hepatic metabolism, slowing of colonic motility and rectal dysfunction. There should be a familiarity with the normal range of laboratory data in the elderly.2. Changes in drug metabolism with aging: Trainees must have an appreciation of the changes in drug metabolism, particularly in the liver, which occur with aging. Trainees should be able to identify and anticipate side effects and interactions of 71
    • medications used for the management of gastrointestinal disorders in the geriatric population3. Gastrointestinal effects of drugs: Trainees should have an appreciation for the presentation and differential diagnosis of gastrointestinal side effects of commonly prescribed drugs in older individuals. These include drugs with significant symptoms or effects on gastrointestinal motility, including neuroleptics, antihistamines, antidepressants, antiarrhythmic agents, and antihypertensive agents (i.e. calcium channel antagonists).4. Effects of aging on nutrition: Trainees should be able to discover malnutrition in the geriatric age group with an awareness of the common disorders resulting from inadequate intake of nutrients (including vitamin deficiencies). There should be a recognition that adaptation of food intake to illness or abrupt changes in physiology is impaired or delayed in older individuals. Trainees should be taught age-appropriate strategies for fluid and nutritional replacement in inpatient and outpatient settings. There should be an appreciation of the presentation of anorexia, obesity and eating disorders in older individuals. The ethical and treatment issues of feeding tube placement should be covered with particular emphasis on risks and benefits in frail and demented patients.5. Common gastrointestinal conditions in the elderly: Trainees should be familiar with the presentation and pathophysiology of common gastrointestinal diseases in the elderly, including dysmotility syndromes affecting oropharynx, stomach and colon. Trainees should also be aware of malabsorption, gastrointestinal bleeding, and oncologic diseases in older patients and they should be aware of the prevalence, diagnosis and treatment. Appropriate management of common disorders in the elderly should be reviewed, as it may be different in the elderly patient. There should also be an understanding of the diagnosis and management of common gastrointestinal problems in institutionalized and bedridden geriatric individuals.6. Effective strategies for inpatient and outpatient management. Trainees should be able to assess the severity and emergent natures o f gastrointestinal complaints in the elderly in inpatient and outpatient settings. Appropriate strategies for fluid/volume assessment and management in the elderly should be appreciated. There should also be an understanding of the subtle and misleadingly benign presentation of acute abdominal conditions in frail older patients and an understanding of the need for early surgical referral if appropriate.Training ProcessTrainees knowledge should be obtained through a variety of experiences1. Didactic lectures (including CD-ROM and Internet-based programs), case presentations, group discussions and seminars, clinical bedside teaching and individualized teaching2. Clinical experience provided primarily by interaction with consultants in both gastroenterology and geriatric medicine.3. Clinical exposure should include both outpatient and inpatient geriatric settings 72
    • TASK FORCE ON TRAINING IN WOMEN’S HEALTH ISSUES IN DIGESTIVE DISEASESWomen’s health issues and awareness of gender differences should be incorporated intothe overall gastroenterology fellowship. The patient population cared for by traineesshould include a minimum of 25% women. There are three broad categories of women’shealth that should be included in the curriculum. These categories are general women’shealth issues, specific digestive diseases and women’s health issues, and pregnancy andchildbearing issues.Goals of trainingGeneral Women’s Health Issues1. Doctor-patient relationship: Development of an understanding of gender differences as they pertain to the doctor-patient relationship2. Cultural and religious issues: The cultural and religious difference between men and women and the manner in which health care is both perceived and sought and with which recommendations or complied should be appreciated.3. Psychosocial issues: Trainees should understand psychosocial issues both as initiating factors in certain disease states in women and as their contribution to ongoing clinical symptoms and pathology and their impact on evaluation and treatment. Patient should be able to elicit information about abuse and understand their consequences upon gastrointestinal issues. Trainees should be able to develop empathy for the special needs of women.4. Laboratory values and diagnostic tests: Trainees should recognize that there are gender differences as well as changes during pregnancy in normal laboratory values, including liver tests, hematocrit, and creatinine values. They should recognize anatomic gender differences on diagnostic tests and changes in women with age and pregnancy.5. Disease presentation and physician visits: Trainees should recognize gender differences in disease presentation as well as different thresholds between women and men in seeking medical care. In addition, there are differences in thresholds for pain perception in difference disease states as well as among individual patients.6. Complementary and alternative medicine: Trainees should be able to elicit a history of the use of complementary and alternative medicine during the routine examination and be aware of the potential impact upon health and disease, as well as the potential complications of some herbal remedies.Specific Digestive Diseases and Women’s Health Issues1. Health and disease states in women: Trainees should understand the presentation and pathophysiology of all gastrointestinal and hepatic disease in both women and men. There should be an awareness of gender differences in demographics and 73
    • epidemiology and pathophysiology of many gastrointestinal and hepatic diseases. There should be an awareness of gender differences in demographics, epidemiology and pathophysiology of many gastrointestinal tract and liver disorders. Trainees should understand the psychosocial impact on many of the gastrointestinal disorders as well as the effect that chronic disease has on a women’s daily life and that an effective treatment plan often includes a multidisciplinary approach.2. The effect of the menstrual cycle and menopause on digestive disease function in health and disease: Trainees should understand the effect of the menstrual cycle and menopause on gastrointestinal tract and liver function in both health and disease. This includes and understanding of estrogen and progesterone and the role of these and other hormones have on gastrointestinal tract and liver function.3. Gender differences in the pharmacokinetics of medications: Trainees should recognize and understand gender differences in medication pharmacokinetics, differences in the prolongation of QT intervals, differences in metabolism of certain medications and differences in the therapeutic response. There should be an appreciation of potential side effects, complications and interactions of medications that are used for the management of gastrointestinal and liver disease in women.Pregnancy and childbearing issues1. Fertility and infertility: Trainees should be cognizant of the issues regarding fertility and pregnancy and be able to appropriately advise women with gastrointestinal and liver disorders who desire pregnancy. There should be a basic knowledge of genetics as it pertains to the gastrointestinal tract and liver disorders and the risk to the women’s unborn infants.2. Pregnancy: Trainees should become knowledgeable about the following: a. Gastrointestinal and liver changes and disorders in normal pregnancy b. Effect of preexisting gastrointestinal and liver disorders on pregnancy c. The initial clinical presentation during pregnancy of a gastrointestinal or liver disorder d. Gastrointestinal and liver disorders that are unique to pregnancy, including acute fatty liver of pregnancy and HELLP syndrome e. The impact of gastrointestinal and liver disorders on a woman’s ability to carry a healthy baby to term as well as the impact of her pregnancy on her gastrointestinal liver disorder f. The risk of maternal-fetal transmission of infectious agents, such as hepatitis B and hepatitis C, and the appropriate treatment of both the mother and the newborn infant g. The different pharmacokinetics and interaction of medications during pregnancy and breast feeding h. The potential harm to the fetus of medications, sedation, endoscopic procedures, and diagnostic tests, including radiographic tests, and the appropriate use of these during pregnancy i. Good nutrition, including increased vitamin and mineral requirements during pregnancy 74
    • 3. Postpartum issues: Trainees should understand that there are gastrointestinal disorders that are caused or affected by delivery and that manifest themselves immediately in the postpartum period or years afterward that the trainees should be able to recognize (i.e. rectal prolapse, urinary and/or fecal incontinence, hemorrhoids).Training ProcessTrainees knowledge should be obtained through a variety of experiences, includingdidactic lectures (which can include CD-ROM and Internet-based programs), caseconferences, self-directed learning, selected readings and clinical experiences. 75
    • APPENDIXContentsASGE first year Endoscopy CourseBoard Review CourseWalter Reed Gastroenterology CourseGME fellow seminar scheduleOrientation agendaNeedEvaluation formsOrientation manualDiscussion with prior fellowsLiver curriculum Meeting with Fairfax Fellows application for Fairfax rotationFellow Rotation scheduleFaculty lecture scheduleClinic scheduleCall scheduleCheck document forGI resident vs. fellow (consistency in citing throughout document) 76
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    • FELLOW CLINIC SCHEDULE CLINIC SCHEDULEMonday Tuesday Wednesday Thursday Friday Inflammatory Bowel Liver Disease Disease Borum BorumGeneral GI General GI Inflammatory Bowel Biliary Disease / General GI / BiliaryEhrlich Borum Disease Motility Disease Ginsberg Nsien Bashir 78
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