Gastroenterology (Director: Joel Bruggen, M.D.)Overview:During the second or third year of residency, each resident spends one month on the GISelective Rotation. The rotation is divided into two half-month blocks.On the inpatient block, the resident is assigned to the GI Consultation Service, whichprovides gastroenterology and hepatology consultations for hospitalized patients on allservices at the North Carolina Baptist Hospital. The resident acts in the same capacity as aGI Fellow, being the first member of the GI Consultation Service to perform a history andphysical examination on the patient. The resident will present their findings, evaluation, andplans for management to the GI Consult Attending. The maximum number ofconsultations performed by the resident in a day is three. The resident will follow eachpatient for which they provide consultation throughout their hospital stay.On the outpatient block, the resident is assigned to the GI Faculty Clinic, which providesoutpatient consultation and follow-up for patients with gastroenterology and liver diseases.The resident acts in the same capacity as a GI Fellow, performing initial history and physicalexaminations on patients attending the clinic. The resident will present their findings,evaluation, and plans for management to the GI Attending in clinic. The resident will alsohave the opportunity to evaluate patients with chronic GI and liver conditions beingfollowed in the GI Faculty Clinic.Principle Teaching/Learning Activities:• Gastroenterology Consultation Service (GCS) – the resident will examine and provide recommendations for the evaluation and management of inpatients for whom consultation has been requested regarding problems related to gastroenterology and hepatology, under the direct supervision of the GI Consult Attending.• GI Inpatient Endoscopy (GIE) – the resident will observe all endoscopic procedures performed on the patients they are following on the Gastroenterology Consultation Service, including EGD, colonoscopy, ERCP, EUS, and associated therapeutic interventions.• Digestive Health Center (DHC) – the resident will examine and provide recommendations for the evaluation and management of outpatients for whom consultation has been requested regarding problems related to gastroenterology and hepatology, under the direct supervision of the GI Attending in clinic. The resident will also evaluate patients with chronic GI and liver conditions being followed in the GI Faculty Clinic.• GI Attending Rounds (GAR) – held daily Monday - Friday, during these Attending Rounds the residents and fellows will present inpatients at the bedside, followed by a detailed discussion of the pertinent GI and Hepatology issues, lead by the GI Consult Attending.• GI Teaching Rounds (GTR) – over the one-month rotation, eight one-hour teaching sessions will be held with the residents and students on the GI Selective Rotation. These teaching sessions will focus on GI and liver diseases that are less common and with
which the residents will have less exposure to in their inpatient and outpatient experiences. These interactive teaching sessions follow a board-review format.• GI Grand Rounds (GGR) – A case-based conference which focuses on the evaluation and management of patients with disorders related to gastroenterology and hepatology, with an emphasis on the evidence which is available to guide our practice.• GI Surgical Conference (GSC) – A case-based conference which focuses on the surgical and medical management of patients with disorders related to gastroenterology and hepatology. This is a joint conference with the General Surgery Residency Program, and these cases are presented by surgical residents and faculty.• GI Pathology Conference (GPC) – A case-based conference which reviews interesting biopsies of inpatients and outpatients with disorders related to gastroenterology and hepatology. This conference is lead by our pathologist who specializes in GI and liver.• GI Core Curriculum Conference (GCC) – An interactive conference which reviews the breadth of gastroenterology and hepatology in a board-review format.• GI Journal Club (GJC) – the purpose of this conference is to review the current medical literature as it applies to gastroenterology and hepatology, and to learn the process of critical appraisal. The articles will be selected with the following attributes in mind: new information of significant clinical or basic research relevance, pertinence to the care of our patients, and controversial topics with conclusions that need to be affirmed or discredited. The types of studies presented should include those pertaining to etiology, diagnosis, treatment, harm, prognosis and cost analysis. This conference will focus on original clinical or basic research, rather than review articles.• GI Basic Science and Physiology Conference (GBS) – this conference focuses on our understanding of the basic science knowledge and physiology which underlies our current practice of gastroenterology and hepatology. It will be a goal of this conference to demonstrate the clinical implications of the information being discussed.• GI Research Conference (GRC) – this conference focuses on the research projects being planned or performed by the GI faculty and fellows, with an emphasis on research design and methods.Principle Educational Goals by Relevant CompetencyIn the tables below, the principle educational goals for the Gastroenterology SelectiveRotation are listed for each of the six ACGME competencies. The second column of thetable indicates the most relevant principle teaching/learning activity for each goal, using thelegend below.* Legend for Learning Activities (See above for descriptions)GSC – Gastroenterology Consultation Service GSC – GI Surgical ConferenceGIE – GI Inpatient Endoscopy GPC – GI Pathology ConferenceDHC – Digestive Health Center GCC – GI Core Curriculum ConferenceGAR – GI Attending Rounds GJC – GI Journal ClubGTR – GI Teaching Rounds GBS – GI Basic Science and Physiology ConferenceGGR – GI Grand Rounds GRC – GI Research Conference
1) Patient CarePrinciple Educational Goals Learning Activities*Effectively obtain an accurate history in patients with GCS, DHC, GARsymptoms of gastrointestinal and liver diseaseEffectively perform a complete physical examination in GCS, DHC, GARpatients with gastrointestinal and liver disease, with anemphasis on the abdominal exam and on systemic stigmata ofchronic liver diseaseAppropriately select and interpret laboratory, imaging, and GCS, DHC, GAR, GTR,pathologic studies for the evaluation of GI and liver disorders GGR, GSC, GPC, GCCLearn the indications and contraindications for endoscopic GIE, GCS, DHC, GAR,procedures, including EGD, colonoscopy, ERCP, EUS, and GTR, GGR, GSC, GCCtheir associated therapeutic interventionsAppropriately select medical and surgical management GCS, DHC, GAR, GTR,strategies for patients with gastrointestinal and liver diseases. GGR, GSC, GCC, GJC2) Medical Knowledge**Please see Appendix A for specific organ-based and symptom-based learning objectives**Principle Educational Goals Learning Activities*Expand clinically applicable knowledge of the basic physiology GCS, DHC, GAR, GTR,of the luminal gastrointestinal tract, pancreaticobiliary system GBSand the liverExpand the ability to construct a clinically relevant differential GCS, DHC, GAR, GTR,diagnosis for patients presenting with GI and liver symptoms GGR, GCCGain a basic understanding of the diagnostic modalities GCS, DHC, GIE, GAR,employed in the evaluation of GI and liver disorders GTR, GGR, GSC, GCCGain a basic understanding of the pharmacologic agents used GCS, DHC, GAR, GTR,in the treatment of GI and liver disorders GGR, GCCGain an understanding of the evidence which guides the GCS, DHC, GAR, GTR,evaluation and management of patients with gastrointestinal GGR, GSC, GCC, GJCand liver disordersGain a working knowledge of current guidelines proposed for GCS, DHC, GAR, GTR,the evaluation, management, and prevention of GI and liver GGR, GCCdisorders3) Practice-Based Learning and ImprovementPrinciple Educational Goals Learning Activities*Identify and acknowledge gaps in personal knowledge and GCS, DHC, GAR, GTEskills in the care of patients with GI and liver diseaseUse the principles of evidence-based medicine to formulate GJC, GCS, DHC, GAR,clinical questions which arise in the care of patients with GI GTE, GGRand liver disease, search the medical literature, critically
appraise such literature, and apply the information to specificpatientsUse evidence-based texts to guide the diagnosis and treatment GCS, DHC, GARof GI and liver disordersDevelop real-time strategies for filling knowledge gaps that GCS, DHCwill benefit patients with GI and liver disorders4) Interpersonal Skills and CommunicationPrinciple Educational Goals Learning Activities*Communicate effectively with patients and families GCS, DHCCommunicate effectively with physician colleagues and GCS, DHCmembers of other health care professions to assure timely,comprehensive patient carePresent patient information concisely and clearly, verbally and GCS, DHC, GARin writingGain skills in effective consultation, communicating in a GCS, DHCsupportive, helpful fashion with members of the primary teamGain an appreciation for the importance of a clearly defined GCS, DHCquestion from the requesting team in effective consultation.Gain an enhanced understanding of the importance of true GIE, GCS, DHCinformed consent when considering invasive procedures5) ProfessionalismPrinciple Educational Goals Learning Activities*Behave professionally toward towards patients, families, Allcolleagues, and all members of the health care teamConsider patient autonomy, beneficence, and social justice as GCS, DHCthe guiding principles of dealing with ethical challenges6) Systems-Based PracticePrinciple Educational Goals Learning Activities*Gain an enhanced understanding of the integral role of a GCS, DHCconsultant in the care of patients with GI and liver disordersCollaborate with other members of the health care team to GCS, DHCassure comprehensive patient careLearn to appropriately utilize diagnostic and therapeutic GCS, DHC, GIE, GAR,resources available within our institution in the care of GTR, GGR, GSC, GPC,patients with GI and liver disorders, especially endoscopic, GCCradiologic, and surgical to assure high quality patient care andoptimumpatient safetyGain an appreciation for the importance of effective GCS, DHC
collaboration with regional liver transplant centers in the careof patients with fulminant hepatic failure and end-stage liverdiseaseUse evidence-based, cost-conscious strategies in the care of GCS, DHC, GAR, GTR,patients with GI and liver diseases GGR, GSC, GCC, GJCRecommended Resources1. We recommend that each resident read through the Gastroenterology and Hepatology syllabus of MKSAP 13 during the month-long rotation.2. We recommend that UpToDate be used as an evidence-based resource for practice- based learning to answer questions which come up during patient-care activities.Evaluation MethodsEvaluations are based on personal observation by the GI faculty of the resident’sperformance in both the inpatient and outpatient clinical settings. Medical knowledge is alsoassessed based on the resident’s performance in the board review format of the GI TeachingRounds, and based on their score on the GI Selective Final Exam. These factors serve asthe basis for completing the standard Department of Medicine resident evaluation form. Thecompleted evaluation is then sent to the medicine program director for review.APPENDIX ASpecific Learning Objectives1. Esophageal disorders: a. Typical and atypical presentations of gastroesophageal reflux disease. b. Evaluation and management of the patient with gastroesophageal reflux disease: 1. appropriate use of radiology, endosopy, and ambulatory pH monitoring. 2. appropriate use of medical and surgical treatment options. 3. appropriate screening for Barretts esophagus in patients with chronic GERD symptoms; appropriate surveillance of patients with Barretts esophagus. c. Differential diagnosis of dysphagia. d. Cost-effective approach to patients with dysphagia; appropriate use of radiology, endoscopy, and manometry.2. Nausea and Vomiting a. Differential diagnosis of nausea and vomiting. b. Effective use of the history, exam, lab, endoscopy, and imaging studies in the evaluation and management of nausea and vomiting.3. Peptic Ulcer Disease: a. Major etiologies of PUD - Helicobacter pylori and NSAIDs. b. Cost effective approach to patients with dyspepsia.
c. Indications for endoscopic evaluation vs. noninvasive evaluation and empiric treatment. d. Indications for and diagnostic utility of radiographic evaluation of PUD. e. Complications of PUD. f. Indications for surgical treatment of PUD g. Recognition and management of clinical syndromes resulting from ulcer surgery.4. GI Bleeding: a. Evaluation and management of acute GI bleeding. b. Differentiation between upper and lower GI tract bleeding. c. Endoscopic evaluation and therapy of GI bleeding.5. Abdominal Pain: a. Differential diagnosis of acute and chronic abdominal pain. b. Evaluation and treatment of the patient with acute or chronic abdominal pain including peptic ulcer disease, cholecystitis, pancreatitis, irritable bowel syndrome, appendicitis, diverticulitis, colitis, bowel obstruction, and non- gastrointestinal disease that can present with abdominal pain. c. Appropriate use of the history, exam, lab, and imaging studies in the evaluation of patients with abdominal pain. d. Indications for inpatient vs. outpatient evaluation and management of patients with abdominal pain. e. Medical vs. surgical treatment of patients with abdominal pain. f. Diagnosis and management of the irritable bowel syndrome.6. Inflammatory Bowel Disease: a. Symptoms and signs of IBD. b. Extraintestinal manifestations of IBD. c. Differentiation between ulcerative colitis and Crohns disease and implications for management. d. Appropriate treatment of acute flares of IBD and maintenance therapy. e. Complications of ulcerative colitis and Crohns disease, and their management.7. Diarrhea: a. Definition of diarrhea. b. Differential diagnosis of acute and chronic diarrhea. c. Appropriate use of the history, exam, lab, endoscopy, and imaging in the evaluation of patients with acute and chronic diarrhea. d. Treatment of patients with acute and chronic diarrhea. e. Recognition and evaluation of the malabsorption syndromes.8. Constipation: a. Definition of constipation. b. Differential diagnosis of acute and chronic constipation. c. Appropriate use of the history, exam, lab, endoscopy, and imaging in the evaluation of patients with constipation. d. Treatment of patients with constipation.
9. Jaundice and Hepatitis: a. Symptoms and signs of acute liver disease. b. Differentiation between hepatocellular injury and cholestatic or obstructive processes. c. Differential diagnosis of acute hepatitis in inpatients vs. outpatients. d. Differentiation between obstructive and cholestatic jaundice. e. Evaluation and management of abnormal liver function tests in the hospital or in the clinic; appropriate use of lab, imaging, ERCP and liver biopsy. f. Indications for hospitalization in patients with acute liver disease. g. Indications and contraindications for liver transplant referral in patients with acute liver disease.10. Cirrhosis: a. Clinical recognition, evaluation and management of the complications of end stage liver disease and portal hypertension: 1. gastrointestinal bleeding from esophageal varices, gastric varices, and portal hypertensive gastropathy. 2. ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome. 3. hepatic encephalopathy b. Appropriate use of TIPS in chronic liver disease, and its complications. c. Indications and contraindications for liver transplantation. d. Appropriate timing for referral for liver transplant evaluation.11. Gallbladder disease: a. Recognition of the clinical syndromes associated with the gallbladder and bile ducts. b. Clinical diagnosis and management of acute cholecystitis, biliary colic, acute cholangitis, and post-cholecystectomy diarrhea. c. Use of history, exam, lab and imaging in evaluation of diseases of the gallbladder and bile ducts.12. Pancreatitis: a. Symptoms and signs of acute and chronic pancreatitis b. Etiologies of acute and chronic pancreatitis. c. Complications of acute and chronic pancreatitis. d. Evaluation and management of patients with acute and chronic pancreatitis.13. GI cancer: a. Symptoms and signs of primary gastrointestinal malignancies. b. Appropriate evaluation of patients with suspected gastrointestinal malignancies. c. Appropriate screening strategies for colorectal cancer in average and high risk patients.14. Nutrition: a. Nutritional requirements in health and disease.
b. Evaluation of nutritional status.c. Methods of nutritional support and their appropriate use.