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www.dept-med.pitt.edu/gi/fellowship/files/Curriculum 10-07.doc

  1. 1. GI FELLOW CURRICULUM: Rotation Goals and Responsibilities
  2. 2. GI Hospital Service Curriculum for Year I, II & III FellowsEducational Purpose:The GI Hospital Service introduces the fellow to inpatient hospital management of patients with gastrointestinaldiseases. During this period, the fellow will have the opportunity to assess a wide variety of acute and chronicgastrointestinal conditions. The fellow will participate in increasing levels of management/ treatment involvement withpatient needs and procedures, depending on the fellow’s level of experience. The fellow will be expected to formulatethe differential diagnosis, institute diagnostic studies and recommend therapy. The amount of learning obtained fromthis rotation is directly proportional to the amount of time spent in the evaluation of the patients.Objectives:Fellows will learn all aspects of inpatient gastrointestinal care and will display all general competencies during thisexperience. Minimum levels of achievement in each competency are expected during each of the three years offellowship training. Those meeting competency will receive a score of 5 in the program’s evaluation system. Fellowsperforming at a level better than expected for that competency receive a score of 6 or 7 in the evaluation system,those at a level better than most fellows at that PGY receive an 8, and those performing at a level deemed to be “oneof the best fellows ever observed” will receive a score of 9. Fellows receiving a score of 4 or below are deemeddeficient in that competency; this will be brought to the attention of the program director immediately, and, ifnecessary, remediation will be implemented.The following are the goals and objectives for each competency at each level of training for the GI Hospital Service: Year I Fellow:Goal: A Year I fellow should be able to assess new patient problems, formulate and execute a treatment plan withguidance and teach basic gastroenterology skills to medical students and other trainees. Year I fellows should begin todevelop basic procedural competencies in diagnostic upper endoscopy and colonoscopy.Patient Care Objectives: Perform an accurate physical examination and present information concisely with an initial assessment plan. Follow the patient’s disease course during the patient’s hospital stay. With attending consultation, formulate and execute an impression and a list of recommendations for the primary service. When indicated, consent patients for procedures and order appropriate diagnostic tests (e.g., endoscopy, radiologic tests, etc.) in conjunction with the primary/referring service. Perform with supervision the following basic gastroenterology procedures (see practicum): o Colonoscopy  By completion of Year I a fellow should be able to perform a diagnostic colonoscopy to the cecum with limited assistance. o EsophagoGastroDuodenoscopy (EGD or Upper Endoscopy)  By completion of Year I a fellow should be able to perform a diagnostic endoscopy to the second portion of the duodenum. Develop expertise in the diagnosis and management of acute and chronic inpatient gastrointestinal diseases including: o Upper & lower GI bleeding o Peptic ulcer disease o GI infections o Ischemic colitis. Learn to provide inpatient care that is safe and compassionate and to develop the ability to thoroughly and clearly educate the inpatient in the relevant areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.Medical Knowledge Objectives:
  3. 3.  Attend core conferences and teaching rounds to learn the pathophysiology, epidemiology, disease management and procedure and medicine management skills for common and uncommon inpatient gastrointestinal diseases including: o Upper & lower GI bleeding o Peptic ulcer disease o GI infections o Ischemic colitis. Accumulate and begin to solve the issues that he/she encounters from other trainees, attendings and related medical professionals. Teach medical students the basics of gastroenterology and hepatology care. Achieve an average percentile score of at least 61.18on the “General” section of the in-service Gastroenterology Training Examination (GTE) exam. This score is the national average on this exam for Year I fellows. By end of Year I, pass the Internal Medicine Board Examination.Practice-Based Learning Objectives: Become familiar with the concepts of quality improvement. Participate in conferences such as M&M, geared to the programmatic review of adverse events. Begin to review, analyze and utilize scientific evidence from the gastrointestinal literature for the management of GI patients. Learn the best practice patterns to facilitate gastroenterology care through clinic operating procedures and patient interactions.Interpersonal Communication Skill Objectives: Interview patients and family members accurately, patiently and compassionately and present information in an understandable and compassionate manner. Convey bad news compassionately and honestly. Learn to communicate effectively with staff, peers, attending gastroenterologists, referring physicians and other consultants.Professionalism Objectives: Learn to understand and demonstrate professional behavior in daily activities. Participate in professionalism-based learning activities through conferences. Learn to interact collegially with his/her peer group and other healthcare professionals. Learn to practice ethical principles with relation to patient care and confidentiality. Learn to practice appropriate interactions with pharmaceutical representatives and be unbiased in prescribing habits. Learn to be sensitive to cultural, age, gender and disability issues. Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues. Participate in program planning, including annual Faculty Meeting attendance, Fellow Curriculum Committee participation and Program Director meetings when requested.Systems-Based Practice Objectives: Attend conferences concerning healthcare system patient management and components of systems of healthcare. Achieve basic understanding of healthcare systems related to gastroenterology care and overall system activities. Learn proper documentation and billing skills to practice cost-effective care. Develop and become familiar with the e-portfolio system for personal documentation management, communication with mentors and other collaborators and related fellowship program documentation. Utilize an appropriate range of healthcare professionals to care for patients, working closely with socials services to maximize patient care and understanding the role of hospice, referring appropriately when needed. Begin involvement to understand the standard operating procedures and quality improvement initiatives within the hospital. Attend national gastroenterology conferences (e.g., ACG and endoscopy training courses). Year II Fellow:
  4. 4. Goal: A Year II fellow should learn to assess and care for a larger volume of patients and learn and teach basictextbook and evidence-based medicine to medical students and other trainees. Year II fellows should independentlyperform diagnostic upper endoscopy and colonoscopy and begin to perform therapeutic maneuvers.Patient Care Objectives: Complete a time-efficient history and physical examination. Critique the work and orders of Year I fellows. Direct the Year I fellows successfully with the appropriate level of intervention for each trainee’s skills. Complete competency-level performance of the following basic gastroenterology procedures (see practicum checklist): o Colonoscopy  By completion of Year II, master all Year I colonoscopic skill requirements. Additionally, perform endoscopic maneuvers, including snare polypectomy and begin to develop competency in control of GI bleeding: sclerotherapy and thermal coagulopathy of bleeding vessels. o Upper Endoscopy  By completion of Year II, master all Year I upper endoscopic skill requirements. Additionally, begin to develop competency in performing therapeutic maneuvers: banding and sclerosing of varices, and sclerotherapy and thermal coagulopathy of bleeding vessels. Develop clear expertise in the diagnosis and management of acute and chronic inpatient gastrointestinal diseases including: o Neuroendocrine diagnosis o Intestinal/colonic pseudobstruction o Secretory diarrheal states o Idiopathic abdominal pain o Upper & lower GI bleeding o Peptic ulcer disease o Inflammatory bowel disease o GI infections o Pancreatitis o Ischemic colitis Present cases succinctly in a direct manner. Know the GI Hospital Service’s patients at a management level. Handle consult calls respectfully and appropriately. Teach good symptom management skills to medical students and other trainees. Provide inpatient care that is safe and compassionate and develop the ability to thoroughly and clearly educate the inpatient in the relevant areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.Medical Knowledge Objectives: Begin to take a leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease management and procedures and medicine management skills for common and uncommon inpatient gastrointestinal diseases including: o Neuroendocrine diagnosis o Intestinal/colonic pseudobstruction o Secretory diarrheal states o Idiopathic abdominal pain o Upper & lower GI bleeding o Peptic ulcer disease o Inflammatory bowel disease o GI infections o Pancreatitis o Ischemic colitis
  5. 5.  Organize the team’s performance at teaching rounds. Read textbook and pertinent literature materials concerning problems encountered. Teach medical students and other trainees about GI disease states and patient management. Achieve an average percentile score of at least 62.98 on the “General” section of the in-service Gastroenterology Training Examination (GTE) exam. This score is the national average on this exam for Year II fellows.Practice-Based Learning Objectives: Participate in project groups, committees and hospital groups when requested. Participate in programmatic reviews and conferences studying adverse events. Give usable feedback to medical students and other trainees based on observation of their performance and assess improvement. Participate in problem-based quality improvement projects. Review, analyze and utilize scientific evidence from the gastrointestinal literature for the management of GI patients. Know the best practice patterns to facilitate gastroenterology care through clinic operating procedures and patient interactions.Interpersonal Communication Skill Objectives: Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner. Convey bad news compassionately and honestly. Plan patient and family conferences. Counsel patients about transitioning to palliative care, when needed. Address or refer patients related to spiritual or existential issues. Communicate effectively with staff, peers, attending gastroenterologists, referring physicians and other consultants. Present cases succinctly, in a problem-based, direct manner. Learn to become a teacher of gastroenterology to junior trainees, medical students and other healthcare professionals.Professionalism Objectives: Begin to mentor medical students, other trainees and Year I fellows in professional conduct. Understand and demonstrate professional behavior in daily activities. Participate in professionalism-based learning activities through conferences. Interact collegially with his/her peer group and other healthcare professionals, including acting responsibly in the larger context of pursuing programmatic successes. Practice ethical principles with relation to patient care and confidentiality. Practice interactions with pharmaceutical representatives and be unbiased in prescribing habits. Practice sensitivity to cultural, age, gender and disability issues. Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues. Participate in program planning, including annual Faculty Meeting attendance, Fellow Curriculum Committee participation and Program Director meetings, when requested.Systems-Based Practice Objectives: Attend conferences concerning healthcare system patient management and components of systems of healthcare. Understand and be able to work effectively related to hospital functions within UPMC and UPP. Understand and practice proper documentation and billing skills to practice cost-effective care. Use the program’s e-portfolio system for personal documentation management, communication with mentors and other collaborators and related fellowship program documentation. Assist other trainees in the utilization of appropriate healthcare resources for the best care of the GI Hospital Service’s patients. Model appropriate interactions in multidisciplinary planning, including standard operating procedures and quality improvement initiatives. Attend national gastroenterology or hepatology conferences (e.g., DDW or AASLD).
  6. 6. Year III Fellows:Goal: The senior-level, Year III fellow should demonstrate rapid assessment and planning skills and near-attendinglevel care planning and management, while teaching medical students and other trainees at near to or exceedingattending level teaching. Year III fellows should be able to perform diagnostic and therapeutic upper endoscopy andcolonoscopy procedures independently.Patient Care Objectives: Master the Year II fellow objectives. Demonstrate efficient organization of the GI Hospital Service and a working knowledge of all patients. Demonstrate near-attending level capacity for program assessment and care planning. Attain trainer level proficiency in the following gastroenterology procedures pertinent to his/her career choices: o Colonoscopy  By completion of Year III, master all Year II colonoscopic skill requirements. Additionally, be able to independently intubate the terminal ileum and begin to develop independent mastery of more advanced maneuvers, e.g., removal of large or complex polyps by saline assisted polypectomy or piecemeal resection and control of bleeding using clips or argon plasma laser coagulation. o Upper Endoscopy  By completion of Year III, master all Year II endoscopic skill requirements. Additionally, be able to pass a side viewing scope to identify the papilla or lesions difficult to observe with forward viewing scope and perform advanced maneuvers, such as placing clips on bleeding vessels or argon plasma laser coagulopathy. Secure expertise in the diagnosis and management of acute and chronic inpatient gastrointestinal diseases including: o Neuroendocrine diagnosis o Intestinal/colonic pseudobstruction o Secretory diarrheal states o Idiopathic abdominal pain o Upper & lower GI bleeding o Peptic ulcer disease o Inflammatory bowel disease o GI infections o Pancreatitis o Ischemic colitis Provide inpatient care that is safe and compassionate with the leadership ability to thoroughly and clearly educate the inpatient and all other trainees regarding relevant areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.Medical Knowledge Objectives: Access and critique the medical literature regarding gastroenterology and hepatology problems encountered. Assume the trainee leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease management, procedures and medicine management skills for common and uncommon inpatient gastrointestinal diseases including o Neuroendocrine diagnosis o Intestinal/colonic pseudobstruction o Secretory diarrheal states o Idiopathic abdominal pain o Upper & lower GI bleeding o Peptic ulcer disease o Inflammatory bowel disease o GI infections o Pancreatitis o Ischemic colitis
  7. 7.  Teach medical students, other trainees and Year I & II fellows at near-attending level. Prepare for the ABIM certifying exam throughout the year. Organize team activities in a smooth and authoritative fashion. Assist Year II fellows’ development directly at teaching conferences and indirectly at work sites. Achieve an average percentile score of at least 64.07 on the “General” section of the in-service Gastroenterology Training Examination (GTE) exam. This score is the national average on this exam for Year III fellows.Practice-Based Learning Objectives: Demonstrate mastery of Year II fellow skills and encourage participation of colleagues. Review, analyze and utilize scientific evidence from the gastrointestinal literature for the management of GI patients, taking a leadership role in guiding Year I & II fellows and sharing relevant literature reviews with them. Know and be able to succinctly communicate the best practice patterns to facilitate gastroenterology care through clinic operating procedures and patient interactions.Interpersonal Communication Skill Objectives: Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner. Convey bad news compassionately and honestly. Supervise Year I & II fellows’ work related to planning patient/family conferences and patient communications/counseling. Communicate effectively as a consultant with staff, peers, attending gastroenterologists, referring physicians and other consultants and lead other trainees related to appropriate fellow-to-medical-professional communications. Present cases succinctly, in a problem-based, direct manner. Assume the role of a teacher of gastroenterology to junior trainees, medical students and other healthcare professionals.Professionalism Objectives: Demonstrate proficiency in Year II objectives. Mentor medical students, other trainees and Year I fellows in professional conduct. Assist in formal teaching exercises as requested. Assert leadership in program planning, including fellow participation in the annual Faculty/Fellow Meeting, Fellow Curriculum Committee and Conference Planning Committees.Systems-Based Practice Objectives: Attend conferences concerning healthcare system patient management and components of systems of healthcare. Assist and mentor other trainees in utilization of appropriate UPMC/UPP healthcare resources for the best care of the GI Hospital Service’s patients, including proper documentation and billing skills. Use and train others on the program’s e-portfolio system for personal documentation management, communication with mentors and other collaborators and related fellowship program documentation. Model appropriate interactions in multidisciplinary planning, including improvements related to standard operating procedures and quality improvement initiatives. Participate in hospital and national medical association committees and multidisciplinary planning groups when requested. Attend national conferences directed at career goals. Demonstrate near-attending level utilization of overall systems of care.Teaching Methods:Gastroenterology fellows participate in the GI Hospital Service during all three fellowship years. Two fellows areassigned to the GI Hospital Service during all rotations. Teaching of medical students, residents and other trainees aswell as appropriate interactions with other healthcare providers are important aspects of this rotation. Participating inall required conferences is mandatory, and rounding is an integral part of this experience. As fellows gain experiencethroughout their training, skills of organization and efficiency as well as team leadership become increasinglyimportant.The GI Hospital Service experience will prepare the fellow to evaluate and manage acute and chronic gastrointestinalillnesses that will be encountered in the fellow’s future practice. This rotation will expose the fellow to a wide variety of
  8. 8. acute abdominal inflammatory processes, major gastrointestinal hemorrhages, oncological emergencies and a widevariety of gastrointestinal problems.Fellows assigned to this service will evaluate all new consults at UPMC Presbyterian and Montefiore Hospitals and willbe assigned to a continuity clinic one-half day per week. They will present new consults to the attending by thefollowing day for routine consults and as soon as possible for emergencies. Fellows will evaluate each patient and willmake initial recommendations regarding diagnostic tests and treatments. They will make arrangements for studiessuch as endoscopy, motility tests, biopsies, etc. They will review the appropriateness of the procedure with theattending before making final scheduling plans. The fellow will follow each patient under active consultation on aregular basis, will make further recommendations as indicated and will keep the attending informed of the patient’sstatus. Fellows must also communicate with the procedure fellow for all diagnostic studies.Disease Mix:Fellows see a complete mix of gastrointestinal diseases and conditions at the GI Hospital Service’s teaching hospitals.UPMC Presbyterian and UPMC Montefiore have a substantial primary care basis, which provides the entire spectrumof internal medicine diagnoses and gastrointestinal care.Diagnoses range from pancreatitis, inflammatory bowel disease, and functional GI motility and pain disorders toprimary and secondary gastrointestinal malignancies, and there is an appropriate concentration of commongastrointestinal diseases such as peptic ulcer disease, gastroesophageal reflux disease and gastrointestinalinfections. In particular, UPMC Presbyterian is a tri-state and international referral center, and there is outstandingdiversity of unusual diagnoses in the teaching services.Patient Characteristics:UPMC Presbyterian and UPMC Montefiore offer a diverse mixes of socioeconomic and gender status. Teachingfaculty provide an abundant supply of upper- and middle-class patients, and our contracts with medical assistance andpro bono care efforts ensure access to lower-income patients. Due to a primary care base simultaneous with thehospitals’ constantly active referrals (complete with helicopter and fixed-wing transport 24/7), patients are seen in bothacute status and in diagnostic dilemma status, with both common and uncommon disorders.Types of Clinical Encounters – Attending Supervision:Encounters are inpatient in nature during the GI Hospital Service. Fellows provide 24/7 consultative care under thesupervision of an attending within duty hour limits and with faculty back up for situations of overload. Daily attendingsupervision is available at both UPMC Presbyterian and UPMC Montefiore seven days per week, and in-housesupervision is available all night as well. The attending has ultimate responsibility for patients.Procedures:During the GI Hospital Service, emergency procedures (e.g. for gastrointestinal bleeding) are performed 24/7 withinduty hour limits by the fellow with the attending. Non-emergent procedures are performed during daytime hours in theGI lab by the fellow under the direct supervision of the attending. Procedure based evaluation is performed twice peryear by a supervising attending (see procedure practicum: direct observation).Evaluation:Fellows are evaluated during all GI Hospital Service rotations and are expected to participate in the evaluation of otherfellows as well. This occurs in the following forms: Detailed, automated evaluations using the myevaluations.com system are submitted for each rotation. These evaluations are reflective of the program’s curriculum requirements. Attendings evaluate fellows, and the fellows evaluate the attending as well. Evaluations include: o 360-degree (attending, nurse, nurse practitioner, staff/clerical, etc.); o Direct observation (Procedure Practicum); o Peer-reviewed; and o Patient. Evaluation summaries become part of the fellows’ and attendings’ promotional documents. Fellows self-evaluate through their e-portfolio participation/communication with mentors and colleagues and through document maintenance. The fellow also evaluates the Gastroenterology Fellowship Program annually through a confidential basis.
  9. 9.  Attendings evaluate the Gastroenterology Fellowship Program annually. A Curriculum Committee oversees major changes to the curriculum. Representative program personnel (i.e., program director, representative faculty and at least one fellow) must be organized to review program goals and objectives and the effectiveness with which they are achieved. This group must conduct a formal documented meeting at least annually for this purpose. In the evaluation process, the group must take into consideration written comments from the faculty, the most recent report of the GMEC of the sponsoring institution and the residents’ confidential written evaluations. If deficiencies are found, the group will prepare an explicit plan of action, which should be approved by the faculty and documented in the minutes of the meeting. The Program Director meets with all fellows individually twice per year. An in-service GTE exam is given to all fellows annually.Bibliography: Resource Documents o Up-To-Date o PubMed o Textbook of Gastroenterology – Yamada, et.al. o Gastrointestinal Diasese: Pathophysiology Diagnosis Management – Sleisenger & Fordtran. o Major Gastroenterology journals online and in the program’s fellow library including Gastroenterology, American Journal of Gastroenterolgy, Gut, and other major publications. o Required reading for IBD interests:  Xavier RJ, Podolsky DK. Unravelling the pathogenesis of inflammatory bowel disease. Nature 2007;448:427-434  Clark M, Colombel JF, Feagan BC, Fedorak RN, Hanauer SB, Kamm MA, Mayer L, Regueiro C, Rutgeerts P, Sandborn WJ, Sands BE, Schreiber S, Targan S, Travis S, Vermeire S. American gastroenterological association consensus development conference on the use of biologics in the treatment of inflammatory bowel disease, June 21-23, 2006. Gastroenterology. 2007 Jul;133(1):312-39. Curricular Design o ACGME Outcome Project documentation (from www.acgme.org). o Graduate Education in Internal Medicine: A Resource Guide to Curriculum Development o The report of the Federated Council for Internal Medicine Task Force on the Internal Medicine Residency Curriculum, 1997. Pertinent Teaching References: o Textbook of Gastroenterology – Yamada, et.al. o Gastrointestinal Diasese: Pathophysiology Diagnosis Management – Sleisenger & Fordtran. Competencies-at-a-Glance GI Hospital Service COMPETENCY LEARNING OPPORTUNITY EVALUATIONPatient Care  Work Rounds  360-global evaluations  Teaching Rounds  GTE in-service exam  Conferences  Direct ObservationMedical Knowledge  Work Rounds  360-global evaluations  Teaching Rounds  GTE in-service exam  ConferencesPractice-Based Learning  Quarterly M&M Conference  360-global evaluations  Work Rounds  E-portfolio procedure documentation  Direct Observation
  10. 10. Interpersonal Skills  Work Rounds  360-global evaluationsProfessionalism  Work Rounds  360-global evaluations  Conferences  E-portfolio self- documentationSystems-Based Practice  Committee Participation  360-global evaluations  Grand Rounds (GI &  E-portfolio collaboration Medical) documentation  ConferencesThe GI Hospital Service is the core fellow rotation related to the teaching and evaluation of all six competencies. Day-to-day patient care, related teaching and the curriculum conferences during the rotation are the greatest elements thatteach the competencies, and the global evaluation (provided for each rotation) is the most important singlemeasurement device. In addition to didactic learning, medical center committee participation is encouraged to bolstersystem-wide knowledge and practice management understanding.Updated:December 2005June 2006February 2007
  11. 11. Hepatology Consultative Service Curriculum for Year I, II & III FellowsEducational Purpose:The Hepatology Consultative Service introduces the fellow to inpatient management of patients with liver diseases.During this period, the fellow will have the opportunity to assess a wide variety of acute and chronic hepatologyconditions. The fellow will participate in increasing levels of management/ treatment involvement with patient needsand procedures depending on the fellow’s level of experience. The fellow will be expected to formulate the differentialdiagnosis, institute diagnostic studies and recommend therapy. The amount of learning obtained from this rotation isdirectly proportional to the amount of time spent in the evaluation of the patients.Objectives:Fellows will learn all aspects of inpatient liver disease care and will display all general competencies during thisexperience. Minimum levels of achievement in each competency are expected during each of the three years offellowship training. Those meeting competency will receive a score of 5 in the program’s evaluation system. Fellowsperforming at a level better than expected for that competency receive a score of 6 or 7 in the evaluation system,those at a level better than most fellows at that PGY receive an 8, and those performing at a level deemed to be “oneof the best fellows ever observed” will receive a score of 9. Fellows receiving a score of 4 or below are deemeddeficient in that competency; this will be brought to the attention of the program director immediately, and, ifnecessary, remediation will be implemented.The following are the goals and objectives for each competency at each level of training for the HepatologyConsultative Service: Year I Fellow:Goal: A Year I fellow should be able to assess new patient problems, formulate and execute a treatment plan withguidance and teach basic hepatology and gastroenterology skills to medical students and other trainees. Year Ifellows should begin to develop basic procedural competencies in diagnostic upper endoscopy and colonoscopy.Patient Care Objectives: Perform an accurate physical examination and present information concisely with an initial assessment plan. Follow the patient’s disease course during the patient’s hospital stay. With attending consultation, formulate and execute an impression and a list of recommendations for the primary service. When indicated, consent patients for procedures and order appropriate diagnostic tests (e.g., endoscopy, radiologic tests, etc.) in conjunction with the primary/referring service. Perform with supervision the following basic procedures (see practicum): o Colonoscopy  By completion of Year I a fellow should be able to perform a diagnostic colonoscopy to the cecum with limited assistance. o EsophagoGastroDuodenoscopy (EGD or Upper Endoscopy)  By completion of Year I a fellow should be able to perform a diagnostic endoscopy to the second portion of the duodenum. o Liver Biopsies:  Fellows must have formal instruction and clinical expertise and must demonstrate competence in the performance of percutaneous liver biopsies. o Abdominal Paracentesis:  Fellows must have formal instruction and clinical expertise, and must demonstrate competence in the performance of diagnostic and therapeutic paracentesis Fellows must have formal instruction and clinical experience and demonstrate competence in: o The prevention of acute and chronic endstage liver disease o The evaluation and management of inpatients with acute and chronic endstage liver disease o The management of fulminant liver failure o The psychosocial evaluation of all candidates, in particular those with a history of substance abuse o Drug hepatotoxicity and the interaction of drugs with the liver
  12. 12. o Diagnosis and mangement of autoimmune hepatitis o Diagnosis and management of cholestatic liver diseases – primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) Learn to provide inpatient care that is safe and compassionate and to develop the ability to thoroughly and clearly educate the inpatient in the relevant areas of disease prevention, detection, progression and therapy to promote liver health.Medical Knowledge Objectives: Attend core conferences and teaching rounds --- especially the Monday and Wednesday Hepatology Conferences --- to learn the pathophysiology, epidemiology, disease management and procedure and medicine management skills for common and uncommon inpatient liver diseases including: o The prevention of acute and chronic endstage liver disease o The evaluation and management of inpatients with acute and chronic endstage liver disease o The management of fulminant liver failure o The psychosocial evaluation of all candidates, in particular those with a history of substance abuse o Drug hepatotoxicity and the interaction of drugs with the liver o Diagnosis and mangement of autoimmune hepatitis o Diagnosis and management of cholestatic liver diseases – primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) Accumulate and begin to solve the issues that he/she encounters from other trainees, attendings and related medical professionals. Teach medical students the basics of gastroenterology and hepatology care. Achieve an average percentile score of at least 59.8 on the liver section of the in-service Gastroenterology Training Examination (GTE) exam. This score is the national average for the liver section for Year I fellows. By end of Year I, pass the Internal Medicine Board Examination.Practice-Based Learning Objectives: Become familiar with the concepts of quality improvement. Participate in conferences such as M&M, geared to the programmatic review of adverse events. Begin to review, analyze and utilize scientific evidence from the hepatology literature for the management of liver disease patients. Learn the best practice patterns to facilitate liver disease care through clinic operating procedures and patient interactions.Interpersonal Communication Skill Objectives: Interview patients and family members accurately, patiently and compassionately and present information in an understandable and compassionate manner. Convey bad news compassionately and honestly. Learn to communicate effectively with staff, peers, attending gastroenterologists/hepatologists, referring physicians and other consultants.Professionalism Objectives: Learn to understand and demonstrate professional behavior in daily activities. Participate in professionalism-based learning activities through conferences. Learn to interact collegially with his/her peer group and other healthcare professionals. Learn to practice ethical principles with relation to patient care and confidentiality. Learn to practice appropriate interactions with pharmaceutical representatives and be unbiased in prescribing habits. Learn to be sensitive to cultural, age, gender and disability issues. Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues. Participate in program planning.Systems-Based Practice Objectives: Attend conferences concerning healthcare system patient management and components of systems of healthcare.
  13. 13.  Achieve basic understanding of healthcare systems related to hepatology care and overall system activities. Learn proper documentation and billing skills to practice cost-effective care. Develop and become familiar with the e-portfolio system for personal documentation management, communication with mentors and other collaborators and related fellowship program documentation. Utilize an appropriate range of healthcare professionals to care for patients, working closely with social services to maximize patient care and understanding the role of hospice, referring appropriately when needed. Begin involvement to understand the standard operating procedures and quality improvement initiatives within the hospital. Attend national gastroenterology conferences (e.g., ACG and endoscopy training courses). Year II Fellow:Goal: A Year II fellow should learn to assess and care for a larger volume of patients and learn and teach basictextbook and evidence-based medicine to medical students and other trainees. Year II fellows should independentlyperform diagnostic upper endoscopy and colonoscopy and begin to perform therapeutic maneuvers.Patient Care Objectives: Complete a time-efficient history and physical examination. Critique the work and orders of Year I fellows. Direct the Year I fellows successfully with the appropriate level of intervention for each trainee’s skills. Complete competency-level performance of the following basic gastroenterology/hepatology procedures (see practicum checklist): o Colonoscopy  By completion of Year II, master all Year I colonoscopic skill requirements. Additionally, perform endoscopic maneuvers, including snare polypectomy and begin to develop competency in control of GI bleeding: sclerotherapy and thermal coagulopathy of bleeding vessels. o Upper Endoscopy  By completion of Year II, master all Year I upper endoscopic skill requirements. Additionally, begin to develop competency in performing therapeutic maneuvers: banding and sclerosing of varices, and sclerotherapy and thermal coagulopathy of bleeding vessels. o Liver Biopsies:  Fellows must have formal instruction and clinical expertise, and must demonstrate competence in the performance of percutaneous liver biopsies. o Abdominal Paracentesis:  Fellows must have formal instruction and clinical expertise, and must demonstrate competence in the performance of diagnostic and therapeutic paracentesis.Fellows must have formal instruction and clinical experience and demonstrate competence in: o The comprehensive management of patients who are high on the transplant list in the intensive care setting with complications of end-stage liver disease including: refractory ascites, hepatic hydrothorax; hepatorenal syndrome, hepatopulmonary and portal pulmonary syndromes, and refractory portal hypertensive bleeding o The management of chronic viral hepatitis in the pre-transplantation, peri-transplantation, and post- transplantation settings o Nutritional support of patients with chronic liver disease o The use of interventional radiology in the diagnosis and management of portal hypertension, as well as biliary and vascular complications Present cases succinctly in a direct manner. Know the Hepatology Consultative Service’s patients at a management level. Handle consult calls respectfully and appropriately. Teach good symptom management skills to medical students and other trainees. Provide inpatient care that is safe and compassionate and develop the ability to thoroughly and clearly educate the inpatient in the relevant areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.
  14. 14. Medical Knowledge Objectives: Begin to take a leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease management and procedures and medicine management skills for common and uncommon inpatient liver diseases including: o The comprehensive management of patients who are high on the transplant list in the intensive care setting with complications of end-stage liver disease including: refractory ascites, hepatic hydrothorax; hepatorenal syndrome, hepatopulmonary and portal pulmonary syndromes, and refractory portal hypertensive bleeding o The management of chronic viral hepatitis in the pre-transplantation, peri-transplantation, and post- transplantation settings o Nutritional support of patients with chronic liver disease o The use of interventional radiology in the diagnosis and management of portal hypertension, as well as biliary and vascular complications Organize the team’s performance at teaching rounds. Read textbook and pertinent literature materials concerning problems encountered. Teach medical students and other trainees about liver disease states and patient management. Achieve an average percentile score of at least 65.7 on the liver section of the in-service Gastroenterology Training Examination (GTE) exam. This score is the national exam average for liver diseases for Year II fellows.Practice-Based Learning Objectives: Participate in project groups, committees and hospital groups when requested. Participate in programmatic reviews and conferences studying adverse events. Give usable feedback to medical students and other trainees based on observation of their performance and assess improvement. Participate in problem-based quality improvement projects. Review, analyze and utilize scientific evidence from the hepatology literature for the management of liver disease patients. Know the best practice patterns to facilitate hepatology care through clinic operating procedures and patient interactions.Interpersonal Communication Skill Objectives: Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner. Convey bad news compassionately and honestly. Plan patient and family conferences. Counsel patients about transitioning to palliative care, when needed. Address or refer patients related to spiritual or existential issues. Communicate effectively with staff, peers, attending hepatologists/gastroenterologists, referring physicians and other consultants. Present cases succinctly, in a problem-based, direct manner. Learn to become a teacher of hepatology to junior trainees, medical students and other healthcare professionals.Professionalism Objectives: Begin to mentor medical students, other trainees and Year I fellows in professional conduct. Understand and demonstrate professional behavior in daily activities. Participate in professionalism-based learning activities through conferences. Interact collegially with his/her peer group and other healthcare professionals, including acting responsibly in the larger context of pursuing programmatic successes. Practice ethical principles with relation to patient care and confidentiality. Practice interactions with pharmaceutical representatives and be unbiased in prescribing habits. Practice sensitivity to cultural, age, gender and disability issues. Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues. Participate in program planning.Systems-Based Practice Objectives:
  15. 15.  Attend conferences concerning healthcare system patient management and components of systems of healthcare. Understand and be able to work effectively related to hospital functions within UPMC and UPP. Understand and practice proper documentation and billing skills to practice cost-effective care. Use the program’s e-portfolio system for personal documentation management, communication with mentors and other collaborators and related fellowship program documentation. Assist other trainees in the utilization of appropriate healthcare resources for the best care of the Hepatology Consultative Service’s patients. Model appropriate interactions in multidisciplinary planning, including standard operating procedures and quality improvement initiatives. Attend national gastroenterology or hepatology conferences (e.g., DDW or AASLD). Year III Fellows:Goal: The senior-level, Year III fellow should demonstrate rapid assessment and planning skills and near-attendinglevel care planning and management, while teaching medical students and other trainees at near to or exceedingattending level teaching. Year III fellows should be able to perform diagnostic and therapeutic upper endoscopy andcolonoscopy procedures independently.Patient Care Objectives: Master the Year II fellow objectives. Demonstrate efficient organization of the Hepatology Consultative Service and a working knowledge of all patients. Demonstrate near-attending level capacity for program assessment and care planning. Attain trainer level proficiency in the following procedures pertinent to his/her career choices: o Colonoscopy  By completion of Year III, master all Year II colonoscopic skill requirements. Additionally, be able to independently intubate the terminal ileum and begin to develop independent mastery of more advanced maneuvers, e.g., removal of large or complex polyps by saline assisted polypectomy or piecemeal resection and control of bleeding using clips or argon plasma laser coagulation. o Upper Endoscopy  By completion of Year III, master all Year II endoscopic skill requirements. Additionally, be able to pass a side viewing scope to identify the papilla or lesions difficult to observe with forward viewing scope and perform advanced maneuvers, such as placing clips on bleeding vessels or argon plasma laser coagulopathy. o Liver Biopsies  Fellows must have formal instruction and clinical expertise and must demonstrate competence in the performance of percutaneous liver biopsies. o Abdominal Paracentesis  Fellows must have formal instruction and clinical expertise and must demonstrate competence in the performance of diagnostic and therapeutic paracentesis. Fellows must have formal instruction and clinical experience and demonstrate competence in: o The diagnosis and management of hepatocellular carcinoma and cholangiocarcinoma including transplantation, non-transplantation, and non-surgical approaches o Transplant immunology including blood group matching, histocompatibility, tissue typing, and infectious and malignant complications of immunosuppression o Ethical considerations relating to liver transplant donors, including questions related to living donors, non-heart beating donors, criteria for brain death, and appropriate recipients o Acquiring a current working knowledge of the organizational and logistic aspects of liver transplantation including the the role of nurse coordinators and other support staff (e.g., social work), organ procurement, and UNOS policies including those regarding organ allocation. Provide inpatient care that is safe and compassionate with the leadership ability to thoroughly and clearly educate the inpatient and all other trainees regarding relevant areas of disease prevention, detection, progression and therapy to promote liver health.
  16. 16. Medical Knowledge Objectives: Access and critique the medical literature regarding hepatology and gastroenterology problems encountered. Assume the trainee leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease management, procedures and medicine management skills for common and uncommon inpatient liver diseases including Fellows must have formal instruction and clinical experience and demonstrate competence in: o The diagnosis and management of hepatocellular carcinoma and cholangiocarcinoma including transplantation, non-transplantation, and non-surgical approaches o Transplant immunology including blood group matching, histocompatibility, tissue typing, and infectious and malignant complications of immunosuppression o Ethical considerations relating to liver transplant donors, including questions related to living donors, non-heart beating donors, criteria for brain death, and appropriate recipients o Acquiring a current working knowledge of the organizational and logistic aspects of liver transplantation including the the role of nurse coordinators and other support staff (e.g., social work), organ procurement, and UNOS policies including those regarding organ allocation. Teach medical students, other trainees and Year I & II fellows at near-attending level. Prepare for the ABIM certifying exam throughout the year. Organize team activities in a smooth and authoritative fashion. Assist Year II fellows’ development directly at teaching conferences and indirectly at work sites. Achieve an average percentile score of at least 70.6 on the liver section of the in-service Gastroenterology Training Examination (GTE) exam. This score is the national exam average for the liver section for Year III fellows.Practice-Based Learning Objectives: Demonstrate mastery of Year II fellow skills and encourage participation of colleagues. Review, analyze and utilize scientific evidence from the hepatology literature for the management of liver disease patients, taking a leadership role in guiding Year I & II fellows and sharing relevant literature reviews with them. Know and be able to succinctly communicate the best practice patterns to facilitate liver disease care through clinic operating procedures and patient interactions.Interpersonal Communication Skill Objectives: Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner. Convey bad news compassionately and honestly. Supervise Year I & II fellows’ work related to planning patient/family conferences and patient communications/counseling. Communicate effectively as a consultant with staff, peers, attending gastroenterologists, referring physicians and other consultants and lead other trainees related to appropriate fellow-to-medical-professional communications. Present cases succinctly, in a problem-based, direct manner. Assume the role of a teacher of hepatology to junior trainees, medical students and other healthcare professionals.Professionalism Objectives: Demonstrate proficiency in Year II objectives. Mentor medical students, other trainees and fellows in professional conduct. Assist in formal teaching exercises as requested. Assert leadership in program planning.Systems-Based Practice Objectives: Attend conferences concerning healthcare system patient management and components of systems of healthcare. Assist and mentor other trainees in utilization of appropriate UPMC/UPP healthcare resources for the best care of the GI Hospital Service’s patients, including proper documentation and billing skills. Use and train others on the program’s e-portfolio system for personal documentation management, communication with mentors and other collaborators and related fellowship program documentation.
  17. 17.  Model appropriate interactions in multidisciplinary planning, including improvements related to standard operating procedures and quality improvement initiatives. Participate in hospital and national medical association committees and multidisciplinary planning groups when requested. Attend national conferences directed at career goals. Demonstrate near-attending level utilization of overall systems of care.Teaching Methods:Gastroenterology fellows participate in the Hepatology Consultative Service during all three fellowship years. Twofellows are assigned to the Hepatology Consultative Service during all rotations.Teaching of medical students,residents and other trainees as well as appropriate interactions with other healthcare providers are important aspectsof this rotation. Participating in all required conferences is mandatory, and rounding is an integral part of thisexperience. As fellows gain experience throughout their training, skills of organization and efficiency as well as teamleadership become increasingly important.The Hepatology Consultative Service experience will prepare the fellow to evaluate and manage acute and chronicliver diseases that will be encountered in the fellow’s future practice. This rotation will expose the fellow to a widevariety of acute and chronic liver diseases. Fellows will learn to incorporate and interact with a multidisciplinary teamapproach with the Liver Transplant Program at the Starzl Transplant Institute, Montefiore University Hospital. Fellowswill learn the appropriate use of interventional radiology facilities capable of performing Transjugular Intrahepatic PortalSystemic Shunts (TIPS) and balloon angioplasty and will learn to share patient co-management responsibilities withtransplant surgeons from the preoperative phase to the outpatient period as well as learn to interact with anexperienced liver transplant pathologist.Fellows assigned to this service will evaluate all new consults at UPMC Presbyterian, Montefiore and Magee WomensHospitals and will be assigned to a continuity clinic one-half day per week. They will present new consults to theattending by the following day for routine consults and as soon as possible for emergencies. Fellows will evaluateeach patient and will make initial recommendations regarding diagnostic tests and treatments. They will makearrangements for studies such as GI endoscopic procedures, liver biopsies (percutaneous and transjugular),abdominal paracenteses and thoracenteses, percutaneous transhepatic cholangiograms (PTC), etc. They will reviewthe appropriateness of the procedure with the attending before making final scheduling plans. The fellow will followeach patient under active consultation on a regular basis, will make further recommendations as indicated and willkeep the attending informed of the patient’s status. Fellows must also communicate with the procedure fellow for alldiagnostic studies.Disease Mix:Fellows see a complete mix of liver diseases and conditions at the Hepatology Consultative Service’s teachinghospitals. UPMC Presbyterian and UPMC Montefiore and the Starzl Transplant Institute have a substantial primarycare basis, which provides the entire spectrum of internal medicine diagnoses and gastroenterology/hepatology care.Diagnoses range from acute viral hepatitis (A/B), drug induced liver injury,fulminant liver failure, chronic viral hepatitispost transplantation, complicated hepatocellular carcinoma and cholangiocarcinoma. There is also an appropriateconcentration of common liver diseases such as evaluation of abnormal liver function tests, management of ascitesincluding refractory ascites, hepatic hydrothorax, hepatorenal syndrome, and portal hypertensive bleeding, diagnosisand management of autoimmune liver diseases and cholestatic liver diseases (PBC and PSC), metabolic liverdiseases (Non-Alcoholic Fatty Liver Disease [NAFLD]), Inherited Liver Diseases such as Genetic Hemochromatosis;Wilson’s Disease and Alpha One Antitrypsin Deficiency. In particular, UPMC Presbyterian/UPMC Montefiore and theStarzl Transplant Institute comprise a tri-state and international referral center, and there is outstanding diversity ofunusual diagnoses in the teaching services.Patient Characteristics:UPMC Presbyterian and UPMC Montefiore offer a diverse mix of socioeconomic and gender status. Teaching facultyprovide an abundant supply of upper- and middle-class patients, and our contracts with medical assistance and probono care efforts ensure access to lower-income patients. Due to a primary care base simultaneous with the hospitals’constantly active referrals (complete with helicopter and fixed-wing transport 24/7), patients are seen in both acutestatus and in diagnostic dilemma status, with both common and uncommon disorders.
  18. 18. Types of Clinical Encounters – Attending Supervision:Encounters are inpatient in nature during the Hepatology Consultative Service. Fellows provide 24/7 consultative careunder the supervision of an attending within duty hour limits and with faculty back up for situations of overload. Dailyattending supervision is available at both UPMC Presbyterian and UPMC Montefiore seven days per week, and in-house supervision is available all night as well. The attending has ultimate responsibility for patients.Procedures:During the Hepatology Consultative Service, emergency procedures (e.g. for acute gastrointestinal bleeding) areperformed 24/7 within duty hour limits by the fellow with the attending. Non-emergent procedures are performedduring daytime hours in the GI lab by the fellow under the direct supervision of the attending. Procedure basedevaluation is performed twice per year by a supervising attending (see procedure practicum: direct observation).Evaluation:Fellows are evaluated during all Hepatology Consultative Service rotations and are expected to participate in theevaluation of other fellows as well. This occurs in the following forms: Detailed, automated evaluations using the myevaluations.com system are submitted for each rotation. These evaluations are reflective of the program’s curriculum requirements. Attendings evaluate fellows, and the fellows evaluate the attendings as well. Evaluations include: o 360-degree (attending, nurse, nurse practitioner, staff/clerical, etc.); o Direct observation; o Peer-reviewed; and o Patient. Evaluation summaries become part of the fellows’ and attendings’ promotional documents. Fellows self-evaluate through their e-portfolio participation/communication with mentors and colleagues and through document maintenance. The fellow also evaluates the Gastroenterology Fellowship Program annually through a confidential basis. Attendings evaluate the Gastroenterology Fellowship Program annually. A Curriculum Committee oversees major changes to the curriculum. Representative program personnel (i.e., program director, representative faculty and at least one fellow) are organized to review program goals and objectives and the effectiveness with which they are achieved. This group conducts a formal documented meeting at least annually for this purpose. In the evaluation process, the group must take into consideration written comments from the faculty, the most recent report of the GMEC of the sponsoring institution and the residents’ confidential written evaluations. If deficiencies are found, the group will prepare an explicit plan of action, which should be approved by the faculty and documented in the minutes of the meeting. The Program Director meets with all fellows individually twice per year. An in-service GTE exam is given to all fellows annually.Bibliography: Resource Documents o Up-To-Date o PubMed o Textbook of Gastroenterology – Yamada, et.al. o Gastrointestinal Disease: Pathophysiology Diagnosis Management – Sleisenger & Fordtran. o Diseases of the Liver - Leon Schiff and Eugene Schiff o Zakim and Boyer’s Hepatology: A Textbook of Liver Disease o Major Gastroenterology/Hepatology/Transplantation journals online and in the program’s fellow library including Gastroenterology, American Journal of Gastroenterolgy, Gut, Hepatology, Liver Transplantation, Journal of Hepatology and other major publications. o Recommended reading and landmark articles are available on the Division of Gastroenterology, Hepatology and Nutrition’s shared-access drive. This information includes:  Practice Guidelines from the American Association for the Study of Liver Diseases (AASLD) [may also be accessed via www.aasld.org].  Transplant Hepatology CAQ
  19. 19. To access the Division’s shared-access drive, go to >  “H:” drive  Click on “GI”  Click on “Public”  Click on the “Chopra” file. Curricular Design o ACGME Outcome Project documentation (from www.acgme.org). o Graduate Education in Internal Medicine: A Resource Guide to Curriculum Development o The report of the Federated Council for Internal Medicine Task Force on the Internal Medicine Residency Curriculum, 1997. Pertinent Teaching References: o Textbook of Gastroenterology – Yamada, et.al. o Gastrointestinal Diasese: Pathophysiology Diagnosis Management – Sleisenger & Fordtran. o Diseases of the Liver - Leon Schiff and Eugene Schiff Competencies-at-a-Glance Hepatology Consultative Service COMPETENCY LEARNING OPPORTUNITY EVALUATIONPatient Care  Work Rounds  360-global evaluations  Teaching Rounds  GTE in-service exam  Conferences  Direct ObservationMedical Knowledge  Work Rounds  360-global evaluations  Teaching Rounds  GTE in-service exam  ConferencesPractice-Based Learning  Quarterly M&M Conference  360-global evaluations  Work Rounds  E-portfolio procedure documentation  Direct ObservationInterpersonal Skills  Work Rounds  360-global evaluationsProfessionalism  Work Rounds  360-global evaluations  Conferences  E-portfolio self-documentationSystems-Based Practice  Committee Participation  360-global evaluations  Grand Rounds (GI & Medical)  E-portfolio collaboration  Conferences documentationThe Hepatology Consultative Service reflects appropriate teaching and evaluation related to all six core competencies.Day-to-day patient care, related teaching and the curriculum conferences during the rotation are the greatest elementsthat teach the competencies, and the global evaluation is the most important single measurement device. In additionto didactic learning, medical center committee participation is encouraged to bolster system-wide knowledge andpractice management understanding.Updated:December 2005June 2006September 2007
  20. 20. Hepatology Outpatient Service Curriculum for Year I, II & III FellowsEducational Purpose:The Hepatology Outpatient Service introduces the fellow to outpatient management of patients with liver diseases.During this period, the fellow will have the opportunity to assess a wide variety of acute and chronic liver conditions.The fellow will participate in increasing levels of management/treatment involvement with patient needs depending onthe fellow’s level of experience. The fellow will be expected to formulate the differential diagnosis, institute diagnosticstudies and recommend therapy. The amount of learning obtained from this rotation is directly proportional to theamount of time spent in the evaluation of the patients.Objectives:Fellows will learn all aspects of outpatient liver disease care and will display all general competencies during thisexperience. Fellows will develop familiarity with standard treatments for common complications such as ascites, portalhypertension or hepatic encephalopathy and will build familiarity with standard treatments of chronic liver diseasessuch as viral hepatitis, autoimmune liver diseases, metabolic liver diseases, drug-induced liver disease, fatty liverdisease and liver tumors. Fellows will obtain exposure to the liver transplantation selection process and will receiveexperience in the timing of referring patients for liver transplantation. Minimum levels of achievement in eachcompetency are expected during each of the three years of fellowship training. Those meeting competency will receivea score of 5 in the program’s evaluation system. Fellows performing at a level better than expected for thatcompetency receive a score of 6 or 7 in the evaluation system, those at a level better than most fellows at that PGYreceive an 8, and those performing at a level deemed to be “one of the best fellows ever observed” will receive a scoreof 9. Fellows receiving a score of 4 or below are deemed deficient in that competency; this will be brought to theattention of the program director immediately, and, if necessary, remediation will be implemented.The following are the goals and objectives for each competency at each level of training for the Hepatology OutpatientService: Year I Fellow:Goal: A Year I fellow should be able to assess new patient problems, formulate and execute a treatment plan withguidance and teach basic hepatology and gastroenterology skills to medical students and other trainees. Year Ifellows should begin to develop basic procedural competencies.Patient Care Objectives: Perform an accurate physical examination and present information concisely with an initial assessment plan. Follow the patient’s disease course from visit to visit with possible.. With attending consultation, formulate and execute an impression and a list of recommendations. When indicated, consent patients for procedures and order appropriate diagnostic tests (e.g., endoscopy, radiologic tests, etc.) in conjunction with the primary/referring service. Perform with supervision the following basic procedures (see practicum): o Colonoscopy  By completion of Year I a fellow should be able to perform a diagnostic colonoscopy to the cecum with limited assistance. o EsophagoGastroDuodenoscopy (EGD or Upper Endoscopy)  By completion of Year I a fellow should be able to perform a diagnostic endoscopy to the second portion of the duodenum. o Liver Biopsies:  Fellows must have formal instruction and clinical expertise and must demonstrate competence in the performance of percutaneous liver biopsies. o Abdominal Paracentesis:  Fellows must have formal instruction and clinical expertise, and must demonstrate competence in the performance of diagnostic and therapeutic paracentesis Fellows will have formal instruction and clinical experience and will demonstrate competence in:
  21. 21. o The prevention of acute and chronic endstage liver disease o The evaluation and management of inpatients with acute and chronic endstage liver disease o The management of fulminant liver failure o The psychosocial evaluation of all candidates, in particular those with a history of substance abuse o Drug hepatotoxicity and the interaction of drugs with the liver o Diagnosis and management of autoimmune hepatitis o Diagnosis and management of cholestatic liver diseases – primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) Learn to provide outpatient care that is safe and compassionate and to develop the ability to thoroughly and clearly educate the patient in the relevant areas of disease prevention, detection, progression and therapy to promote liver health.Medical Knowledge Objectives: Attend core conferences and teaching rounds --- especially the mandatory Wednesday Hepatology Conference --- to learn the pathophysiology, epidemiology, disease management and procedures and medicine management skills for common and uncommon liver diseases including: o The prevention of acute and chronic endstage liver disease o The evaluation and management of inpatients with acute and chronic endstage liver disease o The management of fulminant liver failure o The psychosocial evaluation of all candidates, in particular those with a history of substance abuse o Drug hepatotoxicity and the interaction of drugs with the liver o Diagnosis and amangement of autoimmune hepatitis o Diagnosis and management of cholestatic liver diseases – primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) Accumulate and begin to solve the issues that he/she encounters from other trainees, attendings and related medical professionals. Teach medical students the basics of gastroenterology and hepatology care. Achieve an average percentile score of at least 59.8on the liver section of the in-service Gastroenterology Training Examination (GTE) exam. This score is the national average for the liver section for Year I fellows. By end of Year I, pass the Internal Medicine Board Examination.Practice-Based Learning Objectives: Become familiar with the concepts of quality improvement. Participate in conferences such as M&M, geared to the programmatic review of adverse events. Begin to review, analyze and utilize scientific evidence from the hepatology literature for the management of liver disease patients. Learn the best practice patterns to facilitate liver disease care through clinic operating procedures and patient interactions.Interpersonal Communication Skill Objectives: Interview patients and family members accurately, patiently and compassionately and present information in an understandable and compassionate manner. Convey bad news compassionately and honestly. Learn to communicate effectively with staff, peers, attending gastroenterologists/hepatologists, referring physicians and other consultants.Professionalism Objectives: Learn to understand and demonstrate professional behavior in daily activities. Participate in professionalism-based learning activities through conferences. Learn to interact collegially with his/her peer group and other healthcare professionals. Learn to practice ethical principles with relation to patient care and confidentiality. Learn to practice appropriate interactions with pharmaceutical representatives and be unbiased in prescribing habits. Learn to be sensitive to cultural, age, gender and disability issues. Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues.
  22. 22.  Participate in program planning.Systems-Based Practice Objectives: Attend conferences concerning healthcare system patient management and components of systems of healthcare. Achieve basic understanding of healthcare systems related to hepatology care and overall system activities. Learn proper documentation and billing skills to practice cost-effective care. Develop and become familiar with the e-portfolio system for personal documentation management, communication with mentors and other collaborators and related fellowship program documentation. Utilize an appropriate range of healthcare professionals to care for patients, working closely with social services to maximize patient care and understanding the role of hospice, referring appropriately when needed. Begin involvement to understand the standard operating procedures and quality improvement initiatives within the hospital. Attend national gastroenterology conferences (e.g., ACG and endoscopy training courses). Year II Fellow:Goal: A Year II fellow should learn to assess and care for a larger volume of patients and learn and teach basictextbook and evidence-based medicine to medical students and other trainees. Year II fellows should independentlyperform diagnostic upper endoscopy and colonoscopy and begin to perform therapeutic maneuvers.Patient Care Objectives: Complete a time-efficient history and physical examination. Critique the work and orders of Year I fellows. Direct the Year I fellows successfully with the appropriate level of intervention for each trainee’s skills. Complete competency-level performance of the following basic procedures (see practicum checklist): o Colonoscopy  By completion of Year II, master all Year I colonoscopic skill requirements. Additionally, perform endoscopic maneuvers, including snare polypectomy and begin to develop competency in control of GI bleeding: sclerotherapy and thermal coagulopathy of bleeding vessels. o Upper Endoscopy  By completion of Year II, master all Year I upper endoscopic skill requirements. Additionally, begin to develop competency in performing therapeutic maneuvers: banding and sclerosing of varices, and sclerotherapy and thermal coagulopathy of bleeding vessels. o Liver Biopsies:  Fellows must have formal instruction and clinical expertise and must demonstrate competence in the performance of percutaneous liver biopsies. o Abdominal Paracentesis:  Fellows must have formal instruction and clinical expertise, and must demonstrate competence in the performance of diagnostic and therapeutic paracentesis Fellows will have formal instruction and clinical experience and demonstrate competence in: o The comprehensive management of patients who are high on the transplant list in the intensive care setting with complications of end-stage liver disease including: refractory ascites, hepatic hydrothorax; hepatorenal syndrome, hepatopulmonary and portal pulmonary syndromes, and refractory portal hypertensive bleeding o The management of chronic viral hepatitis in the pre-transplantation, peri-transplantation, and post- transplantation settings o Nutritional support of patients with chronic liver disease o The use of interventional radiology in the diagnosis and management of portal hypertension, as well as biliary and vascular complications Present cases succinctly in a direct manner. Know the Hepatology Outpatient Service’s patients at a management level.
  23. 23.  Handle consult calls respectfully and appropriately. Teach good symptom management skills to medical students and other trainees. Provide outpatient care that is safe and compassionate and develop the ability to thoroughly and clearly educate the patient in the relevant areas of disease prevention, detection, progression and therapy to promote liver health.Medical Knowledge Objectives: Begin to take a leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease management and procedures and medicine management skills for common and uncommon outpatient liver diseases including: o The comprehensive management of patients who are high on the transplant list in the intensive care setting with complications of end-stage liver disease including: refractory ascites, hepatic hydrothorax; hepatorenal syndrome, hepatopulmonary and portal pulmonary syndromes, and refractory portal hypertensive bleeding. o The management of chronic viral hepatitis in the pre-transplantation, peri-transplantation, and post- transplantation settings o Nutritional support of patients with chronic liver disease o The use of interventional radiology in the diagnosis and management of portal hypertension, as well as biliary and vascular complications Organize the team’s performance at teaching rounds. Read textbook and pertinent literature materials concerning problems encountered. Teach medical students and other trainees about liver disease states and patient management. Achieve an average percentile score of at least 65.7 on the liver section of the in-service Gastroenterology Training Examination (GTE) exam. This score is the national exam average for liver diseases for Year II fellows.Practice-Based Learning Objectives: Participate in project groups, committees and hospital groups when requested. Participate in programmatic reviews and conferences studying adverse events. Give usable feedback to medical students and other trainees based on observation of their performance and assess improvement. Participate in problem-based quality improvement projects. Review, analyze and utilize scientific evidence from the hepatology literature for the management of liver disease patients. Know the best practice patterns to facilitate hepatology care through clinic operating procedures and patient interactions.Interpersonal Communication Skill Objectives: Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner. Convey bad news compassionately and honestly. Plan patient and family conferences. Counsel patients about transitioning to palliative care, when needed. Address or refer patients related to spiritual or existential issues. Communicate effectively with staff, peers, attending hepatologists/gastroenterologists, referring physicians and other consultants. Present cases succinctly, in a problem-based, direct manner. Learn to become a teacher of hepatology to junior trainees, medical students and other healthcare professionals.Professionalism Objectives: Begin to mentor medical students, other trainees and Year I fellows in professional conduct. Understand and demonstrate professional behavior in daily activities. Participate in professionalism-based learning activities through conferences. Interact collegially with his/her peer group and other healthcare professionals, including acting responsibly in the larger context of pursuing programmatic successes. Practice ethical principles with relation to patient care and confidentiality. Practice interactions with pharmaceutical representatives and be unbiased in prescribing habits. Practice sensitivity to cultural, age, gender and disability issues.
  24. 24.  Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues. Participate in program planning.Systems-Based Practice Objectives: Attend conferences concerning healthcare system patient management and components of systems of healthcare. Understand and be able to work effectively related to hospital functions within UPMC and UPP. Understand and practice proper documentation and billing skills to practice cost-effective care. Use the program’s e-portfolio system for personal documentation management, communication with mentors and other collaborators and related fellowship program documentation. Assist other trainees in the utilization of appropriate healthcare resources for the best care of the Hepatology Consultative Service’s patients. Model appropriate interactions in multidisciplinary planning, including standard operating procedures and quality improvement initiatives. Attend national gastroenterology or hepatology conferences (e.g., DDW or AASLD). Year III Fellows:Goal: The senior-level, Year III fellow should demonstrate rapid assessment and planning skills and near-attendinglevel care planning and management, while teaching medical students and other trainees at near to or exceedingattending level teaching. Year III fellows should be able to perform diagnostic and therapeutic upper endoscopy andcolonoscopy procedures independentlyPatient Care Objectives: Master the Year II fellow objectives. Demonstrate efficient organization of the Hepatology Outpatient Service and a working knowledge of all patients. Demonstrate near-attending level capacity for program assessment and care planning. Attain trainer level proficiency in the following procedures pertinent to his/her career choices: o Colonoscopy  By completion of Year III, master all Year II colonoscopic skill requirements. Additionally, be able to independently intubate the terminal ileum and begin to develop independent mastery of more advanced maneuvers, e.g., removal of large or complex polyps by saline assisted polypectomy or piecemeal resection and control of bleeding using clips or argon plasma laser coagulation. o Upper Endoscopy  By completion of Year III, master all Year II endoscopic skill requirements. Additionally, be able to pass a side viewing scope to identify the papilla or lesions difficult to observe with forward viewing scope and perform advanced maneuvers, such as placing clips on bleeding vessels or argon plasma laser coagulopathy. o Liver Biopsies:  Fellows must have formal instruction and clinical expertise and must demonstrate competence in the performance of percutaneous liver biopsies. o Abdominal Paracentesis:  Fellows must have formal instruction and clinical expertise, and must demonstrate competence in the performance of diagnostic and therapeutic paracentesis Fellows will have formal instruction and clinical experience and demonstrate competence in: o The diagnosis and management of hepatocellular carcinoma and cholangiocarcinoma including transplantation, non-transplantation, and non-surgical approaches o Transplant immunology including blood group matching, histocompatibility, tissue typing, and infectious and malignant complications of immunosuppression o Ethical considerations relating to liver transplant donors, including questions related to living donors, non-heart beating donors, criteria for brain death, and appropriate recipients
  25. 25. o Acquiring a current working knowledge of the organizational and logistic aspects of liver transplantation including the the role of nurse coordinators and other support staff (e.g., social work), organ procurement, and UNOS policies including those regarding organ allocation Provide outpatient care that is safe and compassionate with the leadership ability to thoroughly and clearly educate the patient and all other trainees regarding relevant areas of disease prevention, detection, progression and therapy to promote liver health.Medical Knowledge Objectives: Access and critique the medical literature regarding hepatology and gastroenterology problems encountered. Assume the trainee leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease management, procedures and medicine management skills for common and uncommon inpatient liver diseases including o The diagnosis and management of hepatocellular carcinoma and cholangiocarcinoma including transplantation, non-transplantation, and non-surgical approaches o Transplant immunology including blood group matching, histocompatibility, tissue typing, and infectious and malignant complications of immunosuppression o Ethical considerations relating to liver transplant donors, including questions related to living donors, non-heart beating donors, criteria for brain death, and appropriate recipients o Acquiring a current working knowledge of the organizational and logistic aspects of liver transplantation including the the role of nurse coordinators and other support staff (e.g., social work), organ procurement, and UNOS policies including those regarding organ allocation Teach medical students, other trainees and Year I & II fellows at near-attending level. Prepare for the ABIM certifying exam throughout the year. Organize team activities in a smooth and authoritative fashion. Assist Year II fellows’ development directly at teaching conferences and indirectly at work sites. Achieve an average percentile score of at least 70.6 on the liver section of the in-service Gastroenterology Training Examination (GTE) exam. This score is the national exam average for the liver section for Year III fellows.Practice-Based Learning Objectives: Demonstrate mastery of Year II fellow skills and encourage participation of colleagues. Review, analyze and utilize scientific evidence from the hepatology literature for the management of liver disease patients, taking a leadership role in guiding Year I & II fellows and sharing relevant literature reviews with them. Know and be able to succinctly communicate the best practice patterns to facilitate liver disease care through clinic operating procedures and patient interactions.Interpersonal Communication Skill Objectives: Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner. Convey bad news compassionately and honestly. Supervise Year I & II fellows’ work related to planning patient/family conferences and patient communications/counseling. Communicate effectively as a consultant with staff, peers, attending gastroenterologists, referring physicians and other consultants and lead other trainees related to appropriate fellow-to-medical-professional communications. Present cases succinctly, in a problem-based, direct manner. Assume the role of a teacher of hepatology to junior trainees, medical students and other healthcare professionals.Professionalism Objectives: Demonstrate proficiency in Year II objectives. Mentor medical students, other trainees and fellows in professional conduct. Assist in formal teaching exercises as requested. Assert leadership in program planning.Systems-Based Practice Objectives:
  26. 26.  Attend conferences concerning healthcare system patient management and components of systems of healthcare. Assist and mentor other trainees in utilization of appropriate UPMC/UPP healthcare resources for the best care of the GI Hospital Service’s patients, including proper documentation and billing skills. Use and train others on the program’s e-portfolio system for personal documentation management, communication with mentors and other collaborators and related fellowship program documentation. Model appropriate interactions in multidisciplinary planning, including improvements related to standard operating procedures and quality improvement initiatives. Participate in hospital and national medical association committees and multidisciplinary planning groups when requested. Attend national conferences directed at career goals. Demonstrate near-attending level utilization of overall systems of care.Teaching Methods:Gastroenterology fellows participate in the Hepatology Outpatient Service during all three fellowship years. Twofellows are assigned to the Hepatology Outpatient Service during all rotations. Teaching of medical students, residentsand other trainees as well as appropriate interactions with other healthcare providers are important aspects of thisrotation. Participating in all required conferences is mandatory, and rounding is an integral part of this experience. Asfellows gain experience throughout their training, skills of organization and efficiency as well as team leadershipbecome increasingly important.The Hepatology Outpatient Service experience will prepare the fellow to evaluate and manage acute and chronic liverdiseases that will be encountered in the fellow’s future practice. This rotation will expose the fellow to a wide variety ofacute and chronic liver diseases. Fellows will learn to incorporate and interact with a multidisciplinary team approachwith the Liver Transplant Program at the Starzl Transplant Institute. Fellows will learn the appropriate use ofinterventional radiology facilities capable of performing Transjugular Intrahepatic Portal Systemic Shunts (TIPS) andballoon angioplasty and will learn to share patient co-management responsibilities with transplant surgeons from thepreoperative phase to the outpatient period and will learn to interact with an experienced liver transplant pathologist.Fellows assigned to this service will rotate through various outpatient Hepatology Clinics (General Hepatology and Pre-and Post-Transplantation Clinics) at the Center for Liver Diseases and the Starzl Transplant Institute. Fellows willevaluate each patient and will make initial recommendations regarding diagnostic tests and treatments. They willmake arrangements for studies such as GI endoscopic procedures, liver biopsies (percutaneous and transjugular),abdominal paracenteses and thoracenteses, percutaneosu transhepatic cholangiograms (PTC), etc. They will reviewthe appropriateness of the procedure with the attending before making final scheduling plans. The fellow will followeach patient under active consultation on a regular basis, will make further recommendations as indicated and willkeep the attending informed of the patient’s status. Fellows must also communicate with the procedure fellow for alldiagnostic studies.Disease Mix:Fellows see a complete mix of liver diseases and conditions at the Center for Liver Diseases (CLD), which is theprimary outpatient liver clinic. A diverse spectrum of internal medicine diagnoses and gastroenterology/hepatologycare is provided at the CLDDiagnoses range from acute viral hepatitis (A/B), drug induced liver injury, fulminant liver failure, chronic viral hepatitispost transplantation, complicated hepatocellular carcinoma and cholangiocarcinoma. There is an appropriateconcentration of common liver diseases related to evalaution of abnormal liver function tests, management of ascitesincluding refractory ascites, hepatic hydrothorax, hepatorenal syndrome and portal hypertensive bleeding. diagnosisand management of autoimmune liver diseases and cholestatic liver diseases (PBC; PSC), metabolic liver diseases(Non-Alcoholic Fatty Liver Disease [NAFLD]), Inherited Liver Diseases such as Genetic Hemochromatosis, Wilson’sDisease and Alpha One Antitrypsin Deficiency. Due to collaborations with UPMC Presbyterian Hospital --- a tri-stateand international referral center --- and the institution’s Starzl Transplantation Institute, there is outstanding diversity ofunusual diagnoses in the teaching services.Patient Characteristics:

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