GASTROENTEROLOGY COMPETENCY-BASED CURRICULUM
RATIONAL AND OVERVIEW
It is estimated that more than 60 million Americans are affected by digestive
diseases, with an annual mortality of about 190,000. Six million people
in the US undergo GI procedures each year, accounting for 14% of the total
procedures done. New advances in the pathophysiology, diagnostic procedures
and treatments have been constantly made, and care for patients with gastrointestinal
disorders is a dynamic challenge.
Internists are having increasing responsibilities caring for patients with
primary or secondary complaints of digestive disorders, either in their
office or in the hospital setting. It is crucial for the medical residents
to recognize and manager common gastrointestinal disorders during their training.
The goal of this gastroenterology rotation for our internal medicine residents
is to acquire sufficient scientific knowledge, clinical skills and professional
attitude to care for these patients.
GOALS
A. Knowledge:
Upon completion of training, we expect our residents to:
- Understand the basic mechanisms of normal GI function, understand the etiology
and pathogenesis of common digestive disorders.
- Master the clinical presentation, natural history, diagnosis and management
strategies of common digestive diseases.
- Properly and effectively use the laboratory, radiologic, endoscopic and
physiologic diagnostic studies in GI disease, and correctly interpret
the results.
- Manage patients with common GI complaints: diarrhea, constipation, abdominal
pain, non cardiac chest pain, N/V, jaundice, ascites, and abnormal liver
function tests.
- Properly evaluate and manage immunocompromised patients presented with
GI problems.
- Manage GI emergencies: massive upper and/or lower GI bleed, complications
of fulminant or severe hepatic failure, and cholangitis.
- Identify situations where appropriate GI or surgery referral is indicated
for optimal patient care.
- Keep up with the new technology and development in GI and liver diseases
including but not limited to capsule endoscopy, diagnosis and management
of H. Pylori, etiology and treatment for IBS, evolving treatments for
IBD, and antiviral therapy for viral hepatitis.
- Be familiar with the indications and contraindications of GI endoscopy
(EGD, ERCP, and colonoscopy), be familiar with the complications of these
procedures and their management.
B. Skills
Upon completion of the GI elective, the resident will be able to:
- Develop the ability to accurately assess clinical situations, obtain a
problem focused comprehensive gastrointestinal history and perform a complete
gastrointestinal physical examination, including rectal examination and
fecal occult blood testing.
- Synthesize a thorough assessment for a specific gastrointestinal illness
and create a rational plan of clinical management.
- Be able to function as part of a team providing care for a patient with
gastrointestinal problem(s).
- Observe and assist in esophagogastroduodenoscopy, colonoscopy and endoscopic
retrograde chlolangiopancreatography to be able to identify the appearance
of common diseases like peptic ulcer disease, various esophagitis, vascular
malformations, polyps and cancerous lesions.
- Know indications and contraindications for paracentesis.
- Assist in and perform paracentesis.
- Be able to correctly interpret diagnostic imaging and laboratory studies.
- Know indications, contraindications and complications of liver biopsy.
- Observe and assist in liver biopsy and recognize histopathology of common
diseases entities.
C. Attitudes:
Upon completion of training, we expect our residents to appreciate those
attitudes valued and nurtured by gastroenterologists, including:
- Viewing medicine as humane science.
- Balancing art with science.
- Recognizing the limitations of technology and the value of clinical insight.
- Making difficult judgments when certainty is elusive.
- Understanding that testing, no matter how advanced or sophisticated, rarely
substitutes for thorough, thoughtful evaluation by an informed clinician.
- Balancing intervention with patience.
- Recognizing limitations of our interventions.
- Appreciating the unique circumstances of caring for patients with chronic,
usually incurable diseases.
- Learning the importance of functional considerations.
Experiences
In order to achieve the goals and objectives for the residency program
the following experiences have been established for the purpose of teaching
Gastroenterology to residents.
1. The Inpatient Experience (IP)
The residents assigned to this rotation will be responsible for supervising
evaluation of inpatient consultations and patients admitted to the gastroenterology
service as well as the continued follow up of these patients during their
hospitalization. Essential in this role is the development and refinement
of clinical evaluation skills of patients with digestive diseases. These
skills include the development of appropriate differential diagnosis,
assessing the need for hospitalization, diagnostic evaluation strategies
and treatment plans. Essential in this rotation will be developing skills
in providing consultation services, to include communicating with the
referring physicians and ensuring support for continuing care of the patients'
gastroenterologic condition. A resident will be called upon to perform
literature research on topics appropriate to the case at hand. They will
participate actively in the teaching activities of the consultation team.
Through this experience the resident will also develop a comprehensive
understanding of the indications, contraindications, techniques, complication
of paracentesis as well as the interpretation of results from this procedure.
The resident will acquire the knowledge of and skill in educating patients
about the procedure and in obtaining informed consent. Faculty supervision
is required in developing these skills.
2. The Ambulatory Experience (AM)
All residents will participate in gastroenterology outpatient activities
appropriately supervised by dedicated attending faculty members. The goals
of this experience will be for the residents to gain expertise in the
outpatient evaluation and management of digestive problems. The experience
provides an opportunity to develop an understanding for the natural history
of these conditions over an extended period of time.
3. Didactic Conferences (DC)
Numerous monthly conferences are held for the residents throughout the
month. They cover a variety of topics in all the major medical subspecialties.
Residents will be required to attend each of the conferences that do not
conflict with their clinical duties.
EVALUATIONS
Assessment Methods (of Resident)
The evaluation methods that apply to these rotations include some or all
of the following:
- Evaluation of resident competence by faculty attendings (AE)- Formal formative
evaluations should occur at the completion of the specific rotation. It
is to be based on direct observation on rounds, at conferences, and at
the bedside. All faculty members are encouraged to complete the form prior
to the completion of the rotation and review their impressions directly
with the resident. All completed evaluation forms are returned to the
Program Director for review and placed in the resident's permanent file.
- Mini CEXs may be used when warranted, particularly in the beginning of
the academic year.
- Self-evaluation by In-service training examination scores
- MKSAP study plan (MKSAP)
- Participation and presentations at didactic conferences (DC)
- Multi Source evaluations by patients and staff (MS)
Assessment Method (of Program)
Residents have the ability to evaluate teaching faculty and experience
at the end of each rotation. They are encouraged to use this opportunity
to give constructive feedback.
Residents are encouraged to maintain a high level of communication with
the Program Director and faculty. These informal meetings can be used
to disseminate information, receive timely feedback, and for other purposes.
Annually, all residents are required to complete and return an evaluation
form of the faculty and the program. Evaluations are collected in a fashion
to assure the anonymity of the resident. The feedback received during
informal meetings, formal meetings, and the semi-annual evaluation form
will be used to make programmatic change.
Competency Based Goals & Objectives:
1) Medical Knowledge
| Goals and Objectives-PGY1 |
Learning Activities* |
Assessment |
| Describe the epidemiology, genetics, natural history, clinical expression
of the GI illness encountered in the inpatient setting. |
IP, AM, DC |
AE, DC, MKSAP |
| Summarize an approach to the evaluation of the common presentations of
GI illness (GI bleed, diarrhea, jaundice / transaminitis, etc) |
IP, AM, DC |
AE, DC, MKSAP |
| Describe structure and function of GI tract, liver and biliary systems |
IP, AM, DC |
AE, DC, MKSAP |
| Generate and prioritize differential diagnoses for patients with digestive disease |
IP, AM, DC |
AE, DC, MKSAP |
| Develop rational, evidence-based management strategies for patients with
digestive disease |
IP, AM, DC |
AE, DC, MKSAP |
|
Goals AND Objectives-PGY2/3 (In addition to above)
|
Learning Activities* |
Assessment |
| Summarize an approach to the evaluation of common GI presentations |
IP, AM, DC |
AE, DC, MKSAP |
| Distinguish patients with functional bowel disorders from those with other
"organic" bowel diseases |
IP, AM, DC |
AE, DC, MKSAP |
| Interpret diagnostic tests used in the evaluation of outpatients with suspected
GI Illness |
IP, AM, DC |
AE, DC, MKSAP |
| Demonstrate ability to critically appraise and cite literature pertinent
to the evaluation of outpatients and inpatients with GI disorders. |
IP, AM, DC |
AE, DC, MKSAP |
2) Patient Care
| Goals and Objectives-PGY1 |
Learning Activities* |
Assessment |
| Effectively perform a comprehensive history and complete physical examination
in patients with GI/biliary symptoms |
IP, AM, DC |
AE, DC, MKSAP |
| Appropriately select and interpret laboratory, imaging, and pathologic
studies used in the evaluation of GI/biliary disorders |
IP, AM, DC |
AE, DC, MKSAP |
|
Goals AND Objectives-PGY2/3 (In addition to above)
|
Learning Activities* |
Assessment |
| Construct a comprehensive treatment plan and assess response to therapy. |
IP, AM, DC |
AE, DC, MKSAP |
| Counsel patients concerning their diagnosis, planned diagnostic testing
and recommended therapies. |
IP, AM, DC |
AE, DC, MKSAP |
| Utilize validated instruments in the assessment of function and quality
of life to monitor and adjust therapy. |
IP, AM, DC |
AE, DC, MKSAP |
3) Practice-Based Learning and Improvement
| Goals and Objectives-PGY1 |
Learning Activities* |
Assessment |
| Identify and acknowledge gaps in personal knowledge and skills in the care
of hospitalized and ambulatory patients with related diseases |
IP, AM, DC |
AE, DC, MKSAP |
| Develop and implement strategies for filling gaps in knowledge and skills
of patients related diseases |
IP, AM, DC |
AE, DC, MKSAP |
| Integrate and apply knowledge obtained from multiple sources to the care
of inpatients and outpatients |
IP, AM, DC |
AE, DC, MKSAP |
| Demonstrate ability to critically assess the scientific literature |
IP, AM, DC |
AE, DC, MKSAP |
|
Goals AND Objectives-PGY2/3 (In addition to above)
|
Learning Activities* |
Assessment |
| Effectively use technology to manage information, support patient care
decisions, and enhance both patient and physician education. |
IP, AM, DC |
AE, DC, MKSAP |
| Demonstrate ability to critically assess the scientific literature |
IP, AM, DC |
AE, DC, MKSAP |
| Set and assess individualized learning goals |
IP, AM, DC |
AE, DC, MKSAP |
| Analyze clinical experience and employ a systematic methodology for improvement |
IP, AM, DC |
AE, DC, MKSAP |
| Develop and maintain a willingness to learn from errors, and use errors
to improve the system or processes of care |
IP, AM, DC |
AE, DC, MKSAP |
4) Interpersonal Skills and Communication
| Goals and Objectives-PGY1 |
Learning Activities* |
Assessment |
| Apply empathy in all patient encounters |
IP, AM, DC |
AE, DC, MKSAP |
| Demonstrate effective skills of listening and speaking with patients, families
and other members of the health care team |
IP, AM, DC |
AE, DC, MKSAP |
| Present patient information concisely and clearly, verbally and in writing |
IP, AM, DC |
AE, DC, MKSAP |
|
Goals AND Objectives-PGY2/3 (In addition to above)
|
Learning Activities* |
Assessment |
| Reliably and accurately communicate the patient's and his/her family's
views and concerns to the attending |
IP, AM, DC |
AE, DC, MKSAP |
| Compose clear and timely admission and progress notes and consultations |
IP, AM, DC |
AE, DC, MKSAP |
| Counsel patients, families and colleagues regarding side effects and appropriate
use of specific medications, providing written documentation when appropriate |
IP, AM, DC |
AE, DC, MKSAP |
| Teach colleagues effectively |
IP, AM, DC |
AE, DC, MKSAP |
5) Professionalism
| Goals and Objectives-PGY1 |
Learning Activities* |
Assessment |
| Be prompt and prepared for all clinical duties |
IP, AM, DC |
AE, DC, MKSAP |
| Recognize the importance of patient primacy, patient privacy, patient autonomy,
informed consent, and equitable respect and care to all |
IP, AM, DC |
AE, DC, MKSAP |
| Respect patients and their families, staff and colleagues |
IP, AM, DC |
AE, DC, MKSAP |
|
Goals AND Objectives-PGY2/3 (In addition to above)
|
Learning Activities* |
Assessment |
| Model ethical behavior by reporting back to the attending and referring
providers any key clinical findings |
IP, AM, DC |
AE, DC, MKSAP |
| Demonstrate integrity |
IP, AM, DC |
AE, DC, MKSAP |
| Respond to phone calls and pages promptly |
IP, AM, DC |
AE, DC, MKSAP |
6) Systems-Based Practice
| Goals and Objectives-PGY1 |
Learning Activities* |
Assessment |
| Demonstrate effective collaboration with other health care providers, including
nursing staff, ancillary staff, therapists, primary care physicians, and
consultants in the care of patients with cardiac diseases |
IP, AM, DC |
AE, DC, MKSAP |
| Develop an understanding of the hospital resources available to the evaluation
and management of patients with problems encountered by the subspecialty. |
IP, AM, DC |
AE, DC, MKSAP |
| Demonstrate a knowledge of and commitment to the rules governing confidentiality
of patient information. |
IP, AM, DC |
AE, DC, MKSAP |
|
Goals AND Objectives-PGY2/3 (In addition to above)
|
Learning Activities* |
Assessment |
| Discuss how the health care system affects the management of inpatients
with endocrine diseases. |
IP, AM, DC |
AE, DC, MKSAP |
| Determine cost-effectiveness of alternative proposed interventions. |
IP, AM, DC |
AE, DC, MKSAP |
| Design cost-effective plans based on knowledge of best practices |
IP, AM, DC |
AE, DC, MKSAP |
| Demonstrate awareness of the impact of diagnostic and therapeutic recommendations
on the health care system, cost of the procedure, insurance coverage,
and resources utilized |
IP, AM, DC |
AE, DC, MKSAP |
Teaching Methods
All residents participate in patient care duties, didactic conferences
and independent reading. They will learn at the bedside from attendings,
nurses and physician extenders, pharmacists, social workers, case managers,
peers, and patients.
Level of Supervision
Interns are supervised in their care of patients by more senior medical
house staff (PGY- 2/3 and Chief Residents) and faculty. PGY2/3 residents
have direct and indirect supervision by Chief Resident and Faculty
REFERENCES
Tadataka Yamada (Editor), David H. Alpers (Editor), Loren Laine (Editor):
Textbook of Gastroenterology, Lippincott Williams & Wilkins Publishers.
Mark Feldman, Lawrence S. Friedman, Marvin H. Sleisenger, Bruce F. Scharschmidt:
Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/
Management (2 Volume Set), W B Saunders.
Sheila Sherlock, James Dooley: Disease of the Liver and Biliary System,
Blackwell Scientific Inc.
Eugene R. Schiff (Editor), Michael F. Sorrell (Editor), Willis C. Maddrey
(Editor): Schiff's Diseases of the Liver, Lippincott Williams &
Wilkins Publishers
Michael V. Sivak (Editor): Gastroenterologic Endoscopy (2 Volume Set),
W B Saunders
RECOMMENDED JOURNALS
Gastroenterology
Hepatology
Gut
Digestive Disease and Sciences
American Journal of Gastroenterology
Journal of Hepatology
Gastrointestinal Endoscopy
FACULTY
Askin, Matthew, M.D., Educational Coordinator
Franzese, John N., M.D.
Green, Jon, M.D., Co Chief
Mogan, Glen R., M.D.
Ramasamy, Dhanasekaran, M.D.
Rosenthal, Laerence, M.D.
Ruffini, Robert A., M.D.
Schrader, Zalman R., M.D.
Schuman, Robert W., M.D.
Sloan, William C., M.D.
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