Standards of Performance

It is assumed that all trainees will have acquired the basic skills of general internal medicine and will be board eligible in Internal Medicine at the time of entry into the program. Prior to completion of specialty training in gastroenterology, they should become ABIM certified. This certification is a required prerequisite for eligibility for board certification in gastroenterology. The training program will build upon the skills of internal medicine to develop clinical and technical competence in the subspecialty of gastroenterology. Specific areas of training are:

1. Medical knowledge
2. Clinical and procedural skills
3. Clinical and medical judgment
4. Commitment to scholarship
5. Professional attitude and humanistic qualities
6. Moral and ethical standards

The training program consists of three years of training: The first two years will focus on clinical training in Gastroenterology and Hepatology with allocated time for research.  The third year focuses on therapeutic endoscopy, liver transplant and further opportunities for research.

This training will be obtained by rotating through the following services:

1st Year	2nd Year	3rd Year
6 months University Consult  6 months VA 1/2 Day VA or UU Clinic	6 months VA Endoscopy 3 months Liver TX 3 months Research 1/2 day VA or UU Clinic	6 months Therapeutics 3 months Liver TX 3 months Research 1/2 day Therapeutics Clinic

SPECIFIC AREAS OF TRAINING:

A. Medical Knowledge
Trainees will develop specialized knowledge in the areas of gastroenterology and hepatology to include the following areas:

1. An understanding of the physiology, pathophysiology, and natural history of disease
2. An understanding of the approach to the diagnosis of disease, to include the appropriate and cost-effective selection and interpretation of tests and procedures.
3. An understanding of the principles of appropriate therapy, to include pharmacologic principles, mechanisms of actions, and benefits and adverse effects of medical, surgical, and endoscopic therapies.

B. Clinical and Procedural Skills
Trainees will develop the skills of a subspecialty consultant in both cognitive and procedural gastroenterology. Specifically, the following skills will be developed:

Clinical Skills
a. The performance of a directed history and physical examination
b. The ability to interpret clinical data, to include laboratory data, imaging studies, pathologic specimens, and specialized gastrointestinal studies (c. The ability to formulate an appropriate differential diagnosis and diagnostic plan based upon clinical findings
d. The ability to communicate clinical data in an organized, succinct, and intelligible fashion
e. Appropriate, safe, and cost-effective selection of laboratory and diagnostic modalities
f. The ability to formulate and carry out an appropriate therapeutic plan for gastrointestinal disorders
g. Humanistic, ethical, and conscientious patient care appropriate for both a primary care provider and a subspecialty consultant

Procedural skills
a. An understanding of the role of endoscopic and interventional procedures in gastrointestinal and hepatobiliary disorders

1. Be able to appropriately recommend endoscopic procedures based upon clinical findings, indications, contraindications, risk factors, potential benefits, and alternative approaches
2. Be able to interpret endoscopic findings, diagnose and treat potential complications/adverse outcomes from these procedures

b. Perform specific procedures safely, completely, and expeditiously; although the skills of each trainee will vary, it is anticipated that each trainee will perform at least the number of procedures listed below (as recommended by the ASGE) while supervised by a faculty member; competence in the performance of each procedure will be determined by faculty members.

1.) Esophagogastroduodenoscopy (diagnostic)
2.) Esophagogastroduodenoscopy (for control of variceal bleeding): 15(5 active)
3.) Esophagogastroduodenoscopy (for control of non-variceal bleeding): 20 (10 active)
4.) Esophageal dilation (bougienage): 15
5.) Esophageal dilation (wire guided): 15
6.) Flexible sigmoidoscopy: 50
7.) Colonoscopy (diagnostic): 100
8.) Colonoscopy (with snare polypectomy): 20
9.) Esophageal manometry: 10
10.) Percutaneous endoscopic gastrostomy: 10
11.) Percutaneous liver biopsy: 25

c. Appropriately document the indications, performance, and result of procedures; this includes the documentation of any complications or adverse events and their treatment recognize personal and procedural limitations and develop the ability to judge when to seek help or terminate procedures

C. Clinical Judgment
Each trainee will develop the ability to integrate medical facts and clinical data to formulate a differential diagnosis, and diagnostic and therapeutic plan. He or she should develop the ability to weigh alternatives and incorporate knowledge of risks and benefits in delivering comprehensive, compassionate, and cost-effective medical care.

D. Commitment to Scholarship
A commitment to scholarship will be developed by regular attendance and participation in the conferences of the training program:

a. Clinical case conference
b. Research conference
c. Pathology conference
d. Radiology conference
e. Basic science/physiology/motility conference
f. Journal Club
g. Medical or Surgical Grand Rounds
All trainees will participate in 6 months of research (clinical or basic science). Each trainee will submit a manuscript, abstract, or review resulting from this activity.

E. Professional Attitude and Humanistic Qualities
Trainees are expected to be compassionate, caring, and respectful of the needs of patients and their families. A professional, cordial attitude must be displayed at all times.

F. Moral and Ethical Standards
The highest moral and ethical behavior is demanded on the part of all trainees. Any activity or conduct detrimental to the profession will not be tolerated. Honesty, integrity, and dedication to the principles of the medical profession are expected at all times.

METHODS OF INSTRUCTION AND TRAINING:

Medical knowledge will be developed by both independent and directed study.
Trainees are expected to display intellectual and clinical curiosity that results in self-motivated learning. Direct teaching will occur on a daily basis through interactions with faculty members in clinic, on rounds, and in informal teaching sessions. Formal teaching will also occur at the conferences outlines above. Faculty members are available for additional directed study or individual teaching.

Clinical skills will be developed through supervised patient care in clinics, inpatient settings and consultation rounds. All of these activities will occur under direct faculty supervision.
Procedural skills will be taught in a step-wise fashion:
An initial cognitive phase where the trainee develops an understanding of the indications, contraindications, risks, benefits, and technical aspects of the procedures. The trainee will observe, but not perform procedures during this stage of training. This period ordinarily lasts approximately one to four weeks. The trainee then enters a second phase of supervision by a faculty member in which the trainee will gradually performs procedures.

After achieving clinical competence in the procedure, trainees will be expected to do procedures  with an attending physician. For diagnostic procedures, this typically occurs within the first year, and for therapeutic in the third year. The general guidelines for the numbers of procedures required to achieve this goal are outlined above. Each trainee, however, will be independently evaluated to graduate to this level of training. The determination of clinical competence will be based upon skill and judgment, not the number of procedures performed.  Faculty supervision will always be available for additional teaching or consultation.  Fellows are expected to take general GI call from home during the week after hours and during the weekend.  The call schedule is shared by all six GI fellows.  While on call, fellows will answer phone calls from patients or other health care providers.  They will also perform consults and necessary endoscopic procedures with the assistance of an on call attending physician.

Research training will be supervised directly by one or more faculty members during the 3 to 6 month research rotation. The trainee will be educated in study design, performance of appropriate study procedures, data collection, data interpretation, ethics of human and animal experimentation, and the final presentation of the results of the study.

EVALUATION OF PERFORMANCE:

Continual feedback by faculty members will be provided to the trainee in each teaching setting (clinic, rounds, conferences, etc.) Quarterly written formal evaluations using the ABIM format will be performed for each trainee. The results of these evaluations will be provided to the trainee. Each trainee will meet with the program director quarterly (more frequently, if needed). Specific feedback will be provided in these meetings regarding the trainee’s progress, strengths, and weaknesses. Information for these sessions will be provided from all sources, both formal and informal. It will include the results of quarterly evaluations, as well as information that may be provided by faculty, nurses, and technical staff. Specific suggestions for improvement will be provided. The trainee will also be asked to give feedback to the program director. If there is inadequate performance or inappropriate conduct, a warning will be given. The trainee will be formally notified of the specific deficiencies to be corrected. Failure of the trainee to correct these problems may result in dismissal from the program, failure to graduate form the program, or the need to repeat part or all of the training.

Once training has been completed satisfactorily, the fellow will be given a certificate indicating satisfactory completion of the program. If otherwise eligible, the candidate will be recommended to the American Board of Internal medicine to sit for the subspecialty examination in gastroenterology.

THIRD YEAR GI FELLOWSHIP:

The third year of the fellowship is a year in which the trainee acquires a higher level of skills in a more specialized area. In general, the third year will include 6 months of research plus 6 months of either Hepatology or therapeutic endoscopy. It is recognized that, depending on the career goals of the trainee, the entire year could be spent in research or, in the case of those seeking an academic career, 18 months of the three years could be spent in research. Also, for those trainees whose primary career foal is in therapeutic endoscopy, some will need an extra 6-12 months of therapeutic endoscopy.

Research Training -
All trainees are required to do 6 months of research. In general, they will do this in the third year, but those desiring an academic career will start their research in the second year and do at least one year of research. For those seeking a clinical career, the research rotation will be 6 months.

The objectives of the research training are:
To appreciate the contribution of research to the advancement of the discipline of gastroenterology
To acquire the ability to critically assess the quality of research in the literature
To appreciate the ethics of medical research involving humans and animals
To acquire skills in either clinical or basic research that will serve as tools for further research

Rationale
Research is the basis of the advancement of the discipline of gastroenterology.  The trainee will design, execute, and write up a clinical or basic research project. This will be done with a mentor who will advise the trainee.

The specific activities will include:

Protocol design
Statistical design and assessment
Institutional Review Board or animal Rights Board application
Acquisition of specific skills needed to execute the protocol
Collection of the data
Analysis of the data
Writing the report in the form of a manuscript
Optional grant application for those seeking an academic career

Hepatology -
Hepatology is an elective in the third year of training. The trainee will spend 6 months doing clinical hepatology and liver transplantas well as an extensive review of a clinical hepatology project.

The specific objectives are:
To become a competent consultant in liver diseases
To complete an extensive review of a research or clinical topic of the trainee’s choice
To be able to do the preoperative assessment and postoperative care of liver transplant patients

Rationale
Hepatology is a rapidly advancing discipline in the area of gastroenterology, both in terms of clinical and basic science. Liver transplantation is widely available, with about 5,000 patients per year receiving organs. Rapid advances in therapeutics are being made. It is anticipated that there will soon be separate boards in Hepatology. Many gastroenterologists will practice primarily hepatology in the future.

Activities
Daily consultation/inpatient rounds at either the University or VA Hospital
Liver clinic – 1 half-day at the VA during the 1st and 2nd year
Liver biopsy session at the University
Transplant evaluation clinic at the University : 1.5 days during 2nd and 3rd year
Transplant conference at the University
GI Multidisciplinary Conference – fellows to do one conference per month on a contemporary liver case
Journal Club – 3 Journal Clubs on liver-related topics
Review of liver topic of fellow’s choice to be written up journal-style and presented during basic science seminar

Evaluation
See Standards of Training

Advanced Endoscopy -
The 6 month training block in therapeutic endoscopy is designed to give the trainee extensive experience in therapeutic and interventional endoscopy, including the technical aspects of the procedure, the consultative aspects of therapeutic endoscopy including indications, contraindications, risks, and potential benefits. In addition, the fellow will be expected to do a clinical research project while on this service.

Rationale
The field of therapeutic endoscopy is advancing rapidly and replacing many standard surgical procedures for the management of biliary and luminal gastrointestinal diseases. While not every gastroenterologist will become competent in this area, this rotation is designed to introduce the fellow to the field and to help them develop skills in this area. Training will occur at the University Hospital and the Veterans Hospital. The trainee will be part of an interventional endoscopy team performing interventional procedures, evaluating patients pre- and post-procedure, and evaluating the results of therapeutic endoscopy.

Endoscopic training

ERCP
Diagnostic and therapeutic endoscopy of the pancreas and biliary tree will be performed at both hospitals. Specific procedures include cholangiography, pancreatography, sphincterotomy, sphincter of Oddi manometry, biliary and pancreatic dilation and stenting, and stone extraction and lithotripsy in both the pancreatic and biliary tree. Limited experience in cholangioscopy is available. Close collaboration with diagnostic and interventional radiologists will provide additional training in the interpretation of radiographs.

Endoscopic hemostasis
Training will be provided in all available methods for endoscopic treatment of gastrointestinal bleeding. These include multipolar electrocautery, heater probe, injection therapy, and argon plasma coagulation and endoscopic clips.  Band ligation of esophageal varices is included in this experience. Emergency procedures will be performed on an on-call basis. Elective procedures will be scheduled through the endoscopy lab.

Endoscopic Ultrasound
The program will provide exposure to basic endoscopic ultrasonography. More intensive training is available, depending upon the interest and skill of the trainee.

Other endoscopic experience
Additional training will include percutaneous gastrostomy and jejunostomy, endoscopic mucosal resection, enteral stents, foreign body removal, colonic decompression, dilation of structures of the esophagus, pylorus and colon, pneumatic dilation for achalasia and endoscopic therapy for Barrett's esophagus.


Hospital Consultations

The trainee will participate as a member of the therapeutic endoscopy team for both hospitals. Consultations from various services regarding interventional procedures will be performed and staffed by a faculty member. Emphasis will be placed upon the appropriate use of endoscopic procedure, including the indications, contraindications, risks and benefits of different procedures. Close working relationships with the medicine, surgery and radiology faculty facilitate this training.

Outpatients Clinics
Participate in a weekly outpatient clinic will allow the evaluation of patients for potential endoscopic therapy and the subsequent care of patients after the procedure is completed. This longitudinal care will emphasize the appropriate role of endoscopy in the overall management of different medical problems.

Conferences
The training program involves participation in all conferences of the Gastroenterology Division. These include a weekly multi-disciplinary conference, monthly journal club, and pathology, radiology, and research conferences, as well as a monthly motility conference.

Research Activities

Clinical trials
The trainee will be expected to participate in at least one clinical trial during the training year. Prospective trials in the field of interventional endoscopy are anticipated. This research will be planned in conjunction with a faculty member, but will be the primary responsibility of the trainee. The project should be initiated at the start of the training period.

Basic research
By special arrangement, opportunities for participation in ongoing basic research are available.

Other activities
A commitment to scholarship is an integral part of the training program. In addition to a prospective clinical trial, the trainee will be expected to prepare at least one additional manuscript for publication. This may be a case report, critical subject review, or retrospective study.
Participation in annual meetings
During the course of the training period, the trainee will be expected to submit an abstract for presentation at one national meeting AGA, ASGE, AASLD, or ACG).

Evaluation
Trainees will be evaluated quarterly on clinical, endoscopic, and cognitive skills. Evaluations will be performed by individual faculty members based on a standard American College of Physicians format. A summary trainee evaluation will be prepared by a faculty committee. This summary will be promptly provided to the trainee, with an opportunity for feedback.