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GASTROENTEROLOGY CURRICULUM

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GASTROENTEROLOGY CURRICULUM Powered By Docstoc
					     GASTROENTEROLOGY
        CURRICULUM

Division of Gastroenterology and Liver Diseases
      The George Washington University




                       1
                        TABLE OF CONTENTS


I.     Faculty                                         2

II.    Introduction                                    3

III.   Mission                                         4

IV.    Program Require ments                           5

V.     Curriculum Overvie w                            6

VI.    Curriculum Requirements                         7

VII.   Clinical Competencies                           10

VIII. Methods of Teaching                              13

IX.    Methods of Evaluation                           14

X.     Performance Crite ria for GI Endoscopy          15

XI.    Principle Learning Activities and Conferences   20

XII.   Principle Educational Goals by Competency       21

XIII. Evaluation of Program and Faculty                33

XIV.   Salaries and Benefits                           34

XV.    AGA Task Force Overview                         38




                                     2
   FACULTY
Marie L. Borum, MD, EdD, MPH
Professor of Medicine
Director, Division of Gastroenterology and Liver Diseases



M. Ali Aamir, MD
Assistant Professor of Medicine

Showkat Bashir, MD
Assistant Professor of Medicine

Paul Chang, MD
Clinical Professor of Medicine

Leonard Ehrlich, MD
Clinical Associate Professor

Allen Ginsbe rg, MD
Professor of Medicine

Sands Irani, MD
Clinical Professor of Medicine

Patricia Latham, MD          (Hepatology)
Associate Professor of Medicine and Pathology

Ephraim Nsien, MD
Assistant Professor of Medicine

Zobair Younossi, MD          (Hepatology)
Professor of Medicine (appointment pending)


Adjunct Faculty
Michael Albert, MD
Clinical Professor of Medicine




                                           3
                                   INTRODUCTION

This curriculum is developed for the use of gastroenterology fellows at The George
Washington University. It is designed to outline the curricular goals and expectations for
the gastroenterology fellows. This curriculum is structured around the six Accreditation
Council of Graduate Medical Education (ACGME) core competencies. There is also
information about the institution, faculty, evaluation processes, schedules and
conferences.




                                             4
                                       MISSION

The Gastroenterology fellowship at the George Washington University is designed to set
the highest standard for excellence in training. The purpose of the gastroenterology
training program is to ensure that trainees have the appropriate breadth and depth of
training in the field of gastroenterology and hepatology. The fellows who complete this
program will:

1.     be competent to act as consultants in the field of gastroenterology / hepatology
2.     be capable of pursuing careers in academic medicine or clinical practice
3.     possess habits of life- long learning that will continue to enhance their knowledge,
       skills and professionalism.




                                             5
                            PROGRAM REQUIREMENTS


EDUCATIONAL PROGRAM
1.  18 months of clinical gastroenterology with 5 months of hepatology
2.  Formal instruction, clinical experience and competence in 26 content areas
3.  Formal instruction, experience and competence in technical procedures
4.  Formal instruction in 8 related topic areas


FACULTY
The key clinical faculty and the program director are board-certified

The gastroenterology program presently consists of 4 fellows with the intention of
program expansion to 6 fellows (2 per training year). There are 9 institutionally-based
key clinical faculty and 2 adjunct faculty. In addition, a minimum of 3 faculty members
and the program director have >10 hours / week devoted to the fellowship. Three of the
clinical faculty members have a hepatology focus. Two of the key clinical faculty must
have advanced endoscopy focus.


PROCEDURAL REQUIREMENTS
The newly proposed procedure requirements are documented in the Curriculum
Requirement Section.


                           FACILITIES AND RESOURCES

GI PROCEDURE LABORATORY
The GI procedure laboratory has an up-to-date array of diagnostic and therapeutic
endoscopic instruments and accessories.


SUPPORT SERVICES
The Division of Gastroenterology has access to support services that include pathology,
radiology, surgery, oncology and parasitology.


FACILITIES
The Division of Gastroenterology has access to Intensive Care Units and the ability to
have close interaction with subspecialties, including surgery, oncology, pediatrics,
radiology and pathology.




                                             6
                             CURRICULUM OVERVIEW

The content of the gastroenterology curriculum is based upon an assessment of the
knowledge and skills desired at the completion of fellowship training, review of the
ACGME requirements and the Tasks Force recommendations from the American
Gastroenterological Association and American Society of Gastrointestinal Endoscopy.
The Task Force recommendations are the results of the efforts of major gastroenterology
/ hepatology societies. This curriculum is written in effort to set the highest standard for
excellence in training.


The gastroenterology training at George Washington University consists of 3 years of
training. The core clinical curriculum requires a minimum of 18 months of clinical
activity and consists of traditional inpatient and outpatient consultation experience
supplemented by conferences and didactic sessions. A longitudinal outpatient experience
is required during their 3 years of training. Training in the ba sic endoscopic skills are
supported by the curriculum. Training in advanced procedures (i.e. ERCP, endoscopic
ultrasound) is reserved for selected trainees who have demonstrated endoscopic skill and
desire procedural experience for advanced interventional endoscopy. Programmatic
requirements for specific content areas and endoscopic expectations are outlined. In
addition there is a requirement for substantive research experience of not less than 6
months.




                                              7
                          CURRICULUM REQUIREMENTS

Gastroenterology fellows have formal instruction, clinical experience and opportunities to
acquire expertise in the evaluation and management of the following disorders

1.     Esophageal diseases
2.     Acid peptic disorders
3.     Motility disorders
4.     Irritable bowel syndrome
5.     Nutrient assimilation disorders
6.     Inflammatory bowel disease
7.     Vascular disorders of the gastrointestinal tract
8.     Gallstones and cholecystitis
9.     Biliary and pancreatic disorders
10.    Acute and chronic hepatitis
11.    Chronic liver disease
12.    Drug- induced hepatic injury
13.    Alcoholic liver disease
14.    Cholestatic syndromes
15.    Infections of the gastrointestinal tract (including bacterial, retroviral, mycotic, and
       parasitic)
16.    Gastrointestinal diseases with an immune basis
17.    Gastrointestinal manifestations of HIV infections
18.    Gastrointestinal and pancreatic neoplasms
19.    Hepatobiliary neoplasms


Gastroenterology fellows have formal instruction, clinical experience and opportunities to
acquire expertise in the evaluation and management of patients with the following
clinical problems

1.     Dysphagia
2.     Abdominal pain
3.     Acute abdomen
4.     Nausea and vomiting
5.     Diarrhea
6.     Constipation
7.     Gastrointestinal bleeding
8.     Jaundice
9.     Cirrhosis and portal hypertension
10.    Malnutrition
11.    Genetic / inherited disorders
12.    Depression, neurosis and somatization syndromes
13.    Surgical care of gastrointestinal disorders




                                              8
The program provides instruction in the indications, contraindications, complications,
limitations and (as appropriate) interpretation of the following diagnostic and therapeutic
techniques and procedures

A.     Imaging of the digestive system, including
       1.    ultrasound
       2.    computed tomography
       3.    magnetic resonance imaging
       4.    vascular radiography
       5.    nuclear medicine

B.     Percutaneous cholangiography
C.     Percutaneous endoscopic gastrostomy
D.     Gastric, pancreatic and biliary secretory tests
E.     Diagnostic and therapeutic procedures utilizing enteral intubatio n and bougienage
F.     Enteral and parenteral alimentation
G.     Liver transplantation
H.     Pancreatic needle biopsy
I.     ERCP, including papillotomy and biliary stent placement


Opportunities are provided for the gastroenterology fellow to gain competence in the
performance of the following procedures. If the ACGME or the gastroenterology
societies suggest a minimum number of procedures, it is noted. A skilled preceptor is
available to teach and to supervise the procedures. Each gastroenterology fellow
documents the procedures performed in a procedure log. The fellow’s log includes the
procedure performed, the indication and outcomes of the procedure, the patient’s
diagnoses and the supervising physician(s).

A.     Esophagogastroduodenoscopy (EGD)                              -      130
B.     Esophageal dilatation                                         -      20
C.     Proctoscopy
D.     Flexible sigmoidoscopy                                        -      30
E.     Colonoscopy                                                   -      140
F.     Colonoscopy with polypectomy                                  -      30
G.     Percutaneous liver biopsy                                     -      20
H.     Percutaneous endoscopic gastrostomy (PEG)                     -      15
I.     Biopsy of the esophagus, stomach, small bowel and colon
J.     Gastrointestinal motility disorders
K.     Nonvariceal hemostasis (upper and lower)                      -       25
                                                                     (10 active bleeders)
L.     Variceal hemostasis                                           -       20
                                                                     (5 active bleeders)
M.     Enteral and parenteral alimentation




                                             9
The program provides instruction and emphasis on the pathogenesis, manifestations and
complications of gastrointestinal disorders, including the behavioral adjustments of
patients to their problems. The impact of various modes of therapy and the appropriate
utilization of laboratory tests and procedures is also stressed.

The program also has formal instruction (lectures, conferences, seminars) on specific
content areas that include the following.

A.     Anatomy, physiology, pharmacology and pathology related to the gastrointestinal
       system, including the liver
B.     The natural history of digestive diseases
C.     Factors involved in nutrition and malnutrition
D.     Surgical procedures employed in relation to digestive system disorders and their
       complications
E.     Prudent, cost-effective and judicious use of special instruments, tests, and therapy
       in the diagnosis and management of gastroenterologic disorders
F.     Liver transplantation
G.     Sedation and sedative pharmacology
H.     Interpretation of abnormal liver chemistries




                                            10
                            CLINICAL COMPETENCIES

The Accreditation Council of Graduate Medical Education (ACGME) Core
Competencies introduced six defined areas of competency which residents must obtain
over the course of their training. The core competencies, established in July 2001, are
outlined below.

1.     PATIENT CARE

Residents are expected to delivery patient care that is compassionate, appropriate,
and effective for the treatment of health proble ms and the promotion of health.
a.     Residents are expected to provide patient care that is compassionate, appropriate
       and effective for the promotion of health, prevention of illness, treatment of
       disease and care at the end of life.
b.     Gather accurate, essential information from all sources, including medical
       interviews, physical examination, records, and diagnostic/therapeutic procedures.
c.     Make informed recommendations about preventive, diagnostic, and therapeutic
       options and interventions that are based on clinical judgement, scientific evidence,
       and patient preferences.
d.     Develop, negotiate and implement patient management plans.
e.     Perform competently the diagnostic procedures considered essential to the
       practice of gastroenterology and hepatology


2.     MEDICAL KNOWLEDGE

Residents are expected to demonstrate knowledge about established and evolving
biome dical, clinical and cognate (e.g. epidemiological and social-behavioral) sciences
and the application of the knowledge in patient care.
a.     Residents are expected to demonstrate knowledge of established and evolving
       biomedical, clinical and social sciences, and demonstrate the application of their
       knowledge to patient care and education of others.
b.     Apply an open- minded and analytical approach to acquiring new knowledge
c.     Develop clinically applicable knowledge of the basic and clinical sciences that
       underlie the practice of gastroenterology and hepatology
d.     Apply this knowledge in developing critical thinking, clinical problem solving
       and clinical decision-making skills.
e.     Access and critically evaluate current medical information and scientific evidence
       and modify knowledge base accordingly.




                                            11
3.     PRACTICE-BASED LEARNING AND IMPROVEMENT

Residents are expected to demonstrate practice-based learning and improve ment
that involves investigation and evaluation of their own patient care, appraisal and
assimilation of scientific evidence, and improvements in patient care.
a.      Residents are expected to be able to use scientific methods and evidence to
        investigate, evaluate, and improve their patient care practices.
b.      Identify areas for improvement and implement strategies to improve their
        knowledge, skills, attitudes and processes of care
c.      Analyze and evaluate their practice experiences and implement strategies to
        continually improve their quality of patient practice
d.      Develop and maintain a willingness to learn from errors and use errors to improve
        the system or processes of care
e.      Use information technology or other available methodologies to access and
        manage information and support patient care decisions and their own education


4.     INTERPERSONAL AND COMMUNICATION SKILLS

Residents are expected to demonstrate interpersonal and communication skills that
result in effective information exchange and teaming with patients, their families
and other health professionals.
a.      Residents are expected to demonstrate interpersonal and communication skills
        that enable them to establish and maintain professional relationships with patients,
        families and other members of health care teams.
b.      Residents are expected to demonstrate interpersonal and communication skills
        that enable them to establish and maintain professional relationships with
        members of the health care teams.
c.      Provide effective and professional consultation to other physicians and health care
        professionals and sustain therapeutic and ethically sound professional
        relationships with patients, their families, and colleagues.
d.      Use effective listening, nonverbal questioning and narrative skills to communicate
        with patients and families
e.      Interact with consultants in a respectful and appropriate fashion
f.      Maintain comprehensive, timely and legible medical records




                                            12
5.     PROFESSIONALISM

Residents are expected to demonstrate professionalis m as manifested through a
commitment to carrying out professional responsibilities, adhe rence to ethical
principles, and sensitivity to a diverse patient population.
a.     Residents are expected to demonstrate behaviors that reflect a commitment to
       continuous professional development and ethical practice.
b.     Residents are expected to demonstrate an understanding and sensitivity to
       diversity and responsible attitude toward their patients, their profession and
       society.
c.     Demonstrate respect, compassion, integrity, and altruism in their relationships
       with patients, families and colleagues.
d.     Demonstrate sensitivity and responsiveness to patients and colleagues, including
       gender, age, culture, religion, sexual preference, socioeconomic status, beliefs,
       behaviors and disabilities
e.     Adhere to principles of confidentiality, scientific/academic integrity, and
       informed consent
f.     Recognize and identify deficiencies in peer performance


6.     SYSTEMS-BASED PRACTICE

Residents are expected to demonstrate systems-based practice as manifested by
actions that de monstrate an aware ness of and responsiveness to the larger context
and system of health care and the ability to effectively call on system resources to
provide care that is of optimal value.
a.     Residents are expected to demonstrate and understanding of the contexts and
       systems in which health care is provided and demonstrate the ability to apply this
       knowledge to improve and optimize health care
b.     Understand access, and utilize the resources and providers necessary to provide
       optimal care
c.     Understand the limitations and opportunities inherent in various practice types
       and delivery systems, and develop strategies to optimize care for the individual
       patient.
d.     Apply evidence-based, cost-conscious strategies to prevention, diagnosis and
       disease management.
e.     Collaborate with other members of the health care team to assist patients in
       dealing effectively with complex systems and to improve systematic processes of
       care.




                                            13
                             METHODS OF TEACHING

In order to achieve the goals and objectives for the fellowship program, the following
experiences have been established for the purpose of teaching gastroenterology fellows.
These methods include: (1) the inpatient gastroenterology experience, (2) the outpatient
gastroenterology experience, (3) interaction with other clinical specialties, (4)
conferences, (5) research experience, and (6) continuing medical education and society
participation.




                                            14
                            METHODS OF EVALUATION

In order for the gastroenterology training program to assess its ability to achieve the goals
and objectives, an evaluation process that includes global assessments, observation,
standardized patients and written examinations has been developed.


1.       GLOBAL ASSESSMENTS
These assessments are conducted twice yearly by gastroenterology attendings and are
included in the permanent record. Twice annually the faculty reviews the performance of
the fellows in written evaluation. These are compiled on standard forms that assess
medical knowledge, clinical skills, clinical judgement, humanistic qualities, professional
attitudes and commitment to scholarship. Evaluations of the fellows are also solicited
from residents, staff and patients (360 o evaluation). The program director receives all of
the written evaluations, which are kept in the fellow’s master file. Fellows may request a
meeting at any time to personally review their files.

Semi-annually, fellows meet individually with the program director to formally review
their evaluations. The meeting is to provide feedback to the fellow on their performance
and to identify areas for professional enhancement. The program director reviews the log
of each fellow’s procedures, consults and conference attendance. A written summary of
this session is placed in the fellow’s permanent record.


2.      OBSERVATION
Focused, personal observation assessments will be completed using the Mini-cex format
by the gastroenterology attendings.


3.      STANDARDIZED PATIENTS
Examinations using standardized patients will be videotaped in the George Washington
University Hospital education resource center that is specifically designed for such
training activities.


4.     WRITTEN EXAMINATION
The residents participate in the annual standardized examination that is offered by the
American Gastroenterological Association. The results are reviewed and an
individualized program of instruction and learning is developed based upon the residents’
performance.




                                             15
                         Guidelines for Endoscopic Training
                             Parameters of Competency

1.    reviews records, x-rays, identified risk factors

2.    understands and discusses appropriate alternative procedures

3.    correctly identified indication, knows how the endoscopic procedure may
      influence management

4.    obtains appropriate informed consent

5.    demonstrates proper use of premedication and noninvasive patient monitoring
      devices

6.    inserts the endoscope using proper technique

7.    performs procedure with attention to patient comfort and safety

8.    correctly identified landmarks

9.    conducts thorough examination of the entire organ

10.   detects and identifies all significant pathology

11.   completes examination within a reasonable time

12.   prepares an accurate report

13.   plans correct management and disposition

14.   discusses findings with patient and other physicians

15.   conducts proper follow- up, review of pathology, case outcome




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            PERFORMANCE CRITERIA FOR EVALUATION OF
             DIAGNOSTIC GASTROINTESTINAL ENDOSCOPY
              Procedure                   Performance Criteria
Esophagogastroduodenoscopy (EGD) Esophageal intubation
                                       Pyloric intubation
Colonoscopy                            Navigation through sigmoid colon
                                       Intubation of splenic flexure
                                       Intubation of the hepatic flexure
                                       Intubation of cecum
                                       Intubation of terminal ileum (desirab le skill)
                                       Retroflexion in the rectum
Sigmoidoscopy                          Navigation through the sigmoid colon
                                       Visualization of the splenic flexure
                                       Retroflexion in the rectum
Endoscopic retrograde                  Cannulation of the desired duct
cholangiopancreatography
                                       Opacification of the desired duct
(ERCP)
                                       Sphincterotomy
                                       Stent placement
                                       Stone extraction
Endoscopic ultrasonography             Intubation of esophagus
                                       Intubation of pylorus
                                       Imaging of desired organ and/or lesion
                                       Successful lesion biopsy
                                       Tumor staging in agreement with the
                                       surgical findings and similar to that
                                       reported in the literature
All procedures                         Accurate recognition of normal and
                                       abnormal findings
                                       Development of appropriate
                                       endoscopic/medical treatment in response
                                       to these findings




                                  17
      ASSESSMENT SCHEME FOR CORE CLINICAL COMPETENCIES

Outlined is an assessment scheme developed for the six ACGME Core Clinical
Competencies with identification of the skill(s) being evaluated.


1.     PATIENT CARE (Health Promotion Skills)
       a.   Direct observation (minimum of 5 attending evaluations per year)
            Skill: information gathering and communicating

       b.     Procedure log signed for a required procedures
              Skill: assessing competence in medical procedures

       c.     Completion of a minimum of 30 supervised hospital consultations
              Skill: assessing clinical judgement

       d.     Global evaluations from attendings
              Skill: assessing effective management of patient illness


2.     MEDICAL KNOWLEDGE (Scientific Understanding)
       a.  Written examination
           Skill: assessing knowledge acquisition

       b.     Attendance at one major gastroenterology or hepatology conference per
              year
              Skill: demonstrating self- improvement and acquisition of life- long
              learning skills

       c.     Attendance at gastroenterology conferences
              Skill: development of the ability to interpret and apply evidence-based
              medicine

       d.     Review of core curriculum checklist and required reading
              Skill: ability to locate useful sources of information to enhance medical
              knowledge

       e.     Managed care tutorial available on- line at the School of Medicine
              Himmelfarb Library
              Skill: assessing knowledge acquisition, evidence-based clinical-decision
              making




                                           18
3.   EVIDENCE-BASED LEARNING AND IMPROVEMENT (Assimilation of
     Scientific Information)
     a.     Presentation at a minimum of 10 conferences
            Skill: assessing ability to locate, interpret and distill relevant science

     b.     Completion of NIH on- line course on The Protection of Human Study
            Subjects with placement of a copy of the certificate on file
            Skill: assessing ethical implementation of study design.

     c.     Participation in a mentored research project
            Skill: assessing the completion of scholarly activity and apply
            biostatistical techniques

     d.     Attendance at monthly Inter-city Gastroenterology Grand Rounds
            Skill: developing the skill to analyze practice experience and facilitate the
            learning of other health care professionals

     e.     Attendance at monthly Gastroenterology-Surgery-Radiology conference
            Skill: developing the skill to analyze practice experience and facilitate the
            learning of other health care professionals

     f.     Attendance at monthly Inflammatory Bowel Disease confere nce
            Skill: developing the skill to analyze practice experience and facilitate the
            learning of other health care professionals

     g.     Attendance at monthly Complicated Case conference
            Skill: developing the skill to analyze practice experience and facilitate the
            learning of other health care professionals

     h.     Attendance at monthly Hepatitis C management conference
            Skill: developing the skill to analyze practice experience and facilitate the
            learning of other health care professionals

     i.     Attendance at monthly Morbidity and Mortality conference
            Skill: developing the skill to analyze practice experience and facilitate the
            learning of other health care professionals

     j.     Attendance at weekly Endoscopy Case conference
            Skill: developing the skill to analyze practice experience and facilitate the
            learning of other health care professionals




                                          19
4.   INTERPERSONAL COMMUNICATION (Effective and Empathetic
     Inte rpersonal Exchange)
     a.      Direct observation
             Skill: effective nonverbal assessment technique

     b.     Standardized patients (direct observation)
            Skill: effective verbal assessment techniques

     c.     Attendance at Fellows’ Core Curriculum lecture series
            Skill: medical records management, effective communication, and
            understanding business and legal practice as it relates to gastroenterology
            and liver disease.


5.   PROFESSIONALISM (Ethics and Cultural Sensitivity)
     a.   Direct Observation
          Skill: demonstrates respect, compassion, integrity and altruism

     b.     Standardized patient examinations (direct observation)
            Skill: demonstrates respect, compassion, and integrity

     c.     Completion of NIH on- line course on The Protection of Human Study
            Subjects with placement of a copy of the certificate on file.
            Skill: recognizes ethical dilemmas and maintains confidentiality.

     d.     Attend Fellows’ Core Curriculum lecture series
            Skill: recognizes impact of disability and cultural issues


6.   SYSTEMS-BASED PRACTICE (Advocacy, partne ring and cost-
     effectiveness in health care delivery)
     a.      Direct observation
             Skill: functions effectively as part of a health care team

     b.     Attend Fellows’ Core Curriculum lecture series
            Skill: familiarity with coding, documentation and reimbursement

     c.     Letters of completion of radiology, pathology and nutrition rotations
            Skill: able to collaborate with ancillary care services




                                          20
           PRINCIPAL LEARNING ACTIVITIES AND CONFERENCES

Attendance at all conferences is required by the Gastroenterology Fellows when they are
fulfilling their duties at George Washington University. Gastroenterology faculty
members are expected to attend scheduled conferences.


PRINCIPAL PATIENT CARE ACTIVITIES

Continuity Clinic
Each fellow is assigned to 2-3 continuity clinics throughout their gastroenterology
fellowship. Each fellow is assigned to a physician for general gastroenterology care. In
addition, specialty clinics to which they are assigned at varying portions of their training
include inflammatory bowel disease, motility disorders, liver disease and pancreatico-
biliary diseases.

Hospital Attending Rounds
Five mornings each week (Monday through Friday) the GI fellows, internal medicine
residents and students on the gastroenterology elective meet with the attending physician
assigned to the inpatient services. All of the patients who are hospitalized are discussed.
There is a review of the pathophysiology of the medical condition supplemented with
literature pertinent to the clinical circumstances resulting. Evidence-based clinical
decision- making is performed. Written consultations are reviewed. Each patient is seen
and examined at the bedside.

Procedure Teaching
All procedures performed on patients (inpatient or outpatient) by gastroenterology
fellows are directly supervised by an attending physician. These procedures include
fiberoptic endoscopy with or without diagnostic procedures (i.e. upper endoscopy, small
bowel enteroscopy, flexible sigmoidoscopy, colonoscopy) advanced endoscopic
procedures (i.e. endoscopic retrograde cholangiopancreatography, endoscopic
ultrasonography), esophageal manometry and pH studies, liver biopsy and capsule
endoscopy. The fellows are required to maintain a log of the procedure s that the have
performed. They are monitored on a yearly basis for completeness and accuracy.




                                             21
ACADEMIC CONFERENCES


Board Review
Conference meets monthly. All fellows and coordinating faculty members are expected to
attend. Cases and questions are discussed to prepare for gastroenterology specialty board
examination.

City-wide Gastroenterology Grand Rounds
Conference meets once a month. Participants include all of the fellows and faculty
members of gastroenterology divisions in the Washington, D.C.-area. Institutions that
participate include George Washington University, Georgetown University, Howard
University, Washington Hospital Center, National Institutes of Health and Walter Reed
Medical Center. The fellows are required to present a case and disc uss findings and
management using evidence-based medical information

Complicated Case and Quality Review Conference
Conference meets once a month. Fellows and faculty present difficult management cases,
complemented by pertinent literature. Systems and judgement errors are reviewed in a
constructive fashion in an effort to continually improve clinical decision- making. Plans
are developed to implement new procedures and policies to avoid similar errors /
complications in the future. Individual judgement errors are addressed as necessary by
the faculty and director of gastroenterology fellowship.

Didactic Lectures
Conference meets three times a month. Faculty members of the Division of
Gastroenterology and Departments of Surgery, Radiology and Pathology offer didactic
session that review pertinent issues important in the gastroenterology and hepatology
fellowship training. These include conferences focussed upon pathophysiology and
disease entities.

Endoscopy Case Confe rence
Conference meets monthly. Participants include faculty, fellows and nursing staff
involved in procedures. The fellows are expected to review a case involving endoscopy
and present a video of the endoscopic procedure with discussion of the literature that
addresses issues related to management and the endoscopic intervention.

Gastroente rology – Surgery – Radiology Confe rence
Conference meets once a month. Participants in the conference include residents, fellows
and faculty members of the Division of Gastroenterology, Department of Surger y and
Department of Radiology. Medical residents and faculty members of other specialties
(i.e. Oncology, Pathology) are invited to attend when there are cases when there is
overlapping specialty interests. Gastroenterology fellows are required to present case and
provide a review of appropriate literature pertinent for the discussion.




                                            22
Graduate Medical Education Core Lecture Series
Conference meets monthly. All internal medicine subspecialty fellows are required to
attend the lecture series. The lectures has been developed to address professionalism
through discussions with experts in areas of: (1) principled negotiation, (2) risk
management, (3) law and medicine, (4) medical errors, (5) medical ethics, (6) ethics
committee, (7) quality assurance.

Inflammatory Bowel Disease Conference
Conference meets once a month. The conference includes a review of cases and
discussion of the literature that addresses issues related to emerging therapies and
management.

Inte rnal Medicine Grand Rounds
Conference meets weekly and is the only conference in which all of the internal medicine
residents, subspecialty fellows and Department of Medicine faculty attend. Local,
national and internationally recognized faculty are invited to address the Department of
Medicine. The subjects are varied and the invited speakers are chosen from a variety of
disciplines. Following the Grand Round presentations, the speaker will often interact with
resident physicians or subspecialty fellows in a lecture format or on rounds. The Division
of Gastroenterology is expected to have faculty members give at least one Grand Round
presentation annually.

Journal Club
Conference meets twice a month. Fellows are required to select a manuscript from an
approved, peer-reviewed journal. Each fellow reviews one article at the conference. The
fellows are expected to discuss the findings providing a critical review of the study
design and application for clinical practice (if appropriate).

Liver Conference
Conference meets quarterly. Fellows and faculty members from George Washington
University and other institutions meet to discuss liver disease cases. Fellows are expected
to discuss the case and provide a review of the pertinent literature.

Morbidity and Mortality Conference
Conference meets monthly. Participants include the faculty, fellows and nursing staff
involved in procedures. The faculty and fellows are expected to present the clinical
outcome and complications of hospitalized patients. Systems and judgement errors are
reviewed in a constructive fashion in an effort to continually improve clinical decision-
making. Plans are developed to implement new procedures and policies to avoid similar
errors / complications in the future. Individual judgement errors are addressed as
necessary by the faculty and director of gastroenterology fellowship.




                                             23
Pathology Conference
Conference meets twice a month. Fellows and faculty members of the Division of
Gastroenterology and Department of Pathology present the cases of individuals who have
pathology specimens for review. Fellows are expected to discuss the case and provide a
review of the pertinent literature.

Research Conferences
Conference meets monthly. The conference reviews research concepts, protocol design
and statistical review. Fellows and faculty members are also responsible for presenting
updates on on-going research, presentations and publications. These research projects are
critically appraised by participants in the conference.

All fellows are expected to design and complete a research project. Ind ividual research
meetings occur with the fellows and Director of the Division reviewing their research
investigations.

The Division director also has research meetings with students and internal medicine
residents who are conducting research in gastroenterology. Fellows are invited to attend
these conferences and are frequently involved in the conduction of these ongoing
projects.

Viral Hepatitis Management Confe rence
Conference meets 2-4 times a month. Participants include fellows, physician assistants
and faculty involved in the care of chronic hepatitis C. The conference is focused upon
the discussion of patients who are actively receiving therapy, have complicated
management issues or are involved or being considered for clinical trials. Review of
pertinent literature is offered. Research trials and study design for patients with chronic
viral hepatitis C are also discussed during this conference.

Visiting Scholars, Professors and Investigators Conference
Conferences in which visiting scholars, professors and investigators are held to support
the stimulation of new thoughts and ideas among fellows and faculty.



                                 Additional Conferences

American Society of Gastrointestinal Endoscopy (ASGE) First-Year Fellow
Endoscopy Course
The first year fellows are given the opportunity to participate in the Endoscopy Course
that is offered by the ASGE. The course offers an overview of endoscopy and hands-on
experience in endoscopic procedures. (The agenda for the course is in the appendix.)




                                             24
William B. Steinbe rg Board Review Course
This 3-day course meets annually in the Washington, D.C. area. Two fellows are given
the opportunity to participate in the course. Additional fellows are given the opportunity
to attend based upon funding sources.

Walter Reed Gastroenterology Course
This 3-day course meets every other year. Two fellows are given the opportunity to
participate in the course. Additional fellows are given the opportunity to attend based
upon funding sources.

Annenberg Inflammatory Bowel Disease Course
This is a 3-day course that meets annually. Application is made annually to offer one
fellow the opportunity to participate in the course.

Society and Educational Meetings
Each fellow attends a minimum of one approved conference annually. The conference
can be an international or national society meeting or educational course approved by the
director. In addition, the fellow may also attend conferences in which they are presenting
research.




Examples of society meetings in which GI fellows have participated include:
      American Gastroenterological Association (AGA)
      American College of Gastroenterology (ACG)
      American Society of Gastroenterology Endoscopy (ASGE)
      American Association of the Society of Liver Diseases (AASLD)
      Digestive Disease Week

Examples of educational meetings in which GI fellows have participated include:
      William B. Steinberg Board Review Courses
      Walter Reed Gastroenterology Review
      International Conference on Capsule Endoscopy
      American Gastroenterological Association (AGA) Educational Symposiums
      American Gastroenterological Association (AGA) Review Course
      Annenberg Inflammatory Bowel Disease Course




                                            25
       DIVISION OF GASTROENTEROLOGY AND LIVER DISEASE
                      CONFERENCE SCHEDULE


Monday
Didactic Sessions / Academic Lectures        noon   2nd
Research Conference                          noon   1st
City-wide Grand Rounds                       5 pm   2nd

Tuesday
Inflammatory Bowel Disease Conference        noon   1st
Journal Club                                 noon   2nd, 4th
Complicated Case Conference                  noon   3rd
GI-Surgery-Radiology Conference              5 pm   1st
Liver Conference                             5 pm   3rd

Wednesday
Didactic Sessions / Academic Lectures        8 am   1st , 3rd
Staff Conference                             noon   1st , 3rd

Thurs day
Internal Medicine Grand Rounds               noon   1st , 2nd, 3rd, 4th
Chronic hepatitis management                 4 pm   1st , 2nd, 3rd, 4th

Friday
Morbidity and Mortality                      8 am   1st
Endoscopy Case Conference                    8 am   1st , 2nd, 3rd, 4th
Pathology Conference                         noon   1st , 3rd
Board Review Conference                      noon   2nd
Fellow Meeting                               noon   4th




                                        26
PRINCIPLE EDUCATIONAL GOALS BY RELEVANT COMPETENCY


Legend for Learning Activities

Direct Patient Care
Continuity Clinics (CC)
Hospital Attending Rounds (HR)
Procedure Teaching (PT)

Educational Conferences and Meetings
Board Review Seminar (BR)
Complicated Case and Quality Review Conference (CCQR)
Didactic Lectures (DL)
Endoscopy Case conference (EC)
Gastroenterology – Surgery – Radiology Conference (GSR)
Graduate Medical Education Core Lectures Series (GME)
Grand Rounds (GR)
Viral Hepatitis Management Conference (HC)
Inflammatory Bowel Disease Conference (IBD)
Inter-City Gastroenterology Grand Rounds (ICGR)
Journal Club (JC)
Liver Conference (LC)
Morbidity and Mortality Conference (MM)
Pathology Conference (PC)
Research Conferences (RC)
Society and Educational Meetings (EM)


Legend for Evaluation Methods

Attending Evaluations (AE)
Directly Supervised Procedures (DSP)
Program Director’s Review (PDR)
Peer Review (PR)
Semi- Annual Exam (SE)
Standardized Patient Evaluation (SPE)




                                        27
PATIENT CARE

Principal Education Goals     Learning Activities     Evaluation Methods
Perform a complete medical    CC, HR                  AE, PDR, SPE
history
Perform a comprehensive       CC, HR, PT              AE, DSP, PDR, SPE
examination
Formulate comprehensive       CC, HR, PT, CCQR, DL.   AE, PDR, SE, SPE
and accurate problem lists    GSR, HC, IBD, LC, MM
Generate and prioritize       CC, HR, PT, CCQR, DL,   AE, PDR, SE, SPE
differential diagnosis        EC, GSR, HC, IBD, LC,
                              MM
Develop rational, evidence-   CC, HR, CCQR, DL, EC,   AE, PDR, SE, SPE
based management              GSR, HC, IBD, LC, MM
strategies
Develop concise, accurate,    CC, HR, PT              AE, DSP, PDR, SPE
rational, informative
consultation
Ability to recognize major    CC, HR, PT, GSR         AE, PDR, SE
abnormalities on radiologic
studies
Ability to determine and      CC, EC, HR, PT          AE, DSP, PDR
perform appropriate
diagnostic and therapeutic
procedures




                                           28
MEDICAL KNOWLEDGE

Principal Education Goals     Learning Activities       Evaluation Methods
Demonstrate knowledge of      BR, CC, HR, PT, CCQR,     AE, PDR, SE, SPE
basic and clinical sciences   DL, GSR, HC, IBD, ICGR,
underlying patient care       LC, MM, PC
Demonstrate an analytical     BR, CC, HR, PT, CCQR,     AE, PDR, SE
approach to acquiring new     DL, GSR, HC, IBD, ICGR,
knowledge                     JC, LC, MM, PC, RC
Demonstrate continued         BR, CC, HR, PT, CCQR,     AE, DSP, PDR, SE, SPE
advancement of knowledge      DL, EC, GSR, HC, IBD,
                              ICGR, JC, LC, MM, PC,
                              RC
Apply knowledge in the        BR, CC, HR, PT, CCQR,     AE, PDR, SE, SPE
development of critical       DL, EC, GSR, HC, IBD,
thinking, problem-solving     ICGR, LC, MM, RC
and decision- making
Assess and critically         BR, CCQR, DL, GSR, HC,    AE, PDR, SE, SPE
evaluate current medical      IBD, ICGR, JC, LC, MM,
information and scientific    PC, RC
evidence and modify
knowledge base accordingly
Demonstrate the knowledge     BR, CC, HR, PT, CCQR,     AE, DSP, PDR, SE, SPE
of the indications for,       EC, GSR, HC, IBD, ICGR,
principles, complications     LC, MM
and interpretations of
specialized tests and
procedures




                                         29
EVIDENCE-BASED LEARNING AND IMPROVEMENT

Principal Education Goals      Learning Activities      Evaluation Methods
Use scientific methods and     CC, HR, CCQR, DL, GSR,   AE, PDR, SE
evidence to investigate,       HC, IBD, ICGR, MM
evaluate and improve
patient care
Identify areas of              CC, HR, CCQR, DL, GSR,   AE, PDR, SE
improvement and                HC, IBD, ICGR, MM
implement strategies to
improve knowledge, skills,
attitudes and care processes
Analyze and evaluate           CC, HR, PT, CCQR, GSR,   AE, PDR, SE
practice experiences and       HC, IBD, ICGR, LC, MM,
continually improve quality    PC
of patient practice
Maintain a desire to learn     CC, HR, PT, CCQR, GSR,   AE, PDR, SE
from errors and improve the    GME, HC, LC, MM, PC,
system or processes of care
Use information technology     CC, HR, PT, CCQR, GSR,   AE, PDR, SE
and other methodologies to     HC, JC, LC, MM, PC
assess and manage
information




                                         30
INTERPERSONAL SKILLS AND COMMUNICATION

Principal Education Goals      Learning Activities     Evaluation Methods
Demonstrate interpersonal      CC, HR, PT              AE, PDR, PR, SPE
skills that establish and
maintain professional
relationships with patients,
families, and members of
health care teams
Demonstrate interpersonal      CC, HR                  AE, PDR, PR, SPE
skills that establish and
maintain professional
relationships with members
of health care teams
Provide effective and          CC, HR, PT, CCQR, HC,   AE, DSP, PDR
professional consultations     IBD, ICGR, LC, MM
Demonstrate effective          CC, HR, PT              AE, PDR, PR, SPE
listening, nonverbal
questioning and narrative
skills to communicate with
patients
Demonstrate respectful and     CC, HR, PT              AE, PDR, PR
appropriate interactions
with consultants
Maintain comprehensive,        CC, HR, PT              AE, PDR
timely and legible medical
records




                                            31
PROFESSIONALISM

Principal Education Goals       Learning Activities       Evaluation Methods
Demonstrate a commitment        CC, HR, PT, CCQR, DL,     AE, DSP, PDR, PR
to professional development     GSR, GME, GR, HC, IBD,
and ethical practice            ICGR, JC, LC, MM, PC,
                                RS, EM
Demonstrate and                 CC, HR, PT, CCQR, DL,     AE, PDR, PR, SPE
understanding and               GME, HC, IBD, LC, MM,
sensitivity to diversity and    EM
responsible attitude toward
patients, profession and
society
Demonstrate respect,            CC, HR, PT, CCQR, GME,    AE, DSP, PDE, PR, SPE
compassion, integrity and       HC, IBD, LC, MM
altruism in relationships
with patients, families and
colleagues
Demonstrate sensitivity and     CC, HR, PT, CCQR, GSR,    AE, PDR, PR, SPE
responsiveness to patients      GME, HC, IBD, ICGR, LC,
and colleagues, including       MM
gender, age, culture,
religion, sexual preference,
socioeconomic status,
beliefs, behaviors and
disabilities
Adhere to principals of         CC, HR, PT, CCQR, GSR,    AE, DSP, PDR
confidentiality,                GME, HC, IBD, ICGR, LC,
scientific/academic integrity   MM, PC
and informed consent
Recognize and identify          CC, HR, PT, CCQR, GSR,    AE, PDR, PR
deficiencies in peer            HC, IBD, ICGR, LC, MM,
performance                     PC, RC, EM




                                          32
SYSTEMS-BASED PRACTICE

Principal Education Goals     Learning Activities       Evaluation Methods
Demonstrate and               CC, HR, PT, CCQR, GSR,    AE, PDR
understanding of the          HC, IBD, ICGR, LC, MM,
contexts and systems in       PC
which health care is
provided and demonstrate
the ability to apply this
knowledge to improve and
optimize health care
Understand, access, and       CC, HR, PT, CCQR, EC,     AE, DSP, PDR
utilize the resources and     GSR, HC, IBD, ICGR, LC,
providers necessary to        MM, PC
provide optimal care
Understand the limitations    CC, HR, PT, CCQR, GSR,    AE, DSP, PDR
and opportunities inherent    HC, IBD, ICGR, LC, MM
in various practice types
and delivery systems, and
develop strategies to
optimize care for the
individual patient.
Apply evidence-based, cost-   CC, HR, PT, CCQR, GSR,    AE, DSP, PDR
conscious strategies to       HC, IBD, ICGR, JC, LC,
prevention, diagnosis and     MM, PC, EM
disease management.
Collaborate with other        CC, HR, PT, CCQR, GSR,    AE, DSP, PDR, PR
members of the health care    HC, IBD, ICGR, LC, MM,
team to assist patients in    PC, EM
dealing effectively with
complex systems and to
improve systematic
processes of care.




                                         33
EVALUATION OF THE PROGRAM AND FACULTY

The program director specifically inquires about the strengths and weaknesses of the
program at regular meetings with the fellows together and separately. At times,
programmatic adjustments are made on the basis of this feedback. Midway through the
fellowship, evaluation forms will be provided to the fellows and are completed and
submitted to a Fellowship Oversight Committee (which does not include any faculty or
staff member from the Division of Gastroenterology and Liver Diseases). A summary of
the evaluations is given to the program director for review.

Upon completion of the fellowship, individuals are contacted for a formal evaluation of
the program. This is reviewed by the program director with a focus on the perceived
deficiencies. The findings are discussed with faculty so that programmatic alterations can
be made as necessary.




                                            34
                              SALARIES AND BENEFITS


                                        SALARIES

Salaries for the 2004-2005 academic years are as follows:

PGY 4          $45,905.93
PGY 5          $47,686.58
PGY 6          $49,098.07



                                        BENEFITS

The following benefits are available to all George Washington University Fellows. All
benefits are subject to change without advance notice.


              LICENSURE AND MEDICAL LIABILITY COVERAGE

Drug Enforcement Administration (DEA) registration fees for eligible fellows
The DEA registration fee is paid for fellows who are required to obtain a DC medical
license because they graduated from a U.S. medical school at least 3 years ago or are
international medical graduates entering the 4 th year of post-graduate training. The
federal DEA registration fee is reimbursed at the rate of 1/3 the total cost for each year
the fellow remains at GW.

Medical Licensure fees
Fellows are required by law to be licensed in the District of Columbia beginning their 4 th
year of post-graduate training. They will be reimbursed by the GME office for the cost of
the license.

The DC Board of Medicine requires any fellow who has obtained a non-restricted license
in another state to apply for licensure in DC. Fellows must comply with this requirement
and submit proof of licensure to the GME office; however, this cost is not reimbursed
unless the fellow meets appropriate criteria as outlined above. Costs for the GME office
pays for temporary licenses required for training in Maryland or Virginia.

Liability Insurance
Professional liability insurance is provided for those activities and services within the
scope of duties as defined by the program director. Liability insurance is not provided for
activities outside the course and scope of duties within the fellowship training (i.e.
moonlighting)




                                             35
         HEALTH, DISABILITY, LIFE AND RETIREMENT INSURANCE

Health Ins urance
Fellows are eligible to participate in several plans, including Care First BC/BS PPO,
CIGNA HMO and CIGNA PPOs and Care First Blue Choice HMO. The cost to the
fellow depends on the options selected.

Flexible Spending Accounts
This program allows fellows to set aside tax- free dollars in special accounts to pay our of
pocket medical and/or dependent care expenses

Voluntary Dental Plan
Fellows are eligible to participate in the Guardian Life Insurance dental plan. Discounted
dental services are available through dentists associated with the Care First Blue Choice
HMO.

Short term Disability Income Plan
Fellows are eligible to purchase this coverage through the Benefits Office. Provident Life
Insurance is the providers.

Long-Term Disability Insurance
For the first year of training, an individual policy is paid by the Medical Center which
provides $2000 / month after 180 days of total disability, with provisions for partial
claims. This coverage can be continued by the fellow on an individual basis at a
discounted rate after the first year. After the first year of training, fellows are enrolled in
the University Long-Term Disability Insurance plan.

Life Insurance
Basic life and Accidental Death and dismemberment coverage equal to the base
annualized salary is provided at no cost. Optional terms and universal insurance is
available at an additional charge.

Retirement Benefits
Fellows must be at least 21 years of age and have completed two years of service to
participate. GW contributes 4% of the annualized regular salary to the plan. Fellows who
contribute a portion of their salary to the plan are eligible to receive matching
contributions equal to 1.5 times the employee contribution, up to a maximum of 6%.




                                               36
                                    LEAVE POLICY

Fellows are eligible for the following leave according to University Policy

1.     Vacation, holiday leave and sick leave. (Determined by each program /
       department)
2.     Family and medical leave
3.     Temporary disability leave
4.     Maternity leave
5.     Leave of absence
6.     Bereavement leave
7.     Leave for jury duty
8.     Leave for court appearances
9.     Military duty leave


                                EDUCATION BENEFITS
Tuition Benefits
Tuition benefits cover a maximum of six credit hours in the fall and spring semesters and
nine credit hours in the summer sessions for courses taken in degree programs. Some
exclusions apply. Benefits for spouses and dependent children vary depending on years
of service to the university.

Tuition Exchange Program
The university is a member of the Tuition Exchange, Inc., which provides a limited
number of tuition remission scholarships for employees of member colleges and
universities. The Benefits Office determines the eligibility.


                                  MISCELLANEOUS
Lab Coats
One personalized white lab coat is provided to each fellow on an annual basis

Parking
Parking is provided free if assigned to University garages and parking lots.

Student Loan Deferment
The GME office will assist in the processing of student loan deferments.

Health and Wellness Center
The Health and Wellness Center is located at 2301 G Street. The annual membership fee
is @395.00 and can be paid through payroll deduction.

Employee Assistance Program
Confidential problem assessment, counseling and referral services are provided.



                                            37
  OVERVIEW OF TASK FORCE RECOMMENDATIONS BY
  AMERICAN GASTROENTEROLOGICAL ASSOCIATION



CLINICAL TASK FORCES
Motility, Diverticular Disease and Functional Illness
Acid-Peptic Disease
Biliary Tract Diseases and Pancreatic Disorders
Gastrointestinal Inflammation, Enteric and Infectious Diseases
Gastrointestinal Malignancy
Hepatology
Gastrointestinal Endoscopy
Nutrition
Pediatric Gastroenterology
Gastrointestinal and Hepatic Pathology
Gastrointestinal Radiology
Surgery
Geriatric Gastroenterology
Women’s Health Issues in Digestive Diseases


OTHER TASK FORCES
Overview of Training in Gastroenterology Research
Gastrointestinal Cellular and Molecular Physiology




                                           38
     TASK FOR ON MOTILITY, DIVERTICULAR DISEASE AND FUNCTIONAL
                            BOWEL ILLNESS


                 MOTILITY AND FUNCTIONAL BOWEL ILLNESS

Knowledge Areas for Motility and Functional Bowel Illnesses
1.    Understanding the management of patients with motility and functional bowel
      disorders
2.    Understanding the physiology of gastrointestinal motility
3.    Understanding the brain- gut axis and visceral sensation
4.    Understanding the nuances of functional bowel disorders
5.    Understanding the importance of psychosocial aspects of functional bowel
      disorders
6.    Understand the usefulness of, indications for and limitations of motility studies


Goals of Training
Includes the understanding of the pathophysiology of the disorders, exposure to
management of adequate numbers of patients under the supervision of experienced
clinicians and understanding the rationale for, usefulness of, and potential pitfalls of
various motility tests that are available. This level of training is expected for all trainees.

1.      Clear understanding of the indications and contraindications of the performance
        of motility studies
2.      Understanding the limitations of interpretation of esophageal manome try,
        esophageal pH studies, esophageal motility with provocative agents, radionuclide
        gastric emptying studies, small bowel motility, colonic transit measurements, anal
        sphincter manometry and anal sphincter biofeedback training.
3.      Recognize the manometric features of major motor disorders of the esophagus
        and anal sphincter, including esophageal achalasia, scleroderma, internal anal
        sphincter weakness, external anal sphincter weakness and absence of rectoanal
        inhibitory reflex
4.      Understand the features of pH testing which indicates reflux and significance of a
        symptom score index
5.      Understand the physiology of motility of different areas of the gut, the brain- gut
        axis and the physiology of visceral sensation
6.      Develop a theoretical framework of the role of main neurotransmitters involved in
        sensory and motor functions
7.      Familiar with the health care-seeking behavior and the associated psychosocial
        factors that appear to be important in patients with functional bowel disorders
8.      Develop an understanding of the use of psychopharmaceuticals in the treatment of
        functional bowel disorders
9.      Understand when and how to refer patients refractory to therapy for psychiatric
        evaluation and management.




                                               39
Training Process

1.     Provide an appropriate clinical outpatient experience that provides an opportunity
       to evaluate and manage patients with possible motility disorders
2.     Development of skills in interview techniques and integration of psychological
       information into clinical reasoning and decision- making
3.     Development of decision- making that incorporates appropriate testing,
       interpretation of test results and treatment the patient under the guidance of
       appropriate staff
4.     Teach the roles of motility, and sensation, in functional bowel disorders
5.     Provide information and instruction in the performance of motility studies,
       including 24- hour pH studies
6.     Offer specific literature and didactic teaching to develop an understanding of the
       pathophysiology of motility disorders
7.     Review motility tracings to enhance interpretation of studies


Assessment of Competence
1.    Appropriately trained preceptors are identified by program director
2.    Preceptors will formally review fellows techniques in evaluating and managing
      patients with motility and functional bowel disorders
3.    Appropriately trained preceptors will formally review fellows skills in conducting
      motility studies
4.    Certification of competence by program director



               DIVERTICULOSIS AND DIVERTICULAR DISEASE

The management of diverticular disease should be encountered by all trainees in an active
clinical program. The clinical program will offer an understanding of presentations of
diverticular diseases and the management of the complications. Therefore, no specific
curriculum was offered by the Task Force.




                                           40
                  TASK FORCE ON ACID PEPTIC DISORDERS

Knowledge Areas
1. Obtain knowledge of acid peptic disorders, including duodenal and gastric ulcers,
   gastroesophageal reflux, gastritides/gastropathies, Zollinger-Ellison syndrome and
   other hypersecretory states and duodenitis.
2. Obtain an understanding of the prevalence, potential for complications, economic
   consequences of the disorders
3. Obtain knowledge of the technology and appropriate skills in the performance of
   diagnostic and therapeutic imaging techniques and understanding the surgical
   approaches to the disease


Goals of Training
The fellow is expected to gain knowledge and understanding of
1.      the anatomy, physiology and pathophysiology of the esophagus, stomach and
        duodenum
2.      the gastric secretion and indications for gastric analysis
3.      the indications for serum gastrin measurement and secretin testing and
        consequences of hypergastrinemia in both hypersecretory and achlorhydric states
4.      the natural history, epidemiology and complications of acid-peptic disorders,
        including recognition of premalignant conditions (i.e. Barrett'’ esophagus)
5.      the role of H. pylori and NSAIDs in acid-peptic diseases
6.      the pharmacology, adverse reactions, efficacy and NSAID-appropriate use of
        drugs for acid-peptic disorders; these include antacids and histamine-2 receptor
        antagonists, proton pump inhibitors, mucosal protective agents, prostaglandin
        analogues, prokinetic agents and antibiotics
7.      the endoscopic and surgical treatments of acid-peptic disorders, including cost-
        effectiveness, complications and side effects, both short-term and long-term

The fellows are expected to develop competence in
1.      the performance of a thorough gastrointestinal-directed history of physical
        examination
2.      the performance diagnostic and therapeutic upper gastrointestinal endoscopy
3.      the performance and interpretation of esophageal pH probe tests and esophageal
        motility studies
4.      the interpretation of plain films of the abdomen, barium examinations of the upper
        gastrointestinal tract, ultrasonography, abdominal computed tomographic scans
        and magnetic resonance imaging
5.      the understanding invasive and noninvasive techniques for diagnosing H. pylori
        infection
6.      the understanding the role of prostaglandins in mucosal protection, the importance
        of prostaglandin inhibitors (NSAIDs, aspirin) in causing ulcers and the effects of
        selective cyclooxygenase-2 inhibitors on the upper gastrointestinal tract




                                            41
Training Process

Care and Management
Fellows must acquire a thorough knowledge of appropriate history-taking, an ability to
perform a comprehensive and accurate examination, develop appropriate differential
diagnosis and outline a logical plan for specific and targeted investigations and a
treatment plan

Proficiency in Endoscopic and Ancillary Investigations
Obtain experience under direct supervision to become competent in performing and
interpreting all procedures and diagnostic tests that are used in the evaluation and
treatment of patients with acid-peptic disorders. This would include the indications,
limitations, technical aspects and complications of the following procedures. Fellows
must also understand the benefits and dangers of conscious sedation.

1.     Upper intestinal endoscopy, both elective and emergent. This would include the
       various modalities for the treatment of upper gastrointestinal bleeding, biopsy and
       polypectomy
2.     Dilatation of benign and malignant esophageal strictures
3.     Performance and interpretation of esophageal motility studies, 24-hour pH
       monitoring and the interpretation of gastric secretory studies
4.     Interpretation of radiological studies of the upper gastrointestinal tract, including
       contrast gastrointestinal examinations, ultrasonography, computed tomographic
       scans and magnetic resonance imaging.
5.     Indications and interpretation of studies for specific entities, such as
       hypersecretory states, H. pylori, and other infections of the upper gastrointestinal
       tract, particularly acquired immunodeficiency syndrome (AIDS)-related disorders
6.     Develop a working knowledge of upper gastrointestinal tract pathology, such as
       mucosal biopsies for gastritis, Barrett’s esophagus and malignant conditions




                                            42
  TASK FORCE ON TRAINING IN BILIARY DISEASES AND PANCREATIC
                          DISORDERS

A major goal in training in biliary tract diseases should be to develop highly skilled
consultants who can provide state-of-the-art care of patients with complex biliary disease.
These physicians should be aware of the advantages and disadvantages of available
options involving the diagnosis and therapy of biliary diseases and of potential
complications. If complications occur, the specialists should be in a position to manage
them.


Goals of Training for Biliary Disease
1.     Become acquainted with varied presentations of biliary tract disease and have
       detailed knowledge about all aspects of biliary disease
2.     Acquire competency in the decision- making process involving the appropriate
       choice of diagnostic procedures, their timing and their sequence
3.     Establish proficiency in diagnostic and therapeutic procedures involving biliary
       tract disease and acquire the ability to perform them safely, successfully and
       expeditiously
4.     Appreciate the advantages and disadvantages of radiological and endoscopic
       procedures and be able to balance the risks and benefits of these procedures for
       patients
5.     Understand the importance of teamwork which involves close collaboration with
       radiologist, surgeons and hepatologists


Goals of Training for Pancreatic Disorders
Trainees should attain knowledge and understanding of
1.     The embryological development and anatomy of the pancreas and pancreatic duct
       system
2.     The regulation of pancreatic growth and differentiation
3.     The physiological processes involved in pancreatic exocrine secretion of digestive
       enzymes, water and electrolytes
4.     The regulation of exocrine secretory processes
5.     The types of digestive enzymes secreted by the pancreas and their roles in the
       digestive system
6.     The mechanisms by which pancreatic enzymes secreted as zymogens are
       activated in the small intestine
7.     The factors that protect the pancreas from autodigestion
8.     The physiological interactions between exocrine and endocrine pancreas
9.     The epidemiology, pathophysiology and natural history of acute pancreatitis,
       chronic pancreatitis and pancreatic cancer




                                            43
Goals for Training for Acute Pancreatitis

In caring for acute pancreatitis, trainees must be able to
1. establish diagnosis and assess severity
2. determine the etiology
3. direct initial volume resuscitation
4. monitor for and treat extra pancreatic complications (i.e. Pulmonary and renal failure)
5. diagnosis and treat expeditiously infected necrosis or pancreatic abscess and other
    septic complications
6. diagnosis and manage pancreatic pseudocysts,
7. pancreatic ascites
8. hemorrhage
9. determine the need for and timing and type of nutritional support
10. evaluate patients for possible treatable occult causes of otherwise ‘idiopathic’ acute
    pancreatitis


Goals for Training for Chronic Pancreatitis

In caring for individuals with chronic pancreatitis, trainees must be able to
1.      establish the diagnosis (particularly in the presentation of occult disease)
2.      develop the differential diagnosis between chronic pancreatitis and pancreatic
        cancer
3.      determine the etiology
4.      manage abdominal pain, pancreatic exocrine and endocrine insufficiency and
        biliary obstruction
5.      diagnosis and manage pancreatic pseudocysts, ascites, pleural effusion and
        vascular complications (i.e.. splenic vein thrombosis, pseudoaneurysm)


Goals for Training for Pancreatic Cancer

Trainees must be able to
1.     use diagnosis tests in a rational and cost-effective manner
2.     assess operability
3.     manage pain, biliary and intestinal obstructions, pancreatic insufficiency and
       splenic vein thrombosis




                                            44
Additional Goals

Trainees must be able to
1.     recognize and diagnosis cystic fibrosis and manage pancreatic insufficiency in
       that setting
2.     diagnosis and treat annular pancreas
3.     assess the importance of pancreas divisum in the etiology of pancreatic disease
4.     understand the indications for and the interpretation of diagnostic tests results in
       the diagnosis and management of disease of the pancreas, including serum
       amylase and lipase determination, serum tumor markers, indirect tests of
       pancreatic secretory function, direct tests of secretory function, duodenal drainage
       with analysis for biliary crystals and fine needle aspiration of pancreatic masses
       and analysis of cytology in endoscopic aspirates of pancreatic juice
5.     Understand the role of other disciplines in the management of pancreatic
       disorders, including therapeutic endoscopy, surgery, interventional radiology,
       anatomic pathology and cytopathology, nutritional support, pan management,
       medical oncology and radiation oncology.


Training Process

Basic science training (physiology and pathophysiology). The fundamental core of
information for all trainees should include
1.     detailed knowledge of hepatobiliary and pancreatic anatomy, including
       developmental anomalies
2.     physiology of bile and factors regulating bile flow
3.     physiological function of bile components (bile acids, phospholipid, cholesterol
       and protein)
4.     gallbladder function, mechanism of bile concentration an regulation of gallbladder
       contraction
5.     regulation of bile duct motility and sphincter of Oddi function (contraction /
       relaxation)
6.     pathophysiology of cholestasis and the mechanisms responsible for alteration of
       bile flow
7.     pathophysiology of gallstone formation (cholesterol, pigment stone)
8.     pathogenesis of motility disorders of the biliary tract
9.     pathophysiology and scientific rationale for therapy of major biliary tract
       disorders and complications of liver transplantation as well as other hepatobiliary
       surgical procedures
10.    basic familiarity with techniques of molecular biology, principles of cell biology
       and physical chemistry




                                            45
Clinical Aspects of biliary diseases

1. understanding of the epidemiology, manifestations, differential diagnosis and natural
    history of major biliary tract disorders
2. familiarity with specific biliary tract disease, including benign and malignant
    strictures, primary and secondary neoplasms, choledocholithiasis, cholecystitis,
    sclerosing cholangitis, congenital abnormalities of the pancreaticobiliary tract (i.e.
    biliary atresia, choledochal cysts), hemobilia, motility disorders of biliary tract, post-
    operative complications of the biliary tree and post- liver transplant biliary problems,
    acute and chronic pancreatitis and pancreatic neoplasms.
3. Senior trainees should obtain more detailed exposure to biliary disease through active
    participation in the medical care of patients with biliary tract diseases through
    inpatient and outpatient consultations

Procedures

1. knowledge of the advantages and disadvantages of the different diagnostic and
    therapeutic procedures used in the diagnosis and treatment of biliary tract disease and
    pancreatic disease, including potential risks, limitations and costs in the evaluation
    and management of biliary tract and pancreatic diseases
2. understand the role of endoscopic techniques and alternative diagnostic and
    therapeutic modalities (medical, surgical and radiological) in the management of
    biliary and pancreatic disease
3. Understand the role of ERCP as the primary tool for accessing the biliary tree and
    pancreatic ductal system and as a major route for therapeutic intervention. Appreciate
    the indications, contraindications, limitations, complications and interpretation.
4. Understand the role of percutaneous transhepatic cholangiography. Appreciate the
    indications, contraindications, limitations, complications and interpretation.
5. Understand and have a basic understanding (indications, advantages and
    disadvantages) and how to interpret the following imaging procedures, including:
    plain abdominal film, cholecystogram, ultrasound, computed tomography, magnetic
    resonance imaging and scintigraphy
6. Exposed to the performance and interpretation of endoscopic ultrasound
7. Exposed to surgical biliary and pancreatic procedures




                                              46
  TASK FORCE ON TRAINING IN GASTROINTESTINAL INFLAMMATION,
               ENTERIC AND INFECTIOUS DISEASES


Goals of training

Trainees must master a basic body of knowledge, including an understanding of
1.     mechanism of inflammation
2.     elements of mucosal defense systems (including the mucosal immune system and
       the components of intestinal barrier function)
3.     composition and function of normal enteric flora (including protection again
       pathogens, colonization resistance, role in the metabolism and effects of
       antibiotics on flora
4.     prevalence, clinical presentation and virulence factors of gastrointestinal
       pathogens (viral, bacterial, fungal, protozoa)
5.     pathophysiology of diarrheal disease
6.     indications and contraindications of antimicrobial therapy, mechanisms of
       microbial drug resistance and risk of infections from altering normal flora


Clinical Skills

Familiarity with the following diagnostic and histopathologic studies
1.     stool examination, fecal leukocytes and ova and parasites
2.     cultures of stool, intestinal fluid and biopsy (specimen collection, handling,
       special stains, media)
3.     mucosal biopsy interpretation
4.     antigen detection (enzyme immunoassay, fluorescent antibody) in stool and fluid
       and stool toxin testing
5.     rapid diagnostic tests (DNA probes or polymerase chain reaction), disinfection
       and antibiotic prophylaxis
6.     liver biopsy and interpretation

Familiarity with the following
1.     selection and use of antibiotic therapy and methods for preventing infection
       during endoscopy (disinfection and antibiotic prophylaxis)
2.     gastrointestinal infection, including the diagnosis and management of patients
       with common infectious presentations, including esophagitis, (fungal, viral ,
       bacterial), ulcer disease and gastritis (emphasis on H. pylori and appropriate
       antibiotic therapy),
3.     acute, chronic, hemorrhagic and traveler's diarrhea
4.     bacterial overgrowth
5.     infections in immunocompromised hosts (transplantation patients)
6.     hepatic inflammation (liver abscesses, hepatitis, cholangitis0
7.     role of liver biopsy




                                           47
8.    concepts of preventive medicine, indications for vaccination, routes of infection,
      dietary an hygienic practice for travelers, appropriate recommendations for
      prophylactic antibiotic therapy


Training process

1.    participation in the evaluation and management of outpatients and inpatients with
      presentation and diagnoses
2.    exposure to appropriate use of diagnostic tests, indications and complications of
      therapy
3.    additional exposure to related sciences (immunology, microbiology and molecular
      biology) and related fields of medicine (infectious disease, and laboratory,
      anatomic an surgical pathology
4.    conferences, seminars and literature reviews




                                           48
               HIV-RELATED GASTROINTESTINAL DISORDERS


Goals of training

1.     AIDS-related from AIDS-unrelated conditions
2.     management of esophageal disorders , including infectious esophagitis
3.     assess AIDS gastropathy and other infectious and neoplastic gastric disorders
4.     assess disorders of the small intestine, including causes o f diarrhea and HIV-
       infected
5.     interpretation of endoscopic, barium and computed tomographic and ultrasound
       examination
6.     treat bacterial,, fungal, viral and protozol infections in patients with AIDS
7.     recognize cause of colorectal disorders, including proctitis, proctocolitis and
       AIDS-related malignancy
8.     familiar with the indications for and interpretation of flexible sigmoidoscopic,
       colonoscopic and radiographic studies

Biliary system
1.      evaluate causes of hepatomegaly, abnormal liver test results (infectious,
        neoplasia, drugs) and interaction of hepatitis virus and HIV
2.      distinguish AIDS cholangiopathy and cholecystitis
3.      assess indications of liver biopsy

Pancreatic disorders
1.     causes of pancreatitis (infectious, neoplastic, toxic)
2.     implications of hyperamylasemia
3.     nutritional evaluation of pancreatic disorders
4.     assessment of nutritional status and development and implementation of
       nutritional therapies (enteral and parenteral)
5.     determine the cause of and prescribe a rational treatment plan for common
       opportunistic and neoplastic conditions in a cost-effective and humanitarian
       fashion.

Training Process

1.     inpatient and outpatient consultative evaluations
2.     exposure to patients with AIDS with dysphagia/odynophagia, diarrhea, rectal
       bleeding, abnormal liver enzymes/hepatomegaly, abdominal pain and
       hyperamylasemia
3.     interaction between trainees and specialists in laboratory medicine, diagnostic and
       interventional radiology and infectious disease and immunology




                                            49
                       INFLAMMATORY BOWEL DISEASE


Goals of Training

1.    recognize clinical and laboratory features of intestinal inflammation and to
      distinguish them from signs of secretory and osmotic diarrhea and from symptom
      of irritable bowel syndrome
2.    differentiate chronic idiopathic IBD from other specific entities, including acute
      self- limited ileitis and colitis, drug- or radiation-induced colitis and diverticulitis
      by history and interpretation of radiological, endoscopic, histological and
      microbiological studies
3.    understand indications for and interpretation of colonoscopy, barium enema,
      upper gastrointestinal and small bowel series, enteroclysis and computed
      tomographic scan
4.    understand the cost-benefit and risk-benefit of procedures
5.    familiarity with different presentations of IBD, including the pediatric
      manifestations, anorectal complications, and inflammatory vs. fistulizing vs.
      fibrostenotic patterns of Crohn’s disease
6.    recognize various presentations of IBD with history-taking, physical examinations
7.    capable of evaluating intestinal (i.e. hemorrhage, obstruction), extraintestinal (i.e.
      ocular, dermatologic, musculoskeletal, hepatobiliary) and nutritional
      complications of ulcerative colitis and Crohn’s disease.
8.    Familiarity with the influence of IBD on pregnancy and of pregnancy on IBD and
      be capable of addressing issues pertaining to family history and genetic
      counseling.
9.    Awareness of long-term cancer risks in ulcerative colitis and Crohn’s disease and
      be able to implement appropriate cost-effective surveillance programs
10.   Sensitivity to psychosocial influences and consequences of IBD on the individuals
      and on family dynamics
11.   Developing a therapeutic plan according to the extent and severity of specific
      disease patterns and to understand the indications, contraindications, and
      pharmacology of nonspecific therapies, including new biologic therapies,
      anticholinergic agents, antidiarrheals and bile salt sequestrants, oral and topical
      aminosalicylates, parenteral, enteral and rectal corticosteroids,
      immunosuppressants and antibiotics used in relevant clinical situations
12.   Understand the indications for enteral and parenteral alimentation and be able to
      implement nutritional therapies
13.   Capable of diagnosing and differentiating other inflammatory disorders, including
      collagenous colitis, microscopic colitis, NSAID enterocolopathies, diverticulitis
      (including medical and surgical complications), radiation enteritis and colitis,
      Whipple’s disease, celiac sprue, diversion colitis, and the solitary rectal ulcer




                                            50
Training Process

1.    able to assume responsibility, encompassing diagnoses, acute and chronic
      therapies, long-term follow-up and counseling of the families and/or significant
      others
2.    exposure to hospitalized as well as ambulatory patients, including the initial
      assessment and longitudinal management of patients with IBD




                                          51
      TASK FORCE ON TRAINING IN GASTROINTESTINAL MALIGNANCY


Goals of training

1.      develop a thorough familiarity with the literature on cancer epidemiology,
        primary prevention and screening for colorectal cancer with fecal occult blood
        tests and well as endoscopic and radiological approaches
2.      become knowledgeable about the recommended guidelines for screening for
        gastrointestinal neoplasia and the literature supporting these recommendations
3.      develop ability to read and interpret literature about the merging technologies and
        able to evaluate novel technologies and approaches
4.      develop a working knowledge of clinical genetics and understand the approaches
        to the genetic diagnosis of FAP, HNPCC and other rarer polyposis syndromes
5.      recognize the clinical characteristics of diseases, the distinctions among the
        familial forms of cancer, the specific diagnostic and screening tests for each and
        the rational approaches to their treatment
6.      learn the principles of neoplastic growth as they relate to therapy, including
        endoscopic treatment as well as traditional surgical approaches
7.      develop a complete understanding of the management of premalignant conditions
8.      familiarity with the pathological interpretation of tissue biopsies (endoscopic and
        percutaneous)
9.      develop a thorough working knowledge of management of dysplastic lesions
10.     understand the distinctions among the varieties of colorectal polyps and their
        management
11.     learn the principles of chemotherapy for gastrointestinal cancer and radiation
        treatment of early and advanced tumors
12.     understand the initial management of patients in whom the diagnosis of
        gastrointestinal cancer has been made
13.     understand how to counsel patients who have had gastrointestinal neoplasia and
        how to manage patients who have positive family histories of gastrointestinal
        cancer
14.     understand the principles and importance of genetic counseling as it pertains to
        genetic testing and the management of inherited gastrointestinal diseases
15.     familiarity with the prognoses associated with different types of gastrointestinal
        cancer
16.     familiarity with the technical considerations in the therapy of colorectal adenomas
        and carcinomas
17.     become thoroughly experienced in colonoscopic polypectomy of pedunculated
        and sessile polyps and ablative therapies for sessile lesions
18.     understand the capabilities and limitations of endoscop ic mucosectomy for early
        gastrointestinal cancer
19.     familiarity with the appropriate surveillance and surveillance interval for patients
        at high risk for developing cancer and those in whom premalignant epithelium has
        already been detected




                                             52
20.    selected individuals should obtain experience in placement of endoscopic stents,
       laser ablation, photodynamic therapy, endoscopic ultrasound, fine needle
       aspiration of tumors, endoscopic mucosectomy and endoscopic celiac ganglion
       block for patients with pancreatic cancer.


Training Process

Throughout the training process, trainees should participate in the screening, diagnosis
and management of all types of gastrointestinal malignancies. Lectures in molecular and
cellular biology as well as clinical oncology and screening, treatment and palliation of
gastrointestinal cancer should be included in the core curriculum. Lectures are sought
from interventional endoscopists, oncological surgeons, medical oncologists, radiation
oncologists and a medical geneticists.


Lectures are provided in the following:

1.     changes in screening and surveillance recommendations
2.     the evolution of genetic testing and counseling for FAP, HNPCC and other
       familial forms of gastrointestinal cancer
3.     novel approaches to the diagnosis of gastrointestinal cancer, including endoscopic
       approaches, radiological approaches, nuclear medicine, ultrasound/endoscopic
       ultrasound and new genetic techniques
4.     staging of gastrointestinal cancer, management options and prognostication
5.     techniques used in the basic science investigation of gastrointestinal cancer,
       including flow cytometry, polymerase chain reaction assays, mutation analysis,
       DNA sequencing and linkage analysis

Endoscopic training in the diagnosis and management of gastrointestinal cancer is
required. Recommendations for the duration and frequency of procedures are noted in the
section on procedures. Areas that are relevant to gastrointestinal malignancy that require
specific attention include:
1.      endoscopic management of Barrett’s esophagus
2.      familiarity and at least limited experience with the indications techniques, and
        management implication of laser therapy and stents for palliating esophageal
        cancers
3.      the management of upper gastrointestinal neoplasia in FAP, including the
        management of gastric, duodenal and periampullary lesions
4.      the endoscopic management of gastric remnants following Billroth I and II
        surgery
5.      recognition of neoplasia in the pancreaticobiliary tree
6.      familiarity and at least limited experience with the indications, techniques and
        management implications of therapeutic endoscopic retrograde
        cholangiopancreatography for pancreatic and biliary cancers




                                            53
7.     proper technique for polypectomy for pedunculated and sessile polyps, including
       saline injection
8.     management of the diminutive adenomatous polyp
9.     surveillance of the colon in IBD, including considerations for normal-appearing
       mucosa and abnormal-appearing mucosa
10.    recognition of anal cancer lesions with the use of the anoscope


Gastroenterology trainees should become familiar with the appearance of cancer by using
the following diagnostic techniques

Radiological
1.     gastrointestinal cancer on barium upper gastrointestinal series
2.     gastrointestinal cancer on barium enema
3.     pancreatic and hepatic cancers on computed tomographic scans and magnetic
       resonance imaging
4.     pancreaticobiliary cancer on endoscopic retrograde cholangiopancreatography

Pathological
1.     identification of adenoma, adenocarcinoma and hyperplastic and other
       nonneoplastic polyps
2.     recognition of the depth of invasion of cancer in the polyp or into the wall of the
       colon and its significance
3.     recognition of dysplasia vs. reactive changes in IBD
4.     recognition of Barrett’s epithelium and dysplastic change in Barrett’s mucosa
5.     recognition of intestinal metaplasia and atrophy in the stomach
6.     recognition of neuroendocrine and stromal cell tumors of the gastrointestinal tract

Certain trainees may elect to receive additional training in advanced endoscopic
procedures. These procedures will be reserved for those who wish to spend the time to
master these techniques. These procedures include the following:
1.     endoscopic ultrasound of the esophagus, stomach, duodenum and rectum
2.     dilating, stenting and tissue sampling of the esophagus and biliary and pancreatic
       tree
3.     ablative therapy of neoplasms using laser
4.     photodynamic treatment of epithelial neoplasia in Barrett’s esophagus
5.     fine-needle aspiration of masses in the liver and pancreas




                                            54
                 TASK FORCE ON TRAINING IN HEPATOLOGY

The faculty should have at least one individual recognized to posses advanced expertise
in liver disease, including continued productivity in clinical or basic research related to
hepatology. Hepatology training should be an integral component of the subspecialty
fellowship with approximately 30% of the 18 clinical months dedicated to hepatology
training. This training should be divided between the management of inpatients with a
variety of hepatic disorders and the treatment of outpatients with liver disease. The
trainees should have experience in the evaluation of patients for liver transplantation.
There should be opportunities for trainees to become familiar with the referral and
management of liver transplant patients. Opportunities should be available for clinical
and/or laboratory research in liver diseases. There should be regularly scheduled
conferences that include didactic lectures, literature reviews, and research seminars.


Goals of training

All training programs must provide trainees with a broad knowledge of the physiology of
the liver and a thorough knowledge of the management of patient with hepatobiliary
diseases. This program requires that the trainee provides the following:

1.     significant fund of knowledge about genetic markers of liver disease,
       immunology, virology, and other pathophysiological mechanism of liver injury;
       the basic biology and pathobiology of the liver and biliary systems as well as a
       thorough understanding of the diagnostic and treatment of a broad range of
       hepatobiliary disorders
2.     skill in the performance of a limited number of diagnostic and therapeutic
       procedures
3.     an appreciation of the indications and use of a number of diagnostic and
       therapeutic procedures that are needed to manage hepatobiliary disorders


Comprehensive teaching of the following subjects occurs
1.    biology and pathobiology of the liver
2.    diagnosis and management of patients with the wide variety of disease of the liver
      and biliary tract systems, including
      a.      acute hepatitis: viral, drug, toxic
      b.      fulminant hepatic failure, including the management of cerebral edema,
              coagulopathy and other complications associated with acute hepatic failure
      c.      recognition and diagnosis of chronic hepatitis and cirrhosis,; chemical,
              biochemical, serological, and histopathologic diagnosis of chronic viral
              hepatitis
      d.      complications of liver disease; ascites, hepatic encephalopathy,
              spontaneous bacterial peritonitis, hepatorenal syndrome, prevention and
              treatment of bleeding esophageal varices and gastropathy, diagnosis and
              treatment of hepatocellular carcinoma



                                             55
       e.     diagnosis and treatment of nonviral causes of chronic liver disease, such as
              alcohol, nonalcoholic fatty liver disease (including nonalcoholic
              steatohepatitis), Wilson’s disease, primary biliary cirrhosis, autoimmune
              hepatitis, hemochromatosis and a-1-antitrypsin deficiency
       f.     gallstone disease, including the appropriate use of medical and surgical
              therapies
       g.     hepatobiliary disorders associated the pregnancy
       h.     preoperative evaluation and postoperative management of patient with
              defined diseases of the liver or evidence of hepatobiliary dysfunction

3.     use of antiviral and immunosuppressive agents in the treatment of liver disease
4.     selection and care of patients awaiting and following liver transplantation,
       including the assessment of patients with alcoholic liver disease for
       transplantation, recognition of alcohol dependence and an understanding of the
       use of immunosuppressive agents; diagnosis and management of rejection and
       recognition of other complications of transplantation, such as certain infections
       and biliary tract and vascular problems.
5.     Management of the nutritional problems associated with chronic liver disease.
6.     An understanding of the principle of experimental design, clinical biostatistics
       and epidemiology sufficient to critically interpret the medical literature
7.     Pediatric and congenital hepatobiliary disorders
8.     Liver pathology, including histological interpretation and specific pathological
       techniques
9.     Liver imaging modalities including interpretation of computed tomography,
       magnetic resonance-based techniques (magnetic resonance imaging, magnetic
       resonance angiography, magnetic resonance cholangiography), hepatic
       angiography and ultrasound (including Doppler evaluation of hepatic
       vasculature). The limitation of each modality should be understood.

Procedural skills

Trainees must acquire competence in the performance of
1.     percutaneous liver biopsy (minimum 20)
2.     diagnostic and therapeutic paracentesis (minimum 20)




                                            56
    TASK FORCE ON TRAINING IN GASTROINTESTINAL ENDOSCOPY


Goals of Training

Trainees will have achieved:
1.     the ability to recommend endoscopic procedures based on findings from personal
       consultations and in consideration of specific indications, contraindications, and
       diagnostic/therapeutic alternatives
2.     the ability to perform a specific procedures safely, completely and expeditiously
3.     the ability to interpret most endoscopic findings correctly
4.     the ability to integrate endoscopic findings or therapy into patient management
       plan
5.     the ability to understand the risk factors attendant to endoscopic procedures and to
       be able to recognize and manage complication
6.     the ability to recognize personal and procedural limits and to know when to
       request assistance

Procedures goals
Outlined in the Curriculum Requirement section.


Training process

All trainees should
1.      have an understanding of indications, limitations, complications and medical and
        surgical implications of the findings of medical and surgical implications of the
        findings of gastrointestinal endoscopy
2.      have an understanding of the underlying pathophysiology of gastrointestinal
        disease and the ability to interpret the endoscopic findings
3.      participate in the performance of endoscopic procedures as part of the continuing
        care of patients.
4.      Participate in the performance of endoscopic procedures with staff
        gastroenterologists or surgeons knowledgeable in the indication for and the
        technique of performing the procedures as well as the method of recording the
        results of the procedures and clinical significance of the findings.
5.      Develop an understanding of the essential components of patient safety during
        endoscopic procedures, including the intravenous administration of medications
        that produce sedation and analgesia and the application and interpretation of
        noninvasive patient monitoring devices.
6.      Become familiar with the care, cleaning and proper maintenance of endoscopy
        equipment.
7.      Develop the capability of independently performing routine endoscopic
        procedures including specific therapeutic maneuvers (i.e. polypectomy,
        hemostasis) when indicated.




                                            57
             PERFORMANCE CRITERIA FOR EVALUATION OF
              DIAGNOSTIC GASTROINTESTINAL ENDOSCOPY
               Procedure                  Performance Crite ria
Esophagogastroduodenoscopy (EGD) Esophageal intubation
                                       Pyloric intubation
Colonoscopy                            Navigation through sigmoid colon
                                       Intubation of splenic flexure
                                       Intubation of the hepatic flexure
                                       Intubation of cecum
                                       Intubation of terminal ileum (desirable
                                       skill)
                                       Retroflexion in the rectum
Sigmoidoscopy                          Navigation through the sigmoid colon
                                       Visualization of the splenic flexure
                                       Retroflexion in the rectum
Endoscopic retrograde                  Cannulation of the desired duct
cholangiopancreatography
                                       Opacification of the desired duct
(ERCP)
                                       Sphincterotomy
                                       Stent placement
                                       Stone extraction
Endoscopic ultrasonography             Intubation of esophagus
                                       Intubation of pylorus
                                       Imaging of desired organ and/or lesion
                                       Successful lesion biopsy
                                       Tumor staging in agreement with the
                                       surgical findings and similar to that
                                       reported in the literature
All procedures                         Accurate recognition of normal and
                                       abnormal findings

                                       Development of appropriate
                                       endoscopic/medical treatment in response
                                       to these findings




                                  58
          Guidelines for Endoscopic Training: Parameters of Competency

16.    reviews records, x-rays, identified risk factors
17.    understands and discusses appropriate alternative procedures
18.    correctly identified indication, knows how the endoscopic procedure may
       influence management
19.    obtains appropriate informed consent
20.    demonstrates proper use of premedication and noninvasive patient monitoring
       devices
21.    inserts the endoscope using proper technique
22.    performs procedure with attention to patient comfort and safety
23.    correctly identified landmarks
24.    conducts thorough examination of the entire organ
25.    detects and identifies all significant pathology
26.    completes examination within a reasonable time
27.    prepares an accurate report
28.    plans correct management and disposition
29.    discusses findings with patient and other physicians
30.    conducts proper follow- up, review of pathology, case outcome


Assessment of Competence

Objective criteria based upon parameters developed to assess competency should be used.
Judgment as well as interpretive and technical skills must be evaluated. Regular ongoing
feedback is essential. All trainees should be observed regularly by supervisors. Faculty
members should substantiate the trainees’ competence. The program director should
document the competency of all gastroenterology trainees. A logbook of procedures
should be maintained by all trainees.




                                           59
TASK FORCE ON TRAINING IN NUTRITION

Goals of training

It is important for the trainees to understand:
1.       basic principles of nutrient requirements, ingestion, digestion, absorption and
         metabolism in health and gastrointestinal diseases
2.       assessment of nutritional status, including specific nutrient deficiencies and
         excesses, protein-energy malnutrition and obesity
3.       metabolic response to starvation and the pathophysiological effects of
         undernutrition
4.       metabolic response to illness and injury and nutrient requirements during stress
         states
5.       indications for nutritional support
6.       implementation and management of nutritional therapy including modified diets,
         enteral tube feeding and parenteral nutrition
7.       pathophysiology and clinical management of obesity
8.       ethical and legal issues involved in providing and withdrawing nutritional support


Training process

1. didactic lectures, case conferences, selected readings, clinical experience
2. involved in providing enteral and parenteral nutrition support to hospitalized patients,
   including those in intensive care units and nutritional management of outpatients
3. clinical experience can include rotation on an inpatient nutrition support service,
   experience on other inpatient services and participation in an outpatient clinic that
   involves nutritional counseling




                                            60
TASK FORCE ON TRAINING IN PEDIATRIC GASTROENTEROLOGY


Goals of Training

Trainees in adult gastroenterology should
1.     appreciate the unique aspects of the field with an increased awareness of the
       clinical problems of pediatric gastroenterology. (The goal is not to develop
       competence because pediatric gastroenterology is a recognized field of
       pediatrics.)
2.     be prepared to participate in limited scope of care when in underserved areas in
       which pediatric gastroenterology consultative services are not available.

Curriculum will include
1.      age-related physiological and psychological variables of children and adults
2.       unique aspects of the disease in pediatric vs. adult patients
3.      manifestation of commonly encountered entities (i.e. abdominal pain,
        constipation, gastrointestinal bleeding, diarrhea, cystic fibrosis)

Training process
1.     clinical conference in which a pediatric cases are discussed
2.     potential for limited experience with pediatric gastroenterology service
3.     visiting professorship of a pediatric gastroenterologist




                                            61
     TASK FORCE ON TRAINING IN GASTROINTESTINAL AND HEPATIC
                          PATHOLOGY

Goals of Training

Trainees should:
1.     appreciate the spectrum of normal histology
2.     learn to recognize patterns of histopathologic change in gastrointestinal and
       hepatic disorders
3.     learn optimal biopsy technique and submit adequate samples
4.     learn to describe endoscopic findings and clinical information to aid the
       pathologist interpretation of biopsy specimens
5.     be able to recognize when a biopsy can or cannot help in investigation or
       management
6.     be familiar with the clinical implications of the pathological findings in biopsy
       and in surgical specimens
7.     know the value and limitation of exfoliative and aspiration cytology
8.     understand the mechanism and the usefulness of new techniques, such as flow
       cytometry, immunohistochemistry and tests based on molecular biology (i.e.
       PCR, in situ hybridization)
9.     have an overview of special techniques and special stains as diagnostic aids in
       gastrointestinal and hepatic pathology (in situ hybridization,
       immunohistochemistry, etc.)
10.    be familiar with recognition of unusual pediatric liver diseases, recognition of
       opportunistic infections with HIV, graft-vs.- host disease and the submission of
       biliary biopsy specimens for detection of cholangiocarcinoma or other bile duct
       changes
11.    recognize the usefulness and limitations of endoscopic biopsy in distinguishing
       different forms of microscopic colitis
12.    understand the approaches to, timing of, flaws, and risks and benefits of dysplasia
       surveillance in chronic inflammatory diseases of the gastrointestinal tract
13.    recognize when gastric biopsy is appropriate in management of upper
       gastrointestinal disorders, the appropriate sites for biopsy and when pursuing
       endoscopic biopsies is indicated.

Training Process

1.     multidisciplinary conferences with gastroenterologists and pathologist weekly or
       biweekly o review specimens
2.     rotation with pathologist for developing an understanding of handling and
       interpretation of gastrointestinal, endoscopic and liver biopsy specimens




                                            62
TASK FORCE ON TRAINING IN GASTROINTESTINAL RADIOLOGY

Goals of Training

Trainees should be able to:
1.     recognize normal anatomy of the alimentary tract and related organs
2.     achieve a basic knowledge of gastrointestinal pathology as demonstrated by pla in
       film radiography, barium studies, computed tomography, ultrasound, magnetic
       resonance imaging, gastrointestinal vascular and interventional studies,
       scintigraphy and positron emission transaxial tomography (PET)
3.     develop and understanding of the logical sequence of using these techniques in
       the evaluation of gastrointestinal problems
4.     have an appreciation for and understanding of the costs for different radiological
       studies
5.     have an understanding of the indications and contraindications for radiological
       interventional studies.


Training Process

1.     participation in work rounds on individual patients which is integral to routine
       patient care
2.     exposure at weekly conference that include a review of radiographic imaging
       studies in relating to gastrointestinal disease
3.     self- instruction programs in gastrointestinal radiology
4.     defined rotations on a radiology service




                                            63
                    TASK FORCE IN TRAINING IN SURGERY

Trainees in gastroenterology must learn about the indications and contraindications for
surgical treatment and the general principles of the surgical procedures that may be used.
Trainees should learn about the expected outcomes of operations that are likely to be
performed on their patients and be prepared to care for patients post-operatively as
appropriate.


Goals of Training

Trainees should:
1. learn the way that surgical procedures are conducted
2. should be thoroughly knowledgeable about the postoperative care of patients after
    major and minor surgical procedures
3. should learn the indications and contraindications for a variety of common operations
    for gastrointestinal disorders
4. be able to judge whether surgery is necessary and what kind of operation is indicated
    and when it should be performed
5. be familiar with common complications and their management
6. be familiar with long-term consequences of surgical treatment of gastrointestinal
    diseases
7. be knowledgeable about esophageal procedures, surgery of the gastrointestinal tract
    and liver malignancies
8. be knowledgeable about surgical vs. endoscopic vs. interventional radiology
    procedure and when to pursue specific techniques

Specific procedures with which the trainees should be familiar include
1. antireflux procedures
2. ulcer operations
3. hepatobiliary operations
4. portosystemic shunts
5. hepatic transplantation
6. pancreatic procedures for benign and malignant disease
7. surgery for BID of the small and large bowel
8. colonic procedures for diverticular disease or cancer
9. various anorectal operations
10. laparoscopic vs. open procedures

Training Process

Lectures constitute a convenient method of conveying knowledge about surgical
procedures and a systematic series of lectures organized by organ or disease process
ensures comprehensive coverage. Participation by trainees in joint medical-surgical
conferences to discuss specific patients is mandatory. Personal learning through literature
searches is an essential element in this effort.



                                            64
Trainees are encouraged to go to the operating room when their patients are undergoing
surgical procedures. Observation of gross pathological abnormalities will help trainees
correlate preoperative information with operative findings. Trainees also will gain an
appreciation of the conduct of operations, the factors entering into surgical judgment and
the recognition and management of postoperative complications. Rotation with the
gastrointestinal surgical team can aid in advancing knowledge about gastrointestinal
surgery.




                                            65
  TASK FORCE ON TRAINING IN GASTROINTESTINAL CELLULAR AND
                  MOLECULAR PHYSIOLOGY

The field of gastroenterology requires and understanding of cellular, molecular and
genetic mechanisms underlying normal physiology, including proliferation,
differentiation and programmed cell death (apoptosis). The importance of the multiple
specialized tissues that encompass gastrointestinal function, ranging from the
musculature to the gut brain, the splanchnic circulation, the endocrine system, the gut
immune system, and the epithelia should be emphasized.


Goals of training

Trainees will
1. Gain exposure to a variety of disciplines, including immunology, genetics,
    physiology, pharmacology, biochemistry and pathology.
2. Develop an operational understanding of technology as well as information on
    cellular and subcellular structure and function.
3. Develop the capacity to understand and interpret the relevant literature as well as to
    comprehend and study future developments
4. Be able to search and critically analyze fundamental scientific information from
    appropriate national and international scientific organizations.


                                    General concepts

Molecular biology

The trainees should understand
1. the function of the gene and chromosome and their location, composition, and the
   mechanisms regulating their replication
2. genomic organization, including the function of the promotor region, introns, exons
   and untranslated regions, and mechanisms regulating the expression of this
   information, including transcription, messenger RNA synthesis, translation, and
   protein synthesis
3. the importance of genetic variability, including single nucleotide polymorphisms and
   other chromosomal aberrations, particularly as they apply to diagnostics and
   therapeutics
4. the molecular processes responsible for maintaining genetic fidelity, such as
   proofreading and repair enzymes, and the consequences of their failure, including
   malignant degeneration
5. the basic cellular mechanisms regulating cell proliferation and differentiation and
   cellular demise, including those of apoptosis and necrosis




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Genetics

The trainees should understand
1. genetic polymorphisms, genetic defects, the genetic basis of gastrointestinal diseases
   such as hemochromatosis, familial pancreatitis, MEN-1, and colon cancer; the gene
   mutations involved; and the nature of human gene mutation
2. oncogenes, tumor suppressor genes, microsatellite instability, genomic imprinting,
   chromosomal rearrangements, gene amplification, and their roles in altered cell
   growth
3. the genetics of colon cancer so that information can be used to identify individual
   patients at risk, guide diagnostic and therapeutic interventions in specific patients and
   their families, and provide guidance, counseling, and answers to questions from
   patients and their families


Cell biology

The trainees should understand
1. the basic subcellular constituents of the cell such as the nuclear, mitochondria, golgi,
   endoplasmic reticulum and lysosomes, along with their normal functions and
   alterations in disease.
2. The normal control of the cell cycle and processes leading to its disruption
3. The fundamental properties of cell types specific to and crucial to the operation of the
   gastrointestinal tract. This includes an understanding of the turnover of the
   gastrointestinal epithelium and the need for continuous differentiation from stem cells
   located within each specific tissue and/or organs comprising the gastrointestinal tract
   as well as the processes regulating normal tissue differentiation and organogenesis
4. The epithelial layer as a modulator of vectorial transport and as critical barrier against
   toxins and pathogens
5. The functional organization of the enteric nervous system, the network of neurons
   embedded within the gastrointestinal wall controlling gastrointestinal function, and
   the extrinsic neurons (afferent and efferent) that contribute to the modulation of
   digestive functions. Segmental differences down the cephalocaudal axis critical to
   function as well as specialized regulatory cells such as the interstitial cells of Cajal
   also must be understood.

Pharmacology and cellular signaling

Trainees should recognize
1. basic receptor pharmacology, including regulation, trafficking, and signaling as well
    as receptor transport mechanisms, cellular transduction and cell- to-cell signaling
2. the existence of different superfamilies of receptors including ion-channel gated G
    protein coupled, and tyrosine kinase-activating receptors, along with the different
    mechanisms by which second messengers are activated to induce a functional
    response




                                             67
3. the rapidly growing field of cellular signal transduction as a mechanism underpinning
   critical regulatory processes in health and disease. These include cell- matrix
   communication, important in host defense; cell-cell communication, important in
   tissue responses; and intracellular pathways critical for cell homeostasis that, when
   disturbed, can cause unregulated growth or premature cell death
4. the existence of numerous transmitters and modulators synthesized and released by
   neurons innervating the digestive system, including classical transmitters such as
   acetylcholine and noradrenaline as well as slow transmitters/modulators such as
   peptides.
5. The existence and importance of the endocrine system that is scattered throughout the
   digestive tract and that are often expresses the same chemical messengers as neurons
6. The disparate mechanism by which different chemical messengers are released and
   reach their sites of action, including endocrine, neuroendocrine, and paracrine
   mechanisms of action. Trainees should develop a basic understanding of hormones
   and of neurotransmitters and their specific receptors as they relate to the
   gastrointestinal tract.
7. The roles of nitric oxide and NO synthase in cellular physiological events and their
   implications related to gastrointestinal physiology and pathophysiology as well as the
   NO pathway in inflammation and splanchnic circulation


Host-environment interactions

Trainees should have an understanding of
1. the factors permitting the existence of commensal organisms and their contribution to
    maintaining host health as well as the processes whereby pathogenic organisms are
    recognized and by which they induce a host response
2. the cellular and molecular biology underlying important infections, including H.
    pylori
3. basic virology so that current infections, including the many cases of hepatitis, as well
    as future disorders can be appreciated.


Immunology

Trainees should have an understanding of
1. the gut-associated immune system, its distinct differences from systemic
    immunology, and the implications of this in understanding gastrointestinal physiology
    and pathophysiology. This includes an understanding of the roles of a variety of
    mediators and modifiers of the inflammatory process, including cytokines and
    chemokines and other related molecular species
2. autoimmune disease and the markers for immune-mediated gastrointestinal diseases
3. basic transplantation biology, including the processes leading to and permitting the
    development of critical disorders such as graft-versus- host disease




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Technologies

Technical advances have played a critical role in allowing bench-to-bedside transfer of
technology. A basic understanding of many critical technologies should be included in
the educational curriculum. These technologies should include

1. Genetic screening techniques: A fundamental understanding of genetics required to
   apply genetic screening techniques effectively
2. Principles of polymerase chain reaction: Understanding the technology as well as its
   utility, limitations, applications, and diagnostic and information acquisition potential
3. Microarray technology: Understanding the methodology, present and projected
   applications, and limitations
4. Recombinant technology: Understanding the techniques and applications of
   development of recombinant human proteins and peptides for their therapeutic and
   diagnostic applications
5. Antibody methodology: Understanding techniques involved in creation of
   hybridomas and the potential application of monoclonal antibod ies obtained using
   this technique. Also, an understanding of the theory and practical use of humanized
   chimeric monoclonal antibodies because of their present and future applications for
   diagnosis and management of patients.
6. Cell sorting technology / flow cytometry: Understanding the basis of these techniques
   and their potential applications to distinguish among specific cell types.
7. Detection of cell markers: Understanding methodologies ranging from microscopic,
   nucleic acid hybridization, immunodetection methods to enzymatic assays, used to
   identify cell markers. Application of such technologies to distinguish the various
   populations of cells involved in inflammatory and neoplastic processes. The
   limitations of these immunological and biochemical detection methods in sorting out
   information regarding specific disease processes.
8. New technologies. An understanding of rapidly developing technologies, including
   phage display technology, filamentous phage biology, and applications form the
   nascent fields of genomics and protenomics.
9. Information acquisition: Understanding the acquisition of information in molecular
   biology or as it pertains to gastroenterology, both now and in the future, via the
   Internet.


Training Process

The experience, training and acquisition of information for trainees can be provided in a
variety of ways, which are not mutually exclusive. The methods of training can include:

1. Specific lectures dedicated to conveying information regarding the topics
2. Appropriate readings and instructional materials with discussion seminars (i.e. journal
   club)
3. Conferences and lectures at local or national meetings



                                            69
4. Seminar-type courses that focus on the cellular and molecular basis of gastrointestinal
   physiology
5. Personal instruction and questioning of trainees d uring the diagnosis and management
   of patients




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TASK FORCE ON TRAINING IN GERIATRIC GASTROENTEROLOGY

Geriatric training in gastroenterology can be divided into 2 broad categories
1. General geriatric issues that need to be addressed include the impact of age on patient
   communication, family and social support, and presentation of disease
2. Geriatric gastroenterology deals with the impact of age on presentation, diagnosis and
   treatment of common and important gastrointestinal conditions in the elderly. An
   important feature of this training is the ability to recognize the effect of age on
   pathophysiology and response to treatment


General Geriatric Issues

1. Pathophysiology of aging: Obtain an overview of the current concepts and models of
   aging, with particular emphasis on the gastrointestinal tract.
2. Demographics and epidemiology of aging: An understanding of the impact of aging
   on the epidemiology of gastrointestinal disease, health care delivery and the issues of
   costs and resources
3. Impact of common geriatric disorders on gastroenterology: Develop an understanding
   of the impact of common diseases, such as depression and dementia, on the
   presentation and evaluation of gastrointestinal disease. Able to assess the patients’
   ability to follow a treatment plan, with emphasis on the effect of cognitive
   impairment on management of gastrointestinal problems
4. Social and ethical issues in aging: Able to asses the patients’ levels of dependence on
   external psychosocial support from family, friends and organizations as part of the
   treatment plan and should be aware of the importance of appropriate communication
   with the patients’ families (or equivalent). Trainees should be aware of common signs
   and symptoms of abuse and have a basic knowledge of community resources
   available for intervention in cases of abuse, neglect, and caregiver stress. Trainees
   should develop an understanding of the special needs of frail older individuals,
   including ethical issues concerning the risk-to-benefit ratio of the investigation and
   treatment of disease as well as end-of- life issues.

Geriatric Gastroenterology

1. Changes in gastrointestinal function with aging: Trainees should be aware of the
   normal or expected changes in the physiology of the gut, pancreas, and liver that
   occur with aging. These include swallowing disorders due to a variety of aging-
   associated changes in oropharyngeal and esophageal motility, impaired gastric
   motility and acid secretion, changes in hepatic metabolism, slowing of colonic
   motility and rectal dysfunction. There should be a familiarity with the normal range
   of laboratory data in the elderly.
2. Changes in drug metabolism with aging: Trainees must have an appreciation of the
   changes in drug metabolism, particularly in the liver, which occur with aging.
   Trainees should be able to identify and anticipate side effects and interactions of




                                            71
     medications used for the management of gastrointestinal disorders in the geriatric
     population
3.   Gastrointestinal effects of drugs: Trainees should have an appreciation for the
     presentation and differential diagnosis of gastrointestinal side effects of commonly
     prescribed drugs in older individuals. These include drugs with significant symptoms
     or effects on gastrointestinal motility, including neuroleptics, antihistamines,
     antidepressants, antiarrhythmic agents, and antihypertensive agents (i.e. calcium
     channel antagonists).
4.   Effects of aging on nutrition: Trainees should be able to discover malnutrition in the
     geriatric age group with an awareness of the common disorders resulting from
     inadequate intake of nutrients (including vitamin deficiencies). There should be a
     recognition that adaptation of food intake to illness or abrupt changes in physiology is
     impaired or delayed in older individuals. Trainees should be taught age-appropriate
     strategies for fluid and nutritional replacement in inpatient and outpatient settings.
     There should be an appreciation of the presentation of anorexia, obesity and eating
     disorders in older individuals. The ethical and treatment issues of feeding tube
     placement should be covered with particular emphasis on risks and benefits in frail
     and demented patients.
5.   Common gastrointestinal conditions in the elderly: Trainees should be familiar with
     the presentation and pathophysiology of common gastrointestinal diseases in the
     elderly, including dysmotility syndromes affecting oropharynx, stomach and colon.
     Trainees should also be aware of malabsorption, gastrointestinal bleeding, and
     oncologic diseases in older patients and they should be aware of the prevalence,
     diagnosis and treatment. Appropriate management of common disorders in the elderly
     should be reviewed, as it may be different in the elderly patient. There should also be
     an understanding of the diagnosis and management of common gastrointestinal
     problems in institutionalized and bedridden geriatric individuals.
6.   Effective strategies for inpatient and outpatient management. Trainees should be able
     to assess the severity and emergent natures o f gastrointestinal complaints in the
     elderly in inpatient and outpatient settings. Appropriate strategies for fluid/volume
     assessment and management in the elderly should be appreciated. There should also
     be an understanding of the subtle and misleadingly benign presentation of acute
     abdominal conditions in frail older patients and an understanding of the need for early
     surgical referral if appropriate.


Training Process

Trainees knowledge should be obtained through a variety of experiences
1. Didactic lectures (including CD-ROM and Internet-based programs), case
    presentations, group discussions and seminars, clinical bedside teaching and
    individualized teaching
2. Clinical experience provided primarily by interaction with consultants in both
    gastroenterology and geriatric medicine.
3. Clinical exposure should include both outpatient and inpatient geriatric settings




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TASK FORCE ON TRAINING IN WOMEN’S HEALTH ISSUES IN DIGESTIVE
                          DISEASES

Women’s health issues and awareness of gender differences should be incorporated into
the overall gastroenterology fellowship. The patient population cared for by trainees
should include a minimum of 25% women. There are three broad categories of women’s
health that should be included in the curriculum. These categories are general women’s
health issues, specific digestive diseases and women’s health issues, and pregnancy and
childbearing issues.


Goals of training

General Women’s Health Issues

1. Doctor-patient relationship: Development of an understanding of gender differences
   as they pertain to the doctor-patient relationship
2. Cultural and religious issues: The cultural and religious difference between men and
   women and the manner in which health care is both perceived and sought and with
   which recommendations or complied should be appreciated.
3. Psychosocial issues: Trainees should understand psychosocial issues both as initiating
   factors in certain disease states in women and as their contribution to ongoing clinical
   symptoms and pathology and their impact on evaluation and treatment. Patient should
   be able to elicit information about abuse and understand their co nsequences upon
   gastrointestinal issues. Trainees should be able to develop empathy for the special
   needs of women.
4. Laboratory values and diagnostic tests: Trainees should recognize that there are
   gender differences as well as changes during pregnancy in normal laboratory values,
   including liver tests, hematocrit, and creatinine values. They should recognize
   anatomic gender differences on diagnostic tests and changes in women with age and
   pregnancy.
5. Disease presentation and physician visits: Trainees should recognize gender
   differences in disease presentation as well as different thresholds between women and
   men in seeking medical care. In addition, there are differences in thresholds for pain
   perception in difference disease states as well as among individual patients.
6. Complementary and alternative medicine: Trainees should be able to elicit a history
   of the use of complementary and alternative medicine during the routine examination
   and be aware of the potential impact upon health and disease, as well as the potential
   complications of some herbal remedies.


Specific Digestive Diseases and Wome n’s Health Issues

1. Health and disease states in women: Trainees should understand the presentation and
   pathophysiology of all gastrointestinal and hepatic disease in both women and men.
   There should be an awareness of gender differences in demographics and



                                            73
   epidemiology and pathophysiology of many gastrointestinal and hepatic diseases.
   There should be an awareness of gender differences in demographics, epidemiology
   and pathophysiology of many gastrointestinal tract and liver disorders. Trainees
   should understand the psychosocial impact on many of the gastrointestinal disorders
   as well as the effect that chronic disease has on a women’s daily life and that an
   effective treatment plan often includes a multidisciplinary approach.
2. The effect of the menstrual cycle and menopause on digestive disease function in
   health and disease: Trainees should understand the effect of the menstrual cycle and
   menopause on gastrointestinal tract and liver function in both health and disease. This
   includes and understanding of estrogen and progesterone and the role of these and
   other hormones have on gastrointestinal tract and liver function.
3. Gender differences in the pharmacokinetics of medications: Trainees should
   recognize and understand gender differences in medication pharmacokinetics,
   differences in the prolongation of QT intervals, differences in metabolism of certain
   medications and differences in the therapeutic response. There should be an
   appreciation of potential side effects, complications and interactions of medications
   that are used for the management of gastrointestinal and liver disease in women.


Pregnancy and childbearing issues

1. Fertility and infertility: Trainees should be co gnizant of the issues regarding fertility
   and pregnancy and be able to appropriately advise women with gastrointestinal and
   liver disorders who desire pregnancy. There should be a basic knowledge of genetics
   as it pertains to the gastrointestinal tract and liver disorders and the risk to the
   women’s unborn infants.
2. Pregnancy: Trainees should become knowledgeable about the following:
   a. Gastrointestinal and liver changes and disorders in normal pregnancy
   b. Effect of preexisting gastrointestinal and liver disorders on pregnancy
   c. The initial clinical presentation during pregnancy of a gastrointestinal or liver
        disorder
   d. Gastrointestinal and liver disorders that are unique to pregnancy, including acute
        fatty liver of pregnancy and HELLP syndrome
   e. The impact of gastrointestinal and liver disorders on a woman’s ability to carry a
        healthy baby to term as well as the impact of her pregnancy on her gastrointestinal
        liver disorder
   f. The risk of maternal- fetal transmission of infectious agents, such as hepatitis B
        and hepatitis C, and the appropriate treatment of both the mother and the newborn
        infant
   g. The different pharmacokinetics and interaction of medications during pregnancy
        and breast feeding
   h. The potential harm to the fetus of medications, sedation, endoscopic procedures,
        and diagnostic tests, including radiographic tests, and the appropriate use of these
        during pregnancy
   i. Good nutrition, including increased vitamin and mineral requirements during
        pregnancy



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3. Postpartum issues: Trainees should understand that there are gastrointe stinal disorders
   that are caused or affected by delivery and that manifest themselves immediately in
   the postpartum period or years afterward that the trainees should be able to recognize
   (i.e. rectal prolapse, urinary and/or fecal incontinence, hemorrhoid s).


Training Process

Trainees knowledge should be obtained through a variety of experiences, including
didactic lectures (which can include CD-ROM and Internet-based programs), case
conferences, self-directed learning, selected readings and clinical experiences.




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APPENDIX
Contents

ASGE first year Endoscopy Course
Board Review Course
Walter Reed Gastroenterology Course
GME fellow seminar schedule
Orientation agenda



Need
Evaluation forms
Orientation manual
Discussion with prior fellows
Liver curriculum
        Meeting with Fairfax
        Fellows application for Fairfax rotation
Fellow Rotation schedule
Faculty lecture schedule
Clinic schedule
Call schedule


Check document for
GI resident vs. fellow (consistency in citing throughout document)




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                                  FELLOW CLINIC SCHEDULE



                                    CLINIC SCHEDULE
Monday       Tuesday               Wednesday            Thurs day           Friday
             Inflammatory Bowel                         Liver Disease
             Disease                                    Borum
             Borum
General GI   General GI            Inflammatory Bowel   Biliary Disease /   General GI / Biliary
Ehrlich      Borum                 Disease              Motility            Disease
                                   Ginsberg             Nsien               Bashir




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