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GASTROENTEROLOGY CLINICAL FELLOWSHIP

VIEWS: 150 PAGES: 115

									DIVISION OF GASTROENTEROLOGY, HEPATOLOGY & NUTRITION

    GASTROENTEROLOGY CLINICAL FELLOWSHIP

               UT HOUSTON PROGRAM

                     HANDBOOK




                                            2010-2011
Table of Contents                                                     Page
  I.      Clinical Fellowship in Gastroenterology
          a. Graduate Medical Education Office (GME)………………………………………     3
  II.     Program Overviews
          a. Affiliated Hospitals………………………………………………………………….             4
          b. Educational Purposes………………………………………………………………               4-5
                i. Clinical Education Overview………………………………………………        4
                ii. Hospital IP Consult Rotations……………………………………………      4
               iii. Hospital OP Rotations…………………………………………………….          5
               iv. Research Rotation…………………………………………………………              5
                  v. Conferences………………………………………………………………..            5-6
  III.    Rotations, Call and Clinic……………………………………………………………….         7- 9
          a. Rotation schedule……………………………………………………………………              7-8
          b. Call Schedule……………………………………………………………………….                8
          c. Fellows’ Continuity Clinic – LBJ……………………………………………………     9
  IV.     Fellowship Citizenship……………………………………………………………………            10-15
          a. Employment Contract UT Medical Foundation……………………………………  10
          b. Level of Training………………………………………………………………………             10
          c. Curriculum Vitae………………………………………………………………………              10
          d. Dress Policy……………………………………………………………………………                12
          e. Endoscopy Policy……………………………………………………………………… 12
          f. Procedure Log…………………………………………………………………………. 12
          g. Duty Hours……………………………………………………………………………… 12
          h. Moonlighting Agreement……………………………………………………………… 12
          i. GI Fellows’ Research…………………………………………………………………. 13
          j. Rotation Goals and Objectives………………………………………………………       13
          k. Evaluations- GMEIS…………………………………………………………………… 13
          l. Benefits…………………………………………………………………………………                  13
          m. Payday…………………………………………………………………………………                    13
          n. Vacation/Education & Other Leave Requests……………………………………… 13
          o. Holidays………………………………………………………………………………… 14
          p. USA Mobility Pagers………………………………………………………………………                   14
          q. ID Badges……………………………………………………………………………… 14
          r. Meals…………………………………………………………………………………… 14
          s. White Coats……………………………………………………………………………                 14
          t. Email……………………………………………………………………………………                    14
          u. Division Office…………………………………………………………………………              15
          v. Fellows’ Office…………………………………………………………………………              15
          w. Mail……………………………………………………………………………………… 15
          x. Library…………………………………………………………………………………… 15
          y. Parking…………………………………………………………………………………. 15
          z. Bookstore………………………………………………………………………………. 15
          aa. Travel…………………………………………………………………………………… 15
          bb. Personal or Professional Concerns…………………………………………………. 15
          cc. Work Life Program…………………………………………………………………….            15
          dd. UTHSC-H Recreation Center………………………………………………………… 15
  V.      Goals and Objectives………………………………………………………………….              16 - 98
  VI.     Rotation Schedule …………………………………………………………………………              Appendix A
  VII.    Call Schedule ……………………………………………………………………………….. Appendix B
  VIII.   Conference Schedules…………………………………………………………………….. Appendix C
  IX.     Telephone Directory ………………………………………………………………………….. Appendix D
  X.      Forms ………………………………………………………………………………………... Appendix C




2 | Page
Graduate Medical Education (GME)
Clinical Fellowship in Gastroenterology
University of Texas at Houston Program - ACGME ID: 1444831017

Physicians pursuing their post-MD/DO graduate training at The University of Texas Health Science
Center at Houston Medical School Gastroenterology Fellowship Training Program (“the GI Fellowship
Training Program” or “Program”) are appointed by The University of Texas System Medical Foundation
(“Foundation”). No property interest in employment is created by such appointment. The Foundation
reserve the right to change any requirements affecting the terms and conditions of employment of
Fellow Physicians. Changes to this Handbook will become effective whenever the proper authorities so
determine and will apply to both prospective Fellow Physicians and those already enrolled in the GI
Fellowship Training Program.

The Foundation, a not-for-profit corporation, in cooperation with The University of Texas Medical
School at Houston (“Medical School”), a component entity of The University of Texas Health Science
Center at Houston, administers all aspects of the GI Fellowship Training Program. The Foundation
performs administrative and educational functions for the benefit of both the GI Fellow Physician and
the Program. These functions include, but are not limited to issuance of paychecks and other
personnel services, maintenance of records, procurement and administration of benefits provided by
the Foundation, and provision of mechanisms for effective coordination of the Program among the
hospitals.

The Policy Review Committee (“PRC”) is charged with administrative governance of the Foundation.
The PRC sets policy and procedures for the Graduate Medical Education (“GME”) Programs and
provides administrative oversight for the Foundation.

The Graduate Medical Education Committee (“GMEC”) is a committee of the Medical School Faculty
Senate that provides academic oversight for the GI Fellowship Training Program and ensures
compliance with the Accreditation Council for Graduate Medical Education (“ACGME”) Institutional,
Common, and Specialty/Subspecialty Program Requirements.

The Graduate Medical Education Office provides administrative services for all residency and
fellowship programs:

                        The University of Texas Medical School at Houston
                               Graduate Medical Education Office

                                    6431 Fannin Street, JJL 310
                                      Houston, Texas 77030
                                       Phone: 713/500-5151
                                        Fax: 713/500-0612

                                   E-mail: ms.gme@uth.tmc.edu

                       Website: http://med.uth.tmc.edu/administration/gme/




3 | Page
PROGRAM OVERVIEW

University of Texas at Houston Program - ACGME ID: 1444831017
The University of Texas at Houston Medical School at Houston fellowship in clinical gastroenterology is approved by
the Accredited Council for Medical Education (ACGME)

AFFILIATED HOSPITALS
Affiliated hospitals for training gastroenterologist and hepatologist are dedicated to providing teaching, research and
clinical activities at the highest standard. These world-class hospital affiliations provide the GI fellow with exposure not
only to a large and diverse population, but also to a faculty renowned in gastrointestinal and liver diseases. Affiliated
Hospitals:
            •    Memorial Hermann Hospital – Texas Medical Center
            •    Harris County LBJ General Hospital
            •    The Methodist Hospital

            •    UT M. D. Anderson Cancer Center

The UT GI Program is a three-year clinical fellowship with research. First-year fellows are accepted to the program
each year. Each fellow will have a basic core curriculum involving rotations at each of the affiliated facilities. With a
faculty mentor fellows will participate in clinical research, basic research, or other scholarly activities. At the conclusion
of the three-year fellowship training, the fellow will be a fully trained gastroenterologist who will be able to diagnose,
treat, and manage all forms of gastrointestinal and liver disease and will be able to practice competently and
independently in the field of gastroenterology.
EDUCATIONAL PURPOSES
Clinical Education Overview: The fellow is introduced to the management of patients with gastroenterological and
liver diseases. During the training, the fellow will have the opportunity to assess a wide variety of acute and chronic
gastroenterological and liver conditions. Minimum levels of achievement in each competency are expected during each
of the three years of fellowship training. Those meeting competency will receive a score of 5 in the program’s
evaluation system. Fellows performing at a level better than expected for that competency receive a score of 6 or 7 in
the evaluation system, those at a level better than most fellows at that PGY receive an 8, and those performing at a
level deemed to be “one of the best fellows ever observed” will receive a score of 9. Fellows receiving a score of 4 or
below are deemed deficient in that competency; this will be brought to the attention of the program director immediately,
and, if necessary, remediation will be implemented.

Hospital IP Consult Rotations: The fellow will evaluate patients on Medicine, Surgery, Ob-Gyn, Oncology, Neurology
or other services. Rounds are made daily with the faculty attending. On rounds, teaching objectives include
formulating a differential diagnosis and evaluating possible diagnostic possibilities and therapeutic options. Attention is
given to an understanding of the underlying physiology and pathophysiology. Procedures, when necessary and
appropriate, are performed by the fellow under the supervision of the faculty attending. Fellows will learn all aspects of
gastroenterology and liver disease care and will display all general competencies during this experience.



4 | Page
Hospital OP Rotations: The fellow will participate in increasing levels of management/treatment involvement with
patient needs depending on the fellow’s level of experience. The fellow will be expected to formulate the differential
diagnosis, institute diagnostic studies and recommend therapy. The amount of learning obtained from each specific
rotation is directly proportional the amount of time spent in the evaluation of the patients and asking questions to the
attending faculty.

        Gastroenterology Focus: Fellows will develop familiarity of problems with complex gastroenterological issues
        related to irritable bowel syndrome, inflammatory bowel disease, motility disorders, malabsorption, and
        screening/surveillance for neoplasia or dysplasia. These are some of the more common conditions
        encountered and include the differential diagnosis of other structural abnormalities involved in the esophagus,
        stomach, or duodenum. Fellows will gain knowledge of management of medications that may have serious
        systemic complications and/or the potential for drug interaction.
         Hepatology Focus: Fellows will develop familiarity with standard treatments for common complications such
        as ascites, portal hypertension or hepatic encephalopathy and will build familiarity with standard treatments of
        chronic liver diseases such as viral hepatitis, autoimmune liver diseases, metabolic liver diseases, drug-
        induced liver disease, fatty liver disease and liver tumors. Fellows will obtain exposure to the liver
        transplantation selection process and will receive experience in the timing of referring patients for liver
        transplantation.

Research Rotation: The fellow is introduced to the field of gastroenterology and hepatology research. While Year I
fellows discuss and plan for future research a specific project and mentor must be selected by the end of the first year.
Research Rotation is primarily designed for Year II and Year III fellows and allows time for research planning, work and
post-research outcomes. The University of Texas at Houston GI Fellowship Program has a large faculty with diverse
clinical and academic interests, ensuring that fellows have complete opportunities to investigate the gastroenterology or
hepatology research project of their choice generally designed and conducted in close interaction with their research
mentor. The fellow will participate in increasing levels of research activities, depending on the fellow’s level of
experience. The amount of learning obtained from this rotation is directly proportional to the amount of time dedicated
to research. Fellows will follow a complete course of research study during this rotation including research ethics,
project exploration, planning, actual research activity, analysis, written outcomes and, ideally, presentation of their
project at a national GI or hepatology meeting or in a peer-reviewed journal.

CONFERENCES:
Weekly GI Reading Conference The GI Reading Conference (weekly core curriculum conference) is established to
insure that all fellows master the basic sciences and major clinical topics relevant to gastroenterology and hepatology.
The contents of the current edition of the major textbook in Gastroenterology and Hepatology (Sleisenger and Fordtran,
9th edition) provide the written curriculum for this conference. These sessions cover, over a three year period, the
specific didactic material recommended by Subspecialty Program Requirements of the ACGME and the
Gastroenterology Core Curriculum, May 2007 (AASLD, AGA, ACG, ASGE) including special task forces on Training in
Acid-Peptic Disease, Biliary Tract Diseases and Pancreatic Disorders, Cellular and Molecular Physiology, Endoscopy,
Ethics, Medical Economics, and System-Based Practice, Geriatric Gastroenterology, Hepatology, Inflammation and
Enteric Infectious Disease, Malignancy, Motility and Functional Illnesses, Nutrition, Pathology, Pediatric
Gastroenterology, Radiology, Research, Surgery, and Women’s Health in Digestive Diseases. Special sessions cover
issues related to evidence based medicine, critical appraisal of medical literature, and research study design and
analysis. The conference occurs Thursday mornings 7-8 AM. A faculty member is responsible for leading a discussion
on the material through guiding questioning. A test written by the faculty member is given each week. This is a
mandatory conference for all fellows. Tests are collected to become part of the fellows’ file.


TMC GI Grand Rounds – UT and BCM GI fellows present clinical cases in which all the competencies are taught to
participating fellows, faculty, and other learners. The goals and objectives of the conference cover the entire
competency based curriculum. In addition, the conference is specifically designed to allow the fellow to learn and
demonstrate Practice Based Learning and Improvement. The encounter of the fellow with the patient shows that the
fellow has limits and deficiencies in knowledge, skills, and attitudes. Through analysis and reflection the fellow sets
learning and improvement objectives. The fellow locates, appraises, and assimilates evidence from scientific studies
related to the patient's health problems. The fellow assembles all appropriate materials, including imaging studies,
pathology slides, endoscopic photos, etc. and contacts the appropriate consultants (radiologists, pathologists,
surgeons, etc.). The fellow incorporates explicit take home lessons into practice for future patients. The fellow presents
to fellows, faculty and other health care professionals. This is a mandatory conference for all fellows.

5 | Page
GI Nutrition Conference – “Nutrition and Gastrointestinal Disease” edited by Mark H. DeLegge, MD: Chapters are
selected monthly with review and discussion lead by the GI fellow assigned. This is a mandatory conference for all
fellows.

GI Pathology Conference ~ Chaired by Patrick Lynch, MD, UTMDACC G1.3616, each Wednesday at 4:00 pm This is
a mandatory conference for the fellow(s) on UTMDACC Rotation(s).

 GI Endoscopy Quality Improvement Conference at LBJ 3rd Thursday, monthly 2nd floor Conference room 12:00-
1:00 pm This is a mandatory conference for fellows on LBJ rotations.

Gastroenterology Journal Club - Current journal articles are presented and discussed once a month. This is a
mandatory conference for all fellows. Meets 2nd Thursday monthly at 5:00 pm. 2009-2010

Hepatology Journal Club- Hepatology journal club every Wednesday morning. This is a mandatory conference for
the fellows on MHH Rotations.
.
Hepatology – Pathology Review of liver pathology by members of the Department of Pathology. This is a mandatory
conference for the fellow on Hepatology Rotation.

Texas Medical Center - GI Research Forum – Weekly series presented every Thursday at 4:00 pm at BCM from
September through May. Speakers include a diverse mix of clinicians and basic scientists, from UT Houston, BCM,
The Methodist Hospital, UTMB in Galveston, UTMDACC and from across the country the fellow on Hepatology. This is
a mandatory conference for all fellows.

Multidisciplinary Conference, The Methodist Hospital – Weekly conference, fellow on TMH rotation presents third
Friday each month. This is a mandatory weekly conference for the fellow on TMH Rotation and is strongly
recommended for all fellows, as assigned rotations allow. Mandatory for all fellows on the third week; when the GI
fellows presents.

Physiology Conference – Monthly Review of Gastrointestinal Physiology 7th Edition. Chapters are assigned by
Program Director and presented by fellows monthly.

Radiology Teaching Rounds with Dr. Herbert Loyd TMH Third Wednesday Scurlock Tower, Suite 500 This is a
mandatory weekly conference for the fellow on TMH Rotation. This conference is strongly recommended for all
fellows, as assigned rotations allow.

Gastroenterology M & M Conference Meets each quarter. This is a mandatory conference for all fellows.

Hepatology - Liver Transplant Medical Review Board This is a mandatory conference for the fellow on Hepatology
Rotation.

Hepatology      Liver Transplant – M&M this is a mandatory conference for the fellow on Hepatology Rotation.

Hepatology      Liver Transplant Listed Patient Meeting This is a mandatory conference for the fellow on Hepatology
Rotation.
.
Hepatology -     Liver Tumor Conference This is a mandatory conference for the fellow on Hepatology Rotation.
Mandatory Conferences and Meetings
Attendance is mandatory for most conferences. If a fellow knows in advance that he/she is unable to attend a conference,
he/she is to call and inform the Program Director and Fellowship Coordinator. Rotations are required to allow fellows to
attend at educational conferences/meetings.

When a fellow is not present and/or on time for any mandatory conferences, a meeting with the Program Director will
be scheduled. Fellows are required to attend a minimum of 90% of conferences during each quarter. If a Fellow’s
attendance falls below 80%, then a letter will be placed in the fellow’s file documenting the lack of attendance.

Approved leaves and prior excused absences will not be counted against the fellow. Otherwise, there are absolutely no
valid excuses for not being present at these conferences.

6 | Page
ROTATIONS, CALL and CLINIC
Rotation Schedules
Each year the rotation schedule is designed, with consideration for the 36 months of fellowship training, using the
Gastroenterology Core Curriculum. The core curriculum for gastroenterology has established the training standards,
guideline, and resources and are regularly updated by the societies representing gastroenterology/hepatology in The
Gastroenterology Core Curriculum Steering Committee composed of representatives from: American College of
Gastroenterology (ACG ); American Association for the Study of Liver Diseases (AASLD), American Gastroenterology
Institute (AGA Institute); and American Society for Gastrointestinal Endoscopy (ASGE).

While every effort is made to accommodate each fellow in the Program, it is very important to follow the yearly rotation
schedule as closely as possible. Each change made affects several people. Therefore, we ask that, barring unforeseen
emergencies, you work the schedule that is outlined for you at the beginning of the academic year. However, if an
emergency arises, the Program Director may adjust the schedule accordingly. Adjustments will be mandatory, not voluntary.


A Fellow will be assigned to the following rotation at all times:
       Memorial Hermann Hospital Texas Medical Center Hospital (MHH):

                 1.      MHH IP – GI Consult Rotation

                 2.      MHH Liver – MHH Hepatology Consult Rotation

                 3.      MHH OP- Rotation
                         a.   GI - Digestive Disease Center (DDC)
                         b.   Hepatology - Texas Liver Center(TLC)

                 4.      MHH PBS - MHH Gastroenterology PancreaticoBiliary Service Rotation

        HCHD: LBJ General Hospital (LBJ):

                 5.      LBJ IP Cons – GI Consult Rotation

                 6.      LBJ OP Proc – GI Procedures Rotation

                 7.      Research –        Clinical Research focused on Gastroenterology Rotation

        UT M D Anderson Cancer Center (MDA)

                 8.      MDA IP - GI Consult Rotation

                 9.      MDA OP- GI Endoscopic and Clinic Rotation

        The Methodist Hospital (TMH)

                 10.     TMH – Methodist: Gastroenterology Rotation

Rotations are monthly, beginning on the first day of each month and ending on the last day. Prior to beginning a new
rotation, the fellow is responsible for contacting the fellow on the rotation to obtain patients list. Rotations are Monday
to Friday, from 7:00 am to 5:00 pm. At times, due to urgent patient needs, the fellow will need to remain on the rotation
past 5:00 pm. The fellow is expected to work the hours the faculty member deems appropriate, within the ACGME
guidelines for duty hour violation and required conferences attendance.

Goals and Objectives: The goals and objectives for each rotation are attached. The fellow is expected to review the
rotation’s goals and objectives with the attending faculty at the start of each rotation.

7 | Page
NOTE: If a fellow is unable to report for a scheduled rotation, the Program Director, Dr. Lukens and the attending
scheduled for the rotation must be called. The Fellowship Coordinator, Helen Tanner should be notified for record
keeping.

                 Frank Lukens, MD           713.617.3008 (pager)              281.785.9567 (cell)
                 Helen Tanner               713.500.6672 (office)             713.494.6458 (cell)

Night/Weekend Call
Call is covered from the fellow’s home but call facilities, if needed, are available and located at Memorial Hermann Hospital,
608 Robertson Pavilion.

While every effort is made to accommodate each fellow in the Program, it is very important to follow the yearly call schedule
as closely as possible. Each change made affects several people. Therefore, we ask that, barring unforeseen
emergencies, you work the schedule that is outlined for you at the beginning of the academic year. However, if an
emergency arises, the Program Director may adjust the schedule accordingly; adjustments will be mandatory, not voluntary.
The call schedule has been designed with consideration given to all 36 months of fellowship and approved by the Program
Director. Since gastroenterology/hepatology is a consult service, the primary team is directly responsible for patients and the
GI fellow a consultant.

The call week starts Friday at 5:00 pm and ends Friday at 7:00 am. Fellows are required to come to the hospital for any
acute GI/hepatology complaint. When a consulting physician asks for a patient to be seen during the night and/or weekend
hours, the on-call fellow should comply. The attending should be called regarding all new consults. If a patient requires an
urgent endoscopy, the attending must be present.

GI fellows have night and weekend call seven weeks, except on the hepatology rotation. The fellow on the Hepatology
Consult Rotation is responsible for providing backup coverage to the in-house medicine residents. They take calls from
home, coming to the hospital for urgent patient care only. Fellows are on Hepatology Consult Rotation for one-month blocks,
and are given the appropriate hours off per ACGME regulations.

On-Call Protocol
All changes require a completed and approved “GI Fellowship Request for Schedule Change 2009-10” to be submitted
to the fellowship coordinator for approval from the Program Director at least 30 days prior to the change. Any change
under 30 days must be considered urgent. The Fellow will not make changes without approval. In the event of an
emergency, please contact the Fellowship Program Director and Fellowship Coordinator as soon as possible.

GI Consult Call
Weekend Call:
Fellows cover MHH and MDA hospitals with the respective attending faculty on call. Weekend rounds at MHH will be
with a UT faculty and MDA rounds will be with the MDA faculty on call.
Week Night Call:
Fellows cover MHH, LBJ and MDA GI Consult Call with the attending faculty on call.

Hepatology Consult Call:
Weekend Call:
Fellows cover MHH Hepatology Call and LBJ GI Call. Weekend MHH rounds will be with the UT faculty on hepatology
service. Weekend rounds at LBJ will be with the UT faculty on GI Service.
        Texas Liver Center Patients
        Established Texas Liver Center patients (Hepatology or Pre-Liver Transplant) will be admitted to Medicine or to
        the surgical transplant service. The Hepatology consult service will actively follow the patient while
        hospitalized.
Week Night Call:
Fellows cover MHH Hepatology Consult with the attending faculty on call. Call is covered from the fellow’s home but
call facilities, if needed, are available and located at Memorial Hermann Hospital, 608 Robertson Pavilion.

A verbal sign-out should be given at the end of the call to the fellow on the rotation and/or call. This should be done
regardless of whether new patients were seen during call. It is the responsibility of the fellow signing out to contact the
fellow for this sign-out.
8 | Page
GI Weekly Fellows’’ Continuity Clinic - LBJ

Fellows’ Continuity Clinic is located at LBJ General Hospital in the medicine clinic and is held every Tuesday (excluding
major holidays) afternoon with at least one faculty supervisor. Incoming PGY 4 fellows are assigned new patients their
first Tuesday and continue to follow these patients throughout their training time. Each clinic session the fellow may see
2 to 3 new and 4 to 5 returning patients. The fellow will have 2 extra slots for overbooking. The 4th Tuesday will have a
liver diseases focus with an attending hepatologist.

The fellow is introduced to the management of clinic patients with gastroenterological and liver diseases. During the
training, the fellow will have the opportunity to assess a wide variety of acute and chronic gastroenterological and liver
conditions. Minimum levels of achievement in each competency are expected during each of the three years of
fellowship training. Those meeting competency will receive a score of 5 in the program’s evaluation system. Fellows
performing at a level better than expected for that competency receive a score of 6 or 7 in the evaluation system, those
at a level better than most fellows at that PGY receive an 8, and those performing at a level deemed to be “one of the
best fellows ever observed” will receive a score of 9. Fellows receiving a score of 4 or below are deemed deficient in
that competency; this will be brought to the attention of the program director immediately, and, if necessary,
remediation will be implemented.

Clinic Closure
When a fellow requests a leave and has been given approval by the Program Director, a Harris County Hospital District
(HCHD) Clinical Closure form must be completed and signed at least 30 days in advance by the Program Director. This
approved form must be given to the Clinic Manager for approval and to move any scheduled patients and block the time. It
is the responsibility of the GI fellow to make certain patients are cancelled for any leave request. The Fellowship Coordinator
will assist by scanning the approved copy and emailing to the clinic manager but the responsibility of clinic closure is the
fellows. Especially, if the leave request is made some months in advance, it is the best policy to double check with the clinic
about 6 weeks before the leave to make certain no patient(s) has been put on the day a clinic closure has been approved




9 | Page
FELLOWSHIP CITIZENSHIP
Employment Contract – UT Medical Foundation
GI fellows are appointed by The University of Texas System Medical Foundation (“Foundation”). No property interest in
employment is created by such appointment. The Foundation reserve the right to change any requirements affecting
the terms and conditions of employment of Fellow Physicians. Refer to the GME Handbook for Residents and Fellows
for additional information. GI Fellows must be a United States citizen, permanent resident or hold a J1 Visa. H1B visas
are not sponsored by this Institution for graduate medical education.

Level of Training
The GI fellowship begins as Post Graduate Year (“PGY”) 4 through 6. However, a physician with additional training post
residency may be assigned to a higher PGY position. The incoming Fellow must have completed three years of Internal
Medicine Residency in an ACGME accredited program and be board eligible or board certified by the American Board of
Internal Medicine. Thereafter, the PGY level to which the Resident Physician is assigned will be determined by the Program
Director and Faculty Fellowship Training Committee in accordance with the fellow’s level of education, ability, and
experience.




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Curriculum Vitae
Your updated CV (sent via email), using the UT CV format is due to the Fellowship Coordinator bi-annually, by the
third week of July and last week of May. An up-dated version may be requested at various times during the
fellowship year as requested by ACGME, UT GME office and/or Program Director. (Example of UT CV format)
                                                        CURRICULUM VITAE AND BIBLIOGRAPHY

                                                                                                                DATE:

       NAME:                Your Name, M.D.

       PRESENT TITLE: Clinical Fellow in Gastroenterology
                                 University of Texas at Houston Program

       ADDRESS:                       The University of Texas Health Science Center at Houston Medical School
                                      Department of Internal Medicine
                                      Division of Gastroenterology, Hepatology and Nutrition
                                      6431 Fannin, MSB 4.234
                                      Houston, TX 77030
       ADDRESS:
       CITIZENSHIP:
       UNDERGRADUATE EDUCATION:
       GRADUATE EDUCATION:
       POSTGRADUATE TRAINING:
       MILITARY SERVICE (IF APPLICABLE):
       ACADEMIC APPOINTMENTS:
       HOSPITAL APPOINTMENTS:
       LICENSURE:
       CERTIFICATION:
       PROFESSIONAL ORGANIZATIONS (AND COMMITTEES OF THESE):
                 LOCAL:
                 REGIONAL:
                 NATIONAL:
       HONORS AND AWARDS:
       EDITORIAL POSITIONS:
       SERVICE ON NATIONAL GRANT REVIEW PANELS, STUDY SECTIONS, COMMITTEES:
       SERVICE ON THE UNIVERSITY OF TEXAS-HOUSTON HEALTH SCIENCE CENTER COMMITTEES:
       SERVICE ON THE UNIVERSITY OF TEXAS-HOUSTON MEDICAL SCHOOL COMMITTEES:
       SERVICE ON GRADUATE SCHOOL COMMITTEES:
       SERVICE ON UT-HMS AFFILIATED HOSPITAL COMMITTEES:
       SERVICE TO THE COMMUNITY:
       SPONSORSHIP OF CANDIDATES FOR POSTGRADUATE DEGREE :
       (include names and years)
       SPONSORSHIP OF POSTDOCTORAL FELLOWS:
       (include names and years)
       CURRENT TEACHING RESPONSIBILITIES:
       CURRENT GRANT SUPPORT: (include project title, P.I., funding agency, award period and amount)
       PAST GRANT SUPPORT: (include project title, P.I., funding agency, award period and amount)
       PUBLICATIONS: (List ONLY those published or accepted for publication.
                                     DO NOT INCLUDE PAPERS SUBMITTED FOR PUBLICATION
                                     OR IN PREPARATION. Use the citation style noted below.
                                     Separate the publications into the following categories.)
              A.     Abstracts
              B.     Refereed Original Articles in Journals
              C.     Invited Articles (Reviews, Editorials, etc.) in Journals
              D.     Chapters
              E.     Books
              F.     Other Professional Communications
                      1. Presentations
                      2. Non-refereed Publications
                      3. Letters to the Editor
                      4. Scientific Exhibits
                      5. Videos
                      6. Other
              G. Visiting Professorships
              Style for citations should be:
                     Berson, S.A., and Yalow, R.S.: Quantitative aspects of the reaction between insulin and insulin-binding antibody. J. Clin.
                     Invest. 38:1996-2016, 1959.
              Note:
                     1.       All authors must be listed in the originally published order.
                     2.       Provide inclusive pagination.
                     3.       Book chapters should provide authors and title of chapter as well as editor(s) and title of book, publisher, city, year and
                              inclusive pagination.




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Dress Policy
As board certified (or eligible) internists and physicians in training in Gastroenterology, appropriate attire is required for
all rotations. The initial appearance to patients and other healthcare professionals is important. White UT-H lab coat
with your name embroidered have been provided as well as free laundry services. It is expected for you to wear a clean
lab coat. Business attire with the white lab coat is expected for all rotations, including Fellows’ Continuity Clinic on
Tuesday. For men, a tie is essential part business attire. Appropriate business attire is expected for all women
physicians in training.

Endoscopy Policy
An attending must be present for all procedures. First-year fellows perform mainly EGD and colonoscopies.
Only 3rd-year fellow or 2nd year fellow during last months of 2nd year perform ERCPs.

Procedure Log
Each fellow is responsible for keeping a computer procedure log of all procedures performed. The excel format sent will be
used for the entire 36 months of fellowship. The format should not be changed except by the program director. This log is to
be provided to the Fellowship Coordinator at the end of every month. Vacation requests will not be approved and will not be
taken unless the log is current.

Duty Hours
Overview: Fellows are provided with a sound academic and clinical education that has been carefully planned and
balanced with concerns for patient safety and fellows’ well-being. The learning objectives of this program are not
compromised by excessive reliance on residents to fulfill service obligations. Didactic and clinical education is given
priority in the allotment of fellows' time and energies. Duty hour assignments recognize that faculty and residents
collectively have responsibility for the safety and welfare of patients.

Supervision: All patient care must be supervised by qualified faculty. The program director will ensure, direct, and
document adequate supervision of fellows at all times. Fellows are provided with pagers for communicating with
supervising faculty. Faculty schedules are structured to provide fellows with continuous supervision and consultation.

Safety: Faculty and fellows are provided with the American Academy of Sleep Medicine product- S.A.F.E.R.: Sleep,
Alertness and Fatigue Education in Residency to recognize the signs of fatigue and adopt and apply policies to prevent
and counteract the potential negative effects. A S.A.F.E.R survey is completed by faculty and fellows on the GMEIS
system.
Duty Hours: Duty hours are defined as all clinical and academic activities related to the program, i.e., patient care
(both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care,
time spent in-house during call activities, and scheduled academic activities such as conferences. Duty hours do not
include reading and preparation time spent away from the duty site. Duty hours are limited to 80 hours per week with
at least 10 hour time period provided between all daily duty periods and after hours call, averaged over a four-week
period. There is adequate time for rest and personal activities provided to all fellows.

Moonlighting
The Division of Gastroenterology forbids moonlighting without approval of Dr. Lukens. Each Fellow must sign a
moonlighting statement annually. The ACGME set forth specific requirements and guidelines for moonlighting. Those
requirements, along with the UTMSH policy are listed with attachments. Fellows will not be required to engage in
professional activities outside the educational program (moonlighting). Under Texas law, professional activities involving the
practice of medicine outside the program are available only to a physician-in-training who holds a medical license from the
Texas Medical Board. An institutional permit or physician-in-training permit does not entitle the Fellow to assume
professional activities outside the educational program. The listed fringe benefits, including coverage for any injury or
disability (I.H.8) incurred, do not apply during such outside or unassigned activity. Professional Liability Insurance (I.H.9) will
not cover the Fellow for any liabilities incurred in such professional activity. All moonlighting activities require a prospective
written statement of approval from the Program Director, for inclusion in the resident’s file. The Program may revoke
approval or initiate corrective action in the event outside professional activity interferes with the ability of the Fellow to fulfill
satisfactorily the obligations of the Program. Any hours that a Fellow works for compensation at the sponsoring institution or
any of the sponsoring institution’s primary clinical sites (internal moonlighting) must be considered part of the 80-hour
weekly limit on duty hours.

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GI Fellows’ Research
Fellows are expected to engage in research and scholarly activities. During their first year, Fellows are encouraged to
select a mentor, as well as potential projects. By the end of their first year, Fellows will have selected a specific project and
mentor. Research efforts will be reviewed during the year with the Fellowship Director. The development of a specific
project is integral to the fellowship program in the second and third year. Fellows have established an impressive track
record in presenting at local and national meetings.

Rotation Goals and Objectives
Each Fellow is required to review Goals and Objectives for every rotation (the last pages of this handbook). The information
will be sent to you via e-mail before the beginning of the rotation. Goals and Objectives should be discussed with the
attending faculty at the beginning of each rotation. This material is also available for your use on the Gastroenterology
Fellowship web page.

Evaluations - GMEIS
GMEIS (Graduate Medical Education Information System), a web based evaluation system used for fellowship evaluations.
GMEIS evaluations are due at the end of each month. At the end of each rotation, the Attending is required to sit down with
the fellow and review his/her performance during the month and complete an evaluation. The Fellow is responsible for
arranging this meeting. At least twice a year, the Program Director meets formally with each Fellow to review his/her
progress. The Program Director summarizes these discussions in a letter to each Fellow

Benefits
Stipends and benefits will be paid to the fellow by the Foundation. Each hospital serves as guarantor of the stipends and
benefits for the number of positions it agrees to support. Stipends will be appropriate to the level of training and
responsibility of the fellow. Attainment of each additional level of training should merit an increase in the stipend. All fellows
at any given level of training will comparably compensated.

Payday
Payday is the last working day of the month. All checks are direct deposit.
http://utsmf.hsc.uth.tmc.edu/payroll.html

Vacation/Educational & Other Leave Requests
Fellows are entitled to three calendar weeks (15 work days) of vacation per year. A maximum of two weeks at one time
may be requested during out-patient rotations. A Request for Leave form must be completed and approved by the
Program Director 30 days prior to leave or, ideally, at the beginning of the academic year. Blank vacation request forms
are posted on the GI website, emailed and are also available in the coordinator’s office. If your leave time includes
cancelling your LBJ Continuity Clinic a HCHD/LBJ clinic closure form must also be submitted, (see above Continuity
Overview.) Your procedure log must be up-to-date and received by the Fellowship Coordinator prior to your leave. Any
conference presentations scheduled must be covered. Other than for GI meetings and with approval by the Program
Director, no more than two fellows may take time leave at one time. June vacation time is limited to no more than two
weeks. Any unused vacation at the end of a fellowship year (June 30) will not carry forward to the next year.

Paid Sick Leave
Paid sick leave accrues at a rate of eight hours each month and accumulates to a maximum of 30 days. Paid sick leave
carries forward from year to year; however, unused sick leave remaining as of the separation date from the Program will be
forfeited without compensation. In the event an illness exceeds accumulated paid sick leave and vacation time, a leave of
absence without pay may be granted (see section II.H.7). Leave of Absence (“LOA”), Including Extended LOA, Military
Leave, Leave Without Pay (“LWOP”) and Family Medical Leave (“FMLA”) All requests for LOA must be approved by the
Program Director in accordance with applicable state and federal laws and specialty board and accreditation requirements.
LOA may be comprised of paid leave (including both paid sick leave and vacation) and/or leave without pay (“LWOP”).
When LOA is requested for a medical reason (including pregnancy), the eligible Fellow must exhaust all accumulated paid
sick leave and accumulated vacation prior to beginning any LWOP.

Funeral Leave
With the prior approval of the Program Director, a fellow shall be granted up to three days of paid leave to attend the funeral
of a family member. Family member is defined as the fellow’s spouse or the fellow’s or spouse's parents, children, brothers,
sisters, grandparents or grandchildren. Funeral leave shall be granted only for scheduled work days.

Urgent Leave Coverage
When an emergency occurs, making it impossible for the fellow to report to a rotation or to take call the fellow must

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notify the Program Director to make arrangement for coverage. If the fellow cannot find another fellow to "switch", the
Program Director will adjust the call schedule accordingly. Adjustments made by the Program Director will be
mandatory, not voluntary.

Holidays
For the academic year 2010-2011, UTHSCH is observing the following holidays. For a “full closure” holiday, the GI
academic office and medical school are closed. For “skeleton crew” holidays the academic office may have limited staff.
The Answering Service will always answer all calls to the academic office during times when the office is closed.
        Note: Fellows are not subject to the UTHSC-H holidays and IP rotations do not observe holidays. Out-
        patient rotations are determined by the Faculty Attending(s) and clinic schedule(s). You must check with the
        attending to determine if the clinic will be closed during any holiday period. For a “full closure” holiday, the GI
        academic office and medical school will be closed.
        •        Independence Day – Monday, July 5, 2010 (“full closure” holiday)
        •        Labor Day – Monday, September 6, 2010 (“full closure” holiday)
        •        Thanksgiving – Thursday and Friday, November 25-26, 2010 (“full closure” holiday)
        •        December Holiday - Friday, December 24, 2010 (“full closure” holidays),
        •        December Holidays - Monday through Thursday, December 27-30, 2010 (“skeleton crew” holiday)
        •        New Year’s Eve Friday, December 31, 2010 (“full closure” holiday)
        •        Martin Luther King Day - Monday, January 17, 2011 (“full closure” holiday)
        •        Memorial Day – Monday, May 30, 2011 (“full closure” holiday)

USA Mobility Pagers
Pagers are provided by the GME office and batteries are provided by the GI division office. A Clinical Fellow Pager
Assignment Sheet must be sign each year indicating you have the assigned pager. If the pager is lost or damaged, you
must pay the replacement cost of $200. If the pager is malfunctioning, a replacement pager may be picked up from the
Memorial Hermann communication operators located at MHH Robertson (located behind Cafe Hermann). The pagers have
both numeric and text abilities.
       You may get a strange five-digit number on your beeper, e.g. “43409”. You will get to know the numbers but for
       starters, the first number usually represents the following:
                4xxxx = 713-704-xxxx (MHH) or 6xxxx = 713-566-xxxx (LBJ)
                2xxxx = 713-792-xxxx (MDA) 4xxxx = 713-794-xxxx (UT MDA)

ID Badges
You will have four ID badges: UTHSC (will double for MHH), UTMDACC, LBJ and TMH. You must have your ID badges
prior to starting rotations. PGY stickers, to be placed on the UTHSC badge, are given annually by the GME office. For MHH
after-hours access, and access to the Transplant ICU on the 3rd floor of Hermann Pavilion, you will need to take your UT
badge the Security Office at MHH, next to the ER, to get your badge programmed. For lost or damaged UT ID badge, you
must go to University Center Tower (UCT), 7000 Fannin, 22nd floor (phone: 713-500-3088). Replacement fee is $10.

Meals
All hospitals have dining facilities open daily for breakfast, lunch, and dinner. A discount is given with an ID badge.

White Coats
Lab coat(s) will be provided to each first year fellow. Fellows will receive one new coat per year thereafter. Coats may be
dropped off and picked up to be laundered in the mailroom, MSB 4.235. Laundry is delivered and picked up every Thursday
and paid for by the division.

Email
Upon meeting all requirements, completing all paperwork relevant to appointment, and signing the Information Resources
Security: Acknowledgment Form, fellows receive a UTHSC-H e-mail address and network access for use during the
duration of their appointment. Fellows are subject to the terms of UTHSC-H HOOP Policy Section 17
(http://legal.uth.tmc.edu/hoop/complete_toc.html#chap17). All use of the UTHSC-H network, including internet access, is a
privilege that must not be abused. Any prohibited or inappropriate use of the network and the e-mail system may result in
termination of such privilege and may be grounds for other adverse action.
          Why use UT e-mail instead of a personal e-mail?                   This is the only way UT will communicate with
          you! All communication from the Program Director, Fellowship Coordinator, GI division office, as well as special UT
          announcements, communication from the GME office, newsletters, etc., are sent to the assigned UT email address.
How to use your UT e-mail
Call the UT Help Desk at 713-500-4848 to get your e-mail address and set your password. To access your email go to
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the mail site: (http://webmail.uth.tmc.edu) to test your password. UT Medical School Home Page:
http://med.uth.tmc.edu/ . Call the UT Help Desk at 713-500-4848 if need any assistance.

Division Office
Normal office hours for the GI Division staff are Monday to Friday from 7:30 am to 5:00 pm. The main telephone
number is 713.500.6677. It is answered 24/7 by the staff and/or the Answering Service. A fax machine is located in the
division’s reception office, MSB 4.234. The fax number is 713.500.6699.

Fellows’ Office
The Fellows’ Office, MSB 4.232, is equipped with a computer, scanner, media equipment, conference table, white board,
and library. Printers are located in both the mailroom (MSB 4.235) and division reception office (MSB 4.234). A key is given
to each fellow that opens the fellows’ office, mailroom and reception office to allow access to both printers and the fax
machine. This office is for the fellows’ use and should be utilized.

Mail
A mailbox is located in the GI division mailroom/storage/kitchen (MSB 4.235). Please check it periodically, and please
do not use the mailbox for storage. Your mailing address is:
                 The University of Texas Medical School-Houston
                 Division of Gastroenterology, Hepatology and Nutrition
                 6431 Fannin, MSB 4.234 Houston, TX 77030
Library
The Houston Academy of Medicine - Texas Medical Center Library is located in the Jesse Jones Library Building at
1133 John Freeman Boulevard. Webber Plaza is between the Medical School – and the library. Additional library
information may be found on the website: http://resource.library.tmc.edu/about/welcome.cfm
,
Parking
Parking is available in the UT Professional Building Garage for a reduced rate and is payroll deducted. The UTHSC badge
is programmed for parking. There are three MDA parking cards for Garage 10. These are passed from one fellow to the next
to be used while on the MDA IP and MDA OP rotations and call. There is no charge for LBJ parking.

Bookstores
Medical School Book store is located in the medical school basement near the green elevators.

Travel
The opportunity to travel is primarily for senior fellows, as well as fellows who are presenting work at national meetings.
Educational support is requested from pharmaceutical companies for fellows presenting work at national meetings. There is
no guarantee as to the availability or amount of such. The opportunity to travel to other meetings may be offered depending
on seniority, interest, and recent travel.

Personal or Professional Concerns
Work/Life Program – Creating Balance in your Life
713-500-3013 7000 Fannin, Suite 1670          www.utworklife.org
The University of Texas Health Science Center-Houston recognizes that the competing demands of work and life may affect
productivity, learning and health, and has therefore established a Work/Life Program to help residents/fellows balance the
competing demands of their work and personal lives. The Work/Life Program promotes flexible practices, programs and a
supportive culture to help reconcile these needs and to help ensure that the Institution’s missions of education, research and
care are productively and humanely accomplished.

UTHSC-H Recreation Center - 713-500-8420 http://ae.uth.tmc.edu/recreat/Mem_Facilities.htm
The UTHSC Recreation Center offers a wide variety of quality facilities, equipment, and programs designed for health
and fitness, as well as for fun and relaxation. Membership is open to all UT fellows at a reduced rate:
         Fellow- Individual or Spouse Membership Fee: $27/monthly; $69/quarterly or $260/yearly
         Family membership package: $67/monthly; $172. Quarterly; $650. Yearly.
Monday - Friday: 6:00 am – 10:00 p.m. Saturday: 8:00 am – 8:00 p.m. Sunday:                  10:00 am – 8:00 p.m.




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               Goals and Objectives




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                                                            Goals and Objectives

                                          Gastroenterology Consult Rotation
                                    Memorial Hermann Hospital Texas Medical Center
                                                    Curriculum for Year I, II & III Fellows


Educational Purpose:
The Gastroenterology Consult Rotation Memorial Hermann Hospital TMC (MHH) introduces the fellow to inpatient hospital management of
patients with gastrointestinal diseases. During this period, the fellow will have the opportunity to assess a wide variety of acute and chronic
gastrointestinal conditions. The fellow will participate in increasing levels of management/ treatment involvement with patient needs and
procedures, depending on the fellow’s level of experience. The fellow will be expected to formulate the differential diagnosis, institute diagnostic
studies and recommend therapy. The amount of learning obtained from this rotation is directly proportional to the amount of time spent in the
evaluation of the patients.

Objectives:
Fellows will learn all aspects of inpatient gastrointestinal care and will display all general competencies during this experience. Minimum levels of
achievement in each competency are expected during each of the three years of fellowship training. Those meeting competency will receive a
score of 5 in the program’s evaluation system. Fellows performing at a level better than expected for that competency receive a score of 6 or 7 in
the evaluation system, those at a level better than most fellows at that PGY receive an 8, and those performing at a level deemed to be “one of
the best fellows ever observed” will receive a score of 9. Fellows receiving a score of 4 or below are deemed deficient in that competency; this
will be brought to the attention of the program director immediately, and, if necessary, remediation will be implemented.

The following are the goals and objectives for each competency at each level of training for the Gastroenterology Consult Service at MHH.

                                                                 Year 1 Fellow:
A Year 1 fellow should be able to assess new patient problems, formulate and execute a treatment plan with guidance and teach basic
gastroenterology skills to medical students and other trainees. Year 1 fellows should begin to develop basic procedural competencies in
diagnostic upper endoscopy and colonoscopy.

Patient Care Objectives:
     Perform an accurate physical examination and present information concisely with an initial assessment plan. Follow the patient’s disease
     course during the patient’s hospital stay. With attending consultation, formulate and execute an impression and a list of recommendations
     for the primary service. When indicated, consent patients for procedures and order appropriate diagnostic tests (e.g., endoscopy, radiologic
     tests, etc.) in conjunction with the primary/referring service.
     Perform with supervision the following basic gastroenterology procedures:
                o Colonoscopy
                                By completion of Year I a fellow should be able to perform a diagnostic colonoscopy to the cecum with limited
                                assistance.
                o EsophagoGastroDuodenoscopy (EGD or Upper Endoscopy)
                                By completion of Year I a fellow should be able to perform a diagnostic endoscopy to the second portion of the
                                duodenum.
     Develop expertise in the diagnosis and management of acute and chronic inpatient gastrointestinal diseases including:
                o Upper & lower GI bleeding
                o Peptic ulcer disease
                o GI infections
                o Ischemic colitis.
     Learn to provide inpatient care that is safe and compassionate and to develop the ability to thoroughly and clearly educate the inpatient in
     the relevant areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.

Medical Knowledge Objectives:
    Attend core conferences and teaching rounds to learn the pathophysiology, epidemiology, disease management and procedure and
    medicine management skills for common and uncommon inpatient gastrointestinal diseases including:
              o Upper & lower GI bleeding
              o Peptic ulcer disease
              o GI infections
              o Ischemic colitis.
    Accumulate and begin to solve the issues that he/she encounters from other trainees, attendings and related medical professionals.

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     Teach medical students the basics of gastroenterology and hepatology care.
     By end of Year I, pass the Internal Medicine Board Examination.
     Achieve an average percentile score of at least 61.18on the “General” section of the in-service Gastroenterology Training Examination
     (GTE) exam. This score is the national average on this exam for Year I fellows.

Practice-Based Learning Objectives:
    Become familiar with the concepts of quality improvement.
    Participate in conferences such as M&M, geared to the programmatic review of adverse events.
    Begin to review, analyze and utilize scientific evidence from the gastrointestinal literature for the management of GI patients.
    Learn the best practice patterns to facilitate gastroenterology care through clinic operating procedures and patient interactions.

Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable and
     compassionate manner. Convey bad news compassionately and honestly.
     Learn to communicate effectively with staff, peers, attending gastroenterologists, referring physicians and other consultants.

Professionalism Objectives:
    Learn to understand and demonstrate professional behavior in daily activities.
    Participate in professionalism-based learning activities through conferences.
    Learn to interact collegially with his/her peer group and other healthcare professionals.
    Learn to practice ethical principles with relation to patient care and confidentiality.
    Learn to practice appropriate interactions with pharmaceutical representatives and be unbiased in prescribing habits.
    Learn to be sensitive to cultural, age, gender and disability issues.
    Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues.
    Participate in program planning, including Program Director meetings.

Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Achieve basic understanding of healthcare systems related to gastroenterology care and overall system activities.
    Learn proper documentation and billing skills to practice cost-effective care.
    Utilize an appropriate range of healthcare professionals to care for patients, working closely with socials services to maximize patient care
    and understanding the role of hospice, referring appropriately when needed.
    Begin involvement to understand the standard operating procedures and quality improvement initiatives within the hospital.
    Attend national gastroenterology conferences (e.g., ACG and endoscopy training courses).

                                                                 YEAR II Fellow:

Goal: A Year II fellow should learn to assess and care for a larger volume of patients and learn and teach basic textbook and evidence-based
medicine to medical students and other trainees. Year II fellows should independently perform diagnostic upper endoscopy and colonoscopy
and begin to perform therapeutic maneuvers.

Patient Care Objectives:
     Complete a time-efficient history and physical examination.
     Critique the work and orders of Year I fellows.
     Direct the Year I fellows successfully with the appropriate level of intervention for each trainee’s skills.
     Complete competency-level performance of the following basic gastroenterology procedures:
                o Colonoscopy
                               By completion of Year II, master all Year I colonoscopic skill requirements. Additionally, perform endoscopic
                               maneuvers, including snare polypectomy and begin to develop competency in control of GI bleeding: sclerotherapy
                               and thermal coagulopathy of bleeding vessels.
                o Upper Endoscopy
                               By completion of Year II, master all Year I upper endoscopic skill requirements. Additionally, begin to develop
                               competency in performing therapeutic maneuvers: banding and sclerosing of varices, and sclerotherapy and
                               thermal coagulopathy of bleeding vessels.
     Develop clear expertise in the diagnosis and management of acute and chronic inpatient gastrointestinal diseases including:
                o Neuroendocrine diagnosis
                o Intestinal/colonic pseudobstruction
                o Secretory diarrheal states
                o Idiopathic abdominal pain
                o Upper & lower GI bleeding
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               o Peptic ulcer disease
               o Inflammatory bowel disease
               o GI infections
               o Pancreatitis
               o Ischemic colitis
     Present cases succinctly in a direct manner.
     Know the GI Hospital Service’s patients at a management level.
     Handle consult calls respectfully and appropriately.
     Teach good symptom management skills to medical students and other trainees.
     Provide inpatient care that is safe and compassionate and develop the ability to thoroughly and clearly educate the inpatient in the relevant
     areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.

Medical Knowledge Objectives:
    Begin to take a leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease
    management and procedures and medicine management skills for common and uncommon inpatient gastrointestinal diseases including:
              o Neuroendocrine diagnosis
              o Intestinal/colonic pseudobstruction
              o Secretory diarrheal states
              o Idiopathic abdominal pain
              o Upper & lower GI bleeding
              o Peptic ulcer disease
              o Inflammatory bowel disease
              o GI infections
              o Pancreatitis
              o Ischemic colitis
    Organize the team’s performance at teaching rounds.
    Read textbook and pertinent literature materials concerning problems encountered.
    Teach medical students and other trainees about GI disease states and patient management.
    Achieve an average percentile score of at least 62.98 on the “General” section of the in-service Gastroenterology Training Examination
    (GTE) exam. This score is the national average on this exam for Year II fellows.

Practice-Based Learning Objectives:
    Participate in project groups, committees and hospital groups when requested.
    Participate in programmatic reviews and conferences studying adverse events.
    Give usable feedback to medical students and other trainees based on observation of their performance and assess improvement.
    Participate in problem-based quality improvement projects.
    Review, analyze and utilize scientific evidence from the gastrointestinal literature for the management of GI patients.
    Know the best practice patterns to facilitate gastroenterology care through clinic operating procedures and patient interactions.

Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner.
     Convey bad news compassionately and honestly.
     Plan patient and family conferences.
     Counsel patients about transitioning to palliative care, when needed.
     Address or refer patients related to spiritual or existential issues.
     Communicate effectively with staff, peers, attending gastroenterologists, referring physicians and other consultants.
     Present cases succinctly, in a problem-based, direct manner.
     Learn to become a teacher of gastroenterology to junior trainees, medical students and other healthcare professionals.

Professionalism Objectives:
    Begin to mentor medical students, other trainees and Year I fellows in professional conduct.
    Understand and demonstrate professional behavior in daily activities.
    Participate in professionalism-based learning activities through conferences.
    Interact collegially with his/her peer group and other healthcare professionals, including acting responsibly in the larger context of pursuing
    programmatic successes.
    Practice ethical principles with relation to patient care and confidentiality.
    Practice interactions with pharmaceutical representatives and be unbiased in prescribing habits.
    Practice sensitivity to cultural, age, gender and disability issues.
    Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues.
    Participate in Program Director meetings.
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Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Understand and practice proper documentation and billing skills to practice cost-effective care.
    Assist other trainees in the utilization of appropriate healthcare resources for the best care of the GI Hospital Service’s patients.
    Model appropriate interactions in multidisciplinary planning, including standard operating procedures and quality improvement initiatives.
    Attend national gastroenterology or hepatology conferences (e.g., DDW or AASLD).

                                                                 YEAR III Fellows:

Goal: The senior-level, Year III fellow should demonstrate rapid assessment and planning skills and near-attending level care planning and
management, while teaching medical students and other trainees at near to or exceeding attending level teaching. Year III fellows should be
able to perform diagnostic and therapeutic upper endoscopy and colonoscopy procedures independently.

Patient Care Objectives:
     Master the Year II fellow objectives.
     Demonstrate efficient organization of the GI Hospital Consult Service and a working knowledge of all patients.
     Demonstrate near-attending level capacity for program assessment and care planning.
     Attain trainer level proficiency in the following gastroenterology procedures pertinent to his/her career choices:
                o Colonoscopy
                                 By completion of Year III, master all Year II colonoscopic skill requirements. Additionally, be able to independently
                                 intubate the terminal ileum and begin to develop independent mastery of more advanced maneuvers, e.g., removal
                                 of large or complex polyps by saline assisted polypectomy or piecemeal resection and control of bleeding using
                                 clips or argon plasma laser coagulation.
                o Upper Endoscopy
                                 By completion of Year III, master all Year II endoscopic skill requirements. Additionally, be able to pass a side
                                 viewing scope to identify the papilla or lesions difficult to observe with forward viewing scope and perform
                                 advanced maneuvers, such as placing clips on bleeding vessels or argon plasma laser coagulopathy.
     Secure expertise in the diagnosis and management of acute and chronic inpatient gastrointestinal diseases including:
                o Neuroendocrine diagnosis
                o Intestinal/colonic pseudobstruction
                o Secretory diarrheal states
                o Idiopathic abdominal pain
                o Upper & lower GI bleeding
                o Peptic ulcer disease
                o Inflammatory bowel disease
                o GI infections
                o Pancreatitis
                o Ischemic colitis
     Provide inpatient care that is safe and compassionate with the leadership ability to thoroughly and clearly educate the inpatient and all other
     trainees regarding relevant areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.

Medical Knowledge Objectives:
    Access and critique the medical literature regarding gastroenterology and hepatology problems encountered.
    Assume the trainee leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease
    management, procedures and medicine management skills for common and uncommon inpatient gastrointestinal diseases including
              o Neuroendocrine diagnosis
              o Intestinal/colonic pseudobstruction
              o Secretory diarrheal states
              o Idiopathic abdominal pain
              o Upper & lower GI bleeding
              o Peptic ulcer disease
              o Inflammatory bowel disease
              o GI infections
              o Pancreatitis
              o Ischemic colitis
    Teach medical students, other trainees and Year I & II fellows at near-attending level.
    Prepare for the ABIM certifying exam throughout the year.
    Organize team activities in a smooth and authoritative fashion.
    Assist Year II fellows’ development directly at teaching conferences and indirectly at work sites.
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     Achieve an average percentile score of at least 64.07 on the “General” section of the in-service Gastroenterology Training Examination
     (GTE) exam. This score is the national average on this exam for Year III fellows.

Practice-Based Learning Objectives:
    Demonstrate mastery of Year II fellow skills and encourage participation of colleagues.
    Review, analyze and utilize scientific evidence from the gastrointestinal literature for the management of GI patients, taking a leadership role
    in guiding Year I & II fellows and sharing relevant literature reviews with them.
    Know and be able to succinctly communicate the best practice patterns to facilitate gastroenterology care through clinic operating
    procedures and patient interactions.

Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner.
     Convey bad news compassionately and honestly.
     Supervise Year I & II fellows’ work related to planning patient/family conferences and patient communications/counseling.
     Communicate effectively as a consultant with staff, peers, attending gastroenterologists, referring physicians and other consultants and lead
     other trainees related to appropriate fellow-to-medical-professional communications.
     Present cases succinctly, in a problem-based, direct manner.
     Assume the role of a teacher of gastroenterology to junior trainees, medical students and other healthcare professionals.

Professionalism Objectives:
    Demonstrate proficiency in Year II objectives.
    Mentor medical students, other trainees and Year I fellows in professional conduct.
    Assist in formal teaching exercises as requested.
    Assert leadership in program planning, including fellow participation in the annual Faculty/Fellow Meeting, Fellow Curriculum Committee and
    Conference Planning Committees.

Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Model appropriate interactions in multidisciplinary planning, including improvements related to standard operating procedures and quality
    improvement initiatives.
    Participate in hospital and national medical association committees and multidisciplinary planning groups when requested.
    Attend national conferences directed at career goals.
    Demonstrate near-attending level utilization of overall systems of care.

Teaching Methods:
Gastroenterology fellows participate in the GI Hospital Consult Service during all three fellowship years. One fellow is assigned to the GI Hospital
Consult Service during all rotations. Teaching of medical students, residents and other trainees as well as appropriate interactions with other
healthcare providers are important aspects of this rotation. Participating in all required conferences is mandatory, and rounding is an integral part
of this experience. As fellows gain experience throughout their training, skills of organization and efficiency as well as team leadership become
increasingly important.

The GI Hospital Consult Service experience will prepare the fellow to evaluate and manage acute and chronic gastrointestinal illnesses that will
be encountered in the fellow’s future practice. This rotation will expose the fellow to a wide variety of acute abdominal inflammatory processes,
major gastrointestinal hemorrhages, and a wide variety of gastrointestinal problems.

Fellows assigned to this service will evaluate all new consults at Memorial Hermann Hospital Texas Medical Center (MHH) and will be assigned
to a continuity clinic one-half day per week. They will present new consults to the attending by the following day for routine consults and as soon
as possible for emergencies. Fellows will evaluate each patient and will make initial recommendations regarding diagnostic tests and treatments.
 They will make arrangements for studies such as endoscopy, motility tests, biopsies, etc. They will review the appropriateness of the procedure
with the attending before making final scheduling plans. The fellow will follow each patient under active consultation on a regular basis, will make
further recommendations as indicated and will keep the attending informed of the patient’s status.

Disease Mix:
Fellows see a complete mix of gastrointestinal diseases and conditions at the GI Hospital Consult Service’s teaching hospital. MHH has a
substantial primary care basis, which provides the entire spectrum of internal medicine diagnoses and gastrointestinal care.

Diagnoses range from pancreatitis, inflammatory bowel disease, and functional GI motility and pain disorders to primary and secondary
gastrointestinal malignancies, and there is an appropriate concentration of common gastrointestinal diseases such as peptic ulcer disease,
gastroesophageal reflux disease and gastrointestinal infections.

21 | P a g e
Patient Characteristics:
Memorial Hermann Hospital TMC offers a diverse mix of socioeconomic and gender status. Teaching faculty provide an abundant supply of
upper- and middle-class patients, and our contracts with medical assistance and pro bono care efforts ensure access to lower-income patients.
Due to a primary care base simultaneous with the hospitals’ constantly active referrals (Memorial Hermann Life Flight is a CAMTS accredited,
critical care, air medical transport service that serves the community within a 150-mile radius of the Texas Medical Center with helicopters and
worldwide using fixed-wing transport), patients are seen in both acute status and in diagnostic dilemma status, with both common and
uncommon disorders.

Types of Clinical Encounters – Attending Supervision:
Encounters are inpatient in nature during the GI Hospital Consult Service. Fellows provide 24/7 consultative care under the supervision of an
attending within duty hour limits and with faculty back up for situations of overload. Daily attending supervision is available at MHH seven days
per week as well as supervision is available all night. The attending has ultimate responsibility for patients.

Procedures:
During the GI Hospital Consult Service, emergency procedures (e.g. for gastrointestinal bleeding) are performed 24/7 within duty hour limits by
the fellow with the attending. Non-emergent procedures are performed during daytime hours in the GI lab by the fellow under the direct
supervision of the attending. Procedure based evaluation is performed twice per year by a supervising attending.

Evaluation:
Fellows are evaluated during all GI Hospital Consult Service rotations and are expected to participate in the evaluation of other fellows as well.
This occurs in the following forms:
     Detailed, automated evaluations using the GMEIS system are submitted for the rotation. These evaluations are reflective of the program’s
     curriculum requirements. Attendings evaluate fellows, and the fellows evaluate the attending as well. Evaluations include:
                o 360-degree (attending, nurse, nurse practitioner, staff/clerical, etc.);
                o Direct observation
                o Peer-reviewed; and
                o Patient.
     Evaluation summaries become part of the fellows’ and attendings’ promotional documents.
     The fellow evaluates the Gastroenterology Fellowship Program annually through a confidential basis.
     Attendings evaluate the Gastroenterology Fellowship Program annually.
     A Curriculum Committee oversees major changes to the curriculum. Representative program personnel (i.e., program director,
     representative faculty and at least one fellow) must be organized to review program goals and objectives and the effectiveness with which
     they are achieved. This group must conduct a formal documented meeting at least annually for this purpose. In the evaluation process, the
     group must take into consideration written comments from the faculty, the most recent report of the GMEC of the sponsoring institution and
     the residents’ confidential written evaluations. If deficiencies are found, the group will prepare an explicit plan of action, which should be
     approved by the faculty and documented in the minutes of the meeting.
     The Program Director meets with all fellows individually twice per year.
     An in-service GTE exam is given to all fellows annually.

Bibliography:
     Resource Documents
               o Up-To-Date
               o PubMed
               o Textbook of Gastroenterology – Yamada, et.al.
               o Gastrointestinal Diasese: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.
               o Major Gastroenterology journals online and in the program’s fellow library including Gastroenterology, American Journal of
                    Gastroenterolgy, Gut, and other major publications.
     Curricular Design
               o ACGME Outcome Project documentation (from www.acgme.org).
               o Graduate Education in Internal Medicine: A Resource Guide to Curriculum Development
               o The report of the Federated Council for Internal Medicine Task Force on the Internal Medicine Residency Curriculum, 1997.
     Pertinent Teaching References:
               o Textbook of Gastroenterology – Yamada, et.al.
               o Gastrointestinal Diasese: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.

                                                         Competencies-at-a-Glance

                                                         GI Hospital Consult Service

22 | P a g e
                       COMPETENCY                        LEARNING OPPORTUNITY                            EVALUATION

            Patient Care                                  Work Rounds                              360-global evaluations
                                                          Teaching Rounds                          GTE in-service exam
                                                          Conferences                              Direct Observation

            Medical Knowledge                             Work Rounds                              360-global evaluations
                                                          Teaching Rounds                          GTE in-service exam
                                                          Conferences

            Practice-Based Learning                       Quarterly M&M Conference                 360-global evaluations
                                                          Work Rounds                              Direct Observation

            Interpersonal Skills                          Work Rounds                              360-global evaluations

            Professionalism                               Work Rounds                              360-global evaluations
                                                          Conferences

            Systems-Based Practice                        Committee Participation                  360-global evaluations
                                                          Grand Rounds (GI & Medical)              documentation
                                                          Conferences


The GI Hospital Consult Service is the core fellow rotation related to the teaching and evaluation of all six competencies. Day-to-day patient
care, related teaching and the curriculum conferences during the rotation are the greatest elements that teach the competencies, and the global
evaluation (provided for each rotation) is the most important single measurement device. In addition to didactic learning, medical center
committee participation is encouraged to bolster system-wide knowledge and practice management understanding.

Revised:
May 2009/ Lukens




                                         Hepatology Consultative Rotation
                                   Memorial Hermann Hospital Texas Medical Center
                                                       Curriculum for PGY 4, 5 and 6


Educational Purpose:
The Hepatology Consultative Rotation introduces the fellow to inpatient management of patients with liver diseases. During this period, the
fellow will have the opportunity to assess a wide variety of acute and chronic hepatology conditions. The fellow will participate in increasing
levels of management/ treatment involvement with patient needs and procedures depending on the fellow’s level of experience. The fellow will
be expected to formulate the differential diagnosis, institute diagnostic studies and recommend therapy. The amount of learning obtained from
this rotation is directly proportional to the amount of time spent in the evaluation of the patients.
23 | P a g e
Objectives:
Fellows will learn all aspects of inpatient liver disease care and will display all general competencies during this experience. Minimum levels of
achievement in each competency are expected during each of the three years of fellowship training. Those meeting competency will receive a
score of 5 in the program’s evaluation system. Fellows performing at a level better than expected for that competency receive a score of 6 or 7 in
the evaluation system, those at a level better than most fellows at that PGY receive an 8, and those performing at a level deemed to be “one of
the best fellows ever observed” will receive a score of 9. Fellows receiving a score of 4 or below are deemed deficient in that competency; this
will be brought to the attention of the program director immediately, and, if necessary, remediation will be implemented.

The following are the goals and objectives for each competency at each level of training for the Hepatology Consultative Service:

                                                                 PGY 4 Fellow:

Goal: A Year I fellow should be able to assess new patient problems, formulate and execute a treatment plan with guidance and teach basic
hepatology and gastroenterology skills to medical students and other trainees. Year I fellows should begin to develop basic procedural
competencies in diagnostic upper endoscopy and colonoscopy.

Patient Care Objectives:
     Perform an accurate physical examination and present information concisely with an initial assessment plan. Follow the patient’s disease
     course during the patient’s hospital stay. With attending consultation, formulate and execute an impression and a list of recommendations
     for the primary service. When indicated, consent patients for procedures and order appropriate diagnostic tests (e.g., endoscopy, radiologic
     tests, etc.) in conjunction with the primary/referring service.
     Perform with supervision the following basic procedures (see practicum):
                o Colonoscopy
                                By completion of Year I a fellow should be able to perform a diagnostic colonoscopy to the cecum with limited
                                assistance.
                o EsophagoGastroDuodenoscopy (EGD or Upper Endoscopy)
                                By completion of Year I a fellow should be able to perform a diagnostic endoscopy to the second portion of the
                                duodenum.
                o Liver Biopsies:
                                Fellows must have formal instruction and clinical expertise and must demonstrate competence in the performance
                                of percutaneous liver biopsies.
                o Abdominal Paracentesis:
                                Fellows must have formal instruction and clinical expertise, and must demonstrate competence in the performance
                                of diagnostic and therapeutic paracentesis
     Fellows must have formal instruction and clinical experience and demonstrate competence in:
                o The prevention of acute and chronic endstage liver disease
                o The evaluation and management of inpatients with acute and chronic endstage liver disease
                o The management of fulminant liver failure
                o The psychosocial evaluation of all candidates, in particular those with a history of substance abuse
                o Drug hepatotoxicity and the interaction of drugs with the liver
                o Diagnosis and mangement of autoimmune hepatitis
                o Diagnosis and management of cholestatic liver diseases – primary biliary cirrhosis (PBC) and primary sclerosing cholangitis
                      (PSC)
     Learn to provide inpatient care that is safe and compassionate and to develop the ability to thoroughly and clearly educate the inpatient in
     the relevant areas of disease prevention, detection, progression and therapy to promote liver health.

Medical Knowledge Objectives:
    Attend core conferences and teaching rounds --- especially all Hepatology Conferences(see attached schedule) --- to learn the
    pathophysiology, epidemiology, disease management and procedure and medicine management skills for common and uncommon
    inpatient liver diseases including:
                o The prevention of acute and chronic endstage liver disease
                o The evaluation and management of inpatients with acute and chronic endstage liver disease
                o The management of fulminant liver failure
                o The psychosocial evaluation of all candidates, in particular those with a history of substance abuse
                o Drug hepatotoxicity and the interaction of drugs with the liver
                o Diagnosis and mangement of autoimmune hepatitis
                o Diagnosis and management of cholestatic liver diseases – primary biliary cirrhosis (PBC) and primary sclerosing cholangitis
                     (PSC)
    Accumulate and begin to solve the issues that he/she encounters from other trainees, attendings and related medical professionals.
24 | P a g e
     Teach medical students the basics of gastroenterology and hepatology care.
     Achieve an average percentile score of at least 59.8 on the liver section of the in-service Gastroenterology Training Examination (GTE)
     exam. This score is the national average for the liver section for Year I fellows.
     By end of Year I, pass the Internal Medicine Board Examination.

Practice-Based Learning Objectives:
    Become familiar with the concepts of quality improvement.
    Participate in conferences such as M&M, geared to the programmatic review of adverse events.
    Begin to review, analyze and utilize scientific evidence from the hepatology literature for the management of liver disease patients.
    Learn the best practice patterns to facilitate liver disease care through clinic operating procedures and patient interactions.

Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable and
     compassionate manner. Convey bad news compassionately and honestly.
     Learn to communicate effectively with staff, peers, attending gastroenterologists/hepatologists, referring physicians and other consultants.

Professionalism Objectives:
    Learn to understand and demonstrate professional behavior in daily activities.
    Participate in professionalism-based learning activities through conferences.
    Learn to interact collegially with his/her peer group and other healthcare professionals.
    Learn to practice ethical principles with relation to patient care and confidentiality.
    Learn to practice appropriate interactions with pharmaceutical representatives and be unbiased in prescribing habits.
    Learn to be sensitive to cultural, age, gender and disability issues.
    Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues.
    Participate in program planning.

Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Achieve basic understanding of healthcare systems related to hepatology care and overall system activities.
    Learn proper documentation and billing skills to practice cost-effective care.
    Utilize an appropriate range of healthcare professionals to care for patients, working closely with social services to maximize patient care
    and understanding the role of hospice, referring appropriately when needed.
    Begin involvement to understand the standard operating procedures and quality improvement initiatives within the hospital.
    Attend national gastroenterology conferences (e.g., ACG and endoscopy training courses).

                                                                  PGY 5 Fellow:

Goal: A Year II fellow should learn to assess and care for a larger volume of patients and learn and teach basic textbook and evidence-based
medicine to medical students and other trainees. Year II fellows should independently perform diagnostic upper endoscopy and colonoscopy
and begin to perform therapeutic maneuvers.

Patient Care Objectives:
     Complete a time-efficient history and physical examination.
     Critique the work and orders of Year I fellows.
     Direct the Year I fellows successfully with the appropriate level of intervention for each trainee’s skills.
     Complete competency-level performance of the following basic gastroenterology/hepatology procedures (see practicum checklist):
                o Colonoscopy
                               By completion of Year II, master all Year I colonoscopic skill requirements. Additionally, perform endoscopic
                               maneuvers, including snare polypectomy and begin to develop competency in control of GI bleeding: sclerotherapy
                               and thermal coagulopathy of bleeding vessels.
                o Upper Endoscopy
                               By completion of Year II, master all Year I upper endoscopic skill requirements. Additionally, begin to develop
                               competency in performing therapeutic maneuvers: banding and sclerosing of varices, and sclerotherapy and
                               thermal coagulopathy of bleeding vessels.
                o Liver Biopsies:
                               Fellows must have formal instruction and clinical expertise, and must demonstrate competence in the performance
                               of percutaneous liver biopsies.
                o Abdominal Paracentesis:
                               Fellows must have formal instruction and clinical expertise, and must demonstrate competence in the performance
                               of diagnostic and therapeutic paracentesis.
25 | P a g e
Fellows must have formal instruction and clinical experience and demonstrate competence in:
               o The comprehensive management of patients who are high on the transplant list in the intensive care setting with
                    complications of end-stage liver disease including: refractory ascites, hepatic hydrothorax; hepatorenal syndrome,
                    hepatopulmonary and portal pulmonary syndromes, and refractory portal hypertensive bleeding
               o The management of chronic viral hepatitis in the pre-transplantation, peri-transplantation, and post-transplantation settings
               o Nutritional support of patients with chronic liver disease
               o The use of interventional radiology in the diagnosis and management of portal hypertension, as well as biliary and vascular
                    complications
     Present cases succinctly in a direct manner.
     Know the Hepatology Consultative Service’s patients at a management level.
     Handle consult calls respectfully and appropriately.
     Teach good symptom management skills to medical students and other trainees.
     Provide inpatient care that is safe and compassionate and develop the ability to thoroughly and clearly educate the inpatient in the relevant
     areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.

Medical Knowledge Objectives:
    Begin to take a leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease
    management and procedures and medicine management skills for common and uncommon inpatient liver diseases including:
              o The comprehensive management of patients who are high on the transplant list in the intensive care setting with
                   complications of end-stage liver disease including: refractory ascites, hepatic hydrothorax; hepatorenal syndrome,
                   hepatopulmonary and portal pulmonary syndromes, and refractory portal hypertensive bleeding
              o The management of chronic viral hepatitis in the pre-transplantation, peri-transplantation, and post-transplantation settings
              o Nutritional support of patients with chronic liver disease
              o The use of interventional radiology in the diagnosis and management of portal hypertension, as well as biliary and vascular
                   complications
    Organize the team’s performance at teaching rounds.
    Read textbook and pertinent literature materials concerning problems encountered.
    Teach medical students and other trainees about liver disease states and patient management.
    Achieve an average percentile score of at least 65.7 on the liver section of the in-service Gastroenterology Training Examination (GTE)
    exam. This score is the national exam average for liver diseases for Year II fellows.

Practice-Based Learning Objectives:
    Participate in project groups, committees and hospital groups when requested.
    Participate in programmatic reviews and conferences studying adverse events.
    Give usable feedback to medical students and other trainees based on observation of their performance and assess improvement.
    Participate in problem-based quality improvement projects.
    Review, analyze and utilize scientific evidence from the hepatology literature for the management of liver disease patients.
    Know the best practice patterns to facilitate hepatology care through clinic operating procedures and patient interactions.

Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner.
     Convey bad news compassionately and honestly.
     Plan patient and family conferences.
     Counsel patients about transitioning to palliative care, when needed.
     Address or refer patients related to spiritual or existential issues.
     Communicate effectively with staff, peers, attending hepatologists/gastroenterologists, referring physicians and other consultants.
     Present cases succinctly, in a problem-based, direct manner.
     Learn to become a teacher of hepatology to junior trainees, medical students and other healthcare professionals.

Professionalism Objectives:
    Begin to mentor medical students, other trainees and Year I fellows in professional conduct.
    Understand and demonstrate professional behavior in daily activities.
    Participate in professionalism-based learning activities through conferences.
    Interact collegially with his/her peer group and other healthcare professionals, including acting responsibly in the larger context of pursuing
    programmatic successes.
    Practice ethical principles with relation to patient care and confidentiality.
    Practice interactions with pharmaceutical representatives and be unbiased in prescribing habits.
    Practice sensitivity to cultural, age, gender and disability issues.
    Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues.
    Participate in program planning.
26 | P a g e
Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Understand and practice proper documentation and billing skills to practice cost-effective care.
    Assist other trainees in the utilization of appropriate healthcare resources for the best care of the Hepatology Consultative Service’s
    patients.
    Model appropriate interactions in multidisciplinary planning, including standard operating procedures and quality improvement initiatives.
    Attend national gastroenterology or hepatology conferences (e.g., DDW or AASLD).

                                                                  PGY 6 Fellows:

Goal: The senior-level, Year III fellow should demonstrate rapid assessment and planning skills and near-attending level care planning and
management, while teaching medical students and other trainees at near to or exceeding attending level teaching. Year III fellows should be
able to perform diagnostic and therapeutic upper endoscopy and colonoscopy procedures independently.

Patient Care Objectives:
     Master the Year II fellow objectives.
     Demonstrate efficient organization of the Hepatology Consultative Service and a working knowledge of all patients.
     Demonstrate near-attending level capacity for program assessment and care planning.
     Attain trainer level proficiency in the following procedures pertinent to his/her career choices:
                o Colonoscopy
                                 By completion of Year III, master all Year II colonoscopic skill requirements. Additionally, be able to independently
                                 intubate the terminal ileum and begin to develop independent mastery of more advanced maneuvers, e.g., removal
                                 of large or complex polyps by saline assisted polypectomy or piecemeal resection and control of bleeding using
                                 clips or argon plasma laser coagulation.
                o Upper Endoscopy
                                 By completion of Year III, master all Year II endoscopic skill requirements. Additionally, be able to pass a side
                                 viewing scope to identify the papilla or lesions difficult to observe with forward viewing scope and perform
                                 advanced maneuvers, such as placing clips on bleeding vessels or argon plasma laser coagulopathy.
                o Liver Biopsies
                                 Fellows must have formal instruction and clinical expertise and must demonstrate competence in the performance
                                 of percutaneous liver biopsies.
                o Abdominal Paracentesis
                                 Fellows must have formal instruction and clinical expertise and must demonstrate competence in the performance
                                 of diagnostic and therapeutic paracentesis.
     Fellows must have formal instruction and clinical experience and demonstrate competence in:
                o The diagnosis and management of hepatocellular carcinoma and cholangiocarcinoma including transplantation, non-
                      transplantation, and non-surgical approaches
                o Transplant immunology including blood group matching, histocompatibility, tissue typing, and infectious and malignant
                      complications of immunosuppression
                o Ethical considerations relating to liver transplant donors, including questions related to living donors, non-heart beating
                      donors, criteria for brain death, and appropriate recipients
                o Acquiring a current working knowledge of the organizational and logistic aspects of liver transplantation including the the role
                      of nurse coordinators and other support staff (e.g., social work), organ procurement, and UNOS policies including those
                      regarding organ allocation.
     Provide inpatient care that is safe and compassionate with the leadership ability to thoroughly and clearly educate the inpatient and all other
     trainees regarding relevant areas of disease prevention, detection, progression and therapy to promote liver health.

Medical Knowledge Objectives:
    Access and critique the medical literature regarding hepatology and gastroenterology problems encountered.
    Assume the trainee leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease
    management, procedures and medicine management skills for common and uncommon inpatient liver diseases including
    Fellows must have formal instruction and clinical experience and demonstrate competence in:
             o The diagnosis and management of hepatocellular carcinoma and cholangiocarcinoma including transplantation, non-
                  transplantation, and non-surgical approaches
             o Transplant immunology including blood group matching, histocompatibility, tissue typing, and infectious and malignant
                  complications of immunosuppression
             o Ethical considerations relating to liver transplant donors, including questions related to living donors, non-heart beating
                  donors, criteria for brain death, and appropriate recipients

27 | P a g e
               o     Acquiring a current working knowledge of the organizational and logistic aspects of liver transplantation including the the role
                     of nurse coordinators and other support staff (e.g., social work), organ procurement, and UNOS policies including those
                     regarding organ allocation.
     Teach medical students, other trainees and Year I & II fellows at near-attending level.
     Prepare for the ABIM certifying exam throughout the year.
     Organize team activities in a smooth and authoritative fashion.
     Assist Year II fellows’ development directly at teaching conferences and indirectly at work sites.
     Achieve an average percentile score of at least 70.6 on the liver section of the in-service Gastroenterology Training Examination (GTE)
     exam. This score is the national exam average for the liver section for Year III fellows.

Practice-Based Learning Objectives:
    Demonstrate mastery of Year II fellow skills and encourage participation of colleagues.
    Review, analyze and utilize scientific evidence from the hepatology literature for the management of liver disease patients, taking a
    leadership role in guiding Year I & II fellows and sharing relevant literature reviews with them.
    Know and be able to succinctly communicate the best practice patterns to facilitate liver disease care through clinic operating procedures
    and patient interactions.

Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner.
     Convey bad news compassionately and honestly.
     Supervise Year I & II fellows’ work related to planning patient/family conferences and patient communications/counseling.
     Communicate effectively as a consultant with staff, peers, attending gastroenterologists, referring physicians and other consultants and lead
     other trainees related to appropriate fellow-to-medical-professional communications.
     Present cases succinctly, in a problem-based, direct manner.
     Assume the role of a teacher of hepatology to junior trainees, medical students and other healthcare professionals.

Professionalism Objectives:
    Demonstrate proficiency in Year II objectives.
    Mentor medical students, other trainees and fellows in professional conduct.
    Assist in formal teaching exercises as requested.
    Assert leadership in program planning.

Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Use and train others on the program’s e-portfolio system for personal documentation management, communication with mentors and other
    collaborators and related fellowship program documentation.
    Model appropriate interactions in multidisciplinary planning, including improvements related to standard operating procedures and quality
    improvement initiatives.
    Participate in hospital and national medical association committees and multidisciplinary planning groups when requested.
    Attend national conferences directed at career goals.
    Demonstrate near-attending level utilization of overall systems of care.

Teaching Methods:
Gastroenterology fellows participate in the Hepatology Consultative Service during all three fellowship years. One fellow is assigned to the
Hepatology Consultative Service during all rotations.Teaching of medical students, residents and other trainees as well as appropriate
interactions with other healthcare providers are important aspects of this rotation. Participating in all required conferences is mandatory, and
rounding is an integral part of this experience. As fellows gain experience throughout their training, skills of organization and efficiency as well as
team leadership become increasingly important.

The Hepatology Consultative Service experience will prepare the fellow to evaluate and manage acute and chronic liver diseases that will be
encountered in the fellow’s future practice. This rotation will expose the fellow to a wide variety of acute and chronic liver diseases. Fellows will
learn to incorporate and interact with a multidisciplinary team approach with the Liver Transplant Program at the Texas Liver Center (TLC).
Fellows will learn the appropriate use of interventional radiology facilities capable of performing Transjugular Intrahepatic Portal Systemic Shunts
(TIPS) and balloon angioplasty and will learn to share patient co-management responsibilities with transplant surgeons from the preoperative
phase to the outpatient period as well as learn to interact with an experienced liver transplant pathologist.

Fellows assigned to this service will evaluate all new consults at MHH and will be assigned to a continuity clinic one-half day per week. They will
present new consults to the attending by the following day for routine consults and as soon as possible for emergencies. Fellows will evaluate
each patient and will make initial recommendations regarding diagnostic tests and treatments. They will make arrangements for studies such as
GI endoscopic procedures, liver biopsies (percutaneous and transjugular), abdominal paracenteses and thoracenteses, percutaneous
28 | P a g e
transhepatic cholangiograms (PTC), etc. They will review the appropriateness of the procedure with the attending before making final scheduling
plans. The fellow will follow each patient under active consultation on a regular basis, will make further recommendations as indicated and will
keep the attending informed of the patient’s status. Fellows must also communicate with the procedure fellow for all diagnostic studies.

Disease Mix:
Fellows see a complete mix of liver diseases and conditions at the Hepatology Consultative Service’s teaching hospitals. MHH and the Texas
Liver Center (TLC) have a substantial primary care basis, which provides the entire spectrum of internal medicine diagnoses and
gastroenterology/hepatology care.

Diagnoses range from acute viral hepatitis (A/B), drug induced liver injury,fulminant liver failure, chronic viral hepatitis post transplantation,
complicated hepatocellular carcinoma and cholangiocarcinoma. There is also an appropriate concentration of common liver diseases such as
evaluation of abnormal liver function tests, management of ascites including refractory ascites, hepatic hydrothorax, hepatorenal syndrome, and
portal hypertensive bleeding, diagnosis and management of autoimmune liver diseases and cholestatic liver diseases (PBC and PSC), metabolic
liver diseases (Non-Alcoholic Fatty Liver Disease [NAFLD]), Inherited Liver Diseases such as Genetic Hemochromatosis; Wilson’s Disease and
Alpha One Antitrypsin Deficiency.

Patient Characteristics:
MHH and Texas Liver Center (TLC) offer a diverse mix of socioeconomic and gender status. Teaching faculty provide an abundant supply of
upper- and middle-class patients, and our contracts with medical assistance and pro bono care efforts ensure access to lower-income patients.
Due to a primary care base simultaneous with the hospital’s constantly active referrals (complete with helicopter and fixed-wing transport 24/7),
patients are seen in both acute status and in diagnostic dilemma status, with both common and uncommon disorders.

Types of Clinical Encounters – Attending Supervision:
Encounters are inpatient in nature during the Hepatology Consultative Service. Fellows provide 24/7 consultative care under the supervision of
an attending within duty hour limits and with faculty back up for situations of overload. Daily attending supervision is available seven days per
week, and in-house supervision is available all night as well. The attending has ultimate responsibility for patients.

Procedures:
During the Hepatology Consultative Service, emergency procedures (e.g. for acute gastrointestinal bleeding) are performed 24/7 within duty hour
limits by the fellow with the attending. Non-emergent procedures are performed during daytime hours in the GI lab by the fellow under the direct
supervision of the attending. Procedure based evaluation is performed twice per year by a supervising attending.

Evaluation:
Fellows are evaluated during all Hepatology Consultative Service rotations and are expected to participate in the evaluation of other fellows as
well. This occurs in the following forms:
     Detailed, automated evaluations using the myevaluations.com system are submitted for each rotation. These evaluations are reflective of
     the program’s curriculum requirements. Attendings evaluate fellows, and the fellows evaluate the attendings as well. Evaluations include:
               o 360-degree (attending, nurse, nurse practitioner, staff/clerical, etc.);
               o Direct observation;
               o Peer-reviewed; and
               o Patient.
     Evaluation summaries become part of the fellows’ and attendings’ promotional documents.
     The fellow also evaluates the Gastroenterology Fellowship Program annually through a confidential basis.
     Attendings evaluate the Gastroenterology Fellowship Program annually.
     A Curriculum Committee oversees major changes to the curriculum. Representative program personnel (i.e., program director,
     representative faculty and at least one fellow) are organized to review program goals and objectives and the effectiveness with which they
     are achieved. This group conducts a formal documented meeting at least annually for this purpose. In the evaluation process, the group
     must take into consideration written comments from the faculty, the most recent report of the GMEC of the sponsoring institution and the
     residents’ confidential written evaluations. If deficiencies are found, the group will prepare an explicit plan of action, which should be
     approved by the faculty and documented in the minutes of the meeting.
     The Program Director meets with all fellows individually twice per year.
     An in-service GTE exam is given to all fellows annually.

Bibliography:
     Resource Documents
              o Up-To-Date
              o PubMed
              o Textbook of Gastroenterology – Yamada, et.al.
              o Gastrointestinal Disease: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.
              o Diseases of the Liver - Leon Schiff and Eugene Schiff
29 | P a g e
           o     Zakim and Boyer’s Hepatology: A Textbook of Liver Disease
           o     Major Gastroenterology/Hepatology/Transplantation journals online and in the program’s fellow library including
                 Gastroenterology, American Journal of Gastroenterolgy, Gut, Hepatology, Liver Transplantation, Journal of Hepatology and
                 other major publications.
            o Recommended reading and landmark articles are available on the Division of Gastroenterology, Hepatology and Nutrition’s
                 shared-access drive. This information includes:
                          Practice Guidelines from the American Association for the Study of Liver Diseases (AASLD) [may also be accessed
                          via www.aasld.org].
                          Transplant Hepatology CAQ
  Curricular Design
            o ACGME Outcome Project documentation (from www.acgme.org).
            o Graduate Education in Internal Medicine: A Resource Guide to Curriculum Development
            o The report of the Federated Council for Internal Medicine Task Force on the Internal Medicine Residency Curriculum, 1997.
  Pertinent Teaching References:
            o Textbook of Gastroenterology – Yamada, et.al.
            o Gastrointestinal Diasese: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.
            o Diseases of the Liver - Leon Schiff and Eugene Schiff




                                                    Competencies-at-a-Glance
                                                  Hepatology Consultative Service

                    COMPETENCY                       LEARNING OPPORTUNITY                           EVALUATION
         Patient Care                                Work Rounds                             360-global evaluations
                                                     Teaching Rounds                         GTE in-service exam
                                                     Conferences                             Direct Observation

         Medical Knowledge                           Work Rounds                             360-global evaluations
                                                     Teaching Rounds                         GTE in-service exam
                                                     Conferences
         Practice-Based Learning                     Quarterly M&M Conference                360-global evaluations
                                                     Work Rounds                             Direct Observation

         Interpersonal Skills                        Work Rounds                             360-global evaluations
         Professionalism                             Work Rounds                             360-global evaluations
                                                     Conferences
         Systems-Based Practice                      Committee Participation                 360-global evaluations
                                                     Grand Rounds (GI & Medical)

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                                                            Conferences

The Hepatology Consultative Rotation reflects appropriate teaching and evaluation related to all six core competencies. Day-to-day patient care,
related teaching and the curriculum conferences during the rotation are the greatest elements that teach the competencies, and the global
evaluation is the most important single measurement device. In addition to didactic learning, medical center committee participation is
encouraged to bolster system-wide knowledge and practice management understanding.

Revised
May 2009, Lukens




                              Gastroenterology and Hepatology Outpatient Rotation
                                Memorial Hermann Hospital Texas Medical Center
                           Digestive Disease Center (DDC) and Texas Liver Center (TLC)
                                                        Curriculum for PGY 4, 5 and 6

Educational Purpose:
The MHH Gastroenterology and Hepatology Outpatient Rotation introduce the fellow to outpatient management of patients with
gastroenterological and liver diseases. During this period, the fellow will have the opportunity to assess a wide variety of acute and chronic
gastroenterological and liver conditions. The fellow will participate in increasing levels of management/treatment involvement with patient needs
depending on the fellow’s level of experience. The fellow will be expected to formulate the differential diagnosis, institute diagnostic studies and
recommend therapy. The amount of learning obtained from this rotation is directly proportional to the amount of time spent in the evaluation of
the patients.

Objectives:
Fellows will learn all aspects of outpatient gastroenterology and liver disease care and will display all general competencies during this
experience. Fellows in the Digestive Disease Center will develop familiarity with problems with complex issues related to irritable bowel
syndrome, inflammatory bowel disease, motility disorders, malabsorption, and screening/surveillance for neoplasia or dysplasia are some of the
more common conditions encountered. These include the differential diagnosis of other structural abnormalities involved in the esophagus,
stomach, or duodenum, and knowledge of management of medications that may have serious systemic complications and/or the potential for
drug interaction. Fellows in the Texas Liver Center will develop familiarity with standard treatments for common complications such as ascites,
portal hypertension or hepatic encephalopathy and will build familiarity with standard treatments of chronic liver diseases such as viral hepatitis,
autoimmune liver diseases, metabolic liver diseases, drug-induced liver disease, fatty liver disease and liver tumors. Fellows will obtain exposure
to the liver transplantation selection process and will receive experience in the timing of referring patients for liver transplantation. Minimum

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levels of achievement in each competency are expected during each of the three years of fellowship training. Those meeting competency will
receive a score of 5 in the program’s evaluation system. Fellows performing at a level better than expected for that competency receive a score
of 6 or 7 in the evaluation system, those at a level better than most fellows at that PGY receive an 8, and those performing at a level deemed to
be “one of the best fellows ever observed” will receive a score of 9. Fellows receiving a score of 4 or below are deemed deficient in that
competency; this will be brought to the attention of the program director immediately, and, if necessary, remediation will be implemented.

The following are the goals and objectives for each competency at each level of training for the Gastroenterology and Hepatology Outpatient
Service:

                                                                 PGY 4 Fellow:

Goal: A Year I fellow should be able to assess new patient problems, formulate and execute a treatment plan with guidance and teach basic
hepatology and gastroenterology skills to medical students and other trainees. Year I fellows should begin to develop basic procedural
competencies.

Patient Care Objectives:
     Perform an accurate physical examination and present information concisely with an initial assessment plan. Follow the patient’s disease
     course from visit to visit with possible.. With attending consultation, formulate and execute an impression and a list of recommendations.
     When indicated, consent patients for procedures and order appropriate diagnostic tests (e.g., endoscopy, radiologic tests, etc.) in
     conjunction with the primary/referring service.
     Perform with supervision the following basic procedures (see practicum):
               o Colonoscopy
                                By completion of Year I a fellow should be able to perform a diagnostic colonoscopy to the cecum with limited
                                assistance.
               o EsophagoGastroDuodenoscopy (EGD or Upper Endoscopy)
                                By completion of Year I a fellow should be able to perform a diagnostic endoscopy to the second portion of the
                                duodenum.
               o Liver Biopsies:
                                Fellows must have formal instruction and clinical expertise and must demonstrate competence in the performance
                                of percutaneous liver biopsies.
               o Abdominal Paracentesis:
                                Fellows must have formal instruction and clinical expertise, and must demonstrate competence in the performance
                                of diagnostic and therapeutic paracentesis

     Fellows will have formal instruction and clinical experience and will demonstrate competence in:
          A. Gastroenterology:
              o The evaluation and management of patients referred for:
                               Dysphagia
                               Abdominal pain
                               Diarrhea
                               Constipation
                               Gastrointestinal bleeding
                               Acid-peptic disorders
                               Inflammatory bowel disorders
                               Irritable bowel syndrome
                               Gastrointestinal motility disorders
                               Malabsorption
                               Gastrointestinal malignancy screening

          B. Hepatology:
              o The prevention of acute and chronic endstage liver disease
              o The evaluation and management of outpatients with acute and chronic endstage liver disease
              o The management of fulminant liver failure
              o The psychosocial evaluation of all candidates, in particular those with a history of substance abuse
              o Drug hepatotoxicity and the interaction of drugs with the liver
              o Diagnosis and management of autoimmune hepatitis
              o Diagnosis and management of viral hepatitis
              o Diagnosis and management of cholestatic liver diseases – primary biliary cirrhosis (PBC) and primary sclerosing cholangitis
                   (PSC)

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               o
     Learn to provide outpatient care that is safe and compassionate and to develop the ability to thoroughly and clearly educate the patient in
     the relevant areas of disease prevention, detection, progression and therapy to promote liver health.

Medical Knowledge Objectives:
    Attend core conferences and teaching rounds (see attached conference schedule) to learn the pathophysiology, epidemiology, disease
    management and procedures and medicine management skills for common and uncommon gastrointestinal and liver diseases including:
         A. Gastroenterology:
              The evaluation and management of patients referred for:
              o Dysphagia
              o Abdominal pain
              o Diarrhea
              o Constipation
              o Gastrointestinal bleeding
              o Acid-peptic disorders
              o Inflammatory bowel disorders
              o Irritable bowel syndrome
              o Gastrointestinal motility disorders
              o Malabsorption
              o Gastrointestinal malignancy screening

          B. Hepatology:
                o The prevention of acute and chronic endstage liver disease
                o The evaluation and management of inpatients with acute and chronic endstage liver disease
                o The management of fulminant liver failure
                o The psychosocial evaluation of all candidates, in particular those with a history of substance abuse
                o Drug hepatotoxicity and the interaction of drugs with the liver
                o Diagnosis and mangement of autoimmune hepatitis
                o Diagnosis and management of viral hepatitis
                o Diagnosis and management of cholestatic liver diseases – primary biliary cirrhosis (PBC) and primary sclerosing cholangitis
                      (PSC)
     Accumulate and begin to solve the issues that he/she encounters from other trainees, attendings and related medical professionals.
     Teach medical students the basics of gastroenterology and hepatology care.
     Achieve an average percentile score of at least 61.18 on the general gastroenterology section and 59.8 on the liver section of the in-service
     Gastroenterology Training Examination (GTE) exam. These scores are the national average for general gastroenterology and liver section
     for Year I fellows.
     By end of Year I, pass the Internal Medicine Board Examination.

Practice-Based Learning Objectives:
    Become familiar with the concepts of quality improvement.
    Participate in conferences such as M&M, geared to the programmatic review of adverse events.
    Begin to review, analyze and utilize scientific evidence from the gastroenterology and hepatology literature for the management of
    gastrointestinal and liver disease patients.
    Learn the best practice patterns to facilitate gastrointestinal and hepatology disease care through clinic operating procedures and patient
    interactions.

Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable and
     compassionate manner. Convey bad news compassionately and honestly.
     Learn to communicate effectively with staff, peers, attending gastroenterologists/hepatologists, referring physicians and other consultants.

Professionalism Objectives:
    Learn to understand and demonstrate professional behavior in daily activities.
    Participate in professionalism-based learning activities through conferences.
    Learn to interact collegially with his/her peer group and other healthcare professionals.
    Learn to practice ethical principles with relation to patient care and confidentiality.
    Learn to practice appropriate interactions with pharmaceutical representatives and be unbiased in prescribing habits.
    Learn to be sensitive to cultural, age, gender and disability issues.
    Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues.
    Participate in program planning.
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Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Achieve basic understanding of healthcare systems related to gastroenterology and hepatology care and overall system activities.
    Learn proper documentation and billing skills to practice cost-effective care.
    Utilize an appropriate range of healthcare professionals to care for patients, working closely with social services to maximize patient care
    and understanding the role of hospice, referring appropriately when needed.
    Begin involvement to understand the standard operating procedures and quality improvement initiatives within the hospital.
    Attend national gastroenterology conferences (e.g., ACG and endoscopy training courses).

                                                                  PGY 5 Fellow:

Goal: A Year II fellow should learn to assess and care for a larger volume of outpatients and learn and teach basic textbook and evidence-based
medicine to medical students and other trainees. Year II fellows should independently perform diagnostic upper endoscopy and colonoscopy
and begin to perform therapeutic maneuvers.

Patient Care Objectives:
     Complete a time-efficient history and physical examination.
     Critique the work and orders of Year I fellows.
     Direct the Year I fellows successfully with the appropriate level of intervention for each trainee’s skills.
     Complete competency-level performance of the following basic procedures (see practicum checklist):
                o Colonoscopy
                               By completion of Year II, master all Year I colonoscopic skill requirements. Additionally, perform endoscopic
                               maneuvers, including snare polypectomy and begin to develop competency in control of GI bleeding: sclerotherapy
                               and thermal coagulopathy of bleeding vessels.
                o Upper Endoscopy
                               By completion of Year II, master all Year I upper endoscopic skill requirements. Additionally, begin to develop
                               competency in performing therapeutic maneuvers: banding and sclerosing of varices, and sclerotherapy and
                               thermal coagulopathy of bleeding vessels.
                o Liver Biopsies:
                               Fellows must have formal instruction and clinical expertise and must demonstrate competence in the performance
                               of percutaneous liver biopsies.
                o Abdominal Paracentesis:
                               Fellows must have formal instruction and clinical expertise, and must demonstrate competence in the performance
                               of diagnostic and therapeutic paracentesis

     Fellows will have formal instruction and clinical experience and demonstrate competence in:
     A. Gastroenterology:
               o The evaluation and management of patients referred for:
                               Chronic abdominal pain syndromes difficult to manage
                               Complex motility disorders
                               Irritable bowel syndrome
                               Evaluation of gastrointestinal bleeding of unclear etiology
                               Difficult to manage inflammatory bowel disease
                               Gastrointestinal neoplasm screening and surveillance
                               Pancreaticobiliary disorders
     B. Hepatology:
               o The comprehensive management of patients who are high on the transplant list in the intensive care setting with
                    complications of end-stage liver disease including: refractory ascites, hepatic hydrothorax; hepatorenal syndrome,
                    hepatopulmonary and portal pulmonary syndromes, and refractory portal hypertensive bleeding
               o The management of chronic viral hepatitis in the pre-transplantation, peri-transplantation, and post-transplantation settings
               o Nutritional support of patients with chronic liver disease
               o The use of interventional radiology in the diagnosis and management of portal hypertension, as well as biliary and vascular
                    complications
     Present cases succinctly in a direct manner.
     Know the Outpatient Service’s patients at a management level.
     Teach good symptom management skills to medical students and other trainees.
     Provide outpatient care that is safe and compassionate and develop the ability to thoroughly and clearly educate the patient in the relevant
     areas of disease prevention, detection, progression and therapy to promote liver health.

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Medical Knowledge Objectives:
    Begin to take a leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease
    management and procedures and medicine management skills for common and uncommon outpatient gastrointestinal and liver diseases
    including:
    A. Gastroenterology:
               o The evaluation and management of patients referred for:
                             Chronic abdominal pain syndromes difficult to manage
                             Complex motility disorders
                             Irritable bowel syndrome
                             Evaluation of gastrointestinal bleeding of unclear etiology
                             Difficult to manage inflammatory bowel disease
                             Gastrointestinal neoplasm screening and surveillance
                             Pancreaticobiliary disorders

     B.    Hepatology:
               o The comprehensive management of patients who are high on the transplant list in the intensive care setting with
                    complications of end-stage liver disease including: refractory ascites, hepatic hydrothorax; hepatorenal syndrome,
                    hepatopulmonary and portal pulmonary syndromes, and refractory portal hypertensive bleeding.
               o The management of chronic viral hepatitis in the pre-transplantation, peri-transplantation, and post-transplantation settings
               o Nutritional support of patients with chronic liver disease
               o The use of interventional radiology in the diagnosis and management of portal hypertension, as well as biliary and vascular
                    complications
     Organize the team’s performance at teaching rounds.
     Read textbook and pertinent literature materials concerning problems encountered.
     Teach medical students and other trainees about liver disease states and patient management.
     Achieve an average percentile score of at least 62.98on general gastroenterology section and 65.7 on the liver section, respectively, of the
     in-service Gastroenterology Training Examination (GTE) exam. This score is the national exam average for liver diseases for Year II
     fellows.

Practice-Based Learning Objectives:
    Participate in project groups, committees and hospital groups when requested.
    Participate in programmatic reviews and conferences studying adverse events.
    Give usable feedback to medical students and other trainees based on observation of their performance and assess improvement.
    Participate in problem-based quality improvement projects.
    Review, analyze and utilize scientific evidence from the gastroenterology and hepatology literature for the management of these disease
    patients.
    Know the best practice patterns to facilitate outpatient care through clinic operating procedures and patient interactions.

Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner.
     Convey bad news compassionately and honestly.
     Plan patient and family conferences.
     Counsel patients about transitioning to palliative care, when needed.
     Address or refer patients related to spiritual or existential issues.
     Communicate effectively with staff, peers, attending hepatologists/gastroenterologists, referring physicians and other consultants.
     Present cases succinctly, in a problem-based, direct manner.
     Learn to become a teacher of gastroenterology and hepatology to junior trainees, medical students and other healthcare professionals.

Professionalism Objectives:
    Begin to mentor medical students, other trainees and Year I fellows in professional conduct.
    Understand and demonstrate professional behavior in daily activities.
    Participate in professionalism-based learning activities through conferences.
    Interact collegially with his/her peer group and other healthcare professionals, including acting responsibly in the larger context of pursuing
    programmatic successes.
    Practice ethical principles with relation to patient care and confidentiality.
    Practice interactions with pharmaceutical representatives and be unbiased in prescribing habits.
    Practice sensitivity to cultural, age, gender and disability issues.
    Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues.
    Participate in program planning.

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Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Understand and practice proper documentation and billing skills to practice cost-effective care.
    Assist other trainees in the utilization of appropriate healthcare resources for the best care of the Hepatology Consultative Service’s
    patients.
    Model appropriate interactions in multidisciplinary planning, including standard operating procedures and quality improvement initiatives.
    Attend national gastroenterology or hepatology conferences (e.g., DDW or AASLD).

                                                                  Year III Fellows:

Goal: The senior-level, Year III fellow should demonstrate rapid assessment and planning skills and near-attending level care planning and
management, while teaching medical students and other trainees at near to or exceeding attending level teaching. Year III fellows should be
able to perform diagnostic and therapeutic upper endoscopy and colonoscopy procedures independently

Patient Care Objectives:
     Master the Year II fellow objectives.
     Demonstrate efficient organization of the MHH Outpatient Service and a working knowledge of all patients.
     Demonstrate near-attending level capacity for program assessment and care planning.
     Attain trainer level proficiency in the following procedures pertinent to his/her career choices:
                o Colonoscopy
                                 By completion of Year III, master all Year II colonoscopic skill requirements. Additionally, be able to independently
                                 intubate the terminal ileum and begin to develop independent mastery of more advanced maneuvers, e.g., removal
                                 of large or complex polyps by saline assisted polypectomy or piecemeal resection and control of bleeding using
                                 clips or argon plasma laser coagulation.
                o Upper Endoscopy
                                 By completion of Year III, master all Year II endoscopic skill requirements. Additionally, be able to pass a side
                                 viewing scope to identify the papilla or lesions difficult to observe with forward viewing scope and perform
                                 advanced maneuvers, such as placing clips on bleeding vessels or argon plasma laser coagulopathy.
                o Liver Biopsies:
                                 Fellows must have formal instruction and clinical expertise and must demonstrate competence in the performance
                                 of percutaneous liver biopsies.
                o Abdominal Paracentesis:
                                 Fellows must have formal instruction and clinical expertise, and must demonstrate competence in the performance
                                 of diagnostic and therapeutic paracentesis

     Fellows will have formal instruction and clinical experience and demonstrate competence in:
     A. Gastroenterology:
              o The evaluation and management of patients referred for:
                               Difficult to manage acid-peptic disorders
                               Refractory and complicated inflammatory bowel disease
                               Complicated functional bowel disorders
                               Difficult to manage pancreaticobiliary disorders
                               Highly skilled and complex endoscopic procedures
                               Refractory motility disorders management

     B.   Hepatology:
               o The diagnosis and management of hepatocellular carcinoma and cholangiocarcinoma including transplantation, non-
                    transplantation, and non-surgical approaches
               o Transplant immunology including blood group matching, histocompatibility, tissue typing, and infectious and malignant
                    complications of immunosuppression
               o Ethical considerations relating to liver transplant donors, including questions related to living donors, non-heart beating
                    donors, criteria for brain death, and appropriate recipients
               o Acquiring a current working knowledge of the organizational and logistic aspects of liver transplantation including the the role
                    of nurse coordinators and other support staff (e.g., social work), organ procurement, and UNOS policies including those
                    regarding organ allocation
     Provide outpatient care that is safe and compassionate with the leadership ability to thoroughly and clearly educate the patient and all other
     trainees regarding relevant areas of disease prevention, detection, progression and therapy to promote overall gastrointestinal health.

Medical Knowledge Objectives:
    Access and critique the medical literature regarding hepatology and gastroenterology problems encountered.
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     Assume the trainee leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease
     management, procedures and medicine management skills for common and uncommon inpatient liver diseases including
     A. Gastroenterology:
               o The evaluation and management of patients referred for:
                               Difficult to manage acid-peptic disorders
                               Refractory and complicated inflammatory bowel disease
                               Complicated functional bowel disorders
                               Difficult to manage pancreaticobiliary disorders
                               Highly skilled and complex endoscopic procedures
                               Refractory motility disorders management
     B. Hepatology:
               o The diagnosis and management of hepatocellular carcinoma and cholangiocarcinoma including transplantation, non-
                     transplantation, and non-surgical approaches
               o Transplant immunology including blood group matching, histocompatibility, tissue typing, and infectious and malignant
                     complications of immunosuppression
               o Ethical considerations relating to liver transplant donors, including questions related to living donors, non-heart beating
                     donors, criteria for brain death, and appropriate recipients
               o Acquiring a current working knowledge of the organizational and logistic aspects of liver transplantation including the the role
                     of nurse coordinators and other support staff (e.g., social work), organ procurement, and UNOS policies including those
                     regarding organ allocation
     Teach medical students, other trainees and Year I & II fellows at near-attending level.
     Prepare for the ABIM certifying exam throughout the year.
     Organize team activities in a smooth and authoritative fashion.
     Assist Year II fellows’ development directly at teaching conferences and indirectly at work sites.
     Achieve an average percentile score of at least 64.02 on general gastroenterology and 70.6 on the liver section, respectively in the in-
     service Gastroenterology Training Examination (GTE) exam. This score is the national exam average for the liver section for Year III
     fellows.

Practice-Based Learning Objectives:
    Demonstrate mastery of Year II fellow skills and encourage participation of colleagues.
    Review, analyze and utilize scientific evidence from the gastroenterology and hepatology literature for the management of diseases, taking
    a leadership role in guiding Year I & II fellows and sharing relevant literature reviews with them.
    Know and be able to succinctly communicate the best practice patterns to facilitate gastrointestinal diseases care through clinic operating
    procedures and patient interactions.

Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner.
     Convey bad news compassionately and honestly.
     Supervise Year I & II fellows’ work related to planning patient/family conferences and patient communications/counseling.
     Communicate effectively as a consultant with staff, peers, attending gastroenterologists, referring physicians and other consultants and lead
     other trainees related to appropriate fellow-to-medical-professional communications.
     Present cases succinctly, in a problem-based, direct manner.
     Assume the role of a teacher of gastroenterology and hepatology to junior trainees, medical students and other healthcare professionals.

Professionalism Objectives:
    Demonstrate proficiency in Year II objectives.
    Mentor medical students, other trainees and fellows in professional conduct.
    Assist in formal teaching exercises as requested.
    Assert leadership in program planning.

Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Model appropriate interactions in multidisciplinary planning, including improvements related to standard operating procedures and quality
    improvement initiatives.
    Participate in hospital and national medical association committees and multidisciplinary planning groups when requested.
    Attend national conferences directed at career goals.
    Demonstrate near-attending level utilization of overall systems of care.

Teaching Methods:
Gastroenterology fellows participate in the Gastroenterology and Hepatology Outpatient Service during all three fellowship years. One fellow is
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assigned to the Outpatient Service during all rotations. Teaching of medical students, residents and other trainees as well as appropriate
interactions with other healthcare providers are important aspects of this rotation. Participating in all required conferences is mandatory, and
rounding is an integral part of this experience. As fellows gain experience throughout their training, skills of organization and efficiency as well as
team leadership become increasingly important.

The Outpatient Service experience will prepare the fellow to evaluate and manage acute and chronic liver diseases that will be encountered in
the fellow’s future practice. This rotation will expose the fellow to a wide variety of acute and chronic gastrointestinal and liver diseases. Fellows
will learn to incorporate and interact with a multidisciplinary team approach with the Liver Transplant Program at the Texas Liver Cernter.
Fellows will learn the appropriate use of interventional radiology facilities capable of performing Transjugular Intrahepatic Portal Systemic Shunts
(TIPS) and balloon angioplasty and will learn to share patient co-management responsibilities with transplant surgeons from the preoperative
phase to the outpatient period and will learn to interact with an experienced liver transplant pathologist.

Fellows assigned to this service will rotate through the outpatient Gastroenterology DDC and Hepatology Texas Liver Center. Fellows will
evaluate each patient and will make initial recommendations regarding diagnostic tests and treatments. They will make arrangements for studies
such as GI endoscopic procedures, liver biopsies (percutaneous and transjugular), abdominal paracenteses and thoracenteses, percutaneosu
transhepatic cholangiograms (PTC), etc. They will review the appropriateness of the procedure with the attending before making final scheduling
plans. The fellow will follow each patient under active consultation on a regular basis, will make further recommendations as indicated and will
keep the attending informed of the patient’s status. Fellows must also communicate with the procedure fellow for all diagnostic studies.

Disease Mix:
Fellows see a complete mix of gastrointestinal and liver diseases and conditions at the Digestive Disease Center (DDC) and Texas Liver Center
(TLC) which are the primary outpatient clinics. A diverse spectrum of internal medicine diagnoses and gastroenterology/hepatology care is
provided at these clinics.

At the DDC Diagnoses range from pancreatitis, inflammatory bowel disease, and functional GI motility and pain disorders to primary and
secondary gastrointestinal malignancies, and there is an appropriate concentration of common gastrointestinal diseases such as peptic ulcer
disease, gastroesophageal reflux disease and gastrointestinal infections.

Particularly at the TLC diagnoses range from acute viral hepatitis (A/B), drug induced liver injury, fulminant liver failure, chronic viral hepatitis post
transplantation, complicated hepatocellular carcinoma and cholangiocarcinoma. There is an appropriate concentration of common liver diseases
related to evalaution of abnormal liver function tests, management of ascites including refractory ascites, hepatic hydrothorax, hepatorenal
syndrome and portal hypertensive bleeding. diagnosis and management of autoimmune liver diseases and cholestatic liver diseases (PBC;
PSC), metabolic liver diseases (Non-Alcoholic Fatty Liver Disease [NAFLD]), Inherited Liver Diseases such as Genetic Hemochromatosis,
Wilson’s Disease and Alpha One Antitrypsin Deficiency.

Patient Characteristics:
Both the DDC and TLC offers a diverse mix of socioeconomic and gender status. Teaching faculty provide an abundant supply of upper- and
middle-class patients, and our contracts with medical assistance and pro bono care efforts ensure access to lower-income patients.

Types of Clinical Encounters – Attending Supervision:
Fellows provide consultative care under the supervision of an attending within duty hour limits and with faculty back up for situations of overload.
 Daily attending supervision is available seven days per week. The attending has ultimate responsibility for patients.

Procedures:
During the Outpatient Service, non-emergent procedures are performed during daytime hours in the GI lab by the fellow under the direct
supervision of the attending. Procedure based evaluation is performed twice per year by a supervising.

Evaluation:
Fellows are evaluated during the Outpatient Service rotations and are expected to participate in the evaluation of rotation and attending as well.
This occurs in the following forms:
     Detailed, automated evaluations using the GMEIS system are submitted for each rotation. These evaluations are reflective of the program’s
     curriculum requirements. Attendings evaluate fellows, and the fellows evaluate the attendings as well. Quarterly evaluations include:
                o 360-degree (attending, nurse, nurse practitioner, staff/clerical, etc.);
                o Patient.
     Evaluation summaries become part of the fellows’ and attendings’ promotional documents.
     The fellow also evaluates the Gastroenterology Fellowship Program annually through a confidential basis.
     Attendings evaluate the Gastroenterology Fellowship Program annually.
     A Curriculum Committee oversees major changes to the curriculum. Representative program personnel (i.e., program director,
     representative faculty and at least one fellow) are organized to review program goals and objectives and the effectiveness with which they
     are achieved. This group conducts a formal documented meeting at least annually for this purpose. In the evaluation process, the group
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    must take into consideration written comments from the faculty, the most recent report of the GMEC of the sponsoring institution and the
    residents’ confidential written evaluations. If deficiencies are found, the group will prepare an explicit plan of action, which should be
    approved by the faculty and documented in the minutes of the meeting.
    The Program Director meets with all fellows individually twice per year.
    An in-service GTE exam is given to all fellows annually.




Bibliography:
     Resource Documents
               o Up-To-Date
               o PubMed
               o Textbook of Gastroenterology – Yamada, et.al.
               o Gastrointestinal Diasese: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.
               o Diseases of the Liver - Leon Schiff and Eugene Schiff
               o Zakim and Boyer’s Hepatology: A Textbook of Liver Disease
               o Major Gastroenterology journals online and in the program’s fellow library including Gastroenterology, American Journal of
                    Gastroenterolgy, Gut, Hepatology, Liver Transplantation, Journal of Hepatology and other major publications.
               o Website of the American Association for the Study of Liver Disease (AASLD) with related links
               o Recommended reading and landmark articles are available on the Division of Gastroenterology, Hepatology and Nutrition’s
                    shared-access drive. This information includes:
                             Practice Guidelines from the American Association for the Study of Liver Diseases (AASLD) [may also be accessed
                             via www.aasld.org].
     Curricular Design
               o ACGME Outcome Project documentation (from www.acgme.org).

    Pertinent Teaching References:
              o Textbook of Gastroenterology – Yamada, et.al.
              o Gastrointestinal Diasese: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.
              o Diseases of the Liver - Leon Schiff and Eugene Schiff
              o Zakim and Boyer’s Hepatology: A Textbook of Liver Disease

                                                        Competencies-at-a-Glance
                                                       Hepatology Outpatient Service
                       COMPETENCY                       LEARNING OPPORTUNITY                              EVALUATION
            Patient Care                                 Work Rounds                               360-global evaluations
                                                         Teaching Rounds                           GTE in-service exam
                                                         Conferences                               Direct Observation

            Medical Knowledge                             Work Rounds                              360-global evaluations
                                                          Teaching Rounds                          GTE in-service exam
                                                          Conferences
            Practice-Based Learning                       Quarterly M&M Conference                 360-global evaluations
                                                          Work Rounds                              Direct Observation

            Interpersonal Skills                          Work Rounds                              360-global evaluations
            Professionalism                               Work Rounds                              360-global evaluations
                                                          Conferences
            Systems-Based Practice                        Committee Participation                  360-global evaluations
                                                          Grand Rounds (GI & Medical)
                                                          Conferences

The Outpatient Service reflects appropriate teaching and evaluation related to all six core competencies. Patient care, teaching and the
curriculum conferences during the rotation are the greatest elements that teach the competencies, and the global evaluation is the most
important single measurement device. In addition to didactic learning, medical center committee participation is encouraged to bolster system-
wide knowledge and practice management understanding.

Revised

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May 2009/ Lukens




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                              Gastroenterology PancreaticoBiliary Consultation Rotation (PBS)
                                     Memorial Hermann Hospital Texas Medical Center
                                                            &
                                        HCHD: Lyndon B. Johnson General Hospital
                                              Curriculum for PGY 4, 5 and 6

                                                       Curriculum for Year II & III Fellows

Educational Purpose:
The Pancreaticobiliary Service at both MHH and LBJ introduces the fellow to inpatient management of patients with pancreas and biliary
diseases. During this period, the fellow will have the opportunity to assess a wide variety of acute and chronic pancreaticobiliary conditions. As
such, there will be an introduction to ERCP, but, for advanced training, fellows will require a fourth year. Additionally, a faculty committee will
decide if certain fellows merit more intensive ERCP training during the three year fellowship. These fellows will be selected by the faculty.
Pancreaticobiliary Consultation Service (PBS) fellows will participate in increasing levels of management/ treatment involvement with patient
needs and procedures, depending on the fellow’s level of experience. The fellow will be expected to formulate the differential diagnosis, institute
diagnostic studies and recommend therapy. The amount of learning obtained from this rotation is directly proportional to the amount of time
spent in the evaluation of the patients.

Objectives:
Fellows will learn all aspects of pancreas and biliary disease care and will display all general competencies during this experience. Minimum
levels of achievement in each competency are expected during Years II and III of training, when fellows may participate in the Pancreaticobiliary
Consultation Service. Those meeting competency will receive a score of 5 in the program’s evaluation system. Fellows performing at a level
better than expected for that competency receive a score of 6 or 7 in the evaluation system, those at a level better than most fellows at that PGY
receive an 8, and those performing at a level deemed to be “one of the best fellows ever observed” will receive a score of 9. Fellows receiving a
score of 4 or below are deemed deficient in that competency; this will be brought to the attention of the program director immediately, and, if
necessary, remediation will be implemented.

The following are the goals and objectives for each competency at each level of training for the Pancreaticobiliary Service:

                                                                  Year II Fellow:

Goal: A Year II fellow should be able to assess and care for a large volume of patients and learn and teach basic textbook and evidence-based
medicine to medical students and other trainees. Year II fellows should independently perform upper endoscopy procedures with a side viewing
scope. Year II fellows should understand the indications for ERCP and EUS as well as risks and benefits of such procedures.

Patient Care Objectives:
     Complete a time-efficient history and physical examination.
     Direct medical students successfully with the appropriate level of intervention for each trainees’ skills.
               o Complete competency-level performance of the following pancreaticobiliary procedures:
               o Upper Endoscopy
               o Passage of side viewing endoscope and visualization of the ampulla of vater.
               o Begin to perform cannulation of the bile duct.
     Develop clear expertise in the diagnosis and management of acute and chronic pancreaticobiliary diseases including:
               o Acute Pancreatitis
               o Chronic Pancreatitis
               o Pancreatis Cancer
               o Bile Duct Stones
               o Liver Cancer
               o Biliary Cancer
               o Post-Operative Injuries to the Liver, Bile Ducts & Pancreas
     Present cases succinctly in a direct manner.
     Know the Pancreaticobiliary Consultation Service’s patients at a management level.
     Handle consult calls respectfully and appropriately.
     Teach good symptom management skills to medical students and other trainees.
     Provide inpatient care that is safe and compassionate and develop the ability to thoroughly and clearly educate the inpatient in the relevant
     areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.

Medical Knowledge Objectives:
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     Begin to take a leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease
     management and procedures and medicine management skills for common and uncommon pancreaticobiliary diseases including:
                 o Acute Pancreatitis
                 o Chronic Pancreatitis
                 o Pancreatis Cancer
                 o Bile Duct Stones
                 o Liver Cancer
                 o Biliary Cancer
                 o Post-Operative Injuries to the Liver, Bile Ducts & Pancreas
     Organize the team’s performance at teaching rounds.
     Read textbook and pertinent literature materials concerning problems encountered.
     Teach medical students and other trainees about pancreas and biliary disease states and patient management.
     Achieve an average percentile score of at least 73.90 on the Biliary Tract section and 48.36 on the Pancreas section of the in-service
     Gastroenterology Training Examination (GTE) exam. These scores are the national exam averages for pancreatiobiliary diseases for Year
     II fellows.

Practice-Based Learning Objectives:
    Participate in project groups, committees and hospital groups when requested.
    Participate in programmatic reviews and conferences studying adverse events.
    Give usable feedback to medical students and other trainees based on observation of their performance and assess improvement.
    Participate in problem-based quality improvement projects.
    Review, analyze and utilize scientific evidence from pancreaticobiliary literature related to patient management.
    Know the best practice patterns to facilitate pancreaticobiliary care through clinic operating procedures and patient interactions.

Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner.
     Convey bad news compassionately and honestly.
     Plan patient and family conferences.
     Counsel patients about transitioning to palliative care, when needed.
     Address or refer patients related to spiritual or existential issues.
     Communicate effectively with staff, peers, attending gastroenterologists, referring physicians and other consultants.
     Present cases succinctly, in a problem-based, direct manner.
     Learn to become a teacher of pancreas and biliary diseases to junior trainees, medical students and other healthcare professionals.

Professionalism Objectives:
    Begin to mentor medical students and other trainees in professional conduct.
    Understand and demonstrate professional behavior in daily activities.
    Participate in professionalism-based learning activities through conferences.
    Interact collegially with his/her peer group and other healthcare professionals, including acting responsibly in the larger context of pursuing
    programmatic successes.
    Practice ethical principles with relation to patient care and confidentiality.
    Practice interactions with pharmaceutical representatives and be unbiased in prescribing habits.
    Practice sensitivity to cultural, age, gender and disability issues.
    Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues.
    Participate in program planning.

Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Understand and be able to work effectively related to hospital functions within MHH and LBJ hospitals.
    Understand and practice proper documentation and billing skills to practice cost-effective care.
    Assist other trainees in the utilization of appropriate healthcare resources for the best care of Pancreaticobiliary Service patients.
    Model appropriate interactions in multidisciplinary planning, including standard operating procedures and quality improvement initiatives.
    Attend national gastroenterology conferences (e.g., DDW, ACG or APA).



                                                                 Year III Fellows:

Goal: The senior-level, Year III fellow should demonstrate rapid assessment and planning skills and near-attending level care planning and
management, while teaching medical students and other trainees at near to or exceeding attending level teaching. Year III fellows should be
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able to perform diagnostic and therapeutic upper endoscopy procedures independently, as well as passage of the side viewing scope.

Patient Care Objectives:
     Master the Year II fellow objectives.
     Demonstrate efficient organization of the Pancreaticobiliary Service and a working knowledge of all patients.
     Demonstrate near-attending level capacity for program assessment and care planning.
     Attain trainer level proficiency in the following procedures pertinent to his/her career choices:
     Complete competency-level performance of the following pancreaticobiliary procedures reflecting Year III responsibilities:
                o Biliary stone extraction
                o Upper Endoscopy
                o ERCP
                o Cannulation of bile duct and perform sphincterotomy and placement of bile duct stents
     Secure expertise in the diagnosis and management of acute and chronic inpatient pancreaticobiliary diseases including:
                o Acute Pancreatitis
                o Chronic Pancreatitis
                o Pancreatic Cancer
                o Pancreatic divisum
                o Congenital biliary abnormalities
                o Biliary strictures and primary sclerosing cholangitis
                o Pancreatic necrosis
                o Management of bile duct injuries related to trauma
                o Bile Duct Stones
                o Liver Cancer
                o Biliary Cancer
                o Post-Operative Injuries to the Liver, Bile Ducts & Pancreas
     Provide inpatient care that is safe and compassionate with the leadership ability to thoroughly and clearly educate the inpatient and all other
     trainees regarding relevant areas of disease prevention, detection, progression and therapy to promote pancreas and biliary health.

Medical Knowledge Objectives:
    Access and critique the medical literature regarding pancreas and biliary problems encountered.
    Assume the trainee leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease
    management, procedures and medicine management skills for common and uncommon inpatient pancreaticobiliary diseases including
                o Acute Pancreatitis
                o Chronic Pancreatitis
                o Pancreatic Cancer
                o Pancreatic divisum
                o Congenital biliary abnormalities
                o Biliary strictures and primary sclerosing cholangitis
                o Pancreatic necrosis
                o Management of bile duct injuries related to trauma
                o Bile Duct Stones
                o Liver Cancer
                o Biliary Cancer
                o Post-Operative Injuries to the Liver, Bile Ducts & Pancreas
    Teach medical students, other trainees and Year I & II fellows at near-attending level.
    Prepare for the ABIM certifying exam throughout the year.
    Organize team activities in a smooth and authoritative fashion.
    Assist Year II fellows’ development directly at teaching conferences and indirectly at work sites.
    Achieve an average percentile score of at least 79.02 on the Biliary Tract section and 54.44 on the Pancreas section of the in-service
    Gastroenterology Training Examination (GTE) exam. These scores are the national exam averages for pancreatiobiliary diseases for Year
    III fellows.

Practice-Based Learning Objectives:
    Demonstrate mastery of Year II fellow skills and encourage participation of colleagues.
    Review, analyze and utilize scientific evidence from the hepatology literature for the management of liver disease patients, taking a
    leadership role in guiding Year I & II fellows and sharing relevant literature reviews with them.
    Know and be able to succinctly communicate the best practice patterns to facilitate liver disease care through clinic operating procedures
    and patient interactions.

Interpersonal Communication Skill Objectives:
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     Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner.
     Convey bad news compassionately and honestly.
     Supervise Year I & II fellows’ work related to planning patient/family conferences and patient communications/counseling.
     Communicate effectively as a consultant with staff, peers, attending gastroenterologists, referring physicians and other consultants and lead
     other trainees related to appropriate fellow-to-medical-professional communications.
     Present cases succinctly, in a problem-based, direct manner.
     Assume the role of a teacher of pancreas and biliary diseases to junior trainees, medical students and other healthcare professionals.

Professionalism Objectives:
    Demonstrate proficiency in Year II objectives.
    Mentor medical students, other trainees and fellows in professional conduct.
    Assist in formal teaching exercises as requested.
    Assert leadership in program planning.

Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Model appropriate interactions in multidisciplinary planning, including improvements related to standard operating procedures and quality
    improvement initiatives.
    Participate in hospital and national medical association committees and multidisciplinary planning groups when requested.
    Attend national conferences directed at career goals.
    Demonstrate near-attending level utilization of overall systems of care.

Teaching Methods:
Gastroenterology fellows participate in the Pancreaticobiliary Consultation Service during Years II and III of fellowship training. One fellow is
assigned to the Pancreaticobiliary Service during all rotations. Teaching of medical students, residents and other trainees as well as appropriate
interactions with other healthcare providers are important aspects of this rotation. Participating in all required conferences is mandatory, and
rounding is an integral part of this experience. As fellows gain experience throughout their training, skills of organization and efficiency as well as
team leadership become increasingly important.

The Pancreaticobiliary Service experience is rigorous and will prepare the fellow to evaluate and manage acute and chronic pancreas and biliary
diseases that will be encountered in the fellow’s future practice. This rotation will expose the fellow to a wide variety of pancreas and biliary
disease diseases and problems.

Fellows assigned to this service will evaluate all new consults at MHH and LBJ hospitals and will be assigned to a continuity clinic one-half day
per week. They will present new consults to the attending by the following day for routine consults and as soon as possible for emergencies.
Fellows will evaluate each patient and will make initial recommendations regarding diagnostic tests and treatments. They will make
arrangements for studies such as upper endoscopy, ERCP, MRCP etc. They will review the appropriateness of the procedure with the attending
before making final scheduling plans. The fellow will follow each patient under active consultation on a regular basis, will make further
recommendations as indicated and will keep the attending informed of the patient’s status. Fellows must also communicate with the procedure
fellow for all diagnostic studies.

Disease Mix:
Fellows see a complete mix of liver diseases and conditions within the Pancreaticobiliary Consultation Service’s teaching hospitals. MHH and
LBJ hospitals have a substantial primary care basis, which provides the entire spectrum of internal medicine diagnoses and gastroenterology
care.

Diagnoses range from acute pancreatitis to pancreatic cancer, and there is an appropriate concentration of common pancreas and biliary
diseases such as Cholangitis, cholelithiasis, biliary strictures. Importantly, LBJ is exposed to a large Hispanic patient population, because of this
there is outstanding diversity of biliary pathology highly prevalent in the group of patients.

Patient Characteristics:
MHH and LBJ offer a diverse mix of socioeconomic and gender status. Teaching faculty provide an abundant supply of upper- and middle-class
patients, and our contracts with medical assistance and pro bono care efforts ensure access to lower income patients. Due to a primary care
base simultaneous with the hospitals’ constantly active referrals (MHH is complete with helicopter and fixed-wing transport 24/7), patients are
seen in both acute status and in diagnostic dilemma status, with both common and uncommon disorders.

Types of Clinical Encounters – Attending Supervision:
Encounters are inpatient in nature during the Pancreaticobiliary Consultation Service. Fellows provide 24/7 consultative care under the
supervision of an attending within duty hour limits and with faculty back up for situations of overload. Daily attending supervision is available at
both MHH and LBJ seven days per week, and in-house supervision is available all night as well. The attending has ultimate responsibility for
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patients.

Procedures:
During the Pancreaticobiliary Consultation Service, emergency procedures are performed 24/7 within duty hour limits by the fellow with the
attending. Non-emergent procedures are performed during daytime hours in the GI lab by the fellow under the direct supervision of the
attending. Procedure based evaluation is performed twice per year by a supervising attending.

Evaluation:
Fellows are evaluated during all Pancreaticobiliary Service rotations and are expected to participate in the evaluation of other fellows as well.
This occurs in the following forms:
     Detailed, automated evaluations using the GMEIS system are submitted for each rotation. These evaluations are reflective of the program’s
     curriculum requirements. Attendings evaluate fellows, and the fellows evaluate the attendings as well. Quarterly evaluations include:
                o 360-degree (attending, nurse, nurse practitioner, staff/clerical, etc.);
                o Peer-reviewed; and
                o Patient.
     Evaluation summaries become part of the fellows’ and attendings’ promotional documents.
     The fellow also evaluates the Gastroenterology Fellowship Program annually through a confidential basis.
     Attendings evaluate the Gastroenterology Fellowship Program annually.
     A Curriculum Committee oversees major changes to the curriculum. Representative program personnel (i.e., program director,
     representative faculty and at least one fellow) are organized to review program goals and objectives and the effectiveness with which they
     are achieved. This group conducts a formal documented meeting at least annually for this purpose. In the evaluation process, the group
     must take into consideration written comments from the faculty, the most recent report of the GMEC of the sponsoring institution and the
     residents’ confidential written evaluations. If deficiencies are found, the group will prepare an explicit plan of action, which should be
     approved by the faculty and documented in the minutes of the meeting.
     The Program Director meets with all fellows individually twice per year.
     An in-service GTE exam is given to all fellows annually.

Additional Instructions for Fellows Participating in the Pancreaticobiliary Service:

I. Patient Care
     1. Consultations/inpatient admissions: Consultations and inpatient admissions are evaluated by the pancreaticobiliary fellow on service
          on the day they are called in. They are to be written up and presented to the attending on service. Additionally, the attending should
          be notified of any urgent consultations or admissions as soon as possible, particularly if a same-day procedure is anticipated.
     2. Pre-procedure evaluation: The fellow is expected to pre-round on inpatients in the morning prior to beginning the day's procedures. If
          issues arise, the attending on service should be contacted as soon as possible. A pre-review of all outpatients slated for procedures
          that day should similarly be completed. This may be done by reviewing the patients electronic medical record (EMR), DDC/hospital
          chart review and, if appropriate, a phone call to the patient to introduce yourself and gather any further information that may be
          applicable. A thorough patient history, physical exam, and a review of the laboratory and radiologic data should be performed prior to
          ERCP. The history should be obtained sufficiently in advance to permit procedural changes as warranted (e.g., general anesthesia,
          correction of coagulation factors, set-up of sphincter of Oddi manometry, enrollment in an ongoing protocol, etc.). The fellow is
          responsible for entering all pertinent patient data into the ERCP database/report generator prior to and following the procedure. The
          attending physician and the fellow are expected to discuss the case in detail prior to proceeding, so that both are in agreement
          regarding the procedure. All inpatients should be seen daily, and a note should be written prior to attending rounds. Attending rounds
          will be performed daily after all procedures have been completed. All admissions and consultations will be seen on the day they are
          called, with rare exceptions as approved by the attending on service.
     3. Intraoperative: The fellow will assist the attending in performance of the ERCP procedure. The goals for the fellow are to build a solid
          foundation in patient assessment, approach to the procedure, endoscopic technique, and familiarity with accessories (such as wires,
          catheters, stents, etc.) as well as the workings of the ERCP team. The number of "successful cannulations, papillotomies, guide wire
          placements, etc." performed should not, by any means, be considered the ultimate measure of success. These come with time, as
          skills mature. Since the risks of therapeutic ERCP are equal to those of many surgical procedures, factors such as patient care and
          safety must remain paramount. Certain cases (high risk, difficult/prior failed procedure, pediatric, etc.) may be considered attending-
          only cases insofar as the actual performance of the procedure is concerned, and limitation of the fellow’s participation in the case will
          be at the discretion of the attending. However, the observant fellow will learn a great deal in assisting the attending and watching
          vigilantly. Such non-hands-on participation is important to the learning process.
     4. Postoperative:
                a. Inpatients: Postop orders are to be written immediately after the procedure is completed. Pertinent postop data must be
                      entered into the database and a preliminary report generated, signed, and placed on the chart before the patient leaves the
                      GI lab. The attending will be responsible for dictating the procedure note. All inpatients who undergo a procedure must be
                      seen on evening rounds, and a post-procedure check must be documented on the chart. The pancreatico-biliary service will
                      be responsible for ALL aspects of the immediate postoperative management, as occurs on a surgical service. The
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                      pancreatico-biliary fellow on service will keep their pagers on, and will be immediately accessible within pager range, 24
                      hours a day, six days per week, respectively while on service, with no exceptions. On Saturdays, the fellow on-service will
                      round with the GI attending on service. On Sunday, the fellow will sign out to the GI team. On Monday am, the
                      pancreaticobiliary fellow will take report from the GI team for Sunday’s events/admissions. The pancreaticobiliary attending
                      will leave their beepers on 24Hr/7Day to serve as a back-up for the fellow and GI team on weekends for complex cases and
                      for call-ins for emergency procedures.
                b. Outpatients: Outpatient post-procedure follow-up mirrors the inpatient model. The fellow will evaluate each patient in the
                      hospital to assess for post-ERCP complications.
          If the fellow has personal business which would interfere with his/her responsibilities while on service, special coverage arrangements
          must be made in advance with the attending. Fellow cross coverage is acceptable only if the cross-covering fellow has had prior
          experience with ERCP and has been adequately familiarized with the patients on the service. The service fellow will remain
          responsible for assuring that cross-coverage proceeds smoothly.

II. ERCP Database
The ERCP database/report generator exists to assist in patient care follow-up and efficient pre-procedure patient review, to aid in research
activities and to provide the fellow with an automatic, detailed, and running logbook of procedures performed. The database is divided into three
parts: preop assessment, procedure report and follow-up.


III. Research Protocols
Fellows are encouraged to become familiar with existing research protocols, while they are on the pancreaticobiliary service. Fellows are
expected to participate in patient enrollment and in carrying out the steps involved in any procedure-related protocols which apply to procedures
they perform. Any fellow wishing to design studies is encouraged to discuss such ideas with the attendings. Fellows with a particular interest in
pancreaticobiliary gastroenterology are encouraged to discuss the research opportunities available in the pancreatico-biliary section with the
attendings, so that they can develop projects early in the fellowship.

Bibliography:
     Resource Documents
               o Up-To-Date
               o PubMed
               o Textbook of Gastroenterology – Yamada, et.al.
               o Gastrointestinal Disease: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.
               o Major Gastroenterology journals online and in the program’s fellow library including Gastroenterology, American Journal of
                    Gastroenterology, Gut, and other major publications.
               o Gastrointestinal Endoscopy: the Journal of the American Society for Gastrointestinal Endoscopy, the endoscopy journal with
                    the widest circulation throughout the world (monthly).
               o Endoscopy: the Journal of the European Society for Gastrointestinal Endoscopy (monthly).
               o Pancreas: the Journal of the American Pancreatic Association.
               o Gastrointestinal Endoscopy Clinics of North America (quarterly).
               o Annual of Gastrointestinal Endoscopy (annual review of therapeutic endoscopy literature worldwide).
               o Practical Gastrointestinal Endoscopy, by Peter Cotton and Christopher Williams, the classic “beginner’s guide to endoscopy”
                    and a perennial favorite of GI fellows.
     Curricular Design
               o ACGME Outcome Project documentation (from www.acgme.org).
               o Graduate Education in Internal Medicine: A Resource Guide to Curriculum Development
               o The report of the Federated Council for Internal Medicine Task Force on the Internal Medicine Residency Curriculum, 1997.
     Pertinent Teaching References:
               o Textbook of Gastroenterology – Yamada, et.al.
               o Gastrointestinal Disease: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.

                                                           Competencies-at-a-Glance
                                                           Pancreaticobiliary Service
                        COMPETENCY                         LEARNING OPPORTUNITY                             EVALUATION
             Patient Care                                  Work Rounds                               360-global evaluations
                                                           Teaching Rounds                           GTE in-service exam
                                                           Conferences                               Direct Observation

             Medical Knowledge                             Work Rounds                               360-global evaluations
                                                           Teaching Rounds                           GTE in-service exam

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                                                           Conferences
             Practice-Based Learning                       Quarterly M&M Conference                 360-global evaluations
                                                           Work Rounds                              Direct Observation

             Interpersonal Skills                          Work Rounds                              360-global evaluations
             Professionalism                               Work Rounds                              360-global evaluations
                                                           Conferences
             Systems-Based Practice                        Committee Participation                  360-global evaluations
                                                           Grand Rounds (GI & Medical)
                                                           Conferences

The Pancreaticobiliary Service reflects appropriate teaching and evaluation related to all six core competencies. Day-to-day patient care, related
teaching and the curriculum conferences during the rotation are the greatest elements that teach the competencies, and the global evaluation is
the most important single measurement device. In addition to didactic learning, medical center committee participation is encouraged to bolster
system-wide knowledge and practice management understanding.

Revised:
May 2009 Lukens




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                                                      Inpatient GI Consult Rotation
                                                            LBJ General Hospital
                                                      Curriculum for Year I, II & III Fellows

Educational Purpose:
The LBJ rotation comprises several aspects of clinical gastroenterology: consultation on inpatients and, when necessary, endoscopic
procedures. The patient population at LBJ provides opportunities for particularly unique experiences within the gastroenterology fellowship.

In terms of evaluation and management, fellows at LBJ have certain opportunities to fulfill critical components of the gastroenterology curriculum:

Fellows at LBJ evaluate and manage abdominal pain, including acute abdominal pain, nausea and vomiting. There is significant exposure to the
spectrum of both upper and lower gastrointestinal bleeding, including variceal and non-variceal bleeding. The fellows have the opportunity to
evaluate and treat patients with both acute and chronic jaundice, abnormal liver function tests, cirrhosis, and malnutrition.

In particular, the rotation at LBJ gives significant opportunities to learn acid peptic, vascular, and infectious disorders of the gastrointestinal tract.
Fellows are exposed to both alcoholic and gallstone pancreatitis. Fellows also see the spectrum of alcoholic liver disease. There is significant
exposure to HIV involvement of the gastrointestinal tract. It is important to mention that fellow will be participating in the care of a large volume of
Hispanic patients. This will create a valuable exposure to certain gastrointestinal diseases that are more prevalent in this group of patients (i.e.
gallstone disease, gastrointestinal infections and other).

In terms of technical proficiency, LBJ allows the fellows to increase their competency in endoscopy, stricture dilation, gastrostomy feeding tube
placements, esophageal variceal banding, and other methods to control acute gastrointestinal bleeding.

Objectives:
Fellows will learn all aspects of inpatient gastrointestinal care and will display all general competencies during this experience. Minimum levels of
achievement in each competency are expected during each of the three years of fellowship training. Those meeting competency will receive a
score of 5 in the program’s evaluation system. Fellows performing at a level better than expected for that competency receive a score of 6 or 7 in
the evaluation system, those at a level better than most fellows at that PGY receive an 8, and those performing at a level deemed to be “one of
the best fellows ever observed” will receive a score of 9. Fellows receiving a score of 4 or below are deemed deficient in that competency; this
will be brought to the attention of the program director immediately, and, if necessary, remediation will be implemented.

The following are the goals and objectives for each competency at each level of training for the Inpatient GI Consult Service at LBJ Hospital:

                                                                     Year I Fellow:

Goal: A Year I fellow should be able to assess new patient problems, formulate and execute a treatment plan with guidance and teach basic
gastroenterology skills to medical students and other trainees. Year I fellows should begin to develop basic procedural competencies in
diagnostic upper endoscopy and colonoscopy.

Patient Care Objectives:
     Perform an accurate physical examination and present information concisely with an initial assessment plan. Follow the patient’s disease
     course during the patient’s hospital stay. With attending consultation, formulate and execute an impression and a list of recommendations
     for the primary service. When indicated, consent patients for procedures and order appropriate diagnostic tests (e.g., endoscopy, radiologic
     tests, etc.) in conjunction with the primary/referring service.
     Perform with supervision the following basic gastroenterology procedures:
                o Colonoscopy
                                By completion of Year I a fellow should be able to perform a diagnostic colonoscopy to the cecum with limited
                                assistance.
                o EsophagoGastroDuodenoscopy (EGD or Upper Endoscopy)
                                By completion of Year I a fellow should be able to perform a diagnostic endoscopy to the second portion of the
                                duodenum.
     Develop expertise in the diagnosis and management of acute and chronic inpatient gastrointestinal diseases including:
                o Upper & lower GI bleeding
                o Peptic ulcer disease
                o GI infections
                o Ischemic colitis.
                o Abdominal Pain
                o Inflammatory bowel disease

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     Learn to provide inpatient care that is safe and compassionate and to develop the ability to thoroughly and clearly educate the inpatient in
     the relevant areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.

Medical Knowledge Objectives:
    Attend core conferences and teaching rounds to learn the pathophysiology, epidemiology, disease management and procedure and
    medicine management skills for common and uncommon inpatient gastrointestinal diseases including:
              o Upper & lower GI bleeding
              o Peptic ulcer disease
              o GI infections
              o Ischemic colitis
              o Inflammatory bowel disease
    Accumulate and begin to solve the issues that he/she encounters from other trainees, attendings and related medical professionals.
    Teach medical students the basics of gastroenterology and hepatology care.
    Achieve an average percentile score of at least 61.18on the “General” section of the in-service Gastroenterology Training Examination
    (GTE) exam. This score is the national average on this exam for Year I fellows.
    By end of Year I, pass the Internal Medicine Board Examination.

Practice-Based Learning Objectives:
    Become familiar with the concepts of quality improvement.
    Participate in conferences such as M&M, geared to the programmatic review of adverse events.
    Begin to review, analyze and utilize scientific evidence from the gastrointestinal literature for the management of GI patients.
    Learn the best practice patterns to facilitate gastroenterology care through clinic operating procedures and patient interactions.

Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable and
     compassionate manner. Convey bad news compassionately and honestly.
     Learn to communicate effectively with staff, peers, attending gastroenterologists, referring physicians and other consultants.

Professionalism Objectives:
    Learn to understand and demonstrate professional behavior in daily activities.
    Participate in professionalism-based learning activities through conferences.
    Learn to interact collegially with his/her peer group and other healthcare professionals.
    Learn to practice ethical principles with relation to patient care and confidentiality.
    Learn to practice appropriate interactions with pharmaceutical representatives and be unbiased in prescribing habits.
    Learn to be sensitive to cultural, age, gender and disability issues.
    Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues.
    Participate in program planning, including annual Faculty Meeting attendance, Fellow Curriculum Committee participation and Program
    Director meetings when requested.

Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Achieve basic understanding of healthcare systems related to gastroenterology care and overall system activities.
    Learn proper documentation and billing skills to practice cost-effective care.
    Utilize an appropriate range of healthcare professionals to care for patients, working closely with socials services to maximize patient care
    and understanding the role of hospice, referring appropriately when needed.
    Begin involvement to understand the standard operating procedures and quality improvement initiatives within the hospital.
    Attend national gastroenterology conferences (e.g., ACG and endoscopy training courses).



                                                                     Year II Fellow:

Goal: A Year II fellow should learn to assess and care for a larger volume of patients and learn and teach basic textbook and evidence-based
medicine to medical students and other trainees. Year II fellows should independently perform diagnostic upper endoscopy and colonoscopy
and begin to perform therapeutic maneuvers.

Patient Care Objectives:
     Complete a time-efficient history and physical examination.
     Critique the work and orders of Year I fellows.
     Direct the Year I fellows successfully with the appropriate level of intervention for each trainee’s skills.
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    Complete competency-level performance of the following basic gastroenterology procedures:
              o Colonoscopy
                             By completion of Year II, master all Year I colonoscopic skill requirements. Additionally, perform endoscopic
                             maneuvers, including snare polypectomy and begin to develop competency in control of GI bleeding: sclerotherapy
                             and thermal coagulopathy of bleeding vessels.
              o Upper Endoscopy
                             By completion of Year II, master all Year I upper endoscopic skill requirements. Additionally, begin to develop
                             competency in performing therapeutic maneuvers: banding and sclerosing of varices, and sclerotherapy and
                             thermal coagulopathy of bleeding vessels.
    Develop clear expertise in the diagnosis and management of acute and chronic inpatient gastrointestinal diseases including:
              o Neuroendocrine diagnosis
              o Intestinal/colonic pseudobstruction
              o Secretory diarrheal states
              o Idiopathic abdominal pain
              o Upper & lower GI bleeding
              o Peptic ulcer disease
              o Inflammatory bowel disease
              o GI infections
              o Pancreatitis
              o Ischemic colitis
    Present cases succinctly in a direct manner.
    Know the GI Hospital Service’s patients at a management level.
    Handle consult calls respectfully and appropriately.
    Teach good symptom management skills to medical students and other trainees.
    Provide inpatient care that is safe and compassionate and develop the ability to thoroughly and clearly educate the inpatient in the relevant
    areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.

Medical Knowledge Objectives:
    Begin to take a leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease
    management and procedures and medicine management skills for common and uncommon inpatient gastrointestinal diseases including:
              o Neuroendocrine diagnosis
              o Intestinal/colonic pseudobstruction
              o Secretory diarrheal states
              o Idiopathic abdominal pain
              o Upper & lower GI bleeding
              o Peptic ulcer disease
              o Inflammatory bowel disease
              o GI infections
              o Pancreatitis
              o Ischemic colitis
    Organize the team’s performance at teaching rounds.
    Read textbook and pertinent literature materials concerning problems encountered.
    Teach medical students and other trainees about GI disease states and patient management.
    Achieve an average percentile score of at least 62.98 on the “General” section of the in-service Gastroenterology Training Examination
    (GTE) exam. This score is the national average on this exam for Year II fellows.

Practice-Based Learning Objectives:
    Participate in project groups, committees and hospital groups when requested.
    Participate in programmatic reviews and conferences studying adverse events.
    Give usable feedback to medical students and other trainees based on observation of their performance and assess improvement.
    Participate in problem-based quality improvement projects.
    Review, analyze and utilize scientific evidence from the gastrointestinal literature for the management of GI patients.
    Know the best practice patterns to facilitate gastroenterology care through clinic operating procedures and patient interactions.


Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner.
     Convey bad news compassionately and honestly.
     Plan patient and family conferences.
     Counsel patients about transitioning to palliative care, when needed.
50 | P a g e
     Address or refer patients related to spiritual or existential issues.
     Communicate effectively with staff, peers, attending gastroenterologists, referring physicians and other consultants.
     Present cases succinctly, in a problem-based, direct manner.
     Learn to become a teacher of gastroenterology to junior trainees, medical students and other healthcare professionals.

Professionalism Objectives:
    Begin to mentor medical students, other trainees and Year I fellows in professional conduct.
    Understand and demonstrate professional behavior in daily activities.
    Participate in professionalism-based learning activities through conferences.
    Interact collegially with his/her peer group and other healthcare professionals, including acting responsibly in the larger context of pursuing
    programmatic successes.
    Practice ethical principles with relation to patient care and confidentiality.
    Practice interactions with pharmaceutical representatives and be unbiased in prescribing habits.
    Practice sensitivity to cultural, age, gender and disability issues.
    Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues.
    Participate in program planning, including annual Faculty Meeting attendance, Fellow Curriculum Committee participation and Program
    Director meetings, when requested.

Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Understand and practice proper documentation and billing skills to practice cost-effective care.
    Assist other trainees in the utilization of appropriate healthcare resources for the best care of the GI Hospital Service’s patients.
    Model appropriate interactions in multidisciplinary planning, including standard operating procedures and quality improvement initiatives.
    Attend national gastroenterology or hepatology conferences (e.g., DDW or AASLD).

                                                                  Year III Fellows:

Goal: The senior-level, Year III fellow should demonstrate rapid assessment and planning skills and near-attending level care planning and
management, while teaching medical students and other trainees at near to or exceeding attending level teaching. Year III fellows should be
able to perform diagnostic and therapeutic upper endoscopy and colonoscopy procedures independently.

Patient Care Objectives:
     Master the Year II fellow objectives.
     Demonstrate efficient organization of the GI Hospital Service and a working knowledge of all patients.
     Demonstrate near-attending level capacity for program assessment and care planning.
     Attain trainer level proficiency in the following gastroenterology procedures pertinent to his/her career choices:
                o Colonoscopy
                                 By completion of Year III, master all Year II colonoscopic skill requirements. Additionally, be able to independently
                                 intubate the terminal ileum and begin to develop independent mastery of more advanced maneuvers, e.g., removal
                                 of large or complex polyps by saline assisted polypectomy or piecemeal resection and control of bleeding using
                                 clips or argon plasma laser coagulation.
                o Upper Endoscopy
                                 By completion of Year III, master all Year II endoscopic skill requirements. Additionally, be able to pass a side
                                 viewing scope to identify the papilla or lesions difficult to observe with forward viewing scope and perform
                                 advanced maneuvers, such as placing clips on bleeding vessels or argon plasma laser coagulopathy.
     Secure expertise in the diagnosis and management of acute and chronic inpatient gastrointestinal diseases including:
                o Neuroendocrine diagnosis
                o Intestinal/colonic pseudobstruction
                o Secretory diarrheal states
                o Idiopathic abdominal pain
                o Upper & lower GI bleeding
                o Peptic ulcer disease
                o Inflammatory bowel disease
                o GI infections
                o Pancreatitis
                o Ischemic colitis
     Provide inpatient care that is safe and compassionate with the leadership ability to thoroughly and clearly educate the inpatient and all other
     trainees regarding relevant areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.

Medical Knowledge Objectives:
51 | P a g e
     Access and critique the medical literature regarding gastroenterology and hepatology problems encountered.
     Assume the trainee leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease
     management, procedures and medicine management skills for common and uncommon inpatient gastrointestinal diseases including
               o Neuroendocrine diagnosis
               o Intestinal/colonic pseudobstruction
               o Secretory diarrheal states
               o Idiopathic abdominal pain
               o Upper & lower GI bleeding
               o Peptic ulcer disease
               o Inflammatory bowel disease
               o GI infections
               o Pancreatitis
               o Ischemic colitis
     Teach medical students, other trainees and Year I & II fellows at near-attending level.
     Prepare for the ABIM certifying exam throughout the year.
     Organize team activities in a smooth and authoritative fashion.
     Assist Year II fellows’ development directly at teaching conferences and indirectly at work sites.
     Achieve an average percentile score of at least 64.07 on the “General” section of the in-service Gastroenterology Training Examination
     (GTE) exam. This score is the national average on this exam for Year III fellows.

Practice-Based Learning Objectives:
    Demonstrate mastery of Year II fellow skills and encourage participation of colleagues.
    Review, analyze and utilize scientific evidence from the gastrointestinal literature for the management of GI patients, taking a leadership role
    in guiding Year I & II fellows and sharing relevant literature reviews with them.
    Know and be able to succinctly communicate the best practice patterns to facilitate gastroenterology care through clinic operating
    procedures and patient interactions.

Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner.
     Convey bad news compassionately and honestly.
     Supervise Year I & II fellows’ work related to planning patient/family conferences and patient communications/counseling.
     Communicate effectively as a consultant with staff, peers, attending gastroenterologists, referring physicians and other consultants and lead
     other trainees related to appropriate fellow-to-medical-professional communications.
     Present cases succinctly, in a problem-based, direct manner.
     Assume the role of a teacher of gastroenterology to junior trainees, medical students and other healthcare professionals.

Professionalism Objectives:
    Demonstrate proficiency in Year II objectives.
    Mentor medical students, other trainees and Year I fellows in professional conduct.
    Assist in formal teaching exercises as requested.
    Assert leadership in program planning, including fellow participation in the annual Faculty/Fellow Meeting, Fellow Curriculum Committee and
    Conference Planning Committees.

Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Model appropriate interactions in multidisciplinary planning, including improvements related to standard operating procedures and quality
    improvement initiatives.
    Participate in hospital and national medical association committees and multidisciplinary planning groups when requested.
    Attend national conferences directed at career goals.
    Demonstrate near-attending level utilization of overall systems of care.

Teaching Methods:
Gastroenterology fellows participate in Inpatient GI Consult Service at LBJ Hospital during all three fellowship years. One fellow is assigned to
the GI Hospital Service during all rotations. Teaching of medical students, residents and other trainees as well as appropriate interactions with
other healthcare providers are important aspects of this rotation. Participating in all required conferences is mandatory, and rounding is an
integral part of this experience. As fellows gain experience throughout their training, skills of organization and efficiency as well as team
leadership become increasingly important.

The GI Consult Service experience will prepare the fellow to evaluate and manage acute and chronic gastrointestinal illnesses that will be
encountered in the fellow’s future practice. This rotation will expose the fellow to a wide variety of acute abdominal inflammatory processes,
52 | P a g e
major gastrointestinal hemorrhages, and a wide variety of gastrointestinal problems.

Fellows assigned to this service will evaluate all new consults at LBJ General Hospital and will be assigned to a continuity clinic one-half day per
week. They will present new consults to the attending by the following day for routine consults and as soon as possible for emergencies.
Fellows will evaluate each patient and will make initial recommendations regarding diagnostic tests and treatments. They will make
arrangements for studies such as endoscopy, motility tests, biopsies, etc. They will review the appropriateness of the procedure with the
attending before making final scheduling plans. The fellow will follow each patient under active consultation on a regular basis, will make further
recommendations as indicated and will keep the attending informed of the patient’s status. Fellows must also communicate with the procedure
fellow for all diagnostic studies.

Disease Mix:
Fellows see a complete mix of gastrointestinal diseases and conditions at the GI Hospital Service’s teaching hospital. LBJ General Hospital has
a substantial primary care basis, which provides the entire spectrum of internal medicine diagnoses and gastrointestinal care.

Diagnoses range from pancreatitis, inflammatory bowel disease, and functional GI motility and pain disorders to primary and secondary
gastrointestinal malignancies, and there is an appropriate concentration of common gastrointestinal diseases such as peptic ulcer disease,
gastroesophageal reflux disease and gastrointestinal infections. In particular, the fellow will be participating in the care of a large volume of
Hispanic patients. This will create a valuable exposure to certain gastrointestinal diseases that are more prevalent in this group of patients (i.e.
gallstone disease, gastrointestinal infections and other

Patient Characteristics:
LBJ General Hospital offers a diverse mix of socioeconomic and gender status. This Hospital provides care to a vast number of patients that are
part of certain minority population of our city district. This includes Hispanics, Asians and others. This is a unique opportunity that is being given
to our fellows since they can be involved in the management of certain gastrointestinal diseases that are highly prevalent is some of these
minorities. An example of this would be gallstone disease and vital hepatitis.

Types of Clinical Encounters – Attending Supervision:
Encounters are inpatient in nature during the GI consult Service. Fellows provide 24/7 consultative care under the supervision of an attending
within duty hour limits and with faculty back up for situations of overload. Daily attending supervision is available at LBJ General Hospital seven
days per week, and in-house supervision is available all night as well. The attending has ultimate responsibility for patients.

Procedures:
During the GI Consult Service, emergency procedures (e.g. for gastrointestinal bleeding) are performed 24/7 within duty hour limits by the fellow
with the attending. Non-emergent procedures are performed during daytime hours in the GI lab by the fellow under the direct supervision of the
attending. Procedure based evaluation is performed twice per year by a supervising attending.

Evaluation:
Fellows are evaluated during all GI Consult Service rotations and are expected to participate in the evaluation of other fellows as well. This
occurs in the following forms:
     Detailed, automated evaluations using the GMEIS system are submitted for each rotation. These evaluations are reflective of the program’s
     curriculum requirements. Attendings evaluate fellows, and the fellows evaluate the attending as well. Evaluations include:
                o 360-degree (attending, nurse, nurse practitioner, staff/clerical, etc.);
                o Direct observation
                o Peer-reviewed; and
                o Patient.
     Evaluation summaries become part of the fellows’ and attendings’ promotional documents.
     The fellow also evaluates the Gastroenterology Fellowship Program annually through a confidential basis.
     Attendings evaluate the Gastroenterology Fellowship Program annually.
     A Curriculum Committee oversees major changes to the curriculum. Representative program personnel (i.e., program director,
     representative faculty and at least one fellow) must be organized to review program goals and objectives and the effectiveness with which
     they are achieved. This group must conduct a formal documented meeting at least annually for this purpose. In the evaluation process, the
     group must take into consideration written comments from the faculty, the most recent report of the GMEC of the sponsoring institution and
     the residents’ confidential written evaluations. If deficiencies are found, the group will prepare an explicit plan of action, which should be
     approved by the faculty and documented in the minutes of the meeting.
     The Program Director meets with all fellows individually twice per year.
     An in-service GTE exam is given to all fellows annually.

Bibliography:
     Resource Documents
              o Up-To-Date
53 | P a g e
               o    PubMed
               o    Textbook of Gastroenterology – Yamada, et.al.
               o    Gastrointestinal Diasese: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.
               o    Major Gastroenterology journals online and in the program’s fellow library including Gastroenterology, American Journal of
                    Gastroenterolgy, Gut, and other major publications.
     Curricular Design
               o ACGME Outcome Project documentation (from www.acgme.org).
               o Graduate Education in Internal Medicine: A Resource Guide to Curriculum Development
               o The report of the Federated Council for Internal Medicine Task Force on the Internal Medicine Residency Curriculum, 1997.
     Pertinent Teaching References:
               o Textbook of Gastroenterology – Yamada, et.al.
               o Gastrointestinal Diasese: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.

                                                          Competencies-at-a-Glance
                                                             GI Consult Service

                      COMPETENCY                          LEARNING OPPORTUNITY                            EVALUATION
             Patient Care                                  Work Rounds                               360-global evaluations
                                                           Teaching Rounds                           GTE in-service exam
                                                           Conferences                               Direct Observation

             Medical Knowledge                              Work Rounds                              360-global evaluations
                                                            Teaching Rounds                          GTE in-service exam
                                                            Conferences
             Practice-Based Learning                        Quarterly M&M Conference                 360-global evaluations
                                                            Work Rounds                              Direct Observation

             Interpersonal Skills                           Work Rounds                              360-global evaluations
             Professionalism                                Work Rounds                              360-global evaluations
                                                            Conferences
             Systems-Based Practice                         Committee Participation                  360-global evaluations
                                                            Grand Rounds (GI & Medical)
                                                            Conferences
The Inpatient GI Consult l Service at LBJ Hospital is the core fellow rotation related to the teaching and evaluation of all six competencies. Day-
to-day patient care, related teaching and the curriculum conferences during the rotation are the greatest elements that teach the competencies,
and the global evaluation (provided for each rotation) is the most important single measurement device. In addition to didactic learning, medical
center committee participation is encouraged to bolster system-wide knowledge and practice management understanding.

Revised
May 09 Frank Lukens




54 | P a g e
                                                    GI Procedure Rotation
                                                   At LBJ General Hospital
                                             Curriculum for Year I, II & III Fellows

Educational Purpose:
The Procedure Rotation at LBJ General Hospital introduces the fellow to inpatient and outpatient gastroenterology procedures and management
of patients in need of these procedures. During this period, the fellow will have the opportunity to perform a wide variety of GI procedures with
appropriate supervision. The fellow will participate in increasing levels of procedure activities, depending on the fellow’s level of experience. The
fellow will be expected to conduct appropriate patient communications, perform the procedure, make post-procedure recommendations and
document the procedure. The amount of learning obtained from this rotation is directly proportional to the amount of time spent conducting
procedures and conferring with supervising attendings.

Objectives:
Fellows will learn all aspects of procedure performance and will display all general competencies during this experience. Minimum levels of
achievement in each competency are expected during each of the three years of fellowship training. Those meeting competency will receive a
score of 5 in the program’s evaluation system. Fellows performing at a level better than expected for that competency receive a score of 6 or 7 in
the evaluation system, those at a level better than most fellows at that PGY receive an 8, and those performing at a level deemed to be “one of
the best fellows ever observed” will receive a score of 9. Fellows receiving a score of 4 or below are deemed deficient in that competency; this
will be brought to the attention of the program director immediately, and, if necessary, remediation will be implemented.

The following are the goals and objectives for each competency at each level of training for the GI Procedure Service:


                                                                   Year I Fellow:

Goal: Year I fellows should begin to develop basic procedural competencies in diagnostic upper endoscopy and colonoscopy.

Patient Care Objectives:
     Perform an accurate physical examination and present information concisely with an initial assessment plan prior any endoscopic
     intervention. With attending consultation, formulate and execute an impression and a list of recommendations for the primary service after
     the procedure has been carried out. He will consent patients for procedures and order appropriate diagnostic tests (e.g., endoscopy,
     radiologic tests, etc.) in conjunction with the primary/referring service when needed.
     Perform with supervision the following basic gastroenterology procedures :

               o    Colonoscopy
                               By completion of Year I a fellow should be able to perform a diagnostic colonoscopy to the cecum with limited
                               assistance.
               o EsophagoGastroDuodenoscopy (EGD or Upper Endoscopy)
                               By completion of Year I a fellow should be able to perform a diagnostic endoscopy to the second portion of the
                               duodenum.
     Develop expertise in the diagnosis and management of acute and chronic inpatient gastrointestinal diseases that need endoscopic
     evaluations as part of the initial work-up including:
               o Upper & lower GI bleeding
               o Peptic ulcer disease
               o GI infections
               o Ischemic colitis
               o Abdominal pain
     Learn to provide inpatient care that is safe and compassionate and to develop the ability to thoroughly and clearly educate the inpatient in
     the relevant areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.

Medical Knowledge Objectives:
    Attend core conferences and teaching rounds to learn the pathophysiology, epidemiology, disease management and procedure and
    medicine management skills for common and uncommon inpatient gastrointestinal diseases including:
              o Upper & lower GI bleeding
              o Peptic ulcer disease
              o GI infections
              o Ischemic colitis
              o Abdominal pain.

55 | P a g e
     By end of Year I, pass the Internal Medicine Board Examination.

     Read textbook and pertinent literature materials concerning procedure problems encountered and start to develop a teaching role with
     medical students and other trainees about general GI procedures.

Practice-Based Learning Objectives:
    Become familiar with the concepts of quality improvement.
    Participate in conferences such as M&M, geared to the programmatic review of adverse events.
    Begin to review, analyze and utilize scientific evidence from the gastrointestinal literature for the management of GI patients.
    Learn the best practice patterns to facilitate gastroenterology care through clinic operating procedures and patient interactions.

Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable and
     compassionate manner. Convey bad news compassionately and honestly.
     Learn to communicate effectively with staff, peers, attending gastroenterologists, referring physicians and other consultants.

Professionalism Objectives:
    Learn to understand and demonstrate professional behavior in daily activities.
    Participate in professionalism-based learning activities through conferences.
    Learn to interact collegially with his/her peer group and other healthcare professionals.
    Learn to practice ethical principles with relation to patient care and confidentiality.
    Learn to be sensitive to cultural, age, gender and disability issues.
    Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues.
    Participate in program planning, including annual Faculty Meeting attendance, Fellow Curriculum Committee participation and Program
    Director meetings when requested.

Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Achieve basic understanding of healthcare systems related to gastroenterology care and overall system activities.
    Learn proper documentation and billing skills to practice cost-effective care.
    Utilize an appropriate range of healthcare professionals to care for patients, working closely with socials services to maximize patient care
    and understanding the role of hospice, referring appropriately when needed.
    Begin involvement to understand the standard operating procedures and quality improvement initiatives within the hospital.
    Attend national gastroenterology conferences (e.g.,endoscopy training courses).



                                                                  Year II Fellow:

Goal: A Year II fellow should learn to assess and care for a large volume of patients. Year II fellows should independently perform diagnostic
upper endoscopy and colonoscopy and begin to perform therapeutic maneuvers.

Patient Care Objectives:
     Complete a time-efficient history and physical examination.
     Critique the work and orders of Year I fellows.
     Direct the Year I fellows successfully with the appropriate level of intervention for each trainee’s skills.
     Complete competency-level performance of the following basic gastroenterology procedures :
                o Colonoscopy
                               By completion of Year II, master all Year I colonoscopic skill requirements. Additionally, perform endoscopic
                               maneuvers, including snare polypectomy and begin to develop competency in control of GI bleeding: sclerotherapy
                               and thermal coagulopathy of bleeding vessels.
                o Upper Endoscopy
                               By completion of Year II, master all Year I upper endoscopic skill requirements. Additionally, begin to develop
                               competency in performing therapeutic maneuvers: banding and sclerosing of varices, and sclerotherapy and
                               thermal coagulopathy of bleeding vessels.
     Present cases succinctly in a direct manner.
     Know Procedure Service patients at a management level.
     Handle consult calls respectfully and appropriately.
     Teach good procedure and symptom management skills to medical students and other trainees.

56 | P a g e
     Provide GI procedure care that is safe and compassionate and develop the ability to thoroughly and clearly educate the patient in the
     relevant areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.

Medical Knowledge Objectives:
    Begin to take a leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease
    management and procedures and medicine management skills for common and uncommon inpatient gastrointestinal diseases including:
              o Neuroendocrine diagnosis
              o Intestinal/colonic pseudobstruction
              o Secretory diarrheal states
              o Idiopathic abdominal pain
              o Upper & lower GI bleeding
              o Peptic ulcer disease
              o Inflammatory bowel disease
              o GI infections
              o Pancreatitis
              o Ischemic colitis
    Organize the team’s performance during procedure rounds.
    Read textbook and pertinent literature materials concerning procedure problems encountered.
    Teach medical students and other trainees about GI procedures and patient management.

Practice-Based Learning Objectives:
    Participate in project groups, committees and hospital groups when requested.
    Participate in programmatic reviews and conferences studying adverse procedure events.
    Give usable feedback to medical students and other trainees based on observation of their performance and assess improvement.
    Participate in problem-based quality improvement projects.
    Review, analyze and utilize scientific evidence from the gastrointestinal literature for the management of GI patients and the utilization of GI
    procedures.
    Know the best practice patterns to facilitate gastroenterology procedure care through GI la operating procedures and patient interactions.

Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner.
     Convey bad news compassionately and honestly.
     Plan patient and family conferences.
     Counsel patients about transitioning to palliative care, when needed.
     Address or refer patients related to spiritual or existential issues.
     Communicate effectively with staff, peers, attending gastroenterologists, referring physicians and other consultants.
     Present cases succinctly, in a problem-based, direct manner.
     Learn to become a teacher of gastroenterology procedures to junior trainees, medical students and other healthcare professionals.

Professionalism Objectives:
    Begin to mentor medical students, other trainees and Year I fellows in professional conduct.
    Understand and demonstrate professional behavior in daily activities.
    Participate in professionalism-based learning activities through conferences.
    Interact collegially with his/her peer group and other healthcare professionals, including acting responsibly in the larger context of pursuing
    programmatic successes.
    Practice ethical principles with relation to patient care and confidentiality.
    Practice interactions with pharmaceutical and medical equipment representatives and be unbiased in prescribing and procedure habits.
    Practice sensitivity to cultural, age, gender and disability issues.
    Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues.
    Participate in program planning, including annual Faculty Meeting attendance, Fellow Curriculum Committee participation and Program
    Director meetings, when requested.

Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Understand and practice proper documentation and billing skills to practice cost-effective care.
    Assist other trainees in the utilization of appropriate healthcare resources for the best care of the GI Hospital Service’s patients.
    Model appropriate interactions in multidisciplinary planning, including standard operating procedures and quality improvement initiatives.
    Attend national gastroenterology or hepatology conferences (e.g., DDW or AASLD).

                                                                 Year III Fellows:
57 | P a g e
Goal: The senior-level, Year III fellow should demonstrate rapid assessment and planning skills and near-attending level care planning and
management, while teaching medical students and other trainees at near to or exceeding attending level teaching. Year III fellows should be
able to perform diagnostic and therapeutic upper endoscopy and colonoscopy procedures independently.

Patient Care Objectives:
     Master the Year II fellow objectives.
     Demonstrate efficient organization of the Procedure Service and a working knowledge of all patients.
     Demonstrate near-attending level capacity for program assessment and care planning.
     Attain trainer level proficiency in the following gastroenterology procedures pertinent to his/her career choices:
                o Colonoscopy
                                 By completion of Year III, master all Year II colonoscopic skill requirements. Additionally, be able to independently
                                 intubate the terminal ileum and begin to develop independent mastery of more advanced maneuvers, e.g., removal
                                 of large or complex polyps by saline assisted polypectomy or piecemeal resection and control of bleeding using
                                 clips or argon plasma laser coagulation.
                o Upper Endoscopy
                                 By completion of Year III, master all Year II endoscopic skill requirements. Additionally, be able to pass a side
                                 viewing scope to identify the papilla or lesions difficult to observe with forward viewing scope and perform
                                 advanced maneuvers, such as placing clips on bleeding vessels or argon plasma laser coagulopathy.
     Provide gastroenterology procedure care that is safe and compassionate with the leadership ability to thoroughly and clearly educate the
     inpatient and all other trainees regarding relevant areas of disease prevention, detection, progression, procedure activities and therapy to
     promote gastrointestinal health.

Medical Knowledge Objectives:
    Access and critique the medical literature regarding gastroenterology and hepatology procedure problems encountered.
    Assume the trainee leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease
    management, procedures and medicine management skills for common and uncommon inpatient gastrointestinal diseases including
              o Neuroendocrine diagnosis
              o Intestinal/colonic pseudobstruction
              o Secretory diarrheal states
              o Idiopathic abdominal pain
              o Upper & lower GI bleeding
              o Peptic ulcer disease
              o Inflammatory bowel disease
              o GI infections
              o Pancreatitis
              o Ischemic colitis
    Teach medical students, other trainees and Year I & II fellows at near-attending level.
    Prepare for the ABIM certifying exam throughout the year.
    Organize procedure team activities in a smooth and authoritative fashion.
    Assist Year II fellows’ development directly at teaching conferences and indirectly at work sites.

Practice-Based Learning Objectives:
    Demonstrate mastery of Year II fellow skills and encourage participation of colleagues.
    Review, analyze and utilize scientific evidence from the gastrointestinal literature for the procedure management of GI patients, taking a
    leadership role in guiding Year I & II fellows and sharing relevant literature reviews with them.
    Know and be able to succinctly communicate the best practice patterns to facilitate gastroenterology procedure care through GI lab
    operating procedures and patient interactions.

Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner.
     Convey bad news compassionately and honestly.
     Supervise Year I & II fellows’ work related to planning patient/family conferences and patient communications/counseling.
     Communicate effectively as a consultant with staff, peers, attending gastroenterologists, referring physicians and other consultants and lead
     other trainees related to appropriate fellow-to-medical-professional communications.
     Present procedure cases succinctly, in a problem-based, direct manner.
     Assume the role of a teacher of gastroenterology procedures to junior trainees, medical students and other healthcare professionals.

Professionalism Objectives:
    Demonstrate proficiency in Year II objectives.
58 | P a g e
     Mentor medical students, other trainees and Year I fellows in professional GI procedure conduct.
     Assist in formal teaching exercises as requested.
     Assert leadership in program planning, including fellow participation in the annual Faculty/Fellow Meeting, Fellow Curriculum Committee and
     Conference Planning Committees.

Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Model appropriate interactions in multidisciplinary planning, including improvements related to standard operating procedures and quality
    improvement initiatives.
    Participate in hospital and national medical association committees and multidisciplinary planning groups when requested.
    Attend national conferences directed at career goals.
    Demonstrate near-attending level utilization of overall systems of care.

Teaching Methods:
Each fellow will have at least one procedure block during the three years of fellowship. Only one fellow is assigned to the GI Procedure Service.
 The Procedure Service experience will prepare the fellow to diagnosis and manage acute and chronic gastrointestinal illnesses that will be
encountered in the fellow’s future practice. This rotation will expose the fellow to a wide variety of acute abdominal inflammatory processes,
major gastrointestinal hemorrhages, oncological emergencies and a wide variety of gastrointestinal problems.

Since endoscopic procedures are integral to the gastroenterology profession, this month should serve as a time to hone skills and work on
specific procedures that may be difficult to master during the inpatient months (e.g., polypectomy, esophageal dilation, etc.). The procedure
month should be viewed as supplemental to the inpatient endoscopies and outpatient procedures performed with the fellow’s clinic attending.

Participating in all required conferences is mandatory. As fellows gain experience throughout their training, skills or organization and efficiency
as well as team leadership become increasingly important.

During the procedure block the fellow should make an effort to work with as many different attendings as possible. The fellow should keep a log
of procedures performed during the month.

The fellow will evaluate each patient and will make initial recommendations regarding diagnostic tests and treatments. He/she will make
arrangements for studies such as endoscopy, motility tests, biopsies, etc. The fellow will review the appropriateness of the procedure with the
attending before making final procedure plans. The fellow should gain experience with upper endoscopy and colonoscopy with biopsies,
polypectomy and esophageal dilations during the procedure rotation.

Disease Mix:
Fellows see a complete mix of gastrointestinal diseases and conditions at the Procedure Service at LBJ General Hospital. This hospital
operates with a substantial primary care basis, which provides the entire spectrum of internal medicine diagnoses and gastrointestinal care.

Diagnoses range from pancreatitis, inflammatory bowel disease, and functional GI motility and pain disorders to primary and secondary
gastrointestinal malignancies, and there is an appropriate concentration of common gastrointestinal diseases such as peptic ulcer disease,
gastroesophageal reflux disease and gastrointestinal infections


Patient Characteristics:
LBJ General Hospital offers a diverse mixes of socioeconomic and gender status.

Types of Clinical Encounters – Attending Supervision:
Encounters are both inpatient and outpatient in nature during the Procedure Service. Fellows provide 24/7 consultative care under the
supervision of an attending within duty hour limits and with faculty back up for situations of overload. Daily attending supervision is available
seven days per week, and in-house supervision is available all night as well. The attending has ultimate responsibility for patients.

Procedures:
During the Procedure Service, emergency procedures (e.g. for gastrointestinal bleeding) are performed 24/7 within duty hour limits by the fellow
with the attending. Non-emergent procedures are performed during daytime hours in the GI lab by the fellow under the direct supervision of the
attending. Procedure based evaluation is performed twice per year by a supervising attending (see procedure practicum: direct observation).

Evaluation:
Fellows are evaluated during all Procedure Service rotations and are expected to participate in the evaluation of other fellows as well. This
occurs in the following forms:

59 | P a g e
    Detailed, automated evaluations using the GMEIS system are submitted for each rotation. These evaluations are reflective of the program’s
    curriculum requirements. Attendings evaluate fellows, and the fellows evaluate the attending as well. Quarterly evaluations include:
              o 360-degree (attending, nurse, nurse practitioner, staff/clerical, etc.);
              o Peer-reviewed; and
              o Patient.
    Evaluation summaries become part of the fellows’ and attendings’ promotional documents.
    Fellows self-evaluate through their e-portfolio participation/communication with mentors and colleagues and through document
    maintenance.
    The fellow also evaluates the Gastroenterology Fellowship Program annually through a confidential basis.
    Attendings evaluate the Gastroenterology Fellowship Program annually.
    A Curriculum Committee oversees major changes to the curriculum. Representative program personnel (i.e., program director,
    representative faculty and at least one fellow) must be organized to review program goals and objectives and the effectiveness with which
    they are achieved. This group must conduct a formal documented meeting at least annually for this purpose. In the evaluation process, the
    group must take into consideration written comments from the faculty, the most recent report of the GMEC of the sponsoring institution and
    the residents’ confidential written evaluations. If deficiencies are found, the group will prepare an explicit plan of action, which should be
    approved by the faculty and documented in the minutes of the meeting.
    The Program Director meets with all fellows individually twice per year.
    An in-service GTE exam is given to all fellows annually.


Bibliography:
     Resource Documents
               o Appropriate use of Gastrointestinal Endoscopy in Gastrointestinal Endoscopy. 52(6), 2000.
               o Complications of colonoscopy in Gastrointestinal Endoscopy. 57(4), 2003.
               o Complications of Upper GI Endoscopy in Gastrointestinal Endoscopy. 55(7), 2002.
               o Visit the Practice Guidelines section of the ASGE website > http://www.asge.org/PublicationsProductsindex.aspx?id=352
     Curricular Design
               o ACGME Outcome Project documentation (from www.acgme.org).
               o Graduate Education in Internal Medicine: A Resource Guide to Curriculum Development
               o The report of the Federated Council for Internal Medicine Task Force on the Internal Medicine Residency Curriculum, 1997.
     Pertinent Teaching References:
               o Textbook of Gastroenterology – Yamada, et.al.
               o Gastrointestinal Diasese: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.




                                                          Competencies-at-a-Glance
                                                           GI LBJ Hospital Rotation

                       COMPETENCY                         LEARNING OPPORTUNITY                            EVALUATION
            Patient Care                                  Work Rounds                              360-global evaluations
                                                          Teaching Rounds                          GTE in-service exam
                                                          Conferences                              Direct Observation

            Medical Knowledge                             Work Rounds                              360-global evaluations
                                                          Teaching Rounds                          GTE in-service exam
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                                                         Conferences
            Practice-Based Learning                      Quarterly M&M Conference                 360-global evaluations
                                                         Work Rounds                              Direct Observation

            Interpersonal Skills                         Work Rounds                              360-global evaluations
            Professionalism                              Work Rounds                              360-global evaluations
                                                         Conferences
            Systems-Based Practice                       Committee Participation                  360-global evaluations
                                                         Grand Rounds (GI & Medical)
                                                         Conferences

Procedure care, related teaching and the curriculum conferences during the rotation are the greatest elements that teach the competencies, and
the global evaluation (provided for each rotation) is the most important single measurement device. In addition to didactic learning, medical
center committee participation is encouraged to bolster system-wide knowledge and practice management understanding.

Revised
May 09 Frank Lukens




61 | P a g e
                                      Gastroenterology PancreaticoBiliary Consultation Rotation (PBS)
                                             Memorial Hermann Hospital Texas Medical Center
                                                                    &
                                                HCHD: Lyndon B. Johnson General Hospital
                                                      Curriculum for PGY 4, 5 and 6


                                                       Curriculum for Year II & III Fellows

Educational Purpose:
The Pancreaticobiliary Service at both MHH and LBJ introduces the fellow to inpatient management of patients with pancreas and biliary
diseases. During this period, the fellow will have the opportunity to assess a wide variety of acute and chronic pancreaticobiliary conditions. As
such, there will be an introduction to ERCP, but, for advanced training, fellows will require a fourth year. Additionally, a faculty committee will
decide if certain fellows merit more intensive ERCP training during the three year fellowship. These fellows will be selected by the faculty.
Pancreaticobiliary Consultation Service (PBS) fellows will participate in increasing levels of management/ treatment involvement with patient
needs and procedures, depending on the fellow’s level of experience. The fellow will be expected to formulate the differential diagnosis, institute
diagnostic studies and recommend therapy. The amount of learning obtained from this rotation is directly proportional to the amount of time
spent in the evaluation of the patients.

Objectives:
Fellows will learn all aspects of pancreas and biliary disease care and will display all general competencies during this experience. Minimum
levels of achievement in each competency are expected during Years II and III of training, when fellows may participate in the Pancreaticobiliary
Consultation Service. Those meeting competency will receive a score of 5 in the program’s evaluation system. Fellows performing at a level
better than expected for that competency receive a score of 6 or 7 in the evaluation system, those at a level better than most fellows at that PGY
receive an 8, and those performing at a level deemed to be “one of the best fellows ever observed” will receive a score of 9. Fellows receiving a
score of 4 or below are deemed deficient in that competency; this will be brought to the attention of the program director immediately, and, if
necessary, remediation will be implemented.

The following are the goals and objectives for each competency at each level of training for the Pancreaticobiliary Service:

                                                                  Year II Fellow:

Goal: A Year II fellow should be able to assess and care for a large volume of patients and learn and teach basic textbook and evidence-based
medicine to medical students and other trainees. Year II fellows should independently perform upper endoscopy procedures with a side viewing
scope. Year II fellows should understand the indications for ERCP and EUS as well as risks and benefits of such procedures.

Patient Care Objectives:
     Complete a time-efficient history and physical examination.
     Direct medical students successfully with the appropriate level of intervention for each trainees’ skills.
               o Complete competency-level performance of the following pancreaticobiliary procedures:
               o Upper Endoscopy
               o Passage of side viewing endoscope and visualization of the ampulla of vater.
               o Begin to perform cannulation of the bile duct.
     Develop clear expertise in the diagnosis and management of acute and chronic pancreaticobiliary diseases including:
               o Acute Pancreatitis
               o Chronic Pancreatitis
               o Pancreatis Cancer
               o Bile Duct Stones
               o Liver Cancer
               o Biliary Cancer
               o Post-Operative Injuries to the Liver, Bile Ducts & Pancreas
     Present cases succinctly in a direct manner.
     Know the Pancreaticobiliary Consultation Service’s patients at a management level.
     Handle consult calls respectfully and appropriately.
     Teach good symptom management skills to medical students and other trainees.
     Provide inpatient care that is safe and compassionate and develop the ability to thoroughly and clearly educate the inpatient in the relevant
     areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.

Medical Knowledge Objectives:

62 | P a g e
     Begin to take a leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease
     management and procedures and medicine management skills for common and uncommon pancreaticobiliary diseases including:
                 o Acute Pancreatitis
                 o Chronic Pancreatitis
                 o Pancreatis Cancer
                 o Bile Duct Stones
                 o Liver Cancer
                 o Biliary Cancer
                 o Post-Operative Injuries to the Liver, Bile Ducts & Pancreas
     Organize the team’s performance at teaching rounds.
     Read textbook and pertinent literature materials concerning problems encountered.
     Teach medical students and other trainees about pancreas and biliary disease states and patient management.
     Achieve an average percentile score of at least 73.90 on the Biliary Tract section and 48.36 on the Pancreas section of the in-service
     Gastroenterology Training Examination (GTE) exam. These scores are the national exam averages for pancreatiobiliary diseases for Year
     II fellows.

Practice-Based Learning Objectives:
    Participate in project groups, committees and hospital groups when requested.
    Participate in programmatic reviews and conferences studying adverse events.
    Give usable feedback to medical students and other trainees based on observation of their performance and assess improvement.
    Participate in problem-based quality improvement projects.
    Review, analyze and utilize scientific evidence from pancreaticobiliary literature related to patient management.
    Know the best practice patterns to facilitate pancreaticobiliary care through clinic operating procedures and patient interactions.

Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner.
     Convey bad news compassionately and honestly.
     Plan patient and family conferences.
     Counsel patients about transitioning to palliative care, when needed.
     Address or refer patients related to spiritual or existential issues.
     Communicate effectively with staff, peers, attending gastroenterologists, referring physicians and other consultants.
     Present cases succinctly, in a problem-based, direct manner.
     Learn to become a teacher of pancreas and biliary diseases to junior trainees, medical students and other healthcare professionals.

Professionalism Objectives:
    Begin to mentor medical students and other trainees in professional conduct.
    Understand and demonstrate professional behavior in daily activities.
    Participate in professionalism-based learning activities through conferences.
    Interact collegially with his/her peer group and other healthcare professionals, including acting responsibly in the larger context of pursuing
    programmatic successes.
    Practice ethical principles with relation to patient care and confidentiality.
    Practice interactions with pharmaceutical representatives and be unbiased in prescribing habits.
    Practice sensitivity to cultural, age, gender and disability issues.
    Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues.
    Participate in program planning.

Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Understand and be able to work effectively related to hospital functions within MHH and LBJ hospitals.
    Understand and practice proper documentation and billing skills to practice cost-effective care.
    Assist other trainees in the utilization of appropriate healthcare resources for the best care of Pancreaticobiliary Service patients.
    Model appropriate interactions in multidisciplinary planning, including standard operating procedures and quality improvement initiatives.
    Attend national gastroenterology conferences (e.g., DDW, ACG or APA).




                                                                 Year III Fellows:

Goal: The senior-level, Year III fellow should demonstrate rapid assessment and planning skills and near-attending level care planning and
63 | P a g e
management, while teaching medical students and other trainees at near to or exceeding attending level teaching. Year III fellows should be
able to perform diagnostic and therapeutic upper endoscopy procedures independently, as well as passage of the side viewing scope.

Patient Care Objectives:
     Master the Year II fellow objectives.
     Demonstrate efficient organization of the Pancreaticobiliary Service and a working knowledge of all patients.
     Demonstrate near-attending level capacity for program assessment and care planning.
     Attain trainer level proficiency in the following procedures pertinent to his/her career choices:
     Complete competency-level performance of the following pancreaticobiliary procedures reflecting Year III responsibilities:
                o Biliary stone extraction
                o Upper Endoscopy
                o ERCP
                o Cannulation of bile duct and perform sphincterotomy and placement of bile duct stents
     Secure expertise in the diagnosis and management of acute and chronic inpatient pancreaticobiliary diseases including:
                o Acute Pancreatitis
                o Chronic Pancreatitis
                o Pancreatic Cancer
                o Pancreatic divisum
                o Congenital biliary abnormalities
                o Biliary strictures and primary sclerosing cholangitis
                o Pancreatic necrosis
                o Management of bile duct injuries related to trauma
                o Bile Duct Stones
                o Liver Cancer
                o Biliary Cancer
                o Post-Operative Injuries to the Liver, Bile Ducts & Pancreas
     Provide inpatient care that is safe and compassionate with the leadership ability to thoroughly and clearly educate the inpatient and all other
     trainees regarding relevant areas of disease prevention, detection, progression and therapy to promote pancreas and biliary health.

Medical Knowledge Objectives:
    Access and critique the medical literature regarding pancreas and biliary problems encountered.
    Assume the trainee leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease
    management, procedures and medicine management skills for common and uncommon inpatient pancreaticobiliary diseases including
                o Acute Pancreatitis
                o Chronic Pancreatitis
                o Pancreatic Cancer
                o Pancreatic divisum
                o Congenital biliary abnormalities
                o Biliary strictures and primary sclerosing cholangitis
                o Pancreatic necrosis
                o Management of bile duct injuries related to trauma
                o Bile Duct Stones
                o Liver Cancer
                o Biliary Cancer
                o Post-Operative Injuries to the Liver, Bile Ducts & Pancreas
    Teach medical students, other trainees and Year I & II fellows at near-attending level.
    Prepare for the ABIM certifying exam throughout the year.
    Organize team activities in a smooth and authoritative fashion.
    Assist Year II fellows’ development directly at teaching conferences and indirectly at work sites.
    Achieve an average percentile score of at least 79.02 on the Biliary Tract section and 54.44 on the Pancreas section of the in-service
    Gastroenterology Training Examination (GTE) exam. These scores are the national exam averages for pancreatiobiliary diseases for Year
    III fellows.



Practice-Based Learning Objectives:
    Demonstrate mastery of Year II fellow skills and encourage participation of colleagues.
    Review, analyze and utilize scientific evidence from the hepatology literature for the management of liver disease patients, taking a
    leadership role in guiding Year I & II fellows and sharing relevant literature reviews with them.

64 | P a g e
     Know and be able to succinctly communicate the best practice patterns to facilitate liver disease care through clinic operating procedures
     and patient interactions.

Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner.
     Convey bad news compassionately and honestly.
     Supervise Year I & II fellows’ work related to planning patient/family conferences and patient communications/counseling.
     Communicate effectively as a consultant with staff, peers, attending gastroenterologists, referring physicians and other consultants and lead
     other trainees related to appropriate fellow-to-medical-professional communications.
     Present cases succinctly, in a problem-based, direct manner.
     Assume the role of a teacher of pancreas and biliary diseases to junior trainees, medical students and other healthcare professionals.

Professionalism Objectives:
    Demonstrate proficiency in Year II objectives.
    Mentor medical students, other trainees and fellows in professional conduct.
    Assist in formal teaching exercises as requested.
    Assert leadership in program planning.

Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Model appropriate interactions in multidisciplinary planning, including improvements related to standard operating procedures and quality
    improvement initiatives.
    Participate in hospital and national medical association committees and multidisciplinary planning groups when requested.
    Attend national conferences directed at career goals.
    Demonstrate near-attending level utilization of overall systems of care.

Teaching Methods:
Gastroenterology fellows participate in the Pancreaticobiliary Consultation Service during Years II and III of fellowship training. One fellow is
assigned to the Pancreaticobiliary Service during all rotations. Teaching of medical students, residents and other trainees as well as appropriate
interactions with other healthcare providers are important aspects of this rotation. Participating in all required conferences is mandatory, and
rounding is an integral part of this experience. As fellows gain experience throughout their training, skills of organization and efficiency as well as
team leadership become increasingly important.

The Pancreaticobiliary Service experience is rigorous and will prepare the fellow to evaluate and manage acute and chronic pancreas and biliary
diseases that will be encountered in the fellow’s future practice. This rotation will expose the fellow to a wide variety of pancreas and biliary
disease diseases and problems.

Fellows assigned to this service will evaluate all new consults at MHH and LBJ hospitals and will be assigned to a continuity clinic one-half day
per week. They will present new consults to the attending by the following day for routine consults and as soon as possible for emergencies.
Fellows will evaluate each patient and will make initial recommendations regarding diagnostic tests and treatments. They will make
arrangements for studies such as upper endoscopy, ERCP, MRCP etc. They will review the appropriateness of the procedure with the attending
before making final scheduling plans. The fellow will follow each patient under active consultation on a regular basis, will make further
recommendations as indicated and will keep the attending informed of the patient’s status. Fellows must also communicate with the procedure
fellow for all diagnostic studies.

Disease Mix:
Fellows see a complete mix of liver diseases and conditions within the Pancreaticobiliary Consultation Service’s teaching hospitals. MHH and
LBJ hospitals have a substantial primary care basis, which provides the entire spectrum of internal medicine diagnoses and gastroenterology
care.

Diagnoses range from acute pancreatitis to pancreatic cancer, and there is an appropriate concentration of common pancreas and biliary
diseases such as Cholangitis, cholelithiasis, biliary strictures. Importantly, LBJ is exposed to a large Hispanic patient population, because of this
there is outstanding diversity of biliary pathology highly prevalent in the group of patients.


Patient Characteristics:
MHH and LBJ offer a diverse mix of socioeconomic and gender status. Teaching faculty provide an abundant supply of upper- and middle-class
patients, and our contracts with medical assistance and pro bono care efforts ensure access to lower income patients. Due to a primary care
base simultaneous with the hospitals’ constantly active referrals (MHH is complete with helicopter and fixed-wing transport 24/7), patients are
seen in both acute status and in diagnostic dilemma status, with both common and uncommon disorders.
65 | P a g e
Types of Clinical Encounters – Attending Supervision:
Encounters are inpatient in nature during the Pancreaticobiliary Consultation Service. Fellows provide 24/7 consultative care under the
supervision of an attending within duty hour limits and with faculty back up for situations of overload. Daily attending supervision is available at
both MHH and LBJ seven days per week, and in-house supervision is available all night as well. The attending has ultimate responsibility for
patients.

Procedures:
During the Pancreaticobiliary Consultation Service, emergency procedures are performed 24/7 within duty hour limits by the fellow with the
attending. Non-emergent procedures are performed during daytime hours in the GI lab by the fellow under the direct supervision of the
attending. Procedure based evaluation is performed twice per year by a supervising attending.

Evaluation:
Fellows are evaluated during all Pancreaticobiliary Service rotations and are expected to participate in the evaluation of other fellows as well.
This occurs in the following forms:
     Detailed, automated evaluations using the GMEIS system are submitted for each rotation. These evaluations are reflective of the program’s
     curriculum requirements. Attendings evaluate fellows, and the fellows evaluate the attendings as well. Quarterly evaluations include:
                o 360-degree (attending, nurse, nurse practitioner, staff/clerical, etc.);
                o Peer-reviewed; and
                o Patient.
     Evaluation summaries become part of the fellows’ and attendings’ promotional documents.
     The fellow also evaluates the Gastroenterology Fellowship Program annually through a confidential basis.
     Attendings evaluate the Gastroenterology Fellowship Program annually.
     A Curriculum Committee oversees major changes to the curriculum. Representative program personnel (i.e., program director,
     representative faculty and at least one fellow) are organized to review program goals and objectives and the effectiveness with which they
     are achieved. This group conducts a formal documented meeting at least annually for this purpose. In the evaluation process, the group
     must take into consideration written comments from the faculty, the most recent report of the GMEC of the sponsoring institution and the
     residents’ confidential written evaluations. If deficiencies are found, the group will prepare an explicit plan of action, which should be
     approved by the faculty and documented in the minutes of the meeting.
     The Program Director meets with all fellows individually twice per year.
     An in-service GTE exam is given to all fellows annually.

Additional Instructions for Fellows Participating in the Pancreaticobiliary Service:

I. Patient Care
     A. Consultations/inpatient admissions: Consultations and inpatient admissions are evaluated by the pancreaticobiliary fellow on service
          on the day they are called in. They are to be written up and presented to the attending on service. Additionally, the attending should
          be notified of any urgent consultations or admissions as soon as possible, particularly if a same-day procedure is anticipated.
     B. Pre-procedure evaluation: The fellow is expected to pre-round on inpatients in the morning prior to beginning the day's procedures. If
          issues arise, the attending on service should be contacted as soon as possible. A pre-review of all outpatients slated for procedures
          that day should similarly be completed. This may be done by reviewing the patients electronic medical record (EMR), DDC/hospital
          chart review and, if appropriate, a phone call to the patient to introduce yourself and gather any further information that may be
          applicable. A thorough patient history, physical exam, and a review of the laboratory and radiologic data should be performed prior to
          ERCP. The history should be obtained sufficiently in advance to permit procedural changes as warranted (e.g., general anesthesia,
          correction of coagulation factors, set-up of sphincter of Oddi manometry, enrollment in an ongoing protocol, etc.). The fellow is
          responsible for entering all pertinent patient data into the ERCP database/report generator prior to and following the procedure. The
          attending physician and the fellow are expected to discuss the case in detail prior to proceeding, so that both are in agreement
          regarding the procedure. All inpatients should be seen daily, and a note should be written prior to attending rounds. Attending rounds
          will be performed daily after all procedures have been completed. All admissions and consultations will be seen on the day they are
          called, with rare exceptions as approved by the attending on service.
     C. Intraoperative: The fellow will assist the attending in performance of the ERCP procedure. The goals for the fellow are to build a solid
          foundation in patient assessment, approach to the procedure, endoscopic technique, and familiarity with accessories (such as wires,
          catheters, stents, etc.) as well as the workings of the ERCP team. The number of "successful cannulations, papillotomies, guide wire
          placements, etc." performed should not, by any means, be considered the ultimate measure of success. These come with time, as
          skills mature. Since the risks of therapeutic ERCP are equal to those of many surgical procedures, factors such as patient care and
          safety must remain paramount. Certain cases (high risk, difficult/prior failed procedure, pediatric, etc.) may be considered attending-
          only cases insofar as the actual performance of the procedure is concerned, and limitation of the fellow’s participation in the case will
          be at the discretion of the attending. However, the observant fellow will learn a great deal in assisting the attending and watching
          vigilantly. Such non-hands-on participation is important to the learning process.
     D. Postoperative:
66 | P a g e
               a.     Inpatients: Postop orders are to be written immediately after the procedure is completed. Pertinent postop data must be
                      entered into the database and a preliminary report generated, signed, and placed on the chart before the patient leaves the
                      GI lab. The attending will be responsible for dictating the procedure note. All inpatients who undergo a procedure must be
                      seen on evening rounds, and a post-procedure check must be documented on the chart. The pancreatico-biliary service will
                      be responsible for ALL aspects of the immediate postoperative management, as occurs on a surgical service. The
                      pancreatico-biliary fellow on service will keep their pagers on, and will be immediately accessible within pager range, 24
                      hours a day, six days per week, respectively while on service, with no exceptions. On Saturdays, the fellow on-service will
                      round with the GI attending on service. On Sunday, the fellow will sign out to the GI team. On Monday am, the
                      pancreaticobiliary fellow will take report from the GI team for Sunday’s events/admissions. The pancreaticobiliary attending
                      will leave their beepers on 24Hr/7Day to serve as a back-up for the fellow and GI team on weekends for complex cases and
                      for call-ins for emergency procedures.
                b. Outpatients: Outpatient post-procedure follow-up mirrors the inpatient model. The fellow will evaluate each patient in the
                      hospital to assess for post-ERCP complications.
          If the fellow has personal business which would interfere with his/her responsibilities while on service, special coverage arrangements
          must be made in advance with the attending. Fellow cross coverage is acceptable only if the cross-covering fellow has had prior
          experience with ERCP and has been adequately familiarized with the patients on the service. The service fellow will remain
          responsible for assuring that cross-coverage proceeds smoothly.

II. ERCP Database
The ERCP database/report generator exists to assist in patient care follow-up and efficient pre-procedure patient review, to aid in research
activities and to provide the fellow with an automatic, detailed, and running logbook of procedures performed. The database is divided into three
parts: preop assessment, procedure report and follow-up.


III. Research Protocols
Fellows are encouraged to become familiar with existing research protocols, while they are on the pancreaticobiliary service. Fellows are
expected to participate in patient enrollment and in carrying out the steps involved in any procedure-related protocols which apply to procedures
they perform. Any fellow wishing to design studies is encouraged to discuss such ideas with the attendings. Fellows with a particular interest in
pancreaticobiliary gastroenterology are encouraged to discuss the research opportunities available in the pancreatico-biliary section with the
attendings, so that they can develop projects early in the fellowship.

Bibliography:
     Resource Documents
               o Up-To-Date
               o PubMed
               o Textbook of Gastroenterology – Yamada, et.al.
               o Gastrointestinal Disease: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.
               o Major Gastroenterology journals online and in the program’s fellow library including Gastroenterology, American Journal of
                    Gastroenterology, Gut, and other major publications.
               o Gastrointestinal Endoscopy: the Journal of the American Society for Gastrointestinal Endoscopy, the endoscopy journal with
                    the widest circulation throughout the world (monthly).
               o Endoscopy: the Journal of the European Society for Gastrointestinal Endoscopy (monthly).
               o Pancreas: the Journal of the American Pancreatic Association.
               o Gastrointestinal Endoscopy Clinics of North America (quarterly).
               o Annual of Gastrointestinal Endoscopy (annual review of therapeutic endoscopy literature worldwide).
               o Practical Gastrointestinal Endoscopy, by Peter Cotton and Christopher Williams, the classic “beginner’s guide to endoscopy”
                    and a perennial favorite of GI fellows.
     Curricular Design
               o ACGME Outcome Project documentation (from www.acgme.org).
               o Graduate Education in Internal Medicine: A Resource Guide to Curriculum Development
               o The report of the Federated Council for Internal Medicine Task Force on the Internal Medicine Residency Curriculum, 1997.
     Pertinent Teaching References:
               o Textbook of Gastroenterology – Yamada, et.al.
               o Gastrointestinal Disease: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.

                                                           Competencies-at-a-Glance
                                                           Pancreaticobiliary Service
                        COMPETENCY                         LEARNING OPPORTUNITY                           EVALUATION
             Patient Care                                  Work Rounds                              360-global evaluations

67 | P a g e
                                                           Teaching Rounds                          GTE in-service exam
                                                           Conferences                              Direct Observation

             Medical Knowledge                             Work Rounds                              360-global evaluations
                                                           Teaching Rounds                          GTE in-service exam
                                                           Conferences
             Practice-Based Learning                       Quarterly M&M Conference                 360-global evaluations
                                                           Work Rounds                              Direct Observation

             Interpersonal Skills                          Work Rounds                              360-global evaluations
             Professionalism                               Work Rounds                              360-global evaluations
                                                           Conferences
             Systems-Based Practice                        Committee Participation                  360-global evaluations
                                                           Grand Rounds (GI & Medical)
                                                           Conferences

The Pancreaticobiliary Service reflects appropriate teaching and evaluation related to all six core competencies. Day-to-day patient care, related
teaching and the curriculum conferences during the rotation are the greatest elements that teach the competencies, and the global evaluation is
the most important single measurement device. In addition to didactic learning, medical center committee participation is encouraged to bolster
system-wide knowledge and practice management understanding.

Revised
May 09 Frank Lukens




68 | P a g e
                           U.T. M.D. Anderson Cancer Center - Inpatient Consult Rotation
                                      Curriculum for Year I, II & III Fellows

Educational Purpose:
The Inpatient Consult Rotation at The University of Texas M.D. Anderson Cancer Center provides a unique opportunity for fellows in training to
consult on hospitalized patients regarding specific issues related to gastrointestinal cancer or GI complications of oncologic treatments and GI
changes associated with non-GI malignancies. This service includes the GI Fellow, GI Faculty, and a Physician Assistant.

Competency is expected in, but not limited to, the following: gastrointestinal cancer diagnosis; endoscopic management of tumor-associated
bleeding and obstruction; diagnosis of GI and hepatic complications of bone marrow transplant (including specifically graft versus host disease,
venoocclusive disease, opportunistic infection); diagnosis of GI complications of chemotherapy and radiation therapy, general, and in the special
contexts of anemia, thrombocytopenia, and neutropenia. Non-cancer related problems may be encountered as well, including complicated acid-
peptic disease, motility disturbances, complicated inflammatory bowel disease, diverticulitis, mesenteric vascular events, gastrointestinal
infections, and pancreaticobiliary disease including cholelithiasis.

Since severely ill and terminal cancer patients populate our inpatient services, an empathic bedside manner will be cultivated and will be
expected. Communication with patients and their families, while time-consuming, carry a premium on this rotation. Collegial relations with nurses
and clerks are expected.


Objectives:
Fellows will learn all aspects of inpatient gastrointestinal care and will display all general competencies during this experience. Minimum levels of
achievement in each competency are expected during each of the three years of fellowship training. Those meeting competency will receive a
score of 5 in the program’s evaluation system. Fellows performing at a level better than expected for that competency receive a score of 6 or 7 in
the evaluation system, those at a level better than most fellows at that PGY receive an 8, and those performing at a level deemed to be “one of
the best fellows ever observed” will receive a score of 9. Fellows receiving a score of 4 or below are deemed deficient in that competency; this
will be brought to the attention of the program director immediately, and, if necessary, remediation will be implemented.

The following are the goals and objectives for each competency at each level of training for the Shadyside Hospital Service:


                                                                   Year I Fellow:

Goal: A Year I fellow should be able to assess new patient problems. This rotation exposes fellows to both acute and chronic gastrointestinal
oncological pathology. They will formulate and execute a treatment plan with guidance and teach basic gastroenterology skills to medical
students and other trainees. Year I fellows should begin to develop basic procedural competencies in diagnostic upper endoscopy and
colonoscopy.

Patient Care Objectives:
     Perform an accurate physical examination and present information concisely with an initial assessment plan. Follow the patient’s disease
     course during the patient’s hospital stay. With attending consultation, formulate and execute an impression and a list of recommendations
     for the primary service. When indicated, consent patients for procedures and order appropriate diagnostic tests (e.g., endoscopy, radiologic
     tests, etc.) in conjunction with the primary/referring service.
     Perform with supervision the following basic gastroenterology procedures (see practicum):
                o Colonoscopy
                                By completion of Year I a fellow should be able to perform a diagnostic colonoscopy to the cecum with limited
                                assistance.
                o EsophagoGastroDuodenoscopy (EGD or Upper Endoscopy)
                                By completion of Year I a fellow should be able to perform a diagnostic endoscopy to the second portion of the
                                duodenum.
     Develop expertise in the diagnosis and management of acute and chronic inpatient gastrointestinal diseases including:

•    Gastrointestinal cancer diagnosis
•    Diagnosis of GI and hepatic complications of bone marrow transplant (including specifically graft versus host disease, venoocclusive
     disease, opportunistic infection)
•    Diagnosis of GI complications of chemotherapy and radiation therapy, including anemia, thrombocytopenia and neutropenia
•    Complicated acid-peptic disease
•    Motility disturbances
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•    Appropriate assessment and treatment options for GI cancer
•    Mesenteric vascular events
•    Gastrointestinal infections

     Learn to provide inpatient and outpatient care that is safe and compassionate and to develop the ability to thoroughly and clearly educate
     the inpatient in the relevant areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.

Medical Knowledge Objectives:
    Attend core conferences and teaching rounds to learn the pathophysiology, epidemiology, disease management and procedure and
    medicine management skills for common and uncommon inpatient gastrointestinal diseases including:

o    Gastrointestinal cancer diagnosis
o    Diagnosis of GI and hepatic complications of bone marrow transplant (including specifically graft versus host disease, venoocclusive
     disease, opportunistic infection)
o    Diagnosis of GI complications of chemotherapy and radiation therapy, including anemia, thrombocytopenia and neutropenia
o    Complicated acid-peptic disease
o    Motility disturbances
o    Appropriate assessment and treatment options for GI cancer
o    Mesenteric vascular events
o    Gastrointestinal infections

     Accumulate and begin to solve the issues that he/she encounters from other trainees, attendings and related medical professionals.
     Achieve an average percentile score of at least 61.18 on the “General” section of the in-service Gastroenterology Training Examination
     (GTE) exam. This score is the national average on this exam for Year I fellows.
     By end of Year I, pass the Internal Medicine Board Examination.

Practice-Based Learning Objectives:
    Become familiar with the concepts of quality improvement.
    Participate in conferences such as M&M, geared to the programmatic review of adverse events.
    Begin to review, analyze and utilize scientific evidence from the gastrointestinal literature for the management of GI patients with emphasis
    in gastrointestinal oncology
    Learn the best practice patterns to facilitate gastroenterology care through operating procedures and patient interactions, particularly in the
    community gastroenterologist setting.

Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable and
     compassionate manner. Convey bad news compassionately and honestly.
     Learn to communicate effectively with staff, peers, attending gastroenterologists, referring physicians and other consultants.

Professionalism Objectives:
    Learn to understand and demonstrate professional behavior in daily activities.
    Participate in professionalism-based learning activities through conferences.
    Learn to interact collegially with his/her peer group and other healthcare professionals.
    Learn to practice ethical principles with relation to patient care and confidentiality.
    Learn to practice appropriate interactions with pharmaceutical representatives and be unbiased in prescribing habits.
    Learn to be sensitive to cultural, age, gender and disability issues.
    Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues.
    Participate in program planning, including annual Faculty Meeting attendance, Fellow Curriculum Committee participation and Program
    Director meetings when requested.

Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Achieve basic understanding of healthcare systems related to gastroenterology care and overall system activities.
    Learn proper documentation to practice cost-effective care.
    Utilize an appropriate range of healthcare professionals to care for patients, working closely with socials services to maximize patient care
    and understanding the role of hospice, referring appropriately when needed.
    Begin involvement to understand the standard operating procedures and quality improvement initiatives within the hospital.
    Attend national gastroenterology conferences (e.g., ACG and endoscopy training courses).


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                                                                 Year II Fellow:

Goal: A Year II fellow should learn to assess and care for a larger volume of patients. They will learn and teach basic textbook and evidence-
based medicine to medical students and other trainees. Year II fellows should independently perform diagnostic upper endoscopy and
colonoscopy and begin to perform therapeutic maneuvers.

Patient Care Objectives:
     Complete a time-efficient history and physical examination.
     Critique the work and orders of Year I fellows.
     Direct the Year I fellows successfully with the appropriate level of intervention for each trainee’s skills.
     Complete competency-level performance of the following basic gastroenterology procedures:
                o Colonoscopy
                               By completion of Year II, master all Year I colonoscopic skill requirements. Additionally, perform endoscopic
                               maneuvers, including snare polypectomy and begin to develop competency in control of GI bleeding: sclerotherapy
                               and thermal coagulopathy of bleeding vessels.
                o Upper Endoscopy
                               By completion of Year II, master all Year I upper endoscopic skill requirements. Additionally, begin to develop
                               competency in performing therapeutic maneuvers: banding and sclerosing of varices, and sclerotherapy and
                               thermal coagulopathy of bleeding vessels.
                               Endoscopic management of tumor-associated bleeding and obstruction

    Develop clear expertise in the diagnosis and management of acute and chronic inpatient gastrointestinal diseases including:

o   Gastrointestinal cancer diagnosis
o   Diagnosis of GI and hepatic complications of bone marrow transplant (including specifically graft versus host disease, venoocclusive
    disease, opportunistic infection)
o   Diagnosis of GI complications of chemotherapy and radiation therapy, including anemia, thrombocytopenia and neutropenia
o   Complicated acid-peptic disease
o   Motility disturbances associated with gastrointestinal malignancies
o   Appropriate assessment and treatment options for GI cancer
o   Mesenteric vascular events
o   Pancreatitis
o   Ischemic colitis
o   Gastrointestinal oncologic emergencies
o   Gastrointestinal opportunistic infections related to chemotherapy
o   Barrett’s Esophagus

    Present cases succinctly in a direct manner.
    Know the M.D. Anderson inpatient consult service patients at a management level.
    Handle consult calls respectfully and appropriately.
    Teach good symptom management skills to medical students and other trainees.
    Provide inpatient care that is safe and compassionate and develop the ability to thoroughly and clearly educate the inpatient in the relevant
    areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.

Medical Knowledge Objectives:
    Begin to take a leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease
    management and procedures and medicine management skills for common and uncommon inpatient gastrointestinal diseases including:
o Gastrointestinal cancer diagnosis
o Diagnosis of GI and hepatic complications of bone marrow transplant (including specifically graft versus host disease, venoocclusive
    disease, opportunistic infection)
o Diagnosis of GI complications of chemotherapy and radiation therapy, including anemia, thrombocytopenia and neutropenia
o Complicated acid-peptic disease
o Motility disturbances associated with gastrointestinal malignancies
o Appropriate assessment and treatment options for GI cancer
o Mesenteric vascular events
o Pancreatitis
o Ischemic colitis
o Gastrointestinal oncologic emergencies
o Gastrointestinal opportunistic infections related to chemotherapy
o Barrett’s Esophagus
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     Organize the team’s performance at teaching rounds.
     Read textbook and pertinent literature materials concerning problems encountered, especially related to GI oncology
     Teach medical students and other trainees about GI disease states and patient management.
     Achieve an average percentile score of at least 62.98 on the “General” section of the in-service Gastroenterology Training Examination
     (GTE) exam. This score is the national average on this exam for Year II fellows.

Practice-Based Learning Objectives:
    Participate in project groups, committees and hospital groups when requested.
    Participate in programmatic reviews and conferences studying adverse events.
    Give usable feedback to medical students and other trainees based on observation of their performance and assess improvement.
    Participate in problem-based quality improvement projects.
    Review, analyze and utilize scientific evidence from the gastrointestinal literature for the management of GI oncological patients
    Know the best practice patterns to facilitate gastroenterology care through clinic operating procedures and patient interactions.

Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner.
     Convey bad news compassionately and honestly.
     Plan patient and family conferences.
     Counsel patients about transitioning to palliative care, when needed.
     Address or refer patients related to spiritual or existential issues.
     Communicate effectively with staff, peers, attending gastroenterologists, referring physicians and other consultants.
     Present cases succinctly, in a problem-based, direct manner.
     Learn to become a teacher of gastroenterology to junior trainees, medical students and other healthcare professionals.

Professionalism Objectives:
    Begin to mentor medical students, other trainees and Year I fellows in professional conduct.
    Understand and demonstrate professional behavior in daily activities.
    Participate in professionalism-based learning activities through conferences.
    Interact collegially with his/her peer group and other healthcare professionals, including acting responsibly in the larger context of pursuing
    programmatic successes.
    Practice ethical principles with relation to patient care and confidentiality.
    Practice interactions with pharmaceutical representatives and be unbiased in prescribing habits.
    Practice sensitivity to cultural, age, gender and disability issues.
    Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues.
    Participate in program planning, including annual Faculty Meeting attendance, Fellow Curriculum Committee participation and Program
    Director meetings, when requested.

Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Understand and be able to work effectively related to hospital functions within M.D. Anderson Cancer Center.
    Understand and practice proper documentation and billing skills to practice cost-effective care.
    Assist other trainees in the utilization of appropriate healthcare resources for the best care of the GI Consult Service’s patients.
    Model appropriate interactions in multidisciplinary planning, including standard operating procedures and quality improvement initiatives.
    Attend national gastroenterology or hepatology conferences (e.g., DDW or AASLD).

                                                                 Year III Fellows:

Goal: The senior-level, Year III fellow should demonstrate rapid assessment and planning skills and near-attending level care planning and
management, while teaching medical students and other trainees at near to or exceeding attending level teaching. Year III fellows should be
able to perform diagnostic and therapeutic upper endoscopy and colonoscopy procedures independently.

Patient Care Objectives:
     Master the Year II fellow objectives.
     Demonstrate efficient organization of the M.D. Anderson Consult Rotation and a working knowledge of all patients.
     Demonstrate near-attending level capacity for program assessment and care planning.
     Attain trainer level proficiency in the following gastroenterology procedures pertinent to his/her career choices:
                o Colonoscopy

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                                By completion of Year III, master all Year II colonoscopic skill requirements. Additionally, be able to independently
                                intubate the terminal ileum and begin to develop independent mastery of more advanced maneuvers, e.g., removal
                                of large or complex polyps by saline assisted polypectomy or piecemeal resection and control of bleeding using
                                clips or argon plasma laser coagulation.
                o Upper Endoscopy
                                By completion of Year III, master all Year II endoscopic skill requirements. Additionally, be able to pass a side
                                viewing scope to identify the papilla or lesions difficult to observe with forward viewing scope and perform
                                advanced maneuvers, such as placing clips on bleeding vessels or argon plasma laser coagulopathy.
    Secure expertise in the diagnosis and management of acute and chronic inpatient gastrointestinal diseases including:
o   Uncommon Gastrointestinal cancer diagnosis
o   Diagnosis of GI and hepatic complications of bone marrow transplant (including specifically graft versus host disease, venoocclusive
    disease, opportunistic infection)
o   Diagnosis of GI complications of chemotherapy and radiation therapy, including anemia, thrombocytopenia and neutropenia
o   Complicated acid-peptic disease
o   Motility disturbances associated with gastrointestinal malignancies
o   Appropriate assessment and treatment options for GI cancer
o   Mesenteric vascular events
o   Pancreatitis
o   Ischemic colitis
o   Gastrointestinal oncologic emergencies
o   Difficult to treat gastrointestinal opportunistic infections related to chemotherapy
o   Barrett’s Esophagus
o   Neuroendocrine gastrointestinal malignancies
o   Intestinal/colonic pseudobstruction
o   Secretory diarrheal states
o   Idiopathic abdominal pain
o   Upper & lower GI bleeding
o   Colon cancer
o   Barrett’s Esophagus
o   Pancreatic Cancer
o   GI oncologic emergencies

    Provide inpatient care that is safe and compassionate with the leadership ability to thoroughly and clearly educate the inpatient and all other
    trainees regarding relevant areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.

Medical Knowledge Objectives:
    Access and critique the medical literature regarding gastroenterology and hepatology problems encountered.
    Assume the trainee leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, cancer
    screening, disease management, procedures and medicine management skills for common and uncommon inpatient gastrointestinal
    diseases including:

o   Uncommon Gastrointestinal cancer diagnosis
o   Diagnosis of GI and hepatic complications of bone marrow transplant (including specifically graft versus host disease, venoocclusive
    disease, opportunistic infection)
o   Diagnosis of GI complications of chemotherapy and radiation therapy, including anemia, thrombocytopenia and neutropenia
o   Complicated acid-peptic disease
o   Motility disturbances associated with gastrointestinal malignancies
o   Appropriate assessment and treatment options for GI cancer
o   Mesenteric vascular events
o   Pancreatitis
o   Ischemic colitis
o   Gastrointestinal oncologic emergencies
o   Difficult to treat gastrointestinal opportunistic infections related to chemotherapy
o   Barrett’s Esophagus
o   Neuroendocrine gastrointestinal malignancies
o   Intestinal/colonic pseudobstruction
o   Secretory diarrheal states
o   Idiopathic abdominal pain
o   Upper & lower GI bleeding

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o    Colon cancer
o    Barrett’s Esophagus
o    Pancreatic Cancer
o    GI oncologic emergencies

     Teach medical students, other trainees and Year I & II fellows at near-attending level.
     Prepare for the ABIM certifying exam throughout the year.
     Organize team activities in a smooth and authoritative fashion.
     Assist Year II fellows’ development directly at teaching conferences and indirectly at work sites.
     Achieve an average percentile score of at least 64.07 on the “General” section of the in-service Gastroenterology Training Examination
     (GTE) exam. This score is the national average on this exam for Year III fellows.

Practice-Based Learning Objectives:
    Demonstrate mastery of Year II fellow skills and encourage participation of colleagues.
    Review, analyze and utilize scientific evidence from the gastrointestinal literature for the management of GI patients, taking a leadership role
    in guiding Year I & II fellows and sharing relevant literature reviews with them.
    Know and be able to succinctly communicate the best practice patterns to facilitate gastroenterology care through operating procedures and
    patient interactions. Attend to the special requirements of a gastroenterologist in a community practice setting.

Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner.
     Convey bad news compassionately and honestly.
     Supervise Year I & II fellows’ work related to planning patient/family conferences and patient communications/counseling.
     Communicate effectively as a consultant with staff, peers, attending gastroenterologists, referring physicians and other consultants and lead
     other trainees related to appropriate fellow-to-medical-professional communications.
     Present cases succinctly, in a problem-based, direct manner.
     Assume the role of a teacher of gastroenterology to junior trainees, medical students and other healthcare professionals.

Professionalism Objectives:
    Demonstrate proficiency in Year II objectives.
    Mentor medical students, other trainees and Year I fellows in professional conduct.
    Assist in formal teaching exercises as requested.
    Assert leadership in program planning, including fellow participation in the annual Faculty/Fellow Meeting, Fellow Curriculum Committee and
    Conference Planning Committees.

Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Assist and mentor other trainees in utilization of appropriate M.D. Anderson Cancer Center healthcare resources for the best care of the GI
    Consult Service’s patients, including proper documentation.
    Model appropriate interactions in multidisciplinary planning, including improvements related to standard operating procedures and quality
    improvement initiatives.
    Participate in hospital and national medical association committees and multidisciplinary planning groups when requested.
    Attend national conferences directed at career goals.
    Demonstrate near-attending level utilization of overall systems of care.

Teaching Methods:
Gastroenterology fellows participate in the Inpatient Consult Service at The University of Texas M.D. Anderson Cancer during all three fellowship
years. One fellow is assigned to this service during all rotations. Teaching of medical students, residents and other trainees as well as
appropriate interactions with other healthcare providers are important aspects of this rotation. Participating in all required conferences is
mandatory, and rounding is an integral part of this experience. As fellows gain experience throughout their training, skills of organization and
efficiency as well as team leadership become increasingly important.

The Inpatient Consult Service at The University of Texas M.D. Anderson Cancer experience will prepare the fellow to evaluate and manage
acute and chronic gastrointestinal illnesses with emphasis in oncology that will be encountered in the fellow’s future practice. Inpatient rounding
will be part of this rotation. This Service will expose the fellow to a wide variety of general gastrointestinal pathology with emphasis in
management GI oncological problems.

Fellows assigned to this service will evaluate all consults at M.D. Anderson Inpatient Consult Service and will be assigned to a continuity clinic
one-half day per week. They will present new consults to the attending by the following day for routine consults and as soon as possible for
emergencies. Fellows will evaluate each patient and will make initial recommendations regarding diagnostic tests and treatments. They will
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make arrangements for studies such as endoscopy, motility tests, biopsies, etc. They will review the appropriateness of the procedure with the
attending before making final scheduling plans. The fellow will follow each patient under active consultation on a regular basis, will make further
recommendations as indicated and will keep the attending informed of the patient’s status. Fellows must also communicate with the procedure
fellow for all diagnostic studies.

Disease Mix:
Fellows see a complete mix of gastrointestinal diseases including gastrointestinal cancers at M.D. Cancer Center. This Center has a substantial
primary care basis for patients with oncological diseases, which provides the entire spectrum of internal medicine diagnoses and gastrointestinal
care.

In addition to a wide variety of gastrointestinal pathology the fellow will also be exposed to conditions that range from pancreatitis, inflammatory
bowel disease, and functional GI motility and pain disorders. There is an appropriate concentration of common gastrointestinal diseases such as
peptic ulcer disease, gastroesophageal reflux disease and gastrointestinal infections. In particular, M.D. Anderson Cancer Center is a national
and international referral center, and there is outstanding diversity of unusual diagnoses in the teaching services.

Patient Characteristics:
The Inpatient Consult Service at The University of Texas M.D. Anderson Cancer experience offers a diverse mix of socioeconomic and gender
status. Teaching faculty provide an abundant supply of upper- and middle-class patients, and our contracts with medical assistance and pro
bono care efforts ensure access to lower-income patients. Due to a primary care base simultaneous with the hospitals’ constantly active
referrals, patients are seen in both acute status and in diagnostic dilemma status, with both common and uncommon disorders.

Types of Clinical Encounters – Attending Supervision:
Encounters are inpatient in nature during this rotation. Fellows provide 24/7 consultative care under the supervision of an attending within duty
hour limits and with faculty back up for situations of overload. Daily attending supervision is available at M.D. Anderson cancer Center seven
days per week, and in-house supervision is available all night as well. The attending has ultimate responsibility for patients.

Procedures:
During this rotation, procedures are performed during daytime hours in the GI lab by the fellow under the direct supervision of the attending.

Evaluation:
Fellows are evaluated during the M.D. Inpatient Consult Service rotation and are expected to participate in the evaluation of other fellows as well.
This occurs in the following forms:
     Detailed, automated evaluations using the GMEIS system are submitted for each rotation. These evaluations are reflective of the program’s
     curriculum requirements. Attendings evaluate fellows, and the fellows evaluate the attending as well. Quarterly evaluations include:
               o 360-degree (attending, nurse, nurse practitioner, staff/clerical, etc.);
               o Peer-reviewed; and
               o Patient.
     Evaluation summaries become part of the fellows’ and attendings’ promotional documents.
     The fellow also evaluates the Gastroenterology Fellowship Program annually through a confidential basis.
     Attendings evaluate the Gastroenterology Fellowship Program annually.
     A Curriculum Committee oversees major changes to the curriculum. Representative program personnel (i.e., program director,
     representative faculty and at least one fellow) must be organized to review program goals and objectives and the effectiveness with which
     they are achieved. This group must conduct a formal documented meeting at least annually for this purpose. In the evaluation process, the
     group must take into consideration written comments from the faculty, the most recent report of the GMEC of the sponsoring institution and
     the residents’ confidential written evaluations. If deficiencies are found, the group will prepare an explicit plan of action, which should be
     approved by the faculty and documented in the minutes of the meeting.
     The Program Director meets with all fellows individually twice per year.
     An in-service GTE exam is given to all fellows annually.

Contact:
Menhaz Shafi, MD is the coordinating physician for the M.D. Anderson Inpatient Consult Service Rotation.

Bibliography:
     Resource Documents
              o Up-To-Date
              o PubMed
              o Textbook of Gastroenterology – Yamada, et.al.
              o Gastrointestinal Diasese: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.
              o Major Gastroenterology journals online and in the program’s fellow library including Gastroenterology, American Journal of
                 Gastroenterolgy, Gut, and other major publications.
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    Curricular Design
              o ACGME Outcome Project documentation (from www.acgme.org).
              o Graduate Education in Internal Medicine: A Resource Guide to Curriculum Development
              o The report of the Federated Council for Internal Medicine Task Force on the Internal Medicine Residency Curriculum, 1997.
    Pertinent Teaching References:
              o Textbook of Gastroenterology – Yamada, et.al.
              o Gastrointestinal Diasese: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.

                                                        Competencies-at-a-Glance
                                                  M.D. Anderson Inpatient Consult Service


                       COMPETENCY                         LEARNING OPPORTUNITY                            EVALUATION
            Patient Care                                  Work Rounds                              360-global evaluations
                                                          Teaching Rounds                          GTE in-service exam
                                                          Conferences                              Direct Observation

            Medical Knowledge                             Work Rounds                              360-global evaluations
                                                          Teaching Rounds                          GTE in-service exam
                                                          Conferences
            Practice-Based Learning                       Quarterly M&M Conference                 360-global evaluations
                                                          Work Rounds                              Direct Observation

            Interpersonal Skills                          Work Rounds                              360-global evaluations
            Professionalism                               Work Rounds                              360-global evaluations
                                                          Conferences
            Systems-Based Practice                        Committee Participation                  360-global evaluations
                                                          Grand Rounds (GI & Medical)
                                                          Conferences

The M.D. Anderson Inpatient Consult Service provides primary fellow exposure to gastrointestinal oncologic patients and career-related
experiences in a community gastroenterology practice setting. All Service responsibilities reflect the teaching and evaluation of all six
competencies. Day-to-day patient care, related teaching and the curriculum conferences during the rotation are the greatest elements that teach
the competencies, and the global evaluation (provided for each rotation) is the most important single measurement device. In addition to didactic
learning, medical center committee participation is encouraged to bolster system-wide knowledge and practice management understanding.

Revised
May 09 Frank Lukens




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                                              UT M.D. Anderson Cancer Center
                                           Outpatient Clinic & Endoscopy Rotation
                                            Curriculum for Year I, II & III Fellows

Educational Purpose:
The Outpatient Clinic and Endoscopy rotation at The University of Texas M.D. Anderson Cancer Center (UTMDACC) provides a unique
opportunity for fellows in training to see patients referred to the outpatient facilities regarding specific issues related to gastrointestinal cancer
problems that often include complex cases, referrals from outside physicians, and second or third opinions regarding diagnosis and
management. . Working one-on-one with faculty in the Endoscopy Unit and clinics provides close interaction between fellows and staff in the
effective analysis of a very wide range of gastrointestinal problems, and the effective management and efficiency of operations related to
outpatient procedures.

The outpatient experience provides an opportunity to relate to family members who often accompany patients to the UTMDACC. The effective
use of symptomatic treatment, as well as specific treatment for structural pathological conditions is emphasized. Fellows will attend outpatient
clinic patient and procedures. Fellows will be assigned 2-4 clinic days per week.

Objectives:
During this rotation the trainee should develop a sound knowledge of tumor biology and develop a thorough familiarity with the literature on
cancer epidemiology, primary prevention, and screening for colorectal cancer. They should become knowledgeable about the recommended
guidelines for screening gastrointestinal neoplasia. It is important for them to have a working knowledge of clinical genetics and understand the
approaches to the genetic diagnosis of FAP, HNPCC and other polyposis syndromes. They should become familiar with the pathologic
interpretations of tissues biopsies. An emphasis should be made in learning the principles of chemotherapy for gastrointestinal cancer and
radiation treatment for early and advanced tumors.

In this outpatient rotation the trainee should understand how to counsel patients who have had gastrointestinal neoplasia and how to manage
patients who inquire the management of positive family histories of gastrointestinal cancer. In addition to this, the trainee should understand the
appropriate surveillance and surveillance intervals for patients at high risk for developing cancer and those in whom premalignant lesions have
been detected

During this important rotation fellows will be responsible for evaluation and management of outpatients who are scheduled for elective
procedures which include, but are not limited to:
  • EGD with or without biopsy, dilation, polypectomy, esophageal banding, stent placement, tumor ablation
  • Colonoscopy with or without biopsy, polypectomy, stent placement, tumor ablation
  • Enteroscopy with or without biopsy, stent placement
PEG/PEJ placement


Minimum levels of achievement in each competency are expected during each of the three years of fellowship training. Those meeting
competency will receive a score of 5 in the program’s evaluation system. Fellows performing at a level better than expected for that competency
receive a score of 6 or 7 in the evaluation system, those at a level better than most fellows at that PGY receive an 8, and those performing at a
level deemed to be “one of the best fellows ever observed” will receive a score of 9. Fellows receiving a score of 4 or below are deemed
deficient in that competency; this will be brought to the attention of the program director immediately, and, if necessary, remediation will be
implemented.

The following are the goals and objectives for each competency at each level of training for the Outpatient Clinic and Endoscopy rotation at
UTMDACC:

                                                                     Year I Fellow:

Goal: A Year I fellow should be able to assess new patient problems. This rotation exposes fellows to both acute and chronic outpatient
gastrointestinal oncological pathology. They will formulate and execute a treatment plan with guidance and teach basic gastroenterology skills to
medical students and other trainees. Year I fellows should begin to develop basic procedural competencies in diagnostic upper endoscopy and
colonoscopy.




Patient Care Objectives:

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     Perform an accurate physical examination and present information concisely with an initial assessment plan. Follow the patient’s disease
     course from visit to visit with possible. With attending consultation, formulate and execute an impression and a list of recommendations.
     When indicated, consent patients for procedures and order appropriate diagnostic tests (e.g., endoscopy, radiologic tests, etc.) in
     conjunction with the primary/referring service.
     Perform with supervision the following basic procedures:
               o Colonoscopy
                                By completion of Year I a fellow should be able to perform a diagnostic colonoscopy to the cecum with limited
                                assistance.
               o EsophagoGastroDuodenoscopy (EGD or Upper Endoscopy)
                                By completion of Year I a fellow should be able to perform a diagnostic endoscopy to the second portion of the
                                duodenum.

     Fellows will have formal instruction and clinical experience and will demonstrate competence in:
     o Primary prevention, and screening for colorectal cancer
     o Knowledge about the recommended guidelines for other screening gastrointestinal neoplasia
     o Basic learning principles of chemotherapy for gastrointestinal cancer
     o Basic learning principles of radiation therapy for early and advanced tumors
     o Counseling patients who have or have had gastrointestinal neoplasia
     o Understand the appropriate surveillance and surveillance intervals for patients at high risk for developing cancer and those in whom
          premalignant lesions have been detected


     Learn to provide outpatient care that is safe and compassionate and to develop the ability to thoroughly and clearly educate the patient in
     the relevant areas of disease prevention, detection, progression and therapy to promote health.

Medical Knowledge Objectives:
    Attend core conferences and teaching rounds to learn the pathophysiology, epidemiology, disease management and procedures and
    medicine management skills for common and uncommon gastrointestinal oncological diseases including:

o    Primary prevention, and screening for colorectal cancer
o    Knowledge about the recommended guidelines for other screening gastrointestinal neoplasia
o    Basic learning principles of chemotherapy for gastrointestinal cancer
o    Basic learning principles of radiation therapy for early and advanced tumors
o    Counseling patients who have or have had gastrointestinal neoplasia
o    Understand the appropriate surveillance and surveillance intervals for patients at high risk for developing cancer and those in whom
     premalignant lesions have been detected

     Accumulate and begin to solve the issues that he/she encounters from other trainees, attendings and related medical professionals.
     Teach medical students the basics of gastroenterology and hepatology care.
     Achieve an average percentile score of at least 61.18 on the “General” section of the in-service Gastroenterology Training Examination
     (GTE) exam. This score is the national average on this exam for Year I fellows.
     By end of Year I, pass the Internal Medicine Board Examination.

Practice-Based Learning Objectives:
    Become familiar with the concepts of quality improvement.
    Participate in conferences such as M&M, geared to the programmatic review of adverse events.
    Begin to review, analyze and utilize scientific evidence from the gastroenterology literature for the management of patients with GI
    oncological diseases.
    Learn the best practice patterns to facilitate gastrointestinal disease care through clinic operating procedures and patient interactions.

Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable and
     compassionate manner. Convey bad news compassionately and honestly.
     Learn to communicate effectively with staff, peers, attending gastroenterologists/hepatologists, referring physicians and other consultants.


Professionalism Objectives:
    Learn to understand and demonstrate professional behavior in daily activities.
    Participate in professionalism-based learning activities through conferences.
    Learn to interact collegially with his/her peer group and other healthcare professionals.
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     Learn to practice ethical principles with relation to patient care and confidentiality.
     Learn to practice appropriate interactions with pharmaceutical representatives and be unbiased in prescribing habits.
     Learn to be sensitive to cultural, age, gender and disability issues.
     Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues.
     Participate in program planning.

Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Achieve basic understanding of healthcare systems related to gastrointestinal oncology care and overall system activities.
    Learn proper documentation skills to practice cost-effective care.
    Utilize an appropriate range of healthcare professionals to care for patients, working closely with social services to maximize patient care
    and understanding the role of hospice, referring appropriately when needed.
    Begin involvement to understand the standard operating procedures and quality improvement initiatives within the hospital.
    Attend national gastroenterology conferences (e.g., ACG and endoscopy training courses).


                                                                  Year II Fellow:

Goal: A Year II fellow should learn to assess and care for a larger volume of outpatients and learn and teach basic textbook and evidence-based
medicine to medical students and other trainees. Year II fellows should independently perform diagnostic upper endoscopy and colonoscopy
and begin to perform therapeutic maneuvers.

Patient Care Objectives:
     Complete a time-efficient history and physical examination.
     Critique the work and orders of Year I fellows.
     Direct the Year I fellows successfully with the appropriate level of intervention for each trainee’s skills.
     Complete competency-level performance of the following basic procedures:
                o Colonoscopy
                               By completion of Year II, master all Year I colonoscopic skill requirements. Additionally, perform endoscopic
                               maneuvers, including snare polypectomy and begin to develop competency in control of GI bleeding: sclerotherapy
                               and thermal coagulopathy of bleeding vessels.
                o Upper Endoscopy
                               By completion of Year II, master all Year I upper endoscopic skill requirements. Additionally, begin to develop
                               competency in performing therapeutic maneuvers: banding and sclerosing of varices, and sclerotherapy and
                               thermal coagulopathy of bleeding vessels. Gastrostomy feeding tube placement (PEG).

     Fellows will have formal instruction and clinical experience and demonstrate competence in:
     o Knowledge of clinical genetics and understand the approaches to the genetic diagnosis of FAP, HNPCC and other polyposis
          syndromes
     o Familiarity with pathologic interpretations of tissues biopsies
     o Diagnosis of GI and hepatic complications of bone marrow transplant (including specifically graft versus host disease, venoocclusive
          disease, opportunistic infection) that present to the outpatient setting
     o Diagnosis of GI complications of chemotherapy and radiation therapy, including anemia, thrombocytopenia and neutropenia that
          present to the outpatient setting
     o Complicated acid-peptic diseases


     Present cases succinctly in a direct manner.
     Know the Outpatient Service’s patients at a management level.
     Handle consult calls respectfully and appropriately.
     Teach good symptom management skills to medical students and other trainees.
     Provide outpatient care that is safe and compassionate and develop the ability to thoroughly and clearly educate the patient in the relevant
     areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.

Medical Knowledge Objectives:
    Begin to take a leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease
    management and procedures and medicine management skills for common and uncommon outpatient gastrointestinal diseases including:


o    Knowledge of clinical genetics and understand the approaches to the genetic diagnosis of FAP, HNPCC and other polyposis syndromes
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o    Familiarity with pathologic interpretations of tissues biopsies
o    Diagnosis of GI and hepatic complications of bone marrow transplant (including specifically graft versus host disease, venoocclusive
     disease, opportunistic infection) that present to the outpatient setting
o    Diagnosis of GI complications of chemotherapy and radiation therapy, including anemia, thrombocytopenia and neutropenia that present to
     the outpatient setting
o    Complicated acid-peptic diseases

     Organize the team’s performance at teaching rounds.
     Read textbook and pertinent literature materials concerning problems encountered.
     Teach medical students and other trainees about gastrointestinal oncological disease states and patient management.
     Achieve an average percentile score of at least 62.98 on the “General” section of the in-service Gastroenterology Training Examination
     (GTE) exam. This score is the national average on this exam for Year II fellows

Practice-Based Learning Objectives:
    Participate in project groups, committees and hospital groups when requested.
    Participate in programmatic reviews and conferences studying adverse events.
    Give usable feedback to medical students and other trainees based on observation of their performance and assess improvement.
    Participate in problem-based quality improvement projects.
    Review, analyze and utilize scientific evidence from the gastroenterology literature for the management of patients with GI oncological
    diseases.
    Know the best practice patterns to facilitate gastrointestinal care through clinic operating procedures and patient interactions.


Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner.
     Convey bad news compassionately and honestly.
     Plan patient and family conferences.
     Counsel patients about transitioning to palliative care, when needed.
     Address or refer patients related to spiritual or existential issues.
     Communicate effectively with staff, peers, attending hepatologists/gastroenterologists, referring physicians and other consultants.
     Present cases succinctly, in a problem-based, direct manner.
     Learn to become a teacher of gastroenterology to junior trainees, medical students and other healthcare professionals.

Professionalism Objectives:
    Begin to mentor medical students, other trainees and Year I fellows in professional conduct.
    Understand and demonstrate professional behavior in daily activities.
    Participate in professionalism-based learning activities through conferences.
    Interact collegially with his/her peer group and other healthcare professionals, including acting responsibly in the larger context of pursuing
    programmatic successes.
    Practice ethical principles with relation to patient care and confidentiality.
    Practice interactions with pharmaceutical representatives and be unbiased in prescribing habits.
    Practice sensitivity to cultural, age, gender and disability issues.
    Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues.
    Participate in program planning.

Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Understand and be able to work effectively related to hospital functions within M.D. Anderson Cancer Center
    Understand and practice proper documentation skills to practice cost-effective care.
    Assist other trainees in the utilization of appropriate healthcare resources for the best care of the Outpatient GI Oncology Consultative
    Service’s patients.
    Model appropriate interactions in multidisciplinary planning, including standard operating procedures and quality improvement initiatives.
    Attend national gastroenterology or hepatology conferences (e.g., DDW or AASLD).




                                                                 Year III Fellows:

Goal: The senior-level, Year III fellow should demonstrate rapid assessment and planning skills and near-attending level care planning and
80 | P a g e
management, while teaching medical students and other trainees at near to or exceeding attending level teaching. Year III fellows should be
able to perform diagnostic and therapeutic upper endoscopy and colonoscopy procedures independently

Patient Care Objectives:
     Master the Year II fellow objectives.
     Demonstrate efficient organization of the Outpatient Service and a working knowledge of all patients.
     Demonstrate near-attending level capacity for program assessment and care planning.
     Attain trainer level proficiency in the following procedures pertinent to his/her career choices:
                o Colonoscopy
                                 By completion of Year III, master all Year II colonoscopic skill requirements. Additionally, be able to independently
                                 intubate the terminal ileum and begin to develop independent mastery of more advanced maneuvers, e.g., removal
                                 of large or complex polyps by saline assisted polypectomy or piecemeal resection and control of bleeding using
                                 clips or argon plasma laser coagulation. Assist in stent placent.
                o Upper Endoscopy
                                 By completion of Year III, master all Year II endoscopic skill requirements. Additionally, be able to pass a side
                                 viewing scope to identify the papilla or lesions difficult to observe with forward viewing scope and perform
                                 advanced maneuvers, such as placing clips on bleeding vessels or argon plasma laser coagulopathy. Assist in
                                 stent placing.
                      o Small bowel enterosocopy

     Fellows will have formal instruction and clinical experience and demonstrate competence in:

o    Difficult to treat gastrointestinal opportunistic infections related to chemotherapy
o    Barrett’s Esophagus
o    Neuroendocrine gastrointestinal malignancies
o    Obscure gastrointestinal bleeding in oncological patients
o    Nutrition counseling in oncological patients

     Provide outpatient care that is safe and compassionate with the leadership ability to thoroughly and clearly educate the patient and all other
     trainees regarding relevant areas of disease prevention, detection, progression and therapy to promote gastroitestinal health.

Medical Knowledge Objectives:
    Access and critique the medical literature regarding gastroenterology problems encountered in oncological patients.
    Assume the trainee leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease
    management, procedures and medicine management skills for common and uncommon outpatient gastrointestinal diseases including:

o    Difficult to treat gastrointestinal opportunistic infections related to chemotherapy
o    Barrett’s Esophagus management
o    Neuroendocrine gastrointestinal malignancies
o    Obscure gastrointestinal bleeding in oncological patients
o    Nutrition counseling in oncological patients


     Teach medical students, other trainees and Year I & II fellows at near-attending level.
     Prepare for the ABIM certifying exam throughout the year.
     Organize team activities in a smooth and authoritative fashion.
     Assist Year II fellows’ development directly at teaching conferences and indirectly at work sites.
     Achieve an average percentile score of at least 64.07 on the “General” section of the in-service Gastroenterology Training Examination
     (GTE) exam. This score is the national average on this exam for Year III fellows.


Practice-Based Learning Objectives:
    Demonstrate mastery of Year II fellow skills and encourage participation of colleagues.
    Review, analyze and utilize scientific evidence from the gastroenterology literature for the management of patients with gastrointestinal
    problems, taking a leadership role in guiding Year I & II fellows and sharing relevant literature reviews with them.
    Know and be able to succinctly communicate the best practice patterns to facilitate gastrointestinal disease care through clinic operating
    procedures and patient interactions.

Interpersonal Communication Skill Objectives:

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     Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner.
     Convey bad news compassionately and honestly.
     Supervise Year I & II fellows’ work related to planning patient/family conferences and patient communications/counseling.
     Communicate effectively as a consultant with staff, peers, attending gastroenterologists, referring physicians and other consultants and lead
     other trainees related to appropriate fellow-to-medical-professional communications.
     Present cases succinctly, in a problem-based, direct manner.
     Assume the role of a teacher of gastroenterology to junior trainees, medical students and other healthcare professionals.

Professionalism Objectives:
    Demonstrate proficiency in Year II objectives.
    Mentor medical students, other trainees and fellows in professional conduct.
    Assist in formal teaching exercises as requested.
    Assert leadership in program planning.

Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Assist and mentor other trainees in utilization of appropriate M.D. Anderson Cancer Center healthcare resources for the best care of the GI
    outpatient service patients, including proper documentation skills.
    Model appropriate interactions in multidisciplinary planning, including improvements related to standard operating procedures and quality
    improvement initiatives.
    Participate in hospital and national medical association committees and multidisciplinary planning groups when requested.
    Attend national conferences directed at career goals.
    Demonstrate near-attending level utilization of overall systems of care.

Teaching Methods:
Gastroenterology fellows participate in the Outpatient Clinic and Endoscopy rotation at The University of Texas M.D. Anderson Cancer Center
Service during all three fellowship years. One fellow is assigned to the Outpatient Service during all rotations. Teaching of medical students,
residents and other trainees as well as appropriate interactions with other healthcare providers are important aspects of this rotation.
Participating in all required conferences is mandatory, and rounding is an integral part of this experience. As fellows gain experience throughout
their training, skills of organization and efficiency as well as team leadership become increasingly important.

This Outpatient experience will prepare the fellow to evaluate and manage acute and chronic gastrointestinal oncological diseases commonly
seen that will be encountered in his future practice. They are to become knowledgeable about the recommended guidelines for screening
gastrointestinal neoplasia. This rotation will expose the fellow to a wide variety of problems seen in patients with gastrointestinal malignancies.

 Fellows will learn to incorporate and interact with a multidisciplinary team at the Outpatient M.D. Anderson Clinic. They will learn to share patient
co-management responsibilities with surgeons, oncologists and other members of this team.

Fellows assigned to this service will rotate through the Outpatient Center. Fellows will evaluate each patient and will make initial
recommendations regarding diagnostic tests and treatments. They will make arrangements for studies such as GI endoscopic procedures. They
will review the appropriateness of the procedure with the attending before making final scheduling plans. The fellow will follow each patient
under active consultation on a regular basis, will make further recommendations as indicated and will keep the attending informed of the patient’s
status. Fellows must also communicate with the procedure fellow for all diagnostic studies.

Disease Mix:
Fellows see a complete mix of gastrointestinal diseases including gastrointestinal cancers at M.D. Cancer Center. This Center has a substantial
primary care basis for patients with oncological diseases, which provides the entire spectrum of internal medicine diagnoses and gastrointestinal
care.

In addition to a wide variety of gastrointestinal pathology the fellow will also be exposed to conditions that range from pancreatitis, inflammatory
bowel disease, and functional GI motility and pain disorders. There is an appropriate concentration of common gastrointestinal diseases such as
peptic ulcer disease, gastroesophageal reflux disease and gastrointestinal infections. In particular, M.D. Anderson Cancer Center is a national
and international referral center, and there is outstanding diversity of unusual diagnoses in the teaching services.


Patient Characteristics:
The Outpatient Consult Service at The University of Texas M.D. Anderson Cancer experience offers a diverse mix of socioeconomic and gender
status. Teaching faculty provide an abundant supply of upper- and middle-class patients, and our contracts with medical assistance and pro
bono care efforts ensure access to lower-income patients. Due to a primary care base simultaneous with the hospitals’ constantly active
referrals, patients are seen in both acute status and in diagnostic dilemma status, with both common and uncommon disorders.
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Types of Clinical Encounters – Attending Supervision:
Fellows provide consultative care under the supervision of an attending within duty hour limits and with faculty back up for situations of overload.
 Daily attending supervision is available seven days per week. The attending has ultimate responsibility for patients.

Procedures:
During the Outpatient Service procedures are performed during daytime hours in the GI lab by the fellow under the direct supervision of the
attending. Procedure based evaluation is performed twice per year by a supervising attending.

Evaluation:
Fellows are evaluated during the Outpatient Service rotation and are expected to participate in the evaluation of other fellows as well. This
occurs in the following forms:
     Detailed, automated evaluations using the GMEIS system are submitted for each rotation. These evaluations are reflective of the program’s
     curriculum requirements. Attendings evaluate fellows, and the fellows evaluate the attendings as well. Quarterly evaluations include:
                o 360-degree (attending, nurse, nurse practitioner, staff/clerical, etc.);
                o Peer-reviewed; and
                o Patient.
     Evaluation summaries become part of the fellows’ and attendings’ promotional documents.
     The fellow also evaluates the Gastroenterology Fellowship Program annually through a confidential basis.
     Attendings evaluate the Gastroenterology Fellowship Program annually.
     A Curriculum Committee oversees major changes to the curriculum. Representative program personnel (i.e., program director,
     representative faculty and at least one fellow) are organized to review program goals and objectives and the effectiveness with which they
     are achieved. This group conducts a formal documented meeting at least annually for this purpose. In the evaluation process, the group
     must take into consideration written comments from the faculty, the most recent report of the GMEC of the sponsoring institution and the
     residents’ confidential written evaluations. If deficiencies are found, the group will prepare an explicit plan of action, which should be
     approved by the faculty and documented in the minutes of the meeting.
     The Program Director meets with all fellows individually twice per year.
     An in-service GTE exam is given to all fellows annually.

Bibliography:
     Resource Documents
               o Up-To-Date
               o PubMed
               o Textbook of Gastroenterology – Yamada, et.al.
               o Gastrointestinal Diasese: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.
               o Diseases of the Liver - Leon Schiff and Eugene Schiff
               o Zakim and Boyer’s Hepatology: A Textbook of Liver Disease
               o Major Gastroenterology journals online and in the program’s fellow library including Gastroenterology, American Journal of
                    Gastroenterolgy, Gut, Hepatology, Liver Transplantation, Journal of Hepatology and other major publications.
     Curricular Design
               o ACGME Outcome Project documentation (from www.acgme.org).
               o Graduate Education in Internal Medicine: A Resource Guide to Curriculum Development
               o The report of the Federated Council for Internal Medicine Task Force on the Internal Medicine Residency Curriculum, 1997.
     Pertinent Teaching References:
               o Textbook of Gastroenterology – Yamada, et.al.
               o Gastrointestinal Diasese: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.
               o Diseases of the Liver - Leon Schiff and Eugene Schiff
               o Zakim and Boyer’s Hepatology: A Textbook of Liver Disease


                                                          Competencies-at-a-Glance
                                                   M.D. Anderson Outpatient Consult Service


                        COMPETENCY                         LEARNING OPPORTUNITY                              EVALUATION
             Patient Care                                  Work Rounds                                360-global evaluations
                                                           Teaching Rounds                            GTE in-service exam
                                                           Conferences                                Direct Observation

             Medical Knowledge                              Work Rounds                               360-global evaluations
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                                                          Teaching Rounds                          GTE in-service exam
                                                          Conferences
            Practice-Based Learning                       Quarterly M&M Conference                 360-global evaluations
                                                          Work Rounds                              Direct Observation

            Interpersonal Skills                          Work Rounds                              360-global evaluations
            Professionalism                               Work Rounds                              360-global evaluations
                                                          Conferences
            Systems-Based Practice                        Committee Participation                  360-global evaluations
                                                          Grand Rounds (GI & Medical)
                                                          Conferences

The M.D. Anderson Outpatient Consult Service provides primary fellow exposure to gastrointestinal oncologic patients and career-related
experiences in a community gastroenterology practice setting. All Service responsibilities reflect the teaching and evaluation of all six
competencies. Day-to-day patient care, related teaching and the curriculum conferences during the rotation are the greatest elements that teach
the competencies, and the global evaluation (provided for each rotation) is the most important single measurement device. In addition to didactic
learning, medical center committee participation is encouraged to bolster system-wide knowledge and practice management understanding.

Revised
May 09 Frank Lukens




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                                                   The Methodist Hospital
                                                          Rotation
                                              Curriculum for Year II & III Fellows

Educational Purpose:

The Methodist Hospital introduces the fellow to both outpatient and inpatient hospital management of patients with gastrointestinal diseases.
During this four-week rotation, fellows will work directly with faculty and community-based gastroenterologists for both clinic and inpatient work.
During this period, the fellow will have the opportunity to assess a wide variety of acute and chronic gastrointestinal conditions and will receive
specialized exposure to advanced endoscopic procedures; given that The Methodist Hospital is a facility that takes care of a significant number
of outside patient referrals for these types of procedures. The fellow will participate in increasing levels of management/ treatment involvement
with patient needs and procedures, depending on the fellow’s level of experience. The fellow will be expected to formulate the differential
diagnosis, institute diagnostic studies and recommend therapy. The amount of learning obtained from this rotation is directly proportional to the
amount of time spent in the evaluation of the patients.

Objectives:

Fellows will learn all aspects of inpatient and outpatient gastrointestinal care and will display all general competencies during this experience.
Minimum levels of achievement in each competency are expected during each of the three years of fellowship training. Those meeting
competency will receive a score of 5 in the program’s evaluation system. Fellows performing at a level better than expected for that competency
receive a score of 6 or 7 in the evaluation system, those at a level better than most fellows at that PGY receive an 8, and those performing at a
level deemed to be “one of the best fellows ever observed” will receive a score of 9. Fellows receiving a score of 4 or below are deemed
deficient in that competency; this will be brought to the attention of the program director immediately, and, if necessary, remediation will be
implemented.

The following are the goals and objectives for each competency at each level of training for The Methodist Hospital Rotation:

Year II Fellow:

Goal: A Year II fellow should learn to assess and care for a larger volume of patients and learn and teach basic textbook and evidence-based
medicine to medical students and other trainees. Year II fellows should independently perform diagnostic upper endoscopy and colonoscopy
and begin to perform therapeutic maneuvers.

Patient Care Objectives:
     Complete a time-efficient history and physical examination.
     Complete competency-level performance of the following basic gastroenterology procedures:
              o Colonoscopy
                              By completion of Year II, master all Year I colonoscopic skill requirements. Additionally, perform endoscopic
                              maneuvers, including snare polypectomy and begin to develop competency in control of GI bleeding: sclerotherapy
                              and thermal coagulopathy of bleeding vessels.
              o Upper Endoscopy
                              By completion of Year II, master all Year I upper endoscopic skill requirements. Additionally, begin to develop
                              competency in performing therapeutic maneuvers: banding and sclerosing of varices, and sclerotherapy and
                              thermal coagulopathy of bleeding vessels.
              o ERCP and EUS
                              Should understand the indications of these procedures as well as risks and benefits of such procedures.
                              Passage of side viewing endoscope and visualization of the ampulla of vater.

     Develop clear expertise in the diagnosis and management of acute and chronic inpatient gastrointestinal diseases including:
              o Neuroendocrine diagnosis
              o Intestinal/colonic pseudobstruction
              o Secretory diarrheal states
              o Idiopathic abdominal pain
              o Upper & lower GI bleeding
              o Peptic ulcer disease
              o Inflammatory bowel disease
              o GI infections

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              o Pancreatitis (acute and chronic)
              o Ischemic colitis
              o Bile duct stones
              o Biliary and liver cancer
              o Post-operative injuries to the liver, bile ducts and pancreas
              o Barrett’s Esophagus
    Present cases succinctly in a direct manner.
    Know The Methodist Hospital patients at a management level.
    Handle consult calls respectfully and appropriately.
    Teach good symptom management skills to other trainees.
    Provide inpatient care that is safe and compassionate and develop the ability to thoroughly and clearly educate the inpatient in the relevant
    areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.

Medical Knowledge Objectives:
    Begin to take a leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, disease
    management and procedures and medicine management skills for common and uncommon inpatient gastrointestinal diseases including:
              o Neuroendocrine diagnosis
              o Intestinal/colonic pseudobstruction
              o Secretory diarrheal states
              o Idiopathic abdominal pain
              o Upper & lower GI bleeding
              o Peptic ulcer disease
              o Inflammatory bowel disease
              o GI infections
              o Pancreatitis (acute and chronic)
              o Ischemic colitis
              o Colon cancer
              o Pancreatitic cancer
              o Bile duct stones
              o Biliary and liver cancer
                             Post-operative injuries to the liver, bile ducts and pancreas
              o Barrett’s Esophagus
    Organize the team’s performance at teaching rounds.
    Read textbook and pertinent literature materials concerning problems encountered, especially related to GI cancers
    Teach other trainees about GI disease states and patient management.
    Achieve an average percentile score of at least 62.98 on the “General” section of the in-service Gastroenterology Training Examination
    (GTE) exam. This score is the national average on this exam for Year II fellows.

Practice-Based Learning Objectives:
    Participate in project groups, committees and hospital groups when requested.
    Participate in programmatic reviews and conferences studying adverse events.
    Give usable feedback to medical students and other trainees based on observation of their performance and assess improvement.
    Participate in problem-based quality improvement projects.
    Review, analyze and utilize scientific evidence from the gastrointestinal literature for the management of GI patients.
    Know the best practice patterns to facilitate gastroenterology care through clinic operating procedures and patient interactions.

Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner.
     Convey bad news compassionately and honestly.
     Plan patient and family conferences.
     Counsel patients about transitioning to palliative care, when needed.
     Address or refer patients related to spiritual or existential issues.
     Communicate effectively with staff, peers, attending gastroenterologists, referring physicians and other consultants.
     Present cases succinctly, in a problem-based, direct manner.
     Learn to become a teacher of gastroenterology to junior trainees, medical students and other healthcare professionals.

Professionalism Objectives:
    Begin to mentor other trainees in professional conduct.
    Understand and demonstrate professional behavior in daily activities.
    Participate in professionalism-based learning activities through conferences.
86 | P a g e
     Interact collegially with his/her peer group and other healthcare professionals, including acting responsibly in the larger context of pursuing
     programmatic successes.
     Practice ethical principles with relation to patient care and confidentiality.
     Practice interactions with pharmaceutical representatives and be unbiased in prescribing habits.
     Practice sensitivity to cultural, age, gender and disability issues.
     Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues.
     Participate in program planning, including annual Faculty Meeting attendance, Fellow Curriculum Committee participation and Program
     Director meetings, when requested.

Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Understand and be able to work effectively related to hospital functions within The Methodist Hospital.
    Understand and practice proper documentation and billing skills to practice cost-effective care.
    Assist other trainees in the utilization of appropriate healthcare resources for the best care of the GI Hospital Service’s patients.
    Model appropriate interactions in multidisciplinary planning, including standard operating procedures and quality improvement initiatives.
    Attend national gastroenterology or hepatology conferences (e.g., DDW or AASLD).



Year III Fellows:

Goal: The senior-level, Year III fellow should demonstrate rapid assessment and planning skills and near-attending level care planning and
management, while teaching other trainees at near to or exceeding attending level teaching. Year III fellows should be able to perform diagnostic
and therapeutic upper endoscopy and colonoscopy procedures independently.

Patient Care Objectives:
     Master the Year II fellow objectives.
     Demonstrate efficient organization of The Methodist Hospital and a working knowledge of all patients.
     Demonstrate near-attending level capacity for program assessment and care planning.
     Attain trainer level proficiency in the following gastroenterology procedures pertinent to his/her career choices:
                o Colonoscopy
                                 By completion of Year III, master all Year II colonoscopic skill requirements. Additionally, be able to independently
                                 intubate the terminal ileum and begin to develop independent mastery of more advanced maneuvers, e.g., removal
                                 of large or complex polyps by saline assisted polypectomy or piecemeal resection and control of bleeding using
                                 clips or argon plasma laser coagulation.

               o    Upper Endoscopy
                            By completion of Year III, master all Year II endoscopic skill requirements. Additionally, be able to pass a side
                            viewing scope to identify the papilla or lesions difficult to observe with forward viewing scope and perform
                            advanced maneuvers, such as placing clips on bleeding vessels or argon plasma laser coagulopathy.

               o    ERCP
                              Cannulation of bile duct and perform sphincterotomy and placement of bile duct stents.
                                  • Pancreatic divisum
                                  • Congential biliary abnormalities
                                  • Biliary strictures and primary sclerosing cholangitis
                                  • Management of bile duct injuries related to trauma

     Secure expertise in the diagnosis and management of acute and chronic inpatient gastrointestinal diseases including:
              o Neuroendocrine diagnosis
              o Intestinal/colonic pseudobstruction
              o Secretory diarrheal states
              o Idiopathis abdominal pain
              o Upper & lower GI bleeding
              o Peptic ulcer disease
              o Inflammatory bowel disease
              o GI infections
              o Pancreatitis (acute and chronic)
              o Ischemic colitis

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               o    Colon cancer
               o    Barrett’s Esophagus
               o    Pancreatic Cancer
               o    Bile duct stones

     Secure expertise in the diagnosis and management of acute and chronic inpatient pancreaticobiliary diseases including:
              o Acute Pancreatitis
              o Chronic Pancreatitis
              o Pancreatic Cancer
              o Pancreatic divisum
              o Congenital biliary abnormalities
              o Biliary strictures and primary sclerosing cholangitis
              o Pancreatic necrosis
              o Management of bile duct injuries related to trauma
              o Bile Duct Stones
              o Liver Cancer
              o Biliary Cancer
              o Post-Operative Injuries to the Liver, Bile Ducts & Pancreas

     Provide inpatient care that is safe and compassionate with the leadership ability to thoroughly and clearly educate the inpatient and all other
     trainees regarding relevant areas of disease prevention, detection, progression and therapy to promote gastrointestinal health.

Medical Knowledge Objectives:
    Access and critique the medical literature regarding gastroenterology and hepatology problems encountered.
    Assume the trainee leadership role at core conferences and teaching rounds regarding the pathophysiology, epidemiology, cancer
    screening, disease management, procedures and medicine management skills for common and uncommon inpatient gastrointestinal
    diseases including
              o Neuroendocrine diagnosis
              o Intestinal/colonic pseudobstruction
              o Secretory diarrheal states
              o Idiopathic abdominal pain
              o Upper and lower GI bleeding
              o Peptic ulcer disease
              o Inflammatory bowel disease
              o GI infections
              o Pancreatitis
              o Ischemic colitis
              o Colon cancer
              o Barrett’s Esophagus
              o Pancreatic Cancer
              o Pancreatic divisum
              o Congenital biliary abnormalities
              o Biliary strictures and primary sclerosing cholangitis
              o Pancreatic necrosis
              o Management of bile duct injuries related to trauma

     Teach medical students, other trainees and Year II fellows at near-attending level.
     Prepare for the ABIM certifying exam throughout the year.
     Organize team activities in a smooth and authoritative fashion.
     Assist Year II fellows’ development directly at teaching conferences and indirectly at work sites.
     Achieve an average percentile score of at least 64.07 on the “General” section of the in-service Gastroenterology Training Examination
     (GTE) exam. This score is the national average on this exam for Year III fellows.

Practice-Based Learning Objectives:
    Demonstrate mastery of Year II fellow skills and encourage participation of colleagues.
    Review, analyze and utilize scientific evidence from the gastrointestinal literature for the management of GI patients, taking a leadership role
    in guiding Year I & II fellows and sharing relevant literature reviews with them.
    Know and be able to succinctly communicate the best practice patterns to facilitate gastroenterology care through clinic operating
    procedures and patient interactions. Attend to the special requirements of a gastroenterologist in a community practice setting.

88 | P a g e
Interpersonal Communication Skill Objectives:
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner.
     Convey bad news compassionately and honestly.
     Supervise Year II fellows’ work related to planning patient/family conferences and patient communications/counseling.
     Communicate effectively as a consultant with staff, peers, attending gastroenterologists, referring physicians and other consultants and lead
     other trainees related to appropriate fellow-to-medical-professional communications.
     Present cases succinctly, in a problem-based, direct manner.
     Assume the role of a teacher of gastroenterology to junior trainees, medical students and other healthcare professionals.

Professionalism Objectives:
    Demonstrate proficiency in Year II objectives.
    Mentor Year II fellows in professional conduct.
    Assist in formal teaching exercises as requested.
    Assert leadership in program planning, including fellow participation in the annual Faculty/Fellow Meeting, Fellow Curriculum Committee and
    Conference Planning Committees.

Systems-Based Practice Objectives:
    Attend conferences concerning healthcare system patient management and components of systems of healthcare.
    Assist and mentor other trainees in utilization of appropriate The Methodist Hospital healthcare resources for the best care of the GI Hospital
    Service’s patients, including proper documentation and billing skills.
    Model appropriate interactions in multidisciplinary planning, including improvements related to standard operating procedures and quality
    improvement initiatives.
    Participate in hospital and national medical association committees and multidisciplinary planning groups when requested.
    Attend national conferences directed at career goals.
    Demonstrate near-attending level utilization of overall systems of care.

Teaching Methods:
Gastroenterology fellows participate in The Methodist Hospital during their second or third fellowship years. One fellow is assigned to this service
during all rotations. Teaching of residents and other trainees as well as appropriate interactions with other healthcare providers are important
aspects of this rotation. Participating in all required conferences is mandatory, and rounding is an integral part of this experience. As fellows
gain experience throughout their training, skills of organization and efficiency as well as team leadership become increasingly important.

The Methodist Hospital Rotation experience will prepare the fellow to evaluate and manage acute and chronic gastrointestinal illnesses that will
be encountered in the fellow’s future practice. Inpatient rounding, clinic responsibilities and exposure to gastroenterology in a community
practice setting will be part of this rotation. The Methodist Hospital Rotation will expose the fellow to a wide variety of acute abdominal
inflammatory processes, major gastrointestinal hemorrhages, pancreatico-biliary pathology and a wide variety of gastrointestinal problems.

Fellows assigned to this rotation will evaluate all new consults at The Methodist Hospital and will be assigned to a continuity clinic one-half day
per week. They will present new consults to the attending by the following day for routine consults and as soon as possible for emergencies.
Fellows will evaluate each patient and will make initial recommendations regarding diagnostic tests and treatments. They will make
arrangements for studies such as endoscopy, motility tests, biopsies, etc. They will review the appropriateness of the procedure with the
attending before making final scheduling plans. The fellow will follow each patient under active consultation on a regular basis, will make further
recommendations as indicated and will keep the attending informed of the patient’s status. Fellows must also communicate with the procedure
fellow for all diagnostic studies.

Disease Mix:
The Methodist Hospital has a substantial primary care basis, which provides the entire spectrum of internal medicine diagnoses and
gastrointestinal care, allowing the Fellows to see a complete mix of gastrointestinal diseases.

Diagnoses range from pancreatitis, inflammatory bowel disease, and functional GI motility and pain disorders to primary and secondary
gastrointestinal malignancies, and there is an appropriate concentration of common gastrointestinal diseases such as peptic ulcer disease,
gastroesophageal reflux disease and gastrointestinal infections. In particular, The Methodist Hospital is a state and international referral center,
and there is outstanding diversity of unusual diagnoses in the teaching services.

Patient Characteristics:
The Methodist Hospital Rotation experience offers a diverse mix of socioeconomic and gender status. Teaching faculty provide an abundant
supply of upper- and middle-class patients, and our contracts with medical assistance and pro bono care efforts ensure access to lower-income
patients. Due to a primary care base simultaneous with the hospitals’ constantly active referrals, patients are seen in both acute status and in
diagnostic dilemma status, with both common and uncommon disorders.
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Types of Clinical Encounters – Attending Supervision:
Encounters are inpatient in nature during The Methodist Hospital Rotation. Fellows provide 24/7 consultative care under the supervision of an
attending within duty hour limits and with faculty back up for situations of overload. Daily attending supervision is available at The Methodist
Hospital seven days per week, and in-house supervision is available all night as well. The attending has ultimate responsibility for patients.

Procedures:
During The Methodist Hospital Rotation, procedures are performed during daytime hours in the GI lab by the fellow under the direct supervision
of the attending.

Evaluation:
Fellows are evaluated during The Methodist Hospital Rotation by the faculty. This occurs in the following forms:
     Detailed, automated evaluations using the GMEIS system are submitted for each rotation. These evaluations are reflective of the program’s
     curriculum requirements. Faculty evaluate fellows, and the fellows evaluate the attending and rotation. Quarterly evaluations include:
               o 360-degree (attending, nurse, nurse practitioner, staff/clerical, etc.);
               o Peer-reviewed; and
               o Patient.
     Evaluation summaries become part of the fellows’ and attendings’ promotional documents.
     The fellow also evaluates the Gastroenterology Fellowship Program annually through a confidential basis.
     Faculty evaluate the Gastroenterology Fellowship Program annually.
     A Curriculum Committee oversees major changes to the curriculum. Representative program personnel (i.e., program director,
     representative faculty and at least one fellow) must be organized to review program goals and objectives and the effectiveness with which
     they are achieved. This group must conduct a formal documented meeting at least annually for this purpose. In the evaluation process, the
     group must take into consideration written comments from the faculty, the most recent report of the GMEC of the sponsoring institution and
     the residents’ confidential written evaluations. If deficiencies are found, the group will prepare an explicit plan of action, which should be
     approved by the faculty and documented in the minutes of the meeting.
     The Program Director meets with all fellows individually twice per year.
     An in-service GTE exam is given to all fellows annually.

Contact:
Alberto Barroso, MD and Attila Ertan MD are appointed Site Supervisors for The Methodist Hospital Rotation.

Bibliography:
     Resource Documents
               o Up-To-Date
               o PubMed
               o Textbook of Gastroenterology – Yamada, et.al.
               o Gastrointestinal Disease: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.
               o Major Gastroenterology journals online and in the program’s fellow library including Gastroenterology, American Journal of
                    Gastroenterology, Gut, and other major publications.
     Curricular Design
               o ACGME Outcome Project documentation (from www.acgme.org).
               o Graduate Education in Internal Medicine: A Resource Guide to Curriculum Development
               o The report of the Federated Council for Internal Medicine Task Force on the Internal Medicine Residency
     Pertinent Teaching References:
               o Textbook of Gastroenterology – Yamada, et.al.
               o Gastrointestinal Disease: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.




                                                           Competencies-at-a-Glance
                                                            The Methodist Hospital

                        COMPETENCY                         LEARNING OPPORTUNITY                            EVALUATION

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             Patient Care                                   Work Rounds                               360-global evaluations
                                                            Teaching Rounds                           GTE in-service exam
                                                            Conferences                               Direct Observation

             Medical Knowledge                              Work Rounds                               360-global evaluations
                                                            Teaching Rounds                           GTE in-service exam
                                                            Conferences
             Practice-Based Learning                        Quarterly M&M Conference                  360-global evaluations
                                                            Work Rounds                               Direct Observation

             Interpersonal Skills                           Work Rounds                               360-global evaluations
             Professionalism                                Work Rounds                               360-global evaluations
                                                            Conferences                               E-portfolio self-documentation

             Systems-Based Practice                         Committee Participation                   360-global evaluations
                                                            Grand Rounds (GI & Medical)
                                                            Conferences

The Methodist Hospital provides primary fellow exposure to gastrointestinal patients and career-related experiences in a community
gastroenterology practice setting. All Service responsibilities reflect the teaching and evaluation of all six competencies. Day-to-day patient care,
related teaching and the curriculum conferences during the rotation are the greatest elements that teach the competencies, and the global
evaluation (provided for each rotation) is the most important single measurement device. In addition to didactic learning, medical center
committee participation is encouraged to bolster system-wide knowledge and practice management understanding.

Revised: January 2010
Frank J. Lukens, MD
Program Director
UT Houston GI Fellowship

Contact:
Attila Ertan, M.D. and Alberto Barroso, M.D. are the coordinating physicians for The Methodist Hospital Rotation


Additional Instructions for Fellows Participating in the Methodist Rotation:

I. Patient Care
     A. Consultations/inpatient admissions: Consultations and inpatient admissions are evaluated by the fellow on service on the day they are
          called in. They are to be written up and presented to the attending on service. Additionally, the attending should be notified of any
          urgent consultations or admissions as soon as possible, particularly if a same-day procedure is anticipated.
     C. Pre-procedure evaluation: The fellow is expected to pre-round on inpatients in the morning prior to beginning the day's procedures. If
          issues arise, the attending on service should be contacted as soon as possible. A pre-review of all outpatients slated for procedures
          that day should similarly be completed. A thorough patient history, physical exam, and a review of the laboratory and radiologic data
          should be performed prior to ERCP. The history should be obtained sufficiently in advance to permit procedural changes as warranted
          (e.g., general anesthesia, correction of coagulation factors, set-up of sphincter of Oddi manometry, enrollment in an ongoing protocol,
          etc.). The attending physician and the fellow are expected to discuss the case in detail prior to proceeding, so that both are in
          agreement regarding the procedure. All inpatients should be seen daily, and a note should be written prior to attending rounds.
          Attending rounds will be performed daily after all procedures have been completed. All admissions and consultations will be seen on
          the day they are called, with rare exceptions as approved by the attending on service.
     D. Intraoperative: The fellow will assist the attending in performance of the ERCP procedure. The goals for the fellow are to build a solid
          foundation in patient assessment, approach to the procedure, endoscopic technique, and familiarity with accessories (such as wires,
          catheters, stents, etc.) as well as the workings of the ERCP team. The number of "successful cannulations, papillotomies, guide wire
          placements, etc." performed should not, by any means, be considered the ultimate measure of success. These come with time, as
          skills mature. Since the risks of therapeutic ERCP are equal to those of many surgical procedures, factors such as patient care and
          safety must remain paramount. Certain cases (high risk, difficult/prior failed procedure, pediatric, etc.) may be considered attending-
          only cases insofar as the actual performance of the procedure is concerned, and limitation of the fellow’s participation in the case will
          be at the discretion of the attending. However, the observant fellow will learn a great deal in assisting the attending and watching
          vigilantly. Such non-hands-on participation is important to the learning process.
     E. Postoperative:


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               a.   Inpatients: Postop orders are to be written immediately after the procedure is completed. Pertinent postop data must be
                    entered into the database and a preliminary report generated, signed, and placed on the chart before the patient leaves the
                    GI lab. The attending will be responsible for dictating the procedure note. All inpatients who undergo a procedure must be
                    seen on evening rounds, and a post-procedure check must be documented on the chart. The pancreatico-biliary service will
                    be responsible for ALL aspects of the immediate postoperative management, as occurs on a surgical service. The
                    pancreatico-biliary fellow on service will keep their pagers on, and will be immediately accessible within pager range, 24
                    hours a day, 5 days per week, respectively while on service, with no exceptions. On Friday, the fellow will sign out to the on-
                    call GI team. On Monday am the pancreaticobiliary fellow will take report from the GI team for Sunday’s events/admissions.
                    The pancreaticobiliary attending will leave their beepers on 24Hr/7Day to serve as a back-up for the fellow and GI team on
                    weekends for complex cases and for call-ins for emergency procedures.
               b.   Outpatients: Outpatient post-procedure follow-up mirrors the inpatient model.
               c.   If the fellow has personal business which would interfere with his/her responsibilities while on service, special coverage
                    arrangements must be made in advance with the attending. Fellow cross coverage is acceptable only if the cross-covering
                    fellow has had prior experience with ERCP and has been adequately familiarized with the patients on the service. The
                    service fellow will remain responsible for assuring that cross-coverage proceeds smoothly.




                                                     Research Rotation
                                            Curriculum for Year I, II & III Fellows

Educational Purpose:
The Research Rotation introduces the fellow to the field of gastroenterology and hepatology research. While Year I fellows discuss and plan for
future research, the Research Service is primarily designed for Year II and Year III fellows and allows time for research planning, work and post-
research outcomes. The Division of Gastroenterology, Hepatology and Nutrition has a large faculty with diverse clinical and academic interests,
ensuring that fellows have complete opportunities to investigate the gastroenterology or hepatology research project of their choice generally
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designed and conducted in close interaction with their mentor . The fellow will participate in increasing levels of research activities, depending on
the fellow’s level of experience. The amount of learning obtained from this rotation is directly proportional to the amount of time dedicated to
research.

Objectives:
Fellows will follow a complete course of research study during this rotation including research ethics, project exploration, planning, actual
research activity, analysis, written outcomes and, ideally, presentation of their project at a national GI or hepatology meeting or in a peer-
reviewed journal. Fellows will display the following ACGME core competencies during this rotation: medical knowledge, practice-based learning,
professionalism and systems-based practice. Minimum levels of achievement in each competency are expected during each of the three years
of fellowship training. Those meeting competency will receive a score of 5 in the program’s evaluation system. Fellows performing at a level
better than expected for that competency receive a score of 6 or 7 in the evaluation system, those at a level better than most fellows at that PGY
receive an 8, and those performing at a level deemed to be “one of the best fellows ever observed” will receive a score of 9. Fellows receiving a
score of 4 or below are deemed deficient in that competency; this will be brought to the attention of the program director immediately, and, if
necessary, remediation will be implemented.

The following are the goals and objectives for each competency at each level of training for the GI Research Service:

                                                                     Year I Fellow:
Goal: The first training year is a time for fellows to attend conferences, explore research project ideas, and meet with current fellows and
potential faculty mentors to discuss research ideas and feasibility. Year I fellows are expected to meet with one and preferably all of the following
faculty leaders related to research goals: fellowship program director, fellowship associate director and division chief. Fellows are expected to
select their research project and mentor before the end of their first year. Year I fellows are expected to attend the GI Research conference
sessions at which Year II and III fellows present their research plans and outcomes.

The first year fellow is required to carry out one small research project during the first twelve months of training. This could be either as a
published case report or abstract. During this period of time the fellow will be exposed to different areas in the field of gastroenterology as well as
working with different faculty members at all facilities.

Medical Knowledge Objectives:
    Attend core conferences and teaching rounds to learn the pathophysiology, epidemiology, disease management and procedure and
    medicine management skills for common and uncommon inpatient gastrointestinal diseases and related basic science, translational and
    clinical research.
    Accumulate and begin to solve the issues that he/she encounters from other trainees, attendings and related medical professionals. Begin
    to apply problem solving skills to research project analysis.
    Develop a commitment to inquisitiveness and novel thinking related to research investigations. While this objective is arguably innate and
    can be least affected by training, it is critical for success in independent investigations.
    By end of Year I, pass the Internal Medicine Board Examination.

Practice-Based Learning Objectives:
    Become familiar with the concepts of quality improvement.
    Participate in conferences such as the GI Research conference
    Begin to review, analyze and utilize scientific evidence from the gastrointestinal literature related to the fellow’s research explorations and
    actual project.

Professionalism Objectives:
    Learn to understand and demonstrate professional behavior in daily activities.
    Participate in professionalism-based learning activities through conferences.
    Learn to interact collegially with his/her peer group and other healthcare professionals.
    Learn about and begin to practice appropriate research organizational skills including background study, hypothesis formulation, study
    design, statistics, data management and data interpretation.
    Learn to practice ethical principles with relation to medical research. Important ethical issues include confidentiality, informed consent, data
    safety, ownership and responsibility, reporting honestly, and authorship fairness.
    Learn to practice appropriate interactions with pharmaceutical representatives.
    Learn to be sensitive to cultural, age, gender and disability issues.
    Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues.
    Participate in program planning, including annual Faculty Meeting attendance, Fellow Curriculum Committee participation and Program
    Director meetings when requested.

Systems-Based Practice Objectives:

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     Attend conferences concerning internal system research practices, research practices elsewhere, Internal Review Board (IRB) policies, and
     similar programs.
     Achieve basic understanding of healthcare systems related to gastroenterology and hepatology research, related translational
     gastroenterology care and overall system activities.
     Learn proper documentation skills to practice cost-effective research activities.
     Utilize an appropriate range of healthcare professionals to explore research opportunities.
     Begin involvement to understand the standard operating procedures and quality improvement initiatives within the hospital.
     Attend national gastroenterology conferences (e.g., ACG).

                                                                  Year II Fellow:

Goal: The primary research rotation blocks occur in Year II, and fellows have three consecutive research rotations. The fellow will formulate a
testable hypothesis, propose a study design and complete most of his/her investigations during Year II, and will concentrating on data acquisition
and management. An understanding of statistical analysis should be achieved. Prior to their research rotation, Year II fellows will meet with the
fellowship program director to ensure reasonable research goals, and Year II fellows are also expected to present their research plans at the GI
Research conference. The fellow will work closely with his/her research mentor to ensure appropriate research ethics including patient privacy,
complete actual research activities and begin abstract or publication materials.

Medical Knowledge Objectives:
    Begin to take a leadership role at core conferences and teaching rounds regarding the research investigations and critiques,
    pathophysiology, epidemiology, disease management and procedures and medicine management skills for common and uncommon
    inpatient gastrointestinal diseases.
    Organize the team’s performance in the research environment.
    Read textbook and pertinent literature materials concerning problems encountered.
    Continue to develop inquisitiveness and novel thinking attributes and apply these character traits to active laboratory investigations.

Practice-Based Learning Objectives:
    Participate in project groups, committees and hospital groups when requested.
    Participate in programmatic reviews and conferences studying adverse events.
    Give usable feedback to research technicians, medical students and other trainees based on observation of their performance and assess
    improvement.
    Participate in problem-based quality improvement projects.
    Review, analyze and utilize scientific evidence from the gastrointestinal and hepatology literature to enhance research productivity and
    outcomes.
    Know the best practice patterns to facilitate quality research projects based on research laboratory procedures and organization.

Interpersonal Communication Skill Objectives (if patient or human subject interactions are needed for Year II research project):
     Interview patients and family members accurately, patiently and compassionately and present information in an understandable manner.
     Practice appropriate informed consent procedures.
     Ensure appropriate patient confidentiality measures.
     Plan patient and family conferences as needed.
     Communicate effectively with research mentor, research staff, administrative staff, peers, attending gastroenterologists, referring physicians
     and other consultants as needed. Ensure reporting honesty and authorship fairness throughout research activities.
     Learn to become a teacher of gastroenterology research to junior trainees, medical students and other healthcare professionals.

Professionalism Objectives:
    Begin to mentor medical students, other trainees and Year I fellows in professional conduct.
    Understand and demonstrate professional behavior in daily activities.
    Participate in professionalism-based learning activities through conferences.
    Interact collegially with his/her peer group and other healthcare professionals, including acting responsibly in the larger context of pursuing
    programmatic and research successes.
    Practice appropriate research organizational skills including background study, hypothesis formulation, study design, statistics, data
    management and data interpretation. Present research plans and to-date research outcomes to peers through presentations and, as
    relevant, in publications.
    Continue to attend to the ethical principles activities and commitment achieved in Year I. Important ethical issues include confidentiality,
    informed consent, data safety, ownership and responsibility, reporting honestly, and authorship fairness.
    Practice interactions with pharmaceutical representatives and be unbiased in research investigations.
    Interact appropriately and present all needed document to the system’s Internal Review Board (IRB).
    Practice sensitivity to cultural, age, gender and disability issues.
    Cross-cover colleagues’ services when needed and conduct this coverage carefully with appropriate feedback to responsible colleagues.
94 | P a g e
     Participate in program planning, including annual Faculty Meeting attendance, Fellow Curriculum Committee participation and Program
     Director meetings, when requested.

Systems-Based Practice Objectives:
    Attend conferences concerning all aspects of research investigation and discovery as well as healthcare system patient management and
    components of systems of healthcare.
    Understand and practice proper research organization and documentation.
    Assist other trainees in the utilization of appropriate research resources.
    Model appropriate interactions in multidisciplinary planning, including standard operating procedures and quality improvement initiatives.
    Attend national gastroenterology or hepatology conferences (e.g., DDW or AASLD).

                                                                 Year III Fellows:

Goal: The senior-level, Year III fellow should demonstrate comprehensive understanding of their area of study, study design, data acquisition
and analysis. In addition, they are expected to prepare a manuscript based on their work for publication in a peer-reviewed journal. Year III
fellows typically dedicate an average of three rotations to finalizing their research projects and writing about their research outcomes. The
development of abstract and/or publication submissions of the fellows’ research project should occur early during Year III. In cases where the
Year III fellow has established themselves in research and has made strides toward a career as an independent researcher, this fellow could
mentor a Year I fellow in conjunction with a faculty researcher. Fellows are required to present or publish their research before graduation. Year
III fellows are expected to present their research outcomes and plans for project outcome submissions in national publications at the GI
Research conference.

Medical Knowledge Objectives:
    Access and critique the research literature regarding gastroenterology and hepatology problems encountered.
    Assume the trainee leadership role at core conferences and teaching rounds regarding the research investigations and reviews,
    pathophysiology, epidemiology, disease management, procedures and medicine management skills for common and uncommon inpatient
    gastrointestinal diseases.
    Prepare for the ABIM certifying exam throughout the year.
    Organize team activities in a smooth and authoritative fashion.
    Assist Year II fellows’ development directly at teaching conferences and indirectly at laboratory sites.

Practice-Based Learning Objectives:
    Demonstrate mastery of Year II fellow skills and encourage participation of colleagues related to research successes.
    Review, analyze and utilize scientific evidence from the gastrointestinal literature related to the critical review of research publications,
    translational research/clinical care management of GI patients, and taking a leadership role in guiding Year I & II fellows and sharing
    relevant literature reviews with them.
    Know and be able to succinctly communicate the best practice patterns to facilitate gastroenterology care through research investigations.
    Achieve acceptance of research outcome submissions in at least one of the following publication/presentation formats:
               o Publication of original research;
               o Review article;
               o Editorial in a peer-reviewed (indexed) journal;
               o Funded peer-reviewed grant;
               o Book chapter in a medical textbook;
               o Abstracts published; and/or
               o Abstracts presented at a national gastroenterology or hepatology meeting.

Professionalism Objectives:
    Demonstrate proficiency in Year II objectives.
    Mentor medical students, other trainees and Year I fellows in professional research conduct.
    Make a commitment to finalize the research project early in Year III, so that appropriate writing and application submissions may be made
    for research publications and national gastroenterology and hepatology meetings.
    Write about research project outcomes and work with research mentor to submit project documentation, abstracts and/or articles to national
    meeting and peer-reviewed journal reviewers.
    Consider the multidisciplinary implications of the fellow’s research project.
    Learn appropriate grant writing skills. If appropriate, work with research mentor to apply for grants.
    Assist in formal research-related teaching exercises as requested.
    Assert leadership in program planning, including fellow participation in the annual Faculty/Fellow Meeting, Fellow Curriculum Committee and
    Conference Planning Committees.

Systems-Based Practice Objectives:
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     Attend conferences concerning all aspects of research investigations, healthcare system patient management and components of systems
     of healthcare..
     Model appropriate interactions in multidisciplinary planning, including improvements related to standard operating procedures and quality
     improvement initiatives.
     Participate in hospital and national medical association committees and multidisciplinary planning groups when requested.
     Attend national conferences directed at career goals.
     Demonstrate near-attending level utilization of overall systems of care.

Teaching Methods:
Principles of gastroenterology and hepatology research are part of the trainees’ entire fellowship experience. Fellows review other peer-reviewed
research during Year I, select their own research mentor and begin planning of their own research projects during this time. Active research lab
work and/or clinical investigations occur during Year II. Year III fellows finalize their research projects and prepare all outcome documentations
for abstract submissions, presentations and/or publications. Fellows will have adequate clinical, laboratory and equipment resources to complete
conduct and complete their research projects. Teaching of medical students, residents and other trainees as well as appropriate interactions with
other research and healthcare providers are important aspects of this rotation. Participation in all required conferences is mandatory. As fellows
gain experience throughout their training, skills of organization and efficiency as well as team leadership become increasingly important.

The GI Research Service experience will prepare the fellow to evaluate and manage gastroenterology and hepatology research and will prepare
the fellow to work on and publish outcomes related to his/her own research projects. Fellows will be prepared for a career in academic
gastroenterology/hepatology and will have the opportunity to write grants for continued research when appropriate. Fellows must communicate
with his/her research mentor and with all relevant research staff and collaborators related to all investigative studies.

Research Format and Expectations:
The Gastroenterology Fellowship Program is committed to a rigorous, challenging and rewarding research experience for its fellows. While most
research skills may be taught and/or mentored, some critical components of research investigations related to investigator eagerness,
commitment and novel thinking are instinctive and may only be encouraged and mentored via high quality teaching. Research faculty, therefore,
maintain strong and valuable commitments to fellow research productivity and are committed to developing fellows’ career goals related to a
research/academic career.

The GI Research Rotation incorporates the following targeting research training goals
    A commitment to research ethics including issues related to confidentiality, informed consent, data safety, ownership and responsibility,
    reporting honestly and authorship fairness.
    A commitment to the thorough and thoughtful review of relevant gastroenterology and hepatology literature, including identifying, reading
    and understanding this literature.
    A commitment to appropriate data acquisition and management both in the lab and among potential subjects.
    A commitment to inquisitiveness and novel thinking. This is an innate ability perhaps least affected by training but critical for success in
    becoming an independent investigator.
    A commitment to research organizational skills including background study, hypothesis formulations, study design, statistics, data
    acquisition and charting, data management and interpretation, presentations to peers and colleagues, and attention to national
    presentations and publications. For fellows pursuing a career in academic gastroenterology, exposure to and understanding of descriptive
    and analytical statistics is important.
    A commitment to the basic principles of grant writing and grant writing encouragement and instruction for those fellows following a career in
    academic medicine.
    A commitment to the identification of unique and talented researchers early on and the development of research mentoring skills in these
    young researchers.

Patient Characteristics:
To the degree that patients or subjects are needed for the fellow’s research project, Memorial Hermann Hospital, LGJ General Hospital, The
Methodist Hospital and MD Anderson Cancer Center offer a diverse mixes of socioeconomic and gender status. Teaching faculty provide an
abundant supply of upper- and middle-class patients, and our contracts with medical assistance and pro bono care efforts ensure access to
lower-income patients. Due to a primary care base simultaneous with the hospitals’ constantly active referrals (complete with helicopter transport
24/7), patients are seen in both acute status and in diagnostic dilemma status, with both common and uncommon disorders.

Evaluation:
Fellows are evaluated during the GI Research Rotation and are expected to participate in the evaluation of other fellows as well. This occurs in
the following forms:
     Detailed, automated evaluations using the GMEIS system are submitted for each rotation. These evaluations are reflective of the program’s
     curriculum requirements. Attendings evaluate fellows, and the fellows evaluate the attending as well. Quarterly evaluations include:
                o 360-degree (attending, nurse, nurse practitioner, staff/clerical, etc.);
                o Peer-reviewed; and
96 | P a g e
              o Patient.
    Evaluation summaries become part of the fellows’ and attendings’ promotional documents.
    The fellow also evaluates the Gastroenterology Fellowship Program annually through a confidential basis.
    Attendings evaluate the Gastroenterology Fellowship Program annually.
    A Curriculum Committee oversees major changes to the curriculum. Representative program personnel (i.e., program director,
    representative faculty and at least one fellow) must be organized to review program goals and objectives and the effectiveness with which
    they are achieved. This group must conduct a formal documented meeting at least annually for this purpose. In the evaluation process, the
    group must take into consideration written comments from the faculty, the most recent report of the GMEC of the sponsoring institution and
    the residents’ confidential written evaluations. If deficiencies are found, the group will prepare an explicit plan of action, which should be
    approved by the faculty and documented in the minutes of the meeting.
    The Program Director meets with all fellows individually twice per year.
    An in-service GTE exam is given to all fellows annually.

Bibliography:
     Resource Documents
                o Up-To-Date
                o PubMed
                o Textbook of Gastroenterology – Yamada, et.al.
                o Gastrointestinal Disease: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.
                o Major Gastroenterology journals online and in the program’s fellow library including Gastroenterology, American Journal of
                    Gastroenterology, Gut, and other major publications.
     Curricular Design
                o ACGME Outcome Project documentation (from www.acgme.org).
                o Graduate Education in Internal Medicine: A Resource Guide to Curriculum Development
The report of the Federated Council for Internal Medicine Task Force on the Internal Medicine Residency Curriculum, 1997.
     Pertinent Teaching References:
                o Textbook of Gastroenterology – Yamada, et.al.
                o Gastrointestinal Disease: Pathophysiology Diagnosis Management – Sleisenger & Fordtran.
.




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                                   Competencies-at-a-Glance
                                     GI Research Rotation

                    COMPETENCY     LEARNING OPPORTUNITY                EVALUATION
         Patient Care              Research Activities           360-global evaluations
                                   Conferences
         Medical Knowledge         Research Activities           360-global evaluations
                                   Conferences
         Practice-Based Learning   Quarterly M&M Conference      360-global evaluations
                                   Research Conference
                                   Journal Club Conferences
                                   Work Rounds

         Interpersonal Skills      Research Activities           360-global evaluations
                                   Subject Interactions
         Professionalism           Research Activites            360-global evaluations
                                   Conferences
         Systems-Based Practice    Committee Participation       360-global evaluations
                                   Grand Rounds (GI & Medical)
                                   Conferences


Revised
May 09 Frank Lukens




   I.      Rotation Schedule ………………………………………………………… Appendix A


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 Fellow:           July        August      September       October      November December             January        February              March              April         May           June
  1st                1            2             3              4             5              6             7                8                   9               10                 11             12
 Nevah            MDA IP    LBJ IP (Con)    MDA OP         MHH HEP        MHH IP         MDA IP      LBJ IP (Con)     MHH OP               MHH IP           MHH HEP LBJ IP (Pro)         MDA IP
 Thosani        MHH HEP       MHH OP         MDA IP         MHH IP      LBJ IP (Con)    MDA OP         MDA IP          MHH IP            MHH HEP LBJ IP (Pro)              MDA IP      LBJ IP (Con)
   2nd
Barrientos LBJ IP (Con)       MDA OP       LBJ IP (Pro)     MDA IP       MHH OP        LBJ IP (Pro)   MHH IP      MHH HEP        TMH       LBJ Research LBJ Research LBJ Research

  Mank           MHH OP     LBJ IP (Pro) MHH HEP LBJ IP (Pro)             MDA IP       LBJ IP (Con) LBJ Research LBJ Research LBJ Research LBJ IP (Con) MDA OP         MHH IP
 O'Shea         LBJ IP (Pro) MHH HEP LBJ IP (Con) LBJ Research LBJ Research LBJ Research              MHH OP           MDA IP             MDA OP             MHH IP      LBJ IP (Con) LBJ IP (Pro)
Richards        LBJ Research LBJ Research LBJ Research    LBJ IP (Con) LBJ IP (Pro)     MHH OP       LBJ IP (Pro)       TMH                MDA IP           MHH OP         MHH IP       MHH HEP
   3rd
  Arora           MHH IP       MDA IP       MHH OP         MHH PBS       MDA OP         MHH PBS         TMH           MDA OP            LBJ Pro / LBJ Con   MHH PBS       MHH HEP         TMH
   Kim          MHH PBS      MHH PBS         MHH IP        MHH OP          TMH            TMH         MHH HEP        MHH PBS            LBJ Con / LBJ Pro   MDA OP          TMH         MDA OP
 Osowo           MDA OP        MHH IP         TMH            TMH         MHH PBS        MHH HEP       MHH PBS       LBJ Pro / LBJ Con     MHH OP             MDA IP       MHH OP        MHH PBS
  Varia           TMH           TMH         MHH PBS        MDA OP        MHH HEP         MHH IP       MDA OP        LBJ Con / LBJ Pro    MHH PBS          TMH             MHH PBS       MHH OP
                MHH                                       LBJ                                        TMH                                                MDACC
           1    MHH IP                                 5 LBJ IP (Pro)                              8 TMH                                              9 MDA IP
           2    MHH HEP                                6 LBJ IP (Con)                                                                                10 MDA OP
           3    MHH OP                                 7 LBJ Research
           4    MHH PBS

                 MHH IP      MHH HEP        MHH OP        MHH PBS       LBJ IP (Pro)   LBJ IP (Con) LBJ Research        TMH               MDA IP            MDA OP
         July     Arora        Thosani        Mank            Kim         O'Shea        Barrientos    Richards          Varia               Nevah            Osowo
    August        Osowo        O'Shea        Thosani          Kim          Mank           Nevah       Richards          Varia               Arora           Barrientos
September          Kim          Mank          Arora          Varia       Barrientos      O'Shea       Richards         Osowo              Thosani            Nevah
   October       Thosani       Nevah           Kim           Arora         Mank         Richards       O'Shea          Osowo             Barrientos           Varia
 November         Nevah         Varia      Barrientos       Osowo        Richards        Thosani       O'Shea            Kim                Mank              Arora
 December          Varia       Osowo        Richards         Arora       Barrientos       Mank         O'Shea            Kim                Nevah            Thosani
   January Barrientos            Kim         O'Shea         Osowo        Richards         Nevah         Mank            Arora             Thosani             Varia
  February       Thosani     Barrientos      Nevah            Kim       Osowo/Varia Varia/Osowo         Mank          Richards             O'Shea             Arora
     March        Nevah        Thosani       Osowo           Varia       Arora/Kim     Kim/ Arora       Mank         Barrientos           Richards           O'Shea
      April       O'Shea       Nevah        Richards         Arora        Thosani         Mank        Barrientos        Varia              Osowo               Kim
         May     Richards       Arora        Osowo           Varia         Nevah         O'Shea       Barrientos         Kim              Thosani             Mank
      June         Mank       Richards        Varia         Osowo         O'Shea         Thosani      Barrientos        Arora               Nevah              Kim




    II.            Call Schedule ……………………………………………………………….. Appendix B


99 | P a g e
                  UT GI Fellowship - Call Schedule         Revised - 6.21.10
                   After Hours & Weekends for Academic Year 2010-2011
             Week days: 5:00 pm to 7:00 am Weekend begins Friday at 5:00 pm
                 2010                                            2011
   July         GI          Hep        PBS     Dec 31-Jan GI           Hep                                                    PBS
 6/28- 7/1     Barrientos     28-30 Mank (Varia 1)      Verma 28-30   31-Jan 6     Thosani        Kim (Richards 31-2)         Osowo
    2-8        Richards        Thosa (Nev ah 2-4)          Kim           7-13       Mank                  Kim                  Arora
   9-15         O'Shea              Thosani                Varia        14-20      Nev ah         Kim (Thosani 14-16)         Osowo
   16-22         Mank       Thosani (Richards 16-18)       Kim          21-27     Barrientos              Kim                  Arora
   23-29        Osowo               Thosani                Varia       28-Feb 3    Thosani         Kim (O'shea 28-2)          Osowo
 30-Aug 5        Arora       Thosani (O'Shea 31-2)         Kim           Feb
   Aug                                                                   4-10       Mank               Barrientos            Richards
   6-12         Nev ah        O'Shea (Mank 6-8)            Varia        11-17      O'Shea       Barrientos (Mank 11-13)         Kim
   13-19       Richards             O'Shea                 Kim          18-24      Nev ah              Barrientos            Richards
   20-26        Osowo       O'Shea (Richards 20-22)        Varia      25- Mar 3    Thosani     Barrientos (Richards 25-27)      Kim
 27- Sep 2     Barrientos           O'Shea                 Kim           Mar
   Sept                                                                  4-10       Mank                Thosani              Barrientos
    3-9           Kim          Mank (Nev ah 3-5)           Varia        11-17     Richards      Thosani (O'Shea 11-13)         Varia
   10-16        Thosani              Mank                 Osowo         18-24      Nev ah               Thosani              Barrientos
   17-23        Osowo        Mank (Thosani 17-19)          Varia        25-31      O'Shea        Thosani (Mank 25-27)          Varia
   24-30        Nev ah               Mank                 Osowo          Apr
    Oct                                                                   1-7       Mank         Nev ah (Barrientos 1-3)       Arora
   1-7         Richards       Nev ah (O'Shea 1-3)          Arora         8-14     Richards              Nev ah                 Varia
   8-14         Thosani             Nev ah                Osowo         15-21     Barrientos     Nev ah (Thosani 15-17)        Arora
  15-21         O'Shea      Nev ah (Barrientos 15-17)      Arora        22-28      Thosani              Nev ah                 Varia
  22-28        Richards             Nev ah                Osowo       29-May-05    O'Shea       Nev ah (Richards 29-31)        Arora
 29- Nov 4     Barrientos     Nev ah (Mank 29-1)           Arora         May
   Nov                                                                   6-12       Mank         Arora (Barrientos 6-8)        Varia
   5-11         Thosani        Varia (O'Shea 5-7)         Osowo         13-19      Nev ah                Arora                  Kim
  12-18          Mank       Varia (Barrientos 12-14)       Kim          20-26     Richards       Arora (Thosani 20-22)         Varia
  19-25         O'Shea        Varia (Nev ah 19-21)        Osowo       27-Jun-02   Barrientos      Arora (Mank 27-29)            Kim
 26-Dec 2       Nev ah       Varia (Richards 26-28)        Kim          June
   Dec                                                                    3-9      Thosani             Richards               Osowo
    3-9         Thosani       Osowo (O'Shea 3-5)           Arora        10-16      Nev ah      Richards (Barrientos 10-12)     Arora
  10-16        Barrientos           Osowo                  Kim          17-23       Mank               Richards               Osowo
  17-23        Richards     Osowo (Barrientos 17-19)       Arora        24-30     Barrientos    Richards (Nev ah 24-26)        Arora
  24-30         Nev ah        Osowo (Mank 24-26)           Kim         Jul 1-7

Arora, Gaurav MD                        713-617-6001                  O'Shea, Noelle DO                     713-617-0939
Barrientos, Ryan MD                     713-617-0673                  Osowo, Ayo MD                         713-617-0161
Kim, "Jose" Hak N. MD                   713-617-6005                  Richards, Dave MD                     713-617-0672
Mank, Jerry MD                          713-617-0743                  Thosani, Nirav MD                     713-617-0665
Nevah, Ilan MD                          713-617-0753                  Varia, Apurv MD                       713-617-2201


   III.      Conference Schedules…………………………………………………….. Appendix C
             a. Fellows’ Monthly Meeting

100 | P a g e
               G AS T R O E N T E R O L O G Y , H E P AT O L O G Y   AN D   NUTRITION

                           GASTROENTEROLOGY FELLOWS’ MEETING
                                      2010 – 2011



                                             JULY 1, 2010

                                            AUGUST 5, 2010

                                          SEPTEMBER 2, 2010

                                           OCTOBER 7, 2010

                                          NOVEMBER 4, 2010

                                          DECEMBER 2, 2010

                                           JANUARY 6, 2011

                                           FEBRUARY 3, 2011

                                            MARCH 3, 2011

                                             APRIL 7, 2011

                                              MAY 5, 2011

                                             JUNE 2, 2010



Fellows’ Meetings
The GI fellows meet monthly with the Program Director, Associate Program Director and Fellowship
Coordinator to discuss the goals and objectives of each rotation, on-going research efforts and other
fellowship concerns.



           b. Fellows’ Monthly Nutritional Conferences


101 | P a g e
                            JULY              AUG   SEPT   OCT   NOV   DEC    JAN       FEB           MAR      APR       MAY   JUNE
       2010-2011:             1                5      2     7     4     2      6         3             3        7         5      2
                                                                             Chapters:
Arora, MD, Gaurav                                    2
Barrientos, MD, Ryan                                                           6




                              No conference
Kim, MD, Jose                                              3
Mank, MD, Jerry                                                                            7
Nevah, MD, Ilan                                1                                                                                   11
O'Shea, DO, Noelle                                                                                     8
Osowo, MD, Ayodele                                                4
Richards, MD, David                                                                                                9
Thosani, MD, Nirav                                                                                                       10
Varia, MD, Apurv                                                        5
                Chapters:                 Topic: (started March 2009)        08-09 09-10                   10-11           11-12
                       1    Nutritional Assessment                           Brenner                  Nevah - Aug
                       2    Malnutrition and Disease Outcomes                            Spinn         Arora - Sept
                       3    Nutrition in Inflammatory Bowel Disease                      Verma          Kim - Oct
                       4    Nutrition Aspects of Liver Failure                           Arora         Osowo -Nov
                       5    Nutrition and Acute Pancreatitis                 Shpaner                   Varia - Dec
                       6    Celiac Disease                                             Hightow er   Barrientos - Jan
                       7    Nutrition in Gastrointestinal Cancer                          Kim          Mank - Feb
                       8    Management of Short Bowel Syndrome                Wolf      Osow o        O'Shea - Mar
                       9    Management of the Obese Patient                              Varia        Richards -Apr
                      10    Enteral Access and Enteral Nutrition                       Barrientos     Thosani - May
                      11    Parenteral Nutrition                              Jafri      Mank         Nevah - June
                      12    Vascular Access for Parenteral Nutrition                    O'Shea

                      13    Nutrition-Based Home Care                                   Richards




             c. Fellows’ Monthly GI Journal Club

                             JULY             AUG   SEPT   OCT   NOV   DEC     JAN        FEB          MAR         APR   MAY   JUNE
        2010-2011                   8          12    2      14    11    9       13          10          10          14   12        9
Arora, MD, Gaurav                  X                        X                   X                                         X
Barrientos, MD, Ryan               X                        X                               X                             X
Kim, MD, Jose                      X                                            X                       X                          X
Mank, MD, Jerry                                      X            X                                     X                          X
Nevah, MD, Ilan                                      X            X                         X
O'Shea, DO, Noelle                             X                  X                         X                             X
Osowo, MD, Ayodele                             X                        X                                           X
Richards, MD, David                            X                        X                               X                          X
Thosani, MD, Nirav                                   X                  X                                           X
Varia, MD, Apurv                                            X                   X                                   X




             d. Fellows’ Monthly Physiology Conferences


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                          JULY               AUG               SEPT       OCT                  NOV        DEC               JAN        FEB                   MAR        APR                   MAY         JUNE
       2010-2011           15                 19                16        21                    18         16                20         17                    17         21                    19          16
Arora, MD, Gaurav                                                                                          11
Barrientos, MD, Ryan                                                                                                                                                     9
Kim, MD, Jose                                                                                   6
Mank, MD, Jerry                                                            5
Nevah, MD, Ilan           3&7                                                                                                                                                                 10
O'Shea, DO, Noelle                                                                                                          12
Osowo, MD, Ayodele                                                                                                                                            2
Richards, MD, David                                             8
Thosani, MD, Nirav                            4                                                                                                                                                                 1
Varia, MD, Apurv                                                                                                                       13
Gastrointestinal Physiology 7th Edition             Leonard Johnson, PhD & Norman Weisbrodt, PhD
       Module I                                                                                                                                                                       2010
Esophagus                3 & 7 Swallowing & Salivary Secretion                                                                                                                 Nevah       July
Stomach                    4    Gastric Emptying                                                                                                                               Thosani     Aug
Duodenum                   8    Gastric Secretion                                                                                                                              Richards    Sept
      Module II
Small Bowel                5    Motility of the Small Intestine                                                                                                                Mank                       Oct
                           6    Motility of the Large Intestine                                                                                                                Kim                        Nov
Colon                     11 Digestion and Absorption                                                                                                                          Arora                      Dec
      Module III                                                                                                                                                                                   2011
Liver                     12 Fluid and Electrolyte Absorption                                                                                                                  O'Shea                     Jan

                           13               Regulation of Food Intake                                                                                                          Varia                      Feb
                           2                Regulation: Nerves and Smooth Muscle                                                                                               Osowo                      Mar
        Module IV
Pancreas                   9                Pancreatic Secretion                                                                                                               Barrientos                 Apr
Biliary                    10               Bile Secretion and Gallbladder Function                                                                                            Nevah                      May
General                    1                Regulation: Peptides of Gastrointestinal Tract                                                                                     Thosani                    June




                e. Fellows’ M & M Conferences

                           JULY               AUG               SEPT       OCT                      NOV     DEC                  JAN        FEB                    MAR        APR              MAY        JUNE
        2010-2011            15                   12                 16         21                  18          16                20          17                   17          21                  19       16
Arora, MD, Gaurav                                                                                   x
Barrientos, MD, Ryan                                                                                                                                                x
Kim, MD, Jose                                                                                                                                                                                      x
                            No conference



                                               No conference




                                                                               No conference




                                                                                                            No conference




                                                                                                                                             No conference




                                                                                                                                                                              No conference




                                                                                                                                                                                                           No conference


Mank, MD, Jerry                                                                                                                   x
Nevah, MD, Ilan                                                                                                                                                     x
O'Shea, DO, Noelle                                                                                                                                                                                 x
Osowo, MD, Ayodele                                                   x
Richards, MD, David                                                                                  x
Thosani, MD, Nirav                                                                                                                x
Varia, MD, Apurv                                                     x




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             f. Fellows’ Quarterly Research Presentation Conferences

                       JULY   AUG   SEPT   OCT   NOV   DEC   JAN   FEB   MAR   APR   MAY   JUNE
       2010-2011                    16                 16                17                 16
Arora, MD, Gaurav

Barrientos, MD, Ryan                                                                        x
Kim, MD, Jose

Mank, MD, Jerry                                                           x
Nevah, MD, Ilan

O'Shea, DO, Noelle                                     X
Osowo, MD, Ayodele

Richards, MD, David                  X
Thosani, MD, Nivav

Varia, MD, Apurv




104 | P a g e
        g. Fellows’ Weekly Reading Conferences
                       TMC BCM & UT Gastroenterology Fellowship Thursday Reading Conference 2010-2011
                 Cullen Bldg Room 201A, 7:00am-7:50 am (Book: Sleisenger & Fordtran GI & Liver Disease, 8th Ed.)
                July Endoscopy Course: Cullen Bldg 201A, 7:00am-9:00am (Book: Cotton) (Rev. 6/24/2010)FL 6.24.10
              Date                                                    Topic                                                   Chapter      Faculty
            07/01/10                Treatment of Hepatitis C in the Fellows' clinic                                                       Hussain
                                  Endoscopy Course: Informed Consent/Sedation                                                               Velez?
            07/08/10
                          Endoscopy Course: Basic Endoscopy; EGD/Colonoscopy                                                            Thirumurthi?
                                       Endoscopy Course: Endoscopic hardware                                                               Qureshi
            07/15/10
                                 Endoscopy Course: Complications of Endoscopy                                                              Lukens
                                            Endoscopy Course: Enteral Access                                                              Dekovich
            07/22/10
                                           Endoscopy Course: Stricture Dilation                                                            Graham
                                                Endoscopy Course: ERCP basics                                                               Cole?
            07/29/10
                                                 Endoscopy Course: EUS Basics                                                                Vela
            08/05/10    Esophageal Neuromuscular Function and Motility Disorders                                                 42        M . Vela
            08/12/10                 Symptoms of Esophageal Disease and GERD                                                   12, 43        Shafi
            08/19/10                                     Barrett's Esophagus                                                     44         Davila
            08/26/10                                 Tumors of the Esophagus                                                     46       Dekovich
            09/02/10    Esophageal Disorders Caused by Meds, Trauma, & Infection                                                 45         Gould
            09/09/10                                      Helicobacter pylori                                                    50        Graham
            09/16/10                                 Gastritis and Gastropathies                                                 51     N. Abraham
            09/23/10                      Peptic Ulcer Disease and its Treatment                                               52, 53        Scott
            09/30/10                Adenocarcinoma and other Tumors of the Stomach                                              54            Lee
            10/07/10                          Gastrointestinal Carcinoid Tumors                                                  31        Bhutani
            10/14/10                     ACG Meeting 10/15-10/20, San Antonio
            10/21/10                                                 Diarrhea                                                    15          Velez
            10/28/10                        AASLD Meeting 10/29-11/2, Boston
            11/04/10                           Maldigestion and Malabsorption                                                   101          Sellin
            11/11/10              Enteric Microbiota and SB Bacterial Overgrowth                                                102        Dupont
            11/18/10                                   Short Bowel Syndrome                                                     103        Barroso
            11/25/10                           BCM Holiday: Thanksgiving Day
            12/02/10                                           Celiac Disease                                                   104       Schwartz
            12/09/10     Infectious Enteritis, Proctocolitis, Bacterial Food Poisoning                                          107          Ross
            12/16/10                                         Crohn's Disease                                                    111          Hou
            12/23/10                                          Winter Holiday
            12/30/10                                          Winter Holiday
            01/06/11                                        Ulcerative Colitis                                                  112      B. Abraham
            01/13/11                   Colonic Polyps and Polyposis Syndromes                                                   122         Lynch
            01/20/11                                       Colorectal Cancer                                                    123          Raju
            01/27/11                     Wilson's Disease and Hemochromatosis                                                  74,75       Vierling
            02/03/11                                         Hepatitis B & D                                                     78       Hollinger
            02/10/11                                         Hepatitis A & C                                                   77, 79     Hussain
            02/17/11                                   Alcoholic Liver Disease                                                   84          Jalal
            02/24/11                                                 NAFLD                                                      85    Alaguguruswamy
            03/03/11                                   Autoimmune Hepatitis                                                      88           Pan
            03/10/11     Primary Biliary Cirrhosis and Primary Sclerosing Cholangitis                                          89, 68       Anand
            03/17/11                       Portal Hypertension and GI Bleeding                                                   90       Machicao
            03/24/11                              Tumors and Cysts of the Liver                                                  94         Misra
            03/31/11                        Hepatic Encephalopathy, HRS, HPS                                                     92         Fallon
            04/07/11                                       Acute Pancreatitis                                                    58        Lukens
            04/14/11                                     Chronic Pancreatitis                                                    59        Qureshi
            04/21/11                                   Tumors of the Pancreas                                                    60          Guha
            04/28/11               Endocrine Tumors of the Pancreas and GI Tract                                                 32         Shaib
            05/05/11                                                  Ethics                                                            McCullough
            05/12/11                                       Gallstone Disease                                                     65         S. Vela
            05/19/11    Tre a tm e nt o f Ga lls to ne Dis e a s e a nd B ilia ry Tra c t M o to r F unc tio n/Dys func tio n  66, 63        Cole
            05/26/11                 Tumors of Bile Ducts, Gall Bladder, and Ampulla                                            69          Ertan
            06/02/11                                 Evidence Based Medicine                                                              El-Serag
            06/09/11                                  GI Consequences of HIV                                                    33           Wolf
            06/16/11                            Vascular Lesions of the GI Tract                                                 36         Shelby
            06/23/11                                          End of the year
        h. Fellows’ Weekly Grand Rounds with BCM
105 | P a g e
        TMC: BCM - UT Gastroenterology Fellows' Thursday Grand Rounds Conference 2010-2011
      Cullen Bldg Room 201A, 8:00am-9:00 am (Book: Sle isenge r & Fordtran GI & Live r Dise ase , 8th Ed.)

   Date
 08/05/10                                    Shail Maheshwari / Apura Varia
 08/12/10                                        Gia Landry / Ayo Osowo
 08/19/10                                     Chami Amaratunge / Jose Kim
 08/26/10                                      Yemi Fasakin / Gaurav Arora
 09/02/10                                       Nadim Jafri / Noelle O'Shea
 09/09/10                                      Kuang Daci / Dave Richards
 09/16/10                                         Clark Hair / Jerry Mank
 09/23/10                                     Ruchir Patel / Ryan Barrientos
 09/30/10                                 Manuel Berzosa Corella / Nirav Thosani
 10/07/10                                       Charles Hotte / Ilan Nevah
 10/14/10                                 ACG Meeting 10/15-10/20, San Antonio
 10/21/10                                   Hashim Khandwalla / UT Pedi GI
 10/28/10                                  AASLD Meeting 10/29-11/2, Boston
 11/04/10                                      Kiran Narsinh / Apurv Varia
 11/11/10                                       Bezhad Zafar / Ayo Osowo
 11/18/10                                     Chami Amaratunge / Jose Kim
 11/25/10                                       Holiday: Thanksgiving Day
 12/02/10                                      Yemi Fasakin / Gaurav Arora
 12/09/10                                       Nadim Jafri / Noelle O'Shea
 12/16/10                                   Shail Maheshwari /Dave Richards
 12/23/10                                             Winter Holiday
 12/30/10                                             Winter Holiday
 01/06/11                                        Kuang Daci / Jerry Mank
 01/13/11                                      Clark Hair / Ryan Barrientos
 01/20/11                                      Ruchir Patel / Nirav Thosani
 01/27/11                                  Manuel Berzosa Corella /Ilan Nevah
 02/03/11                                       Charles Hotte / UT Pedi GI
 02/10/11                                   Hashim Khandwalla / Apruv Varia
 02/17/11                                      Kiran Narsinh / Ayo Osowo
 02/24/11                                        Bezhad Zafar / Jose Kim
 03/03/11                                   Shail Maheshwari / Gaurav Arora
 03/10/11                                       Nadim Jafri / Noelle O'Shea
 03/17/11                                     Yemi Fasakin / Dave Richards
 03/24/11                                    Chami Amaratunge / Jerry Mank
 03/31/11                                     Ruchir Patel / Ryan Barrientos
 04/07/11                                       Clark Hair / Nirav Thosani
 04/14/11                                        Kuang Daci / UT Pedi GI
 04/21/11                                       Bezhad Zafar / Apurv Varia
 04/28/11                                      Kiran Narsinh / Ayo Osowo
 05/05/11                                    Hashim Khandwalla / Jose Kim
 05/12/11                                      Charles Hotte / Gaurav Arora
 05/19/11                                 Manuel Berzosa Corella / Noelle O'Shea
 05/26/11                                   Shail Maheshwari / Dave Richards
 06/02/11                                        Nadim Jafri / Jerry Mank
 06/09/11                                    Yemi Fasakin / Ryan Barrientos
 06/16/11                                  Chami Amaratunge / Nirav Thosani
 06/23/11                                               End of Year




106 | P a g e
  IV.   Telephone Directory ……………………………………………………..                                                        Appendix D
           FACULTY                                           Office          Room #           Pager
           Alagugurusamy, MD, Suresh                      713-566-5222     LBJ - GI Lab   713-617-0037
           DuPont, MD, Drew                                   6687         MSB 4.248      713.617.1961
           Edwards, Ph D, Marily n                            6675         MSB 4.244       713-617-0340
           Fallon, MD, Michael                                6696         MSB 4.234       713-617-5670
           Gagliardi, MD, Michael                             6683         MSB 4.230       713-617-3027
           Kochar, MD, Rajan                                  6648         MSB 4.240       713.617.0022
           Lukens, MD, Frank                                  6686         MSB 4.228       713-617-3008
           Machicao, MD, Victor                               6682         MSB 4.231       713-617-1805
           Pan, MD, Jen-Jeng "JJ"                             6649         MSB 4.226       713.617.0340
           Scott, MD, Larry                               713-566-5983      UT Annex       713.617.0747
           Wolf, MD, Dav id                                   6681         MSB 4.236       713-617-0464
           Zhang, MD, PhD, Junlan                             6673         MSB 4.248            ---
           CLASSIFIED                                        Office          Room #           Pager
           Al-Rehani, Zaena                                   6676         MSB 4.246            ---
           Burk, Stacy                                        5232         MSB 4.246
           Deming, NP, Diane                                LBJ Hosp        LBJ Hosp       281-439-0085
           Ojeda, Eunice                                      6685         MSB 4.242
           Tanikella, Raj                                     6691         MSB 4.243
           Tanner, Helen K                                    6672         MSB 4.238            ---
           Woods, Becky                                       6685         MSB 4.242            ---
           Xie, Minggian                                      6673         MSB 4.248
           Yang, Wenli                                        6673         MSB 4.248
           Zapien, Connie                                     6671         MSB 4.234            ---
           FELLOWS                                           Office          Room #           Pager
           Arora, MD, Gaurav                                  6684         MSB 4.232       713-617-6001
           Barrientos, MD, Ry an                              6684         MSB 4.232       713-617-0673
           Kim, MD, Hak "Jose"                                6684         MSB 4.232       713-617-6005
           Mank, MD,Gerald "Jerry "                           6684         MSB 4.232       713-617-0743
           Nevah, MD, Ilan                                    6684         MSB 4.232       713-617-0753
           Osowo, MD, Ay o                                    6684         MSB 4.232       713-617-0161
           O'Shea, DO, Catherine "Noelle"                     6684         MSB 4.232       713-617-0939
           Richards, MD, Dav id                               6684         MSB 4.232       713.617.0672
           Thosani, MD, Nirav                                 6684         MSB 4.232       713-617-0665
           Varia, MD, Apurv                                   6684         MSB 4.232      713-617-2201
           Internal Medicine: Department Office              Office         Room #            Pager
           Anderson, Jennifer (buy er)                        6116           JJLB
           Coziar, Clara (asst. to Dr. Dy er)                 6505         MSB 1.150
           Dyer, MD, Carmela (IM Vice Chair)                  6290         MSB 1.150
           Galletti, Shari                                    6501         MSB 1.150
           Hill, Candace (Time Keeper)                        6532         MSB 1.150
           Hernandez, Kristie (accounts)                      7857         MSB 1.150
           Jenkins, Erdest (Clinical Billing Manager)     832-325-7640     MSB 1.150
           McPherson, MD, Dav id (IM Chair)                   6553          UTB 1450
           Rose, Karen DMO                                    6509         MSB 1.252
                           Corporate Travel                     866.366.1142
                          Answering Service                     713.428.6373
           UT GI ACADEMIC OFFICE:                            Office          Room #           Pager
           UT Medical School Blg 6431 Fannin
           MSB 4.234           Houston, TX 77030          713-500-6677
           DIGESTIVE DISEASE CENTER (DDC):                   Office          Room #           Pager
           6414 Fannin, Suite G.125 Hou,TX 77030
           Main Number                                    713-704-5910                    Clinic Mgr:
           Kim (Scheduling)                               713.704.5901
           Nurses' Back Line:                             713.704.5916
           GI Lab (Hospital)                              713-704-3409
           TEXAS LIVER CENTER (TLC):                         Office          Room #           Pager
            6410 Fannin, # 370 Hou, TX 77030              713-704-6800                    Clinic Mgr:
           Main Number                                    800-985-4837
           Toll Free Number                               713-704-6616
           Nina Cambell                                   713.704.6806
           Fax (nex t to Nina's Desk)                     713-704-6909
           Clinic Fax                                    713-704.6616
           LBJ HOSPTIAL: 5656 Kelley Hou,TX 77026            Office          Room #           Pager
           GI Lab                                         713-566-5222
           Clinic                                         713-566-4463                    Clinic Mgr:
           Clinic Area                                    713-566-4921
           Doctor's area GI Lab                           713-566-5221                    Lab Mgr:
           Doctor's area Clinic                          713.566.5067
           Tel list revised 6.24.10                     SB Security Desk          5895




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  V.    Forms ………………………………………………………………………... Appendix E




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                    University of Texas System Medical Foundation
                             Request for Leave 2010-2011
      Please note that Medical Foundation employees are entitled to 5 business days of educational leave per contract year and a
      maximum of 30 business days of sick leave, which accrues at the rate of 1 day per month and carries over through contract years.
      Fellows have three-calendar weeks (15 business days) of vacation. Leave may be taken only during out-patient rotations.
      It is the responsibility of the Fellow to make certain all call/conference responsibilities are covered during any requested time.
      Procedure logs must be up-to-date and received by the Fellowship Coordinator for approval and/or to be taken. Vacation time
      does not carry over between contract years. As Medical Foundation employees, Fellows do not have holidays. If the out-patient
      clinic the Fellow is scheduled to work is closed for a holiday, the Fellow also may have a holiday. If the clinic is open during a
      holiday time, the Fellow must use vacation time to be scheduled off. Please do not put multiple dates on one request.

      Name:
                 Please Print Name                                                Signature                                Date

      I request that I be granted                                                             days of leave (1 day = 8 hours)

       from:                                                          to:                                               (both inclusive)
       To be charged as:
            Vacation *              Sick Leave                  Jury Duty               Funeral Leave (3 days maximum)
                 *GME Policy: Holidays taken are charged against vacation.

            Educational Leave:
                                                 Purpose: (attend conference, present paper, interview, USMLE/Board Exams)
           Leave of Absence:
                                                 Reason: (maternity/paternity; family emergency; away elective, etc.)
      Jury Duty, Funeral Leave & Education Leave require the attachment of supporting documents, such as copy of jury summons and release;
      obituary; exam registration confirmation, conference registration, etc.


      Will LBJ Fellows’ Clinic be closed?              Yes      No          Rotation:
      (If yes, attach LBJ clinic closure form)
                                                                             Are you assigned for any conference?
      Are you scheduled for call?                                                            Yes    No
                                                                                If yes, which?




      Program Administrative Action:
                Procedure log up current and received?             Yes       No
                Presentations covered?                             Yes       No
                Call covered?                                      Yes       No



                                                                      Frank Lukens, MD                                  Date
                                                                      Program Director
                                                                      Approved                       Yes        No

                                      Vacation                                    Sick Leave                                   Educational Leave

      Balance through this month      ________ Balance through this month         _________Balance through this month          ________
      Charged This Request            ________ Charged This Request               ________ Charged This Request                ________
      Balance                         ________ Balance                            ________ Balance                             ________




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  GI F ELLOWSHIP R EQUEST FOR S CHEDULE C HANGE ~ 2010-2011

DATE OF REQUEST:                NAME OF REQUESTOR:


SIGNATURE OF REQUESTOR:


□ ROTATION SCHEDULE          □ CALL SCHEDULE         □ GRAND ROUNDS SCHEDULE
□ OTHER:


Current Schedule:




Change Request:




Reason for Request:


Name of Fellow in Agreement to Change:


Signature of above Fellow:



Approval:




Frank Lukens, MD, Program Director                          Date




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                           The University of Texas Medical School-Houston
                               Gastroenterology Fellowship Program
                                      Moonlighting Statement
                                              2010-2011



     This is to verify that I have received a copy of the ACGME specific requirements and guidelines
     for moonlighting and The University of Texas Medical School-Houston Gastroenterology
     Fellowship Program “Policy on ‘Moonlighting’” and understand its contents. I also understand
     that a copy of this signed statement will be placed in my file.


     This is to confirm that I:          do                    do not    moonlight.

             I moonlight _________ days/nights per week. – Approximate hours:

             I moonlight _________ days/nights per month. Approximate hours:

     Listed below are the locations where I moonlight:

     _______________________________________________

     _______________________________________________

     _______________________________________________

     _______________________________________________


     Signature:            _____________________________

     Date:                 _____________________________

     Printed Name:         _____________________________




     Program Director’s Signature: _________________________________________




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APPROVAL FOR RESIDENT MOONLIGHTING
(This form must be completed prior to commencing moonlighting activity)

TO BE COMPLETED BY RESIDENT
(Residents must abide by the terms of their Program’s Moonlighting Policy. Moonlighting activity not approved by the
Program Director may result in disciplinary action against the resident for failure to complete this form).

Please check type of activity you will be performing:
_____ External Moonlighting – professional activity that is outside the course and scope of your educational
program, and takes place at a hospital/clinic that is not a participating institution for your program. You must
have professional liability insurance coverage that either you or the entity hiring you for moonlighting service has
purchased.

 You are not covered by your UT System professional liability insurance for this work and you are not supervised
by an attending. You must have a full Texas medical license. The hours worked do not count towards Duty Hours.
_____ Internal Moonlighting – professional activity that is outside the course and scope of your educational
program, and takes place at a participating institution for your program.
You must have professional liability insurance coverage which either you or the entity hiring you for moonlighting
service has purchased. You are not covered by UT System professional liability insurance for this work and you
are not supervised by an attending. You must have a full Texas medical license. The hours worked DO COUNT
towards Duty Hours.
_____ Extra Call for Extra Pay – professional activity that is within the course and scope of your educational
program and is provided only at a participating institution for your program. Your UT System professional liability
insurance covers this activity. You are supervised by an attending and this activity can be done with a physician in
training permit. The hours worked DO COUNT towards Duty Hours.


Name of Resident:
__________________________________________________________________________________
Moonlighting Facility & Service:
_______________________________________________________________________
(A new form must be completed for each facility)
Address of Facility: _______________________________________________________ Phone
Number:____________
Dates and Hours of Proposed Moonlighting:
____________________________________________________________
OR


Maximum Number of Hours of Moonlighting: _______/week or ________/month
Description of Moonlighting Activity:
___________________________________________________________________


For External and Internal Moonlighting:
Texas Medical License # _______________


Professional Liability Insurance: Attach a copy of your PLI policy




______________________________________ ___________________
Signature of Resident Date




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       UT GI Fellows Duty Hours Worked                                        Weekly Report 
       
       FELLOW:                                                                                                                Call ?:  yes  no 
       10 HR Violation?    yes  no                    When?                                           
               MON                    TUES                                WED                                  THUR                        FRI
               Date:                  Date:                               Date:                                Date:                       Date

          Faculty:                       Faculty:                       Faculty:                         Faculty:                 Faculty:


          Arrival Time:                  Arrival Time:                  Arrival Time:                    Arrival Time:            Arrival Time:


          Departure Time:                Departure Time:                Departure Time:                  Departure Time:          Departure Time:


          Total Hours Worked:            Total Hours                    Total Hours                      Total Hours              Total Hours
                                         Worked:                        Worked:                          Worked:                  Worked:

          S. Guha, M.D., Site Supervisor                                              Frank J. Lukens, M.D., Program Director
          UT MDACC                                                                    UT-Houston GI Fellowship


          ________________________________________                                    _______________________________________




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                       The University of Texas Medical School-Houston
                        Gastroenterology Clinical Fellowship Program

     This is to verify that I have received the following books to be used as the textbooks for
     my fellowship. I will return the books, in excellent condition at the end of my fellowship.

             Gastrointestinal PHYSIOLOGY, 7th Edition Leonard R. Johnson, PhD
             Nutrition and Gastrointestinal Disease Mark H. DeLegge, MD

     To be use first year only and returned in excellent condition at the end of my first year.

     Practical Gastrointestinal Endoscopy – The Fundamentals 6th Edition
           Peter B. Cotton

     I also understand that a copy of this signed statement will be placed in my file.




     Signature:                  _____________________________


     Date:                       _____________________________


     Printed Name:               _____________________________




     Program Director’s Signature: _________________________________________
                                          Frank J. Lukens, MD




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                                   The University of Texas Medical School-Houston
                                    Gastroenterology Clinical Fellowship Program
                                            Required Research Activity
                                                      2010-2011

     The first year fellow is required to carry out one small research project during the first twelve months of
     training. This could be either as a published case report or abstract. During this period of time the fellow will
     be exposed to different areas in the field of gastroenterology as well as being able to work with different
     faculty members at all facilities.

     At the end of the first year of training the fellow is required to choose a program faculty research mentor who
     will guide the research activities throughout the rest of the fellowship. Both parties should agree on working
     together during these two years and express this in writing to the fellowship program director no later than the
     last week of their first year. In addition to this agreement, the letter should contain a brief summary of the
     research plans that they have for the remaining two years of the fellowship. The fellow is expected to carry out
     one primary study which should be prospective and one or more secondary projects. The later could be
     anything from a retrospective study, case series, book chapter, etc. All projects have to be approved by the
     fellowship research committee prior the fellow getting involved with them. This committee will be integrated
     by the fellowship program director, and two other program faculty members that have a well known research
     background in the field of gastroenterology. Ideally, the fellow is expected to publish all projects in a
     manuscript rather than an abstract form. Fellow will be encouraged to present projects at national or
     international meetings.

     Each program faculty mentor will be objectively evaluating the fellow’s research activity progress quarterly
     during the second and third years of fellowship training. The fellow will be required to meet with the
     fellowship program director to review his evaluation and to update the research progress. It will be up to the
     fellow’s mentor whether to approve or disapprove any other research activity that the fellow may be asked to
     do by any of the other program faculty members. This will allow the fellow to focus on the primary research
     projects.

     During the last two years of training, the fellow will have a total of four months of research protected time that
     he will take advantage of to carry out his projects. Two of these months will be assigned during his second
     year of training and the other two during his last. Additional research time may be requested and will need
     prior approval by the fellowship program director.
     This is to verify that I have aware of the Required Research Activity during by fellowship training.
     I also understand that a copy of this signed statement will be placed in my file.


     Signature:

     Date:

     Printed Name:                                                                PGY:


     Program Director’s Signature: __




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