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GOALS AND OBJECTIVES

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					                              GOALS AND OBJECTIVES

                                     GI Ward Service

Mission Statement:
To provide the opportunity for fellows to learn the art and science of clinical care in a
tertiary hospital in the subspecialty discipline of Gastroenterology-Hepatology, to include
the approach to patient diagnosis with or suspected of having gastrointestinal disease as
well as the study of testing, procedures and drug therapy in the treatment of these
diseases.

Program Objectives:
Patient Care:
     To improve basic clinical skills as applied to the evaluation of patients with
        known or suspected gastrointestinal disease.
     To learn how to maximally utilize diagnostic testing in the evaluation and
        management of gastrointestinal and liver disease. This includes integrating
        information provided by the diagnostic radiologists and pathologists into clinical
        care of patients.
     To utilize a multi-disciplinary approach in diagnosing and managing the patient
        with gastrointestinal and liver disease. This includes services of the physicians in
        different disciplines (surgery, diagnostic radiology, interventional radiology,
        pathology, critical care medicine, radiation oncology, medical oncology) and
        ancillary care staff (case managers, social workers) to optimally care for the
        patient.

Medical Knowledge:
   To gain exposure to complex gastrointestinal problems requiring hospitalization
      to the GI Ward service
   To become familiar with procedures used in diagnosis and treatment of
      Gastrointestinal Disease.
   To learn the medical management of complex gastrointestinal disorders including
      chronic abdominal pain, inflammatory bowel disease, gastrointestinal bleeding,
      and pancreatitis
   To learn appropriate diagnostic testing for these disorders.
   To learn better appreciation for the treatment of pain and end of life care.
   Supervise and teach House staff including provision of didactic sessions.

Practice Based Learning: See Core Competencies
Interpersonal Skills and Communication: See Core Competencies.
Professionalism: See Core Competencies
System Based Practice: See Core Competencies

Program Components
In this required 4 week rotation, fellows will spend time working on the GI Ward at
University Hospital treating patients hospitalized with gastrointestinal disorders.
Activities on this rotation will include:
    30 minute lecture before rounds – minimum three times per week by fellow or
        attending.
    Review journal article topic pertaining to a patient on the ward service weekly
    Radiology rounds on new patients and as needed –review CT scans, ABD US,
        MRI, and HIDA scans etc with GI attending and radiologist

In addition, the fellows will attend the various multi-disciplinary conferences (Radiology
Conference, GI-Pathology Conference, Hepato-Billary Conference, Liver –Pathology
Conference, GI Grand Rounds.

Focused Areas for Study:
    Upper GI bleeding
    Lower GI bleeding
    Obscure GI bleeding
    Acid-Peptic disorders including peptic ulcer disease and
      Zollinger-Ellison Syndrome
    Acute pancreatitis – both simple and complicated
    Chronic pancreatitis
    Inflammatory Bowel Disease
    Chronic Diarrhea
    Infections of the GI tract
    Vascular disorders of the GI tract
    Acute and chronic abdominal pain
    Dysphagia
    Post-procedure complications
    Intractable nausea and vomiting
    Biliary tract disease including gallstones
    Gastrointestinal Neoplasms
    GI manifestations of HIV

Specific Goals Specified Per Training Year for GI Wards
   1. 1st Year: Trainees are expected to be knowledgeable of at least the topics outlined
       below. It is likely that you will care for patients with each disease process at
       some point during your 2-3 month GI Ward rotations.
   2. 2nd Year: The corresponding articles provided and chapters in Sleisenger and
       FORTRAN’s text should be read during the 2-3 month GI Ward rotations.
   3. 3rd Year: Trainees are expected to advance their knowledge base with further
       readings of the most current information in the field of GI and Hepatology

Educator Role
The supervising attending in this rotation will act as a liaison between the physicians
ordering specialized tests, or whose patient have developed problems so that clinical
information needed to interpret tests can be communicated to the appropriate parties and
results and significance of tests and physical findings will be accurately transmitted to the
patient’s team.

Evaluation and Feedback
The supervising attending physician will provide direct and written feedback to the
fellow based upon direct observation based on the following six competencies:
Patient Care
    1) Gathers essential and accurate information about the patient through interviews,
        examination and complete history; appropriately accesses additional sources of
        information, such as other health care facilities, non-UAB or VAMC physicians,
        and family members.
    2) Interacts with other health-care professionals to facilitate the process of diagnosis
        and treatment planning.
    3) Carries out patient management plans based on age, other co morbid conditions,
        psychosocial issues, including arranging appropriate follow-up of diagnostic tests.

Medical Knowledge
  1)      Understands the approach to the patient with known or suspected
          gastrointestinal disease
  2)      Understands the principles of treatment drugs and or procedures and their
          administration
  3)      Understands the principles regarding gastrointestinal disease and related
          complications

Practice-Based Learning
   1)      Uses feedback to identify areas of improvement
   2)      Seeks opportunities to strengthen deficits in knowledge/skills
   3)      Demonstrates initiative in researching current scientific evidence using
           modern information technology and applying it to problems encountered in
           daily practice.

   Interpersonal and Communication Skills
   1) Communicates effectively with other members of a multi-disciplinary team
   2) Maintains a comprehensive, timely and legible medical record
   3) Communicates comprehensively and compassionately with patients and their
       family members
   4) Provides accurate and timely feedback to the attending physician as well as to the
       referring physician

Professionalism
   1)      Recognizes ethical dilemmas and utilizes appropriate consultation where
           needed
   2)      Adheres to laws and rules governing the confidentiality of patient information
   3)      Adheres to the institution’s Code of Conduct

Systems-Based Practice
   1)      Demonstrates a commitment to the practice of cost-effective medical care and
           resource allocation
   2)      Partners with other members of the health-care team to manage complex
           patient issues
   3)      Advocates and facilitates patient advancement through the health care system


In the interest of improving the quality of learning environment in fellowship, the fellows
must confidentially provide a written evaluation of each teaching attending at the end of
the rotation. We also require that the fellows complete a questionnaire critically
assessing the completeness of their acquisitions of the knowledge expected for the
rotation, and, if their knowledge acquisition is not adequate, their plans to “fill the gaps”.

Reading List

I. Topics commonly seen on GI Wards
1. Esophageal Disorders
    Barrett’s Esophagus-
     Updated Guidelines for the Diagnosis, Surveillance, and Therapy of Barrett’s
        Esophagus. AJG (2002) 97(8): 1888-1895. (Sampliner RE)
    Achalasia-
     Diagnosis and Management of Achalasia. AJG (1999) 94(12): 3406-3412.
        (Vaezi and Richter)
    Esophageal Cancer-
     Esophageal Cancer. AJG (1999) 94(1): 20-29. (Lightdale)
    Eosinophilic Esophagitis-
     Eosinophilic Esophagitis. Dig Dis Sciences. (2003) 48(1):22-      29. (Khan S)
2. GERD
     Updated Guidelines for the Diagnosis and Treatment of Gastroesophageal
        Reflux Disease. AJG (2005) 100: 190-200. (DeVault KR)
3. Feeding Tubes
     Tube Feeding in Patients with Advanced Dementia. JAMA (1999) 282(14):
        1365-1370. (Finucane TE)
     See PPT presentation by Steve McClave (Louisville, Kentucky).
4. Acute Pancreatitis
     Acute Necrotizing Pancreatitis. NEJM (1999), 340 (18): 1412-1417. (Baron)
     Idiopathic Acute Pancreatitis. J Clin Gastro (2003), 37(3):238-250. (Kim H J)
5. Chronic Pancreatitis
     Pathogenesis of Chronic Pancreatitis: An Evidence-Based Review of Past
        Theories and Recent Developments.          AJG (2004), 99(11): 2256-.
6. Peptic Ulcer Disease- Helicobacter Pylori and NSAIDS
     Guidelines for the Management of Helicobacter pylori Infection. AJG (1998)
        93(12):        2330-2338. (Howden CW)
     A Guideline for the Treatment and Prevention of NSAID-Induced Ulcers.
        AJG (1998) 93(11): 2037-3046. (Lanza)
       Gastrointestinal Toxicity of Nonsteroidal Anti-inflammatory Drugs. NEJM
        (1999) 340(24): 1888-1899. (Wolfe MM)
7. Zollinger-Ellison Syndrome
     Zollinger-Ellison syndrome: Pathogenesis, diagnosis, and management. AJG
        (1997) 92 (4 Suppl): S44-. (Hirschowitz)
8. Upper GI Bleeding
     Endoscopic Treatment Compared with Medical Therapy for the Prevention
        of Recurrent Ulcer Hemorrhage in Patients with Adherent Clots. Gastro
        Endo (2003) 58(5): 707-714 (Bini EJ)
9. Lower GI Bleeding
     Management of Adult Patients with Acute Lower Gastrointestinal Bleeding.
        AJG (1998) 93(8): 1202-1208. (Zuccaro)
     Colonoscopic Management of Lower Gastrointestinal Hemorrhage. Cur
        Gastro Reports        (2001) 3:425-432. (Terdiman JP)
     Urgent Colonoscopy for the Diagnosis and Treatment of Severe Diverticular
               Hemorrhage. NEJM (2000) 342: 78-82. (Jensen)
     Hormonal Therapy for Gastrointestinal Angiodysplasia. Lancet (2002)
        359:1630-1631. (Hodgson H)
10. Occult GI Bleeding
     AGA Technical Review on the Evaluation and Management of Occult and
        Obscure        Gastrointestinal Bleeding. Gastro (2000) 118: 201-221.
        (Zuckerman GR)
11. Ulcerative colitis
     Ulcerative Colitis Practice Guidelines in Adults (Update): American College
        of     Gastroenterology Practice Parameters Committee. AJG (2004)
        attached.      (Kornbluth A)
     Cyclosporin for Severe Ulcerative Colitis: A User’s Guide. AJG (1997) 92(9):
        1424-28.       (Kornbluth A)
12. Crohn’s Disease
     Management of Crohn’s Disease in Adults. AJG (2001) 96(3):635-643.
        (Hanauer SB)
13. Diverticulosis
     Diagnosis and Management of Diverticular Diseases of the Colon in Adults.
        AJG (1999) 94(11): 3110-3121. (Stollman NH)
     New Developments in Diverticular Disease. Cur Gastro Reports (2001) 3:
        420-424. (Cima RR)
14. Colon Cancer
     Polyp Guideline: Diagnosis, Treatment, and Surveillance for Patients With
        Colorectal     Polyps. AJG (2000) 95(11): 3053-3063.
     The Hereditary Nonpolyposis Colorectal Cancer Syndrome: Genetics and
        Clinical       Implications. Ann Intern Med (2003) 138: 560-570. (Chung
        DC)
15. Acute Diarrhea
     Guidelines for the Management of Acute Diarrhea in Adults. J of Gastro and
        Hep (2002) 17 (Suppl): S54-71. (Manatsathit and Dupont)
16. Clostridium Difficile
     Breaking the Cycle: Treatment Strategies for 163 Cases of Clostridium
       Difficile Disease. (2002 97(7): 1769-1775. (McFarland)



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