Core Components for the First Year Fellow (PL-4)
A. Outpatient Continuity Care Clinic Experience:
The first year subspecialty fellow will spend one-half day each week for 8 weeks in the outpatient clinic, where he/she will evaluate patients and interact with attendings that specialize in Pediatric Gastroenterology/ Nutrition and Pediatric Hepatology. These first 8 weeks will transition into their Continuity Care Clinic experience as patients are accumulated from the outpatient and inpatient settings.
Goals and Objectives
- Develop skills in evaluation and managing outpatient gastroenterology and hepatology problems.
- Develop skills in managing outpatients receiving home central hyper-alimentation, including an understanding of indications for parenteral nutrition.
- Develop skills in caring for outpatients who have undergone liver transplantation including management of immunosuppression, hypertension, acute and chronic allograft rejection, and lymphoproliferative disorder (with appropriate consultants).
- Develop expertise in the management of patients with abdominal pain, vomiting and chronic diarrhea, especially as it pertains to interpretation of appropriate radiographs and key blood studies, in addition to a progressive knowledge of when to consider endoscopy evaluations.
- Develop expertise in the management of benign esophageal and gastrointestinal problems such as infantile esophageal reflux, constipation, and encopresis.
- Develop skills in evaluating and managing common gastroenterologic and hepatobiliary problems including inflammatory bowel disease (ulcerative colitis, Crohn’s disease, and indeterminate colitis), hematemesis, hematochezia, melena, failure to thrive, feeding and swallowing difficulties, acid-peptic disease, esophageal reflux disease (GERD), jaundice, abnormal liver function, coagulopathy, hypoalbuminemia, acute and chronic pancreatitis, gastroparesis, and colonic polyps, Hirschsprung’s disease, and intestinal dysmotility syndromes.
- Develop skills in diagnosing and treating infections of the disease and biliary tract.
- Develop skills in diagnosing and managing celiac disease and other malabsorption syndromes.
- Develop skills in diagnosing and managing acute and chronic liver failure and its complications, and describing indications for liver transplantation.
- Learn to describe the indications for intestinal transplantation.
- Describe indications for the following procedures: Upper endoscopy, flexible sigmoidoscopy, colonoscopy, endoscopic retrograde pancreatico-cholangiography (ERCP), prolonged esophageal pH monitoring, esophageal and anorectal manometry, rectal suction biopsy, liver biopsy, paracentesis, and pancreatic stimulation test.
- Describe indications for the following ancillary studies: Upper gastrointestinal contrast study, CAT and MR Enterography studies, magnetic resonance cholangraphy (MRCP), gastric emptying study, barium enema and abdominal ultrasound.
- Learn to safely perform the following procedures with proficiency including recognition and treatment of complications with appropriate consultation: Esophagogastroduodenoscopy, flexible sigmodoscopy, colonoscopy, small intestinal and rectal biopsy, percutaneous liver biopsy, paracentestis, and removal of foreign bodies from esophagus and gastrointestinal tract.
- Diagnose and treat severe gastrointestinal bleeding with proficiency in the following specialized therapeutic procedures (sometimes with Adult Gastroenterology and Pediatric Surgery Consultants): Esophageal variceal banding or sclerosis, polypectomy, heater probe and injection of bleeding ulcer and vascular malformation and endoscopic percutaneous gastrostomy tube placement.
- Learn to competently interpret the following specialized tests: Breath hydrogen analysis, prolonged pH probe study (12-24 hours), esophageal and anorectal manometry and pancreatic stimulation test.
- Develop skills in managing patient referrals and communicating with referring physicians.
- Develop skills in delivery of appropriate telephone advice and telephone triage.
- Learn to interact effectively with the entire gastroenterology/hepatology division team.
- Learn to manage patients on a continuous long-term basis.
- Develop skills in integrating the collaboration of the clinical social workers and psychologists with emphasis on family stress, school issues, and financial issues.
- Develop skills in interacting with and integrating the support of child-life services and the pediatric GI nurses to prepare patients for invasive procedures or other stressful interventions such as Golytely colonic cleanouts.
- Develop leadership skills re: the patient care team that enhances the quality care of patients.
- Over the first year of fellowship, develop an area of academic interest including an understanding of research protocols and ethical issues in managing patients on divisional and institutional protocols.
Competencies Involved
Patient Care, Medical Knowledge, Practice Based Learning and Improvement, Communication and Interpersonal Skills, Professionalism, System-Based Practice
Methods of Evaluation
Evaluation by all Faculty Attendings, Faculty and Fellow Self- Assessment (IDP) of Presenting Skills (Clinical Cases and Core Lectures) and Procedural Skills, Feedback from Nursing/ Support Staff/ and Parents of Patients (360 degree evaluation)
B. Pediatric Gastroenterology/Hepatology Ward Rotations/Consult Service
The subspecialty fellow (PL-4) manages patients on the general pediatric floors and performs consultations in the intensive care units (PICU, CICU, and NICU), the pediatric ward floors, and in the Emergency department, always with supervision by the faculty attending and after the fellow has an opportunity to independently assess the patient.
Goals and Objectives
- Develop skills re: the inpatient management of Pediatric Gastroenterology and Hepatology related problems (As Noted for Outpatient Experience).
- Develop the ability to effectively educate parents and their hospitalized children about the diagnosis, treatment plan and prognosis.
- Learn to work effectively the gastroenterology and hepatology treatment team in clinical social workers, psychologist, child-life personnel and members by other subspecialty services.
- Learn to teach residents and medical students about gastroenterology and hepatology.
- Learn to expeditiously respond to consultations from general and other subspecialties services, the PICU and NICU.
- Learn to write inpatient central hyperalimentation orders and recognize and manage the complications of parental nutrition.
- Learn to understand and request appropriate use of surgical therapy in managing patients with acute gastrointestinal and liver disease, e.g., for the timely management of the surgical complications of inflammatory bowel disease.
- Learn how to facilitate new patient referrals, especially outside hospital transfers.
- Learn how to provide appropriate and non-litigious phone advice while on-call.
- Continue development of evidence based medicine skills as related to the sick inpatient.
- Understand and provide adequate nutrition to patients including use of nasogastric or nasoduodenal tube, gastrostomy tube placement and peripheral/central hyperalimentation.
- Learn how to function as part of a multidisciplinary team.
- Learn the skill of communicating and counseling patients and their parents.
- Continue to develop procedural skills in caring for the more ill pediatric inpatient.
Competencies Involved
Patient Care, Medical Knowledge, Practice-Base Learning and Improvement, Communication and Interpersonal Skills, Professionalism, Systems-Based Practice
Methods of Evaluation
Evaluation by Faculty Attendings, Faculty and Fellow Self-Assessment of Clinical Skills and Procedural Skills, 360 degree evaluations, Feedback from pediatric house staff as to the fellow’s guidance and teaching abilities
C. NICU and PICU Gastroenterology and Hepatology
The specialty fellow will consult on patients in the NICU and PICU with follow up and participation in management of these actively ill patients with the faculty attending.
Goals and Objectives
- Respond to consultation requests regarding NICU and PICU patients with gastroenterologic, nutritional, and hepatologic problems.
- Learn to understand and treat the common gastroenterology, nutrition, and hepatologic problems unique to neonates and acutely ill PICU patients.
- Perform pertinent procedures for patients in the intensive care units with the faculty attending. Also, the fellow will communicate with the Critical Care Unit physician after discussion of the acutely ill patient with the gastroenterology or hepatology attending.
- Review and interpret all tissue histologies with the pathologist and results of ancillary studies such as prolonged pH probe and gastric emptying analysis with the gastroenterology attending.
Competencies Involved
Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Communication and Interpersonal Skills, Professionalism, Systems-Based Practice.
Methods of Evaluation
Evaluations by Faculty Attendings, Faculty and Fellow Self-Assessment of Clinical Skills and Procedural Skills, 360 Degree Evaluations.
The senior subspecialty fellows (PL-5, PL-6) continue to follow Continuity Care Clinic patients throughout their training for 1/2 day each week. Also, they will be on-call one week (at night) per month, including one weekend each month. The week night call is from home unless a gastroenterology or hepatology patient requires night-time admission. Ward and ICU rounds are completed with the faculty attending during the on-call weekend. The PL-6 fellow is given greater independence involving all patient care activities in addition to supervision and teaching of residents and medical students. If the fellow is required to evaluate an ill patient for significant hours beyond 12 midnight, he/she will be excused the following day from clinical or research activities. The gastroenterology or hepatology attending will provide back-up on-call for the fatigued-fellow until the following day.
The major emphasis the second and third year will be on research. The subspecialty fellow must develop and complete a research project in conjunction with a mentor. All senior fellows (PL-5, PL-6) must choose a project in clinical or basic science research. Each fellow must present their scholarly work at least twice each year to a scholarship oversight committee.
Core Components for the Second Year Fellow (PL-5)
- Must fulfill all of the learning objectives of the first year fellow (except that the main focus is research, not the clinical focus on patient management and care).
- Research
Goals and Objectives
- Develop skills in organizing a research project, gathering and analyzing data, defending and presenting conclusions to a Scholarship Oversight Committee (and local and national meeting).
- Develop knowledge, understanding and skills in biostatistical methods.
- Develop a knowledge and understanding of ethics in research.
- Develop skills in writing manuscripts and eventually, grant writing.
- Learn to be skillful in the presentation of research data.
- Continue to develop a critical read of the biomedical literature
- Participate in a 2-week Clinical Research Center course entitled “The Science of Clinical Research” to include didactic lectures as follows: Grants and grantsmanship, Statistical methods in data analysis in patient oriented research, Study design and analysis in patient oriented research, Patient safety and data confidentiality, Grants resource and Pharmcogenomics.
- At the end of the first fellowship year, identify a research mentor and select a Scholarship Oversight Committee (SOC) composed of at least three individuals with research experience, one of which is outside the fellow’s department. It is the responsibility of this committee to determine whether the PL-5 fellow has selected a specific research project appropriate to meet the ABP guidelines for scholarly activity.
- Present research to the SOC at least twice each year.
- Present research data at local and national meetings.
- Apply for research funding.
Competencies Involved
Medical Knowledge, Practice-Based Learning and Improvement, Communication and Interpersonal Skills, Professionalism.
Method of Evaluation
Regular review by faculty mentor; Review by SOC at least twice a year; Grade reports and evaluation of writing skills by Clinical Investigation Master’s Program personnel ( IF fellow chooses to apply and be accepted by such a program); Evaluation of research presentations at local and national meetings.
Core Components for the Third Year Fellow (PL-6)
- Must meet all of the learning objectives of the first and second year fellows (except that the primary focus is completion of research objectives).
- Research
Goals and Objectives
- Present research data at local and national meetings.
- Write a research manuscript to submit to ABP for approval to take Pediatric Gastroenterology, Hepatology and Nutrition Boards (and, submit to Research Journal for peer review).
- Apply for (continued) research funding.
Competencies Involved
Medical Knowledge, Practice-Based Learning and Improvement, Communication and Interpersonal Skills, Professionalism.
Method of Evaluation
Evaluation by Faculty Attendings; 360 degree evaluations; and, same methods of evaluation as noted for PL-5 fellow.