VA Hospital Rotation
The educational goals and objectives for the VA Hospital Rotation are detailed in this section of the curriculum document.Educational Purpose-- The following are the educational purposes of this rotation:
1. Trainees will gain broad exposure and acquire expertise in the evaluation and management of adult patients with a broad range of acute and chronic GI problems in the supervised hospital setting.
2. Trainees will become proficient in the technical and interpretative performance of standard GI endoscopic procedures, and will understand their indications, contraindications, how to act upon the findings, limitations, and complications.
3. The clinical training of fellows on this rotation will be supplemented by the outpatient experience they get as they attend a weekly, supervised VA GI clinic and their weekly Continuity Clinic.
4. Medical knowledge of trainees is enhanced in a number of ways-- through patient care contacts, by attending teaching rounds, by reading about the problems and conditions their patients have, and through teaching conferences and seminars they attend during this rotation.
5. The rotation will provide trainees with the ability to develop competence in practice-based learning and improvement that involves the investigation and evaluation of care for their patients, the appraisal and assimilation of scientific evidence, and improvement in patient care.
6. The rotation will provide trainees competence in systems-based practice as manifested by actions that demonstrate an awareness and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.
7. As trainees go about their clinical duties they will develop improved communication skills that result in effective exchange of information and collaboration with patients, their families, and other health professionals.
8. The rotation will provide trainees the ability to develop competence in professionalism, manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to patients of diverse backgrounds.
Type of Clinical Encounters-- On this rotation, GI fellows typically spend an average of 45 hours per week on duty. Meaningful patient responsibility takes place during the performance of supervised inpatient consults and the performance of procedures at the VA Hospital, similar to what is done at the University. Patients with a diverse array of GI and liver illnesses are seen. Fellows see and evaluate patients, and have supervised responsibility for direct patient care, including diagnostic and management planning, order writing, and record keeping. Fellows on this rotation also attend the Monday afternoon GI clinic at the VA Hospital, and their weekly afternoon Continuity Clinic at the University. Each fellow takes night and weekend call from home, sharing call responsibilities with the other fellows.
Teaching Methods-- The principle teaching method is in-depth case-based discussions by the fellow and the attending physician. Trainees initially evaluate the patient, including performing a history and physical exam, and gathering appropriate laboratory and x-ray data. The trainee often does preliminary educational reading about the case at this point. The case is then presented to the attending. The attending verifies key portions of the history and physical exam. The attending also provides teaching and discussion on pertinent clinical and pathophysiologic aspects of the case. The teaching method used by supervisory attendings in the fellow’s Continuity Clinic and the VA Clinic is similar, except that fellows are taught the importance of time management. [Not every follow-up clinic patient is physically seen by the attending.]
During the rotation, trainees gain technical and interpretative skills in the performance of endoscopic procedures, under the direct supervision of an attending physician. Early on, trainees watch their attending physician perform procedures. Then, they perform procedures with ongoing feedback from the attending. Finally, as the fellow becomes increasingly proficient, he/she will be able to perform the procedure without the need for constant feedback. The attending will just be able to observe, and offer constructive comments when needed. The complexity of procedures performed will increase during the course of the fellowship, and is individualized based on the trainee’s skills. Discussions also take place between the fellow and attending regarding the indications and appropriateness of procedures, risk/benefit, and how to use the information obtained from the procedure in the patient’s overall management.
Teaching on this rotation is also supplemented by conference attendance, by conference presentations and discussions, and by independent self-learning.
During this rotation, fellows also assist in the teaching of residents and medical students, which also helps them learn and apply medical information better.
Lines of Supervision-- This rotation has a designated attending physician who is responsible for the supervision of the trainee. There is a separate attending assigned to night-time and weekend call. The trainee should address questions and concerns first to the attending on the rotation or on-call. The Program Director and the Division Director are available, in sequence, for clinical back-up and for resolution of unsettled concerns. Whenever possible, individual patient questions will be addressed to the attending responsible for that patient’s ongoing care. On clinical rotations, the trainee will also be responsible for reviewing patient evaluations of students and residents on the service in preparation for teaching rounds.
Patient Characteristics-- The inpatient and outpatient population at the VA provides trainees with exposure to a vast array of GI and liver illnesses. The gender of the patients is weighed much more heavily toward males at the VA. Patients do encompass a broad age range, including geriatric patients, and diverse range of socio-economic and educational backgrounds. Patients in the fellow’s weekly Continuity Clinic at the University are evenly split between male and female patients.
Mix of Diseases Encountered-- A vast array of diseases is encountered on this rotation, including diseases of the esophagus, acid-peptic disorders of the GI tract, motor disorders of the GI tract, irritable bowel syndrome, disorders of nutrient assimilation, inflammatory bowel disease, vascular diseases of the GI tract, GI infections (including bacterial, viral, fungal, and parasitic), GI diseases with an immune basis, gallstones and cholecystitis, alcoholic liver disease, cholestatic syndromes, drug-induced hepatic injury, chronic liver disease, GI neoplastic disease, acute and chronic hepatitis, biliary and pancreatic diseases, GI bleeding, cirrhosis and portal hypertension, genetic/inherited disorders, medical management of patients under surgical care for GI disorders, and management of GI emergencies in acutely ill patients.
Specific Procedures Performed on this Rotation-- Trainees will achieve proficiency in the performance of GI procedures, including esophagogastroduodenoscopy, esophageal dilation, percutaneous endoscopic gastrostomy, flexible sigmoidoscopy, push enteroscopy, colonoscopy, polypectomy, nonvariceal hemostasis, variceal hemostasis, conscious sedation, and percutaneous liver biopsy. Senior fellows participate in ERCP and EUS procedures.
Pathological Material-- Biopsy material from the esophagus, stomach, small bowel, colon, liver, biliary tree, and pancreas is studied as part of patient care during this rotation.
Reading Lists and Educational Resources to be Used-- GI fellows are encouraged to purchase at least one textbook in gastroenterology and one in liver disease when they start their fellowship. [The Sleisenger & Fortran textbook listed below actually contains both in one source.] These books can then serve as primary reading and reference sources throughout the fellowship. In addition, GI division libraries contain a number of other helpful books. Beyond that, the University of Missouri Health Sciences Library is a full-service, outstanding medical school library in our complex that contains a vast array of helpful reference books, journals, interlibrary loan services, and the like. Medline searches can conducted on-line (via the internet) 24 hours a day, 364 days a year through the Health Sciences Library website. Many journals and other resources are increasingly becoming available on-line. The medical library at the VA Hospital is also quite useful. UpToDate Online, available to all GI fellows and faculty, is a tremendous clinical and educational resource (covering gastroenterology and internal medicine). It is available on our computers 24 hours per day, 364 days a year. Some specific helpful references and sources are listed below:
Sleisenger & Fordtran’s Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis and Management (7th edition). Feldman M, Friedman LS, Sleisenger MH (eds). Philadelphia: Saunders (Elsevier Science), 2002.
Textbook of Gastroenterology (4th edition). Yamada T (ed). Philadelphia: Lippincott Williams & Wilkins, 2003.
Schiff’s Diseases of the Liver (8th edition). Schiff ER, Sorrell MF, Maddrey WC (eds). Philadelphia: Lippincott-Raven Publishers, 2003.
Diseases of the Liver and Biliary System. Sherlock S, Dooley J. Malden (MA): Oxford, 2002.
Transplantation of the Liver. Maddrey WC, Schiff ER, Sorrell MF (eds). Philadelphia: Lippincott Williams & Wilkins, 2001.
Gastroenterologic Endoscopy. Sivak MV Jr (ed). Philadelphia: Saunders, 2000.
UpToDate Online 13.1 (2005). Available on-line to GI fellows (and faculty) 24 hours every day, 364 days a year.
Medline Literature Searches can be done on-line (via internet) 24 hours per day through the University of Missouri Health Sciences Library. They can also be done at the VA Hospital medical library during regular library hours.
The University of Missouri Health Sciences Library (located within our complex) has an outstanding selection of textbooks and other books in the field of gastroenterology and liver disease, as well as access to every relevant medical journal in the world. Medline searches can be conducted on-line at all times. Librarians are also available during regular operating hours for more specialized library services. The medical library at the VA Hospital also has a good selection of books and journals, and library services.
American Society for Gastrointestinal Endoscopy (ASGE) Policy and Procedure Manual for Gastrointestinal Endoscopy: Guidelines for Training and Practice 2005 has been installed on many GI division and Endoscopy Center computers.
The websites of the American Gastroenterologic Association (AGA), American College of Gastroenterology (ACG), and American Society for Gastrointestinal Endoscopy (ASGE) also contain much helpful educational materials and practice guidelines.
Methods of Evaluation for Fellow Competence-- Ongoing feedback is given to the trainee throughout the rotation. For instance, the inpatient attending critiques case presentations, clinical and scientific literature understanding, and management recommendations of the trainee on a case-by-case basis. Procedural competence is assessed by direct observation by the attending physician. Ongoing feedback is given to the fellow during procedures and throughout the rotation. Procedural assessment encompasses technical competence, the ability of the trainee to recognize normal and abnormal findings, and the ability of the trainee to apply the information learned from the procedure to the patient’s management plan.
Trainees also undergo a formal monthly written evaluation by those attendings whom they have worked with over that period. This evaluation looks at the six ACGME competency areas-- (1) patient care, (2) medical knowledge, (3) practice-based learning and improvement, (4) interpersonal and communication skills, (5) professionalism, and (6) systems-based practice. Technical competency in procedures is assessed separately. In addition, comments are made regarding the fellow’s conference attendance and educational presentations during the period.
The numbers of procedures that trainees do is used to establish whether they meet the minimum threshold numbers for assessing competency for an individual procedure. [Specific threshold numbers are given in the section called “Overview of Program Content.”] To this end, trainees are required to keep a formal procedure log throughout their fellowship, which has also been previously described.
Periodically the trainee’s procedural competence will also be assessed by seeing where their performance stands against objective performance standards (e.g. rate of cecal intubation for colonoscopy, rate of successful intubation of the esophagus and pylorus for EGD).
The Program Director conducts a formal written evaluation of the fellow’s performance on a quarterly basis, that includes formal evaluation of the knowledge, skills, and professional growth of the fellow and any required counseling that they might need. This is detailed more in the Evaluation Section of this document.
Revised 6/15/2005
