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Clinical Curriculum
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The clinical curriculum is a series of independent rotations
dovetailed into ongoing outpatient experience. Core rotations occur at
Barnes-Jewish Hospital and the Veterans’ Administration Medical Center
(VAMC). At Barnes-Jewish Hospital, fellows participate in the care of more
than 90 percent of patients visited by the full-time faculty members. Three
to eight new consultations are provided daily on the inpatient
gastroenterology service. The VAMC (two miles from Washington University
Medical Center) shares its gastroenterology service with Saint Louis University.
Fellows participate in all gastroenterology-related inpatient and
outpatient services. The number of gastroenterology consults ranges from
two to six per day.
Fellows attend outpatient clinics throughout all three
years. Near the beginning of the first year, the trainee spends one entire
rotation in the ambulatory setting with the full-time faculty to gain
experience in outpatient gastroenterology without the burden of additional
clinical responsibilities. This rotation supplements a series of one-year
continuity clinics, during which the fellow is assigned to a specific
preceptor for one half-day clinic per week. Trainees change preceptors at
the end of each academic year.
Preceptor assignments are in general gastroenterology
for the first year, hepatology for the second year, and specialized areas
of gastroenterology (e.g., inflammatory bowel disease, pancreatico-biliary
disease) for the third year. Trainees are allowed to transfer patients from
preceptor to preceptor across academic years. On average, fellows see one
to three new patients and three to four follow-up patients each half-day
clinic session.
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Elements of the Clinical Curriculum
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General GI Consult Service
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Objectives
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Gain exposure to commonly encountered clinical GI issues
in an inpatient setting. Develop ability to accurately assess clinical
situations and triage need for therapeutic maneuvers and diagnostic
procedures. Develop ability to function in the role of a consultant and to
supervise medical students and residents.
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Description
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Each first-year fellow spends an average of six months on
this 24-hour service. One of the first-year fellows takes requests for
inpatient consults and procedures from various departments and clinical
services. Pancreatico-biliary and hepatology consults are directed to the
appropriate fellow on these services. Fellows evaluate the patients
themselves or supervise medical students and residents rotating through the
service. The patients are then presented to a faculty supervisor, and a
management plan is made. This provides an opportunity for didactic teaching
on patient- and management-related topics, including indications,
contraindications and risks. The faculty supervisor then examines the
patient and confirms clinical findings. Fellows follow patients until the
clinical problem is resolved. This may include performing diagnostic or
therapeutic endoscopic procedures.
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Evaluation
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Direct feedback from the attending faculty supervisor.
Formal written evaluation following each rotation. (See form: Fellow
Evaluation by Faculty).
Quarterly feedback sessions with the division chief.
Fellow evaluation form. (See form: Fellow Evaluation by Faculty).
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Hepatology/Transplant Service
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Objectives
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Gain exposure to commonly encountered liver problems in
a clinical gastroenterological practice. Develop an understanding of the
clinical management of common liver problems. Learn to manage liver
transplant issues, both in the post-operative phase and in the long term.
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Description
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Fellows spend an average of 12-15 weeks on the
hepatology and liver transplant service during their first two years of
fellowship. Second-year fellows provide weekend coverage every other
weekend while on the private GI service. The fellow on the
hepatology/transplant service takes liver consults from other departments/divisions
and takes calls for inpatient transfers from referring physicians from
outside medical facilities 24 hours a day. In addition, the fellow takes
calls from patients followed by the faculty practice nights and weekends.
They see consults, admissions, transfers and post-transplant patients on
rounds daily with the faculty supervisor on service. Fellows perform liver
biopsies and large-volume paracenteses on working days in the morning
hours. Fellows also attend the hepatology clinic and the liver transplant
clinic every week. The fellow selects cases for the liver pathology
conference and presents the cases at the conference. The fellow also
attends the liver transplant candidate selection conference that occurs
each week. The fellow also is responsible for teaching residents and
students on service.
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Evaluation
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Direct feedback from the attending faculty supervisor
after consult rounds, or after emergency cases are presented to the backup
faculty supervisor off hours. Direct feedback after procedures.
Direct feedback during pathology and transplant conferences.
Formal written evaluation following each rotation. (See form: Fellow
Evaluation by Faculty).
Quarterly feedback sessions with the division chief.
Fellow evaluation form. (See form: Fellow Evaluation by Faculty).
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Inpatient Gastroenterology Service
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Objectives
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Gain exposure to complicated gastroenterological and
biliary problems in an inpatient setting, including the management of inflammatory
bowel disease (IBD), and commonly
encountered biliary and pancreatic problems in a clinical gastroenterology
practice. Performance of
procedures of intermediate difficulty, including colonoscopy, percutaneous
gastrostomy tube (PEG) placement, percutaneous jejunostomy tube (PEJ)
placement and pneumatic dilation of achalasia. Develop an understanding of the clinical management of
common biliary and pancreatic problems. Understand the indications and
contraindications for diagnostic and therapeutic endoscopic retrograde
cholangio-pancreatography (ERCP), endoscopic ultrasound, laser treatment,
placement of esophageal stents.
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Description
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Second and third-year fellows are assigned to the inpatient
gastroenterology service while rotating through the GI consult service.
Clinical fellows spend four months and research fellows spend two months on
this rotation. Fellows follow the patients from the time they are admitted
and serve as a liaison between the patient’s gastroenterologist and other
consult services. The service consists of about 50-60 percent IBD-related
problems, including patients admitted for surgery. The fellow directs house
staff when the patients are admitted to house-staff covered services and teaches
residents, interns and students about management of complicated
gastroenterological problems. The fellow follows the patients until
discharge and then dictates a letter to the referring or primary care
physician. The fellow also performs consults for specialized procedures
including ERCP, PEG and PEJ placement and pneumatic dilation of achalasia.
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Evaluation
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Direct feedback from the attending faculty supervisor.
Formal written evaluation following each rotation. (See form: Fellow
Evaluation by Faculty).
Quarterly feedback sessions with the division chief.
Fellow evaluation form. (See form: Fellow Evaluation by Faculty).
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Inpatient Endoscopy Rotation
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Objectives
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Develop the technical and procedural skills required for
the performance of inpatient endoscopy. Develop an understanding of the
indications, contraindications and risks of performing these procedures.
Understand potential complications and identify post-procedural
complications.
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Description
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Fellows spend an average of 4 months on this service during
their last two years of fellowship in the clinician track, and 2 months in
the investigator track. The fellow reviews the indication for the
procedure, obtains informed consent and performs a quick physical
examination to determine if the patient is fit to undergo conscious
sedation. The indication and nature of the procedure are then reviewed with
the faculty supervisor. The fellow performs the endoscopic procedure under
faculty supervision. After the procedure, the fellow is responsible for the
procedure report, communicating with the referring physician, explanation
the findings to the patient and relatives, and follow-up on biopsy results.
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Evaluation
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Direct feedback from the attending faculty supervisor
after the procedure.
Attending faculty critique of the procedure report.
Formal written evaluation following each rotation. (See form: Fellow
Evaluation by Faculty).
Quarterly feedback sessions with the division chief.
Fellow evaluation form. (See form: Fellow Evaluation by Faculty).
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Extramural Rotations
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Objectives
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Expose the fellow to alternative teaching methods and
differing patient populations in other centers within the U.S. and abroad.
Provide the opportunity to learn skills not available or not taught at our
program.
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Description
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Interested fellows are encouraged to arrange an
extramural rotation during one of their research months. The rotation can be
arranged with the assistance of the research mentor or the program
director. The rotation is typically four to five weeks when the fellow is
not assigned any inpatient call or internal duties. The purpose of the
rotation is clearly identified during correspondence with the extramural
center and could include a short collaborative research project, learning
of a new technique, or any other educational activity at the discretion of
the research mentor. The fellow works with a mentor from the extramural facility
for the period of the rotation. The fellow is expected to present his
extramural experience/research at his next assigned division rounds.
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Evaluation
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Direct one-to-one feedback and critique from both the
fellow’s research mentor and the extramural mentor.
Critique from the rest of the faculty at division rounds.
Formal written evaluation following each rotation. (See form: Fellow
Evaluation by Faculty).
Quarterly feedback sessions with the division chief.
Fellow evaluation form. (See form: Fellow Evaluation by Faculty).
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Nutrition Service
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Objectives
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Exposure to nutrition-related problems, including the management
of obesity. Introduction to the administration of total parenteral
nutrition (TPN) and complications seen with intensive nutritional support.
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Description
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This service is elective. The fellow performs consults on
all patients on whom TPN is requested to determine indications and
contraindications. The actual caloric requirements and method of
administration are determined in consultation with the dietary nurse. The
consults are staffed with the faculty supervisor on the nutrition service.
The fellow follows the nutrition faculty supervisor’s patients when they
are admitted. The fellow can attend the evening obesity clinics on weekday
evenings if interested.
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Evaluation
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Direct feedback from the attending faculty supervisor.
Formal written evaluation following each rotation. (See form: Fellow
Evaluation by Faculty).
Quarterly feedback sessions with the division chief.
Fellow evaluation form. (See form: Fellow Evaluation by Faculty).
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Outpatient clinic rotation
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Objectives
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Develop an understanding of outpatient gastroenterological
problems commonly encountered at a referral center.
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Description
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All first year fellows spend four weeks in the
outpatient clinic offices of the faculty supervisors within the first four
months of initiation of fellowship training. The fellows and the faculty
supervisors get to know one another, and develop a mutual trust and
understanding. The new fellows are exposed to outpatient
gastroenterological problems and learn to perform a directed history and
physical examination. They also learn to order appropriate investigative
tests, including endoscopic procedures. Management of the patients with
appropriate follow up is also stressed.
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Evaluation
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Direct feedback after the patients are seen and findings
confirmed by the faculty supervisor.
Formal written evaluation following each rotation.
Quarterly feedback sessions with the division chief.
Fellow evaluation form.
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Continuity Clinic
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Objectives
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Gain exposure to outpatient gastroenterological
problems. Develop an understanding of outpatient gastroenterological
problems commonly encountered at a referral center. Understand the
importance of outpatient follow-up, and see patients in follow-up with
their outpatient clinic mentor.
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Description
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All fellows are assigned a half day clinic session for
their continuity clinic, which will remain fixed throughout their
fellowship. Fellows are expected to see an average of 3 new patients each
week and follow them throughout their evaluation and managment. Fellows
also see 3-6 return patients each week. Fellows are expected to dictate complete clinical
assessments and communicate with patients as well as referring physicians
when necessary. First-year fellows focus on general GI outpatients, and
outpatient treatment of inflammatory bowel disease is stressed. Second-year
fellows learn outpatient management of liver disease. Third-year fellows focus
on complicated referrals and pancreaticobiliary disease. All fellows are required to see
their patients when they return for follow up visits.
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Evaluation
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Direct feedback after the patients are seen and findings
confirmed by the outpatient faculty mentor.
Formal written evaluation following each rotation. (See form: Fellow
Evaluation by Faculty).
Quarterly feedback sessions with the division chief.
Fellow evaluation form. (See form: Fellow Evaluation by Faculty).
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Outpatient Endoscopy Rotation
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Objectives
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Develop the technical and procedural skills required for
the performance of outpatient endoscopy. Develop an understanding of the
indications, contraindications and risks of performing these procedures.
Understand potential complications and identify post-procedural
complications before patients are discharged.
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Description
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Fellows spend four weeks per year performing outpatient
endoscopy throughout their fellowship. On average, six to eight endoscopic
procedures are performed by the fellow on each weekday of the rotation. The
fellow reviews the indication for the procedure, obtains informed consent
and performs a quick physical examination to determine if the patient is
fit to undergo conscious sedation. The indication and nature of the
procedure are then reviewed with the faculty supervisor. The fellow
performs the endoscopic procedure under faculty supervision. After the
procedure, the fellow is responsible for the procedure report,
communicating with the referring physician, explanation the findings to the
patient and relatives, and follow-up on biopsy results.
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Evaluation
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Direct feedback from the attending faculty supervisor
after the procedure.
Attending faculty critique of the procedure report.
Formal written evaluation following each rotation. (See form: Fellow
Evaluation by Faculty).
Quarterly feedback sessions with the division chief.
Fellow evaluation form. (See form: Fellow Evaluation by Faculty).
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Veteran's Administration Rotation
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Objectives
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Gain exposure to commonly encountered clinical GI,
hepatobiliary and pancreatic issues in a Veterans Administration hospital.
Develop ability to accurately assess clinical situations and triage need
for therapeutic maneuvers and diagnostic procedures. Develop ability to
function as a consultant. Develop ability to supervise medical students and
residents during their clinical GI rotations.
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Description
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Each first-year fellow spends an average of three months
on this 24-hour service. The fellow takes requests for inpatient consults
and procedures from various departments and clinical services. The GI
service is shared between Washington University and Saint Louis University,
with one fellow from each university working together to handle inpatient
duties and call. Attending faculty from both universities serve as
consultation and endoscopy attending supervisors. Pancreatobiliary and
hepatology consultations are also covered by the fellow on this service.
The fellows evaluate the patients themselves or supervise medical students
and residents rotating through the service. The patients are then presented
to one of the faculty supervisors covering the service, and a management
plan is made. This provides an opportunity for discussion of management
related topics, including indications, contraindications and risks of
diagnostic and therapeutic procedures. The faculty supervisor then examines
the patient and confirms the clinical findings. Fellows follow their patients
until the clinical problem is resolved. This may include performance of
diagnostic or therapeutic endoscopic procedures. The fellows also perform
endoscopic procedures at the VA endoscopy suite and see outpatient consults
and follow-ups at the VA GI clinic weekly.
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Evaluation
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Direct feedback from the attending faculty supervisor
after rounds or after emergency cases are presented to the backup faculty
supervisor.
Formal written evaluation following each rotation. (See form: Fellow
Evaluation by Faculty).
Quarterly feedback sessions with the division chief.
Fellow evaluation form. (See form: Fellow Evaluation by Faculty).
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Division of Gastroenterology
Department of Medicine
Washington University School of Medicine
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