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Procedural Training
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The fellowship curriculum provides all training necessary
for competence in the procedures required for board certification in
gastroenterology and for program certification by the ACGME. In addition,
the third year of the clinician track provides an opportunity for fellows
to obtain skills in diagnostic and therapeutic endoscopic retrograde
cholangio-pancreatography (ERCP) as well as other advanced endoscopic
procedures.
Procedural training is integrated into the clinical
curriculum. For example, basic upper and lower endoscopy is taught
primarily during the gastroenterology inpatient/outpatient and endoscopy
rotations, whereas liver biopsy is learned during the hepatology rotation.
Trainees maintain a log of all procedures performed during the three-year
curriculum. Performance is assessed in an ongoing fashion by endoscopy
attendings, and all procedures in this fellowship program are directly
supervised by faculty members. Exposure to procedures during the three-year
curriculum readily meets proposed minimal standards for trainee assessment
(see table below). Supplemental training can be provided to trainees whose
performance falls below division standards. Average number of procedures
performed by trainees in the 1997-98 academic year also are listed below.
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Diagnostic and
Therapeutic Procedures Performed by Trainees in the Program (1995-98)
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Procedure
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ACGME
requires
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Society
recommends*
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Year 1
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Year 2
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Year 3
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EGD
|
100
|
100
|
289
|
86
|
108
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EGD with treatment of nonvariceal hemorrhage (actively
bleeding)
|
20
(10)
|
20
(10)
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31
(15)
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23
(7)
|
16
(7)
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EGD with treatment of variceal hemorrhage (actively
bleeding)
|
15
(5)
|
15
(5)
|
19
(8)
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11
(6)
|
5
(4)
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Esophageal dilation
|
15
|
15
|
26
|
18
|
5
|
|
Flexible sigmoidoscopy
|
25
|
25
|
59
|
18
|
12
|
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Colonoscopy
|
100
|
100
|
114
|
188
|
90
|
|
Colonoscopy with snare polypectomy
|
20
|
20
|
32
|
64
|
41
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Percutaneous endoscopic gastrostomy
|
10
|
10
|
10
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17
|
7
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Percutaneous liver biopsy
|
20
|
20
|
22
|
62
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3
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Mucosal biopsy: during EGD
|
|
|
147
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41
|
30
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Mucosal biopsy: during colonoscopy
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|
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66
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68
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12
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Small bowel biopsy
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|
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41
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12
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1
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Pneumatic dilation
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|
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3
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3
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5
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Diagnostic and therapeutic paracentesis
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20
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37
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40
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7
|
|
|
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|
|
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The Gastroenterology Leadership Council (AASLD, ACG, AGA,
ASGE). Training the gastroenterologist of the future: the gastroenterology core
curriculum. Gastroenterology 110:1266-1300 (1996).
Accreditation Council for Graduate Medical Education
(ACGME). Program requirements for residency education in gastroenterology.
ACGME, June 1993; effective July 1995.
Elements of Procedural Training
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Diagnostic and Therapeutic Endoscopy
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Objectives
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Training in technical competence and procedural aspects
of diagnostic endoscopy. Develop an understanding of the indications,
contraindications, and risks of the procedures and learn to interpret
normal and abnormal findings at endoscopy. Training in therapeutic
procedures and biopsy techniques during endoscopy.
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Description
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Esophagogastroduodenoscopy (EGD), colonoscopy, flexible
sigmoidoscopy, small bowel enteroscopy and endoscopy through a stoma are the
commonly performed endoscopic procedures. Associated procedures include
standard biopsy, Maloney and Savary dilation of esophageal strictures,
balloon dilation of esophageal, pyloric and colonic strictures, endoscopic
small bowel (Gowen tube) and large bowel decompression tube placement, and
placement of rectal brachytherapy tubes. Indications and contraindications
of the procedures are emphasized during consult rounds and pre-procedure
discussions with the endoscopy preceptor. Technical competence is developed
under close faculty direction on a one-to-one basis during the performance
of each procedure. Safe biopsy techniques are emphasized during these
sessions. Fellows are exposed to therapeutic aspects of endoscopy during
consult service rotations and during emergency endoscopic procedures.
Therapeutic maneuvers performed include heater probe application,
epinephrine injection, variceal band ligation and injection sclerotherapy.
Fellows in their first year of training are initially trained in the techniques
of EGD and flexible sigmoidoscopy, and graduate to performing colonoscopy
and other advanced endoscopy procedures.
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Evaluation
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Direct discussions of indications, contraindications and
risks of procedure during consult rounds and before each procedure.
Direct feedback from the attending faculty supervisor during and after the
procedure.
Attending faculty critique of the procedure report.
Quality assurance conference quarterly.
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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Liver Biopsy
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Objectives
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Develop understanding of the indications, risks,
contraindications and interpretation of liver biopsy. Develop procedural
competence in the performance of liver biopsy. Understand objectives of
post-procedure monitoring, and learn to manage complications.
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Description
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Liver biopsy is performed in the evaluation of common
and uncommon liver diseases. Indications, contraindications and risks are emphasized
during consultation rounds and pre-procedure discussions. Close supervision
is provided with an attending faculty member. The fellow supervises
post-procedure monitoring, with attending guidance, and takes follow-up
phone calls from patients with post-procedure complaints or problems.
Fellows manage patients with complications under close attending
supervision. Interpretation of the biopsy is performed at the weekly liver
pathology conference.
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Evaluation
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Direct discussions of indications, contraindications and
risks of procedure during consult rounds and before each procedure.
Direct feedback from the attending faculty supervisor during and after the
procedure.
Attending faculty critique of interpretation at pathology sessions.
Quality assurance conference quarterly.
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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Interventional Procedures
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Objectives
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Training in technical competence and procedural aspects of
interventional endoscopic procedures, including percutaneous endoscopic
gastrostomy (PEG) and percutaneous endoscopic jejunostomy (PEJ) placement
and maintenance, use of Nd:YAG laser and argon plasma coagulator device, performance
of botulinum toxin injection and pneumatic dilation for achalasia. Develop an understanding of the
indications, contraindications and risks of these procedures, and be able
to interpret normal and abnormal findings.
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Description
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The fellow is introduced to advanced and interventional
endoscopic procedures during the second and third years of fellowship after
technical competence is attained in routine endoscopic procedures. Interested
fellows with be taught to pass a side viewing endoscope, but ERCP and EUS
procedures are only performed by the 4th year Advanced Endoscopy
Fellow. Indications and contraindications of the procedures are emphasized
during consultation rounds and pre-procedure discussions with the endoscopy
preceptor. Technical competence is developed under close faculty direction.
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Evaluation
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Direct discussion of indications, contraindications and
risks of procedure during consult rounds and before each procedure.
Direct feedback from the attending faculty supervisor during and after the
procedure.
Quality assurance conference quarterly.
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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Function Studies and Other Procedures
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Objectives
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Develop understanding of the indications, contraindications,
and risks as well as methods of performing and interpreting function
studies, including esophageal manometry, 24 hour pH monitoring, secretin
stimulation tests and gastric analyses. Develop understanding of the
indications, contraindications, risks and performance of other
gastrointestinal procedures, including large volume paracentesis,
diagnostic paracentesis, Sengstaken-Blakemore tube placement.
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Description
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Function studies are generally performed in outpatients at
the endoscopy laboratory by a trained nurse under faculty supervision.
Fellows are encouraged to learn the technical aspects of the various
procedures, including indications, contraindications and risks. Initial
interpretation can be performed by interested fellows before final faculty
interpretation. Large-volume paracentesis is performed by the fellow under
attending faculty supervision in the endoscopy laboratory, medical
procedure area or patient room. Sengstaken-Blakemore tube placement is
performed in the intensive care units under faculty supervision when
indicated. The risks and contraindications are emphasized on a one-to-one
basis preceding and during the procedures
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Evaluation
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Direct discussions of indications, contraindications and
risks of procedure during consult rounds and before each procedure.
Direct feedback from the attending faculty supervisor during and after the
procedure.
Quality assurance conference quarterly.
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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Quality Assurance Review
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Objectives
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Develop a critical approach to prevention of
complications from endoscopy and other gastroenterologic procedures by
discussion of morbidity and mortality following such procedures at our
facility.
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Description
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This forum is held every quarter. Complicated cases,
morbidity or mortality from gastroenterologic procedures, and problems from
conscious sedation over the previous three months are discussed; the
opinions of faculty members and fellows are heard. The intent is to learn
from the complications and to develop a preventative approach. Specific
cases are presented in brief by the fellow or faculty supervisor involved,
and the indications, performance of the procedure and post-procedure
monitoring and follow-up are discussed.
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Evaluation
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Direct feedback from the faculty members.
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Back to top | Back to Fellowships | Application
Division of Gastroenterology
Department of Medicine
Washington University School of Medicine
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