Clinical Rotations

The clinical curriculum consists of 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 ten 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 six month 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 six month period.

Preceptor assignments are in general gastroenterology for the first year, hepatology and specialized areas of gastroenterology (e.g., inflammatory bowel disease, pancreatico-biliary disease) for the second and third years. Trainees are allowed to transfer patients from preceptor to preceptor across academic years. On average, fellows see two to four new patients and three to four follow-up patients each half-day clinic session.

Inpatient care and consults

General GI consult service

Objectives

  • 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.

Description

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.

Evaluation

  • Direct feedback from the attending faculty supervisor.
  • Formal written evaluation following each rotation.
  • Quarterly feedback sessions with the division chief.
  • Fellow evaluation form.

Hepatology/transplant service

Objectives

  • 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.

Description

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.

Evaluation

  • 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.
  • Quarterly feedback sessions with the division chief.
  • Fellow evaluation form.

Inpatient gastroenterology service

Objectives

  • 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.

Description

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.

Evaluation

  • Direct feedback from the attending faculty supervisor.
  • Formal written evaluation following each rotation.
  • Quarterly feedback sessions with the division chief.
  • Fellow evaluation form.

Inpatient endoscopy rotation

Objectives

  • 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.

Description

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.

Evaluation

  • Direct feedback from the attending faculty supervisor after the procedure.
  • Attending faculty critique of the procedure report.
  • Formal written evaluation following each rotation.
  • Quarterly feedback sessions with the division chief.
  • Fellow evaluation form.

Veteran’s administration rotation

Objectives

  • 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.

Description

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.

Evaluation

  • 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.
  • Quarterly feedback sessions with the division chief.
  • Fellow evaluation form.

Electives

Extramural rotations

Objectives

  • 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.

Description

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.

Evaluation

  • 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.
  • Quarterly feedback sessions with the division chief.
  • Fellow evaluation form.

Nutrition service

Objectives

  • 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.

Description

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.

Evaluation

  • Direct feedback from the attending faculty supervisor.
  • Formal written evaluation following each rotation.
  • Quarterly feedback sessions with the division chief.
  • Fellow evaluation form.

Outpatient care

Outpatient clinic rotation

Objectives

Develop an understanding of outpatient gastroenterological problems commonly encountered at a referral center.

Description

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.

Evaluation

  • 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.

Continuity clinic

Objectives

  • 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.

Description

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.

Evaluation

  • Direct feedback after the patients are seen and findings confirmed by the outpatient faculty mentor.
  • Formal written evaluation following each rotation.
  • Quarterly feedback sessions with the division chief.
  • Fellow evaluation form.

Outpatient endoscopy rotation

Objectives

  • 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.

Description

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.

Evaluation

  • Direct feedback from the attending faculty supervisor after the procedure.
  • Attending faculty critique of the procedure report.
  • Formal written evaluation following each rotation.
  • Quarterly feedback sessions with the division chief.
  • Fellow evaluation form.