Procedural Training

The gastroenterology fellowship curriculum provides all training necessary for competence in the procedures required for board certification and for program certification by the ACGME.

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 during an academic year also are listed below.

Diagnostic and therapeutic endoscopy

Objectives

  • 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.

Description

Esophagogastroduodenoscopy (EGD), colonoscopy, flexible sigmoidoscopy, small bowel enteroscopy (push enteroscopy, single balloon enteroscopy), capsule endoscopy 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 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, hemoclip application, variceal band ligation, injection sclerotherapy and injection of botulinum toxin. 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.

Evaluation

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

Liver biopsy

Objectives

  • 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.

Description

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.

Evaluation

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

Interventional procedures

Objectives

  • 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 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.

Description

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.

Evaluation

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

Function studies and other procedures

Objectives

  • Develop understanding of the indications, contraindications, and risks as well as methods of performing and interpreting function studies, including high resolution esophageal manometry, ambulatory pH and pH impedance monitoring, secretin stimulation tests, gastric analyses, high resolution and 3D anorectal manometry.
  • Develop understanding of the indications, contraindications, risks and performance of other gastrointestinal procedures, including large volume paracentesis, diagnostic paracentesis, Sengstaken-Blakemore tube placement.

Description

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. Interpretation sessions are scheduled regularly throughout the year. 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.

Evaluation

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

Quality assurance review

Objectives

Develop a critical approach to prevention of complications from endoscopy and other gastroenterological procedures by discussion of morbidity and mortality following such procedures at our facility.

Description

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.

Evaluation

Direct feedback from the faculty members.