shadow_tr

Clinical Training


PGY-1 Fellows:

First year fellows are accepted within the National Residency Matching Program. The fellow is assigned to the GASTROENTEROLOGY Service at one of the participating training institutions. He or she is under the supervision of the Chair of the Department, the Program Director, full time faculty, and supervising fellows.

The goal of the first year is to acquire diagnostic, therapeutic and prognostic skills through participation in direct patient care in supervised inpatient and outpatient settings. A typical year includes:

1.Four months on the Out Patient Clinics / Endoscopy (VA/Tulane)
2.Four months on the In Patient Consult Service/ Endoscopy(Tulane/UH)
3.Two months on the Hepatology service (Tulane)
4.Two months on Tulane backup/ Research.
5.Four weeks of vacation (incorporated into the monthly schedules)

General Knowledge:  

The first-year fellows obtains knowledge related to the presenting manifestations, natural history, complications, pathophysiology, differential diagnosis, and appropriate diagnostic and management plans for the most common diseases and conditions in the practice of the specialty. This includes diseases and conditions seen in ambulatory patients, emergency departments, regular hospital services and intensive care units. The intern develops proficiency in the interpretation of diagnostic studies used in the evaluation of common diseases in the specialty. First year fellow also acquire knowledge about the indications, limitations, complications and cost effectiveness of common diagnostic tests and procedures. The first year fellow obtains knowledge of the therapeutic indications used for the management of the common diseases in the specialty. In this year fellows are given the opportunity (through didactics and self directed learning, and teaching residents and students) to relate pathophysiology to the disease processes of luminal GI and hepatology.

 Ambulatory Clinics

First year fellows are taught the essentials of the GI history and physical exam, as well as differential diagnosis and management. They learn to build upon the base knowledge of internal medicine to develop the skills of a gastroenterologist.

Charity Clinic (MCLNO)

The first year fellow participates with faculty in the evaluation and treatment of patients seen in the MCLNO/Charity ambulatory care clinics. GI fellows maintain their own continuity clinic one half day per week. This is considered a general GI/hepatology clinic. With faculty supervision, these fellows obtain histories and physicals from each patient, order indicated laboratory and diagnostic studies treat diagnosed digestive and liver disease, and counsel patients regarding their health and disease. Fellows see at least one, but not more than four new patients per clinic. Fellows see not less than two, but not more than four established patients per clinic. The clinic is staffed with faculty preceptors at a ratio of 1 preceptor per 2 first year fellows.

Out-Patient Clinics—Dedicated Luminal GI or Hepatology (VA, Tulane Hospital)

The first year fellow participates with faculty supervision in VA clinics which are general GI (including hepatology) as well as a dedicated hepatology clinic. The first year fellow also participates in subspecialty clinics at Tulane which cover general GI, inflammatory bowel disease, motility disorders, and hepatology. Assigment to hepatology and subspecialty GI clinics at Tulane will vary between fellows in a single year, but all fellows will have received the same clinic exposure by the end of the program. All first year fellows will have the same exposure in that year to VA general GI clinics.

In-Patient Consult Service (Tulane Hospital, MCLNO):

The first year fellow is taught the essentials of the GI consultation, building upon the knowledge acquired in internal medicine training and learning to direct focus towards GI disease.

The first year fellow serves as the supervising fellow in performing consults on inpatients on the wards and the ICU, as well as those admitted patients in the ER, unless they are paired with a more senior fellow, who would assume this role . This includes:

1. Directly supervising interns, medical fellows and medical students in:
a. Obtaining a history and physical on all patients
b. Writing orders for patients if authorized by the admitting service
c. Advising on a management plan as well as indicated laboratory and diagnostic studies

2. Fellows also continue to increase their knowledge of the indications, contra-indications, risks and benefits, and interpretation of diagnostic procedures. They learn how to perform procedures commiserate with their level of training (vida infra). (see Endoscopy service, below)

3. Leading and organizing a GI consult service. This responsibility includes:
a. Supervising all intern and medical student ward activities
b. Organizing work and teaching rounds
c. Providing evaluation and feedback for each member of the ward team.
4. Urgent consults will be seen within the hour. Non urgent consults will be seen that day or within 24 hours of the consult request.

GI Endoscopy Service

First year GI fellows typically have no or very little hands-on experience with endoscopic procedures on entering the program, despite some familiarity with the indications for endoscopy. In the first year they will learn the essential cognitive and practical principles of endoscopic diagnosis and management.


First year GI fellows will primarily perform esophagogastroscopy (EGD, including foreign body removal, hemostasis of bleeding, variceal ligation, stricture dilation and diagnostic biopsy) and colonoscopy (including hemostasis of bleeding, decompression of Ogilvy’s syndrome, polypectomy and diagnostic biopsy) while on call. They will be assisted as needed by second or third year GI fellows on home backup call with them during the first month. They will not perform supervised ERCP or EUS in the first year. First year fellows will always perform procedures under the direct supervision of GI faculty who are in the room at all times. Basic competency in EGD and colonoscopy is expected by the end of the first year, with competency in associated diagnostic and therapeutic procedures to develop over the next two years.


PGY-2 Fellows:

General Knowledge:

The second-year fellow is expected to expand the fundamental knowledge obtained in the first year of training. Specifically, knowledge on the diagnosis and treatment of less common diseases is acquired during the second year. By the beginning of the second year, the fellows should have performed enough procedures and/or patient encounters to begin to demonstrate mastery of each. During the second year, the fellow improves mastery of these skills.

Second-year fellows are expected to continue to develop interpersonal skills, leadership, self-reflection and improvement, an understanding of systems of care, clinical education and ethical and professional refinement.

Ambulatory Clinics

The second-year fellow continues the clinic rotations established in the first year of training. As experienced GI fellows they are expected to use the knowledge and skills acquired in the first year to diagnose and treat outpatients, as well as to act as a resource for first year fellows, residents and students.

Charity Clinic—MCLNO

Fellow maintain their own continuity clinic one half day per week, and serve as the primary GI care provider for these patients. With faculty supervision, second year fellows augment their understanding of ambulatory management of gastrointestinal and liver disease. Fellows continue to hone their skills in obtaining histories and physicals, ordering indicated laboratory and diagnostic studies, treating diagnosed digestive and liver disease, and counseling patients regarding their health and disease. Fellows see at least one, but not more than four new patients per clinic. Fellows see not less than three, but not more than four established patients per clinic. The clinic is staffed with faculty preceptors at a ratio of one preceptor per two second year fellows. While in the clinic, fellows are responsible for obtaining histories and physicals and consulting with supervising staff physicians in the management of the patient’s disease.

Out-Patient Clinics—Dedicated Luminal GI or Hepatology (VA, Tulane Hospital)

The second year fellow participates with faculty supervision in VA clinics which are general GI (including hepatology) as well as a dedicated hepatology clinic. The second year fellow also participates in subspecialty clinics at Tulane which cover general GI, inflammatory bowel disease, motility disorders, and hepatology. Assigment to hepatology and subspecialty GI clinics at Tulane will vary between fellows in a single year, but all fellows will have received the same clinic exposure by the end of the program.

 In-Patient GI Consult Service

The second year fellow assigned to consult services at Tulane Hospital or University Hospital will continue the learning process started in the first year, but due to his/her added experience will act as a resource to junior house staff as well as first year fellows, taking a greater leadership role.

The second year fellow serves as the supervising fellow in performing consults on inpatients on the wards and the ICU, as well as those admitted patients in the ER. This includes:

1. Directly supervising interns, medical fellows and medical students in:
a. Obtaining a history and physical on all patients
b. Writing orders for patients if authorized by the admitting service
c. Advising on a management plan as well as indicated laboratory and diagnostic studies

2. Fellows also continue to increase their knowledge of the indications, contra-indications, risks and benefits, and interpretation of diagnostic procedures. They learn how to perform procedures commiserate with their level of training (vida infra). (see Endoscopy service, below)

3. Leading and organizing a GI consult service. This responsibility includes:
a. Supervising all intern, first year fellow and medical student ward activities
b. Organizing work and teaching rounds
c. Providing evaluation and feedback for each member of the ward team.
4. Urgent consults will be seen within the hour. Non urgent consults will be seen that day or within 24 hours of the consult request.

In-Patient Service:

Assignment to the Consult Service is designed to expose fellows to patients that are suspected of or who have documented acute and/or chronic disease of the digestive tract and through this exposure to educate fellows about:

  • the broad array, types, frequency and epidemiology of digestive diseases in the region and that present to a specific type of hospital system
  • the diversity of the signs and symptoms for presentation and complications that occur in patients with digestive diseases and that present to a specific type of hospital system

Liver Service:

The second year fellow will add to his/her knowledge and skills in the care of patients with advanced liver disease. Liver disease has become an increasingly important component of the practice of Gastroenterology. This increase reflects both an improvement in the recognition of patients with liver disease and significant advances in therapy. The novel and effective therapies for viral hepatitis and the improvement in survival of orthotopic liver transplants have increased the need for clinicians with expertise of liver disease.

Training in management of these patients is essential for all gastroenterologists, although practitioners providing the bulk of transplant hepatology care may require additional training beyond that offered in a typical gastroenterology training program (level-3, Transplant Hepatology).

The Tulane program provides level 1 training as per guidelines of the AGA (American Gastroenterological Association) Task Force on training in Hepatology. This includes education in a broad range of knowledge of the physiology of the liver and biliary system and a thorough knowledge for the diagnosis and management of patients with hepatobiliary disease.

The goals and objectives on the liver service are achieved by lectures, conferences, seminars and exposure to inpatients and outpatients with hepatobiliary disease, including those pre-transplant and post-transplant. The specific goals and objectives are outlined below:

GI Endoscopy Service

In addition to Tulane Hospital endoscopy duties, all second and third year fellows are assigned to outpatient and inpatient endoscopy at University Hospital. These procedures are mostly performed in the DTD unit, but may be done in the emergency room or intensive care unit. Procedures which will be performed are EGD (including foreign body removal, hemostasis of bleeding, variceal ligation, stricture dilation and diagnostic biopsy) and colonoscopy (including hemostasis of bleeding, decompression of Ogilvy’s syndrome, polypectomy and diagnostic biopsy). ERCP, EUS and esophageal stenting are not routinely done by second year fellows, but may if no third year fellow is available. Second year fellows will always perform procedures under the direct supervision of GI faculty who are in the room at all times. Competency in basic EGD and colonoscopy should already be established by the beginning of the second year, with expectation of further development of the basic skills as well as the additional diagnostic and therapeutic maneuvers described above.

ON CALL RESPONSIBILITIES:

Second year fellows take home call for GI or hepatology emergencies at Tulane Medical Center and (on alternate weekends) MCLNO University Hospital GI emergencies. They will round daily with on call faculty on inpatients being followed by the GI Consult service at Tulane University Medical Center wards AND either TATU (Tulane Abdominal Transplant Unit) or MCLNO (alternate weekend responsibilities). All fellows of any year will contact staff with new consults for review and decision making consultation.


PGY-3 Fellows:

The longitudinal development of the fellow’s clinical and diagnostic skills culminates in the third year of GI training. The goal is to solidify the knowledge and skills of the specialty. A major emphasis is on supervision and teaching of junior fellows and housestaff. Additional experience in a supervisory capacity is provided. As a consultant, the fellow further develops skills to provide consultation of the specialty to other specialties. The third year is also structured to afford maximum flexibility to allow indepth exposure to subspecialty activities such as advanced endoscopy/pancreaticobiliary disorders or concentration on specific clinics in IBD, motility or liver. A typical third-year schedule includes:

1. Three to six months on University Hospital In Patient Consult services/ Endoscopy.
2. One to six months on the Out Patient Consult service/ Endoscopy.
3. One to six months on the Hepatology Service
4. Three to six months on the Tulane Endoscopy Service (Theraputic/Advanced Procedures)
5. Up to one month elective time
6. One-month vacation

General Knowledge:

The third-year fellows increases his or her knowledge of core topics in the specialty, with special interest in subspecialty areas of the specialty. The curriculum is tailored to the fellow’s individual interests. The fellow continues improving the life-long habits of self-study, self-reflection and improvement, reading the medicine literature, teaching and research.

Ambulatory Clinics

The third-year fellow continues the Charity GI continuity clinic established in the first two years of training. Fellows maintain their own continuity clinic one half days per week, and serve as the primary GI provider for these patients. With faculty supervision, fellows augment their understanding of ambulatory management of digestive and liver disease. Fellows continue to hone their skills in obtaining histories and physicals, ordering indicated laboratory and diagnostic studies, treating diagnosed digestive and liver disease, and counseling patients regarding their health and disease. Third year fellows see at least one, but not more than four new patients per clinic. R3’s see not less than three, but not more than four established patients per clinic. The clinic is staffed with faculty preceptors at a ratio of 1 preceptor per 4 third year fellows.

While in the subspecialty clinics, fellows are responsible for obtaining histories and physicals from each patient and consulting with subspecialty physicians in the management of the patient’s disease.

Out-Patient Clinics—Dedicated Luminal GI or Hepatology (VA, Tulane Hospital)

The third year fellow participates with faculty supervision in VA clinics which are general GI (including hepatology) as well as a dedicated hepatology clinic. The third year fellow also participates in subspecialty clinics at Tulane which cover general GI, inflammatory bowel disease, motility disorders, pancreaticobiliary disease and hepatology. Assigment to hepatology and subspecialty GI clinics at Tulane will take into account the interests of the individual third year fellow, allowing more in depth interaction with supervising staff in the management of complex patients with liver, inflammatory bowel and neurogastroenterological disorders. The third year also has clinic exposure to pancreaticobiliary disorders, as part of the their endoscopy rotation concentrating on advanced endoscopy.

GI Endoscopy

All GI fellows (second and third year) are assigned to outpatient and inpatient endoscopy at University Hospital. These procedures are mostly performed in the DTD unit, but may be done in the emergency room or intensive care unit. Procedures which will be performed are EGD (including foreign body removal, hemostasis of bleeding, variceal ligation, stricture dilation, PEG tube placement and diagnostic biopsy) and colonoscopy (including hemostasis of bleeding, decompression of Ogilvy’s syndrome, polypectomy and diagnostic biopsy). By the end of the third year fellows are expected to be competent enough to perform these procedures without supervision. ERCP, EUS and non-biliary tract stenting are almost exclusively performed by third year fellows. These procedures are offered to the third year fellows in order to expose them to these techniques and provide a basis for further advanced endoscopy training which can be taken elsewhere in an elective non-ACGME accredited fourth year. Third year fellows may perform non-emergency EGD and colonoscopy under the supervision of GI faculty who are in the unit, but the faculty need not be in the room during the procedures (UH ONLY). This is in keeping with the increased skill level of the third year fellows who have by this time have exceeded the minimum number of these procedures required for independent practice by the ASGE. Third year fellows take an active role in mentoring junior fellows in endoscopic techniques, but only with a faculty member present in the room during the procedure. Emergency procedures done by third year fellows will always be under the direct supervision of a GI faculty member.

Liver Service:

Third year fellows will be assigned to the inpatient Liver Transplant service on request, with greater emphasis on outpatient management of complex hepatology patients. The third year can be used as a dedicated year heavily weighted in hepatology for those fellows who seek eventual UNOS certification in hepatology.

Liver disease has become an increasingly important component of the practice of Gastroenterology. This increase reflects both an improvement in the recognition of patients with liver disease and significant advances in therapy. The novel and effective therapies for viral hepatitis and the improvement in survival of orthotopic liver transplants have increased the need for clinicians with expertise of liver disease. Training in management of these patients is essential for all gastroenterologists, although practitioners providing the bulk of transplant hepatology care may require additional training beyond that offered in a typical gastroenterology training program (level-3, Transplant Hepatology). The Tulane program provides level 1 training as per guidelines of the AGA (American Gastroenterological Association) Task Force on training in Hepatology. This includes education in a broad range of knowledge of the physiology of the liver and biliary system and a thorough knowledge for the diagnosis and management of patients with hepatobiliary disease. The goals and objectives on the liver service are achieved by lectures, conferences, seminars and exposure to inpatients and outpatients with hepatobiliary disease, including those pre-transplant and post-transplant

1430 Tulane Ave, New Orleans, LA 70112 504-988-5263 medsch@tulane.edu