Fellowship Program Description
	Fellowship Application 2008

University of Rochester
School of Medicine and Dentistry
Gastroenterology Fellowship
Subspecialty Residency Program

Updated 2006

Arthur J. DeCross, M.D.
Program Director

Program Leadership

Department of Medicine Chair

• Mark B. Taubman, M.D.

• Donald Bordley, M.D.

• Richard G. Farmer, M.D.

• Arthur J. DeCross, M.D.

• Andrea Hagen

• Bonnie Austin

CONTENT 1. ACGME PROGRAM CONTENT REQUIREMENTS for RESIDENCY EDUCATION in GASTROENTEROLOGY 2. DESCRIPTION of FACILITIES/RESOURCES 3. OVERVIEW of PROGRAM CONTENT for 3 YEAR FELLOWSHIP TRAINING 1. ACGME PROGRAM CONTENT REQUIREMENTS for RESIDENCY EDUCATION in GASTROENTEROLOGY

1. Specific Program Content

A. Clinical Experience

1. The training program must provide opportunities for residents to develop clinical competence in the field of gastroenterology, including hepatology, clinical nutrition, and gastrointestinal oncology.

2. At least 18 months of the clinical experience should be in general gastroenterology, including hepatology, which should comprise approximately 30% of this experience. The additional 18 months of training must be dedicated to elective fields of training oriented to enhance competency.

3. Residents must have formal instruction, clinical experience, or opportunities to acquire expertise in the evaluation and management of the following disorders:

1. Diseases of the esophagus.
2. Acid peptic disorders of the gastrointestinal tract.
3. Motor disorders of the gastrointestinal tract.
4. Irritable bowel syndrome.
5. Disorders of nutrient assimilation.
6. Inflammatory bowel diseases.
7. Vascular disorders of the gastrointestinal tract.
8. Gastrointestinal infections, including retroviral, mycotic, and parasitic diseases.
9. Gastrointestinal and pancreatic neoplasms.
10. Gastrointestinal disease with an immune basis.
11. gallstones and cholecystitis.
12. alcoholic liver diseases.
13. cholestatic syndromes.
14. drug-induced hepatic injury.
15. hepatobiliary neoplasms.
16. chronic liver diseases.
17. gastrointestinal manifestations of HIV Infections.
18. Gastrointestinal neoplastic disease.
19. Acute and chronic hepatitis.
20. biliary and pancreatic diseases.

4. Residents must have formal instruction, clinical experience, and opportunities to acquire expertise in the evaluation and management of patients with the following clinical problems:

1. dysphagia.
2. abdominal pain
3. acute abdomen
4. nausea and vomiting
5. diarrhea
6. constipation
7. gastrointestinal bleeding
8. jaundice
9. cirrhosis and portal hypertension
10. malnutrition
11. genetic/inherited disorders
12. depression, neurosis, and somatization syndromes.
13. surgical care of gastrointestinal disorders.

B. Technical and Other Skills

1. The program must provide for instruction in the indications, contraindications, complications, limitations, and (where applicable) interpretation of the following diagnostic and therapeutic techniques and procedures:

1. Imaging of the digestive system, including
1. Ultrasound
2. computed tomography
3. magnetic resonance imaging
4. vascular radiography
5. nuclear medicine
2. percutaneous cholangiography
3. percutaneous endoscopic gastrostomy
4. gastric, pancreatic, and biliary secretory tests
5. other diagnostic and therapeutic procedures utilizing enteral intubation and bougienage.
6. enteral and parenteral alimentation
7. liver transplantation
8. pancreatic needle biopsy
9. ERCP, including papillotomy and biliary stent placement.

2. Opportunities also must be provided for the resident to gain competence in the performance of the following procedures. A skilled preceptor must be available to teach and to supervise them. The performance of these procedures must be documented in the resident’s record, giving indications, outcomes, diagnoses, and supervisors.

1. esophagogastroduodenoscopy; residents should perform a minimum of 100 supervised studies.
2. esophageal dilation; residents should perform a minimum of 15 supervised studies.
3. proctoscopy
4. flexible sigmoidoscopy; residents should perform a minimum of 25 supervised studies.
5. colonoscopy with polypectomy; residents should perform a minimum of 100 supervised colonoscopies and 20 supervised polypectomies.
6. percutaneous liver biopsy; residents should perform a minimum of 20 supervised studies.
7. percutaneous endoscopic gastrostomy; residents should perform a minimum of 10 supervised studies.
8. biopsy of the mucosa of esophagus, stomach, small bowel and colon.
9. gastrointestinal motility studies.
10. non-variceal hemostasis (upper and lower); residents should perform 20 supervised cases, including 10 active bleeders.
11. variceal hemostasis; residents should perform 15 supervised cases; including 5 active bleeders.
12. enteral and parenteral alimentation.

C. Formal Instruction

The program must include emphasis on the pathogenesis, manifestations, and complications of gastrointestinal disorders, including the behavior adjustments of patients to their problems. The impact of various modes of therapy and the appropriate utilization of laboratory tests and procedures should be stressed. Additional specific content areas that must be included in the formal program (lectures, conferences, and seminars) include the following:

1. Anatomy, physiology, pharmacology, and pathology related to the gastrointestinal system, including the liver.
2. The natural history of digestive diseases.
3. Factors involved in nutrition and malnutrition.
4. Surgical procedures employed in relation to digestive system disorders and their complications.
5. Prudent, cost-effective, and judicious use of special instruments, tests, and therapy in the diagnosis and management of gastroenterologic disorders.
6. Liver transplantation.
7. Sedation and sedative pharmacology.
8. Interpretation of abnormal liver chemistries.

2. DESCRIPTION of FACILITIES/RESOURCES

Strong Memorial Hospital at the University of Rochester, New York, has approximately 750 beds. Pertinent to the training program in Gastroenterology, there are several points to highlight. Strong is the only hospital campus on which the activities of the fellowship are conducted.

The Division of Gastroenterology is based in a new outpatient facility attached to the hospital. This houses the professional faculty offices and clerical support areas, and an extensive 6 room endoscopy suite dedicated to Gastroenterology, with one room functioning as an independent suite for ERCP. Endoscopic equipment was upgraded in 2003 to the most current line of Olympus video equipment with Image manger software, and the ERCP suite features state of the art digital image management. There is a large 10-bed recovery area. A 7 th room is dedicated to esophageal pH and manometry testing, with equipment and personnel to perform other physiologic tests in diagnostic Gastroenterology, such as hydrogen breath testing, secretin stimulation assay, gastric acid analysis, and ano-rectal manometrics. Adjoining rooms are available for outpatient clinical consultations. (Outpatient consultations also occur in an off-campus office suite which provides 6 exam rooms, and also houses our video-capsule endoscopy equipment). The Gastroenterology Fellows have a dedicated fellow’s office, complete with personal computers, and a fully stocked fellow’s library of texts and reference materials. The unit also provides an expansive conference room for the educational program. There is a GI fellow’s laptop computer with projector to facilitate conference presentations by the fellows. Nearby, an extensive 4000 square-foot laboratory complex is occupied by the research personnel of the Gastroenterology division, and also includes another fellow’s office for their research endeavors.

There is a new Emergency Department with over 40 acute care beds, trauma unit, self-contained radiology suite, observation unit, and adequate facilities to comfortably support endoscopic procedures when needed. Extensive experience is obtained in consultation and procedural intervention in the emergent and urgent care setting.

Intensive Care Units include Medical Intensive Care, Surgical Intensive Care, Burn Unit Intensive Care, Cardiac Care Unit, Post-Cardio-Thoracic Surgery Unit, and Respiratory Rehabilitation Units. These units all house a variety of critically ill patients with special requirements for hemodynamic support, respiratory support, cardiac support, and often anticoagulation. They provide extensive experience in consultation and procedural intervention in the critically ill under a host of adverse clinical circumstances.

The Dept. of Surgery (pertinent to Gastroenterology training) has numerous surgical subspecialists and subdivisions in General Gastrointestinal Surgery, Gastrointestinal Oncologic Surgery, Biliary and Pancreatic Surgery, Thoracic Surgery, and Liver Transplantation. We enjoy a close relationship with our surgical colleagues, including exchange of speakers between Medical and Surgical Grand Rounds, frequent conferences, and a working relationship in a Intra-disciplinary Oncology Board, and a Intra-disciplinary Nutrition Support Clinic.

The Dept. of Radiology is extensive, with facilities for ultrasound, CT scan, MRI, nuclear medicine, angiography, and a dedicated interventional Radiology department providing support when needed (for Gastroenterology) in terms of percutaneous cholangiography, biliary stent placement, percutaneous gastrostomy, and therapeutic angiography for hemostasis.

The Dept of Pathology provides personnel with dedicated special interests in GI and Liver pathology, and joint conferences are provided monthly as well. Conferences are facilitated by a teaching video microscope, which allows any number of attendees to view the images simultaneously and under direction by the Pathologist.

In Pediatrics, there are 2 full time Pediatric Gastroenterologists. The pediatric GI faculty and fellows regularly attend and participate in our clinical and literature review conferences. The adult GI fellowship program sponsors a didactic curriculum in Pediatric conferences for our trainees. Pediatric Gastroenterology has their own fellowship training program, and the adult program hosts each pediatric fellow in clinical rotation for a month each year.

Strong also supports a large intra-disciplinary Nutrition Support Team, with dedicated pharmacists, dietitians specializing in various intensive care settings, and nurse practitioners specializing in home parenteral nutrition support. Physician participation on the team is provided by an attending gastrointestinal surgeon, an attending gastroenterologist, and a pediatric gastroenterologist. Our program sponsors 4 weeks of a dedicated rotation in Nutrition Support for our fellows, which includes weekly hospital ICU rounds, nutrition support clinic, intensive instruction in TPN formulation and calculations, mangagement of home TPN formulations and patient assessment, and supervised nutrition support consultations in the intensive care settings.

In addition to the experience provided by a large general medicine and surgery patient mix, there are several additional areas of excellence in patient care at Strong Memorial which provide additional exposure and experience for the Gastroenterology trainee. There is a large Hematology/Oncology Division which provides extensive exposure to the diagnosis and management of all the gastrointestinal and hepatic solid tumors, as well as providing experience in caring for the gastrointestinal and hepatic complications of primary hematologic malignancy, including the complications of bone marrow transplantation. A weekly tumor board meeting includes participation from our attending faculty who perform ERCP and endoscopic ultrasound, pancreatico-biliary and oncologic surgeons, oncologists, and geneticists when applicable. A large division of Infectious Disease includes a subdivision dedicated to the care of patients with HIV, and this provides our trainees with exposure to the gastrointestinal and hepatic complications of this illness. Lastly, extensive clinical activity in solid organ transplantation currently includes programs in kidney, liver and heart transplantation, also providing a unique breadth and depth of exposure for the gastroenterology trainee to the special needs and considerations of these populations as well.

3. OVERVIEW of PROGRAM CONTENT for 3 YEAR FELLOWSHIP TRAINING

The Gastroenterology Fellowship Training Program at Strong Memorial Hospital, University of Rochester, is an accredited 3 year program. As of the entering class of July 2003, three fellows are accepted per year.

The first and third years of the fellowship are dedicated to clinical education. The second year is a dedicated continuous research experience. Clinics, including fellow’s long-term continuity clinic, and call are maintained throughout the 3 year curriculum.

The program is structured to provide a gradual advancement in the depth and complexity of education and responsibility.

In year I, each first year fellow will spend 8 months on Consult Service (during which they do inpatient consults and procedures), 3 months of protected endoscopy rotation to facilitate endoscopic skills, two weeks of nutrition support elective, and two weeks of radiology elective. By the end of the first year, the fellows have been able to meet the requirements for competency in the basic endoscopic core procedures of Gastroenterology. All fellows participate in one half-day clinic session with the same attending preceptor for 6-12 months, before rotating with another faculty member. In addition, there is a (faculty supervised) fellow’s long-term continuity clinic which provides a panel of patients for whom the fellow is the principal (consultant) care provider for 3 years. First year fellows participate in supervising the medical residents and students rotating on their Gastroenterology elective. They rotate responsibility with the other fellows in preparing didactic conferences which include weekly case-based clinical topic conference, and monthly basic science/research conference. First year fellows are mentored by basic science/research faculty in preparation for this conference. For the weekly clinical conference, they are assigned to the more basic clinical topics. They select cases for review in Pathology joint conferences, and they present literature reviews at monthly Journal Club. A GI-Board Review Conference Series is also held, which helps provide an overview of the entire specialty to the first year fellows. A morning report dedicated teaching rounds is provided every week. Morbidity and mortality conference is held monthly. Evening and weekend calls are shared in rotation with the other fellows. First year fellows are mentored by clinical faculty in preparing clinical abstracts for submission in June (end of first year) to the American College of Gastroenterology, and if accepted for presentation, the fellow is sponsored to travel to the scientific meeting to present his/her poster. All first year fellows participate in the Fellowship Steering Committee.

In year II, the fellow is dedicated to a research project. Second year fellows are sponsored to attend the annual national Digestive Disease Week conference held in May, which is an extensive scientific session on clinical and bench research in Gastroenterology and Hepatology, sponsored by the major professional societies in these disciplines. The fellow will also be sponsored to attend any additional scientific meetings to which he/she has had a paper accepted for presentation. During year II, educational activities, call duties, and clinic duties continue. The fellows continue to participate in an attending preceptor’s clinic 1 half-day session per week, and continue their weekly long-term continuity clinic. They continue to participate in didactic conference presentations, most often being assigned to the more clinically integrated topics. They continue to present critical reviews of the scientific literature at Journal Club, and continue to attend Morbidity and Mortality conference, Morning Report, GI-Pathology Conference, the GI Board Review Conference Series, Basic Science and Research Conferences, and one of the second year fellows chosen by their peers is selected to participate in the Fellowship Steering Committee. Evening and weekend calls are shared in rotation with the other fellows.

In year III, the fellows perform a supervisory role on the Consult rotation and rotate as Chief Fellow. The supervisory role is principally clinical oversight and guidance to the first year fellows, teaching of the first year fellows and rotating medical residents and students, and participation in procedures. The experience is designed to allow for a deeper exploration of clinical issues, with the expectation that more time is available for assisting the first year fellows in medical literature reviews. The remainder of the year is devoted to endoscopy, including advanced procedures and techniques, and two months of structured elective time is encouraged under supervision of the Program Director and Division Chief, including a return to Nutrition Support and Radiology electives. These electives ideally allow the fellow to uniquely enhance and develop competencies in a manner that enriches their clinical training. All senior fellows receive training in the techniques and interpretation of Motility studies. During year III, educational activities, call duties, and clinic duties continue. The senior fellows participate in an attending preceptor’s clinic one half-day session per week, and continue their long-term continuity clinic exposure. They continue to participate in didactic conference presentations, and are now being assigned to more focused and controversial topics for review. They continue to present critical reviews of the scientific literature at Journal Club, and continue to participate in GI-Pathology Conference, Basic Science and Research Conferences, the GI Board Review Conference Series, Morbidity and Mortality conference, and one of the third year fellows chosen by their peers is selected to participate in the Fellowship Steering Committee. Evening and weekend calls are shared in rotation with the other fellows. Third year fellows are sponsored to attend national meeting if they are making a presentation. Chief Fellows are involved in formal review of program evaluations, teaching participation of second year medical students in the Disease Processes and Therapeutics course of the medical school, participation in committee work such as peer selected representation to Internal Review of other residency programs, and organize and coordinate the fellow call schedules and conference schedules.

With respect to advanced procedures, it must be recognized by applicants that at the time of this writing, there is debate and initiative within the national professional societies of Gastroenterology, the American Board of Internal Medicine, and the American College of Graduate Medical Education regarding the issue of reserving training in advanced endoscopic procedures, principally ERCP and endoscopic ultrasound, to a separate additional 4 th year of training available at limited institutions. The issue has not been resolved as of July 2004. Our program will provide exposure of these advanced procedures to each fellow. We reserve the right to subjectively identify which trainee, if any, possesses sufficient skill to be considered for full training in such a procedure, with the intention to credential the trainee in that procedure if they demonstrate sufficient competence. This means that not every senior fellow will be trained in every advanced procedure. These procedures are not core to GI fellowship training, and for this reason the issue of removing them entirely from GI fellowship exposure is being actively debated by the above societies.