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Acting Consultant on Inpatient Service (3rd year consults)

Overview

The goal of this rotation is to provide a significant demonstration of the progressive growth, independence, maturity and clinical consultative skills of our GI fellows prior to their graduation.  In 2 separate two week blocks, in the latter half of the third year of fellowship, our senior fellows will function on the inpatient consult service as nearly independent “acting” consultants.  They will be paired with one first year fellow on the inpatient consult service, but will function and interact differently with the supervisory attendings than they did as first year fellows.  They will divide the consultation cases equally with the first year fellows, according to the usual distribution patterns established by the fellows (dependent on individual clinic schedules).  However, the third year fellow functioning as an “acting consultant” is expected to independently assess and make arrangements for the evaluation/management of the patient.  They are required to competently review the case with the attending on consult service.  They may choose to round with the consult service attending, or allow the consult service attending to round independently on the patient.  It is the expectation of the program leadership that the consult service attending will accord the fellow “acting” consultant the clinical latitude for independent decision making, while maintaining oversight that appropriate clinical standards of care are met.  Disagreements must be discussed between the attending and the fellow.  While it is the program leadership expectation that the consult service attending will not micromanage decisions, it is established the consult service attending will nonetheless have the final and binding decision making capacity regarding the disposition of clinical issues.  The fellow as “acting” consultant is expected to participate in procedures that they have recommended for the patient, in exactly the same way that they would be expected to do so as a recently graduated private attending consultant.  

Principal Teaching/Learning Activities

The fellow “acting” consultant will conduct their completed evaluation of a patient, and then review the case for the supervising consult service attending.  This may be done verbally, or at the discretion of the attending, by immediately and jointly rounding on the patient.  If the attending is not available to immediately round on the patient, then it is the expectation of the program leadership that the consult service attending will round independently on the patient.   The experience of the fellow “acting” consultant is not to mimic the experience of the first year fellow on inpatient consult service.  The role of the consult service attending will be to provide feedback on the clinical decision making.

Problem mix/Patient characteristics/Types of encounters

The fellows are exposed to consultations from all over the hospital, including the emergency room, the acute care clinics, the various Intensive Care Units, Surgical floors, OB/GYN floors, general medical floors, and to some extent from the Pediatric floors  (teenagers).  The Fellow is exposed to a wide variety of consultative questions which fully embrace the complete lists of clinical disorders and clinical problems as contained in the outline of the ACGME Specific Program Content within Program Requirements for Residency Education in Gastroenterology.  Patients may be critically ill, in need of urgent stabilization, post-operative, acutely ill, convalescing, or ambulatory.

Purpose and Principal Educational Goals and Objectives by Competency

Patient Care

Principal Educational Goals

  • Demonstrate that the fellow has acquired the capacity to extract critical elements of pertinent history and physical exam findings pertinent to the accurate construction of a differential diagnosis, for clinical scenarios in consultative Gastroenterology and Hepatology.
  • Demonstrate that the fellow has acquired the capacity to formulate an appropriate, focused, rationale differential diagnosis supported by the elements of history and exam, and other clinical data.
  • Demonstrate the fellow can develop rational clinical evaluation and management plans.
  • Demonstrate that the fellow recognizes and responds to the indications, contraindications, special needs, alternatives, and risk/benefits of any recommended diagnostic or therapeutic Gastrointestinal procedures.

Medical Knowledge

Principal Educational Goals

  • Demonstrate the medical knowledge base applicable to the clinical scenarios encountered in Gastroenterology and Hepatology subspecialty consultation, which would be sufficient to function as an independent consultant.

Practice-Based Learning and Improvement

Principal Educational Goals

  • Identify gaps in personal knowledge and clinical skills in the consultative assessment of clinical disorders and problems in Gastroenterology and Hepatology.
  • Implement strategies for correcting these deficits.

Interpersonal Skills and Communication

Principal Educational Goals

  • Communicate effectively with patients and families.
  • Communicate effectively with referring physicians and other members of the health care team.
  • Coordinate urgent patient care effectively to avoid unnecessary delays in diagnostic or therapeutic procedures.
  • Present patient information clearly and concisely, verbally and in writing.

Professionalism

Principal Educational Goals

  • Demonstrate respect, compassion, and honesty in relationships with patients, families and colleagues.
  • Demonstrate sensitivity to patients and colleagues on issues of gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities.
  • Adhere to principles of patient confidentiality.
  • Practice informed consent and informed refusal.

Systems-Based Practice

Principal Educational Goals

  • Demonstrate the ability to cooperate and collaborate with colleagues in other disciplines for complex patient problems that require multidisciplinary management.
  • Use evidence-based, cost-conscious strategies in management of patient problems.

Evaluation

Direct feedback from the supervising consult attending at the end of the rotation is an important component of the rotation, and separately there is also a global performance assessment.  The key to this rotation is that the fellows are being evaluated on their demonstration that they have indeed acquired the clinical skills necessary to function as an independent consultant in Gastroenterology and Hepatology.

Recommended Reading

While the basics of the standard textbooks should have been mastered at this point, our program continues to recommend the Sleisenger and Fordtran text – Gastrointestinal and Liver Disease -  for its organization, thoroughness, and reliability of references.   The use of on-line data bases of medical literature (such as UpToDate) is strongly encouraged as well, and is available free for the fellows, and accessible on-line through the University of Rochester Medical Center library from their individual computer work stations in the fellows’ office.