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Endoscopy

Overview

During the first year, the fellows will perform some endoscopy while on Consult Service, but in addition, there will be four months set aside for dedicated protected time on an Endoscopy rotation to facilitate acquisition and improvement of endoscopic skills. The fellow will be closely supervised by a skilled faculty preceptor in the performance of all core and elective advanced procedures of Gastroenterology as defined by the National GI Core Curriculum and the ACGME.  Fellows will generate procedure reports to referring physicians.

With respect to advanced procedures (particularly ERCP and EUS), the issue is now specifically addressed at a national level by the core curriculum in Gastroenterology.  The core curriculum was constructed by the AGA, the ASGE, the AASLD, and ACG (our professional colleges), and adopted for implementation by the American Board of Medicine and the ACGME effective July 1, 2005 pertinent to the issues of training in advanced endoscopic procedures.  In essence, the curriculum states that training in ERCP or EUS is not part of the core training during GI fellowship, but may be available to trainees who fulfill the requirements of what has been designated level II training.  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 specifically means that not every fellow will be trained to a level of competence in ERCP and/or EUS. 

Principal Teaching/Learning Activities

During orientation, new fellows are exposed to an upper endoscope and biopsy forceps simulation to become familiar with the mechanics and feel of these tools. All new fellows attend the ASGE endoscopy simulation course in typically in August. All fellows are afforded the opportunity to practice in the UR animal endoscopic lab on their own time as well as at an annual CME endoscopy course.

Emphasized continually throughout the Endoscopy rotation, the fellows are taught the procedural indications and contraindications, and special issues in endoscopy such as antibiotic prophylaxis and management of anticoagulation.  Instructional technique videotapes from the ASGE library are reviewed at orientation and any time thereafter as desired.  Conscious sedation and sedative pharmacology credentialing in accordance with University guidelines occurs during orientation, and consists of review of written and video materials followed by an examination.

Early in the year the fellows focus on upper endoscopy and flexible sigmoidoscopy, and as the advancement of skills permit, gradually move on to colonoscopies.  Facility in diagnostic procedures is required before the fellows are permitted to perform therapeutic procedures.  These include variceal and non-variceal hemostasis, percutaneous placement of gastrostomy tubes (PEGs), esophageal dilatation, and polypectomy.  Liver biopsies are no longer required in training, although they may be performed throughout the year, with a particular focus while on the Transplant Hepatology rotation, if desired.  By the end of the first year, the fellows generally already exceed minimum thresholds of procedural numbers for competence (see ACGME Program Requirements).  Note that video capsule enteroscopy reading is reserved for the senior fellows however, due to the time commitment of each study.  In addition to the mechanics of technical performance, the visual interpretation of findings and subsequent management is emphasized. 

As above, only certain senior fellows will be designated in advance to learn the advanced procedural techniques of ERCP and endoscopic ultrasound.  In addition to the technical aspects of these procedures, the clinical management of hepatobiliary disorders and imaging interpretation are emphasized.        

The program has purchased the entire ASGE DVD/video library, inclusive of 67 videos on all aspects of core and advanced endoscopic procedures.  This resource is at the disposal of the fellows.

Problem mix/Patient characteristics/Types of encounters

Endoscopic procedures of the upper and lower GI tract, as well as small intestine, are generally performed by first year fellows in the evaluation of dysphagia, chronic abdominal pain, new onset abdominal pain, nausea and emesis, diarrhea and constipation, gastrointestinal overt and occult bleeding, iron deficiency anemia, portal hypertension, malabsorptive disorders, certain genetic and family syndromes, functional GI complaints, diseases of the esophagus, acid peptic disorders, dyspepsia, irritable bowel, inflammatory bowel disease, ischemic bowel injury, gastrointestinal neoplasms, opportunistic infections of HIV disease, and graft-vs-host syndrome.  Patients may be ambulatory out-patients, or they may be referred from the inpatient Consult Service (see problem mix/patient characteristics and types of encounters under Consult Service).     

Purpose and Principal Educational Goals by Competency

Patient Care

Principal Educational Goals

  • Learn the proper indications, contraindications, special needs, and procedural preparations for diagnostic and therapeutic Gastroenterologic procedures.
  • Learn appropriate endoscopic surveillance regimens for various forms of upper and lower endoscopic pathology.
  • Achieve procedural technical competence in the performance of Gastroenterologic core diagnostic and therapeutic procedures.
  • Learn the role and function of other members of the endoscopic procedure team.
  • Correlate visual and pathologic findings at endoscopy with clinical conditions.
  • Learn how to safely administer conscious sedation to provide for patient comfort during procedures.

Medical Knowledge

Principal Educational Goals

  • Expand clinically applicable knowledge base of patient’s tolerance of endoscopic procedures, as well as the findings that correlate with the varied mix of clinical disorders and problems evaluated in the varied patient populations studied.

Practice-Based Learning and Improvement

Principal Educational Goals

  • Identify areas of personal deficiency in skill and knowledge in the performance of endoscopic and other core procedures of Gastroenterology and Hepatology.
  • Develop and implement strategies for correcting these deficiencies.
  • Learn to identify procedural complications and formulate strategies for avoiding those complications.

Interpersonal Skills and Communication

Principal Educational Goals

  • Learn to interact effectively with other members of the endoscopy suite team in order to optimize patient care.
  • Learn to interact effectively with patients and families to communicate the purpose of procedures and their results, and complications of procedures if necessary.
  • Learn to formulate comprehensive, clear and concise procedural reports to referring physicians.

Professionalism

Principal Educational Goals

  • Demonstrate compassion and empathy in dealing with patients undergoing procedures.
  • Adhere to principles of patient confidentiality.
  • Practice informed consent and informed refusal
  • Identify and understand risk management issues in the performance of endoscopic procedures.

Systems-Based Practice

Principal Educational Goals

  • Understand the system under which outpatient and inpatient endoscopic procedures are provided.
  • Collaborate with other team members in helping patients effectively negotiate the system.
  • Understand the role of endoscopic management in a multidisciplinary approach to various patient disorders and problems.
  • Utilize evidence-based therapeutic management strategies to optimize patient care.

Evaluation

Each fellow’s performance is evaluated by the faculty as discussed in detail later.  Proficiency and competence in technique is based upon the observations from close supervision of the faculty preceptors in Endoscopy.  However, particularly relevant to the certification of procedural competence is the required maintenance of a procedural log  This log contains patient name and unit numbers, diagnoses, findings, preceptor name and independent performance of interventions and cecal intubation as appropriate to the case.  Four times each academic year, the fellows are required to submit procedural tallies according to the following ASGE outline:

Core Procedures

  1. Diagnostic EGD (with/without mucosal biopsy)
  2. Esophageal Dilation
    • Non-guidewire
    • Guidewire
  3. PEGs
  4. Non-variceal hemostasis (active/inactive)
  5. Variceal hemostasis (active/inactive)
  6. Colonoscopy (total number)
  7. Colonoscopy (with snare polypectomy)
  8. Video capsule enteroscopy

Advanced

  1. ERCP (total)
  2. ERCP (with sphincterotomy)
  3. ERCP (with other therapeutics)
  4. EUS
  5. Pneumatic dilation for achalasia
  6. Liver biopsy, percutaneous
  7. BARRX radiofrequency ablation
  8. Esophageal stent placement

Endoscopy metrics

The program collects data on upper endoscopy and colonoscopy completion rates each year.  A minimum of 90% cecal intubation rate on colonoscopy appears to have gained acceptance as a national metric for competence in colonoscopy, and will be used as the threshold prior to determining that a fellow is competent to independently perform the procedure.  The program director personally performs a very high percentage/volume of procedures with the first year fellows throughout the entire first year, and uses a global performance assessment to determine that the fellow is fit to progress to more advanced procedures.

An endoscopic metric tracking log is collected 4 times a year, signed off by the fellows endoscopy supervisors.

In the event that a fellow is struggling with endoscopic technique and progress, arrangement is coordinated by the Program Director with the clinical faculty for additional instruction, time and attention to the problem until satisfactory progress is re-established.    

Recommended Reading

A text and computerized data base service is recommended as per the recommended reading under the Inpatient Consult Service.  In addition, a basic textbook of endoscopy and an atlas of endoscopic findings are recommended.  Baille’s Practical Endoscopy serves as an excellent primer.  These are available in the fellows’ library.  The program has purchased the entire ASGE DVD/video library, inclusive of 67 videos on all aspects of core and advanced endoscopic procedures.  This resource is at the disposal of the fellows; each DVD must be signed out from the program coordinator, and there is a $100 replacement fee for lost videos.