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Inpatient Consult Service

Overview

Fellows spend 7 months of their first year on Consult Service.  There are always two fellows concurrently on the Consult service. Typically, first-year fellows will also try to do the endoscopy on those patients for whom they provided a consult, unless it is an advanced therapeutic procedure to be performed by a third year fellow.  First year fellows see all consults, whether for gastroenterology, liver-related disease, nutrition support consults, or ERCP requests.  The Consult Service fellows perform all of the consults called between 8 AM and 5 PM, Monday thru Friday.  Purely elective consults of no clinical urgency called to the on-call fellow in the evening may be deferred to the Consult Fellow in the morning.  All consults should be seen immediately for a quick triage in the event that a diagnostic or therapeutic procedure is promptly indicated.  During the first few months of the academic year, first-year fellows are expected to run all cases by a senior fellow for a quick triage.  Fellows are expected to identify issues of clinical interest brought up during the consult day in order to prompt an in-depth review of the matter for discussion during consult rounds with the attending.  The consults are presented by the fellows (and/or any medical residents rotating on the GI Consult Service) to the Attending during teaching rounds at a pre-arranged time.  The fellows may have a medical resident or medical student rotating with them.  Medical residents may see consults independently, but they must present them to the fellow who will be responsible for the patient as well.  The fellows will participate in the selection of educationally appropriate consultations for the medical residents.  Medical students may not see consults independently and instead may accompany the fellows through the consult process.    It is important that the fellow remains responsible for knowing the clinical information pertaining to any patient seen by the medical residents or students.  All encounters are to be fully supervised (staffed) by a qualified Attending Physician.  Fellows are expected to follow up on pathology results from endoscopic or liver biopsies performed on the Consult Service patients and communicate those results to the referring physician by dictated letter. 

Principal Teaching/Learning Activities

Teaching rounds will consist of pertinent bedside history and physical examination teaching, discussion of differential diagnoses and the clinical data used to support them, discussion of recommendations and plans and review of pertinent medical literature to support such recommendations, and review of pertinent Radiologic studies.  Review of Pathology may be deferred to the combined GI-Pathology conference unless an urgent review by the Consult team will affect patient management. 

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.

Throughout the 30 clinical months of this training program, the fellows are exposed to general Hepatology during Inpatient Consult rotations, during all attending’s clinics, and during their own Fellow’s Longitudinal Clinic.  In addition, a full eight months are rotations though outpatient and inpatient Transplant Hepatology, which are exclusively Hepatology experiences.

Purpose and Principal Educational Goals and Objectives by Competency

Patient Care

Principal Educational Goals

  • Learn the critical elements and more skillfully extract these elements of patient history pertinent to their problem.
  • Learn the pertinent physical exam findings and more skillfully elicit these findings relevant to the patient’s problem.
  • Learn what information in the form of past and current diagnostic and therapeutic studies are relevant to the evaluation of the patient’s problem.
  • Formulate focused differential diagnoses supported by the elements of history and exam, and other clinical data.
  • Develop rational management plans.
  • Address the indications, contraindications, special needs, alternatives, risk/benefit and purpose of any recommended diagnostic or therapeutic gastrointestinal procedures.

Medical Knowledge

Principal Educational Goals

  • Expand the fellow’s clinically applicable knowledge base of the basic and clinical sciences that underlie the basis of Gastroenterology.
  • Critically evaluate the current medical literature relevant to a patient’s problem.
  • Gain clinically applicable knowledge of the full range of clinical disorders and clinical problems listed in the outline of the ACGME Specific Program Content within Program Requirements for Residency Education in Gastroenterology.

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.
  • Teach and supervise residents and students effectively.
  • 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 a willingness and enthusiasm for work.
  • 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

Specific to their performance on the consult service, it is expected that the teaching attending provides ongoing feedback to the fellow during the course and at the end of the rotation.  In addition, performance is evaluated quarterly by faculty as discussed in detail later.  Endoscopy nurses and administrative staff also participate in evaluation of the fellows in a 360 degree review process.   

Recommended Reading

One of the general Gastroenterology texts is recommended as a basis for reading on patient problems; this program prefers the Sleisenger and Fordtran text for its organization, thoroughness, and reliability of references.   The use of computerized data bases of medical literature (such as UpToDate) is strongly encouraged as well and available free for the fellows.