Endoscopy

Overview

First Year

• Perform some endoscopy while on Consult Service, appropriate to the level of experience and clinical complexity
• Four months set aside for dedicated protected time on an Endoscopy Rotation to facilitate acquisition and improvement of endoscopic skills on outpatients
  • Primarily routine outpatient endoscopy at an ambulatory surgical center
  • Fellows will perform pre-procedure assessments, learn moderate sedation administration, perform endoscopic procedures with direct attending supervision, and participate in post-procedure care
• 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.

Second Year

• No dedicated endoscopy rotation, but fellows are able to perform endoscopy during their other rotations. 

Third Year

• Endoscopy rotation devoted to inpatient and advanced procedures at SMH
• Endoscopy-C rotation devoted to outpatient endoscopy 
• Advanced Procedures (particularly ERCP and EUS)
  • Issue is specifically addressed at a national level by the core curriculum in Gastroenterology
  • 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
  • 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
  • Not every fellow will be trained to a level of competence in ERCP and/or EUS

Principal Teaching/Learning Activities

• Exposed to an upper endoscope and biopsy forceps simulation during orientation to become familiar with the mechanics and feel of these tools
• New fellows attend the ASGE endoscopy simulation course,typically in August
• 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. This resource is for the fellows to borrow at any time.
• 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
• 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)
• Video capsule enteroscopy reading is reserved for the second year 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

Problem mix/Patient characteristics/Types of encounters

• 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)
• Endoscopic procedures of the upper and lower GI tract, as well as small intestine, are generally performed by first year fellows for the following:
  • Dysphagia
  • New onset abdominal pain
  • Diarrhea and constipation
  • Iron deficiency anemia
  • Malabsorptive disorders
  • Functional GI complaints
  • Acid peptic disorders
  • Irritable bowel
  • Ischemic bowel injury
  • Opportunistic infections of HIV disease
  • Chronic abdominal pain
  • Nausea and emesis
  • Gastrointestinal overt and occult bleeding
  • Portal hypertension
  • Certain genetic and family syndromes
  • Diseases of the esophagus
  • Dyspepsia
  • Inflammatory bowel disease
  • Gastrointestinal neoplasms
  • Graft-vs-host disease