Gastroenterology Core Curriculum Oversight Committee
LAWRENCE S. FRIEDMAN, M.D. (Chair)
Boston, Massachusetts
THOMAS D. BOYER, M.D.
Atlanta, Georgia
MARTIN H. FLOCH, M.D.
Norwalk, Connecticut
JOHN GOLLAN, M.D., Ph.D.
Boston, Massachusetts
JAMES H. GRENDELL, M.D.
New York, New York
WALTER L. PETERSON, M.D.
Dallas, Texas
BRUCE F. SCHARSCHMIDT, M.D.
San Francisco, California
EUGENE R. SCHIFF, M.D.
Miami, Florida
JACQUES VAN DAM, M.D., Ph.D.
Boston, Massachusetts
Participants in the Gastroenterology Core Curriculum Project Consensus Conference: March 9-10, 1995, Bethesda, Maryland
LAWRENCE S. FRIEDMAN, M.D. (Chair)
Boston, Massachusetts
THOMAS D. BOYER, M.D.
Atlanta, Georgia
DOUGLAS BRAND, M.D.
Stony Brook, New York
MARTIN H. FLOCH, M.D.
Norwalk, Connecticut
HENRY I. GOLDBERG, M.D.
San Francisco, California
STEPHEN E. GOLDFINGER, M.D.
Boston, Massachusetts
JOHN GOLLAN, M.D., Ph.D.
Boston, Massachusetts
JAMES H. GRENDELL, M.D.
New York, New York
STEPHEN B. HANAUER, M.D.
Chicago, Illinois
ANN OUYANG, M.D.
Hershey, Pennsylvania
WALTER L. PETERSON, M.D.
Dallas, Texas
DON W. POWELL, M.D.
Galveston, Texas
BRIAN J. REID, M.D., Ph.D.
Seattle, Washington
JOEL E. RICHTER, M.D.
Cleveland, Ohio
BRUCE F. SCHARSCHMIDT, M.D.
San Francisco, California
THEODORE R. SCHROCK, M.D.
San Francisco, California
EUGENE R. SCHIFF, M.D.
Miami, Florida
JACQUES VAN DAM, M.D., Ph.D.
Boston, Massachusetts
Z. RENO VLAHCEVIC, M.D.
Richmond, Virginia
HARLAND WINTER, M.D.
Boston, Massachusetts
Introduction
There has been a dramatic explosion of knowledge and technology related to the science and practice of gastroenterology over the past generation. Although new diagnostic tests, procedures, and therapies have been introduced into practice, the training curriculum and the duration of training have not undergone critical evaluation. Currently, fully half of all trainees in gastroenterology complete a 2-year fellowship, just as trainees did 25 years ago; the other half complete a 3-year fellowship. Gastroenterology as practiced today requires increasingly complex decision-making; mastery of a growing number of endoscopic techniques, both diagnostic and therapeutic; an understanding of the sensitivity, specificity, risk-benefit, and cost-benefit of a broad array of diagnostic techniques and therapeutic options; and knowledge of the increasingly complex science that underlies gastroenterological practice.
The Gastroenterology Leadership Council (GLC) Training Directors Committee was established in 1992, under the auspices of the four societies representing gastroenterology, known collectively as the GLC: the American Association for the Study of Liver Diseases (AASLD), the American College of Gastroenterology (ACG), the American Gastroenterological Association (AGA), and the American Society for Gastrointestinal Endoscopy (ASGE). Because training in gastroenterology is a central mission of all four societies, it was believed that a single committee representing the four societies would be in the best interest of gastroenterology. Not surprisingly, the GLC Training Directors Committee determined early on that examination of the length of training and content of the curriculum for trainees in gastroenterology should be a high priority. Although the question of the optimal duration of training in gastroenterology was made moot in early 1995 when the American Board of Internal Medicine (ABIM) mandated an increase in the duration of training required for board certification in gastroenterology from 2 to 3 years, critical examination of the content of the curriculum has remained a high priority.
Traditionally, training in gastroenterology has been designed to produce a competent "undifferentiated" general gastroenterologist. Although advanced training in selected areas, such as hepatology and interventional endoscopy, could be obtained or at least initiated during the course of a standard 2-year fellowship, in practice such advanced training was often acquired after the fellowship had been completed, either in an advanced ("third-tier") position or, more commonly, in practice (on-the-job training). However, with the advent of medical practice based in great part on managed care and capitation and with an increasing emphasis on cost reduction and cost-effectiveness in clinical practice, on-the-job training will no longer be acceptable. Gastroenterologists will need to be trained for fewer positions requiring a higher level of skill in an increasingly competitive job market. In this scenario, the training program director will be held accountable for the quality of the finished product. Moreover, advances in the diagnosis and management of gastrointestinal disorders as well as the future vitality of our subspecialty will require gastroenterologists who are at the cutting edge of clinical and basic research, technology development, and teaching.
Thus, a number of factors have come to bear on the Gastroenterology Core Curriculum Project. Specifically, these include the desire to ascertain the optimal minimal duration of training, to examine critically the content of training, and to assure that training is relevant to the jobs that will be required (and available) in the future.
The GLC Training Directors Committee served as the Oversight Committee for the Gastroenterology Core Curriculum Project. The field of gastroenterology was divided into 15 areas encompassing the breadth of knowledge and skills required for the practice of gastroenterology. These areas included not only the traditional curricular content of gastroenterology and hepatology, but also associated disciplines, such as nutrition, pathology, radiology, surgery, endoscopy, and research. For each broad area, an expert was invited to chair a task force to consider in detail the importance of the area to training in gastroenterology; the goals (knowledge, skills, behaviors, and attitudes) to be achieved by training; the actual recommended training process, including the venue in which training should take place (inpatient or outpatient service, conferences, etc.); and specific requirements for evaluating trainees in that area. The task force chair was asked to identify additional individuals with expertise in that area or in related areas and a strong interest in education and training to serve on the task force. Each task force report was then reviewed by the Oversight Committee and sent back for revision and refinement. Throughout the process, various advisors were contacted for additional input on the documents, and members of the governing boards of each of the societies were given an opportunity to consider various issues that arose. The process culminated in a consensus conference in Bethesda, Maryland, on March 9 and 10, 1995, in which the Oversight Committee, task force chairs (or their representatives), and various members of the governing boards of the societies reviewed each document for content and consistency and deliberated over major and, in some cases, controversial issues. The final document was then sent to the governing boards of the four societies for approval.
The resulting Gastroenterology Core Curriculum represents a significant enhancement of standards of training in gastroenterology in the United States. At the same time, the curriculum recognizes the need to allow sufficient flexibility to permit trainees the opportunity to prepare for a range of career options and to take advantage of differing strengths among training programs. Beyond a basic core curriculum required of every trainee, additional training permits broad latitude based on the individual needs of the trainee and attributes of the program.
The curriculum affirms the decision of the ABIM to require a minimum of 3 years of training in gastroenterology. The core clinical curriculum requires a minimum of 18 months and consists of traditional inpatient and outpatient consultation experience as well as an array of conferences and didactic sessions. A longitudinal outpatient experience is mandated for the full 3 years of training. Programmatic guidelines for training in hepatology, including the requirement for a faculty member recognized as a hepatologist, are greatly enhanced. The long-accepted guidelines of the ASGE for training in basic endoscopic skills are affirmed and strengthened by the explicit requirement that assessment of competency in basic endoscopy cannot be considered before the minimum threshold levels are met; in virtually all cases, substantial additional experience will likely be required before a program director can attest to the competence of the trainee in endoscopy. Procedural experience in endoscopic retrograde cholangiopancreatography is no longer included in the core clinical curriculum of all trainees but is reserved as an advanced procedure for selected trainees desiring enhanced skill in interventional endoscopy. Explicit programmatic requirements are indicated in the areas of nutrition, gastrointestinal and hepatic pathology, gastrointestinal radiology, and surgery. The requirement for a substantive research experience of not less than 6 months as a prerequisite for developing an inquiring and critical mind is affirmed.
Beyond the 18-month core clinical curriculum and the 6-month research requirement, additional training is required so as to permit flexibility commensurate with the trainee's skills, interests, and career goals. In most cases, this translates into another 12 months of clinical work, bringing the total clinical experience to 30 months, plus the 3-year longitudinal outpatient experience. Guidelines for enhanced, or level 2, training in interventional endoscopy and hepatology are detailed; both require 12 months beyond the core curriculum requirement. In the case of hepatology, specific experience in transplant hepatology is required. Level 2 training guidelines are also provided for motility disorders, biliary tract disease, and nutrition. Trainees pursuing careers in the clinical practice of gastroenterology are expected to have specific instruction in the clinical sciences that underlie the scientific basis of practice today and to have the opportunity to participate in meaningful scholarly activity. For trainees preparing for careers in laboratory or clinical investigation, an intensive research experience during the second 18 months of fellowship training is prescribed, with the recognition that such training will need to be continued well beyond the standard 3-year period of training to prepare the trainee for a career as an independent investigator. This training should include course work appropriate for a career in clinical or basic research, e.g., epidemiology, statistics, research methodology, outcomes and effectiveness research, decision analysis, cell biology, molecular genetics, and ethics, as well as supervised research activity under the guidance of a qualified mentor.
Throughout this document, the paramount importance of practice and research based on the highest principles of ethics, humanism, and professionalism is reinforced. The importance of the scientific method and of preparation for lifelong learning based on independent and critical thinking, a desire for self-improvement, and a love of learning is emphasized.
Finally, the Gastroenterology Core Curriculum should be viewed as a living document. It provides a framework for developing an individual plan of study and growth and should be tailored to meet the needs of the trainee and to enhance the strengths and special qualities of the training program. The curriculum must also evolve with time as new knowledge, methods of learning, technologies, and challenges arise. The document recommends a number of tools that can be used to assess the competence of a trainee, including direct observation, in-service examinations, clinical competency examinations, and procedural competency examinations. In each case, numerical guidelines provide only a minimal standard; regardless of the duration of training, the numbers of patients seen, and the numbers of procedures performed, the ultimate goal must always be excellence that is uncompromising and unqualified.
LAWRENCE S. FRIEDMAN, M.D.
Chair, Gastroenterology Core Curriculum Project
Task Force on Overview of Training in Gastroenterology
A gastroenterology consultant must possess a range of attributes, including a broad knowledge base, the ability to generate a relevant differential diagnosis based on an accurate history and physical examination, an understanding of the indications and contraindications for diagnostic and therapeutic procedures, skill at performing these procedures, the ability to think critically, and an appreciation of the humanistic and ethical aspects of medicine. Such attributes can emanate only from clinical training programs that provide a firm foundation in pathophysiology as well as abundant exposure to patients under the supervision of experienced, thoughtful clinical teachers. This exposure must be long enough for a trainee to understand the natural history of disease and the impact of treatment both on the disease and on the patient. Instructors in procedures must impart a thoughtful, cost-conscious approach to the use of technology as an extension of the subspecialist's craft rather than as an end in itself. Facilities must be available for trainees to participate actively in research as a means of fostering the inquisitive thought processes demanded of a skilled consultant, to create new knowledge, and to improve patient care. Surrounding all these activities must be a dedication to the patient as a person; technical expertise in the absence of humanism represents the antithesis of the skilled practitioner, whether generalist or subspecialist.
General Aspects of Training
Prerequisites for Training
Trainees in gastroenterology must have completed a 3-year residency in internal medicine at an institution accredited by the Accreditation Council for Graduate Medical Education (ACGME) or a foreign equivalent.
Training Institutions
Gastroenterology training must take place only in medical institutions that are accredited for internal medicine and gastroenterology by the ACGME and are affiliated with established medical schools. As outlined in the Special Requirements for Graduate Education in the Subspecialties of Internal Medicine (July 1994), evidence of institutional commitment to education must include financial resources adequate to support appropriate compensation for sufficient faculty and trainees, adequate and modern facilities, space and equipment to accomplish the overall educational program, adequate clinical support services provided on a 24-hour basis, peer interaction among specialty and subspecialty trainees, and sponsorship of meaningful biomedical research by the primary training site. The primary training site must sponsor a minimum of three accredited subspecialty programs.
Educational Program
Gastroenterology training programs must provide an intellectual environment for acquiring the knowledge, skills, clinical judgment, attitudes, and values of professionalism that are essential to the practice of gastroenterology. As defined by the ABIM:
Professionalism in medicine requires the physician to serve the interests of the patient above his or her self-interest. Professionalism aspires to altruism, accountability, excellence, duty, service, honor, integrity, and respect for others. The elements of professionalism encompass a commitment to the highest standards of excellence in the practice of medicine and in the generation of knowledge, a commitment to sustain the interests and welfare of patients, and a commitment to be responsive to the health needs of society. (ABIM Document on Professionalism, 1995)
The program must also stress the role of the gastroenterologist as a consultant and the need to establish the skills necessary to communicate effectively with the referring physician. The objectives of training can be achieved only when the program leadership, supporting staff, faculty, and administration are fully committed to the educational program and when appropriate resources and facilities are available. While it is recognized that trainees provide substantial service to their teaching hospital, service commitments should never compromise the achievement of educational goals and objectives.
Every aspect of training should include the cultivation of an attitude of skepticism and inquiry and a dedication to continuing education that will remain with the trainee throughout his or her professional career. A major contributor to the enhancement of a scholarly attitude is active participation in one or more research projects, ideally followed by presentation of the work at a national meeting and publication of a paper in a peer-reviewed journal.
Duration of Training
A number of factors argue strongly for requiring that training programs be at least 3 years in duration. First, there has been a remarkable increase in the scientific information to be learned in gastroenterology, for example, the body of knowledge and therapeutic modalities required to deal with inflammatory bowel disease (IBD), peptic ulcer disease, and nutrition. Second, the field of liver diseases has seen major changes in the diagnosis and treatment of viral hepatitis as well as the selection and management of patients for liver transplantation. Third, expansion of the variety and difficulty of diagnostic and therapeutic procedures requires that substantial time be committed to mastering these skills. Fourth, with the expanding roles and skills of general internists under managed care, gastroenterologists, as specialists, will be expected to possess ever greater levels of expertise. Thus, a premium will be placed on experience; the more experience gained under supervision during training, the more skilled the specialist. Such experience should include the long-term management of patients with a variety of diseases in order to be exposed to the natural history of gastrointestinal and hepatic diseases as well as the effectiveness and limitations of therapy. Finally, as training progresses, it is important for the future specialist to develop independence. A 3-year training program will allow sufficient time for a gradual reduction in the level and degree of supervision, so that by the end of the training period, the trainee will feel confident in his or her own abilities to manage independently the most complicated of cases.
Program Faculty
Program Director
The training director must be board-certified in gastroenterology or possess equivalent qualifications. He or she must be committed full-time to the training program and related activities and must be based at the primary training site of the program.
Faculty
Programs must include a minimum of three full-time faculty members, including the training director, each of whom must be board-certified in gastroenterology or possess equivalent qualifications. For programs with more than three trainees, a ratio of faculty to trainees of at least 1:1.5 must be maintained. At least one faculty member must be a fully trained hepatologist, as defined by the Task Force on Training in Hepatology. Above and beyond a minimum number of faculty, there must be enough additional full-time or part-time faculty to ensure adequate supervision of trainees and coverage of all programmatic components.
Each full-time faculty member must devote at least 20 hours per week to teaching, research, administration, and/or the critical evaluation of the performance, progress, and competence of trainees. In addition, faculty members must serve as appropriate role models by active participation in the clinical practice of gastroenterology, their own continuing education, regional and national scientific societies, research activities, and the presentation and publication of scientific studies and scholarly reviews.
Environment for Training in Gastroenterology
Relationship to Training in Internal Medicine
Trainees in gastroenterology must maintain their skills in general internal medicine and develop appropriate lines of responsibility with internal medicine residents and faculty.
Relationship to Other Disciplines
Because care of the patient with a gastrointestinal disease often involves a multidisciplinary approach, trainees must learn to work effectively and efficiently with members of other specialties and subspecialties. This is especially true for the internal medicine subspecialties of cardiology, critical care medicine, and oncology, and the specialties of surgery, pathology, and radiology. Increasingly, trainees will need to develop skills in management so as to be able to lead multidisciplinary teams. Particular instruction and experience in collaborating with primary caregivers in a managed care setting will be essential.
Facilities and Resources
The following facilities and resources are essential for the training program.
- There must be a sufficient number of new and follow-up patients to ensure adequate inpatient and outpatient experience. Pregnant patients as well as adolescent and geriatric patients of both sexes and wide ethnic diversity should be included. Such patients should have a broad variety of gastrointestinal and hepatic diseases. There must be faculty supervision of trainees seeing patients in both the inpatient and outpatient settings.
- Up-to-date inpatient and ambulatory care facilities are essential to accomplish the overall mission of the training program.
- There must be a fully equipped and staffed procedure laboratory that includes state-of-the-art diagnostic and therapeutic endoscopic instruments and motility equipment. The laboratory must also be capable of performing, or have access to, specialized serological, parasitological, immunologic, metabolic, and toxicological studies applicable to hepatobiliary disorders. Ideally, computers should be available with appropriate software to permit trainees to record results of procedures and establish a database. There must be the capability to perform basic gastrointestinal function tests.
- Supporting services, such as a full-service emergency room, diagnostic and interventional radiology unit, pathology laboratory, medical imaging and nuclear medicine facility, general and hepatobiliary surgical unit, and oncology unit, must be available.
- There must be a modern, fully staffed unit for the intensive care of critically ill patients with gastrointestinal and hepatic disorders.
- A well-stocked library with on-line capabilities for computer-assisted literature searches is essential.
- Appropriate facilities and faculty must be available to provide training and support in gastrointestinal research.
Specific Program Content
Patient Care Experience
The patient care experience for trainees is comprised of three major elements.
- Every gastroenterology training program must include a core curriculum of 18 months to be completed by all trainees. This period will consist of clinical training in the inpatient and outpatient diagnosis and management of gastrointestinal and hepatic diseases as outlined by each of the relevant task forces on training in gastrointestinal diseases and the Task Forces on Training in Hepatology and Training in Biliary Tract Diseases. Approximately 30% of this experience must consist of clinical training in hepatic diseases. There must be exposure to both acutely and chronically ill patients. During this time, adequate numbers of routine endoscopic procedures must be performed to exceed the minimum standards as described by the Task Force on Training in Gastrointestinal Endoscopy and Gastrointestinal Bleeding. Trainees must have appropriate supervised experience to develop skills in providing consultative services and communicating with physicians and other members of the health care team.
- For those individuals whose career goals consist primarily of patient care, a further 18 months of training will include a total of at least 6 months of scholarly activity consisting of basic or clinical research, course work, or other structured activity not primarily involving direct patient care (see Task Force on Training in Research). The remaining months will include additional experience in general consultative gastroenterology and experience in specialized areas depending on the interests and career goals of the trainee and the opportunities available in the program. Such areas of study might include enhanced competence in hepatic diseases, motility disorders, IBD, nutrition, or endoscopy (see appropriate task force reports). Where formal guidelines for attaining enhanced competence in an area are provided, the designation of level 2 training is applied.
- In recognition of the importance of outpatient medicine to the practice of gastroenterology, all trainees must spend at least half a day per week for the entire 3-year period in an ambulatory care clinic in which both new and continuing care patients with gastroenterological and hepatic diseases are evaluated and managed.
Training Through Conferences and Other Nonpatient Care Activities
In addition to the patient care experience, trainees should have extensive involvement in other types of experiences.
- Trainees should, through independent study, develop a scholarly approach to education by reading current textbooks and monographs, relevant scientific literature, and distributed syllabus materials. Trainees should be encouraged to attend seminars, postgraduate courses, and annual scientific meetings of the major digestive disease societies.
- A clinical conference should be held on a weekly basis. Trainees must be actively involved in the planning and conduct of these conferences.
- Basic science, journal club, and research conferences should be held regularly, at least monthly. The journal club should be used as a tool to teach the skills of critical reading, detection of biases, assessment of validity of controls, application of statistics, generalizability of results, and related attributes of scientific studies.
- Interdisciplinary conferences with radiology, pathology, and surgery services should be held at least monthly.
- A series of lectures/discussions should be held throughout the period of training to cover a core curriculum of physiology, pathophysiology, and clinical pharmacology.
- Visiting scholars, professors, and investigators should be brought in to stimulate new thoughts and ideas among trainees as well as faculty.
- Participation in quality assurance and continual quality improvement programs should be required.
- The opportunity to study formally the elements of study design, decision analysis, outcomes and effectiveness research, statistics, epidemiology, and other skills necessary to conduct clinical investigation should be available to all trainees yearly.
Teaching Experience
Trainees must participate actively in the teaching of medical students, medical residents, and less advanced trainees in gastroenterology. In addition, ample opportunity must be provided for trainees to participate in seminars and conferences. The ability to interweave basic and clinical material in a cohesive manner and to present and defend concepts in an open forum is invaluable for a career as a subspecialty consultant.
Evaluation of Trainee Competence
Formal procedures for trainee assessment and feedback are required both by ACGME mandate and for objective documentation for purposes of credentialing. Training programs must have an established committee to evaluate trainee competence, regular written records detailing the progress of each trainee, and a defined program of feedback to the trainee.
Elements of Competence to Be Evaluated
Trainees should demonstrate the following.
- An understanding and commitment to all elements of professionalism.
- A thorough knowledge of history-taking, including family, genetic, psychosocial, and environmental histories, and the ability to perform a comprehensive and accurate physical examination.
- The ability to arrive at an appropriate differential diagnosis, to outline a logical plan for specific and targeted investigations pertaining to the patient's complaints, and to formulate a plan for management and follow-up treatment of the patient.
- The ability to present effectively the results of a consultation orally and in writing and to defend the clinical assessment, differential diagnosis, and diagnostic and management plan.
- A core fund of knowledge in gastroenterological and hepatic physiology, pathophysiology, and clinical pharmacology as outlined in the goals of each task force report.
- Procedural skills appropriate to the level of training as outlined by the Task Force on Training in Gastrointestinal Endoscopy and Gastrointestinal Bleeding.
Methods of Evaluating Trainee Competence
The following methods should be used to evaluate the trainee's competence.
- Observation during procedures, rounds, and conferences.
- Formal evaluation forms from each faculty member who comes in contact with the trainee.
- Formal in-service examination to test the knowledge base, including mastery of interpretation of endoscopic, radiological, and pathological findings.
- Formal assessment of clinical skills using a patient-based examination.
- Log books and competency examinations for all endoscopic procedures and all level 2 skills.
Task Force on Overview of Training in Gastroenterology
WALTER L. PETERSON, M.D. (Chair)
Dallas, Texas
THOMAS D. BOYER, M.D.
Atlanta, Georgia
MARTIN H. FLOCH, M.D.
Norwalk, Connecticut
LAWRENCE S. FRIEDMAN, M.D.
Boston, Massachusetts
JOHN GOLLAN, M.D., Ph.D.
Boston, Massachusetts
JAMES H. GRENDELL, M.D.
New York, New York
BRUCE F. SCHARSCHMIDT, M.D.
San Francisco, California
EUGENE R. SCHIFF, M.D.
Miami, Florida
JACQUES VAN DAM, M.D., Ph.D.
Boston, Massachusetts
The Task Force on Overview of Training in Gastroenterology thanks Drs. Robert Burakoff, Harris R. Clearfield, Mark Feldman, Stephen E. Goldfinger, Steve Goldschmid, Richard Goodgame, Don W. Powell, Nicholas F. LaRusso, Joel E. Richter, and Richard E. Sampliner for advice in the preparation of this paper.
Task Force on Training in Motility, Diverticular Disease, and Functional Illnesses
Importance
Functional bowel disease and motility disorders account for nearly 40% of patients being seen by practicing gastroenterologists and may prove to be among the most challenging. An understanding of the management of patients with motility disorders and functional bowel disease involves an understanding of the physiology of intestinal motility and an understanding and appreciation of the brain-gut axis and visceral hyperalgesia. Exposure to good patient management by physicians with experience and expertise in the field is an integral part of the training of an effective and compassionate gastroenterologist. Understanding the nuances of functional bowel disease and a degree of confidence in the management of these patients is also important in the training of a cost-effective consultant. The importance of the psychosocial aspects of functional bowel disease needs to be fully understood and integrated into the management of patients. Many studies that allow the measurement of motility in various parts of the gastrointestinal tract are now available. It is important that the fully trained gastroenterologist understand the usefulness, indications for, and limitations of these motility studies in the diagnosis and management of patients with motility disorders.
Diverticulosis is found in approximately 50% of the American population older than 50 years of age; thus, it is essential that gastroenterologists be familiar with the management of the complications of diverticular disease. The management of the many potential presentations of diverticular disease should be encountered by all trainees in an active clinical program. Therefore, no specific curriculum was developed for learning how to manage diverticular disease and its complications.
Two levels of training are recommended for training in motility disorders. Level 1 includes understanding of the pathophysiology of these disorders, exposure to managing adequate numbers of patients with these disorders under the tutelage of an experienced clinician, and understanding the rationale for, usefulness of, and potential pitfalls of the various motility tests that are available. This level of training is expected of all trainees.
Level 2 training is important for any trainee who wishes to perform these studies as a consultant to other physicians. Not all trainees completing the fellowship are required to perform all motility studies, but the trainee should be appropriately trained in each of the studies he or she wishes to conduct.
Goals of Training
Level 1: Basic Level of Training for All Trainees
With respect to motility studies, all trainees should have a clear understanding of the indications and potential pitfalls in the performance of motility studies and the limitations of interpretation of esophageal manometry, esophageal pH studies, esophageal motility with provocative agents, radionuclide gastric emptying studies, small bowel motility, anal sphincter manometry, anal sphincter electromyographic studies (including pudendal nerve latencies), and anal sphincter biofeedback training. This level of training would be primarily on an intellectual level with an understanding of the value and limitations in interpreting the findings of the tests to know when they would be valuable in the management of a patient. It is expected that this level of training will be incorporated in the first 18 months of clinical training.
All trainees should have an understanding of the specifics of how tests are performed to know when they might be contraindicated in any individual patient. In addition, trainees should be able to recognize the manometric features of major motor disorders of the esophagus and anal sphincter. Trainees should understand the features of pH testing, which indicates reflux, and the significance of a symptom score index. It is also important to recognize the factors that may introduce artifact into a study so that reports can be interpreted by the referring physician without relying completely on the physician performing the test.
With respect to functional bowel disorders and motility disorders, trainees should have an understanding of the physiology of motility of the different areas of the gut, the brain-gut axis, and the physiology of visceral sensation. They should be familiar with health care seeking behavior and of the associated psychosocial factors that appear to be important in patients with functional bowel disease. They should receive instruction in the use of psychopharmaceuticals in the treatment of functional bowel disorders and learn when and how to refer patients refractory to therapy for psychiatric evaluation and management.
Level 2: Enhanced Competence in Motility Studies
The goal of this higher level of training is to provide appropriate instruction for subspecialty trainees who will conduct and interpret motility studies after training and act as consultants to other gastroenterologists and other clinicians. It is recognized that major therapeutic decisions rest on the results of these studies, including decisions regarding surgical procedures and use of drugs for long-term therapy. It is required that trainees who wish to be able to provide this consultative service be personally involved in a number of studies and should be completely familiar with the logistics of performing studies, the potential technical problems with the techniques that might affect the interpretation of the studies, and the nuances of interpreting the manometric studies. In the age of computer-generated printouts, it is important that the physician be familiar with the interpretation of these studies and that he or she not rely on numerical analysis of waveforms by computer programs alone.
Training Process
Functional Bowel Disease
The process of developing the expertise to manage patients with functional bowel disease is difficult to codify. However, an understanding of the physiology of the brain-gut axis, the physiology of motility of the gut, and an understanding of the psychosocial forces that modify symptom presentation and behavior are critical to the care of these patients. It is likely that this will be even more important as newer drugs are introduced. There are many experienced clinicians who can apply both the "art" and "science" of medicine. Subspecialty trainees should acquire skills in interview techniques and the integration of psychological information into clinical reasoning and decision-making as well as in the diagnosis and treatment of disease. This is particularly important in caring for patients with functional bowel disease. It is recommended that all trainees spend at least 10% of their time in a continuity clinic seeing general gastrointestinal patients (which should have about 40% of patients with functional bowel disease) under the preceptorship of an experienced clinician with the expertise to skillfully manage patients having these disorders.
Motility Disorders: Level 1
Trainees should be provided with an appropriate clinical outpatient experience in which to see and manage patients with possible motility disorders. This experience should include exposure to making decisions as to appropriate testing, interpreting test results, and treating the patient under the guidance of appropriate staff. This appears to be critical to training future gastroenterologists who are able to understand the role of motility and functional bowel disorders in their patients. In addition to the acquisition of the knowledge concerning motility tests, trainees should have the opportunity for hands-on experience in motility studies, including 24-hour pH studies, to understand what the test will mean to patients as well as the potential artifacts that can affect waveforms and their interpretation. Specific literature and didactic teaching should be developed by the training program to allow trainees to understand and become familiar with the pathophysiology of motility disorders and the available studies. A library of motility tracings should also be developed for training at level 1.
Motility Disorders: Level 2
The recommended numbers of studies required to achieve a measurable degree of expertise in each of the motility investigations is listed below. These numbers were derived by consensus among the members of the task force, each of whom has had extensive experience in working with trainees to enable them to become proficient in performing and interpreting motility studies. These numbers have also been endorsed by the Subcommittee on Training of the American Motility Society.
In addition, a specific amount of time should be spent by trainees to become familiar with the appropriate indications, conduct, and interpretation of these studies under the preceptorship of a faculty member who is experienced in the studies. The amount of time will vary from program to program, depending on the level of activity at the motility laboratory at that institution. It will be the responsibility of the preceptor to design the training program such that he or she can certify that the trainee is appropriately trained. In general, as well as performing a minimum number of tests themselves, trainees should spend at least 3 months in a motility laboratory that is actively studying patients under the preceptorship of a clinician who is experienced in the performance of these studies. To be considered trained to level 2 for any specific motility test, the trainee should have a documented log of appropriate numbers of the types of studies performed by the trainee and interpreted under supervision.
Three areas of motility are recognized for level 2 training. The number of studies recommended that trainees perform and read are listed in Table 1. The trainee can achieve level 2 competence for any of these studies.
A bibliography of appropriate literature in each area (functional bowel disease and motility disorders) should also be available and updated yearly.
| Esophageal motility studies | No. of studies |
|---|---|
| Standard esophageal motility | 50 |
| Esophageal motility with provocative testing | 20 |
| Quantitative measurement of acid reflux (e.g., prolonged esophageal pH recording) | 25 |
| Gastric and small bowel motility studies Either perfused catheter or solid state transducers | 25 |
| Indications, interpretation, and significance of scintigraphic measurement of gastric emptying | 25 |
| Anorectal motility studies Anal sphincter manometric studies | 30 |
| Anal sphincter biofeedback training | 10 |
| Anal sphincter electromyographic studies including pudendal nerve latencies | 20 |
Assessment of Competence
Level 1 training should be certified by the program director, who should identify the preceptor for outpatient clinical care of patients. The preceptor in the outpatient clinic should formally critique the trainee's interview techniques and skills in management of patients with functional bowel disease.
For level 2 training, a log of the patients studied and the techniques used should be documented. The studies should be performed in an active motility laboratory where there will be appropriate discussion and training in the technical areas of performing the studies as well as the interpretation of tests provided by a technical support person. The preceptor in this area should also certify that the trainee is appropriately trained in the technical aspects of each test as well as sign off on the number of cases. The trainee should be observed in the performance of these studies.
Task Force on Training in Motility, Diverticular Disease, and Functional Illness
ANN OUYANG, M.D. (Chair)
Hershey, Pennsylvania
MICHAEL CAMILLERI, M.D.
Rochester, Minnesota
DOUGLAS DROSSMAN, M.D.
Chapel Hill, North Carolina
PETER J. KAHRILAS, M.D.
Chicago, Illinois
JAMES C. REYNOLDS, M.D.
Upper St. Clair, Pennsylvania
JOEL E. RICHTER, M.D.
Cleveland, Ohio
REZA SHAKER, M.D.
Milwaukee, Wisconsin
Task Force on Training in Acid-Peptic Disease
Importance
Acid-peptic disorders (duodenal and gastric ulcer, gastroesophageal reflux disease, gastritides/gastropathies, Zollinger-Ellison syndrome and other hypersecretory states, duodenitis, nonulcer dyspepsia) are common afflictions. It has been estimated that 7% of the U.S. population experience heartburn symptoms daily and almost half on a monthly basis. Peptic ulcer disease affects more than 5% of the U.S. population. Helicobacter pylori gastritis is a major risk factor for peptic ulcer and probably gastric carcinoma and lymphoma. Not only do these conditions cause morbidity, but they may result in serious complications leading to hospitalization, surgery, or even death. Because of their prevalence, potential for complications, and economic consequences, acid-peptic disorders represent an important group of diseases.
The ability to diagnose disorders of the upper gastrointestinal tract has been greatly enhanced by endoscopy. Not only can a diagnosis be reliably established, but definitive therapy may be performed during endoscopy for disorders such as esophageal stricture and bleeding ulcers.
The practice of gastroenterology now involves more than just the time-honored physician skills of history-taking and physical examination. Both the cognitive and technical skills of endoscopy must be acquired and continuously maintained. Technology in diagnostic and therapeutic imaging techniques and surgical approaches to disease have changed dramatically. Great strides have been made in understanding the pathophysiology and therapy of these disorders. The acquisition of skills in these multiple disciplines as they relate to the evaluation and management of acid-peptic disorders will best ensure a well-trained gastroenterologist.
Goals of Training
Trainees will be expected to master the cognitive skills and develop knowledge and understanding of the following.
- Anatomy, physiology, and pathophysiology of the esophagus, stomach, and duodenum.
- Gastric secretion and indications for gastric analysis.
- The indications for serum gastrin measurement and secretin testing and consequences of hypergastrinemia in both hypersecretory and achlorhydric states.
- The natural history, epidemiology, and complications of acid-peptic disorders, including recognition of premalignant conditions (e.g., Barrett's esophagus).
- The role of H. pylori in acid-peptic diseases.
- The pharmacology, adverse reactions, efficacy, and appropriate use of drugs used in acid-peptic disorders. These include antacids and anticholinergic agents, histamine-2 receptor antagonists, proton pump inhibitors, mucosal protective agents, prostaglandin analogues, prokinetic agents, antibiotics, and antifungal agents.
- Endoscopic and surgical treatments of acid-peptic disorders, including cost-effectiveness, complications, and side effects, both short-term and long-term (see Task Forces on Training in Gastrointestinal Endoscopy and Gastrointestinal Bleeding and Training in Surgery).
- Nonulcer dyspepsia and diagnostic/therapeutic approaches.
Trainees will also be expected to develop competence in the following.
- Performing a thorough gastrointestinal-directed history and physical examination.
- Performing diagnostic and therapeutic upper gastrointestinal endoscopy (see Task Force on Training in Gastrointestinal Endoscopy and Gastrointestinal Bleeding).
- Performing and interpreting esophageal pH probe tests and esophageal motility studies (see Task Force on Training in Motility, Diverticular Disease, and Functional Illnesses).
- Interpreting plain films of the abdomen, barium examinations of the upper gastrointestinal tract, ultrasonography, abdominal computed tomographic scans, and magnetic resonance imaging (see Task Force on Training in Gastrointestinal Radiology).
- Understanding invasive and noninvasive techniques for diagnosing H. pylori infection.
Training Process
Training in Patient Care and Management
Trainees must acquire a thorough knowledge of appropriate history-taking, which should include family, genetic, psychosocial and environmental histories, and the ability to perform a comprehensive and accurate physical examination in patients with acid-peptic disease. This should include an examination of the whole patient with particular reference to the extra-abdominal manifestations of acid-peptic disease. Trainees should be able to arrive at an appropriate differential diagnosis and be able to outline a logical plan for specific and targeted investigations pertaining to the patient's complaints and have a scheme of management and a follow-up treatment plan.
Attaining Proficiency in Endoscopic and Ancillary Investigations Relevant to Acid-Peptic Disorders
Trainees must obtain experience under direct supervision to become totally competent and certifiable in performing and interpreting all the procedures and diagnostic tests that are used routinely in the evaluation and treatment of patients with acid-peptic disorders (see Task Force on Training in Gastrointestinal Endoscopy and Gastrointestinal Bleeding). This should include the indications, limitations, technical aspects, and complications of the following procedures as well as an understanding of the benefits and dangers of conscious sedation.
- Upper intestinal endoscopy, both elective and emergent; this should include the various modalities for the therapy of upper gastrointestinal bleeding, biopsy, brush cytology, and polypectomy.
- Dilatation of benign and malignant esophageal strictures.
- The performance and interpretation of esophageal motility studies, 24-hour pH monitoring, and gastric secretory studies.
- Interpretation of radiological studies of the upper gastrointestinal tract, including contrast gastrointestinal examinations, ultrasonography, computed tomographic scans, and magnetic resonance imaging.
- Indications and interpretation of studies for specific entities, such as hypersecretory states, mucosal resistance, H. pylori, and other infections of the upper gastrointestinal tract, particularly acquired immunodeficiency syndrome-related disorders.
- A working knowledge of upper gastrointestinal tract pathology, such as mucosal biopsies for gastritis, Barrett's esophagus, and malignant conditions (see Task Force on Training in Gastrointestinal and Hepatic Pathology).
Assessment of Competence
Knowledge of the acid-peptic disease curriculum should be assessed as part of the overall evaluation of the trainee in gastroenterology during and after the fellowship as outlined by the Task Force on Overview of Training in Gastroenterology. No specific examination or other instrument of assessment need be developed for this portion of the training.
Task Force on Training in Acid-Peptic Disease
MARK FELDMAN, M.D. (Chair)
Dallas, Texas
SIMMY BANK, M.D.
New Hyde Park, New York
DAVID Y. GRAHAM, M.D.
Houston, Texas
LOREN LAINE, M.D.
Los Angeles, California
KATHERINE E. MCARTHUR, M.D.
Dallas, Texas
SEYMOUR SABESIN, M.D.
Chicago, Illinois
C. MEL WILCOX, M.D.
Birmingham, Alabama
Task Force on Training in Pancreatic Disorders, Gastrointestinal Hormones, and Diarrheal Diseases
Importance
Pancreatic Disorders
Pancreatic disorders are common diseases that present a multifaceted challenge to the gastroenterologist. For example, patients with acute pancreatitis may rapidly develop a variety of potentially life-threatening complications; patients with chronic pancreatitis have a long-standing, frequently debilitating disease. In caring for patients with pancreatic cancer, the gastroenterologist must make an expeditious and cost-effective diagnosis and weigh possible curative or palliative treatment options. Because of the complexity of these diseases, the wide assortment of potential diagnostic modalities, and the lack of consensus in many aspects of diagnosis and management, the gastroenterologist is commonly the primary consultant or direct caregiver for patients with pancreatic disease.
Gastrointestinal Hormones
Although clinical syndromes related to overproduction of specific gastrointestinal hormones and regulatory peptides are relatively uncommon, the gastroenterologist is the specialist frequently called on to determine if such a syndrome is present in a patient with an unusual or refractory presentation of such common diseases as peptic ulcer or diarrhea. In addition, mastery of the physiology and pathophysiology of gastrointestinal hormones is essential to a solid understanding of the integrated physiology of the digestive tract as well as to gastrointestinal pathophysiology and pharmacology.
Diarrheal Diseases
Although diarrheal diseases are among the most important causes of morbidity and mortality worldwide, in industrialized countries such as the United States, acute diarrhea is frequently a mild, self-limited disease that is either self-treated or cared for by primary care physicians.
However, for the more severe cases of acute diarrhea and for patients with chronic diarrhea, the gastroenterologist is typically called on to differentiate among the many potential causes and to recommend appropriate and specific therapy.
Goals of Training
Pancreatic Disorders
To diagnose and treat pancreatic disorders effectively, the trainee in gastroenterology must attain knowledge and understanding of the following.
- The embryological development and anatomy of the pancreas and the pancreatic duct system.
- The regulation of pancreatic growth and differentiation.
- The physiological processes involved in pancreatic exocrine secretion of digestive enzymes, water, and electrolytes.
- The regulation of exocrine secretory processes.
- The types of digestive enzymes secreted by the pancreas and their role in the digestive process.
- The mechanisms by which pancreatic enzymes secreted as zymogens are activated in the small intestine.
- The factors that protect the pancreas from autodigestion.
- The physiological interactions between the exocrine and endocrine pancreas.
- The epidemiology, pathophysiology, and natural history of acute pancreatitis, chronic pancreatitis, and pancreatic cancer.
In caring for patients with acute pancreatitis, the trainee must be able to establish the diagnosis and assess severity; determine the etiology; direct initial volume resuscitation; monitor for and treat extrapancreatic complications (e.g., pulmonary and renal failure); diagnose and treat expeditiously infected necrosis or pancreatic abscess and other septic complications; diagnose and manage pancreatic pseudocysts, pancreatic ascites, and hemorrhage; determine the need for and timing and type of nutritional support; and evaluate patients for possible treatable occult causes of otherwise "idiopathic" acute pancreatitis.
For patients with chronic pancreatitis, trainees must be able to establish the diagnosis, particularly in the setting of occult disease and in the differential diagnosis between chronic pancreatitis and pancreatic cancer; determine the etiology; manage abdominal pain, pancreatic exocrine and endocrine insufficiency, and biliary obstruction; and diagnose and manage pancreatic pseudocysts, ascites, pleural effusions, and vascular complications (e.g., splenic vein thrombosis, pseudoaneurysms).
For patients with pancreatic cancer, the trainee must be able to use diagnostic tests in a rational and cost-effective manner, assess operability, and manage pain, biliary and intestinal obstruction, pancreatic exocrine insufficiency, and splenic vein thrombosis.
Trainees must also be able to recognize and diagnose cystic fibrosis and manage pancreatic insufficiency in that setting, diagnose and treat annular pancreas, and assess the importance of pancreas divisum in the etiology of pancreatic disease.
The trainee in gastroenterology must understand the basis and indications for and the interpretation of diagnostic test results in the diagnosis and management of diseases of the pancreas, in particular, serum amylase and lipase determination, serum tumor markers (e.g., CA 19-9), radiological and endoscopic imaging studies (see Task Forces on Training in Gastrointestinal Endoscopy and Gastrointestinal Bleeding and on Training in Gastrointestinal Radiology), indirect tests of pancreatic secretory function (e.g., fecal chymotrypsin test, bentiromide test), direct tests of secretory function (e.g., secretin and secretin/cholecystokinin stimulation tests, test meals), duodenal drainage with analysis for biliary crystals, and fine needle aspiration of pancreatic masses and analysis of cytology in endoscopic aspirates of pancreatic juice.
Trainees in gastroenterology must also understand the role the following disciplines play in the diagnosis and management of pancreatic disorders and must have direct experience working with these disciplines in the care of individual patients: therapeutic endoscopy, surgery, interventional radiology, anatomic pathology and cytopathology, nutritional support service, pain management service, medical oncology, and radiation oncology (see Task Forces on Training in Gastrointestinal Endoscopy and Gastrointestinal Bleeding, Training in Surgery, Training in Gastrointestinal Radiology, Training in Gastrointestinal and Hepatic Pathology, and Training in Nutrition).
Gastrointestinal Hormones
To understand the role of gastrointestinal peptides in both normal physiology and disease, the trainee in gastroenterology must attain knowledge and understanding of the characteristics of the gastrointestinal peptide families; the major biological actions of specific hormones and regulatory peptides; the mechanisms of gastrointestinal hormone signaling; the modes of transmitter action; and the recognition, diagnosis, and treatment of clinical syndromes caused by overproduction of specific gastrointestinal peptides.
Trainees should acquire an understanding of how the members of each of the gastrointestinal peptide families are similar in genetic ancestry, amino acid sequence, and biological activity. Trainees should also know the major biological actions of the following hormones and regulatory peptides: gastrin, cholecystokinin, secretin, vasoactive intestinal peptide, glucagon, neuropeptide Y, pancreatic polypeptide, peptide YY, bombesin, somatostatin, substance P, tachykinins, and opioids. Understanding should also be achieved with regard to how extracellular signals are converted to intracellular signals: receptor binding, receptor coupling through G proteins, signal transduction through generation of second (intracellular) messengers through adenylyl cyclase or the phosphoinositide cascade. In addition, trainees should be able to recognize that gastrointestinal hormones and peptides are regulatory transmitters that can act by one of several distinct pathways or modes: endocrine, paracrine, and neurocrine.
Trainees must be able to recognize the clinical syndromes caused by overproduction of specific gastrointestinal peptides. These syndromes include gastrinoma, vasoactive intestinal peptide secreting tumor (VIPoma), somatostatin-secreting tumor (somatostatinoma), insulinoma, and glucagonoma. Trainees in gastroenterology must know when to suspect the particular syndrome, how to make the diagnosis of specific gastrointestinal peptide-related disease, and how to treat the particular disease.
Trainees in gastroenterology should be able to interpret and incorporate into patient care a number of procedural and laboratory tests, including measurement of gastric pH; measurement of gastric acid secretion following pentagastrin stimulation and modified sham feeding; assessment of blood levels of gastrin, vasoactive intestinal peptide, somatostatin, insulin, and glucagon; secretin stimulation test and calcium infusion test for diagnosis of gastrinoma; and imaging studies (abdominal ultrasonography, computed tomography, magnetic resonance imaging, endoscopic ultrasonography, radionuclide scanning) and venous sampling in the localization of peptide-screening tumors (see Task Forces on Training in Gastrointestinal Radiology and Training in Acid-Peptic Disease).
Diarrheal Diseases
To diagnose and treat diarrheal disorders effectively, the trainee in gastroenterology must attain knowledge and understanding of the following.
- Intestinal anatomy and functional anatomy.
- Mechanisms of digestion and absorption of carbohydrates, protein, lipids, and certain vitamins (e.g., folate, cobalamin) and minerals (e.g., iron, calcium).
- Regulation of digestive and absorptive function.
- Mechanisms of intestinal fluid and electrolyte absorption and secretion.
- Pathogenesis of steatorrhea.
- Definition and characterization of diarrhea.
- Diagnosis and treatment of acute and chronic diarrheal diseases.
- Mechanisms of action of drugs used in the treatment of diarrhea.
The trainee in gastroenterology must also understand the basis and indications for and interpretation of diagnostic test results in the diagnosis and management of diarrheal diseases, in particular, microbiological studies involving stool, duodenal fluid, intestinal and colonic biopsy specimens; radiological procedures (see Task Force on Training in Gastrointestinal Radiology); stool volume, electrolytes, and fat content; D-xylose test; Schilling test; and breath tests for lactose intolerance, bacterial overgrowth, and bile acid malabsorption. In addition, the trainee should be able to obtain adequate biopsy specimens for histological evaluation from both the small intestine and colon and to identify the histological abnormalities present in diseases producing diarrhea or malabsorption (e.g., celiac sprue, tropical sprue, Whipple's disease, lymphoma, intestinal lymphangiectasia, abetalipoproteinemia, cytomegalovirus infection) (see Task Force on Training in Gastrointestinal and Hepatic Pathology).
Training Process
The goals described above are required for all trainees in gastroenterology and should be part of the training provided to all trainees in every program. A critical aspect of this training experience is the ability to evaluate and treat patients with complex problems longitudinally on an outpatient basis. This will require a minimum of 2-3 years of significant clinical participation in an outpatient setting in addition to sufficient experience providing direct and/or consultative care for hospitalized patients. Scholarly activity (e.g., didactic course work, basic or clinical research) and structured presentations (e.g., conferences, rounds, seminars) are also essential elements of training in gastroenterology and must be provided for in addition to the requisite clinical experience. Additional exposure to related sciences (immunology, microbiology, and molecular biology) and related fields of medicine (infectious diseases, laboratory medicine, pathology, and nutrition) can be obtained through conferences, seminars, and literature reviews as well as practical demonstration of techniques.
Assessment of Competence
Knowledge of the pancreatic disorders, gastrointestinal hormones, and diarrheal diseases curriculum should be assessed as part of the overall evaluation of the trainee in gastroenterology during and after the fellowship, as outlined by the Task Force on Overview of Training in Gastroenterology. In particular, there would be advantages to having an in-service examination at some point during the training process to provide both trainees and program directors with information about possible areas of deficiency.
Task Force on Training in Pancreatic Disorders, Gastrointestinal Hormones, and Diarrheal Diseases
JAMES H. GRENDELL, M.D. (Chair)
New York, New York
HENRY J. BINDER, M.D.
New Haven, Connecticut
RODGER A. LIDDLE, M.D.
Durham, North Carolina
Task Force on Training in Gastrointestinal Inflammation
Gastrointestinal inflammation (IBD), whether infectious, noninfectious, or idiopathic, is a primary reason for referral to specialists with digestive disease training. Therefore, it is imperative that trainees be exposed to diagnostic and therapeutic aspects of gastrointestinal inflammatory disorders as a component of their fellowship experience. The unique aspects of gastrointestinal infections (related or not related to human immunodeficiency virus [HIV]) and idiopathic inflammatory bowel diseases will be discussed separately. The differential diagnoses overlap due to the nonspecific presentation of acute or chronic, small or large bowel inflammatory disorders.
Gastrointestinal Infections in Non-HIV Settings
Importance
The gastrointestinal tract is host to a large and complex microbial flora. In addition, all levels of the gastrointestinal tract (including the liver and biliary tree) are subject to acute and chronic infection by a variety of pathogenic microbial agents (viruses, bacteria, fungi, and protozoa). These infections present, acutely or chronically, as disordered organ function manifested by diarrhea, malabsorption, bleeding, ulceration, etc., symptoms that are commonly seen by primary care physicians and frequently are the indications for gastroenterological referral. Our understanding of gastritis and duodenal ulcer disease has been revolutionized by the recognition of the role of H. pylori, whereas the agents responsible for some gastrointestinal diseases known to be infectious (e.g., tropical sprue, Whipple's disease) remain to be completely defined. Many gastrointestinal diseases currently regarded as idiopathic are likely to be the result of infection by currently unrecognized pathogens or idiosyncratic reactions of the host to normal flora. New forms of common pathogens are continually appearing, such as the toxin-producing Escherichia coli responsible for hemorrhagic colitis. A gastroenterological specialist, therefore, should be knowledgeable regarding the epidemiology, differential diagnosis, confirmatory diagnostic studies, therapy, and outcomes of treated and untreated gastrointestinal infections in the adult and pediatric population.
Goals of Training
Trainees must master basic knowledge regarding gastrointestinal infections, including an understanding of the following.
- The mechanisms of inflammation.
- Elements of the mucosal defense system (including the mucosal immune system and the components of intestinal barrier function).
- The composition and function of normal enteric flora (including protection against pathogens, colonization resistance, role in metabolism [nitrogen, carbohydrate, fat, vitamins, bile salts], and the effects of antibiotics on the flora).
- The prevalence, clinical presentation, and virulence factors (including mechanism of toxin action, colonization, translocation, and invasion) of gastrointestinal pathogens (viral, bacterial, fungal, and protozoal).
- The pathophysiology of diarrheal diseases.
- The indications and contraindications of antimicrobial therapy, mechanisms of microbial drug resistance, and risk of infections from altering normal flora (e.g., Clostridium difficile).
Clinical skills should include a familiarity with the following diagnostic and histopathologic studies (see Task Force on Training in Gastrointestinal and Hepatic Pathology).
- Stool examination, fecal leukocytes, and ova and parasites.
- Culture of stool, intestinal fluid, and biopsy (specimen collection, handling, special stains, and media).
- Mucosal biopsy interpretation.
- Antigen detection in stool and fluid (enzyme immunoassay, fluorescent antibody), and stool toxin testing.
- Rapid diagnostic tests (DNA probes or polymerase chain reaction).
- Liver biopsy and interpretation (see report of Task Force on Training in Hepatology).
Clinical skills should also encompass the selection and use of antibiotic therapy and methods for preventing infection during endoscopy (disinfection and antibiotic prophylaxis).
Clinical exposure to gastrointestinal infections should include the diagnosis and management of patients with common infectious presentations such as esophagitis (fungal, viral, bacterial); ulcer disease and gastritis (emphasizing the role of H. pylori and appropriate antibiotic therapies); acute, chronic, hemorrhagic, and traveler's diarrhea; bacterial overgrowth; infections in immunocompromised hosts (e.g., transplantation patients); and hepatic inflammation (e.g., liver abscess, hepatitis, cholangitis), including the role of liver biopsy.
In addition, concepts of preventive medicine, such as indications for vaccination, routes of infection, dietary and hygienic practice for travelers, and appropriate recommendations for prophylactic antibiotic therapy, should be included in training.
Training Process
The training and experience for gastrointestinal infection should include participation in the evaluation and management of outpatients and inpatients with the presentations and diagnoses listed above and should include the appropriate use of diagnostic tests, indications, and complications, and application of therapy in these disorders. Additional exposure to related sciences (immunology, microbiology, and molecular biology) and related fields of medicine (infectious diseases and laboratory, anatomic, and surgical pathology) can be obtained through conferences, seminars, and literature reviews as well as practical demonstration of techniques.
HIV-Related Gastrointestinal Disorders
Importance
According to a 1992 report of the World Health Organization, 30-40 million men, women, and children will be infected with HIV by the year 2000, and AIDS will be the third most common cause of death in the United States by the turn of the century. Most, if not all, patients with AIDS will manifest at least one AIDS-related disorder of the gastrointestinal tract, hepatobiliary system, or pancreas. Therefore, it is important for gastroenterological specialists to recognize and know how to evaluate and treat these abnormalities.
Goals of Training
The goals of training should be to assess the broad range of gastrointestinal symptoms and signs of AIDS-related illness and to differentiate AIDS-related from AIDS-unrelated conditions. Esophageal disorders include infectious esophagitis (fungal, viral, HIV, and neoplasms). The trainee should be able to assess AIDS gastropathy and other infectious and neoplastic gastric disorders. The trainee should be able to assess disorders of the small intestine including causes of diarrhea in HIV-infected patients; interpret endoscopic, barium, and computed tomographic and ultrasound examinations; and treat bacterial, fungal, viral, and protozoal infections of the small bowel in patients with AIDS. The trainee should also recognize causes of colorectal disorders, including proctitis, proctocolitis, and AIDS-related malignancies (e.g., Kaposi's sarcoma) and should be familiar with the indications and interpretation of flexible sigmoidoscopic, colonoscopic, and radiographic studies of the colon. Within the biliary system, the trainee should be capable of evaluating causes of hepatomegaly, abnormal liver test results (infections, neoplasia, drugs), and the interaction of hepatitis viruses and HIV; distinguish AIDS cholangiopathy and cholecystitis; and assess indications for liver biopsy. AIDS-associated pancreatic disorders, including causes of pancreatitis (infectious, neoplastic, toxic), the implications of hyperamylasemia, and the nutritional evaluation of pancreatic disorders in patients with AIDS (assessment of nutritional status and development and implementation of nutritional therapies, including enteral and parenteral) should be incorporated (see Task Force on Training in Nutrition). The trainee should be able to determine the cause of and prescribe a rational treatment plan for common opportunistic and neoplastic conditions in a cost-effective and humanitarian fashion.
Training Process
Depending on the institutional setting and number of patients with AIDS, training and experience within the 18-month core clinical experience may include inpatient and outpatient consultative evaluations and specifically exposure to patients with AIDS with dysphagia/odynophagia, diarrhea, rectal bleeding, abnormal liver enzymes/hepatomegaly, abdominal pain, and hyperamylasemia. In addition, extensive interactions between trainees and specialists in laboratory medicine, diagnostic and interventional radiology, and infectious disease and immunology should be available to the trainee through formal conferences and in the evaluation and management of individual patients.
IBD
Importance
IBD is a unique circumstance in which gastroenterologists provide both primary care as well as consultative services. Because these diseases are uncommon in the general community, the general internist or family physician typically has little experience in the spectrum of clinical presentation and therapeutic options. Expertise in the diagnosis, ability to interpret diagnostic studies, and potential to implement a therapeutic plan and assume longitudinal follow-up for patients with these chronic disorders differentiates the gastroenterological specialist from primary care physicians.
Goals of Training
The goals of training in IBD should be to recognize clinical and laboratory features of intestinal inflammation and to distinguish them from signs of secretory and osmotic diarrhea and from symptoms of irritable bowel syndrome; differentiate chronic idiopathic IBD from other specific entities, such as acute, self-limited ileitis and colitis, drug- or radiation-induced colitis, and diverticulitis by history and interpretation of radiological, endoscopic, histological, and microbiological studies; understand indications for and interpretation of colonoscopy, barium enema, upper gastrointestinal and small bowel series, enteroclysis, and computed tomographic scan; and understand the cost benefit and risk benefit of these procedures. Furthermore, the trainee should be familiar with different presentations of IBD, including the pediatric manifestations, anorectal complications, and inflammatory vs. fistulizing vs. fibrostenotic patterns of Crohn's disease, and should be able to recognize these various presentations on history-taking and physical examination. The trainee should be capable of evaluating intestinal (e.g., hemorrhage, obstruction), extraintestinal (e.g., ocular, dermatologic, musculoskeletal, hepatobiliary), and nutritional complications of ulcerative colitis and Crohn's disease. The trainee should become familiar with the influence of IBD on pregnancy and of pregnancy on IBD and be capable of addressing issues pertaining to family history and genetic counseling. The trainee should be aware of the long-term cancer risks in ulcerative colitis and Crohn's disease and be able to implement appropriate cost-effective surveillance programs. Due to the long duration and multiple impacts on the individual and family, the trainee should be sensitive to psychosocial influences on, as well as the consequences of, IBD on the individual and on family dynamics.
Trainees should be capable of developing a therapeutic plan according to the extent and severity of specific disease patterns and to understand the indications, contraindications, and pharmacology of nonspecific therapies, including anticholinergic agents, antidiarrheals, and bile salt sequestrants; oral and topical aminosalicylates; parenteral, enteral, and rectal corticosteroids; and immunosuppressants and antibiotics used in relevant clinical situations. The trainee should also understand the indications for enteral and parenteral alimentation and be able to implement nutritional therapies (see Task Force on Training in Nutrition).
The trainee should also be capable of diagnosing and differentiating other inflammatory disorders, including collagenous colitis, microscopic colitis, nonsteroidal anti-inflammatory drug enterocolopathies, diverticulitis (including medical and surgical complications), radiation enteritis and colitis, Whipple's disease, celiac sprue, diversion colitis, and the solitary rectal ulcer.
Training Process
Unlike many other consultative aspects of gastroenterology, the trainee should be able to assume responsibility for both inpatients and outpatients with IBD and related disorders, encompassing their diagnoses, acute and chronic therapies, long-term follow-up, and counseling of the families and/or significant others. Adequate experience should include exposure to hospitalized as well as ambulatory patients as well as the initial assessment and longitudinal management of patients with IBD, particularly in the ambulatory setting, under the supervision of a skilled attending physician.
Assessment of Competence
Knowledge of the gastrointestinal inflammation curriculum should be assessed as part of the overall evaluation of the trainee in gastroenterology during and after the fellowship, as outlined by the Task Force on Overview of Training in Gastroenterology. No specific examination or other instrument of assessment need be developed for this portion of the training.
Task Force on Training in Gastrointestinal Inflammation
STEPHEN B. HANAUER, M.D. (Chair)
Chicago, Illinois
E. C. BOEDEKER, M.D.
Washington, D.C.
LAWRENCE J. BRANDT, M.D.
Bronx, New York
SAMUEL MEYERS, M.D.
New York, New York
DAVID B. SACHAR, M.D.
New York, New York
CHRISTINA M. SURAWICZ, M.D.
Seattle, Washington
Task Force on Training in Gastrointestinal Malignancy
Importance
The digestive tract has the highest incidence of cancer of any organ system of the body. Approximately 24% of cancer deaths in the United States are due to gastrointestinal cancers; 230,000 gastrointestinal cancers occur each year, with 123,000 deaths. Cancer is among the more lethal of the problems that gastroenterologists face. Importantly, appropriate intervention can dramatically alter the natural history of certain diseases, and patients who are treated in a timely way can usually return to perfectly normal lives and are not usually burdened by crippling chronic disease.
The potential for effective intervention in the natural history of digestive tract cancer can be seen in several areas. It has been shown that a 33% reduction in mortality from colorectal cancer can be achieved using a program based on annual fecal occult blood testing. Two case-control studies have suggested that routine sigmoidoscopy, perhaps repeated only once per decade, may reduce the cancer-specific mortality rate in the distal colon and rectum by 70%-80%. The judicious use of colonoscopy and polypectomy has been shown to produce a substantial reduction in cancer incidence (and presumably mortality), perhaps on the order of 60%-80%. There are few diseases for which the appropriate management can produce such gratifying reductions in mortality. For this reason alone, gastroenterologists have an obligation to understand the theoretical and practical foundations of managing gastrointestinal cancer.
Gastroenterologists are responsible for the management of several patient groups who are at high risk for gastrointestinal cancer. These groups include persons at risk for familial colorectal cancer; patients with a history of gastrointestinal neoplasia, chronic IBD, Barrett's esophagus, or chronic atrophic gastritis; and patients who are postgastrectomy or infected with H. pylori. In addition, gastroenterologists manage patients with chronic viral hepatitis B and C, which predisposes them to developing hepatocellular carcinoma. Furthermore, patients with primary sclerosing cholangitis and certain other related conditions are at risk of developing biliary tract cancers. Each of these high-risk conditions has a unique natural history and lends itself more or less to diagnostic surveillance or therapeutic intervention.
Gastrointestinal cancer has been an area in which there has been a rapid emergence of new concepts. First, there has been an explosion of information in the area of tumor genetics. A genetic model for sporadic colorectal cancer has been developed. This has led to the characterization of the APC gene, which is the locus of germline mutations in familial adenomatous polyposis and is the "gatekeeper gene" for the development of sporadic cancer of the colon and rectum. Knowledge of the nature of this gene and the mechanism by which it becomes damaged has led to the emergence of new diagnostic tests for the disease. A family of genes has been characterized that has provided an understanding for the development of hereditary nonpolyposis colorectal cancer (or Lynch syndrome). This has led to an understanding of how this disease develops and the emergence of diagnostic tests for the presymptomatic state. In addition, knowledge of tumor genetics is leading to the development of genetic markers for the early diagnosis of sporadic colon cancer.
A second important concept is the chemoprevention of cancer. This area has its roots in the understanding of the role of fruits, vegetables, fiber, and other macronutrients in the genesis of cancer. A number of potentially important vitamins and other micronutrients were identified from this information, which eventually led to the proposition that pharmacological agents might play a role in the prevention of cancer. Currently, aspirin and a number of other compounds are under investigation for their role in preventing cancer in certain high-risk groups. The application of these modalities could become commonplace at some time in the future.
In addition, a number of novel treatment modalities are currently available or have been proposed for clinical application. These include the use of stents and other mechanical devices for strictured areas of the gastrointestinal tract. Ablative therapy for metaplastic tissues in the esophagus has been explored. The role of chemotherapy, although it has limited impact in the treatment of advanced gastrointestinal disease, has developed into routine therapy for the adjuvant treatment of specific stages of colorectal cancer. The role of radiation therapy as an adjuvant technique in the treatment of rectal cancer and as a palliative therapy for certain advanced tumors has been refined. Novel therapies that are nearly upon us include injection therapy for hepatocellular carcinoma and a variety of immunotherapies.
Because of the substantial impact of cancer in the overall picture of gastrointestinal disease, the potential contribution of proper intervention with screening and surveillance, and the rapid emergence of new concepts and techniques in the area of gastrointestinal cancer, this field deserves particular emphasis in the education of the trainee in gastroenterology.
Goals of Training
The goals of training can be divided into three general categories: the cognitive component, the endoscopic procedures component, and the consultative role.
The gastrointestinal trainee must master the body of knowledge of tumor biology to a level similar to that traditionally achieved for acid-base physiology or smooth muscle physiology. During the historical development of the field of gastroenterology, knowledge of tumor biology has lagged behind other areas of physiology. Action should be taken to provide balanced training that reflects the relative importance of cancer to the field of gastroenterology. Trainees should develop a thorough familiarity with the literature on cancer epidemiology, primary prevention, and screening for colorectal cancer using fecal occult blood tests, endoscopic approaches, and radiological approaches. Trainees should have a complete knowledge of the recommended guidelines for screening for gastrointestinal neoplasia and the literature supporting these recommendations.
Trainees should also have a working knowledge of clinical genetics and understand the approaches to the genetic diagnosis of familial adenomatous polyposis, hereditary nonpolyposis colorectal cancer, and the rarer polyposis syndromes. They should recognize the clinical characteristics of these diseases, the distinctions among the familial forms of cancer, the specific diagnostic tests for each, and the rational approaches to their treatment. Trainees should learn the principles of neoplastic growth as they relate to therapy, including endoscopic treatment as well as traditional surgical approaches. A complete understanding of the management of premalignant conditions is necessary. Trainees should learn the principles of chemotherapy for gastrointestinal cancer and radiation treatment for early and advanced tumors.
Trainees must be thoroughly familiar with the technical considerations in the therapy of colorectal adenomas and carcinomas. They should be thoroughly experienced in colonoscopic polypectomy of the pedunculated polyp and ablative therapies for sessile lesions. Trainees should have a complete knowledge of the appropriate surveillance intervals for patients at high risk of developing cancer. Appropriate surveillance of premalignant epithelium must be ensured. For selected trainees, there should be experience in the placement of endoscopic stents, laser ablation, photodynamic therapy, endoscopic ultrasound, fine needle aspiration of tumors, and the performance of flow cytometry on selected tissues (see below).
Training Process
Throughout the entire period of training, trainees should participate in the outpatient screening for and diagnosis of all types of gastrointestinal malignancy and the outpatient and inpatient management of patients with gastrointestinal cancers. Lectures in basic science and clinical oncology, including screening, treatment, etc., should be included in the core curriculum for trainees. Lectures should be sought from an interventional endoscopist, an oncological surgeon, a medical oncologist, a radiation oncologist, and a medical geneticist. Some of these lectures may be combined, and not all of them necessarily require a full hour of teaching. To achieve these goals, many programs will be required to invite outside consultants.
Lecture updates should be provided on the following.
- Changes in screening and surveillance recommendations.
- The evolution of genetic testing for familial adenomatous polyposis, hereditary nonpolyposis colorectal cancer, and other familial forms for gastrointestinal cancer.
- Novel approaches to the diagnosis of gastrointestinal cancer, including endoscopic approaches, radiological approaches, nuclear medicine, ultrasound/endoscopic ultrasound, genetic approaches, and flow cytometry.
- Staging of gastrointestinal cancer and management options.
- Techniques used in the basic science investigation of gastrointestinal cancer, including flow cytometry, polymerase chain reaction assays, mutation analysis, DNA sequencing, and linkage analysis.
Endoscopic training in the diagnosis and management of gastrointestinal cancer is required. Recommendations for the duration, intensity, number of procedures, and other details are covered by the Task Force on Training in Gastrointestinal Endoscopy and Gastrointestinal Bleeding. However, areas relevant to gastrointestinal malignancy that require specific attention include the following.
- Proper technique for polypectomy for pedunculated polyps.
- Management of the diminutive adenomatous polyp.
- Surveillance of the colon in IBD, including considerations for normal-appearing mucosa and abnormal-appearing mucosa.
- The endoscopic management of Barrett's esophagus.
- The management of upper gastrointestinal neoplasia in familial adenomatous polyposis, including the management of gastric, duodenal, and periampullary lesions.
- Recognition of neoplasia in the pancreaticobiliary tree.
- The endoscopic management of the gastric remnant following Billroth II surgery.
- Recognition of anal cancer lesions using the anoscope.
Gastrointestinal trainees should become familiar with the appearance of cancer using the following diagnostic techniques.
For radiology:
- Gastrointestinal cancer on barium swallow
- Gastrointestinal cancer on barium enema
- Pancreatic and hepatic cancers on computed tomographic scans or magnetic resonance imaging
- Pancreaticobiliary cancers on endoscopic retrograde cholangiopancreatography
For pathology:
- Identification of adenoma, adenocarcinoma, and hyperplastic and other nonneoplastic polyps
- Recognition of the depth of invasion of cancer in the polyp or into the wall of the colon and its significance
- Recognition of dysplasia vs. reactive changes in IBD
The roles of radiology and pathology are specifically addressed by the Task Forces on Training in Gastrointestinal Radiology and Training in Gastrointestinal and Hepatic Pathology.
Certain trainees may elect additional training in advanced endoscopic procedures (see report of Task Force on Training in Gastrointestinal Endoscopy and Gastrointestinal Bleeding). These procedures should not be attempted by all trainees; rather, they should be reserved for those who wish to spend the time to master these techniques, and they may be reserved for selected centers.
For endoscopy:
- Endoscopic ultrasound of the esophagus, stomach, duodenum, and rectum
- The placement of mechanical stents in the esophagus, and the placement of stents in the biliary tree
- Ablative therapy of neoplasms using laser
- Photodynamic treatment of epithelial neoplasia in Barrett's esophagus
- Fine needle aspiration of masses in the liver and pancreas
- Preparation of samples for flow cytometry
Assessment of Competence
Knowledge of the malignancy curriculum should be assessed as part of the overall evaluation of the trainee in gastroenterology during and after the fellowship, as outlined by the Task Force on Overview of Training in Gastroenterology. No specific examination or other instrument of assessment need be developed for this portion of the fellow's training.
Task Force on Training in Gastrointestinal Malignancy
C. RICHARD BOLAND, M.D. (Chair)
San Diego, California
DENNIS J. AHNEN, M.D.
Denver, Colorado
RANDALL W. BURT, M.D.
Salt Lake City, Utah
STEVEN H. ITZKOWITZ, M.D.
New York, New York
BRIAN J. REID, M.D., Ph.D.
Seattle, Washington
Task Force on Training in Hepatology
Importance
Liver disease has become an increasingly important component of the practice of gastroenterology. This increase reflects both an improvement in the recognition of patients with liver disease and advances in therapy. Cirrhosis is one of the 11 leading causes of death in the United States and causes additional morbidity in a large number of patients. Hence, the management of patients with liver disease is associated with a significant cost. The refinement of liver transplantation into a widely accepted form of therapy for the treatment of end-stage liver disease and the development of new treatments for viral hepatitis have had a major impact on the practice of hepatology and have led to changes in training.
Each year, approximately 4000 patients undergo orthotopic liver transplantation. Survival rates at 1 year are now 90%, and the positive impact of liver transplantation on the lives of patients with advanced liver disease is immeasurable. The success of liver transplantation has had a significant impact on training programs. The number of hepatologists required to care for the patients awaiting liver transplantation has increased. The care of these patients is quite specialized because they have life-threatening complications of cirrhosis, such as variceal bleeding, bacterial infections, and nutritional deficiencies. Given the long waiting times for transplantation, the experienced management of these complications is crucial to the survival of the patient. Moreover, the postoperative care of the transplant patient is also in part the responsibility of the hepatologist, increasing the need for training of individuals with this expertise. The success of liver transplantation and the return of increasing numbers of transplant patients into the community has had a significant impact on the practicing gastroenterologist, who needs to know when to refer patients to a transplant center. In addition, following a liver transplant, many patients return to areas that are distant from the transplant center. The care of these patients falls to the local gastroenterologist, who needs to be trained in the management of the transplant patient to fulfill this new role.
The development of new treatments for viral hepatitis also has had a significant impact on the practicing gastroenterologist. The identification of the hepatitis C virus has increased the number of patients with liver disease, and the concurrent development of treatments for hepatitis B and C has increased the importance of identifying infected patients. The treatment of these patients, however, is not simple because the end points of therapy are poorly defined and treatment is associated with significant side effects. A thorough understanding of the disease process is required to manage these patients in an appropriate manner. Because most of the patients will be cared for by the practicing gastroenterologist and not the hepatologist, it is essential that training programs provide the necessary experience in the management of these patients.
Goals of Training
The overall goal of training in hepatology is to produce gastroenterologists who are competent to manage the broad spectrum of hepatological problems encountered in a typical gastroenterology practice. To meet this goal, level 1 training will be required. This level of training is to be distinguished from level 2 training, which is designed to prepare an individual to practice hepatology exclusively, usually in an academic setting. The basic fund of knowledge required for both levels of training is similar; the major differences between the two are the experience in liver transplantation and length of training devoted to hepatology. Both levels may be completed during a standard 3-year period of training, although a fourth year may be required to achieve level 2 training. To be a transplant physician, additional criteria must be met, as required by the United Network for Organ Sharing. These criteria include at least 6 months on an active transplant service and 6 additional months devoted to transplant-related activities, including research in transplantation. The 12 months must be contiguous and would be completed during a fourth year of training (UNOS by-laws. Appendix B; Section IIIC(2)(c). UNOS Update, August 1994, 50-52).
All training programs must provide trainees with a broad knowledge of the physiology of the liver and a thorough knowledge of the management of patients with hepatobiliary diseases. A program must ensure that the trainee acquires the following.
- A significant fund of knowledge about the basic biology and pathobiology of the liver and biliary systems as well as a thorough understanding of the diagnosis and treatment of a broad range of hepatobiliary disorders.
- Skill in the performance of a limited number of diagnostic and therapeutic procedures.
- An appreciation of the indications and use of a number of diagnostic and therapeutic procedures that are needed to manage hepatobiliary disorders.
During the training period, comprehensive teaching of the following subjects is essential.
- The biology and pathobiology of the liver.
- Diagnosis and management of patients with the following diseases of the liver and biliary tract system.
a. Acute hepatitis: viral, drug, toxic.
b. Fulminant hepatic failure, including the management of cerebral edema, coagulopathy, and other complications associated with acute hepatic failure (level 2).
c. Recognition and diagnosis of chronic hepatitis and cirrhosis; chemical, biochemical, serological, and histopathologic diagnosis of chronic viral hepatitis.
d. Complications of liver disease: ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, hepatorenal syndrome, prevention and treatment of bleeding esophageal varices and gastropathy, diagnosis and treatment of hepatocellular carcinoma.
e. Diagnosis and treatment of nonviral causes of chronic liver disease, such as alcohol, Wilson's disease, primary biliary cirrhosis, autoimmune hepatitis, hemochromatosis,
1-antitrypsin deficiency, etc.
f. Gallstone disease, including the appropriate use of medical and surgical therapies (see Task Force on Training in Biliary Tract Diseases).
g. Hepatobiliary disorders associated with pregnancy.
h. Preoperative evaluation and postoperative management of patients with known disease of the liver or with evidence of hepatobiliary dysfunction.
- Use of antiviral and immunosuppressive agents in the treatment of liver disease.
- Selection and care of patients awaiting and following liver transplantation, including the assessment of patients with alcoholic liver disease for transplantation, recognition of alcohol dependence, and an understanding of the use of immunosuppressive agents; diagnosis and management of rejection; and recognition of other complications of transplantation, such as certain infections and biliary tract and vascular problems.
- Management of the nutritional problems associated with chronic liver disease (see Task Force on Training in Nutrition).
- An understanding of the principles of experimental design, clinical biostatistics, and epidemiology sufficient to critically interpret the medical literature (see Task Force on Training in Research).
- Pediatric and congenital hepatobiliary disorders (see Task Force on Training in Pediatric Gastroenterology).
- Liver pathology, including histological interpretation and specific pathological techniques (see Task Force on Training in Gastrointestinal and Hepatic Pathology).
Training Process
Program Faculty
The program in hepatology must be conducted under the auspices of a program director who is highly competent in the subspecialty of hepatology (see Task Force on Overview of Training in Gastroenterology). The director of the program must be board certified in internal medicine and preferably board certified in gastroenterology. The director must have recognized expertise in liver diseases, including continued productivity in clinical or basic research related to hepatology. For level 2 training, the director of the program or associated faculty should be expert in the evaluation and management of liver transplant recipients.
Prerequisites for Training
Training in hepatology should take place after trainees have successfully completed at least 3 years of postdoctoral education in internal medicine. Level 1 and level 2 training will take place in the context of training in gastroenterology.
Duration of Training
For level 1 training, approximately 30% of the 18 months devoted to clinical training in gastroenterology should be dedicated to training in hepatology. This training should include experience equally divided between the management of inpatients with a variety of hepatic disorders and the treatment of outpatients with liver disease. To provide an adequate experience, at least 30% of the inpatients seen by the trainee in his or her capacity as primary physician or consultant should have liver disease. An opportunity for trainees to become familiar with the referral and management of liver transplant patients should also be provided.
The minimum requirement for level 2 training includes the preparation of the individual to diagnose and manage all types of liver disease, acquisition of the procedural skills listed below, and proficiency in performing liver consultations. In addition, experience in the evaluation of patients for liver transplantation is essential. It is assumed that to meet these criteria, at least 18 months of training will be devoted to training in hepatology. This could be completed during the 3-year fellowship in gastroenterology or necessitate a fourth year of training devoted to hepatology. Two of the months must be spent on a liver transplant service. This may require that the trainee rotate through another institution for this training.
Required Procedural Skills
The trainee must acquire competence in the performance of the following procedures in addition to understanding their indications, contraindications, limitation, complications, and interpretation. The procedures are the following.
- Performance of percutaneous liver biopsy: minimum 20
- Diagnostic and therapeutic paracentesis: minimum 20
- Use of ultrasound for marking for percutaneous liver biopsy: level 2 only
Training in Hepatology Research
All trainees should participate in research during their fellowship. The research can be either clinical or basic in nature. The trainee should be actively involved in the design of the research and should understand how to develop a successful research program. For those interested in academic medicine, this portion of the training may require additional years of fellowship before the trainee is prepared to be an independent investigator (see Task Force on Training in Research).
Training Through Conferences, Seminars, Literature Review, and Lectures
There must be regularly scheduled conferences that include didactic lectures, literature reviews, and research seminars. Trainees also must be responsible for teaching and supervising residents in internal medicine as well as medical and other medical personnel (see Task Force on Overview of Training in Gastroenterology).
Assessment of Competence
Knowledge of the hepatology curriculum should be assessed as part of the overall evaluation of the trainee in gastroenterology during and after the fellowship, as outlined by the Task Force on Overview of Training in Gastroenterology. Because there is no mechanism of certification in hepatology, the program director should write a letter that details the trainee's qualifications as a specialist in hepatology, particularly for level 2 trainees. Details as to training in the preoperative and postoperative management of patients who have undergone liver transplantation, management of difficult problems such as refractory ascites, and bleeding varices are essential to document competence for level 2 training. If certification as a transplant hepatologist is desired, then documentation that the trainee has fulfilled United Network of Organ Sharing criteria must be provided.
This report was developed by the Training and Education Committee of the American Association for the Study of Liver Diseases. In addition, the previously published recommendations for training in hepatology (Hepatology 1992;16:1084-1086) were used in the creation of this document.
Task Force on Training in Hepatology
THOMAS D. BOYER, M.D. (Chair)
Atlanta, Georgia
JOSEPH R. BLOOMER, M.D.
Birmingham, Alabama
GREGORY T. EVERSON, M.D.
Denver, Colorado
MICHAEL GERBER, M.D.
New Orleans, Louisiana
NORMAN GITLIN, M.D.
Atlanta, Georgia
JENNY HEATHCOTE, M.D.
Toronto, Ontario, Canada
J. MICHAEL HENDERSON, M.D.
Cleveland, Ohio
PATRICIA LATHAM, M.D.
Baltimore, Maryland
KEITH D. LINDOR, M.D.
Rochester, Minnesota
KAREN L. LINDSAY, M.D.
Los Angeles, California
RICHARD A. SAMPLINER, M.D.
Tucson, Arizona
EUGENE R. SCHIFF, M.D.
Miami, Florida
RICHARD A. WILLSON, M.D.
Seattle, Washington
Task Force on Training in Biliary Tract Diseases
Importance
Biliary tract diseases occupy a significant portion of the practice of gastroenterology. The diagnosis and therapy of these diseases represent a major challenge to practicing gastroenterologists because of rapid advances in technology that require skills not previously taught (e.g., invasive endoscopic and radiological procedures, endoscopic ultrasound, scintigraphy). These new technological developments provide gastroenterologists and their patients with new diagnostic and therapeutic options. To achieve maximal effectiveness, minimize the risk, reduce the costs, and provide the best possible care for the patients, specialized training is required that emphasizes knowledge of anatomy, physiology, pathophysiology, and clinical presentation of biliary tract diseases. The gastroenterologist must be familiar with and be in a position to apply new technology for the benefit of his or her patients.
Goals of Training
A major goal of the training in biliary tract diseases should be to train highly skilled consultants who can provide state-of-the-art care to patients with complex biliary tract diseases. The highly trained specialist should be aware of advantages and disadvantages of available options involving diagnosis and therapy of biliary diseases, be aware of potential complications, and, if they occur, be in a position to manage them. To accomplish this goal, trainees should do the following.
- Be acquainted with varied presentations of biliary tract diseases and have detailed knowledge of cognitive aspects of biliary diseases.
- Acquire competency in the decision-making process involving the appropriate choice(s) of diagnostic procedures, their timing, and their sequence.
- Establish proficiency in diagnostic and therapeutic procedures involving biliary tract diseases and acquire the ability to perform them safely, successfully, and expeditiously.
- Appreciate the advantages and disadvantages of radiological and endoscopic procedures and be able to balance risks and benefits of these procedures for the patient (see Task Forces on Training in Gastrointestinal Endoscopy and Gastrointestinal Bleeding and Training in Gastrointestinal Radiology).
- Understand the importance of teamwork, which involves close collaboration with radiologists, surgeons, and hepatologists.
The experience necessary to become proficient in the diagnosis and therapy of biliary tract diseases should be offered only in institutions that have a large patient referral base, a wide range of patients with biliary tract diseases, and experienced faculty in gastroenterology, radiology, surgery, and clinical pathology.
Training in biliary tract diseases should also result in physicians/educators who will be able to teach general internists, patients, and the public about biliary tract diseases.
Finally, training in biliary tract diseases should result in physician-scientists who will expand the frontiers of biomedical knowledge and apply the knowledge to diagnosis and treatment of biliary tract diseases.
Training Process
Two levels of training should be offered. Level 1 training is for those trainees who will be a part of the general gastroenterology program and have exposure to diseases of the biliary tract. Level 2 training is intended for those who will be selected to spend the entire year of training in biliary tract diseases in the third year of training.
Level 1 Training
Basic science training (physiology and pathophysiology).
The fundamental core of information for all trainees should include the following.
- Detailed knowledge of hepatobiliary and pancreatic anatomy, including developmental anomalies.
- Physiology of bile and factors regulating bile flow.
- Physiological function of bile components (bile acids, phospholipid, cholesterol, and proteins).
- Gallbladder function, mechanism of bile concentration, and regulation of gallbladder contraction.
- Regulation of bile duct motility and sphincter of Oddi function (contraction/relaxation).
- Pathophysiology of cholestasis and the mechanisms responsible for alteration of bile flow.
- Pathophysiology of gallstone formation (cholesterol, pigment stones).
- Pathogenesis of motility disorders of the biliary tract.
- Pathophysiology and scientific rationale for therapy of major biliary tract disorders.
- Basic familiarity with techniques of molecular biology, principles of cell biology, and physical chemistry as they relate to the biliary tract.
This fundamental core of information should be acquired in the first 18 months (core clinical) of training through individual reading, presentation of core curriculum at gastroenterological/radiological/surgical clinical conferences, lectures by invited speakers, journal clubs, and through daily contact with the attending physicians.
Training in clinical aspects of biliary tract diseases.
An accomplished consultant should have a thorough familiarity with the epidemiology, presenting manifestations, differential diagnosis, and natural history of all major biliary tract disorders, including those disorders that present predominantly in children. All trainees should become familiar with specific biliary tract diseases, such as benign and malignant strictures of the biliary tract, primary and secondary neoplasms involving the biliary tree, choledocholithiasis, cholecystitis, sclerosing cholangitis, congenital abnormalities of the pancreaticobiliary tract (biliary atresia, choledochal cysts), hemobilia, motility disorders of the biliary tract, postoperative complications of the biliary tree and post-liver transplant biliary problems, acute and chronic pancreatitis, and pancreatic neoplasms. This basic knowledge should be acquired in the first 18 months of training.
More detailed exposure to biliary disease may take place during additional rotation through a biliary tract diseases service. During these rotations (in the second 18 months), the trainees should participate actively in the medical care of patients with biliary tract diseases through inpatient consultations with the attending physicians. They should also learn the principles of outpatient consultations in the outpatient clinic or office setting of the attending physicians specializing in biliary tract diseases.
Procedures.
All trainees should have a thorough knowledge of the endoscopic techniques used in the diagnosis and treatment of biliary tract diseases, including their potential risks, limitations, and costs. The trainee also must understand the role of alternative diagnostic and therapeutic modalities (medical, surgical, and radiological) in the evaluation and management of biliary tract diseases. They should understand the advantages and disadvantages of different diagnostic and therapeutic procedures available to them.
Endoscopic retrograde cholangiopancreatography represents the major tool for accessing the biliary tree and a major route for therapeutic intervention. The understanding of percutaneous transhepatic cholangiography and performance and interpretation of endoscopic retrograde cholangiopancreatography (indications, contraindications, limitations, complications, and interpretation) should be acquired through participation in and observance of those procedures under supervision of the attending physician and with the assistance of a radiologist. These complex procedures require extensive training difficult to give to all trainees. The level of experience required for performing endoscopic retrograde cholangiopancreatography may vary with the career expectations of the trainee. Several levels of training are proposed (see Task Force on Training in Gastrointestinal Endoscopy and Gastrointestinal Bleeding).
- Familiarity. This level involves minimal exposure to biliary endoscopy for those trainees who do not plan to perform them. Examples might include trainees who are planning academic careers in basic science, specializing in hepatology or nutrition, or planning careers as teacher-clinicians. "Minimal exposure" to endoscopic retrograde cholangiopancreatography is defined as understanding of indications and contraindications of endoscopic procedures, advantages and disadvantages, complications, alternative diagnostic and therapeutic options, and interpretation of findings. This knowledge could be acquired through conferences, teaching rounds, courses, and 1-2-month rotations through the biliary tract service. No hands-on experience in biliary procedures is expected of this group of trainees.
- Proficiency. This level involves at least 12 months of advanced training in pancreaticobiliary endoscopy (see Task Force on Training in Gastrointestinal Endoscopy and Gastrointestinal Bleeding) and is aimed at individuals who seek to be true experts in endoscopic management of biliary tract diseases (level 2, see below).
In addition to a knowledge and understanding of endoscopic procedures, all level 1 trainees should have a general understanding of the indications, advantages, and disadvantages of imaging procedures, such as plain film of the abdomen, cholecystogram, ultrasound, computed tomography, magnetic resonance imaging, and scintigraphy. As part of this process, they should have a basic understanding of how to interpret these procedures. This knowledge will be acquired through daily contacts with radiologists and nuclear medicine specialists during which the findings obtained in their patients will be discussed. Alternatively, the chief of the biliary team may arrange for the trainee to have a 1-2-month rotation through radiology. The interpretation of liver biopsy specimens and histopathology should be accomplished informally by reviewing biopsy slides on their patients with pathologists and/or at formal biopsy interpretation sessions involving a pathologist with a special interest in gastroenterology and hepatology (see Task Forces on Training in Hepatology and Training in Hepatic Pathology). Lastly, trainees should be exposed to the performance and the interpretation of endoscopic ultrasound and observe several surgical biliary procedures during the course of training (see Task Forces on Training in Gastrointestinal Radiology and Training in Surgery).
Level 2 Training
The major goal for trainees at level 2 (see also Task Force on Training in Gastrointestinal Endoscopy and Gastrointestinal Bleeding) is to acquire an in-depth knowledge of pathophysiology, clinical presentation, diagnosis, epidemiology, and therapy of biliary tract diseases. In general, trainees in biliary tract diseases at this level should have completed at least 18 months of training in general gastroenterology and should spend up to an additional year specializing in biliary tract diseases. The trainee in biliary tract diseases will be selected based on the previous record of excellent clinical performance and verified endoscopic skills. Following selection, the leader of the biliary tract diseases team will be responsible for providing the selected trainee(s) with the opportunity to perform an adequate number of procedures, receive supervised teaching, and ensure involvement in clinical research. While the endoscopic training is important, level 2 training should produce an expert in managing all aspects of biliary tract diseases.
In addition to these one-on-one teaching exercises, all trainees at both level 1 and level 2 who rotate through the biliary tract diseases section should attend core curriculum sessions focusing on biliary tract diseases and accompanying procedures organized by the team leader and contributed to by the trainees. This core curriculum should be given weekly and aim at covering cognitive and endoscopic aspects of biliary tract diseases with updated knowledge of the literature, multidisciplinary case reviews, biliary service endoscopic retrograde cholangiopancreatography reviews, and question-and-answer sessions. In terms of cognitive and diagnostic acumen, the level 2 trainees should be expected to know physiology, pathophysiology, diagnosis, and therapy of biliary tract diseases in greater detail than those at level 1 of training.
All trainees at level 2 of training should also be involved in clinical or basic research. Trainees in the biliary section will be expected to acquire an understanding of clinical research, including study design, methodology, statistical analysis, writing the protocols, submitting protocols to Institutional Review Boards, writing informed consent, enrolling patients into studies, analyzing and interpreting data, presenting at national meetings, and writing papers. Individual preceptors should teach basic or clinical research on a one-on-one basis and at research conferences. It is anticipated that most physicians participating at level 2 training will enter an academic environment, which will allow them to continue in the multidisciplinary area of treating patients with biliary tract diseases as well as teaching and conducting clinical research.
Assessment of Competence
Knowledge of the biliary tract diseases curriculum should be assessed as part of the overall evaluation of the trainee in gastroenterology during and after the fellowship, as outlined by the Task Force on Overview of Training in Gastroenterology. No specific examination or other instrument need be developed for this portion of the training. Evaluation of competency in advanced biliary endoscopic procedures is discussed by the Task Force on Training in Gastrointestinal Endoscopy and Gastrointestinal Bleeding.
Task Force on Training in Biliary Tract Diseases
Z. RENO VLAHCEVIC, M.D. (Chair)
Richmond, Virginia
JOHN BAILLIE, M.D.
Durham, North Carolina
HANS FROMM, M.D.
Washington, D.C.
ROBERT H. HAWES, M.D.
Charleston, South Carolina
DOUGLAS M. HEUMAN, M.D.
Richmond, Virginia
RICHARD A. KOZAREK, M.D.
Seattle, Washington
SUM P. LEE, M.D.
Seattle, Washington
MARY ANN TURNER, M.D.
Richmond, Virginia
ALVIN M. ZFASS, M.D.
Richmond, Virginia
Task Force on Training in Gastrointestinal Endoscopy and Gastrointestinal Bleeding
Importance
Gastrointestinal endoscopy is an essential part of modern clinical gastroenterology. Therefore, all gastroenterologists must be knowledgeable regarding endoscopic procedures. The gastroenterologist performing routine diagnostic and therapeutic endoscopy requires training to achieve basic and clinical knowledge, judgmental skills, and the technical competence requisite for performing these studies. The gastroenterologist who performs advanced endoscopic procedures, such as endoscopic retrograde cholangiopancreatography, endoscopic laser therapy, or endoscopic ultrasound, requires additional training in therapeutic endoscopy in addition to advanced training in hepatobiliary diseases, pancreatic diseases, and oncology. Not all trainees can or should be offered comprehensive training in advanced endoscopy. Not all programs need to provide training in all advanced endoscopic procedures to each trainee.
The ABIM defines procedural skills as the learned manual skills (including supervision of technical aspects) necessary to perform certain diagnostic and therapeutic procedures in gastroenterology. Successful mastery of these skills includes technical proficiency; an understanding of their indications, contraindications, and complications; and the ability to interpret their results.
Goals of Training
The objective of endoscopic training programs is to provide trainees with critical, supervised instruction in gastrointestinal endoscopy to assure quality care for patients with digestive diseases. Endoscopic procedures are not isolated technical activities but must be regarded by the instructor and trainee as integral aspects of clinical problem-solving. Endoscopic decision-making, technical proficiency, and patient management are equally important, and the interdependence of these skills must be emphasized repeatedly during the training period.
At the completion of training, the trainee should have achieved the following.
- The ability to recommend endoscopic procedures based on findings of a personal consultation and in consideration of specific indications, contraindications, and diagnostic/therapeutic alternatives.
- The ability to perform a specific procedure safely, completely, and expeditiously.
- The ability to interpret most endoscopic findings correctly.
- The ability to integrate endoscopic findings or therapy into the patient management plan.
- The ability to understand the risk factors attendant to endoscopic procedures and to be able to recognize and manage complications.
- The ability to recognize personal and procedural limits and to know when to request help.
In addition, the gastroenterologist should be skilled in the approach to the diagnosis and the endoscopic and/or medical management of the patient with gastrointestinal hemorrhage, including acute upper gastrointestinal hemorrhage of both variceal and nonvariceal origin, and lower gastrointestinal bleeding of either acute or chronic presentation.
Two levels of endoscopic training for two distinct types of gastroenterologists should be recognized.
- The gastroenterologist performing routine gastrointestinal endoscopic and nonendoscopic procedures as part of the practice of gastroenterology and the gastroenterologist specializing in nonendoscopic aspects of gastroenterology, including but not limited to the study of liver diseases, motility, nutrition, and basic science research (level 1).
- The gastroenterologist who, in addition to all or part of the above, performs advanced diagnostic and therapeutic gastrointestinal endoscopy including endoscopic retrograde cholangiopancreatography (with sphincterotomy, lithotripsy, stent placement, etc.), endoscopic ultrasound, endoscopic laser therapy, and laparoscopy (level 2). It is recommended that the gastroenterologist who performs advanced endoscopic procedures assume the responsibility for teaching advanced endoscopic procedures to trainees where appropriate, conduct endoscopic research, and critically assess and evaluate new and emerging endoscopic procedures for safety and efficacy.
Facilities and Resources
Endoscopic training should take place within the framework of clinical care and problem-solving. The basic requirements for successful programs are skilled, experienced endoscopic supervisors who continually maintain and improve their abilities and possess the talents required to teach endoscopy; trainees with sound general medical or surgical training who have the motivation and aptitude for endoscopy; a structured training experience with ongoing evaluation of each trainee's progress in relation to interests, aptitudes, and career goals; and the opportunity for adequate clinical and endoscopic experience. Endoscopic procedures should be preceded by a careful clinical evaluation, including indications and individual risk factors.
Faculty
The endoscopy training supervisor should be a sound clinician and teacher who is well trained, experienced, and skilled in endoscopy. Endoscopy instructors should have a demonstrated aptitude for teaching endoscopy because it is recognized that not all expert endoscopists are expert teachers. The supervisor should be responsible for appropriate didactic instruction and supervision (or delegation of supervision to other instructors) of all elective and emergency procedures. Supervision consists of observing and directing the trainee as he or she manipulates the endoscope. The actual process is comprised of verbal directions for a series of complex physical maneuvers with the instructor at the side of the trainee. In addition, the endoscopy instructor should be responsible for continuing instruction in endoscopic decision-making, technique, and interpretation of findings and the ongoing evaluation of procedures, reports, and photographic records.
Facilities
Modern inpatient, ambulatory care, clinical laboratory, radiology, and pathology facilities to accomplish the overall educational program must be available and functioning at the primary training site. The clinical environment must include emergency as well as intensive care facilities to ensure adequate exposure to patients with acute upper and lower gastrointestinal hemorrhage. In addition, safe and efficient performance of gastrointestinal endoscopy relies on the availability of the following.
- Properly trained gastrointestinal endoscopists.
- Properly trained ancillary personnel.
- Functioning, well-maintained equipment.
- Adequately furnished preparation, endoscopy, and recovery areas.
- Equipment and trained personnel to perform cardiopulmonary resuscitation.
- A functioning quality improvement program.
| Procedure | Required numbera |
|---|---|
| Esophagogastroduodenoscopy | 100 |
| Including treatment of nonvariceal hemorrhage | 20 (10 actively bleeding) |
| Including treatment of variceal hemorrhage | 15 (5 actively bleeding) |
| Esophageal dilation | 15 |
| Flexible sigmoidoscopy | 25 |
| Colonoscopy | 100 |
| Including snare polypectomy | 20 |
| Percutaneous endoscopic gastrostomy placement | 10 |
aRequired number represents the threshold number of procedures that must be performed before competency can be assessed. The number represents a minimum, and it is understood that most trainees will require more (never less) than the stated number. The information expressed in the table represents the current recommendations of the ASGE (Statement on endoscopic training. ASGE publication no. 1001, 1986 and Methods of granting hospital privileges to perform gastrointestinal endoscopy. ASGE publication no. 1012, revised 1992).
Endoscopic Experience
The trainee must be exposed to a sufficient number of new and follow-up inpatients and outpatients of varied age (adult and geriatric) and of both sexes and with a variety of common and uncommon digestive disorders to permit a broad endoscopic experience. It is essential that endoscopic experience be attained in patients presenting with both acute and chronic, upper and lower gastrointestinal hemorrhage, including acute variceal hemorrhage. The trainee should achieve competence in a variety of methods of endoscopic therapy, e.g., endoscopic hemostasis for both variceal and nonvariceal gastrointestinal hemorrhage. Table 1 provides guidelines for endoscopic training in routine procedures. Each required number of procedures noted in Table 1 represents the threshold number of procedures that must be performed before competency can be assessed. The number represents a minimum, and it is understood that most trainees will require more (never less) than the stated number. Trainees must learn that when performing a diagnostic procedure, they should be prepared to conduct needed therapeutic interventions as well should that become necessary. Trainees must assume continuing responsibility for both acute and chronically ill patients, before and after endoscopy, to learn the natural history of gastroenterological disorders as well as the effectiveness of therapeutic endoscopic procedures. The use of teaching aids such as endoscopy simulators, viewing videotaped recordings of previously performed endoscopic procedures, use of endoscopy atlases, attendance at endoscopy courses, and ongoing review of the endoscopic literature is encouraged but should not be viewed as a substitute for hands-on experience in performing procedures.
Training Process
Level 1
All trainees should have a clear understanding of the indications, limitations, complications, and medical and surgical implications of the findings of gastrointestinal endoscopy. This includes an understanding of the underlying pathophysiology of gastrointestinal diseases and the ability to interpret the endoscopic findings for each. All trainees should complete at least 18 months of training on an inpatient consultation service and participate in a continuity outpatient clinic and perform endoscopic procedures as part of the continuing care of patients. Trainees should participate in the performance of endoscopic procedures with a staff gastroenterologist or surgeon knowledgeable in the indications for and the technique of performing the procedure as well as the method of recording the results of the procedure and the clinical significance of the findings. Essential components of patient safety during endoscopic procedures must be mastered, including the intravenous administration of medications that produce conscious sedation and the application and interpretation of noninvasive patient monitoring devices. Trainees should be familiar with the care, cleaning, and proper maintenance of endoscopy equipment. Technical skills for endoscopic procedures must be acquired in a sequential fashion. Proficiency develops as an incremental process through performance of sufficient numbers of procedures under direct supervision in a methodical sequence of increasing complexity. After suitable supervision, the trainee should be capable of independently performing routine endoscopic procedures including specific therapeutic maneuvers (e.g., polypectomy, hemostasis) when indicated (Table 1). The required number of procedures noted in Table 1 represents the threshold number of procedures that must be performed before competency can be assessed. The number represents a minimum, and it is understood that most trainees will require more (never less) than the stated number.
Level 2
Trainees who elect to pursue additional training in gastrointestinal endoscopy should have completed at least 18 months of a standard gastroenterology training program (core clinical curriculum) or equivalent training and should have documented competence in "standard" (i.e., not advanced) endoscopic procedures (Table 1). The minimum duration of training required to achieve advanced technical and cognitive skills is 12 months. Programs offering advanced endoscopic training should have a minimum of two endoscopists capable of performing and providing instruction in advanced endoscopy. Each instructor should be acknowledged as an expert by his or her peers and should have a proven record of endoscopic research and teaching experience as documented by substantial published reports, reviews, editorials, and/or participation in local, regional, or national symposia and/or postgraduate courses. Trainees should participate in the performance of advanced endoscopic procedures with an experienced endoscopist knowledgeable in the indications for the procedure, the techniques of performing and the method of recording the results of the procedure, and the clinical significance of the findings. The trainee who wishes to perform endoscopic retrograde cholangiopancreatography must have a basic understanding of radiation safety, fluoroscopy, normal radiological anatomy, and radiographic interpretation. The trainee desiring to perform endoscopic ultrasound must have a clear understanding of cross-sectional human anatomy (both gross and microscopic), the principles of ultrasonography, and the principles of oncology as they pertain to the staging of gastrointestinal malignancies. Trainees desiring to perform endoscopic laser therapy and/or laser tumor ablation must have a clear understanding of cross-sectional human gross anatomy, the principles of laser physics and technology, the principles of laser safety, and the principles of oncology as they pertain to tumor growth and staging. Technical skills for advanced endoscopic procedures must be acquired in a sequential fashion. Proficiency develops incrementally through performance of sufficient numbers of procedures under direct supervision in a methodical sequence of increasing complexity. After suitable supervision, the trainee should be capable of performing advanced diagnostic and therapeutic endoscopic procedures independently (Table 2). The required number of procedures noted in Table 2 represents the threshold number of procedures that must be performed before competency can be assessed. The number represents a minimum, and it is understood that most trainees will require more (never less) than the stated number.
| Procedure | Required numbera |
|---|---|
| Endoscopic retrograde cholangiopancreatography | Substantially in excess of the number required for minimal competency (no specific numerical recommendation)b |
| Endoscopic ultrasound | 100 (at least 50% should include tumor staging or pancreaticobiliary examinations) |
| Endoscopic laser therapy | 25 |
| Laparoscopy | Substantially in excess of the number required for minimal competency (no specific numerical recommendation)c |
aRequired number represents the threshold number of procedures that must be performed before competency can be assessed. The number represents a minimum, and it is understood that most trainees will require more (never less) than the stated number. The information expressed in the table represents the current recommendations of the American Society for Gastrointestinal Endoscopy (Guidelines for advanced endoscopic training. ASGE publication no. 1026, 1994).
bThe threshold or minimum number of procedures that must be performed before competency can be assessed, as determined by the ASGE, is 100 (75 diagnostic and 25 therapeutic). Although no specific numerical recommendation has been established for training in advanced procedures, it has been established that substantially more procedures are required before competence can be assessed in technically demanding therapeutic procedures. Competence of graduates of advanced training programs in biliary endoscopy may be assessed by the demonstrated ability to reliably (at least an 80% success rate) obtain access to (selectively and freely cannulate) the desired duct without assistance. Cases used to assess competency for endoscopic retrograde cholangiopancreatography should exclude those procedures in which the native anatomy of the patient has been surgically or otherwise altered (e.g., gastric outlet obstruction, Billroth II anastomosis), prior sphincterotomy has been performed, or a routine stent exchange is being performed (Guidelines for advanced endoscopic training. ASGE publication no. 1026, 1994).
cThe number of procedures required for minimal competency, as determined by the ASGE, is 25.
Assessment of Competence
Endoscopic competence is difficult to define and quantitate. Evaluation remains largely subjective. An example of objective parameters used to assess competency for endoscopy is shown in Table 3. Judgment as well as interpretive and technical skills must be evaluated in every trainee. Regular ongoing feedback is an essential component of trainee evaluation and should be provided in a formal setting similar to that recommended for the nonendoscopic components of gastrointestinal training.
The ABIM has determined that specific methods for observation, evaluation, and documentation of procedural skills be left to the discretion of the program director. When performing endoscopic procedures early in training, each trainee should be observed regularly by a supervisor. Faculty members should substantiate the trainee's competence by documenting the performance of the designated procedures. Simpler procedures may require fewer observations, whereas those that are technically complex may require more. The competency of all gastroenterology trainees should be documented by the program director and by the endoscopy director. The program director has the responsibility to confirm or deny the technical competency and endoscopic exposure of trainees.
The ABIM has recommended that documentation be provided by a procedure card, computer record, or logbook that identifies and evaluates the procedure(s) performed and any complications and includes the faculty supervisor's signature. This evaluation should become part of the trainee's file. The ABIM provides documentation logbooks for training programs to distribute to trainees for documenting training and achievement of technical proficiency.
Reviews records, x-rays, identifies risk factors, Understands and discusses appropriate alternative procedures Correctly identifies indication, knows how study will influence management Obtains appropriate informed consent Demonstrates proper use of premedication and noninvasive patient monitoring devices Inserts the endoscope using proper technique Performs procedure with attention to patient comfort and safety Correctly identifies landmarks Conducts thorough examination of the entire organ Detects and identifies all significant pathology Completes examination within a reasonable time Prepares accurate report Plans correct management and disposition Discusses findings with patient and other physicians Conducts proper follow-up, review of pathology, case outcome |
|---|
*Adapted and reprinted with permission from Bond J. Observational methods to assess endoscopic competence. Report of the 1993 Gastroenterology Leadership Council Training Director's Conference. Am J Gastroenterol 1994;89:1434-1435.
References
American Board of Internal Medicine Clinical Competence Programs. A system for evaluating clinical competence: guidelines for gastroenterology. 1993.
American Society for Gastrointestinal Endoscopy. Statement on endoscopic training. ASGE publication no. 1001, 1986.
American Society for Gastrointestinal Endoscopy. Guidelines for establishment of gastrointestinal areas. ASGE publication no. 1003, 1989.
American Society for Gastrointestinal Endoscopy. Monitoring of patients undergoing gastrointestinal endoscopic procedures. ASGE publication no. 1022, 1990. Gastrointest Endosc 1990;37:120-121.
American Society for Gastrointestinal Endoscopy. Methods of granting hospital privileges to perform gastrointestinal endoscopy. ASGE publication no. 1012, revised 1992.
American Society for Gastrointestinal Endoscopy. Guidelines for advanced endoscopic training. ASGE publication no. 1026, 1994.
Bond J. Observational methods to assess endoscopic competence. Report of the 1993 Gastroenterology Leadership Council Training Director's Conference. Am J Gastroenterol 1994;89:1434-1435.
Fleischer D. Training in advanced endoscopy. Report of the 1993 Gastroenterology Leadership Council Training Director's Conference. Am J Gastroenterol 1994;89:1431-1432.
Task Force on Training in Gastrointestinal Endoscopy and Gastrointestinal Bleeding
JACQUES VAN DAM, M.D., Ph.D. (Chair)
Boston, Massachusetts
JOHN H. BOND, M.D.
Minneapolis, Minnesota
JAMES L. BORLAND, Jr., M.D.
Jacksonville, Florida
DAVID E. FLEISCHER, M.D.
Washington, D.C.
BARBARA B. FRANK, M.D.
Philadelphia, Pennsylvania
BENNETT E. ROTH, M.D.
Burbank, California
MICHAEL V. SIVAK, Jr., M.D.
Cleveland, Ohio
Task Force on Training in Nutrition
Importance
An appropriate nutrition plan is essential for all patients. Consequently, it is the most commonly used prescription. As our knowledge base has increased in nutrition, it is important to be aware of specific nutrient requirements in health and in various disease states. Knowledge of specific nutrient-drug interactions is also essential. Furthermore, malnutrition and obesity have become important comorbidities that can change disease outcome. Because all nutrients enter the body through the gastrointestinal tract, it is of utmost importance that the gastroenterologist understand all nutrient mechanisms and all the details of appropriate ingestion, digestion, absorption, and metabolism. Whenever these mechanisms fail, an appropriate alternative nutrition support plan must be made available. We now have reached a level of knowledge that allows a nutrition plan with adequate intake to be devised for all patients.
Goals of Training
Nutrition Assessment
A complete understanding of and expertise in the use of techniques for assessment of nutritional status should be obtained. Nutritional assessment is important at the onset as well as during the course of treatment to monitor the patient's progress. The ability to apply the techniques of assessment is essential for identifying patients at high risk and for evaluating specific problems in intake or delivery of the appropriate nutrients. Techniques of assessment should include determination of body composition, metabolic status, functional status of the gastrointestinal tract, and complicating organ failure.
Basic Nutrition Requirements
A full understanding of the metabolism of micronutrients and macronutrients is essential to understand the basic requirements and variability of requirements caused by illness.
Specific Needs, Specific Gastrointestinal Disorders, and Other Allied Diseases
The changes in micronutrient and macronutrient needs in various disease states must be understood. Examples of this are the need for Vitamin B12 in small bowel resection, the hyperzincuria that occurs in some illnesses, the delivery of an absolutely gluten-free diet in gluten enteropathy, the limitation of protein intake in renal failure, and the increased caloric and protein needs in hypermetabolic states such as posttrauma.
Enteral Nutrition
It is essential that the gastroenterology trainee understand all of the various formulations of enteral feeding, enteral delivery systems, and enteral nutrition devices. In addition, the trainee must learn to recognize complications associated with enteral nutrition therapy.
Parenteral Nutrition
A full understanding of parenteral formulas, delivery systems, and how to recognize complications must be obtained both for the inpatient and home care systems.
Diet Therapy
Trainees should know how to order oral foods that conform to specific needs or restrictions in all disease states.
Training Process
To obtain a core knowledge base to reach the goals for nutrition assessment and adequate nutrition requirements, it is recommended that trainees be exposed to a didactic lecture curriculum. This should include basic lectures in all aspects of micronutrients and macronutrients, digestion, absorption, and metabolism. Trainees should review assessment techniques from a practical, clinical aspect. In addition, trainees should review the most recent studies in research techniques, such as body compartment studies using radioisotopes. Although many of these nutritional assessment methods are not available at all institutions, an understanding of these methods should be made possible for trainees through appropriate didactic sessions. The didactic material can be taught in a process of an introductory lecture series or during a block time rotation on a nutrition service and should be reviewed in a regular, organized nutrition conference. A faculty that is knowledgeable in these areas should be available at the base institution of training or be made available in a block rotation through an appropriate university affiliation.
To gain clinical expertise in these areas, the trainee should be exposed during the years of clinical training to either block rotations through a multidisciplinary nutrition support service or in an ongoing clinical responsibility in which knowledgeable faculty are available to review the nutritional assessment, the nutritional plans, and the ongoing monitoring of the nutrition treatment.
The trainee must be exposed to specific nutritional problems in all areas of gastroenterology therapy. Case material should be available in chronic esophageal disease, gastric emptying disorders, various enteropathies, colonic dysfunction, chronic liver disease, and chronic pancreatic disease. In addition, trainees should become familiar with enteral and parenteral support for nutritional problems that occur in intensive care areas as well as pulmonary, renal, surgical, and obstetric problems that occur, such as hyperemesis gravidarum. This experience can only be obtained in either an extended block time rotation on a nutrition consultation service or in a longitudinal experience in which the gastroenterology service is responsible for nutritional problems.
It is also strongly recommended that this material be included in clinical conferences so that there is an ongoing involvement on an interdisciplinary level.
The trainee should obtain enough knowledge and experience from rounds with the nutrition service and didactic lectures to be able to develop enteral formulas. The trainee should develop the ability to select and change formulas in accordance with patient needs and the most recent information available. This expertise can only be obtained by an ongoing experience in the use of formulas. Experience in parenteral nutrition is required in a manner similar to that required for enteral nutrition. The knowledge to adapt a parenteral nutritional formula to the needs of a specific case is obtained from ongoing participation in nutrition service rounds. An ongoing experience in the use of parenteral nutrition should also be afforded in either a metabolic unit or an intensive care unit where there is a daily evaluation by attending staff.
The trainee also should have exposure to issues related to long-term enteral and parenteral nutrition, including case material in the home care setting.
The training should include experience in selecting the correct form of enteral nutritional therapy device. The trainee should be aware of, and be able to monitor, devices that are placed surgically, such as jejunostomy tubes. The trainee should have adequate experience in the placement of nasoenteric tubes, percutaneous gastrostomy, and percutaneous jejunostomy. While placement of central intravenous lines for parenteral nutrition need not be the primary responsibility of the gastroenterologist, the trainee should be sophisticated in the maintenance of these lines so that he or she can be the sole monitor of inpatient and home care therapy.
Level 2 Training
Level 2 training in nutrition may be available at institutions where there is full-time faculty in nutrition. The level 2 training should last approximately 12 months and might be in the form of a nutrition fellowship separate from the gastroenterology fellowship or as a selected third year of the program. The trainee should spend an extended period of time on a nutrition service (approximately 9-12 months) and should select a nutrition subject for the research component of the gastroenterology fellowship. To provide level 2 training, the institution and program should have a faculty that is experienced in nutrition research, has demonstrated scholarly activity in the field of nutrition, and presents and participates in national nutrition meetings.
Level 2 nutrition training should include exposure to nutritional problems in renal disease, adolescent and geriatric nutrition, obesity, nutritional intolerances, and allergies as well as a detailed cognitive understanding of all micronutrients and macronutrients in human metabolism. The trainee should also have a full understanding of epidemiological and socioeconomic problems in the field of nutrition. The detail in level 2 training is above that expected in level 1 gastroenterology training and is at the level expected by the American Board of Nutrition.
Assessment of Competence
Knowledge of the nutrition curriculum should be assessed as part of the overall evaluation of the trainee in gastroenterology during and after the fellowship, as outlined by the Task Force on Overview of Training in Gastroenterology. No specific examination or other instrument need be developed for this portion of the training.
Task Force on Training in Nutrition
MARTIN H. FLOCH, M.D. (Chair)
Norwalk, Connecticut
DONNA CIPOLLA, M.D., R.D.
Norwalk, Connecticut
JOAN CULPEPPER-MORGAN, M.D.
Norwalk, Connecticut
Task Force on Training in Pediatric Gastroenterology
Importance
Trainees in gastroenterology should have experience in pediatric gastroenterology. Although their knowledge base and endoscopic skills relating to pediatric gastroenterology will not be sufficient to manage pediatric patients independently, they should achieve an understanding of congenitally acquired disorders and disease in the growing child. As they begin to assume care for these patients as adults, these experiences will be beneficial.
Goals of Training
Trainees in gastroenterology should not be expected to achieve any level of competency in pediatric gastroenterology beyond general concepts. Competency requires completion of a pediatric gastroenterology training program. After their training is completed, trainees in gastroenterology should be able to do the following.
- Appreciate the unique aspects of the field. A goal of the experience in pediatric gastroenterology is to increase awareness of the clinical problems of pediatric gastroenterology, not to develop competence.
- Be prepared to participate in limited scope of care when, in underserved areas, pediatric gastroenterology consultation is not available.
It is unlikely that a broader scope of activity would be possible because a prerequisite for subspecialty care of children must be adequate training in both pediatrics and in gastroenterology (parallel to the requirements for the practice of Internal Medicine-Gastroenterology).
The pediatric gastroenterology component of the curriculum should focus on several aspects.
- Age-related physiological and psychological variables of children and adults.
- Unique aspects of the disease in the pediatric vs. the adult patient. An example is hepatitis B; if the disease is acquired in early life, the rate of development of the chronic carrier state is up to 90%, whereas acquisition later in life is associated with lower carriage rates.
- Manifestations of commonly encountered entities (e.g., abdominal pain, constipation, gastrointestinal bleeding, diarrhea, cystic fibrosis).
Training Process
Trainees should attend clinical conferences at which at least one pediatric case is discussed. A limited experience with a pediatric gastroenterology service offers further exposure. In addition, an enrichment program might include lectures (or a visiting professorship) by a pediatric gastroenterologist.
Assessing Competence
Knowledge of pediatric curriculum should be assessed as part of the overall evaluation of the trainee in gastroenterology during and after the fellowship, as outlined by the Task Force on Overview of Training in Gastroenterology. Questions relating to pediatric gastroenterology should be included on the board examination and reflect a general, but limited, knowledge of pediatric gastroenterology.
Task Force on Training in Pediatric Gastroenterology
WILLIAM F. BALISTRERI, M.D. (Chair)
Cincinnati, Ohio
RALPH GIANNELLA, M.D.
Cincinnati, Ohio
JUDY SONDHEIMER, M.D.
Denver, Colorado
HARLAND WINTER, M.D.
Boston, Massachusetts
ROBERT WYLLIE, M.D.
Cleveland, Ohio
Task Force on Training in Gastrointestinal and Hepatic Pathology
Importance
An understanding of gastrointestinal and hepatic pathology, which includes gross, surgical, histological, and cytological pathology as well as the pertinent areas of clinical pathology, laboratory medicine, and diagnostic molecular biology, is essential to the practice of modern gastroenterology. Training in gastrointestinal pathology helps the trainee in three ways. First, it is critical to an understanding of the etiology of gastrointestinal and hepatobiliary disorders. Second, it provides the basis for knowledge of the diagnostic usefulness and the limitations of pathological studies across the broad range of these disorders. Finally, the integration of these two areas of knowledge, that is, the pathogenesis and the usefulness of specific pathological tests, permits the development of links between pathological test results and therapeutic possibilities, which form the basis of many treatment decisions.
Goals of Training
The overall goal of such training is competency in recognizing and understanding the significance of the endoscopic, gross pathological, and/or histological characteristics of certain disorders and diseases. The following objectives are important in attaining such competence.
- Trainees should appreciate the spectrum of normal histology.
- Trainees should be able to recognize patterns of histopathologic change in gastrointestinal and hepatic disorders. These include normal architectural patterns and those reflecting inflammation, dysplasia, neoplasm, and the evolution of a disease over time.
- Trainees should learn to recognize when biopsies are adequate and to orient them so that suitable material will be available for the pathologist to interpret.
- Trainees should learn to describe endoscopic findings and clinical information to aid the pathologist's interpretation of biopsy specimens. They also should be trained to ask questions in conference, on requisitions, and at the microscope that will help the pathologist focus on specific diagnoses. Examples include providing appropriate clinical information in patients with liver disease, being able to describe endoscopic findings in such a way that the pathologist can visualize what was seen, and asking specific clinical questions in a differential diagnosis. In addition, it is important to describe the site and specific location of the biopsy specimens; for instance, in esophageal biopsies, trainees should be able to describe the relationship of the biopsy specimen to the gastroesophageal junction. Specific information should include techniques for biopsies, such as looking for iron, copper, or fatty liver of pregnancy in liver biopsy specimens. Additionally, it is important to obtain biopsy specimens from normal areas in IBD, describe polyps that may become fragmented, and use a needle to identify the stalk of the polyp. One mechanism to facilitate such communication is to send the endoscopic report, when possible, with the biopsy request.
- Trainees should be able to recognize when a biopsy can or cannot help in investigation or management and why or why not. Examples include the need for submucosal tissue in ruling out amyloid as well as the difficulty in differentiating ischemic from radiation changes in some mucosal biopsy specimens. Trainees should be clearly able to recognize the clinical problem and whether or not a biopsy will be helpful.
- Trainees should be familiar with the clinical implications of the pathological findings in biopsies and in surgical specimens. Examples of this include being able to interpret changes in a wedge vs. needle liver biopsy and understanding the problem of overdiagnosis of chronic inflammation in the gastrointestinal mucosa.
- Trainees should know the value and limitation of exfoliative and aspiration cytology.
- Trainees should understand the mechanisms and the usefulness of new techniques, such as flow cytometry, immunohistochemistry, and tests based in molecular biology (e.g., polymerase chain reaction, in situ hybridization).
- Trainees should be familiar with specific areas that are becoming increasingly important, such as the recognition of unusual pediatric liver diseases, the recognition of opportunistic infections, and the submission of biliary biopsy specimens for detection of cholangiocarcinoma or other bile duct changes.
Training Process
The teaching of gastrointestinal and hepatic pathology should rely heavily on multidisciplinary conferences of gastroenterologists and pathologists, weekly or every two weeks, to achieve regular review of biopsy specimens taken. These conferences can take a variety of formats and may include any or all of the following: viewing endoscopic slides or videos, reviewing the histology of endoscopic or liver biopsy specimens, examining surgical specimens, and reviewing radiological films and videos. Combining these formats can enhance their value. For example, one useful combination would be to hold endoscopic slide/video review conferences, with the biopsy specimens taken from the same cases presented for histological review and discussion. Thus, the endoscopic appearance of specific lesions would be reviewed at the same time as the usefulness and limitations of performing a biopsy on them, thereby maximizing the educational impact.
Whenever possible, the format of the conferences should consist of carefully prepared presentations by the trainees, covering three or four cases an hour. With the inclusion of a block rotation on histopathology (see below), the trainee should become expert enough to lead or colead histology conferences, with guidance from a pathologist or a gastroenterologist with special expertise in pathology.
When possible, it is strongly encouraged that the gastroenterology trainee spend a 1-month block rotation in gastrointestinal pathology in which he or she works side-by-side with a resident in pathology assigned to the handling and interpretation of gastrointestinal surgical, endoscopic, and liver biopsy specimens. During the same rotation, the trainee should spend time in clinical pathology and laboratory medicine, learning the pertinent areas of these fields, including the molecular biology-based tests listed in goal 8.
Assessment of Competence
Key assessment methods include direct and specific feedback on the quality of the conferences prepared and presented by the fellows; evaluation of the work done during the rotation on pathology; and assessment by the attending endoscopists of the trainee's decision-making regarding the indications for diagnostic procedures, including biopsies, and the skill with which the biopsy specimens are taken, oriented, and described on the requisition.
Task Force on Training in Gastrointestinal and Hepatic Pathology
CHRISTINA M. SURAWICZ, M.D. (Chair)
Seattle, Washington
DOUGLAS L. BRAND, M.D.
Stony Brook, New York
TERRY BRENTNALL, M.D.
Seattle, Washington
JOANNE DONOVAN, M.D.
Roxbury, Massachusetts
CYRUS E. RUBIN, M.D.
Seattle, Washington
WILLFRED M. WEINSTEIN, M.D.
Los Angeles, California
Task Force on Training in Gastrointestinal Radiology
Importance
The understanding of radiological principles of demonstrating gastrointestinal disease, interpretation of images, and familiarity with appropriate sequence of imaging studies is of definite importance to the overall mission of training gastroenterologists. Not only is this intrinsically clear to directors of gastroenterology training programs, but it is recognized by the ABIM. Because trainees are required to interpret imaging studies as part of their board certification examination as well as to demonstrate knowledge of appropriate choices of imaging techniques that apply to specific problems in gastrointestinal disease, a definite training period in gastrointestinal radiology is necessary.
For gastroenterology trainees who will use fluoroscopy in their practices for monitoring of stricture dilations and performance of endoscopic retrograde cholangiopancreatography, a knowledge of radiation safety is required. Because state licensing boards require all users of fluoroscopy to obtain a supervisor's certificate, which requires passing an examination in radiation safety, principles of radiation safety must be part of the curriculum of these gastroenterology trainees.
Goals of Training
The gastroenterologist in training should do the following.
- Be able to recognize normal anatomy of the alimentary tract and related organs.
- Achieve a basic knowledge of gastrointestinal pathology as demonstrated by plain film radiography, barium studies of the gastrointestinal tract, computed tomographic scans, ultrasound, magnetic resonance imaging, and gastrointestinal vascular and interventional studies, scintigraphy, and positron emission transaxial tomography.
- Have an understanding of the logical sequence of using these techniques in the evaluation of gastrointestinal problems as well as the indications and contraindications of radiological interventional studies.
These goals of recognition, knowledge, and understanding apply to all trainees. The actual performance of these radiological techniques is not a goal of the training program.
Training Process
There are four major methods of providing education in interpretation of radiological techniques and in the algorithmic approach to diagnostic imaging. These include the following.
- Participation in work rounds on individual patients, which is integral to routine patient care.
- Exposure at weekly conferences that include radiographic imaging studies in relation to gastrointestinal disease.
- Self-instructional programs in gastrointestinal radiology.
- Defined rotations on a radiology service.
The didactic approach most widely available to gastroenterology trainees is exposure at regular conferences dealing with imaging interpretation and a choice of imaging studies. These include gastrointestinal radiology correlation clinical conferences, radiological/pathological/gastroenterological correlation conferences, gastrointestinal/surgery/radiology/medicine conferences, or permutations of these three types of conferences. The process should also include some form of lecturing in specific, defined topics in gastrointestinal radiology. This includes the broad range of diagnostic modalities, the proper choice of diagnostic tests for specific clinical problems, and principles of interpretation.
Self-instructional programs can be carried out using various techniques developed in medical centers for self-instructional work in radiology. These include videotapes and video disks, computer interactive teaching programs, and syllabi prepared by radiology staff for teaching gastrointestinal radiology. These techniques provide gastroenterology trainees with an opportunity to be exposed to gastrointestinal radiology at times of their own choosing.
Specific, dedicated time rotating in the radiology department is also an effective method of teaching gastrointestinal radiology and exposing trainees to all aspects of this subject. However, a rotation in radiology may not be applicable to or possible for all trainees. Nevertheless, if possible, a 4-week rotation in gastrointestinal radiology with a radiologist specializing in this area is desirable.
Assessment of Competence
Knowledge of the gastrointestinal radiology curriculum should be assessed as part of the overall evaluation of the trainee in gastroenterology during and after the fellowship, as outlined by the Task Force on Overview of Training in Gastroenterology. In addition, if a 1-month rotation by a trainee on the gastrointestinal radiology service takes place, then competency can be judged, or at least semiquantitated, by providing an examination in the form of a film quiz at the end of this period of time.
Task Force on Training in Gastrointestinal Radiology
HENRY I. GOLDBERG, M.D. (Chair)
San Francisco, California
JOHN P. CELLO, M.D.
San Francisco, California
PATRICK FREENY, M.D.
Seattle, Washington
DAVID GELFAND, M.D.
Winston-Salem, North Carolina
RICHARD GORE, M.D.
Chicago, Illinois
EDWARD STEWART, M.D.
Milwaukee, Wisconsin
Task Force on Training in Surgery
Importance
Surgery is the primary and preferred method of management of some gastrointestinal disorders, e.g., acute appendicitis, colonic cancer, and mechanical obstruction of the small intestine. In other conditions, surgical management becomes an option after an initial period of medical therapy; IBD is an example. Still other gastrointestinal problems rarely or never require surgical management, and there are many conditions in this category. Because the usual sequence is referral of a patient by a gastroenterologist to a surgeon, trainees in gastroenterology must learn about the indications and contraindications for surgical treatment and the general principles of the surgical procedures that may be used. Gastroenterologists frequently follow up patients over the long term postoperatively; therefore, trainees should learn about the expected outcomes of operations that are likely to be performed on their patients.
Goals of Training
Trainees should learn the principles of how surgical procedures are conducted, and they should become thoroughly knowledgeable about the postoperative care of patients after major and minor surgical procedures.
Trainees should learn the indications and contraindications for a variety of common operations for gastrointestinal disorders. It is important for gastroenterologists to know the basics of judgment about whether surgery is necessary, what kind of operation is indicated, and when it should be performed. Common complications and their management should be learned, and the trainee should become familiar with the long-term consequences of surgical treatment of gastrointestinal diseases. Specifically, trainees should learn about antireflux procedures, ulcer operations, hepatobiliary operations, portosystemic shunts, hepatic transplantation, pancreatic procedures for benign and malignant disease, surgery for IBD of the small and large bowel, colonic procedures for diverticular disease or cancer, various anorectal operations, and others.
Trainees should learn surgical anatomy and the important relationships of ductal, vascular, and luminal structures by participation in surgical procedures.
Training Process
All trainees should meet the goals of training in surgery.
Indications and contraindications can be learned by reading and by didactic teaching. Lectures are a convenient method of conveying knowledge about surgical procedures, and a systematic series of lectures organized by organ or disease process ensures comprehensive coverage. It is mandatory that trainees participate in joint medical-surgical conferences to discuss specific patients. Retention of information about surgical alternatives is most secure when learning is linked to individual patients. Personal learning through literature searches is an essential element in this effort.
Trainees are encouraged to go to the operating room when their patients are undergoing surgical procedures. Observation of gross pathological abnormalities will help trainees correlate preoperative information with operative findings. Trainees will also gain an appreciation of the conduct of operations, the factors entering into surgical judgment, and the recognition and management of postoperative complications. A block of time on a rotation as a member of the surgical team on a busy gastrointestinal surgical service is advantageous but optional.
Assessment of Competence
Knowledge of the surgical curriculum is assessed as part of the overall evaluation of the trainee in gastroenterology during and after the fellowship, as outlined by the Task Force on Overview of Training in Gastroenterology. No specific examination or other instrument of assessment need be developed for this purpose.
Task Force on Training in Surgery
THEODORE R. SCHROCK, M.D. (Chair)
San Francisco, California
JOHN P. CELLO, M.D.
San Francisco, California
HAILE T. DEBAS, M.D.
San Francisco, California
SEAN J. MULVIHILL, M.D.
San Francisco, California
HOWARD A. SHAPIRO, M.D.
San Francisco, California
LAWRENCE W. WAY, M.D.
San Francisco, California
Task Force on Training in Research
Importance
The subspecialty of gastroenterology is dedicated to continued progress in the prevention, diagnosis, and treatment of gastrointestinal disorders. This mission requires the availability of talented and committed physician-investigators appropriately trained to elucidate biological mechanisms and the natural history of gastrointestinal diseases and to develop outcome-based approaches to treatment and the use of resources. It further requires that all future gastroenterologists be familiar with research principles and methods. It is therefore recommended that all gastroenterology training be performed in institutions where research opportunities are readily available either on site or through programmatic affiliation with a research institution. It is further recommended that every gastroenterology trainee, including those preparing for a career in clinical practice (i.e., clinical track trainees), participate in research for a period of at least 6 months. This document summarizes specific skills that trainees in gastroenterology who wish to pursue investigative careers (i.e., research track trainees) will need to acquire, elements of the training curriculum necessary to acquire these skills, and approaches to evaluating the training program and trainee to help ensure that the program objectives are met.
Goals of Training
Research may either be basic (i.e., laboratory-based) or clinical (i.e., patient-based). The specific skills or competencies that trainees seeking careers in basic research or clinical research need to acquire are summarized below.
Basic Research
Trainees seeking careers in basic research require an advanced understanding of the physiology of the digestive tract and of the principles of cellular and molecular biology. They also must acquire basic laboratory skills and become competent in identifying the research question and formulating a working hypothesis, study design, biostatistics, the appropriate use of animals, and state-of-the-art techniques in cellular and molecular biology. They must develop a clear understanding of current knowledge in their area of interest, of unanswered questions most relevant to gastrointestinal biology and disease, and of research ethics. They need to acquire practical experience in critical analysis of current scientific literature, in the use of computers (e.g., literature review, gene or protein sequence analysis), in scientific writing and presentation, and in the preparation of research proposals for funding and for evaluation by institutional review boards.
Clinical Research
Trainees seeking careers in patient-based research need to acquire advanced and practical skills in state-of-the-art clinical research methods, including literature study, the choice of research question and study design, use of cost-effectiveness and quality of life models, approaches to sampling populations and making clinical measurements, techniques of biostatistics and sample size estimations, ways to optimize quality control and data management, and ways to avoid bias. They must develop a clear understanding of current knowledge and important unanswered questions in their area of interest and of the ethics of research and human investigation. They need to acquire practical experience in the critical analysis of current literature, in the use of computers (e.g., literature review, data base management and analysis, communication), in presentation of their work in written and oral form, and in preparation of proposals for funding and for evaluation by institutional review boards.
Training Process
The Research Mentor
The research mentor is an extremely important element of the training experience. The mentor must have a commitment to and experience in the training of fledgling investigators and an established record of productivity in sponsored research and excellence in his or her field. The mentor may be a faculty member of the gastroenterology training program or of another division or department in the institution engaged in research pertinent to gastrointestinal biology or disease. The mentor must be aware of opportunities for collaborative interaction locally and nationally in the area under study by the trainee and be principally responsible for fostering the development of the trainee into an independent investigator.
Structured Curriculum
The trainee should have the opportunity to participate in formal course work, taught by qualified faculty, necessary to acquire the specific skills outlined above in laboratory-based research, including course work in cell biology, molecular biology, and molecular genetics. In patient-based research, this includes course work in clinical research methods, biostatistics, epidemiology, and ethics.
Protected Time
While preparation for a successful independent investigative career will typically require 1 or more years of supervised research experience beyond the period of training required for subspecialty board eligibility, the trainee must have sufficient protected time during the training period to participate in the course work outlined above and to initiate a well-defined, prospective, hypothesis-driven research project. The period of protected time may vary depending on a variety of factors, including the specific career objectives of the applicant and the funding mechanism. For the research track trainee, the period of protected time should be no shorter than 18 months and may appropriately include the entire period of subspecialty training beyond that required to acquire the core cognitive and technical skills outlined elsewhere in the curriculum. Program directors should be given sufficient flexibility in the organization of clinical training activities so as to comply with current National Institutes of Health guidelines pertaining to trainees supported by individual or institutional National Research Service Awards. For clinical track trainees, the minimum period of participation in research is 6 months. This time should be allocated in sufficiently large blocks as to permit meaningful scholarly activity.
Research Environment
The training should be conducted in a stimulating and intellectually rich research environment that provides scientific background in the particular discipline. Faculty of the training program must include individuals with established skills in basic or clinical research. The trainee should have the opportunity to participate in critical analysis of the current scientific and clinical literature, in research conferences during which the trainee presents and defends his or her own work, and, under the supervision of his or her mentor, in the peer review of articles submitted for publication. The trainee should acquire practical experience in the development of questions, the conduct of basic and/or clinical research designed to answer these questions, and the preparation of abstracts, scientific reports, and funding proposals.
Assessment of Competence
Monitoring and evaluating the trainee's progress should begin before he or she selects a mentor and project, and it should continue throughout the training period. This monitoring and evaluation should be conducted by a group of individuals, including the mentor and other experienced faculty, who have had direct interaction with the trainee (e.g., coursework instructors, participants in the research conference at which the trainee presents and defends his or her own research hypothesis and results, faculty familiar with work being prepared or submitted by the trainee to peer-reviewed publications). Evaluation and feedback should occur sufficiently frequently, at least twice yearly, so that corrections or adjustments in the training curriculum may be made when necessary and appropriate.
Task Force on Training in Research
BRUCE F. SCHARSCHMIDT, M.D. (Chair)
San Francisco, California
NATHAN M. BASS, M.D.
San Francisco, California
DAVID A. BRENNER, M.D.
Chapel Hill, North Carolina
JAY H. HOOFNAGLE, M.D.
Bethesda, Maryland
STEPHEN B. HULLEY, M.D.
San Francisco, California
DAVID A. LIEBERMAN, M.D.
Portland, Oregon
DAVID A. PEURA, M.D.
Charlottesville, Virginia
JOEL E. RICHTER, M.D.
Cleveland, Ohio
Address requests for reprints to: Anthony S. Tavill, M.D., Division of Digestive Diseases, Mount Sinai Medical Center, One Mount Sinai Drive, Cleveland, Ohio 44106-4198. Fax: (216) 421-5789.
Administrative support provided by Rebecca Bonsaint and William Maloney of the American Society for Gastrointestinal Endoscopy, and technical support provided by Anne Brown Rodgers (Technical Resources International, Inc., Rockville, Maryland).
The Gastroenterology Leadership Council Training Directors Committee thanks Drs. Jack Ende and Joseph S. Alpert for advice regarding curriculum development.
© 1996 by the American Gastroenterological Association