This rotation will take place in various outpatient clinics at all 3 sites as well as on the GI and Liver inpatient consult services. Residents will interact with both fellows and attendings. Making use of these settings has afforded us the opportunity to expose house staff to diverse patient populations, pathologies, diagnostic and interventional modalities, and practice settings.
This rotation is a 2-4-week structured clinical experience under direct supervision to provide experience managing patients with gastroenterology and hepatology disorders. This rotation is a combined inpatient consult, inpatient service, and outpatient clinic rotation for PGY2 and PGY3 residents.
Subspecialty Consults and Clinic Expectations for Residents
Goals and Objectives for GI Hybrid Inpatient Gastroenterology and Hepatology Consults
- Effectively consult on inpatients, develop, and execute assessment and management plans
- PGY-2: Learn the steps required to be an effective gastroenterology and hepatology consultant. Recognize how to prioritize patient problems. Develop management plans for the GI and liver problems identified in admitted patients
- PGY-3: Understand interactions between patient GI disorders, hepatology disorders, and other medical issues and develop advanced strategies to prioritize management
- Competancy: Patient care
- Effectively admit patients to the inpatient service, develop, and execute assessment and management plans.
- PGY-2: Learn the steps required to effectively care for patients with gastroenterology and hepatology disorders. Recognize how to prioritize patient problems. Develop management plans for the GI and liver problems identified in admitted patients
- PGY-3: Understand interactions between patient GI disorders, hepatology disorders, and other medical issues and develop advanced strategies to prioritize management
- Competancy: Patient care
- Effectively execute day-to-day management of patients
- PGY-2: Learn to manage patients with GI and liver problems including a daily assessment and determining progress in clinical problems Understand how to adjust treatment plans based on patient progress and determine the need for additional assistance such as subspecialty consultation
- PGY-3: Recognize how to manage complex gastroenterology and hepatology problems and manage both expected and unexpected complications.
- Competancy: Patient care
- Interdisciplinary care and discharge planning
- PGY-2: Learn how to communicate effectively with the interdisciplinary care team and anticipate patient needs for discharge and effective follow-up Recognize the unique needs of patients with GI and liver disorders and help integrate patient needs with available resources
- PGY-3: Learn how to manage advanced situations such as end-of-life decisions, transplant evaluation, and complex transitions of care and advocate for patients when resources are limited
- Competancy: Patient care, System-base practice
- Developing diagnosis skills
- PGY-2: Learn how to effectively use bedside clinical examination in patients with GI and liver disorders and demonstrate subtle bedside clinical findings of GI and liver disease
- PGY-3: Learn how to correlate bedside clinical findings with imaging and other data in patients with GI and liver disorders
- Competancy: Patient care, Medical knowledge
- Rational ordering of lab tests and imaging studies
- PGY-2: Learn how to interpret laboratory findings and imaging commonly used in patients with GI and liver disorders
- PGY-3: Gain advanced knowledge of high value principles in the ordering of laboratory studies and imaging in patients with GI and liver disorders
- Competancy: Practice-based learning and improvement, Medical knowledge
- Familiarity with the electronic health record and optimization of its use
- PGY-2: Understand how to effectively use the electronic health record in evaluation and management of patients with GI and liver disorders
- PGY-3: Develop an understanding of advanced medical informatics in the care of patients with GI and liver disorders by utilizing additional resources in the HER
- Competancy: Systems-based practice
- Communication and teamwork
- PGY-2: Develop effective and timely communication strategies with the interdisciplinary care team for patients with GI and liver diseases
- PGY-3: Use advanced communication methods to engage and coordinate care with the interdisciplinary care team for patients with GI and liver disorders
- Competancy: Professionalism, Interpersonal and communication skills
Resources
- Recommended Textbooks
- Sleisenger & Fordtran’s Gastrointestinal & Liver Disease
- Professional Society Guidelines
- American College of Gastroenterology – www.gi.org
- American Association for the Study of Liver Diseases – www.aasled.org
- American Gastroenterological Assocaition – www.gastro.org
- American Society for Gastrointestinal Endoscopy – www.asge.org
- Documents from the fellows
CUH GI Inpatient/Consults
- Hours: 7 AM to 6 PM M-F, 7 AM to 3 or 4 PM Saturday
You are expected to arrive between 7 and 7:30 AM every morning Monday through Saturday. You are off on Sundays. - Typically a 2-week inpatient block and consists of both inpatients and consults.
Service Description
- Team Composition: attending, 2 GI fellows, 1 resident, and a PA.
The attending changes weekly (every Friday). You should have the same fellows for 2 weeks most of the time, but your main fellows will be off on the weekends, which are covered by 1 weekend fellow (Sat/Sun, unless there is a long weekend in which they will be covering Monday as well). As a result, day 1 of your rotation will be with a weekend fellow who does not know the patients. - Function: For residents, this is primarily meant to be a consult rotation but you will be asked to help out with inpatients in the situations detailed below.
- Service caps: None. See details below. You should never be carrying more than 10 patients/writing more than 10 notes (combination of inpatients and consults).
- Rounds: Rounds are less structured and generally, patient presentations table rounds are between endoscopies in the GI lab (2-South). Typically the attending will round on the inpatients in the morning, so if you are carrying inpatients, you should see them first. You will usually staff new consults or discuss follow up consults in the afternoon, either between endoscopies or after all endoscopies are done around 3-4 PM.
Inpatient service
- The PA, Justin Philip, takes care of all of the inpatients Monday through Friday between 7 AM and 3 PM – he should be primary on all the patients and should be handling admissions and discharges between these hours. After 3 PM, the fellow becomes primary / first call on all these patients. If an admission comes in between 3:00 PM and 6:00 PM, the fellow or the resident is responsible for the H&P, admission orders, and ensuring the patient is admitted safely. There are usually 1-2 admissions after 3 PM because there are direct admits from clinic, so you and the fellow are expected to self-organize and share these. The next day, the patient will be taken over by Justin.
- If the inpatient service is overloaded (ie, > approximately 13-14 patients), you may be asked to assist in coverage of some inpatients, in which case you will be primary.
- On the few weeks per year that Justin is on vacation, residents will not be asked to see inpatients during the week unless there are more than 10 patients on the inpatient service; if there are fewer than 10 patients, these should be split between the 2 fellows.
- On weekends when Justin is gone and there is a covering fellow, the resident will be responsible for a maximum of 5 inpatients.
Consult service
- When on service, consults should be divided evenly between the resident and the two fellows.
CUH Liver Inpatient/Consults
- Hours: 7 AM to 5 PM M-F, 7 AM to 4 PM Saturday
You are expected to arrive at 7 AM every morning Monday through Saturday. You are off every Sunday (including the first Sunday of your month). - Typically a 2-week inpatient block and consists of both inpatients and consults.
Service Description
- Team Composition: Attending (transplant hepatologist), a general GI fellow, a resident and for 6-8 months of the year, a liver transplant fellow who serves as a junior attending.
- The attending changes weekly (every Friday). You should have the same fellow for 2 weeks most of the time, but your main fellow will be off on the weekends, which are covered by a weekend fellow (Sat/Sun, unless there is a long weekend in which they will be covering Monday as well). As a result, day 1 of your rotation will be with a weekend fellow who does not know the patients.
- Function: For residents, this is primarily an inpatient rotation but you will be asked to help out with consults. For your inpatients, you are expected to be primary. In general, the resident and fellows will self-organize the division of inpatients and consults but you should never be carrying more than 10 patients total (combination of inpatients and consults). You are expected to do paracentesis on the patients you are following, however you are not obligated to perform paracentesis for patient you are not primary on.
- Service caps: None. See details below. You should never be carrying more than 10 patients / writing more than 10 notes (combination of inpatients and consults).
- Rounds: The rounding room is the conference room in the endoscopy suite on near the elevators on 2 Blue. Rounds begin at 9 AM and begin with Transplant Surgery rounds. At this time, only the patients being considered for transplant or post-transplant (this hospitalization) will be discussed. Then you see these patients together with the transplant surgery team. After this, you split off from the surgery team and round separately with your attending and fellow(s). Depending on the attending, you may have structured PM rounds as well between 3 and 4 PM. Consults will be staffed either in the morning or the afternoon depending on when they come in.
Conferences
- Interdisciplinary Rounds with the surgery team from 9-10 AM on weekdays and so, will miss morning report every day.
- Residents are encouraged to attend GI conference 7 AM to 9:30 AM
- Liver transplant evaluation committee meeting every Tuesday at noon – discuss location and attendance with the fellow.
- Residents are expected to attend noon conferences and be excused from rounds if necessary
Parkland GI/Liver Consults
- Location: 2nd Floor, GI/Endoscopy/Bronch lab physician workroom. See map below.
- Hours: 8 AM to 5 PM. Monday through Friday.
- 1-3 residents will be assigned to this week at any given time. Minimum one on GI.
Service Description
- Team composition: Attending staff, gastroenterology/hepatology fellow, 1-2 residents
- Functions as a consultant service for inpatient services and the emergency department
- Meet in the fellows work room of the GI lab.
- Residents will either be assigned to the gastroenterology service or the hepatology service.
- During this rotation, residents are encouraged to attend GI conference 7-9:30 AM on Wednesday morning in POB I, Suite HA1.100. Residents should also attend the internal medicine noon conferences.
- Residents on both services are encouraged to observe ongoing endoscopy when not working on clinical duties
Location
VA GI/Liver Consults
- Location: VA GI Lab; 5th floor of clinical addition (opposite side of atrium from MICU/CCU)
- Hours: You are expected to go to morning report from 9:00 AM to 10:00 AM and then report to your fellow in the GI lab.
- 0 to 2 residents will be assigned to this week at any given time
Service Description
- Team Composition: Attending staff, gastroenterology/hepatology fellow, 0-2 residents
- Functions as a consultant service for inpatient services and the Emergency Department.
- Contact: Cindy Pahanish 214-857-1603; GI lab general #: 214-857-1590
- Residents will be assigned to either the gastroenterology service or the hepatology service depending on resident interest, case mix, and patient volume.
Clinics
Goals and Objectives for Outpatient Clinics: Hepatology, GI
- Assess acute and chronic problems in the outpatient setting
- PGY-2: Learn the initial assessment and develop and advanced understanding of acute and chronic GI and hepatology problems in the outpatient setting
- PGY-3: Understand the intersections between acute and chronic GI and liver problems and subtle variations in presentation
- Competancy: Patient care
- Understand the principles of chronic disease management
- PGY-2: Learn the common medications utilized for the management of GI and liver disorders and understand how to manage complicated GI and liver problems and develop specific therapeutic strategies
- PGY-3: Learn how to develop personalized care plans for GI and liver patients with intersecting clinical problems
- Competancy: Medical knowledge
- Understand the differential diagnosis of common clinical scenarios
- PGY-2: Develop an expanded differential diagnosis for common clinical scenarios in patients with GI and liver disorders.
- PGY-3: Recognize unusual presentations of common clinical situations in patients with GI and liver disease.
- Competancy: Medical knowledge
- Develop and utilize patient dashboards to engage in population management
- PGY-2: Identify noncompliance or patients with GI and liver disorders who are outliers in the patient dashboards (i.e. not compliant with colorectal cancer screening or hepatocellular carcinoma screening)
- PGY-3: Develop advanced care plans with the interdisciplinary care team to manage patients were noncompliant or not meeting parameters in the patient dashboards
- Competancy: System-base practice, Practice-based learning and improvement
- Understand the unique outpatient needs of patients
- PGY-2: Understand the community resources available to patients with GI and liver disorders
- PGY-3: Learn how to work with an interdisciplinary care team to optimize the availability and utilization of community resources available to patients with GI and liver disorders
- Competancy: Patient care, Systems-based practice
- Rational ordering of lab tests and imaging studies
- PGY-2: Learn how to interpret laboratory findings and imaging commonly used in patients with GI and liver disorders
- PGY-3: Gain advanced knowledge of high value principles in the ordering of laboratory studies and imaging in patients with GI and liver disorders
- Competancy: Practice-based learning and improvement, Medical knowledge
Conferences
- VA GI Board Review: Wednesday Afternoon, starts at 1:00 PM in VA GI Lab (same room as consults)
- VA Liver Tumor Board: VA IR Suite (will meet GI fellow in GI lab and walk over with them)
- Parkland/ UTSW GI Conference (recommended): Wednesday Morning 7:00-9:30am
Please discuss conferences for the week with your fellow as they may change.