GI Core Curriculum
The Gastroenterology Core Curriculum (PDF) was first published in 1996; in 2007, the third edition of the Gastroenterology Core Curriculum for gastroenterology fellowship training was released. The core curriculum constitutes a living document that represents the four societies’ vision of best practices in gastroenterology training. It provides a framework for developing an individual plan of study and growth that should be tailored to meet the needs of each individual trainee based on the strengths and special qualities of each individual training program. The curriculum will continue to evolve with time as new knowledge, methods of learning, novel techniques and technologies, and challenges arise.
We will be featuring one chapter of the Core Curriculum every other week to help trainees focus on training expectations in each of the Core Curriculum areas. Brief Introductions to each chapter, highlighting key concepts and essential pathophysiologic mechanisms, have been written by Helen M. Shields, AGA Councillor for Education and Training, Professor of Medicine at Harvard Medical School and Attending Gastroenterologist at Beth Israel Deaconess Medical Center and Paul S. Sepe, Third-Year Fellow in Gastroenterology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts.
Training in Women’s Health Issues in Digestive Diseases (Chapter 17)
Being called to the Obstetrics or Labor and Delivery Floor at the hospital is always a cause for anxiety as a GI consultant Attending and Fellow. We both worry about the acuity of the situation, the high risk of weighing in on a diagnosis and therapy for two individuals, though one is unborn, and the necessity of communicating quickly our recommendations with a series of important people including the patient, obstetrician, spouse, parents, nurses, children of the patient, if they are old enough to understand, and other consultants.
The pregnant patient causes us to be more vigilant and circumspect in our recommendations for medications, tests and procedures. We discuss, check and re-check our medication dosages, cognizant that different doses may be recommended in pregnancy and certain drugs may not be approved for use. Consultations during pregnancy require more time and more thought because so much is riding on a successful outcome. Only rarely will an endoscopic procedure be recommended for life-threatening bleeding, a suspected malignancy or unrelenting diarrhea. Endoscopy in the pregnant patient should be done only after great deliberation given the potential negative consequences of procedure induced hypoxia or hypotension on the fetus. Hypoxia or hypotension may occur in response to the sedation and pain medications given for the procedure.
It is important for you as the fellow to recognize that post-partum patients may develop complications of pregnancy many years later including rectal prolapse, urinary and/or fecal incontinence and hemorrhoids. Also important to understand and take into account in any woman patient is the impact of the menstrual cycle and hormone levels on bowel complaints as well as symptoms and signs.
Performing a screening colonoscopy for colon cancer in any woman patient who has had prior pelvic surgery including Cesarean section is generally more difficult and is associated with a lower completion rate to the cecum. Women also may prefer a woman gastroenterologist to do the procedure and this is sometimes not easy or possible to arrange within a reasonable time frame. The presence of endometrial or ovarian cancers may raise the possibility of a genetic colon cancer syndrome such as the Lynch Syndrome which needs to have special consideration for earlier and more frequent screening for polyps and cancer.
Certain illnesses such as gallstones, irritable bowel syndrome, autoimmune hepatitis, primary biliary cirrhosis, endometriosis, eating disorders and obesity are more frequently seen in women patients. Keep these diseases in mind when seeing patients in clinic and as consults.
In initial interviews and for consultations, routinely ask women patients about sexual abuse as a child or adult. If a positive history is elicited, the work with psychiatrists and/or social workers as well as with the patient to forge a therapeutic alliance built on mutual trust. In these patients, performing an endoscopic procedure, whether upper or lower procedure, may hold particular terrors. Not always can an invasive procedure be done if the trauma of the sexual abuse is still vivid in the patient’s mind.
During fellowship you should acquire the thoughtful approach, special knowledge, and empathic viewpoint derived from observing attending role models, reading the literature and supervised practical experience that are essential to developing and maintaining successful therapeutic alliances with women patients.
Assess Your Knowledge
Training standards, guidelines, and resources are regularly updated by individual societies. For up-to-date and/or expanded information, please check the Web sites of the gastroenterological societies: