GI Core Curriculum

As you progress through your training in gastroenterology, hepatology, and nutrition, assess your knowledge with free self-assessment questions. Use the link titled “Assessment Questions” under each chapter highlight to access the questions. You will receive a certificate of completion for each set of questions answered.

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Introduction to Acid Peptic Disorders (Chapter 1)

During your fellowship you will see a large number of patients with heartburn, reflux esophagitis and peptic ulcers due to NSAIDs or Helicobacter pylori. Because these disorders are so common and because the medications to heal them are generally effective, you may feel more comfortable and even complaisant about their management. We would encourage you to use these common illnesses as the jumping off point for understanding normal esophageal physiology and the pathophysiology of acid peptic disease. We expect you to master the complexities of normal lower esophageal sphincter pressure and the mechanisms that routinely maintain it, as well as the pathophysiology of Barrett’s epithelium and its current management options. In addition, you should understand the physiologic drivers of gastric acid secretion and the mechanisms of gastric defense. These defenses are compromised by commonly used NSAID medications. It is also important to recognize the complex host-bacterium relationships that permit Helicobacter pylori to survive in a hostile environment for many years undisturbed.

This first major core curriculum chapter effectively lays out concepts in anatomy, physiology and pathophysiology that you will be expected to know on the wards and for the specialty board examination.

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Introduction to Biliary Tract Diseases and Pancreatic Disorders: (Chapter 2)

Recognition of pancreatico-biliary disorders has experienced exponential growth recently due to advances in non-invasive imaging and endoscopic procedures. Although our repertoire in approaching such diseases is now vast, the multitude of options in imaging offers a unique challenge to the gastroenterologist. Choosing between ultrasound, CT, MRCP, MRCP with secretin, ERCP, EUS, and scintigraphy requires fundamental knowledge of the anatomy and physiology of the normal biliary tract and pancreas. Right upper quadrant and “biliary-type” pain is a common patient presentation, and the physician must use a detailed and tailored history, laboratory findings, and anatomic and physiologic knowledge to guide his or her initial evaluation. The gastroenterologist is expected to master the pathophysiology of benign disorders such as cholelithiasis, choledocholithiasis, cholecystitis, choledochal cysts, acute pancreatitis, pancreatic cystic disease, and motility disorders such as gallbladder dyskinesia and sphincter of Oddi dysfunction. Chronic pancreatitis is characterized by distinct imaging features and specific functional abnormalities. When the pancreas functions abnormally, the importance of the exocrine pancreas in daily normal digestion is highlighted. Trainees should also understand the epidemiology, etiology, natural history, and management of pancreatic cancer and biliary tract malignancies. Early diagnosis of these disorders is the single most important prognostic factor. Effective management, therefore, relies heavily on ordering the appropriate imaging modalities.

This second Core Curriculum chapter effectively outlines the biliary tract and pancreatic core competencies expected of you during your training. These competencies will prove invaluable to you during your fellowship, once you are a practicing attending physician, and for your specialty board examination.

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Training in Cellular and Molecular Physiology (Chapter 3)

Gastroenterology fellowship is the ideal time to relearn the normal physiology of the gastrointestinal and hepatobiliary tract. As a fellow you should gain familiarity with the cellular mechanisms that regulate proliferation, differentiation, and cellular demise, the molecular mechanisms that are responsible for maintaining genetic fidelity, and the consequences of their failure. It will also be important to understand the genetic basis of gastrointestinal diseases such as hemochromatosis, Wilson’s disease, cystic fibrosis, polyposis syndromes, colorectal cancer and Crohn’s disease.

Fellowship is the time to gain an understanding of the enteric nervous system, the gut immune system, the mesenteric and splanchnic circulations, and the endocrine influence on normal gastrointestinal function. It is essential to have exposure to basic concepts in transplantation biology, basic genetic screening techniques and molecular imaging techniques. Ultimately, your fellowship is the time to master the pathophysiology of inflammatory, infectious and neoplastic diseases of the gastrointestinal and hepatobiliary tract.

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Training in Endoscopy (Chapter 4)

Endoscopic procedures are an essential part of clinical gastroenterology and include a broad range of diagnostic and therapeutic modalities. Esophagogastroduodenoscopy (EGD), colonoscopy, diagnostic biopsy, polyp removal, esophageal dilation, percutaneous endoscopic gastrostomy (PEG) placement, and capsule endoscopy are all considered routine procedures to master during your fellowship. Advanced procedures that may require additional training include, but are not limited to, diagnostic and therapeutic ERCP, endoscopic ultrasound, and enteral stent placement. This chapter outlines the approach to minimal competency in procedural skills and highlights important goals of training.

As a fellow, you should understand how to interpret and integrate procedural findings into your patient’s clinical plan, be familiar with the indications and contraindications of a particular procedure, have the technical ability to perform it safely, understand when to ask for help, and be able to recognize and manage complications. Each procedure has a minimum number (threshold) that you must meet during training in order for your teachers to assess competency – a prerequisite at all levels of training. Procedural competency is particularly important as advanced endoscopic procedures and emerging technologies are increasingly being integrated into routine clinical practice.

In addition to outlining the trainee’s approach to endoscopic training, this chapter also highlights essential components that your supervisor/teacher must demonstrate to you both in basic and advanced endoscopic training. These essential components include but are not limited to expertise in procedural skills, an interest in teaching, consistent patience, and recognition of a fellow’s limitations as an endoscopy trainee. Taken together, the quality of your endoscopic education and supervising/teaching faculty are key to making you an independent, competent, high quality, and safe endoscopist.

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Training in Ethics, Medical Economics and System-Based Practice
(Chapter 5)

It is too late to learn about ethical issues, medical economics and system-based practice after you have signed a contract with a private practice group. Avail yourself of opportunities to learn about each of these critically important topics for the clinical practitioner before you commit to a particular practice or practice model. The best place to gain essential, unbiased knowledge is at annual Gastroenterology and Liver society meetings’ courses, or discussion groups, designated workshops or seminars put on by the various societies’ experts.

Explore the myriad practice models for the clinical practitioner by spending time talking with and /or shadowing physicians in private group practice, academic group practice, health maintenance organizations, urban practice, suburban, rural practice, independent practice organizations, public health clinics and hospitals, and military medicine. Make inquiries about who governs the practice, his or her style, the reward system, on-call expectations, teaching and attending obligations, and the number of clinical and endoscopic sessions per week. In addition, determine who will be helping you. Will nurse practitioners be answering patient calls and discussing laboratory and endoscopy results with patients? Will technicians do vital signs and weights? How will your notes be transcribed or will you be expected to type the notes while seeing the patients? Will you spend a significant amount of time commuting between or among various office sites or ambulatory surgery centers where you will perform endoscopies? Who will help you with weekend emergencies that require endoscopy?

Improving the quality and efficiency of health care should be the goal of every gastroenterologist in clinical practice. To do this, practitioners must analyze practice patterns and focus on improving outcomes. Joining a Registry for Digestive Diseases may be desirable as a method for comparing one’s own practice outcomes with others nationally for common and important problems such as colon cancer, adenoma detection rates, inflammatory bowel disease hospitalization rates and frequency of complications of Crohn’s and ulcerative colitis. Almost every department of medicine has experts in quality measurements and clinical research initiatives. Ask during your fellowship to perform a research project focused on quality clinical practice initiatives.

Learn the ins and outs of the art of coding office visits, consults and procedures to maximize your reimbursement for professional services while staying within the confines of the law.

Be aware of ethical issues in coding, reimbursement, covering for another physician and billing for your services, patient privacy concerns, e-mail consults with patients, consultations, complications and deaths resulting from procedures or a missed diagnosis.

Before signing a contract, take a short course in contract negotiation or hire a lawyer to review the offered contract for whether it is fair and equitable to you and your family.

This short Core Curriculum chapter highlights the essential elements important in ethical training and effective system-based practice.

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Training in Geriatric Gastroenterology (Chapter 6)

It has been estimated that by the year 2020, approximately 22% of the population will be 65 years of age and older. This highlights the importance of a solid knowledge base in geriatric medicine as the United States as a society grows older. Geriatric patients offer a unique set of challenges for the gastroenterologist, and make training in geriatric issues imperative during fellowship. As individuals age, there are important changes that occur in gastrointestinal pathophysiology and function. The trainee should recognize the “normal” or expected aging changes in physiology of the gut, pancreas and liver, and should be able to differentiate these from the abnormal. Older individuals are predisposed to a number of gastrointestinal problems including impaired swallowing and associated aspiration, motility problems and fecal incontinence, as well as an increased risk for colon cancer.

Recognition of atypical presentations of common gastrointestinal diseases in the elderly is paramount. However, recognition may be more complex since depression and dementia impact clinical assessment and treatment. The trainee should be familiar with common gastrointestinal conditions in the elderly including oropharyngeal, esophageal, stomach, and colonic dysmotility syndromes, malabsorption, gastrointestinal bleeding, and oncological disease. The elderly are predisposed to increased drug side effects due to altered drug metabolism.

In addition to familiarity with organic disease in the elderly, trainees must also empathize and appreciate the vast social and ethical issues associated with aging. A systematic approach to communicating “bad news” or negative findings to patients and their families and learning to work within the constraints of a patient’s support network will be important factors in providing optimal care.

This chapter highlights the core competencies in geriatric gastroenterology that you are expected to master during your fellowship. Knowledge of geriatric gastrointestinal disease will not only help you with your specialty board examination, but also will be of the utmost importance to your success in clinical practice because the elderly population in our society continues to grow.

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The Gastroenterology Core Curriculum Training in Hepatology (Chapter 7)

Until liver transplantation became highly successful and the benefits of new drugs for viral hepatitis outweighed their side effects, liver diseases were of intellectual interest but not particularly gratifying to treat. Now the world of liver disease is alive with change and hope.

During your fellowship you will decide whether to delve more deeply into liver disease by pursuing a fourth year of training to learn Transplant Hepatology. Regardless, both general and advanced fellows need in depth exposure and knowledge of the anatomy, pathophysiology, clinical presentations and current management options for hepatic and biliary diseases. Specifically, fellows should gain a working knowledge of cirrhosis and its complications, including portal hypertension, ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, variceal bleeding, and hepatorenal syndrome. Fellows should be familiar with the various types of viral hepatitis, the mechanisms for the evolution of alcoholic hepatitis into cirrhosis, and metabolic diseases that affect the liver such as hemochromatosis, alpha-1-antitrypsin disease and Wilson’s disease. Fellowship is the time to understand the genetics of hemochromatosis, the anatomy and complications of congenital cystic diseases of the liver, the varied faces of gallstone disease and the abnormalities in biochemistry underlying non-alcoholic fatty liver disease. During fellowship, you will learn the major differences between acute and chronic liver disease, the indications for transplantation, the MELD Scoring system and the methods for skillfully keeping patients alive so that they can ultimately be transplanted.

To learn liver disease is to learn liver pathology as well. Fellowship is the time to attend weekly or biweekly liver pathology conferences to learn the classic histological findings for major liver diseases such as autoimmune hepatitis, primary biliary cirrhosis,
hemochomatosis, alcoholic cirrhosis, viral hepatitis, hepatocellular carcinoma, drug toxicities and sclerosing cholangitis. You will acquire the skill of performing diagnostic and therapeutic paracentesis safely. The more advanced skill of performing percutaneous liver biopsies under ultrasound guidance may be relegated to fourth year fellows who are taking an advanced year of liver disease. However, as a GI Fellow you will be expected to know the indications for and the safety aspects of a liver biopsy.

The recognition and management of biliary diseases have benefited enormously from the safety and low complication rates of ERCP, endoscopic ultrasound, and laparoscopic cholecystectomy. These diseases are managed skillfully by a joint team approach by interventional gastroenterologists and hepatobiliary surgeons.

In no other area of medicine are ethics and disparities more on display than in liver transplantation where insurance and influence have come into play in several well-publicized cases. It is up to GI Fellows to recognize when disparities may be occurring in order to stem the tide of unequal care in the United States.

We hope that fellowship will result in a solid knowledge base in hepatobiliary diseases and a life-long curiosity to understand new management and therapeutic options in this field. As a general gastroenterologist in private or academic practice you will frequently be called upon to evaluate and manage these complex and challenging illnesses.

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The Gastroenterology Core Curriculum Enteric Infectious Diseases (Chapter 8)

Enteric infections and inflammatory bowel disease can present similarly and at times can be difficult to differentiate. Enteric infections represent a broad spectrum of disorders frequently encountered first by the primary care physician. Bacterial infections such as E. coli, campylobacter, and salmonella are common offenders. C. difficile is becoming increasingly recognized as an important pathogen not only affecting hospitalized patients on antibiotics, but those in the community as well. Viruses such as norovirus cause frequent outbreaks especially during winter months. Patients who are immunosuppressed pose a particular challenge because the differential broadens significantly. Worldwide increases in HIV and AIDs, more frequent organ transplantation, and cancer patients receiving chemotherapy all contribute to the increased prevalence of enteric infections in immunosuppressed patients. Trainees should be familiar with the pathophysiology as well as common and atypical presentations of GI disorders in these patients.

Inflammatory bowel disease (IBD) is commonly seen by GI physicians. Thus, gastroenterologists frequently provide both primary care and consultative services to these patients. During training, fellows should become familiar with the GI and extra-intestinal manifestations of disease, the recognition of clinical and laboratory features suggestive of IBD, differentiation of IBD from other forms of enteric inflammation, and options for treatment. Optimal care for these patients requires familiarity with the indications, benefits, and adverse effects of the commonly used medications for IBD, as well as the indications and complications of surgical management.

Gastrointestinal inflammation, whether it is infectious or non-infectious, represents a significant portion of the patient population that you will see during fellowship. This chapter highlights the core concepts that must be mastered during your fellowship in order to excel in clinical practice and on the specialty board examination.

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The Gastroenterology Core Curriculum Training in Malignancy (Chapter 9)

Not a day goes by without a newspaper or media story on one of the gastrointestinal cancers. Close to 24% of all cancer deaths in the United States are due to cancer of the digestive tract. The major reason to gain an outstanding knowledge base concerning both cancers and pre-cancers is that a significant number of these cancers are eminently treatable if detected early and surgically removed.

As a gastroenterologist, you will be expected to know the high risk groups for colon cancer such as Familial Adenomatous Polyposis, Lynch Syndrome (Hereditary Nonpolyposis Colon Cancer), Peutz-Jeghers syndrome and Juvenile Polyposis syndromes, not only for their intestinal cancers but also for the extra-intestinal cancers that these patients need to be screened and followed for frequently in specific High-Risk Clinics. In addition, fellowship is the time to master the other non-syndromic diseases that have increased malignancy associated with them such as celiac disease, chronic atrophic gastritis, Barrett’s esophagus, post-gastrectomy stomachs, and inflammatory bowel disease. Patients with a family history or personal history of colon polyps or prior gastrointestinal cancer require scheduled monitoring. Patients with Hepatitis B, Hepatitis C and hemochromatosis have a higher incidence of hepatocellular cancer.

Familiarity with interventions that may decrease the risk of cancer in the above diseases is essential. Thus, in the case of colon cancer, chemoprevention with aspirin has significantly decreased recurrence, while vaccination for Hepatitis B has decreased the risk of contracting Hepatitis B and the development of hepatocellular carcinoma. Antibiotic therapy for Helicobacter pylori has decreased the incidence of gastric cancer in patients who are infected.

Fellowship is the time to understand the adenoma to carcinoma sequence and the multiplicity of genetic mutations that lead to an adenoma, colon cancer or genetic syndrome associated with colon cancer. The components of a complete family history for colon cancer should be memorized. It is the time to learn the smorgasbord of colon cancer screening tests and the evidence for and against each. Fellowship gives the opportunity to recognize the medical and endoscopic management options for pre-cancerous conditions such as Barrett’s esophagus, and large or small tubular or villous adenomas. Fellows need guidance with endoscopic procedures to remove polyps safely and completely.

While periodic pathology conferences are extremely helpful to learning the pathological interpretation of tissue biopsies, it is important for fellows to seek routine review by a pathology attending on their endoscopic biopsy cases. Only then will the nuances of interpretation of various cancers, dysplastic lesions and polyps become clearer and second nature as they move toward being an attending in Gastroenterology and/or Liver Diseases.

Newer radiologic techniques and their pluses and minuses for identification of cancer and pre-cancer should be part of a fellow’s basic education and ultimate clinical skill set. If a patient is diagnosed with cancer it is imperative to recognize current chemotherapy and radiation regimens and their potential complications.

Cancer of the gastrointestinal tract is assuming an ever increasing role in gastroenterology practice as infectious causes of gastrointestinal diseases are coming under better control or being eradicated. Fellowship is the time to learn how to diagnose and treat cancer. It is also the time to learn how to interact with and reassure patients and their families about a diagnosis of cancer and to explain clearly the required treatment plan.

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Training in Motility and Functional Illnesses (Chapter 10)

Functional bowel disease and motility disorders account for 40% of patients seen by gastroenterologists each year; a number that continues to grow. Irritable bowel syndrome is being increasingly recognized, while esophageal dysmotility, small bowel and colonic functional disease, disorders of gastric emptying, and functional dyspepsia remain prevalent. Given this, the trainee must understand basic physiologic and pathophysiologic mechanisms and how they relate to disease. Comprehension of the enteric nervous system, the brain-gut axis, the anatomical and physiological basis of visceral sensation, the interstitial cells of Cajal, esophageal and gastric motor physiology, small bowel and colonic motor function, and the pharmacological approach to disease will be key to recognizing and effectively treating patients with these problems. A basic understanding of the various tests to evaluate these processes will be necessary, including esophageal motility studies, impedance testing, gastric and small bowel motility studies, scintigraphic measurement of gastric emptying, colonic motility studies, anorectal manometry, anal sphincter biofeedback training, and colonic transit studies using radiopaque markers. Trainees may choose to integrate a general understanding of motility and functional disease into their gastroenterology fellowship. However, some may prefer to focus a majority of their training on these principles and procedures.

All trainees need to recognize the importance and role of clinical psychology as it relates to the management of patients with chronic functional disorders. This includes an understanding of cognitive behavioral therapy, hypnosis, acupuncture, and other forms of alternative medicine. In addition, a fellow should learn the risks and benefits of psychopharmaceuticals in order to effectively manage patients with these disorders.

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Training in Nutrition (Chapter 11)

It is important for gastroenterologists to recognize protein-calorie malnutrition in both inpatients and outpatients.1 Loss of total body protein impairs end-organ function. Muscle strength decreases over time and respiratory function suffers.1 Wound healing, cardiac output and immune function are impaired.1 Repletion of nutritional status can reverse negative patient outcomes.1

Learning how to assess nutritional status involves first, taking a weight history.Weight loss of more than 5% in 1 month or 10% in 6 months before hospitalization is clinically significant.1 Second, fellows should be exposed to using anthropometric measurements obtained with a Lange calipers to calibrate the triceps skin fold thickness for a patient’s body fat stores and a tape measure to detect midarm muscle circumference at the bedside to estimate indirectly protein stores.1 Finally, during fellowship it is useful to learn to order relevant laboratory tests such as the importance of serum albumin and pre-albumin to assess the nutritional state.1

Illnesses such as pancreatitis, Crohn’s disease, celiac disease, short bowel syndrome, radiation enteritis, chronic liver disease and hyperemesis gravidarum spring to mind as ones where nutritional support is paramount to helping the patient get well. Choosing the right type of nutritional supplementation requires a cohesive team of physicians, dietitians, nutritional experts and pharmacists. Whether enteral or parenteral nutrition should be used will need to be debated on a case-by case basis.2 Home parenteral nutrition may ultimately be needed for post-hospital care.2 Fellows should be exposed to the rigors of decision making in this area and learn to write the appropriate orders for each type of nutritional care. They are responsible for knowing the indications, contraindications and potential complications of each type of therapy.2

Fellows need exposure and expertise in the complex decision making that goes into feeding tube placement particularly in patients who are unable to swallow without aspiration due to neurological impairments. Fellows will be taught endoscopic placement of percutaneous gastrostomy and jejunostomy tubes, in addition to nasogastric and nasojejunal tubes.

Fellows should understand the risks of obesity, the indications and referrals for obesity surgery, and the complications of obesity surgery such as stomal ulceration, stomal stenosis, intestinal hernias and nutrient deficiencies.

Nutritional planning frequently involves grave issues of ethics and legal consequences. Fellows need guidance in the nutritional support of terminally-ill patients, end-stage dementia patients, patients who are unable to give consent and patients who refuse nutritional therapy, but are unable to maintain an adequate nutritional status without artificial feedings. All of these complex situations provide valuable educational opportunities for a fellow before he/she becomes an attending and is in charge of making these difficult decisions.

References:

1. Delegge MH, Drake LM. Nutritional assessment. Gastroenterol Clin N Am 2007; 36:1-22.

2. DiBaise JK, Scolapio JS. Home parenteral and enteral nutrition. Gastroenterol Clin N Am. 2007; 36: 123-144.

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Training in Pathology (Chapter 12)

An understanding of gastrointestinal (GI) and hepatic pathology is vital to the correct diagnosis and management of GI and liver disease. Trainees should familiarize themselves with the spectrum of normal histology, and be able to differentiate the normal from the abnormal. Understanding the difference between autoimmune hepatitis and active viral hepatitis, between dysplasia and inflammatory changes in ulcerative colitis, between Barrett’s metaplasia and low or high grade dysplasia, and many other critical distinctions, comes only with first hand consultation with an attending pathologist. Learning what constitutes an adequate biopsy or cytology specimen to make a correct diagnosis will be of utmost importance, whether via endoscopic biopsy, percutaneous liver biopsy, endoscopic ultrasound guided fine needle aspiration, or ERCP directed brushings. Familiarity with the various stains, fixatives, and limitations of pathological testing will help guide appropriate collection and analyses. This knowledge requires ongoing communication between gastroenterologists and pathologists. This information should be obtained prior to performing the procedure, particularly in cases where lymphoma or viral etiologies are being considered.

Formal pathology conferences and didactics should be scheduled and attended on a weekly or bimonthly basis utilizing various educational formats, such as multi-headed or projected microscopic review, endoscopic videos, and multidisciplinary rounds. This will maximize the educational impact by highlighting the clinical utility and importance of pathologic examination to patient care. This preparation will help trainees excel in their specialty board examination, where a general knowledge of pathology is required.

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Training in Pediatric Gastroenterology (Chapter 13)

Each week our Combined Clinical Conference has a Pediatric Gastrointestinal or Hepatobiliary Case from our Children’s Hospital presented along side the adult cases. These cases and the pediatric fellow’s erudite summary of the literature and bibliography handout give the adult gastrointestinal and hepatology fellows much needed exposure to particular illnesses that they may not otherwise see, but will be expected to know for their Boards and for understanding of pathophysiology.

Certain pediatric problems such as Hirschsprung’s disease, Meckel’s diverticulum, Crigler-Najjar Syndrome, biliary atresia, and cystic fibrosis are more commonly discussed while others such as galactosemia, Alagille’s Syndrome, Congenital Hepatic Fibrosis and esophageal atresia are less commonly mentioned, but are none the less important to understand and to have in a differential diagnosis. The approach to the patient who is jaundiced, whether it is a neonate, infant, toddler or adolescent, has a much wider spectrum of potential diseases to consider in this population.

Pediatric illnesses must include caring for not only the patient but also the parents and siblings. A sensitivity and awareness of parental concerns is essential as is the ability to take a careful family history looking for genetic causes of illness. Dietary restrictions affect the patient as well as the family. Nutritional requirements should be assessed and repletion undertaken with guidance from experts.

The environmental influences such as pets, allergies, lead paint, and unsanitary or crowded living conditions need to be asked about and may play a large role in the presentation, as well as the natural history of the patient’s illness whether it be a parasitic illness, Helicobacter pylori, or abdominal pain.

Trainees will be expected to understand and know pediatric illnesses, their pathophysiology, diagnosis and treatment. The training program should provide ample opportunities to achieve this goal.

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Training in Radiology (Chapter 14)

Training in radiologic interpretation, and the correct sequence of tests for gastrointestinal diseases is essential for fellows. This training may be most easily obtained by a specific rotation through an abdominal radiology service, but the time away from clinics and inpatient units may be difficult to arrange. Instead, most programs offer didactic training in radiologic interpretation by having an attending or resident radiologist teach at weekly conferences. The radiologist not only names the diagnosis and points out normal and abnormal structures but also explains why it is the correct diagnosis. In addition, self-instructional programs provide much needed resources for learning the interpretation and the correct order of examinations. Trainees who will use fluoroscopy need to become familiar with radiation safety practices.

Newer imaging modalities include MR Enterography, which is replacing the small bowel series as the preferential method for diagnosing Crohn’s disease, CT colonography to diagnose colon cancer and polyps in patients unable or unwilling to undergo colonoscopy, and Positron Emission Tomography scans for tumor identification and localization.

Each radiologic study has advantages and disadvantages, indications and contraindications. These are best learned over time by consistently consulting a radiologist on each inpatient or outpatient who has radiologic studies performed. It is not enough to read the report and view the X-rays as a trainee. Instead, each patient’s X-rays should be reviewed with an expert radiologist who can provide pertinent teaching points on each exam.

Radiology questions will be on the Specialty Board Examination. Trainees should learn core radiologic principles and acquire a working knowledge of normal and abnormal structures as well as the classic findings in each major disease through daily consultations with radiology faculty, residents and fellows.

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Training in Research (Chapter 15)

Learning how to perform a successful research project requires a set of skills that trainees acquire by close contact over time with expert mentors who are interested in transmitting their knowledge. The two major types of research are basic, which focuses on understanding physiology and pathophysiology at the molecular and cellular levels, and clinical research on human subjects which includes clinical trials of medications, record and chart reviews as well as epidemiologic and behavioral research. Basic and clinical research both focus on asking questions, formulating hypotheses and developing a rational study design. Supervisors for a new research fellow should be generous with their time for teaching laboratory techniques, monitoring progress, and observing data collection and record keeping closely. Dedicated time of at least 18 months out of a 3-year fellowship is generally needed to complete a research project using appropriate biostatistical methods. During this time the fellow should have minimal clinical responsibilities. The mentor helps the trainee learn how to write, present and publish an abstract as well as a full manuscript that details the background literature search, methods, results and conclusions.

Trainees benefit significantly from programs that provide a formal, structured curriculum and coursework for neophyte researchers. Writing grants and papers and understanding the ethical conduct of research are some of the skills that are needed to pursue a successful career in laboratory investigation. To learn these skills, the trainees must have exposure to experienced faculty members who have successfully competed for grants and published in high quality journals. Part of the research training also includes journal clubs, research presentations to peers and mentors both locally and nationally at the specialty society meetings.

Trainees will take courses on the humane treatment of animals, the responsible conduct of research and the handling of protected health information in line with HIPPA regulations.

The NIH training website has excellent information about trainee funding opportunities. KO8 awards (for physician scientists interested in basic research) and K23 awards (for physicians interested in patient-oriented research) are wonderful ways to begin an academic career.

Research in Gastrointestinal and Liver Diseases provides a satisfying career of asking and answering questions as long as funding is available and awarded and the researcher learns the best methods to pursue the answers to a question. Fellows should choose mentors for research who have an excellent track record of obtaining grant funding, publishing papers and producing physicians who can successfully compete for an academic position at the end of the fellowship.

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Training in Surgery (Chapter 16)

Each Thursday morning from 7:00 AM-8:00 AM, our gastroenterology fellows and faculty are expected to attend a joint surgical-medical conference for abdominal and general surgeons and gastroenterologists and hepatologists. This conference has a surgical resident and a gastroenterology fellow presenting two fascinating cases each for thirty-minutes with a literature review and PowerPoint slide set. Attending surgeons and attending gastroenterologists have lively discussions about the indications, complications and preferred anatomic approach during these conferences.

A radiology resident and radiology faculty discuss the relevant X-rays giving the differential diagnosis and a pathology resident and pathology attending describe the pathology findings. All of these teaching pearls make for a rich weekly conference. Here our gastroenterology fellows solidify their understanding of the indications and contraindications to surgical procedures and the complications and desired outcomes. Fellows learn these same concepts as ward consultants and specialty doctors in a longitudinal gastrointestinal clinic, but it helps to have a formal weekly didactic session in addition to hands-on experience.

In order to obtain exposure to surgical procedures, it is useful for you to go to the operating room on a particular case you have been following to understand the anatomy, the surgical approach and view the specimen. You will see the short-term post-operative problems by carefully following patients in hospital and soon after discharge. The longitudinal changes in a patient’s bowels, appetite and sense of well-being may take months to plateau and continued follow-up is necessary especially once the patient is discharged from the surgeon’s care. This is when the patient may ask the gastroenterologist many questions about diet and activity that frequently require a joint discussion with the surgeon as well as creative solutions on the part of the gastroenterologist and a skilled dietitian. Patients with inflammatory bowel disease may exchange one set of symptoms for another after a large resection of small bowel or complete resection of large bowel and need guidance on diet and essential supplements such as vitamin B12.

Respect for the surgical approach and the miracles of appropriately timed life-saving surgeries should be balanced with current knowledge of indications, complications, outcomes and preferred surgical approaches. During your fellowship, you need to see surgeons in action, and learn the management of post-operative problems over time from both the surgeon’s approach and your own careful follow-up of these patients in consultation with an attending gastroenterologist.

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Acknowledgment

The assessment questions associated with the Core Curriculum Chapter Highlights were reviewed and selected by:

Helen M. Shields, MD, AGAF
Professor of Medicine, Harvard Medical School
Attending Gastroenterologist, Beth Israel Deaconess Medical Center
AGA Councillor for Education and Training

Byron Vaughn, MD
Third Year Fellow in Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, Massachusetts

Questions and Comments

Submit questions and comments to the following email address: GITraining@gastro.org

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