January, 2008
Gastroenterology Fellowship
University of Oklahoma Health Sciences Center
Objectives and Curriculum
The University of Oklahoma, College of Medicine sponsors the Gastroenterology Fellowship at
the University of Oklahoma. The institution’s participating and supporting the Fellowship
includes OU Medical Center (OUMC) and the Oklahoma City VA Medical Center (VAMC). The
Fellowship is a daughter program of the Internal Medicine Residency Program. The Fellowship
is structured in three consecutive years of training. All trainees entering the program must
complete a three year accredited residency program in Internal Medicine. Fellowship candidates
are selected to enter the fellowship approximately one and a half years before beginning the
fellowship in a competitive interview process and that follows all the policies and procedures set
forth by the University.
The curriculum for the Fellowship Program is essentially derived from the GI core curriculum
established by the Gastroenterology Leadership Counsel and published in the journal
Gastroenterology in April 2003 (updated draft for 2006 in press used as of 2006-07 academic
year). Fellows completing this training program are expected to be expert in all areas outline in
that curriculum document with the broad topics outlined below. The trainee will achieve
competence when, in the judgment of the Program Director and the Key Faculty, the trainee has
established a knowledge base, procedural skills, communications skills, and the ability to
maximize patient care through self-learning and recruitment of all necessary health care
resources necessary to serve as a consultant in Gastroenterology. The following document
summarizes the content of the curriculum and the objectives of the Fellowship Program as well
as the means of supervision and documentation of competency among the trainees. The
curriculum will be reviewed at least annually by the Curriculum Committee of the Section of
Digestive Diseases and adjustments made based on outcome measures such as performance on
Board Exams and Inservice Exams and feedback from graduating trainees. Changes will also be
dictated by new technologies and the need to incorporate new scientific discoveries.
Responsibility for Resident Education & Supervision
The Program assumes full academic and administrative responsibility for the planning and
execution of the educational program, including, but not limited to, selection and appointment to
residency positions, advancement or promotion of residents, final determination of residents’
satisfactory completion of training requirements, programming, curriculum content, and faculty
appointments. The individual responsible for resident education and supervision in this Program
is William M. Tierney, the residency Program Director.
William M. Tierney, M.D.
Associate Professor of Medicine
1
Department of Medicine
920 SL Young Blvd. WP 1360
Oklahoma City, OK 73104
Telephone Number: (405) 271-5428
FAX Number: (405) 271-5803
Dr. Tierney works with colleagues on the faculty to determine the educational goals and
objectives, the period of assignments, teaching, supervision, and evaluation of residents, and
develops policies and procedures for residents.
Educational Goals and Objectives
Educational Goals: The ultimate goal of this three-year training experience is to have
individuals leave our program who are skilled and respected gastroenterology consultants. At the
completion of their residency, our trainees will:
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Possess a broad knowledge base,
Become skilled in patient care and be able to generate a relevant differential diagnosis based
on accurate history and physical examination, and review of relevant clinical data,
Be able to communicate effectively with other health care providers and demonstrate
compassion and benevolence in all patient interactions including the capacity to communicate
effectively with patients and their families,
Understand the indications and contraindications for diagnostic and therapeutic procedures,
Be skilled at performing these procedures,
Be able to think critically, and participate in a scholarly research project,
Demonstrate commitment to professionalism and possess an appreciation of the humanistic
and ethical aspects of medicine.
Be able to achieve practice-based learning (improving practice thru the care of patients and
their educational activities).
Appreciate the entire scope of health care system and call upon resources in the system to
optimize patient care and outcomes
Professionalism in medicine, personal integrity and the ability to communicate effectively with
referring physicians, colleagues and support personnel will be stressed at each level of training.
Educational Objectives: The program director, faculty and participating hospitals will provide
the supervision, facilities and resources for trainees to have didactic experience and ongoing
direct patient contact in both an inpatient and outpatient setting to gain a core knowledge base,
expertise and skill in the diagnosis and management of the following disorders or disciplines as
outlined in the Gastroenterology Core Curriculum (Gastroenterology, 2003; updated draft from
2006 in press used as of 2006-07):
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cellular and molecular physiology
gastrointestinal pathology
motility, diverticular disease and functional bowel diseases
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acid-peptic diseases
pancreatic disorders, gastrointestinal hormone and diarrheal diseases
gastrointestinal inflammation to include inflammatory bowel diseases, gastrointestinal
infections (non-HIV related) and gastrointestinal infections (HIV related)
gastrointestinal malignancies
hepatology
biliary tract diseases
gastrointestinal endoscopy and gastrointestinal bleeding
nutrition
gastrointestinal and hepatic pathology
gastrointestinal radiology
medical ethics and economics
women’s gastrointestinal health issues
common pediatric digestive disorders
digestive function and disease associated with aging
The thirty-six month fellowship will be structured so that approximately thirty months will be
devoted to clinical activities and at least six months to research and scholarly activity. The initial
eighteen months of clinical experience (level 1) will be directed toward achieving the above
educational goals. The final twelve months of clinical training (level 2) will continue the
progression of clinical training in the inpatient and outpatient setting. Increasing responsibility
will be given to higher level trainees so that they will continue to develop skills in diagnosis and
management of gastrointestinal hepatic diseases (approximately 30% of overall clinical
experience). Inpatient and outpatient encounters will represent a broad range of clinical
problems from acute and chronically ill individuals. As trainees advance into the second and
third year of training they will be given more independence and encouraged to become more
directive teachers of general internal medicine trainees. At all times, however, supervision of
patient care by attending faculty will be direct and expedient.
All trainees will be educated on the indications, contraindications, technical skills, interpretation,
and decision making process for upper and lower endoscopic procedures as well as percutaneous
liver biopsy. This includes esophagogastroduodenoscopy, flexible sigmoidoscopy, colonoscopy,
and percutaneous gastrostomy placement. Therapeutic maneuvers for both upper and lower
endoscopy including biopsy, polypectomy, dilation, and control of variceal and nonvariceal
hemorrhage will be incorporated in the educational experience once trainees have mastered
diagnostic endoscopy. Percutaneous liver biopsy and paracentesis will also be an integral part of
the procedural training. Having achieved an adequate number of routine endoscopic procedures
that exceed the minimum standards set forth the trainee will be allowed participate more fully in
consultations and advanced endoscopic procedures including management of gastrointestinal
bleeding, endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound
(EUS). While all trainees will be educated on the indications, contraindications, and limitations
of advanced procedures, the program will not train all trainees to be competent in ERCP and
EUS. Select fellows may be assessed for competence if they perform >200 procedures. All
fellows will be given basic introduction to esophageal motility and 24 hour pH monitoring and
video capsule endoscopy. In those individuals desiring advanced training in gastrointestinal
3
motility procedures or capsule endoscopy, these experiences will be available. During the entire
three-year training period, trainees will attend outpatient clinics two ½ days per week (½ day VA,
½ day OUMC). In all of these clinical encounters the trainee will have the opportunity to
enhance their practice based learning through review of state of the art literature; navigate their
patients through the entire health care delivery system; enhance their commitment to
professionalism; and maturation of their interpersonal skills. These competency based goals and
objectives are further outlined in specific learning assignments below.
Guidelines for Endoscopic Training in Routine Procedures:
Threshold for Assessing Competence
Required number1
Procedure
Esophagogastroduodenoscopy
Including treatment of upper and lower nonvariceal
hemorrhage
Including treatment of variceal hemorrhage
Esophageal dilation
Flexible sigmoidoscopy
Colonoscopy
Including snare polypectomy
Percutaneous endoscopic gastrostomy placement
Percutaneous liver biopsy
130
25 (10 actively bleeding)
20 (5 actively bleeding)
20
25
140
30
15
20
1
Required 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 and the ACGME program
requirements.
Educational Rotations:
PRESBYTERIAN TOWER CONSULTATION SERVICE
Assignment: One fellow per month.
Description: The Presbyterian Hospital Consultation Fellow will serve as the primary contact
and coordinating physician for all inpatient consultations requested by all services at Presbyterian
Hospital.
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Objectives: Develop skill of performing specialty-based consultations on inpatients. Establish
teaching skills with instruction of residents and students rotating on the consult service. Using
literature and reference material review to improve knowledge of digestive diseases through case
based learning and practice based improvement. Improve and apply knowledge of all aspects of
digestive diseases, as outlined in the GI Core Curriculum. Understand the role of inpatient
services and the importance of continuity in transitioning from inpatient to outpatient
management in caring for patients acutely ill with digestive diseases.
Educational Resources: Yamada’s Textbook of Gastroenterology; Schiff’s Hepatology Text,
other gastroenterology textbooks and atlases, online resources including the OUHSC library’s
subscription to Up-to-Date, and OVID for literature searching for primary references.
Expectation and Responsibilities: Consult Fellow will maintain his pager and be available
from 7:00 AM to 5:00 PM. Monday through Friday for all consultations requested on inpatients
at Presbyterian Hospital. This includes consults requested from the emergency room from these
hospitals during assigned hours. The fellow will then directly evaluate and perform an
assessment and develop a diagnostic and management plan for all consultations. This will
include review of all relevant clinical data including radiographic studies, pathology, laboratory
data, and endoscopic findings, in addition to performing a specialty based comprehensive history
and physical exam. This fellow is also charged with delegating some consults to medical
students and internal medicine trainees who are rotating on the GI Consultation Service. It is
expected that the fellow will also directly evaluate patients who are seen by these other trainees
on the initial consultation. Subsequent follow up visits on these consultations may be performed
solely by the other trainees, however, the majority of patients delegated to Internal Medicine
Residents and medical students should also be continuously evaluated by the fellow in training.
The consult fellow is responsible for notifying the attending physician of any emergent
consultations that require immediate input from the attending physician. All consultations will
be reviewed and evaluated by the consult attending within 24 hours of their request. The fellow
is responsible for communicating with the physician requesting the consultation. There will be
no more than 10 new patients evaluated by the consult fellow in any 24-hour period. All
additional consults will be evaluated by the attending.
The Consult Fellow is also responsible for assisting in the education of medical students
and Internal Medicine trainees on the consult service through informal lectures and literature
searches. The fellow should demonstrate practice based learning by identifying appropriate
literature relative to patient’s digestive disorders and disseminate that material to the general
medicine house officers and students on the team requesting consultation.
While there are no assigned endoscopic responsibilities during the consultation month,
urgent or emergent endoscopy, will often be performed directly by the Consult Fellow under the
supervision of the attending for the consult service.
The Presbyterian Consult fellow will be expected to attend their weekly OU Medical
Center continuity clinic.
Evaluation: The fellow will be evaluated on their evaluation and management skills as well as
their teaching efforts, communication skills, knowledge acquisition, systems-based learning, and
practice-based learning throughout the month by the supervising attending on the consult service.
5
Systems based learning will be evaluated based on the ability of the trainee to mobilize
appropriate medical, social, and home-based resources for their patients especially at the time of
discharge. As with all rotations, quarterly evaluations will be completed by all faculty and select
nurses to contribute to the 360-degree evaluation of their overall performance including their
continuity clinics.
Goals (Year 1)
 Improve knowledge base of digestive diseases
 Improve communication and interpersonal skills
 Learn to navigate health care delivery system involving many specialties
 Learn to provide consultative services in the specialty of gastroenterology
 Enhance practice-based learning skills
 Learn to lead a team of specialists
 Improve teaching skills
 Enhance an internist’s level history and exam skills to the level of a digestive disease
specialist.
(Years 2 and 3) In addition to above:
 Develop expert (faculty level) knowledge base of digestive diseases
 Graduate to more independent level of complex decision making in digestive disease
management
 Further enhance practice-based learning skills and familiarity with systems of care
Objectives (Year 1)
 Have dedicated experience in evaluation and management of inpatient digestive diseases
 This includes performing comprehensive history and examination with emphasis on
digestive processes.
 In the process of diagnostic or therapeutic management recommendations, make
decisions on appropriateness of gastrointestinal endoscopy and communicate risks and
benefits to patient while obtaining informed consent
 Work with several internal medicine residents and/or students to coordinate care delivery
provided by consult team
 Communicate consult findings and recommendations to requesting physician(s)
 Communicate recommendations and findings of diagnostic studies directed towards
digestive diseases to patients and family as appropriate.
 Review literature on disease processes encountered in patients and utilize this literature
and new knowledge to optimize patient care
 Teach basic digestive diseases to earlier level trainees and internal medicine trainees
requesting consultations.
 Work with other health care providers including social workers, case managers,
gastroenterology nursing staff, pharmacists, and other allied health professionals to
optimize resources available to patients.
(Years 2 and 3) In addition to above:
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Have further experience in evaluation and management of inpatient digestive diseases
with more independence in decision making
Maturation of communication skills as process of training advances with background
expectation of practicing as competent gastroenterologist without the need for
supervision.
Make complex management decisions with supervising faculty serving as learning
resource and providing guidance
Further experience reviewing literature and using evidenced based medicine to optimize
care
Perform more extensive teaching of residents and lower level trainees and even Internal
Medicine faculty on the nature and pathophysiology of digestive diseases
PRESBYTERIAN ENDOSCOPY FELLOW
Assignment: One fellow per month. (Second or Third Year Fellow)
Description: Presbyterian Endoscopy Fellow will be directly responsible for performing all
endoscopy procedures in Presbyterian Endoscopy Lab including outpatients and inpatients. This
fellow will also serve as the advanced endoscopy fellow responsible for ERCP both at
Presbyterian Hospital and at the VA Medical Center.
Objectives: Learn techniques, interpretation, and appropriate indications of basic upper and
lower endoscopy including but not limited to therapeutic maneuvers such as polypectomy,
dilation, gastrostomy tube placement, control of variceal and non-variceal bleeding. Learn skill
of endoscopic report generation and communication with referring physicians. Learn appropriate
surveillance practices for patients at risk for gastrointestinal neoplasia. Learn techniques and
appropriate indications of percutaneous liver biopsy. Develop an exposure to ERCP techniques
and be able to understand the indications, contraindications, and limitations of ERCP. Improve
and apply knowledge of all aspects of digestive diseases, as outlined in the GI Core Curriculum,
in the care of patients undergoing gastrointestinal endoscopy.
Educational Resources: Yamada’s Textbook of Gastroenterology; Schiff’s Hepatology Text,
other gastroenterology textbooks and atlases, online resources including the OUHSC library’s
subscription to Up-to-Date, and OVID for literature searching for primary references.
Expectation and Responsibilities: The fellow assigned will be responsible for performing a
preprocedural assessment, including determining appropriateness of the indications for the
procedure and obtaining informed consent from the patient prior to initiation of any procedures.
The fellow is responsible for discussing the appropriateness and indications with the attending
physician assigned to the endoscopy lab prior to proceeding with the procedure. The fellow will
be directly responsible for performing the procedure with the direct supervision of the attending
physician. All findings and impressions will be discussed with the attending physician prior to
the generation of the report. The fellow is responsible for generating a written report including
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documentation of the preprocedural assessment, medications used during moderate sedation if
appropriate, findings, impressions and recommendations. This report is to be generated and
included into the patient’s OU Medical Center Medical Records. Fellows are expected to follow
up all pathology specimens and communicate results to the patient and referring physician.
In addition to performing standard procedures at the VA Endoscopy Lab, the Presbyterian
Endoscopy Fellow is also responsible for scheduling and coordinating all ERCP at Presbyterian
Hospital and at the VA Medical Center. This includes the identification of the appropriateness of
the procedure, the preprocedural evaluation, and informed consent prior to proceeding with the
procedure. As with standard endoscopy, the case will be discussed with the attending physician
responsible for supervising the fellow for the procedure. Also, as with the standard endoscopic
procedures, the fellow will be responsible for performing the procedure under the direct
supervision of the attending and then generating a report under the same guidelines as the general
endoscopy procedure protocol. Fellows are expected to demonstrate practice-based learning
through reading of primary literature relevant to disease states encountered during their
procedure encounters.
While on this rotation the fellow will spend one day per week reviewing all esophageal
motility studies performed at both OU medical center and the VA medical center with the faculty
member responsible for reviewing esophageal motility studies.
At times the Presbyterian Endoscopy Fellow will be called upon to assist with the
consultative services at Presbyterian Hospital and will work directly with the Presbyterian
Consult Fellow in coordinating care for consults requested. During the month of the rotation the
fellow will also attend their outpatient continuity clinics at OU Medical Center and at the VA
Medical Center.
Evaluation: The fellow on the Presbyterian Endoscopy Rotation will be evaluated by the
attending physicians supervising him/her for procedures on at least a quarterly basis and there
will be at least monthly written evaluations of individual procedures performed in the manner
similar to a mini-CEX. This is designed to show the acquisition of procedural skills towards the
goal of competency. Systems based learning will be evaluated based on the ability of the trainee
to mobilize appropriate medical, social, and home-based resources for their patients.
Goals (Year 2 and 3 only)
 Expand experience with appropriate pre-procedural preparation recommendations based
on evidenced based guidelines
 Enhance understanding of informed consent process and optimal practice of providing
patient education on the risks and benefits of GI endoscopy
 Expand experience with basic endoscopic techniques with emphasis on
esophagogastroduodenoscopy and colonoscopy with relevant therapeutics. Other
techniques such as percutaneous liver biopsy and paracentesis will be learned
 Enhance level of expertise in endoscopic interpretation
 Learn more complex decision making based on real time endoscopic findings
 Learn more advanced procedures (i.e. complex polypectomy, ERCP, small bowel
endoscopy)
 Achieve skills to independently perform all basic endoscopic techniques and apply
therapeutic appropriately
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Make complex decisions during and after endoscopic procedures with increased
independence in year 3
Learn complications of endoscopic procedures and appropriate management
Improve knowledge base of digestive diseases
Improve communication and interpersonal skills
Learn to navigate health care delivery system involving many specialties
Enhance practice-based learning skills
Objectives (Year 2 and 3 only)
 Evaluate patients presenting for GI endoscopy with emphasis on the appropriateness and
or contraindication to proceeding with scheduled procedure
 Evaluate patients with more complex digestive diseases requiring gastrointestinal
endoscopy
 Counsel patients on the risks and benefits of advanced endoscopic procedures and obtain
informed consent
 Perform more complex procedures such as small bowel enteroscopy, endoscopic stent
placement, endoscopic ablation of vascular malformations, gastrointestinal hemorrhage in
the critically ill, complex polypectomy and endoscopic mucosal resection.
 Evaluate all patients being considered for ERCP
 Perform ERCP with a goal of becoming familiar with but not procedurally competent
with therapeutic biliary endoscopy
 Perform history and physical prior to all endoscopic procedures
 Further experience in counseling patients and family on risks, benefits, and alternatives to
relevant procedures and obtaining informed consent prior to endoscopic procedures, liver
biopsy, or paracentesis
 Work as part of a team in performing endoscopic procedures
 Perform moderate sedation with focus on optimizing patient comfort and safety
 Perform basic diagnostic endoscopy including esophagogastroduodenoscopy and
colonoscopy with basic therapeutic maneuver including forceps biopsy, polypectomy,
stricture dilation, control of gastrointestinal hemorrhage, and percutaneous gastrostomy
 Perform percutaneous liver biopsy and paracentesis
 Generate comprehensive procedure report indicating personnel involved, indication,
detailed description of procedure, findings, pathology specimens, overall impression, and
recommendation
 Formulate management plan for digestive disease based on endoscopic findings or
therapy applied.
 Communicate findings to patient and/or family
 Follow-up all pathology specimens and communicate findings and change in management
plans based on pathologic findings to patients and referring physicians.
 Read relative source material and literature to optimize patient management
 Assist with coordination of patient follow-up in outpatient clinics or referral to other
specialties based on endoscopic findings
 Coordinate other specialty resources such as unusual pharmacy or device needs to
optimize therapy (e.g. obtaining non-formulary drugs).
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VA HOSPITAL CONSULTATION SERVICE
Assignment: One fellow per month.
Description: The Consultation Fellow will serve as the primary contact and coordinating
physician for all inpatient consultations requested by all services at the VA Medical Center.
Objectives: Develop skill of performing specialty-based consultations on inpatients. Establish
teaching skills with instruction of residents and students rotating on the consult service. Using
literature and reference material review to improve knowledge of digestive diseases through case
based learning and practice based improvement. Improve and apply knowledge of all aspects of
digestive diseases, as outlined in the GI Core Curriculum. Understand the role of inpatient
services and the importance of continuity in transitioning from inpatient to outpatient
management in caring for patients acutely ill with digestive diseases.
Educational Resources: Yamada’s Textbook of Gastroenterology; Schiff’s Hepatology Text,
other gastroenterology textbooks and atlases, online resources including the OUHSC library’s
subscription to Up-to-Date, and OVID for literature searching for primary references
Expectation and Responsibilities: Consult Fellow will maintain his pager and be available
from 7:00 AM to 5:00 PM. Monday through Friday for all consultations requested on inpatients
at the VA Hospital and consults requested at the OU Women’s and Children’s Hospital. This
includes consults requested from the emergency room from these hospitals during assigned
hours. The fellow will then directly evaluate and perform an assessment and develop a
diagnostic and management plan for all consultations. This will include review of all relevant
clinical data including radiographic studies, pathology, laboratory data, and endoscopic findings,
in addition to performing a specialty based comprehensive history and physical exam. This
fellow may also be charged with delegating some consults to medical students and internal
medicine trainees who are rotating on the GI Consultation Service. It is expected that the fellow
will also directly evaluate patients who are seen by these other trainees on the initial consultation.
Subsequent follow up visits on these consultations may be performed solely by the other trainees,
however, the majority of patients delegated to Internal Medicine Residents and medical students
should also be continuously evaluated by the fellow in training. The consult fellow is
responsible for notifying the attending physician of any emergent consultations that require
immediate input from the attending physician. All consultations will be reviewed and evaluated
by the consult attending within 24 hours of their request. The fellow is responsible for
communicating with the physician requesting the consultation. There will be no more than 10
new patients evaluated by the consult fellow in any 24-hour period. All additional consults will
be evaluated by the attending.
The Consult Fellow is also responsible for assisting in the education of medical students
and Internal Medicine trainees on the consult service through informal lectures and literature
searches. The fellow should demonstrate practice based learning by identifying appropriate
10
literature relative to patient’s digestive disorders and disseminate that material to the general
medicine house officers and students on the team requesting consultation.
The VA Consultation Fellow will be expected to attend their weekly continuity clinic at
the VA Medical Center.
The VA Consultation Fellow will also be directly involved in the performance of
endoscopies on both ambulatory patients and inpatients in the endoscopy suite at the VA Medical
Center.
Evaluation: The fellow will be evaluated on their evaluation and management skills as well as
their teaching efforts, communication skills, knowledge acquisition, systems-based learning, and
practice-based learning throughout the month by the supervising attending on the consult service.
Systems based learning will be evaluated based on the ability of the trainee to mobilize
appropriate medical, social, and home-based resources for their patients especially at the time of
discharge. As with all rotations, quarterly evaluations will be completed by all faculty and select
nurses to contribute to the 360-degree evaluation of their overall performance including their
continuity clinics.
Goals (Year 1)
 Improve knowledge base of digestive diseases
 Improve communication and interpersonal skills
 Learn to navigate health care delivery system involving many specialties
 Learn to provide consultative services in the specialty of gastroenterology
 Enhance practice-based learning skills
 Learn to lead a team of specialists
 Enhance an internist’s level history and exam skills to the level of a digestive disease
specialist.
(Years 2 and 3) In addition to above:
 Develop expert (faculty level) knowledge base of digestive diseases
 Graduate to more independent level of complex decision making in digestive disease
management
 Further enhance practice-based learning skills and familiarity with systems of care
Objectives (Year 1)
 Have dedicated experience in evaluation and management of inpatient digestive diseases
 This includes performing comprehensive history and examination with emphasis on
digestive processes.
 In the process of diagnostic or therapeutic management recommendations, make
decisions on appropriateness of gastrointestinal endoscopy and communicate risks and
benefits to patient while obtaining informed consent
 Work with several internal medicine residents and/or students to coordinate care delivery
provided by consult team
 Communicate consult findings and recommendations to requesting physician(s)
11
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Communicate recommendations and findings of diagnostic studies directed towards
digestive diseases to patients and family as appropriate.
Review literature on disease processes encountered in patients and utilize this literature
and new knowledge to optimize patient care
Teach basic digestive diseases to earlier level trainees and internal medicine trainees
requesting consultations.
Work with other health care providers including social workers, case managers,
gastroenterology nursing staff, pharmacists, and other allied health professionals to
optimize resources available to patients.
(Years 2 and 3) In addition to above:
 Have further experience in evaluation and management of inpatient digestive diseases
with more independence in decision making
 Maturation of communication skills as process of training advances with background
expectation of practicing as competent gastroenterologist without the need for
supervision.
 Make complex management decisions with supervising faculty serving as learning
resource and providing guidance
 Further experience reviewing literature and using evidenced based medicine to optimize
care
 Perform more extensive teaching of residents and lower level trainees and even Internal
Medicine faculty on the nature and pathophysiology of digestive diseases
VA HOSPITAL ENDOSCOPY FELLOW
Assignment: Two or three fellows per month.
Description: Trainees assigned to the VA Endoscopy Service will be responsible for performing
a full array of endoscopic services on outpatients and inpatients at the VA Medical Center under
the direct supervision of the attending physician assigned to the VA Endoscopy Lab.
Objectives: Learn techniques, interpretation, and appropriate indications of basic upper and
lower endoscopy including but not limited to therapeutic maneuvers such as polypectomy,
dilation, gastrostomy tube placement, control of variceal and non-variceal bleeding. Learn skill
of endoscopic report generation and communication with referring physicians. Learn appropriate
surveillance practices for patients at risk for gastrointestinal neoplasia. Learn techniques and
appropriate indications of percutaneous liver biopsy. Improve skills of radiology interpretation.
Improve and apply knowledge of all aspects of digestive diseases, as outlined in the GI Core
Curriculum, in the care of patients undergoing gastrointestinal endoscopy.
Educational Resources: Yamada’s Textbook of Gastroenterology; Schiff’s Hepatology Text,
other gastroenterology textbooks and atlases, online resources including the OUHSC library’s
subscription to Up-to-Date, and OVID for literature searching for primary references
12
Expectation and Responsibilities: Endoscopy Fellows will be responsible for performing a
preprocedure evaluation, including obtaining informed consent for all procedures performed at
the VA Medical Center. The fellow is responsible for discussing the appropriateness and
indications with the attending physician assigned to the endoscopy lab prior to proceeding with
the procedure. The fellow will be directly responsible for performing the procedure with the
direct supervision of the attending physician. All findings and impressions will be discussed
with the attending physician prior to the generation of the report. The fellow is responsible for
generating a written report including documentation of the preprocedural assessment,
medications used during moderate sedation if appropriate, findings, impressions and
recommendations. This report is to be directly entered into the VA Medical Records. When
procedures are performed on inpatients, the fellow is responsible for directly communicating
with both the consulting fellow and the inpatient primary service regarding the findings and
recommendations of the procedure. Fellows are expected to follow up all pathology specimens
and communicate results to the patient and referring physician. Fellows are expected to
demonstrate practice-based learning through reading of primary literature relevant to disease
states encountered during their procedure encounters.
Fellows assigned to the VA Endoscopy Rotation will also be expected to attend their
ambulatory continuity clinics at the OU Medical Center, VA hospital, and the VA hepatitis
clinic. One day per week the fellows will review radiographic studies with attending
radiologists at OU Medical Center as a means to solidify experience in computed tomography,
ultrasonography, and plain film interpretation.
Evaluation: The fellows on the VA Endoscopy Rotation will be evaluated, by faculty members
assigned on a daily basis to the endoscopy lab, on procedural skills including the appropriateness
of preprocedural evaluations and post-procedure counseling. There will be at least one monthly
formal written evaluations of procedural skills observed during an individual patient encounter
similar to a mini-CEX evaluation. This instrument is used to assess procedural competency as
well as patient communication, report generation, and ability to establish plan of care. Systems
based learning will be evaluated based on the ability of the trainee to mobilize appropriate
medical, social, and home based resources for their patients. As with all rotations, quarterly
evaluations will be completed by all faculty and select nurses to contribute to the 360-degree
evaluation of their overall performance including their continuity clinics.
Goals (Year 1)
 Learn indications and contraindications of endoscopic procedures
 Learn appropriate techniques of moderate sedation and requisite monitoring practices
 Learn appropriate preprocedural preparation recommendations based on evidenced based
guidelines
 Learn basic endoscopic techniques with emphasis on esophagogastroduodenoscopy and
colonoscopy with relevant therapeutics. Other techniques such as percutaneous liver
biopsy and paracentesis will be learned
 Learn basic interpretation of endoscopic findings
 Learn complications of endoscopic procedures and appropriate management
 Enhance understanding of informed consent process and optimal practice of providing
patient education on the risks and benefits of GI endoscopy
13
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




Learn basic decision making based on real time endoscopic findings
Improve knowledge base of digestive diseases
Improve communication and interpersonal skills
Learn to navigate health care delivery system involving many specialties
Enhance practice-based learning skills
Learn radiology interpretation with focus on gastrointestinal radiology
(Years 2 and 3)In addition to all above:
 Learn more advanced procedures (i.e. complex polypectomy, ERCP, small bowel
endoscopy)
 Achieve skills to independently perform all basic endoscopic techniques and apply
therapeutic appropriately
 Enhance level of expertise in endoscopic interpretation
 Make complex decisions during and after endoscopic procedures with increased
independence in year 3
Objectives (Year 1)
 Evaluate patients presenting for GI endoscopy with emphasis on the appropriateness and
or contraindication to proceeding with scheduled procedure
 Perform history and physical prior to all endoscopic procedures
 Experience in counseling patients and family on risks, benefits, and alternatives to
relevant procedures and obtaining informed consent prior to endoscopic procedures, liver
biopsy, or paracentesis
 Work as part of a team in performing endoscopic procedures
 Perform moderate sedation with focus on optimizing patient comfort and safety
 Perform basic diagnostic endoscopy including esophagogastroduodenoscopy and
colonoscopy with basic therapeutic maneuver including forceps biopsy, polypectomy,
stricture dilation, control of gastrointestinal hemorrhage, and percutaneous gastrostomy
 Perform percutaneous liver biopsy and paracentesis
 Generate comprehensive procedure report indicating personnel involved, indication,
detailed description of procedure, findings, pathology specimens, overall impression, and
recommendation
 Formulate management plan for digestive disease based on endoscopic findings or
therapy applied.
 Communicate findings to patient and/or family
 Follow-up all pathology specimens and communicate findings and change in management
plans based on pathologic findings to patients and referring physicians.
 Read relative source material and literature to optimize patient management
 Assist with coordination of patient follow-up in outpatient clinics or referral to other
specialties based on endoscopic findings
 Coordinate other specialty resources such as unusual pharmacy or device needs to
optimize therapy (e.g. obtaining non-formulary drugs).
 Spend one- half day per week reviewing gastrointestinal x-rays with faculty radiologists.
14
(Year 2 and 3) In addition to above:
 Evaluate patients with more complex digestive diseases requiring gastrointestinal
endoscopy
 Counsel patients on the risks and benefits of advanced endoscopic procedures and obtain
informed consent
 Perform more complex procedures such as small bowel enteroscopy, endoscopic stent
placement, endoscopic ablation of vascular malformations, gastrointestinal hemorrhage in
the critically ill, complex polypectomy and endoscopic mucosal resection.
 Evaluate patients being considered for ERCP when the Presbyterian Endoscopy Fellow is
unavailable.
 Perform ERCP with a goal of becoming familiar with but not procedurally competent
with therapeutic biliary endoscopy
OU Physicians ENDOSCOPY FELLOW
Assignment: Up to one fellow per month.(Third Year Fellow)
Description:
Senior Fellow will work directly with one attending each day of the week in performing standard
and advanced endoscopy (EUS) at the ambulatory endoscopy center at the OU Physicians
building. (Note: Facility is administered by OU Medical Center, and hence is a hospital
endoscopy center but all patients are outpatients).
Objectives: Learn techniques, interpretation, and appropriate indications of basic upper and
lower endoscopy including but not limited to therapeutic maneuvers such as polypectomy,
dilation. Obtain exposure to endoscopic ultrasound and understand its indications, limitations
and role in managing digestive diseases. Learn skill of endoscopic report generation and
communication with referring physicians. Learn appropriate surveillance practices for patients at
risk for gastrointestinal neoclassic. Improve and apply knowledge of all aspects of digestive
diseases, as outlined in the GI Core Curriculum, in the care of patients undergoing
gastrointestinal endoscopy. Rotation designed to provide experience similar to community based
endoscopy center with less acutely ill patients relative to the inpatient endoscopy lab but more
similar to ambulatory private practice.
Educational Resources: Yamada’s Textbook of Gastroenterology; Schiff’s Hepatology Text,
other gastroenterology textbooks and atlases, online resources including the OUHSC library’s
subscription to Up-to-Date, and OVID for literature searching for primary references
Expectation and Responsibilities: The fellow assigned will be responsible for performing a
preprocedural assessment, including determining appropriateness of the indications for the
procedure and obtaining informed consent from the patient prior to initiation of any procedures.
The fellow is responsible for discussing the appropriateness and indications with the attending
physician assigned to the endoscopy lab prior to proceeding with the procedure. The fellow will
be directly responsible for performing the procedure with the direct supervision of the attending
15
physician. All findings and impressions will be discussed with the attending physician prior to
the generation of the report. The fellow is responsible for generating a written report including
documentation of the preprocedural assessment, medications used during moderate sedation if
appropriate, findings, impressions and recommendations. This report is to be generated and
included into the patient’s OU Medical Center medical records. The experience is intended to
broaden the exposure to ambulatory patients, similar to the population seen in community
practice. Furthermore, trainees will be directly involved in performing EUS. Fellows assigned
to this rotation will be expected to develop a knowledge base of the rationale, limitations,
indications and appropriateness of EUS but not necessarily develop full competence. Assigned
reading will be provided. Fellows are expected to demonstrate practice-based learning through
reading of primary literature relevant to disease states encountered during their procedure
encounters.
.
Evaluation: The fellow on the OUPB Endoscopy Rotation will be evaluated by the attending
physicians supervising him/her for procedures on at least a quarterly basis and there will be
periodic written evaluations of individual procedures performed in the manner similar to a miniCEX. This instrument is used to assess procedural competency as well as patient
communication, report generation, and ability to establish plan of care. As with all rotations
quarterly evaluations will be completed by all faculty and select nurses to contribute to the 360degree evaluation of their overall performance including their continuity clinics.
Goals (Year 3 only)
 Solidify experience in evaluation of patients referred for gastrointestinal endoscopy with
focus on ambulatory patients similar to community gastroenterology practice
 Enhance understanding of informed consent process and optimal practice of providing
patient education on the risks and benefits of GI endoscopy with focus on ambulatory
patients presenting for elective procedures
 Improve decision making based on real time endoscopic findings with focus on
ambulatory patients
 Learn indications, contraindications, and complications of endoscopic ultrasound (EUS)
with or without fine needle aspiration or other EUS guided therapies
 Learn science of ultrasound imaging
 Learn basic technique of EUS and EUS-guided FNA and ultrasound interpretation to
level of familiarity with procedure but not competence
 Learn GI cancer staging and complex decision making related to stage specific therapies
in patients presenting for EUS staging of gastrointestinal malignancies
 Improve knowledge base of digestive diseases
 Improve communication and interpersonal skills necessary for successful ambulatory
community based practice
 Learn to navigate health care delivery system involving many specialties including
numerous disciplines involved in care of patients with GI malignancy
 Enhance practice-based learning skills
Objectives (Year 3 only)
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Evaluate patients presenting for GI endoscopy with emphasis on the appropriateness and
or contraindication to proceeding with scheduled procedure
Evaluate patients with more complex digestive diseases requiring gastrointestinal
endoscopy
Counsel patients on the risks and benefits of advanced endoscopic procedures and obtain
informed consent
Perform history and physical prior to all endoscopic procedures
Further experience in counseling patients and family on risks, benefits, and alternatives to
relevant procedures and obtaining informed consent prior to endoscopic procedures.
Work as part of a team in performing endoscopic procedures in an ambulatory procedure
area vs hospital based endoscopy areas in earlier training experiences
Perform moderate sedation with focus on optimizing patient comfort and safety
Perform basic diagnostic endoscopy including esophagogastroduodenoscopy and
colonoscopy with basic therapeutic maneuver including forceps biopsy, polypectomy, and
stricture dilation.
Perform basic EUS and assist with EUS-FNA with goal of being exposed to this
advanced endoscopic procedure.
Generate comprehensive procedure report indicating personnel involved, indication,
detailed description of procedure, findings, pathology specimens, overall impression, and
recommendation
Acting with more independence formulate management plan for digestive disease based
on endoscopic findings or therapy applied.
Communicate findings to patient and/or family
Follow-up all pathology specimens and communicate findings and change in management
plans based on pathologic findings to patients and referring physicians.
Read relative source material and literature to optimize patient management
Read syllabus of EUS literature covering science of ultrasound, the role of EUS in
evaluating patients with GI disease, and technical information unique to instruments used
in EUS.
Assist with coordination of patient follow-up in outpatient clinics or referral to other
specialties based on endoscopic findings.
RESEARCH FELLOW
Assignment: One or two fellows per month.
Description: When assigned to the Research Rotation, the fellow will generally have six
contiguous months dedicated solely to research activity. The fellow will not be assigned to
consultative or endoscopy services with the exception of the rare need to cover for the absence of
other fellows due to limited availability of personnel, such as when national meetings occur.
Objective: Establish expertise in a focused basic or clinical area within gastroenterology.
Understand the regulatory requirements for research involving human subjects. Produce
scholarly writings in gastroenterology.
17
Educational Resources: Yamada’s Textbook of Gastroenterology; Schiff’s Hepatology Text,
other gastroenterology textbooks and atlases, online resources including the OUHSC library’s
subscription to Up-to-Date, and OVID for literature searching for primary references.
Expectation and Responsibilities: The fellow is expected to work directly with a faculty
mentor or mentors to develop research projects. This includes the development of an
Institutional Review Board proposal identifying the hypothesis, methodology and statistical
analysis planned for the particular protocol. The fellow should be directly involved with the
scientific review required to adequately prepare the protocol. Once the IRB protocol is approved,
the fellow will be directly responsible and involved in the data collection, subsequent data
analysis, development of abstracts, presentations at national meetings, and finally the writing and
completion of a publishable manuscript. During the course of the fellowship, it is required that
the fellow achieve and experience during the six months of research training that results in a
manuscript publishable in a peer-review or non-peer-review journal. During the research time
the fellow will continue to have his ambulatory continuity clinics at the VA Medical Center and
at OU Medical Center.
Evaluation: The fellow will be evaluated, by all faculty members, at least on a quarterly basis
but particularly by the research mentors as to the commitment and successful completion of the
responsibilities as outlined above. As with all rotations quarterly evaluations will be completed
by all faculty and select nurses to contribute to the 360 degree evaluation of their overall
performance including their continuity clinics.
Goals (Year 2 only) The following is all under the guidance of research project mentor
 Gain experience, with guidance of faculty member, in development of specific research
(clinical or basic) question
 Expand knowledge base of focused area relevant to research question
 Learn to design research protocol to answer question
 Become familiar with regulatory requirements for patient oriented research
 Learn to communicate research findings in public forum either with poster or oral
presentation
 Learn to communicate research or scholarly work through publication
Objective (Year 2 only) The following is all under the guidance of research project mentor
 Write a summary or research project proposal(s) prior to initiating research rotation
 Read background literature for research project(s)
 Submit IRB proposal if human subjects involved
 Spend at least 6 months carrying out protocol
 Submit results to local and/or national meeting for presentation (oral or poster)
 Submit at least one manuscript of original research or other scholarly work to a peerreviewed journal.
18
Continuity Clinics
OU Medical Center Continuity Clinic
Assignment: All active fellows throughout their period of training
Description:
All fellows will attend a one half-day outpatient clinic at OU Medical Center. The trainee will
follow a cohort of patients throughout their training with supervision provided by dedicated
clinic faculty. All patients will be directly scheduled with the trainee and patients will identify
the trainee as their gastroenterologist.
Objectives: Establish experience and learn the diagnosis and management of ambulatory
digestive disorder including but not limited to: acid-peptic disease, inflammatory bowel disease,
diarrheal diseases, gallbladder and biliary diseases, pancreatic diseases, viral and non-viral liver
diseases, functional bowel diseases, gastrointestinal malignancies, nutritional disorders and
therapy, motility disorders, and disorders specific to women and geriatric populations. Fellows
will also learn the role of preventive services including screening for gastrointestinal neoplasia,
vaccination, nutritional therapy, and substance abuse treatment and counseling. Improve and
apply knowledge of all aspects of digestive diseases, as outlined in the GI Core Curriculum, in
the care of patients undergoing gastrointestinal endoscopy. Develop skill with educating patients
and families in outpatient disorders and shepherding them through other aspects of the health
care system including the need for consultation with other specialists such as gastrointestinal
surgeons, transplant services, and other medical and surgical subspecialties.
Educational Resources: Yamada’s Textbook of Gastroenterology; Schiff’s Hepatology Text,
other gastroenterology textbooks and atlases, online resources including the OUHSC library’s
subscription to Up-to-Date, and OVID for literature searching for primary references
Expectation and Responsibilities: The Fellow will be assigned approximately 1-3 new patients
and 4-6 return visits for each half day encounter. Fellows will be excused from clinic only when
they are assigned to the consult service at the alternative training site (VA Medical Center) or on
vacation leave. They will never be absent for more than one continuous month. (Note: fellows
will participate in their continuity clinic at the VA medical center during their absence while on
assignment at the VA consult service). At each visit fellows will perform a complete history and
physical exam, review relevant laboratory, endoscopy, radiology, and pathology findings and
develop and independent assessment of the patients digestive disorder including a differential
diagnosis when appropriate. The fellow will then formulate a diagnostic and therapeutic plan
individualized for the patient’s condition. The entire findings of their evaluation and
management plan will be reviewed with the supervising attending and a consensus plan will be
established and the fellow will document the entire findings and plan in a well organized
progress note in the patient’s medical records. The attending will then review this record entry
for accuracy and organizational content before documenting his or her approval. At each
encounter fellows are expected to communicate their plans to the patient or the patient’s
representative. The fellow is expected to follow-up any diagnostic testing and arrange
appropriate follow-up visits to review these findings and/or therapeutic responses with the
patient. Given the office hours only occur one half-day per week; fellows will be responsible for
19
communicating with patients outside of usual clinic office hours in order to foster a strong
patient-physician relationship over time. Likewise, fellows will be expected to advocate for
their patients when attempting to Sheppard them through the health care system. Fellows are
expected to demonstrate practice-based learning through reading of primary literature relevant to
disease states encountered during their clinic encounters.
.
Evaluation: As with all rotations quarterly evaluations will be completed by all faculty and
select nurses to contribute to the 360-degree evaluation of their overall performance in their
continuity clinics. Fellows will also provide select continuity patients with an evaluation form
assessing the fellow’s performance as their subspecialty physician.
Goals (All three years)
 Learn to evaluate ambulatory patients with digestive diseases
 Learn to serve as a digestive disease consultant for ambulatory patients
 Expand history and exam skills beyond general internist level to level capable of more
completely evaluating digestive complaints or detecting digestive disorders
 Learn diagnostic and therapeutic decision making with increasing complexity as graduate
to later years of training
 Learn to communicate with patients and family members
 Learn importance of commitment to continuity of care with emphasis on ensuring
continuous availability, prompt follow-up of tests, and provision of superior care
 Practice patient advocacy
 Expand knowledge base of digestive disease with emphasis on practice based learning
Objectives (All three years)
 Participate in weekly half-day clinic consisting of panel of patients (one average 1-3 new
patients; 4-6 return patients) identified as trainee’s patients.
 Perform detailed history and physical on all patients
 Review all laboratory, pathology, imaging data for individual patients
 Independently formulate diagnostic and therapeutic plan
 All patients reviewed with digestive disease faculty member to ensure supervised care
and enhance instruction
 Communicate recommendations in considerate fashion to both patient and referring
physicians
 In the process of communication appreciate cultural and gender specific concerns
 Follow-up, in timely fashion, all tests ordered at time of encounter
 Utilize other specialties and allied health services to optimize patient care
 Shepard patients through health care system when other specialty services or referrals are
needed
 Read up to date literature on disease states encountered in patients for purpose of
expanding knowledge and optimizing patient care
VA Medical Center Continuity Clinic
20
Assignment: All active fellows throughout their period of training
Description:
All fellows will attend a one half-day outpatient clinic at the VA Medical Center. The trainee
will follow a cohort of patients throughout their training with supervision provided by dedicated
clinic faculty. All patients will be directly scheduled with the trainee and patients will identify
the trainee as their gastroenterologist.
Objectives: Establish experience and learn the diagnosis and management of ambulatory
digestive disorder including but not limited to: acid-peptic disease, inflammatory bowel disease,
diarrheal diseases, gallbladder and biliary diseases, pancreatic diseases, viral and non-viral liver
diseases, functional bowel diseases, gastrointestinal malignancies, nutritional disorders and
therapy, motility disorders, and disorders specific to geriatric populations. Fellows will also
learn the role of preventive services including screening for gastrointestinal neoplasia,
vaccination, nutritional therapy, and substance abuse treatment and counseling. Improve and
apply knowledge of all aspects of digestive diseases, as outlined in the GI Core Curriculum, in
the care of patients undergoing gastrointestinal endoscopy. Develop skill with educating patients
and families in outpatient disorders and shepherding them through other aspects of the health
care system including the need for consultation with other specialists such as gastrointestinal
surgeons, transplant services, and other medical and surgical subspecialties.
Educational Resources: Yamada’s Textbook of Gastroenterology; Schiff’s Hepatology Text,
other gastroenterology textbooks and atlases, online resources including the OUHSC library’s
subscription to Up-to-Date, and OVID for literature searching for primary references
Expectation and Responsibilities: The Fellow will be assigned approximately 1-3 new patients
and 4-6 return visits for each half-day encounter. Fellows will be excused from clinic only when
they are assigned to the consult service at the alternative training site (OU Medical Center) or on
vacation leave. They will never be absent for more than one continuous month. (Note: fellows
will participate in their continuity clinic at the OU medical center during their absence while on
assignment at the OU consult service). At each visit fellows will perform a complete history and
physical exam, review relevant laboratory, endoscopy, radiology, and pathology findings and
develop and independent assessment of the patients digestive disorder including a differential
diagnosis when appropriate. The fellow will then formulate a diagnostic and therapeutic plan
individualized for the patient’s condition. The entire findings of their evaluation and
management plan will be reviewed with the supervising attending and a consensus plan will be
established and the fellow will document the entire findings and plan in a well organized
progress note in the patient’s medical records. The attending will then review this record entry
for accuracy and organizational content before documenting his or her approval. At each
encounter fellows are expected to communicate their plans to the patient or the patient’s
representative. The fellow is expected to follow-up any diagnostic testing and arrange
appropriate follow-up visits to review these findings and/or therapeutic responses with the
patient. Given the office hours only occur one half-day per week; fellows will be responsible for
communicating with patients outside of usual clinic office hours in order to foster a strong
patient-physician relationship over time. Likewise, fellows will be expected to advocate for
their patients when attempting to shepard them through the health care system. Fellows are
21
expected to demonstrate practice-based learning through reading of primary literature relevant to
disease states encountered during their clinic encounters.
.
Evaluation: As with all rotations quarterly evaluations will be completed by all faculty and
select nurses to contribute to the 360-degree evaluation of their overall performance in their
continuity clinics. Fellows will also provide select continuity patients with an evaluation form
assessing the fellow’s performance as their subspecialty physician.
Goals (All three years)
 Learn to evaluate ambulatory patients with digestive diseases
 Learn to serve as a digestive disease consultant for ambulatory patients
 Expand history and exam skills beyond general internist level to level capable of more
completely evaluating digestive complaints or detecting digestive disorders
 Learn diagnostic and therapeutic decision making with increasing complexity as graduate
to later years of training
 Learn to communicate with patients and family members
 Learn importance of commitment to continuity of care with emphasis on ensuring
continuous availability, prompt follow-up of tests, and provision of superior care
 Practice patient advocacy
 Expand knowledge base of digestive disease with emphasis on practice based learning
Objectives (All three years)
 Participate in weekly half-day clinic consisting of panel of patients (one average 1-3 new
patients; 4-6 return patients) identified as trainee’s patients.
 Perform detailed history and physical on all patients
 Review all laboratory, pathology, imaging data for individual patients
 Independently formulate diagnostic and therapeutic plan
 All patients reviewed with digestive disease faculty member to ensure supervised care
and enhance instruction
 Communicate recommendations in considerate fashion to both patient and referring
physicians
 In the process of communication appreciate cultural and gender specific concerns
 Follow-up, in timely fashion, all tests ordered at time of encounter
 Utilize other specialties and allied health services to optimize patient care
 Shepard patients through a confined VA health care system when other specialty services
or referrals are needed
 Read up to date literature on disease states encountered in patients for purpose of
expanding knowledge and optimizing patient care
VA Medical Center Hepatology Clinic
Assignment: Two fellows per month
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Description: Fellows assigned to the VA will spend one half-day per week in the Hepatology
Clinic. This specialty clinic evaluates and treats patients with chronic viral hepatitis, and patients
with advanced liver disease being considered for transplantation or status post transplantation.
These last patients are also co-managed in the transplant clinic operated by the Department of
Surgery.
Objectives: Establish experience in the evaluation and management of patients with liver
disorders. While there is ongoing continuity of care for patients with liver disorders in the
general continuity clinic, the VA Hepatology Clinic provides a focused experience dedicated to
the initial evaluation of patients with liver diseases. While the majority of patients have chronic
hepatitis C, patients with all forms of chronic liver disease leading to cirrhosis are managed in
this clinic. Indeed the experience emphasizes the diagnostic evaluation of new patients
presenting with signs, symptoms, or laboratory evidence of liver disease. This is also the
opportunity to work in a multidisciplinary clinic with pharmacologists, psychologists, and nurse
practitioners, fostering the notion of utilizing other health care professionals to optimize patient
care. These disciplines are integrated into the clinic specifically to streamline and optimize the
care for patients being treated for chronic hepatitis C. This experience builds upon and solidifies
the knowledge of interferon-based therapies with particular emphasis on appropriate selection of
candidates and monitoring of therapy response and side effects. Fellows also receive an
exposure to pre-transplant evaluation and the process of referral to a transplant center when
patients are deemed suitable candidates. A limited exposure to post-transplant care is provided
as the clinic manages patients well after the immediate post-transplant period.
Expectation and Responsibilities: Since the focus of the experience is initial evaluation of
patients with liver diseases, the Fellow will be assigned approximately 3-4 new patients and 0-2
return visits for each half-day encounter. At each visit fellows will perform a complete history
and physical exam, review relevant laboratory, endoscopy, radiology, and pathology findings and
develop and independent assessment of the patients digestive disorder including a differential
diagnosis when appropriate. The fellow will then formulate a diagnostic and therapeutic plan
individualized for the patient’s condition. The entire findings of their evaluation and
management plan will be reviewed with the supervising attending and a consensus plan will be
established and the fellow will document the entire findings and plan in a well organized
progress note in the patient’s medical records. The attending will then review this record entry
for accuracy and organizational content before documenting his or her approval. At each
encounter fellows are expected to communicate their plans to the patient or the patient’s
representative. The fellow is expected to follow-up any diagnostic testing and arrange
appropriate follow-up visits to review these findings and/or therapeutic responses with the
patient. Fellows are expected to demonstrate practice-based learning through reading of primary
literature relevant to disease states encountered during their clinic encounters.
Evaluation: As with all rotations quarterly evaluations will be completed by all faculty and
select nurses to contribute to the 360-degree evaluation of their overall performance in their
continuity clinics.
Goals (All three years)
 Learn to evaluate ambulatory patients with liver disease
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Expand history and exam skills to include skills specific to liver disease
Understand the complexities of viral hepatitis therapy including indications,
contraindications of various regimens
Learn to communicate with patients and family members
Learn importance of commitment to continuity of care with emphasis on ensuring
continuous availability, prompt follow-up of tests, and provision of superior care
Learn to work as part of a multidisciplinary team
Expand knowledge base of liver diseases with emphasis on practice based learning and
preventive care
Objectives (All three years)
 Evaluate new patients presenting to the clinic
 Formulate diagnostic plan including serologic evaluation, imaging studies, and possibly
liver biopsy
 Review results of diagnostic studies and decide on appropriateness of antiviral therapy
 Review all patients with hepatology faculty member for instruction and supervision
 Screen appropriate patients for liver cancer
 Vaccinate appropriate patients based on guidelines to prevent viral hepatitis
 Communicate to patients diagnostic findings, therapeutic plans, side effect profiles of
drugs, and importance of compliance and follow-up monitoring/care
 Work directly with allied health professionals (pharmacist, nurse practitioner, and
psychologist) in a multidisciplinary clinic
 Read relevant literature on liver diseases to optimize patient care and expand knowledge
Training through conferences and other non-patient care activities: The Gastroenterology
Section has scheduled regular recurring conferences that are outlined below:
1. GI Core Clinical Conference; weekly. Presentations of core lecture series by fellows, faculty,
and visiting faculty. Topics rotated annually and assigned by Program Director to ensure
broad representation of digestive diseases based on the GI Core Curriculum and state of the
art gastroenterology as well as topics important for professionalism in medicine. Topics
include review of biostatistic methods and study design and other topics required for broad
based education (topics available from prior assignment schedules). Lectures throughout the
3 year training experience will address specifically or have incorporated in them the required
fields of medical genetics, ethics, palliative care, pain management, risk management,
physician impairment, substance abuse, quality improvement, and medical coding and billing.
2. Systems of Care Improvement (Complications Conference); monthly. Cases presented and
discussed by fellow or staff. Quality Improvement initiatives planned and implemented at
least yearly.
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3. Advanced Endoscopy Conference; Monthly. Cases presented by fellow, radiographs
reviewed by fellows and faculty and issues of case management discussed in open forum.
4. Consult Service Clinical Case Conference; monthly. At least one challenging case from both
consult services presented and brief presentation of teaching points with literature references
to promote practice based learning.
5. Pathology conference; biweekly. Fellows present cases and slides reviewed with staff
pathologist. GI staff members are in attendance.
6. Journal Club; monthly to biweekly. Two fellows and one staff review pertinent articles from
the recent literature.
7. Pathophysiology discussion; biweekly. Fellows are expected to read pertinent chapters in
current reference textbooks. Staff preceptor reviews these readings with fellows and
discusses basic science principles in addition to organ specific physiology and disease
specific pathophysiology. Principles of disease specific epidemiology, therapeutics, and
prevention are also reviewed. During the course of three years two years dedicated to
covering comprehensive gastroenterology textbook (prior to 2007 Yamada; Schleisenger and
Fortran as of 2007); and one year dedicated to covering comprehensive hepatology textbook
(Schiff). Program improvement for 2007- each session is accompanied by review of 5-6
board review questions based on topics in the reading. Faculty responsible for directing the
conference are responsible for identifying or creating appropriate questions to consolidate
knowledge reviewed. Database of all questions reviewed maintained by Program
Coordinator
8. Research Conference; monthly. Research (both Basic and Clinical Sciences) in progress
presented by staff, fellows and visitors.
9. Professor Rounds- monthly. Fellows present interesting case with included radiographs and
discuss diagnostic possibilities and therapeutic options with affiliated faculty member, Dr.
Phil Miner.
10. Multidisciplinary GI Tumor Board; weekly. Fellows and faculty attend clinical case
discussion in collaboration with trainees and faculty of Departments of Surgery, Pathology,
Radiology, Radiation Oncology and Section of Oncology.
11. Central Oklahoma Gut Club; biannually. Attended by fellows and staff. Speaker, usually,
nationally known figure. Often this individual will serve as visiting professor and will have
direct contact with fellows.
12. National annual meeting of the AGA, ACG and AASLD will be available for residents to
attend. Fellows will be encouraged to attend at least one meeting per year and funding
provided for travel to one meeting annually.
13. Evidenced Based Medicine and Teaching Skills Workshop- All faculty and fellows
encouraged to attend (senior fellows required to attend). Administered annually by College
of Medicine. Teaches practice based learning skills and tools to promote effective teacher to
learner communication.
14. Practice of Medicine Seminar- Sponsored annually by College of Medicine and the Southern
Medical Society. (All senior fellows required to attend) Incorporates broad introduction to
health care systems including legal, ethical, and fiscal topics important for practice of
medicine.
15. Completion of LIFE curriculum: Program improvement for 2007- Computer based video
modules with completion questionnaire. The modules focus on resident fatigue, physician
25
impairment, patient relationship boundaries, interpersonal skills, and other areas focused on
professionalism.
16. Completion of Digestive Disease Self –Evaluation Modules version 5.0. Program
improvement for 2007- AGA sponsored self-directed learning computer based modules
designed to systematically add to trainee’s knowledge base. All trainees required to log time
spent reviewing modules with goal of completing entire CD based program in 12-24 months.
Designed to improve knowledge and promote practice based learning and life long habit of
self-learning.
Research activity/practice based learning: Trainees will be expected to participate in practice
based learning throughout their training experience. This will include participation in formal
didactic sessions outlined above including Journal Club, Research Conference, and Systems of
Care Improvement Conference. In addition, they will be expected to have self-motivated learning
with extending their medical knowledge based on their experience in the clinical services and
this skill will be assessed by the faculty during clinical supervision of inpatient and outpatient
encounters.
Scholarly activity and, in particular, research projects employing valid scientific methods will be
required of all trainees. Each trainee will be guaranteed; at least, six months of protected time to
participate in a designed and institutional review board approval process for a clinical or basic
science research project. The trainee is expected to carry out this project and the results published
at an annual national or international meeting. In addition, the trainee will be encouraged to
publish the results in a peer reviewed journal and to present their project in a thesis based format
at the sections research conference. All trainees are required to have a manuscript submitted to a
peer-reviewed journal before completion of the Fellowship. This may be the above project or
other scholarly activity such as review article, several case series or reports. Several resources on
campus will be utilized to support this mission including statistical resources within the
Department of Epidemiology and Biostatistics and basic laboratory facilities in other sections
within the Department of Internal Medicine and the Departments of Surgery, Physiology, and
Cell Biology. About six months of protected time will be provided for the trainee to dedicate
work to this project, ongoing participation in their project during their clinical training will also
be encouraged and more prolonged protected time available to trainees wishing to pursue
research as a career similar to a “research tract” fellowship.
Evaluation of trainee competence: Trainees are evaluated by individual staff members on a
quarterly basis. Individual residents have their written evaluations reviewed with the Program
Director. Deficiencies are noted and a plan of remediation outlined with expectations clearly
delineated. Bi-annual written report is provided to individual fellows noting their progress, areas
that need addition work and constructive criticism.
For trainees to be deemed competent they should demonstrate the following:
1. An understanding and commitment to all elements of professionalism including but not
limited to participation in national societies, commitment to self-education, commitment to
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professional growth as demonstrated in maintenance of a comprehensive professional
portfolio, dedication to superior patient care and quality improvement.
2. A thorough knowledge of history taking and the ability to perform a comprehensive and
accurate physical examination.
3. The ability to arrive at an appropriate differential diagnosis, to outline the 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.
4. The ability to communicate, effectively, the results of a consultation orally and in writing and
to defend the clinical assessment, differential diagnosis, and diagnostic and management
plan. This includes the ability to discuss findings with referring physicians, educate lower
level trainees, and communicate with patients and their families. The last trait requires the
trainee to be sensitive to the cultural and educational background of individual patients.
5. A core fund of knowledge in gastroenterology and hepatic physiology, pathophysiology and
clinical pharmacology. All areas of the GI core curriculum should be mastered to a level to
pass the ABIM certifying exam for gastroenterology.
6. An understanding of procedure indications, contraindications, and limitations.
7. Proficient technical skills to permit independent, safe and thorough completion of standard
gastrointestinal procedures (outlined above) as indicated by direct evaluation of individual
procedure encounters.
8. An ability to appropriately interpret endoscopic findings and independently apply them in
complex decision making for individual patients
9. Practice-based learning with continual efforts towards experience based improvement in
delivery of clinical care.
10. System based learning with appreciation of resources available for patient care.
Guidelines for Endoscopic Training: Parameters of Competency
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
Prepare accurate report
Plans correct management and disposition
Discusses findings with patient and other physician
Conducts proper follow up, review of pathology, case outcome
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The following methods will be used to evaluate trainees’ competence:
1. Observation during rounds, conferences and review of written consultations.
2. Formal evaluation forms evaluating each of the six core competencies completed each faculty
member who comes in contact with the trainee (quarterly).
3. Monthly evaluations of the six core competencies at completion of all consult service months
with evaluation completed and reviewed with trainee by the faculty member assigned to the
monthly rotation (monthly).
4. Observations during procedures to determine competence in individual components of the
endoscopic procedure (at least once monthly when assigned to endoscopy rotations).
5. 360-degree evaluations completed by nursing staff and patients (in addition to faculty and self
evaluations) on annually basis with forms designed to assess six core competencies.
6. Maintenance of a professional portfolio by the trainee outlining professional
accomplishments and growth. Biannual review by the Program Director.
7. Self-evaluations by the trainee.
8. Annual In service Examination
Each Core Competency will be assessed with specific tools as outlined:
1. Patient Care- History and Exam skills and medical decision making skills will be
assessed in monthly consult service evaluations, quarterly faculty evaluations, other 360
degree evaluations (nurses and patients), endoscopy evaluations (similar to mini CEX).
Procedure competency will be based on procedure logs and evaluations of specific
encounters using a specific endoscopy evaluation form (mini CEX).
2. Medical Knowledge- Will be assessed with observation and evaluation from monthly
consult evaluations, quarterly evaluations (based on presentation by the trainee during
core clinical conferences, journal clubs, pathophysiology discussions, review of clinical
cases during endoscopy rotations, discussions in pathology conference), In service
examination results
3. Interpersonal and Communication Skills- Will be assessed by 360-degree evaluations
including evaluations completed by nurses and patients. Faculty will also evaluate the
trainee based on observation during consult months, endoscopy evaluations (mini CEX),
and quarterly evaluations based on encounters in continuity clinics. Unsolicited feedback
(both negative and positive) from other departments will also be maintained in the
trainee’s folder for consideration. Presentation skills during conferences will be assessed
during quarterly evaluations
4. Professionalism- Will be assessed by 360-degree evaluations including observations from
faculty and nurses commenting on the ability of the trainee to act ethically and
compassionately with an understanding of the cultural, educational, and psychosocial
needs of individual patients. Review of the trainee maintained portfolio will document
engagement in professional societies and the maintenance of the portfolio itself will
establish commitment to professional growth. Success and commitment to scholarly
activity will be assessed with quarterly evaluations and documented publications in
portfolio.
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5. Practice-Based Improvement- Will be assessed through quarterly evaluations with
specific attention to performance in journal clubs, and systems of care improvement
conference (complications conference). Monthly consult evaluations, quarterly
evaluations will also grade the trainee based on using self-education to provide optimal
care for patients in inpatient consult services and outpatient continuity clinics. Selfevaluations will be assessed for insight into needed areas for self-improvement.
Attendance at national and regional meetings will also serve as a measure of selfeducation. Portfolios will also be assessed for national conference attendance, journal
club participation, and overall commitment to education.
6. Systems-Based Practice-Will be assessed with 360-degree evaluations, with feedback by
nurses and patients used to assess awareness of trainee of resources in health care system.
Faculty will also evaluate trainee in monthly consult rotation evaluations, and quarterly
evaluations based on ability of trainee to mobilize resources needed by their patients (i.e.
social services, pharmaceutical assistance, referral to specialty services including
transplantation centers, mental health services). Specific notation of these skills will be
made by the Program Director. Participation in the College of Medicine sponsored
seminar on Health Care Systems will be documented by a certificate of attendance.
Outcomes Assessment
As a means to continually improve the education content and outcome of the fellowship
program the Program Director will monitor several parameters and based on this
feedback design improvements in the curriculum. Outcomes currently monitored include
results of the Gastroenterology In Training Examination. All fellows will participate in
the examination typically given in April of the academic year. The program will receive
individual trainee results as well as program results in specific organ sites with
comparisons to nationwide averages. This allows the Program Director to design the
Core Conference topic assignment for the following academic year with emphasis placed
on organ sites or disease states that trainees systematically achieved lower scores. In
addition, performance on ABIM certifying exam will be used to assess the success of the
curriculum. In the future the program will use feedback from the graduates and
colleagues of the graduates on the success of the trainees transitioning into the successful
practice of gastroenterology and their ability to continue a life long practice of selfimprovement and self-education for the purpose of enhancing patient care.
Period of Assignment of Residents
The Program Director shall assign residents to the two hospitals on a rotating basis to meet the
educational needs of the Program. The specific rotations and their duration shall be determined
by the Program Director as outlined above. The residents will be assigned on a monthly basis
with one resident providing consultative services at OU Medical Center and another resident will
be assigned to provide consultative services at the VAMC . One resident will be assigned to the
outpatient/inpatient endoscopy center at Presbyterian Tower OUMC and based on the number of
residents assigned to research; another resident may be assigned to the separate outpatient
endoscopy center at OU Physicians Building (facility part of OUMC). Two residents will be
assigned to the endoscopy center at the VA Medical center. At least one resident will be
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assigned to a research rotation on a monthly basis with a minimum of six continuous months.
The goals, objectives, responsibilities, and evaluation process for each rotation is described in
detail in a separate section (above). The number of resident physicians to be assigned shall be in
conformance with the Annual Supplemental Agreement for Graduate Medical Education
between the College of Medicine and the Hospital.
Work Hours
All trainees will be prohibited from working beyond the work hour restriction established by the
ACGME. This includes prohibition of working more than 24 hours consecutively. Also trainees
will have at least four 24-hour periods off averaged over 4 weeks and will have at least 10 hours
off between in house duties. Work hours are monitored by the University’s TOAD reporting
system on a monthly basis. On call responsibilities will be from home and generally assigned
one week at a time. In the event that a trainee is called in to the hospital for an emergency this
will be recorded as work hours, and if there is extenuating circumstance that keeps the trainee in
the hospital for a large portion of an overnight period the trainee will be excused from duty the
following day and the person assigned call the following week will assume at home call for the
next 24 hour period. Moonlighting will only occur with the expressed written consent of the
Program Director and any moonlighting at OUMC or the VA medical center will be tabulated in
TOAD reporting. All other off campus moonlighting will be reported to the Program
Coordinator to ensure the activity does not, in conjunction with usual reported work hours, lead
to total hours beyond the above restrictions.
Institutional Responsibility for Teaching, Supervision and Evaluation of Residents
The University Of Oklahoma College Of Medicine performs certain responsibilities as the
sponsoring institution of the graduate medical education program as described in the “Essentials
of Accredited Residencies” published by the ACGME. This includes establishment and
maintenance of a Graduate Medical Education Committee whose membership includes program
directors, residents, and representatives of the major affiliated institutions.
The individual residency program and Program Director are responsible for teaching,
supervision, and evaluation of residents in the Program as established by ACGME general and
program specific requirements and College of Medicine requirements. This responsibility
includes determination of advancement or promotion of residents and determination of resident’s
satisfactory completion of training requirements. An Internal Institutional Review conducted by
the Graduate Medical Education Committee of the College of Medicine assesses these functions
periodically. They are also assessed during residency program accreditation site visits performed
by the ACGME and its residency review committees.
Policies and Procedures That Govern Residents
The University Of Oklahoma College Of Medicine has established policies and procedures to
govern the graduate medical education programs of the College in compliance with ACGME
standards. These policies are disseminated to residents, program directors, and hospitals in the
form of a Resident Handbook, which is revised periodically. The Resident Handbook is
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incorporated as part of the Residency Agreement executed with each resident. The handbook
includes specific procedures for grievances.
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