The mission of the Brigham and Women's Hospital Gastroenterology Fellowship
Program is to train physician-investigators and future academic leaders in
Gastroenterology.
Mastery of the principles of clinical gastroenterology and the role of consultant requires that a fellow observe and manage a patient’s illness in the office setting over an extended period of time. Each fellow follows a panel of his/her own patients for three years in a weekly longitudinal clinic at BWH mentored full – time by a faculty mentor. The fellow is responsible for all aspects of the patient’s care including proper documentation of all written and verbal communications. The fellow works with a team which includes a physician’s assistant or nurse practitioner, medical assistant, support staff and practice administrator. The fellow will be evaluated regularly by the mentor and other members of the healthcare team based on the six core competencies.
Year One of Training:
Fellows will perform a thorough history and physical that incorporates all data required to synthesize a differential diagnosis, scholarly discussion, and safe and effective treatment plan, based on published guidelines, that is appropriate for the individual patient that is clearly communicated to the entire healthcare team. They are able to monitor test results and discuss them with faculty and act on them. The fellows can function well in a team and recognize clinical trends in their patient panels.
Year Two of Training:
Fellows will be aware of the more subtle manifestations of the common digestive diseases and be able to discuss alternative treatment methods as they apply to individual patients. They are able to teach their peers, residents and students proper clinical management. They analyze trends and formulate improvements in best-practice for the benefit of their patients. They will use these observations to design and perform scientific studies as well as give didactic presentations.
Year Three of Training:
The fellow will have a high level of understanding of the clinical subtleties of digestive disease and be able to apply it a therapeutic plan that can be used to influence the quality of care beyond their own clinic.. The fellows will seek ways to improve patient care and complete evidence –based studies based on their clinical observations of patients.
Goal
Fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Fellows are expected to:
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Competencies:
1. Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to:
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 communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families gather essential and accurate information about their patients make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment develop and carry out patient management plans counsel and educate patients and their families use information technology to support patient care decisions and patient education perform competently all medical and invasive procedures considered essential for the area of practice provide health care services aimed at preventing health problems or maintaining health work with health care professionals, including those from other disciplines, to provide patient-focused care.
Objectives:
1. The fellow will obtain a complete medical history and a thorough physical examination in a respectful and courteous manner.
2. The fellow will communicate the findings and recommendations to the patient and family with compassion and respect and will incorporate this information in a polished, lucid scholarly report in a timely fashion to the referring physician.
3. The fellow will make well – informed decisions about any recommendations for evaluation and treatment based on a combination of the patient’s condition, personal preferences, up-to-date evidence – based scientific evidence and expert clinical judgment.
4. The fellow will educate the patient and family about their illness and its prevention and the maintenance of future health.
5. The fellow will take advantage of all members of the healthcare team including consultants to provide patient – focused excellent care.
6. The fellow will maintain in standard fashion an up-to-date log of all new patient clinic consultation diagnoses and procedures performed on these patients and make this log readily available to their clinic mentor and the Program Office to assure proper clinical experience.
Goal
Fellows must demonstrate competence in the knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the
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application of this knowledge to the diagnosis and longitudinal care of gastrointestinal disease as it is manifested in the office practice of a tertiary medical center and discussed in the Program weekly didactic conferences designed in compliance with the
Gastroenterology Core Curriculum, 3 rd
Edition, May 2007. Fellows are expected to:
Competencies:
Fellow must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Fellows are expected to:
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 demonstrate an investigatory and analytic thinking approach to clinical situations know and apply the basic and clinically supportive sciences which are appropriate to their discipline.
Objectives
1. Fellows will manage proficiently the following diseases by the end of their three years of fellowship:
XIV. Specific Program Content (ACGME)
1. diseases of the esophagus;
2. acid peptic disorders of the gastrointestinal tract;
3. motor disorders of the gastrointestinal tract;
4. irritable bowel syndrome;
5. disorders of nutrient assimilation;
6. inflammatory bowel diseases;
7. vascular disorders of the gastrointestinal tract;
8. gastrointestinal infections, including retroviral, mycotic, and parasitic diseases;
9. gastrointestinal diseases with an immune basis;
10. gallstones and cholecystitis;
11. alcoholic liver diseases;
12. cholestatic syndromes;
13. drug-induced hepatic injury;
14. hepatobiliary neoplasms;
15. chronic liver disease;
16. gastrointestinal manifestations of HIV infections;
17. gastrointestinal neoplastic disease;
18. acute and chronic hepatitis;
19. biliary and pancreatic diseases;
20. women’s health issues in digestive diseases;
21. geriatric gastroenterology;
22. gastrointestinal bleeding;
23. cirrhosis and portal hypertension;
24. genetic/inherited disorders;
25. medical management of patients under surgical care for gastrointestinal disorders
26. management of GI emergencies in the acutely ill patient.
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2. Fellows will apply the clinical and scientific principles acquired from the following
Program conferences.
Monday:
Endoscopy Conference: Complications, Standards and QA (BWH)
Research Conference: Intra-Divisional (BWH)
Tuesday:
Liver Histopathology Conference (BWH)
IBD Conference (BWH)
GI Medical/Surgical Conference (BWH)
Boston Swallowing & Motility Conference (VAH)
Intercity Evening Rounds (monthly-rotating)
Wednesday:
Academic Enrichment Conference (AEC)
Clinicopathology Conference
Journal Club
Liver Conference
Research Conference
Thursday:
Didactic Conference
GI Combined Clinical Conference (Longwood – BWH, CH, BIDMC)
Friday:
Pancreas Study Group
Medical Grand Rounds
3. Fellows will use an evidence – based (EBM) approach to medical decision - making using published treatment guidelines from experts eg., the ACG and AGA .
4. Each fellow will be evaluated for competence commensurate with their training year based on objective evaluations including OSCE, Mini CEX, the Program In – House exam, the AGA GI Training Exam and six-month evaluations by their clinic mentor.
Goal
Fellows must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life long learning. Fellows are expected to develop skills and habits to be able to:
Competencies:
 Identify strengths, deficiencies and limits in one’s knowledge and expertise;
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Set learning and improvement goals
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Identify and perform appropriate learning activities
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Systematically analyze practice, using quality improvement methods, and implement changes with the goal of practice improvement
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Incorporate formative evaluation feedback into daily practice
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Participate in the education of patients, families, students, residents and other
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health professionals, as documented by evaluations of a resident’s teaching abilities by faculty and/or learners.
Objectives
1. Each fellow will analyze periodically their clinic practice to confirm compliance with published treatment guidelines and will present these results to the Division at Quality
Assurance Conference.
2. Each Fellow will present to clinic colleagues and staff a case example of EMB database analysis of a challenging case from their practice once a week.
Goal
Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Fellows are expected to:
Competencies
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Coordinate patient care within the health care system relevant to gastroenterology.
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Incorporate cost awareness and risk-benefit analysis in patient care
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Advocate for and enhance patient safety and improve patient care quality
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Participate in identifying systems errors and implementing systems solutions
Objectives
1. Each fellow will analyze and discuss twice a year a common practice system problem impacting on the access to, cost of, and quality of care received by patients in their practice and present it for discussion and resolution with clinic colleagues and staff.
2. Each fellow will recognize, and understand the role of each member of their clinic health care team.
Goal
Fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Fellows are expected to demonstrate:
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Compassion, integrity, and respect for the diversity in others
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Responsiveness to patient needs and autonomy that supersedes self-interest
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Accountability to patients, society, and the profession
Objectives:
1. Each fellow will demonstrate respect and compassion for others, manage conflict, and behave in a manner consistent with the principles of Brigham and Womens’ Hospital and the Partners Healthcare System.
2. Each fellow will act in an ethical fashion with sensitivity toward to difference between themselves and their colleagues and patients.
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Goal
Fellows must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates. Fellows are expected to:
Competencies
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Communicate effectively with patients and families across a broad range of socioeconomic and cultural backgrounds
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Communicate effectively with physicians, other health professionals or related agencies
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Work effectively as a member or leader of a health care or professional group
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Act in a consultative role to other physicians and health professionals
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Maintain comprehensive, well – organized, grammatical, timely, and legible medical records
Objectives
1. Each fellow will demonstrate strong leadership skills through respectful consideration of the opinion of all members of the healthcare team, including the patient.
2. Each fellow will communicate frankly, clearly and empathically with colleagues, staff and patients.
3. Each fellow will maintain a medical record that will serve as an ideal template for patient care.
4. Each fellow will learn the components of teacher excellence including introspection, patience, humility, compassion, candor, and effective use of bedside observation, the advice of colleagues, and the medical literature.
1. Faculty review of every case seen by the fellow.
2. Faculty – fellow (s) end-of-session case summary discussion weekly.
3. “Two-Minute Preceptor”
4. Selected review of EBM Literature by fellow
5. Bedside Teaching with the Patient
1. OSCE bi-annually
2. Mini – CEX
3. 360 degree Observation bi-annually
4. Six – Month Evaluation by Clinic mentor
5. In-House Exam and GI Training Exam annually
6. GI Board Exam
7. Standardized evaluation by faculty monthly:
Core-competency based 9 point evaluation to be completed before by the end of rotation and reviewed by the In-Service faculty member and fellow.
Evaluations must be signed by the faculty and fellow during this meeting.
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The evaluation will be made based on the following levels of training:
Guide To Level-Based Evaluation
Fellowship Year 1
A. 1 st
Segment (July – October)
Makes clinical decisions based on well-established rules and communicates them clearly and succinctly to all members of the healthcare team and referring physicians.
B. 2 nd
Segment (November – February)
Grasps situational aspects of knowledge, particularly the major GI illnesses. Understands program mission and future role as consultant, educator and investigator.
C. 3 rd
Segment (March – June)
Recommendations are based on a firm understanding of pathophysiology. Discriminates between data. Pathway to physician-investigator/academic leader is better defined.
Fellowship Year 2
Reasons more intuitively in decision – making. Increasing mastery of core curriculum and relevant literature. Thinks more independently and creatively as teacher and role model.
Fellowship Year 3
Provides subtle discriminations in clinical observations and immediate intuitive analysis.
Relishes challenge clinical challenges. Mastery of an area as teacher and investigator.
Next career step firmly established.
after Dreyfuss, H. 2007
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Fellows’ Retreat annually
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Faculty Retreat annually
3.
Zoomerang Anonymous Education Survey - annual
1. Faculty member assigned to each fellow for each clinic session reviews all communications, laboratory and diagnostic studies, and management decisions with the fellow.
2. Nurse practitioner and/or physician’s assistant at each clinic
3. Practice administrator
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1. PC with software for access to Pubmed, Medline, UptoDate, Medical Library.
2. Medical Library staffed full-time.
Created 07/01/07
Revised 07/20/07
Revised 10/30/2008
FLM/cb
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