Endoscopy Curriculum



Endoscopy Curriculum

University of Chicago

Contributing Author: Dr. Charles Dye

Written description for Fellows and Training Committee

Last updated 3-12-07

Educational Goals (knowledge, skills, attitudes):

Fellow Year 1:

Exposure to and understanding of:

1. The indications, limitations, and contraindications

of endoscopic procedures.

2. Procedure complications and their management.

3. The principles of safe conscious sedation/analgesia

techniques and patient monitoring and

when to consider alternate forms of anesthesia.

4. Medical, radiological and surgical alternatives

to endoscopic therapy.

5. Issues of informed consent, advanced directives

and medical ethics as pertains to gastrointestinal

endoscopy (as in the evaluation of

gastrostomy and cancer palliation candidates).

Thorough exposure to basic outpatient diagnostic endoscopy

Initial exposure to therapeutic and inpatient endoscopic procedures. Encounters may include observing or performing non-critical portions of the procedures

Develop patient trust as it relates to procedures and learn management flow for outpatient encounters

Build endoscopy team relationships and understand the role of endoscopy nurses pre, during, and post-procedure

Fellow year 2:

Continued exposure to and understanding of the numbered factors listed under fellow year 1.

Heightened exposure to inpatient and therapeutic procedures with expectation of progression to performing the entire procedure as skills improve.

Learn to direct endoscopic management for emergency call and consultative services

Develop educational skills focused on residents and students

Discuss recent literature and evaluate its role in current practice

Begin to adopt the role of endoscopy team leader.

Fellow Year 3:

By the last rotations, be prepared to:

1. Appropriately recommend endoscopic procedures

as indicated by the findings of consultative

evaluation, with explicit understanding of

accepted specific indications, contraindications

and diagnostic/therapeutic alternatives.

2. Perform procedures safely, completely and expeditiously,

including possessing a thorough understanding

of the principles of conscious sedation/

analgesia techniques and pre-procedural

clinical assessment and patient monitoring.

3. Correctly interpret endoscopic findings and

integrate them into medical or endoscopic therapy.

4. Identify risk factors for each procedure, understand

how to minimize each and to recognize

and appropriately manage complications when

they occur.

5. Acknowledge the limitations of endoscopic procedures

and personal skills and know when to

request help.

Focus on refining diagnostic endoscopy skills with regard to comfort, efficiency, successful completion rates.

Complete training in therapeutic procedures

Continue to nurture educational skills for residents and students and integrate recent literature into practice pattern

Become comfortable in the role of endoscopy team leader

Overview of the Rotation:

Year 1:

Orientation days:

-Orientation to endoscopy, informed consent, report writing, and the procedure unit (1/2 day)

-Sedation training course with sedation module questionnaire (1/2 day)

1st endoscopy rotation:

-Informed consent and complications of Basic procedures from Gastrointestinal Disease; An Endoscopic Approach

-Written materials for the technique of EGD and Colonoscopy provided from Blackstone Text

-Equipment overview

-Elective outpatient procedures

-Indications for endoscopy and patient interactions reviewed with each case

-Informed consent, procedure techniques, report writing, and discharge instructions under the direct supervision of the endoscopy attending

-Scope handling and processing instruction by procedure unit technician.

1st year fellow’s endoscopy course by ASGE:

-Comprehensive 2 day introductory course sponsored by the American Society of Gastrointestinal Endoscopy

-Includes a formal review of informed consent and complications

-Highlights pre-procedure antibiotic prophylaxis and peri-procedure anticoagulant management

-Includes hands on lab including experience with therapeutic techniques

Endoscopy rotations and Consultative services:

-Two outpatient endoscopy month long rotations and one-two inpatient consult months

-Ongoing exposure to outpatient and intial exposure to inpatient procedures under the supervision of endoscopy and consult attending staff

- Four-five Emergency on-call blocks

Weekly 1st year fellow endoscopy clinic:

-Focus on appropriate care and follow-up of patients with gastrointestinal diseases who have required or require ongoing endoscopic diagnosis and management

-Under the direction of an attending assigned to this clinic

Yearly fellow Hands on Endoscopy Lab in the Carlson Animal Facility at the University of Chicago using anesthetized pigs under the direction of Dr. Dye (1 day):

-Hemostasis techniques including injection therapy, Bipolar cautery, Argon plasma coagulation, endoscopic clipping, and variceal band ligation.

-Mucosal resection techniques including submucosal injections, strip technique, ligator and cap technique

Spring review and overview of objectives for second year training by Dr. Dye:

-Evaluations compiled and discussed with individual fellow

-Strengths and areas for further concentration identified

-Second year objectives reviewed and video selections for independent review discussed

Year 2:

Endoscopy rotations and Consultative services:

-One-two outpatient endoscopy month long rotations and one inpatient consult month at University of Chicago

- One-two month long rotations performing outpatient and inpatient consultative and endoscopy services at Weiss Memorial Hospital

-Four-five weeks of emergency endoscopy call

-Ongoing exposure to outpatient and intial exposure to inpatient procedures under the supervision of endoscopy and consult attending staff

Yearly fellow Hands on Endoscopy Lab in the Carlson Animal Facility at the University of Chicago using anesthetized pigs under the direction of Dr. Dye (1 day) with time spent concentrating on skills where further concentration required:

-Hemostasis techniques including injection therapy, Bipolar cautery, Argon plasma coagulation, endoscopic clipping, and variceal band ligation.

-Mucosal resection techniques including submucosal injections, strip technique, ligator and cap technique

Spring review and overview of objectives for third year training by Dr. Dye:

-Evaluations compiled and discussed with individual fellow

-Strengths and areas for further concentration identified

-Provation database log reviewed with attention to ASGE suggested core requirements

-Third year objectives reviewed and video selections for independent review discussed.

Year 3:

Endoscopy rotations and Consultative service:

-Two outpatient endoscopy month long rotations and 3 inpatient consult months

-One-two month long rotations performing outpatient and inpatient consultative and endoscopy services at Weiss Memorial Hospital

-Four-five weeks of emergency endoscopy call

-Ongoing exposure to outpatient and intial exposure to inpatient procedures under the supervision of endoscopy and consult attending staff

Yearly fellow Hands on Endoscopy Lab in the Carlson Animal Facility at the University of Chicago using anesthetized pigs under the direction of Dr. Dye (1 day) with time spent concentrating on skills where further concentration required:

-Hemostasis techniques including injection therapy, Bipolar cautery, Argon plasma coagulation, endoscopic clipping, and variceal band ligation.

-Mucosal resection techniques including submucosal injections, strip technique, ligator and cap technique

Spring review and overview of practice plans by Dr. Dye:

-Evaluations compiled and discussed with individual fellow

-Strengths and areas for further concentration identified

-Provation database logs reviewed with attention to ASGE core number requirements

-Video selections for independent review discussed.

-Core requirement deficiencies remedied

Teaching Methods/Clinical Encounters:

1. Daily endoscopy practice on rotations

a. outpatient endoscopy blocks

b. consult service blocks

c. emergency on-call weeks

d. Weiss hospital rotations

2. Weekly 1st year fellow endoscopy clinic followed by fellow continuity clinic in years 2 and 3

3. Monthly endoscopy conference with case management, radiographic review, and discussion of the literature concentrating on pancreaticobiliary disease, ERCP and EUS- led by Dr. Dye

4. Quarterly Quality Assurance conference with review of all procedure related complications for the section and discussion of literature and practice patterns- led by Dr. Dye

5. Presentation of cases from an outpatient endoscopy rotation selected on a yearly basis for GI grand rounds

6. ASGE first year fellow’s endoscopy course- Two day course led by national experts selected by the American Society for Gastrointestinal Endoscopy

7. Yearly therapeutic endoscopy hands-on Animal Lab- One day practical sessions

8. Majority of exposure to variceal endoscopic management provided on hepatology core rotations

9. Majority of exposure to PEG procedures provided on nutrition support core rotations and during month long rotations at Weiss Hospital.

10. ASGE videos in second and third years

Patient Characteristics/Disease Mix:

Inpatient and Outpatient encounters on diverse patients from many ethnicities and socioeconomic backgrounds requiring diagnostic and therapeutic endoscopy

Procedures and Skills:

Total diagnostic upper endoscopy: at least 130

Total colonoscopy: at least 140

Sigmoidoscopy: at least 25

Enteroscopy beyond the ligament of Treitz: at least 10

Capsule endoscopy: reading at least 10

Routine biopsy: at least 20

Snare polypectomy: at least 20

Dilation of peptic strictures: at least 15 over a guidewire and 10 with balloon dilators

Nonvariceal Hemostasis (include upper and lower): at least 10 active bleeders

Variceal Hemostasis: at least 5 active bleeders

PEG: at least 10 performing endoscopy and 10 performing percutaneous portions

Colon decompression: at least 3 procedures

Tatooing: instruction in hands on lab

Mucosal resection: instruction in hands on lab

Faculty Supervision:

Provided by faculty members with significant endoscopic experience and consultative experience.

Method of Evaluation:

-Faculty member evaluations

-Director of endoscopic education yearly reviews in conjunction with the director of fellowship training comprehensive reviews

-Log books documenting endoscopic curriculum compliance and progression

Attitudes/Behaviors:

1) Patient care:

-Demonstrate respect, compassion and empathy for patients

2) Medical knowledge:

-Appropriate understanding of indications for procedures, care of endoscopy equipment and pre- and post-procedure evaluation of patients

-Interpretation of endoscopic findings and pathologic results in the clinical care of patients

-Incorporation of endoscopic procedures in the ongoing care of patients including screening and prevention

3) Practice based learning and improvement:

-Utilization of medical literature, especially relevant clinical guidelines and trials, to guide practice, recommendations to patients and formulate treatment strategies

4) Interpersonal skills and communication:

-Develop and improve communication skills to patients and families

-Faculty will help foster a team approach to the delivery of endoscopic services

5) Professionalism:

-Demonstrate integrity in practice

-Demonstrate timeliness, respect toward duties, and respect for team members

6) Systems Based Practice:

-Effectively integrate radiographic information and pathologic studies

into diagnostic and management considerations

-Learn the pivotal role of the primary care MD in open-access outpatient procedure units

-Learn to utilize related consultants, particularly in radiology and surgery

Resources:

Gastrointestinal Disease; An Endoscopic Approach. Dimarino AJ jr., Benjamin SB. Slack incorporated, 2nd edition, 2002

Endoscopic Interpretation. Blackstone MA. Raven Press Incorporated, 1984.

American Society for Gastrointestinal Endoscopy (ASGE) practice guidelines and information for program directors: website links

Principles of Training in Gastrointestinal Endoscopy. ASGE standards of training committees. GI Endoscopy; vol 49(6): 845-853, 1999

Training the gastroenterologist of the future: The Gastroenterology Core Curriculum. Gastroenterology; 110:1266-1300, 1996

ASGE learning library selected videos:

-Techniques of colonoscopy and polypectomy

-Diagnosis of flat and depressed colorectal cancer

-Endoscopic mucosal resection

-Endoscopy in the bariatric patient

-Management of benign and malignant strictures

-Endoscopic removal of foreign bodies

-Management of variceal and non-variceal upper GI bleeding

-Endoscopic techniques for enteral access

-Evaluation of the small intestine

-Diagnostic ERCP

Conferences:

- Monthly endoscopy conference with attention to pancreaticobiliary diseases, ERCP, EUS

- Quarterly quality assurance conferences (mandatory) reviewing endoscopic procedure related complications

- Weekly GI grand rounds where endoscopy oriented cases routinely presented and fellows are assigned yearly endoscopy cases to discuss

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