Advanced Endoscopy

Overview

The senior fellow further hones the skills required for the competent performance of all core procedures in Gastroenterology and Hepatology.  As always, the fellow is completely supervised by a skilled faculty preceptor.

In addition, all fellows are permitted exposure in the advanced procedures, namely ERCP and endoscopic ultrasound.  These procedures require experience and training that ideally resides in centers of excellence, and are not intended to be practiced widely at the community level.  Fellows require training to a high level of competence, and mere exposure to a specific number of procedures is insufficient to guarantee that competence.  The issue is now specifically and formally addressed at a national level by the core curriculum in Gastroenterology.  The core curriculum was constructed by the AGA, the ASGE, the AASLD, and ACG (our professional colleges), and adopted for implementation by the American Board of Medicine and the ACGME effective July 1, 2005 pertinent to the issues of training in advanced endoscopic procedures.  In essence, the curriculum states that training in ERCP or EUS is not part of the core training during GI fellowship, but may be available to trainees who fulfill the requirements of what has been designated level II training.  Our program will provide exposure of these advanced procedures to each fellow.  We reserve the right to subjectively identify which trainee, if any, possesses sufficient skill to be considered for full training in such a procedure, with the intention to credential the trainee in that procedure if they demonstrate sufficient competence.  This specifically means that not every fellow will be trained to a level of competence in ERCP and/or EUS, and those fellows selected for training are not guaranteed that they will be judged competent for credentialing.

Principal Teaching/Learning Activities

Although the first-year fellow will perform all inpatient consultations in which an ERCP or EUS is requested or indicated, the ERCP or EUS fellow is still required to be intimately familiar with the entire clinical case, and will have to present the case to the Attending physician performing the ERCP or EUS.  The fellow will perform the procedures under the close supervision of a skilled faculty preceptor.  The fellow is responsible for all of the necessary preparation for the study, including issues in management of antibiotic prophylaxis and anticoagulation, and arrangements for General Anesthesia when appropriate.  The fellow will follow up the patient post-procedure in a supervisory role to the first-year fellow.  The fellow is responsible for dictating the procedure notes to the referring physician.

Other advanced Endoscopic procedures which the senior fellow will be exposed to includes Pneumatic Dilation for Achalasia, Tumor Ablation, and Esophageal Stenting. Fellows are not likely to perform enough of these latter cases for procedural competence.

Problem Mix / Patient Characteristics / Types Of Encounters

For ERCPs and EUS, fellows generally see patients for the evaluation and therapy of biliary and pancreatic diseases.  The majority of therapeutic cases involve either sphincterotomy with common bile duct stone extraction, biliary stenting of biliary or pancreatic neoplasms, biliary stenting of post-operative bile duct leaks, and EUS guided sampling of pancreatic masses or adenopathy.  Inpatient and outpatient ERCP or EUS consults will occasionally include Pediatric patients, usually performed in conjunction with the Attending Physician on Endoscopy as well as the Pediatric Gastroenterologist.

The general endoscopy experience is as described under the Endoscopy rotation.

Purpose and Principal Educational Goals by Competency

Patient Care

Principal Educational Goals

• Learn the proper indications, contraindications, special needs, and procedural preparations for core Gastroenterologic procedures, as well as ERCP or EUS.
• Recognize and respond to the complications of diagnostic and therapeutic ERCP or EUS.
• Achieve procedural technical competence in the performance of Gastroenterologic core diagnostic and therapeutic procedures, as well as ERCP or EUS.
• Learn the unique functions of the ERCP/EUS nurse procedural assistant.
• Correlate visual and pathologic findings at endoscopy/ERCP/EUS with clinical conditions.
• Learn how to safely administer conscious sedation to provide for patient comfort during procedures, and when General Anesthesia is appropriately indicated.

Medical Knowledge

Principal Educational Goals

• Expand clinically applicable knowledge base of biliary/pancreatic disorders, including patient’s tolerance of ERCP?EUS in their management.

Practice-Based Learning and Improvement

Principal Educational Goals

• Identify areas of personal deficiency in skill and knowledge in the performance of endoscopic and other core procedures of Gastroenterology and Hepatology.
• Develop and implement strategies for correcting these deficiencies.
• Learn to identify procedural complications and formulate strategies for avoiding those complications.

Interpersonal Skills and Communication

Principal Educational Goals

• Learn to interact effectively with other members of the endoscopy suite team in order to optimize patient care.
• Learn to interact effectively with patients and families to communicate the purpose of procedures and their results, and complications of procedures if necessary.
• Learn to formulate comprehensive, clear and concise procedural reports to referring physicians.

Professionalism

Principal Educational Goals

• Demonstrate compassion and empathy in dealing with patients undergoing procedures.

• Adhere to principles of patient confidentiality.

• Practice informed consent and informed refusal.
• Identify and understand risk management issues in the performance of endoscopic procedures, especially relatively higher risk ERCP.

Systems-Based Practice

Principal Educational Goals

• Understand the system under which outpatient and inpatient endoscopic procedures are provided.
• Collaborate with other team members in helping patients effectively negotiate the system.
• Understand the role of endoscopic management in a multidisciplinary approach to various patient disorders and problems.
• Utilize evidence-based therapeutic management strategies to optimize patient care.

Evaluation

Fellow’s performance is evaluated by faculty as discussed in detail later.  The Key clinical faculty in advanced endoscopy will make the final determination regarding a fellow’s competence in a specific advanced procedure.

Recommended Reading

Fellows are expected to be familiar with the cognitive aspects of biliary and pancreatic disease, and these are well covered in the general Gastroenterology textbook as previously described.  Current medical information is also obtained through the previously referenced computerized data base.  The program recommends the fellows obtain an atlas of general Endoscopic and ERCP/EUS findings, and an ERCP or EUS specific text.  Teaching DVD videos from the ASGE are available to the fellows and maintained by the program coordinator.