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A Journey Toward Excellence: Training Future Gastroenterologists

THE GASTROENTEROLOGY CORE CURRICULUM Third Edition – May 2007

Presented by the American Association for the Study of (AASLD) American College of Gastroenterology (ACG) AGA Institute American Society for Gastrointestinal (ASGE) SPONSORING SOCIETIES

Training standards, guidelines, and resources are regularly updated by societies representing gastroenterology/ . For up-to-date and/or expanded information, please visit the following web sites:

American Association for the Study of Liver Diseases (AASLD)

1001 North Fairfax Suite 400 Alexandria, VA 22314 703.299.9766 www.aasld.org

American College of Gastroenterology (ACG)

6400 Goldsboro Road Suite 450 Bethesda, MD 20817 301.263.9000 www.acg.gi.org

AGA Institute

4930 Del Ray Avenue Bethesda, MD 20814 301.654.2055 www.gastro.org

American Society for Gastrointestinal Endoscopy (ASGE)

1520 Kensington Road Suite 202 Oak Brook, IL 60523 630.573.0600 www.asge.org

This third edition of the Gastroenterology Core Curriculum, published in May 2007, supersedes all previous editions. All rights reserved. Table of Contents

Page

Preface 2

Overview of Training in Gastroenterology 4

Training in Acid-Peptic 10

Training in Diseases and Pancreatic Disorders 12

Training in Cellular and Molecular Physiology 15

Training in Endoscopy 19

Training in Ethics, Medical Economics, and System-Based Practice 24

Training in Geriatric Gastroenterology 25

Training in Hepatology 29

Training in Inflammation and Enteric Infectious Disease 32

Training in Malignancy 35

Training in Motility and Functional Illnesses 38

Training in Nutrition 42

Training in 45

Training in Pediatric Gastroenterology 47

Training in 48

Training in Research 50

Training in 53

Training in Women’s Health in Digestive Diseases 54

Appendixes

I. Roster of Contributing Editors 58

II. Diagnostic Procedural Competency Form 60

Diagnostic Upper Endoscopy Procedural Competency Form 62 2 THE GASTROENTEROLOGY CORE CURRICULUM Preface The Gastroenterology Core Curriculum was first assessment to the ACGME Outcome Project’s published in 1996; this document contains the third General Competencies and as such recommends a edition of the Gastroenterology Core Curriculum number of tools that can be used to assess the com - for gastroenterology training. The Core petence of trainees, including direct observation by Curriculum constitutes a living document that rep - qualified faculty, log books, periodic patient care resents the four societies’ vision of best practices in record reviews, portfolios, patient surveys, 360° gastroenterology training. It provides a framework global rating evaluations, and formal examinations. for developing an individual plan of study and Numerical guidelines provide only a minimum stan - growth that should be tailored to meet the needs of dard for competency and instead should be viewed each individual trainee based on the strengths and as a threshold level after which competency-based special qualities of each individual training pro - assessment should be instituted. Regardless of the gram. The curriculum will continue to evolve with duration of training, the number of patients seen, or time as new knowledge, methods of learning, novel the number of procedures performed, the ultimate techniques and technologies, and challenges arise. goal must always remain excellence in all aspects of This edition has been divided into an overview of patient care, scholarship, and a commitment to life - training and 17 chapters encompassing the breadth long learning. of knowledge and skills required for the practice of gastroenterology. These areas include not only the traditional curricular content of gastroenterology The Quality Initiative in The Quality Initiative in American medicine is an and hepatology but also associated disciplines such effort to improve outcomes, maximize safety, and as pathology, radiology, and surgery. New areas simultaneously increase the value of care for health - that have been incorporated into the third edition care consumers. Severe cost pressures in the U.S. of the Gastroenterology Core Curriculum include healthcare delivery system over the past several new antireflux techniques, advanced training (cer - decades have forged alliances among corporate pay - tificate of added qualification [CAQ]) in hepatol - ers to maximize the cost-effectiveness of care (e.g., ogy, moderate sedation, novel techniques and tech - the Leapfrog Group, 2000). Reports related to med - nologies, and CT colonography. Additionally, all ical errors and patient safety (To Err Is Human, areas have been linked to the Accreditation Council 1999) raised concerns and drew the attention of on Graduate (ACGME) many public and private entities. The Institute of Outcome Project’s General Competencies. Medicine’s recommendations for an improved health This edition of the curriculum represents a joint care system (Crossing the Chasm a New Health collaborative effort among the national gastroen - System for the 21st Century, 2001) urged the align - terology societies—the American Gastroenter- ment of payment with quality improvement. ological Association (AGA) Institute, the American The Center for Medicare and Medicaid Services’ College of Gastroenterology (ACG), the American (CMS) took up that challenge and continues efforts Association for the Study of Liver Diseases to contain expenditures for its beneficiaries. (AASLD), and the American Society for Gastro- Clinical quality data around the variability of care intestinal Endoscopy (ASGE). The training commit - (e.g., CABG rates in different regions of the coun - tees of each of the four sponsoring societies, as well try) and outcomes (e.g., CAD mortality rates as several subject matter experts, made specific rec - unchanged, despite uneven intensity of care), have ommendations for revising the core curriculum. also spurred public demand for a more transparent Each society then named two representatives who and predictable standard of care. In recent years, were charged with overall responsibility for devel - the growth of evidence-based medicine has con - oping, communicating, and distributing the curricu - tributed to healthcare quality and its measurement. lum (see page 3). Additionally, the Gastroenterology Training programs must assure that fellows under - Steering Committee received input on the draft cur - stand the importance of quality measurement in riculum from several training directors and faculty their future practice of gastroenterology and that members and extends its sincere gratitude for their fellows are familiar with the techniques used to support. Those who provided substantive editorial measure quality and with methods used to enhance contributions to this edition are featured in performance. For more information on quality in I, along with the names of contributing gastroenterology, please visit www.gastro.org, editors for the previous edition that was published Clinical Practice section. in 2003. Throughout this document, the paramount importance of practice and research based on the highest principles of ethics, humanism, and profes - sionalism is reinforced. This document links trainee 3

The Gastroenterology Core Curriculum Steering Committee

AASLD Representatives AGA Institute Representatives Don C. Rockey, MD Deborah D. Proctor, MD Professor of Medicine Associate Professor of Medicine Chief, Division of Digestive and Liver Diseases Gastroenterology Fellowship Program Director University of Texas Southwestern Medical Center Yale University School of Medicine 5323 Harry Hines Boulevard Dept. of Internal Medical/Section of GI Dallas, TX 75390-8887 333 Cedar Street, Room 1080 LMP 214.648.3444 New Haven, CT 06520 [email protected] 203.785.3408 [email protected] Stephen A. Harrison, MD, MAJ(P), MC Chief of Hepatology M. Michael Wolfe, MD Division of Gastroenterology and Hepatology Professor of Medicine Department of Medicine Chief, Section of Gastroenterology Brooke Army Medical Center Boston University Medical Center Fort Sam Houston, TX 78234 650 Albany Street - Evans Rooms 504 210.916.2881 Boston, MA 02118-2393 [email protected] 617.638.8330 [email protected]

ACG Representatives ASGE Representatives Roy K. H. Wong, MD Chief of Gastroenterology Robynne Chutkan, MD Walter Reed Army Medical Center Assistant Professor of Medicine Professor of Medicine Division of Gastroenterology Director, Division of Digestive Diseases Georgetown University Uniformed Services University of the Health Sciences 5530 Wisconsin Avenue, Suite 1248 Bethesda, MD 20307 Chevy Chase, MD 20815 202.782.7256 301.215.7700 [email protected] [email protected]

Lawrence R. Schiller, MD John J. Vargo, MD, MPH Program Director, Gastroenterology Fellowship Head, Section of Therapeutic and Hepatobiliary Endoscopy Baylor University Medical Center Department of Gastroenterology and Hepatology GI, 3 Truett Cleveland Foundation 3500 Gaston Avenue 9500 Euclid Avenue Dallas, TX 75246 Cleveland, OH 44195 214.820.2671 216.445.5012 [email protected] [email protected]

Staff Liaison Allison Waxler, Director of Training AGA Institute 4930 Del Ray Avenue Bethesda, MD 20814 301.941.2624 [email protected]

The Gastroenterology Core Curriculum, third edition, is dedicated to Ingrid T. Thomas (1961-2006), AGA Institute Director of Training (2003-2006). 4 THE GASTROENTEROLOGY CORE CURRICULUM Overview of Training in Gastroenterology accomplish the overall educational pro gram. Importance Specifically, as directed by the ACGME, section II.A.4: Gastroenterology consultants must possess a range of “The sponsoring institution must assure that attributes, including a broad knowledge base, the abili - adequate salary support is provided to the pro - ty to generate a relevant differential diagnosis based on gram director for the administrative activities an accurate history and physical examination, an of the program. understanding of the indications and contraindications The program director must not be required to for diagnostic and therapeutic procedures, skill at per - generate clinical or other income to provide forming these procedures, the ability to think critically, this administrative support. It is suggested that and an appreciation of the humanistic and ethical this support be 25-50% of the program direc - aspects of medicine. Such attributes can emanate only tor’s salary, depending on the size of the pro - from a clinical training program that provides a firm gram. (See Section III.A.4f).” foundation in pathophysiology as well as abundant In addition, training institutions must provide exposure to patients under the supervision of experi - adequate clinical support services on a 24-hour enced, thoughtful educators. This exposure must be basis, foster peer interaction among specialty and long enough for trainees to understand the natural his - subspecialty trainees, and sponsor meaningful bio - tory of disease and the impact of treatment both on medical research. the disease and on the patient. Instructors in proce - dures must impart a thoughtful, cost-conscious Educational Program approach to the use of technology as an extension of Gastroenterology training programs must provide the subspecialist’s craft rather than as an end in itself. an intellectual environment for acquiring the Facilities must be available for trainees to participate knowledge, skills, clinical judgment, attitudes, and actively in research as a means of fostering the inquisi - values of professionalism that are essential to the tive thought processes demanded of skilled consultants, practice of gastroenterology. As defined by the to create new knowledge, and to improve patient care. ABIM in the 2001 Project Professionalism: Surrounding all of these activities must be a dedication “Professionalism in medicine requires the to the patient as a person; technical expertise in the to serve the interests of the patient absence of humanism represents the antithesis of the above his or her self-interest. Professionalism skilled practitioner, whether generalist or subspecialist. aspires to altruism, accountability, excellence, duty, service, honor, integrity, and respect for others. The elements of professionalism encom - General Aspects of Training pass a commitment to the highest standards of Prerequisites for Training excellence in the practice of medicine and in Trainees in gastroenterology must have completed a the generation of knowledge, a commitment to 3-year in internal medicine, or be in the sustain the interests and welfare of patients, American Board of Internal Medicine (ABIM) and a commitment to be responsive to the Research Pathway, at an institution accredited by health needs of society.” the ACGME or a foreign equivalent. The training The program also must stress the role of gastroen - requirements referenced herein reflect the terologists as consultants and the need to establish ACGME’s Program Requirements for Fellowship the skills necessary to communicate effectively with Education in the of Internal referring . The objectives of training can Medicine and the Program Requirements for be achieved only when the program leadership, sup - Fellowship Education in Gastroenterology , effective porting staff, faculty, and adminis tration are fully July 2005 (see www.acgme.org). committed to the educational program and when Training Institutions appropriate resources and facilities are available. Gastroenterology training must take place only in While it is recognized that trainees provide substan - medical institutions that are accredited for internal tial service to their teaching hospital, service com - medicine and gastroenterology training by the mitments should never compromise the achieve - ACGME and are affiliated with established medical ment of educational goals and objectives. schools. As outlined in the July 2005 ACGME Every aspect of training should include the cultiva - Program Requirements for Fellowship Education in tion of an attitude of skepticism and inquiry and a the Subspecialties of Internal Medicine and the dedication to continuing education that will remain Program Requirements for Fellowship Education in with the trainees throughout their professional Gastroenterology, evidence of institutional commit - careers. A major contributor to the enhancement of ment to education must include financial resources a scholarly attitude is active participation in one or adequate to support appropriate compensation for more research projects, ideally followed by presenta - sufficient faculty and trainees, adequate and modern tion of the work at a national meeting and publica - facilities, sufficient space and current equipment to tion of a paper in a peer-reviewed journal. 5

Duration of Training A substantive research experience of 3 –6 months Training programs must be at least 3 years in dura - as a stimulus for developing an inquiring and criti - tion and must include a minimum of 18 months of cal mind is required. As important as direct patient clinical training experience. A premium is placed care, and woven throughout the 3-year fellowship, on experience. The more experience gained under is the requirement for an array of conferences and supervision during training, the more skilled the didactic sessions. Trainees are expected to have spe - specialist will become. Such experience should cific instruction throughout the fellowship in the include the long-term management of patients with clinical, translational, and basic sciences that a variety of diseases and exposure of trainees to the underlie the scientific basis of practice today and to natural history of gastrointestinal and hepatic dis - have the opportunity to participate in meaningful eases as well as the effectiveness and limitations of scholarly activity. . As training progresses, it is important for Beyond the 18-month core clinical curriculum the trainees to develop independence. A 3-year and the 3 –6 month research requirement, 12 addi - training program allows sufficient time for a grad - tional months are required to complete fellowship ual reduction in the level and degree of supervision training. This time will permit flexibility for activi - so that, by the end of the training period, trainees ties outside of the prerequisites of the core clinical feel confident in their own abilities to independent - curriculum that meets the trainee’s needs, interests, ly manage complicated disorders. and career goals. This may translate into 12 months of additional clinical training or research Duty Hours training, specialized training in specific skills, or Trainee duty hours should be monitored to ensure elective experiences. that they meet guidelines established by the Level 2 training, or enhanced clinical training, is ACGME (see Section VI). specifically for any gastroenterologist who wishes Levels of Training to provide specialized services as a consultant to The curriculum continues to require a minimum of 3 other physicians and is detailed for , nutri - years of training in gastroenterology. The core clini - tion, advanced endoscopic procedures, motility cal curriculum requires a minimum of 18 months of studies, biliary tract diseases and pancreatic disor - patient care experience and consists of traditional ders, and hepatology. Detailed criteria that mirror inpatient and outpatient consultative and specialized the requirements set by the ABIM before sitting for care experience. A longitudinal outpatient ambulato - the examination for added qualifications in trans - ry experience is mandated for the full 3 years of plant hepatology are included, but would necessari - training. Explicit programmatic recommendations ly be accomplished during a fourth year of training. are indicated in the areas of acid-peptic disease, bil - In most cases, up to 12 additional months of iary tract diseases and pancreatic disorders, cellular clinical or research training beyond the core clinical and molecular physiology, endoscopy, ethics, medical curriculum may be required to attain level 2 economics and system-based practice, geriatric gas - expertise in a given area. It is anticipated that troenterology, hepatic pathology, hepatology, inflam - under most circumstances, level 2 training can be mation and enteric infectious disease, malignancy, accomplished for some within the context of the 3- motility and functional illnesses, nutrition, pediatric year training period. However, in some circum - gastroenterology, radiology, research, surgery, and stances, such as expertise in advanced therapeutic women’s health issues. A central feature of training procedures, an additional year, that is, a fourth in gastroenterology remains the requirement for ded - year may be necessary to satisfactorily complete all icated training in hepatology. Included in the guide - requirements for level 2 training. lines for training in hepatology is the requirement For trainees preparing for careers in laboratory that at least one faculty member is recognized as or clinical investigation, an intensive research expe - having expertise in . rience during fellowship training is recommended, ASGE guidelines for training in basic endoscopic with the recognition that such training may need to skills are affirmed with the explicit requirement that be continued well beyond the standard 3-year peri - certification of competency in basic endoscopy can - od of training to prepare the trainee for a career as not be considered before minimum threshold levels an independent investigator. This training may are met; competency-based assessment demands include university course work appropriate for attainment of substantial skill and experience before careers in clinical or basic research, for example, program directors can attest to the competence of the epidemiology, statistics, research methodology, out - trainees in endoscopy. Achievement of expertise in comes and effectiveness research, decision analysis, endoscopic retrograde cholangiopancreatography cell biology, molecular genetics, and/or ethics as (ERCP) and endoscopic ultrasonography (EUS) is not well as supervised research activity under the guid - included as an objective for all trainees, but is ance of qualified mentors. reserved for selected trainees desiring enhanced skills Throughout this document, the paramount impor - in interventional endoscopy. See Appendix II for the tance of practice and research based on the highest Diagnostic Colonoscopy Procedural Competency principles of ethics, humanism, and professionalism is Form and the Diagnostic Upper Endoscopy reinforced. The importance of the scientific method Procedural Competency Form . and of preparation for lifelong learning based on 6 THE GASTROENTEROLOGY CORE CURRICULUM

independent and critical thinking, a desire for self- Relationship to Other Disciplines improvement, and a love of learning is emphasized. Care of patients with digestive diseases often involves a multidisciplinary approach. Therefore, trainees must learn to work effectively and efficiently with members Program Faculty of other specialties and subspecialties. This is especial - Program Director ly true for the internal medicine subspecialties of car - A single training director must be responsible for the diology, critical care medicine, and as well as program. She or he must be board certified in gas - the specialties of surgery, pathology, and radiology. troenterology or possess equivalent qualifications and Increasingly, trainees will need to develop skills in must have 5 years of participation as an active faculty management to enable them to lead multidisciplinary member in the subspecialty. The training director is teams. Particular instruction and experience in collab - expected to ensure adequate time to coordinate and orating with primary caregivers in a managed care set - direct training-related activities. In accordance with ting is essential. ACGME guidelines, the director must be based at the primary training site of the program (see Section Facilities and Resources III.4.c) and must dedicate an average of 20 hours per The following facilities and resources are essential week to the training program (see Section III.4.f). for the training program: 1. There must be a sufficient number of new and Faculty follow-up patients, with a broad variety of gas - In addition to the program director, the program trointestinal and hepatic diseases, to ensure must provide a minimum of four institutionally- adequate inpatient and outpatient experiences. based key clinical faculty members who all must be Both men and women and—to the extent pos - certified in gastroenterology or possess equivalent sible pregnant women and adolescents—and qualifications. For programs with an approved geriatric patients of both sexes must be includ - compliment of more than six, a ratio of key clinical ed in the fellow’s panel of patients. Patient faculty to fellows of at least 1:1.5 must be main - backgrounds should be diverse and represent a tained (see Section XII). range of ethnic, cultural, and socioeconomic At least one full-time faculty member must be a groups. Qualified faculty must supervise fully trained hepatologist, as defined within the trainees in all aspects of patient care, including Training in Hepatology chapter. At least one full- care delivered in both inpatient and outpatient time faculty member must be skilled and demon - settings and during procedures. strate expertise in advanced endoscopic procedures, 2. Up-to-date inpatient and facil - as defined within the Training in Gastrointestinal ities are essential to accomplish the overall mis - Endoscopy chapter. Above and beyond a minimum sion of the training program. number of faculty, there must be enough additional 3. There must be a fully equipped and staffed pro - full-time or part-time faculty to ensure adequate cedure laboratory that includes state-of-the-art supervision of trainees and coverage of all pro - diagnostic and therapeutic endoscopic instru - grammatic components. At all times, fellows will ments and motility equipment. The laboratory be adequately supervised by staff physicians. must be capable of performing, or have access Each full-time faculty member must devote at to, specialized serological, parasitological, least 10 hours per week, averaged over 1 year, to immunologic, metabolic, and toxicological stud - teaching, research, administration, and/or the criti - ies applicable to gastrointestinal and hepatobil - cal evaluation of the performance, progress, and iary disorders. Computers should be available competence of trainees. In addition, faculty mem - with appropriate software to permit trainees to bers must serve as appropriate role models by access medical literature online, perform Internet active participation in the clinical practice of gas - searches, record results of procedures, and estab - troenterology, their own continuing education, lish a database. The capability to perform basic regional and national scientific societies, research gastrointestinal function tests is essential. activities, and the presentation and publication of 4. Supporting services, such as a full-service emer - scientific studies and scholarly reviews. gency department, diagnostic and intervention - Faculty should be evaluated at intervals by trainees al radiology department, medical imaging and to assure that the trainees’ needs are being met. facility, pathology laboratory, Please visit www.acgme.org for more information on general and hepatobiliary surgical unit, and program faculty requirements for gastroenterology. oncology unit must be available. 5. There must be a modern, fully-staffed unit for Environment for Training in the intensive care of critically ill patients with Gastroenterology gastrointestinal and hepatic disorders. 6. A library with online capabilities for providing Relationship to Training in Internal Medicine adequate access to the literature and including Gastroenterology fellows must maintain their skills computer-assisted literature searches is required. in general internal medicine and develop appropri - 7. Adequate administrative support for the fel - ate lines of communication and responsibility with lowship program, including financial support internal medicine residents and faculty. for a fellowship coordinator or assistant, OVERVIEW OF TRAINING IN GASTROENTEROLOGY 7

access to computers for personnel management diseases are evaluated and managed. The and scheduling, and a budget to provide office arrangements must be such that patients recog - supplies and other administrative expenses to nize the fellow as the physician who is involved run a program. in providing their continuous care. To understand the natural history and long-term outcome of digestive diseases, trainees must attend the same Specific Program Content clinic for a minimum of 6 months. Patient Care Experience The patient care experience for trainees is com - Training Through Conferences and Other prised of three major elements. Nonpatient Care Activities 1. While training should be tailored to reflect the In addition to the patient care experience, trainees ultimate career goals of the individual fellow, should have extensive involvement in other types every gastroenterology training program must of experiences. include a core clinical training experience of 18 1. Trainees should, through independent study, months to be completed by all trainees. This develop a scholarly approach to education by period will consist of clinical training in the reading current textbooks and monographs, inpatient and outpatient diagnosis and man - relevant scientific literature, and distributed agement of digestive diseases as outlined by syllabus materials. Trainees should be encour - each of the relevant chapters on training, with aged to attend seminars, postgraduate courses, approximately 5 months of this experience and annual scientific meetings of the major devoted to training in liver disorders (see digestive diseases societies. Section XI.C). During the core clinical train - 2. Clinical conferences should be held on a week - ing, adequate numbers of routine endoscopic ly basis. Trainees must be actively involved in procedures must be performed to exceed the the planning and content of these conferences. minimum standards as described within the 3. Basic science, journal club, and research confer - chapter, Training in Endoscopy. Trainees must ences should be held regularly, at least monthly. have appropriate supervised experience to The journal club should be used as a tool to develop skills in providing consultative services teach the skills of critical reading, detection of and communicating with physicians and other biases, assessment of validity of controls, appli - members of the team. cation of statistics, generalizability of results, and 2. For those individuals whose career goals con - related attributes of scientific studies. sist primarily of patient care, a further 18 4. Interdisciplinary conferences with radiology, months of training will include a total of at pathology, and surgery services should be held least 6 months of scholarly activity consisting at least monthly. of basic or clinical research, course work, or 5. A series of lectures/discussions should be held other structured activity not primarily involv - throughout the period of training to cover a ing direct patient care (see Training in core curriculum of physiology, pathophysiolo - Research). The remaining months will include gy, and clinical pharmacology. additional experience in general consultative 6. Visiting scholars, professors, and investigators gastroenterology and experience in specialized should be brought in to stimulate new thoughts areas, depending on the interests and career and ideas among trainees as well as faculty. goals of the trainees and the opportunities 7. Participation in quality assurance and continu - available in the programs. Such areas of study ous quality improvement programs should be might include enhanced competence in hepatic required. Discussion of systems-based practice diseases, motility disorders, inflammatory should be an integral part of this effort. bowel disease, nutrition, or interventional 8. The opportunity to formally study the elements endoscopy (see appropriate chapters). of study design, decision analysis, outcomes and Where formal guidelines for attaining effectiveness research, statistics, epidemiology, enhanced competence in an area are provided, and other skills necessary to conduct and evalu - the designation of level 2 training is applied. ate clinical investigation should be available to Level 2 training will designate that the trainee all trainees yearly. can act as a consultant to other gastroenterolo - Teaching Experience gists and other clinicians in that area of expert - Trainees should actively participate in the teaching ise. Upon satisfactory completion of level 2 of medical students, medical residents, and less training, the trainee will receive a letter or advanced trainees in gastroenterology. In addition, other document that indicates that this level of ample opportunity must be provided for trainees to expertise has been reached. participate in seminars and conferences. The ability 3. In recognition of the importance of outpatient to interweave basic and clinical material in a cohe - medicine to the practice of gastroenterology, all sive manner and to present and defend concepts in trainees must spend at least one half-day per an open forum is invaluable for a career as a sub - week for the entire 3-year period in an ambulato - specialty consultant. ry care clinic in which both new and continuing care patients with gastroenterological and hepatic 8 THE GASTROENTEROLOGY CORE CURRICULUM

including family, genetic, psychosocial, and I. Evaluation of Trainees environmental histories, and the ability to per - Formal evaluations of each trainee’s progress and form a comprehensive and accurate physical final competence are required by the ACGME and examination. The ability to arrive at an appro - for objective documentation for purposes of creden - priate differential diagnosis, outline a logical tialing. Training programs must have established plan for specific and targeted investigations methods to evaluate trainee competence, regular pertaining to the patient’s complaints, and for - written records detailing the progress of all trainees, mulate a plan for management and follow-up and a defined program of verbal and written feed - treatment of the patient is critical. The ability back to the trainees. The trainee must receive appro - to effectively present the results of a consulta - priate and timely feedback throughout the training tion orally and in writing and to defend the experience, including formative and summative eval - clinical assessment, differential diagnosis, and uations in all areas being evaluated. diagnostic and management plans is essential. Elements of Competence to be Assessed In addition, trainees must demonstrate proce - As outlined in the ACGME General Competencies, dural skills essential for the practice of gas - trainees should be evaluated in the following areas troenterology and hepatology. (Table 1): 2. Medical knowledge – Trainees must demon - 1. Patient care – Trainees must be able to provide strate a core fund of knowledge in gastroen - patient care that is appropriate, effective and terological and hepatic physiology, pathophysi - compassionate. This would include, but not be ology, clinical pharmacology, radiology, and limited to, the following: history-taking, surgery as outlined in the goals of each chapter

Table 1 – Methods for Assessing ACGME General Competencies 1. PATIENT CARE c. Portfolios a. Direct observation by qualified faculty during a) work and d. Formal evaluation forms from faculty members, nurses, allied teaching rounds, b) patient history-taking and physical exami - health personnel, and patients who come into contact with the nation, c) procedures, and d) conferences trainees (360° evaluation) b. Formal evaluation forms from faculty members, nurses, allied e. Formal examinations to test the practice-based learning and health personnel, and patients who come into contact with improvement in clinical skills and medical knowledge of the the trainees (360° evaluation) trainee c. Patient care record review d. Patient and staff surveys (360° evaluation) 4. INTERPERSONAL AND COMMUNICATION SKILLS e. Formal examinations to test the clinical skills and medical a. Direct observation by qualified faculty during a) work and knowledge of the trainee, including mastery of the interpreta - teaching rounds, b) patient history-taking and physical exami - tion of endoscopic, radiologic, and pathologic findings, such as nation, c) procedures, and d) conferences an in-service training examination. b. Formal evaluation forms from faculty members, nurses, allied f. Portfolios health personnel, and patients who come into contact with g. Procedural skills (as defined by each training chapter) the trainees (360° evaluation) h. Log books (preferably computerized) and objective compe - c. Patient and staff surveys (360° evaluation) tency determinations of all endoscopic procedures and liver biopsies and all level 2 skills 5. PROFESSIONALISM a. Direct observation by qualified faculty during a) work and 2. MEDICAL KNOWLEDGE teaching rounds, b) patient history-taking and physical exami - a. Formal examinations nation, c) procedures, and d) conferences b. Direct observation by qualified faculty during a) work and b. Formal evaluation forms from faculty members, nurses, allied teaching rounds, b) patient history-taking and physical exami - health personnel, and patients who come into contact with nation, c) procedures, and d) conferences the trainees (360° evaluation) c. Formal evaluation forms from faculty members, nurses, allied c. Patient and staff surveys (360° evaluation) health personnel, and patients who come into contact with the trainees (360° evaluation) 6. SYSTEMS-BASED PRACTICE d. Patient care record review a. Direct observation by qualified faculty during a) work and e. Formal examinations to test the clinical skills and medical teaching rounds, b) patient history-taking and physical exami - knowledge of the trainee, including mastery of the interpreta - nation, c) procedures, and d) conferences tion of endoscopic, radiologic, and pathologic findings, such as b. Formal evaluation forms from faculty members, nurses, allied an in-service training examination. health personnel, and patients who come into contact with the trainees (360° evaluation) 3. PRACTICE-BASED LEARNING AND IMPROVEMENT c. Observation during involvement in continuous quality a. Direct observation by qualified faculty during a) work and teach - improvement activities ing rounds, b) patient history-taking and physical examination, c) d. Formal examinations to test the system-based practice clini - procedures, and d) conferences cal skills and medical knowledge of the trainee, such as an in- b. Patient care record review service training examination OVERVIEW OF TRAINING IN GASTROENTEROLOGY 9

on training. Trainees must be able to demon - • Portfolios (a collection of products prepared strate an analytic approach and use appropri - by the trainee that provides evidence of ate investigations, including the practice of evi - learning and achievement related to the dence-based medicine. learning plan. It might include a log of clini - 3. Practice-based learning and improvement – cal procedures performed; a summary of the Trainees must be able to investigate, evaluate, and research literature reviewed when selecting a improve their patient care practice by analyzing treatment option; a quality improvement and assimilating both scientific evidence as well as project plan and report of results; ethical their own prior experience into their practices. dilemmas faced and how they were handled; They should be able to apply knowledge of statis - a computer program that tracks patient care tical methods to critically appraise clinical studies outcomes; or a recording or transcript of and be able to use information technology to sup - counseling provided to patients, etc.) port their own education. They must be involved • Patient surveys in teaching and be able to facilitate the learning of • 360° evaluations (an evaluation method that other students and health care professionals. incorporates feedback by all members of the 4. Interpersonal and communication skills – health care team, colleagues, and patients). Trainees must be able to demonstrate interper - This “full circle” evaluation provides multi - sonal and communication skills that result in ple perspectives on one’s performance. effective information exchange with their • Formal in-service examinations to test the clini - patients, families, and other health care profes - cal skills and medical knowledge of the trainee, sionals. This would include, but not be limited including mastery of interpretation of endo - to, verbal and written communication as a scopic, radiologic, and pathologic findings consultant and to generation of endoscopic reports that are accurate and timely. Trainees must be able to work effectively as members II. Evaluation of Graduates The training director should attempt to evaluate and leaders of the health care team. the performance of graduates from the program on 5. Professionalism – Trainees must demonstrate a routine basis. Suggested components of this eval - an understanding of and commitment to all uation include the following: elements of professionalism, including respect, a. Scores on Certification and Recertification compassion and integrity toward their patients, examinations administered by the ABIM patient families, and other health care profes - b. Licensure and practice status of graduates sionals. They must demonstrate ethical behav - c. Involvement in postgraduate educational cours - ior, responsiveness, and sensitivity to a diverse es and other Continuing Medical Education gender, ethnic, socioeconomic, and aging (CME) programs patient population. d. Involvement in teaching and research activities 6. Systems-based practice – Trainees must e. Publications demonstrate an understanding of, awareness of, and responsiveness to the larger context and system of health care delivery. The trainees III. Evaluation of Training Program and should understand how their patient care prac - Faculty tice impacts other health care professionals, Training programs, including curricular and faculty the larger health care system, and society in performance, must be evaluated in a rigorous and general. They should be able to practice cost- meaningful fashion on a regular basis. effective health care without compromising a. Graduates should be surveyed at intervals quality of care for their patients. The trainee about the relevance of what they were should be able to advocate for timely, quality taught to their current activities and areas in patient care and know how to partner with which additional educational efforts by the other health care providers to provide the opti - training programs are needed. mal health care for their patients. b. Trainees must be given the opportunity to Methods for Assessing Trainee Competence anonymously evaluate the faculty and train - Depending upon the specific area that the trainee is ing program at regular intervals, but mini - being evaluated in, the following methods may be mally at the end of each rotation. used to evaluate the trainee’s performance: c. The program director must regularly meet • Direct observation by qualified faculty dur - with the faculty and trainees to evaluate the ing a) work and teaching rounds, b) patient curriculum and whether the training objec - history-taking and physical examination, c) tives are being met. procedures, and d) conferences d. Standardized testing should be used to assess • Log books (preferably computerized) and the individual performance of trainees, as well objective competency determinations for all as the program’s success in achieving its speci - endoscopic procedures and all level 2 skills fied educational milestones. • Periodic patient care record reviews 10 THE GASTROENTEROLOGY CORE CURRICULUM Training in Acid-Peptic Disease 4. The natural history, epidemiology, and compli - Importance cations of acid-peptic disorders, including Acid-peptic disorders (gastroduodenal ulcer, gastro- recognition of premalignant conditions (e.g., esophageal reflux disease, gastritides/gastropathies, Barrett’s metaplasia). , Zollinger-Ellison syndrome and other 5. The role of H. pylori in acid-peptic hypersecretory states) are common afflictions. It diseases; trainees should gain an understanding has been estimated that 7% of the U.S. population of the properties of H. pylori infection, includ - experiences symptoms daily and almost ing its epidemiology and pathophysiology, such half on a monthly basis. Dyspepsia accounts for as factors specific to the organism (e.g., the upwards of 10% of all physician encounters. Peptic CagA protein), factors specific to the host (e.g., ulcer disease affects more than 5% of the U.S. pop - interleukin polymorphisms), and factors specif - ulation. (H. pylori ) is a ic to the environment (e.g., diet and antisecre - major risk factor for peptic ulcer as well as gastric tory therapy). carcinoma and lymphoma. The use of nonsteroidal 6. The role of NSAIDs in the pathogenesis of gas - anti-inflammatory drugs (NSAIDs) and/or aspirin troduodenal ulcers and their complications, also is a major risk factor for peptic ulcers. These including an understanding of risk factors for conditions cause morbidity and may result in seri - developing NSAID-related ulcers and the relative ous complications leading to hospitalization, sur - risks posed by different individual NSAID prepa - gery, or even death. Because of their prevalence, rations based on various different properties. potential for complications, and economic conse - 7. The pharmacology, adverse reactions, efficacy, quences, acid-peptic disorders encompass an impor - and appropriate use and routes of administra - tant group of diseases. tion of drugs for acid-peptic disorders; these Technology in diagnostic and therapeutic imaging include antacids and histamine-2 receptor techniques and in surgical, radiologic, and endo - antagonists, proton pump inhibitors, mucosal scopic management of these disorders has changed protective agents, prostaglandin analogues, dramatically. Great strides have been made in prokinetic agents, and antibiotics. understanding the pathophysiology of, and therapy 8. Endoscopic and surgical treatments of acid- for, disorders of the upper . peptic disorders. It is suggested that trainees The ability to reliably diagnose such disorders has gain an understanding of clinical indications been greatly enhanced by endoscopy, and definitive and relative cost effectiveness, complications, therapy may be performed during endoscopy for and , both in the short-term and disorders such as and bleeding long-term (see chapters on Training in ulcers. Endoscopic techniques for the management Endoscopy and Training in Surgery). of gastroesophageal reflux disease have also recent - ly been described. Unless otherwise noted, trainees must also develop The practice of gastroenterology now involves more competence in the following: than just the time-honored physician skills of history- 1. Performing a thorough gastrointestinal-directed taking and physical examination. Both the cognitive history and physical examination. and technical skills of endoscopy must be acquired 2. Performing diagnostic and therapeutic upper and continuously maintained. The acquisition of skills gastrointestinal endoscopy. It is suggested that in these multiple disciplines as they relate to the evalu - trainees gain familiarity with endoscopic modal - ation and management of acid-peptic disorders will ities for the treatment of gastroesophageal reflux best ensure well-trained gastroenterologists. disease, such as application of radiofrequency, energy injection therapy, and mechanical devices (see Training in Endoscopy). Goals of Training 3. Familiarity with capsule endoscopy and its During fellowship, trainees should gain an under - applicability to the evaluation of upper gastro- standing of the following: intestinal disease. 1. Anatomy, physiology, and pathophysiology of 4. Trainees should learn to perform, read, and the , , and . interpret esophageal pH probe tests, including 2. Gastric secretion and indications for gastric wireless technology, esophageal impedance analysis (i.e., measuring output). testing, and esophageal motility studies (see 3. The indications for serum gastrin measurement Training in Motility and Functional Illnesses). and secretin testing for the diagnosis of gastrino - 5. Trainees should gain experience in interpreting ma and consequences of hypergastrinemia in plain films of the abdomen, barium examina - both hypersecretory and achlorhydric states; tions of the upper gastrointestinal tract, ultra - trainees should also gain an understanding of the sonography, abdominal computed tomographic mechanisms involved in the development of sec - scans, magnetic resonance imaging, angiogra - ondary hypergastrinemia due to low acid states. 11

phy, and somatostatin receptor scintigraphy the endoscopic treatment modalities for hem - (see Training in Radiology). orrhage (including injection therapy, cautery, 6. Understanding invasive and noninvasive tech - banding, and clipping), biopsy, and polypecto - niques for diagnosing H. pylori infection. my. It is suggested that trainees become famil - 7. Understanding the role of prostaglandins in iar with the placement of radiotelemetry mucosal protection, the importance of devices and have experience with endoscopy in prostaglandin inhibitors (NSAIDs, aspirin) in patients with surgically altered anatomy (fun - causing ulcers, and the effects of selective doplication, ulcer , gastric bypass) cyclooxygenase-2 (COX-2) inhibitors on 2. Dilatation of benign and malignant mucosal integrity in the upper gastrointestinal esophageal strictures tract, on platelet function, and on the patho - 3. The performance and interpretation of genesis of thrombotic events. Other potential esophageal motility studies, 24-hour pH moni - effects of COX inhibition, such as possible toring including wireless technology, and the beneficial benefits in the treatment of dysplasia interpretation of gastric secretory studies. It is in Barrett’s esophagus and prophylaxis of col - suggested that trainees gain familiarity with orectal polyps, should be discussed. impedance testing (see Training in Motility and Functional Illnesses). 4. Trainees should gain experience in the inter - Training Process pretation of radiological studies of the upper Trainees must acquire a thorough knowledge of gastrointestinal tract, including contrast gas - appropriate history-taking, which should consist of trointestinal examinations, ultrasonography, family, genetic, psychosocial, and environmental computed tomographic scans, magnetic reso - histories, including a detailed history of prescrip - nance imaging, somatostatin receptor scintigra - tion and over-the-counter (nonprescription) drug phy, and angiography use, particularly NSAIDs and aspirin, and the abili - 5. Indications and interpretation of studies for ty to perform a comprehensive and accurate physi - specific entities, such as hypersecretory states, cal examination in patients with acid-peptic dis - H. pylori , and other of the upper ease. This should include an examination of the gastrointestinal tract, particularly acquired whole patient. Trainees should be able to arrive at immunodeficiency syndrome (AIDS)-related an appropriate differential diagnosis, be able to disorders outline a logical plan for specific and targeted 6. It is suggested that trainees gain a working investigations pertaining to the patient’s com - knowledge of upper gastrointestinal tract plaints, and be able to design an appropriate pathology, such as mucosal biopsies for gastri - scheme of management and follow-up. tis, Barrett’s esophagus, and malignant condi - Trainees must develop expertise under direct tions (see Training in Pathology). supervision in performing and interpreting all of the procedures and diagnostic tests that are rou - tinely used in the evaluation and treatment of Assessment of Competence patients with acid-peptic disorders (see Training in Knowledge of acid-peptic disease should be assessed Endoscopy). This experience should include the as part of the overall evaluation of trainees in indications, limitations, technical aspects, and com - gastroenterology during and after the fellowship, as plications of the following procedures as well as an outlined in Overview of Training in Gastroenter- understanding of the benefits and dangers of mod - ology. Questions relating to acid-peptic disease erate sedation: should be included on the board examination and 1. Upper intestinal endoscopy, both elective and should reflect a general knowledge of this content. emergent, including proficiency in the use of 12 THE GASTROENTEROLOGY CORE CURRICULUM Training in Biliary Tract Diseases and Pancreatic Disorders recurrent pyogenic cholangitis, parasitic and Importance opportunistic infections. Biliary Tract Diseases 7. Other inflammatory disorders of the gallblad - Biliary tract diseases occupy a significant portion of der such as acalculous . the practice of gastroenterology. The diagnosis of 8. Neoplastic diseases of the gallbladder and bile and therapy for these diseases represent major chal - ducts. lenges to practicing gastroenterologists because 9. Motility disorders including gallbladder dyski - rapid advances in technology require skills not pre - nesia, sphincter of Oddi dysfunction. viously taught (e.g., invasive endoscopic and radio - 10. Principles of evaluation and treatment of com - logical procedures, , scintig - mon clinical syndromes: raphy). To achieve maximal effectiveness, minimize a. risk, reduce costs, and provide the best possible b. RUQ and “biliary-type” pain care for patients, specialized training is required c. Incidental findings on radiographic testing that emphasizes knowledge of anatomy, physiology, 11. Radiographic evaluation of the biliary tree: pathophysiology, and clinical presentation of biliary basic principles, utility and lesion recognition: tract diseases. Gastroenterologists must be familiar a. Ultrasonography with new technology and be in a position to apply b. CT it for the benefit of their patients. c. MRI Pancreatic Disorders d. Scintigraphic techniques Pancreatic disorders are common diseases that pres - e. MRCP ent multifaceted challenges to gastroenterologists. 12. Principles, utility, and complications of biliary For example, acute may lead to the surgery. rapid development of a variety of potentially life- 13. Procedural competence—see below. threatening complications; is a Pancreatic long-standing, frequently debilitating disease. In 1. The embryological development and anatomy caring for patients with , gastroen - of the and the pancreatic duct system terologists must make an expeditious and cost- and congenital disorders such as pancreas divi - effective diagnosis and weigh possible curative or sum, annular pancreas. palliative treatment options. Because of the com - 2. The physiological processes involved in pancre - plexity of these diseases, the wide assortment of atic exocrine secretion of digestive enzymes, potential diagnostic modalities, and the lack of water, and electrolytes. consensus in many aspects of diagnosis and man - 3. The types of digestive enzymes secreted by the agement, gastroenterologists are commonly the pri - pancreas, their mechanisms of activation and mary consultants or direct caregivers for patients their roles in the digestive process. with . 4. The factors that protect the pancreas from autodigestion. Goals of Training 5. The epidemiology, etiology, pathophysiology, During fellowship, trainees should gain an under - natural history, and management of acute pan - standing of the following: creatitis in all spectra of severity and its com - plications. Biliary 6. The epidemiology, etiology, pathophysiology, 1. Basic embryology and anatomy of the biliary natural history, and management of chronic tree and congenital structural anomalies, pancreatitis with particular emphasis on man - including duplications and cysts. agement of exocrine insufficiency and chronic 2. Hormonal and neural regulation of bile flow pain. and gallbladder function. 7. The epidemiology, etiology, natural history, 3. Physiology of bile secretion and its derange - and management of pancreatic cancer and its ment in cholestatic disorders. complications. 4. Bile composition in health and disease. 8. The molecular genetics of pancreatic disease 5. Cholelithiasis—epidemiology, etiology, clinical with particular reference to hereditary pancre - manifestations and complications, treatment atitis and cystic fibrosis, their diagnosis and modalities. management. 6. Other disorders of the bile ducts, including 9. Radiographic evaluation of the pancreas: basic 13

principles, utility, and lesion recognition: creatic diseases. Trainees will be provided the a. Ultrasonography opportunity to perform an adequate number of b. EUS procedures, receive supervised teaching, and to be c. CT involved in clinical research. While the endoscopic d. MRI training is important, level 2 training should aim to e. MRCP produce an expert in managing all aspects of bil - 10. Principles, utility, and complications of pancre - iary tract diseases. In terms of cognitive and diag - atic surgery. nostic acumen, level 2 trainees should be expected 11. The basis and indications for and the interpre - to know physiology, pathophysiology, diagnosis, tation of diagnostic test results in the diagnosis and therapy of biliary and pancreatic diseases in and management of diseases of the pancreas, greater detail than those at level 1 of training. in particular, serum amylase and lipase deter - All trainees at level 2 should also be given the mination, markers for chronic pancreatitis opportunity to be involved in clinical or basic (fecal elastase, serum tryspinogen-like research. Trainees in the biliary and pancreatic immunoreactivity, etc.) serum tumor markers sections will be expected to acquire an under - (e.g., CA 19-9), radiological and endoscopic standing of clinical research, including study imaging studies (see Training in Endoscopy design, methodology, statistical analysis, writing and Training in Radiology), indirect tests of the protocols, submitting protocols to institutional pancreatic secretory function, direct tests of review boards, writing informed consent, enrolling secretory function (e.g., secretin and patients into studies, analyzing and interpreting secretin/cholecystokinin stimulation tests, test data, presenting at national meetings, and writing meals), duodenal drainage with analysis for papers. Individual preceptors should teach basic biliary crystals, fine-needle aspiration of pan - or clinical research on a one-on-one basis and at creatic masses, and analysis of cytology in research conferences. It is anticipated that most endoscopic aspirates of pancreatic juice. physicians participating in level 2 training will 12. Principles and practice of nutritional support for enter an academic environment, which will allow patients with both acute and chronic pancreatitis. them to continue in the multidisciplinary area of 13. Procedural competence—see below. treating patients with biliary and pancreatic dis - eases as well as teaching and conducting clinical Training Process research. As with most specialties a combination of cogni - Procedural Training tive/clinical skills and knowledge, along with proce - All trainees should have a thorough knowledge of dural proficiency is necessary for training in the the endoscopic techniques used in the diagnosis care of patients with these disorders. Two levels of and treatment of biliary tract diseases and pancre - training should be offered. Level 1 training is for atic diseases, including their potential risks, limita - those trainees who will be a part of the general gas - tions, and costs. Trainees also must understand the troenterology program and have exposure to dis - role of alternative diagnostic and therapeutic eases of the biliary tract and pancreas. Level 2 modalities (medical, surgical, and radiological) in training is intended for those who will be selected the evaluation and management of biliary tract and to spend the entire third year of training and/or an pancreatic diseases. They should understand the additional fourth year of training in biliary tract advantages and disadvantages of the different diag - diseases and/or pancreatic diseases. nostic and therapeutic procedures available. Endoscopic retrograde cholangiopancreatogra - Clinical/Cognitive Training phy and endoscopic ultrasound are the primary Level 1 tools for accessing the biliary tree and the pancreat - At this level, all trainees should acquire the funda - ic ductal system and a major route for therapeutic mental core of information outlined above in the first intervention. Trainees should attain an understand - 18 months (core clinical) of training through individ - ing of percutaneous transhepatic cholangiography ual reading, presentation of core curriculum at gas - and the performance and interpretation of endo - troenterological/radiological/surgical clinical confer - scopic retrograde cholangiopancreatography and ences , lectures by invited speakers, journal clubs, endoscopic ultrasound (indications, contraindica - and daily contact with the attending physicians. tions, limitations, complications, and interpreta - Level 2 tion) through participation in and observance of The major goal for trainees at level 2 (see also those procedures under supervision of the attending Training in Endoscopy) is to acquire an in-depth physician and with the assistance of a radiologist. knowledge of pathophysiology, clinical presenta - These complex procedures require extensive train - tion, diagnosis, epidemiology, and therapy of bil - ing, which is difficult to give to all trainees. The iary and pancreatic diseases. In general, trainees in level of experience required for performing endo - biliary and pancreatic diseases at this level should scopic retrograde cholangiopancreatography may have completed at least 18 months of training in vary with the career expectations of the trainees. general gastroenterology and should spend up to As above, training can be stratified into two levels an additional year specializing in biliary and pan - (see also Training in Endoscopy). 14 THE GASTROENTEROLOGY CORE CURRICULUM

Level 1 Level 2 This level involves minimal exposure to biliary This level involves at least 12 months of advanced and pancreatic endoscopy for those trainees who training in pancreaticobiliary endoscopy (see do not plan to perform them. “Minimal exposure” Training in Endoscopy) and is aimed at individuals is defined as an understanding of the indications who seek to be true experts in endoscopic manage - and contraindications of ERCP and EUS, the ment of biliary tract diseases (level 2). The experi - advantages and disadvantages, complications, ence necessary to become proficient in the diagno - alternative diagnostic and therapeutic options, and sis and therapy of biliary tract diseases should be interpretation of findings. This knowledge could offered only in institutions that have a large patient be acquired through conferences, teaching rounds, referral base, a wide range of patients with biliary courses, and 1- to 2-month rotations through the tract diseases, and experienced faculty in gastroen - biliary tract service. Hands-on experience in bil - terology, radiology, surgery, and . iary procedures is encouraged but not required in Trainees in gastroenterology must understand the this group of trainees. role the following disciplines play in the diagnosis and In addition to a knowledge and understanding management of pancreatic disorders and must have of endoscopic procedures, all level 1 trainees direct experience working with these disciplines in the should have a general understanding of the indica - care of individual patients: therapeutic endoscopy, sur - tions, advantages, and disadvantages of imaging gery, , anatomic pathology procedures, such as plain film of the abdomen, and , nutritional support service, pain cholecystogram, ultrasound, computed tomogra - management service, medical oncology, and radiation phy, magnetic resonance imaging, and scintigra - oncology (see Training in Endoscopy, Training in phy. As part of this process, they should have a Surgery, Training in Radiology, Training in Hepatic basic understanding of how to interpret these Pathology, and Training in Nutrition). studies. This knowledge will be acquired through regular and frequent contacts with radiologists and nuclear medicine specialists and/or a 1- to 2- Assessment of Competence Knowledge of biliary tract diseases and pancreatic month rotation through radiology. Lastly, trainees disorders should be assessed as part of the overall should be exposed to the performance and the evaluation of trainees in gastroenterology during and interpretation of endoscopic ultrasound and endo - after the fellowship, as outlined in Overview of scopic retrograde cholangiopancreatography and Training in Gastroenterology. Questions relating to should observe several surgical biliary and pancre - biliary tract diseases and pancreatic disorders should atic procedures during the course of training (see be included on the board examination and should Training in Radiology and Training in Surgery). reflect a general knowledge of this content. 15 Training in Cellular and Molecular Physiology 2. , including the function Importance of the promoter region, introns, exons, and Instruction in the fundamentals of cellular and untranslated regions, and mechanisms regulat - molecular physiology provides an essential founda - ing the expression of this information, includ - tion for the overall educational program in modern ing transcription, messenger RNA synthesis, gastroenterology. A complete understanding of nor - translation, and protein synthesis. mal and abnormal gastrointestinal processes cannot 3. The importance of genetic variability, including be achieved without a working knowledge of life at single nucleotide polymorphisms and other its most fundamental level. The following goals chromosomal aberrations, particularly as they must be acquired by those trainees planning a apply to diagnostics and therapeutics. career in basic biomedical research, while all 4. The molecular processes responsible for maintain - trainees must gain exposure to gastrointestinal cel - ing genetic fidelity, such as proofreading and lular and molecular physiology. repair enzymes, and the consequences of their fail - ure, including malignant cellular transformation. Goals of Training 5. The basic cellular mechanisms regulating cell During fellowship, trainees should gain an under - proliferation and differentiation and cellular standing of a variety of disciplines, including demise, including those of apoptosis, anoikis, , genetics, physiology, neurogastroen - and necrosis. terology, pharmacology, biochemistry, and patholo - 6. The role of epigenetic factors and chromatin gy. Such exposure should result in an operational remodeling in regulating gene expression, includ - understanding of technology as well as information ing DNA methylation and histone acetylation. on cellular and subcellular structure and function Genetics pertinent to each discipline. Trainees should develop Trainees should acquire a basic understanding of the capacity to understand and interpret the relevant the following: literature as well as to comprehend and study future 1. Genetic polymorphisms, genetic defects, the developments in the field. Furthermore, trainees genetic basis of gastrointestinal diseases such should be able to search and critically analyze fun - as hemochromatosis, Wilson’s disease, familial damental scientific and related pertinent information pancreatitis, cystic fibrosis, MEN-1, intestinal from appropriate national and international pub - polyposis syndromes, , lished literature. Finally, it is suggested that they Crohn’s disease, and inborn errors of metabo - learn how to search for suitable funding organiza - lism; the gene mutations involved; and the tions and regulatory agencies, such as the National nature of human gene mutations involved in Institutes of Health, National Science Foundation, disease pathogenesis. and the U.S. Food and Drug Administration, to 2. Oncogenes, tumor suppressor genes, apply for research funds, including the national gas - microsatellite and genetic instability, genomic troenterology societies, and from which to obtain imprinting, chromosomal rearrangements, gene updated information on newly developed therapeutic amplification, and epigenetics, and their roles approaches and drugs. These skills will provide the in altered cell growth. trainees with the means to access information to 3. Trainees must gain an understanding of the answer specific questions regarding molecular mech - genetics of colorectal cancer and other disor - anisms and molecular disorders that may occur in ders listed above to enable the identification of patients with gastrointestinal diseases and how to individual patients at risk, guide diagnostic approach their management. and therapeutic interventions in specific Concepts patients and their families, and provide guid - Although a precise curriculum cannot be specified ance, counseling, and answers to questions because of the rapidly advancing scientific environ - from patients and their families. ment, it is suggested that the following be covered. Cell Biology Molecular Biology It is suggested that trainees gain knowledge in the The trainees should understand the following: following: 1. The function of genes and chromosomes and 1. The basic subcellular constituents of the cell such their location, composition, and the mecha - as the nucleus, mitochondria, Golgi, endoplas - nisms regulating their replication. mic reticulum, and lysosomes, along with their 16 THE GASTROENTEROLOGY CORE CURRICULUM

normal functions and alterations in disease. knowledge of the complexity of the innervation 2. The normal control of the cell cycle and and transmitter/modulator system governing the processes leading to its disruption. various digestive functions must be acquired. 3. The fundamental properties of cell types specific 5. The existence and importance of the endocrine to and crucial to the operation of the gastroin - system that is scattered throughout the diges - testinal tract. This includes an understanding of tive tract and that often expresses the same the turnover of the gastrointestinal epithelium regulatory peptides and other chemical messen - and the need for continuous differentiation from gers as neurons. stem cells located within each specific tissue 6. The existence of immune cells that activate and/or comprising the gastrointestinal local and systemic defense systems by interact - tract as well as the processes regulating normal ing with endocrine cells and neurons. Immune tissue differentiation and organogenesis. messages are converted by local lymphocytes 4. The epithelial layer as a modulator of vectorial and amplified by circulating lymphocytes in solute transport, as a sensory organ, and as a response to luminal antigen activation. critical barrier against toxins and pathogens. 7. The disparate mechanisms by which different Mechanisms that lead to the establishment of chemical messengers are released and reach cell polarity and the appropriate development their sites of action, including endocrine, neu - of intercellular junctions that are central to roendocrine, paracrine, and autocrine mecha - epithelial barrier function both under normal nisms of action. Trainees should have a basic conditions and in disease states such as inflam - understanding of regulatory peptides and of matory bowel disease. neurotransmitters and their specific receptors 5. The functional and structural organization of the as they relate to the gastrointestinal tract. enteric nervous system, the network of neurons Appreciating the molecular basis of this initial embedded within the gastrointestinal wall con - signaling step is essential for interpreting trolling gastrointestinal function, and the extrin - potential genetic alterations as well as the basis sic neurons (afferent and efferent) that contribute of pharmacological interventions. to the modulation of digestive functions. 8. The roles of nitric oxide and NO synthase in Segmental differences along the cephalocaudal cellular physiological events and their implica - axis critical to function as well as specialized reg - tions related to gastrointestinal physiology and ulatory cells such as the interstitial cells of Cajal pathophysiology as well as the NO pathway in and immune cells also must be understood. inflammation and splanchnic circulation and its likely interaction with the glutamate system. Pharmacology and Cellular Signaling It is strongly suggested that trainees be able to rec - Host-environment Interactions ognize the following: Trainees should have an understanding of the 1. Basic receptor pharmacology, including regula - following: tion, trafficking, and signaling as well as recep - 1. The factors permitting the existence of commen - tor transport mechanisms, cellular signal trans - sal organisms and their contribution to main - duction, and cell-to-cell signaling. taining host health as well as the processes 2. The existence of different superfamilies of whereby pathogenic organisms are recognized receptors, including ion-channel gated, G pro - and by which they induce a host response tein coupled, nuclear, and tyrosine kinase- 2. The principles that underlie the efficacy of pro - activating receptors, along with the different biotic organisms in gastrointestinal diseases. pathways through which second messengers 3. The cellular and molecular biology underlying are activated to induce a functional response. important infections, including H. pylori , The existence and complexity of cross-talk Salmonella species, E. coli , and other enteric among these various signaling pathways at pathogens both the intracellular and extracellular level. 4. Basic virology so that current infections, 3. The rapidly growing field of cellular signal including the many causes of , HIV, transduction as a mechanism underpinning and gastroenteric infections as well as future critical regulatory processes in health and dis - disorders can be appreciated; an understanding ease. These include cell-matrix communication, of viral life cycle, genome organization, regula - important in host defense; cell–cell communi - tion of replication, and pathophysiologic mech - cation, important in tissue responses; and anisms of disease intracellular pathways critical for cell home - Immunology ostasis that, when disturbed, can cause unregu - Unless otherwise noted, it is strongly suggested lated growth or premature cell death. that trainees have a fundamental knowledge of 4. The existence of numerous transmitters and the following: modulators synthesized and released by neurons 1. -associated immune system. Trainees innervating the digestive system, including clas - should gain familiarity with gut-associated sical transmitters such as acetylcholine and immune system and distinct differences from noradrenaline as well as slow transmitters/ systemic immunology and the implications of modulators (e.g., regulatory peptides). A clear TRAINING IN CELLULAR AND MOLECULAR PHYSIOLOGY 17

this particular system in understanding gas - and their use in radioimmunoassay and trointestinal physiology and pathophysiology. immunohistochemistry as well as an under - This knowledge should include a clear under - standing of antibody specificity and sensitivity. standing of the roles of a variety of mediators 8. Cell sorting technology/flow cytometry. and modifiers of the inflammatory process, Understanding the basis of these techniques including cytokines and chemokines and other and their potential applications to distinguish related molecular species. among specific cell types. For example, their 2. Autoimmune diseases. Trainees should gain famil - use in the elucidation of cell populations iarity with autoimmune diseases and the markers involved in inflammatory responses and/or for immune-mediated gastrointestinal diseases. neoplastic processes. 3. Basic transplantation biology. Trainees should 9. Detection of cell markers. Understanding gain familiarity with basic transplantation biol - methodologies ranging from microscopic, ogy, including the processes leading to and per - nucleic acid hybridization, immunodetection mitting the development of critical disorders methods to enzymatic assays, used to identify such as graft-versus-host disease. cell markers. Application of such technologies 4. Innate and adaptive immunity. Trainees should to distinguish the various populations of cells gain familiarity with innate and adaptive involved in inflammatory and neoplastic immunity, such as Th1 and Th2 responses. processes. The limitations of these immunolog - ical and biochemical detection methods in sort - Technologies ing out information regarding specific disease Technical advances have played a critical role in processes. allowing bench-to-bedside transfer of technology. 10. Imaging techniques. Understanding how fluo - Therefore, a basic understanding of many critical rescent and other markers can be used to technologies must be included in the education of assess cell signaling events in real time gastroenterology trainees. 11. New technologies. An understanding of rapidly 1. Genetic screening techniques. A fundamental developing technologies, including phage dis - understanding of genetics required to apply play technology, filamentous phage biology, genetic screening techniques effectively. and applications from the nascent fields of 2. Principles of polymerase chain reaction. genomics and proteomics. Understanding the technology as well as its 12. Information acquisition. Understanding the utility, limitations, applications, and diagnostic acquisition of information in molecular biolo - and information acquisition potential. gy or as it pertains to gastroenterology, both 3. Microarray technology. Understanding the now and in the future, via the Internet. For methodology, present and projected applica - example, DNA and RNA relationships and tions, and limitations. DNA sequences, DNA databases, SNPs, and 4. Recombinant DNA technology. Understanding permutations in DNA sequences, such as gene the techniques and applications of develop - mutations and deletions, applicable to gas - ment of recombinant human proteins and pep - trointestinal diseases. tides for their therapeutic and diagnostic appli - cations; basic knowledge of strategies in gene In summary, the nature of gastroenterology therapy, including familiarity with the use of requires an understanding of the cellular, molecular, oligonucleotides, anti-sense DNA, small inter - and genetic mechanisms underlying normal physi - fering RNA, and micro RNA. ology, including proliferation, differentiation, and 5. Basic understanding of genetic animal models programmed cell death (apoptosis). The impor - of disease, such as transgenic and gene knock tance of the multiple specialized tissues that encom - out or knock in technologies as well as their pass gastrointestinal function, ranging from the limitations with respect to pathophysiology of musculature to the gut brain, the splanchnic circu - human disease. lation, the endocrine system, the gut immune sys - 6. Proteomic methodology. Understanding of tem, and the epithelia, cannot be minimized. methods applied to the assessment of the Equally crucial is an appreciation of what goes amount and activation status of specific pro - awry in altered physiological states seen in inflam - teins within cells, including Western blotting, mation, infection, and neoplasia. electrophorectic separation, and mass spectro - metric approaches. 7. Antibody methodology. Understanding tech - Training Process Ideally, any training program should seek to com - niques involved in creation of hybridomas and bine the acquisition of fundamental information the potential application of monoclonal anti - pertaining to gastrointestinal morphology, physiol - bodies obtained using this technique, an under - ogy, and biology, with presentation of information standing of the theory and practical use of on altered cellular events in gastrointestinal disor - humanized chimeric monoclonal antibodies ders. Training in gastroenterology provides unique because of their present and future applica - opportunities to do this because there are numer - tions for diagnosis and management of ous examples in the field where the information patients, familiarity with polyclonal antibodies 18 THE GASTROENTEROLOGY CORE CURRICULUM

can be presented in tandem. Equally relevant, the and-answer sessions, and trainee presentations. trainees should be educated in methods to acquire 5. An emphasis on basic mechanisms in direct and critically interpret information from the litera - one-on-one instruction and questioning of ture now and in the future. Most important is the trainees during the diagnosis and management recognition by faculty and trainees that a thorough of patients. Instruction in basic cellular and understanding of the fundamental physiological, molecular physiology must be incorporated cellular, and molecular mechanisms is imperative into all aspects of clinical training and cannot for the well-trained gastroenterologist. be divorced from that training so as to appear The experience, training, and acquisition of separate from, and possibly irrelevant to, clini - information for trainees in these areas may be pro - cal practice. vided in a variety of ways, which are not mutually 6. Direct involvement in research activities from exclusive. basic science to translational research that uti - 1. Specific lectures dedicated to conveying infor - lize the tools and techniques of cell and molec - mation regarding the topics indicated above as ular physiology to ask questions pertinent to well as inclusion of relevant basic science in the pathophysiology of gastrointestinal and clinical lectures. hepatobiliary diseases. 2. Appropriate readings including primary litera - ture and instructional materials with critical discussions in an appropriate forum such as Assessment of Competence Knowledge of cellular and molecular physiology journal clubs. should be assessed as part of the overall evaluation of 3. Conferences and lectures at local, national, or the trainees in gastroenterology during and after the international meetings. fellowship, as outlined in Overview of Training in 4. Seminar-type courses that focus on the cellular Gastroenterology. No specific examination or other and molecular basis of gastrointestinal physiology instrument of assessment needs to be developed for for credit in academic institutions. Instruction can this portion of the training. It is recommended that be based on a combination of prior reading the program director or a faculty committee oversee assignments, didactic discourse with question- the accomplishment of these goals. 19 Training in Endoscopy 5. Recognition of risk factors attendant to endo - Importance scopic procedures and to be able to recognize Gastrointestinal endoscopy is an essential part of and manage complications. modern clinical gastroenterology. Therefore, all 6. Personal and procedural limits and to know gastroenterologists must be knowledgeable about when to request help. endoscopic procedures. Gastroenterologists per - 7. Indications, complications, and risks of capsule forming routine diagnostic and therapeutic endoscopy and how to integrate this technology endoscopy (e.g., control of gastrointestinal bleed - into the overall clinical evaluation of the patient. ing) require training to achieve basic and clinical 8. Safe and appropriate use of moderate sedation. knowledge, judgment skills, and the technical competence requisite for performing these studies. In addition, gastroenterologists should be skilled Furthermore, gastroenterologists who perform in the approach to the diagnosis and the endo- advanced endoscopic procedures, such as endo - scopic and/or medical management of patients scopic retrograde cholangiopancreatography with gastrointestinal hemorrhage, including acute (ERCP), endoscopic ultrasound (EUS), endoscopic upper gastrointestinal hemorrhage of both variceal mucosal resection (EMR), placement of enteral and nonvariceal origin and lower gastrointestinal stents and endoscopic GERD therapy require addi - bleeding of either acute or chronic presentation. tional training in therapeutic endoscopy as well as Two levels of endoscopic training for two distinct advanced training in hepatobiliary diseases, pan - types of gastroenterologists should be recognized. creatic diseases, and oncology. Not all trainees can • Level 1 includes gastroenterologists per - or should be offered comprehensive training in forming routine gastrointestinal endoscopic advanced endoscopy. Furthermore, not all pro - and non-endoscopic procedures as part of grams are capable of providing training in all the practice of gastroenterology and gas - advanced endoscopic procedures to all trainees. troenterologists specializing in non-endo - The ABIM defines procedural skills as the scopic aspects of gastroenterology, includ - learned manual skills (including supervision of ing, but not limited to, the study of liver technical aspects) necessary to perform certain diseases, motility, nutrition, and basic sci - diagnostic and therapeutic procedures in gastroen - ence research. terology. Successful mastery of these skills includes • Level 2 includes gastroenterologists who, in technical proficiency; an understanding of their addition to all or part of the above, per - indications, contraindications, and complications; form some or all advanced (both diagnostic and the ability to interpret their results. and therapeutic) gastrointestinal endoscopy procedures, including endoscopic retro - grade cholangiopancreatography (with Goals of Training sphincterotomy, lithotripsy, stent place - The objective of endoscopic training programs is to ment, etc.), endoscopic ultrasound, endo - provide trainees with critical, supervised instruction scopic mucosal resection, endoscopic in gastrointestinal endoscopy to ensure quality care GERD therapy, and laparoscopy. for patients with digestive diseases. Endoscopic Gastroenterologists who perform advanced procedures are not isolated technical activities but endoscopic procedures should assume must be regarded by the instructors and trainees as responsibility for teaching these advanced integral aspects of clinical problem solving. endoscopic procedures to designated Endoscopic decision making, technical proficiency, trainees if appropriate, conduct endoscopic and patient management are equally important, research, and critically assess and evaluate and the interdependence of these skills must be new and emerging endoscopic technology/ emphasized repeatedly during the training period. procedures for safety and efficacy. During fellowship, trainees should gain an understanding of the following: Faculty 1. Appropriate recommendation of endoscopic Endoscopy training instructors should be sound cli - procedures based on findings from personal nicians and teachers who are well trained, experi - consultations and in consideration of specific enced, and skilled in endoscopy. Endoscopy instruc - indications, contraindications, and diagnostic/ tors should have a demonstrated aptitude for therapeutic alternatives. teaching because it is recognized that not all expert 2. Performance of specific procedures safely, com - endoscopists are expert teachers. The optimal pletely, and expeditiously. endoscopic instructor should be sensitive to the 3. Correct interpretation of most endoscopic and level of training and will demonstrate sufficient capsule endoscopic findings. patience according to the trainee’s appropriate level 4. Integration of endoscopic findings or therapy of training. Instructors should be responsible for into the patient management plan. appropriate didactic instruction and supervision (or 20 THE GASTROENTEROLOGY CORE CURRICULUM

delegation of supervision to other instructors) of all 1. Properly trained gastrointestinal endoscopists elective and emergency procedures. Supervision 2. Properly trained nurses and endoscopy techni - consists of observing and directing the trainees as cians they manipulate the endoscope. 3. Well-maintained and functioning equipment The actual process is comprised of verbal direc - 4. Adequately furnished preparation, endoscopy, tions for a series of complex physical maneuvers and recovery areas with the instructors at the sides of the trainees. In 5. Equipment and trained personnel to perform addition, the endoscopy instructors should be cardiopulmonary resuscitation, if needed responsible for continuing instruction in endoscop - 6. A functioning quality-improvement program ic decision making, technique, and interpretation Endoscopic Experience of findings and the ongoing evaluation of proce - Trainees must be exposed to a sufficient number of dures, reports, and photographic records. Timely new and follow-up inpatients and outpatients of and accurate evaluation of the trainee’s skills is varied ages (adult and geriatric) and of both sexes essential to ensure the proper development of and with a variety of common and uncommon skills and the identification of deficiencies that can digestive disorders to permit a broad endoscopic be quickly corrected. experience. It is essential that endoscopic experi - Facilities ence be attained in patients presenting with both Modern inpatient, ambulatory care, clinical labo - acute and chronic upper and lower gastrointestinal ratory, radiology, and pathology facilities to hemorrhage, including acute variceal hemorrhage. accomplish the overall educational program must Trainees should achieve competence in a variety of be available and be functioning at the primary methods of endoscopic therapy (e.g., endoscopic training sites. The clinical environment must hemostasis for both variceal and nonvariceal gas - include emergency as well as intensive care facili - trointestinal hemorrhage). Table 2 provides guide - ties to ensure adequate exposure to patients with lines for endoscopic training in routine procedures. acute upper and lower gastrointestinal hemor - Each required number of procedures noted in rhage. In addition, safe and efficient performance Table 2 represents the threshold number of proce - of gastrointestinal endoscopy relies on the avail - dures that must be performed before competency ability of the following: can be assessed. The number represents a mini -

Table 2 – Guidelines for Endoscopic Training in Routine Procedures: Threshold for Assessing Competence

Procedure Required number a Esophagogastroduodenoscopy 130 Including treatment of nonvariceal hemorrhage (10 actively bleeding) 25 Including treatment of variceal hemorrhage (5 actively bleeding) 20 Esophageal dilation (guidewire and through the scope) 20 Colonoscopy 140 Including snare and hemostasis 30 Percutaneous endoscopic gastrostomy placement b 15 Capsule endoscopy (small bowel) 25

NOTE. The information in this table represents the current recommendations of the ASGE. Because ASGE guidelines are living documents, they undergo frequent revision. Please check the ASGE web site (www.asge.org) to obtain the most current information.

a Required number represents the threshold number of procedures that must be performed before compe - tency can be assessed. The number represents a minimum, and it is understood that most trainees will require more (never less) than the stated number to meet the competency standards based on existing data.

b Refers to the gastric component of the PEG tube placement. TRAINING IN ENDOSCOPY 21 mum, and it is understood that most trainees will esophagus and has not been evaluat - require more (never less) than the stated number. ed, most experienced endoscopists who have com - Trainees must learn that, when performing a diag - pleted a formal gastroenterology fellowship readily nostic procedure, they must be prepared to con - master this technique. duct needed therapeutic interventions as well, Essential components of patient safety during should that become necessary. Trainees must endoscopic procedures must be mastered, includ - assume continuing responsibility for both acute ing the intravenous administration of medications and chronically ill patients, before and after that produce moderate sedation and analgesia and endoscopy, to learn the natural history of gas - the application and interpretation of noninvasive troenterological disorders as well as the effective - patient monitoring devices. Familiarity in the ness of therapeutic endoscopic procedures. The administration of deep sedation, with such agents use of teaching aids such as endoscopy simulators, as propofol, during endoscopic procedures should videotaped recordings of previously performed also be included. Trainees should be familiar with endoscopic procedures, use of endoscopy atlases, the care, cleaning, and proper maintenance of attendance at endoscopy courses, including short endoscopy equipment. Technical skills for endo - hands-on animal courses, and ongoing review of scopic procedures must be acquired in a sequential the endoscopic literature is encouraged but should fashion. Proficiency develops as an incremental not be viewed as substitutes for hands-on experi - process through performance of sufficient num - ence in performing procedures. bers of procedures under direct supervision in a methodical sequence of increasing complexity. After suitable supervision, the trainees should be Training Process capable of independently performing routine Endoscopic training should take place within the endoscopic procedures, including specific thera - framework of clinical care and problem solving. peutic maneuvers (e.g., polypectomy, hemostasis Successful programs require skilled, experienced techniques) when indicated (Table 2). endoscopic supervisors who continually maintain and improve their abilities and possess the talents Level 2 required to teach endoscopy; trainees with sound Trainees who elect to pursue additional training in general medical or surgical training who have the gastrointestinal endoscopy should have completed motivation and aptitude for endoscopy; a struc - at least 18 months of a standard gastroenterology tured training experience with ongoing evaluation training program (core clinical curriculum) or of all trainees’ progress in relation to interests, apti - equivalent training and should have documented tudes, and career goals; and the opportunity for competence in “standard” (i.e., not advanced) adequate clinical and endoscopic experience. endoscopic procedures (Table 2). The minimum Endoscopic procedures should be preceded by a duration of training required to achieve advanced careful clinical evaluation, including indications technical and cognitive skills is 12 months. and individual risk factors. Programs offering advanced endoscopic training should have a minimum of two endoscopists capa - Level 1 ble of performing and providing instruction in All trainees should have a clear understanding of advanced endoscopy. The instructors should be the indications, limitations, complications, and acknowledged as experts by their peers for the medical and surgical implications of the findings of advanced procedures being studied and should gastrointestinal endoscopy. This includes an under - have proven records of endoscopic research and standing of the underlying pathophysiology of gas - teaching experience as documented by substantial trointestinal diseases and the ability to interpret the published reports, reviews, editorials, and/or par - endoscopic findings for each. All trainees should ticipation in local, regional, or national symposia complete at least 18 months of clinical training in and/or postgraduate courses. gastroenterology and hepatology, including inpa - Trainees should participate in the performance tient consultation, outpatient care, and extensive of advanced endoscopic procedures with an expe - training in endoscopic procedures. Trainees should rienced endoscopist knowledgeable in the indica - participate in the performance of endoscopic proce - tions for the procedure, the techniques of perform - dures with gastroenterologists knowledgeable in ing and the method of recording the results of the the indications for and the technique of performing procedure, and the clinical significance of the find - the procedures as well as the method of recording ings. Trainees who wish to perform endoscopic the results of the procedures and the clinical signifi - retrograde cholangiopancreatography must have a cance of the findings. Trainees should also be basic understanding of radiation safety, fluo - trained in the indications, techniques, and interpre - roscopy, normal radiological anatomy, and radi - tation of emerging technologies, including capsule ographic interpretation. Those intending to per - endoscopy (esophageal and small bowel). form endoscopic ultrasound must have a clear Specifically, trainees should be able to understand understanding of cross-sectional human anatomy the indications, contraindications, and risk of cap - (both gross and microscopic), the principles of sule endoscopy. While the minimal training needed ultrasonography, and the principles of oncology as to competently perform capsule endoscopy of the 22 THE GASTROENTEROLOGY CORE CURRICULUM

they pertain to the staging of gastrointestinal technically demanding therapeutic procedures. malignancies. It is essential for trainees planning Competence of graduates of advanced training to perform endoscopic ablation therapy to have a programs in ERCP may be assessed by the demon - clear understanding of cross-sectional human gross strated ability (at least an 80% success rate) to anatomy and the principles of oncology as they obtain access to (selectively and freely cannulate) pertain to tumor growth and staging. the desired duct reliably without assistance in nor - Technical skills for advanced endoscopic proce - mal anatomy cases. Cases that are used to assess dures must be acquired in a sequential fashion. competency for ERCP should exclude those proce - Proficiency develops incrementally through perform - dures in which the native anatomy of the patient ance of sufficient numbers of procedures under has been surgically or otherwise altered (e.g., gas - direct supervision in a methodical sequence of tric outlet obstruction, Billroth II anastomosis), increasing complexity. After suitable supervision and where prior sphincterotomy has been performed, completion of training, the trainees should be capa - or where a routine stent exchange is being per - ble of performing advanced diagnostic and therapeu - formed (ASGE ERCP Core Curriculum. tic endoscopic procedures independently (Table 3). Gastrointestinal Endoscopy 2006; 63:361-76). The required number of procedures noted in Table 3 Endoscopic competence is difficult to define and represents the threshold number of procedures that quantify. Evaluation remains largely subjective; must be performed before competency can be however, the objective Assessment of Competence assessed. The number represents a minimum, and it is more desirable. Examples of objective parameters is understood that most trainees will require more used to assess competency for endoscopy are (never less) than the stated number. shown in Table 4. Endoscopic Ultrasound (EUS). For comprehen - The ABIM has determined that specific methods sive competence in EUS, at least 150 supervised for observation, evaluation, and documentation of cases should be performed, with 50 EUS-guided procedural skills should be left to the discretion of fine-needle aspirations (25 for nonpancreatic and the program directors. When performing endoscop - 25 for pancreatic lesions) and at least 75 pancre - ic procedures early in training, all trainees should aticobiliary cases. For trainees interested in mucos - be observed regularly by supervisors. Faculty mem - al and submucosal lesions only and not pancreati - bers should substantiate the trainees’ competence cobiliary imaging, a minimum of 100 supervised by documenting the performance of the designated cases should be completed. At least 50% of these procedures. Simpler procedures may require fewer cases should be for tumor staging. For pancreati - observations, whereas those that are technically cobiliary competency, a minimum of 75 cases ded - complex may require more. The competency of all icated to pancreaticobiliary pathology should be gastroenterology trainees should be documented by performed, with most for tumor staging. These the program directors and by the endoscopy direc - numbers exclude therapeutics, such as fine-needle tors. The program directors have the responsibility aspiration and celiac plexus neurolysis. (ASGE of confirming or denying the technical competency guidelines for credentialing and granting privileges and endoscopic exposure of trainees. for EUS. ASGE publication no. 1056, May 2001). The ABIM has recommended that documenta - Endoscopic Retrograde Cholangiopancreato- tion be provided by a procedure card, computer graphy (ERCP). Although no specific numerical record, or log book that identifies and evaluates recommendation has been clearly established for the procedure(s) performed and any complications training in advanced procedures, it has been deter - and includes the faculty supervisors’ signatures. mined that substantially more procedures are This evaluation should become part of the required before competence can be assessed in trainees’ files. The ABIM provides documentation

Table 3 – Guidelines for Endoscopic Training in Advanced Procedures: Minimum Threshold for Assessing Competence

Procedure Required number a Endoscopic retrograde cholangiopancreatography 200 Endoscopic ultrasound 150

aThe required number of procedures 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. TRAINING IN ENDOSCOPY 23 log books for training programs to distribute to part of the overall evaluation of trainees in gas - trainees for documenting training and achievement troenterology during and after the fellowship, as of technical proficiency. outlined in Overview of Training in Gastro- enterology. Questions relating to endoscopy should be included on the board examination and Assessment of Competence should reflect a general knowledge of this content. Knowledge of endoscopy should be assessed as

Table 4 – Suggested Objective Performance Criteria for the Evaluation of Gastrointestinal Endoscopy (Also see Appendix II)

Procedure Performance criteria Esophagogastroduodenoscopy Esophageal intubation Pyloric intubation Colonoscopy Intubation of splenic flexure Intubation of terminal (desirable skill) Retroflexion Endoscopic retrograd cholangiopancreatography Cannulation of the desired duct Opacification of the desired duct Sphincterotomy Stent placement Stone extraction Endoscopic ultrasonography Intubation of esophagus Intubation of pylorus Imaging of desired organ and/or lesion Successful lesion fine-needle aspiration Tumor staging in agreement with the surgical findings and similar to that reported in the literature All procedures Recognizes normal and abnormal findings Develops appropriate endoscopic/medical treatment in response to these findings Obtains appropriate informed consent Inserts the endoscope using proper technique and detects and identifies all significant pathology Conducts thorough examination of the entire organ and correctly identify landmarks Completes examination within a reasonable time and prepares accurate report Recognizes and manages any complications expeditiously Plans correct management and disposition and discusses findings with patient and other physicians Conducts proper follow-up, review of pathology, case outcome

Adapted from ASGE Publication: Principles of Training in Gastrointestinal Endoscopy, GIE volume 49, number 6, 1999. Visit www.asge.org. 24 THE GASTROENTEROLOGY CORE CURRICULUM Training in Ethics, Medical Economics, and System-Based Practice schemes should be available for trainees to Importance question about their experiences in working in Trainees eventually complete training and must find these different settings. their way in the medical marketplace whether in aca - 2. Offering sufficient training about medical eco - demics or practice. This marketplace has become nomics, including contract negotiations, so that increasingly complex as physicians change from solo trainees can evaluate different employment practice or small group practices to more complicat - opportunities and make plans for a career that ed arrangements both inside and outside of institu - is satisfactory for them. tions. Many graduates have expressed concern that 3. Teaching the mechanics of insurance schemes, training programs did not prepare them well for the coding, and billing so that reimbursement for business aspects of medical practice. This has professional services can be sought without become an important issue for medical practice as violating the law. contracting, reimbursement, and economic matters 4. Imbuing trainees with the moral values necessary impact more and more on the ability of physicians to to engage in satisfying and ethical professional provide medical services. In addition, increased interactions with colleagues and patients. enforcement efforts have resulted in more prosecu - 5. Involving fellows with quality assessment pro - tion for fraud and abuse in relation to medical grams and quality improvement initiatives dur - billing and in more licensing boards taking discipli - ing their training so that they can understand nary action against physicians for moral lapses. the methods employed to assess quality of care Finally, at every level of medical care attention has and initiate improvement schemes. been focused on providing quality care and improv - ing quality by analyzing practice patterns with an eye toward reducing medical errors and improving Training Process outcomes. Trainees must understand how this can be Didactic lectures, experience on quality assessment done effectively. Although the main emphasis of committees, involvement with continuous quality training programs must continue to be the practice improvement activities in the clinic and gastroin - and science of medicine, one can not ignore these testinal laboratory, “career days” in which trainees ethical, economic, and systemic issues. Trainees are can interact with graduates practicing in a variety encouraged to attend national meetings, seminars, of settings, and mentoring by physicians from a and workshops on these topics offered regularly by variety of settings are some of the means that can the professional societies. be used to provide training to fellows. In addition, each of the professional societies involved in producing this curriculum has seminars Goals of Training and other activities that address these issues. During fellowship, trainees should gain an under - standing of the following: 1. Providing unbiased information about different Assessment of Competence systems of providing medical care, such as solo Knowledge of ethics, medical economics, and practice, private group practice, academic system-based practice should be assessed as part of group practice, health maintenance organiza - the overall evaluation of trainees in gastroenterolo - tions, independent practice organizations, pub - gy during and after the fellowship, as outlined in lic health and , and military Overview of Training in Gastroenterology. medicine. This information should include dis - Questions relating to ethics, medical economics, cussion of the governance of these organiza - and system-based practice should be included on tions and the roles of physicians in providing the board examination and should reflect a general care and in managing these systems. When knowledge of this content. possible, physicians participating in these 25 Training in Geriatric Gastroenterology towards use of functional status and comorbidities Importance to define populations benefiting from screening. As individuals age, there are important changes More data are available on the gastrointestinal that occur in gastrointestinal pathophysiology and problems of the very old, as the numbers of nona - function that predispose older adults to a variety of genarians and centarians increase rapidly. As the clinical problems. These include impaired swallow - demographics of hospitalized patients shifts to ing and aspiration, increased risk of acid- and include ever-increasing numbers of patients over NSAID-mediated mucosal injury, increased colon age 80, gastroenterologists need to be aware of the cancer risk, slowing of colonic motility with subse - social issues and problems of treatment in frail quent and , and older patients at high risk for iatrogenic complica - diminished functional reserve to cope with super - tions of treatment. imposed . In addition, older patients also have other comorbidities, such as car - diovascular disease, hypertension, and impairments Goals of Training in cognition and mobility that impact the ability of During fellowship, trainees must be provided with gastroenterologists to provide clinical care. The formal instruction and clinical experience in the eval - issue is becoming increasingly important as the uation and management of gastrointestinal, hepato - population ages. It has been estimated that by the biliary, pancreatic, and nutritional disorders of the year 2020, approximately 22% of the population elderly. Fellows must demonstrate competence in the will be 65 years of age and the percentage of indi - evaluation and management of older patients. viduals older than 85 years will have increased Geriatric training in gastroenterology is divided several-fold. Improved delivery of specialty care in into two levels. Level 1 represents the basic training gastroenterology to this population requires in geriatrics required for all trainees. Level 2 repre - updated knowledge of both the pathophysiology of sents advanced training in geriatric gastroenterolo - aging in the gastrointestinal tract and the special gy and is limited to individuals who complete the issues and concerns of geriatric patients who have fellowship requirements for board certification in gastrointestinal disease. both gastroenterology and geriatric medicine. The aging of the population has significant impli - Therefore, level 2 training could not be accom - cations for clinical practice. Certain diseases, such plished within the 3 years of gastroenterology fel - as gastrointestinal tract cancer and neurodegenera - lowship without formal and separate training in tive motility disorders, are far more common in geriatric medicine. older persons. Impairments in appetite control, Level 1 absorption, and food intake are important causes 1. Level 1 training includes general geriatric of malnutrition in older individuals. Aging- issues that addresses the impact of age on associated changes in drug metabolism and patient communication, family and social sup - increased usage of multiple drugs in older patients port, and presentation of disease. have resulted in an increased number of reports of 2. Level 1 training also includes geriatric gas - serious interactions and side effects of drugs used troenterology dealing with the impact of age to treat gastrointestinal disease. Depression and on presentation, diagnosis, and treatment of dementia are common disorders in the aged popu - common and important gastrointestinal condi - lation that have a profound effect on patient nutri - tions in the elderly. An important feature of tion, symptom presentation, and response to thera - this training is the ability to recognize the py. Gastrointestinal disease may present with atypi - effect of age on pathophysiology and response cal features in older individuals compared with to treatment. those in younger patients, often due to age- associated decline in sensory and autonomic neu - The fellowship program should provide training ronal reflexes. The ability of gastroenterologists to required to achieve the above stated goals, includ - recognize the impact of common geriatric disorders ing the following topics: on gastrointestinal tract function is essential for 1. Pathophysiology of aging. An overview of the adequate delivery of specialty care to the aged. current concepts and models of aging, with par - Gastroenterologists participate in important ticular emphasis on the gastrointestinal tract and health maintenance screening for conditions such liver, should be presented. Examples of current as colon cancer and Barrett’s esophagus. In the past cellular models include acquisition of genetic few years there have been significant changes in the errors in rapidly replicating tissue, damage from recommendations for colon cancer screening, based oxidants or other injurious substances, limitation on new data obtained in geriatric patients indicat - of growth by replicative “clocks,” and changes ing a higher risk of right-sided colonic neoplasia in metabolic signal pathways with aging that than was previously appreciated. Cost effectiveness impair cellular responses. of screening is evolving from age-based cutoffs 2. Demographics and epidemiology of aging. 26 THE GASTROENTEROLOGY CORE CURRICULUM

Trainees should be aware of the impact of delivering bad news (e.g. pancreatic cancer) to aging on the epidemiology of gastrointestinal the patient or next of kin (if needed). Effective disease, health care delivery, and the issues of discussions will improve the patient’s and the costs and resources. family’s ability to plan for setting realistic goals 3. Impact of commom geriatric disorders on gas - and for emotional support. Communication with troenterology. Trainees should appreciate the such patients involves preparation to ensure impact of common diseases, such as depression medical facts, exploring the patient knowledge and dementia, on the presentation and evalua - of illness, and the patient’s desire to know the tion of gastrointestinal and liver disease. They diagnosis. Trainees should be instructed to deliv - should be aware of the importance of functional er information in a sensitive, straightforward assessment of activities of daily living in the geri - manner, avoiding technical language. atric population and be able to implement 7. Geriatric patients are a very heterogeneous screening maneuvers in the office setting to diag - population. Trainees should learn how to nose functional and/or cognitive impairment. approach the elderly patients who could be Trainees should be able to assess the patient’s very healthy or may present with gastroen - ability to follow a treatment plan, with emphasis terology-associated illnesses associated with on the effect of cognitive impairment on man - several comorbid conditions, such as cognitive - agement of gastrointestinal problems. ly impaired, demented and agitated, depressed 4. Social and ethical issues in aging. Trainees and delusional or dying patient. Elderly should be able to assess the patient’s level of patients should be treated similarly to other dependence on external psychosocial support patients, with dignity, honor, integrity, account - from family, friends, and organizations as part ability, excellence, and respect to other. The of the treatment plan and should be aware of trainees should be familiar with the patient’s the importance of appropriate communication advanced directives. These directives will guide with the patient’s family (or equivalent). the physician’s commitment to ethical princi - Abused and neglected geriatric patients can ples pertaining to provision or withholding of present with various gastrointestinal com - clinical care. plaints or malnutrition. Trainees should be 8. Effective strategies for inpatient and outpatient aware of common signs and symptoms of management. Trainees should be able to assess abuse and have basic knowledge of community the severity and emergent nature of gastroin - resources available for intervention in cases of testinal complaints in the elderly in inpatient abuse, neglect, and caregiver stress. Training and outpatient settings. The increase in comor - should enable trainees to develop empathy for bid illnesses in the elderly may require a multi - and understanding of the special needs of frail disciplinary approach. Trainees must learn to older individuals. This includes ethical issues work effectively and efficiently with members concerning the risk-to-benefit ratio of the of other specialties. The pitfalls of routine investigation and treatment of disease as well assessment maneuvers used in younger as end-of-life issues. patients, such as skin turgor, should be stressed 4. Cultivation of an attitude of inquiry and assim - and appropriate strategies for fluid/volume ilation of scientific evidence to improve patient assessment and management in aged individu - care practices in aging. Trainees should note als developed. Trainees should be aware of that aged individuals may differ from younger adverse cardiovascular and central nervous sys - patients in the presentation and response to tem effects of rapid volume replacement in treatment of conditions such as peptic ulcer older individuals. They should have an appre - disease, gastritis, and . The demographics ciation for the subtle and misleadingly benign and special management of IBD, irritable presentation of acute abdominal conditions in bowel syndrome, and biliary disorders in older frail older patients and an understanding of the patients should be understood. Trainees should need for early surgical referral. Trainees should be encouraged to participate in geriatric learn to practice cost-effective health care and research, including analysis of practice experi - resource allocation that does not compromise ence and perform practice-based improvement quality of care. Finally, trainees should be activities using systematic methodology. aware that there are considerable deficits in 5. Effective listening skills and creation of a thera - our understanding of gastrointestinal disease in peutic and ethically sound relationship with eld - older patients and that there is a need for erly patient and their families. This issue becomes research in this area. The importance of more crucial in the dying patient. For many older evidence-based medicine and an ability to persons, dying is characterized by physical stress, assess outcome measures of treatment should fragmented care systems, poor to absent commu - be stressed in level 1 training. nication among doctors, patients, and families, 9. Changes in gastrointestinal function with and enormous strain on caregivers. aging. Trainees should be aware of the 6. Communicating bad news to the elderly. “normal” or expected changes in physiology Trainees should learn a systematic approach to of the gut, pancreas, and liver that occur with TRAINING IN GERIATRIC GASTROENTEROLOGY 27

aging. Particular emphasis should be placed on the effects of aging on prevalence, diagnosis, and functions shown to be affected by aging. These treatment of these conditions. Management of include swallowing disorders due to a variety common syndromes, such as reflux disease, is of aging-associated changes in oropharyngeal changing rapidly as new information concerning and esophageal motility, impaired gastric oncogenic risk and treatment becomes available. motility and acid secretion, changes in hepatic Trainees should be informed about the prevalence metabolism, slowing of colonic motility, and of substance abuse, particularly alcohol, in the rectal dysfunction. Familiarity with the normal elderly. The effects of alcohol on gastrointestinal range of laboratory data in the elderly is function and common presenting signs and symp - required. An appreciation of the range of nor - toms of alcohol abuse should be covered. Finally, mal gastrointestinal function in the aged trainees should have an appreciation for the diag - patient will assist trainees in distinguishing nosis and management of common gastrointesti - between normal aging and abnormal findings nal problems in institutionalized and bedridden due to disease. geriatric individuals. As an example, trainees 10. Changes in drug metabolism with aging. Trainees should be able to recognize the importance of must have an appreciation of the changes in drug as a risk factor for urinary incon - metabolism, particularly in the liver that occurs tinence and should be taught appropriate strate - with aging. Evolving areas of research, such as gies for management. absorption and metabolism of drugs in the gas - Level 2 trointestinal mucosa, also should be covered. At this time, it is anticipated that level 2 training will Trainees should be able to identify and anticipate be limited to individuals who complete the fellow - side effects and interactions of medications used ship requirements for board certification in both gas - for the management of gastrointestinal disorders troenterology and geriatric medicine. Level 2 trainees in the geriatric population. should have an in-depth understanding and docu - 11. Gastrointestinal effects of drugs. Trainees mented clinical experience in all aspects of level 1 should have an appreciation for the presenta - training. In addition they will have extensive knowl - tion and differential diagnosis of gastrointesti - edge of geriatric medicine and the psychosocial nal side effects of commonly prescribed drugs issues involved in geriatric care, based on providing in older individuals. These include drugs with care to geriatric patients in clinical settings specifical - significant symptoms or effects on gastroin - ly designed to maximize the percentage of older testinal motility, such as neuroleptics, antihist - patients. These can include geriatric gastroenterology amines, antidepressants, antiarrhythmic agents, outpatient clinics, inpatient geriatric units, and long- and antihypertensive agents such as calcium term care facilities. They should have considerable channel antagonists. information about the community resources avail - 12. Effect of aging on nutrition. Using a nutrition - able for management of complicated geriatric issues al assessment tool, trainees should be able to and a full understanding of the range of gastroen - discover malnutrition in the geriatric age terological disease in the older population. Level 2 group. They should be aware of the common trainees should have experience in teaching geriatric disorders predisposing to inadequate intake of gastroenterology to medical students, house staff, nutrients (including vitamin deficiencies) in and level 1 gastroenterology fellows. Trainees com - aged patients. In addition, they should recog - pleting level 2 training should be able to serve as nize that adaptation of food intake to illness or specialty consultants to specific geriatric popula - abrupt changes in physiology is impaired or tions, including specialized geriatric outpatient terti - delayed in older individuals. Trainees should ary referral centers and home residents. be taught age-appropriate strategies for fluid They should be qualified to organize and direct a and nutritional replacement in inpatient and teaching program in geriatric gastroenterology. outpatient settings. Presentation of anorexia, , and eating disorders in older individu - als should be covered. The ethical and treat - Training Process ment issues of feeding tube placement should Level 1 be covered, with particular emphasis on risks To obtain the knowledge required for level 1 train - and benefits in frail or demented patients. ing, trainees should be exposed to a variety of 13. Common gastrointestinal conditions in the elderly. teaching experiences that include topics and issues Trainees should be familiar with the presentation pertinent to geriatric gastroenterology. These and pathophysiology of common gastrointestinal should include didactic lectures (including CD- diseases in the geriatric population. These include ROM and Internet-based programs), case presenta - dysmotility syndromes affecting the oropharynx, tions, group discussions and seminars, clinical bed - stomach, and colon as well as due to a side teaching, and individualized teaching. The clin - variety of conditions. , gastro- ical experience should jointly cover all areas listed intestinal bleeding, and oncological diseases are as goals of training and be provided primarily by important causes of gastrointestinal morbidity in interaction with consultants in both gastroenterolo - older patients, and trainees should be aware of gy and geriatric medicine as part of the clinical 28 THE GASTROENTEROLOGY CORE CURRICULUM

rotation in gastroenterology. Trainees should be should provide trainees with experience in diagno - involved in assessment and management of gas - sis and management of other common geriatric trointestinal problems in geriatric-aged patients in problems, such as dementia, depression, delirium, both the inpatient and outpatient setting. If specific urinary incontinence, falls, mobility impairment, geriatric venues are not used, then other methods osteoporosis, and chronic pain. The trainees should of tracking and documenting treatment of older serve as consultants for other physicians in both patients, such as a log, should be maintained. general geriatric medicine and geriatric gastroen - Faculty who are knowledgeable in geriatric gas - terology. At least 25% of training should be allo - troenterology should be available at the base insti - cated to assessment and management of geriatric tution of training or be made available in a block patients in skilled nursing facilities, long-term care rotation through an appropriate academic affilia - settings, and specialized dementia units. Trainees tion. Involvement of faculty in geriatric medicine is should perform research in clinical or pathophysio - suggested, particularly for teaching general geriatric logic aspects of geriatric gastroenterology and issues if such knowledge is not available from gas - should be mentored by faculty with expertise in troenterology faculty. In institutions without a for - this area. Trainees should be involved in the train - mal geriatric medicine program, training by affiliat - ing of level 1 gastroenterology fellows and should ed family practice groups with a substantial geri - be given guidance concerning effective teaching atric population is an alternative strategy. methods and presentation skills. Level 2 Level 2 training should be obtained only at institu - Assessment of Competence tions that have faculty with expertise in geriatric Knowledge of geriatric gastroenterology should be gastroenterology and a fellowship program in geri - assessed as part of the overall evaluation of trainees in atric medicine that can provide the trainee with the gastroenterology during and after the fellowship, as components of training required for the CAQ in outlined in Overview of Training in Gastroenterology. geriatric medicine over a 12-month period. In addi - Questions relating to geriatric gastroenterology should tion to specific training in geriatric gastroenterolo - be included on the board examination and should gy clinics and inpatient settings, the program reflect a general knowledge of this content. 29 Training in Hepatology challenges to the practicing gastroenterologist. A Importance thorough understanding of the disease process is Liver disease is one of the 10 leading causes of death required to manage these patients in an appropriate in the United States; it additionally leads to substan - manner, particularly as treatment options continue tial morbidity in many patients. As a result, the to evolve rapidly. social and financial burdens of liver disease are sig - There is increasing evidence that nonalcoholic nificant and the management of patients with liver (NAFLD), associated with the disease is associated with a significant cost. Thus, epidemics of obesity and diabetes, is a major liver disease has become an increasingly important emerging health problem in the United States and component of the practice of internal medicine and other developed countries. A significant number of gastroenterology. This increase reflects both an patients with NAFLD appear to progress to cirrho - improvement in the recognition of patients with liver sis; their long-term prognosis is similar to patients disease and significant advances in therapy. One of with HCV-related disease. As the pathogenesis of the major advances has been in the area of ortho - this disease becomes clearer, novel treatment strate - topic liver transplantation, which has become a gies are evolving for patients with NAFLD. Finally, widely accepted form of therapy for the treatment of it is imperative that all gastroenterologists are end-stage liver disease. A second major advance has familiar with other liver diseases (acute liver fail - been the evolution of specific treatment for patients ure, drug-induced liver disease, alcohol-induced with . These recent advances have liver disease, hemochromatosis, Wilson’s disease, necessitated appreciable changes in subspecialty etc.) and their management. training in the area of liver disease. The success of liver transplantation has had a major impact on gastroenterology and hepatology Goals of Training practice. Each year, approximately 5000 patients The overall goal of training in liver disease is to undergo orthotopic liver transplantation. Survival train gastroenterologists who are competent to rates at 1 year and 3 years generally exceed 85% manage the broad spectrum of liver problems and 65%, respectively. Given the limited supply of encountered in a typical gastroenterology practice. donor organs and the resulting long waiting times Training programs must provide trainees with a for transplantation, the expert management of broad knowledge of the physiology of the liver and these complications is crucial to the survival of the a thorough knowledge of the management of patient. It is critical that patients be referred in a patients with hepatobiliary diseases. timely fashion, and that practitioners are familiar Levels of Training with the care of disorders common in patients with • Level 1 training encompasses a basic under - end-stage liver disease (which often occur prior to standing of liver disease in general, with an transplant), including gastrointestinal bleeding; ability to recognize, diagnose, and treat all bacterial infections; hemodynamic, hematological, types of routinely seen liver diseases. This pulmonary, renal, and neurological complications; level of training can be completed in a 3- and nutritional deficiencies. Moreover, the postop - year gastroenterology fellowship program. erative care of the transplant patient with complex • Level 2 entails advanced formal training in immunosuppressive regimens has increased the transplant hepatology and requires an addi - need for training of individuals with this expertise. tional fourth year of training with specific ele - It is essential that gastroenterology training pro - ments that fulfill the requirements for addi - grams provide the necessary experience in the eval - tional training (i.e., CAQ) in hepatology. See uation and management of these patients. www.aasld.org for more information. The development of novel and more effective for viral hepatitis in particular has had a Level 1 training is designed to prepare an indi - major impact on the practicing gastroenterologist. vidual to develop clinical and/or research expertise The identification of the virus has in hepatology. While this usually occurs in the increased the number of patients with liver disease context of an academic setting, some subspecial - who seek medical evaluation and treatment, and ists in community-based practices may devote the the concurrent development of treatments for hepa - majority of their professional efforts toward titis B and C has increased the importance of iden - patients with liver disease. To obtain the core tifying infected patients. The treatment of these knowledge required for level 1 training, trainees patients, however, is not straightforward. should be exposed to didactic lectures, case con - Variations in treatment regimens in patient sub - ferences, selected readings (which can include CD- groups, the use of combination therapies, the appli - ROMs and Internet-based programs), and clinical cation of varied therapeutic endpoints, and the experience that jointly cover all areas listed above. spectrum of side effects of current therapies present The clinical experience can be obtained by rota - 30 THE GASTROENTEROLOGY CORE CURRICULUM

tion on an inpatient hepatology service, exposure mal liver tests as well as those with severe to liver transplant physicians and team members, liver disease associated with pregnancy. and/or participation in an outpatient clinic focused i. Perioperative care of patients with defined on hepatology. disease of the liver or evidence of hepatobil - Level 2 training is the advanced formal training iary dysfunction. in advanced hepatology and transplant hepatology j. Selection and care of patients awaiting liver and is not currently feasible within the scope of the transplantation, including the assessment of 3-year curriculum in gastroenterology and requires the candidacy of patients for transplantation. an additional year of training. Guidelines for this k. Care of patients following liver transplanta - training experience have been developed by the tion, including an understanding of the use American Society for Transplantation (AST) and of immunosuppressive agents; diagnosis and the AASLD ( Liver Transplantation , Vol 8 No 1, management of rejection; and recognition of 2002: pp 85 –87). other complications of transplantation, such Training programs should ensure that the trainee as certain infections and biliary tract and acquires the following specific basic knowledge/ vascular problems. skill(s): l. Use of antiviral agents in the treatment of 1. Significant knowledge about genetic markers of liver disease. liver disease, immunology, virology, and other 3. Management of the nutritional problems asso - pathophysiological mechanisms of liver injury; ciated with (see Training the basic biology and pathobiology of the liver in Nutrition). and biliary systems as well as a thorough 4. Liver pathology, including histological interpre - understanding of the diagnostic and treatment tation and specific pathological techniques (see of a broad range of hepatobiliary disorders. Training in Pathology). 2. Skill in the performance of a limited number of 5. Pediatric and congenital hepatobiliary disorders diagnostic and therapeutic procedures. (see Training in Pediatric Gastroenterology). 3. An appreciation of the indications and use of a 6. Liver imaging modalities, including interpreta - number of diagnostic and therapeutic procedures tion of computed tomography, magnetic that are needed to manage hepatobiliary disorders. resonance-based techniques (magnetic resonance imaging, magnetic resonance angio- During the training period, comprehensive teach - graphy, magnetic resonance cholangiography), ing of the following subjects is essential: hepatic angiography, and ultrasound (including 1. The biology and pathophysiology of liver diseases Doppler evaluation of hepatic vasculature). 2. Diagnosis and management of patients with The limitations of each modality should be the wide variety of diseases of the liver and bil - understood. Some programs may choose to iary tract systems, including the following: provide selected fellows with hands-on training a. Acute hepatitis: viral, drug, toxic, drug-induced. in hepatic ultrasound for guidance; b. Fulminant hepatic failure, including the tim - formal training in liver biopsy requires an ing to transplant, management of cerebral understanding of the use of ultrasound in the edema, , and other complica - setting of liver biopsy. tions associated with acute hepatic failure. 7. An understanding of the principles of experi - c. Chronic hepatitis (and ); chemical, mental design, clinical biostatistics, and epi - biochemical, serological, and histopatho- demiology sufficient to critically interpret the logic diagnosis of chronic viral hepatitis. medical literature (see Training in Research). d. Complications of chronic liver disease, including complications of portal hyperten - sion (, spontaneous bacterial peritoni - Training Process tis, prevention and treatment of bleeding Program Faculty and gastropathy), hepatic The faculty should include at least one individual encephalopathy, . recognized to possess advanced expertise in liver e. Hepatocellular carcinoma (screening and diseases, including continued productivity in clini - diagnostic options, treatment options). cal or basic research related to hepatology. f. Nonviral causes of chronic liver disease, Programs offering training in hepatology should such as alcohol, nonalcoholic fatty liver dis - include at least two individuals whose primary ease (including nonalcoholic ), focus within gastroenterology is liver disease, Wilson’s disease, primary biliary cirrhosis, including at least one with significant experience hemochromatosis, with liver transplantation. and -antitrypsin deficiency. α1 Prerequisites for Training g. disease, including the appropriate Level 1 training (and level 2 training) in hepatology use of medical and surgical therapies (see will take place as an integral part of subspecialty Training in Biliary Tract Diseases and fellowship training in gastroenterology, after Pancreatic Disorders). trainees have successfully completed at least 3 years h. Hepatobiliary disorders associated with preg - of postdoctoral education in internal medicine. nancy, including care of patients with abnor - TRAINING IN HEPATOLOGY 31

Level 2 training requires specific exposure to trans - in hepatology apart from the formal additional plant hepatology. Training in advanced hepatology year of training (i.e., the CAQ year). Training in will typically occur following successful completion liver biopsy is a mandatory part of the formal of a 3-year gastroenterology fellowship. advanced training process. Duration of Training Training in Hepatology Research In level 1 training, at least 5 months devoted to Opportunities should be available for clinical and/or clinical training in gastroenterology should be dedi - laboratory-based research activity in liver diseases. cated to training in hepatology (see Section XI.C). Trainees should be encouraged to participate in This training should include experience equally research activities related to liver disease, under the divided between the management of inpatients with guidance of mentors with research training and expe - a variety of hepatic disorders and the treatment of rience and a focus on liver physiology and/or disease outpatients with liver disease. To provide an ade - processes. For trainees interested in developing quate experience, at least 30% of the inpatients careers in academic medicine, training beyond the 3- seen by the trainees in their capacity as primary year gastroenterology fellowship may be necessary. physicians or consultants should have hepatobiliary Training Through Conferences, Seminars, disease. An opportunity for trainees to become Literature Review, and Lectures familiar with the referral and management of liver There must be regularly scheduled conferences that transplant patients should also be provided. This include didactic lectures, literature reviews, and may require that the trainees rotate through anoth - research seminars focused on liver disease topics. er institution for this training. Trainees should be responsible for liver disease- Procedural Skills related teaching and supervising residents in inter - The trainees must demonstrate understanding of nal medicine as well as medical and other medical the indications, contraindications, limitations, com - personnel (see Overview of Training in plications, and interpretation of the following: Gastroenterology). 1. Percutaneous liver biopsy 2. Diagnostic and therapeutic paracentesis Assessment of Competence Training in the performance of liver biopsy is not Knowledge of hepatology should be assessed as a requirement for level 1 competency in hepatology part of the overall evaluation of trainees in gastro- training, although all other aspects of gaining enterology during and after the fellowship, as out - familiarity with liver biopsy are required, including lined in Overview of Training in Gastroenterology. specific reading and interpretation of liver biopsy. Questions relating to hepatology should be includ - It is recognized that some training programs will ed on the board examination and should reflect a offer percutaneous liver biopsy as part of training general knowledge of this content. 32 THE GASTROENTEROLOGY CORE CURRICULUM Training in Inflammation and Enteric Infectious Diseases Gastrointestinal inflammation, whether infectious, 1. The mechanisms of inflammation noninfectious, or idiopathic, is a primary mecha - 2. Elements of the mucosal defense system nism of disease for many patients referred to spe - (including the mucosal immune system and the cialists in digestive diseases. Therefore, it is impera - components of intestinal barrier function) tive that trainees be exposed to diagnostic and ther - 3. The composition and function of normal apeutic aspects of gastrointestinal inflammatory enteric flora (including protection against disorders as components of their fellowship experi - pathogens, colonization resistance, role in ence. The unique aspects of gastrointestinal infec - metabolism [nitrogen, carbohydrate, fat, vita - tions (related or not related to human immunodefi - mins, bile salts], and the effects of antibiotics ciency virus [HIV]) and idiopathic inflammatory on the flora) bowel diseases (IBD) will be discussed separately. 4. The prevalence, clinical presentation, and viru - The differential diagnoses overlap due to the non - lence factors (including mechanism of toxin specific presentation of acute or chronic small or action, colonization, translocation, and inva - large bowel inflammatory disorders. sion) of gastrointestinal pathogens (viruses, bacteria, fungi, and protozoa) 5. The pathophysiology of due to infection I. GASTROINTESTINAL INFECTIONS IN 6. The indications and contraindications for antimi - NONIMMUNOSUPPRESSED PATIENTS crobial therapy, mechanisms of microbial drug resistance, and risk of infections from altering Importance normal flora (e.g., Clostridium difficile ) The gastrointestinal tract is host to a large and com - plex microbial flora. In addition, all levels of the gas - Clinical skills should include a familiarity with trointestinal tract (including the liver and biliary tree) the following diagnostic and histopathologic stud - are subject to acute and chronic infection by a variety ies (see Training in Pathology): of pathogenic microbial agents (viruses, bacteria, 1. Microscopic examination of stool: fecal leuko - fungi, and protozoa). These infections present, acutely cytes and ova and parasites or chronically, as disordered organ function manifest - 2. Culture of stool, intestinal fluid, and mucosal ed by diarrhea, malabsorption, bleeding, or ulcera - biopsy specimens (specimen collection, han - tion, symptoms that are commonly seen by primary dling, special stains, and media) care physicians and frequently are the indications for 3. Mucosal biopsy interpretation gastroenterological referral. The understanding of gas - 4. Antigen detection in stool and fluid (enzyme tritis and duodenal ulcer disease has been revolution - immunoassay, fluorescent antibody) and stool ized by the recognition of the role of H. pylori, where - toxin testing as the agents responsible for some gastrointestinal dis - 5. Rapid diagnostic tests (DNA probes or poly - eases known to be infectious (e.g., Tropheryma whip - merase chain reaction) pelii for Whipple’s disease) have only recently been 6. Liver biopsy and interpretation (see Training identified. Many gastrointestinal diseases currently in Hepatology) regarded as idiopathic are likely to be the result of Clinical skills should also encompass the selec - infection by currently unrecognized pathogens or idio - tion and use of antibiotic therapy and methods for syncratic reactions of the host to normal flora. New preventing infection during endoscopy (disinfection forms of common pathogens are continually appear - and antibiotic prophylaxis). Clinical exposure to ing, such as the toxin-producing Escherichia coli gastrointestinal infections should include the diag - responsible for hemorrhagic colitis. A gastroenterolog - nosis and management of patients with common ical specialist, therefore, should be knowledgeable infectious presentations, such as (fun - regarding the epidemiology, differential diagnoses, gal, viral, bacterial); ulcer disease and gastritis confirmatory diagnostic studies, therapy, and out - (emphasizing the role of H. pylori and appropriate comes of treated and untreated gastrointestinal infec - antibiotic therapies); acute, chronic, hemorrhagic, tions in the adult and pediatric populations. and traveler’s diarrhea; bacterial overgrowth; infec - tions in immunocompromised hosts (e.g., trans - Goals of Training (GI Infections in plantation patients); and hepatic inflammation Noniummunosuppressed Patients) (e.g., , hepatitis, cholangitis), including During fellowship, trainees should gain an under - the role of liver biopsy. In addition, concepts of standing of gastrointestinal infections, including preventive medicine, such as indications for vacci - the following: nation, routes of infection, dietary and hygienic 33 practice for travelers, and appropriate recommen - bowel in patients with AIDS. Trainees should also dations for prophylactic antibiotic therapy, should recognize causes of colorectal disorders, including be included in training. , , and AIDS-related malignan - cies (e.g., Kaposi’s sarcoma) and should be familiar with the indications for and interpretation of flexi - Training Process ble sigmoidoscopic, colonoscopic, and radiographic The training and experience for the diagnosis and studies of the colon. treatment of gastrointestinal infection should Within the biliary system, trainees should be include participation in the evaluation and manage - capable of evaluating causes of , ment of outpatients and inpatients with the presen - abnormal liver test results (infections, neoplasia, tations and diagnoses listed above and should drugs), and the interaction of hepatitis viruses and include the appropriate use of diagnostic tests, indi - HIV; distinguish AIDS cholangiopathy and chole - cations, complications, and application of therapy cystitis; and assess indications for liver biopsy. in these disorders. Additional exposure to related AIDS-associated pancreatic disorders, including sciences (immunology, microbiology, and molecular causes of pancreatitis (infectious, neoplastic, toxic), biology) and related fields of medicine (infectious the implications of hyperamylasemia, and the nutri - diseases and laboratory, anatomic, and surgical tional evaluation of pancreatic disorders in patients pathology) can be obtained through conferences, with AIDS (assessment of nutritional status and seminars, and literature reviews as well as practical development and implementation of nutritional demonstration of techniques. therapies, including enteral and parenteral) should be incorporated (see Training in Nutrition). II. GASTROINTESTINAL DISORDERS IN Trainees should be able to determine the cause of and prescribe a rational treatment plan for com - IMMUNOSUPPRESSED PATIENTS mon opportunistic and neoplastic conditions in a Importance cost-effective and humanitarian fashion. According to a 2004 report of the World Health Organization, 40 million people worldwide are infected with HIV. AIDS is the leading cause of Training Process Training and experience within the 18-month core death of persons aged 15–59. In 2005, the clinical experience should include inpatient and National Institutes of Health reported that 40,000 outpatient consultative evaluations of patients with new HIV infections occur annually in the United AIDS who have /, diarrhea, States and the infection rate in African American rectal bleeding, abnormal liver enzymes/ males has doubled over the past 10 years. Most, if hepatomegaly, , and hyperamy - not all, patients with AIDS will manifest at least lasemia. In addition, extensive interactions between one AIDS-related disorder of the gastrointestinal trainees and specialists in laboratory medicine, tract, hepatobiliary system, or pancreas. Many diagnostic and interventional radiology, and infec - other patients are immunosuppressed due to con - tious disease and immunology should be available genital or acquired conditions or due to the effects through formal conferences and in the evaluation of immunosuppressive drugs given to treat other and management of individual patients. ailments or to prevent rejection of transplanted organs. Many of these patients also suffer from opportunistic infections. Therefore, it is important III. IDIOPATHIC INFLAMMATORY for gastroenterological specialists to recognize and know how to evaluate and treat infections in BOWEL DISEASE immunosuppressed patients. Importance IBD is a unique disorder for which gastroenterolo - gists provide both primary care and consultative Goals of Training (GI Disorders in services. Because these diseases are uncommon in Immunosuppressed Patients) the general community, general internists and fami - During fellowship, trainees should be able to assess ly physicians typically have little experience in the the broad range of gastrointestinal symptoms and spectrum of clinical presentation and therapeutic signs of illness in immunosuppressed patients and options. Expertise in diagnosis, including the inter - be able to differentiate AIDS-related from AIDS- pretation of diagnostic studies and ability to imple - unrelated conditions. Esophageal disorders include ment a therapeutic plan and assume longitudinal infectious esophagitis (fungal, viral, HIV, and neo - follow-up for patients with these chronic disorders, plasms). Trainees should be able to assess AIDS differentiates gastroenterological specialists from gastropathy and other infectious and neoplastic primary care physicians. gastric disorders. They should be able to assess dis - orders of the small intestine, including causes of diarrhea in immunosuppressed patients; interpret Goals of Training (Idiopathic endoscopic, barium, and computed tomographic Inflammatory Bowel Disease) and ultrasound examinations; and treat bacterial, During fellowship, trainees should become profi - fungal, viral, and protozoal infections of the small cient in the following: 34 THE GASTROENTEROLOGY CORE CURRICULUM

1. Recognition of clinical and laboratory features after ileo-anal anastomoses) and Crohn’s dis - (including serum antibody testing) of intestinal ease (including the differentiation and manage - inflammation that may aid in differentiating ment of postoperative diarrhea). between Crohn’s disease and . 15. Sensitivity to psychosocial influences as well as 2. Distinction between the signs of intestinal the consequences of IBD on patients and on inflammation from those of secretory and family dynamics. osmotic diarrhea and from symptoms of irrita - 16. Capability of developing a therapeutic plan ble bowel syndrome. commensurate with disease extent severity for 3. Differentiation of chronic idiopathic IBD from both ulcerative colitis and Crohn’s disease. other specific entities, such as acute self-limited 17. Understanding the indications, contraindications, (infectious) and colitis, drug- or radiation- and pharmacology of nonspecific therapies, induced colitis, ischemic bowel disease and including new biologic therapies such as inflix - . imab, anticholinergic agents, antidiarrheals, and 4. Understanding the indications for and interpreta - bile salt sequestrants; oral and topical aminosali - tion of serologic, endoscopic, radiological, histo - cylates; parenteral, enteral, and rectal corticos - logical, and microbiological studies used in the teroids; and immunosuppressants (purine ana - diagnosis and evaluation of patients with IBD. logues and methotrexate) antibiotics and probi - 5. Understanding the cost-benefit and risk-benefit otics used in relevant clinical situations. ratios for endoscopic and radiological proce - 18. Understanding the impact of antibodies to bio - dures used to diagnose, define disease extent logic agents and how to prevent, diagnose, and and severity, and to assess complications of manage immunogenicity to biologic agents. ulcerative colitis and Crohn’s disease. 19. Understanding the indications for enteral and 6. Recognition of different presentations of IBD, parenteral alimentation and be able to implement including the pediatric manifestations, anorectal nutritional therapies (see Training in Nutrition). complications, and inflammatory versus fistulizing In addition, trainees should be capable of diagnos - versus fibrostenotic patterns of Crohn’s disease, ing and differentiating other inflammatory disorders, and be able to recognize these various presenta - including collagenous and , NSAID tions on history-taking and physical examination. enterocolopathies, diverticulitis (including medical 7. Recognition and management of the intestinal and surgical complications), radiation and (hemorrhage, obstruction), extraintestinal (ocular, colitis, Whipple’s disease, celiac sprue, diversion coli - dermatologic, musculoskeletal, hepatobiliary, uri - tis, graft-versus-host disease involving the gastroin - nary tract), and nutritional complications of ulcer - testinal tract, and the solitary rectal ulcer. ative colitis and Crohn’s disease. 8. Understanding the influence of IBD on preg - nancy and of pregnancy on IBD and acquire Training Process knowledge on the safe use of IBD medications Unlike many other purely consultative aspects of during pregnancy. gastroenterology, trainees should be able to assume 9. Recognition and management of the adverse responsibility for the care of both inpatients and effects of used in the treatment of outpatients with IBD, encompassing diagnosis, IBD, including the role of measuring serum acute and chronic treatment, long-term follow-up, enzyme (thiopurine methyltransferase) and 6- and counseling of the families and/or significant mercaptopurine metabolite levels in conjunc - others. Adequate experience should include expo - tion with the use of immunomodulators. sure to hospitalized as well as ambulatory patients, 10. Addressing issues pertaining to family history including the initial assessment and longitudinal and genetic counseling, including knowledge management of patients with IBD, particularly in about the implications of gene mutations rele - the ambulatory setting, under the supervision of vant to IBD. skilled attending physicians. 11. Awareness of the long-term cancer risks in ulcerative colitis and Crohn’s disease and be Assessment of Competence able to implement appropriate cost-effective Knowledge of inflammation and enteric infectious surveillance programs. diseases should be assessed as part of the overall eval - 12. Understanding the histopathologic criteria for uation of trainees in gastroenterology during and diagnosis of dysplasia in ulcerative colitis. after the fellowship, as outlined in Overview of 13. Understanding the indications for surgery in Training in Gastroenterology. Questions relating to ulcerative colitis and Crohn’s disease. inflammation and enteric infectious diseases should 14. Diagnosing postoperative complications of sur - be included on the board examination and should gery in ulcerative colitis (including pouchitis reflect a general knowledge of this content. 35 Training in Malignancy the gastroenterologist to understand the indications Importance for and uses of chemopreventive agents. In view of The digestive tract has the highest incidence of can - the major advances in the prevention, diagnosis, cer of any organ system of the body. Approxi- staging, and treatment of gastrointestinal malignan - mately 24% of cancer deaths in the United States cy and the impact these advances will have on the are due to gastrointestinal cancers; 230,000 gas - practice of gastroenterology, this field deserves par - trointestinal cancers occur each year in the United ticular emphasis in the education of gastroenterolo - States, with 110,000 deaths (American Cancer gy trainees. Society statistics, 2005). Importantly, appropriate intervention can dramatically alter the natural his - tory and mortality of certain malignant and prema - Goals of Training lignant diseases. Patients who are treated in a time - During fellowship, trainees should: ly manner can usually return to normal lives and 1. Develop a sound knowledge of tumor biology will not be burdened by crippling chronic disease. to a level similar to that traditionally achieved For example, in theory, colon cancer is almost for acid-base or smooth muscle physiology. entirely preventable. Balanced training now should reflect the state- Gastroenterologists are responsible for the man - of-the-art and the relative importance of can - agement of several patient groups who are at par - cer to this field. ticularly high risk for gastrointestinal and associat - 2. Develop a thorough familiarity with the litera - ed extraintestinal cancers. These include groups of ture on cancer epidemiology, primary preven - patients with FAP, HNPCC, Peutz-Jeghers syn - tion, and screening for colorectal cancer with drome, and the juvenile polyposis syndromes; tests as well as endoscopic patients with nonsyndromic family histories of can - and radiological approaches. cer (particularly colorectal cancer); patients with a 3. Become knowledgeable about the recommend - prior history of gastrointestinal neoplasia, IBD, ed guidelines for screening for gastrointestinal gastroesophageal reflux disease, Barrett’s esopha - neoplasia and the literature supporting these gus, chronic , chronic pancreatitis, recommendations. and celiac disease; patients who previously have 4. Be able to read and interpret literature about had a gastrectomy; and patients infected with H. the emerging technologies and know how to pylori . In addition, gastroenterologists manage evaluate novel technologies and approaches. patients with chronic viral and C, which 5. Have a working knowledge of clinical genetics predisposes them to the development of hepatocel - and understand the approaches to the genetic lular carcinoma (HCC), as do the iron storage dis - diagnosis of FAP, HNPCC, and other rarer poly - eases, for which diagnostic testing is now available. posis syndromes. They should recognize the clini - Furthermore, patients with primary sclerosing cal characteristics of these diseases, the distinc - cholangitis and certain other related conditions are tions among the familial forms of cancer, the spe - at risk for developing biliary tract cancers. Each of cific diagnostic and screening tests for each, and these high-risk conditions has a unique natural his - the rational approaches to their treatment. tory and lends itself to diagnostic surveillance or 6. Learn the principles of neoplastic growth as they therapeutic intervention. relate to therapy, including endoscopic treatment has been an area in as well as traditional surgical approaches. A which there has been a rapid emergence of new complete understanding of the management of concepts. There has been an explosion of informa - premalignant conditions is necessary. tion in the area of tumor genetics. A model of mul - 7. Become familiar with the pathological interpreta - tistep carcinogenesis for colorectal cancer has been tion of tissue biopsies (endoscopic and percuta - developed, which represents the first coherent for - neous) and have a thorough working knowledge mulation of cancer pathogenesis. Two important of the management of dysplastic lesions. They concepts are the role of nutrition in the genesis of must understand the distinctions among the vari - gastrointestinal cancers and the emerging role of eties of colorectal polyps and their management. cancer chemoprevention for high-risk groups. It has 8. Learn the principles of chemotherapy for gas - recently been appreciated that aspirin and related trointestinal cancer and radiation treatment for compounds may play an important role in prevent - early and advanced tumors. They must under - ing cancer. New classes of pharmacological agents stand the initial management of those patients (including aspirin and certain nonsteroidal anti- in whom the diagnosis of gastrointestinal can - inflammatory agents) may be indicated in the pri - cer has just been made. mary prevention of colon and other gastrointestinal 9. Understand how to counsel patients who have cancers. The application of these modalities is like - had gastrointestinal neoplasia and how to ly to become commonplace, making it essential for manage patients who inquire about the man - 36 THE GASTROENTEROLOGY CORE CURRICULUM

agement of positive family histories of gas - mutation analysis, methylation assays, DNA trointestinal cancer. Trainees should under - sequencing, and linkage analysis. stand the principles and importance of genetic Endoscopic counseling as it pertains to genetic testing and Endoscopic training in the diagnosis and manage - the management of the inherited gastrointesti - ment of gastrointestinal cancer is required. nal diseases. They should be familiar with the Recommendations for the duration, frequency of prognoses associated with different types of procedures, and other details are covered in gastrointestinal cancer. Training in Endoscopy. However, areas relevant to 10. Become familiar with the technical considera - gastrointestinal malignancy that require specific tions in the therapy of colorectal adenomas attention include the following: and carcinomas. They should be thoroughly 1. Endoscopic management of Barrett’s esophagus. experienced in colonoscopic polypectomy of 2. Familiarity and at least limited experience pedunculated and sessile polyps and ablative with the indications, techniques, and manage - therapies for sessile lesions. Trainees must ment implications of laser therapy, photody - understand the capabilities and limitations of namic therapy, and stents for palliating endoscopic mucosectomy for early gastroin - esophageal cancers. testinal cancers. 3. Management of upper gastrointestinal neopla - 11. Understand the appropriate surveillance and sur - sia in FAP, including the management of gas - veillance intervals for patients at high risk for tric, duodenal, and periampullary lesions. developing cancer and those in whom premalig - 4. Endoscopic management of the gastric remnant nant epithelium has already been detected. following Billroth I and II surgery 12. Gain additional experience, for those who desire 5. Recognition of neoplasia in the pancreatico - advance training, in the placement of endoscopic biliary tree. stents, laser ablation, photodynamic therapy, 6. Familiarity and at least limited experience with endoscopic ultrasound, fine-needle aspiration of the indications, techniques, and management tumors, endoscopic mucosectomy, and endo - implications of therapeutic endoscopic retro - scopic celiac ganglion block for patients with grade cholangiopancreatography for pancreatic pancreatic cancer (level 2 training). and biliary cancers. 7. Proper technique for polypectomy for peduncu - Training Process lated and sessile polyps, including saline injection. Cognitive 8. Familiarity with the indications, techniques, Throughout the entire fellowship period, trainees and management implications of the emerging should participate in the screening, diagnosis, and endoscopic imaging techniques for surveillance management of all types of gastrointestinal malignan - of gastrointestinal malignancies such as confo - cies. Lectures in molecular and cellular biology as well cal laser endoscopy, chromoendoscopy, and as clinical oncology and screening, treatment, and pal - optical coherence endoscopy. liation of gastrointestinal cancer should be included in 9. Familiarity with recommendations for endo - the core curriculum. Lectures should be provided by scopic screening for colon cancer in average- experts in interventional endoscopy, oncology (med - risk individuals. ical and surgical aspects), radiation oncology, and 10. Surveillance of the colon in IBD, including con - . It is critical that trainees understand siderations for normal-appearing mucosa and the emerging role of the gastroenterologist in multiple abnormal-appearing mucosa. aspects of gastrointestinal cancer. To achieve these 11. Recognition of anal cancer lesions. goals, many programs will be required to invite out - Gastroenterology trainees should become familiar side consultants. with the appearance of cancer by using the follow - Coverage of the following topics should also ing radiological and pathological techniques: be provided: 1. Radiological: gastrointestinal cancer on barium 1. Changes in screening and surveillance recom - upper gastrointestinal series, barium , mendations. CT colography, CT scans, and MRI/MRCP 2. The evolution of genetic testing and counseling 2. Pathological: for FAP, HNPCC, and other familial forms of a. Recognition of Barrett’s epithelium and dys - gastrointestinal cancer. plastic change in Barrett’s mucosa 3. Novel approaches to the diagnosis of gastroin - b. Recognition of intestinal metaplasia and testinal cancer, including endoscopic approach - atrophy in the stomach es, radiological approaches, nuclear medicine, c. Recognition of neuroendocrine and stromal ultrasound/endoscopic ultrasound, and new cell tumors of the gastrointestinal tract genetic techniques. d. Identification of neoplastic and non-neoplastic 4. Staging of gastrointestinal cancer, management polyps and malignancies options, and prognostication. e. Recognition of the depth of invasion of can - 5. Techniques used in the basic science investiga - cer in the polyp or into the wall of the colon tion of gastrointestinal cancer, including flow and its significance cytometry, polymerase chain reaction assays, TRAINING IN MALIGNANCY 37

f. Recognition of dysplasia versus reactive esophagus and biliary and pancreatic tree changes in IBD 3. Ablative therapy of neoplasms using laser 4. Photodynamic treatment of epithelial neoplasia The roles of radiology and pathology are specifi - in Barrett’s esophagus cally addressed by Training in Radiology and 5. Fine-needle aspiration of masses in the liver Training in Pathology. and pancreas. Certain trainees may elect to receive additional training in advanced endoscopic procedures, level 2 training (see Training in Endoscopy). These proce - Assessment of Competence dures should not be attempted by all trainees; Knowledge of malignancy should be assessed as rather, they should be reserved for those who wish part of the overall evaluation of trainees in gas - to spend the time to master these techniques and troenterology during and after the fellowship, as may be reserved for selected centers. outlined in Overview of Training in Gastroenter- These procedures include the following: ology. Questions relating to malignancy should be 1. Endoscopic ultrasound of the esophagus, stom - included on the board examination and should ach, duodenum, and reflect a general knowledge of this content. 2. Dilating, stenting, and tissue sampling of the 38 THE GASTROENTEROLOGY CORE CURRICULUM Training in Motility and Functional Illnesses system: fasting and postprandial programs of Importance motility and secretion. Functional bowel and motility disorders account 3. Anatomical and physiological basis of visceral for visits by nearly 40% of patients being seen by afferent signaling, including vagal and spinal practicing gastroenterologists and are among the pathways, neurobiology of pain signaling, and most challenging disorders to manage. An effective visceral sensitization. approach to the evaluation and management of 4. Brain–gut interactions and the biopsychosocial patients with motility and functional bowel disor - continuum. ders involves several key elements: 5. Pharmacology of agents modulating motility 1. An understanding of the physiology of the and sensation, including prokinetic drugs, enteric nervous system, gastrointestinal muscle antidiarrheals, and laxatives function, and familiarity with concepts of the 6. Development of the enteric nervous system and brain–gut axis, visceral sensation, and the reg - congenital disorders of motility such as ulation of gut function during feeding and fast - Hirschsprung’s Disease and hypertrophic ing conditions. . 2. Exposure to state-of-the-art patient manage - 7. Physiology of deglutition and neural control ment by physicians with experience and mechanisms and disorders of swallowing, expertise in the field is an integral part of the including secondary and primary etiologies. training of effective and compassionate gas - 8. Esophageal motor physiology, esophageal dys - troenterologists. motility, including achalasia, diffuse esophageal 3. Appreciation of the importance of the psy - spasm and other spastic disorders, noncardiac chosocial aspects of functional bowel disorders chest pain. and familiarity with effective treatments for 9. Physiology and pathophysiology of gastroe - chronic pain, depression, and anxiety. sophageal reflux, singultus, and belching. 4. An understanding of the utility, indications, 10. Organization and control of gastric motor and limitations of diagnostic motility studies. activity and physiology of gastric emptying, Recommendations about the use of these stud - and postsurgical gastric syn - ies should acknowledge consensus documents dromes, nonulcer dyspepsia. commissioned by the various gastrointestinal 11. Small bowel physiology, congenital and acquired professional societies. disorders of small bowel motility, including dia - A major goal of the training in motility and func - betes, scleroderma, and pseudo-obstruction. tional bowel disorders is to develop highly trained 12. Colonic and defecatory physiology and patho - specialists that are familiar with the clinical nuances physiology, colonic inertia, anorectal and of these complicated problems. Patients with motility pelvic outlet/floor disorders, irritable bowel disorders and functional illnesses offer unique oppor - syndrome, and diverticular disease. tunities to develop this competency due to the combi - 13. Motility of the biliary tract, Sphincter of Oddi nation of chronicity, disability, and psychological dis - dysfunction, and gallbladder dyskinesia tress characteristic of many of these disorders. For 14. Systemic disorders affecting gastrointestinal example, chronic and chronic pain produce motility (diabetes mellitus, scleroderma, thy - great suffering in these patients and require great roid disease, paraneoplastic syndromes, and compassion by the treating physician in addition to neurologic disorders including ). detailed knowledge of effective management strate - 15. Principles of clinical psychology as it relates to gies. These conditions also require a great deal of the management of patients with chronic disor - judgment on the part of the treating physician. For ders including an understanding of cognitive- example, the management of chronic idiopathic intes - behavioral therapy, hypnosis, and other forms tinal pseudo-obstruction demands difficult and of indications and appro - appropriate decision making for medications and sur - priate use of psychopharmaceuticals. gical procedures that might be required to promote The chronic nature and social impact of many dis - motility and vent static portions of the gastrointesti - orders of dysmotility necessitates the cooperation and nal tract. support of family members in the care of these To diagnose and treat motility and functional dis - patients. Fellows should develop effective techniques orders effectively, trainees in gastroenterology must for interacting with family members to accomplish attain knowledge and understanding of the follow - these goals. Management of these patients also ing specific topics: requires a multidisciplinary approach requiring coor - 1. Organization of the contractile apparatus of dination with several other specialties, including gen - the gastrointestinal tract including smooth eral surgery, nutrition, clinical psychology, and pain muscle and interstitial cells of Cajal. management. Motility disorders require an intense 2. Anatomy and physiology of the enteric nervous commitment and professionalism on the part of the 39 physician because of the chronic and often intractable It is anticipated that most physicians participat - nature of the symptoms. and ing in level 2 training will practice in an academic understanding of the psychosocial factors driving ill - environment; therefore, all level 2 trainees should ness behavior can be particularly challenging. gain expertise in clinical or basic research. This The numerous systemic diseases that adversely includes mastery of study design, methodology, sta - affect gastrointestinal motility require cooperation tistical analysis, protocol writing, drafting informed among many specialties in medicine, such as neuro- consent documents, submission of protocols to logy, , surgery, , clinical institutional review boards, enrollment of patients psychology, and gynecology. The high expense and into studies, analyzing and interpreting data, pre - technical expertise of resources for these diseases senting at national meetings, and writing papers. also demand judicious use of health care resources Having effective mentorship is essential for success such as total parenteral nutrition and small bowel at clinical or basic research. transplantation. Procedural Training Goals of Training Level 1 As with most specialties, a combination of cogni - With respect to motility studies, all trainees should tive/clinical skills and knowledge along with proce - have a clear understanding of the indications and dural proficiency is necessary for training in the potential pitfalls in the performance of motility stud - care of patients with these disorders. Two levels of ies and the limitations of interpretation of esophageal training should be offered. Level 1 is for all manometry, esophageal pH studies, esophageal motil - trainees who will be a part of the general gastroen - ity with provocative agents, radionuclide gastric emp - terology program and who need to develop a famil - tying studies, small bowel motility, colonic transit iarity with motility and functional disorders. Level measurements, anal sphincter manometry, and anal 2 is intended for those who will specialize in motil - sphincter and pelvic floor biofeedback training. ity and functional disorders and require more Trainees gain experience with these tests in the course intensive training. of the clinical care of their patients, however, this level of training is done primarily on an intellectual Level 1 level to produce an understanding of the value and At this level all trainees should acquire the funda - limitations in interpreting the findings of the tests and mental core of information outlined above through to know when they would be valuable in the man - supervised patient care experiences, mentored inter - agement of a patient. It is expected that this level of pretation of diagnostic tests, individual reading, training will be incorporated in the first 18 months of presentation of core curriculum at gastroenterologi - clinical training. cal/radiological/surgical clinical conferences, lec - All trainees should have an understanding of the tures by invited speakers, journal clubs, and con - specifics of how tests are performed to know when tact with attending physicians. they might be contraindicated in any individual Level 2 patient. In addition, trainees should be able to rec - The major goal for trainees at level 2 is to acquire ognize the manometric features of major motor dis - an in-depth knowledge of pathophysiology, clinical orders of the esophagus and anal sphincter. These presentation, diagnosis, epidemiology, and therapy disorders include , diffuse of gastrointestinal motility and functional disorders. , ineffective esophageal motility In general, trainees at this level should have com - and scleroderma, internal anal sphincter weakness, pleted at least 18 months of training in general external anal sphincter weakness, and absence of gastroenterology and should spend up to an addi - the rectoanal inhibitory reflex. Trainees should tional 18 months concentrating on motility and understand the features of esophageal pH testing functional disorders. Trainees seeking advanced and the limitations of this study as a measure of training in motility and functional disorders should gastroesophageal reflux. Trainees also should learn be selected on the basis of demonstrated interest and to recognize the factors that may introduce artifact a record of excellent clinical performance in the gen - into a study so that reports can be interpreted by eral gastroenterology track. Selected trainees must the referring physicians without the need to rely be provided with the opportunity to perform an completely on the physician performing the test. adequate number of motility studies and motility- Level 2 directed therapeutic procedures (e.g., pneumatic This level involves additional training in the inter - dilation), to receive supervised teaching, and to be pretation of diagnostic tests and is aimed at indi - involved in clinical research. Ideally, level 2 training viduals who seek to be true experts in manage - should produce an expert capable of managing all ment of motility and functional disorders. The aspects of motility and functional disorders. In experience necessary to become proficient in the terms of cognitive and diagnostic acumen, level 2 diagnosis and therapy of these types of diseases trainees are expected to know physiology, patho - should be offered only in institutions that have a physiology, diagnosis, and therapy of dysmotility, large patient referral base, a wide range of functional, and diverticular diseases in greater detail patients with motility and functional disorders, than those at level 1 of training. 40 THE GASTROENTEROLOGY CORE CURRICULUM

adequate facilities, and faculty expert in the man - bowel disorders. Subspecialty trainees should agement of these conditions. acquire skills in interview techniques, physical Specifically, the goal of this higher level of training examination, particularly for pelvic floor disorders, is to provide appropriate instruction for subspecialty and the integration of psychological information trainees who will conduct and interpret motility stud - into clinical reasoning and decision making. ies after training and act as consultants to other gas - Although many of these skills can be learned by troenterologists and other clinicians. Major therapeu - caring for patients with these disorders under the tic decisions rest on the results of these studies, preceptorship of experienced clinicians, formal dis - including decisions regarding surgical procedures and cussion of these skills may be valuable, particularly use of drugs for long-term therapy. Trainees who during multidisciplinary conferences. wish to be able to provide this consultative service Level 1 are required to be involved in a sufficient number of Trainees should be provided with appropriate clini - studies and to be completely familiar with the logis - cal experiences during which patients with possible tics of performing studies, potential technical prob - motility disorders can be evaluated and managed lems with the techniques that might affect the inter - under the guidance of the faculty. This experience pretation of the studies, and the nuances of interpret - should include discussion about appropriate test - ing these studies. It is important that level 2 trainees ing, interpretation of test results, and treatment of are able to interpret these studies without relying on patients under the guidance of appropriate staff. In computer analyses alone. Level 2 trainees also are addition to learning about motility tests, trainees expected to be familiar with emerging technologies, should have the opportunity for hands-on experi - such as intraluminal impedance measurements, ence doing motility studies, including ambulatory advanced scintigraphic transit measurements and pH studies, to understand what the test experience assessments of accommodation, and gastrointestinal will involve so that they can more accurately wall movements, even though these are not in wide - explain the tests to patients. This also will allow spread use yet. appreciation of potential limitations and artifacts that can affect test interpretation. Specific literature Training Process and didactic teaching should be developed by the Functional Bowel Disorders training program so that trainees can become The process of developing the expertise to manage familiar with and understand the pathophysiology patients with functional bowel disorders is difficult of motility disorders and the available studies. A to codify. However, an understanding of the physi - library of motility tracings should be maintained ology of the brain–gut axis and the physiology of for review by level 1 trainees. motility and sensation of the gut as well as an Level 2 understanding of the psychosocial forces that modi - Threshold numbers of proctored studies required fy symptom presentation and behavior are critical before assessing competence in each of the motility to the care of these patients. It is likely that this investigations are listed in Table 5. will be even more important as newer drugs and These numbers were derived by consensus among other treatments are introduced. A goal of training the members of the task force, each of whom has should be to develop experienced clinicians who had extensive experience in working with trainees can apply both the “art” and “science” of medicine to enable them to become proficient in performing to the management of patients with functional and interpreting motility studies. The numbers for

Table 5 – Guidelines for Level 2 Training in Motility: Threshold Number of Proctored Studies Required Before Assessing Competence

Studies Required number Standard esophageal motility 50 Gastric and small bowel motility studies (either perfused catheter or solid-state transducers, or impedance catheters) 25 Indications, interpretation, and significance of scintigraphic measurement of gastric emptying 25 Colonic motility studies (either perfused catheter or solid-state transducers) 20 Anorectal motility studies/anal sphincter manometric studies 30 Anal sphincter biofeedback training 10 Colonic transit with radiopaque markers or scintigraphy 20 TRAINING IN MOTILITY AND FUNCTIONAL ILLNESSES 41 most of these procedures have also been endorsed depending on the level of activity at the motility labo - by the Subcommittee on Training of the American ratory at that institution. It will be the responsibility Motility Society. of the preceptors to design the training programs in To gain expertise in these procedures, trainees such a way that they can certify that the trainees are should be exposed to the management of patients trained appropriately. To be considered trained at with the disorders for which these tests are used. level 2 for any specific motility test, the trainee Although a proposed number of patients with each should have a documented log demonstrating appro - of these diseases to be seen by the trainee would be priate numbers of the types of studies performed and arbitrary, it is expected that trainees will have interpreted under supervision. extensive clinical exposure to patients with motility and functional disorders. In addition, a specific amount of time should be Assessment of Competence Knowledge of motility and functional illnesses spent by trainees to become familiar with the appro - should be assessed as part of the overall evaluation priate indications for, to conduct, and to interpret of trainees in gastroenterology during and after the these studies under the preceptorship of faculty mem - fellowship, as outlined in Overview of Training in bers who are experienced in them. This should Gastroenterology. Questions relating to motility involve hands-on performance of the studies as well and functional illnesses should be included on the as analysis and interpretation of the results. The board examination and should reflect a general amount of time will vary from program to program, knowledge of this content. 42 THE GASTROENTEROLOGY CORE CURRICULUM Training in Nutrition 6. Implementation and management of nutrition - Importance al therapy, including modified diets, enteral The major function of the gastrointestinal tract is tube feeding, and parenteral nutrition. to ingest, digest, and absorb nutrients. Therefore, 7. Pathophysiology and clinical management patients with diseases of the gastrointestinal tract of obesity. are at increased risk for developing nutritional 8. Ethical and legal issues involved in provision abnormalities because of alterations in nutrient and withdrawal of nutrition support. intake, decreases in nutrient and absorp - tion, and increased nutrient losses. Advances made during the last 3 decades have made it possible to Goals of Training feed all patients who are unable or unwilling to Nutrition training for gastroenterology fellows is ingest or who are unable to absorb an adequate divided into two levels. Level 1 represents the basic amount of nutrients. Certain interventional feeding training in nutrition that should be provided to all techniques require endoscopic expertise. trainees. Level 2 represents advanced training for Appropriate use of nutrition support requires an fellows who have a specific interest in nutrition and understanding of the principles of energy require - desire additional experience and proficiency in clin - ments, macronutrient and micronutrient metabo - ical nutrition and nutrition research. lism, and fluid balance. The ability to evaluate the Level 1 clinical efficacy of nutrition support and the clinical The gastroenterology fellowship should provide a knowledge of the interaction between the patient’s core curriculum that provides all trainees with a disease process and nutritional status is necessary general understanding of the following topics: to provide the appropriate nutrition support. 1. Basic nutritional principles. Trainees should Many gastrointestinal conditions are treated with have an understanding of normal micronutri - dietary manipulation and patients often ask for ent and macronutrient function, requirements, nutritional guidance even when dietary manage - digestion, absorption, and metabolism and the ment is not established scientifically. An example of effects of gastrointestinal diseases and resec - the former is use of a gluten-free diet in celiac dis - tion on these processes. They should under - ease. An example of the latter is use of a high-fiber stand the nutritional aspects of celiac disease diet for management of of the colon. and other mucosal diseases associated with Gastroenterologists should be familiar with dietary malabsorption, Crohn’s disease, liver disease, management of gastrointestinal and liver disease so , pancreatic insufficiency, that they can address their patients’ needs. limited ileal resection, and short-bowel syn - In addition to understanding the principles of drome. Trainees should also understand the identifying and treating nutritional deficiencies, process of intestinal adaptation following knowledge of overfeeding and obesity is also essen - massive small bowel resection. tial. Obesity can cause gastrointestinal diseases 2. Nutritional assessment. Trainees should be because of the adverse effects of excess adiposity on able to determine when a patient is at risk for specific gastrointestinal organs. Currently, treat - malnutrition. They should be able to identify ment of obesity consists of dietary advice, medica - specific nutrient deficiencies and excesses and tions with limited efficacy, and, increasingly, sur - protein-energy malnutrition by using a focused gery. However, new medications and endoscopic history and physical examination and appro - treatment for obesity that alters the anatomy of the priate laboratory tests. The specific criteria gastrointestinal tract are on the horizon. that increase the patient’s risk for malnutrition Therefore, is an integral compo - and associated medical complications, includ - nent of the management of many patients seen by ing abnormally low plasma nutrient concentra - gastroenterologists. To adequately treat these tions, weight loss, and body mass index, must patients, it is strongly suggested that gastroenterol - be understood clearly. ogists understand the following: 3. Malnutrition. Trainees should understand the 1. Basic principles of nutrient requirements, inges - physiological consequences of underfeeding, tion, digestion, absorption, and metabolism in including the metabolic response to starvation, the healthy and diseased gut. alterations in body composition and organ 2. Assessment of nutritional status, including spe - function that occur with inadequate protein cific nutrient deficiencies and excesses, protein- and energy intake, and the clinical effects of energy malnutrition, and obesity. specific nutrient deficiencies. The adverse 3. Metabolic response to starvation and the effects of aggressive refeeding of the severely pathophysiological effects of malnutrition. malnourished patient also must be understood. 4. Metabolic response to illness and injury and 4. Stress states. Trainees should understand the nutrient requirements during stress states. metabolic response to illnesses and injury and 5. Indications for nutrition support. 43

the effects of illness and injury on nutrient and long-term (home) therapy. metabolism and requirements. 7. Obesity. Trainees should obtain a general 5. Specific gastrointestinal disease states. Trainees understanding of the pathogenesis of obesity should understand and be able to implement and the factors involved in the regulation of nutrition management plans that are based on food intake and energy balance. They should current evidence-based literature, related to severe understand the medical complications associat - acute pancreatitis, liver disease and transplanta - ed with obesity, particularly the gastrointesti - tion, inflammatory bowel disease, gastrointestinal nal complications (gastroesophageal reflux dis - fistulas, short-bowel syndrome, radiation enteritis, ease, , pancreatitis, liver dis - and celiac disease. Trainees should also under - ease, and colon cancer). Trainees should stand how to systematically evaluate a patient understand the principles of weight manage - with intestinal malaborption such as chronic pan - ment, including behavior modification, diet, creatitis, bacterial overgrowth, celiac disease, and physical activity, pharmacotherapy, and surgi - protein-losing . cal therapy. The trainees should also be aware 6. Nutrition support. Trainees should understand of endoscopic and surgical treatments for how to use oral, enteral, and parenteral feed - weight loss. Trainees should understand how ing techniques to prevent or correct specific to appropriately diagnose and manage compli - nutrient deficiencies and to provide appropri - cations of obesity surgery, including stomal ate protein, energy, fluid, vitamin, and mineral ulceration, stomal stenosis, intestinal , intake in patients who are unable to maintain and nutrient deficiencies. an adequate oral intake of nutrients because of 8. Ethical and legal issues. Trainees should short-bowel syndrome, nausea and , obtain an understanding of the ethical and inability to swallow, severe illness, psychiatric legal issues involved in providing and with - illness, or altered mentation. Specific knowl - drawing enteral and parenteral nutrition sup - edge of the following topics is essential: port for terminally ill patients, end-stage a. Energy and macro- and micronutrient dementia, patients who are unable to give con - requirements sent, and patients who refuse nutritional thera - b. Indications for enteral and parenteral py but are unable to maintain adequate nutri - nutritional support tional status without artificial feeding. c. Appropriate timing of the initiation of Level 2 nutritional support via enteral or par - Level 2 trainees must have an in-depth understand - enteral nutrition ing and documented clinical experience in all areas d. Benefits and complications associated required for level 1 training. In addition, the level 2 with both enteral and parenteral nutri - trainees should achieve the following: tion in specific disease states 1. Familiarity with nutrient requirements e. How to calculate and implement enteral throughout the life cycle and parenteral therapy, including indi - 2. Competency in the appropriate outpatient and cations, administration options, compo - inpatient nutritional management of diverse sition and proper selection of formula - patient populations who might not have gastroin - tions, monitoring techniques, and evalu - testinal diseases, such as those with diabetes, dys - ation for complications lipidemias, wasting diseases (e.g., cancer and f. Indications for and composition of diets AIDS), eating disorders, cardiovascular disease, modified in nutrients or consistency osteoporosis, pulmonary diseases, renal disease, g. The physiological principles of oral and those who are pregnant or lactating rehydration therapy and appropriate use 3. Understanding of the importance of nutrition of oral rehydration solutions in health promotion and disease prevention h. The use of enteral tube feeding, including 4. Familiarity with methods for assessing energy indications, feeding tube options, tube expenditure and body composition placement techniques, composition and 5. Understanding of the organizational and admin - proper selection of liquid formulations, istrative structure of inpatient and outpatient monitoring tube feeding, and complications nutrition support services and outpatient weight i. Proficiency in the endoscopic placement management programs as well as the economic of PEG and PEJ feeding tubes issues involved in managing such programs j. Management of access catheters for 6. Familiarity with the management of patients parenteral nutrition, including place - receiving home parenteral and enteral nutri - ment, maintenance, complications and tion, including the indications for and compli - their treatment cations of these therapies k. Criteria and indications for implementing 7. Understanding the indications for isolated and home enteral and parenteral nutrition combined liver and intestinal transplantation l. Drug–nutrient interactions 8. Experience in teaching nutrition to other med - Knowledge of these nutrition support princi - ical trainees, such as medical students, house ples is needed for both short-term (inpatient) staff, and level 1 gastroenterology fellows 44 THE GASTROENTEROLOGY CORE CURRICULUM

After completion of level 2 training, trainees should Trainees should receive formal training and hands- be able to serve as consultants for both inpatient and on experience in nasogastric and nasojejunal tube outpatient nutritional issues, medical directors of placement and endoscopic placement of percuta - inpatient nutrition support services, medical directors neous gastrostomy and jejunostomy tubes. of home nutrition support programs, or medical Level 2 directors of obesity treatment programs. Level 2 training in nutrition can be obtained only at institutions where there are faculty members Training Process with expertise in clinical nutrition or nutrition Level 1 research and established clinical nutrition services. To obtain the core knowledge required for level 1 Achievement of competence in level 2 training training, trainees should be exposed to didactic lec - requires an average of 12 months of clinical nutri - tures, case conferences, selected readings (which tion and nutrition research, which can be provided can include CD-ROMs and Internet-based pro - as nutrition fellowships separate from the gastroen - grams), and clinical experience that jointly cover all terology fellowships or as part of the third year of areas listed above. Trainees should be involved in the gastroenterology training program. Trainees providing and writing orders for enteral and par - should spend at least 6 months participating in enteral nutrition support to hospitalized patients, clinical nutrition activities, including inpatient including those in intensive care units, and nutri - (interdisciplinary nutrition support service) and tional management of outpatients. These clinical outpatient (nutrition and weight management clin - experiences can be obtained by rotation on an ics) services. Trainees should serve as clinical nutri - inpatient gastroenterology service, exposure to a tion consultants for other physicians in both inpa - nutrition support service, experience on other inpa - tient and outpatient settings; at least 25% of the tient services, or participation in an outpatient clin - clinical experience should be gained in an inpatient ic that involves nutrition counseling, such as man - setting and at least 25% in an outpatient setting. agement of patients receiving long-term enteral and Trainees should be involved in the nutrition train - parenteral nutrition support. ing of level 1 gastroenterology fellows and given A faculty member who is knowledgeable in nutri - guidance on presentation and teaching techniques. tion should be available at the base institution of They should select a nutrition topic for the research training or be made available in a block rotation component of their gastroenterology fellowships. through an appropriate university affiliation. Trainees also should have active interaction with pharmacists and dieticians involved with nutrition - Assessment of Competence Knowledge of nutrition should be assessed as part al support as part of a total team approach of car - of the overall evaluation of trainees in gastroen - ing for patients requiring nutrition support. terology during and after the fellowship, as out - Nutrition topics and cases should be included as lined in Overview of Training in Gastroenterology. part of routine lecture series and clinical confer - Questions relating to nutrition should be included ences provided for gastroenterology training so that on the board examination and should reflect a there is ongoing interdisciplinary involvement. general knowledge of this content. 45 Training in Pathology risks and benefits of dyplasia surveillance in Importance chronic inflammatory disorders, such as Barrett’s An understanding of gastrointestinal and hepatic esophagus and inflammatory bowel disease. pathology, which includes surgical pathology (both 6. Trainees should be familiar with the clinical gross and microscopic findings) and cytological implications of the pathological findings in pathology as well as the pertinent areas of clinical biopsies and in surgical specimens. Examples pathology, and diagnostic molecular biology, is of this include being able to interpret changes essential to the practice of modern gastroenterolo - in a wedge versus needle liver biopsy and gy. Training in gastrointestinal pathology helps understanding the problem of overdiagnosis of trainees in three ways. First, it is critical to an chronic inflammation in the gastrointestinal understanding of the etiology of gastrointestinal mucosa. Another example is understanding and hepatobiliary disorders. Second, it provides the dysplasia and its therapeutic implications. basis for understanding the diagnostic usefulness 7. Trainees should know the value and limita - and the limitations of pathological studies across tions of exfoliative and aspiration cytology. the broad range of these disorders. Third, it pro - 8. Trainees should become familiar with the vides the basis for productive discussions between mechanisms and the usefulness of new tech - clinician and pathologist regarding diagnostically niques, such as flow cytometry, immunohisto - challenging cases. Finally, the integration of these chemistry, and tests based in molecular biology two areas of knowledge (i.e., the pathogenesis and (e.g., polymerase chain reaction, in situ the usefulness of specific pathological tests) permits hybridization), as well as an understanding of the development of links between pathological test special tissue handling procedures for some of results and therapeutic possibilities, which form the these procedures. basis of many treatment decisions. 9. Trainees should have a familiarity with specific special techniques and special stains as diagnos - Goals of Training tic aids in gastrointestinal and hepatic pathology, The overall goal of such training is competency in including in situ hybridization (e.g., immuno- recognizing and understanding the significance of globulin receptors and/or EBV assessment in the endoscopic, gross pathological, and/or histolog - lymphoma workups) and immunohistochemistry ical characteristics of certain disorders and diseases. (e.g., CMV, HBV stains in viral infection work- The following objectives are important in attaining ups, cytokeratin stains for bile ducts, differentia - such competence: tion markers of neuroendocrine tumors, onco - 1. Trainees should appreciate the spectrum of gene and proliferation markers in premalignant normal histology for gastroenterological tissue. and malignant lesions). 2. Trainees should learn to recognize patterns of 10. Trainees should gain familiarity with a broad histopathologic change in gastrointestinal and range of gastrointestinal pathology to include hepatic disorders. These include normal archi - unusual pediatric liver diseases, the recognition tectural patterns and those reflecting inflam - of opportunistic infections with HIV, and mation, dysplasia, cancer, and the evolution of graft-versus-host disease, and the submission a disease over time. of pancreatobiliary biopsy and cytology speci - 3. Trainees should learn what constitutes an ade - mens for detection of carcinoma or other pan - quate biopsy sample appropriate for patholog - creatic and changes. ic interpretation. 11. Trainees should have an understanding of the 4. Trainees should master the art of correlative utility and limitations of fine-needle aspiration clinical information with pathological speci - and brush biopsy in the workup of gastroin - mens to assist the pathologist in interpretation testinal and pancreatobiliary pathology, espe - of biopsy tissue. Specifically, cially as they relate to the use of endoscopic a. provide appropriate background ultrasound procedures. clinical information 12. Trainees should understand when and how b. provide appropriate macroscopic biopsies should be submitted to the pathology description of tissue with specific loca - laboratory for other than routine processing in tion of biopsy specimens formalin (e.g., saline for lymphoma evaluation, 5. Trainees should become adept at understanding electron microscopy fixative, etc.). appropriateness of when to biopsy, how it may 13. It is suggested that trainees be exposed to aid the diagnosis, as well as understand the limi - emerging technologies that may in the future, tations of biopsy. Examples include the need for optimize traditional biopsy techniques, such as submucosal tissue in ruling out amyloid, difficul - supravital staining, autofluorescence spec - ty in differentiating ischemic from radiation troscopy, magnification endoscopy, and molec - changes and the approach to, timing of, flaws, ular pathology. 46 THE GASTROENTEROLOGY CORE CURRICULUM

cussion. Thus, the endoscopic and/or endoscopic Training Process ultrasound appearance of specific lesions would be The teaching of gastrointestinal and hepatic patholo - reviewed at the same time as the usefulness and limi - gy should rely heavily on multidisciplinary confer - tations of performing a biopsy on them, thereby ences of gastroenterologists and pathologists, weekly maximizing the educational impact. or bimonthly, to review biopsy and gross specimens. These conferences can take a variety of formats and may include any or all of the following: viewing Assessment of Competence endoscopic slides or videos, reviewing the histology Knowledge of pathology should be assessed as part of endoscopic or liver biopsy specimens, examining of the overall evaluation of trainees in gastroen - surgical specimens, and reviewing radiological films terology during and after the fellowship, as out - and videos. Combining these formats can enhance lined in Overview of Training in Gastroenterology. their value. For example, one useful combination Questions relating to pathology should be included would be to hold endoscopic slide/video review con - on the board examination and should reflect a ferences, with the biopsy specimens taken from the general knowledge of this content. same cases presented for histological review and dis - 47 Training in Pediatric Gastroenterology testinal bleeding, diarrhea, cystic fibrosis). Importance Special emphasis should be given to the transi - Trainees in gastroenterology should have some expe - tion of care from the pediatric gastroenterolo - rience in pediatric gastroenterology. Although their gist to the adult gastroenterologist as the knowledge base and endoscopic skills relating to patient moves from adolescence to adulthood. pediatric gastroenterology will not be sufficient to Trainees should also be aware of differences in manage pediatric patients independently, they should the presentation of these disorders and their achieve an understanding of congenitally acquired management in the pediatric population. disorders and disease in the growing child. As they 4. Congenital abnormalities and gastrointestinal begin to assume care for these patients as adults, conditions that are much more common in these experiences will be beneficial. infants and children than in adults, such as necrotizing , Meckel’s diverticu - Goals of Training lum, intestinal intussusception, and mid-gut Trainees in gastroenterology should not be expected . Trainees should gain familiarity with to achieve any level of competency in pediatric gas - causes of neonatal , conjugated and troenterology beyond general concepts. Competency unconjugated hyperbilirubinemia encountered requires completion of a pediatric gastroenterology in pediatric patients, and inborn errors of training program. After their training is completed, it metabolism leading to jaundice, such as disor - is suggested that trainees in pediatric gastroenterolo - ders of carbohydrate and lipid storage. gy should be able to do the following: 1. Appreciate the unique aspects of the field; a goal of the experience in pediatric gastroen - Training Process It is strongly suggested that trainees attend regular terology is to increase awareness of the clinical clinical conferences at which pediatric cases are dis - problems of pediatric gastroenterology, not to cussed. A limited experience with a pediatric gas - develop competence. troenterology service offers further exposure. In 2. Be prepared to participate in limited scope of addition, an enrichment program might include lec - care when, in underserved areas, pediatric gas - tures (or a visiting professorship) by a pediatric troenterology consultation is not available. gastroenterologist. Finally, trainees should be It is unlikely that a broader scope of activity is possi - encouraged to work with pediatric gastroenterolo - ble because a prerequisite for subspecialty care of chil - gists in transitioning patients from the pediatric to dren must be adequate training in both and adult practitioners as the patient moves from ado - gastroenterology (parallel to the requirements for the lescence into adulthood. Because patients with con - practice of internal medicine and gastroenterology). genital diseases, such as cystic fibrosis, are surviv - It is suggested that the pediatric gastroenterology ing longer as a result of improved long-term nutri - component of the curriculum should focus on sev - tion and medical treatment and as a result of liver eral aspects. They include the following: and small intestinal transplantation, such interac - 1. Age-related physiological and psychological tions are becoming even more important. variables of children and adults. 2. Unique aspects of the disease in the pediatric Assessment of Competence versus the adult patient. An example is hepati - Knowledge of the pediatric curriculum should be tis B; if the disease is acquired in early life, the assessed as part of the overall evaluation of trainees in rate of development of the chronic carrier state gastroenterology during and after the fellowship, as is up to 90%, whereas acquisition later in life outlined in Overview of Training in Gastroenterology. is associated with lower carriage rates. Questions relating to pediatric gastroenterology 3. Manifestations of gastroenterologic diseases should be included on the board examination and that span the pediatric and adult age groups should reflect a general knowledge of this content. (e.g., abdominal pain, constipation, gastroin - 48 THE GASTROENTEROLOGY CORE CURRICULUM Training in Radiology dilations and performing endoscopic retrograde Importance cholangiopancreatography must become familiar An understanding of radiological principles, the with radiation safety practices. Many state licensing ability to interpret images demonstrating gastroin - boards require users of fluoroscopy to obtain a testinal diseases, and familiarity with the appropri - supervisor’s certificate, which requires passing an ate use of imaging studies are important aspects of examination in radiation safety. gastroenterology practice. Thus, because gastroen - terologists are required to interpret imaging studies as well as to demonstrate knowledge of appropriate Goals of Training choices of imaging techniques that apply to specific Gastroenterologists in training should gain famil - problems in gastrointestinal disease, specific train - iarity with the wide variety of radiological studies ing in gastrointestinal radiology is necessary. frequently used to evaluate the gastrointestinal tract Gastroenterology trainees who will use fluo - and liver (see Table 6). As a result of this experi - roscopy in their practices for monitoring stricture ence, trainees must:

Table 6 – Radiological Studies/Techniques Important for Gastroenterology Training

Study type Examples Plain abdominal film Flat, upright, and decubitus films Barium study Esophogram (including use of a barium pill and fluoroscopy) Upper gastrointestinal series Small bowel follow-through series, enteroclysis Air contrast barium enema Defecography Computed tomography (CT) Abdominal/pelvic CT CT angiogram CT colonography Magnetic resonance imaging (MRI) Abdominal/pelvic MRI Magnetic resonance cholangiopancreatography Magnetic resonance angiography Interventional/therapeutic study Visceral angiography, portal venography Catheter drainage of cysts, abscesses Transjugular intrahepatic portosystemic shunt Fluoroscopic vessel embolization Interpretation of endoscopic cholangiopancreatography radiograms Placement of enteral tubes/catheters Ultrasound Complete abdominal/pelvic ultrasound (including Doppler studies) Ultrasound-guided liver biopsy Nuclear medicine scan Technetium-99m tagged red blood cell scan Gastric emptying scan Biliary scintigraphy Radiolabeled octreotide scan Positron emission tomography (PET) Tumor localization 49

1. Become familiar with radiological tests that are 2. Trainees must have exposure at regular confer - appropriate for evaluation of patients with ences that include a review of radiographic imag - gastrointestinal, biliary, and liver diseases, ing studies in relation to gastrointestinal disease. including ultrasound, computed tomography, Further, it is suggested that: magnetic resonance imaging, vascular radiolo - 3. Trainees have defined rotations on a radiology gy, contrast radiology, and nuclear medicine. service. 2. Understand the methods by which radiograph - 4. Trainees participate in self-instructional pro - ic studies are performed. grams in gastrointestinal radiology. 3. Become familiar with radiological tests to gain expertise in recognizing normal anatomy The didactic approach most widely available to and function of the alimentary tract and gastroenterology trainees is exposure at regular related organs. conferences dealing with imaging interpretation 4. Learn to identify structural defects and abnor - and the choice of imaging studies. These include malities of motility. gastrointestinal radiology correlation conferences 5. Understand the logical sequence of using these and multispecialty clinical conferences. Trainees techniques in the evaluation of gastrointestinal must participate in joint multidisciplinary confer - and liver problems. ences, which include radiologists, to discuss specific 6. Have an appreciation for and understanding of patients. The process should also include some the costs for different radiological studies. form of lecturing on specific, defined topics in gas - 7. Understand the indications and contraindica - trointestinal radiology. This includes the broad tions for interventional radiological studies. range of diagnostic modalities, the proper choice of 8. Understand the advantages and limitations of diagnostic tests for specific clinical problems, and these studies compared to endoscopy and other principles of interpretation. diagnostic modalities. Providing specific, dedicated time for rotating in a 9. Gain familiarity with the detection of neo - radiology department is effective for teaching gastroin - plasms of the colon during the performance of testinal radiology and exposing trainees to all aspects CT colonography and other similar techniques. of this subject. Although a rotation in radiology may not be applicable to or possible for all trainees, a 4- Trainees should be encouraged to consult with week rotation in gastrointestinal radiology with radiol - radiologists when interpreting studies, correlate ogists specializing in this area is suggested. findings with the clinical presentation, and develop Self-instruction in radiology can be carried out the ability to make appropriate management deci - using various techniques developed for this purpose. sions based on the findings. It is expected that care - These include videotapes and videodisks, computer ful review of specific studies with radiologists will interactive teaching programs, and syllabi prepared facilitate accomplishment of the objectives high - for teaching gastrointestinal radiology. These tech - lighted above. niques provide gastroenterology trainees with an opportunity for exposure to gastrointestinal radiolo - Training Process gy at times of their own choosing. There are four major methods of providing educa - tion in the interpretation of radiological techniques and in the algorithmic approach to diagnostic Assessment of Competence Knowledge of radiology should be assessed as part imaging. These include the following: of the overall evaluation of trainees in gastroen - 1. Trainees must participate in work rounds on terology during and after the fellowship, as out - individual patients, which is integral to routine lined in Overview of Training in Gastroenterology. patient care, including specific review and dis - Questions relating to radiology should be included cussion of radiology studies with a radiologists on the board examination and should reflect a in the context of routine clinical care. general knowledge of this content. 50 THE GASTROENTEROLOGY CORE CURRICULUM Training in Research of-the-art techniques in cellular and molecular biolo - Importance gy. They must develop a clear understanding of the The subspecialty of gastroenterology is dedicated to current body of knowledge in their areas of interest, continued progress in the prevention, diagnosis, of unanswered questions most relevant to their and treatment of gastrointestinal disorders. This research question(s). They need to acquire practical mission requires the availability of talented and experience in critical analysis of current scientific lit - committed physician-investigators appropriately erature, in the use of computers (e.g., literature trained to elucidate biological mechanisms and the review, gene or protein sequence analysis), in scientif - natural history of gastrointestinal diseases and to ic writing and presentation, and in the preparation of develop outcome-based approaches to treatment research proposals for funding and for evaluation by and the use of resources. It further requires that all institutional review boards. Trainees must understand future gastroenterologists be familiar with research the ethical issues surrounding conduct of research. principles and methods. It is suggested that all gas - They should be required to write abstracts and troenterology training be performed in institutions papers and submit them for publication. where research opportunities are readily available either on site or through programmatic affiliation Clinical Research with a research institution. Clinical research includes research in which the intact This document summarizes specific skills that human is the unit of observation and includes clinical trainees in gastroenterology who wish to pursue trials, physiologic or pharmacologic studies, epidemi - investigative careers (i.e., research track trainees) ological research, and behavioral studies. Clinical will need to acquire, elements of the training cur - research, such as outcome research, retrospective riculum necessary to acquire these skills, and studies, do not require face-to-face interaction approaches to evaluating the training program and between the investigator and a human subject. The trainees to help ensure that the program objectives disciplines relevant to clinical research are epidemiol - are met. The “research track” is defined as that ogy, biostatistics, health policy, decision sciences, involving an emphasis on basic research (i.e., labo - health services research, and technology development ratory-based) or clinical research (i.e., patient- that may interface with engineering and other special - based). Research-oriented gastroenterologists can ties. Trainees seeking careers in clinical research must ultimately pursue, independently or via collabora - acquire advanced and practical skills in state-of-the- tion, any of a number of different types of research. art clinical research methods. The clinical researcher Several examples include the following: pure funda - should be formally trained in critical appraisal, study mental science, disease-oriented research, and design, decision sciences, biostatistics, data manage - patient-oriented research. ment, quality control, health quality, and health It is strongly suggested that continuous blocks of behavior. Trainees must develop a clear understand - protected research time (at least 3–6 months) be set ing of the current body of knowledge and important aside for fellows to pursue scholarly activity and unanswered questions in their areas of interest and of research. It is expected that fellows publish a scien - the ethics of research and human investigation. They tific manuscript in a peer-reviewed journal and/or must understand and comply with current policies to present the results of their research activity at a protect health information. Trainees pursuing dedi - national scientific meeting. cated research training must acquire practical experi - ence in the critical appraisal of current literature, in the use of computers (e.g., literature review, database Goals of Training management, analysis, and communication), and in The specific skills or competencies that trainees the presentations of their work in written and oral seeking careers in basic research (primarily funda - forms. Trainees should have experience preparing mental or disease-oriented) or clinical research (pri - proposals for funding and for evaluation by institu - marily patient-oriented) need to acquire are sum - tional review boards where appropriate. They should marized below. be required to write abstracts and papers and submit Basic Research them for publication. Trainees seeking a career in basic research require advanced understanding of the physiology and patho - physiology of the part of the digestive tract they have Training Process 1. Research Mentors focused on. They should be familiar with the princi - Research mentors are essential elements of the train - ples of cellular and molecular biology. They also ing experience. They must have a commitment to and must acquire basic laboratory skills and become com - experience in the training of fledgling investigators, petent in identifying a research question or questions, an established record of productivity in sponsored formulating a working hypothesis, and developing a research, and excellence in their fields. Mentors may rationale study design. They must be trained in bio - be faculty members in the gastroenterology training statistics, the appropriate use of animals, and state- 51 program or engaged in research pertinent to gastroin - Trainees who pursue rigorous research training testinal biology or disease in another division or during their fellowship must be involved in an department in the institution. Mentors must be aware approved training activity for the remaining 18 of opportunities for collaborative interaction locally months of the 3-year fellowship. In many settings, and nationally in the areas under study by the research training exceeds 18 months depending on trainees and be principally responsible for fostering the research training needs of the trainee. Examples the development of the trainees into independent of approved training activities include obtaining an investigators. Mentors must have experience in schol - MS degree in a clinically-related area, such as health arly activities, including performance of research, research policy, clinical study design, or publication in peer-reviewed journals, and the pro - epidemiology), or research training under an NIH curement of extramural funding. T32 Training Grant, or involvement in a well-defined and mentored research project. For some fellows, the 2. Structured Curriculum training period may exceed the proscribed 3-year fel - Trainees should have the opportunity to participate in lowship to meet the research objectives set forth in formal course work, taught by qualified faculty, to the NIH training grant. acquire the specific skills outlined above in laboratory- based research, including course work in cell biology, 4. Research Environment molecular biology, and molecular genetics. In patient- The training should be conducted in a stimulating based research, this includes course work in clinical and intellectually rich research environment that pro - research methods, biostatistics, epidemiology, decision vides scientific background in the particular disci - sciences, health policy, health services research, and pline. Faculty of the training program must include ethics. In addition, all trainees should receive training individuals with established skills in basic or clinical in critical appraisal of the literature, writing of grants research. Trainees should have the opportunity to and papers, and ethical conduct of research. participate in critical appraisal of the current scientif - ic and clinical literature, in research conferences dur - 3. Protected Time and Meeting Rigorous Clinical ing which they present and defend their own work, and Basic Research Training Needs and, under the supervision of their mentors, in the While preparation for a successful independent peer review of articles submitted for publication. investigative career will typically require more than Trainees should acquire practical experience in the 1 year of supervised research experience beyond development of questions, the conduct of basic the period of training required for subspecialty and/or clinical research designed to answer these board eligibility, trainees must have sufficient pro - questions, and the preparation of abstracts, scientific tected time during the training period to participate reports, and funding proposals. in the course work outlined above and to initiate a An integral feature in success within a research well-defined, prospective, hypothesis-driven career is the ability to direct a laboratory and to research project. The period of protected time may mentor students, fellows, and technical and admin - vary depending on a variety of factors, including istrative staff. This aspect of research should be a the specific career objectives of the applicants and topic of formal discussion between mentors and the funding mechanism. Program directors should trainees, and trainees should be exposed to the be given sufficient flexibility in organizing clinical styles and skills of more than one mentor. It is also training activities so as to comply with current recommended that training programs develop doc - National Institutes of Health (NIH) guidelines per - uments and workshops to instruct trainees on taining to trainees supported by individual or insti - appropriate management and mentoring skills. tutional National Research Service Awards. These should include attention to the following: Trainees who elect to pursue rigorous clinical or a. Responsibilities of members of the research basic research training during their fellowship are team to design studies, communicate plans, typically supported by NIH T32 Training Grants and plan evaluative data (generally during their second and third year of train - b. Record-keeping, including notebooks and ing) that require they spend at least 75% of their storage and cataloging of data time involved in research activities, but may also be c. Do’s and don’ts of planning collaborations supported by other means. This training must be and sharing research materials added to the 18 months of minimum clinical patient d. Consideration of scope and feasibility of care experience; of which, hepatology should com - research projects for graduate students prise at least 5 months of this experience as required and fellows by the ACGME as part of the standard first 3 years e. Information about important landmarks in of fellowship. The 18 months of clinical patient care doctoral and postdoctoral level training experience need not be continuous, but a minimum such as presentations at national meetings of 9–12 months must be continuous. The remaining and publications 6–9 months of the 18 months minimum clinical f. Mechanisms to formally and informally evalu - experience requirement may include direct clinical ate the performance of individuals who are exposure, such as continuity clinic, endoscopy time, placed under the direction of the trainees and patient-related activities or encounters during g. Conflict management skills (hanndling and off-hour call responsibilities. resolving difficulties) 52 THE GASTROENTEROLOGY CORE CURRICULUM

h. Appropriate behavior in the research work - the form of the Research Career Award series: K08 place as it relates to possible problems due to (for physician scientists interested in basic research) discrimination based on race, ethnicity, gender, and K23 (for those interested in patient-oriented or sexual orientation or to sexual harassment research), both immediately following fellowship training. Other options, like the K01 award, are Humane treatment of animals and ethical treat - available from some NIH Institutes for PhD ment of patients are increasingly important topical trainees. The NIH also has two loan repayment issues. Although current ethics training courses programs for trainees interested in clinical or pedi - address the theoretical basis and legalities of these atric research careers (http://www.lrp.nih.gov/). issues, most trainees never see an application for Additional information regarding training sup - Institutional Animal Care and Use Committee port opportunities is available through the: approval or Institutional Review Board approval • Department of Veterans Affairs until they become independent investigators. It is rec - (http://www1.va.gov/resdev/) ommended that trainees participate in the prepara - • Crohn’s & Colitis Foundation of America tion of such a document or receive some form of for - (http://www.ccfa.org/science/research/) mal instruction in planning and preparing such docu - • Howard Hughes Medical Institute ments as part of their training programs. Trainees (http://www.hhmi.org). should be trained in the responsible conduct of sci - ence and in the handling of protected health informa - In addition, each of the gastroenterology societies tion in accordance with HIPAA regulations. has funding opportunities and travel awards includ - ing the: • AASLD (https://www.aasld.org/) Funding Opportunities • ACG (http://www.acg.gi.org/) Trainees should be aware of funding mechanisms. • AGA (http://www.gastro.org/) Multiple funding opportunities are available, • ASGE (http://www.asge.org/) including the NIH, other government agencies, and private foundations. The most common means of To locate all available funding opportunities, take funding research training are NIH-supported Ruth advantage of GrantsNet (http://www.grantsnet.org/). L. Kirschstein National Research Service Award institutional training grants (T32s) or individual fellowships (F32s). The NIH training website Assessment of Competence Knowledge of research should be assessed as part (http://grants1.nih.gov/training/extramural.htm) has of the overall evaluation of trainees in gastroen - details regarding trainee funding opportunities. The terology during and after the fellowship, as out - program director, division chief, or mentor(s) lined in Overview of Training in Gastroenterology. should guide trainees in applying for research train - Questions relating to research should be included ing support and other funding opportunities appro - on the board examination and should reflect a priate for the fellow’s level of training. general knowledge of this content. More advanced NIH training support comes in 53 Training in Surgery plantation. They should be knowledgeable about Importance esophageal procedures, surgery of the gastrointesti - Surgery is the primary and preferred method of nal, pancreatic and hepatobiliary tracts, gallbladder management for some gastrointestinal disorders, surgery and liver malignancies. Trainees must be such as acute , colorectal cancer, and knowledgeable about when to pursue endoscopic, mechanical obstruction of the small intestine. In interventional radiology, or surgical procedures and other conditions, surgical management becomes an which route offers the best treatment option for an option after an initial period of medical therapy, individual patient. such as inflammatory bowel disease. Still other gas - It is strongly suggested that trainees learn surgi - trointestinal problems rarely if ever require surgical cal anatomy and the important relationships of management; there are many conditions in this cat - ductal, vascular, and luminal structures by partici - egory. Because the usual sequence is patient referral pation in surgical procedures. from a gastroenterologist to a surgeon, trainees in gastroenterology must be knowledgeable about the indications and contraindications for surgical treat - Training Process ment and general principles and complications of Indications and contraindications to surgical inter - surgical procedures that may be used. Gastroenter- vention can be taught through literature and by ologists frequently follow patients over the long- didactic teaching. Lectures constitute a convenient term postoperatively; therefore, trainees must be method of conveying knowledge about surgical knowledgeable about the expected outcomes and procedures, and a systematic series of lectures complications of operations that are likely to be organized by organ or disease process ensures com - performed on their patients. prehensive coverage. Trainees must participate in joint medical–surgical multidisciplinary conferences to discuss specific patients. Retention of informa - Goals of Training tion about surgical alternatives is most secure when Additional training or separate rotations are not learning is linked to individual patients. Personal necessary to fulfill the goals of training in surgery. learning through literature searches is an essential Instead, surgical training must be incorporated and element in this effort. integrated into the overall training process that It is suggested that trainees go to the operating occurs during a gastroenterology fellowship. room when their patients are undergoing surgical Trainees must learn the medical management of procedures. Observation of gross pathological patients under surgical care for gastrointestinal and abnormalities will help trainees correlate preopera - hepatic disorders and become thoroughly knowl - tive information with operative findings. Trainees edgeable about the postoperative care of patients also will gain an appreciation of the conduct of after major and minor surgical procedures. operations, the factors entering into surgical judg - Trainees should learn the way that surgical proce - ment, and the recognition and management of dures are conducted. postoperative complications. A block of time on a Trainees should learn the indications and con - rotation as a member of the surgical team on a traindications for a variety of common operations busy gastrointestinal surgical service is advanta - for gastrointestinal and hepatic disorders. It is geous but optional. important for trainees to learn to judge whether a Trainees must learn the relative utility of laparo - surgical procedure is necessary, what kind of opera - scopic, open surgical, endoscopic, or interventional tion is indicated, and when it should be performed. radiologic methods for managing specific gastroin - Surgical complications and their management testinal and hepatobiliary diseases and be knowl - should be explored, and trainees should become edgeable about when to pursue which method. familiar with the long-term consequences of surgi - cal treatment of gastrointestinal and hepatic dis - eases. Specifically, trainees should learn about Assessment of Competence antireflux procedures, ulcer operations, surgery for Knowledge of surgery should be assessed as part of obesity, hepatobiliary operations, gallbladder sur - the overall evaluation of trainees in gastroenterolo - gery, pancreatic procedures for benign and malig - gy during and after the fellowship, as outlined in nant disease, surgery for inflammatory bowel dis - Overview of Training in Gastroenterology. ease of the small and , colonic proce - Questions relating to surgery should be included on dures for diverticular disease or cancer, various the board examination and should reflect a general anorectal operations, laparoscopic versus open pro - knowledge of this content. cedures, portosystemic shunts, and hepatic trans - 54 THE GASTROENTEROLOGY CORE CURRICULUM Training in Women’s Health Issues in Digestive Diseases Gastroenterologists need to be aware of these gender Importance differences when caring for their female patients. Women comprise 50.8% of the population (July As recently as 1987, only 13.5% of the budget of 2003 Census figures). They make more than 580 the NIH was used to study women’s health issues. million outpatient visits each year to physicians in Until only a decade ago, women were actually the United States, which represents 59.6% of all excluded from most clinical trials because of fears of ambulatory visits (CDC, National Ambulatory pregnancy and potential harm to the fetus and/or Medical Care Survey: 2002 Summary). Women that the menstrual cycle or other hormonal changes make 11,714,000 visits each year to gastroenterolo - could skew some results. Results for men were gists in the United States, which represents 56.2% extrapolated to women. Physicians should be aware of all visits to gastroenterologists (2000 NDTI Data of this and recognize that much prior research has Source). Although many gastrointestinal and liver not accounted for potential gender differences. A diseases are the same in women and men, many notable example in gastroenterology is one major differences exist that require specific knowledge of study of the natural history of gallstone disease that gender-based biology and the pathophysiology of principally studied men although the disease primari - digestive diseases in women. Current research has ly affects women. Fortunately, this gender bias in shown that there are gender and cultural differ - clinical studies was recognized and in 1994, the NIH ences in the: revised its inclusion policy to meet the NIH 1. epidemiology of many gastrointestinal and Revitalization Act of 1993 that mandated that liver diseases, women and minorities must be included in all of its 2. responses of patients to health and illness, clinical research studies. To understand health and 3. treatment responses and complications, and disease states in women more accurately, researchers 4. ability to request and undergo a complete must include women in clinical trials, and all clinical endoscopic evaluation, especially colonoscopy. trials should have separate analyses by gender. Appropriate delivery of subspecialty digestive dis - ease care to women requires up-to-date knowledge Goals of Training of the pathophysiology of both health and disease The goals of training for gastroenterology fellows in states in women as well as an understanding of the women’s health issues can be divided into three broad special issues and concerns of female patients who categories, all of which must be included in level 1 have digestive diseases. training. No additional training or separate rotation Pregnancy poses numerous challenges for the gas - is necessary to fulfill the goals of training. Instead, troenterologist. Recent improvements in therapy have women’s health issues and awareness of gender dif - enabled more women with chronic digestive diseases ferences must be incorporated into the overall gas - to become pregnant. This in turn has raised new troenterology fellowship. An important feature of this issues regarding their management and treatment. training is the ability to recognize gender differences Appropriate delivery of subspecialty care in digestive in the pathophysiology of health and disease states diseases to women requires an understanding of how and different responses to treatment. gastrointestinal and liver diseases affect fertility and The gastroenterology fellowship core curriculum pregnancy and vice versa. Treatment of common should provide all trainees with an understanding problems of pregnancy such as heartburn (present in of the following topics: 80% of pregnant women) requires special knowledge of drug safety and pathophysiology of gastro- I. General Women’s Health Issues esophageal reflux disease in pregnancy. Evaluation of 1. Trainees must understand gender differences as potentially serious problems such as abdominal pain they pertain to the doctor–patient relationship. in pregnancy requires a special understanding of the Examples include methods of history-taking, causes and time of occurrence of this symptom dur - listening, confidentiality, modesty, physical ing pregnancy. contact, active patient participation in treat - The doctor –patient relationship is an integral part ment plans, and women’s preference for a gen - of understanding and caring for patients. This often der concordant endoscopist. requires addressing not only physical concerns but 2. There are cultural and religious differences also psychosocial, cultural, and religious issues and between men and women and the manner in needs. In addition, the interpersonal relationship which health care is perceived and sought between a woman and her physician is unique and after and with which recommendations are different from that between a man and his physician. complied. Examples include certain cultures 55

that do not permit a man, including a male be aware that there are gender differences in physician, to perform an examination on a the demographics, epidemiology, and patho - female patient without the permission of a physiology of many gastrointestinal tract and male family member. In addition, societal liver disorders. One example is irritable bowel differences influence the likelihood of pres - syndrome, which is the most common func - entation of diseases; for example, men from tional gastrointestinal disorder, with a preva - India with are lence of 15%–20% in adult Western popula - more likely to present to physicians for tions; there is a clear predominance in women, treatment than are Indian women, even because 70%–80% of patients with irritable though irritable bowel syndrome is more bowel syndrome are women. Other examples prevalent in females. Trainees should be include chronic constipation, autoimmune dis - aware of these cultural differences and orders, and gender differences in gastrointesti - should be exposed to cultural training as nal manifestations of systemic diseases, chron - part of their gastroenterology fellowship. ic abdominal and/or pelvic pain, pelvic floor 3. Trainees should understand psychosocial disorders, eating disorders, obesity, endo- issues as initiating factors in certain disease metriosis, osteoporosis, , and biliary states, their contribution to ongoing clinical tract and liver diseases such as nonalcoholic symptoms and pathology, and their impact on steatohepatitis. Trainees must understand the evaluation and treatment. Examples include effect of obesity on the gastrointestinal tract sexual, physical, and emotional abuse and and liver function. their consequences on gastrointestinal health Women are less likely to be referred for issues. Trainees should be able to elicit an endoscopic procedures such as screening abuse history during the routine examination. colonoscopy by their primary care physi - They should have a working knowledge of cians. Moreover, numerous studies have local resources available for intervention in found that colonoscopy is more difficult in cases of ongoing abuse. women due to a longer, more redundant 4. Trainees should recognize there are gender colon, and the fact that more of the colon lies differences as well as changes during preg - within the pelvis, as compared to their male nancy in normal laboratory values, includ - counterparts. Colonoscopy is also frequently ing liver tests, hematocrit, and creatinine more difficult posthysterectomy, with lower values. They must recognize anatomic gen - completion rates in this population. Trainees der differences on diagnostic tests and should understand this and a minimum of changes in women with age and pregnancy. 25% of their procedures must be on female 5. Trainees should recognize gender differences patients (see Training Process below). in disease presentation as well as different Women with certain gastrointestinal tract thresholds between women and men in and liver disorders are predisposed to other seeking medical care. In addition, there are diseases. In conjunction with the patients’ differences in thresholds for pain perception primary physicians, trainees must be able to in different disease states as well as among advise and appropriately screen their other - individual patients. For example, patients wise asymptomatic patients for these dis - with irritable bowel syndrome have eases. Examples include steroid use and increased sensitivity for small intestinal osteoporosis, inflammatory bowel disease and/or colonic distention at lower thresh - and colon cancer, primary biliary cirrhosis olds than healthy controls. and breast cancer as well as chronic diseases 6. Women remain the major caregivers for their (including obesity) and nutritional disorders. children and their own parents, yet 60.3% of Trainees should understand that cancers women older than 19 years are now that affect women, such as breast, ovarian, employed at least part time (seasonally adjust - and uterine cancer, potentially increase a ed, January 2005 figures). Trainees should be woman’s risk of developing colorectal can - adept at eliciting a history of family, home, cer and that the patient should therefore be and work conflicts and responsibilities and be screened appropriately. able to incorporate this understanding of Trainees should understand the psychoso - competing demands and the need for flexibili - cial impact on many of these disorders as ty into the treatment plan. well as the effect that chronic disease has on a patient’s daily life and that an effective II. Specific Digestive Diseases and Women’s treatment plan often includes a multidisci - Health Issues plinary approach. 1. Trainees should understand gender differences 2. Trainees should understand the effect of the in the normal functioning of the digestive dis - menstrual cycle and menopause on gastroin - ease tract in health. Trainees should under - testinal tract and liver function in both health stand the presentation and pathophysiology of and disease. This includes an understanding all gastrointestinal and hepatic diseases in both of estrogen and progesterone and the role women and men. In addition, trainees should 56 THE GASTROENTEROLOGY CORE CURRICULUM

these and other hormones have on gastroin - g. The different pharmacokinetics and testinal tract and liver function, such as their interactions of medications during influence on reflux symptoms and gastroin - pregnancy and breast-feeding testinal tract motility. Trainees should under - h. Adequate and appropriate nutrition, stand the potential emotional and physical including increased vitamin and min - impact that premenstrual syndrome and eral requirements during pregnancy menopausal symptoms have on female i. The potential harm to the fetus of med - patients in both health and disease states. ications, sedation, endoscopic proce - 3. Trainees should recognize and understand dures, including ERCP, and diagnostic gender differences in medication pharmacoki - tests, including radiographic tests, (e.g., netics, differences in prolongation of QT ultrasound, barium studies, MRI, and intervals, differences in metabolism and inter - CT scanning, and the appropriate use actions of medications, and differences in the of these during pregnancy) therapeutic response. Evolving areas of In general, endoscopic procedures in the preg - research such as gender differences in the nant patient are only recommended in situations absorption and metabolism of medications where not doing the procedure could result in harm should be covered. They should understand to the mother or fetus. Potential indications include and be able to anticipate side effects, compli - life-threatening gastrointestinal bleeding, suspicion cations, and interactions of medications that of a colonic malignancy, or severe unremitting diar - are used for the management of gastrointesti - rhea with an unrevealing noninvasive evaluation. nal and liver diseases in women as well as Maternal–fetal monitoring should be considered as interactions of these medications with those well as standard patient monitoring. Preprocedure prescribed by nongastroenterologists. Because consultation with an obstetrician is recommended obesity is more common in women, trainees and care must be taken to avoid maternal hypoxia should recognize the differences that obesity and hypotension, both of which are extremely causes in drug metabolism. detrimental to the fetus. The ASGE guidelines for III. Pregnancy and Childbearing Issues endoscopy in pregnant and lactating women recom - 1. Trainees should be cognizant of the issues mend the following general principles: regarding fecundity, fertility, and pregnancy 1. Always have a strong indication, particularly and be able to appropriately advise women in high-risk pregnancies with gastrointestinal and liver disorders who 2. Defer endoscopy to the second trimester when - desire pregnancy. They should understand the ever possible impact that gastrointestinal and liver disorders 3. Use the lowest effective dose of sedative med - have on women’s ability to become pregnant. ications Trainees should have a basic knowledge of 4. Wherever possible, use category A or B drugs genetics as it pertains to gastrointestinal and 5. Minimize procedure time liver disorders and the inheritance risk to the 6. Position the pregnant patient in the left pelvic woman’s unborn fetus. tilt or left lateral position to avoid vena caval 2. Trainees should be knowledgeable about the or aortic compression following conditions during pregnancy: 7. The presence of fetal heart sounds should be a. Gastrointestinal and liver changes and confirmed before sedation is begun and after disorders in normal pregnancy the endoscopic procedure b. The impact of gastrointestinal and liver 8. Obstetric support should be available in the disorders on a woman’s ability to carry event of a pregnancy-related complication a healthy baby to term as well as the 9. Endoscopy is contraindicated in obstetric compli - impact of her pregnancy on her gas - cations such as placental abruption, imminent trointestinal or liver disorder (e.g., IBD) delivery, ruptured membranes, or eclampsia c. The initial clinical presentation during There are gastrointestinal disorders that are pregnancy of a gastrointestinal or caused or affected by delivery and that manifest liver disorder (e.g., gallstones) themselves immediately in the postpartum period d. Gastrointestinal and liver disorders that or years afterward that trainees should be able to are unique to pregnancy, including, but recognize. Examples include , uri - not limited to, acute fatty liver of preg - nary and/or fecal incontinence, and . nancy and HELLP syndrome Trainees should understand the mechanisms and e. The method of infant delivery that is pathophysiology of these disorders and be able to most appropriate for the mother’s dis - appropriately treat their female patients. ease state (e.g., Cesarean section vs. vaginal delivery in Crohn’s disease) f. The risk of maternal –fetal transmis - Training Process sion of infectious agents and the All trainees must meet the goals of training in appropriate treatment of both the women’s health issues in digestive diseases. In mother and newborn infant order to do this, trainees will need a variety of TRAINING IN WOMEN’S HEALTH ISSUES IN DIGESTIVE DISEASES 57 teaching and learning experiences that should span terologist with an interest and experience in the entire period of training. They should be women’s health issues should be available for the exposed to didactic lectures (which can include trainees. At institutions where this does not exist, CD-ROM and Internet-based programs), case con - an alternative but less optimal strategy would be ferences, self-directed learning, selected readings, for the trainees to receive some or all of this train - and clinical experiences that jointly cover all areas ing from nongastroenterologists who focus on discussed above. women’s health issues. It is anticipated that close alliances and consulta - tions with obstetricians and gynecologists will be necessary for adequate training in the issues relat - Assessment of Competence Knowledge of women’s health issues in digestive ing to endometriosis, fertility, pregnancy, and the diseases should be assessed as part of the overall postpartum period. evaluation of trainees in gastroenterology during A minimum of 25% of the panel of patients who and after the fellowship, as outlined in Overview of are evaluated and treated by trainees during their Training in Gastroenterology. Questions relating to clinical experience, including inpatients, outpatients women’s health issues in digestive diseases should evaluated in the ambulatory continuity clinics, and be included on the board examination and should procedures, must be women. At least one gastroen - reflect a general knowledge of this content. 58 THE GASTROENTEROLOGY CORE CURRICULUM Appendix I Gastroenterology Core Curriculum Contributing Editors – 2006 Edition The following gastroenterologists are acknowledged for their significant editorial contributions to the 2006 iteration:

Bashar M. Attar, MD, PhD Deborah D. Proctor, MD Training in Geriatric Gastroenterology Training in Geriatric Gastroenterology Training in Radiology Training in Surgery Carl L. Berg, MD Training in Women’s Health Issues in Training in Hepatology Digestive Diseases Training in Pathology

Don C. Rockey, MD Robynne K. Chutkan, MD Training in Hepatology Training in Biliary Tract Diseases and Training in Malignancy Pancreatic Disorders Training in Radiology Training in Endoscopy Training in Research Training in Malignancy Training in Pathology Training in Women’s Health in Digestive Diseases Lawrence R. Schiller, MD Training in Acid-Peptic Disease Training in Motility and Functional Illnesses Marcia R. Cruz-Correa, MD, PhD Training in Inflammation and Training in Malignancy Enteric Infectious Diseases Training in Endoscopy Training in Nutrition

Karen E. Hall, MD, PhD James S. Scolapio, MD Training in Geriatric Gastroenterology Training in Nutrition Training in Geriatric Gastroenterology Stephen A. Harrison, MD Training in Hepatology Christian D. Stone, MD, MPH Training in Pathology Training in Inflammation and Enteric Training in Research Infectious Disease Training in Radiology Esther J. Israel, MD Training in Pediatric Gastroenterology Jacques Van Dam, MD, PhD Training in Radiology David A. Katzka, MD Training in Motility and Functional Illnesses John J. Vargo, MD, MPH Training in Biliary Tract Diseases and Walter E. Longo, MD Pancreatic Disorders Training in Surgery Training in Endoscopy Training in Pathology David C. Metz, MD Training in Acid-Peptic Disease M. Michael Wolfe, MD Training in Acid-Peptic Disease Training in Cellular and Molecular Physiology Bishr Omary, MD. PhD Training in Nutrition Training in Hepatology Training in Pediatric Gastroenterology Training in Research Training in Cellular and Molecular Physiology Roy K. H. Wong, MD Training in Motility and Functional Illnesses Pankaj J. Pasricha, MD Training in Motility and Functional Illnesses Training in Biliary Tract Diseases and Pancreatic Disorders APPENDIX I 59

Gastroenterology Core Curriculum Contributing Editors – 2003 Edition

Introduction Training in Nutrition Ann Ouyang, MD Sanuel Klein, MD (Chair) Jamie Aranda-Michel, MD Alan L. Buchman, MD. MSPH Overview of Training in GI Martin H. Floch, MD Lawrence Friedman, MD William D. Heizer, MD Frank G. Gress, MD Lee M. Kaplan, MD, PhD Philip Katz, MD Training in Pediatric Gastroenterology Ann Ouyang, MD Harland S. Winter, MD Joel E. Richter, MD Hugo R. Rosen, MD Training in Gastrointestinal and Hepatic Pathology Kenneth E. Sherman, MD, PhD Christina M. Surawicz, MD (Chair) Charles Bernstein, MD Training in Motility, Diverticular Disease, and Wilifred M. Weinstein, MD Functional Illnesses Michael Camilleri, MD (Chair) Training in Gastrointestinal Radiology Ann Ouyang, MD Thomas W. Faust, MD (Chair) Douglas A. Drossman, MD Richard F. Harty, MD Peter J. Kahrilas, MD James M. Richter, MD Reza Shaker, MD Training in Surgery Deborah D. Proctor, MD Arun J. Sanyal, MD Training in Acid-Peptic Disease Mark Feldman, MD Training in Research Bruce F. Scharschmidt, MD (Chair) Training in Biliary Tract Diseases and Nathan M. Bass, MD, PhD Pancreatic Disorders David A. Brenner, MD Sum P. Lee, MD. PhD Jay H. Hoofnagle, MD Peter Franks, MD Stephen Hulley, MD David A. Lieberman, MD Training in Inflammation, David A. Peura, MD Enteric and Infectious Disease Joel E. Richter, MD Stephen B. Hanauer, MD Training in Gastrointestinal Cellular and Training in Gastrointestinal Malignancy Molecular Physiology C. Richard Boland, MD (Chair) Richard V. Benya, MD (Chair) Dennis J. Ahnen, MD James E. McGuigan, MD Steven H. Itzkowitz, MD Mrinalini C. Rao, PhD Catia Sternini, MD John F. Valentine, MD Training in Hepatology Lee M. Kaplan, MD, PhD, (Chair) Kenneth Sherman, MD, PhD (Co-Chair) Training in Geriatric Gastroenterology Hugo R. Rosen, MD Karen E. Hall, MD, PhD (Chair) Nathan M. Bass, MD, PhD Bashar M. Attar, MD, PhD Peter R. Holt, MD Makau P. Lee, MD. PhD Training in Gastrointestinal Endoscopy Charlene M. Prather, MD Frank G. Gress, MD (Chair) Russell D. Brown, MD Lawrence Friedman, MD Training in Women’s Health Issues in Peter D. Stevens, MD Digestive Diseases Deborah D. Proctor, MD (Chair) James M. Anderson, MD, PhD Rosemarie L. Fisher, MD Jacqueline L. Wolf, MD 60 THE GASTROENTEROLOGY CORE CURRICULUM Appendix II Diagnostic Colonoscopy Procedural Competency Form A. Preprocedural assessment Displays appropriate knowledge for the indications for the procedure, including risks, benefits, and alternative testing/procedures. Unsatisfactory Average Outstanding JJJJ JJJJJ 1 23456789

Displays appropriate knowledge for the use of preprocedural antibiotic coverage. Unsatisfactory Average Outstanding JJJJ JJJJJ 1234 56789

Effectively obtains informed consent. Unsatisfactory Average Outstanding JJJJ JJJJJ 1234 56789

B. Procedural assessment Effectively administers sedation and analgesia. Utilizes physiologic monitoring and supplemental oxygen appropriately. Unsatisfactory Average Outstanding JJJJ JJJJJ 1234 56789

Procedural Components Technical Passes instrument from rectum to splenic flexure.

Instructor intervention required Average Outstanding JJJJ JJJJJ 1234 56789

Passes instrument from splenic flexure to hepatic flexure.

Instructor intervention required Average Outstanding JJJJ JJJJJ 1234 56789

Passes instrument from hepatic flexure to cecum.

Instructor intervention required Average Outstanding JJJJ JJJJJ 1234 56789

Intubates the terminal ileum.

Instructor intervention required Average Outstanding JJJJ JJJJJ 1234 56789

Able to retroflex the instrument to examine the rectum.

Instructor intervention required Average Outstanding JJJJ JJJJJ 1234 56789 APPENDIX II 61

Able to perform mucosal biopsy.

Instructor intervention required Average Outstanding JJJJ JJJJJ 1234 56789

Able to perform polypectomy.

Instructor intervention required Average Outstanding J JJJJJJJJ 1234 56789

Able to perform other required therapeutic intervention (list)______.

Instructor intervention required Average Outstanding JJJJ JJJJJ 1234 56789

Cognitive Appropriately recognizes anatomic landmarks. Unsatisfactory Average Outstanding JJJJ JJJJJ 1234 56789

Recognizes abnormalities. Unsatisfactory Average Outstanding JJJJ JJJJJ 1234 56789

C. Postprocedural assessment Provides postprocedural effective communication to patient, including endoscopic findings and manage - ment plan. Unsatisfactory Average Outstanding JJJJ JJJJJ 1234 56789

Recognizes and appropriately treats complication(s). Unsatisfactory Average Outstanding JJJJ JJJJJ 1234 56789

D. Overall assessment of trainee’s performance Unsatisfactory Average Outstanding JJJJ JJJJJ 1234 56789

Comments:______

Was this reviewed with the trainee? Yes______No______

Instructor’s signature______Trainee’s signature______62 THE GASTROENTEROLOGY CORE CURRICULUM

Diagnostic Upper Endoscopy Procedural Competency Form A. Preprocedural assessment Displays appropriate knowledge for the indications for the procedure, including risks, benefits, and alternative testing/procedures. Unsatisfactory Average Outstanding J JJJJJJJJ 1234 56789

Displays appropriate knowledge for the use of preprocedural antibiotic coverage. Unsatisfactory Average Outstanding JJJJ JJJJJ 1234 56789

Effectively obtains informed consent. Unsatisfactory Average Outstanding JJJJ JJJJJ 1234 56789

B. Procedural assessment Effectively administers sedation and analgesia. Utilizes physiologic monitoring and supplemental oxygen appropriately. Unsatisfactory Average Outstanding JJJJ JJJJJ 1234 56789

Procedural Components Technical Passes instrument from oral cavity to hypopharynx.

Instructor intervention required Average Outstanding JJJJ JJJJJ 1234 56789

Intubates the esophagus.

Instructor intervention required Average Outstanding JJJJ JJJJJ 1234 56789

Traverses the GE junction.

Instructor intervention required Average Outstanding JJJJ JJJJJ 1234 56789

Traverses the pylorus.

Instructor intervention required Average Outstanding JJJJ JJJJJ 1234 56789

Able to pass the endoscope from the bulb to second duodenal portion.

Instructor intervention required Average Outstanding JJJJ JJJJJ 1234 56789

Able to retroflex the instrument to examine the fundus/cardia.

Instructor intervention required Average Outstanding JJJJ JJJJJ 1234 56789 APPENDIX II 63

Able to perform mucosal biopsy.

Instructor intervention required Average Outstanding JJJJ JJJJJ 1234 56789

Able to perform other required therapeutic intervention (list)______.

Instructor intervention required Average Outstanding J JJJJJJJJ 1234 56789

Cognitive Appropriately recognizes anatomic landmarks. Unsatisfactory Average Outstanding JJJJ JJJJJ 1234 56789

Recognizes abnormalities. Unsatisfactory Average Outstanding JJJJ JJJJJ 1234 56789

C. Postprocedural assessment Provides postprocedural effective communication to patient, including endoscopic findings and manage - ment plan if necessary. Unsatisfactory Average Outstanding JJJJ JJJJJ 1234 56789

Recognizes and appropriately treats complication(s). Unsatisfactory Average Outstanding JJJJ JJJJJ 1234 56789

D. Overall assessment of trainee’s performance Unsatisfactory Average Outstanding JJJJ JJJJJ 1234 56789

Comments:______

Was this reviewed with the trainee? Yes______No______

Instructor’s signature______Trainee’s signature______