Clinical Experience

1. Patient care

The fellows must be able to provide care to gastroenterology patients in the hospital that is compassionate, appropriate and effective.

• Demonstrate competency in gathering essential and accurate gastrointestinal history from patients, formulate a course of action and convey the information in a succinct manner to the attending.
• The fellow evaluates the patient and initiates appropriate management in a timely manner.
• The fellow is available to the patient, gastroenterology staff and attendings to address ongoing changes in patient status.

2. Medical knowledge

• The resident must demonstrate knowledge about established and evolving practices and apply their knowledge to patient care.
• To demonstrate basic knowledge in the pathophysiology of gastrointestinal disorders.
• Demonstrate awareness of the psychosocial issues as they pertain to gastrointestinal disorders.
• Demonstrate knowledge as it pertains to indications for endoscopic procedures as well as other diagnostic studies. A fellow must demonstrate the ability to perform essential components of an initial history and physical with specific attention to gastrointestinal disorders.
• Be able to select and interpret appropriate laboratory data.
• Be able to review appropriate radiologic studies. Be able to perform endoscopic studies including sigmoidoscopy, upper endoscopy, colonoscopy, and ERCP, depending on their level of training and personal ability. Trainees need to be aware of pharmacodynamics of commonly used gastrointestinal therapeutics and their complications. They need to demonstrate competency in recognition and management of typical gastrointestinal ailments.

3. Technical skills

The gastroenterology fellows will be able to demonstrate proficiency in technical skills performing various procedures including paracentesis, liver biopsy, flexible sigmoidoscopy, colonoscopy, upper endoscopy, and ERCP. At completion of the program they will also be to treat bleeding esophageal varices, bleeding ulcers, perform esophageal dilatation, placement of biliary stents, biliary sphincterotomy, esophageal manometry, 24-hour pH tests, perform polypectomies, be able to use electrocautery as well as heater probe and YAG Laser for ablation of tumor and hemostasis.

4. Practice-based learning and improvement

The fellow must be able to investigate and evaluate their patient care practice, appraise and assimilate scientific evidence and improve their patient’s care practices.

• The fellow must be able to use scientific data to evaluate and manage their patients.
• The fellow must facilitate learning of other health professionals.
• The fellow must apply knowledge gained from journal club discussions and other review of current data to appraise the study design and statistical method of clinical studies on diagnostic and therapeutic effectiveness.

5. Interpersonal and communication skills

The fellow must be able to demonstrate interpersonal communication skills that result in effective information exchange in teaming with patients, patient’s families and all personnel involved in patient care.

• The fellow must demonstrate an effective relationship with other health care professionals.
• The fellow must create and sustain a therapeutic and ethically sound relationship with patients.
• The fellow must use effective listening skills and demonstrate effective non-verbal explanatory and questioning writing skills.
• The fellow must demonstrate an ability to work effectively with others as a member of the health care team in gastroenterology.

6. Professionalism

The fellow must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to a diverse patient population in gastroenterology.

• The fellow must demonstrate adherence to professional ethical standards.
• The fellow must be willing to admit to an error in judgment.
• The fellow must demonstrate a commitment to ethical principles pertaining to confidentiality of patient information, informed consent and business practices.
• The fellow must demonstrate sensitivity and responsiveness to patient culture, age, gender and disability.

7. System-based practice

• The fellow must demonstrate awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.
• The fellow will demonstrate how their patient care and other professional practices affect other health care professionals, health care organizations, and the larger society and how these elements affect their own practice.
• The fellow will learn the limits of length-of-stay allowed for various gastroenterology conditions based on managed care and other insurance.
• The fellow will demonstrate effective resource utilization by reviewing it with the attending physician and practice guidelines that do not compromise quality of care.
• The fellow will demonstrate patient advocacy in dealing with complex health systems.
• The fellow will learn and show how they partner with health care managers and providers to assess, coordinate, and improve health care of their patients and how these activities affect the system performance.

Each fellow will conduct GI clinic one afternoon a week. Presently, it is Thursday from 1:00–4:00 pm. Every fellow is expected to attend clinic with the exception of the fellow doing a clinical rotation off campus. Attending physicians will be available during GI clinic for consultation. The fellow will review the case with the attending physician and, together, determine a course of action, select the appropriate laboratory studies as well as endoscopic and/or radiologic studies.

GI clinic is an integral part of the fellowship. The clinic provides a longitudinal follow-up of the fellow’s own patients and provides the opportunity to generate indicated endoscopic procedures. All procedures are performed under the supervision of the attending physician who, together with the fellow, determines the procedures to be performed.

It is imperative that fellows keep a logbook of all procedures. A list of all procedures performed must be submitted to the Program Director on a quarterly basis. This practice allows the Program Director to monitor endoscopic progress and adjust for any deficiencies that might arise. The logbook should include the patient’s name, medical record number, indications for the procedure, outcome of the procedure, and complications.

Each fellow is required to rotate at least one month a year on the liver transplant service at Thomas Jefferson University Hospital as part of their hepatology training. In addition, they will rotate at least one month during their three-year fellowship at Graduate Hospital in training for esophageal manometry. They are also encouraged to take electives in research, both basic science and clinical, either at Lankenau Medical Center Research Center or at another facility. In addition, they are also encouraged to take elective outside the institution, particularly for additional training in therapeutic endoscopy and other gastrointestinal specialties such as pediatric gastroenterology.

The call schedule for the fellows involves taking call every third weekend for hospital patients and emergency room patients. This call starts in the second year of the fellowship and goes up to and including the third year of fellowship training. Fellows on call round on Saturdays of each weekend and are expected to take both outpatient and inpatient call as well as emergency room call in order to foster experience with outpatient gastroenterology. They are expected to come into the hospital either Saturday or Sunday if the situation calls for it and if any endoscopic procedure is performed. These procedures are always performed under the supervision of an attending gastroenterologist.

All consultations from the gastroenterology service are called into the office of Main Line Gastroenterology. Those consults are forwarded to the "long" fellow and subsequently distributed to other members of the clinical team by that fellow. Each fellow doing a consult documents the consultation in the logbook. The consult will be reviewed by the attending physician on service at the time regardless of the specific attending requested. This will hold true unless otherwise specified by the attending physician on service. The consult should be performed on the day it is called in by the fellow, resident or student and reviewed by the attending physician on that day. The consult may be dictated, however, a note needs to be written on the chart in lieu of a complete dictated consult. The attending physician must also write a note documenting the patient was seen and the consult reviewed.

The fellows need to work very closely with the residents and students involved in the care of the patient with whom they are consulting. The consultation should be brief and to the point and contain pertinent history and physical findings, laboratory values, diagnostic formulation along with recommendations. The consult should concentrate on gastrointestinal aspects of the case and involve internal medicine issues only as it pertains to gastrointestinal issues. Each consultation should be accompanied by a detailed note by the attending.

The fellow, resident or student needs to write a daily note on patients on whom they have consulted and be responsible for collating and reviewing all appropriate lab studies and X-rays. In addition, the house staff should be made aware of all recommendations and the case reviewed with the appropriate house staff.

One of the gastroenterology fellows is on call each night. On average, each fellow is on call no more than once every third night and no more than one out of every other weekend. During a seven-day week cycle each fellow will have at least one full 24-hour period of time off. The fellows take call from home and come in to evaluate a patient on an as needed basis.

The senior fellow is responsible for developing an on-call schedule for all three fellows. That call schedule is made available to the attending staff, hospital operator, emergency department, and Ambulatory Surgical Center at least one month prior to the effect of the schedule. There is always one fellow on-call each week night and each weekend. The fellows are responsible for coordinating their schedule, avoiding any lapse in coverage. Each fellow assigned to night call begins coverage at 5:00 pm and ends coverage at 7:00 am after which the “long” fellows resumes primary responsibility.

On weekends, one fellow is responsible for call from 5:00 pm Friday until 7:00 am Monday morning. If there are any changes in the call schedules, Dr. Mercogliano needs to be informed. The fellows should keep a log of all calls received from patients while on call. The fellow on-call is responsible for all emergency department calls as well as hospital calls and hospital consults. They are not responsible for outpatient calls distributed via Main Line Gastroenterology phone service. When called by the emergency department or hospital for a gastrointestinal problem, the fellow on-call is expected to evaluate, assess and determine a plan of action regarding that patient, and, if necessary, call the attending physician for consultation and assistance.

All endoscopic procedures are performed under the supervision of an attending physician. If the attending physician is not called at night, he or she must be made aware of specific problems that occurred as well as any changes in therapy the following morning.

Moonlighting during the first year of fellowship is discouraged. Moonlighting during the second and third year is acceptable as long as it does not interfere with the daily clinical services or research assignments of the fellowship. The program director needs to be made aware of any moonlighting activities.