Mission and Objectives
The mission of the GI Fellowship Program at UTMB is to train academic gastroenterologists for leadership positions in the specialty. To this end, the fellowship is heavily weighted to providing the overall cognitive and technical skills required for a meaningful career in academic gastroenterology. We recognize the importance of clinical training and take great pride in offering our trainees an exciting educational experience with state of the art procedural components. Our curriculum is designed to provide trainees the opportunity to acquire the cognitive information, procedural skills, professional attitudes and practical experience in the specialty of gastroenterology.
Overall Structure and Organization
The GI fellowship program consists of three years of training. The first year is almost exclusively focused on clinical training in gastroenterology and hepatology. Years 2-3, focus on refining clinical expertise in specific areas of GI (sub-subspecialty) and developing the scholarly foundation for an academic career in Gastroenterology The following graph summarizes the approximate distribution of time spent in each of these areas over the three-year training period. It should be noted that much of this experience is obtained on an on-going basis throughout the year but the approximate total time per year is estimated in this table. Gastrointestinal pathology and radiology are incorporated into the training program throughout.
|Rotation Blocks||Year 1||Year 2||Year 3|
|1||GI Consult||Consults (PBS)||Consults (PBS)|
|2||GI Consult||Consults (PBS)||Consults (PBS)|
|3||GI Consult||Research||Consults (Luminal)|
|4||GI Consult||Research||Consults (Luminal)|
|5||GI Consult||Research||Consults (Luminal)|
|6||GI Consult||Research||Consults (Luminal)|
Recognizing that academic gastroenterology may include a diversity of career paths, training in the second and third year is individualized to meet the goals and aspirations of the trainee. Fellows will meet with program director Dr. Soloway during their first year to develop a curriculum that may consist of:
- Basic Research
- Masters in Clinical Science
- Clinical Research/Scholarly activities
We aim to provide opportunities for the development of a wide spectrum of scientific scholars ranging from a fundamental emphasis on molecular biology and basic pathogenic mechanisms to clinical or epidemiologically based investigations. Several instructional tools will be used to achieve these aims including relatively formalized formats for didactic courses, coordination of individualized training and transition to junior faculty positions.
A. First Year
The first year of fellowship is focused on developing the arts and crafts of a clinical gastroenterologist and consultant. The GI service generally has two first year fellows simultaneously while the hepatology service has one fellow. These are consultant services. There is also a new GI Medicine Service, staffed by the hepatology group for which the hepatology fellow acts as "consultant" . The hepatology fellow also consults on the Liver Transplant Service and rounds daily with the Surgical Team.
B. Years Two and Three
1. Basic Research Training
The basic research training pathway is intended for training and development of future clinician scientists who are most interested in research on the underlying mechanisms of digestive disorders. They will learn to utilize state-of-the-art investigative and educational techniques under the mentorship of one or more active established investigators. The training program will include the following key elements:
- Acquisition of a core of knowledge in GI and liver biology and pathobiology with further rigorous emphasis on a focused area of interest, including
- Design and completion of a mentored research project, which includes rigorous training on methods needed to test a specific research hypotheses
- Training and experience in manuscript and grant writing
- Development of intellectual curiosity, research integrity and collegial attitudes in a mentored environment
The expected outcome is a competitive clinician-scientist with the expertise to identify and investigate fundamental biological questions related to causes and treatment of digestive diseases.
Examples of recent research projects:
- Experimental endoscopic approaches to GERD therapy
- Colonic motility in a rat model of IBS
- Neonatal inflammation and stress induced alterations of neuromuscular regulation of colonic motor activity
- Evaluation of US vs CT as the initial screening modality for HCC in patients with HCV and cirrhosis
- Pathophysiological mechanisms of visceral hyperalgesia in IBS patients
- Intestinal pacing and gastric motility
- Toll receptor expression in human intestinal myofibroblasts
- Colonic myofibroblasts and inflammation
- Mechanisms of ERCP-induced pancreatitis
- HCV and alcohol induced cytotoxicity involves synergistic reactive oxygen production and mitochondrial depolarization
- Botulinum toxin for gastrointestinal disorders: therapy and mechanisms
- Metolazone in diuretic refractory ascites
- Myofibroblasts and the colonic epithelial stem cell niche
- Pathophysiology of IBD symptoms in experimental models of inflammation
- Prospective camparison of treatment of porphyria cutanea tarda by phlebotomy or low-dose hydroxychloroquine
2. Masters in Clinical Science Track
The Clinical Science Track is intended for fellows interested in clinical and translational research. The objective is to train future clinical and translational investigators in gastroenterology who are skilled in patient-oriented or health services research. The degree is awarded by the Graduate School of Biomedical Sciences (GSBS). The curriculum includes required courses in statistics and epidemiology and additional electives that may include basic science courses offered by the GSBS. The required master's thesis includes completion of an original research project mentored by an experienced investigator in gastroenterology or a related scientific field. Admission requirements of the GSBS must be met. (See Clinical Science website www.gsbs.utmb.edu )
The Clinical Science Master's Program offers two tracks:
- The Clinical Investigation Track emphasizes laboratory-based patient-oriented research. Facilities of UTMB's General Clinical Research Center (GCRC) are available for studies of basic disease mechanisms in humans and for clinical trials. Students in this track are may be expected to gain a strong understanding of basic science principles and laboratory methods as related to their area of research interest.
- The Health Services Research Track emphasizes research methods used for assessing and improving the delivery of effective and cost efficient health care. These may include epidemiologic methods for the study of groups of individuals or use of existing databases of health-related information.
An application to the GSBS and the Clinical Science Program is usually submitted early in the first year of the GI fellowship (deadline April 1). Most required and elective courses are completed during the second fellowship year, during which clinical responsibilities are limited (e.g. one weekly clinic or endoscopy session). The master's thesis project is usually completed and approved early in the third year prior to graduation from the GSBS.
Combining a GI fellowship with this degree program is an effective and efficient means of educating young, motivated clinicians to become clinical and translational investigators in gastroenterology. There is a great need for physician scientists with this training and career orientation at many academic medical centers. Pursuit of a PhD in Clinical Science is also possible, and would require identification of a source of support for an additional year in the graduate program. UTMB also offers the MPH degree for residents and fellows interested in public health practice.
Examples of recent master's thesis topics :
- Increased vascular endothelial growth factor and hypoxia inducible factor–1α transcription in gastric sporadic acquired angiodysplasias Long-term Survival after Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Refractory Ascites and Recurrent Variceal Bleed.
- Experimental endoscopic approaches to GERD therapy.
- Neonatal inflammation and stress induced alterations of neuromuscular regulation of colonic motor activity.
- Microspectroscopy increasing the accuracy of measurement of hepatic fibrosis in patients with hepatitis C.
- Pathophysiological Mechanisms of Visceral Hyperalgesia in IBS patients.
- Intestinal pacing and gastric motility.
- Toll Receptor Expression in Human Intestinal Myofibroblasts .
- Role of Endoscopic Simulators in Training.
- Mechanisms of ERCP-induced Pancreatitis.
- HCV and Alcohol induced Cytotoxicity Involves Synergistic Reactive Oxygen
- Effect of Race and Ethnicity on Perceptions of Inflammatory Bowel Disease.
- Comparing the Response Rate of an Accelerated Vaccination Schedule Using a
- Combination Hepatitis A and B Vaccine (Twinrix) in populations with and without Hepatitis C.
- Role of EUS FNA in pancreatic cystic lesions.
- Botulinum toxin for gastrointestinal disorders: therapy and mechanisms.
- Investigating the feasibility of using capsule esophagoscopy as an initial screening method to detect esophageal varices in patients without prior screening.
- Increased vascular endothelial growth factor and hypoxia inducible factor-1α transcription in gastric sporadic acquired angiodysplasias
- Associations among Susceptibility Factors in Patients with Porphyria Cutanea Tarda.
- Role of Immunosuppressives in Lymphocytopenia in Inflammatory Bowel Disease.
- Metolazone in diurectic refractory ascites
- Comparison of the efficacy and safety of Phlebotomy and hydroxychloroquine in the treatment of porphyria cutanea tarda: A prospective study
3. Clinical Scholar Track
Trainees may elect to pursue a non-degree track that would involve significant scholarly activity in a focused area of gastroenterology. Presently such training is available in Inflammatory Bowel Disease. Given the establishment of a Liver Transplant Service, we expect that a similar program would be available in that area. A detailed plan of education training will be developed in correlation with the training director.
C. Third year Sub-subspecialty Tracks.
In the third year, there are focused rotations in specific sub-specialty aspects of IBD including
1) Luminal Rotation
- The Luminal Rotation has two major components: a) Inflammatory Bowel Disease and b) GI Motility. The rotation is supervised by faculty with specific expertise in these areas and involves primarily outpatient clinics and procedures.
- IBD. The IBD component involves 3-4 half days of clinic and endoscopy. The emphasis is placed on understanding the clinical challenges in managing these complex diseases, the rational use of biologics and Immunosuppressives, and the endoscopic spectrum of UC and Crohn's disease.
2) Pancreaticobiliary Service
Goals and Objectives
The Pancreaticobiliary Service is an inpatient rotation for the advanced fellows. Evaluation and management of complex patients with pancreatic disease or disorders of the biliary tract are handled by this team.
Specific learning objectives:
During the rotation the trainee should develop and understanding of:
- The complexity of disorders involving the pancreas or biliary tree
- The assessment of patients with diseases of the pancreas or biliary tree
- The indication and scope of use for endoscopic and radiological procedures for diagnostic and therapeutic interventions including endoscopic retrograde pancreatography(ERCP)
- The principles of management of these patients, including unique metabolic and nutritional consequences of the diseases
- Observation of and participation in performance of ERCP, sphicterotomy and stone removal, endoscopic biliary and pancreatic drainage
Gastroenterology Consult Rotation
Goals and Objectives
The goal of the consult rotation is to impart the basic skills of a gastroenterology consultant to the fellow. These include: a broad knowledge base, the ability to generate a relevant differential diagnosis based on an accurate history and physical examination, an understanding of the indications and contraindications for diagnostic and therapeutic procedures, skill at performing these procedures, the ability to think critically, and an appreciation of the humanistic and ethical aspects of medicine. The fellow will also have learned how to manage complex multifaceted disease processes in a coordinated way with multiple health care providers from varying disciplines.
Method of Teaching
The consult service assists in the management of patients while they are under the direct care of virtually every other clinical department on campus, including Family Medicine, Obstetrics & Gynecology, Internal Medicine, Neurology & Neurosurgery, Vascular Surgery, General Surgery, Cardiothoracic Surgery, Pediatrics, Psychiatry, and Geriatrics. At the present time there are three consult teams, one for general gastroenterology, pancreaticobiliary and one for hepatology.
- The Hepatology Service: Serves as the Medical Hepatology Team to the Liver Transplant Service, attends the weekly Wednesday Liver Transplant Conferences and the UTMB Liver Tumor Board consisting of invasive radiologists, oncologists, hepatic surgeons and hepatologists. This service has a hepatology or GI attending, 1 resident, 1 intern and several third year students or fourth year acting interns. It also serves as the Liver Consult Service for the Gastroenterology-General Internal Medicine Service for both patient care and teaching. It has a hepatologist faculty, 1 GI fellow, and a various number of residents and third and fourth year medical students.
- The Gastroenterology Service: Serves as the Internal Consult to the Liver Transplant Service and GIM Maroon Team answering consultations in this area. There is a GI faculty and 2 fellows (who split the consults and procedures), various number of residents and students rotate as well.
- The Pancreaticobiliary Service: Answers consults from all services and consults for ERCP and EUS.
Each fellow will have 30 days of consultation and GI Clinic at MD Anderson Cancer Center. While there the fellow will return for our Friday conferences and TDC Clinic,and the pathology and radiology conferences. Fellows see patients independently, assimilate the core clinical information from a variety of sources (i.e., pathology, surgery, radiology, nutrition service), construct a problem list and a list of the differential diagnoses, and develop a diagnostic and therapeutic plan. This evaluation is then presented to the faculty on the service at the bedside on the same day as the initial evaluation. The faculty reviews the findings and modifies the assessment and plan formulated by the fellow according to any additional data that comes to light during the review of the case, and the faculty's own experience and knowledge. The faculty attending serves as a role model in developing the skills of a consultant and to foster a broad and scholarly approach to consultative gastroenterology. Risk/benefit and cost/benefit ratios are emphasized in these discussions. The role of the physician as a compassionate caregiver and teacher for the patient and his/her family is also emphasized and encouraged. Pathologic and radiologic findings and other primary data are reviewed by the team of housestaff and the attending GI faculty with experts in those areas. The fellows are expected to follow up on patients throughout the period of hospitalization and, where appropriate, in a longitudinal manner in the outpatient GI clinic after discharge.
In addition to the many conferences and didactic lectures that take place on a weekly basis, fellows on this rotation are also encouraged to study independently and develop a scholarly approach to the clinical problems they encounter on the consult rotation by reading current textbooks and monographs and, especially, current and relevant journal articles. Readings are readily available in the GI Library, which has all of the recent major textbooks and houses an impressive journal article file. During this rotation, the fellow acts as both a student and a teacher of housestaff and students, utilizing his/her experience as well as the core resources available (e.g., the GI library).
Method of Evaluation
Faculty on the consult rotation daily observe the fellows' skill and competence in history taking, physical exam, clinical judgment, and consulting skills. By rounding on patients and informally meeting with the fellow, the faculty also have the opportunity to evaluate the fellows' communication skills, attitude/behavior, and commitment to the field of gastroenterology. At the conclusion of the month's rotation, the faculty complete an ABIM approved numerical ranking form which also allows for candid comments in a narrative section of the form. Fellows will meet individually with the program director every six months. These meetings will allow evaluation summaries and discussions of the fellow's progress. These meetings also provide an opportunity for the individual fellow to reflect on their progress, and to provide feedback to the program director regarding the fellowship program. Fellows will be asked to evaluate their supervising faculty on a monthly basis. These evaluations are performed online. Faculty will not see the actual evaluation, but will receive a composite evaluation at the end of six months from all evaluation materials.
Elements of Competence to be Evaluated in Consultative Gastroenterology and Hepatology
An understanding and commitment to all elements of professionalism.
A thorough knowledge of history-taking, including family, genetic, psychosocial, and environmental histories, and the ability to perform a comprehensive and accurate physical examination.
The ability to arrive at an appropriate differential diagnosis, to outline a logical plan for specific and targeted investigations pertaining to the patient's complaints, and to formulate a plan for management and follow-up treatment of the patient.
The ability to present effectively the results of a consultation orally and in writing and to defend the clinical assessment, differential diagnosis, and diagnostic and management plan.
A core fund of knowledge in gastroenterological and hepatic physiology, palhophysiology, and clinical pharmacology as outlined in the goals of each task force report.
Procedural skills appropriate to the level of training.
The goal of the core training program in Hepatology is to teach the fellow the methods and mechanisms of diagnosing, managing, and treating hepatobiliary disorders, either alone or in the setting of concurrent medical problems. These goals are achieved largely while rotating on the hepatology consultative service which includes a weekly clinic. Training in liver disease also takes place on the endoscopy rotations and various other settings. During the first 12 months of clinical (core period) training the fellow will accumulate significant experience with the common and unusual hepatobiliary diagnoses, the complications of acute and chronic liver disease, the role of liver biopsy and radiographic investigations (including invasive radiology i.e., transjugular intrahepatic portosystemic shunt (TIPS), portal venography, arteriography, and wedged hepatic vein pressure measurements), and the technique of liver biopsy. There is ample opportunity on the hepatology rotation to interact in a meaningful way with physicians from a variety of disciplines and manage complex, multifaceted disease processes in a coordinated way. Fellows will learn the natural history of liver disorders and risk of procedures (including surgical procedures, i.e. cholecystectomy in a cirrhotic patient) in the management of patients with liver disease.
Ambulatory Care Training
The goal of the ambulatory care experience are to provide fellows with the opportunity to see a broad spectrum of patients in an ambulatory care setting. Patients from a diverse ethnic, socioeconomic and cultural background present with a wide range of conditions presenting with manifestations ranging from mild to severe, the course of illnesses ranging from early to late. A specific objective of the ambulatory care experience is to provide the opportunity to provide continuing care of patients during the three years of fellowship training. Rotations in specialty clinics allow fellows to develop additional expertise in the management of conditions including complicated GI motility disorders, hepatology cases (pre- and post-liver transplantation patients included), inflammatory bowel disease, nutritional disorders and pediatric gastroenterology.
The objective of the Endoscopy Rotation is to provide trainees with critical, supervised instruction in gastrointestinal endoscopy to assure quality care for patients with digestive diseases.
The department of internal medicine is developing evidence based clinical protocols which will be available in EPIC (as order sets) for use when admitting patients with these diagnoses. Their AIM is to standardize care and decrease length of stay and readmission rates.Currently available protocols are:
- CAP - Community Acquired Pneumonia Order set
- Congestive Heart Failure (CHF)
- Chronic Obstructive Pulmonary Disease (COPD)
- Diabetic Ketoacidosis Adult, ICU
- General Medicine Admission
- Immunodeficiency Flow Panel
- MICU/CCU Admission Order Set
- Oral Analgesic Medications
- Parenteral Opioids
- Sepsis, Adult ICU
- 111 - Stroke Alert
- 112 - Stroke Activation
- 300086 - Stroke Floor Admission
- 3000000001 - Stroke Critical care without tPA
- 300088 Stroke - Transfer from Critical care to floor
- 3004002 - Stroke Discharge
All protocols can be found in the EPIC order set section.
The department of Internal Medicine has a large role in the Meaningful Use Initiative. Our participation is key for the success of the initiative. Please visit the meaningful use website for important communication and updates from the Meaningful Use Initiative.