Goals and Objectives
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.
General Learning Objectives of the Endoscopy ProgramAt the completion of the first 12 months of core clinical training, the trainee should have achieved the following:
- The ability to recommend endoscopic procedures based on findings of a personal consultation and in consideration of specific indications, contraindications, and diagnostic/therapeutic alternatives.
- The ability to perform a specific procedure safely, completely, and expeditiously.
- The ability to interpret most endoscopic findings correctly.
- The ability to integrate endoscopic findings or therapy into the patient management plan.
- The ability to understand the risk factors attendant to endoscopic procedures and to be able to recognize and manage complications.
- The ability to recognize personal and procedural limits and to know when to request help.
- Knowledge of patient safety procedures during endoscopy including the intravenous administration of medications that produce conscious sedation and the application and interpretation of noninvasive patient monitoring devices.
- Familiarity with the care, cleaning, and proper maintenance of endoscopy equipment.
Specific Learning ObjectivesBoth the cognitive and technical (including mental skills) aspects of routine diagnostic and therapeutic endoscopic procedures are taught including the following:
- Diagnostic esophagogastroduodenoscopy and mucosal biopsies.
- Diagnostic colonoscopies and sigmoidoscopies including mucosal biopsies.
- Esophageal dilations using both fluoroscopic and nonfluoroscopic techniques.
- Polyp resection of both the stomach and colon.
- Endoscopic techniques of hemostasis such as variceal sclerotherapy and band ligation, epinephrine injection and bipolar cautery of bleeding ulcers, and cautery of arteriovenous malformations in both the upper and lower gastrointestinal tract.
At the end of the first 12 months of core clinical training, the fellow is expected to achieve basic and clinical knowledge, judgmental skills, and the technical competence requisite for performing these procedures. Thus the endoscopic rotation not only includes technical proficiency but also an understanding of their indications, contraindications, and complications of the various endoscopic procedures and the ability to interpret their results.
Method of TeachingFacilities and Resources
At the present time, the endoscopy training supervisor is Dr. Gurinder Luthra who is an experienced and skilled endoscopist. Dr. Luthra trained at UTMB. He is ultimately responsible for the didactic instruction and supervision of all elective and emergency procedures as well as maintaining quality assurance. Faculty supervision in the endoscopy unit is provided by rotation in half-day blocks, of a cadre of skilled endoscopists including Drs. Duchini, Goodgame, Parupudi, Reddy, Shabot, Szauter, Variyam. Endoscopic supervision in the Unit consists not only of directly observing and guiding the trainee as he or she manipulates the endoscope but also continuing instruction in endoscopic decision-making, technique, and interpretation of findings and the ongoing evaluation of procedures, reports, and photographic records.
The present endoscopy unit is a modern inpatient and ambulatory care facility that provides a safe and efficient environment for both emergent and routine endoscopy. The unit is staffed by well trained RNs and technicians all of whom are properly trained as gastrointestinal endoscopy assistants. It is equipped with modern videoscopic equipment in three procedure rooms and in addition has a dedicated X-ray suite with a state-of-the-art fluoroscopy unit for the performance of ERCPs. The unit is provided with an eleven-bed recovery area staffed by 2-3 nurses.
Figure 1: Number of selected endoscopic procedures performed in the Endoscopy Unit at UTMB for 2010. These volumes of procedures are more than adequate to meet the ASGE guidelines for achieving the threshold for competence in routine procedures (Table 1).
Minimum number of procedures before competency can be assessed
* Included in total number
# Includes at least 40 sphincterotomies and 10 stent placements
+ For competence in imaging both mucosal and submucosal abnormalities, a minimum of 100 supervised cases is recommended.
For comprehensive competence in all aspects of EUS, a minimum of 150 supervised cases, of which 75 should be pancreatobiliary and 50 EUS guided FNA is recommended.
‡ Intramural lesions or lymph nodes. Must be competent to perform mucosal EUS.
‡‡ Must be competent to perform pancreaticobiliary EUS.
** Data is not yet available on the minimum number of enteroscopies performed Our fellows are exposed to sufficient numbers of new and follow-up inpatients and outpatients of varied age (adult and geriatric) and of both sexes and with a variety of common and uncommon digestive disorders to permit a broad endoscopic experience. Endoscopic experience with gastrointestinal hemorrhage encompasses acute and chronic bleeding of the upper and lower gastrointestinal tract, including acute variceal hemorrhage.
Evaluation Procedure and Assessment of Competence
Judgment as well as interpretive and technical skills are evaluated in every trainee (Table 2). Regular, ongoing feedback is provided both verbally by the supervising faculty and by means of a quarterly written report filled by all attending faculty, similar in format to that for the nonendoscopic components of the training program. The competency of all fellows is documented by the training program director and by the endoscopy director. The program director has the responsibility to confirm or deny the technical competency and endoscopic exposure of trainees. Documentation of procedures performed is recorded through a computer database that identifies and evaluates the procedure(s) performed and any complications.Competency in performing endoscopic procedures requires that the trainee:
- Reviews records, x-rays, and identifies risk factors prior to performing procedures
- Understands and discusses appropriate alternative procedures
- Correctly identifies indications, knows how study will influence management
- Obtains appropriate informed consent
- Demonstrates proper use of premedication and noninvasive patient monitoring devices
- Inserts the endoscope using proper technique
- Performs the procedure with attention to patient comfort and safety
- Correctly identifies anatomic landmarks
- Conducts a thorough examination of the entire organ
- Detects and identifies all significant pathology
- Completes examination within a reasonable time
- Prepares an accurate report
- Plans correct management and disposition of the case
- Discusses findings with patient and other physicians
- Conducts proper follow-up including review of pathology, case outcome
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 Orderset
- 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 Medicaitons
- 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.