Gastroenterology Fellowship Training Experiences

The inpatient consultation service is the cornerstone of the fellows’ educational experience. Fellows will spend a total of twenty-four months on inpatient care: eighteen months on the inpatient gastroenterology consultation service and six months on the inpatient hepatology service. The Gastroenterology service provides consultative services to patients admitted to the Hospitalist and Teaching Services.

The inpatient consultation service exposes the fellow to wide variety of gastrointestinal diseases. The most common encountered indications for consultation are upper and lower gastrointestinal bleeding, acute and chronic abdominal pain, anemia, abnormal liver function tests, jaundice, dysphagia and weight loss.

The Hepatology service is a primary service with a full-time intern and resident and usually has 6-12 patients admitted with complications of end-stage liver disease.

A total of three fellows staff the inpatient consultation service at one time in conjunction with one supervising attending physician. The consultations are distributed evenly among the fellows in a rotation fashion during daytime hours, with an on-call fellow handling the new consults in the evening. In addition, there are often medical residents or Tufts medical students who may assist the fellows in seeing new consultations or providing educational support by researching pertinent topics or giving brief talks to the consultation team. The total census on this service averages between fifteen and thirty patients. Therefore, each fellow carries roughly five to ten patients at a time.

Fellows typically spend the morning hours from 8:00 am – 11:00 am seeing the patients already on the service as well as perhaps evaluating a new consultation. Attending rounds take place from 11:30 am to 12:30 pm. During this hour new cases are discussed as well as ongoing cases with active issues.

In the afternoon, fellows spend their time either seeing new consults, performing endoscopic procedures on their patients, once a week seeing outpatients in their continuity clinic.

If a patient does not have a primary gastroenterologist, the fellow will assume the outpatient care for that patient in the longitudinal outpatient clinic after discharge.

Gastroenterology fellows partake in ambulatory assessment through several avenues: ambulatory longitudinal out-patient clinic, same day ambulatory emergency consultation, and on-call triaging and answering patient phone calls. Third year fellows also rotate into subspecialty IBD and Hepatology clinics.

Longitudinal Ambulatory Clinic

Each fellow is assigned to a longitudinal ambulatory clinic which meets one half session per week. During this attending supervised out-patient clinic, the fellow will see on average two new patient consultations (sixty minutes) and four return follow-up visits (30 minutes each).

Each new consultation is seen in conjunction with the clinic attending and involves a discussion of differential diagnoses, diagnostic strategies, and treatment options. These patients then become part of the fellow’s clinical practice. Patient progress is addressed by the fellow with the supervision of the clinic attending. The Fellow Clinic attendings rotate so that each fellow is exposed to a variety of management approaches and strategies.

An important part of ambulatory gastroenterology is the ability to handle the emergency outpatient consult. Fellows will assess patients referred from physicians in medical and surgical subspecialties, emergency room or within the department practice who have an emergent problem. Examples of common visits are acute hepatitis of unclear etiology, flare of inflammatory bowel disease, bright red blood per rectum and acute dysphagia.

These consultations are supervised by an attending physician. The attending and fellow discuss the appropriate short-term and long-term evaluations, differential diagnoses and follow-up plan. Patients who require admission will then be followed by the fellow on the in-patient service while those that will require longitudinal gastroenterological follow-up will become part of the fellow’s ambulatory clinic.

On-Call Triaging and Patient Phone Calls

As part of their on-call responsibilities, fellows will answer phone calls from the GI department’s patient population. An attending physician is always available to discuss over the problem or return the patient’s call if necessary. Fellow’s in this manner learn how to take a pertinent review of systems over the phone, access acuity of illness and triage patient questions and complaints.

Fellows Schedules

The following pages include some examples of fellows’ appointment schedules and the variety of diseases which may be encountered throughout the day.

Over a three year period, fellows will receive formal lectures with the review of the indications and contraindications for various procedures as well as the incidence and management of complications. Simulation training is provided at the start of fellowship and then periodically over the next three years as endoscopic milestones are attained.

Fellows under the direct supervision of the various staff attendings become skilled in a wide range of subspecialty procedures including:

First Year

• flexible sigmoidoscopy
• diagnostic upper endoscopy
• therapeutic upper endoscopy including:
  • BICAP and injection therapy
  • sclerotherapy
  • band ligation
  • PEG and PEJ placement
  • post-pyloric feeding tube placement
  • stricture dilation
• colonoscopy and polypectomy

Second & Third Years

• small bowel enteroscopy
• intra-operative endoscopy
• therapeutic colonoscopy:
  • bicap cautery
  • piecemeal polypectomy
  • saline injection polypectomy
  • endo-clip ligation
• diagnostic and therapeutic ERCP techniques including:
  • sphincterotomy
  • stone extraction and mechanical lithotripsy
  • biliary stent placement and exchange
  • pancreatic stent placement
  • biliary needle aspiration, biopsy, and brush cytology
  • Sphincter of Oddi manometry
  • metal expandable stent placement
  • balloon dilation of biliary strictures
• endoscopic ultrasound
• esophageal stent placement

Hepatology

Fellows will receive extensive training in hepatology during all three years of fellowship on our busy hepatology/transplant service, including two dedicated months each year. Fellows will learn the inpatient management of complicated patients with liver disease including variceal bleeding, refractory ascites, hydrothorax, encephalopathy, and liver associated renal failure. Fellows will gain expertise in therapeutic modalities including variceal sclerotherapy and band ligation, large volume paracentesis, and transjugular intrahepatic portosystemic shunting. Participation in the outpatient hepatology clinic will give fellows experience in managing a wide variety of liver diseases including hepatitis C, hepatitis B, cholestatic liver diseases, autoimmune hepatitis, and non-alcoholic steatohepatitis.

Gastroenterology fellows will also participate in the liver transplant program at the Lahey Hospital in both the inpatient and outpatient settings. Fellows will become proficient in pre-transplant assessment, immediate post-operative management, and long term outpatient management including immunosuppressive therapy. Fellows will also have the opportunity to participate in our Living Donor Adult Liver Transplant program, one of the largest in the nation.

Therapeutic Endoscopy

Under the supervision of the pancreatico-biliary staff, fellows gain expertise in ERCP. Fellows can expect to perform up to 150 ERCP’s during their fellowship training. Diagnostic cholangiopancreaticography, biliary sphincteronomy, and techniques of stone extraction and biliary stent placement will be covered. Fellows will also gain understanding of the appropriate indications for ERCP. In addition, fellows will gain exposure to endoscopic ultrasound in the diagnosis and staging of esophageal and pancratic malignancies.

Esophageal & Anorectal Motility

Under the direct supervision of the gastroesophageal faculty as well as the colorectal surgeons, fellows learn how to perform and interpret manometric tracings from both the upper and lower GI tract. In addition, the fellow will have the opportunity to be involved in clinical protocols involving acid perfusion tests and 24-hour pH monitoring.

Nutrition

Fellows will rotate on the Nutrition Support Service learning the fundamentals of parenteral and enteral feedings and becoming skilled on in-patient and out-patient consultations for a variety of disease states. Fellows will be responsible for indications, contraindications and complications of parental nutrition, PEG, PEJ as well as post-pyloric tube placement.

• On-Call Schedule: All fellows will rotate call every sixth night.
• Benefits: Lahey Hospital & Medical Center provides full medical, dental, disability and life insurance benefits.
• Vacation: Each fellow will receive 15 vacation days not including weekends and clinic holidays. Fellows can accumulate vacation time and carry it over from one year to the next to cover a planned absence with the Program Director’s approval.
• Paid Holidays: Fellows receive 10 paid holidays per year: New Year’s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, Christmas Day as well as Martin Luther King Day, President’s Day, Patriots Day and Columbus Day.
• Family Leave: After the initial 90 days, fellows are eligible for a 12 week unpaid leave for the birth of a child, or care of an immediate family member with a serious health condition.
• Conferences and Didactic Teaching: All in-patient and out-patient consultations seen by the fellow are reviewed at length on team rounds by the service attending. All in-patient and out-patient procedures are performed by the fellow under the direct supervision of an attending. The weekly conference schedule is designed to cover interesting management and diagnostic issues in hepatology and gastroenterology as listed below.
• Case Presentation Conference: (Each fellow presents one case conference yearly) A one hour in-depth interactive discussion of complex, interesting and important cases by one of the fellows. Discussion points center on the differential diagnoses, rational choice of procedures in work-up and therapy, and review of the literature.
• Endoscopy Conference: (Each fellow presents one case conference yearly) This informal conference discusses endoscopic techniques by reviewing photographs, video tapes and radiographs of recent cases. Fellows and attendings informally share interesting endoscopic findings, radiological correlation, and management decisions. Pertinent literature pertaining to cases is reviewed.
• Gastroenterology Grand Rounds: (Once a year) Visiting lecturers from the field of gastroenterology/hepatology and related subspecialties lecture on pertinent state-of-the-art topics. Fellows have the opportunity to review cases and have informal discussions with the outside guests.
• Core Curriculum: (Once a week) Didactic talk in which attending physicians cover pertinent and practical diagnostic and management issues in hepatology and gastroenterology. This lecture series is geared to the needs of the fellow as they transition from internist to gastroenterologist.
• Morbidity & Mortality Conference: (Once a month) At this conference two cases will be presented usually by a staff physician with a fellow assigned to provide a five minute literature review. The cases presented may be from clinic, Endoscopy or the hospital service.
• Pathophysiology Lecture Series: (Each fellow presents one pathophysiology lecture yearly) Fellows will be responsible for reviewing the pertinent literature on selected topics in GI and liver pathophysiology. Emphasis on the mechanisms of disease provides a strong foundation for later clinical experience.
• Journal Club: (Once a week) Pertinent studies from the major GI, Liver and Internal Medicine journals are discussed. Fellows and attendings choose relevant studies for critical discussion. Two “clusters” of journals will be covered in each session. Reviewers are asked to summarize and critically review at least three important articles from the month’s selections and they briefly discuss several other significant contributions. Copies of the articles discussed are then distributed to fellows and staff upon request for their personal files and review.
• Abdominal Imaging Conference: (Once a week) This weekly conference combines the expertise of GI Radiology, Invasive Imaging, General and Colorectal Surgery, as well as Gastroenterology in reviewing and discussing the best and most challenging cases seen throughout the Lahey Clinic in the preceding weeks. Cases are presented by fellows from all of the subspecialties with the emphasis on radiologic correlation of surgical and endoscopic findings, case management and clinical decision making.
• Interhospital Gastroenterology Rounds: (Six times a year) This rotating monthly conference brings Boston’s major teaching hospitals together to present and discuss fascinating cases. Lahey Hospital sponsors the event one month out of the year with the fellows presenting and briefly discussing the most unique and interesting cases seen in the preceding year.
• GI/Colorectal Surgery: (Conference once a month): This monthly conference covers a broad range of clinical problems confronting both the gastroenterologist and the surgeon on an inpatient and outpatient basis. Each GI and Colon Rectal fellow presents one conference yearly.
• Hepatology Lecture Series: (Each fellow presents one hepatology conference yearly) This conference reviews topics in the field of hepatology with emphasis on the radiologic and pathologic interpretation of liver disease. Management decisions, review of disease processes, current recommendations and guidelines for the diagnosis and treatment of a broad range of liver diseases will be covered.
• Pathology Lecture Series: (Twice a month on Tuesdays: 12:15 pm – 1:15 pm) The fellows meet with various members of the pathology department’s attending staff and review the biopsies from the inpatient and outpatient services. Fellows are given a firm foundation in “normal” histology and then review the basics of pathologic diagnosis. Special attention is given to liver biopsy interpretation as well as criteria for various diagnoses (Primary Biliary Cirrhosis, Hemochromatosis, Alcoholic Liver Disease). In addition, fellows receive didactic sessions that review the management of important pathologic diagnosis (e.g. malignant polyp, dysplasia in ulcerative colitis, dysplasia in Barrett’s esophagus).
• CPC Conference: Once per year each fellow will formally discuss an unknown case provided to them by a staff physician.

Clinical research is a requirement for all GI fellows. This research may take the form of retrospective chart reviews or short prospective studies. Case reports are also encouraged. It is our goal for each fellow to present his/her work at national meetings and submit manuscripts for publication in peer review journals. In order to accomplish this goal, training programs aim to provide gastroenterology fellows with the time, resources, supervision and guidance to engage in research during the three-year training program. By design, this mandate has been left flexible with the recognition that gastroenterology fellows are likely to pursue a variety of career paths upon completion of training.