The longitudinal development of the fellow’s clinical and diagnostic skills culminates in the third year of GI training. The goal is to solidify the knowledge and skills of the specialty. A major emphasis is on supervision and teaching of junior fellows and housestaff. Additional experience in a supervisory capacity is provided. As a consultant, the fellow further develops skills to provide consultation of the specialty to other specialties. The third year is also structured to afford maximum flexibility to allow indepth exposure to subspecialty activities such as advanced endoscopy/pancreaticobiliary disorders or concentration on specific clinics in IBD, motility or liver. A typical third-year schedule includes:
The third-year fellows increases his or her knowledge of core topics in the specialty, with special interest in subspecialty areas of the specialty. The curriculum is tailored to the fellow’s individual interests. The fellow continues improving the life-long habits of self-study, self-reflection and improvement, reading the medicine literature, teaching and research.
The third-year fellow continues the Charity GI continuity clinic established in the first two years of training. Fellows maintain their own continuity clinic one half days per week, and serve as the primary GI provider for these patients. With faculty supervision, fellows augment their understanding of ambulatory management of digestive and liver disease. Fellows continue to hone their skills in obtaining histories and physicals, ordering indicated laboratory and diagnostic studies, treating diagnosed digestive and liver disease, and counseling patients regarding their health and disease. Third year fellows see at least one, but not more than four new patients per clinic. R3’s see not less than three, but not more than four established patients per clinic. The clinic is staffed with faculty preceptors at a ratio of 1 preceptor per 4 third year fellows.
While in the subspecialty clinics, fellows are responsible for obtaining histories and physicals from each patient and consulting with subspecialty physicians in the management of the patient’s disease.
The third year fellow participates with faculty supervision in VA clinics which are general GI (including hepatology) as well as a dedicated hepatology clinic. The third year fellow also participates in subspecialty clinics at Tulane which cover general GI, inflammatory bowel disease, motility disorders, pancreaticobiliary disease and hepatology. Assigment to hepatology and subspecialty GI clinics at Tulane will take into account the interests of the individual third year fellow, allowing more in depth interaction with supervising staff in the management of complex patients with liver, inflammatory bowel and neurogastroenterological disorders. The third year also has clinic exposure to pancreaticobiliary disorders, as part of the their endoscopy rotation concentrating on advanced endoscopy.
All GI fellows (second and third year) are assigned to outpatient and inpatient endoscopy at University Hospital. These procedures are mostly performed in the DTD unit, but may be done in the emergency room or intensive care unit. Procedures which will be performed are EGD (including foreign body removal, hemostasis of bleeding, variceal ligation, stricture dilation, PEG tube placement and diagnostic biopsy) and colonoscopy (including hemostasis of bleeding, decompression of Ogilvy’s syndrome, polypectomy and diagnostic biopsy). By the end of the third year fellows are expected to be competent enough to perform these procedures without supervision. ERCP, EUS and non-biliary tract stenting are almost exclusively performed by third year fellows. These procedures are offered to the third year fellows in order to expose them to these techniques and provide a basis for further advanced endoscopy training which can be taken elsewhere in an elective non-ACGME accredited fourth year. Third year fellows may perform non-emergency EGD and colonoscopy under the supervision of GI faculty who are in the unit, but the faculty need not be in the room during the procedures (UH ONLY). This is in keeping with the increased skill level of the third year fellows who have by this time have exceeded the minimum number of these procedures required for independent practice by the ASGE. Third year fellows take an active role in mentoring junior fellows in endoscopic techniques, but only with a faculty member present in the room during the procedure. Emergency procedures done by third year fellows will always be under the direct supervision of a GI faculty member.
Third year fellows will be assigned to the inpatient Liver Transplant service on request, with greater emphasis on outpatient management of complex hepatology patients. The third year can be used as a dedicated year heavily weighted in hepatology for those fellows who seek eventual UNOS certification in hepatology.
Liver disease has become an increasingly important component of the practice of Gastroenterology. This increase reflects both an improvement in the recognition of patients with liver disease and significant advances in therapy. The novel and effective therapies for viral hepatitis and the improvement in survival of orthotopic liver transplants have increased the need for clinicians with expertise of liver disease. Training in management of these patients is essential for all gastroenterologists, although practitioners providing the bulk of transplant hepatology care may require additional training beyond that offered in a typical gastroenterology training program (level-3, Transplant Hepatology). The Tulane program provides level 1 training as per guidelines of the AGA (American Gastroenterological Association) Task Force on training in Hepatology. This includes education in a broad range of knowledge of the physiology of the liver and biliary system and a thorough knowledge for the diagnosis and management of patients with hepatobiliary disease. The goals and objectives on the liver service are achieved by lectures, conferences, seminars and exposure to inpatients and outpatients with hepatobiliary disease, including those pre-transplant and post-transplant