First Year Fellow (PGY-4)
First year fellows are accepted within the National Residency Matching Program. The fellow is assigned to the Gastroenterology Service at one of the participating training institutions. This fellow is under the supervision of the Chair of the Department, the Program Director, full time faculty, and supervising fellows.
The goal of the first year is to acquire diagnostic, therapeutic and prognostic skills through participation in direct patient care in supervised inpatient and outpatient settings. A typical year includes:
- Three months on Hepatology Service (Tulane Abdominal Transplant Unit)
- Three months on Inpatient Consult Service/Endoscopy (Tulane)
- Four Months on Inpatient Consult Service or Outpatient Endoscopy (VA)
- One month of Research
- One month vacation (Incorporated into the monthly schedules)
In addition to the above monthly rotations, first year fellows also participate in a weekly continuity clinic every Wednesday afternoon at University Medical Center at New Orleans (UMCNO).
The first-year fellow obtains knowledge related to the presenting manifestations, natural history, complications, pathophysiology, differential diagnosis, and appropriate diagnostic and management plans for the most common diseases and conditions in the practice of the specialty. This includes diseases and conditions seen in ambulatory patients, emergency departments, regular hospital services and intensive care units. The fellow develops proficiency in the interpretation of diagnostic studies used in the evaluation of common diseases in the specialty. First year fellow also acquire knowledge about the indications, limitations, complications and cost effectiveness of common diagnostic tests and procedures. The first year fellow obtains knowledge of the therapeutic indications used for the management of the common diseases in the specialty. In this year fellows are given the opportunity (through didactics and self directed learning, and teaching residents and students) to relate pathophysiology to the disease processes of luminal GI and hepatology.
First year fellows are taught the essentials of the GI history and physical exam, as well as differential diagnosis and management. They learn to build upon the base knowledge of internal medicine to develop the skills of a gastroenterologist.
The first year fellow participates with faculty in the evaluation and treatment of patients seen in the UMCNO ambulatory care clinics. GI fellows maintain their own continuity clinic one half day per week. This is considered a general GI/hepatology clinic. With faculty supervision, these fellows obtain histories and physicals from each patient, order indicated laboratory and diagnostic studies treat diagnosed digestive and liver disease, and counsel patients regarding their health and disease. Fellows see up to eight clinic patients per half day, typically starting at a lower volume and increasing as the year goes on. These patients are a mix of new patient referrals, hospital follow-ups, and established clinic patients. The clinic is staffed with two faculty preceptors, encouraging continuity of care and a consistent foundation as general GI knowledge is gained.
The first year fellow participates with faculty supervision in GI VA clinics during the outpatient portion of their VA month rotation. These VA clinics offer the full breadth of gastroenterology.
At the Tulane site, the inpatient GI consult fellow rotates a half day a week on the Tulane Hospital Clinic, located within the same complex of Tulane Hospital. This clinic is expected to expand in the future to include subspecialty GI care, but for now remains a general GI experience. Faculty staffing this clinic are seasoned community based providers and provides the fellow an opportunity to learn from a faculty mentor with a private practice background.
The first year fellow is taught the essentials of the GI consultation, building upon the knowledge acquired in internal medicine training and learning to direct focus towards GI disease. Fellows on the VA rotation will spend part of their month performing inpatient consult service, whereas fellows rotating on Tulane will spend the entire month on the inpatient consult service.
The first year fellow serves as the supervising fellow in performing consults on inpatients on the wards and the ICU, as well as those admitted patients in the ER, unless they are paired with a more senior fellow, who would assume this role . This includes:
- Directly supervising interns, medical residents and medical students in:
- Obtaining a history and physical on all patients
- Writing orders for patients if authorized by the admitting service
- Advising on a management plan as well as indicated laboratory and diagnostic studies
- Fellows also continue to increase their knowledge of the indications, contra-indications, risks and benefits, and interpretation of diagnostic procedures. They learn how to perform procedures commiserate with their level of training (vida infra). (see Endoscopy service, below)
- Leading and organizing a GI consult service. This responsibility includes:
- Supervising all intern and medical student ward activities
- Organizing work and teaching rounds
- Providing evaluation and feedback for each member of the ward team.
- Urgent consults will be seen within the hour. Non urgent consults will be seen that day or within 24 hours of the consult request.
The first year fellow will gain knowledge and skills in the care of patients with advanced liver disease. During the first year of fellowship, there are three months dedicated to hepatology including transplant. 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.
First year GI fellows typically have no or very little hands-on experience with endoscopic procedures upon entering the program, despite some familiarity with the indications for endoscopy. In our program first year fellows will learn the essential cognitive and practical principles of endoscopic diagnosis and management, but will also have the unique opportunity to have plenty of hands-on endoscopy time when possible.
First year GI fellows will primarily perform esophagogastroscopy (EGD, including foreign body removal, hemostasis of bleeding, variceal ligation, stricture dilation and diagnostic biopsy) and colonoscopy (including hemostasis of bleeding, decompression of Ogilvie’s Syndrome, polypectomy and diagnostic biopsy) while on call. However the fellowship program has recognized the importance of building the endoscopic skill set early on and thus even in the first year, fellows have the opportunity for dedicated outpatient endoscopy time, starting within the first 1-3 months of training. The first year fellow will be assisted as needed by second or third year GI fellows on home backup call with them during the first month. They will not perform supervised ERCP or EUS in the first year. First year fellows will always perform procedures under the direct supervision of GI faculty who are in the room at all times. Basic competency in EGD and colonoscopy is expected by the end of the first year, with competency in associated diagnostic and therapeutic procedures to develop over the next two years.
All fellows take home call for GI or hepatology and there is no primary gastroenterology service at any of the sites. Sites covered by home call include VA, Tulane Medical Center, and University Medical Center-New Orleans (UMCNO). UMCNO call is shared jointly with LSU-New Orleans GI. Fellows on call for the weekend, will round daily with the call faculty on inpatients followed by GI or hepatology consult services at the hospital sites they have assigned call. All fellows on-call will contact staff with new consults for review and decision making consultation.
