Second Year Curriculum

The second-year fellow is expected to expand the fundamental knowledge obtained in the first year of training. Specifically, knowledge on the diagnosis and treatment of less common diseases is acquired during the second year. By the beginning of the second year, the fellows should have performed enough procedures and/or patient encounters to begin to demonstrate mastery of each. During the second year, the fellow improves mastery of these skills.

Second-year fellows are expected to continue to develop interpersonal skills, leadership, self-reflection and improvement, an understanding of systems of care, clinical education and ethical and professional refinement.

The second-year fellow continues the clinic rotations established in the first year of training. As experienced GI fellows they are expected to use the knowledge and skills acquired in the first year to diagnose and treat outpatients, as well as to act as a resource for first year fellows, residents and students.

Fellows maintain their own continuity clinic one half day per week, and serve as the primary GI care provider for these patients. With faculty supervision, second year fellows augment their understanding of ambulatory management of gastrointestinal 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. Fellows typically see up to ten patients per half day. These patients are a mix of new patient referrals, hospital follow-ups, and established clinic patients. The clinic is staffed with faculty preceptors at a ratio of one preceptor per two to three second year fellows. While in the clinic, fellows are responsible for obtaining histories and physicals and consulting with supervising staff physicians in the management of the patient’s disease.

The second 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.

Starting in September 2022, dedicated outpatient hepatology clinics at UMCNO will commence. Building on the intensive first year inpatient loaded hepatology rotation, this educational opportunity gives the second and third year fellow more experience to handle common and complex hepatology problems on the outpatient setting. An inpatient UMCNO hepatology rotation is planned for the future.

The second year fellow assigned to consult services at Tulane Hospital, VA, or UMCNO will continue the learning process started in the first year, but due to their added experience will act as a resource to junior house staff as well as first year fellows, taking a greater leadership role.

The second 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. This includes:

1. Directly supervising interns, medical fellows and medical students in:
   
   1. Obtaining a history and physical on all patients
   2. Writing orders for patients if authorized by the admitting service
   3. Advising on a management plan as well as indicated laboratory and diagnostic studies
2. 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)
    
3. Leading and organizing a GI consult service. This responsibility includes:
   
   1. Supervising all intern, first year fellow and medical student ward activities
   2. Organizing work and teaching rounds
   3. Providing evaluation and feedback for each member of the ward team.
4. 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 second year fellow will add to their knowledge and skills in the care of patients with advanced liver disease. During the second year of fellowship, there is one month dedicated to hepatology including transplant at Tulane Hospital and Clinic. As mentioned above, an inpatient UMCNO hepatology rotation is planned for the future.

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.

In addition to VA and Tulane Hospital endoscopy experiences that remain in place throughout first, second, and third year, all second and third year fellows are assigned to outpatient and inpatient endoscopy at University Medical Center of New Orleans (UMCNO). These procedures are mostly performed in the hospital based endoscopy suite, 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 and diagnostic biopsy) and colonoscopy (including hemostasis of bleeding, decompression of Ogilvie's Syndrome, polypectomy and diagnostic biopsy). ERCP, EUS and esophageal stenting procedures are shared with third year fellows. Second year fellows will always perform procedures under the direct supervision of GI faculty who are in the room at all times. Competency in basic EGD and colonoscopy should already be established by the beginning of the second year, with expectation of further development of the basic skills as well as the additional diagnostic and therapeutic maneuvers described above.

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.