Third Year Fellow (PGY-6)
The longitudinal development of a 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. There is also a strong emphasis 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 flexibility and allow indepth exposure to subspecialty activities in the individual fellow's area of interest such as advanced endoscopy/pancreaticobiliary disorders or concentration on specific clinics in IBD, motility or liver. A typical third-year schedule includes:
- Three to five months on UMCNO Inpatient Consult Services/Outpatient Endoscopy.
- Four months of VA Inpatient Consult Service/Outpatient Endoscopy and Clinic
- Up to two months on the Hepatology Service
- One month elective time
- One month of research
- One-month vacation
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 at the UMCNO GI continuity clinic established in the first two years of training. Fellows maintain their own continuity clinic one half day 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 GI 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 third year fellows. While in the clinic, 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 in continued clinic experiences similar to those previously outlined in the first and second year curriculum. There is an opportunity for third year fellows to design their outpatient experience and tailor it to areas of specialty interest, such as hepatology, IBD, or advanced therapeutic endoscopy.
The third year fellow assigned to consult services at VA or UMCNO will continue the learning process, but due to their added experience will act as a resource to junior house staff as well as first and second year fellows, taking a formal leadership role.
The third 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:
- Directly supervising interns, medical fellows 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, first year fellow 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.
n 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 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 fourth year. 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. Dedicated outpatient hepatology clinics will continue at UMCNO as it was as second year of fellowship. The third year can be used as a dedicated year heavily weighted in hepatology for those fellows who seek fourth year transplant hepatology fellowship training.
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
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.
