Adult Gastroenterology Training Program

Hamilton General Site Junior Attending Consult Rotation

Rotation-Specific Objectives

OVERVIEW

The General Site offers a busy Gastroenterology consultation service. With state-of-the-art facilities, the General Site is recognized as a regional center of excellence in cardiovascular care, neurosciences, trauma and burn treatment. Residents on consultation service gain exposure to gastrointestinal and nutritional complications of these complex medical conditions. In addition, residents have the opportunity to gain experience in the outpatient Hepatology clinic run by Dr. Witt-Sullivan. A busy endoscopy unit with on-site ERCP service is led by Drs. Lumb and Seaton.

There are no in-patient beds at the General site. Emergency patients are not admitted to the General site but rather, referred to the consultant on call at the Juravinski site and arrangements will be made for their transfer to this site. In extraordinary circumstances, a very unstable GI bleed may be determined to be unsafe for transfer at which point the GI resident may be asked to take part in the resuscitation and investigation of this patient. In-patients with life threatening gastrointestinal bleeding will be managed at the General site unless it is determined that their management needs to be referred on to the Juravinski site. However, these individuals will remain under the primary service rather than being transferred to the Gastroenterologist on-call in terms of most responsible physician.

The busy rotation at the consultation service provides excellent exposure to consultative practice in a tertiary care setting. Widely diverse gastrointestinal problems, both acute and chronic, will be encountered. Consultations will arise from inpatient services and the intensive care units (Cardiac and Neurotrauma). Many of the patients referred to the consultation service, such as those with active upper and lower GI tract bleeding and biliary tract disease, require urgent endoscopic evaluation. The consultation rotation will expose residents to a variety of practice styles and clinical approaches by the members of the GI Division and will in turn increase the resident’s competence and confidence in managing a wide variety of common GI problems.

The inpatient rotation consists of inpatient consultations, inpatient and ambulatory endoscopy and one ½ day Hepatology clinic per week. The primary goal of this rotation is to provide in-depth exposure to common GI problems in an adult tertiary care centre.

Responsibilities of the Resident

The consult rotation is 4 weeks in duration and includes patient care activities in both an inpatient and outpatient setting, as well as educational and scholarly activities. This rotation is only for Second Year GI residents. The duties and responsibilities of the GI resident are advanced, as per the principle of graduated responsibility.

The overall goals of this rotation are:

  1. To develop the skills necessary to function independently as an attending physician on a GI consult service and
  2. To develop the skills necessary to function as the manager and teacher in a tertiary care centre

Inpatient Experience
The inpatient experience at the General Site is a consultation based service. The consultation service is structured such that one consultant is on call on a rotational basis for referrals (every 2 weeks). The resident will be expected to function as a junior attending. He/She will triage consults, assess patients, and perform any necessary endoscopic procedures under supervision. The junior attending resident will also liaise with consulting services and allied health professionals to optimize the care of the patients under their care. He/She will provide teaching to junior residents and medical students on the Medicine team.

The attending physician will serve as a supervisor / observer in the background to the junior attending resident, observing all aspects of patient care behavior, medical expert and the other CanMEDS competencies expected of a Junior Faculty. During this time, the junior attending resident assumes all the day to day attending responsibilities. The attending physician will only intervene if he/she believes that significant change in the medical plan is necessary for patient safety.

Through these activities, the junior attending resident gains confidence as an independent consultant.

The following are general guidelines that may assist the junior attending resident on this rotation:

  1. On the first day of the rotation, paging should be contacted to confirm the rotation dates of the resident.
  2. The junior attending resident will complete all consults from the inpatient services at the General Site within 24 hours of their referrals. The junior attending resident is also responsible for the occasional consults for admitted OB/GYN patients at the McMaster Site. Referrals for un-admitted patients in the emergency room as an initial consult service request from the emergency doctor should be directed to the GI service at the Juravinski Site. The policy is that stable GI patients are to be transferred to the Juravinski Site. Patients deemed unstable need to have another admitting service (e.g. Medicine / Surgery) involved first prior to consulting GI. Adherence to this triage policy is important to avoid confusion among the referring physicians and paging system. The assessments and recommendations of all consults are then reviewed with the attending physician at least once daily. Patients are followed closely throughout their hospitalization by the junior attending resident in consultation with the attending gastroenterologist. Effective communication with the attending physician and the consulting service is crucial and will be assessed.
  3. The junior attending resident will be expected to perform all procedures, with hands-off supervision by the attending staff. The junior attending resident is strongly encouraged to attend elective endoscopy lists on a daily basis. There is an urgent access endoscopy list every Friday. In addition, each day there are slots set aside in the endoscopy schedule for in-patient procedures. The consultation service endeavors to provide timely endoscopy for those patients requiring these investigations. The specific timing for any inpatient procedure should be negotiated with the nursing staff in the endoscopy unit as well as with the consultant on-call keeping in mind the level of urgency. However, the endoscopy unit should be notified as soon as possible if an endoscopy is required for any patient (even prior to reviewing with the attending staff) as it is always much easier to cancel an endoscopy spot than to find one at the last minute. In the case of after hours, a note with the patient’s name, location and general information can be left on a desk in the endoscopy suite and a request can be made for the nurses to page the resident in the morning to arrange an endoscopy. Acute bleeding patients will be able to be accommodated within a short interval. At times, an alternate consultant may be asked to carry out an endoscopic procedure on an in-patient. This practice helps to facilitate rapid access to endoscopy for in-patients during intervals when the specific consultant on-call may not be immediately available.
  4. ERCP consults should be reviewed with the attending physician first. If a decision is made that the patient will require an ERCP, an endoscopist with ERCP expertise (Dr. Lumb, Dr. Seaton, Dr. Tse) should be contacted immediately in order to coordinate the procedure with the endoscopy nurses, the fluoroscopy unit, and the endoscopist. It is important to ensure pre-procedural care has been properly managed including anticoagulation, bloodwork (CBC, INR) and prophylactic antibiotics if necessary. After the procedure has been successfully performed, it is important to reassess the patient the following day to ensure no major complication has occurred (e.g. bleeding post sphincterotomy, sepsis, pancreatitis, perforation etc.) before signing off on the patient.
  5. Patients undergoing endoscopic procedures, transfusion, liver biopsy or paracentesis should have an appropriate consent form completed and available on the chart. Specific risks and benefits related to the individual procedures should be reviewed with the patients and/or families to allow for informed consent.
  6. For PEG consults, informed consent with the patients / families will need to be completed well in advance as it is often difficult to track down family members in a timely manner when the patient is in the endoscopy unit ready for the procedure. It is also important to ensure pre-procedural care has been properly managed including anticoagulation, bloodwork (CBC, INR), and prophylactic antibiotics
  7. All patients seen, should have an initial consultation note dictated on the same day as being seen. In addition to a dictated consultation note, an appropriate hand-written note should be completed. Provided that a detailed consultation note is dictated, these notes need not be unduly long. The note however should indicate a clear understanding of the clinical issues and an appropriate investigation and/or management plan. Patients seen on the consultation service who are no longer active or require further Gastroenterology follow up do not need to be followed. However, it is mandatory that patients who are still active under the Gastroenterology service be seen on a daily basis. At the end of the consultation process, a note should be written in the chart indicating that the patient has been “signed off”.
  8. The attending physician formally rounds with the junior attending resident at a frequency at his/her discretion, depending on the volume of consultations, their complexity, and acuity. At the end of each working day or prior to weekend, the junior attending resident will update the signover list of inpatients in Citrix, and sign out critically ill patients to the resident on call to ensure continuity of care.
  9. If the resident is post call and has been called in between midnight and 6 am, the attending physician should be notified first thing in the AM (08:00 to 09:00 AM) to provide backup coverage for emergency consults if necessary. Any non-urgent consults can be done the following day when the resident is back on service.
  10. A small room with computer / internet access is available in the endoscopy unit for the resident. The endoscopy nurses can provide direction to the room.
  11. It is the GI Divisional policy that the General site be covered at all times. It is the responsibility of the resident to arrange alternative coverage by another resident(s) in the case of vacation / conference leaves. The default resident(s) to provide alternative coverage is the resident on for McMaster outpatient rotation followed by research and elective in that sequence. However, the alternative resident coverage needs to be arranged ahead of time as soon as the vacation / leaves are confirmed. The Site Coordinator, on-service staff, chief residents and paging will need to be notified about the alternative arrangement.
  12. The resident is encouraged to contact Dr. Helga Witt-Sullivan (424 in the McMaster Clinic) should there be any problems encountered during this rotation (especially with an emergency situation and the attending physician is not on site yet).

Outpatient Experience
This rotation offers the opportunity for the junior attending resident to gain experience in the outpatient Hepatology clinic under the supervision of Dr. H. Witt-Sullivan in the OPD area (Tuesday 08:30 AM). The junior attending resident is expected to attend one Hepatology clinic each Tuesday morning at the General Site, where they have the opportunity to assess new and return patients with hepatic conditions. If the resident is not able to attend this clinic due to vacation / leave, alternative coverage for this clinic will need to be arranged as extra patients are booked ahead of time for teaching purpose. If the resident is scheduled to be on call on any Monday night during this rotation, the chief residents will need to be informed ahead of time to arrange a switch in call dates to avoid being post call for this clinic. Residents also attend elective endoscopy sessions on a daily basis.

Educational and Scholarly activities
Educational activities, which are a priority for the GI resident, include both scheduled rounds and other academic sessions. The resident is expected to attend the Gastroenterology Residents’ academic half-day, including the Farncombe noon rounds, on a weekly basis. In addition, the resident is expected to identify a topic of interest to review with the attending physician on a weekly basis.

The resident will be expected to do one formal presentation on a topic of their choice during CTU noon rounds. It is the responsibility of the junior attending resident to contact the GIM chief resident at the beginning of the rotation to arrange a suitable date for the presentation.

Evaluation of the Resident

An orientation session will take place during the first week of the rotation to discuss the goals and description of this rotation with the resident. The specific objectives of the resident will be discussed and an attempt made to integrate these objectives into the overall objectives of the rotation.

Residents are encouraged to seek informal verbal feedback throughout the rotation concerning their proficiency at managing clinical problems and performing endoscopic procedures. A formal evaluation session with the resident will take place at the end of the rotation with the supervisors (every 2 weeks) and the General Site Coordinator (at the end of the 4-week rotation). Input is sought from other members of the clinic team who have worked with the resident (e.g. nurses, nurse practitioners, other allied health professionals). The Site Coordinator should be informed a few days prior to the end of the rotation to collate comments from all supervisors and health professionals. A Multi-source evaluation tool is used to assess the resident’s skill in the collaborator role. Based on all feedback received, at the end of the rotation, a formal web-based CanMEDS compliant ITER is compiled by the supervisors. Final evaluations are discussed with the resident. The resident’s teaching skills will also be evaluated by junior residents formally through the GI Residents Teaching Evaluation Tool. It is the responsibility of the residents to distribute these forms to the junior residents during rounds, and forward them to the Program Administrator (Debbie Fewer) after completion.

Evaluation of the Rotation

Residents are encouraged to provide feedback on how the rotation and teaching are structured. If issues arise during the rotation, the resident is encouraged to bring these to the attention of the rotation supervisor and the Site Coordinator. A mechanism for dealing with any shortcomings will then be discussed with the resident and subsequently at the Residency Program Committee meeting. As with all rotations, an anonymous rotation evaluation is handled by the One 45 WebEval System. Each teaching faculty is evaluated separately in a similar manner. The Residency Program Committee meets semi-annually to compile a collective rotation and faculty evaluation, respecting anonymity. This has been important to maintaining feedback.