Adult Gastroenterology Training Program

Juravinski Site In-Patient Rotation

Rotation-Specific Objectives

OVERVIEW

The Juravinski Site is a regional referral centre for patients with a wide variety of gastrointestinal and hepatological conditions. The large population of patients with inflammatory bowel disease and liver diseases followed at the McMaster site constitutes the majority of in-patients under the GI service. These cases are often complicated, and provide a challenging learning experience for the trainees. The Juravinski Site also houses the Cancer Centre, and offers exposure to gastrointestinal complications of malignancy. The clinical service comprises an endoscopy unit, a joint Gastroenterology-oncology ward on 3C, and an outpatient facility. The Juravinski Site admits patients from outpatient practice of attending gastroenterologists and also from the Emergency Departments at two acute-care sites of Hamilton Health Sciences (Juravinski and General Sites). In addition, many patients are transferred from community hospitals that do not have the resources or expertise to manage complex GI conditions. Our clinical faculty encompasses expertise in all areas of GI including inflammatory bowel disease, irritable bowel syndrome, motility, acid-related disorders, nutrition, hepatology, and interventional endoscopy (ERCP and endoscopic ultrasound).

A multi-disciplinary team (gastroenterologists, Gastroenterology residents, rotating medical residents, medical students, nursing unit manager, nurses, pharmacists, occupation therapists, physiotherapists, nutritionists, social workers and discharge coordinators) manages patients in the inpatient unit. The inpatient rotation consists of inpatient consultations, inpatient and ambulatory endoscopy and one ½ day GI clinic per week. The primary goal of this rotation is to provide in-depth exposure to complex GI problems in an adult tertiary care, referral population.

Responsibilities of the Resident

The inpatient 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.

Inpatient Experience
The inpatient service at the Juravinski Site is usually responsible for 7-10 inpatients on the joint Gastroenterology-oncology ward (3C). Patients on this ward have serious medical illnesses such as exacerbation of inflammatory bowel disease, gastrointestinal hemorrhage, liver failure and GI infection.

The resident will function under the supervision of the attending physicians who assume responsibility for the inpatient unit on a rotational basis (every 2 weeks). A team consists of two GI residents, rotating medical residents, medical students and the attending physician. Residents gain clinical experience by functioning as consultants in Gastroenterology. Inpatient consultations are first done by residents. Their assessments and recommendations are then reviewed with the attending staff. The GI resident will be expected to be an active member of the team providing primary care to the inpatients, taking responsibility for the day-to-day care of a proportion of the in-patients commensurate with their level of training, and provide supervision and facilitate teaching of junior housestaff. It is expected that the GI resident will be familiar with all patients on the ward and act as a resource for other members of the team providing primary care to these patients. This care will include the development of skills in diagnosis, primary therapy, and supportive care including dealing with the psychosocial aspects of these diseases that affect both the patients and their families. The GI resident also performs endoscopic procedures under the supervision of the attending staff on patients seen in consultation. Booking of procedures should be coordinated with the charge nurse in the endoscopy unit. The GI resident will attend short daily morning ward rounds (09:00 AM) with the nursing staff on C3 to coordinate discharge planning. There is also a multi-disciplinary meeting held on a weekly basis, and residents are expected to attend and contribute effectively to patient are. Attending rounds with the residents are generally held daily, depending on the volume of consultations, their complexity, and acuity. At the end of each working day or prior to weekend, the resident will update the signover list of patients in Citrix, and sign out critically ill patients to the resident on call to ensure continuity of care.

On discharge, the resident will review the diagnosis, prognosis, implications and medications with the patients and families. He/She will dictate a discharge summary promptly on discharge and communicate with the referring physician and/or patient’s own gastroenterologist regarding hospital course and follow-up plans.

The resident will also provide a consultation service to other inpatient areas. These consultations will be completed under the supervision of the attending physician responsible for inpatient consultations. If the care of such a patient requires the ongoing input from the Gastroenterology service, the resident will provide follow-up assessment and recommendations to the referring service.

Through these activities, trainees gain an in-depth experience in both common and uncommon GI problems.

Outpatient Experience
Ambulatory clinic experience is considered to be an important component of the inpatient rotation. While on the inpatient rotation, trainees attend at least one outpatient clinic each week, where they have the opportunity to assess new and return patients with a wide variety of gastrointestinal, hepatic and pancreatic conditions under the supervision of a faculty attending physician. Residents also attend one elective endoscopy session each week.

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 attend weekly structured teaching sessions with the Juravinski Site Coordinator (Monday 0800 h to 0900 h). These are structured teaching sessions with an overview of major topics in GI and Hepatology. In addition, an informal teaching session led by the attending staff on service at the Juravinski site occurs on a weekly basis (Thursday or Friday). There is also bedside teaching session with a focus on physical examination skills in GI and Hepatology every two weeks conducted by the McMaster Site Coordinator (Tuesday 0800 h to 0900 h). The resident’s educational activities will also include the regular ward rounds with the attending staff. The resident will be expected to do one formal presentation on a topic of their choice during CTU noon rounds or team rounds.

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 and the Juravinski Site Coordinator. 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). 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 Juravinski Site Coordinator after completion.

Evaluation of the Rotation

Residents are encouraged to provide feedback on how the rotation and teaching are structured. At the time of the weekly structured teaching session with the Juravinski Site Coordinator and final evaluation of the resident, feedback regarding the rotation, including its strengths and shortcomings, is requested from the resident. If issues arise during the rotation, the resident is encouraged to bring these to the attention of the rotation supervisor and the Site Coordinator(s). 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.

GI/GIM Collaborative Agreement

The GIM/CTU (including the GIM physician covering the MD-Based team) and GI services at the Juravinski Site have agreed to adopt the following guidelines to assist the ED physicians with the most appropriate service for referral of patients presenting to the ED with GIM/GI problems.

The following is a guideline and does not pre-empt the ED physician from referring to either service based on their assessment of the clinical problem and the most appropriate service to consult. Both services will consult on any patients referred and will retain the option of transferring care between the two services as agreed upon by the two consultants (GIM/CTU and GI) after both services/staff have had an opportunity to review the case. The MRP service will also retain the option of asking the other service to continue to follow the patient as a consulting service.

The ED physician will use the guidelines for any patient whom they feel is likely to require admission to hospital. The ED physician can refer any patient to the General Internal Medicine Rapid Assessment Outpatient Clinic (GIMRAOC) or the urgent GI clinic, if in their opinion the patient does not need admission or an ED consult, but can be safely discharged with urgent follow-up using the existing protocol for referral to either of these clinics.

Patients with the following acute problems who are likely to need admission to hospital can be referred to the GIM/CTU service on call:

  1. Undifferentiated nausea and vomiting.
  2. Undifferentiated diarrhoea.
  3. Undifferentiated severe or symptomaticanemia.
  4. Non-surgical abdominal pain.
  5. Undifferentiated abnormal liver tests.
  6. Undifferentiated ascites.
  7. Uncomplicated decompensated cirrhosis.
Patients with the following acute problems who are likely to need admission to hospital can be referred to the GI service:
  1. Acute flare of IBD
  2. Acute GI bleeds
  3. Complicated decompensated cirrhosis
  4. Any patient followed on a regular basis by the GI service.
  5. Any patient hospitalized under the GI service in the past 6 months.
  6. Any patient already referred to the GI service urgently or electively who becomes ill and attends the ED.