Adult Gastroenterology Training Program

McMaster Site Outpatient Rotation

Rotation-Specific Objectives

OVERVIEW

McMaster University Medical Centre is a tertiary care facility and a regional referral centre for patients with a wide variety of gastrointestinal and hepatological conditions.  It supports a comprehensive outpatient facility that hosts 30 clinics per week, including a specialty Barrett’s clinic and the Multi-disciplinary Inflammatory Bowel Disease (IBD) clinic. A unique Gastrointestinal Investigational Unit offers special testing that is often not found at other medical centres including hydrogen breath testing (for fructose malabsorption, small bowel bacterial overgrowth and delayed orocecal transit) and 24 hour pH-metry. The associated GI Motility Laboratory performs numerous diagnostic studies including esophageal and anorectal manometry, and small bowel capsule endoscopy studies.

Extensive exposure to outpatient practice is a key component of training in Adult Gastroenterology. In addition to longitudinal participation in outpatient clinics and elective endoscopy lists through all rotations, residents are specifically assigned to a dedicated outpatient clinic block in Year 1 and four blocks in Year 2. Residents on this 4-week rotation will be exposed to ambulatory aspects of gastrointestinal and liver diseases through the following venues: Gastroenterology clinic, Hepatology clinic, IBD clinic, and out-patient endoscopy. This will be performed under the supervision of staff gastroenterologists and hepatologists. This rotation serves to complement in-patient rotations by providing comprehensive experience in the assessment and management of patients in the ambulatory care environment. With exposure to dedicated IBD clinics, residents develop an appreciation of the multi-disciplinary team approach to management of inflammatory bowel disease. The overall structure of the rotation is designed to provide trainees with graded responsibility as they progress from the First to the Second year.

Residents on this rotation are expected to attend four outpatient clinics each week. First year residents are expected to perform the initial assessment of at least 2 to 4 new referrals and 2 to 4 follow-up visits each week. Second Year residents are expected to assess a greater proportion of follow-up patient visits than new referrals. At this level, the resident is expected to provide an expert opinion on gastrointestinal problems, with a management plan that is analogous to that of the supervising consultant. Second Year residents also have the invaluable opportunities to participate in the Urgent Clinic and Rapid Assessment Clinic as junior consultants where they will learn how to run an outpatient clinic independently and effectively from screening and triaging referrals to providing a management plan for patients. Throughout the Second Year, residents have a weekly longitudinal clinic geared towards their specific subspecialty interests where they assess and follow outpatients under the supervision of the assigned staff. Residents are also expected to attend four ambulatory endoscopy sessions each week under the supervision of a staff physician. At the end of their second-year experience, residents should be able to complete diagnostic and therapeutic upper and lower endoscopic procedures independently and competently with minimal help from the supervising consultant.

Over the course of these ambulatory experiences, the resident is given increasing responsibility and by the end of the Second Year should be ready for independent practice. Residents will learn to function as consultants in the ambulatory setting through the integration of all of the CanMEDS roles.

Ambulatory block rotation can be combined with Motility, Clinical Nutrition, or Hepatology curricula. Those curricula are described separately.              

Responsibilities of the Resident

Rotation schedule is prepared by the Chief Residents on a monthly basis. Residents are expected to attend each assigned clinic and endoscopy list, to be punctual, and to complete procedure notes and consultation notes on all patients seen in the clinic in a timely fashion. Clinical supervisors must be informed of vacation / professional leave at least 4 weeks prior to the start date of the rotation. In addition, clinical supervisors must be informed when residents are unable to attend clinic or endoscopy lists post-call. Residents are expected to develop, implement and monitor a personal continuing education strategy. To facilitate this objective, at least one half day is set aside per week for self-directed, integrated learning related to topics and diseases encountered in the clinics. 

Prior to the beginning the Second Year, residents are provided with a list of available ambulatory clinics and are responsible for arranging to participate in a longitudinal clinic with the Chief Residents. The resident is given freedom in choosing a clinic supervisor from amongst the faculty members of the GI Division. Second Year residents are responsible for triaging of referrals for the Urgent GI and Rapid Assessment Clinics. Residents assigned to Dr. Collins’ Clinic are responsible to follow-up on any laboratory or imaging tests ordered during the clinic. The McMaster Site Coordinator is available to provide mentorship for triaging of referrals and clinic management.

Urgent GI clinic, Rapid Assessment Clinic, and Dr. Collin’s Clinic are mandatory clinics. Alternative coverage for these clinics will need to be arranged with another resident in the event of vacation / professional leave. The default resident(s) will be the resident(s) attending other clinics in the same time slot. However, it is the resident’s responsibility to confirm and arrange alternative coverage when necessary. 

Evaluation of the Resident

Residents are encouraged to seek regular informal verbal feedback about their proficiency at managing clinical problems and performing endoscopic procedures over the course of their outpatient clinic experience. A formal evaluation session with the resident will take place at the end of the 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). Based on all feedback received, a formal web-based CanMEDS compliant ITER is compiled by the supervisor. Final evaluations are discussed with the resident.

To directly assess and improve the ability of residents to communicate effectively with referring physicians, written documentation will be evaluated during every outpatient clinic rotation by means of a Written Consultation Dictation Evaluation Form. It is the expectation that the resident will review one consultation letter with an attending staff and have the evaluation form completed for each outpatient clinic rotation.

Evaluation of the Rotation

Residents are encouraged to provide feedback on how the rotation and teaching are structured. 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 resident anonymity. This has been important for the purposes of constructive feedback.