Adult Gastroenterology Training Program

Clinical Nutrition Rotation

OVERVIEW

The recognition and management of malnutrition, including nutritional deficiencies associated with gastrointestinal and hepatopancreaticobiliary dysfunction as well as the gastrointestinal luminal, hepatic and pancreatic consequences of overweight and obesity are key elements of Gastroenterology practice. There is a general expectation, on the part of health care professionals and patients, that gastroenterologists are, or should be expert in the area of nutrition and nutrition is one of the topics highlighted in the Royal College curriculum for subspecialty Gastroenterology training programs. Despite this, there is evidence that practising gastroenterologists do not consider that they have had adequate training in the field of nutrition, either to provide comprehensive nutritional care for their patients with gastrointestinal diseases or to advise other health care professionals with respect to nutritional care (Singh H, Duerksen DR. Can J Gastroenterol 2006;20:527-30).

In Canada, the Royal College of Physicians and Surgeons of Canada (RCPSC) requires training in nutrition in GI residency programs and, in the U.S., a consortium of Gastroenterology associations has designated nutrition training of GI fellows as a mandatory component of their training programs (Heimburger DC. J Clin Gastroenterol 2002;34:505-8)

The overall goal of the Clinical Nutrition Curriculum is to acquire practical knowledge and skills in the major clinical nutrition domains relevant to gastroenterologists. These include:

  1. The management of patients with gastrointestinal disorders (e.g. inflammatory bowel disease, dysmotility, celiac disease and structural abnormalities of the gastrointestinal tract) associated with malnutrition
  2. The placement of feeding tubes (e.g. gastrostomy or jejunostomy tubes, endoscopically or radiologically) in patients to provide access for enteral nutrition
  3. The management of nutritional support for patients (e.g. with short bowel syndrome) requiring short- and long-term total parenteral nutrition, in hospital and in the community
  4. The management of obesity, non-alcoholic fatty liver disease and the sequelae of anti-obesity therapy

Dr. David Armstrong is the Coordinator for the Clinical Nutrition Curriculum.

Clinical Nutrition Curriculum

The Clinical Nutrition Curriculum includes the following components:

  1. Clinical Nutrition Rotation (4-week block):
    • Weekly Nutrition Ward Rounds on a Monday afternoon (1330 h -1600 h):
      • Inpatient Nutrition rounds (Juravinski Site)
      • Nutrition Topic Review presented by the Resident
    • Weekly Ambulatory Care Nutrition Clinics on a Thursday morning (0900 h – 1200 h)
      • 09:00 – 10:00 Digestive Diseases Program Dietician (Suzanne Hansen, RD)
      • 10:00 – 12:00 Home Parenteral Nutrition Clinic (Stella Stevens RN; Suzanne Hansen RD; David Armstrong MD)
        • Outpatient Home Parenteral Nutrition Rounds: including review of current test result and clinical status for 25 patients managed by the HHS HPN Team
        • Outpatient HPN patient evaluation: 1-2 patients weekly
    • Weekly Inpatient Consultations for patients referred by inpatient services for evaluation of nutritional compromise (David Armstrong MD, Jodie Hoard RD)
    • Opportunity to participate in the weekly Adult Cystic Fibrosis Clinic (3Z) at the MUMC site (Wednesday afternoon, 13:00 to 16:30) and gain an understanding of the nutritional, gastrointestinal and hepatic sequelae of cystic fibrosis
  2. Four academic half-day lectures (2 per year) focused on:
    • Nutritional assessment with particular reference to patients with GI diseases
    • Management of nutritionally compromised individuals by enteral nutrition
    • Management of nutritionally compromised individuals by parenteral nutrition
    • Management of nutritional issues related to inflammatory bowel disease, celiac disease, cystic fibrosis, liver disease, obesity, bariatric surgery, short bowel syndrome and eating disorders
  3. One introductory session on the principles of enteral and parenteral nutrition at the start of each academic year. This will be run by one of the registered Digestive Diseases Program dieticians (Suzanne Hansen RD)
  4. There will be clinical research opportunities that should be reviewed with the Program Director, the Research Coordinator and the Clinical Nutrition Curriculum Coordinator at the start of the year.

The Clinical Nutrition Rotation can be incorporated into an Outpatient Rotation or an Elective Block in the Second Year.

At completion of the Nutrition Curriculum, the Gastroenterology resident will:

  1. Have an understanding of normal and stress metabolism
  2. Be proficient in nutritional assessments
  3. Be able to evaluate the risks and benefits of specialized nutrition support
  4. Understand the principles of determining caloric requirements by calculation and indirect calorimetry
  5. Be able to design formulae for parenteral or enteral nutrition
  6. Be proficient in monitoring for and managing the complications of nutrition support, central catheters, enteral tubes
  7. Be proficient in the outpatient management of TPN, obesity, celiac disease, and other nutritional problems

Responsibilities of the Resident

Rotation schedule is prepared by the Chief Residents on a monthly basis. However, the rotation schedule should be confirmed with the Nutrition Curriculum Coordinator 4 weeks prior to the start date of the rotation. 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 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 due to post-call reasons. 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 learning of topics and diseases encountered in the clinics.

Rotation Schedule

 

AM

PM

Monday

Endoscopy

Nutrition Ward Rounds (JH)

Tuesday

Endoscopy

Dr. Armstrong Clinic (2F)

Wednesday

Academic Half Day

Cystic Fibrosis Clinic

Thursday

Nutrition Clinic (2F)

Dr. Armstrong Clinic (2F)

Friday

Reading day

Evaluation of the Resident

Residents are encouraged to seek informal verbal feedback throughout the Clinical Nutrition Rotation concerning their proficiency at diagnosing and managing clinical problems related to nutritional disorders. 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. motility nurse, other allied health professionals). Based on all feedback received, at the end of the rotation, a formal web-based CanMEDS compliant ITER is compiled by the supervisor. Final evaluations are discussed with the resident.

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 anonymity. This has been important to maintaining feedback.