Adult Gastroenterology Training Program

Goals and Objectives of the Clinical Nutrition Rotation (Year 2)

Rotation-Specific Objectives

Specific goals and objectives of the Clinical Nutrition Curriculum in CanMEDs format are as follows:

Medical Expert

Key Competencies: Physicians are able to

  1. Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal, ethical and patient-centered medical care
  2. Establish and maintain clinical knowledge, skills and attitudes appropriate to Gastroenterology
  3. Perform a complete and appropriate assessment of a patient
  4. Use preventive and therapeutic interventions effectively
  5. Demonstrate proficient and appropriate use of procedural skills, both diagnostic and therapeutic
  6. Seek appropriate consultation from other health professionals, recognizing the limits of their expertise

Specific Requirements: Gastroenterology residents are able to

  1. Develop knowledge in the following general areas via case-based learning, interactive discussion, or self-directed learning:
    • Nutrients:
      • Absorption
      • Digestion
      • Requirements: macronutrients micronutrients, water
      • Deficiency
      • Toxicity
    • Diet and Activity:
      • Canada Food Guide to Health Eating
      • Diets, including vegetarianism, fads
      • Activity guidelines
    • Nutritional Assessment:
      • History and Physical; SGA
      • Laboratory evaluation
      • Anthropometry
      • Indirect calorimetry
    • Nutritional Therapy
      • Diet - e.g. gluten free diet, high fibre diet etc
      • Enteral nutrition – access / requirements/ products / complications
      • Parenteral nutrition – access / requirements / prescription / complications
      • Refeeding syndrome
      • Home nutrition support
    • An approach to the management of nutrition in disease states. This will include:
      • IBD
      • Chronic liver disease
      • Celiac disease
      • Pancreatitis
      • Allergy
      • Intestinal failure / short bowel syndrome
      • Eating disorders
      • Osteoporosis
      • Critical care
    • Nutrition and the lifecycle:
      • Growth and development
      • Pregnancy
      • Aging
      • Ethical considerations
    • Bariatric Medicine:
      • Physiology / gut hormones
      • Diet / medical / surgical therapy
      • Endoscopic therapy
      • NAFLD / NASH
    • Anatomy, physiology and pathology of the digestive system, including the pancreas and liver; with respect to intake and absorption of macronutrients and micronutrients
    • The principles of gastrointestinal surgery including the effect of operations on the gastrointestinal tract on patients’ nutritional status
    • Indications, contraindications and complications of enteral and total parenteral nutrition (e.g. refeeding syndromes, feeding tube complications, line sepsis and other metabolic problems)
    • Current methodologies for assessing nutritional status including biochemical parameters, subjective global assessment and the use of the metabolic cart
    • Various enteral products currently on the market, distinguishing characteristics of each and advantages / disadvantages of each preparation in various clinical situations
    • Controversial areas in the area of nutrition including hepatic encephalopathy, pre-operative feeding and terminal cancer
    • New advances in the management of nutritional disorders (e.g. organ transplantation, endoscopic feeding tube placement, growth factors, specialized nutritional supplements)
  2. Assess and investigate patients with nutritional compromise:
    • Establish a professional relationship and interact with patients
    • Perform a complete history and physical exam that is relevant, comprehensive and appropriate with particular emphasis on areas specific to patients with nutritional compromise
    • Select medically appropriate investigative methods in a resource-effective and ethical manner, including:
      • Laboratory investigations (bloodwork)
      • Imaging modalities (ultrasound, CT, MRI)
      • Tests commonly employed in GI function laboratories (breath tests, motility studies)
      • Upper GI endoscopy and colonoscopy
    • Use clinical databases appropriately to formulate problems and to correctly develop investigation and management plans
  3. Understand and appropriately respond to relevant ethical issues arising in the investigation and care of patients with common motility disorders
  4. Demonstrate the ability to perform advanced diagnostic and therapeutic endoscopy under supervision, including:
    • Percutaneous endoscopic gastrostomy (PEG)
    • PEG tube exchange

Communicator

Key Competencies: Physicians are able to

  1. Develop rapport, trust, and ethical therapeutic relationships with patients and families
  2. Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues, and other professionals
  3. Convey relevant information and explanations accurately to patients and families, colleagues and other professionals
  4. Develop a common understanding on issues, problems and plans with patients, families, and other professionals to develop a shared plan of care
  5. Convey effective oral and written information about a medical encounter

Specific Requirements: Gastroenterology residents are able to

  1. Establish effective relationship with patients and their families in order to obtain a meaningful history, conduct a relevant physical examination, and to properly manage a patient’s medical problem
  2. Convey information about diagnosis, prognosis, risks/benefits of tests and treatment options to patients and families and referring physicians accurately and effectively under supervision
  3. Communicate effectively with clinic staff and discuss appropriate information with all members of the health care team
  4. Effectively present verbal reports of clinical encounters and plans
  5. Compose succinct, accurate and comprehensive consultation letters, procedure reports and specialty test reports with appropriate support from the supervising consultant

Collaborator

Key Competencies: Physicians are able to

  1. Participate effectively and appropriately in an interprofessional health care team
  2. Work with other health professionals effectively to prevent, negotiate, and resolve interprofessional conflict

Specific Requirements: Gastroenterology residents are able to

  1. Appreciate the vital and diverse contributions from each of the nutrition care team members including physicians, specialized nurses and dieticians
  2. Develop a care plan for a patient, including investigation, treatment and continuing care, in collaboration with the members of the interdisciplinary nutrition care team
  3. Participate in an interdisciplinary nutrition care team meeting, demonstrating the ability to accept, consider and respect the opinions of other team members, while contributing expertise in the field of clinical nutrition and Gastroenterology
  4. Establish effective collaborations in clinical care, both within and between institutions

Manager

Key Competencies: Physicians are able to

  1. Participate in activities that contribute to the effectiveness of their health care organizations and systems
  2. Manage their practice and career effectively
  3. Allocate finite health care resources appropriately
  4. Serve in administration and leadership roles, as appropriate

Specific Requirements: Gastroenterology residents are able to

  1. Set priorities and manage time to balance patient care, practice requirements, outside activities and personal life
  2. Institute cost-effective management plans for patients with nutritional compromise by utilizing the available resources in both outpatient and inpatient settings
  3. Demonstrate good time management by assessing patients accurately, comprehensively and efficiently with timely dictation of consultation notes, procedure notes and / or subspecialty test reports

Health Advocate

Key Competencies: Physicians are able to

  1. Respond to individual patient health needs and issues as part of patient care
  2. Respond to the health needs of the communities that they serve
  3. Identify the determinants of health for the populations that they serve
  4. Promote the health of individual patients, communities, and populations

Specific Requirements: Gastroenterology residents are able to

  1. Understand the causes, consequences and prevalence of malnutrition in hospital inpatients and long-term health care facility residents
  2. Understand the funding and challenges of long-term nutritional therapy in Ontario
  3. Understand the determinants of health that may present as obstacles for patients with nutritional compromise to remain in the ambulatory setting
  4. Identify opportunities for advocacy, health promotion and disease prevention with the individual patients that they serve, including helping patients obtain Limited Use medications, preparing documents for patients (insurance, disability, application for medications or nutrition) that describe and outline the nature of the patient’s problem and the recommended treatments, and the use of screening and surveillance tests
  5. Understand the role of a gastroenterologist in advocating for patients’ access to care through private insurers, provincial formularies and wait lists
  6. Work with specialty societies and other associations to identify “at risk” groups (e.g. candidates for nutritional support) and apply available knowledge about prevention to “at risk” groups. Contribute “group data” for better understanding of health problems within the population (e.g. Canadian CNS Home PN Registry, Canadian Malnutrition Task Force [CMTF])

Scholar

Key Competencies: Physicians are able to

  1. Maintain and enhance professional activities through ongoing learning
  2. Critically evaluate medical information and its sources, and apply this appropriately to practice decisions
  3. Facilitate the learning of patients, families, students, residents, other health professionals, the public and others
  4. Contribute to the development, dissemination, and translation of new knowledge and practices

Specific Requirements: Gastroenterology residents are able to

  1. 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.
  2. Demonstrate efficiency and competence in searching, appraising and applying medical literature to address a clinical question
  3. Understand the role of research in advancing the understanding of nutritional disorders
  4. Demonstrate a willingness to teach others including patients, caregivers, students, trainees from other disciplines and allied health care professionals

Professional

Key Competencies: Physicians are able to

  1. Demonstrate a commitment to their patients, profession, and society through ethical practice
  2. Demonstrate a commitment to their patients, profession and society through participation in profession-led regulation
  3. Demonstrate a commitment to physician health and sustainable practice

Specific Requirements: Gastroenterology residents are able to

  1. Deliver highest quality care with honesty, integrity and compassion
  2. Exhibit appropriate personal and interpersonal professional behavior
  3. Be courteous and punctual
  4. Follow-up on patients evaluated and arrange additional investigations, as appropriate for patient problems
  5. Evaluate one’s own abilities, knowledge, skills and limitations of professional competence
  6. Demonstrate strategies to maintain and advance professional competence
  7. Recognize the roles, in clinical nutrition practice, of ethical issues such as consent, advanced directives, confidentiality, end-of-life care, conflict of interest, resource allocation and research ethics