Adult Gastroenterology Training Program

Clinical Nutrition Mini-Curriculum

Introduction

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).

Scope of Nutritional Practice

  1. The major clinical nutrition domains relevant to gastroenterologists include:
  2. 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,
  3. The placement of feeding tubes (e.g. gastrostomy or jejunostomy tubes, endoscopically or radiologically) in patients to provide access for enteral nutrition,
  4. 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,
  5. The management of obesity, non-alcoholic fatty liver disease and the sequelae of anti-obesity therapy

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)

Framework for Nutrition Training

The elements of the Nutrition Training Module are organized, in line with the CanMEDS framework, around seven roles: Medical Expert (Central Role), Communicator, Collaborator, Health Advocate, Manager, Scholar and Professional (RCPSC. Objectives of training and specialty training requirements in adult and pediatric gastroenterology. 2004).

Medical Expert
Communicator
Collaborator
Manager
Health Advocate
Scholar
Professional

Medical Expert / Clinical Decision Maker

General Requirements

  • Demonstrate diagnostic and therapeutic skills for ethical and effective care of the patient who may be nutritionally compromised
  • Access and apply relevant information to clinical nutrition practice
  • Demonstrate effective consultation services with respect to patient care, education, ethical and legal opinions

Specific Requirements

In keeping with their backgrounds in Internal Medicine and Gastroenterology, residents will demonstrate knowledge of:

  1. The anatomy, physiology and pathology of the digestive system, including the pancreas and liver; with respect to intake and absorption of macronutrients and micronutrients
  2. The principles of gastrointestinal surgery including the effect of operations on the gastrointestinal tract on patients’ nutritional status;
  3. New advances in the management of gastrointestinal disorders (e.g. organ transplantation, therapeutic endoscopy) in patients with nutritional compromise.

All residents will demonstrate the following clinical and technical skills:

  1. The ability to perform a complete history and physical exam that is relevant, sufficiently elaborate and appropriate with particular emphasis on areas specific to the patient with nutritional compromise;
  2. The selection, performance, and interpretation of tests commonly employed in gastrointestinal function laboratories (including breath tests and motility studies)
  3. The selection, performance and interpretation of endoscopic procedures, diagnostic and therapeutic, of the upper and lower gastrointestinal tract (including colonoscopy, upper endoscopy, sigmoidoscopy and percutaneous endoscopic gastrostomy)
  4. The ability to recognize, evaluate and manage medical emergencies including abdominal pain, liver failure, vascular thrombosis and occlusion and line-related sepsis, in patients with nutritional compromise;
  5. The ability to recognize the common disorders affecting adolescents in transition and their nutritional status (e.g. inflammatory bowel disease, celiac disease, cystic fibrosis, functional abdominal pain, hepatitis).

Communicator

General Requirements

  • Establish a therapeutic relationship with patients, families and caregivers of patients with nutritional compromise or eating disorders

Specific Requirements

  1. Understand and demonstrate the importance of cooperation and communication among health professionals (e.g.nurses, pharmacists, surgeons, radiologists, pathologists and clinical dietitians) involved in the care of individual patients with nutritional needs such that the roles of these professionals are delineated and consistent messages are delivered to patients and their families.
  2. Effectively provide information to healthcare organizations (including hospitals, CCACs and LIHNs), the general public and the media about areas of local concern in the discipline.

Collaborator

General Requirements

  • Consult effectively with other physicians and health care professionals

Specific Requirements

  1. Develop a care plan for a patient, including investigation, treatment and continuing care, in collaboration with the members of the interdisciplinary nutrition care team.
  2. 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.

Manager

General Requirements

  • Utilize information technology to optimize patient care, life-long learning and other activities

Specific Requirements

  1. Make clinical decisions and judgements based on sound evidence for the benefit of individual patients with nutritional compromise and the population served.
  2. Be able to work effectively as a member of a nutrition care team or a partnership and to accomplish tasks whether one is a team leader or a team member.

Health Advocate

General Requirements

  • Recognize and respond to nutritional issues for which advocacy is appropriate

Specific Requirements

  1. Demonstrate an understanding of health advocacy by identifying the patient's status with respect to determinants of nutritional health (i.e., unemployment); adapting the assessment and management accordingly (i.e., the medical history to the patient's social circumstances); and assessing the patient's ability to access various services in the health and social system.
  2. Work with specialty societies and other associations to identify current "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 CSCN Home PN Registry).

Scholar

General Requirements

  • Critically appraise sources of clinical nutritional information

Specific Requirements

  1. Recognize the importance of continuing medical education in clinical nutrition and demonstrate a willingness to teach others including patients, caregivers, students, trainees from other disciplines and allied health care personnel.
  2. Demonstrate knowledge of new advances in the management of nutritional disorders (e.g. organ transplantation, endoscopic feeding tube placement, growth factors, specialized nutritional supplements).

Professional

General Requirements

  • Deliver highest quality care with integrity, honesty and compassion
  • Practise medicine ethically consistent with obligations of a physician

Specific Requirements

  1. Demonstrate knowledge and comprehension of the professional, legal and ethical codes to which physicians are bound, with reference to nutritional care.
  2. 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.

Clinical Goals of the Nutrition Training Module

At completion of the GI Residency Program, the gastroenterology resident will:

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

Outline of the Nutrition Training Module

  1. There will be 4 formal 1-hour didactic teaching sessions (2 per year) during the academic half day to address:
    1. Nutritional assessment with particular reference to patients with gastrointestinal diseases
    2. The management of nutritionally compromised individuals by enteral nutrition
    3. The management of nutritionally compromised individuals by parenteral nutrition
    4. The management of nutritional issues related to inflammatory bowel disease, celiac disease, cystic fibrosis, liver disease, obesity, bariatric surgery, short bowel syndrome and eating disorders. .
  2. There will be one 1-hour introductory session on the principles of enteral and parenteral nutrition at the start of each academic year: this will be run by one or both of the registered Digestive Diseases Program dietitians ( Suzanne Hansen RD, Carol Rodrigues RD)
  3. There will be a 1-month longitudinal module that will occur during the second year of the GI Residency Program in conjunction with outpatient activities at the McMaster Site.
  4. The nutrition module may be combined, at the discretion of the Program Director and Nutrition Module supervisor (Dr. Armstrong), with other elective training modules.
  5. The major clinical nutrition opportunities will be:
    1. Weekly Rounds on a Monday afternoon (1300h-1600h) which will include:
      1. Inpatient nutrition rounds [MUMC] – Wards 4Y & 4Z [Digestive Diseases], 3Z [Hematology] and Adult ICU. (David Armstrong MD, Suzanne Hansen RD, Carol Rodrigues RD)
      2. Nutrition Topic Review presented by the Resident
    2. Weekly Ambulatory Care Nutrition Clinics on a Tuesday morning (0900h-1200h)
      1. 09:00-10:00 Digestive Diseases Program Dietitian (Carol Rodrigues, RD)
      2. 10:00-12:00 Home Parenteral Nutrition Clinic (Stella Stevens RN; Suzanne Hansen RD; David Armstrong MD)
        1. Outpatient Home Parenteral Nutrition Rounds – including review of current test result and clinical status for 25 patients managed by the HHS HPN Team
        2. Outpatient HPN patient evaluation – 1-2 patients weekly in 4V1 or 2F Ambulatory Care Clinics
    3. Weekly Inpatient Consultations for patients referred by inpatient services for evaluation of nutritional compromise (David Armstrong MD, Suzanne Hansen RD, Carol Rodrigues RD)
  6. There is an opportunity to participate in the weekly Adult Cystic Fibrosis Clinic at the MUMC site (Wednesday afternoon – 3Z; 13:00-16:30) and gain an understanding of the nutritional, gastrointestinal and hepatic sequelae of cystic fibrosis.
  7. There will be clinical research opportunities that should be reviewed with the Program Director, the Research Director and the Nutrition Module Director at the start of the year.

References

  1. Singh H, Duerksen DR. Survey of clinical nutrition practices of Canadian gastroenterologists. Can J Gastroenterol 2006;20:527-30.
  2. Heimurger DC, Intersociety Professional Nutrition Education Consortium (IPNEC). Training and certifying gastroenterologists as physician nutrition specialists. J Clin Gastroenterol 2002;34:505-8.
  3. Royal College of Physicians and Surgeons of Canada. Objectives of training and specialty training requirements in adult and pediatric gastroenterology. 2004 http://rcpsc.medical.org/residency/certification/training/gastroenterology_e.pdf (Accessed 3rd July 2007)