Adult Gastroenterology Training Program

St. Joseph's Site Inpatient Rotation

Rotation-Specific Objectives

OVERVIEW

The St. Joseph’s Site offers a busy clinical Gastroenterology service with specialized interests in gastrointestinal motility and functional disorders. It also has a large endoscopy unit, including interventional endoscopy, ERCP, argon plasma coagulation and YAG-laser. As the hospital also provides regional and tertiary specialty services in respirology, rheumatology, nephrology and psychiatry, trainees gain exposure to gastrointestinal and nutritional aspects of behavioral, psychiatric and complex multisystem diseases, such as the cardiovascular and gastrointestinal complications of end-stage renal disease (and dialysis). Psychiatric patients also present complex biopsychosocial issues often requiring a thoughtful approach from consulting services. The presence of inpatient geriatric and rehabilitation services also present specific patient populations with particular needs. A large outpatient clinic allows the residents to experience not only inpatient consultation but also ambulatory care. Unique aspects of the outpatient experience reflect the expertise of the gastroenterologists at this site and include gastrointestinal neoplasia and laser therapy (Dr. Morgan), functional and motility disorders (Dr. Ganguli), and hepatology (Dr. Tsoi).

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 common GI problems in an adult tertiary care centre.

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 St. Joseph’s Site is usually responsible for 7-10 inpatients on the joint Gastroenterology-surgery ward (6th Floor, May Grace Wing). 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 week). 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 a multi-disciplinary meeting held on every Friday morning, 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 inpatients 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 provide a consultation service to the emergency room and 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 in-depth experience in common 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 Dr. S. Ganguli (Thursday 8:00 – 9:00 AM) and D. Morgan (Tuesday 8:00 – 9:00 AM), St. Joseph’s Gastroenterology Rounds (Friday 7:30 – 8:30 AM), St. Joseph’s Medical Grand Rounds (Wednesday 8:00 – 9:00 AM) and St. Joseph’s Combined GI Surgery/GI Medicine Rounds (Wednesday 4:30 – 5:30 PM). The resident’s educational activities will also include the regular ward rounds with the attending staff.

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 St. Joseph’s 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 St. Joseph’s 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 St. Joseph’s 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. 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.