Beyond Fellowship…..Beyond Fellowship…..Seeking Additional TrainingSeeking Additional Training

GI Division RoundsGI Division Rounds

Brian Brauer, MDBrian Brauer, MD

February 14, 2006February 14, 2006

Who?Who?Should consider advanced Should consider advanced

training….training….

Primarily those with an interest in an Primarily those with an interest in an academic career when adequate exposure academic career when adequate exposure is not received during the standard is not received during the standard fellowship programfellowship program

A few other isolated instancesA few other isolated instances

What:What:

Advanced EndoscopyAdvanced Endoscopy

Transplant HepatologyTransplant Hepatology

IBDIBD

MotilityMotility

Other organ specific programs: Other organ specific programs: esophagus, pancreas, etc. “If there’s an esophagus, pancreas, etc. “If there’s an organ, Mayo has a program for it”organ, Mayo has a program for it”

Things to ConsiderThings to Consider

How to find programs: Is it a secret?How to find programs: Is it a secret?

Funding Funding

AccreditationAccreditation

ExperienceExperience

Additional responsibilitiesAdditional responsibilities

Time commitmentTime commitment

Application timetablesApplication timetables

Finding ProgramsFinding Programs

Most societies offer a list of programs that Most societies offer a list of programs that offer advanced trainingoffer advanced training

Most of these include all fellowship Most of these include all fellowship programs, not just those providing “third programs, not just those providing “third tier” trainingtier” training

Most lists are outdatedMost lists are outdated

Finding ProgramsFinding Programs

Resources:Resources:– Faculty in that areaFaculty in that area– Faculty that trained at highly subspecialized Faculty that trained at highly subspecialized

institutionsinstitutions– Other fellows that have appliedOther fellows that have applied– Journal classified adsJournal classified ads– Web searches (I found some programs on Web searches (I found some programs on

GoogleGoogle™ that weren’t listed elsewhere)™ that weren’t listed elsewhere)

Finding programsFinding programs

University of Southern California/LACMichael M. Kline,

MDMichael M. Kline,

MD Loren Laine, MD Loren Laine, MD

Scripps Clinic/Scripps Green HospitalWilliamson B. Strum,

MDWilliamson B.

Strum, MD   Martin Poleski, MD

Loma Linda University Medical CenterJohn McCracken,

MDJohn McCracken,

MD   Michael Walter, MD

University of California Health System (Davis)

Christopher Bowlus, MD

Christopher Bowlus, MD   John Lee, MD

University of California (Irvine)

Andrezej S. Tarnawski, MD

Andrezej S. Tarnawski, MD   Ken Chang, MD

University of California (San Francisco) Program

Jonathan P. Terdiman, MD

Jonathan P. Terdiman, MD   John Cello, MD

University of California (San Diego) Medical Center

John M. Carethers, MD

John M. Carethers, MD   Tom Savides, MD

Charles R. Drew University Medical Center

Ioannis Giannikopoulos, MD

Ioannis Giannikopoulos, MD    

COLORADO        

University of Colorado HSC Joel Levine, MD Joel Levine, MD Yang Chen, MD Yang Chen, MD

CONNECTICUT        

Bridgeport Hospital/Yale UniversityIngram M. Roberts,

MDIngram M. Roberts,

MD Harry Aslanian, MD Ingram Roberts, MD

Yale-New Haven Medical CenterDeborah D. Proctor,

MDDeborah D. Proctor,

MD   Mark Topazian, MD

FundingFunding

These are non-ACGME accredited These are non-ACGME accredited fellowships: most GME departments don’t fellowships: most GME departments don’t fund the positionfund the positionMany provide no salaryMany provide no salaryFor funded programs, it is important to find For funded programs, it is important to find out where the funding is derived, and what out where the funding is derived, and what additional responsibilities are incurred to additional responsibilities are incurred to support the funding (endoscopy, consult support the funding (endoscopy, consult services)services)

AccreditationAccreditation

CAQ: ABIM Certificate of Added CAQ: ABIM Certificate of Added Qualification for transplant hepatology, Qualification for transplant hepatology, single day examination beginning single day examination beginning November 2006November 2006

Other specialties are more subjective and Other specialties are more subjective and rely on program directors’ determination of rely on program directors’ determination of competence and procedure experiencecompetence and procedure experience

ExperienceExperience

Does the program offer training in everything Does the program offer training in everything you desire?you desire?Is there adequate procedural experience/ patient Is there adequate procedural experience/ patient exposure?exposure?How much time is spent doing research or non-How much time is spent doing research or non-patient care activities?patient care activities?Program philosphy: in advanced endoscopy, Program philosphy: in advanced endoscopy, some are “purists” who don’t believe it is some are “purists” who don’t believe it is possible to become truly proficient in both ERCP possible to become truly proficient in both ERCP and EUSand EUS

Additional ResponsibilitiesAdditional Responsibilities

Is there significant or unnecessary call?Is there significant or unnecessary call?

Are there responsibilities outside your Are there responsibilities outside your specified area of training (general specified area of training (general GI/endoscopy, general medicine GI/endoscopy, general medicine responsibilities)responsibilities)

Are these activities required to fund your Are these activities required to fund your position?position?

Time CommitmentTime Commitment

Weekend/call responsibilitiesWeekend/call responsibilitiesWork hoursWork hoursCan you complete the training you want in the Can you complete the training you want in the allotted amount of time?allotted amount of time?If a program focuses on one area, is there the If a program focuses on one area, is there the opportunity to learn others-i.e. “If I spend a year opportunity to learn others-i.e. “If I spend a year learning ERCP, can I stay a 2learning ERCP, can I stay a 2ndnd year to learn year to learn EUS?”EUS?”If there is a research requirement, is there If there is a research requirement, is there protected time?protected time?

Application timetablesApplication timetables

Think about your ultimate goals when planning Think about your ultimate goals when planning research time and projectsresearch time and projectsYou should generally start obtaining information You should generally start obtaining information and securing letters 18-24 months before and securing letters 18-24 months before anticipated start dateanticipated start dateNo uniform application timetable, more No uniform application timetable, more competitive programs tend to start earliercompetitive programs tend to start earlierThere is no harm in contacting a program early There is no harm in contacting a program early to inquire about their application process, to inquire about their application process, especially in the era of e-mailespecially in the era of e-mail

EndoscopyEndoscopy

EndoscopyEndoscopy

Duration: 1 year, may include ERCP, EUS, Duration: 1 year, may include ERCP, EUS, or bothor both

Aliases: Advanced Endoscopy, Aliases: Advanced Endoscopy, Interventional Endoscopy, Therapeutic Interventional Endoscopy, Therapeutic Endoscopy, Biliary Endoscopy, Endoscopy, Biliary Endoscopy, Pancreaticobiliary EndoscopyPancreaticobiliary Endoscopy

What is an “advanced” procedure?What is an “advanced” procedure?

ERCP and all interventionsERCP and all interventionsEUSEUSDilation of complicated esophageal stricturesDilation of complicated esophageal stricturesLaparoscopyLaparoscopyLuminal stentsLuminal stentsPDTPDTLaser therapyLaser therapyMucosectomyMucosectomyEndoscopic tumor ablationEndoscopic tumor ablation

ASGE, ASGE, 20062006

What Constitutes Advanced What Constitutes Advanced Training?Training?

The American Society for Gastrointestinal Endoscopy (ASGE) has The American Society for Gastrointestinal Endoscopy (ASGE) has proposed that “more complex diagnostic and therapeutic procedures proposed that “more complex diagnostic and therapeutic procedures are used less frequently than standardized procedures and are are used less frequently than standardized procedures and are more likely to have complications. Therefore, their successful more likely to have complications. Therefore, their successful performance requires fewer endoscopists with more skill and performance requires fewer endoscopists with more skill and experience, gathered during a longer training period. It is not experience, gathered during a longer training period. It is not possible for all training programs to teach all endoscopic procedures possible for all training programs to teach all endoscopic procedures to all fellows, nor is it necessary for optimal patient care. Acquisition to all fellows, nor is it necessary for optimal patient care. Acquisition of advanced skills by selected fellows seeking such experience of advanced skills by selected fellows seeking such experience usually requires an additional period of training, often for one year usually requires an additional period of training, often for one year after fellowship.”after fellowship.”

Principles of Training in Gastrointestinal Endoscopy. Manchester, Massachusetts: The American Society for Principles of Training in Gastrointestinal Endoscopy. Manchester, Massachusetts: The American Society for Gastrointestinal Endoscopy, February 1998. Gastrointestinal Endoscopy, February 1998.

ERCP RequirementsERCP Requirements

ERCP: 180-200 procedures recommended, at least 50% ERCP: 180-200 procedures recommended, at least 50% with a therapeutic component (sphincterotomy, stone with a therapeutic component (sphincterotomy, stone extraction, lithotripsy, stricture dilation, stent placement, extraction, lithotripsy, stricture dilation, stent placement, cholagioscopy/pancreatoscopy)cholagioscopy/pancreatoscopy)– Cases in which native anatomy is altered (prior sphincterotomy, Cases in which native anatomy is altered (prior sphincterotomy,

routine stent change) excludedroutine stent change) excluded– Cannulation of desired duct with >80% success rateCannulation of desired duct with >80% success rate

Jowell et all showed 180 as the minimum for Jowell et all showed 180 as the minimum for competence, success rate approached 90% with 200+ competence, success rate approached 90% with 200+ proceduresprocedures

ASGE 2006ASGE 2006Jowell et al., Ann Int Jowell et al., Ann Int

Med 1996Med 1996

ERCP RequirementsERCP Requirements

Kowalski et al showed in a survey of graduating Kowalski et al showed in a survey of graduating GI fellows, 69 completed survey, 36% of fellows GI fellows, 69 completed survey, 36% of fellows achieved 80% success rate and appropriate achieved 80% success rate and appropriate comfort level for performing sphincterotomy, comfort level for performing sphincterotomy, 64% did not achieve competence, 33% reported 64% did not achieve competence, 33% reported inadequate ERCP training, yet 91% responded inadequate ERCP training, yet 91% responded they expected to perform ERCP’s unsupervised they expected to perform ERCP’s unsupervised following trainingfollowing training

Kowalski et al., GIE 2003Kowalski et al., GIE 2003

Endoscopic Ultrasound (EUS)Endoscopic Ultrasound (EUS)

Trainess should be skilled Trainess should be skilled in diagnostic in diagnostic endosonography prior to endosonography prior to undertaking interventional undertaking interventional aspects of EUS such as aspects of EUS such as FNAFNAASGE guidelines are ASGE guidelines are outdated, much has outdated, much has evolved since they were evolved since they were created in 1999created in 1999Van Dam J et al. GIE 1999;49:829-33Van Dam J et al. GIE 1999;49:829-33

Faigel D et al. Ensuring Competetency in Endoscopy. ASGE/ACG 2005.

EUS Trainee RequirementsEUS Trainee Requirements

1. Perform EUS based upon findings from a personalconsultation/evaluation and consideringother diagnostic and therapeutic alternativesavailable as well as understanding the risksand complications of the procedure.2. Perform the procedure in a safe and efficientmanner.3. Interpret most EUS findings for a variety ofindications.4. Recognize and manage complications related tothe procedure.

Van Dam J et al. GIE 1999;49:829-33Van Dam J et al. GIE 1999;49:829-33

ERCP Trainee RequirementsERCP Trainee RequirementsTrainees who are seeking to acquire skills in advanced endoscopic training must Trainees who are seeking to acquire skills in advanced endoscopic training must have completed standard endoscopy training during an approved GI fellowship (or have completed standard endoscopy training during an approved GI fellowship (or equivalent training) and have documented competence in general routine (i.e., not equivalent training) and have documented competence in general routine (i.e., not advanced) endoscopic procedures. advanced) endoscopic procedures. The trainee must devote a substantial portion of his/her advanced endoscopic The trainee must devote a substantial portion of his/her advanced endoscopic training to developing skills in the cognitive as well as technical component of training to developing skills in the cognitive as well as technical component of procedures, including understanding the appropriate indications for, as well as the procedures, including understanding the appropriate indications for, as well as the contraindications to, performing these procedures. They should be taught to contraindications to, performing these procedures. They should be taught to manage patients through all aspects of their endoscopic care with particular manage patients through all aspects of their endoscopic care with particular emphasis on pre and post procedure evaluation as well as managing procedure-emphasis on pre and post procedure evaluation as well as managing procedure-related complications that may occur. The trainee should have the ability to explain related complications that may occur. The trainee should have the ability to explain the procedure to the patient, including obtaining informed consent. the procedure to the patient, including obtaining informed consent. Trainees are required to maintain a log of all advanced therapeutic procedures Trainees are required to maintain a log of all advanced therapeutic procedures performed under supervision to document indications, specific procedure(s) performed under supervision to document indications, specific procedure(s) performed and complications to enable them to document comparison of their performed and complications to enable them to document comparison of their findings with an objective standard. findings with an objective standard. Advanced procedure trainees are expected to perform clinical research and/or Advanced procedure trainees are expected to perform clinical research and/or scholarly activities related to advanced therapeutic endoscopy and develop skills scholarly activities related to advanced therapeutic endoscopy and develop skills to prepare them to become teachers of endoscopy. to prepare them to become teachers of endoscopy.

ASGE, ASGE, 20062006

Advanced Endoscopy Program Advanced Endoscopy Program RequirementsRequirements

focus clinical responsibilities so as to enable the trainee to develop an focus clinical responsibilities so as to enable the trainee to develop an approach to the patient requiring therapeutic/interventional endoscopy, approach to the patient requiring therapeutic/interventional endoscopy, understand appropriate indications for advanced procedures, perform understand appropriate indications for advanced procedures, perform pre- and post-endoscopic evaluations, and manage procedure-related pre- and post-endoscopic evaluations, and manage procedure-related complications; complications; limit outpatient responsibilities (not related to therapeutic endoscopy) to limit outpatient responsibilities (not related to therapeutic endoscopy) to no more than one half-day per week; no more than one half-day per week; minimize time performing “routine” consults; minimize time performing “routine” consults; create an environment with an emphasis on endoscopic research; create an environment with an emphasis on endoscopic research; provide time and facilities (amounting to at least 30% of effort) for provide time and facilities (amounting to at least 30% of effort) for “academic pursuits” (e.g. designing/writing research protocols, attending “academic pursuits” (e.g. designing/writing research protocols, attending courses in statistics, epidemiology, study design, writing original papers courses in statistics, epidemiology, study design, writing original papers and reviews under the supervision of senior staff, etc.); and reviews under the supervision of senior staff, etc.); provide advanced trainees with the time and funds to attend at least one provide advanced trainees with the time and funds to attend at least one scientific meeting per year—preferably one related to therapeutic scientific meeting per year—preferably one related to therapeutic endoscopy; endoscopy; provide an exposure to endoscopy unit management (scheduling, provide an exposure to endoscopy unit management (scheduling, staffing, equipment maintenance, management skills, etc.) staffing, equipment maintenance, management skills, etc.)

Where to find programsWhere to find programs

EUS programs: EUS programs: http://www.asge.org/pages/education/training/eus.cfmhttp://www.asge.org/pages/education/training/eus.cfm– This is a list of all programs that offer some degree of This is a list of all programs that offer some degree of

EUS training, not all are 4EUS training, not all are 4thth year programs, but does year programs, but does provide a description and funding statusprovide a description and funding status

ERCP/combined programs: list available from ERCP/combined programs: list available from ASGE but includes all programs, not just 4ASGE but includes all programs, not just 4 thth year year– AGA Program Directors’ website lists some programs AGA Program Directors’ website lists some programs

that offer advanced endoscopy, but is very outdatedthat offer advanced endoscopy, but is very outdated

Other things to find out:Other things to find out:

If a program offers training in both ERCP If a program offers training in both ERCP and EUS, it is important to know if some and EUS, it is important to know if some faculty members do both proceduresfaculty members do both procedures– Programs in which some faculty do both Programs in which some faculty do both

procedures tend to be more innovativeprocedures tend to be more innovative

Transplant HepatologyTransplant Hepatology

Transplant HepatologyTransplant Hepatology

Usually 1 yearUsually 1 year

Probably the most recognized sub-Probably the most recognized sub-subspecialty in GIsubspecialty in GI

ABIM Certificate of Added Qualification ABIM Certificate of Added Qualification slated to begin in November 2006slated to begin in November 2006

In preparation, the American Society for In preparation, the American Society for Transplantation and AASLD have Transplantation and AASLD have recommended a standardized curriculumrecommended a standardized curriculum

Training Program RequirementsTraining Program Requirements

1. The transplant program must be United Network for Organ Sharing (UNOS)-approved (or Canadian equivalent), in good standing as a liver transplant program, and be affiliated with an ACGME approved gastroenterology training program.

2. The transplant program must perform at least 30 liver transplantations per year or 20 transplantations per year for each liver transplant fellow to be trained.

3. The program must have a full-time faculty member or members capable of teaching a curriculum with a broad base of knowledge in transplant medicine and hepatology. At least one faculty member

must be a fully trained hepatologist, defined by the Task Force on Training in Hepatology.

Rosen H et al. Liver Transplantation 2002;8:85-7.

Training Program RequirementsTraining Program Requirements

The medical director of the program must have recognized expertise in liver diseases, including ongoing productivity

in clinical or basic research related to liver diseases and transplantation. The program must provide patient comanagement responsibility with transplant surgeons from the preoperative phase to the outpatient period. The program must provide training in the indications for, performance of, and interpretation of liver transplant biopsies. Furthermore, the program must provide didactic experi-ence with the trainee reviewing liver transplant biopsy specimens with an experienced liver transplant pathologist.

Rosen H et al. Liver Transplantation 2002;8:85-7.

Training Program RequirementsTraining Program Requirements4. The curriculum designed by the training program director should follow the guidelines summarized next and must include training and experience in end-stage liver disease; training in the selection of appropriate transplantation recipients and donors (cadaveric and living), including ethical issues; understanding of surgical procedures; and experience in the immediate and long-term medical care of the transplant recipient (e.g., recurrent disease). Additionally, there must be an emphasis on the management of immunosuppressive agents (including pharmacokinetics and drug-drug interactions) and evaluation of liver allograft dysfunction. It is strongly recommended that the didactic section of the program follow the AST’s Primer on Transplantation.5. The program must have a close working affiliation with an interventional radiology program experienced in the broad range of interventions pertinent to the management of hemodynamic, vascular, and biliary problems occurring in end-stage liver disease and transplant recipients.6. The liver transplant fellowship program must provide training in living donor transplantation. If such training is not available on site, the program must provide the fellow with travel and accommodation to gain this experience. Specifically, a multidisciplinary approach to issues in donor selection and evaluation and recipient criteria in a well established program are recommended.

Rosen H et al. Liver Transplantation 2002;8:85-7.

Requirements for TraineesRequirements for Trainees

Must meet level 1 and 2 training requirements per AGA Must meet level 1 and 2 training requirements per AGA core curriculum in Hepatology before or during training core curriculum in Hepatology before or during training period:period:The minimum requirement for level 2 training includes the The minimum requirement for level 2 training includes the

preparation of the individual to diagnose and manage all types of preparation of the individual to diagnose and manage all types of liver disease, acquisition of the procedural skills listed below, liver disease, acquisition of the procedural skills listed below, and proficiency in performing liver consultations. In addition, and proficiency in performing liver consultations. In addition, experience in the evaluation of patients for liver transplantation experience in the evaluation of patients for liver transplantation is essential. It is assumed that to meet these criteria, at least 18 is essential. It is assumed that to meet these criteria, at least 18 months of training will be devoted to training in hepatology. This months of training will be devoted to training in hepatology. This could be completed during the 3-year fellowship in could be completed during the 3-year fellowship in gastroenterology or necessitate a fourth year of training devoted gastroenterology or necessitate a fourth year of training devoted to hepatology. Two of the months must be spent on a liver to hepatology. Two of the months must be spent on a liver transplant service. transplant service.

Rosen H et al. Liver Transplantation 2002;8:85-Rosen H et al. Liver Transplantation 2002;8:85-7.7.

AGA Core Curriculum, 1996.AGA Core Curriculum, 1996.

Requirements for TraineesRequirements for Trainees(In addition to meeting level 1 & 2 training requirements)(In addition to meeting level 1 & 2 training requirements)

1. The trainee must have at least 1 year of specialized training in liver transplantation under the direct supervision of a qualified (UNOS-certified) transplant hepatologist and in conjunction with a liver transplant surgeon at a UNOS-approved (or Canadian equivalent) liver transplant center. The 12 months of training would preferably be contiguous, but must consist of a minimum of 4 months on the clinical inpatient adult liver transplant service, with weekly continuity clinic for the 12 months. The remaining months should consist of other hepatology or transplant-related experience, including involvement in basic or clinical transplant research.

Requirements for TraineesRequirements for Trainees2. The trainee must be thoroughly acquainted in principle and practice with the management of patients with acute and chronic end-stage liver disease.This will include the following criteria: (a)Experience in the comprehensive management of patients at high listing status in the intensive care setting, with complications including refractory ascites and hepatic hydrothorax, hepatorenal syndrome, hepatopulmonary and portopulmonary syndromes, and refractory portal hypertensive bleeding. A detailed familiarity with the principles and application of transjugular intrahepatic portosystemic shunts is essential.

(b) The diagnosis and management of hepatocellular carcinoma and cholangiocarcinoma, including transplantation, nontransplantation surgical, and nonsurgical approaches.

(c) The management of chronic viral hepatitis in the pretransplantation, peritransplantation, and posttransplantation settings.

(d) The management of fulminant liver failure, including principles of intracranial pressure monitoring. (e) The psychosocial evaluation of all candidates, in particular, those with a history of substance

abuse. (f ) A working knowledge of transplant immunology, including blood group matching, histocompatibility

and tissue typing, and infectious and malignant complications of immunosuppression. (g) Drug hepatotoxicity and the interaction of drugs and the liver. (h) Nutritional support of patients with chronic liver disease. (i) Use of interventional radiology in the diagnosis and management of portal

hypertension, as well as biliary and vascular complications.(j) Ethical considerations relating to liver transplant donors, including questions related to living

donors, non–heart-beating donors, criteria for brain death, and appropriate recipients.

Requirements for TraineesRequirements for Trainees

3. The trainee must be involved in the primary evaluation, presentation, and discussion at selection conferences of 20 or more potential transplant candidates.

4. The trainee must follow up at least 20 new liver transplant recipients for a minimum of 3 months from the time of their transplantation. The trainee will be directly supervised in the evaluation and management of patients from the preoperative to outpatient period. The liver transplantation trainee must actively participate in transplant recipients’ medical care, including acute cellular rejection, recurrent disease, infectious diseases, and biliary tract complications. Furthermore, the trainee must serve as a primary member of the transplantation team and participate in making decisions about immunosuppression.

Requirements for TraineesRequirements for Trainees

5. The trainee must be involved in the follow-up of 30 or more liver transplant recipients who have survived more than 1 year after liver transplantation to gain familiarity and expertise with the management of common long-term problems (e.g., cardiovascular disease, nephrotoxicity, screening for malignancies, and diagnosis and treatment of recurrent disease).

6. The trainee must understand the indications, contraindications, complications, and interpretation of allograft biopsies and must perform a minimum of 30 percutaneous biopsies during the training period. The trainee also should be familiar with the appropriate use of ultrasound-localized and laparoscopy-guided liver biopsies.

7. The trainee must acquire a current working knowledge of the organizational and logistical aspects of liver transplantation, including the training and role of nurse coordinators and other support staff (e.g., social work), organ procurement, and UNOS policies.

Requirements for TraineesRequirements for Trainees8. The trainee must participate as an observer in three cadaveric liver procurements and

three liver transplantations. The trainee is expected to learn the principles of donor selection and rejection (e.g.,hemodynamic management, donor organ steatosis,and indication for liver biopsy).

9. The trainee should be exposed to the evaluation of at least five adult-to-adult living donor liver transplantations, even though this procedure is not available in the current training program (see trainingprogram requirements). During this experience, the trainee must become familiar with the principles of living donor selection, including appropriate surgical, psychosocial, and ethical considerations.

10. The trainee must become familiar with the following factors: (a) principles and practice of pediatricliver transplantation, (b) principles and application of artificial liver support, and (c) clinical research issues in transplant hepatology.

Rosen H et al. Liver Transplantation 2002;8:85-7.Rosen H et al. Liver Transplantation 2002;8:85-7.

Where to Find ProgramsWhere to Find Programs

AASLD provides a list of programs, this list AASLD provides a list of programs, this list includes all liver transplant programsincludes all liver transplant programs

https://www.aasld.org/eweb/DynamicPagehttps://www.aasld.org/eweb/DynamicPage.aspx?Site=AASLD3&WebKey=f4c4c8ab-.aspx?Site=AASLD3&WebKey=f4c4c8ab-0ed2-4d70-9ab2-c03458f668a90ed2-4d70-9ab2-c03458f668a9

Does give listing of volume and fellowship Does give listing of volume and fellowship slotsslots

Other ResourcesOther Resources

Inflammatory Bowel DiseaseInflammatory Bowel Disease

Inflammatory Bowel DiseaseInflammatory Bowel Disease

Duration: 1-2 years depending on Duration: 1-2 years depending on research requirementresearch requirement

Less structured and regulated than other Less structured and regulated than other advanced training programsadvanced training programs

Core Curriculum GuidelinesCore Curriculum Guidelines

Training Process:Training Process:Unlike many other consultative aspects of gastroenterology, the Unlike many other consultative aspects of gastroenterology, the trainee should be able to assume responsibility for both inpatients trainee should be able to assume responsibility for both inpatients and outpatients with IBD and related disorders, encompassing their and outpatients with IBD and related disorders, encompassing their diagnoses, acute and chronic therapies, long-term follow-up, and diagnoses, acute and chronic therapies, long-term follow-up, and counseling of the families and/or significant others. Adequate counseling of the families and/or significant others. Adequate experience should include exposure to hospitalized as well as experience should include exposure to hospitalized as well as ambulatory patients as well as the initial assessment and ambulatory patients as well as the initial assessment and longitudinal management of patients with IBD, particularly in the longitudinal management of patients with IBD, particularly in the ambulatory setting, under the supervision of a skilled attending ambulatory setting, under the supervision of a skilled attending physician.physician.

AGA Core Curriculum, 1996.AGA Core Curriculum, 1996.

Core Curriculum GuidelinesCore Curriculum Guidelines

Assessment of Competence:Assessment of Competence:

Knowledge of the gastrointestinal inflammation Knowledge of the gastrointestinal inflammation curriculum should be assessed as part of the overall curriculum should be assessed as part of the overall evaluation of the trainee in gastroenterology during and evaluation of the trainee in gastroenterology during and after the fellowship, as outlined by the Task Force on after the fellowship, as outlined by the Task Force on Overview of Training in Gastroenterology. No specific Overview of Training in Gastroenterology. No specific examination or other instrument of assessment need be examination or other instrument of assessment need be developed for this portion of the training.developed for this portion of the training.

AGA Core Curriculum, 1996.AGA Core Curriculum, 1996.

Help is on the way….Help is on the way….

Other SubspecialtiesOther Subspecialties

Other ProgramsOther Programs

MotilityMotilityOther organ-specific subspecialtiesOther organ-specific subspecialtiesUsually one year or lessUsually one year or lessNo standardized training guidelines, but No standardized training guidelines, but recommended minimal experience for recommended minimal experience for interpretation of motility studies existinterpretation of motility studies existMany of these such programs are Many of these such programs are “unofficial” or “informal” fellowships “unofficial” or “informal” fellowships consisting of a few months trainingconsisting of a few months training

MotilityMotility

AGA Core Curriculum

Where to Find ProgramsWhere to Find Programs

Mainly word of mouth: ask the experts in Mainly word of mouth: ask the experts in the area of interestthe area of interest

SummarySummary

There is wide variation in structure and and There is wide variation in structure and and philosophy or advanced training programsphilosophy or advanced training programs

Start early if you’re interestedStart early if you’re interested

Ask around, get the “inside scoop”Ask around, get the “inside scoop”

Determine your career goals prior to applying, Determine your career goals prior to applying, this may ultimately help with fundingthis may ultimately help with funding

Select a program that will provide the training Select a program that will provide the training you want; don’t go to a program expecting you want; don’t go to a program expecting training in an area it doesn’t claim to providetraining in an area it doesn’t claim to provide