Division of Digestive and Liver Diseases. Fellowship Resource Manual. Policies, Procedures, and Curriculum. Fellowship Directors:

Transcription

1 Division of Digestive and Liver Diseases Fellowship Resource Manual Policies, Procedures, and Curriculum Fellowship Directors: Amit Singal, M.D. Arjmand Mufti, M.D. Rozy Mithani, M.D. Program Director Associate Program Director Associate Program Director Program Administration: Debra Riggs Tonya Crews Education Coordinator Education Coordinator Fellowship Site Directors: Christian Mayorga, M.D. Robert D Schmidt, M.D. Rajiv Jain, M.D. Rozy Mithani, M.D. Parkland Memorial Hospital Dallas VA Medical Center Texas Health Resources Presbyterian Hospital of Dallas Clements University Hosptial

2 Table of Contents 1. Program Description 1.1 Goals and Objectives 1.2 Our Values 1.3 Elements of the Program 1.4 Supervision Policy 1.5 Hand-off Policy 1.6 Faculty Responsibilities 2. General Policies 2.1 Services 2.2 General Conduct Consults Procedures Rounding on Inpatients 2.3 Role of Housestaff 2.4 Role of Advanced Practic Practitioners 3. Rotations and Training Sites 3.1 Parkland Memorial Hospital (PHHS) Parkland GI Consult Service Parkland Endoscopy Unit Parkland Liver Consults Advanced Endoscopy/Biliary Parkland Ambulatory Parkland Continuity Clinic 3.2 Dallas VA Medical Center (VA) VA GI Consult Service VA Endoscopy Unit VA Liver Fellow VA Ambulatory VA Continuity Clinic VA Research Elective 3.3 Texas Health Resources Presbyterian Hospital of Dallas (THR) 3.4 Clements University Hospital Services (CUH) CUH GI Consult and Inpatient Service CUH Liver Service Hospitalist Coverage of Liver and GI Services CUH Ambulatory Rotation 3.5 Zale Lipshy University Hospital Consult Service (ZL) 3.6 Electives Research Pathology Pediatric GI Radiology GI Surgery Liver Transplantation External Electives 4. Requirements for Endoscopic Competency 4.1 Endoscopy Training Objectives 4.2 Procedures 2

3 4.3 Endoscopy for Surgery Residents 5. Educational Conferences 5.1 Attendance 5.2 GI/Liver Conferences at UTSW Core Curriculum Visiting Professors Lectures UTSW GI and Liver Pathology UTSW Radiology Conference Case Presentations Fellow State of the Art Talks Morbidity and Mortality Joint Pediatric Adult/GI Liver Symposium Fellow/Faculty Development Sessions 5.3 Additional Conferences Outside of Monday/Wednesday Series Hepatocellular Carcinoma Conference GI Malignancy Conference Obesity and Nutrition Conference Ethics Grand Rounds Internal Medicine Grand Rounds Liver Transplant Selection Committee Meeting Liver Conference 5.4 GI/Liver Conferences at the Dallas VA Hospital VA GI Pathology Conference VA Journal Club GI-Surgery Conference 6. Scholarly Activity 6.1 Expectations Clinical Track Fellow Expectations Faculty Expectations Expectations for T32 Research Fellows 6.2 Documentation of Published Research 6.3 Timeline of Expected Research Activities and Presentation of Data First Year Second Year Third Year 6.4 Benchmarks 6.5 Sources of Support 7. Feedback and Evaluations 7.1 Fellow Evaluations 7.2 Faculty Evaluations 7.3 Program Evaluations 8. Educational Funds 8.1 Travel Policies 8.2 Reimbursements 8.3 Book Allowance 9. Duty Hour Limits 3

4 10. Administrative Contact 11. Mail 12. Compensation and Insurance 13. Parking 14. Pagers 15. Dress Code 15.1 Lab Coats 16. Media Services 17. Vacation/House Staff FMLA 18. Resident Wellness 18.1 Sleep and Deprivation 18.2 Fellow Safety 19. Fellow Jeopardy (emergency backup coverage) system 20. Fellow Training 20.1 Licensure 20.2 ACLS 20.3 Moderate Sedation 20.4 Research CITI 21. Professional Societies 22. Moonlighting 23. Personal Data 24. Administrative Responsibilities 25. Professionalism/Other Appendices I Faculty Contact information II Fellow Contact information III Handbook Attestation IV Important Websites V UTSW Patient Care Priniciples and Professional Standards VI CUH Subspecialty and Hospitalist Call VII CUH Important Phone Numbers 4

5 1. Program Description 1.1 Goals and Objectives Goals Prepare exceptional physicians for successful careers in gastroenterology and hepatology Educate fellows to become leaders in clinical and basic research Offer comprehensive training comprised of clinical teaching, didactic instruction, and structured mentoring Foster a culture of collaboration and reflective learning Create an educational environment in which the well-being and professional development of our fellows are highly valued Maintain a system of patient care that prioritizes efficiency and patient satisfaction Objectives Understand management of a variety of GI disorders in hospitalized and ambulatory patients Know indications, contraindications, and complications of common GI procedures Gain technical expertise for basic diagnostic and therapeutic endoscopic procedures Learn the role of the consultant as part of the management team 1.2 Our Values Compassion, Collaboration, and Communication The values that distinguish exceptional physicians from good ones are the same values that are critical to creating a culture of excellence in our fellowship program. Compassion: Fostering compassion in the workplace improves the learning environment for fellows and results in better patient care. Collaboration: Seamless collaboration between faculty, fellows and other team members is a critical component to delivering exceptional medical care and aids fellow learning. Communication: With the twin goals of patient care and fellow education, candid two-way communication between faculty and fellows is of paramount importance. Competencies (including ACGME milestones): 1. Scholarly activity Trainees must participate in scholarly activity, whether it be patient-oriented, basic science research, or medical education development. 2. Education Trainees are active participants in educating medical students, housestaff and junior fellows. Fellows who wish to pursue a career as a clinical educator should develop expertise in being an effective teacher. 3. Patient care Trainees must be able to provide patient care that is appropriate, effective and compassionate, including, but not limited to, history taking and performing a comprehensive and accurate physical examination. Trainess should be able to arrive at an appropriate differential diagnosis, outline a logical plan for targeted investigations pertaining to the patient s complaints, formulate a plan for management of the patient, and defend their clinical assessment and management plan. Trainees should take ownership of the care for their assigned patients and follow through with 5

6 results of tests and ensure appropriate follow up. In addition, trainees should demonstrate procedural skills essential for gastroenterology. 4. Medical knowledge Our expectation is that each fellow is self-motivated to learn, and plays an important role in taking on the responsibility for his/her own education. Trainees must demonstrate a core fund of knowledge in gastroenterological and hepatic physiology, pathophysiology, clinical pharmacology, radiology, and surgery. Trainees must be able to demonstrate an analytic approach and use appropriate investigations, including the practice of evidence-based medicine. 5. Practice-based learning and improvement Trainees must be able to investigate, evaluate, and improve their patient care practice by analyzing and assimilating scientific evidence and their experience in patient care. They are trained in evidence-based medicine and they should apply knowledge of statistical methods to critically appraise clinical studies as well as use information technology to support their education. 6. Interpersonal and communication skills Trainees must be able to demonstrate interpersonal and communication skills that result in effective information exchange with patients, families, and health care professionals. This includes, but is not limited to, verbal and written communication as a consultant; generation of endoscopic reports that are accurate, timely, and support patient care; as well as hand-offs of patient care. Communication with others must be courteous, helpful, respectful, and prompt, whether verbal, written, or electronic. Trainees must be able to work effectively as members and leaders of the health care team. 7. Professionalism Trainees must demonstrate commitment to all elements of professionalism, including respect, compassion, integrity, and responsiveness toward patients, families, and other health care professionals. Conscientiousness should be exhibited in all professional responsibilities, including patient care as well as regulatory, educational, and administrative requirements. 8. Systems-based practice Trainees must demonstrate an understanding of and responsiveness to the larger context of health care delivery. Trainees should understand how their patient care practice impacts other health care professionals, larger health care systems, and society. They should be able to practice cost-effective care without compromising quality of care for their patients. The trainee should be able to advocate for timely, quality care and know how to partner with other health care providers to provide optimal health care for patients. Trainees should participate in quality improvement initiatives. 1.3 Elements of the Program Clinical Training - The UT Southwestern fellowship program provides exposure to a diverse patient population encompassing a wide range of problems of the gastrointestinal tract and liver. Fellows are involved in care of hospitalized and ambulatory patients. Trainees learn to care for patients as a consultant as well as primary caregiver of patients requiring inpatient management. Fellows are leaders of the GI service at each site. The expectation is for trainees to learn through focused patient care and by educating colleagues, residents and students. The fellow must know pertinent history and physical findings for each patient, formulate a differential diagnosis, and provide succinct recommendations for diagnostic studies and therapeutic interventions. This should occur before discussing the patient with faculty during rounds, particularly if the patient is presented by house-staff. During rounds, key areas are covered in detail, providing fellows with an opportunity to gain further clinical experience though discussion with faculty. Endoscopic Training - Fellows learn to perform endoscopic procedures on patients under direct supervision of faculty. Endoscopic training is provided in diagnostic and therapeutic procedures such as EGD and colonoscopy. Although trainees are exposed to advanced endoscopy such as EUS and ERCP, competency will not be achieved within the standard 3-year fellowship program. UT Southwestern has an advanced endoscopy Fellowship program that allows 4 th year Fellows to perform the bulk of ERCP and EUS procedures. 6

7 Medical Education - The program provides an intellectual environment for acquiring knowledge, skills, clinical judgment, attitudes, and values of professionalism. The curriculum includes learning through clinical rotations, didactic conferences, printed and electronic resources, and a reading list of key articles in GI and Hepatology. While trainees provide service to the teaching hospitals, service commitments should not compromise educational goals and objectives. Research Training - Fellows will be provided on average 6 months of elective time during fellowship, which can be used for scholarly research activities. Trainees choosing more focused research may be eligible for training through the NIH T32 grant. 1.4 Supervision Policy Please see the document, Program Description and Competency Based Educational Goals and Objectives, in MedHub. In brief, faculty will provide supervision for fellows during all rotations. 1.5 Handoff Policy Systematic use of informative hand-offs is critical. Important hand-off times include: 1. The on-service physician to the on-call physician (and back again) 2. The mid-level to the Fellow on service and on call 3. The scheduled change of Fellow of record for each service 4. Admission of patients from clinic and discharges from inpatient back to clinic 5. Transfer of patients between hospital systems Each handoff should include notification prior to the start time of patient roster, identifying information, active problems, pending tests, management plan, and any special concerns. The handoff should utilize a written/electronic list, as well as two-way communication between parties (verbal or secure ). 1.6 Faculty Responsibilities Faculty members are expected to ensure the team is a positive and productive consultative (or primary) enterprise and foster a scholarly and investigative environment. Basic responsibilities of faculty on service include: Explicitly outline specific expectations to the team at the onset of the rotation. Lead and be responsible for the positive conduct of the team (the inpatient and consult teams should operate in an timely, professional, and service-oriented fashion including writing helpful notes, communicating effectively with other teams, and providing timely and helpful service) Supervise the fellow(s) on the team, including all procedures. Round daily with the team, see patients, and write daily notes. Focus on teaching activities during rounds. Facilitate availability of team members for conferences and other educational responsibilities. Be available to the fellow on service during majority, if not all, of the day Provide written and face-to face verbal feedback to each team member at the end of the rotation. 7

8 2. General Policies Please see Programs Goals and Objectives Manual in MedHub for further details. 2.1 Services Program sites include: 1) Parkland Memorial Hospital, 2) Dallas VA Medical Center, 3) UT Southwestern University Hospitals (Clements and Zale Lipshy), and 4) Texas Health Presbyterian. Fellows may serve solely as consultants or as the primary inpatient team, depending on the service and clinical site. 2.2 General Conduct (at all sites) Consults It is expected fellows show up on time to work and stay until end of the day. If there are extenuating circumstances where a fellow must arrive late or leave early, this must be discussed and approved by faculty on service. Coverage should be arranged as appropriate. Any absences longer than half-day (> 4 hours) must also be discussed with and approved by fellowship PD/APDs. All consults must be received in a polite and professional manner, and we do not refuse consults under any circumstances. Curbside consults are strongly discouraged, and it is expected that the fellow involved in any curbside consult should ask the other physician to request a consult so that we may see the patient in consultation. If any recommendation is made without a consult, the case should still be discussed with faculty and a note should be added to the patient s chart. Extensive questioning of the referring physician is time consuming and can be interpreted as badgering, so questions should be limited to basic information needed to triage the consult and ensure patient safety. Time to consult is a quality performance measure. In electronic medical records, the time to consult begins when the primary team enters the order and ends when a note is linked electronically to the request (usually by checking a box). Every effort should be made to see consults the same day. A quick visit to determine severity of illness is essential for consults called in late in the day. For urgent consults, including patients who may need endoscopy the same day (e.g. acute GI hemorrhage) and Emergency Room consults, it is imperative those consults be seen expeditiously, typically within 2 hours. Consults from the emergency room should be seen and staffed and recommendations communicated back to the ER physician in a timely manner in order to facilitate emergency care. The decision whether to admit the patient or not rests with the ER physician. On-call consults should be triaged appropriately in discussion with faculty. Consults received after 5 PM are to either be seen immediately by fellow on call or the first thing (before endoscopy or conference) on the following day by fellow assigned to the service. This is a decision that should be made by fellow on call after discussing with faculty. If a patient is not available ( off the floor ) a note should be placed in the chart indicating that an attempt to see the patient was made. When a consult is seen, a note summarizing the case, assessment and plan should be written in patient s chart. A full consult includes Chief Complaint, History of the Present Illness, Past Medical/Surgical History, Medications, Allergies, Social History, Family History, 12-system Review of Systems, Comprehensive Physical Examination, Laboratory, Radiology, Endoscopy, Differential Diagnosis (including rationale for most likely diagnosis), and Assessment and Plan. Consult note should contain the names of the provider requesting the consult. Consults are to be staffed in person with faculty within 24 hours of receipt of the consult. After staffing consult with faculty, plan should be verbally communicated to provider requesting the consult Rounding on Inpatients All active follow-up patients are to be seen and progress notes written every day. Decisions regarding appropriate time to sign off should be made after discussion with faculty. The Fellow is responsible for knowing each patient s condition, recent test results, and formulating a plan of care at the time of rounds. 8

9 The Fellow is expected to review appropriate literature regarding the disease states afflicting their patients and reflect said effort when solicited by faculty during rounds. Any change in assessment or plan should be verbally discussed with primary team Patients should be arranged for appropriate outpatient follow-up in clinic after signing off or discharge Procedures All procedures will be performed under direct staff supervision. It is necessary to communicate with faculty on service or on call to ask for advice before deciding to perform a procedure. Procedures on hospitalized patients should be performed as soon as possible after the consult and almost always within 24 hours after receipt of the consult, as appropriate per patient clinical condition. Pre-procedure consent and H&P must be documented according to CMS and JCO requirements prior to any procedure being performed. Anesthesia should be considered for any high-risk patients for sedation, including those with significant cardiopulmonary disease, metabolic derangements, ASA 4, morbid obesity, ongoing substance abuse, or those with active upper GI bleeding or esophageal foreign bodies. Active participation in time out is required. This means when a nurse calls for time out, you stop doing what you are doing, listen, and say I agree. Immediately after all procedures, a detailed report will be generated in Provation. The report should contain fellow performing the procedure, faculty of record, name and description of the procedure, findings, estimated blood loss, specimens removed, and post procedure diagnosis. Findings of a procedure should be communicated verbally to the referring provider or a member of their team. A brief progress note summarizing findings and recommendations should be put in charts of hospitalized patients. Fellows must discuss endoscopy plans with the appropriate ordering or faculty member. Fellows must check on prospective endoscopy patients to make certain the proposed procedure can be performed (i.e.: appropriate bowel prep, NPO, anticoagulation, whether the patient may need anesthesia, or another procedure, such as an EGD on top of a colonoscopy, etc.). All patients in whom a procedure is done should be followed-up, typically the morning of the day after the procedure was performed for inpatients. Procedure Log Documentation of procedures performed is necessary to confirm that fellows are being exposed to the endoscopy goals of the program. This information will be reviewed with the program director and clinical competency committee every 6 months and is a critical component of hospital privileges upon graduation from the program. Fellow Responsibility Fellows are responsible for maintaining a procedure log. All procedures need to be electronically captured using Medhub within 30 days of the procedure date. Procedures that are not logged will not be counted as completed by the program and will not be credited to the fellow. It is the responsibility of the trainees to keep their information backed up using a procedure diary that would be used in the unusual circumstance that electronic information is lost. The procedure log must include the procedure performed, any instrumentation (biopsies, control of bleeding polypectomies, etc), and whether the procedure was completed with/without faculty intervention. Faculty Responsibility Faculty at all sites must supervise each procedure in accordance with the minimum standards set forth in the GME supervision grid, which is graduated from 100% direct total supervision to partial direct and 9

10 indirect supervision based upon the skill level of the trainee. Faculty will need to sign off the procedures on a regular basis. Faculty are responsible for completing one-on-one assessments of cognitive and technical skills (so called Mini-CEX) and providing feedback to the trainee. 2.3 Role of House-staff Fellows should communicate with house-staff on a frequent basis about pertinent clinical issues and endoscopic procedures on any patients house-staff are following. Fellows should act as intermediate supervisors and teachers of house-staff. Dedicated time for observing procedures should be made available to house-staff Fellows should provide a reasonable number of patients (and appropriate acuity) to the house-staff to allow sufficient time to read about patients. House-staff should be provided a good educational opportunity, not simply service. House-staff are expected to be at the weekly GI conferences on Monday evenings and Wednesday mornings. An exception will be made for the Housestaff assigned to Liver Transplantation at CUH in the event that patient care and rounding with the Attending necessitate their absence. House-staff should also be excused, outside of extenuating clinical circumstances, to attend their residency lectures. 2.4 Role of Advanced Practice Practioners Nurse Practitioners and Physician Assistants are sometimes included as part of the GI or Hepatology services. Their responsibilities vary according to the service assigned and are determined by their faculty supervisor. However, their duties should facilitate delivery of clinical care and not take away from educational experience of the fellow. Fellows should act as intermediate supervisors and teachers of NPs and PAs. 3. Rotations 3.1 Parkland Memorial Hospital (PHHS) Parkland GI Consult Service The GI consult team at Parkland is one of the busiest services. It is a minimal expectation that Fellows on the service arrive early to work, before 7:00am, and in general at a time proportional to their expected workload. The GI consult team is expected to function as a team, with a structure similar to that seen in residency training (i.e. work together to manage patients and teach each other). The team is composed of at least one faculty, two junior fellows, two senior fellows, and a mix of medical residents, surgery residents, and medical students. Fellows are expected to be active in seeing patients in consultation and in performing endoscopies. The Attending physician supervises all aspects of the inpatient service, including inpatient procedures. Consults should be seen and presented to a faculty member in a timely manner according to the severity of illness. While some consults will be seen by a faculty member within minutes, others may wait up to 24 hours. Every effort should be made to see consults from the Parkland Emergency Room within 2 hours. Under no circumstances should any consult go without being seen by a faculty member for longer than 24 hours. The senior Fellows on this service are expected to take on a leadership role in the team structure. This Fellow must be an excellent role model, is expected to make meaningful contributions during Attending rounds and participate in the teaching of junior Fellows, residents, and medical students. The senior Fellows should exemplify qualities of teamwork and share the responsibility of seeing consults and obtaining consents with other members of the team. The senior Fellows will be expected to perform the more complicated endoscopy procedures, particularly early in the year. While the majority of consults will be seen by the junior Fellow assigned to consults, it is expected that the senior Fellows assist in this role throughout the day, especially during gaps in procedures and once procedures for that day are completed. 10

11 General Surgery Resident - The general surgery resident is typically a 4 th year resident, and is generally experienced in the surgical and medical care of patients with a range of GI diseases. Although the surgery residents are generally inexperienced in endoscopy procedures, they are expected to complete an endoscopy curriculum and endoscopy simulator experience offered by the Department of Surgery prior to their rotation on the GI service. The surgery resident will function the same as a (new) first year GI Fellow (includes seeing new consults and doing endoscopy). Goals and expectations for the surgery resident are described in a separate document that is reviewed with the resident on service at the start of their rotation (see section 4.3). Medical Residents - Medical residents rotating on the service play an active role in consultation. They also are expected to be active in rounds, and observe endoscopy for patients they see in consultation. Consult Attending Physician Attending faculty rotate in one-week blocks. The faculty supervises procedures and consults, starting at 7 am. The attending will conduct teaching rounds and personally see patients actively being followed by the consult team. A second and third Attending will also be available Monday - Friday from 7:30 AM to 3 PM to staff outpatient procedures. 5:30-7:00 AM It is usually necessary for members of the team to pre-round on their patients. It is not acceptable to wait to follow-up patients until the afternoon. 7AM- mid-pm Afternoon Conference: Outpatient endoscopies are performed by the senior Fellows, the junior Fellow assigned to endoscopy, and the surgery resident. New consults are seen by the junior Fellow assigned to consults, the resident(s), and medical student(s). In the event of short staffing or high patient volumes, all team members are expected to switch/share roles as needed to optimize the efficiency and learning experience of the service. Consult Attending rounds. After Attending rounds, the junior and senior endoscopy Fellows are responsible for ensuring that appropriate procedure and prep orders are written, consents are signed, and that procedure information is communicated to the GI lab charge nurse (and anesthesia teams if necessary) Consults and procedures are not expected to interfere with conferences, which are held from Wednesdays 8AM-9AM and Mondays 5PM-6PM. Clinical work is expected to be done before and after conference Parkland Endoscopy Unit - Detailed Responsibilities of the fellows All fellows assigned to Parkland Endoscopy unit should be present by 7:00AM. The first procedure is expected to be started at 7:30 and the consent,and H&P for the first case should be completed by 7:15. Efficient working in the unit requires teamwork this means that you should help your co-fellow in getting consent, taking to family etc. whenever feasible. Pre-Procedure: Inpatients Place the order for the inpatient procedures in EPIC as soon as the decision is taken to perform the procedure. The charge nurse can then see the request and take necessary action. Consent: The fellows should get the inpatient consents the day prior to the procedure. The consent should be witnessed by any mentally capable adult (usually a nurse) on the floor and dated and timed. This should be done via I-med consent in Epic. However, if computer availability is an issue, paper consents are acceptable. Request for consult: All inpatients needing endoscopies have to be seen by the fellow and a consult should be placed by the referring physician (i.e. the referring team cannot just ask for an endoscopy). 11

12 H&P: The inpatients will require a pre-procedure H&P. This has to be completed in Epic before the procedure is started. Follow these steps: o Go to Notes, then select the H&P tab o Click on New Note o In the service bar, type Gastroenterology o In the Insert SmartText bar, type GI. Now select GI PREPROCEDURE H&P INPATIENT o Hit the F2 button to input all required fields. Once completed, sign the note. Outpatients Consent: The consents have to be obtained in the pre-procedure area. The nurses cannot move the patients into the procedure room without the consent. For optimal room turn over, make sure that the next patient is consented soon after you complete the procedure. Every effort should be made to be at least two consents ahead to avoid any delays in the procedure room being loaded due to lack of consent. H&P: The outpatients will also require a pre-procedure H&P. This has to be completed in Epic before the procedure is started. Follow these steps: o Go to Notes, then select the H&P tab o Click on New Note o In the service bar, type Gastroenterology o In the Insert SmartText bar, type GI. Now select GI PREPROCEDURE H&P OUTPATIENT o Hit the F2 button to input all required fields. Once completed, sign the note. Endoscopy notes: (better note writing) The referring physician should be mentioned. Do not fill the requesting provider. The requesting provider does not show in the final Epic note. Provation is unable to remove the field requesting provider. Indication: You will be choosing indications in Provation and there are different options (for example, for a patient with a history of polyps you can choose surveillance colonoscopy or personal history of polyps or follow-up of polyps etc. You can choose anything but have to make sure that the following points are covered (you may have to free text) Surveillance: year last colonoscopy was performed, if polyps were seen, path of polyps Screening: average risk or high risk, if there is family history of colon cancer mention who in the family has colon cancer and at what age Varices: history of bleeding? Last banding? On propranolol? Anemia: Mention Hb, iron studies,. Impression and Findings are two different entities. In Provation, clicking auto impression only reiterates the findings. For example, Finding: erythematous area in stomach; Autoimpression: erythematous area in stomach. Instead, tell the referring physician what this erythematous area is e.g. erythematous area suggestive of gastritis OR erythematous area suggestive of gastritis, to be confirmed by biopsies OR erythematous area, likely non-specific finding ; or if the patient had presented with severe abdominal pain, erythematous area suggestive of gastritis but this is unlikely to be a cause of If the procedure was performed with anesthesia, mention the reason. You should still run the auto-impression since it is linked to coding (for the billers) but you can edit the main document before signing. If you have taken the biopsies, mention the reason (for example, don t just say Biopsies taken from duodenum. Instead say, Biopsies taken from duodenum to rule out celiac disease or malignancy etc. If you are ordering CT, mention 1) abdomen alone or abdomen and pelvis 2) with / without contrast, IV or oral or both 3) any specific protocol 4) time 5) reason. For example, CT abdomen with IV contrast, pancreas protocol in 6 months to evaluate the pancreas cyst. 12

13 Fellow Endoscopic Skills: Enter your year of fellowship and how far the scope was passed unassisted. The faculty will complete and evaluation of your cognitive and hands-on skills. Post-procedure: HIPPA compliance: If you need to discuss endoscopic findings with your patient, introduce yourself to the other family members and ask the patient if it is acceptable to discuss results in front of them (especially true for significant findings). When discussing sensitive information, try taking them into private area. Communication with referring team: After the procedure, text page the intern / resident / hospitalist with the findings. For a significant finding, talk to them. Follow-up procedures: If a patient needs a follow-up procedure, the order should be placed in EPIC prior to discharge from the recovery room. For all out-patient procedures requested within 30 days (like repeat banding, dilations, pancreatic or biliary stent removal etc.) tell the front office (Becky) that you have placed an order and she will give a time and date for the procedure to the patient before they leave the endoscopy unit. If a procedure is needed after 30 days, then place an order in EPIC. The schedulers will call the patient. Discharge order and medications: A discharge order should be written for each patient after reconciling the list of medications. For any new prescriptions, the order should be placed in EPIC prior to discharge from the recovery area. Follow-up: The fellows are expected to complete reviewing ALL of their biopsy results within 1 week of the time they are available on EPIC and mail letter using the standard template in Notewriter EPIC. The supervising attending should be cc d on the letter. When there are important diagnoses such as a malignancy, high-grade dysplasia, or an abnormality that warrants a referral to other service or requires another procedure, the responsible fellow should call the patient (in addition to sending the letter) and document in EPIC that the patient was called and that the request for referral or follow-up procedure has been placed. Emergency cases: The techs and the nurses are available to assist you at all times. Anesthesia Assistance: For high risk patients, call the anesthesia board runner to discuss the case and agree on a time where both services can be present for the case. Cases to be done in Endoscopy Unit: During weekends and off hours, you need to page the oncall tech and the nurse. Their pager numbers are listed in the on call directory or you can call the operator and ask to page GI nurse and tech on call. Once paged, the nurses and techs are expected to respond within 15 minutes. Cases to be done in ICU or ER: Only the tech comes in (do not need a nurse, since the sedation will be provided by the ER or ICU nurses). To call the travel tech, look in the on-call directory or ask the operator to page. Before you page them checklist o Patient name, MR number and location o GI attending knows about the patient and agrees to endoscopy o Time when you want to start the procedure While the technicians are always available, we expect the fellows to know how to set up the travel cart. Use every opportunity to set up the cart yourself under the watchful eyes of the techs. Parkland Endoscopy Unit Role of the Attending: 13

14 Attending presence: Medicare requires an attending to be present for the entire procedure in order to bill for the attending s presence in addition to the fellow s salary. The patients may be brought into the room and sedated but the fellow will not be able to start until the attending is present in the room. While this is not a requirement by other insurances, it has been decided by the Parkland administration that there should be only one standard (Medicare standard) for all patients. Signing Provation reports: The reports should be signed by the Attending as soon as possible. Attending should edit the report and educate the fellows whenever necessary. Attendings should arrive no later than 7:30 AM. This is the time at which procedures scheduled with anesthesia begin. Our goal is to have the patients in the endoscopy room by 7: Parkland Liver Consults The expectations for general conduct, timing of seeing and staffing consults and interaction with residents, interns, and students are the same for GI and liver consult services at PHHS. On Fridays at 11 AM, the liver team will meet with the liver pathology attending on service to review interesting liver biopsies using the multi-head scope. It is the responsibility of the fellow to contact the pathology attending approximately 2 days beforehand and coordinate which biopsies to review Biliary/Advanced Endoscopy Definition of Advanced Endoscopy Procedures: Diagnostic and therapeutic EUS, ERCP, enteral stents, endoscopic mucosal resection, complex stricture dilation, endoscopy requiring fluoroscopic guidance, complex polypectomy, endoscopic ablation techniques, EUS-guided cyst and abscess drainage, device-assisted deep enteroscopy It is the philosophy of this division that training and proficiency in EUS and ERCP procedures requires an additional year of training following categorical GI fellowship. During the GI Fellow s rotation on this service, it is expected that the Fellow will: 1. Function as a consultant in pancreatobiliary disease in the inpatient and outpatient settings 2. Learn to work in a multidisciplinary environment (interventional radiology, surgery, oncology, etc) 3. Understand the indications and contraindications for advanced procedures such as ERCP and Endoscopic ultrasound with relation to pancreatobiliary disease 4. Learn how to interpret basic ERCP and EUS images 5. Understand the indications and technical processes of the advanced endoscopy procedures 6. Understand how to manage endoscopic complications 7. Critically review the literature and foster research thinking Advanced Fellow Clinical Responsibilities: 1. Pre-procedure evaluation of inpatient and outpatients for all advanced endoscopy procedures including labs, radiographic images, and history. 2. Function as the primary endoscopist for all advanced endoscopy procedures at Parkland 3. Consent, history and physical and necessary documentation in EMR before and after procedure 4. Communication with the patient s family members as well as the primary physician service 5. Perform appropriate post-procedure visits in hospital and arrange for outpatient follow-up 6. Follow-up on all pathology results for all advanced endoscopy procedures including those performed by the attending physician alone or by rotating fellows 7. Pancreatobiliary clinic one afternoon per week 14

15 8. Attend relevant multidisciplinary patient management meetings (GI tumor board, Thoracic tumor board, etc) 9. Attend the Pancreaticobiliary Case Conference 4 th Thursday of the month at 5:30pm 10. Complete a clinical research project with submission of abstract and completion of a manuscript The Fellow will be expected to present his/her work during a State of the Art talk at the end of the year. 11. Serve as attending on the General GI service for several months, in preparation for a career in academic GI. Categorical Biliary Rotation Fellow Responsibilities: 1. Assist the Advanced Fellow in inpatient and outpatient pre-procedure evaluation and consents as above 2. Assist the Advanced Fellow in performing inpatient consultations for the biliary service 3. Observe all EUS and ERCP procedures with the intent of learning image interpretation for endosonography and cholangiograms 4. At the discretion of the attending physician, the rotating fellow may be permitted to perform certain technical aspects of the ERCP and EUS procedures but the goal is not to obtain proficiency in this short rotation 5. At the discretion of the attending physician, perform other advanced endoscopy procedures listed above 6. Round with the attending and/or advanced fellow on consultations and follow-ups daily 7. Attend the weekly multimodality GI tumor board conference. 8. Attend scheduled GI clinics and report to advanced fellow after the completion of clinic to assist with any outstanding consults or procedures 9. Attend the Pancreaticobiliary Case Conference 4 th Thursday of the month at 5:30pm 10. Present a pancreatobiliary case at division case conference per assignment In an effort to formalize biliary service operations and ensure that our patients receive timely care, please adhere to the following workflow for all biliary consults at both PMH and CUH: 1. Patients will be staffed and rounded on by biliary faculty during the week. The biliary service list will be actively managed by the biliary attending together with the fellow(s) rotating in the biliary service. 2. On weekends and holidays, biliary patients will be seen by the fellow covering the liver service and will be staffed and rounded on by the General GI faculty. This means that the fellow rounding on biliary cases during the week will check out his/her patients to the liver fellow covering the weekend. 4. It is the expectation that if the fellow covering the liver service has a large census, the fellow covering GI will help out his/her colleague in the liver service. 5. Whenever the evaluation involves possible procedures, the rounding team should discuss the case over the phone with biliary attending on call to avoid any miscommunications Parkland Ambulatory Large volume paracenteses are performed by the Parkland Ambulatory fellow (or liver consult fellow if the former has an excused absence) on Tuesday and Friday mornings. There will usually be a resident that can either assist with the paracentesis (interns) or perform them independently (upper level resident). Liver pathology is reviewed in person with the pathologist on Fridays at 11AM and the results called to the patient and documented in EPIC. Additional responsibilities include: o o Capsule Endoscopy and Motility Studies: The Parkland Ambulatory Fellow reads the capsule endoscopies and motility studies in concert with Drs. Lisa Casey and William Santangelo, respectively. An initial assessment that the capsule has passed must be performed as soon as the video is downloaded by the nurse. The formal report should be signed out with the attending by the end of the week. Dr Santangelo usually meets on Wednesday mornings to review the motility studies. Assist the liver and GI services as needed, including seeing consults at Zale Lipshy Hospital 15

16 AM Monday Tuesday Wednesday Thursday Friday Paracentesis with residents E-consults (Tian) Administrative time (in-basket, pt calls, review HRM/WCE) GI Grand Rounds HRM & ph studies (Santangelo) IBD Clinic 1 st /3 rd (Kwon) GI Genetics Clinic 2 nd /4 th (Getachew) Paracentesis with residents Administrative time (in-basket, pt calls, review HRM/WCE) Liver pathology 11am-12pm PM Pancreas cyst clinic 1 st /3 rd (Porembka/Wang) Radiology 2 nd /4 th (Khatri/Lakshmi) Parkland/VA Continuity Clinic WCE (Casey) & ARM (Patel) Parkland Resident Clinic HCC Conference 12pm-1pm Parkland Resident Clinic 1 st /3 rd HCC Clinic 2 nd /4 th Parkland Continuity Clinic - Two faculty per clinic day Tuesday PM 1 st Year Fellows Thursday PM 2 nd Year Fellows + Parkland Ambulatory Fellow Friday PM 3rd Year Fellows There will be at least 2 medicine residents in the clinic each day. The residents will have their own Resident Template consisting of established clinic patients that are deemed to require clinic follow-up but not complex enough to require a GI fellow. Patients will be scheduled from 12:30-3:30 PM.. The expectation is that after finishing with patients and prior to leaving the clinic, you will clean out your in-basket and make patient phone calls. Patient Number: o Fellow templates include 3 new to clinic patients each week and 5 follow-up patients per week, with two overbook slots under control of the Fellow. o First years will schedule a total of 6 patients for July and 7 patients in August then increase to 10 possible patients (8 plus 2 overbooks). o Inpatients requiring follow-up in GI clinic, whether or not they are already established clinic patients, should be referred directly to the clinic via this process: o Send a message via an Epic Telephone encounter to the GI/Liver Business Pool or Patty Esparza (referral coordinator) o The above message should contain the following: patient name, MRN, clinic name (eg. IBD clinic, GI Genetics, HCV treatment or GI/Liver clinic), clinic day (Tuesday, Thursday, or Friday), timeframe (2 weeks, 4 weeks, 3 months, etc), specific fellow to whom the patient should be assigned OR Resident Template if patient can be seen by a Resident. o Whenever possible, the fellow should attempt to schedule unassigned patients to either themselves or a fellow within their buddy system. If the patient s primary fellow does not have openings, they will schedule an interim visit and then return the patient to the primary fellow. 16

17 Continuity is very important and everyone will be expected to facilitate this. Inherent in this is communication between the consult team and primary fellow when someone gets admitted. Parkland Ambulatory Fellow will be expected to report to Thursday PM clinic and every other Friday PM clinic. The Fellow will act as a junior attending and supervise/assist the Residents seeing their assigned patients. The Fellow and Resident will then present the case to the Faculty. Any labs or imaging ordered on Resident template patients should be done so by the Fellow to provide continuity to the patient. Documentation: All patient related communications and decisions must be documented in the electronic medical record, including phone calls, left messages, refills, etc. even when you are at home, in the GI lab, at the VA. Basically, if you do not document it, it did not happen. This helps everyone else who is taking care of the patient know exactly what is going on. We have many more patients than slots, so expeditiously discharge all patients that do not need to be seen in clinic and set up realistic intervals for follow up patients. Virtual chart checks: There are many patients who need frequent or long term labs or follow up of other results but not necessarily a clinic visit with a physician. In-basket and results: Management of the in-basket is not just an expectation of our clinic but of the hospital overall as this is tied to patient care and satisfaction. There is an expectation that all fellows will have Epic access from home and will follow up on their results and in-basket messages at least twice weekly at minimum bearing in mind that the actual hospital expectation is daily. Please keep in mind that per Parkland policy, Epic InBasket messages/results aged 30 days or greater will result in Suspension/Sanction of hospital/epic privileges. Hospital follow-ups: GI fellows should refer inpatient follow-ups (not the primary teams) since schedulers will know our fellows. There are no urgent inpatient follow-ups without a GI or liver consult. Overbooks: Each fellow is expected to manage his/her own 2 overbook slots. A fellow can only overbook into his/her own clinic. Evaluations: As per ACGME requirements, the fellows will be evaluated by clinic patients at the end of clinic, the clinic staff and faculty. No shows: Clinic staff do not currently review or manage no shows. The fellow is expected to review the no-show patient s charts and determine if they need to be urgently seen, need a phone call, need to be rescheduled or need to be discharged from clinic. Contacts: (all are in PHHS system) o Clinic Manager: Susan Cauley o Senior Clinic Scheduler: Patricia Garrett o Referral Navigator and Coordinator: Cheryl Horton , Patty Esparza o For inpatient follow-ups, send Epic messages via Telephone Encounters to the GI/Liver Business Pool. 3.2 Dallas VA Medical Center (VAMC) The general conduct of consultations at the Dallas VA should be handled with the same high standards as all consultations in the UT Southwestern system. This includes a high level of professionalism in accepting consult requests (received both by phone and in CPRS), discouraging curbside consults, promptly evaluating patients and providing recommendations for diagnostic and therapeutic interventions (including a full H&P consult in CPRS), performing endoscopic procedures on the consult patients, and providing prompt follow-up and discussion of the results from these procedures with the patient s primary service. Remote access to the VA medical records system (CPRS) is required and will be arranged for all fellows VA GI Consult Service The GI consult team is composed of a GI Attending, two junior trainees, an upper level fellow, a medical resident, and occasionally medical students. The GI attendings generally rotate in one week blocks. The junior 17

18 trainees assigned to the GI service will equally split the month in regards to who is primarily responsible for seeing consults and who is performing endoscopies on both the outpatients and inpatients. The junior trainee primarily seeing consults is expected to be available to see new consults between 7am and 5pm daily, Monday through Friday. If the Fellows assigned to endoscopy are not busy with endoscopy, they will help with any consults as needed. The junior Fellows assigned to GI and liver are responsible for establishing rounding times with the GI Attending each day. The junior Fellow assigned to primarily be performing endoscopies and the senior Fellow will be available for procedures during all working hours of the GI lab (typically 7:30am 5pm). The junior Fellow performing endoscopies and the senior Fellow are both expected to be present during rounds with the GI Attending unless actively engaged in performing procedures VA Endoscopy Unit GI Lab hours are 7:30 AM 4:00 PM. Outpatients are prepared for GI procedures on 4B Day Surgery. Nurses call for patients on arrival to the GI Lab. Outpatient procedures are done in the AM with inpatients called for as the schedule permits. It is the duty of the GI Fellow on consults to prioritize all inpatients so that every attempt can be made to do the most urgent cases before 4:00 PM. Documentation All endoscopy procedures performed at the Dallas VA must be documented in the electronic documentation system, Provation (including those done in the ICU), which transfers a note to CPRS (the electronic medical record) once signed by the Attending. The Fellow is responsible for writing post-procedure orders in CPRS after the completion of the endoscopy on all inpatients. Outpatient procedures follow Day Surgery protocol unless you have specific orders for the patient. The Fellow is responsible for writing an oncwatch colonoscopy note for all colonoscopy procedures and an Oncwatch Barrett s esophagus note for patients who had endoscopy for evaluation of Barrett s esophagus. The Fellow is also responsible for follow-up of all pathology with written notification (oncwatch note and oncwatch biopsy results letters for colonoscopy and Barrett s surveillance, pathology results letters for other procedures) to the patient within two weeks of the procedure. Log books of procedures with patient identification cannot be kept at the VA. You must document your procedures in your Med Hub Procedure Log. Emergency Procedures (with travel cart) Emergency procedures are performed by the on-call GI Fellow under the supervision of the on-call GI Attending. Prior to performing endoscopy on an emergency basis, the patient should be seen by the fellow, an H&P completed and discussed with the attending on call, and informed consent obtained. The majority of oncall procedures are performed in the ICU, although in some situations they may be performed in the GI lab (with the anesthesia service) or in the OR. All travel procedures must be documented in Provation. There is a GI tech available on-call for all emergency procedures. The on call tech schedule is posted in the GI Fellow Conference Room. The on-call pager for the tech is VA Liver Fellow The liver service includes a hepatology attending, one fellow (can be a junior fellow or an upper level fellow), and a resident. The liver fellow will see all inpatient liver consults and present them to the liver attending daily. This includes all new consults and daily follow-ups. The liver fellow attends the VA Monday afternoon liver clinic (staffed by Dr. Mazhar), which starts at 1pm and is located in clinic 5 on the third floor of the clinical addition. VA Liver clinic is also scheduled for Tuesday and Wednesday mornings, which is located in clinic 6 (3 rd floor of the clinical addition). Drs. Mazhar and O Leary will be present to staff these clinics. Wednesday morning liver clinic begins at 8. However, due to the timing of UTSW conferences, fellows should attend the UTSW teaching conferences and return promptly to the VA, to begin seeing liver patients by 10:00 am. Liver Tumor Board is scheduled on Thursday afternoons at 2pm. The location of this meeting is in 3 rd floor Radiology (MRI section). Representatives from hepatology, diagnostic radiology, and interventional radiology will be present for the Liver Tumor Board. The liver fellow will be given a list of patients that will be discussed that day during Liver Tumor Board and is expected to be prepared with all relevant labs, Childs-Pugh and MELD scores for each patient. A Liver Tumor Board Note will be generated during the meeting for each patient with specific recommendations and management plans. The liver fellow is expected to contact all 18

19 patients (via telephone) discussed during liver tumor board as requested by the liver attending. The liver fellow also attends the VA Inflammatory Bowel Disease clinic (Monday mornings, starting at 8am in clinic 6, third floor clinical addition building). The liver Fellow is responsible for following up on any labs or studies they order on any patients they see in these clinics. Any liver patient admitted from one of the liver clinics is followed by the liver Fellow to ensure the management plan developed by the liver fellow and liver Attending is followed. The liver Fellow should confer with the liver staff as the management plan evolves. The liver Fellow is expected to round on all inpatient follow-ups prior to arrival at the above clinics. They are expected, if need be, to round/communicate with the GI team daily in case there is any GI concerns to address with the Liver inpatients, such as gastrointestinal bleeding from esophageal varices Inpatient Liver All liver transplant patients, both post and pre (as indicated by the liver transplant clinic notes), should be admitted to a medicine team. For liver transplant patients that report to the emergency room, the Fellow on call should be contacted. The Fellow will discuss the case with the inpatient GI staff and if further questions, call the Liver staff. Once a liver transplant patient is admitted, the Liver Fellow should follow the case daily and notify the Hepatologist with changes in status and medical management. For patients with acute liver failure or severe acute liver injury, the Fellow should promptly notify the liver attending, so that transplant evaluation (if deemed necessary) can be expedited. All other general hepatology consultations received via CPRS consult or phone contact are to be seen promptly (but no later than 24 hours from the time of consult) Rounding times will be determined daily between the liver fellow and liver attendings. Transplant patient admissions It is the responsibility of the Liver Fellow to communicate with the appropriate transplant center point of contact (POC). After discussing the plan with the Dallas VA staff hepatologist, the transplant center should be notified of the admission, diagnosis, and management plan. Any further recommendations from the transplant center should be discussed at the time of contact. Within the first 2-3 days, update the transplant center POC as to the clinical course and any new findings. For prolonged hospitalizations, update the transplant center POC at least weekly or with any clinical changes that could lead to liver failure or death from any cause. Notify the liver transplant center and the Dallas VA liver nurse (Mayra Huerta) upon discharge as to disposition and outpatient follow up. Immunosuppressive level policies Immunosuppressive levels can be posted in CPRS on Fridays for post-transplant patients that were seen in the Tuesday or Wednesday AM liver clinics. The on-call fellow over the weekend may be paged by the lab for levels that are resulted over the weekend The liver nurse will eventually follow-up on all immunosuppressive levels, but it is expected that the fellow who saw the patient will be responsible for reviewing the level, interpreting it, and discussing accordingly with the liver attending. CPRS notes are generated by Mayra Huerta, RN (with a cosignature of the liver attending) for the on call Fellow, and/or the Liver Fellow. For all questionable immunosuppressive levels, the Fellow should discuss with the liver attending immediately. Hand off from Midlevel provider to Fellow The midlevel providers are active in seeing liver patients during normal business hours. If the results of a procedure and/or laboratory test will be reported after 4:00 pm, the midlevel provider will notify the Liver Fellow. The Liver Fellow is expected to hand off pending items to the GI Fellow on call. The on call Fellow should contact the liver staff when the results are abnormal VA Ambulatory One Fellow will be assigned to the VA ambulatory rotation each month. This Fellow is in addition to the Fellows on the above mentioned GI and liver teams. When not in clinic or not actively engaged in reading capsule endoscopies or ph/motility studies, this Fellow will join the inpatient consult team and assist with procedures or consults, as needed. 19

20 *Procedures: priority should be given to reading capsule endoscopies (with Dr Feagins) and manometry & ph studies (with Dr. Dunbar), and only then should the fellow perform EGDs/colonoscopies VA GI Continuity Clinic All fellows have continuity clinic scheduled every other week at the Dallas VA on Tuesday afternoons. The GI continuity clinic is located in clinic 6, on the 3 rd floor of the clinical addition. Clinic begins promptly at 1:00pm with a total of eight patients scheduled for each fellow with the last appointment time at 3:20pm It should be noted that for the first two months of the academic year (July and August), the new incoming Fellows will only see six GI patients with their last appointment time slot at 2:40pm. Fellows should return calls from patients promptly and follow up on tests and labs ordered from GI clinic VA Research Elective / Special Elective Fellows assigned to VA research most often have a research mentor at the VA. Space is available to work on VA research projects in the fellows office and other locations. Fellows on the VA research rotation / special elective are required to attend the educational conferences, including VA pathology conference and journal club, the Friday GI surgery conference, and Monday/Wednesday educational conferences at UTSW. 3.3 Texas Health Resources Presbyterian Hospital of Dallas Objective: This rotation is devoted to gaining experience as a gastroenterology consultant in an inpatient and outpatient private-practice setting. The goal of the rotation is to develop highly skilled consultants who can provide state-of-the-art care of patients with complex gastrointestinal disorders. These skills will be acquired through direct patient care, teaching rounds, conferences, and review of the pertinent medical literature. Specific Fellow Responsibilities: 1. In-patient consultations and admissions 2. One weekend of being on call per month of service with weekend call starting 7 am on Friday continuing through Monday. 3. Daily rounds on in-patient service beginning at 7 am with appropriate timely follow-up of patients through the course of the day. 4. If interested in inflammatory bowel disease (IBD), the Fellow may see: a. Outpatients with Dr. Persley as well as other staff. b. All in-patient IBD consultations and procedures. 5. If pursing a career in advanced endoscopy, the Fellow may have the opportunity to gain additional exposure in diagnostic and therapeutic advanced procedures and acquire the ability to perform them safely, successfully, and expeditiously. 6. Participation in conferences: 7. GI Journal Club: Held monthly, usually on the last Friday of the month at 7 am. The Fellow will be responsible for presenting one article at this forum. 8. UT Southwestern Citywide Conference: The Fellow will be responsible for case presentations. 9. Internal Medicine Lunch Conferences: Daily, attendance at Fellows discretion. 10. It is the Fellow s responsibility to make specific areas of interest known to the faculty and pursue opportunities to explore these interests in a private practice setting. Texas Health Resources Presbyterian Hospital of Dallas GI Faculty: Abrar Ahmed, M.D. abahmed@tddctx.com Amit Desai, M.D. amitpdesai@gmail.com Mark Feldman, M.D. MarkFeldman@texashealth.org Rajeev Jain, M.D. rjain@tddctx.com Cell: ; Michael Nunez, M.D. mnunez@tddctx.com Kim Persley, M.D. kpersley66@aol.com William (Bill) Stevens, M.D. bmbcactus@yahoo.com 20

21 Additional Contact Information: TDDC Practice Contact: Rashonda Wisner, Practice Manager Texas Digestive Disease Consultants, 8230 Walnut Hill Lane, Suite 610, Dallas, Texas Office: (214) Fax: (214) Administrative Contact: Marcie Hawk Graduate Medical Education Coordinator - Texas Health Presbyterian Hospital Dallas 8200 Walnut Hill Lane, Dallas, TX MarcieHawk@texashealth.org Office: (214) Fax: (214) Clements University Hospital (CUH) The GI and Hepatology services are each comprised of a senior Fellow, a resident or intern and may include medical students. Faculty available include one assigned each to the GI Service, Hepatology and Liver Transplant Service and Pancreaticobiliary service. The GI service also has a mid level provider. Patients with a primary GI, liver, or biliary reason for admission may be admitted to the GI or Liver service according to the standard admitting guidelines (see Appendix). The following patients are to be admitted to the inpatient services (after discussion with the Attending): GI Inpatient Service 1. GI Bleeding without significant co-morbidities 2. IBD exacerbations in patients followed in the GI clinic 3. Cholangitis 4. Foreign body ingestion 5. Any patient (without significant comorbidities) actively followed in GI clinic who is being admitted for a GI related problem 6. Any complication within 48 hrs of a GI intervention Hepatology Inpatient Service 1. Marked LFT abnormalities as the primary reason for admission 2. Liver disease and it s complications as the primary indication for admission 3. Acute Hepatitis 4. Severe alcoholic liver disease (jaundice) 5. Pre and Post-liver transplant a. Immediate post liver transplant patients (within the first 28 days) are admitted to transplant surgery b. Other transplant patients are admitted to Hepatology, with notification to the transplant surgery team CUH GI Consult Service On this service, trainees are responsible for seeing GI consults and patients on the service according to the severity of their disease, usually every day. Whenever possible, the Fellow should perform the endoscopic procedures on patients they have seen and know. The mid-level assists in taking care of inpatients primarily, but may also help with consults if the inpatient service is not busy. Specific Duties for the Clements University Hospital Services Fellow Responsibilities GI Inpatients All patients will be assessed by ED first before triaging the patient Triaging of GI Inpatients to GI Service: o 7am to 6pm: call GI Attending using GI Inpatient WebOnCall 21

22 o o 6pm to 7pm: call Hospitalist 7pm to 7am: call XCover Hospitalist Hospitalist will discuss patient with inpatient GI attending on a prn basis Inpatient admissions received between 7am and 6pm Monday through Friday are to be seen that day by the Fellow assigned to the service. The mid-level provider or housestaff may perform the initial H&P between the hours of 7am and 3pm, but this should then be reviewed with the Fellow assigned to the service so that a management plan determined. Between 6pm and 7am Monday through Friday, the hospitalist service admits the GI/Liver inpatients and will transfer their care in the morning. (See Handoff Policy) The Fellow will continue to provide cross-coverage for existing inpatients until 8PM, at which time the hospitalist service will provide inhouse cross-coverage for GI/liver inpatients. Inpatients received from 6pm on Friday to 7am on Monday should be seen during the weekend by the Fellow on call the timing is based on urgency and patients are expected to be seen by a faculty member within 24 hours of receiving the inpatient admission at the latest. During the day, admissions from the emergency room will be called to the faculty member on the inpatient service, who is then responsible for notifying the other team members. During the evenings, non-acute admissions will be admitted to the hospitalist and the GI/Liver faculty member will be called. Acutely ill patients will be admitted to the ICU and the GI/Liver faculty will be called. Pre-transplant ICU patients will be admitted to the MICU service. The Fellow on call will be expected to consult promptly on all critical care GI/Liver patients as well as any other patient which the faculty believes needs urgent evaluation/admission by a fellow, regardless of the admission time. Daily progress notes must be written on all inpatients by either the Fellow on service or the mid-level provider and addended by the Attending physician. On the day of discharge, a full discharge summary may substitute for the daily progress note. Every effort should be made to discharge patients early in the morning (before 9AM) so that beds will open up for other patients waiting. Consults Consults received between 7am and 6pm Monday through Friday are to be seen that day by the Fellow assigned to the consult service (judgment will be utilized on non-urgent cases late in the day). The housestaff or mid level provider may perform the initial consult, but the case should be reviewed with the Fellow. Consults received after 6pm are technically assigned to the Fellow on call; again, judgment must be used in assigning these patients, depending on the severity of illness. Consults received from 6pm on Friday to 7am on Monday should be seen during the weekend by the Fellow on call the timing is based on urgency and patients are expected to be seen by a faculty member within 24 hours of receiving the consult at the latest. Inpatient Procedures Procedures are routinely performed from 8am to 5pm Monday through Friday in the hospital endoscopy suite (please be sure and communicate early with Charge RN (Filosha) about the procedure being scheduled. After hours and weekend procedures are scheduled through the nursing supervisor who can be contacted through the page operator. Procedures will be performed by either the Fellow on service or on call with faculty supervision. Rounding Rounds on patients will occur daily with the GI Attending. 22

23 All patients will be seen and progress notes written by either the consult Fellow or mid-level provider, ideally prior to rounding and then finalized after attending recommendations made. The Fellow is responsible for knowing each patient s condition, recent test results, and formulating a plan of care at the time of rounds. The Fellow is expected to review appropriate literature regarding the disease states affecting their patients and reflect said effort when solicited by the Attending during rounds. Practice based learning is a core mission while on service. Housestaff Inpatient Responsibilities Two resident/intern are assigned to the GI/Liver rotation per month - assigned to either GI or liver and switch mid-month. They will be closely supervised by the service Attending, Fellow and PA. Housestaff will admit up to 2 inpatients and up to 3 new Consults daily in addition to seeing and writing notes on follow-up patients. A maximum of 10 patients will be assigned to the housestaff, including inpatients and consults. The fellow can choose to reassign follow-up patients to the mid-level to allow the housestaff to see additional new patients where the greatest learning opportunity lies. Mid Level Responsibilities CUH GI service: The primary responsibility of the inpatient GI PA is to provide care for the inpatient service. In the event that the inpatient service becomes very busy ( e.g. > 10 Patients) or that care is needed outside of the PA hours (7a-4p), then the Fellows and housestaff are expected to assist with any and all responsibilities of caring for the inpatients CUH Liver Service Patients: Pre-transplant patients, re-admitted post transplant patients, and non-transplant patients admitted for complications of liver disease who are followed in the outpatient liver clinic will be admitted to the inpatient liver service. All patients who are in the ICU and actively listed for liver transplantation, or transferred to CUH ICU with the purpose of urgent evaluation and listing for liver transplantation will be on the MICU service, with Hepatology (and the GI Fellow assigned to the liver service) in the consultant role. After liver transplantation, patients will remain on the Transplant Surgery service, with Hepatology (and the GI Fellow assigned to the liver service) in the consultant role. Liver Admissions: All patients will be assessed by ED first before triaging the patient 1. Triaging of Liver Patients a. Triage to Inpatient Liver Service - All admissions to the service must be approved by the Hepatology Attending on call (Liver/Hepatology Inpatient WebOnCall) i. Admitting responsibility 1. 7 am to 5 pm: GI fellow assigned to the liver service 2. 5pm to 6 pm: on-call GI fellow 3. 6 pm to 7 pm: on-call Hospitalist 4. 7pm to 7am: on-call XCover Hospitalist ii. Eligible Patients 1. Post-liver transplantation 2. Active on the Liver transplant waiting list 3. Undergoing liver transplant evaluation 4. All patients from Liver faculty clinic if admission is for a primary liver problem 5. New patients with liver disease on per case basis b. Inconclusive Triaging or Possible Discharge from ED i. Calls 23

24 ii. Anytime: ED to discuss patient with Hepatology Attending on call (Liver/Hepatology Inpatient WebOnCall) prior to admission/discharge Liver Fellow Responsibilities for CUH Liver Service Fellow is responsible for all patients on the inpatient service Supervise the internal medicine resident on the service A transplant hepatology fellow also rounds on the service but has a supernumerary/supervisory role and is not expected to admit patients or see consults Participate in multi-disciplinary transplant rounds at 9am M-F. Fellows are excused from rounds on Wednesday morning for conference but must make every effort to learn and implement the plan determined on rounds. Evaluate and write a consult note at the time of admission on all patients admitted to the service and for all consults Formal handoff of ongoing medical issues for all patients should be done with the Fellow taking overnight call, on a daily basis. Attend liver transplant selection committee on Tuesday at noon on the 5th floor of POB I if clinic schedule allows Hospitalist Coverage of Liver and GI Services: Liver: After 6 pm, the ED admits patients to Liver Service and calls the hospitalist. The Liver Fellow will send a Liver patient checkout list to on call hospitalist by 7:00 PM. The hospitalist admits and evaluates the patient and then notifies the Liver Attending on call. Hospitalist will send a hand-off note by to the liver attending and rounding fellow by 7:00 AM. For significant cross cover issues, contact the liver fellow on call followed by the Liver attending on call GI: After 6 pm, the ED admits patients to GI service and calls the hospitalist The hospitalist admits the patient and determines whether the patient has an urgent problem such as GI bleeding that requires immediate consultation with GI attending on-call. If no urgent consult is needed, the hospitalist will notify the GI Inpatient Attending of new admissions and any issues regarding cross-cover in the morning, usually by . For significant cross cover issues Fellow on call will be notified. GI Fellow will send a GI patient checkout list to the on call physician by 7:00 PM. This list will also include the GI on call attending and GI Inpatient attending. Urgent Overnight Issues and Consults: For significant cross cover issues including a change in medical status as well as new urgent consults must be seen and evaluated by the on call fellow and discussed with the appropriate on call attending. If needed, there are call rooms at CUH and Charles Sprague o o CUH Ambulatory Objectives: Between 8:00am-4:30pm, contact Lori Holmes at x50113 After 4:30pm, contact the House Supervisor to be assigned a room. Provide your first and last name and the service you are on. UH Clements House Supervisor: x30398 UH Zale Lipshy House Supervisor: x

25 Gain experience performing efficient consultations and follow-up care in a tertiary referral clinic including exposure to specialty clinics for IBD, Pancreaticobiliary, Motility, Liver Transplant, General Gastroenterology, Pelvic Floor disorders and Colorectal Surgery Structure: Fellow will be assigned to a variety of specialty clinics with a focus on providing supplemental exposure to patients not often encountered in other areas of training. Capsule endoscopy and manometry may also be incorporated. Fellow are also required to attend their own GI Continuity clinics AM PM Outpatient Building (OPB) 6 th floor Monday Tuesday Wednesday Thursday Friday GI Grand Liver Transplant Rounds IR Procedures Clinic (Mufti) & (Sanjeeva Kalva) Administrative time If no GI procedures, Hepatology Clinic (Lee) Anorectal Manometry (Craig Olson) Weight Loss Clinic (Jaime Almandoz) 1 st week of month (and If Mufti out) Motility Clinic (Gavini) VA Clinic (InBasket, Pt Calls, Procedure log, etc.) IBD Clinic (Ahmed) Motility Clinic (Mithani) Pelvic Floor Clinic (Kelly Scott) PMH Clinic IBD Clinic (Kwon) Bariatric Clinic (Sara Hennessy) 1 st week of month (and if Kwon out) Pancreatic Cyst Clinic* (Kubiliun) * 11a-12p Conference 2 nd week PMH Clinic 3.5 Zale Lipshy University Hospital Consult Service GI or Liver consults generated at Zale Liphsy University Hospital during weekdays will be seen by the Parkland Ambulatory fellow and during weekends by the Parkland on call fellow. The GI or Liver Attending at Parkland will be responsible for staffing the consults. The GI team on at CUH performs endoscopies on patients deemed to require endoscopic evaluation (patients are transported by ambulance from Zale to CUH for their procedures). Thus, communication between Parkland and CUH services is essential for patients who will need an endoscopic procedure. The Fellow will need to know the pertinent history and it will be expected that a differential diagnosis and treatment plan has been formulated for these patients. All consults after 5pm will be seen/staffed by the on-call team according to the severity of illness. If a patient is not available ( off the floor ) a note should be placed in the chart indicating that an attempt to see the patient was made. 3.6 Electives Several electives are possible during the full training period. To request a clinical elective, a written request for a specific elective must be submitted to the program director by the 15 th of the preceding month at the latest. These forms are available on the MedHub website. The form must be completed and signed by the faculty 25

26 member supervising the elective. The request will be reviewed by the Program Director meeting and signed off, if approved. If no request for research or a clinical elective is received, then the Fellow will be assigned to clinical service for the month. Approved Electives within UT Southwestern: GI/Liver Pathology Pediatric GI GI Radiology Surgery Advanced Hepatology/Liver Transplant Additional electives may be created to suit individual needs with agreement between the Fellow and the program director, but sufficient time (usually 2-3 months) is needed in order to set up a special elective, both logistically and with the GME office to make the elective eligible for ACGME credit Scholarly Activities Precede Clinical Electives In order to ensure meeting the ACGME scholarly activity requirements, fellows should use their research/elective blocks for scholarly activities until substantial progress has been made on their project (see benchmarks in section 6.4). During the research/elective months, the fellow will also serve as backup to the clinical services in the event of a personal emergency for another fellow assigned to clinical service. Research/elective rotations are hospital-specific. In other words, if a fellow is assigned to VA Research they must be physically present at the VA in the designated research area for the majority of the day and attend the VA teaching conferences. There is a sign-in sheet located at the VA (with Cindy Pahanish) and Parkland (with Debra Riggs), which serves as documentation that the fellow was on site daily during elective/research time GI/Liver Pathology - Dr. Lan Peng Assistant Professor Objectives: Understand the indications for obtaining pathology sampling in clinical gastroenterology and hepatology. Learn indications and contraindications to gastrointestinal and hepatic pathology tests. Understand the technical aspects and limitations of obtaining, preparing and interpreting pathology such as liver biopsies, special stains, etc. Learn with supervision of a pathologist how to identify basic abnormalities of gastrointestinal and liver biopsies Understand limitations to biopsies and how the clinician can help the pathologist. Description: It is usually a two week rotation, however the length of the rotation can be adjusted upon approval of the GI fellowship program director and Dr. Lan Peng. The rotating GI fellow meets with Dr. Peng in the first/starting day of the elective rotation for a brief orientation and schedule discussion. The GI fellow attends daily reading and discussion of the available cases in the morning (8:30 to 11:30 am) and in the afternoon (1:00 to 4:00 pm) if he or she does not have clinics duty, research or conference. Interesting GI cases would be discussed. On the last day of the rotation, the GI fellow meets with Dr. Peng to discuss overall rotation experience. Evaluation: The GI fellow is evaluated based on attendance, interpersonal and communication skills, medical knowledge, practice-based learning and improvement, professionalism, system-based practices and overall/summary as listed in MedHub system Pediatric GI Objectives: Understand the common and uncommon disorders of pediatric gastroenterology. 26

27 Perform consultation on pediatric patients and learn the differences from adult patients. Learn the indications and contraindications and limitations to endoscopic procedures. Learn how to follow-up pediatric patients into an adult gastrointestinal practice. * Note that obtaining privileges at Children s Medical Center can take up to 6 months, so fellows who wish to rotate at CMC must plan to do so far in advance in concert with the Program Director and Fellowship Coordinator GI Radiology - Dr. Edward Chen - Chief of GI Radiology, Associate Professor in Radiology Pager: Objectives: Understand the indications for radiographic imaging in clinical gastroenterology and hepatology. Learn indications and contraindications to gastrointestinal and hepatic radiographic tests. Understand the technical aspects and limitations of performing a radiographic test such as sonogram, CT scan, MRI, angiography, fluoroscopic studies, etc. Learn normal basic anatomy as seen on CT abdomen, sonography, plain abdominal films. Learn basic abnormal findings and be able to generate a differential diagnosis. Description: It is usually a two week rotation, however the length of the rotation can be adjusted upon approval of the GI fellowship program director) and Dr. Edward Chen. Depending upon the total fellow complement, this rotations may be either mandatory or elective. The main contact radiology staffs for the elective rotation are Dr. Edward Chen, Dr. Anthony Setiawan and Dr. Ivan Pedrosa (Chief of MRI). Both Drs. Chen and Setiawan work in Parkland Hospital body imaging division (CT abdomen, Ultrasound and Fluoroscopy). The rotating GI fellow meets with Dr. Chen in the first/starting day of the elective rotation for brief orientation and schedule discussion. The GI fellow attends daily reading and discussion of the available cases in the morning (8:30 to 11:30 am) and in the afternoon (1:00 to 4:00 pm) if he or she does not have clinics duty, research or conference. Interesting GI cases would be discussed. If Dr. Chen and Dr. Setiawan are not available (due to scheduling, procedures, etc.), other radiology staff in the reading room will be available for observation at their workstations. The modalities covered for the rotation will include CT scan, ultrasound and fluoroscopy, with possible MRI and interventional radiology exposure depending upon the length of the rotation and availability. The fellow needs to attend HCC multidisciplinary conferences which takes place in CUH conference room every Friday at 12 pm, as well as GI Malignancy Work Group conference at the North campus (ND3.218). The cases covered by different modalities are not limited only to gastrointestinal system, will likely also include GU system and trauma. On the last day of the rotation, the GI fellow meets with Dr. Chen to discuss overall rotation experience. Evaluation: The GI fellow is evaluated based on attendance, interpersonal and communication skills, medical knowledge, practice-based learning and improvement, professionalism, system-based practices and overall/summary as listed in MedHub system. Textbook/Resource: Available and will be provided during the elective rotation GI Surgery Objectives: Understand the indications for surgical management of GI disease general surgery or subspecialty such as hepatobiliary, colorectal, etc. 27

28 Perform consultations and evaluations on surgical patients as required of the service. Perform minor surgical procedures as deemed appropriate from the service Attending. Learn about surgical risks and complications and how to handle post-operative patients. Observe a variety of complex surgeries and how this integrates into care of gastrointestinal or liver disease Liver Transplantation Objectives: To learn the appropriate testing necessary for assessment of and consideration for orthotopic liver transplantation. To learn the appropriate pre- and post-operative management of patients awaiting and who have undergone liver transplantation, in both the inpatient and outpatient setting. AM Noon PM Monday Tuesday Wednesday Thursday Friday 9.00 OLT Inpt 8:00 GI Grand 9.00 OLT Inpt Rounds 9.00 OLT Rounds Rounds 8:00 OLT Clinic Inpt Rounds 9:00 IR Procedures (POB#700) 1:00 Pediatric Tx Clinic 4:00 Peds Immuno Rounds OLT Selection Conf 1:00 GI CC or OLT Clinic Liver Transplant Meetings* 1:00 GI CC or Mayo Clinic 12-1Liver Conference 1:00 Thiele Clinic Tx = transplant; OLT = liver transplant * 1st Wednesday: transplant protocols; 2nd Wednesday: Outreach; 3rd Wednesday: M&M Schedule Priorities Liver Transplants/Procurements go to OR, even at night to observe IR procedures never seen before (TIPS, TACE, etc.) Urgent inpatient liver transplant evaluations Check IR schedule (go and see procedures you ve never seen before) 8:00 IM Grand Rounds 12-1 Liver Tumor Board 1:00 GI CC or Mayo/Jordan Clinic External Rotations Occasionally a Fellow s desired are of expertise would benefit from an experience rotating outside UTSW. The GI Fellowship Program recognizes that there is often great educational value in these experiences, although there are important caveats to consider. Fellow salaries come from the hospital at which they are assigned, and are not transferable to another institution. Thus, a regular paycheck from Parkland will not be received during the time that a Fellow is on an external rotation. Some foundations provide stipends for Fellows rotating at centers of expertise (e.g Crohns & Colitis, American Motility Society) to offset this financial loss. If a Fellow uses their vacation time for an external rotation, they will, of course, continue to receive their regular paycheck. ABIM does not allow more than 30 days away from the program (including all vacation and other time off) per year, so this also has to be considered. ACGME also stipulates that the Fellow may not be away from their continuity clinic for more than 30 days. 4. Requirements for Endoscopic Competency Adequate training in endoscopy involves more than reaching a landmark, such as the cecum. The trainee must become competent in detecting and interpreting normal and abnormal mucosa or lesions and must learn how to deal with them. Procedures can only be counted as completed if they fulfill the following: 28

29 They must be logged EGD requires advancement of the endoscope into the second portion of the duodenum Enteroscopy requires advancing the endoscope beyond the ligament of Treitz Colonoscopy requires advancing the endoscope into the cecum/terminal ileum, with identification of the ileocecal valve, appendiceal orifice, cecal strap or an anastomosis Flexible sigmoidoscopy requires advancing the colonoscope at least 40 cm into the colon The minimal number of procedures suggested by the ASGE that must be completed to be considered for competency are: Esophagogastroduodenoscopy 130 Non-variceal hemorrhage 25 Variceal hemorrhage 20 Esophageal dilatation 20 Colonoscopy 140 Snare polypectomy and hemostasis 30 Percutaneous endoscopic gastrostomy 15 Capsule endoscopy 25 Number of procedures alone does not determine competency. The level of endoscopic competency (novice, master, expert) is determined through a combination of procedure numbers AND evaluations of cognitive and technical skills. It is recognized that proficiency may take longer for some individuals than for others. The Program Director will certify competency for a specific procedure if it is the faculty s opinion that competency has been achieved based on review by the Clinical Competency Committee of all evaluations. 4.3 Endoscopy for Surgery Residents This document briefly outlines education objectives for Surgery Residents rotating on the UTSW GI service. The UTSW Division of Digestive and Liver Diseases Surgery Resident Policy and Procedure Manual highlights expectations of surgery residents rotating at Parkland hospital and serves as another document with which to highlight the objectives of the rotation. We require all surgery residents to read this document carefully. The GI endoscopy experience is to enhance endoscopy skills and assist in training for GI related illness. It is necessary for the surgery resident to train with the endoscopy simulator (Simbionix) equipment located in the endoscopic skill training center located on the 6th floor of the SIMS unit prior to the endoscopy rotation. Competency in endoscopy is not assured in this brief rotation as the volume is typically less than minimal threshold standards set by the American Society of Gastrointestinal Endoscopy, Society of American Gastrointestinal and Endoscopic Surgeon, and American Society of Colon and Rectal Surgeons. Objectives Recognize and understand pathophysiology of common gastrointestinal disorders, including but not limited to esophageal dysmotility, GERD, peptic ulcer disease, GI bleeding, portal hypertension, intestinal dysmotility syndromes, pancreatic insufficiency, intestinal ischemia, and diarrhea Know indications for and potential complications of endoscopic procedures. Procedures The surgery resident is expected to arrive at by 7am every day and leave when the entire GI team has completed the day s work. Surgery residents are excused from the GI service to attend the Department of Surgery Grand Rounds. Under appropriate supervision, demonstrate proficiency in these endoscopic procedures: Esophagogastroduodenoscopy Flexible sigmoidoscopy 29

30 Colonoscopy with biopsy and polypectomy 5. Educational Conferences Trainees participate and present in a number of conferences throughout the Fellowship program. Objectives Advance knowledge of Fellows, Faculty, Housestaff, Students, and Consultants from other disciplines Stimulate research and scholarly activities Provide opportunities to improve teaching and public speaking skills Facilitate interaction with experts outside of our division and institution 5.1 Attendance Every effort should be made by Fellows and encouraged by Faculty to attend relevant educational conferences. The majority of the conferences occur on Wednesday mornings and Monday evenings, when routine clinical responsibilities have been cancelled, thus attendance is mandatory. A sign-up log is kept (Fellows can opt to sign in via EthosCE for CME credit but this will not be used towards tracking fellowship attendance). Failure to attend a minimal number of conferences may result in not fulfilling the ACGME requirements for graduation (90% Department expectation, 80% ACGME expectation), and will result in removal of moonlighting privileges. Prompt arrival at all conferences is emphasized. 5.2 GI/Liver Conferences at UT Southwestern The educational conferences held at UT Southwestern offer a broad array of educational opportunities and encompass multiple disciplines of GI and Liver diseases. The Division of Digestive & Liver Diseases follows the core curriculum suggested by the American Gastroenterological Association. All essential topics are covered at least once every 3-years to ensure that Fellows are educated on all basic and clinical aspects of GI and Liver diseases during their Fellowship tenure.. Most conferences are held on Wednesday mornings from 8:00-9:00 am and Monday evenings from 5:00-6:00 pm. Exceptions are noted below. Administrative support is available to answer your pages and take messages during the Wednesday morning conferences. Please refrain from using cellphones and/or texting during conference as this only detracts from the learning objectives Core Curriculum The Core Curriculum Series teaches clinical assessment and management of common GI and Liver diseases. Didactic talks are provided by UT Southwestern Faculty and are geared specifically towards Fellows. Theres talks are generally delivered during the Monday conference times. Topics covered in the Core Curriculum are important topics that every gastroenterologist should know. The Core Curriculum follows a 3-year rotational pattern to ensure that each Fellow receives a comprehensive education Visiting Professors The Division of Digestive and Liver Diseases supports a robust program of visiting professors which seeks to bring to UT Southwestern the most prominent scholars in our field. Several named lectureships exist that support specific areas of interest. For example, the Burton Combes lectureship supports a leader in the field of hepatology, and the Willis Maddrey lectureship supports a pediatric-adult gastroenterologist. Visiting professors typically stay for 2 days and are available to meet with any Fellow who is interested. Our visiting professors are sometimes also scheduled to talk at Internal Medicine Grand Rounds on Fridays at 8am and Fellows are strongly encouraged to attend these talks as well GI Grand Rounds UT Southwestern has a breadth of faculty expertise in the basic and clinical sciences, so faculty lectures may be given by members of the Division of Digestive & Liver Diseases, or by members of other 30

31 divisions/departments. These talks are generally given during the Wednesday 8 9 am conference and offer a higher level State of the Art talk including controversial topics and innovative areas in the field UTSW GI and Liver Pathology Faculty from the Department of Pathology lead case-based discussion and instruction of pathological findings. The pathology series includes an Introductory talk in GI and Liver separately as well as a Board Review/High- Yield talk in each area UTSW Radiology Conference Faculty from the Department of Radiology lead instruction of GI/Liver-relevant radiological findings. Fellows may be assigned specific radiology conferences for which they are responsible for identifying potential cases for discussion. If so, the assigned Fellow should discuss the cases with the Radiology faculty member at least 2 weeks prior to the conference date and should be prepared to provide relevant clinical information on the cases at the conference Citywide Clinical Case Conference Case presentations are utilized during conferences as an interactive method of teaching the development of a differential diagnoses and management of both common and uncommon GI and liver diseases. Conferences include IBD, Motility, Hepatology and Pancreaticobiliary cases. Faculty are assigned specific times to moderate cases and will work with the Fellows to discuss instructional cases. Typically, the Fellow will present the case (succinctly) and the faculty moderator will punctuate the presentation by engaging the audience in developing the differential diagnosis, management plan, and discussion of nuances of the case. The assigned Fellow should discuss the cases with the faculty moderator at least 2 weeks prior to the conference date. Faculty with expertise in the area being discussed should be specifically invited to be present and comment upon the case discussion Fellow State of the Art Talk See section on SAC below. Briefly the fellow presents a Grand Rounds-style talk in their area of expertise that they have developed during fellowship through their scholarly pursuits. The talk should be of the same substance and caliber of an invited talk at another academic institution or a talk given when interviewing for a position as an Assistant Professor. Every effort should be made by the faculty mentor to be present at the time of the presentation to the division Morbidity & Mortality M&M conference is held regularly to discuss, issues of quality improvement for patient care. These may be case-based discussions or comprehensive evaluations of system-based practices. Both Fellows and Faculty work jointly to develop the program for this conference Joint Pediatric Adult GI/Liver Symposium There is an annual joint conference co-sponsored by the Division of Pediatric Gastroenterology and the Division of Digestive & Liver Diseases. The symposium highlights a prominent speaker in an area that is relevant to both pediatric and adult gastroenterology/hepatology and case discussions are held. The purpose of the symposium is to stimulate interaction between the two divisions Fellow/Faculty Development Sessions Scattered throughout the year are sessions dedicated towards professional development. Examples of topics include career advice and training in new system practices. 5.3 Additional Conferences Outside of Monday/Wednesday Series Hepatocellular Carcinoma Conference HCC Conference is held on Fridays at noon in the CUH Education Center conference room. This is a multi-disciplinary case management conference where radiology, surgical oncology, and hepatology review 31

32 HCC cases and determine the best plan of action. Attendance at this conference is mandatory for the Fellow rotating on the Parkland Ambulatory rotation. Potential cases for discussion should be submitted to Janet Ingram the week prior to conference GI Malignancy Conference GI Malignancy conference is held on Wednesday mornings at 7am on the North campus. This is a multidisciplinary working conference where case management of GI and liver malignancies is discussed with gastroenterologists, hepatologists, surgeons, radiologists, and oncologists Obesity & Nutrition Conference Obesity & Nutrition conference is held on Thursdays at noon. Visiting professors and presentations from UT faculty and trainees highlight the pathophysiology of obesity and its complications Ethics Grand Rounds Ethics Grand Rounds is held monthly in the D building. Visiting professors discuss ethical issues in medicine such as end-of life care, organ transplant allocation, physician biases and influences, and impact of religion and socioeconomic status on medical care Internal Medicine Grand Rounds Internal Medicine Grand Rounds is held Fridays at 8am in the D building conference rooms. Faculty from the Division of Digestive and Liver Diseases and visiting professors invited by our division frequently speak at this venue and Fellows are expected to attend their talks Liver Transplant Selection Committee Meeting The liver transplant selection committee convenes on Tuesdays at noon in 5 th floor POB 1 Suite 520 to discuss potential candidates for transplantation. Fellows who are rotating at Clements University Hospital on the liver transplant service are expected to make every effort to attend and may be asked to present cases to the committee or provide updates on inpatients Liver Conference This is a multidisciplinary multifunctional conference that addresses issues in liver disease. It occurs each Thursday at noon in the 5 th floor POB 1 conference room Suite 520. Topics include pathology, cases, research, journal club. It is open to all fellows, but the fellow rotating at Clements University Hospital on the liver transplant service should make a special effort to attend. 5.4 GI/Liver Conferences at the Dallas VA Hospital In addition to the conferences at the medical school on Monday evenings and Wednesday mornings, all GI/liver Fellows assigned to rotations at the Dallas VA will attend the following conferences held on the VA campus VA GI Pathology Conference 7:30 am on the 1 st and 3 rd Tuesdays Held in the Pathology Microscope room in the DVAMC pathology department. This conference is both a didactic and working conference, with a focus on learning GI pathology for the GI board exam, and for review of interesting patient cases. The GI pathologist at the conference, Dr. Teri Crook, should be contacted several days prior to conference with a list of interesting cases that can be reviewed VA Journal Club 7:00am on the 2 nd and 4 th Thursdays Held in the GI Fellows conference room in the GI lab. Two presenters are assigned to each conference date (one Attending and one Fellow). A schedule for the year of these presenters is distributed at the beginning of each academic year. The Fellow is responsible for review of current advances and publications in the literature, presenting approximately 5-6 articles each journal club. The complete journal club schedule for the year and more detailed instructions will be sent via . 32

33 5.4.3 GI-Surgery Conference 7:00am on Fridays Held in the surgery conference room, 5B-606, on the 5 th floor. The junior Fellow assigned to GI consults and the surery residents will alternate weeks presenting one case for discussion. This is a didactic as well as a working conference where the Fellow should try to present a case relevant to both the GI and surgery teams, if possible. 6. Scholarly Activity 6.1 Expectations - Clinical Fellow (non-t32) Expectations There is a formal expectation that all fellows will actively participate in scholarship. This is not only a priority for the division but also a requirement for the fellowship to maintain ACGME accreditation. Each first-year fellow must choose between the Clinical Educator and Clinical Research tracks. CLINICAL EDUCATOR TRACK The Aims of the Clinical Educator Pathway are to: Engage fellows in clinical teaching Provide an opportunity to create and give didactic lectures Provide an opportunity to produce a substantive educational product or complete an education-related research project Fellows will have opportunities to receive formal training in education and program building. Year 1 of Fellowship Apply for Clinician Educator Track Identify a mentor and decide on an educational scholarly project Years 2 and 3 Design and complete educational scholarly project Additional requirements: Deliver two advanced level lectures per year during the second and third years of fellowship on a clinical topic (total of four lectures during fellowship) Alternatively, fellows can choose to run one evening board review session as a substitute for the second lecture Complete one original or non-original work Definitions for Clinical Educator Track Definition of Original Educational Project Fellows must be active participants in the design, performance, and evaluation of any educational project. Wherever feasible, fellows are encouraged to publish or present results at national meetings, although this is not a requirement per se and may not be applicable to some projects. 1. Develop a curriculum, including concept, design, recruiting speakers, advertisement, CME accreditation and funding (if applicable), and post event evaluation. The curriculum could be for: a. Medical students b. Residents (e.g. ambulatory lecture series) c. GI Fellows (e.g. use of simulators, endoscopic skills camps) d. Nursing staff e. Faculty Development 33

34 2. Develop and validate a method of assessment for competence or an educational tool, for example a. Endoscopic skills assessment b. Video instructional tool 3. Complete a systematic review / meta analysis on a chosen topic and present the results to the fellows and faculty Definition of Clinical Educator Lecture a. A Review of a Clinical Topic to be presented at Wednesday am conference on a given topic to be chosen in advance. There will be a faculty mentor for each presentation and it is expected that the content will be reviewed with the assigned mentor. b. Each presentation will last 45 minutes and there will be15 minutes for questions CLINICAL RESEARCH TRACK The aim of this track is to train future leaders in clinical and outcomes research. Fellows who show outstanding aptitude may be considered for enrollment in the T32 Research Fellowship track Year 1 Apply for Clinical Research Track Work with program directors to identify research mentorship team and potential areas of research Years 2 and 3 Develop and start project with research mentors Complete Research Project Additional Requirements: Deliver a State of the Art lecture at Digestive and Liver Disease Grand Rounds (Wednesday Forum) on area of clinical research (Year 3) Complete two original research projects Complete one non-original work Complete the online training of Research HIPPA, Good Clinical Practices, and Human Subject s Protection Definitions for Clinical Research Track Definition of Original Research Project Fellows must be active participants in the design, performance, and submission for publication of any study. Studies must include a hypothesis, aim(s), appropriate methodology, collection of data, creation of an appropriate dataset, analysis of data, and production of a manuscript under the guidance of a member of the GI division. Research projects may occur outside of the division, only with the approval of the Fellowship Program Director and the Fellowship Research Committee. Examples of acceptable and encouraged clinical research include the following: Systematic review Case-control study Prospective cohort study Clinical trial Cost-effectiveness analysis Meta-analysis Definition of State of the Art Research Talk for Clinical Research Track Fellows a. the type of talk that an Assistant Professor candidate would give when interviewing for a position 34

35 b. 60 minutes in duration, with 45-minute presentation and 15 minutes for questions c. First 30 minutes is usually a grand-rounds overview of the field of study, followed by 15-minute presentation of the research project and results. General Expectations It is expected that time allotted for scholarly activities will be used for that purpose. It is also expected that the Fellow will be physically present at their assigned hospital site performing their scholarly activities. Time away from scholarly activities during the research/elective rotation is allowed for: Regularly scheduled teaching conferences The Fellow s ongoing GI and/or liver continuity clinic Absences for any other reason need to be approved by the fellowship program leadership Because failure to complete the scholarly activity requirements could result in a deferment of board eligibility, if a Fellow's scholarly activity is not progressing as expected (determined by the minimum benchmarks listed below), it is expected that clinical electives will be used to provide the necessary additional time required to complete their activities. Activities that will not meet the scholarly activity requirement for completing the Fellowship include: Collection of research data only with no attempt at publication Submission of data in abstract format only (without acceptance and presentation). Research manuscript in progress at the end of Fellowship. Planning of educator project without carrying it through Faculty Expectations The faculty in the division will facilitate scholarly activities of Fellows by cultivating an environment that encourages and rewards research, education, and scholarship. Faculty mentors should provide a suitable environment and be available to adequately supervise projects by meeting regularly with the trainee. Prior to research/elective blocks, faculty mentors should meet with their mentee and clearly explain goals, expectations, and set meeting times. The scholarly activity request form should be completed and submitted to the Fellowship Scholarly Activity committee for approval by the 15 th of the preceding month. Faculty are expected to provide close guidance in preparation of Works in Progress Sessions (WIPS) presentations and to make every effort to be present for these talks. Strong commitment to the trainee and the project is essential. A crucial element of the Fellows projects is that they need to have some assurance of completion during the training period. In most instances, research studies will not require prolonged follow-up or the development of new techniques; rather, they will build upon existing techniques or databases that are available in a mentor s laboratory or clinic. It is expected that faculty will exemplify professional integrity in ethical matters such as appropriate authorship, conflict of interest, relationships with vendors, human subject protection, and scientific conduct T32 Research Fellow Expectation The requirements for the T32 Research Pathway are to 1. Complete* one original research project 2. Deliver a state of the art talk to the Digestive & Liver Diseases Division in the area of This represents a minimum level of satisfactory productivity and in general the expectations for T32 fellows are higher, given the increased time protected for research.. Acceptable research will consist of hypothesis driven collection of data followed by submission of data for publication. Research performed in the T32 program is generally highly mentored and structured individually 6.2 Documentation of Publications UTSW is proud of the scholarly accomplishments of their trainees. The program must generate frequent reports to ACGME, GME, NIH, and other governing bodies with detailed descriptions of scholarly output of trainees in the program. Thus, it is imperative that we have a single and complete source of documentation for reference. Submitted and accepted publications should be entered into MedHub on a timely basis. At a bare 35

36 minimum, this needs to be updated twice a year. At the time of final checkout, graduating Fellows must have this section up to date. 7. Feedback and Evaluations Evaluations are filled out electronically through Medhub. It is also expected that the Attending physician will confidentially provide a verbal evaluation at the end of each rotation. 7.1 Faculty Evaluations of the Fellow Each member of the faculty will be asked to fill out an electronic evaluation for each Fellow after each rotation. The evaluation is only available to the trainee after they have completed their evaluation of the faculty member. Each trainee meets with a member of the Clinical Competency Committee twice a year. Trainee progress and specific suggestions for improvement are discussed. The trainee will receive a written report that must be signed by the Fellow and Program Director and is placed in the trainees file. An additional component of the Fellow evaluation is termed 360-degree feedback. 360-degree feedback is an evaluation method that incorporates feedback from the Fellow, his/her peers, superiors, staff (generally nurses and patients). Results of such confidential surveys are tabulated and shared with the Fellow annually. The primary reason to use this full circle of confidential reviews is to provide the Fellow with information about his/her performance from multiple perspectives. 7.2 Fellow Evaluation of the Faculty These evaluations are an absolute requirement of the program. They are performed with our web based evaluation tool (MedHub) and are anonymous. To ensure confidentiality so that the faculty is unable to tell which Fellows made comments, results of the evaluations are released to the faculty at 6-month intervals and not after the end of each rotation. If for any reason, any Fellow believes there is any unprofessional or retaliatory behavior on the part of an Attending, the Fellow should inform any program director, or the division chief without fear that specific information will be divulged. 7.3 Program Evaluation Fellows complete two anonymous mandatory surveys every year about the program. One is an internal survey ( Review Roundup ). Results of this survey are collated, anonymized, and reviewed with the Program Evaluation Committee, the faculty, and trainees. If changes need to be made to the program as a result of the survey, deficiencies or areas of strength are identified, these are taken up by the Fellowship Program Director, who will make changes based on the responses. The second is administered directly by the ACGME to the fellows as a source of information to help determine credentialing status of the program. If deficiencies are identified, the ACGME may either issue a formal citation(s) to fix the issue(s) immediately, or place the program on probation. 8. Educational Funds Each fellow is allotted $1200 annually for Educational Use including travel to conferences and books. Unused funds do not carry over into the next academic year. The Division will also provide limited access to statistical support for Fellow s projects (max $500). 8.1 Educational Travel In general, if you know that you would like to attend a conference, it is preferable to have this encumbered when the annual schedule is made. However, given the flux of abstract submission and the possibility that an abstract may or may not be accepted, it may be difficult to organize the trip far in advance. If you submit an abstract and are eligible to attend a national meeting, you must submit a leave request (located on the 36

37 MedHub homepage) to Debra Riggs, the Program Coordinator. This request must be approved by the Program Director. Coverage for missed clinical service, call, and clinic are the responsibility of the Fellow. Absence from clinical duties for conferences are counted as personal time off (PTO) days, which are capped at 25 weekdays per year. Illness, interviews, funerals, jury duty, vacation and holidays are also PTO days. Basically, any weekday not spent at work is a PTO day. Most fellows schedule 15 days of vacation per year (the upper limit), so we strongly recommend limiting conference days to 5 per year, which will then allow for 5 days for illness interviews, early departure for another fellowship, etc. Each fellow is allowed 3 weekdays and 2 weekend days of guaranteed coverage and $1000 to go to any conference(s) from this list: ASGE First Year Course ACG Second Year Course ACG annual meeting AASLD annual meeting DDW Steinberg or Mayo Review Course ACGME annual meeting AAMC annual meeting Other meetings would require approval from the Program Director. For example, fellows who have applied for additional advanced endoscopy fellowship training may be eligible to attend an advanced endoscopy course. Fellows are encouraged to submit their scholarly activities for presentation at one of these meetings, and that would count for their 1 st meeting that year. If the 3 weekdays are not used for the 1 st meeting, they may be applied to a 2 nd meeting. Reimbursable costs for all meetings together are capped at the annual education funds allotment. If they have no scholarly activities to submit, they may still go to one of those meetings each year. If they have multiple scholarly activities to present at multiple meetings in the same year, then the subsequent meetings have to be approved by the Program Director. If approved, the fellow must use their PTO. Other sources (T32 funds, travel grants, mentor s funds, personal money etc.) may be used to supplement fellow travel. Coverage of clinical duties is to be arranged by the traveling fellow and approved by the Chief Fellow and Program Director. Travel Policies a) Fellows will need to notify the Fellowship Program Coordinator as soon as possible for assistance in completing the necessary travel paperwork. This is critical for reimbursement also. b) Policy regarding attendance to outside conferences Conferences offered specifically for Fellows-in-training may have full or partial funding. Often, only one or at most two Fellows can be nominated by each Fellowship program for a travel grant. Our aim is to allow educational conferences approved by the Fellowship directors to be attended by a variety of Fellows with first preference being given to those with specific academic career plans or research interests that fit the specific course topic. This process is expected to provide fair and equitable access to educational conferences to our Fellows. Attendance to all outside conferences must be approved by the Fellowship directors and must not conflict with other scheduled duties. c) There are several general principles that should be kept in mind. 1. Neither a mentor nor the division will be expected to fund companion (i.e. significant-other) related travel expenses. 2. To maximize our educational funds we ask that trainees attempt to share costs as much as possible ( e.g. share a double room) 3. Depending on other responsibilities and availability of funds, fellows should not expect to attend the entire meeting. 37

38 4. For those Fellows in whom the mentor has funding to support travel, it is imperative that the Fellow and mentor adjust their travel budget to what is available to them, as the Division will generally not be expected to make up any difference. 8.2 Reimbursements a) All airfare must be booked with UT Southwestern Travel Agencies Anthony Travel or Corporate Travel Planners (Tonya Crews will make reservations). Please send all trip details to Tonya. All business related trips require a prior Travel Authorization to be submitted at least 30 days in advance. Fellows will not be reimbursed for travel purchased outside of this agency. b) Fellows are expected to keep all original receipts for reimbursement. Alcohol is non-reimbursable. As any expenses approved after 90 days becomes taxable, it is recommended that all receipts are submitted to Tonya Crews within 5 days of returning. 8.3 Book Allowance Each fellow can use a portion of their annual educations funds towards the purchase of study material or poster printing. The exact item(s) should be approved by the Program Director before purchasing. 9. Duty Hour Limits Limits set forth by the ACGME are strictly adhered to. Trainees are not allowed to work over 80 hours per week averaged over a 4 week period, must have at least one day off per week averaged over a 4 week period and cannot work more than 24 consecutive hours. Moonlighting activities (see below) count towards the work hour limit and thus, if you moonlight, you must not exceed the total work hour limit. Fellows must fill out a daily work hour monitoring sheet (electronic) every week in MedHub). Completion of duty hours in MedHub is monitored closely by the GME office and is not optional. Any breach of the duty hour limits will be electronically reported to the training program director and the GME office. 10. Administrative Contact Debra Riggs & Tonya Crews are our Program Coordinators, and may be contacted for all administrative issues related to the Fellowship Training Program; they can be reached as follows: OFFICE: PHONE: POB 1, Suite HP5.520A (214) Deb (214) Tonya FAX: (214) MAIL: Box Debra.Riggs@UTSouthwestern.edu Tonya.Crews@UTSouthwestern.edu 11. Mail You must check your at least once daily - unless you are on vacation. Mailbox: Your mailbox is on South Campus 5 th floor Building J room 146, the door code is Be sure to check it frequently. You will receive important information by mail that you will miss if you do not check your mail regularly. Important information may also be mailed to your home address in an envelope labeled FELLOWSHIP INFORMATION. Mailing Address: Gastroenterology (9151) UT Southwestern Medical Center 5323 Harry Hines Blvd Dallas, TX

39 12. Compensation and insurance Paychecks are issued by Parkland Memorial Hospital. Questions about compensation and insurance should be directed to PMH Coordinator, Elizabeth Ponce ( ). At the current time, it is a policy of the division that Fellows at the identical PGY level receive the same salary, regardless of track. 13. Parking VAMC: Parking is free. UTSW: Parking permits cost $400 (faculty level) or $120 (student level) per year, pro-rated to September 1, when the price may go up. Permits can be purchased in the Visitor s Information Booth on the Plaza (South Campus). Fellows usually park at Parkland. PMH: Parking permits cost $15 per pay period (automatic deduction, $390 yearly) and can be purchased from the Parkland Security. A free UT parking tag will be issued if you pay full parking at Parkland. Note that Fellow parking in the faculty garage (#1) is limited to the rooftop. You may contact Juanita Diaz at for any questions. 14. Pagers Pagers are issued for use by GI Fellows. Replacement batteries are your own responsibility, but can be found in virtually any administrative area. Any problems relating to your pager will be handled by Tonya Crews at POB 1, Suite 520, HP5.520A ( ). You are responsible for these, and their loss may result in replacement costs. A list of faculty and Fellow pagers and phone numbers are included (see Appendix). 15. Dress Code Dress falls under the rubric of professionalism, and fellows should dress professionally at all times (including research/elective months). Business or business-casual dress is expected. Specific hospitals have specific dress codes which must be followed (appendix). Hospital-issued scrubs are the only acceptable alternative to business-casual dress, although scrubs should not be worn in clinic. Fellows traveling to conferences are ambassadors of our institution and are expected to dress in business attire for presentations and business casual at other times Lab coats Three personalized laboratory coats will be purchased by the division for each Fellow through the UT Southwestern Student Store (C.1002, next to the cafeteria) during the Fellowship. Tonya will order your coats per lab coat request form sent to you via and will notify you when your coats are ready to be picked up. One additional lab coat will be provided each year. Additional coats may be ordered at your own expense. Lab coats are expected to be kept clean.. In order to assist with this, the department provides free drycleaning of coats for the fellows. Coats can be dropped off in the laundry basket located in the J5 mailroom (J5.146) and will be available for pick up the following week. 16. Media services Currently, the vast majority of media available from the library is available electronically for free. If you are unsure as to how to access the library, please do not hesitate to ask. In general, most artwork and presentation can now be prepared electronically and typically should not encumber additional cost. Whenever possible, is recommended that you have necessary artwork done at the VAMC, where this is provided free of charge. 17. Vacation Trainees are allowed 15 weekdays of vacation every year, which are counted as PTO (personal time off). Requests for vacations must be turned in by the 1 st of May before the start of the academic year to incorporate this into the yearly schedule. Fellows are strongly encouraged to take vacation in one week blocks to allow for 39

40 ease of scheduling and coverage. Fellows are required to designate another Fellow to cover clinic patients and other calls during working hours. No more than two weeks may be taken in a row, except by approval from the Program Director. Unused vacation time does not carry over for the next academic year. Vacations are discouraged during consult blocks. Vacations only involve the stipulated time-off dates. Extra-time off taken for travel arrangements need to be counted as a vacation day. Note, any terminal vacation i.e. that at the end of Fellowship is not allowed (unless this is specifically planned and built into the schedule when the schedule is developed). If you must leave before the end of Fellowship for a new job and do not have appropriate vacation time available, then you will be expected to take leave without pay. Employee check-out process is required and Debra will assist you with this. A Fellow absence request must be completed at least 10 days PRIOR to vacation and completed upon your return from any sick time. The form is to be initiated in Medhub by the fellows and will be approved by the Program Director and/or Debra Riggs, Program Coordinator. HOUSE STAFF FMLA: At Parkland there is no official paid maternity or paternity leave for House Staff (residents/fellows) or any other employee. However, the Parkland paid residents and/or fellow can use their 25 allocated days of PTO which is five weeks plus any other time using FMLA without pay. Note that ABIM requires no more than 30 days absent per year from the fellowship program for any cause. If more time away is needed, then the fellowship may be prolonged. If you plan to go out on leave for maternity or any other type of leave you have to contact MetLife at to start the paperwork process. Upon returning from leave the Parkland Graduate Medical Education (GME) office requires a work release from their physician stating that they are fit to return to work. In some instances a physician statement is not required; these will be handled on a one-on-one basis. 18. Resident Wellness The Medical Residency Program has recently hired Penny Daus, a nurse with 25 years of experience (military and VA) to be their wellness coordinator and the GI fellowship program has access to her services. If you need to see a psychologist, psychiatrist, therapist, urgent care, general internist, obstetrician/gynecologist, pediatrician, dentist, or any other provider, simply your request to her at Penny.Daus@UTSouthwestern.edu. Please make sure to provide her with: Insurance Information: Insurance, Group ID, Member ID Date of Birth Contact number Mailing address DFW area of preference She will look up available providers and arrange an appointment for you. She will make sure that your insurance is accepted and will determine your deductible and co-pay and assist with any paperwork you may need to submit. Remember, this service will remain confidential, and nobody in the program leadership (Chiefs, APD's, Dr. Kazi, or Dr. Scielzo) will be aware of your requests and appointments scheduled through Penny, unless there is a concern about your personal safety or the safety of others. 40

41 If you have other specific needs pet care, child care, or other general inquiries regarding services that you might need, please Penny and she will find the right options for you Sleep and Deprivation Sleep is important for performance as well as health. Beyond discussion of the importance of sleep and adherence to the 80 hour work week, there are abundant resources that fellow are expected and encouraged to utilize. These include required online training, required PowerPoint presentation about duty hours and resident fatigue in MedHub, and specific courses at UTSW Fellow Safety The Safety and well-being of our fellows is of the utmost importance. If you are ever threatened or uncomfortable in your work environment, please notify the Police Office immediately. There is an escort service available to all employees at all training sites to escort you to your vehicle. The Police at PHHS and SPUH can be reached at x At the VA the following applies: Trainees arriving at the VA after dark are encouraged to park in the lot closest to the Emergency Department. Ideally cars will be moved to an authorized location before 8am. If cars must be left in the lot near the ED during the day, resulting tickets should be taken to the Security Office, where they may be dismissed. Trainees leaving the VA after dark are asked to come to the Police Office by the ED for escort to their vehicles by the first available officer. While the safety and security of the individual residents is of vital concern to the VA police force, campus security must always be the first priority. This may sometimes result in delays. 19. Fellow Jeopardy (emergency back up coverage) system Coverage will be provided by the research fellows assigned for the month and in some cases by T32 fellows (with previous authorization by the Chief of GI and Clinical Program Director Ezra Burstein). On weekends for better patient care, it is preferable if coverage is needed for one day (e.g. Saturday morning with rounds) that the entire weekend is switched. An exemption to this can be emergency night coverage where only calls are covered and no patient rounding other than emergency is involved. 20. Fellow Training Periodically throughout fellowship various training is mandatory. Please be prompt in completing these training before any deadlines Licensure All Fellows must have either a valid Texas Medical License or a Texas Institutional Permit. If you have a Texas Medical License, it is your responsibility to renew your license in a timely manner. You must notify the Texas State Board of Medical Examiners of any change of address in order to receive notification that your license is due to expire. If your license is due to expire and you have not received notification from the Medical Board, it is your responsibility to write or call them and take care of this matter immediately. Texas State Medical Board P.O. Box Austin, TX (512) Please give Debra Riggs a copy of your license renewal registration as soon as you receive it every year. Copies are needed for UT Southwestern Internal Medicine for malpractice insurance coverage, for the Department of Internal Medicine administration, and for Parkland Memorial Hospital. Note: If you do not have a Texas license, your Institutional Permit will need to be renewed before the beginning of the next Fellowship year. Note that there is a 3 year limit on Institutional Permits during GI fellowship and the fellow must obtain their own license after that. 41

42 20.2 ACLS All Fellows are required to have current certification in BLS and ACLS. Recertification is the responsibility of the trainee however the fellowship will assist in allowing time to schedule this activity Moderate Sedation All Fellows are required to have current training in moderate (conscious) sedation Research CITI MANDATORY UNIVERSITY HOSPITAL LEARNING WEBSITE FOR ALL HOUSESTAFF All new fellows are required to complete online mandatory training modules prior to their start date and thereafter ALL fellows are required to complete the training quarterly. You will receive notification from the Parkland GME office with login instructions. 21. Professional Societies Fellows are encouraged to join the different medical societies. Membership to the AGA is mandatory (this is because the AGA is considered the premier society, and in addition, membership to it provides Fellows with subscriptions to Gastroenterology and Clinical Gastroenterology and Hepatology, and because this also provides a discounted rate for DDW registration. The price of membership for AGA will be paid for by the Program. Each Fellow should complete the paperwork to join the AGA prior to beginning their first year, and renew annually for their duration at UT Southwestern. If a first year Fellow has been a previous member then you will need to pay for the membership and then reimbursed. AGA membership renewals can be turned in to Debra Riggs, Program Coordinator for reimbursement with proof of membership and payment within 30 days of transaction. Other memberships will be the responsibility of the Fellow. 22. Moonlighting Moonlighting in the Southwestern GI Fellowship program is discouraged, as it can be disruptive to the education process. Fellows who do not moonlight tend to excel during fellowship and perform better on standardized exams. Upper level Fellows in good standing with the program may be allowed to moonlight, when not on call, with previous written approval from the Program Director. In general, a fellow must be in excellent standing, with in-service score of>40%, conference attendance > 80%, and superior rotation evaluations in order to be approved for moonlighting privileges. First-year fellows are not allowed to moonlight. A moonlighting form must be filled out for each episode of moonlighting since this activity will be counted towards work hour limits established by the ACGME. There is a no tolerance policy re: interference with clinical, educational, or research activities, and moonlighting privileges will be suspended if they interfere with any responsibilities or affect the 80-hour limit. 23. Personal Data Each Fellow has a personal data file that is kept in a file at Debra Riggs office. Please keep her informed of any change of address, phone number, marital status, birth, etc. A copy of your evaluations is also kept. 24. Administrative Responsibilities As a member in good standing of the university community, each Fellow will be expected to complete specific administrative responsibilities (e.g. HIPAA training, EPIC training, TB testing, information technology training),. These elements are considered a professional responsibility (see below). These administrative responsibilities should be completed on time or early. If you are late in completing these, your privileges can be revoked, your paycheck withheld, and you may not be paid for days you do not work. 42

43 Appendix I - Faculty Contact information Contact information has been removed from this public document 43

44 Appendix II - Fellows Contact Information Contact information has been removed from this public document 44

45 Appendix III Handbook Attestation Division of Digestive & Liver Diseases Attestation I have read the Division of Digestive and Liver Diseases Fellowship Resource Manual and agree to abide by the rules set forth. I understand that the Fellowship Resource Manual is a living document which is continually updated with new policies and that a reference copy of the policies is available on MedHub., M. D. Date: 45

46 Appendix IV Important Websites Parkland (PMH): For EPIC Citi portal, paging, Micromedex and much more Med Hub: To view schedules, log procedures, and other Fellowship information Clinical Portal: To access University wide EPIC, PACS, paging Outlook: (or can type gw.swmed.edu in address line) Phone number extensions: 2xxxx = xxxx (PMH) Ex: x28828 (GI lab) 5xxxx = xxxx (UT) 7xxxx = xxxx (VA) 3xxxx = xxxx (CUH) Ext: x34203 (GI lab) Code to Old Parkland GI Lab: 351* 46

47 Appendix V - UTSW Patient Care Priniciples and Professional Standards 47

48 Appendix VI - CUH Subspecialty and Hospitalist Call 48

49 Appendix VII CUH Important Phone Numbers 49