GASTROENTEROLOGY 

GENERAL OBJECTIVES:Gastroenterology is that specialty which concerns itself with the investigation, diagnosis and medical management of disorders of the digestive system including the pancreas and liver.

Only candidates certificated in Internal Medicine or Pediatrics may be eligible for the Certificate of Special Competence in Gastroenterology.

Specialists in gastroenterology are expected to be competent consultants with well founded knowledge of gastroenterology who are capable of establishing an effective professional relationship with patients. They must have sound knowledge of general internal medicine or pediatrics and an appreciation and understanding of the close relationship that often exists between diseases of the gastrointestinal tract and of other organ systems. They should be capable of teaching gastroenterology to students, trainees and allied health care personnel.

SPECIFIC OBJECTIVES:In keeping with their backgrounds in Intemal Medicine or Pediatrics, residents will emphasize the acquisition of knowledge, clinical and technical skills, and attitudes in areas of greater relevance to the appropriate age group. On successful completion of program candidates will demonstrate competence with respect to:

1. Knowledge
   1. the anatomy, embryology, physiology and pathology of the digestive system including the pancreas and liver;
   2. the principles of biochemistry and genetics as they apply to the digestive system;
   3. pharmacology including the principles of metabolism, action and toxicity of drugs commonly used in gastroenterology;
   4. the principles of endocrinology, metabolism and nutrition, oncology, microbiology and psychiatry as they apply to the digestive system;
   5. a sound grounding in the principles of gastrointestinal surgery including the indications for and the complications of operations on the gastrointestinal tract,
   6. a thorough knowledge of diseases affecting the digestive system, pancreas and liver including the epidemiology, pathophysiology, methods of diagnosis, management and prognosis of such diseases;
   7. knowledge of the indications, interpretations, limitations, and complications of diagnostic procedures performed on the digestive tract;
   8. knowledge of new advances in the management of gastrointestinal disorders (e.g. organ transplantation, therapeutic endoscopy).
2. Clinical and Technical Skills
   1. the ability to perform a complete history and physical with particular emphasis on areas specific to the digestive system and its disorders.
   2. the appropriate use of the clinical database to formulate problems and to correctly develop investigational and management plans;
   3. the evaluation and management of gastrointestinal emergencies including acute gastrointestinal hemorrhage, acute abdominal pain, liver failure and removal of foreign bodies from the gastrointestinal tract;
   4. communicating and interacting with patients, families and allied health care personnel;
   5. the selection and interpretation of x-rays and other imaging techniques of the digestive system, pancreas and liver;
   6. the selection, performance, and interpretation of tests commonly employed in gastrointestinal function laboratories (including motility studies);
   7. the selection, performance and interpretation of:
      1. tissue biopsies of the gastrointestinal tract and liver;
      2. endoscopic procedures of the upper and lower gastrointestinal tract; the trainee should be knowledgeable in the use and care of equipment.
   8. appraising and evaluating scientific publications in the field of gastroenterology.
3. Attitudes

Candidates should demonstrate:

1. empathy and compassion for patients and their families;
2. concern for the need of the patient and their families to understand the nature of their illness and the goals and possible complications of investigations and treatment;
3. concern for the psychosocial aspects of the patient's illness;
4. respect for and ability to work harmoniously with other allied health care personnel;
5. recognition of the importance of self-assessment and of continuing medical education in gastroenterology and a willingness to teach others including students, trainees from other disciplines and allied health care personnel;
6. an understanding and appreciation of the role and significance of research in the advancement of knowledge.
7. an understanding of ethical and medico-legal requirements and responsibilities.

CONTENT AND ORGANIZATION OF THE RESIDENCY PROGRAM:

There must be an organized program of rotations and other educational experiences, both mandatory and elective, designed to provide each resident with the opportunity to fulfill the educational requirements and achieve competence in the specialty.

The content and organization of each accredited program in adult gastroenterology must be consistent with the specialty training requirements.

In addition to offering the components noted in the specialty training requirements all accredited programs in adult gastroenterology should offer community-based learning experiences.

Residents must be provided with a graduated increase in individual professional responsibility, appropriate to their level of competence. During the training period, residents must have responsibility for the care of patients with digestive diseases, and must also have experience in the laboratory and in endoscopic and other procedures required for the optimum care of patients.

Exposure to pediatric gastroenterology, if offered, should be separately and specifically identified. This does not require formal affiliation with pediatric programs. Adequate pediatric exposure can be achieved by utilising didactic lectures, seminars, and/or journal clubs as well as in-patient teaching and ambulatory exposure to pediatric patients seen in consultation by the program. Where pediatric and adult gastroenterology programs exist in the same centre it is desirable for residents in the adult gastroenterology program to rotate through the pediatric program.

RESOURCES:There must be sufficient resources including teaching faculty, the number and variety of patients, physical and technical resources, as well as the supporting facilities and services necessary to provide the opportunity for all residents in the program to achieve the educational objectives and receive full training as defined by the specialty training requirements in gastroenterology.

In those cases where a university has sufficient resources to provide most of the training in adult gastroenterology but lacks one or more essential elements, the program may still be accredited provided that formal arrangements have been made to send residents to another accredited residency program for periods of appropriate prescribed training.

Learning environments must include experiences that facilitate the acquisition of knowledge, skills, and attitudes relating to aspects of age, gender, culture, and ethnicity appropriate to adult gastroenterology.

1. Teaching Faculty

There must be a sufficient number of qualified teaching staff to supervise residents, and to provide training in the basic and clinical sciences related to gastrointestinal and hepatic diseases. The teaching staff should have an appropriate nucleus of full-time teachers.

2. Number and Variety of Patients

There must be adequate numbers of patients available to provide opportunities for training and experience in the following areas of adult gastroenterology:

• general aspects of common digestive diseases including those involving the liver and pancreas;
• specific diseases involving all levels of the alimentary tract including genetic, congenital, endocrine, functional, infectious, inflammatory, immunological, metabolic, neoplastic, and nutritional disorders;
• training must be available in the collaborative care of patients undergoing surgical procedures.
2. Clinical Services Specific to Gastroenterology

a.       In-Patient

It is desirable that the service contain designated beds. However, if there are no designated beds, it is essential that there be adequate numbers of patients in whose management the service participates.

b.      Ambulatory

In-patient and out-patient teaching services should be integrated as much as possible, in order to provide continuity of observation of patients both in and out of hospital. Organized clinics or other facilities must be available to provide opportunities for pre-admission investigation and post-discharge follow-up of patients with digestive diseases. Special clinics, such as clinics for hepatic or inflammatory bowel disease, may provide an important part of training.

c.       Consultation

There must be well-developed and efficient intra- and inter- departmental consulting services in the participating institutions with an adequate number of consultations performed annually. In addition to assuming appropriate and progressive responsibility for the care of patients, residents should take an active part in providing a consultation service under supervision.

d.      Community Learning Experiences

Community experiences should be available which provide a learning environment with appropriate supervision and evaluation based on rotation specific objectives. This assumes administrative support and linkages with the program.

e.       Intensive Care Units

Intensive care units, organized for teaching, are required to provide experience in the care of critically ill and injured patients presenting with problems involving the gastrointestinal tract, liver and pancreas, undergoing medical or surgical treatment.

f.        Emergency Care

There must be systematic supervision of residents in order to ensure expertise in the initial management of all types of emergencies involving the digestive system. A broad exposure to medical and surgical emergencies requires an organized consultation service, in which residents participate fully, to all clinical areas, including the emergency department

4. Supporting Services — Clinical, Diagnostic, Technical

There must be appropriate liaison with teaching services in specialized areas relevant to the practice of gastroenterology including all of the following related areas: general surgery, anatomical or general pathology, and diagnostic radiology.

The following facilities and services must be available and coordinated with the overall program for the training of residents:

 .        Adequate diagnostic laboratory facilities and personnel under competent medical/scientific supervision, including all standard hematological, biochemical, and microbiological services. The latter should include virology, mycology and parasitology. In addition, there should be a laboratory capable of performing immunological investigations.

a.       Gastrointestinal function laboratory facilities, adequately staffed and under competent medical supervision. These facilities must be capable of providing well-supervised studies over a broad range of the common gastrointestinal function procedures. The technical staff and the volume and variety of work must be considered adequate by the specialty committee of the College.

b.      A department of pathology with provision for the study of biopsies and other alimentary tract material.

c.       A department of radiology equipped for the performance of routine and specialized techniques applicable to the investigation of digestive diseases including angiography, ultrasound, computer tomography, and facilities for radioisotopic diagnosis and scanning.

d.      Facilities for all commonly used techniques of upper and lower gastrointestinal endoscopy with adequate volume of patients and adequate supervision.

e.       An active general surgical service working in close association with the program, and providing opportunities for collaborative investigation and care of surgical patients. Integration of medical and surgical gastroenterological services, clinics, and conferences may provide an excellent training environment.

f.        Adequate nutritional facilities and personnel for enteral and parenteral nutrition.

g.       There must be adequate facilities and arrangements to ensure the attainment of the technical skills required for the practice of the specialty. These include endoscopy of the upper and lower gastrointestinal tract, biopsy of the liver, esophagus, stomach, small and large intestine and interpretation of functional studies such as secretion and absorption tests, motility studies, pancreatic function, hepatic metabolism and other biochemical and assay techniques.

ACADEMIC AND SCHOLARLY ASPECTS OF THE PROGRAM:

The academic and scholarly aspects of the program must be commensurate with the concept of a university postgraduate education. The quality of scholarship in the program will in part, be demonstrated by a spirit of enquiry during clinical discussions, rounds, and conferences. Scholarship implies an in-depth understanding of basic mechanisms of normal and abnormal states and the application of current knowledge to practice.

1. Organized Scholarly Activities

Organized scholarly activities such as regular teaching rounds and conferences, combined conferences with radiology, surgery, and pathology, tissue biopsy rounds, journal clubs, specific reading assignments, and a formal basic science teaching program must be part of the program.

2. Basic and Clinical Sciences Relevant to Gastroenterology

The academic program must provide education in the basic and clinical sciences related to gastrointestinal and hepatic diseases. This should include the anatomy, embryology, biochemistry, physiology and pathology of the gastrointestinal system; pharmacology and toxicology of agents used in treatment; psychiatry, immunology, genetics, and nutrition.

3. Biomedical Ethics

The academic program must ensure that residents gain an understanding of the basic principles and practice of biomedical ethics and their application to adult gastroenterology.

4. Communication Skills

The program must ensure that residents learn effective communication skills for interacting with patients and their families, colleagues, co-workers from other disciplines and students. Clearly defined educational objectives for teaching these skills and mechanisms of formal assessment should be in place.

5. Patient Care Team

Residents must be given opportunities to develop effective skills in collaborating with all members of the patient care team.

6. Teaching Skills

Residents must be given opportunities to develop effective teaching skills by teaching junior colleagues and students, as well as through conference presentations, clinical and scientific reports, and patient education.

7. Management Skills

Residents must be given opportunities to develop skills in management as applied to adult gastroenterology such as efficient practice and records management and the ethical use of health care resources. Residents should also be prepared for their role as a health care advocate.

8. Quality Assurance/Improvement

The program must provide residents with opportunities to gain an understanding of the principles and practice of quality assurance/improvement. Opportunities should be provided for residents to participate actively in such programs in their hospital departments.

9. Research Opportunities for Residents

There must be a faculty member with the responsibility to facilitate the involvement of residents in research and other scholarly work. The academic program must provide the opportunity for residents to learn biostatistics and the critical appraisal of research methodology and medical literature. Such teaching must include issues related to age, gender, culture, and ethnicity in research protocols and data presentation and discussion. Residents should be encouraged to participate in clinical research during the course of the residency program.

The milieu of scholarship should be enhanced wherever possible by close association between residents and active investigators on the staff.

10. Faculty Research

A satisfactory level of research and scholarly activity must be maintained among the faculty identified with the program.

11. Life-Long Learning

All programs must promote development of skills in self-assessment and self-directed life-long learning. To promote this end, the program should provide opportunities for residents to attend conferences outside their own university.

SPECIALTY REQUIREMENTS:

1. Certification in Paediatrics or Internal Medicine.
2. Approved residency in gastroenterology.

PROGRAMS (WITH TRAINING REQUIREMENTS):

Doctor of Medicine(M.D):

Eighteen months of approved residency training.

Doctor of Philosophy(Ph.D):

Forty eight months(four years)of approved residency training.