gastro 2007 version core curriculum

7/31/2019 GASTRO 2007 Version Core Curriculum

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Presented by the

American Association for the Study of Liver Diseases (AASLD)

American College of Gastroenterology (ACG)

AGA Institute

American Society for Gastrointestinal Endoscopy (ASGE)

THE GASTROENTEROLOGY

CORE CURRICULUMThird Edition May 2007

A Journey Toward Excellence:

Training Future Gastroenterologists


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SPONSORING SOCIETIES

Training standards, guidelines, and resources are regularly updated by societies representing gastroenterology/

hepatology. For up-to-date and/or expanded information, please visit the following web sites:

American Association for the Study of Liver Diseases (AASLD)

1001 North Fairfax

Suite 400

Alexandria, VA 22314

703.299.9766

www.aasld.org

American College of Gastroenterology (ACG)

6400 Goldsboro Road

Suite 450

Bethesda, MD 20817

301.263.9000

www.acg.gi.org

AGA Institute

4930 Del Ray AvenueBethesda, MD 20814

301.654.2055

www.gastro.org

American Society for Gastrointestinal Endoscopy (ASGE)

1520 Kensington Road

Suite 202

Oak Brook, IL 60523

630.573.0600www.asge.org

This third edition of the Gastroenterology Core Curriculum, published in May 2007, supersedes all previous editions. All rights reserved.


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Table of ContentsPage

Preface 2

Overview of Training in Gastroenterology 4

Training in Acid-Peptic Disease 10

Training in Biliary Tract Diseases and Pancreatic Disorders 12

Training in Cellular and Molecular Physiology 15

Training in Endoscopy 19

Training in Ethics, Medical Economics, and System-Based Practice 24

Training in Geriatric Gastroenterology 25

Training in Hepatology 29

Training in Inflammation and Enteric Infectious Disease 32

Training in Malignancy 35

Training in Motility and Functional Illnesses 38

Training in Nutrition 42

Training in Pathology 45

Training in Pediatric Gastroenterology 47

Training in Radiology 48

Training in Research 50

Training in Surgery 53

Training in Womens Health in Digestive Diseases 54

Appendixes

I. Roster of Contributing Editors 58

II. Diagnostic Colonoscopy Procedural Competency Form 60

Diagnostic Upper Endoscopy Procedural Competency Form 62


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The Gastroenterology Core Curriculum was firstpublished in 1996; this document contains the thirdedition of the Gastroenterology Core Curriculumfor gastroenterology fellowship training. The Core

Curriculum constitutes a living document that rep-resents the four societies vision of best practices ingastroenterology training. It provides a frameworkfor developing an individual plan of study andgrowth that should be tailored to meet the needs ofeach individual trainee based on the strengths andspecial qualities of each individual training pro-gram. The curriculum will continue to evolve withtime as new knowledge, methods of learning, noveltechniques and technologies, and challenges arise.

This edition has been divided into an overview oftraining and 17 chapters encompassing the breadthof knowledge and skills required for the practice ofgastroenterology. These areas include not only thetraditional curricular content of gastroenterologyand hepatology but also associated disciplines suchas pathology, radiology, and surgery. New areasthat have been incorporated into the third editionof the Gastroenterology Core Curriculum includenew antireflux techniques, advanced training (cer-tificate of added qualification [CAQ]) in hepatol-ogy, moderate sedation, novel techniques and tech-nologies, and CT colonography. Additionally, allareas have been linked to the Accreditation Councilon Graduate Medical Education (ACGME)Outcome Projects General Competencies.

This edition of the curriculum represents a joint

collaborative effort among the national gastroen-terology societiesthe American Gastroenter-ological Association (AGA) Institute, the AmericanCollege of Gastroenterology (ACG), the AmericanAssociation for the Study of Liver Diseases(AASLD), and the American Society for Gastro-intestinal Endoscopy (ASGE). The training commit-tees of each of the four sponsoring societies, as wellas several subject matter experts, made specific rec-ommendations for revising the core curriculum.Each society then named two representatives whowere charged with overall responsibility for devel-oping, communicating, and distributing the curricu-lum (see page 3). Additionally, the Gastroenterology

Steering Committee received input on the draft cur-riculum from several training directors and facultymembers and extends its sincere gratitude for theirsupport. Those who provided substantive editorialcontributions to this edition are featured inAppendix I, along with the names of contributingeditors for the previous edition that was publishedin 2003.

Throughout this document, the paramountimportance of practice and research based on thehighest principles of ethics, humanism, and profes-sionalism is reinforced. This document links trainee

assessment to the ACGME Outcome ProjectsGeneral Competencies and as such recommends anumber of tools that can be used to assess the com-petence of trainees, including direct observation by

qualified faculty, log books, periodic patient carerecord reviews, portfolios, patient surveys, 360global rating evaluations, and formal examinations.Numerical guidelines provide only a minimum stan-dard for competency and instead should be viewedas a threshold level after which competency-basedassessment should be instituted. Regardless of theduration of training, the number of patients seen, orthe number of procedures performed, the ultimategoal must always remain excellence in all aspects ofpatient care, scholarship, and a commitment to life-long learning.

The Quality Initiative in MedicineThe Quality Initiative in American medicine is aneffort to improve outcomes, maximize safety, andsimultaneously increase the value of care for health-care consumers. Severe cost pressures in the U.S.healthcare delivery system over the past severaldecades have forged alliances among corporate pay-ers to maximize the cost-effectiveness of care (e.g.,the Leapfrog Group, 2000). Reports related to med-ical errors and patient safety (To Err Is Human,1999) raised concerns and drew the attention ofmany public and private entities. The Institute ofMedicines recommendations for an improved healthcare system (Crossing the Chasm a New HealthSystem for the 21st Century, 2001) urged the align-ment of payment with quality improvement.

The Center for Medicare and Medicaid Services(CMS) took up that challenge and continues effortsto contain expenditures for its beneficiaries.Clinical quality data around the variability of care(e.g., CABG rates in different regions of the coun-try) and outcomes (e.g., CAD mortality ratesunchanged, despite uneven intensity of care), havealso spurred public demand for a more transparentand predictable standard of care. In recent years,the growth of evidence-based medicine has con-tributed to healthcare quality and its measurement.

Training programs must assure that fellows under-stand the importance of quality measurement intheir future practice of gastroenterology and thatfellows are familiar with the techniques used tomeasure quality and with methods used to enhanceperformance. For more information on quality ingastroenterology, please visit www.gastro.org,Clinical Practice section.

2 THE GASTROENTEROLOGY CORE CURRICULUM

Preface


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3

AASLD Representatives

Don C. Rockey, MDProfessor of MedicineChief, Division of Digestive and Liver DiseasesUniversity of Texas Southwestern Medical Center5323 Harry Hines BoulevardDallas,TX [email protected]

Stephen A. Harrison, MD, MAJ(P), MCChief of HepatologyDivision of Gastroenterology and HepatologyDepartment of MedicineBrooke Army Medical Center

Fort Sam Houston,TX [email protected]

ACG Representatives

Roy K. H. Wong, MDChief of GastroenterologyWalter Reed Army Medical CenterProfessor of MedicineDirector, Division of Digestive DiseasesUniformed Services University of the Health SciencesBethesda, MD [email protected]

Lawrence R. Schiller, MDProgram Director, Gastroenterology FellowshipBaylor University Medical CenterGI, 3 Truett3500 Gaston AvenueDallas,TX [email protected]

AGA Institute Representatives

Deborah D. Proctor, MDAssociate Professor of MedicineGastroenterology Fellowship Program DirectorYale University School of MedicineDept. of Internal Medical/Section of GI333 Cedar Street, Room 1080 LMPNew Haven, CT [email protected]

M. Michael Wolfe, MDProfessor of MedicineChief, Section of GastroenterologyBoston University Medical Center

650 Albany Street - Evans Rooms 504Boston, MA [email protected]

ASGE Representatives

Robynne Chutkan, MDAssistant Professor of MedicineDivision of GastroenterologyGeorgetown University Hospital5530 Wisconsin Avenue, Suite 1248Chevy Chase, MD [email protected]

John J. Vargo, MD, MPHHead,Section of Therapeutic and Hepatobiliary EndoscopyDepartment of Gastroenterology and HepatologyCleveland Clinic Foundation9500 Euclid AvenueCleveland, OH [email protected]

Staff Liaison

Allison Waxler, Director of TrainingAGA Institute4930 Del Ray AvenueBethesda, MD [email protected]

The Gastroenterology Core Curriculum Steering Committee

The Gastroenterology Core Curriculum, third edition, is dedicated to Ingrid T.Thomas (1961-2006),

AGA Institute Director of Training (2003-2006).


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ImportanceGastroenterology consultants must possess a range ofattributes, including a broad knowledge base, the abili-

ty to generate a relevant differential diagnosis based onan accurate history and physical examination, anunderstanding of the indications and contraindicationsfor diagnostic and therapeutic procedures, skill at per-forming these procedures, the ability to think critically,and an appreciation of the humanistic and ethicalaspects of medicine. Such attributes can emanate onlyfrom a clinical training program that provides a firmfoundation in pathophysiology as well as abundantexposure to patients under the supervision of experi-enced, thoughtful educators. This exposure must belong enough for trainees to understand the natural his-tory of disease and the impact of treatment both onthe disease and on the patient. Instructors in proce-

dures must impart a thoughtful, cost-consciousapproach to the use of technology as an extension ofthe subspecialists craft rather than as an end in itself.Facilities must be available for trainees to participateactively in research as a means of fostering the inquisi-tive thought processes demanded of skilled consultants,to create new knowledge, and to improve patient care.Surrounding all of these activities must be a dedicationto the patient as a person; technical expertise in theabsence of humanism represents the antithesis of theskilled practitioner, whether generalist or subspecialist.

General Aspects of Training

Prerequisites for TrainingTrainees in gastroenterology must have completed a3-year residency in internal medicine, or be in theAmerican Board of Internal Medicine (ABIM)Research Pathway, at an institution accredited bythe ACGME or a foreign equivalent. The trainingrequirements referenced herein reflect theACGMEs Program Requirements for FellowshipEducation in the Subspecialties of InternalMedicine and the Program Requirements forFellowship Education in Gastroenterology, effective

July 2005 (see www.acgme.org).

Training Institutions

Gastroenterology training must take place only inmedical institutions that are accredited for internalmedicine and gastroenterology training by theACGME and are affiliated with established medicalschools. As outlined in the July 2005 ACGMEProgram Requirements for Fellowship Education inthe Subspecialties of Internal Medicine and theProgram Requirements for Fellowship Education inGastroenterology, evidence of institutional commit-ment to education must include financial resourcesadequate to support appropriate compensation forsufficient faculty and trainees, adequate and modernfacilities, sufficient space and current equipment to

accomplish the overall educational program.Specifically, as directed by the ACGME, section II.A.4:

The sponsoring institution must assure thatadequate salary support is provided to the pro-gram director for the administrative activitiesof the internal medicine subspecialty program.The program director must not be required togenerate clinical or other income to providethis administrative support. It is suggested thatthis support be 25-50% of the program direc-tors salary, depending on the size of the pro-gram. (See Section III.A.4f).

In addition, training institutions must provideadequate clinical support services on a 24-hourbasis, foster peer interaction among specialty andsubspecialty trainees, and sponsor meaningful bio-medical research.

Educational ProgramGastroenterology training programs must providean intellectual environment for acquiring theknowledge, skills, clinical judgment, attitudes, andvalues of professionalism that are essential to thepractice of gastroenterology. As defined by theABIM in the 2001 Project Professionalism:

Professionalism in medicine requires thephysician to serve the interests of the patientabove his or her self-interest. Professionalismaspires to altruism, accountability, excellence,duty, service, honor, integrity, and respect forothers. The elements of professionalism encom-

pass a commitment to the highest standards ofexcellence in the practice of medicine and inthe generation of knowledge, a commitment tosustain the interests and welfare of patients,and a commitment to be responsive to thehealth needs of society.

The program also must stress the role of gastroen-terologists as consultants and the need to establishthe skills necessary to communicate effectively withreferring physicians. The objectives of training canbe achieved only when the program leadership, sup-porting staff, faculty, and administration are fullycommitted to the educational program and whenappropriate resources and facilities are available.

While it is recognized that trainees provide substan-tial service to their teaching hospital, service com-mitments should never compromise the achieve-ment of educational goals and objectives.

Every aspect of training should include the cultiva-tion of an attitude of skepticism and inquiry and adedication to continuing education that will remainwith the trainees throughout their professionalcareers. A major contributor to the enhancement ofa scholarly attitude is active participation in one ormore research projects, ideally followed by presenta-tion of the work at a national meeting and publica-tion of a paper in a peer-reviewed journal.


Overview of Training in Gastroenterology


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Duration of TrainingTraining programs must be at least 3 years in dura-tion and must include a minimum of 18 months ofclinical training experience. A premium is placedon experience. The more experience gained undersupervision during training, the more skilled thespecialist will become. Such experience shouldinclude the long-term management of patients witha variety of diseases and exposure of trainees to thenatural history of gastrointestinal and hepatic dis-eases as well as the effectiveness and limitations oftherapy. As training progresses, it is important forthe trainees to develop independence. A 3-yeartraining program allows sufficient time for a grad-ual reduction in the level and degree of supervisionso that, by the end of the training period, traineesfeel confident in their own abilities to independent-ly manage complicated disorders.

Duty HoursTrainee duty hours should be monitored to ensurethat they meet guidelines established by theACGME (see Section VI).

Levels of TrainingThe curriculum continues to require a minimum of 3years of training in gastroenterology. The core clini-cal curriculum requires a minimum of 18 months ofpatient care experience and consists of traditionalinpatient and outpatient consultative and specializedcare experience. A longitudinal outpatient ambulato-ry experience is mandated for the full 3 years oftraining. Explicit programmatic recommendationsare indicated in the areas of acid-peptic disease, bil-iary tract diseases and pancreatic disorders, cellularand molecular physiology, endoscopy, ethics, medicaleconomics and system-based practice, geriatric gas-

troenterology, hepatic pathology, hepatology, inflam-mation and enteric infectious disease, malignancy,motility and functional illnesses, nutrition, pediatricgastroenterology, radiology, research, surgery, andwomens health issues. A central feature of trainingin gastroenterology remains the requirement for ded-icated training in hepatology. Included in the guide-lines for training in hepatology is the requirementthat at least one faculty member is recognized ashaving expertise in liver disease.

ASGE guidelines for training in basic endoscopicskills are affirmed with the explicit requirement thatcertification of competency in basic endoscopy can-

not be considered before minimum threshold levelsare met; competency-based assessment demandsattainment of substantial skill and experience beforeprogram directors can attest to the competence of thetrainees in endoscopy. Achievement of expertise inendoscopic retrograde cholangiopancreatography(ERCP) and endoscopic ultrasonography (EUS) is notincluded as an objective for all trainees, but isreserved for selected trainees desiring enhanced skillsin interventional endoscopy. See Appendix II for theDiagnostic Colonoscopy Procedural CompetencyForm and the Diagnostic Upper EndoscopyProcedural Competency Form.

A substantive research experience of 36 monthsas a stimulus for developing an inquiring and criti-cal mind is required. As important as direct patientcare, and woven throughout the 3-year fellowship,is the requirement for an array of conferences anddidactic sessions. Trainees are expected to have spe-cific instruction throughout the fellowship in theclinical, translational, and basic sciences thatunderlie the scientific basis of practice today and tohave the opportunity to participate in meaningfulscholarly activity.

Beyond the 18-month core clinical curriculumand the 36 month research requirement, 12 addi-tional months are required to complete fellowshiptraining. This time will permit flexibility for activi-ties outside of the prerequisites of the core clinicalcurriculum that meets the trainees needs, interests,and career goals. This may translate into 12months of additional clinical training or researchtraining, specialized training in specific skills, orelective experiences.

Level 2 training, or enhanced clinical training, is

specifically for any gastroenterologist who wishesto provide specialized services as a consultant toother physicians and is detailed for geriatrics, nutri-tion, advanced endoscopic procedures, motilitystudies, biliary tract diseases and pancreatic disor-ders, and hepatology. Detailed criteria that mirrorthe requirements set by the ABIM before sitting forthe examination for added qualifications in trans-plant hepatology are included, but would necessari-ly be accomplished during a fourth year of training.

In most cases, up to 12 additional months ofclinical or research training beyond the core clinicalcurriculum may be required to attain level 2expertise in a given area. It is anticipated that

under most circumstances, level 2 training can beaccomplished for some within the context of the 3-year training period. However, in some circum-stances, such as expertise in advanced therapeuticprocedures, an additional year, that is, a fourthyear may be necessary to satisfactorily complete allrequirements for level 2 training.

For trainees preparing for careers in laboratoryor clinical investigation, an intensive research expe-rience during fellowship training is recommended,with the recognition that such training may need tobe continued well beyond the standard 3-year peri-od of training to prepare the trainee for a career asan independent investigator. This training mayinclude university course work appropriate forcareers in clinical or basic research, for example,epidemiology, statistics, research methodology, out-comes and effectiveness research, decision analysis,cell biology, molecular genetics, and/or ethics aswell as supervised research activity under the guid-ance of qualified mentors.

Throughout this document, the paramount impor-tance of practice and research based on the highestprinciples of ethics, humanism, and professionalism isreinforced. The importance of the scientific methodand of preparation for lifelong learning based on

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independent and critical thinking, a desire for self-improvement, and a love of learning is emphasized.

Program FacultyProgram DirectorA single training director must be responsible for theprogram. She or he must be board certified in gas-troenterology or possess equivalent qualifications and

must have 5 years of participation as an active facultymember in the subspecialty. The training director isexpected to ensure adequate time to coordinate anddirect training-related activities. In accordance withACGME guidelines, the director must be based at theprimary training site of the program (see SectionIII.4.c) and must dedicate an average of 20 hours perweek to the training program (see Section III.4.f).

FacultyIn addition to the program director, the programmust provide a minimum of four institutionally-based key clinical faculty members who all must becertified in gastroenterology or possess equivalent

qualifications. For programs with an approvedcompliment of more than six, a ratio of key clinicalfaculty to fellows of at least 1:1.5 must be main-tained (see Section XII).

At least one full-time faculty member must be afully trained hepatologist, as defined within theTraining in Hepatology chapter. At least one full-time faculty member must be skilled and demon-strate expertise in advanced endoscopic procedures,as defined within the Training in GastrointestinalEndoscopy chapter. Above and beyond a minimumnumber of faculty, there must be enough additionalfull-time or part-time faculty to ensure adequatesupervision of trainees and coverage of all pro-

grammatic components. At all times, fellows willbe adequately supervised by staff physicians.

Each full-time faculty member must devote atleast 10 hours per week, averaged over 1 year, toteaching, research, administration, and/or the criti-cal evaluation of the performance, progress, andcompetence of trainees. In addition, faculty mem-bers must serve as appropriate role models byactive participation in the clinical practice of gas-troenterology, their own continuing education,regional and national scientific societies, researchactivities, and the presentation and publication ofscientific studies and scholarly reviews.

Faculty should be evaluated at intervals by traineesto assure that the trainees needs are being met.Please visit www.acgme.org for more information onprogram faculty requirements for gastroenterology.

Environment for Training inGastroenterologyRelationship to Training in Internal MedicineGastroenterology fellows must maintain their skillsin general internal medicine and develop appropri-ate lines of communication and responsibility withinternal medicine residents and faculty.

Relationship to Other DisciplinesCare of patients with digestive diseases often involvesa multidisciplinary approach. Therefore, trainees mustlearn to work effectively and efficiently with membersof other specialties and subspecialties. This is especial-ly true for the internal medicine subspecialties of car-diology, critical care medicine, and oncology as well asthe specialties of surgery, pathology, and radiology.Increasingly, trainees will need to develop skills inmanagement to enable them to lead multidisciplinaryteams. Particular instruction and experience in collab-orating with primary caregivers in a managed care set-ting is essential.

Facilities and ResourcesThe following facilities and resources are essentialfor the training program:1. There must be a sufficient number of new and

follow-up patients, with a broad variety of gas-trointestinal and hepatic diseases, to ensureadequate inpatient and outpatient experiences.Both men and women andto the extent pos-sible pregnant women and adolescentsandgeriatric patients of both sexes must be includ-ed in the fellows panel of patients. Patientbackgrounds should be diverse and represent arange of ethnic, cultural, and socioeconomicgroups. Qualified faculty must supervisetrainees in all aspects of patient care, includingcare delivered in both inpatient and outpatientsettings and during procedures.

2. Up-to-date inpatient and ambulatory care facil-ities are essential to accomplish the overall mis-sion of the training program.

3. There must be a fully equipped and staffed pro-cedure laboratory that includes state-of-the-art

diagnostic and therapeutic endoscopic instru-ments and motility equipment. The laboratorymust be capable of performing, or have accessto, specialized serological, parasitological,immunologic, metabolic, and toxicological stud-ies applicable to gastrointestinal and hepatobil-iary disorders. Computers should be availablewith appropriate software to permit trainees toaccess medical literature online, perform Internetsearches, record results of procedures, and estab-lish a database. The capability to perform basicgastrointestinal function tests is essential.

4. Supporting services, such as a full-service emer-gency department, diagnostic and intervention-

al radiology department, medical imaging andnuclear medicine facility, pathology laboratory,general and hepatobiliary surgical unit, andoncology unit must be available.

5. There must be a modern, fully-staffed unit forthe intensive care of critically ill patients withgastrointestinal and hepatic disorders.

6. A library with online capabilities for providingadequate access to the literature and includingcomputer-assisted literature searches is required.

7. Adequate administrative support for the fel-lowship program, including financial supportfor a fellowship coordinator or assistant,



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access to computers for personnel managementand scheduling, and a budget to provide officesupplies and other administrative expenses torun a program.

Specific Program ContentPatient Care ExperienceThe patient care experience for trainees is com-

prised of three major elements.1. While training should be tailored to reflect the

ultimate career goals of the individual fellow,every gastroenterology training program mustinclude a core clinical training experience of 18months to be completed by all trainees. Thisperiod will consist of clinical training in theinpatient and outpatient diagnosis and man-agement of digestive diseases as outlined byeach of the relevant chapters on training, withapproximately 5 months of this experiencedevoted to training in liver disorders (seeSection XI.C). During the core clinical train-ing, adequate numbers of routine endoscopicprocedures must be performed to exceed theminimum standards as described within thechapter, Training in Endoscopy. Trainees musthave appropriate supervised experience todevelop skills in providing consultative servicesand communicating with physicians and othermembers of the health care team.

2. For those individuals whose career goals con-sist primarily of patient care, a further 18months of training will include a total of atleast 6 months of scholarly activity consistingof basic or clinical research, course work, orother structured activity not primarily involv-

ing direct patient care (see Training inResearch). The remaining months will includeadditional experience in general consultativegastroenterology and experience in specializedareas, depending on the interests and careergoals of the trainees and the opportunitiesavailable in the programs. Such areas of studymight include enhanced competence in hepaticdiseases, motility disorders, inflammatorybowel disease, nutrition, or interventionalendoscopy (see appropriate chapters).

Where formal guidelines for attainingenhanced competence in an area are provided,the designation of level 2 training is applied.

Level 2 training will designate that the traineecan act as a consultant to other gastroenterolo-gists and other clinicians in that area of expert-ise. Upon satisfactory completion of level 2training, the trainee will receive a letter orother document that indicates that this level ofexpertise has been reached.

3. In recognition of the importance of outpatientmedicine to the practice of gastroenterology, alltrainees must spend at least one half-day perweek for the entire 3-year period in an ambulato-ry care clinic in which both new and continuingcare patients with gastroenterological and hepatic

diseases are evaluated and managed. Thearrangements must be such that patients recog-nize the fellow as the physician who is involvedin providing their continuous care. To understandthe natural history and long-term outcome ofdigestive diseases, trainees must attend the sameclinic for a minimum of 6 months.

Training Through Conferences and Other

Nonpatient Care ActivitiesIn addition to the patient care experience, traineesshould have extensive involvement in other typesof experiences.1. Trainees should, through independent study,

develop a scholarly approach to education byreading current textbooks and monographs,relevant scientific literature, and distributedsyllabus materials. Trainees should be encour-aged to attend seminars, postgraduate courses,and annual scientific meetings of the majordigestive diseases societies.

2. Clinical conferences should be held on a week-ly basis. Trainees must be actively involved inthe planning and content of these conferences.

3. Basic science, journal club, and research confer-ences should be held regularly, at least monthly.The journal club should be used as a tool toteach the skills of critical reading, detection ofbiases, assessment of validity of controls, appli-cation of statistics, generalizability of results, andrelated attributes of scientific studies.

4. Interdisciplinary conferences with radiology,pathology, and surgery services should be heldat least monthly.

5. A series of lectures/discussions should be heldthroughout the period of training to cover a

core curriculum of physiology, pathophysiolo-gy, and clinical pharmacology.6. Visiting scholars, professors, and investigators

should be brought in to stimulate new thoughtsand ideas among trainees as well as faculty.

7. Participation in quality assurance and continu-ous quality improvement programs should berequired. Discussion of systems-based practiceshould be an integral part of this effort.

8. The opportunity to formally study the elementsof study design, decision analysis, outcomes andeffectiveness research, statistics, epidemiology,and other skills necessary to conduct and evalu-ate clinical investigation should be available to

all trainees yearly.

Teaching ExperienceTrainees should actively participate in the teachingof medical students, medical residents, and lessadvanced trainees in gastroenterology. In addition,ample opportunity must be provided for trainees toparticipate in seminars and conferences. The abilityto interweave basic and clinical material in a cohe-sive manner and to present and defend concepts inan open forum is invaluable for a career as a sub-specialty consultant.

OVERVIEW OF TRAINING IN GASTROENTEROLOGY 7


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I. Evaluation of TraineesFormal evaluations of each trainees progress andfinal competence are required by the ACGME andfor objective documentation for purposes of creden-tialing. Training programs must have establishedmethods to evaluate trainee competence, regularwritten records detailing the progress of all trainees,and a defined program of verbal and written feed-

back to the trainees. The trainee must receive appro-priate and timely feedback throughout the trainingexperience, including formative and summative eval-uations in all areas being evaluated.

Elements of Competence to be AssessedAs outlined in the ACGME General Competencies,trainees should be evaluated in the following areas(Table 1):1. Patient care Trainees must be able to provide

patient care that is appropriate, effective andcompassionate. This would include, but not belimited to, the following: history-taking,

including family, genetic, psychosocial, andenvironmental histories, and the ability to per-form a comprehensive and accurate physicalexamination. The ability to arrive at an appro-priate differential diagnosis, outline a logicalplan for specific and targeted investigationspertaining to the patients complaints, and for-mulate a plan for management and follow-uptreatment of the patient is critical. The abilityto effectively present the results of a consulta-tion orally and in writing and to defend theclinical assessment, differential diagnosis, anddiagnostic and management plans is essential.In addition, trainees must demonstrate proce-dural skills essential for the practice of gas-troenterology and hepatology.

2. Medical knowledge Trainees must demon-strate a core fund of knowledge in gastroen-terological and hepatic physiology, pathophysi-ology, clinical pharmacology, radiology, andsurgery as outlined in the goals of each chapter


1. PATIENT CAREa. Direct observation by qualified faculty during a) work and

teaching rounds, b) patient history-taking and physical exami-nation, c) procedures, and d) conferences

b. Formal evaluation forms from faculty members, nurses, alliedhealth personnel, and patients who come into contact withthe trainees (360 evaluation)

c. Patient care record reviewd. Patient and staff surveys (360 evaluation)e. Formal examinations to test the clinical skills and medical

knowledge of the trainee, including mastery of the interpreta-tion of endoscopic, radiologic, and pathologic findings, such asan in-service training examination.

f. Portfoliosg. Procedural skills (as defined by each training chapter)h. Log books (preferably computerized) and objective compe-

tency determinations of all endoscopic procedures and liver

biopsies and all level 2 skills

2. MEDICAL KNOWLEDGEa. Formal examinationsb. Direct observation by qualified faculty during a) work and


c. Formal evaluation forms from faculty members, nurses, allied

health personnel, and patients who come into contact withthe trainees (360 evaluation)

d. Patient care record reviewe. Formal examinations to test the clinical skills and medical

knowledge of the trainee, including mastery of the interpreta-tion of endoscopic, radiologic, and pathologic findings, such as

an in-service training examination.

3. PRACTICE-BASED LEARNING AND IMPROVEMENTa. Direct observation by qualified faculty during a) work and teach-

ing rounds, b) patient history-taking and physical examination, c)procedures, and d) conferences

b. Patient care record review

c. Portfoliosd. Formal evaluation forms from faculty members,nurses, allied

health personnel,and patients who come into contact with thetrainees (360 evaluation)

e. Formal examinations to test the practice-based learning andimprovement in clinical skills and medical knowledge of the

trainee

4. INTERPERSONAL AND COMMUNICATION SKILLSa. Direct observation by qualified faculty during a) work and



c. Patient and staff surveys (360 evaluation)

5. PROFESSIONALISMa. Direct observation by qualified faculty during a) work and



c. Patient and staff surveys (360 evaluation)

6. SYSTEMS-BASED PRACTICEa. Direct observation by qualified faculty during a) work and



c. Observation during involvement in continuous qualityimprovement activities

d. Formal examinations to test the system-based practice clini-cal skills and medical knowledge of the trainee, such as an in-service training examination

Table 1 Methods for Assessing ACGME General Competencies


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on training. Trainees must be able to demon-strate an analytic approach and use appropri-ate investigations, including the practice of evi-dence-based medicine.

3. Practice-based learning and improvement Trainees must be able to investigate, evaluate, andimprove their patient care practice by analyzingand assimilating both scientific evidence as well astheir own prior experience into their practices.They should be able to apply knowledge of statis-tical methods to critically appraise clinical studiesand be able to use information technology to sup-port their own education. They must be involvedin teaching and be able to facilitate the learning ofother students and health care professionals.

4. Interpersonal and communication skills Trainees must be able to demonstrate interper-sonal and communication skills that result ineffective information exchange with theirpatients, families, and other health care profes-sionals. This would include, but not be limitedto, verbal and written communication as a

consultant and to generation of endoscopicreports that are accurate and timely. Traineesmust be able to work effectively as membersand leaders of the health care team.

5. Professionalism Trainees must demonstratean understanding of and commitment to allelements of professionalism, including respect,compassion and integrity toward their patients,patient families, and other health care profes-sionals. They must demonstrate ethical behav-ior, responsiveness, and sensitivity to a diversegender, ethnic, socioeconomic, and agingpatient population.

6. Systems-based practice Trainees must

demonstrate an understanding of, awarenessof, and responsiveness to the larger contextand system of health care delivery. The traineesshould understand how their patient care prac-tice impacts other health care professionals,the larger health care system, and society ingeneral. They should be able to practice cost-effective health care without compromisingquality of care for their patients. The traineeshould be able to advocate for timely, qualitypatient care and know how to partner withother health care providers to provide the opti-mal health care for their patients.

Methods for Assessing Trainee CompetenceDepending upon the specific area that the trainee isbeing evaluated in, the following methods may beused to evaluate the trainees performance:

Direct observation by qualified faculty dur-ing a) work and teaching rounds, b) patienthistory-taking and physical examination, c)procedures, and d) conferences

Log books (preferably computerized) andobjective competency determinations for allendoscopic procedures and all level 2 skills

Periodic patient care record reviews

Portfolios (a collection of products preparedby the trainee that provides evidence oflearning and achievement related to thelearning plan. It might include a log of clini-cal procedures performed; a summary of theresearch literature reviewed when selecting atreatment option; a quality improvementproject plan and report of results; ethicaldilemmas faced and how they were handled;a computer program that tracks patient careoutcomes; or a recording or transcript ofcounseling provided to patients, etc.)

Patient surveys 360 evaluations (an evaluation method that

incorporates feedback by all members of thehealth care team, colleagues, and patients).This full circle evaluation provides multi-ple perspectives on ones performance.

Formal in-service examinations to test the clini-cal skills and medical knowledge of the trainee,including mastery of interpretation of endo-scopic, radiologic, and pathologic findings

II. Evaluation of GraduatesThe training director should attempt to evaluatethe performance of graduates from the program ona routine basis. Suggested components of this eval-uation include the following:

a. Scores on Certification and Recertificationexaminations administered by the ABIM

b. Licensure and practice status of graduatesc. Involvement in postgraduate educational cours-

es and other Continuing Medical Education(CME) programs

d. Involvement in teaching and research activities

e. Publications

III. Evaluation of Training Program and

FacultyTraining programs, including curricular and facultyperformance, must be evaluated in a rigorous andmeaningful fashion on a regular basis.

a. Graduates should be surveyed at intervalsabout the relevance of what they weretaught to their current activities and areas inwhich additional educational efforts by thetraining programs are needed.

b. Trainees must be given the opportunity to

anonymously evaluate the faculty and train-ing program at regular intervals, but mini-mally at the end of each rotation.

c. The program director must regularly meetwith the faculty and trainees to evaluate thecurriculum and whether the training objec-tives are being met.

d. Standardized testing should be used to assessthe individual performance of trainees, as wellas the programs success in achieving its speci-fied educational milestones.

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ImportanceAcid-peptic disorders (gastroduodenal ulcer, gastro-esophageal reflux disease, gastritides/gastropathies,

duodenitis, Zollinger-Ellison syndrome and otherhypersecretory states) are common afflictions. Ithas been estimated that 7% of the U.S. populationexperiences heartburn symptoms daily and almosthalf on a monthly basis. Dyspepsia accounts forupwards of 10% of all physician encounters. Pepticulcer disease affects more than 5% of the U.S. pop-ulation. Helicobacter pylori (H. pylori) gastritis is amajor risk factor for peptic ulcer as well as gastriccarcinoma and lymphoma. The use of nonsteroidalanti-inflammatory drugs (NSAIDs) and/or aspirinalso is a major risk factor for peptic ulcers. Theseconditions cause morbidity and may result in seri-ous complications leading to hospitalization, sur-

gery, or even death. Because of their prevalence,potential for complications, and economic conse-quences, acid-peptic disorders encompass an impor-tant group of diseases.

Technology in diagnostic and therapeutic imagingtechniques and in surgical, radiologic, and endo-scopic management of these disorders has changeddramatically. Great strides have been made inunderstanding the pathophysiology of, and therapyfor, disorders of the upper gastrointestinal tract.The ability to reliably diagnose such disorders hasbeen greatly enhanced by endoscopy, and definitivetherapy may be performed during endoscopy for

disorders such as esophageal stricture and bleedingulcers. Endoscopic techniques for the managementof gastroesophageal reflux disease have also recent-ly been described.

The practice of gastroenterology now involves morethan just the time-honored physician skills of history-taking and physical examination. Both the cognitiveand technical skills of endoscopy must be acquiredand continuously maintained. The acquisition of skillsin these multiple disciplines as they relate to the evalu-ation and management of acid-peptic disorders willbest ensure well-trained gastroenterologists.

Goals of TrainingDuring fellowship, trainees should gain an under-standing of the following:1. Anatomy, physiology, and pathophysiology of

the esophagus, stomach, and duodenum.2. Gastric secretion and indications for gastric

analysis (i.e., measuring gastric acid output).3. The indications for serum gastrin measurement

and secretin testing for the diagnosis of gastrino-ma and consequences of hypergastrinemia inboth hypersecretory and achlorhydric states;trainees should also gain an understanding of themechanisms involved in the development of sec-ondary hypergastrinemia due to low acid states.

4. The natural history, epidemiology, and compli-cations of acid-peptic disorders, includingrecognition of premalignant conditions (e.g.,Barretts metaplasia).

5. The role ofH. pylori infection in acid-pepticdiseases; trainees should gain an understandingof the properties of H. pylori infection, includ-ing its epidemiology and pathophysiology, suchas factors specific to the organism (e.g., theCagA protein), factors specific to the host (e.g.,interleukin polymorphisms), and factors specif-ic to the environment (e.g., diet and antisecre-tory therapy).

6. The role of NSAIDs in the pathogenesis of gas-troduodenal ulcers and their complications,including an understanding of risk factors fordeveloping NSAID-related ulcers and the relative

risks posed by different individual NSAID prepa-rations based on various different properties.7. The pharmacology, adverse reactions, efficacy,

and appropriate use and routes of administra-tion of drugs for acid-peptic disorders; theseinclude antacids and histamine-2 receptorantagonists, proton pump inhibitors, mucosalprotective agents, prostaglandin analogues,prokinetic agents, and antibiotics.

8. Endoscopic and surgical treatments of acid-peptic disorders. It is suggested that traineesgain an understanding of clinical indicationsand relative cost effectiveness, complications,and side effects, both in the short-term and

long-term (see chapters on Training inEndoscopy and Training in Surgery).

Unless otherwise noted, trainees must also developcompetence in the following:1. Performing a thorough gastrointestinal-directed

history and physical examination.2. Performing diagnostic and therapeutic upper

gastrointestinal endoscopy. It is suggested thattrainees gain familiarity with endoscopic modal-ities for the treatment of gastroesophageal refluxdisease, such as application of radiofrequency,energy injection therapy, and mechanical devices(see Training in Endoscopy).

3. Familiarity with capsule endoscopy and itsapplicability to the evaluation of upper gastro-intestinal disease.

4. Trainees should learn to perform, read, andinterpret esophageal pH probe tests, includingwireless technology, esophageal impedancetesting, and esophageal motility studies (seeTraining in Motility and Functional Illnesses).

5. Trainees should gain experience in interpretingplain films of the abdomen, barium examina-tions of the upper gastrointestinal tract, ultra-sonography, abdominal computed tomographicscans, magnetic resonance imaging, angiogra-


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phy, and somatostatin receptor scintigraphy(see Training in Radiology).

6. Understanding invasive and noninvasive tech-niques for diagnosing H. pylori infection.

7. Understanding the role of prostaglandins inmucosal protection, the importance ofprostaglandin inhibitors (NSAIDs, aspirin) incausing ulcers, and the effects of selective

cyclooxygenase-2 (COX-2) inhibitors onmucosal integrity in the upper gastrointestinaltract, on platelet function, and on the patho-genesis of thrombotic events. Other potentialeffects of COX inhibition, such as possiblebeneficial benefits in the treatment of dysplasiain Barretts esophagus and prophylaxis of col-orectal polyps, should be discussed.

Training ProcessTrainees must acquire a thorough knowledge ofappropriate history-taking, which should consist offamily, genetic, psychosocial, and environmentalhistories, including a detailed history of prescrip-tion and over-the-counter (nonprescription) druguse, particularly NSAIDs and aspirin, and the abili-ty to perform a comprehensive and accurate physi-cal examination in patients with acid-peptic dis-ease. This should include an examination of thewhole patient. Trainees should be able to arrive atan appropriate differential diagnosis, be able tooutline a logical plan for specific and targetedinvestigations pertaining to the patients com-plaints, and be able to design an appropriatescheme of management and follow-up.

Trainees must develop expertise under directsupervision in performing and interpreting all of

the procedures and diagnostic tests that are rou-tinely used in the evaluation and treatment ofpatients with acid-peptic disorders (see Training inEndoscopy). This experience should include theindications, limitations, technical aspects, and com-plications of the following procedures as well as anunderstanding of the benefits and dangers of mod-erate sedation:1. Upper intestinal endoscopy, both elective and

emergent, including proficiency in the use of

the endoscopic treatment modalities for hem-orrhage (including injection therapy, cautery,banding, and clipping), biopsy, and polypecto-my. It is suggested that trainees become famil-iar with the placement of radiotelemetrydevices and have experience with endoscopy inpatients with surgically altered anatomy (fun-doplication, ulcer surgeries, gastric bypass)

2. Dilatation of benign and malignantesophageal strictures3. The performance and interpretation of

esophageal motility studies, 24-hour pH moni-toring including wireless technology, and theinterpretation of gastric secretory studies. It issuggested that trainees gain familiarity withimpedance testing (see Training in Motility andFunctional Illnesses).

4. Trainees should gain experience in the inter-pretation of radiological studies of the uppergastrointestinal tract, including contrast gas-trointestinal examinations, ultrasonography,computed tomographic scans, magnetic reso-

nance imaging, somatostatin receptor scintigra-phy, and angiography

5. Indications and interpretation of studies forspecific entities, such as hypersecretory states,H. pylori, and other infections of the uppergastrointestinal tract, particularly acquiredimmunodeficiency syndrome (AIDS)-relateddisorders

6. It is suggested that trainees gain a workingknowledge of upper gastrointestinal tractpathology, such as mucosal biopsies for gastri-tis, Barretts esophagus, and malignant condi-tions (see Training in Pathology).

Assessment of CompetenceKnowledge of acid-peptic disease should be assessedas part of the overall evaluation of trainees ingastroenterology during and after the fellowship, asoutlined in Overview of Training in Gastroenter-ology. Questions relating to acid-peptic diseaseshould be included on the board examination andshould reflect a general knowledge of this content.

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ImportanceBiliary Tract DiseasesBiliary tract diseases occupy a significant portion ofthe practice of gastroenterology. The diagnosis ofand therapy for these diseases represent major chal-lenges to practicing gastroenterologists becauserapid advances in technology require skills not pre-viously taught (e.g., invasive endoscopic and radio-logical procedures, endoscopic ultrasound, scintig-raphy). To achieve maximal effectiveness, minimizerisk, reduce costs, and provide the best possiblecare for patients, specialized training is requiredthat emphasizes knowledge of anatomy, physiology,pathophysiology, and clinical presentation of biliarytract diseases. Gastroenterologists must be familiarwith new technology and be in a position to applyit for the benefit of their patients.

Pancreatic DisordersPancreatic disorders are common diseases that pres-ent multifaceted challenges to gastroenterologists.For example, acute pancreatitis may lead to therapid development of a variety of potentially life-threatening complications; chronic pancreatitis is along-standing, frequently debilitating disease. Incaring for patients with pancreatic cancer, gastroen-terologists must make an expeditious and cost-

effective diagnosis and weigh possible curative orpalliative treatment options. Because of the com-plexity of these diseases, the wide assortment ofpotential diagnostic modalities, and the lack ofconsensus in many aspects of diagnosis and man-agement, gastroenterologists are commonly the pri-mary consultants or direct caregivers for patientswith pancreatic disease.

Goals of TrainingDuring fellowship, trainees should gain an under-standing of the following:

Biliary1. Basic embryology and anatomy of the biliary

tree and congenital structural anomalies,including duplications and cysts.

2. Hormonal and neural regulation of bile flowand gallbladder function.

3. Physiology of bile secretion and its derange-ment in cholestatic disorders.

4. Bile composition in health and disease.5. Cholelithiasisepidemiology, etiology, clinical

manifestations and complications, treatmentmodalities.

6. Other disorders of the bile ducts, including

recurrent pyogenic cholangitis, parasitic andopportunistic infections.

7. Other inflammatory disorders of the gallblad-der such as acalculous cholecystitis.

8. Neoplastic diseases of the gallbladder and bileducts.

9. Motility disorders including gallbladder dyski-nesia, sphincter of Oddi dysfunction.

10. Principles of evaluation and treatment of com-mon clinical syndromes:

a. Cholestasisb. RUQ and biliary-type painc. Incidental findings on radiographic testing

11. Radiographic evaluation of the biliary tree:basic principles, utility and lesion recognition:

a. Ultrasonographyb. CTc. MRId. Scintigraphic techniquese. MRCP

12. Principles, utility, and complications of biliarysurgery.

13. Procedural competencesee below.

Pancreatic1. The embryological development and anatomy

of the pancreas and the pancreatic duct system

and congenital disorders such as pancreas divi-sum, annular pancreas.2. The physiological processes involved in pancre-

atic exocrine secretion of digestive enzymes,water, and electrolytes.

3. The types of digestive enzymes secreted by thepancreas, their mechanisms of activation andtheir roles in the digestive process.

4. The factors that protect the pancreas fromautodigestion.

5. The epidemiology, etiology, pathophysiology,natural history, and management of acute pan-creatitis in all spectra of severity and its com-plications.

6. The epidemiology, etiology, pathophysiology,natural history, and management of chronicpancreatitis with particular emphasis on man-agement of exocrine insufficiency and chronicpain.

7. The epidemiology, etiology, natural history,and management of pancreatic cancer and itscomplications.

8. The molecular genetics of pancreatic diseasewith particular reference to hereditary pancre-atitis and cystic fibrosis, their diagnosis andmanagement.

9. Radiographic evaluation of the pancreas: basic


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principles, utility, and lesion recognition:a. Ultrasonographyb. EUSc. CTd. MRIe. MRCP

10. Principles, utility, and complications of pancre-atic surgery.

11. The basis and indications for and the interpre-tation of diagnostic test results in the diagnosisand management of diseases of the pancreas,in particular, serum amylase and lipase deter-mination, markers for chronic pancreatitis(fecal elastase, serum tryspinogen-likeimmunoreactivity, etc.) serum tumor markers(e.g., CA 19-9), radiological and endoscopicimaging studies (see Training in Endoscopyand Training in Radiology), indirect tests ofpancreatic secretory function, direct tests ofsecretory function (e.g., secretin andsecretin/cholecystokinin stimulation tests, testmeals), duodenal drainage with analysis for

biliary crystals, fine-needle aspiration of pan-creatic masses, and analysis of cytology inendoscopic aspirates of pancreatic juice.

12. Principles and practice of nutritional support forpatients with both acute and chronic pancreatitis.

13. Procedural competencesee below.

Training ProcessAs with most specialties a combination of cogni-tive/clinical skills and knowledge, along with proce-dural proficiency is necessary for training in thecare of patients with these disorders. Two levels oftraining should be offered. Level 1 training is for

those trainees who will be a part of the general gas-troenterology program and have exposure to dis-eases of the biliary tract and pancreas. Level 2training is intended for those who will be selectedto spend the entire third year of training and/or anadditional fourth year of training in biliary tractdiseases and/or pancreatic diseases.

Clinical/Cognitive TrainingLevel 1At this level, all trainees should acquire the funda-mental core of information outlined above in the first18 months (core clinical) of training through individ-ual reading, presentation of core curriculum at gas-troenterological/radiological/surgical clinical confer-ences, lectures by invited speakers, journal clubs,and daily contact with the attending physicians.

Level 2The major goal for trainees at level 2 (see alsoTraining in Endoscopy) is to acquire an in-depthknowledge of pathophysiology, clinical presenta-tion, diagnosis, epidemiology, and therapy of bil-iary and pancreatic diseases. In general, trainees inbiliary and pancreatic diseases at this level shouldhave completed at least 18 months of training ingeneral gastroenterology and should spend up toan additional year specializing in biliary and pan-

creatic diseases. Trainees will be provided theopportunity to perform an adequate number ofprocedures, receive supervised teaching, and to beinvolved in clinical research. While the endoscopictraining is important, level 2 training should aim toproduce an expert in managing all aspects of bil-iary tract diseases. In terms of cognitive and diag-nostic acumen, level 2 trainees should be expectedto know physiology, pathophysiology, diagnosis,and therapy of biliary and pancreatic diseases ingreater detail than those at level 1 of training.

All trainees at level 2 should also be given theopportunity to be involved in clinical or basicresearch. Trainees in the biliary and pancreaticsections will be expected to acquire an under-standing of clinical research, including studydesign, methodology, statistical analysis, writingthe protocols, submitting protocols to institutionalreview boards, writing informed consent, enrollingpatients into studies, analyzing and interpretingdata, presenting at national meetings, and writingpapers. Individual preceptors should teach basic

or clinical research on a one-on-one basis and atresearch conferences. It is anticipated that mostphysicians participating in level 2 training willenter an academic environment, which will allowthem to continue in the multidisciplinary area oftreating patients with biliary and pancreatic dis-eases as well as teaching and conducting clinicalresearch.

Procedural TrainingAll trainees should have a thorough knowledge ofthe endoscopic techniques used in the diagnosisand treatment of biliary tract diseases and pancre-atic diseases, including their potential risks, limita-

tions, and costs. Trainees also must understand therole of alternative diagnostic and therapeuticmodalities (medical, surgical, and radiological) inthe evaluation and management of biliary tract andpancreatic diseases. They should understand theadvantages and disadvantages of the different diag-nostic and therapeutic procedures available.

Endoscopic retrograde cholangiopancreatogra-phy and endoscopic ultrasound are the primarytools for accessing the biliary tree and the pancreat-ic ductal system and a major route for therapeuticintervention. Trainees should attain an understand-ing of percutaneous transhepatic cholangiographyand the performance and interpretation of endo-

scopic retrograde cholangiopancreatography andendoscopic ultrasound (indications, contraindica-tions, limitations, complications, and interpreta-tion) through participation in and observance ofthose procedures under supervision of the attendingphysician and with the assistance of a radiologist.These complex procedures require extensive train-ing, which is difficult to give to all trainees. Thelevel of experience required for performing endo-scopic retrograde cholangiopancreatography mayvary with the career expectations of the trainees.As above, training can be stratified into two levels(see also Training in Endoscopy).

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Level 1This level involves minimal exposure to biliaryand pancreatic endoscopy for those trainees whodo not plan to perform them. Minimal exposureis defined as an understanding of the indicationsand contraindications of ERCP and EUS, theadvantages and disadvantages, complications,alternative diagnostic and therapeutic options, andinterpretation of findings. This knowledge couldbe acquired through conferences, teaching rounds,courses, and 1- to 2-month rotations through thebiliary tract service. Hands-on experience in bil-iary procedures is encouraged but not required inthis group of trainees.

In addition to a knowledge and understandingof endoscopic procedures, all level 1 traineesshould have a general understanding of the indica-tions, advantages, and disadvantages of imagingprocedures, such as plain film of the abdomen,cholecystogram, ultrasound, computed tomogra-phy, magnetic resonance imaging, and scintigra-phy. As part of this process, they should have a

basic understanding of how to interpret thesestudies. This knowledge will be acquired throughregular and frequent contacts with radiologistsand nuclear medicine specialists and/or a 1- to 2-month rotation through radiology. Lastly, traineesshould be exposed to the performance and theinterpretation of endoscopic ultrasound and endo-scopic retrograde cholangiopancreatography andshould observe several surgical biliary and pancre-atic procedures during the course of training (seeTraining in Radiology and Training in Surgery).

Level 2This level involves at least 12 months of advancedtraining in pancreaticobiliary endoscopy (seeTraining in Endoscopy) and is aimed at individualswho seek to be true experts in endoscopic manage-ment of biliary tract diseases (level 2). The experi-ence necessary to become proficient in the diagno-sis and therapy of biliary tract diseases should beoffered only in institutions that have a large patientreferral base, a wide range of patients with biliarytract diseases, and experienced faculty in gastroen-terology, radiology, surgery, and clinical pathology.

Trainees in gastroenterology must understand therole the following disciplines play in the diagnosis andmanagement of pancreatic disorders and must havedirect experience working with these disciplines in thecare of individual patients: therapeutic endoscopy, sur-gery, interventional radiology, anatomic pathologyand cytopathology, nutritional support service, painmanagement service, medical oncology, and radiationoncology (see Training in Endoscopy, Training inSurgery, Training in Radiology, Training in Hepatic

Pathology, and Training in Nutrition).

Assessment of CompetenceKnowledge of biliary tract diseases and pancreaticdisorders should be assessed as part of the overallevaluation of trainees in gastroenterology during andafter the fellowship, as outlined in Overview ofTraining in Gastroenterology. Questions relating tobiliary tract diseases and pancreatic disorders shouldbe included on the board examination and shouldreflect a general knowledge of this content.



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ImportanceInstruction in the fundamentals of cellular andmolecular physiology provides an essential founda-tion for the overall educational program in moderngastroenterology. A complete understanding of nor-mal and abnormal gastrointestinal processes cannotbe achieved without a working knowledge of life atits most fundamental level. The following goalsmust be acquired by those trainees planning acareer in basic biomedical research, while alltrainees must gain exposure to gastrointestinal cel-lular and molecular physiology.

Goals of TrainingDuring fellowship, trainees should gain an under-standing of a variety of disciplines, includingimmunology, genetics, physiology, neurogastroen-terology, pharmacology, biochemistry, and patholo-gy. Such exposure should result in an operationalunderstanding of technology as well as informationon cellular and subcellular structure and functionpertinent to each discipline. Trainees should developthe capacity to understand and interpret the relevantliterature as well as to comprehend and study futuredevelopments in the field. Furthermore, traineesshould be able to search and critically analyze fun-damental scientific and related pertinent informationfrom appropriate national and international pub-lished literature. Finally, it is suggested that theylearn how to search for suitable funding organiza-tions and regulatory agencies, such as the NationalInstitutes of Health, National Science Foundation,and the U.S. Food and Drug Administration, toapply for research funds, including the national gas-troenterology societies, and from which to obtainupdated information on newly developed therapeuticapproaches and drugs. These skills will provide thetrainees with the means to access information toanswer specific questions regarding molecular mech-

anisms and molecular disorders that may occur inpatients with gastrointestinal diseases and how toapproach their management.

ConceptsAlthough a precise curriculum cannot be specifiedbecause of the rapidly advancing scientific environ-ment, it is suggested that the following be covered.

Molecular BiologyThe trainees should understand the following:1. The function of genes and chromosomes and

their location, composition, and the mecha-nisms regulating their replication.

2. Genomic organization, including the functionof the promoter region, introns, exons, anduntranslated regions, and mechanisms regulat-ing the expression of this information, includ-ing transcription, messenger RNA synthesis,translation, and protein synthesis.

3. The importance of genetic variability, includingsingle nucleotide polymorphisms and otherchromosomal aberrations, particularly as theyapply to diagnostics and therapeutics.

4. The molecular processes responsible for maintain-ing genetic fidelity, such as proofreading andrepair enzymes, and the consequences of their fail-

ure, including malignant cellular transformation.5. The basic cellular mechanisms regulating cell

proliferation and differentiation and cellulardemise, including those of apoptosis, anoikis,and necrosis.

6. The role of epigenetic factors and chromatinremodeling in regulating gene expression, includ-ing DNA methylation and histone acetylation.

GeneticsTrainees should acquire a basic understanding ofthe following:1. Genetic polymorphisms, genetic defects, the

genetic basis of gastrointestinal diseases such

as hemochromatosis, Wilsons disease, familialpancreatitis, cystic fibrosis, MEN-1, intestinalpolyposis syndromes, colorectal cancer,Crohns disease, and inborn errors of metabo-lism; the gene mutations involved; and thenature of human gene mutations involved indisease pathogenesis.

2. Oncogenes, tumor suppressor genes,microsatellite and genetic instability, genomicimprinting, chromosomal rearrangements, geneamplification, and epigenetics, and their rolesin altered cell growth.

3. Trainees must gain an understanding of thegenetics of colorectal cancer and other disor-

ders listed above to enable the identification ofindividual patients at risk, guide diagnosticand therapeutic interventions in specificpatients and their families, and provide guid-ance, counseling, and answers to questionsfrom patients and their families.

Cell BiologyIt is suggested that trainees gain knowledge in thefollowing:1. The basic subcellular constituents of the cell such

as the nucleus, mitochondria, Golgi, endoplas-mic reticulum, and lysosomes, along with their

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normal functions and alterations in disease.2. The normal control of the cell cycle and

processes leading to its disruption.3. The fundamental properties of cell types specific

to and crucial to the operation of the gastroin-testinal tract. This includes an understanding ofthe turnover of the gastrointestinal epitheliumand the need for continuous differentiation fromstem cells located within each specific tissueand/or organ comprising the gastrointestinaltract as well as the processes regulating normaltissue differentiation and organogenesis.

4. The epithelial layer as a modulator of vectorialsolute transport, as a sensory organ, and as acritical barrier against toxins and pathogens.Mechanisms that lead to the establishment ofcell polarity and the appropriate developmentof intercellular junctions that are central toepithelial barrier function both under normalconditions and in disease states such as inflam-matory bowel disease.

5. The functional and structural organization of the

enteric nervous system, the network of neuronsembedded within the gastrointestinal wall con-trolling gastrointestinal function, and the extrin-sic neurons (afferent and efferent) that contributeto the modulation of digestive functions.Segmental differences along the cephalocaudalaxis critical to function as well as specialized reg-ulatory cells such as the interstitial cells of Cajaland immune cells also must be understood.

Pharmacology and Cellular SignalingIt is strongly suggested that trainees be able to rec-ognize the following:1. Basic receptor pharmacology, including regula-

tion, trafficking, and signaling as well as recep-tor transport mechanisms, cellular signal trans-duction, and cell-to-cell signaling.

2. The existence of different superfamilies ofreceptors, including ion-channel gated, G pro-tein coupled, nuclear, and tyrosine kinase-activating receptors, along with the differentpathways through which second messengersare activated to induce a functional response.The existence and complexity of cross-talkamong these various signaling pathways atboth the intracellular and extracellular level.

3. The rapidly growing field of cellular signaltransduction as a mechanism underpinning

critical regulatory processes in health and dis-ease. These include cell-matrix communication,important in host defense; cellcell communi-cation, important in tissue responses; andintracellular pathways critical for cell home-ostasis that, when disturbed, can cause unregu-lated growth or premature cell death.

4. The existence of numerous transmitters andmodulators synthesized and released by neuronsinnervating the digestive system, including clas-sical transmitters such as acetylcholine andnoradrenaline as well as slow transmitters/modulators (e.g., regulatory peptides). A clear

knowledge of the complexity of the innervationand transmitter/modulator system governing thevarious digestive functions must be acquired.

5. The existence and importance of the endocrinesystem that is scattered throughout the diges-tive tract and that often expresses the sameregulatory peptides and other chemical messen-gers as neurons.

6. The existence of immune cells that activatelocal and systemic defense systems by interact-ing with endocrine cells and neurons. Immunemessages are converted by local lymphocytesand amplified by circulating lymphocytes inresponse to luminal antigen activation.

7. The disparate mechanisms by which differentchemical messengers are released and reachtheir sites of action, including endocrine, neu-roendocrine, paracrine, and autocrine mecha-nisms of action. Trainees should have a basicunderstanding of regulatory peptides and ofneurotransmitters and their specific receptorsas they relate to the gastrointestinal tract.

Appreciating the molecular basis of this initialsignaling step is essential for interpretingpotential genetic alterations as well as the basisof pharmacological interventions.

8. The roles of nitric oxide and NO synthase incellular physiological events and their implica-tions related to gastrointestinal physiology andpathophysiology as well as the NO pathway ininflammation and splanchnic circulation andits likely interaction with the glutamate system.

Host-environment InteractionsTrainees should have an understanding of thefollowing:

1. The factors permitting the existence of commen-sal organisms and their contribution to main-taining host health as well as the processeswhereby pathogenic organisms are recognizedand by which they induce a host response

2. The principles that underlie the efficacy of pro-biotic organisms in gastrointestinal diseases.

3. The cellular and molecular biology underlyingimportant infections, including H. pylori,Salmonella species, E. coli, and other entericpathogens

4. Basic virology so that current infections,including the many causes of hepatitis, HIV,and gastroenteric infections as well as future

disorders can be appreciated; an understandingof viral life cycle, genome organization, regula-tion of replication, and pathophysiologic mech-anisms of disease

ImmunologyUnless otherwise noted, it is strongly suggestedthat trainees have a fundamental knowledge ofthe following:1. Gut-associated immune system. Trainees

should gain familiarity with gut-associatedimmune system and distinct differences fromsystemic immunology and the implications of



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this particular system in understanding gas-trointestinal physiology and pathophysiology.This knowledge should include a clear under-standing of the roles of a variety of mediatorsand modifiers of the inflammatory process,including cytokines and chemokines and otherrelated molecular species.

2. Autoimmune diseases. Trainees should gain famil-iarity with autoimmune diseases and the markersfor immune-mediated gastrointestinal diseases.

3. Basic transplantation biology. Trainees shouldgain familiarity with basic transplantation biol-ogy, including the processes leading to and per-mitting the development of critical disorderssuch as graft-versus-host disease.

4. Innate and adaptive immunity. Trainees shouldgain familiarity with innate and adaptiveimmunity, such as Th1 and Th2 responses.

TechnologiesTechnical advances have played a critical role inallowing bench-to-bedside transfer of technology.Therefore, a basic understanding of many criticaltechnologies must be included in the education ofgastroenterology trainees.1. Genetic screening techniques. A fundamental

understanding of genetics required to applygenetic screening techniques effectively.

2. Principles of polymerase chain reaction.Understanding the technology as well as itsutility, limitations, applications, and diagnosticand information acquisition potential.

3. Microarray technology. Understanding themethodology, present and projected applica-tions, and limitations.

4. Recombinant DNA technology. Understanding

the techniques and applications of develop-ment of recombinant human proteins and pep-tides for their therapeutic and diagnostic appli-cations; basic knowledge of strategies in genetherapy, including familiarity with the use ofoligonucleotides, anti-sense DNA, small inter-fering RNA, and micro RNA.

5. Basic understanding of genetic animal modelsof disease, such as transgenic and gene knockout or knock in technologies as well as theirlimitations with respect to pathophysiology ofhuman disease.

6. Proteomic methodology. Understanding ofmethods applied to the assessment of the

amount and activation status of specific pro-teins within cells, including Western blotting,electrophorectic separation, and mass spectro-metric approaches.

7. Antibody methodology. Understanding tech-niques involved in creation of hybridomas andthe potential application of monoclonal anti-bodies obtained using this technique, an under-standing of the theory and practical use ofhumanized chimeric monoclonal antibodiesbecause of their present and future applica-tions for diagnosis and management ofpatients, familiarity with polyclonal antibodies

and their use in radioimmunoassay andimmunohistochemistry as well as an under-standing of antibody specificity and sensitivity.

8. Cell sorting technology/flow cytometry.Understanding the basis of these techniquesand their potential applications to distinguishamong specific cell types. For example, theiruse in the elucidation of cell populationsinvolved in inflammatory responses and/orneoplastic processes.

9. Detection of cell markers. Understandingmethodologies ranging from microscopic,nucleic acid hybridization, immunodetectionmethods to enzymatic assays, used to identifycell markers. Application of such technologiesto distinguish the various populations of cellsinvolved in inflammatory and neoplasticprocesses. The limitations of these immunolog-ical and biochemical detection methods in sort-ing out information regarding specific diseaseprocesses.

10. Imaging techniques. Understanding how fluo-

rescent and other markers can be used toassess cell signaling events in real time

11. New technologies. An understanding of rapidlydeveloping technologies, including phage dis-play technology, filamentous phage biology,and applications from the nascent fields ofgenomics and proteomics.

12. Information acquisition. Understanding theacquisition of information in molecular biolo-gy or as it pertains to gastroenterology, bothnow and in the future, via the Internet. Forexample, DNA and RNA relationships andDNA sequences, DNA databases, SNPs, andpermutations in DNA sequences, such as gene

mutations and deletions, applicable to gas-trointestinal diseases.

In summary, the nature of gastroenterologyrequires an understanding of the cellular, molecular,and genetic mechanisms underlying normal physi-ology, including proliferation, differentiation, andprogrammed cell death (apoptosis). The impor-tance of the multiple specialized tissues that encom-pass gastrointestinal function, ranging from themusculature to the gut brain, the splanchnic circu-lation, the endocrine system, the gut immune sys-tem, and the epithelia, cannot be minimized.Equally crucial is an appreciation of what goes

awry in altered physiological states seen in inflam-mation, infection, and neoplasia.

Training ProcessIdeally, any training program should seek to com-bine the acquisition of fundamental informationpertaining to gastrointestinal morphology, physiol-ogy, and biology, with presentation of informationon altered cellular events in gastrointestinal disor-ders. Training in gastroenterology provides uniqueopportunities to do this because there are numer-ous examples in the field where the information

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can be presented in tandem. Equally relevant, thetrainees should be educated in methods to acquireand critically interpret information from the litera-ture now and in the future. Most important is therecognition by faculty and trainees that a thoroughunderstanding of the fundamental physiological,cellular, and molecular mechanisms is imperativefor the well-trained gastroenterologist.

The experience, training, and acquisition ofinformation for trainees in these areas may be pro-vided in a variety of ways, which are not mutuallyexclusive.1. Specific lectures dedicated to conveying infor-

mation regarding the topics indicated above aswell as inclusion of relevant basic science inclinical lectures.

2. Appropriate readings including primary litera-ture and instructional materials with criticaldiscussions in an appropriate forum such asjournal clubs.

3. Conferences and lectures at local, national, orinternational meetings.

4. Seminar-type courses that focus on the cellularand molecular basis of gastrointestinal physiologyfor credit in academic institutions. Instruction canbe based on a combination of prior readingassignments, didactic discourse with question-

and-answer sessions, and trainee presentations.5. An emphasis on basic mechanisms in direct

one-on-one instruction and questioning oftrainees during the diagnosis and managementof patients. Instruction in basic cellular andmolecular physiology must be incorporatedinto all aspects of clinical training and cannotbe divorced from that training so as to appearseparate from, and possibly irrelevant to, clini-cal practice.

6. Direct involvement in research activities frombasic science to translational research that uti-lize the tools and techniques of cell and molec-ular physiology to ask questions pertinent tothe pathophysiology of gastrointestinal andhepatobiliary diseases.

Assessment of CompetenceKnowledge of cellular and molecular physiologyshould be assessed as part of the overall evaluation ofthe trainees in gastroenterology during and after thefellowship, as outlined in Overview of Training inGastroenterology. No specific examination or otherinstrument of assessment needs to be developed forthis portion of the training. It is recommended thatthe program director or a faculty committee overseethe accomplishment of these goals.



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ImportanceGastrointestinal endoscopy is an essential part ofmodern clinical gastroenterology. Therefore, allgastroenterologists must be knowledgeable about

endoscopic procedures. Gastroenterologists per-forming routine diagnostic and therapeuticendoscopy (e.g., control of gastrointestinal bleed-ing) require training to achieve basic and clinicalknowledge, judgment skills, and the technicalcompetence requisite for performing these studies.Furthermore, gastroenterologists who performadvanced endoscopic procedures, such as endo-scopic retrograde cholangiopancreatography(ERCP), endoscopic ultrasound (EUS), endoscopicmucosal resection (EMR), placement of enteralstents and endoscopic GERD therapy require addi-tional training in therapeutic endoscopy as well as

advanced training in hepatobiliary diseases, pan-creatic diseases, and oncology. Not all trainees canor should be offered comprehensive training inadvanced endoscopy. Furthermore, not all pro-grams are capable of providing training in alladvanced endoscopic procedures to all trainees.

The ABIM defines procedural skills as thelearned manual skills (including supervision oftechnical aspects) necessary to perform certaindiagnostic and therapeutic procedures in gastroen-terology. Successful mastery of these skills includestechnical proficiency; an understanding of theirindications, contraindications, and complications;and the ability to interpret their results.

Goals of TrainingThe objective of endoscopic training programs is toprovide trainees with critical, supervised instructionin gastrointestinal endoscopy to ensure quality carefor patients with digestive diseases. Endoscopicprocedures are not isolated technical activities butmust be regarded by the instructors and trainees asintegral aspects of clinical problem solving.Endoscopic decision making, technical proficiency,and patient management are equally important,and the interdependence of these skills must beemphasized repeatedly during the training period.

During fellowship, trainees should gain anunderstanding of the following:1. Appropriate recommendation of endoscopic

procedures based on findings from personalconsultations and in consideration of specificindications, contraindications, and diagnostic/therapeutic alternatives.

2. Performance of specific procedures safely, com-pletely, and expeditiously.

3. Correct interpretation of most endoscopic andcapsule endoscopic findings.

4. Integration of endoscopic findings or therapyinto the patient management plan.

5. Recognition of risk factors attendant to endo-scopic procedures and to be able to recognizeand manage complications.

6. Personal and procedural limits and to know

when to request help.7. Indications, complications, and risks of capsuleendoscopy and how to integrate this technologyinto the overall clinical evaluation of the patient.

8. Safe and appropriate use of moderate sedation.

In addition, gastroenterologists should be skilledin the approach to the diagnosis and the endo-scopic and/or medical management of patientswith gastrointestinal hemorrhage, including acuteupper gastrointestinal hemorrhage of both varicealand nonvariceal origin and lower gastrointestinalbleeding of either acute or chronic presentation.

Two levels of endoscopic training for two distinct

types of gastroenterologists should be recognized. Level 1 includes gastroenterologists per-forming routine gastrointestinal endoscopicand non-endoscopic procedures as part ofthe practice of gastroenterology and gas-troenterologists specializing in non-endo-scopic aspects of gastroenterology, includ-ing, but not limited to, the study of liverdiseases, motility, nutrition, and basic sci-ence research.

Level 2 includes gastroenterologists who, inaddition to all or part of the above, per-form some or all advanced (both diagnosticand therapeutic) gastrointestinal endoscopy

procedures, including endoscopic retro-grade cholangiopancreatography (withsphincterotomy, lithotripsy, stent place-ment, etc.), endoscopic ultrasound, endo-scopic mucosal resection, endoscopicGERD therapy, and laparoscopy.Gastroenterologists who perform advancedendoscopic procedures should assumeresponsibility for teaching these advancedendoscopic procedures to designatedtrainees if appropriate, conduct endoscopicresearch, and critically assess and evaluatenew and emerging endoscopic technology/procedures for safety and efficacy.

FacultyEndoscopy training instructors should be sound cli-nicians and teachers who are well trained, experi-enced, and skilled in endoscopy. Endoscopy instruc-tors should have a demonstrated aptitude forteaching because it is recognized that not all expertendoscopists are

gastro 2007 version core curriculum

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