Curriculum

1. Inpatient GI/ liver consult service at LMC (6 months): Fellows provide consultative services on a wide range of acute GI and liver issues including GI bleeding, acute colitis, acute liver failure, and evaluation of abdominal pain, nausea, vomiting and abnormal liver enzymes. You will perform inpatient endoscopic procedures including diagnostic and therapeutic upper endoscopies, push enteroscopies, colonoscopies, variceal banding, and non-variceal bleed control with epinephrine, cautery and clips. You will have the opportunity to perform cases such as food bolus removals, foreign body removals, esophageal dilations, and argon plasma coagulation. You will learn the role of being a consultant and the multi-disciplinary approach to GI and liver care.

2. Inpatient liver service at JH (1 month): Fellows learn how to manage patients with acute hepatitis of multiple etiologies, how to evaluate patients with abnormal liver labs, how to work up and manage patients pre- and post- liver transplantation, and how to manage patients with acute liver failure. JH is a major regional transplant referral center and will be your primary site for learning how to evaluate and manage both pre- and post-transplant clinical issues, as well as high acuity liver patients with a broad range of liver diseases. Fellows also have the opportunity to work in a university setting which presents different opportunities and challenges from a community hospital setting. Dr. Dina Halegoua-Demarzio, Transplant Hepatology Fellowship Program Director and Director of the Fatty Liver Center at Jefferson Hospital, oversees this rotation.

3. Outpatient liver rotation at JH (1 month): Fellows work closely with the Jefferson hepatology faculty to evaluate and manage patients with acute and chronic hepatitis from a broad range of etiologies. You will see both pre- and post-transplant patients and learn how to manage issues pertaining specifically to transplantation including post transplantation complications, management of immunosuppressants, MELD scores, exception points, contraindications to transplantation, diagnosis and management of hepatocellular carcinoma.

4. Outpatient faculty practice rotation at LMC (1 month): Outpatient gastroenterology will comprise the majority of your practice when you finish fellowship and it is critical to have a good understanding of outpatient GI and liver diseases and how to manage these patients in the outpatient setting. For this reason, we start this rotation in the first year of training, to begin your exposure and education in outpatient GI. You will shadow the various GI attendings at LMC in their outpatient practice. You will see the differences in their styles of practice and learn different approaches to outpatient gastroenterology, as well as standard of care practices based on society guidelines. You will have the chance to see patients at the discretion of each GI attending.

5. Radiology at LMC (1 month): Imaging of the GI tract and liver is an important and essential part of both diagnostic and therapeutic interventions in gastroenterology and hepatology. It is essential to know when to use radiographic studies and which studies to choose. You will work with the Lankenau radiology department to become familiar with imaging modalities including abdominal plain films, ultrasound, CT scans, MRI, MRCP, angiograms, enterographies. You will learn the indications for different modalities and risks and benefits of each for assisting with the diagnosis of GI and liver disease. You will become familiar with upper GI fluoroscopic studies including barium swallow, modified barium swallow, video swallow, UGI series, small bowel follow through and understand when to use which. You will also become familiar with lower GI fluoroscopic studies including barium enemas and defecography. You will work with our nuclear radiology group to understand gastric emptying scans, PET scans, and HIDA scans. You will also work with the Lankenau Interventional Radiology department to become familiar with provocation studies, image- guided biopsies of the GI tract and liver, TIPS procedures, and embolization of bleeding vessels.

6. Research (2 months): All fellows are required to participate in research through their fellowship which should result in AT LEAST ONE publication, abstract, or poster presentation at a major GI society conference. Fellows must design and complete AT LEAST ONE quality improvement (QI) project during their fellowship. Fellows also have the opportunity to participate in ongoing GI basic science research with Dr. Jim Mullin at LIMR. Project ideas, designing projects, and updates will be discussed at monthly research meetings. A formal research presentation day will occur at the end of each year, where all fellows must present their project(s) to the GI faculty who will be in attendance. Mentorship will be provided by the GI faculty, but may be extended to faculty members in any department. Help with statistics is available from a statistician through LIMR. Dr. Cathy Kuntz (pulmonary) and Dr. Wong (Gi) can help with basic statistics. This blocks offers protected research time.

1. Inpatient GI/liver consult service at LMC (4 months)- Fellows provide consultative services on a wide range of acute GI and liver issues including GI bleeding, acute colitis, acute liver failure, and evaluation of abdominal pain, nausea, vomiting and abnormal liver enzymes. You will perform inpatient endoscopic procedures including diagnostic and therapeutic upper endoscopies, push enteroscopies, colonoscopies, variceal banding, and non-variceal bleed control with epinephrine, cautery and clips. You will have the opportunity to perform cases such as food bolus removals, foreign body removals, esophageal dilations, and argon plasma coagulation. You will learn the role of being a consultant and the multi-disciplinary approach to GI and liver care.

2. Inpatient GI/liver consult service at BMH (2 months): Second year fellows rotate on the inpatient GI and liver consultation service at our sister hospital, BMH, in the Main Line Health System. Here, you will have the opportunity to work with a different group of GI faculty in another community hospital setting. You will have exposure to different styles of practice and management of acute liver and GI issues as well as a different patient demographic from LMH. You will have the opportunity to perform advanced endoscopic procedures here, such as ERCPs.

3. Inpatient liver service at JH (1 month): Fellows learn how to manage patients with acute hepatitis of multiple etiologies, how to evaluate patients with abnormal liver labs, how to work up and manage patients pre- and post- liver transplantation, and how to manage patients with acute liver failure. JH is a major regional transplant referral center and will be your primary site for learning how to evaluate and manage both pre- and post-transplant clinical issues, as well as high acuity liver patients with a broad range of liver diseases. Fellows also have the opportunity to work in a university setting which presents different opportunities and challenges from a community hospital setting. Dr. Dina Halegoua-Demarzio, Transplant Hepatology Fellowship Program Director and Director of the Fatty Liver Center at Jefferson Hospital, oversees this rotation.

This extra month of exposure to inpatient liver patients was added in the 2019-2020 academic year to provide more exposure to inpatient liver diagnosis and management with the Jefferson Hepatology faculty.

4. ERCP at LMC (1 month): Fellows provide consultations on inpatient pancreatic and biliary cases at LMC and have the opportunity to perform ERCPs. This may include cannulating the pancreatic duct, sphincterotomies, stone extractions and stent placements. You will become familiar with diagnosing and managing bile duct stones, cholangitis, malignancies, and complicated pancreatitis. This month of exposure during your second year will help you decide whether you would like to pursue extended time with ERCP training during your third year (5 months) or limited time (2 month), (See third year fellowship section).

5. Outpatient liver rotation at JH (1 month): Fellows work closely with the Jefferson hepatology faculty to evaluate and manage patients with acute and chronic hepatitis from a broad range of etiologies. You will see both pre- and post-transplant patients and learn how to manage issues pertaining specifically to transplantation including post transplantation complications, management of immunosuppressants, MELD scores, exception points, contraindications to transplantation, diagnosis and management of hepatocellular carcinoma.

6. Outpatient faculty practice at LMC (1 month): Outpatient gastroenterology will comprise the majority of your practice when you finish fellowship and it is critical to have a good understanding of outpatient GI and liver diseases and how to manage these patients in the outpatient setting. For this reason, we start this rotation in the first year of training, to begin your exposure and education in outpatient GI. You will shadow the various GI attendings at LMC in their outpatient practice. You will see the differences in their styles of practice and learn different approaches to outpatient gastroenterology, as well as standard of care practices based on society guidelines. You will have the chance to see patients at the discretion of each GI attending.

7. Research (2 months): All fellows are required to participate in research through their fellowship which should result in AT LEAST ONE publication, abstract, or poster presentation at a major GI society conference. Fellows must design and complete AT LEAST ONE quality improvement (QI) project during their fellowship. Fellows also have the opportunity to participate in ongoing GI basic science research with Dr. Jim Mullin at LIMR. Project ideas, designing projects, and updates will be discussed at monthly research meetings. A formal research presentation day will occur at the end of each year, where all fellows must present their project(s) to the GI faculty who will be in attendance. Mentorship will be provided by the GI faculty, but may be extended to faculty members in any department. Help with statistics is available from a statistician through LIMR. Dr. Cathy Kuntz (Pulmonary) and Dr. Wong (GI) can help with basic statistics. This blocks offers protected research time.

1. Inpatient GI/liver consult service at LMC (2 months): Fellows provide consultative services on a wide range of acute GI and liver issues including GI bleeding, acute colitis, acute liver failure, and evaluation of abdominal pain, nausea, vomiting and abnormal liver enzymes. You will perform inpatient endoscopic procedures including diagnostic and therapeutic upper endoscopies, push enteroscopies, colonoscopies, variceal banding, and non-variceal bleed control with epinephrine, cautery and clips. You will have the opportunity to perform cases such as food bolus removals, foreign body removals, esophageal dilations, and argon plasma coagulation. You will learn the role of being a consultant and the multi-disciplinary approach to GI and liver care.

2. Inpatient Gi/liver consult service at BMH (2 months): Second year fellows rotate on the inpatient GI and liver consultation service at our sister hospital, BMH, in the Main Line Health System. Here, you will have the opportunity to work with a different group of GI faculty in another community hospital setting. You will have exposure to different styles of practice and management of acute liver and GI issues as well as a different patient demographic from LMH. You will have the opportunity to perform advanced endoscopic procedures here, such as ERCPs.

3. ERCP rotation at LMC (2 months): Fellows provide consultations on inpatient pancreatic and biliary cases at LMC and have the opportunity to perform ERCPs. This may include cannulating the pancreatic duct, sphincterotomies, stone extractions and stent placements. You will become familiar with diagnosing and managing bile duct stones, cholangitis, malignancies, and complicated pancreatitis. This month of exposure during your second year will help you decide whether you would like to pursue extended time with ERCP training during your third year (5 months) or limited time (2 month), (See third year fellowship section).

4. Subspecialty elective rotation at various hospitals (1 month): Third year fellows have the opportunity to learn about the subspecialties within GI on this rotation which focuses on outpatient GI diagnosis and management of patients. Electives include inflammatory bowel disease, motility, functional bowel disease, colorectal disease, bariatric surgery, nutrition, GI oncology, and hepatology (full description of electives available).

In the 2019-2020 academic year, we created 2 new rotations, to further supplement the areas of expertise our fellows can gain exposure to. These are rotations with 1) Dr. Joseph Bonn in interventional radiology at LMC, 2) Dr. Dina Halegoua-Demarzio on the inpatient liver service at JH. In the 2021-22 academic year, we created 2 more rotations which are 1) Conscious sedation with the pulmonary faculty and 2) Nutrition rotation at the University of Pennsylvania Hospital with Dr. Octavia Pickett-Blakely, Director of GI nutrition (application required)

Each elective rotation must be at least 2 weeks in duration and it is up to the fellow to design this block to optimize their learning as it pertains to their interests. Each rotation has an attending who has been appointed to oversee the rotation and learning experience. Various rotations will take place at LMC, BMH, Paoli Hospital, JH, and Temple University. Fellows may also request rotations at hospitals outside of the Philadelphia area if they feel that they may gain added exposure to an area of interest to them. These may include, but are not limited to applying to the American Neurogastoenterology and Motility Society (ANMS) Clinical Training Program to spend 4 weeks at a top motility center and the CCFA visiting IBD fellow to spend 4 weeks rotating at a major IBD center.

5. Elective rotations: ERCP or subspecialty electives (3 months): Third year fellows are given the option to pursue further inpatient pancreaticobiliary training with ERCPs or more time on subspecialty elective rotations, depending on their personal interest. If they pursue the 3 months of ERCP experience, they have the opportunity to be certified in ERCP at the end of their 3 years of fellowship. However, this is at the discretion of Dr. Babek Etemad, the Chief of Interventional endoscopy at LMC, who oversees this rotation. Opportunities to assist or perform other advanced techniques such as placing luminal stents, endoscopic ultrasound (EUS), radiofrequency ablations, laser therapy, cyst-gastrostomies, and double balloon enteroscopies are also available.

6. Outpatient liver rotation at JH (1 month): Fellows work closely with the Jefferson hepatology faculty to evaluate and manage patients with acute and chronic hepatitis from a broad range of etiologies. You will see both pre- and post-transplant patients and learn how to manage issues pertaining specifically to transplantation including post transplantation complications, management of immunosuppressants, MELD scores, exception points, contraindications to transplantation, diagnosis and management of hepatocellular carcinoma.

7. Outpatient faculty practice rotation at LMC (1 month): Outpatient gastroenterology will comprise the majority of your practice when you finish fellowship and it is critical to have a good understanding of outpatient GI and liver diseases and how to manage these patients in the outpatient setting. For this reason, we start this rotation in the first year of training, to begin your exposure and education in outpatient GI. You will shadow the various GI attendings at LMC in their outpatient practice. You will see the differences in their styles of practice and learn different approaches to outpatient gastroenterology, as well as standard of care practices based on society guidelines. You will have the chance to see patients at the discretion of each GI attending.

The LMC fellowship program is very heavily clinically focused and emphasizes developing a broad and deep understanding of GI and liver diseases. This includes recognizing the various presentations of diseases, understanding appropriate studies used for evaluation, and knowing the risks and benefits of various therapeutic options. We train our fellows to develop critical analytical skills in their approach to medicine and to apply appropriate evidence-based knowledge. We emphasize both inpatient acute care of patients as well as ambulatory longitudinal care of chronic disorders, which is oftentimes underemphasized in fellowship training. We expose our fellows to a very broad and diverse range of clinical disorders and patient demographics by providing both community hospital and tertiary care hospital rotations throughout all three years. We teach our fellows how to effectively serve as a consulting physician and to communicate and function effectively within a multi-disciplinary team. As fellows progress through their training, we give them increasing autonomy to make clinical decisions and take charge of the care of their patients, in the inpatient and outpatient setting, under the supervision of an attending physician. The GI attending physicians also have a very close relationship to our fellows, and strive to provide mentorship and to serve as role models for excellent clinical care.

Teaching is an integral part of the fellowship program. Every fellow is expected to teach medical residents and students on rounds and to provide consultation and information to all healthcare providers involved in the care of mutual patients. In addition, fellows are assigned didactic lectures as part of their weekly conferences. For fellows with a particular interest in teaching, there are ample opportunities to give formal lectures to students and residents throughout the year. Senior fellows also provide mentorship to the junior fellows in both endoscopic procedures and clinical training.

Each fellow participates in the GI Fellows Ambulatory Clinic one afternoon a week, Thursdays from 1:00–4:00 pm. Every fellow is expected to attend clinic, even while on clinical rotations off campus. The clinic provides fellows with the opportunity to provide longitudinal care to their outpatients and to gain experience in the management and care of GI and liver patients in the ambulatory setting. Fellows gain exposure to the evaluation and management of typical GI issues such as heartburn, dysphagia, abdominal pain, anemia and functional bowel disease. They also learn how to diagnose and manage more complex patients with IBD, GI motility disorders, and advanced liver disease. The GI clinic is precepted by 2 GI faculty members who review and discuss cases with fellows. However, fellows’ clinic allows the fellows to take charge of their own patients with appropriate supervision.

All fellows keep a logbook of endoscopic procedures. A list of all procedures performed must be submitted to the Program Director on a quarterly basis. This practice allows the Program Director to monitor endoscopic progress and adjust for any deficiencies that might arise.

One fellow provides overnight call coverage from 5 pm to 7 am the following day every day of the week. Call is taken from home, but fellows are expected to be within 20 minutes of the hospital in case of emergencies. Call coverage only includes hospital inpatients and new consultations. Fellows are not expected to cover their outpatient clinic patients or the attendings’ private office patients while on call. Fellows take call with an attending physician who is available for all questions and any emergencies. First year fellows take call every third week for one week. Second year fellows cover every sixth week for one week. And third year fellows take no call.