• Post-Graduate Medical Education Office, McMaster University
• Internal Medicine Residency Program
• External Program Ombudsperson
• Residency Program Committee

1. The Ombudsperson is a member of the Department of Medicine who does not have an administrative role in the Residency Program. Dr. Darin Treleaven is the Ombudsperson for the Adult Gastroenterology Residency Training Program.
2. The function of the Ombudsperson is to be available to the residents to discuss any problems either personal or professional that the resident may have. The Ombudsperson can offer advice and assistance, and if appropriate and with the resident's permission, act on the resident's behalf in the resolution of those problems

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The Residency Program Committee (RPC) assists the Program Director in the planning, organization, and supervision of the Adult Gastroenterology Training Program.

Composition of Committee

1. Program Director chairs the RPC.
2. The RPC is composed of representatives from major components of the education program. The Program Director, after consultation with the Divisional Chief, appoints individual committee members. Members are typically chosen because of their interest in resident education.
3. The RPC includes representation from the residents in the program, at least one of whom is to be a resident representative, selected by his or her peers.

The RPC meets regularly, at least quarterly, and keep minutes. Agenda and any relevant documentation are pre-circulated to RPC members prior to each meeting. Minutes are sent to all staff and residents, as well as the Assistant Dean of Postgraduate Education and the General Internal Medicine Program Director. 

Responsibilities of the Residency Program Committee

The RPC is responsible for the overall operations of this two-year residency program. This includes the global objective of providing the environment, mentorship and uniform experience whereby each resident will have access to the educational experience sufficient to successfully complete the program objectives. The RPC committee is responsible for assisting and contributing to the program functions for the Adult Gastroenterology Training Program at McMaster University, including the following important domains:

1. Training Program Design
   1. The development of a clear program plan including goals and objectives based on CanMEDS competencies relating to knowledge, skills, and attitudes and based upon the objectives of training in the specialty as published in the specialty training requirements of the College. The plan includes the methods by which the objectives are to be achieved and the role played by each rotation and by each participating institution.
   2. The conduct of the program including the rotation of residents to ensure that each resident is advancing and gaining in experience, skills and responsibility in accordance with the educational plan.
   3. Conducting an annual review of the program to assess the quality of the educational experience and to review the resources available in order to ensure that maximal benefit is being derived from the integration of the components of the program. The opinions of the residents are considered in this review. Appropriate faculty / resident interaction and communication must take place in an open and collegial atmosphere so that a free discussion of the strengths and weaknesses of the program can occur without hindrance. This review includes:
      1. an assessment of each clinical and academic component of the program to ensure that the educational objectives are being met
      2. an assessment of resource allocation to ensure that resources and facilities are being utilized with optimal effectiveness
      3. an assessment of teaching  in the program, including teaching in areas such as biomedical ethics, medicolegal considerations, and administrative and management issues
      4. an evaluation of the performance of each teacher and / or supervisor
      5. an assessment of the learning environment of each component of the program
2. Resident Evaluation
   1. The assessment of performance of each resident through a well-organized program of in-training evaluation.
   2. Evaluation and promotion of residents in accordance with policies determined by the Postgraduate Education Committee. This includes evaluation for the completion of the Final In Training Evaluation (FITER) at the end of the program as required by the College.
   3. Coordination and development of the bi-annual mock OSCE / written exam
3. Appeals
   1. The maintenance of an appeal mechanism in accordance with policies determined by the Faculty Postgraduate Education Committee.
   2. Receive and review Level One appeals from residents which are unresolved at the informal stage with the rotation supervisor and, where appropriate, refer the matter to the Postgraduate Education Committee.
4. Recruitment
   1. The selection of residents for admission to the program including application reviews, interviews and ranking of candidates.
5. Resident Well-being
   1. Maintenance of mechanisms by which residents receive career planning and counseling
   2. Maintenance of mechanisms for residents to access available services to manage stress and performance problems

Site coordinators are primarily responsible for coordinating the resident rotations at their site and ensuring the educational value of those rotations. 

At the beginning of each block, the residents are expected to meet with the Site Coordinators for orientation to review both the clinical setting, and objectives and expectations specific to the individual. 

Specific issues relating to scheduling clinics, endoscopy lists and teaching sessions will be reviewed.  Over the course of each rotation, the Site Coordinators are available as resources for conflicts that arise and for help in coordinating the evaluation process. 

Site coordinators distribute and collate resident evaluations for rotations at their site and review those evaluations with residents.

Hepatology curriculum coordinator is primarily responsible for coordinating the mandatory Hepatology rotation during the First Year and elective in Hepatology during the Second Year, and ensuring the educational value of the rotation / elective.

At the beginning of each Hepatology rotation / elective, the residents are expected to meet with the Hepatology curriculum coordinator for orientation to review both the clinical setting, and objectives and expectations specific to the rotation.

Specific issues relating to scheduling clinics, endoscopy lists, paracentesis / liver biopsy, and teaching sessions will be reviewed. Over the course of the rotation / elective, the Hepatology curriculum coordinator is available as a resource for conflicts that arise and for help in coordinating the evaluation process.

Hepatology curriculum coordinator distributes and collates resident evaluations for the Hepatology rotation / elective and reviews those evaluations with residents.

In addition, the Hepatology curriculum coordinator is responsible for organizing academic half day sessions and journal club series on Hepatology topics.

Motility Curriculum Coordinator is primarily responsible for coordinating the Motility rotation during the Second Year and Motility elective during the Second Year, and ensuring the educational value of the rotation / elective.

At the beginning of each Motility rotation / elective, the residents are expected to meet with the Motility Curriculum Coordinator for orientation to review both the clinical setting, and objectives and expectations specific to the rotation.

Specific issues relating to scheduling clinics, endoscopy lists, motility and pH-metry sessions (observation and interpretation of test results), and teaching sessions will be reviewed. Over the course of the rotation / elective, the Motility Curriculum Coordinator is available as a resource for conflicts that arise and for help in coordinating the evaluation process. Motility Curriculum Coordinator distributes and collates resident evaluations for the Motility rotation / elective and reviews those evaluations with residents.

In addition, the Motility Curriculum Coordinator is responsible for organizing Academic Half-Day sessions on Motility topics.

Nutrition Curriculum Coordinator is primarily responsible for coordinating the Clinical Nutrition rotation during the Second Year and Clinical Nutrition elective during the Second Year, and ensuring the educational value of the rotation / elective.

At the beginning of each Clinical Nutrition rotation / elective, the residents are expected to meet with the Nutrition Curriculum Coordinator for orientation to review both the clinical setting, and objectives and expectations specific to the rotation.

Specific issues relating to scheduling clinics, endoscopy lists, ward rounds and teaching sessions will be reviewed. Over the course of the rotation / elective, the Nutrition Curriculum Coordinator is available as a resource for conflicts that arise and for help in coordinating the evaluation process. Nutrition Curriculum Coordinator distributes and collates resident evaluations for the Nutrition rotation / elective and reviews those evaluations with residents.

In addition, the Nutrition Curriculum Coordinator is responsible for organizing Academic Half-Day sessions on Clinical Nutrition topics.

Each trainee is assigned a mentor who will be available to discuss problems ranging from personal (e.g. stress) to professional (e.g. career choices).

The mentor is expected to develop a special relationship with the trainee over the duration of his or her stay in the program. The mentor should assist the trainee in meeting his or her goals within the context of the program, and specifically with respect to general objectives #4 and #6 of the second year.

The role of the mentor does not conflict with the roles of the Program Director or the Site Coordinators; all will contribute to resolving a trainee's particular problems and all will be directly involved in achieving general objective #5 of the second year.

The Research Coordinator is responsible for guiding and monitoring the research activity of GI residents. 

Specifically, the coordinator ensures that each resident identifies a research project and supervisor for their first year block, reviews their progress over that block, and assesses their eligibility for more research time in the second year.

The Research Coordinator also ensures that residents meet the core productivity requirements of the research block.

The Academic Half Day Coordinator is responsible for assisting the Program Director in developing, monitoring and evaluation of the academic half day curriculum in the Adult Gastroenterology Training program. A syllabus is outlined for each year by the Chief Resident, Academic Half Day Coordinator and the Program Director.

Specific issues relating to the structure, content, and scheduling of the half-day sessions are reviewed by the Academic Half Day Coordinator and the Program Director. The Academic Half Day Coordinator is also available as a resource for issues arising during the half-day sessions.

The Academic Half Day Coordinator collates resident evaluations for all half-day sessions and reviews these evaluations with the Chief Resident and the Program Director at the end of the year. The data is then analyzed annually for program review and faculty feedback.

All residents participate in mock OSCE and written examinations twice a year. The experience is invaluable preparation for the Royal College of Physicians and Surgeons of Canada licensing examinations, and also facilitates organized thinking around problems and dilemmas in Gastroenterology. The results of these tests are reviewed and used as formative assessment tools to guide future learning objectives.

OSCE stations are generated by the OSCE Coordinating Committee and reviewed by the OSCE Coordinator and the Program Director before being implemented. Written exams are prepared by 2 faculty members (1 luminal and 1 hepatology) and submitted to the OSCE coordinator for review and approval prior to implementation.

The Chief Gastroenterology Resident is selected from the second year gastroenterology residents by a faculty vote. The position provides an opportunity for the resident to be involved with the administrative organisation and day-to-day running of the training program. The Chief Resident attends meetings of regional gastroenterologists and provides residency input. He/she is a member of the interview committee to admit candidates into the Training Program. Additional responsibilities of the Chief Resident include:

1. Participating in the GI Training Program Education Committee.
2. Allocating GI residents and rotating core medical and/or surgical residents to rotations and outpatient clinics in consultation with the Site Coordinators and the Program Director.
3. Organizing schedules for resident participation in outpatient clinics and endoscopy clinics, including participation by residents not on active clinical service (e.g. research or elective).
4. Scheduling call rota for GI and rotating residents (including revision of rota in the event of sickness or vacation/professional leave) in keeping with current PAIRO collective agreements.
5. Contributing to the organization of the Academic Half-Day in consultation with the Program Director.

The Chief Resident receives a small stipend for these duties. In some years, the position is shared by two residents (each serves a 6-month term).  On an ad hoc basis, the Chief Resident may delegate specific responsibilities to other residents. A second Resident Representative to the Gastroenterology Training Program Education Committee is elected following a ballot of all residents. 

A resident representative (separate from the Chief Resident) is elected by the Gastroenterology residents following a ballot of all residents. This resident provides input and representation to the Residency Program Committee.

Definition

Gastroenterology is the medical specialty that deals specifically with the investigation, diagnosis and management of disorders of the digestive system including the pancreas and liver. The specialty is further defined by pediatric and adult disciplines based on differences in knowledge and technical skills. There is overlap in some aspects of the two disciplines at the adolescent transition.

General Objectives

Only candidates certificated by the Royal College of Physicians and Surgeons of Canada in Internal Medicine or Pediatrics may be eligible for the Certificate of Special Competence in Gastroenterology.

Specialists in Gastroenterology are expected to be competent consultants with well-founded knowledge of all aspects of Gastroenterology including relevant basic sciences, research and teaching and appropriate technical capabilities who are able to establish effective professional relationships with patients and their families and care givers. They must have sound knowledge of either general internal medicine or pediatrics and an appreciation and understanding of the close relationship that commonly exists between diseases of the digestive organs and of other organ systems. They are competent self-directed learners who can adapt practice patterns according to the general principles of evidence-based medicine.

Residents must demonstrate the knowledge, skills and attitudes relating to gender, culture and ethnicity pertinent to Gastroenterology. In addition, all residents must demonstrate an ability to incorporate gender, cultural and ethnic perspectives in research methodology, data presentation and analysis.

Goals

Upon completion of training, a resident is expected to be a competent subspecialist in Gastroenterology, capable of assuming a consultant’s role in the subspecialty. The resident must acquire a working knowledge of the theoretical basis of the subspecialty, including its foundations in the basic medical sciences and research.

Only candidates certified by the Royal College of Physicians and Surgeons of Canada in Internal Medicine or Pediatrics may be eligible for certification in Gastroenterology.

Residents must demonstrate the requisite knowledge, skills, and attitudes for effective patient-centered care and service to a diverse population. In all aspects of subspecialist practice, the graduate must be able to address issues of gender, sexual orientation, age, culture, ethnicity and ethics in a professional manner.

Medical Expert

Definition:

As Medical Experts, Gastroenterologists integrate all of the CanMEDS Roles, applying medical knowledge, clinical skills, and professional attitudes in their provision of patient-centered care. Medical Expert is the central physician Role in the CanMEDS framework.

Key and Enabling Competencies: Gastroenterologists are able to…

1. Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal, ethical and patient-centered medical care
1.1. Perform a consultation, including the presentation of well-documented assessments and recommendations in written and/or verbal form in response to a request from another health care professional
1.2. Demonstrate effective use of all CanMEDS competencies relevant to Gastroenterology
1.3. Identify and appropriately respond to relevant ethical issues arising in patient care
1.4. Demonstrate the ability to prioritize professional duties when faced with multiple patients and problems
1.5. Demonstrate compassionate and patient-centered care
1.6. Recognize and respond to the ethical dimensions in medical decision-making
1.7. Demonstrate medical expertise in situations other than patient care, such as providing expert legal testimony or advising governments, as needed

2. Establish and maintain clinical knowledge, skills and attitudes appropriate to Gastroenterology
2.1. Apply knowledge of the clinical, socio-behavioural, and fundamental biomedical sciences relevant to Gastroenterology, including:
2.1.1. Anatomy, embryology, physiology and pathology of the digestive system including the pancreas and liver
2.1.2. Principles of biochemistry, molecular biology and genetics as they apply to the digestive system
2.1.3. Principles of metabolism, pharmacokinetics, pharmacodynamics and toxicity of drugs commonly used in Gastroenterology
2.1.4. Principles of endocrinology, intermediary metabolism and nutrition, oncology, microbiology and psychiatry as they apply to the digestive system
2.1.5. Principles of gastrointestinal surgery including the indications for and the complications of operations on the gastrointestinal tract
2.1.6. Diseases affecting the digestive system, pancreas and liver including the epidemiology, pathophysiology, methods of diagnosis, management and prognosis of such diseases
2.1.7. Indications, interpretations, limitations, and complications of diagnostic procedures performed on the digestive tract
2.1.8. Hazards of endoscopic procedures for the operator, assistants and patient, and the measures appropriate to minimize such hazards
2.1.9. Principles of fluoroscopy used during endoscopic procedures including the safe use of X-rays for both patient and operator
2.1.10. Advances in the management of gastrointestinal disorders, including organ transplantation, therapeutic endoscopy
2.2. Describe the CanMEDS framework of competencies relevant to Gastroenterology
2.3. Apply lifelong learning skills of the Scholar Role to implement a personal program to keep up-to-date, and enhance areas of professional competence
2.4. Contribute to the enhancement of quality care and patient safety in Gastroenterology, integrating the available best evidence and best practices

3. Perform a complete and appropriate assessment of a patient
3.1. Identify and explore issues to be addressed in a patient encounter effectively, including the patient’s context and preferences
3.2. Elicit a history that is relevant, concise and accurate to context and preferences for the purposes of prevention and health promotion, diagnosis and/or management
3.3. Perform a focused physical examination that is relevant and accurate for the purposes of prevention and health promotion, diagnosis and/or management, with particular emphasis on areas specific to the digestive system and its disorders including nutritional deficiencies
3.4. Select and interpret medically appropriate investigative methods in a resource-effective and ethical manner, including:
3.4.1. Imaging modalities (barium studies, ultrasound, computerized tomography (CT) scan, magnetic resonance imaging (MRI), radioisotope scan, endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound, capsule endoscopy) for the digestive system, pancreas and liver
3.4.2. Tests commonly employed in gastrointestinal function laboratories including breath tests and motility studies
3.4.3. Tissue biopsies of the gastrointestinal tract and liver
3.4.4. Endoscopic procedures including biopsies of the upper and lower gastrointestinal tract including, but not limited to, colonoscopy, upper endoscopy and sigmoidoscopy
3.4.4.1. Appropriate use and care of equipment used in endoscopic procedures
3.4.5. Appropriate use of clinical data to formulate problems and to correctly develop investigation and management plans to deal with the patient’s problem(s)
3.5. Demonstrate effective clinical problem solving and judgment to address patient problems, including interpreting available data and integrating information to generate differential diagnoses and management plans for gastrointestinal diseases
3.5.1. Demonstrate the ability to recognize, evaluate and manage gastrointestinal emergencies, including, but not limited to:
3.5.1.1. Acute gastrointestinal hemorrhage
3.5.1.2. Acute abdominal pain
3.5.1.3. Fulminant colitis
3.5.1.4. Biliary obstruction, including ascending cholangitis
3.5.1.5. Liver failure
3.5.1.6. Ingested foreign bodies

4. Use preventive and therapeutic interventions effectively
4.1. Implement an effective management plan in collaboration with a patient and their family
4.2. Demonstrate effective, appropriate, and timely application of preventive and therapeutic interventions relevant to Gastroenterology, including, but not limited to:
4.2.1. Screening colonoscopy
4.2.2. Upper endoscopy for Barrett’s esophagus
4.2.3. Upper endoscopy for portal hypertension
4.2.4. Surveillance for hepatobiliary malignancy
4.3. Ensure appropriate informed consent is obtained for therapies and transfusion of blood products
4.4. Ensure patients receive appropriate end-of-life care

5. Demonstrate proficient and appropriate use of procedural skills, both diagnostic and therapeutic
5.1. Demonstrate effective, appropriate, and timely performance of diagnostic procedures relevant to Gastroenterology including:
5.1.1. Upper gastrointestinal (GI) endoscopy and biopsy
5.1.2. Colonoscopy and biopsy
5.1.3. Esophageal manometry
5.1.4. Paracentesis (adult patients only)
5.2. Demonstrate effective, appropriate, and timely performance of therapeutic procedures relevant to Gastroenterology including:
5.2.1. Luminal dilation
5.2.2. Polypectomy
5.2.3. Endoscopic hemostasis
5.2.4. Foreign body removal
5.3. Ensure appropriate informed consent is obtained for procedures
5.4. Document and disseminate information related to procedures performed and their outcomes
5.5. Ensure adequate follow-up is arranged for procedures performed

6. Seek appropriate consultation from other health professionals, recognizing the limits of their expertise
6.1. Demonstrate insight into their own limits of expertise
6.2. Demonstrate effective, appropriate, and timely consultation of another health professional as needed for optimal patient care
6.3. Arrange appropriate follow-up care services for a patient and their family

Definition:

As Communicators, Gastroenterologists effectively facilitate the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter.

Key and Enabling Competencies: Gastroenterologists are able to…

1. Develop rapport, trust, and ethical therapeutic relationships with patients and families
1.1. Recognize that being a good communicator is a core clinical skill for Gastroenterologists, and that effective physician-patient communication can foster patient satisfaction, physician satisfaction, adherence and improved clinical outcomes
1.2. Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty and empathy
1.3. Respect patient confidentiality, privacy and autonomy
1.4. Listen effectively
1.5. Communicate effectively in order to obtain a thorough and relevant patient history
1.6. Be aware of and responsive to nonverbal cues
1.7. Demonstrate sensitivity to patient concerns when presenting in the presence of a patient and/or family
1.8. Facilitate a structured clinical encounter effectively

2. Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues, and other professionals
2.1. Gather information about a disease and about a patient’s beliefs, concerns, expectations and illness experience
2.2. Seek out and synthesize relevant information from other sources, such as a patient’s family, caregivers and other professionals

3. Convey relevant information and explanations accurately to patients and families, colleagues and other professionals
3.1. Deliver information to a patient and family, colleagues and other professionals in a humane manner and in such a way that it is understandable, encourages discussion and participation in decision-making

4. Develop a common understanding on issues, problems and plans with patients, families, and other professionals to develop a shared plan of care
4.1. Identify and explore problems to be addressed from a patient encounter effectively, including the patient’s context, responses, concerns, and preferences
4.2. Respect diversity and difference, including but not limited to the impact of gender, religion and cultural beliefs on decision-making
4.3. Encourage discussion, questions, and interaction in the encounter
4.4. Engage patients, families, and relevant health professionals in shared decision-making to develop a plan of care
4.5. Address challenging communication issues effectively such as delivering bad news, and addressing anger, confusion, misunderstanding and language barriers

5. Convey effective oral and written information about a medical encounter
5.1. Maintain clear, concise, accurate and appropriate records of clinical encounters and plans
5.2. Demonstrate effective consultation skills in presenting well documented assessments and recommendations in written and/or verbal form including:
5.2.1. Procedural and specialty test reports
5.2.2. Responses to requests by other health professionals and third parties
5.3. Present medical information effectively to the public or media about a medical issue

Definition:

As Collaborators, Gastroenterologists effectively work within a health care team to achieve optimal patient care.

Key and Enabling Competencies: Gastroenterologists are able to…

1. Participate effectively and appropriately in an interprofessional health care team
1.1. Describe the Gastroenterologist’s roles and responsibilities to other professionals
1.2. Describe the roles and responsibilities of other professionals within the health care team, especially general surgeons, radiologists, pathologists, nurse practitioners, dieticians, social workers and speech language pathologists
1.3. Recognize and respect the diversity of roles, responsibilities and competences of other professionals in relation to their own
1.4. Work with others to assess, plan, provide and integrate care for individual patients (or groups of patients)
1.5. Work with others to assess, plan, provide and review other tasks, such as research problems, educational work, program review or administrative responsibilities
1.6. Participate effectively in interprofessional team meetings
1.7. Enter into interdependent relationships with other professions for the provision of quality care
1.8. Describe the principles of team dynamics
1.9. Respect team ethics, including confidentiality, resource allocation and professionalism
1.10. Demonstrate leadership in a health care team, as appropriate

2. Work with other health professionals effectively to prevent, negotiate, and resolve interprofessional conflict
2.1. Demonstrate a respectful attitude towards other colleagues and members of an interprofessional team
2.2. Work with other professionals to prevent conflicts
2.3. Employ collaborative negotiation to resolve conflicts
2.4. Respect differences and address misunderstandings and limitations in other professionals
2.5. Recognize one’s own differences, misunderstanding and limitations that may contribute to interprofessional tension
2.6. Reflect on interprofessional team function

Definition:

As Managers, Gastroenterologists are integral participants in health care organizations, organizing sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the health care system.

Key and Enabling Competencies: Gastroenterologists are able to…

1. Participate in activities that contribute to the effectiveness of their health care organizations and systems
1.1. Work collaboratively with others in their organizations
1.1.1. Organize junior trainees to maximize clinical care and educational opportunities
1.2. Participate in systemic quality process evaluation and improvement, such as patient safety initiatives
1.2.1. Describe the principles behind the operation of a safe and effective endoscopy unit including infection control and sedation
1.3. Describe the structure and function of the health care system as it relates to Gastroenterology, including the roles of physicians
1.4. Describe principles of health care financing, including physician remuneration, budgeting and organizational funding

2. Manage their practice and career effectively
2.1. Set priorities and manage time to balance patient care, practice requirements, outside activities and personal life
2.2. Manage a practice including finances and human resources
2.3. Implement processes to ensure personal practice improvement
2.4. Employ information technology appropriately for patient care

3. Allocate finite health care resources appropriately
3.1. Recognize the importance of just allocation of health care resources, balancing effectiveness, efficiency and access with optimal patient care
3.2. Apply evidence and management processes for cost-appropriate care

4. Serve in administration and leadership roles
4.1. Chair or participate effectively in committees and meetings including but not limited to endoscopy administration
4.2. Lead or implement change in health care
4.3. Plan relevant elements of health care delivery

Definition:

As Health Advocates, Gastroenterologists responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations.

Key and Enabling Competencies: Gastroenterologists are able to…

1. Respond to individual patient health needs and issues as part of patient care
1.1. Identify the health needs of an individual patient
1.2. Identify opportunities for advocacy, health promotion and disease prevention with individuals to whom they provide care
1.3. Demonstrate an understanding of the role of screening tests in reducing mortality from colorectal cancer and hepatocellular carcinoma

2. Respond to the health needs of the communities that they serve
2.1. Describe the practice communities that they serve
2.2. Identify opportunities for advocacy, health promotion and disease prevention in the communities that they serve, and respond appropriately
2.2.1. Describe, in broad terms, the key issues currently under debate regarding changes in the Canadian health care system, indicating how these changes might affect societal health outcomes and how Gastroenterologists can advocate to decrease the burden of illness at a community or societal level of conditions or problems relevant to Gastroenterology
2.2.2. Describe population-based approaches to health care services including screening and immunization programs and their implications for medical practice
2.3. Appreciate the possibility of competing interests between the communities served and other populations

3. Identify the determinants of health for the populations that they serve
3.1. Identify the determinants of health of the populations, including barriers to access to care and resources, and apply this understanding to common problems and conditions in Gastroenterology
3.2. Identify vulnerable or marginalized populations within those served, including but not limited to candidates for hepatitis B virus (HBV) vaccine, hepatitis C virus (HCV) screening amongst high risk populations and respond appropriately, applying the available knowledge about prevention to "at risk" groups within the practice

4. Promote the health of individual patients, communities, and populations
4.1. Describe an approach to implementing a change in a determinant of health of the populations they serve
4.2. Describe how public policy impacts on the health of the populations served
4.2.1. Identify current policies that affect gastrointestinal health, either positively or negatively including but not limited to immunization for viral hepatitis, anti-tobacco legislation, alcohol and substance abuse programs and health care for high risk populations
4.3. Identify points of influence in the health care system and its structure
4.4. Describe the ethical and professional issues inherent in health advocacy, including altruism, social justice, autonomy, integrity and idealism
4.5. Appreciate the possibility of conflict inherent in their role as a health advocate for a patient or community with that of manager or gatekeeper
4.6 Describe the role of the medical profession in advocating collectively for health and patient safety

Definition:

As Scholars, Gastroenterologists demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of medical knowledge.

Key and Enabling Competencies: Gastroenterologists are able to…

1. Maintain and enhance professional activities through ongoing learning
1.1. Describe the principles of maintenance of competence
1.2. Describe the principles and strategies for implementing a personal knowledge management system
1.3. Recognize and reflect on learning issues in practice
1.4. Conduct a personal practice audit
1.5. Pose an appropriate learning question
1.6. Access and interpret the relevant evidence
1.7. Integrate new learning into practice
1.7.1. Demonstrate knowledge of new advances in the management of gastrointestinal disorders including but not limited to organ transplantation, therapeutic endoscopy, endoscopic ultrasound and capsule endoscopy
1.8. Evaluate the impact of any change in practice
1.9. Document the learning process

2. Critically evaluate medical information and its sources, and apply this appropriately to practice decisions
2.1. Describe the principles of critical appraisal
2.2. Critically appraise retrieved evidence in order to address a clinical question
2.3. Integrate critical appraisal conclusions into clinical care
2.3.1. Describe and critically appraise recent landmark articles that impact current Gastroenterology practice

3. Facilitate the learning of patients, families, students, residents, other health professionals, the public and others
3.1. Describe principles of learning relevant to medical education
3.2. Identify collaboratively the learning needs and desired learning outcomes of others
3.3. Select effective teaching strategies and content to facilitate others’ learning
3.4. Demonstrate an effective lecture or presentation
3.5. Assess and reflect on a teaching encounter
3.6. Provide effective feedback
3.7. Describe the principles of ethics with respect to teaching

4. Contribute to the development, dissemination, and translation of new knowledge and practices
4.1. Describe the principles of research and scholarly inquiry
4.2. Describe the principles of research ethics
4.3. Pose a scholarly question
4.4. Conduct a systematic search for evidence
4.5. Select and apply appropriate methods to address the question
4.6. Disseminate the findings of a study

Definition:

As Professionals, Gastroenterologists are committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behaviour.

Key and Enabling Competencies: Gastroenterologists are able to…

1. Demonstrate a commitment to their patients, profession, and society through ethical practice
1.1. Exhibit appropriate professional behaviors in practice, including honesty, integrity, disclosure, commitment, compassion, respect and altruism
1.2. Demonstrate a commitment to delivering the highest quality care and maintenance of competence
1.3. Recognize and appropriately respond to ethical issues encountered in practice
1.4. Manage conflicts of interest
1.5. Recognize the principles and limits of patient confidentiality as defined by professional practice standards and the law
1.6. Maintain appropriate relations with patients

2. Demonstrate a commitment to their patients, profession and society through participation in profession-led regulation
2.1. Demonstrate knowledge and an understanding of the professional, legal and ethical codes of practice, including physician-industry interaction
2.2. Fulfill the regulatory and legal obligations required of current practice
2.3. Demonstrate accountability to professional regulatory bodies
2.4. Recognize and respond to others’ unprofessional behaviours in practice
2.5. Participate in peer review

3. Demonstrate a commitment to physician health and sustainable practice
3.1. Balance personal and professional priorities to ensure personal health and a sustainable practice
3.2. Strive to heighten personal and professional awareness and insight
3.3. Recognize other professionals in need and respond appropriately

The primary objective of the Gastroenterology Training Program is to produce a competent gastroenterologist with the requisite knowledge, skills and attitudes for providing ethical and effective patient-centred care for a wide variety of gastrointestinal conditions. These include disorders of the gastrointestinal tract, pancreas, biliary tree and liver.

The resident will acquire in-depth knowledge of aspects of biochemistry, genetics, immunology, pathology, pathophysiology, diagnosis and treatment of gastrointestinal diseases and will learn the conditions unique to pediatric and obstetric patients. He/she will learn about the psychosocial care of patients with gastrointestinal diseases, with an understanding of and sensitivity to issues involving disabilities, gender, sexual orientation, race and culture.  The resident will develop skills required for the performance of diagnostic and therapeutic procedures and interpretation of laboratory tests relevant to the practice of Gastroenterology.

The graduating resident is expected to be able to accurately convey relevant information and explanations to patients and their families, colleagues, and other professionals; to effectively collaborate within the healthcare team; to exhibit managerial skills pertinent to the operation of outpatient Gastroenterology clinic and endoscopy unit; to demonstrate a commitment to self-directed learning; to critically evaluate scientific information and facilitate the education of colleagues, students, residents, and other healthcare workers; and to practice in an ethical and professional manner.

It is expected that trainees will meet the requirements for Subspecialty Certification in Gastroenterology by the Royal College of Physicians and Surgeons of Canada. The Gastroenterology Training Program endorses the CanMEDS competency framework of the Royal College of Physicians and Surgeons of Canada. This framework identifies seven physician roles that must be addressed by all Canadian postgraduate training programs. Throughout their training and upon its completion, residents are expected to fulfil all of these roles. Goals and objectives specific to the McMaster University training program are listed below to supplement but not replace those of the Royal College. Trainees are encouraged to review details of the CanMEDS objectives on the Royal College website (www.rcpsc.medical.org). 

Specific Objectives

Medical Expert

In his/her role as Medical Expert, the resident is expected to demonstrate:

• Effective consultation skills with integration of all of the CanMEDS Roles to provide optimal, ethical and patient-centred medical care
• Sound knowledge base of the structure and function of the gastrointestinal tract in health and in disease, a strong familiarity with the clinical expression of gastrointestinal disease in our society, and a firm grasp of the underlying pathophysiology
• Sound knowledge of the pharmacology of drugs that modify gastrointestinal function
• Familiarity with the histopathology of the gastrointestinal tract in health and disease
• Familiarity with the radiological appearance of the gastrointestinal tract in health and disease (including barium contrast, ultrasound, CT, MRI, radioisotope scan, ERCP, EUS, capsule endoscopy) with working knowledge of each technique
• Ability to perform a complete and appropriate assessment of  a patient with sound judgement in all clinical domains of Gastroenterology, from the care of elective outpatients to the management of critically ill patients in the emergency room or intensive care unit
• Demonstrate effective, appropriate and timely application of preventive and therapeutic interventions relevant to Gastroenterology
• Effective, appropriate and timely use of procedural skills, both diagnostic and therapeutic, in upper and lower gastrointestinal endoscopy and abdominal paracentesis, with a sound understanding of their indications, contraindications, and complications
• Meaningful awareness of the interrelationship between behaviour and GI disease with the results that (i) appropriate use is made of support services and other health care professionals (addiction treatment groups, social and psychiatric counselling etc.) and (ii) that the physician adopts an appropriately sympathetic and positive attitude to patients with functional disorders of the GI tract

Communicator

In his/her role as Communicator, the resident is expected to:

• Establish a trusting and professional rapport with the patients and families, and health care professionals
• Provide clear and relevant information and explanations to patients and families, colleagues and other health care professionals
• Encourage full participation of the patients and families, and health care professionals in shared decision making and management
• Demonstrate effective consultation skills in presenting well documented assessments and recommendations in both written and verbal forms

Collaborator

In his/her role as Collaborator, the resident is expected to:

• Work effectively and appropriately in an interdisciplinary team to optimize patient care
• Take on an appropriate share of team assignments and assist others as required
• Demonstrate leadership in a health care team, as appropriate
• Maintain a straightforward and respectful approach with all health care professionals and peers

Manager

In his/her role as Manager, the resident is expected to:

• Work collaboratively with others in the health care team to enhance patient safety and improve patient care quality
• Display organizational skills with effective time management
• Use information technology effectively to optimize patient care and continue self-learning
• Incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population based care as appropriate

Health Advocate

In his/her role as Health Advocate, the resident is expected to:

• Identify situations where advocacy, health promotion and disease prevention are required in response to the health needs of an individual patient and the communities that they serve
• Identify the determinants of health of the populations that they serve
• Understand the role of a gastroenterologist as a health advocate in influencing public health and policy

Scholar

In his/her role as Scholar, the resident is expected to:

• Attend and contribute to rounds and other learning events
• Accept and act on constructive feedback
• Critically appraise sources of medical information and take an evidence-based approach
• Implement strategies for maintenance of professional competence
• Use opportunities to teach and supervise juniors effectively
• Contribute to the development, dissemination, and translation of new knowledge and practices through research and scholarly inquiry

Professional

In his/her role as Professional, the resident is expected to:

• Report facts accurately, including own errors
• Perform duties and assignments in a timely and ethical manner
• Maintain appropriate boundaries in work and learning situations
• Respect diversity of race, age, gender, disability, intelligence and socio-economic status
• Recognize limitations and seek advice and consultation when needed
• Exercise initiative within the limits of knowledge and training

These objectives are expanded to specific first and second year general objectives.

General Objective

The first year of training emphasizes knowledge and experience in clinical Gastroenterology. The trainee is expected to fulfil all of the CanMEDS roles described above. Additional goals and objectives specific to the first year of training in Adult Gastroenterology include:

Specific Objectives

Medical Expert

The residents must be able to:

• Perform a consultation, including the presentation of well-documented assessments and recommendations in written and/or verbal form in response to a request from another health care professional
• Identify and appropriately respond to relevant ethical issues arising in patient care
• Demonstrate knowledge of the anatomy, embryology, physiology, pharmacology, pathology and molecular biology related to the gastrointestinal system, including the liver, biliary tract and pancreas
• Demonstrate knowledge of surgical procedures employed in relation to digestive system disorders and their complications
• Demonstrate competence in the prevention, evaluation and management of common diseases affecting the digestive system, pancreas and liver (epidemiology, pathophysiology, methods of diagnosis, management and prognosis). This will include both primary gastrointestinal disorders (acid peptic disorders of the gastrointestinal tract, achalasia, celiac disease, inflammatory bowel disease, irritable bowel syndrome, infectious gastroenteritis, angiodysplasia, hemorrhoids, anal fissures, gastrointestinal malignancy, acute and chronic pancreatitis, cholelithiasis, acute and chronic liver diseases) and systemic disorders involving the gastrointestinal tract (diabetes mellitus, scleroderma)
• Demonstrate knowledge of the indications, contraindications, limitations, complications, techniques and interpretation of results of those diagnostic and therapeutic procedures performed on the digestive tract, including the appropriate indication for and use of screening tests / procedures
• Take a history that is relevant, concise and accurate to context
• Perform a focused physical exam that is relevant and accurate
• Select medically appropriate investigative methods in a resource-effective and ethical manner, including:
  • Laboratory investigations (bloodwork)
  • Imaging modalities (barium studies, ultrasound, CT, MRI, radioisotope scan, ERCP, EUS, capsule endoscopy)
  • Tests commonly employed in gastrointestinal function laboratories (breath tests, motility studies)
  • Biopsies of the gastrointestinal tract and liver
  • Diagnostic and therapeutic endoscopy of the upper and lower gastrointestinal tract
• Recognize, evaluate and manage gastrointestinal emergencies (e.g. acute gastrointestinal hemorrhage, acute abdominal pain, fulminant colitis, biliary obstruction, liver failure, ingested foreign bodies)
• Implement an effective management plan in collaboration with patients, families and  health care professionals
• Demonstrate proficiency in the performance of basic diagnostic endoscopy under supervision, including:
  • Upper gastrointestinal endoscopy with biopsy
  • Flexible sigmoidoscopy with biopsy
• Demonstrate proficiency at diagnostic and therapeutic paracentesis
• Recognize the limits of their expertiseand seek help appropriately

Communicator

The residents must be able to:
 

• Establish positive therapeutic relationship with patients and their families that are characterized by understanding, trust, respect, honesty and empathy
• Understand the principles of patient-centred care by considering patient’s beliefs, concerns, expectations and illness experience,  and by synthesizing relevant information from other sources, such as patient’s family, caregivers and other professionals
• Convey information about diagnosis, prognosis, risks/benefits of tests and treatment options to patients and families, colleagues and other professionals accurately and effectively 
• Engage patients, families and members of the multidisciplinary health care team in shared decision-making  to optimize patient care
• Compose succinct, accurate and comprehensive consultation letters, discharge summaries, progress notes, and test reports with appropriate support from the supervising consultant

Collaborator

The residents must be able to:
 

• Understand and implement multidisciplinary care of patients with gastrointestinal diseases, with appropriate input and support from allied health professionals (e.g. surgeons, radiologists, pathologists, nurses, dieticians, social workers, occupational therapy, physical therapy, speech language pathologists, pain control services, primary care physicians)
• Participate effectively in interdisciplinary team meetings that contribute to the collaborative investigation, management and disposition of patients
• Demonstrate a respectful attitude towards other colleagues and members of an interprofessional team
• Establish effective and successful collaborations in research

Manager

The residents must be able to:
 

• Understand the structure and function of regional, provincial and federal health care systems
• Show confidence and competence in directing management of urgent and emergent clinical scenarios
• Demonstrate skills in negotiating, allocating and managing finite heath care resources (e.g. bed booking, referral triaging, pharmacy budgets)
• Set priorities and manage time to balance patient care, practice requirements, outside activities and personal life
• Access and apply information technology appropriately for patient care
• Institute efficient management plans for patients with gastrointestinal disease by utilizing the available resources
• Participate effectively in interprofessional team meetings

Health Advocate

The residents must be able to:
 

• Identify opportunities for advocacy, health promotion and disease prevention with the individual patients that they serve
• Understand the role of screening and surveillance tests (colorectal cancer,  hepatocellular carcinoma, Barrett’s esophagus, portal hypertension)
• Understand the key determinants of health in common gastrointestinal diseases (e.g. socioeconomic, psychosocial, lifestyle-induced and biologic)
• Be able to assess the impact of gastrointestinal disease on individual patients’ social function, relationships, productivity and access to health services
• Understand the role of a gastroenterologist in advocating for patients’ access to care through private insurers, hospital/provincial formularies and wait lists

Scholar

The residents must be able to:

• Recognize the importance of self-assessment to identify gaps in knowledge
• Demonstrate efficiency and competence in searching, appraising and applying medical literature to address a clinical question
• Demonstrate effective teaching of students and junior house staff and allied health professionals
• Understand the role of research in advancing the understanding of gastrointestinal disease
• Pose a scholarly question and develop a research proposal

Professional

The residents must be able to:

• Exhibit appropriate professional behaviours in practice, including maintaining appropriate professional boundaries and relationships with other physicians and other health care team members, and avoiding conflicts of interests
• Balance personal and professional priorities to ensure personal health and a sustainable practice
• Evaluate one’s own abilities, knowledge, skills and limitations of professional competence
• Participate in peer review
• Recognize and respond to others’ unprofessional behaviours in practice, taking into account local and provincial regulations

General Objective

The second year of training consolidates and extends experience gained in the first year, and allows the trainee to gain confidence as a consultant in Gastroenterology. The trainee is expected to fulfil all of the CanMEDS roles described above. In addition, the second-year trainee is also expected to assimilate knowledge gained in the first year to function as a consultant gastroenterologist. Goals and objectives specific to the second year of training in Adult Gastroenterology include:

Specific Objectives

Medical Expert

The residents must be able to:

• Recognize and respond to the ethical dimensions in medical decision-making
• Demonstrate medical expertise in situations other than patient care (e.g. presentations, medico-legal cases)
• Recognize common problems affecting children and adolescents in transition (inflammatory bowel disease, celiac disease, cystic fibrosis, functional abdominal pain, irritable bowel syndrome, chronic liver diseases) and special technical aspects of pediatric endoscopy including special needs for sedation (Adult Gastroenterology residents are not expected to possess the cognitive database of a resident in a pediatric program and are not expected to be expert in pediatric endoscopy)
• Recognize women’s health issues in digestive diseases
• Discuss and integrate new advances in the management of gastrointestinal disorders (biologic therapies, organ transplantation, therapeutic endoscopy)
• Critically assess controversies in the management of gastrointestinal disorders, integrating the available best evidence and best practices
• Discuss the performance (accuracy/efficacy), risks and complications of gastrointestinal tests and procedures, with recognition of current controversies and alternative approaches
• Implement a personal program to keep up-to-date, and enhance areas of professional competence
• Demonstrate effective problem-solving skills and judgment to address patient problems, including interpreting available data and integrating information to generate extensive differential diagnosis for presenting problems and comprehensive management plans for gastrointestinal diseases
• Demonstrate effective, appropriate, and timely application of preventive and therapeutic interventions relevant to Gastroenterology, including, but not limited to:
  • Screening colonoscopy
  • Upper endoscopy for Barrett’s esophagus
  • Upper endoscopy for portal hypertension
  • Surveillance for hepatobiliary malignancy
• Demonstrate proficiency at advanced diagnostic and therapeutic endoscopy under supervision, including:
  • Colonoscopy and polypectomy
  • Endoscopic hemostasis (including injection, thermal therapy, clips and band ligation)
  • Luminal dilation
  • Foreign body removal
  • Percutaneous endoscopic gastrostomy
• Identify and interpret endoscopic findings with confidence, including those that are uncommon or elusive (Dieulafoy lesions, eosinophilic esophagitis, celiac disease, gastric antral vascular ectasia, solitary rectal ulcers, discrimination of Crohn's disease and ulcerative colitis)
• Demonstrate effective, appropriate and timely consultation of another health professional as needed, recognizing the limits of their expertise 

Communicator

The residents must be able to:

• Communicate with patients and/or families independently without the immediate supervision of the consultant
• Communicate and cooperate effectively and independently with physicians, allied health professionals and health related agencies in the care of individual patients
• Demonstrate effective consultation skills in presenting well-documented assessment and recommendations in written and/or verbal form including:
  • Procedural and specialty test reports
  • Responses to requests by other health professionals and health parties
• Demonstrate skills to provide effective medical information to the general public and scientific communities about gastrointestinal illness

Collaborator

The residents must be able to:

• Demonstrate confidence in leading a multidisciplinary health care team
• Employ collaborative negotiation to resolve conflicts with and between other members of the health care team
• Establish effective and successful collaborations in research, educational work, program review, or administrative responsibilities
• Understand how health care governance influences patient care, research and educational activities at a local, provincial, regional, and national level

Manager

The residents must be able to:

• Demonstrate leadership (e.g. in organizing junior trainees) to maximize clinical care and educational opportunities
• Demonstrate understanding of the principles of health care financing, including physician remuneration, budgeting and organizational funding
• Understand the operational aspects of an endoscopy unit, such as planning, budgeting and evaluation
• Understand the administrative aspects of an outpatient practice and inpatient hospital service
• Make career decisions related to:
  • Practice environment (academic vs. private, location)
  • Practice emphasis (advanced endoscopy, specific disorders, motility)
  • Teaching
  • Research
• Tailor the structure and content of the second year elective and/or research rotations to accommodate and facilitate career decisions
• Show an ability to advocate for individual patients yet recognize societal needs when monitoring and allocating resources
• Demonstrate leadership in administrative roles (education, clinical, research, educational work, or program review)

Health Advocate

The residents must be able to: 

• Identify opportunities for advocacy, health promotion and disease prevention with the practice communities that they serve
• Understand current public policies that affect gastrointestinal health
• Identify key controversies in the Canadian health care system that affect gastrointestinal illness and advocate for policy that reduces the burden of illness
• Understand the advocacy roles of professional society, patient groups and private organizations in reducing the burden of gastrointestinal disease
• Appreciate the possibility of conflict inherent in their role as a health advocate for a patient or community with that of a manager
• Understand the cost-benefit relationship of emerging therapies for chronic gastrointestinal disorders (e.g. inflammatory bowel disease, viral hepatitis)

Scholar

The residents must be able to: 

• Develop and demonstrate strategies for implementing life-long continuing education and personal practice audit
• Integrate advanced critical appraisal skills into clinical care
• Synthesize and present knowledge to local rounds and provincial/national symposia through effective teaching strategies and content to facilitate others’ learning
• Critically analyse and disseminate the findings of a research study in oral and written format with presentation in local rounds and provincial /  national symposia, and preparation of a manuscript suitable for journal submission

Professional

The residents must be able to: 

• Demonstrate strategies to maintain and advance professional competence
• Recognize and appropriately respond to ethical issues in practice (e.g. informed consent, patient confidentiality, PEG placement)
• Understand the professional, legal and ethical codes of practice to which physicians are bound
• Strive to heighten personal and professional awareness and insight

The goals of an optional third year of training are tailored to individual needs, as identified during the second year. They may include acquiring skills in advanced therapeutic endoscopy, motility, medical education, research methodology, or any combination thereof. The availability of a third year is subject to salary support from peer-reviewed granting agencies (e.g. Canadian Institutes for Health Research, Canadian Association of Gastroenterology, Canadian Digestive Health Foundation, American Society for Gastrointestinal Endoscopy, American College of Gastroenterology, Crohn’s and Colitis Foundation of Canada), the private sector, or the Department of Medicine (e.g. Clinical Scholar model). Trainees interested in a third year of training are asked to discuss their plans early in the second year to permit sufficient time for applications to external or mobilization of internal resources.

 

These objectives are met under the direct supervision of consulting gastroenterologists at each training location. These locations differ in the emphasis of their clinical services and supporting resources.

For example, the McMaster Site offers extensive outpatient services focused on inflammatory bowel disease, functional bowel disease, acid-peptic disease and liver disease, with on-site exposure to pediatrics and obstetrics/gynecology.

The Juravinski Site offers a busy inpatient service, with complex cases focused on inflammatory bowel diseases, motility disorders, liver diseases, and acid-peptic diseases. The Juravinski Site also houses the Cancer Centre, and offers exposure to gastrointestinal complications of malignancy. It receives inpatient gastroenterology admissions from the Hamilton General Hospital.

The Hamilton General Site offers a busy consultation service with on-site exposure to interventional cardiology, cardiovascular surgery, burns, trauma and neurosurgery.

The St. Joseph´s Site offers outpatient and inpatient general gastroenterology services with on-site exposure to hepatobiliary endoscopy/surgery, rheumatology, respirology, nephrology and psychiatry.

All locations (except the McMaster Site) offer active emergency rooms and busy general medical and surgical wards. All sites have full spectrums of endoscopy facilities.

Thus, the rotation-specific objectives serve to identify the particular opportunities afforded by each institution and should be read in conjunction with the General Objectives of a given year.

McMaster University Medical Centre is a tertiary care facility and a regional referral centre for patients with a wide variety of gastrointestinal and hepatological conditions.  It supports a comprehensive outpatient facility that hosts 30 clinics per week, including a specialty Barrett’s clinic and the Multi-disciplinary Inflammatory Bowel Disease (IBD) clinic. A unique Gastrointestinal Investigational Unit offers special testing that is often not found at other medical centres including hydrogen breath testing (for fructose malabsorption, small bowel bacterial overgrowth and delayed orocecal transit) and 24 hour pH-metry. The associated GI Motility Laboratory performs numerous diagnostic studies including esophageal and anorectal manometry, and small bowel capsule endoscopy studies.

Extensive exposure to outpatient practice is a key component of training in Adult Gastroenterology. In addition to longitudinal participation in outpatient clinics and elective endoscopy lists through all rotations, residents are specifically assigned to a dedicated outpatient clinic block in Year 1 and four blocks in Year 2. Residents on this 4-week rotation will be exposed to ambulatory aspects of gastrointestinal and liver diseases through the following venues: Gastroenterology clinic, Hepatology clinic, IBD clinic, and out-patient endoscopy. This will be performed under the supervision of staff gastroenterologists and hepatologists. This rotation serves to complement in-patient rotations by providing comprehensive experience in the assessment and management of patients in the ambulatory care environment. With exposure to dedicated IBD clinics, residents develop an appreciation of the multi-disciplinary team approach to management of inflammatory bowel disease. The overall structure of the rotation is designed to provide trainees with graded responsibility as they progress from the First to the Second year.

Residents on this rotation are expected to attend four outpatient clinics each week. First year residents are expected to perform the initial assessment of at least 2 to 4 new referrals and 2 to 4 follow-up visits each week. Second Year residents are expected to assess a greater proportion of follow-up patient visits than new referrals. At this level, the resident is expected to provide an expert opinion on gastrointestinal problems, with a management plan that is analogous to that of the supervising consultant. Second Year residents also have the invaluable opportunities to participate in the Urgent Clinic and Rapid Assessment Clinic as junior consultants where they will learn how to run an outpatient clinic independently and effectively from screening and triaging referrals to providing a management plan for patients. Throughout the Second Year, residents have a weekly longitudinal clinic geared towards their specific subspecialty interests where they assess and follow outpatients under the supervision of the assigned staff. Residents are also expected to attend four ambulatory endoscopy sessions each week under the supervision of a staff physician. At the end of their second-year experience, residents should be able to complete diagnostic and therapeutic upper and lower endoscopic procedures independently and competently with minimal help from the supervising consultant.

Over the course of these ambulatory experiences, the resident is given increasing responsibility and by the end of the Second Year should be ready for independent practice. Residents will learn to function as consultants in the ambulatory setting through the integration of all of the CanMEDS roles.

Ambulatory block rotation can be combined with Motility, Clinical Nutrition, or Hepatology curricula. Those curricula are described separately.              

Responsibilities of the Resident

Rotation schedule is prepared by the Chief Residents on a monthly basis. Residents are expected to attend each assigned clinic and endoscopy list, to be punctual, and to complete procedure notes and consultation notes on all patients seen in the clinic in a timely fashion. Clinical supervisors must be informed of vacation / professional leave at least 4 weeks prior to the start date of the rotation. In addition, clinical supervisors must be informed when residents are unable to attend clinic or endoscopy lists post-call. Residents are expected to develop, implement and monitor a personal continuing education strategy. To facilitate this objective, at least one half day is set aside per week for self-directed, integrated learning related to topics and diseases encountered in the clinics. 

Prior to the beginning the Second Year, residents are provided with a list of available ambulatory clinics and are responsible for arranging to participate in a longitudinal clinic with the Chief Residents. The resident is given freedom in choosing a clinic supervisor from amongst the faculty members of the GI Division. Second Year residents are responsible for triaging of referrals for the Urgent GI and Rapid Assessment Clinics. Residents assigned to Dr. Collins’ Clinic are responsible to follow-up on any laboratory or imaging tests ordered during the clinic. The McMaster Site Coordinator is available to provide mentorship for triaging of referrals and clinic management.

Urgent GI clinic, Rapid Assessment Clinic, and Dr. Collin’s Clinic are mandatory clinics. Alternative coverage for these clinics will need to be arranged with another resident in the event of vacation / professional leave. The default resident(s) will be the resident(s) attending other clinics in the same time slot. However, it is the resident’s responsibility to confirm and arrange alternative coverage when necessary. 

Evaluation of the Resident

Residents are encouraged to seek regular informal verbal feedback about their proficiency at managing clinical problems and performing endoscopic procedures over the course of their outpatient clinic experience. A formal evaluation session with the resident will take place at the end of the rotation. Input is sought from other members of the clinic team who have worked with the resident (e.g. nurses, nurse practitioners, other allied health professionals). Based on all feedback received, a formal web-based CanMEDS compliant ITER is compiled by the supervisor. Final evaluations are discussed with the resident.

To directly assess and improve the ability of residents to communicate effectively with referring physicians, written documentation will be evaluated during every outpatient clinic rotation by means of a Written Consultation Dictation Evaluation Form. It is the expectation that the resident will review one consultation letter with an attending staff and have the evaluation form completed for each outpatient clinic rotation.

Evaluation of the Rotation

Residents are encouraged to provide feedback on how the rotation and teaching are structured. As with all rotations, an anonymous rotation evaluation is handled by the One 45 WebEval System. Each teaching faculty is evaluated separately in a similar manner. The Residency Program Committee meets semi-annually to compile a collective rotation and faculty evaluation, respecting resident anonymity. This has been important for the purposes of constructive feedback.

Rotation-Specific Objectives

In addition to the general objectives outlined above, rotation-specific goals and objectives for the First Year of Training in Adult Gastroenterology at McMaster University are listed below.

Medical Expert

Key Competencies: Physicians are able to

1. Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal, ethical and patient-centered medical care
2. Establish and maintain clinical knowledge, skills and attitudes appropriate to Gastroenterology
3. Perform a complete and appropriate assessment of a patient
4. Use preventive and therapeutic interventions effectively
5. Demonstrate proficient and appropriate use of procedural skills, both diagnostic and therapeutic
6. Seek appropriate consultation from other health professionals, recognizing the limits of their expertise

Specific Requirements: Gastroenterology residents are able to

1. Demonstrate knowledge in the following general areas:

• An approach to the management of common gastrointestinal disorders seen in an outpatient setting. This will include dyspepsia, peptic ulcer disease, esophageal disease, maldigestion and malabsorption, celiac disease, pancreatic and gallstone disease, irritable bowel syndrome, inflammatory bowel disease, colon polyps and colon cancer screening, iron deficiency anemia, viral hepatitis, alcoholic liver disease, autoimmune liver disease, metabolic liver disease, non-alcoholic fatty liver disease, autoimmune liver disease, metabolic liver disease, non-alcoholic fatty liver disease, hepatocellular carcinoma, portal hypertension, assessment for liver transplantation.
• Epidemiology, pathophysiology, methods of diagnosis, management and prognosis of common gastrointestinal conditions involving the digestive system, liver and pancreas
• Pharmacology of drugs commonly used in Gastroenterology
• Indications, contraindications, limitations, complications, techniques and interpretation of results of the common diagnostic and therapeutic procedures performed on the digestive tract, including the appropriate indications for and use of screening tests / procedures. This will include upper GI endoscopy, sigmoidoscopy, colonoscopy, barium studies, ultrasound, CT, MRI, radioisotope scan, ERCP, EUS, and capsule endoscopy.
• Surgical procedures employed in relation to digestive system disorders and their complications

1. Assess and investigate patients with common gastrointestinal conditions:

• Establish a professional relationship and interaction with patients
• Take a history that is relevant, concise and accurate to context
• Perform a focused physical exam that is relevant and accurate
• Select medically appropriate investigative methods in a resource-effective and ethical manner, including:
  • Laboratory investigations (bloodwork)
  • Imaging modalities (barium studies, ultrasound, CT, MRI, radioisotope scan, ERCP, EUS, capsule endoscopy)
  • Tests commonly employed in GI function laboratories (breath tests, motility studies)
  • Biopsies of the gastrointestinal tract and liver
  • Diagnostic and therapeutic endoscopy of the upper and lower gastrointestinal tract
• Use clinical databases appropriately to formulate problems and to correctly develop investigation and management plans

1. Identify, understand and appropriately respond to relevant ethical issues arising in the investigation and care of patients with common gastrointestinal conditions involving the digestive system, liver and pancreas

1. Demonstrate the ability to perform basic diagnostic endoscopy under supervision in the elective setting, including:

• Upper gastrointestinal endoscopy with biopsy
• Flexible sigmoidoscopy with biopsy

Communicator

Key Competencies: Physicians are able to

1. Develop rapport, trust, and ethical therapeutic relationships with patients and families
2. Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues, and other professionals
3. Convey relevant information and explanations accurately to patients and families, colleagues and other professionals
4. Develop a common understanding on issues, problems and plans with patients, families, and other professionals to develop a shared plan of care
5. Convey effective oral and written information about a medical encounter

Specific Requirements: Gastroenterology residents are able to

1. Establish effective relationship with patients and their families in order to obtain a meaningful history, conduct a relevant physical examination, and to properly manage a patient’s medical problem
2. Convey information about diagnosis, prognosis, risks/benefits of tests and treatment options to patients and their families, as well as referring physicians accurately and effectively within a supervised clinical environment
3. Communicate effectively with clinic staff and discuss appropriate information with all members of the health care team
4. Effectively present verbal reports of clinical encounters and plans
5. Compose succinct, accurate and comprehensive consultation letter or procedure note with appropriate support from the supervising consultant

Collaborator

Key Competencies: Physicians are able to

1. Participate effectively and appropriately in an interprofessional health care team
2. Work with other health professionals effectively to prevent, negotiate, and resolve interprofessional conflict

Specific Requirements: Gastroenterology residents are able to

1. Contribute clinically useful management options on patients referred for consultation, including ordering and arranging for specific testing or procedures, administering required therapy, and conveying the results of the management options to referring physicians. This process involves integrating information from multiple sources to construct a clear diagnosis which is then used to guide the patient's therapy. This may require integrating the results of endoscopic procedures with histopathological interpretation, radiologic tests, GI motility or laboratory results and haematological investigations.
2. Consult and collaborate with physicians, clinic staff, endoscopy unit staff, and other health care professionals, and contribute effectively to the collaborative investigation and management of patients

Manager

Key Competencies: Physicians are able to

1. Participate in activities that contribute to the effectiveness of their health care organizations and systems
2. Manage their practice and career effectively
3. Allocate finite health care resources appropriately
4. Serve in administration and leadership roles, as appropriate

Specific Requirements: Gastroenterology residents are able to

1. Set priorities and manage time with attention to a balance in personal and professional activities
2. Institute effective and efficient management plans for patients with gastrointestinal disease by utilizing the available resources in an outpatient setting
3. Demonstrate good time management in an outpatient setting by assessing patients accurately, comprehensively and efficiently with timely dictation of consultation notes and / or procedure notes
4. Demonstrate knowledge of the different roles and responsibilities of patients, physicians, nurses, clerical staff and allied health professionals in the outpatient management of gastrointestinal conditions

Health Advocate

Key Competencies: Physicians are able to

1. Respond to individual patient health needs and issues as part of patient care
2. Respond to the health needs of the communities that they serve
3. Identify the determinants of health for the populations that they serve
4. Promote the health of individual patients, communities, and populations

Specific Requirements: Gastroenterology residents are able to

1. Demonstrate an understanding of the health care needs of patients with gastrointestinal diseases in an outpatient setting
2. Identify opportunities for advocacy, health promotion and disease prevention with the individual patients that they serve, including helping patients obtain Limited Use medications, preparing documents for patients (insurance, disability, application for biologic medications) that describe and outline the nature of the patient's problem and the recommended treatments, arranging appropriate vaccinations, smoking cessation advocacy and the proactive use of screening and surveillance tests (colorectal cancer; hepatocellular carcinoma, Barrett's esophagus, portal hypertension)
3. Understand the role of a gastroenterologist in advocating for patients; access to care through private insurers, provincial formularies and wait lists

Scholar

Key Competencies: Physicians are able to

1. Maintain and enhance professional activities through ongoing learning
2. Critically evaluate medical information and its sources, and apply this appropriately to practice decisions
3. Facilitate the learning of patients, families, students, residents, other health professionals, the public and others
4. Contribute to the development, dissemination, and translation of new knowledge and practices

Specific Requirements: Gastroenterology residents are able to

1. Develop, implement and monitor a personal continuing medical education and knowledge management strategy. To facilitate this objective, at least one half day is set aside per week for self-directed learning of topics and diseases encountered in the clinics.
2. Demonstrate efficiency and competence in searching, critically appraising and applying medical literature to address a clinical question
3. Understand the role of research in advancing the understanding of gastrointestinal disease

Professional

Key Competencies: Physicians are able to

1. Demonstrate a commitment to their patients, profession, and society through ethical practice
2. Demonstrate a commitment to their patients, profession and society through participation in profession-led regulation
3. Demonstrate a commitment to physician health and sustainable practice

Specific Requirements: Gastroenterology residents are able to

1. Deliver highest quality care with honesty, integrity and compassion
2. Exhibit appropriate personal and interpersonal professional behavior
3. Be courteous and punctual
4. Follow-up on issues and investigations for patients evaluated and arrange additional investigations, as appropriate for patient problems
5. Evaluate one’s own abilities, knowledge, skills and limitations of professional competence
6. Demonstrate durable and ongoing strategies to maintain and advance professional competence

Rotation-Specific Objectives

The second-year McMaster Site Outpatient Clinic Rotation consolidates and extends experience gained in the first year, and allows the resident to gain confidence as a consultant in Gastroenterology. The resident is expected to fulfil all of the CanMEDS roles described in the first year. In addition, the second-year resident is expected to assimilate knowledge gained in the first year to function as a consultant gastroenterologist in an outpatient setting.

In addition to the general objectives outlined above, rotation-specific goals and objectives for the Second Year of Training in Adult Gastroenterology at McMaster University are listed below.

Medical Expert

Key Competencies: Physicians are able to

1. Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal, ethical and patient-centered medical care
2. Establish and maintain clinical knowledge, skills and attitudes appropriate to Gastroenterology
3. Perform a complete and appropriate assessment of a patient
4. Use preventive and therapeutic interventions effectively
5. Demonstrate proficient and appropriate use of procedural skills, both diagnostic and therapeutic
6. Seek appropriate consultation from other health professionals, recognizing the limits of their expertise

Specific Requirements: Gastroenterology residents are able to

1. Demonstrate in-depth knowledge in the following general areas, including the ability to:
   • Demonstrate a confident approach to the management of common gastrointestinal disorders seen in an outpatient setting. This will include dyspepsia, peptic ulcer disease, esophageal disease, maldigestion and malabsorption, celiac disease, pancreatic and gallstone disease, irritable bowel syndrome, inflammatory bowel disease, colon polyps and colon cancer screening, iron deficiency anemia, viral hepatitis, alcoholic liver disease, autoimmune liver disease, metabolic liver disease, non-alcoholic fatty liver disease, autoimmune liver disease, metabolic liver disease, non-alcoholic fatty liver disease, hepatocellular carcinoma, portal hypertension, assessment for liver transplantation.
   • Discuss and integrate new advances in the management of gastrointestinal disorders (biologic therapies, organ transplantation, therapeutic endoscopy)
   • Critically assess controversies in the management of gastrointestinal disorders, integrating the available best evidence and best practices
   • Demonstrate sound knowledge of surgical procedures for the diagnosis and treatment of gastrointestinal disease
   • Demonstrate medical expertise in situations other than patient care (e.g. presentations, medico-legal cases)
   • Discuss the performance (accuracy/efficacy), risks and complications of gastrointestinal tests and procedures, with recognition of current controversies and alternative approaches
2. Assess and investigate patients with common gastrointestinal conditions:
   • Demonstrate effective, appropriate, and timely application of preventive and therapeutic interventions relevant to Gastroenterology, including, but not limited to:
     • Screening colonoscopy
     • Upper endoscopy for Barrett's esophagus
     • Upper endoscopy for portal hypertension
     • Surveillance for hepatobiliary malignancy
   • Demonstrate effective problem-solving skills and judgment to address patient problems, including interpreting available data and integrating information to generate extensive differential diagnosis for presenting problems and comprehensive management plans for gastrointestinal diseases
3. Recognize and appropriately respond to relevant ethical issues arising in the investigation and care of patients with common gastrointestinal conditions involving the digestive system, liver and pancreas
4. Demonstrate the ability to perform advanced diagnostic and therapeutic endoscopy under supervision, including:
   • Colonoscopy and polypectomy
   • Luminal dilation
   • Accurate identification and interpretation of endoscopic findings, including those that are uncommon or elusive (Dieulafoy lesions, eosinophilic esophagitis, celiac disease, gastric antral vascular ectasia, solitary rectal ulcers, discrimination of Crohn's disease and ulcerative colitis)
5. Interpret esophageal manometry

Communicator

Key Competencies: Physicians are able to

1. Develop rapport, trust, and ethical therapeutic relationships with patients and families
2. Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues, and other professionals
3. Convey relevant information and explanations accurately to patients and families, colleagues and other professionals
4. Develop a common understanding on issues, problems and plans with patients, families, and other professionals to develop a shared plan of care
5. Convey effective oral and written information about a medical encounter

Specific Requirements: Gastroenterology residents are able to

1. Establish effective relationship with patients and their families in order to obtain a meaningful history, conduct a relevant physical examination, and to properly manage a patient’s medical problem
2. Convey information about diagnosis, prognosis, risks/benefits of tests and treatment options to patients and their families, and referring physicians accurately and effectively without the immediate supervision of the consultant
3. Communicate and cooperative effectively with clinical staff, allied health professionals and medical colleagues in the care of individual patients
4. Demonstrate effective consultation skills in presenting well-documented assessment and recommendations in written and/or verbal form with minimal support or revision by the consultant, including:
   • Procedural and specialty test reports
   • Consultation and follow-up assessment letters

Collaborator

Key Competencies: Physicians are able to

1. Participate effectively and appropriately in an interprofessional health care team
2. Work with other health professionals effectively to prevent, negotiate, and resolve interprofessional conflict

Specific Requirements: Gastroenterology residents are able to

1. Develop strategies to manage complex chronic disease in an outpatient setting, including optimal use of multidisciplinary support systems (e.g. nutrition, psychiatry, social work, and pain management).
2. Demonstrate confidence in leading a multi-disciplinary health care team, and contribute effectively to interdisciplinary team activities within and between hospitals, other health care facilities and collaborative groups.

Manager

Key Competencies: Physicians are able to

1. Participate in activities that contribute to the effectiveness of their health care organizations and systems
2. Manage their practice and career effectively
3. Allocate finite health care resources appropriately
4. Serve in administration and leadership roles, as appropriate

Specific Requirements: Gastroenterology residents are able to

1. Understand and demonstrate skills necessary to effectively manage an outpatient Gastroenterology clinic
2. Understand the operational aspects of an endoscopy unit, such as planning, budgeting and evaluation
3. Ensure timeliness and appropriateness of referrals (triaging of referrals on the basis of apparent urgency) and follow-up appointments
4. Demonstrate understanding of cost/benefit ratios of diagnostic and therapeutic interventions, cost containment and evidence-based principles of cost-efficacy as they relate to quality assurance

Health Advocate

Key Competencies: Physicians are able to

1. Respond to individual patient health needs and issues as part of patient care
2. Respond to the health needs of the communities that they serve
3. Identify the determinants of health for the populations that they serve
4. Promote the health of individual patients, communities, and populations

Specific Requirements: Gastroenterology residents are able to

1. Identify opportunities for advocacy, health promotion and disease prevention with the individual patients and the practice communities that they serve
2. Understand current public policies that affect gastrointestinal health
3. Identify key controversies in the Canadian health care system that affect gastrointestinal illness and advocate for policy that reduces the burden of illness, including colorectal cancer screening, immunization for viral hepatitis, biologic medications for inflammatory bowel disease, and wire capsule endoscopy for obscure GI bleeding
4. Understand the advocacy roles of professional society, patient groups and private organizations in reducing the burden of gastrointestinal disease
5. Understand the cost-benefit relationship of emerging therapies for chronic gastrointestinal disorders (e.g. inflammatory bowel disease, viral hepatitis)

Scholar

Key Competencies: Physicians are able to

1. Maintain and enhance professional activities through ongoing learning
2. Critically evaluate medical information and its sources, and apply this appropriately to practice decisions
3. Facilitate the learning of patients, families, students, residents, other health professionals, the public and others
4. Contribute to the development, dissemination, and translation of new knowledge and practices

Specific Requirements: Gastroenterology residents are able to

1. Apply advanced critical appraisal skills to the medical literature
2. Develop a basic understanding of clinical trials research methodology
3. Appreciate the practical aspects of clinical trials conducted locally by the Division of Gastroenterology, including patient screening and enrolment, process of informed consent, performing structured follow-ups and appropriate documentation
4. Identify the learning needs of others (e.g. junior residents, nurses, allied health professionals) and select and demonstrate effective teaching strategies
5. Develop, implement and monitor a personal continuing education strategy. To facilitate this objective, at least one half day is set aside per week for self-directed learning of topics and diseases encountered in the clinics.

Professional

Key Competencies: Physicians are able to

1. Demonstrate a commitment to their patients, profession, and society through ethical practice
2. Demonstrate a commitment to their patients, profession and society through participation in profession-led regulation
3. Demonstrate a commitment to physician health and sustainable practice

Specific Requirements: Gastroenterology residents are able to

1. Deliver highest quality care with honesty, integrity and compassion
2. Exhibit appropriate personal and interpersonal professional behavior
3. Be courteous and punctual
4. Follow-up on patients evaluated and arrange additional investigations, as appropriate for patient problems
5. Evaluate one's own abilities, knowledge, skills and limitations of professional competence
6. Demonstrate strategies to maintain and advance professional competence

Rotation-Specific Objectives

OVERVIEW

The Juravinski Site is a regional referral centre for patients with a wide variety of gastrointestinal and hepatological conditions. The large population of patients with inflammatory bowel disease and liver diseases followed at the McMaster site constitutes the majority of in-patients under the GI service. These cases are often complicated, and provide a challenging learning experience for the trainees. The Juravinski Site also houses the Cancer Centre, and offers exposure to gastrointestinal complications of malignancy. The clinical service comprises an endoscopy unit, a joint Gastroenterology-oncology ward on 3C, and an outpatient facility. The Juravinski Site admits patients from outpatient practice of attending gastroenterologists and also from the Emergency Departments at two acute-care sites of Hamilton Health Sciences (Juravinski and General Sites). In addition, many patients are transferred from community hospitals that do not have the resources or expertise to manage complex GI conditions. Our clinical faculty encompasses expertise in all areas of GI including inflammatory bowel disease, irritable bowel syndrome, motility, acid-related disorders, nutrition, hepatology, and interventional endoscopy (ERCP and endoscopic ultrasound).

A multi-disciplinary team (gastroenterologists, Gastroenterology residents, rotating medical residents, medical students, nursing unit manager, nurses, pharmacists, occupation therapists, physiotherapists, nutritionists, social workers and discharge coordinators) manages patients in the inpatient unit. The inpatient rotation consists of inpatient consultations, inpatient and ambulatory endoscopy and one ½ day GI clinic per week. The primary goal of this rotation is to provide in-depth exposure to complex GI problems in an adult tertiary care, referral population.

Responsibilities of the Resident

The inpatient rotation is 4 weeks in duration and includes patient care activities in both an inpatient and outpatient setting, as well as educational and scholarly activities.

Inpatient Experience
The inpatient service at the Juravinski Site is usually responsible for 7-10 inpatients on the joint Gastroenterology-oncology ward (3C). Patients on this ward have serious medical illnesses such as exacerbation of inflammatory bowel disease, gastrointestinal hemorrhage, liver failure and GI infection.

The resident will function under the supervision of the attending physicians who assume responsibility for the inpatient unit on a rotational basis (every 2 weeks). A team consists of two GI residents, rotating medical residents, medical students and the attending physician. Residents gain clinical experience by functioning as consultants in Gastroenterology. Inpatient consultations are first done by residents. Their assessments and recommendations are then reviewed with the attending staff. The GI resident will be expected to be an active member of the team providing primary care to the inpatients, taking responsibility for the day-to-day care of a proportion of the in-patients commensurate with their level of training, and provide supervision and facilitate teaching of junior housestaff. It is expected that the GI resident will be familiar with all patients on the ward and act as a resource for other members of the team providing primary care to these patients. This care will include the development of skills in diagnosis, primary therapy, and supportive care including dealing with the psychosocial aspects of these diseases that affect both the patients and their families. The GI resident also performs endoscopic procedures under the supervision of the attending staff on patients seen in consultation. Booking of procedures should be coordinated with the charge nurse in the endoscopy unit. The GI resident will attend short daily morning ward rounds (09:00 AM) with the nursing staff on C3 to coordinate discharge planning. There is also a multi-disciplinary meeting held on a weekly basis, and residents are expected to attend and contribute effectively to patient are. Attending rounds with the residents are generally held daily, depending on the volume of consultations, their complexity, and acuity. At the end of each working day or prior to weekend, the resident will update the signover list of patients in Citrix, and sign out critically ill patients to the resident on call to ensure continuity of care.

On discharge, the resident will review the diagnosis, prognosis, implications and medications with the patients and families. He/She will dictate a discharge summary promptly on discharge and communicate with the referring physician and/or patient’s own gastroenterologist regarding hospital course and follow-up plans.

The resident will also provide a consultation service to other inpatient areas. These consultations will be completed under the supervision of the attending physician responsible for inpatient consultations. If the care of such a patient requires the ongoing input from the Gastroenterology service, the resident will provide follow-up assessment and recommendations to the referring service.

Through these activities, trainees gain an in-depth experience in both common and uncommon GI problems.

Outpatient Experience
Ambulatory clinic experience is considered to be an important component of the inpatient rotation. While on the inpatient rotation, trainees attend at least one outpatient clinic each week, where they have the opportunity to assess new and return patients with a wide variety of gastrointestinal, hepatic and pancreatic conditions under the supervision of a faculty attending physician. Residents also attend one elective endoscopy session each week.

Educational and Scholarly activities
Educational activities, which are a priority for the GI resident, include both scheduled rounds and other academic sessions. The resident is expected to attend the Gastroenterology Residents’ academic half-day, including the Farncombe noon rounds, on a weekly basis. In addition, the resident is expected to attend weekly structured teaching sessions with the Juravinski Site Coordinator (Monday 0800 h to 0900 h). These are structured teaching sessions with an overview of major topics in GI and Hepatology. In addition, an informal teaching session led by the attending staff on service at the Juravinski site occurs on a weekly basis (Thursday or Friday). There is also bedside teaching session with a focus on physical examination skills in GI and Hepatology every two weeks conducted by the McMaster Site Coordinator (Tuesday 0800 h to 0900 h). The resident’s educational activities will also include the regular ward rounds with the attending staff. The resident will be expected to do one formal presentation on a topic of their choice during CTU noon rounds or team rounds.

Evaluation of the Resident

An orientation session will take place during the first week of the rotation to discuss the goals and description of this rotation with the resident. The specific objectives of the resident will be discussed and an attempt made to integrate these objectives into the overall objectives of the rotation.

Residents are encouraged to seek informal verbal feedback throughout the rotation concerning their proficiency at managing clinical problems and performing endoscopic procedures. A formal evaluation session with the resident will take place at the end of the rotation with the supervisors and the Juravinski Site Coordinator. Input is sought from other members of the clinic team who have worked with the resident (e.g. nurses, nurse practitioners, other allied health professionals). A Multi-source evaluation tool is used to assess the resident’s skill in the collaborator role. Based on all feedback received, at the end of the rotation, a formal web-based CanMEDS compliant ITER is compiled by the supervisors. Final evaluations are discussed with the resident. The resident’s teaching skills will also be evaluated by junior residents formally through the GI Residents Teaching Evaluation Tool. It is the responsibility of the residents to distribute these forms to the junior residents during rounds, and forward them to the Juravinski Site Coordinator after completion.

Evaluation of the Rotation

Residents are encouraged to provide feedback on how the rotation and teaching are structured. At the time of the weekly structured teaching session with the Juravinski Site Coordinator and final evaluation of the resident, feedback regarding the rotation, including its strengths and shortcomings, is requested from the resident. If issues arise during the rotation, the resident is encouraged to bring these to the attention of the rotation supervisor and the Site Coordinator(s). A mechanism for dealing with any shortcomings will then be discussed with the resident and subsequently at the Residency Program Committee meeting. As with all rotations, an anonymous rotation evaluation is handled by the One 45 WebEval System. Each teaching faculty is evaluated separately in a similar manner. The Residency Program Committee meets semi-annually to compile a collective rotation and faculty evaluation, respecting anonymity. This has been important to maintaining feedback.

GI/GIM Collaborative Agreement

The GIM/CTU (including the GIM physician covering the MD-Based team) and GI services at the Juravinski Site have agreed to adopt the following guidelines to assist the ED physicians with the most appropriate service for referral of patients presenting to the ED with GIM/GI problems.

The following is a guideline and does not pre-empt the ED physician from referring to either service based on their assessment of the clinical problem and the most appropriate service to consult. Both services will consult on any patients referred and will retain the option of transferring care between the two services as agreed upon by the two consultants (GIM/CTU and GI) after both services/staff have had an opportunity to review the case. The MRP service will also retain the option of asking the other service to continue to follow the patient as a consulting service.

The ED physician will use the guidelines for any patient whom they feel is likely to require admission to hospital. The ED physician can refer any patient to the General Internal Medicine Rapid Assessment Outpatient Clinic (GIMRAOC) or the urgent GI clinic, if in their opinion the patient does not need admission or an ED consult, but can be safely discharged with urgent follow-up using the existing protocol for referral to either of these clinics.

Patients with the following acute problems who are likely to need admission to hospital can be referred to the GIM/CTU service on call:

1. Undifferentiated nausea and vomiting.
2. Undifferentiated diarrhoea.
3. Undifferentiated severe or symptomaticanemia.
4. Non-surgical abdominal pain.
5. Undifferentiated abnormal liver tests.
6. Undifferentiated ascites.
7. Uncomplicated decompensated cirrhosis.

Patients with the following acute problems who are likely to need admission to hospital can be referred to the GI service:

1. Acute flare of IBD
2. Acute GI bleeds
3. Complicated decompensated cirrhosis
4. Any patient followed on a regular basis by the GI service.
5. Any patient hospitalized under the GI service in the past 6 months.
6. Any patient already referred to the GI service urgently or electively who becomes ill and attends the ED.

Rotation-Specific Objectives

The first-year rotation at the Juravinski site centers on the inpatient GI service, but with weekly exposure to ambulatory clinic and endoscopy service. In addition to the general objectives outlined above, rotation-specific goals and objectives for the First Year of Training in Adult Gastroenterology at McMaster University are listed below.

Medical Expert

Key Competencies: Physicians are able to

1. Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal, ethical and patient-centered medical care
2. Establish and maintain clinical knowledge, skills and attitudes appropriate to Gastroenterology
3. Perform a complete and appropriate assessment of a patient
4. Use preventive and therapeutic interventions effectively
5. Demonstrate proficient and appropriate use of procedural skills, both diagnostic and therapeutic
6. Seek appropriate consultation from other health professionals, recognizing the limits of their expertise

Specific Requirements: Gastroenterology residents are able to

1. Demonstrate knowledge in the following general areas:
   • An approach to the management of common gastrointestinal disorders seen in an inpatient setting. This will include acute gastrointestinal bleeding, acute diarrhea, inflammatory bowel disease, chronic and end-stage liver disease, acute liver disease, foreign body ingestion, pancreatitis and gallstone disease, functional bowel disease and complications of endoscopy.
   • Recognize, evaluate and manage gastrointestinal emergencies. This will include acute gastrointestinal bleeding, acute abdominal pain, fulminant colitis, biliary obstruction, ascending cholangitis, liver failure, and ingested foreign bodies.
   • Principles underlying enteral and parenteral nutritional support for patients with feeding difficulty, including the indications, risks and benefits
   • Recognize situations that require urgent or emergency endoscopy, and in employing hemostatic techniques in acute GI bleeding
   • Epidemiology, pathophysiology, methods of diagnosis, management and prognosis of common gastrointestinal conditions seen in an inpatient setting
   • Pharmacology of drugs commonly used in Gastroenterology
   • Indications, contraindications, limitations, complications, techniques and interpretation of results of the common diagnostic and therapeutic procedures performed on the digestive tract. This will include upper GI endoscopy, sigmoidoscopy, colonoscopy, ultrasound, CT, MRI, ERCP, EUS, and capsule endoscopy.
   • Surgical procedures employed in relation to digestive system disorders and their complications
   • Interventional radiology procedures employed in relation to digestive system disorders and their complications (e.g. Transjugular intrahepatic portosystemic shunt, transjugular liver biopsy, biliary stent, angiogram and embolization, percutaneous gastrostomy and gastrojejunostomy, drainage of abscess)
2. Assess and investigate patients with common gastrointestinal conditions:
   • Establish a professional relationship and interact with patients
   • Take a history that is relevant, concise and accurate to context
   • Perform a focused physical exam that is relevant and accurate
   • Select medically appropriate investigative methods in a resource-effective and ethical manner, including:
     • Laboratory investigations (bloodwork)
     • Imaging modalities (ultrasound, CT, MRI, angiogram, ERCP, EUS, capsule endoscopy)
     • Biopsies of the gastrointestinal tract and liver
     • Diagnostic and therapeutic endoscopy of the upper and lower gastrointestinal tract
• Use clinical databases appropriately to formulate problems and to correctly develop investigation and management plans
3. Understand and appropriately respond to relevant ethical issues arising in the investigation and care of patients with common gastrointestinal conditions involving the digestive system, liver and pancreas
4. Demonstrate the ability to perform basic diagnostic endoscopy under supervision in the inpatient setting, including:
   • Upper gastrointestinal endoscopy with biopsy
   • Flexible sigmoidoscopy with biopsy
5. Demonstrate proficiency at diagnostic and therapeutic paracentesis

Communicator

Key Competencies: Physicians are able to

1. Develop rapport, trust, and ethical therapeutic relationships with patients and families
2. Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues, and other professionals
3. Convey relevant information and explanations accurately to patients and families, colleagues and other professionals
4. Develop a common understanding on issues, problems and plans with patients, families, and other professionals to develop a shared plan of care
5. Convey effective oral and written information about a medical encounter

Specific Requirements: Gastroenterology residents are able to

1. Establish effective relationship with patients and their families in order to obtain a meaningful history, conduct a relevant physical examination, and to properly manage a patient’s medical problem
2. Convey information about diagnosis, prognosis, risks/benefits of tests and treatment options to patients and families, and referring physicians accurately and effectively under supervision
3. Communicate effectively with a multi-disciplinary team to optimize patient care
4. Communicate clearly, thoroughly and as frequently as needed with medical colleagues, particularly those who carry out diagnostic tests (e.g. radiologists, pathologists) and referring physicians to ensure the best outcome for the patient
5. Effectively present concise and accurate verbal reports of clinical encounters including differential diagnoses and plans on daily ward rounds
6. Compose succinct, accurate and comprehensive consultation letters, progress notes, discharge summaries and procedure notes with appropriate support from the supervising consultant

Collaborator

Key Competencies:Physicians are able to

1. Participate effectively and appropriately in an interprofessional health care team
2. Work with other health professionals effectively to prevent, negotiate, and resolve interprofessional conflict

Specific Requirements: Gastroenterology residents are able to

1. Contribute clinically useful management options on patients referred for consultation, including ordering and arranging for specific testing or procedures, administering required therapy, and conveying the results of the management options to referring physicians. This process involves integrating information from multiple sources to construct a clear diagnosis which is then used to guide the patient’s therapy. This may require integrating the results of endoscopic procedures with histopathological interpretation, radiologic tests, and haematological investigations.
2. Consult and collaborate with physicians, nurses, pharmacists, endoscopy unit staff, and other health care professionals (e.g. dieticians, speech language pathologists, physical and occupational therapists, social workers, pain specialists and psychiatrists), and contribute effectively to the collaborative investigation, management and disposition of patients
3. Participate effectively in interprofessional team meetings
4. Demonstrate a respectful attitude towards other colleagues and members of an interprofessional team

Manager

Key Competencies: Physicians are able to

1. Participate in activities that contribute to the effectiveness of their health care organizations and systems
2. Manage their practice and career effectively
3. Allocate finite health care resources appropriately
4. Serve in administration and leadership roles, as appropriate

Specific Requirements: Gastroenterology residents are able to

1. Set priorities and manage time to balance patient care, practice requirements, outside activities and personal life
2. Reserve time for reading and keeping current with the literature to optimize patient care
3. Demonstrate good time management in an inpatient setting by assessing patients accurately, comprehensively and efficiently with timely diction of consultation notes and / or procedure notes
4. Access and apply various information sources of information in managing inpatients with gastrointestinal disorders
5. Show confidence and competence in directing management of urgent and emergent clinical scenarios
6. Institute effective and efficient management plans for patients with gastrointestinal disease by utilizing the available resources in an inpatient setting
7. Demonstrate skills in negotiating, allocating and managing finite heath care resources (e.g. bed booking, referral triaging, pharmacy budgets)
8. Exercise time management to optimize the investigation and treatment while minimizing length of stay
9. Demonstrate knowledge of the different roles and responsibilities of patients, physicians, nurses, and allied health professionals in the inpatient management of gastrointestinal conditions
10. Coordinate in-hospital care with ambulatory and community based resources for follow-up

Health Advocate

Key Competencies: Physicians are able to

1. Respond to individual patient health needs and issues as part of patient care
2. Respond to the health needs of the communities that they serve
3. Identify the determinants of health for the populations that they serve
4. Promote the health of individual patients, communities, and populations

Specific Requirements: Gastroenterology residents are able to

1. Demonstrate an understanding of the health care needs of patients with gastrointestinal diseases in an inpatient setting
2. Identify non-medical factors (e.g. ethnic, cultural, socioeconomic, psychosocial, life-style induced factors) that may influence the health and discharge planning of the patients
3. Understand the importance of patient education in the management of many common GI conditions and facilitate such learning when possible
4. Identify opportunities for advocacy, health promotion and disease prevention with the individual patients that they serve
5. Understand the role of a gastroenterologist in advocating for patients’ access to care through private insurers, hospital / provincial formularies and wait lists

Scholar

Key Competencies: Physicians are able to

1. Maintain and enhance professional activities through ongoing learning
2. Critically evaluate medical information and its sources, and apply this appropriately to practice decisions
3. Facilitate the learning of patients, families, students, residents, other health professionals, the public and others
4. Contribute to the development, dissemination, and translation of new knowledge and practices

Specific Requirements: Gastroenterology residents are able to

1. Recognize the importance of self-assessment to identify gaps in knowledge
2. Attend and contribute to rounds, conferences, and other learning events
3. Demonstrate ongoing learning by quoting recent reading and/or literature on topics related to patients
4. Demonstrate efficiency and competence in searching, appraising and applying medical literature to address a clinical question
5. Take an evidence-based approach to patient management
6. Demonstrate effective teaching of students and junior house staff and allied health professionals
7. Demonstrate an effective lecture or presentation
8. Understand the role of research in advancing the understanding of gastrointestinal disease

Professional

Key Competencies: Physicians are able to

1. Demonstrate a commitment to their patients, profession, and society through ethical practice
2. Demonstrate a commitment to their patients, profession and society through participation in profession-led regulation
3. Demonstrate a commitment to physician health and sustainable practice

Specific Requirements: Gastroenterology residents are able to

1. Balance personal and professional priorities to ensure personal health and a sustainable practice
2. Deliver highest quality care with honesty, integrity and compassion
3. Exhibit appropriate personal and interpersonal professional behavior
4. Be courteous and punctual
5. Follow-up on patients evaluated and arrange additional investigations, as appropriate for patient problems
6. Evaluate one’s own abilities, knowledge, skills and limitations of professional competence
7. Demonstrate strategies to maintain and advance professional competence
8. Recognize and respond to others’ unprofessional behaviours in practice, taking into account local and provincial regulations

Rotation-Specific Objectives

The second year Juravinski Site Inpatient Rotation centres on consolidating and extending clinical skills acquired during the first year, and allows the resident to gain confidence as a consultant in Gastroenterology. Second-year residents serve as senior GI residents and function as junior consultants to provide teaching and supervision of the day-to-day patient management for first-year GI residents, medical residents, and medical students rotating through the GI inpatient service, and allied health professionals. The resident is expected to fulfil all of the CanMEDS roles described in the first year. In addition, the second year resident is expected to assimilate knowledge gained in the first year to function as a consultant gastroenterologist in an inpatient setting.

In addition to the general objectives outlined above, rotation-specific goals and objectives for the Second Year of Training in Adult Gastroenterology at McMaster University are listed below.

Medical Expert

Key Competencies: Physicians are able to

1. Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal, ethical and patient-centered medical care
2. Establish and maintain clinical knowledge, skills and attitudes appropriate to Gastroenterology
3. Perform a complete and appropriate assessment of a patient
4. Use preventive and therapeutic interventions effectively
5. Demonstrate proficient and appropriate use of procedural skills, both diagnostic and therapeutic
6. Seek appropriate consultation from other health professionals, recognizing the limits of their expertise

Specific Requirements: Gastroenterology residents are able to

1. Demonstrate in-depth knowledge in the following general areas, including the ability to:
   • Demonstrate a confident approach to the management of complex gastrointestinal disorders seen in an inpatient setting. This will include inflammatory bowel disease, motility and functional bowel disease, chronic and end-stage liver disease, acute liver disease, obscure GI bleeding, gastrointestinal cancers, short gut and malnutrition. This approach must include an understanding of: (a) current concepts of pathogenesis and pathophysiology; (b) clinical expression; (c) current and emerging therapies; and (d) support systems for patients and families.
   • Discuss and integrate new advances in the management of gastrointestinal disorders (biologic therapies, organ transplantation, therapeutic endoscopy)
   • Critically assess controversies in the management of gastrointestinal disorders, integrating the available best evidence and best practices
   • Demonstrate sound knowledge of surgical and interventional radiology procedures for the diagnosis and treatment of gastrointestinal disease
   • Demonstrate medical expertise in situations other than patient care (e.g. presentations, medico-legal cases)
   • Discuss the performance (accuracy/efficacy), risks and complications of gastrointestinal tests and procedures, with recognition of current controversies and alternative approaches
2. Assess and investigate patients with common gastrointestinal conditions:
   • Identify and explore issues to be addressed in a patient encounter effectively
   • Select medically appropriate investigative methods in a resource-effective and ethical manner, including:
     • Laboratory investigations (bloodwork)
     • Imaging modalities (ultrasound, CT, MRI, angiogram, ERCP, EUS, capsule endoscopy)
     • Biopsies of the gastrointestinal tract and liver
     • Diagnostic and therapeutic endoscopy of the upper and lower gastrointestinal tract
   • Demonstrate effective problem-solving skills and judgment to address patient problems, including interpreting available data and integrating information to generate extensive differential diagnosis for presenting problems and comprehensive management plans for gastrointestinal diseases
3. Demonstrate effective, appropriate and timely consultation of another health professional as needed, recognizing the limits of their expertise
4. Recognize and appropriately respond to relevant ethical issues arising in the investigation and care of patients with common gastrointestinal conditions involving the digestive system, liver and pancreas
5. Demonstrate the ability to perform advanced diagnostic and therapeutic endoscopy under supervision, including:
   • Colonoscopy and polypectomy
   • Endoscopic hemostasis (including injection, thermal therapy, clips and band ligation)
   • Luminal dilation
   • Foreign body removal
   • Percutaneous endoscopic gastrostomy
   • Identification and interpretation of endoscopic findings with confidence, including those that are uncommon or elusive (Dieulafoy lesions, eosinophilic esophagitis, celiac disease, gastric antral vascular ectasia, solitary rectal ulcers, discrimination of Crohn's disease and ulcerative colitis)

Communicator

Key Competencies: Physicians are able to

1. Develop rapport, trust, and ethical therapeutic relationships with patients and families
2. Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues, and other professionals
3. Convey relevant information and explanations accurately to patients and families, colleagues and other professionals
4. Develop a common understanding on issues, problems and plans with patients, families, and other professionals to develop a shared plan of care
5. Convey effective oral and written information about a medical encounter

Specific Requirements: Gastroenterology residents are able to

1. Establish effective relationship with patients and their families in order to obtain a meaningful history, conduct a relevant physical examination, and to properly manage a patient’s medical problem
2. Convey information about diagnosis, prognosis, risks/benefits of tests and treatment options to patients and families, and referring physicians accurately and effectively without the immediate supervision of the consultant
3. Communicate and cooperative effectively with allied health professionals and medical colleagues in the care of individual patients
4. Demonstrate effective consultation skills in presenting well-documented assessment and recommendations in written and/or verbal form with minimal support or revision by the consultant, including:
   1. Procedural reports
   2. Consultation letters, progress notes and discharge summaries

Collaborator

Key Competencies:Physicians are able to

1. Participate effectively and appropriately in an interprofessional health care team
2. Work with other health professionals effectively to prevent, negotiate, and resolve interprofessional conflict

Specific Requirements:Gastroenterology residents are able to

1. Develop strategies to manage complex chronic disease in an inpatient setting, including optimal use of multidisciplinary support systems (e.g. dieticians, speech language pathologists, physical and occupational therapists, social workers, pain specialists and psychiatrists)
2. Demonstrate confidence in leading a multi-disciplinary health care team as a junior consultant, and contribute effectively to interdisciplinary team activities within and between hospitals, other health care facilities and collaborative groups
3. Work with other members of the health care team to prevent and resolve conflicts

Manager

Key Competencies:Physicians are able to

1. Participate in activities that contribute to the effectiveness of their health care organizations and systems
2. Manage their practice and career effectively
3. Allocate finite health care resources appropriately
4. Serve in administration and leadership roles, as appropriate

Specific Requirements:Gastroenterology residents are able to

1. Understand the administrative aspects of an inpatient hospital service and outpatient practice
2. Understand the operational aspects of an endoscopy unit, such as planning, budgeting, and evaluation
3. Ensure timeliness and appropriateness of referrals (triaging of referrals on the basis of apparent urgency from the emergency departments, other in-patient services and primary care physicians), and become adept at recognizing problems which require inpatient care in a tertiary care hospital and at triaging less severe problems to be managed in an ambulatory setting
4. Organize junior trainees to maximize clinical care and educational opportunities
5. Demonstrate understanding of cost/benefit ratios of diagnostic and therapeutic interventions, cost containment and efficacy as they relate to quality assurance

Health Advocate:

Key Competencies:Physicians are able to

1. Respond to individual patient health needs and issues as part of patient care
2. Respond to the health needs of the communities that they serve
3. Identify the determinants of health for the populations that they serve
4. Promote the health of individual patients, communities, and populations

Specific Requirements:Gastroenterology residents are able to

1. Counsel patients effectively on gastrointestinal disorders
2. Understand current public policies that affect gastrointestinal health
3. Identify key controversies in the Canadian health care system that affect gastrointestinal illness and advocate for policy that reduces the burden of illness, including biologic medications for inflammatory bowel disease and wire capsule endoscopy for obscure GI bleeding
4. Understand the advocacy roles of professional society, patient groups and private organizations in reducing the burden of gastrointestinal disease
5. Understand the cost-benefit relationship of emerging therapies for chronic gastrointestinal disorders (e.g. inflammatory bowel disease, viral hepatitis)
6. Appreciate the possibility of conflict inherent in their role as a health advocate for a patient or community with that of a manager or gatekeeper

Scholar

Key Competencies:Physicians are able to

1. Maintain and enhance professional activities through ongoing learning
2. Critically evaluate medical information and its sources, and apply this appropriately to practice decisions
3. Facilitate the learning of patients, families, students, residents, other health professionals, the public and others
4. Contribute to the development, dissemination, and translation of new knowledge and practices

Specific Requirements:Gastroenterology residents are able to

1. Integrate advanced critical appraisal skills to the medical literature
2. Demonstrate knowledge of new advances in the management of gastrointestinal disorders including but not limited to organ transplantation, therapeutic endoscopy, endoscopic ultrasound and capsule endoscopy
3. Identify collaboratively the learning needs of others and desired learning outcomes of others, (e.g. junior residents, nurses, allied health professionals) and select effective teaching strategies and content to facilitate others’ learning
4. Develop, implement and monitor a personal continuing education strategyand personal practice audit

Professional

Key Competencies:Physicians are able to

1. Demonstrate a commitment to their patients, profession, and society through ethical practice
2. Demonstrate a commitment to their patients, profession and society through participation in profession-led regulation
3. Demonstrate a commitment to physician health and sustainable practice

Specific Requirements: Gastroenterology residents are able to

1. Balance personal and professional priorities to ensure personal health and a sustainable practice
2. Deliver highest quality care with honesty, integrity and compassion
3. Exhibit appropriate personal and interpersonal professional behavior
4. Be courteous and punctual
5. Follow-up on patients evaluated and arrange additional investigations, as appropriate for patient problems
6. Evaluate one’s own abilities, knowledge, skills and limitations of professional competence
7. Demonstrate strategies to maintain and advance professional competence, recognize and respond to others’ unprofessional behaviours in practice

Rotation-Specific Objectives

OVERVIEW

The St. Joseph’s Site offers a busy clinical Gastroenterology service with specialized interests in gastrointestinal motility and functional disorders. It also has a large endoscopy unit, including interventional endoscopy, ERCP, argon plasma coagulation and YAG-laser. As the hospital also provides regional and tertiary specialty services in respirology, rheumatology, nephrology and psychiatry, trainees gain exposure to gastrointestinal and nutritional aspects of behavioral, psychiatric and complex multisystem diseases, such as the cardiovascular and gastrointestinal complications of end-stage renal disease (and dialysis). Psychiatric patients also present complex biopsychosocial issues often requiring a thoughtful approach from consulting services. The presence of inpatient geriatric and rehabilitation services also present specific patient populations with particular needs. A large outpatient clinic allows the residents to experience not only inpatient consultation but also ambulatory care. Unique aspects of the outpatient experience reflect the expertise of the gastroenterologists at this site and include gastrointestinal neoplasia and laser therapy (Dr. Morgan), functional and motility disorders (Dr. Ganguli), and hepatology (Dr. Tsoi).

A multi-disciplinary team (gastroenterologists, Gastroenterology residents, rotating medical residents, medical students, nursing unit manager, nurses, pharmacists, occupation therapists, physiotherapists, nutritionists, social workers and discharge coordinators) manages patients in the inpatient unit. The inpatient rotation consists of inpatient consultations, inpatient and ambulatory endoscopy and one ½ day GI clinic per week. The primary goal of this rotation is to provide in-depth exposure to common GI problems in an adult tertiary care centre.

Responsibilities of the Resident

The inpatient rotation is 4 weeks in duration and includes patient care activities in both an inpatient and outpatient setting, as well as educational and scholarly activities.

Inpatient Experience
The inpatient service at St. Joseph’s Site is usually responsible for 7-10 inpatients on the joint Gastroenterology-surgery ward (6th Floor, May Grace Wing). Patients on this ward have serious medical illnesses such as exacerbation of inflammatory bowel disease, gastrointestinal hemorrhage, liver failure and GI infection.

The resident will function under the supervision of the attending physicians who assume responsibility for the inpatient unit on a rotational basis (every week). A team consists of two GI residents, rotating medical residents, medical students and the attending physician. Residents gain clinical experience by functioning as consultants in Gastroenterology. Inpatient consultations are first done by residents. Their assessments and recommendations are then reviewed with the attending staff. The GI resident will be expected to be an active member of the team providing primary care to the inpatients, taking responsibility for the day-to-day care of a proportion of the in-patients commensurate with their level of training, and provide supervision and facilitate teaching of junior housestaff. It is expected that the GI resident will be familiar with all patients on the ward and act as a resource for other members of the team providing primary care to these patients. This care will include the development of skills in diagnosis, primary therapy, and supportive care including dealing with the psychosocial aspects of these diseases that affect both the patients and their families. The GI resident also performs endoscopic procedures under the supervision of the attending staff on patients seen in consultation. Booking of procedures should be coordinated with the charge nurse in the endoscopy unit. The GI resident will attend a multi-disciplinary meeting held on every Friday morning, and residents are expected to attend and contribute effectively to patient are. Attending rounds with the residents are generally held daily, depending on the volume of consultations, their complexity, and acuity. At the end of each working day or prior to weekend, the resident will update the signover list of inpatients in Citrix, and sign out critically ill patients to the resident on call to ensure continuity of care.

On discharge, the resident will review the diagnosis, prognosis, implications and medications with the patients and families. He/She will dictate a discharge summary promptly on discharge and communicate with the referring physician and/or patient’s own gastroenterologist regarding hospital course and follow-up plans.

The resident will provide a consultation service to the emergency room and other inpatient areas. These consultations will be completed under the supervision of the attending physician responsible for inpatient consultations. If the care of such a patient requires the ongoing input from the Gastroenterology Service, the resident will provide follow-up assessment and recommendations to the referring service.

Through these activities, trainees gain in-depth experience in common GI problems.

Outpatient Experience
Ambulatory clinic experience is considered to be an important component of the inpatient rotation. While on the inpatient rotation, trainees attend at least one outpatient clinic each week, where they have the opportunity to assess new and return patients with a wide variety of gastrointestinal, hepatic and pancreatic conditions under the supervision of a faculty attending physician. Residents also attend one elective endoscopy session each week.

Educational and Scholarly activities
Educational activities, which are a priority for the GI resident, include both scheduled rounds and other academic sessions. The resident is expected to attend the Gastroenterology Residents’ academic half-day, including the Farncombe noon rounds, on a weekly basis. In addition, the resident is expected to attend weekly structured teaching sessions with Dr. S. Ganguli (Thursday 8:00 – 9:00 AM) and D. Morgan (Tuesday 8:00 – 9:00 AM), St. Joseph’s Gastroenterology Rounds (Friday 7:30 – 8:30 AM), St. Joseph’s Medical Grand Rounds (Wednesday 8:00 – 9:00 AM) and St. Joseph’s Combined GI Surgery/GI Medicine Rounds (Wednesday 4:30 – 5:30 PM). The resident’s educational activities will also include the regular ward rounds with the attending staff.

Evaluation of the Resident

An orientation session will take place during the first week of the rotation to discuss the goals and description of this rotation with the resident. The specific objectives of the resident will be discussed and an attempt made to integrate these objectives into the overall objectives of the rotation.

Residents are encouraged to seek informal verbal feedback throughout the rotation concerning their proficiency at managing clinical problems and performing endoscopic procedures. A formal evaluation session with the resident will take place at the end of the rotation with the supervisors and the St. Joseph’s Site Coordinator. Input is sought from other members of the clinic team who have worked with the resident (e.g. nurses, nurse practitioners, other allied health professionals). A Multi-source evaluation tool is used to assess the resident’s skill in the collaborator role. Based on all feedback received, at the end of the rotation, a formal web-based CanMEDS compliant ITER is compiled by the supervisors. Final evaluations are discussed with the resident. The resident’s teaching skills will also be evaluated by junior residents formally through the GI Residents Teaching Evaluation Tool. It is the responsibility of the residents to distribute these forms to the junior residents during rounds, and forward them to the St. Joseph’s Site Coordinator after completion.

Evaluation of the Rotation

Residents are encouraged to provide feedback on how the rotation and teaching are structured. At the time of the weekly structured teaching session with the St. Joseph’s Site Coordinator and final evaluation of the resident, feedback regarding the rotation, including its strengths and shortcomings, is requested from the resident. If issues arise during the rotation, the resident is encouraged to bring these to the attention of the rotation supervisor and the Site Coordinator. A mechanism for dealing with any shortcomings will then be discussed with the resident and subsequently at the Residency Program Committee meeting.  As with all rotations, an anonymous rotation evaluation is handled by the One 45 WebEval System. Each teaching faculty is evaluated separately in a similar manner. The Residency Program Committee meets semi-annually to compile a collective rotation and faculty evaluation, respecting anonymity. This has been important to maintaining feedback.

Rotation-Specific Objectives

The first-year rotation at the St. Joseph’s site centers on the inpatient GI service, but with weekly exposure to ambulatory clinic and endoscopy service. In addition to the general objectives outlined above, rotation-specific goals and objectives for the First Year of Training in Adult Gastroenterology at McMaster University are listed below.

Medical Expert

Key Competencies:Physicians are able to

1. Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal, ethical and patient-centered medical care
2. Establish and maintain clinical knowledge, skills and attitudes appropriate to Gastroenterology
3. Perform a complete and appropriate assessment of a patient
4. Use preventive and therapeutic interventions effectively
5. Demonstrate proficient and appropriate use of procedural skills, both diagnostic and therapeutic
6. Seek appropriate consultation from other health professionals, recognizing the limits of their expertise

Specific Requirements:Gastroenterology residents are able to

1. Demonstrate knowledge in the following general areas:
   • An approach to the management of common gastrointestinal disorders seen in an inpatient setting. This will include acute gastrointestinal bleeding, acute diarrhea, inflammatory bowel disease, chronic and end-stage liver disease, acute liver disease, foreign body ingestion, pancreatitis and gallstone disease, functional bowel disease and complications of endoscopy.
   • Recognize, evaluate and manage gastrointestinal emergencies. This will include acute gastrointestinal bleeding, acute abdominal pain, fulminant colitis, biliary obstruction, ascending cholangitis, liver failure, and ingested foreign bodies.
   • Recognize situations that require urgent or emergency endoscopy, and in employing hemostatic techniques in acute GI bleeding
   • The gastrointestinal and nutritional aspects of renal, rheumatologic and psychiatric disorders
   • Endoscopic management and palliation of gastrointestinal neoplasia (e.g. laser, stenting)
   • Epidemiology, pathophysiology, methods of diagnosis, management and prognosis of common gastrointestinal conditions seen in an inpatient setting
   • Pharmacology of drugs commonly used in Gastroenterology
   • Indications, contraindications, limitations, complications, techniques and interpretation of results of the common diagnostic and therapeutic procedures performed on the digestive tract. This will include upper GI endoscopy, sigmoidoscopy, colonoscopy, ultrasound, CT, MRI, ERCP, endoscopic ultrasound and capsule endoscopy.
   • Surgical procedures employed in relation to digestive system disorders and their complications
   • Interventional radiology procedures employed in relation to digestive system disorders and their complications (e.g. Transjugular intrahepatic portosystemic shunt, transjugular liver biopsy, biliary stent, angiogram and embolization, percutaneous gastrostomy and gastrojejunostomy, drainage of abscess)
2. Assess and investigate patients with common gastrointestinal conditions:
   • Establish a professional relationship and interact with patients
   • Take a history that is relevant, concise and accurate to context
   • Perform a focused physical exam that is relevant and accurate
   • Select medically appropriate investigative methods in a resource-effective and ethical manner, including:
     • Laboratory investigations (bloodwork)
     • Imaging modalities (ultrasound, CT, MRI, angiogram, ERCP, EUS, capsule endoscopy)
     • Biopsies of the gastrointestinal tract and liver
     • Diagnostic and therapeutic endoscopy of the upper and lower gastrointestinal tract
   • Use clinical databases appropriately to formulate problems and to correctly develop investigation and management plans
3. Understand and appropriately respond to relevant ethical issues arising in the investigation and care of patients with common gastrointestinal conditions involving the digestive system, liver and pancreas
4. Demonstrate the ability to perform basic diagnostic endoscopy under supervision in the inpatient setting, including:
   • Upper gastrointestinal endoscopy with biopsy
   • Flexible sigmoidoscopy with biopsy
5. Demonstrate proficiency at diagnostic and therapeutic paracentesis

Communicator

Key Competencies:Physicians are able to

1. Develop rapport, trust, and ethical therapeutic relationships with patients and families
2. Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues, and other professionals
3. Convey relevant information and explanations accurately to patients and families, colleagues and other professionals
4. Develop a common understanding on issues, problems and plans with patients, families, and other professionals to develop a shared plan of care
5. Convey effective oral and written information about a medical encounter

Specific Requirements:Gastroenterology residents are able to

1. Establish effective relationship with patients and their families in order to obtain a meaningful history, conduct a relevant physical examination, and to properly manage a patient’s medical problem
2. Convey information about diagnosis, prognosis, risks/benefits of tests and treatment options to patients and families, and referring physicians accurately and effectively under supervision
3. Communicate effectively with a multi-disciplinary team to optimize patient care
4. Communicate clearly, thoroughly and as frequently as needed with medical colleagues, particularly those who carry out diagnostic tests (e.g. radiologists, pathologists) and referring physicians to ensure the best outcome for the patient
5. Effectively present concise and accurate verbal reports of clinical encounters including differential diagnoses and plans on daily ward rounds
6. Compose succinct, accurate and comprehensive consultation letters, progress notes, discharge summaries and procedure notes with appropriate support from the supervising consultant

Collaborator

Key Competencies:Physicians are able to

1. Participate effectively and appropriately in an interprofessional health care team
2. Work with other health professionals effectively to prevent, negotiate, and resolve interprofessional conflict

Specific Requirements:Gastroenterology residents are able to

1. Contribute clinically useful management options on patients referred for consultation, including ordering and arranging for specific testing or procedures, administering required therapy, and conveying the results of the management options to referring physicians. This process involves integrating information from multiple sources to construct a clear diagnosis which is then used to guide the patient’s therapy. This may require integrating the results of endoscopic procedures with histopathological interpretation, radiologic tests, and haematological investigations.
2. Consult and collaborate with physicians, nurses, pharmacists, endoscopy unit staff, and other health care professionals (e.g. dieticians, speech language pathologists, physical and occupational therapists, social workers, pain specialists and psychiatrists), and contribute effectively to the collaborative investigation, management and disposition of patients
3. Participate effectively in interprofessional team meetings
4. Demonstrate a respectful attitude towards other colleagues and members of an interprofessional team

Manager

Key Competencies:Physicians are able to

1. Participate in activities that contribute to the effectiveness of their health care organizations and systems
2. Manage their practice and career effectively
3. Allocate finite health care resources appropriately
4. Serve in administration and leadership roles, as appropriate

Specific Requirements:Gastroenterology residents are able to

1. Set priorities and manage time to balance patient care, practice requirements, outside activities and personal life
2. Reserve time for reading and keeping current with the literature to optimize patient care
3. Demonstrate good time management in an inpatient setting by assessing patients accurately, comprehensively and efficiently with timely diction of consultation notes and / or procedure notes
4. Access and apply various information sources of information in managing inpatients with gastrointestinal disorders
5. Show confidence and competence in directing management of urgent and emergent clinical scenarios
6. Institute effective and efficient management plans for patients with gastrointestinal disease by utilizing the available resources in an inpatient setting
7. Demonstrate skills in negotiating, allocating and managing finite heath care resources (e.g. bed booking, referral triaging, pharmacy budgets)
8. Exercise time management to optimize the investigation and treatment while minimizing length of stay
9. Demonstrate knowledge of the different roles and responsibilities of patients, physicians, nurses, and allied health professionals in the inpatient management of gastrointestinal conditions
10. Coordinate in-hospital care with ambulatory and community based resources for follow-up

Health Advocate

Key Competencies:Physicians are able to

1. Respond to individual patient health needs and issues as part of patient care
2. Respond to the health needs of the communities that they serve
3. Identify the determinants of health for the populations that they serve
4. Promote the health of individual patients, communities, and populations

Specific Requirements:Gastroenterology residents are able to

1. Demonstrate an understanding of the health care needs of patients with gastrointestinal diseases in an inpatient setting
2. Identify non-medical factors (e.g. ethnic, cultural, socioeconomic, psychosocial, life-style induced factors) that may influence the health and discharge planning of the patients
3. Understand the importance of patient education in the management of many common GI conditions and facilitate such learning when possible
4. Identify opportunities for advocacy, health promotion and disease prevention with the individual patients that they serve
5. Understand the role of a gastroenterologist in advocating for patients’ access to care through private insurers, hospital / provincial formularies and wait lists

Scholar

Key Competencies:Physicians are able to

1. Maintain and enhance professional activities through ongoing learning
2. Critically evaluate medical information and its sources, and apply this appropriately to practice decisions
3. Facilitate the learning of patients, families, students, residents, other health professionals, the public and others
4. Contribute to the development, dissemination, and translation of new knowledge and practices

Specific Requirements:Gastroenterology residents are able to

1. Recognize the importance of self-assessment to identify gaps in knowledge
2. Attend and contribute to rounds, conferences, and other learning events
3. Demonstrate ongoing learning by quoting recent reading and/or literature on topics related to patients
4. Demonstrate efficiency and competence in searching, appraising and applying medical literature to address a clinical question
5. Take an evidence-based approach to patient management
6. Demonstrate effective teaching of students and junior house staff and allied health professionals
7. Demonstrate an effective lecture or presentation
8. Understand the role of research in advancing the understanding of gastrointestinal disease

Professional

Key Competencies:Physicians are able to

1. Demonstrate a commitment to their patients, profession, and society through ethical practice
2. Demonstrate a commitment to their patients, profession and society through participation in profession-led regulation
3. Demonstrate a commitment to physician health and sustainable practice

Specific Requirements:Gastroenterology residents are able to

1. Balance personal and professional priorities to ensure personal health and a sustainable practice
2. Deliver highest quality care with honesty, integrity and compassion
3. Exhibit appropriate personal and interpersonal professional behavior
4. Be courteous and punctual
5. Follow-up on patients evaluated and arrange additional investigations, as appropriate for patient problems
6. Evaluate one’s own abilities, knowledge, skills and limitations of professional competence
7. Demonstrate strategies to maintain and advance professional competence
8. Recognize and respond to others’ unprofessional behaviours in practice, taking into account local and provincial regulations

Rotation-Specific Objectives

The second year St. Joseph’s Site Inpatient Rotation centres on consolidating and extending clinical skills acquired during the first year, and allows the resident to gain confidence as a consultant in Gastroenterology. Second-year residents serve as senior GI residents and function as junior consultants to provide teaching and supervision of the day-to-day patient management for first-year GI residents, medical residents, and medical students rotating through the GI inpatient service, and allied health professionals. The resident is expected to fulfil all of the CanMEDS roles described in the first year. In addition, the second year resident is expected to assimilate knowledge gained in the first year to function as a consultant gastroenterologist in an inpatient setting.

In addition to the general objectives outlined above, rotation-specific goals and objectives for the Second Year of Training in Adult Gastroenterology at McMaster University are listed below.

Medical Expert

Key Competencies: Physicians are able to

1. Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal, ethical and patient-centered medical care
2. Establish and maintain clinical knowledge, skills and attitudes appropriate to Gastroenterology
3. Perform a complete and appropriate assessment of a patient
4. Use preventive and therapeutic interventions effectively
5. Demonstrate proficient and appropriate use of procedural skills, both diagnostic and therapeutic
6. Seek appropriate consultation from other health professionals, recognizing the limits of their expertise

Specific Requirements:Gastroenterology residents are able to

1. Demonstrate in-depth knowledge in the following general areas, including the ability to:
   • Demonstrate a confident approach to the management of complex gastrointestinal disorders seen in an inpatient setting. This will include inflammatory bowel disease, motility and functional bowel disease, chronic and end-stage liver disease, acute liver disease, obscure GI bleeding, gastrointestinal cancers, short gut and malnutrition. This approach must include an understanding of: (a) current concepts of pathogenesis and pathophysiology; (b) clinical expression; (c) current and emerging therapies; and (d) support systems for patients and families.
   • Discuss and integrate new advances in the management of gastrointestinal disorders (biologic therapies, organ transplantation, therapeutic endoscopy)
   • Critically assess controversies in the management of gastrointestinal disorders, integrating the available best evidence and best practices
   • Demonstrate sound knowledge of surgical and interventional radiology procedures for the diagnosis and treatment of gastrointestinal disease
   • Demonstrate medical expertise in situations other than patient care (e.g. presentations, medico-legal cases)
   • Discuss the performance (accuracy/efficacy), risks and complications of gastrointestinal tests and procedures, with recognition of current controversies and alternative approaches
2. Assess and investigate patients with common gastrointestinal conditions:
   • Identify and explore issues to be addressed in a patient encounter effectively
   • Select medically appropriate investigative methods in a resource-effective and ethical manner, including:
     • Laboratory investigations (bloodwork)
     • Imaging modalities (ultrasound, CT, MRI, angiogram, ERCP, EUS, capsule endoscopy)
     • Biopsies of the gastrointestinal tract and liver
     • Diagnostic and therapeutic endoscopy of the upper and lower gastrointestinal tract
   • Demonstrate effective problem-solving skills and judgment to address patient problems, including interpreting available data and integrating information to generate extensive differential diagnosis for presenting problems and comprehensive management plans for gastrointestinal diseases
3. Demonstrate effective, appropriate and timely consultation of another health professional as needed, recognizing the limits of their expertise
4. Recognize and appropriately respond to relevant ethical issues arising in the investigation and care of patients with common gastrointestinal conditions involving the digestive system, liver and pancreas
5. Demonstrate the ability to perform advanced diagnostic and therapeutic endoscopy under supervision, including:
   • Colonoscopy and polypectomy
   • Endoscopic hemostasis (including injection, thermal therapy, clips and band ligation)
   • Luminal dilation
   • Foreign body removal
   • Percutaneous endoscopic gastrostomy
   • Identification and interpretation of endoscopic findings with confidence, including those that are uncommon or elusive (Dieulafoy lesions, eosinophilic esophagitis, celiac disease, gastric antral vascular ectasia, solitary rectal ulcers, discrimination of Crohn's disease and ulcerative colitis)

Communicator

Key Competencies: Physicians are able to

1. Develop rapport, trust, and ethical therapeutic relationships with patients and families
2. Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues, and other professionals
3. Convey relevant information and explanations accurately to patients and families, colleagues and other professionals
4. Develop a common understanding on issues, problems and plans with patients, families, and other professionals to develop a shared plan of care
5. Convey effective oral and written information about a medical encounter

Specific Requirements: Gastroenterology residents are able to

1. Establish effective relationship with patients and their families in order to obtain a meaningful history, conduct a relevant physical examination, and to properly manage a patient’s medical problem
2. Convey information about diagnosis, prognosis, risks/benefits of tests and treatment options to patients and families, and referring physicians accurately and effectively without the immediate supervision of the consultant
3. Communicate and cooperative effectively with allied health professionals and medical colleagues in the care of individual patients
4. Demonstrate effective consultation skills in presenting well-documented assessment and recommendations in written and/or verbal form with minimal support or revision by the consultant, including:
   1. Procedural reports
   2. Consultation letters, progress notes and discharge summaries

Collaborator

Key Competencies: Physicians are able to

1. Participate effectively and appropriately in an interprofessional health care team
2. Work with other health professionals effectively to prevent, negotiate, and resolve interprofessional conflict

Specific Requirements: Gastroenterology residents are able to

1. Develop strategies to manage complex chronic disease in an inpatient setting, including optimal use of multidisciplinary support systems (e.g. dieticians, speech language pathologists, physical and occupational therapists, social workers, pain specialists and psychiatrists)
2. Demonstrate confidence in leading a multi-disciplinary health care team as a junior consultant, and contribute effectively to interdisciplinary team activities within and between hospitals, other health care facilities and collaborative groups
3. Work with other members of the health care team to prevent and resolve conflicts

Manager

Key Competencies: Physicians are able to

1. Participate in activities that contribute to the effectiveness of their health care organizations and systems
2. Manage their practice and career effectively
3. Allocate finite health care resources appropriately
4. Serve in administration and leadership roles, as appropriate

Specific Requirements: Gastroenterology residents are able to

1. Understand the administrative aspects of an inpatient hospital service and outpatient practice
2. Understand the operational aspects of an endoscopy unit, such as planning, budgeting, and evaluation
3. Ensure timeliness and appropriateness of referrals (triaging of referrals on the basis of apparent urgency from the emergency departments, other in-patient services and primary care physicians), and become adept at recognizing problems which require inpatient care in a tertiary care hospital and at triaging less severe problems to be managed in an ambulatory setting
4. Organize junior trainees to maximize clinical care and educational opportunities
5. Demonstrate understanding of cost/benefit ratios of diagnostic and therapeutic interventions, cost containment and efficacy as they relate to quality assurance

Health Advocate

Key Competencies: Physicians are able to

1. Respond to individual patient health needs and issues as part of patient care
2. Respond to the health needs of the communities that they serve
3. Identify the determinants of health for the populations that they serve
4. Promote the health of individual patients, communities, and populations

Specific Requirements: Gastroenterology residents are able to

1. Counsel patients effectively on gastrointestinal disorders
2. Understand current public policies that affect gastrointestinal health
3. Identify key controversies in the Canadian health care system that affect gastrointestinal illness and advocate for policy that reduces the burden of illness, including biologic medications for inflammatory bowel disease and wire capsule endoscopy for obscure GI bleeding
4. Understand the advocacy roles of professional society, patient groups and private organizations in reducing the burden of gastrointestinal disease
5. Understand the cost-benefit relationship of emerging therapies for chronic gastrointestinal disorders (e.g. inflammatory bowel disease, viral hepatitis)
6. Appreciate the possibility of conflict inherent in their role as a health advocate for a patient or community with that of a manager or gatekeeper

Scholar

Key Competencies: Physicians are able to

1. Maintain and enhance professional activities through ongoing learning
2. Critically evaluate medical information and its sources, and apply this appropriately to practice decisions
3. Facilitate the learning of patients, families, students, residents, other health professionals, the public and others
4. Contribute to the development, dissemination, and translation of new knowledge and practices

Specific Requirements: Gastroenterology residents are able to

1. Integrate advanced critical appraisal skills to the medical literature
2. Demonstrate knowledge of new advances in the management of gastrointestinal disorders including but not limited to organ transplantation, therapeutic endoscopy, endoscopic ultrasound and capsule endoscopy
3. Identify collaboratively the learning needs of others and desired learning outcomes of others, (e.g. junior residents, nurses, allied health professionals) and select effective teaching strategies and content to facilitate others’ learning
4. Develop, implement and monitor a personal continuing education strategy and personal practice audit

Professional

Key Competencies: Physicians are able to

1. Demonstrate a commitment to their patients, profession, and society through ethical practice
2. Demonstrate a commitment to their patients, profession and society through participation in profession-led regulation
3. Demonstrate a commitment to physician health and sustainable practice

Specific Requirements: Gastroenterology residents are able to

1. Balance personal and professional priorities to ensure personal health and a sustainable practice
2. Deliver highest quality care with honesty, integrity and compassion
3. Exhibit appropriate personal and interpersonal professional behavior
4. Be courteous and punctual
5. Follow-up on patients evaluated and arrange additional investigations, as appropriate for patient problems
6. Evaluate one’s own abilities, knowledge, skills and limitations of professional competence
7. Demonstrate strategies to maintain and advance professional competence, recognize and respond to others’ unprofessional behaviours in practice

Rotation-Specific Objectives

OVERVIEW

The General Site offers a busy Gastroenterology consultation service. With state-of-the-art facilities, the General Site is recognized as a regional center of excellence in cardiovascular care, neurosciences, trauma and burn treatment. Residents on consultation service gain exposure to gastrointestinal and nutritional complications of these complex medical conditions. In addition, residents have the opportunity to gain experience in the outpatient Hepatology clinic run by Dr. Witt-Sullivan. A busy endoscopy unit with on-site ERCP service is led by Drs. Lumb and Seaton.

There are no in-patient beds at the General site. Emergency patients are not admitted to the General site but rather, referred to the consultant on call at the Juravinski site and arrangements will be made for their transfer to this site. In extraordinary circumstances, a very unstable GI bleed may be determined to be unsafe for transfer at which point the GI resident may be asked to take part in the resuscitation and investigation of this patient. In-patients with life threatening gastrointestinal bleeding will be managed at the General site unless it is determined that their management needs to be referred on to the Juravinski site. However, these individuals will remain under the primary service rather than being transferred to the Gastroenterologist on-call in terms of most responsible physician.

The busy rotation at the consultation service provides excellent exposure to consultative practice in a tertiary care setting. Widely diverse gastrointestinal problems, both acute and chronic, will be encountered. Consultations will arise from inpatient services and the intensive care units (Cardiac and Neurotrauma). Many of the patients referred to the consultation service, such as those with active upper and lower GI tract bleeding and biliary tract disease, require urgent endoscopic evaluation. The consultation rotation will expose residents to a variety of practice styles and clinical approaches by the members of the GI Division and will in turn increase the resident’s competence and confidence in managing a wide variety of common GI problems.

The inpatient rotation consists of inpatient consultations, inpatient and ambulatory endoscopy and one ½ day Hepatology clinic per week. The primary goal of this rotation is to provide in-depth exposure to common GI problems in an adult tertiary care centre.

Responsibilities of the Resident

The consult rotation is 4 weeks in duration and includes patient care activities in both an inpatient and outpatient setting, as well as educational and scholarly activities. This rotation is only for Second Year GI residents. The duties and responsibilities of the GI resident are advanced, as per the principle of graduated responsibility.

The overall goals of this rotation are:

1. To develop the skills necessary to function independently as an attending physician on a GI consult service and
2. To develop the skills necessary to function as the manager and teacher in a tertiary care centre

Inpatient Experience
The inpatient experience at the General Site is a consultation based service. The consultation service is structured such that one consultant is on call on a rotational basis for referrals (every 2 weeks). The resident will be expected to function as a junior attending. He/She will triage consults, assess patients, and perform any necessary endoscopic procedures under supervision. The junior attending resident will also liaise with consulting services and allied health professionals to optimize the care of the patients under their care. He/She will provide teaching to junior residents and medical students on the Medicine team.

The attending physician will serve as a supervisor / observer in the background to the junior attending resident, observing all aspects of patient care behavior, medical expert and the other CanMEDS competencies expected of a Junior Faculty. During this time, the junior attending resident assumes all the day to day attending responsibilities. The attending physician will only intervene if he/she believes that significant change in the medical plan is necessary for patient safety.

Through these activities, the junior attending resident gains confidence as an independent consultant.

The following are general guidelines that may assist the junior attending resident on this rotation:

1. On the first day of the rotation, paging should be contacted to confirm the rotation dates of the resident.
2. The junior attending resident will complete all consults from the inpatient services at the General Site within 24 hours of their referrals. The junior attending resident is also responsible for the occasional consults for admitted OB/GYN patients at the McMaster Site. Referrals for un-admitted patients in the emergency room as an initial consult service request from the emergency doctor should be directed to the GI service at the Juravinski Site. The policy is that stable GI patients are to be transferred to the Juravinski Site. Patients deemed unstable need to have another admitting service (e.g. Medicine / Surgery) involved first prior to consulting GI. Adherence to this triage policy is important to avoid confusion among the referring physicians and paging system. The assessments and recommendations of all consults are then reviewed with the attending physician at least once daily. Patients are followed closely throughout their hospitalization by the junior attending resident in consultation with the attending gastroenterologist. Effective communication with the attending physician and the consulting service is crucial and will be assessed.
3. The junior attending resident will be expected to perform all procedures, with hands-off supervision by the attending staff. The junior attending resident is strongly encouraged to attend elective endoscopy lists on a daily basis. There is an urgent access endoscopy list every Friday. In addition, each day there are slots set aside in the endoscopy schedule for in-patient procedures. The consultation service endeavors to provide timely endoscopy for those patients requiring these investigations. The specific timing for any inpatient procedure should be negotiated with the nursing staff in the endoscopy unit as well as with the consultant on-call keeping in mind the level of urgency. However, the endoscopy unit should be notified as soon as possible if an endoscopy is required for any patient (even prior to reviewing with the attending staff) as it is always much easier to cancel an endoscopy spot than to find one at the last minute. In the case of after hours, a note with the patient’s name, location and general information can be left on a desk in the endoscopy suite and a request can be made for the nurses to page the resident in the morning to arrange an endoscopy. Acute bleeding patients will be able to be accommodated within a short interval. At times, an alternate consultant may be asked to carry out an endoscopic procedure on an in-patient. This practice helps to facilitate rapid access to endoscopy for in-patients during intervals when the specific consultant on-call may not be immediately available.
4. ERCP consults should be reviewed with the attending physician first. If a decision is made that the patient will require an ERCP, an endoscopist with ERCP expertise (Dr. Lumb, Dr. Seaton, Dr. Tse) should be contacted immediately in order to coordinate the procedure with the endoscopy nurses, the fluoroscopy unit, and the endoscopist. It is important to ensure pre-procedural care has been properly managed including anticoagulation, bloodwork (CBC, INR) and prophylactic antibiotics if necessary. After the procedure has been successfully performed, it is important to reassess the patient the following day to ensure no major complication has occurred (e.g. bleeding post sphincterotomy, sepsis, pancreatitis, perforation etc.) before signing off on the patient.
5. Patients undergoing endoscopic procedures, transfusion, liver biopsy or paracentesis should have an appropriate consent form completed and available on the chart. Specific risks and benefits related to the individual procedures should be reviewed with the patients and/or families to allow for informed consent.
6. For PEG consults, informed consent with the patients / families will need to be completed well in advance as it is often difficult to track down family members in a timely manner when the patient is in the endoscopy unit ready for the procedure. It is also important to ensure pre-procedural care has been properly managed including anticoagulation, bloodwork (CBC, INR), and prophylactic antibiotics
7. All patients seen, should have an initial consultation note dictated on the same day as being seen. In addition to a dictated consultation note, an appropriate hand-written note should be completed. Provided that a detailed consultation note is dictated, these notes need not be unduly long. The note however should indicate a clear understanding of the clinical issues and an appropriate investigation and/or management plan. Patients seen on the consultation service who are no longer active or require further Gastroenterology follow up do not need to be followed. However, it is mandatory that patients who are still active under the Gastroenterology service be seen on a daily basis. At the end of the consultation process, a note should be written in the chart indicating that the patient has been “signed off”.
8. The attending physician formally rounds with the junior attending resident at a frequency at his/her discretion, depending on the volume of consultations, their complexity, and acuity. At the end of each working day or prior to weekend, the junior attending resident will update the signover list of inpatients in Citrix, and sign out critically ill patients to the resident on call to ensure continuity of care.
9. If the resident is post call and has been called in between midnight and 6 am, the attending physician should be notified first thing in the AM (08:00 to 09:00 AM) to provide backup coverage for emergency consults if necessary. Any non-urgent consults can be done the following day when the resident is back on service.
10. A small room with computer / internet access is available in the endoscopy unit for the resident. The endoscopy nurses can provide direction to the room.
11. It is the GI Divisional policy that the General site be covered at all times. It is the responsibility of the resident to arrange alternative coverage by another resident(s) in the case of vacation / conference leaves. The default resident(s) to provide alternative coverage is the resident on for McMaster outpatient rotation followed by research and elective in that sequence. However, the alternative resident coverage needs to be arranged ahead of time as soon as the vacation / leaves are confirmed. The Site Coordinator, on-service staff, chief residents and paging will need to be notified about the alternative arrangement.
12. The resident is encouraged to contact Dr. Helga Witt-Sullivan (424 in the McMaster Clinic) should there be any problems encountered during this rotation (especially with an emergency situation and the attending physician is not on site yet).

Outpatient Experience
This rotation offers the opportunity for the junior attending resident to gain experience in the outpatient Hepatology clinic under the supervision of Dr. H. Witt-Sullivan in the OPD area (Tuesday 08:30 AM). The junior attending resident is expected to attend one Hepatology clinic each Tuesday morning at the General Site, where they have the opportunity to assess new and return patients with hepatic conditions. If the resident is not able to attend this clinic due to vacation / leave, alternative coverage for this clinic will need to be arranged as extra patients are booked ahead of time for teaching purpose. If the resident is scheduled to be on call on any Monday night during this rotation, the chief residents will need to be informed ahead of time to arrange a switch in call dates to avoid being post call for this clinic. Residents also attend elective endoscopy sessions on a daily basis.

Educational and Scholarly activities
Educational activities, which are a priority for the GI resident, include both scheduled rounds and other academic sessions. The resident is expected to attend the Gastroenterology Residents’ academic half-day, including the Farncombe noon rounds, on a weekly basis. In addition, the resident is expected to identify a topic of interest to review with the attending physician on a weekly basis.

The resident will be expected to do one formal presentation on a topic of their choice during CTU noon rounds. It is the responsibility of the junior attending resident to contact the GIM chief resident at the beginning of the rotation to arrange a suitable date for the presentation.

Evaluation of the Resident

An orientation session will take place during the first week of the rotation to discuss the goals and description of this rotation with the resident. The specific objectives of the resident will be discussed and an attempt made to integrate these objectives into the overall objectives of the rotation.

Residents are encouraged to seek informal verbal feedback throughout the rotation concerning their proficiency at managing clinical problems and performing endoscopic procedures. A formal evaluation session with the resident will take place at the end of the rotation with the supervisors (every 2 weeks) and the General Site Coordinator (at the end of the 4-week rotation). Input is sought from other members of the clinic team who have worked with the resident (e.g. nurses, nurse practitioners, other allied health professionals). The Site Coordinator should be informed a few days prior to the end of the rotation to collate comments from all supervisors and health professionals. A Multi-source evaluation tool is used to assess the resident’s skill in the collaborator role. Based on all feedback received, at the end of the rotation, a formal web-based CanMEDS compliant ITER is compiled by the supervisors. Final evaluations are discussed with the resident. The resident’s teaching skills will also be evaluated by junior residents formally through the GI Residents Teaching Evaluation Tool. It is the responsibility of the residents to distribute these forms to the junior residents during rounds, and forward them to the Program Administrator (Cindy Potter) after completion.

Evaluation of the Rotation

Residents are encouraged to provide feedback on how the rotation and teaching are structured. If issues arise during the rotation, the resident is encouraged to bring these to the attention of the rotation supervisor and the Site Coordinator. A mechanism for dealing with any shortcomings will then be discussed with the resident and subsequently at the Residency Program Committee meeting. As with all rotations, an anonymous rotation evaluation is handled by the One 45 WebEval System. Each teaching faculty is evaluated separately in a similar manner. The Residency Program Committee meets semi-annually to compile a collective rotation and faculty evaluation, respecting anonymity. This has been important to maintaining feedback.

Rotation-Specific Objectives

The junior attending consult rotation centres on consolidating and extending clinical skills acquired during the first year, and allows the resident to gain confidence as a consultant in Gastroenterology. The overall goals of this experience are to develop consultancy and time management skills required to practice Gastroenterology, as well as to allow the resident experience in education of junior residents and medical students. The resident is expected to fulfil all of the CanMEDS roles described in the first year. In addition, the second year resident is expected to assimilate knowledge gained in the first year to function as a consultant gastroenterologist in an inpatient consultation based setting.

In addition to the general objectives outlined above, rotation-specific goals and objectives for the Second Year of Training in Adult Gastroenterology at McMaster University are listed below.

Medical Expert

Key Competencies: Physicians are able to

1. Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal, ethical and patient-centered medical care
2. Establish and maintain clinical knowledge, skills and attitudes appropriate to Gastroenterology
3. Perform a complete and appropriate assessment of a patient
4. Use preventive and therapeutic interventions effectively
5. Demonstrate proficient and appropriate use of procedural skills, both diagnostic and therapeutic
6. Seek appropriate consultation from other health professionals, recognizing the limits of their expertise

Specific Requirements: Gastroenterology residents are able to

1. Demonstrate in-depth knowledge in the following general areas, including the ability to:
   • Demonstrate a confident approach to the management of common GI disorders seen in an inpatient consultation-based setting. This will include acute GI bleeding, acute/chronic diarrhea, inflammatory bowel disease, motility and functional bowel disease, chronic and end-stage liver disease, acute liver disease, obscure GI bleeding, gastrointestinal cancers, malnutrition, pancreatitis, gallstone disease, and complications of endoscopy.
   • Understand the indications, contraindications, limitations and complications of ERCP to effectively manage and coordinate the care of patients with known or suspected pancreaticobiliary disease
   • Understand the indications, contraindications, complications and ethical aspects of nutritional support in neurological diseases
   • Discuss and integrate new advances in the management of gastrointestinal disorders (biologic therapies, viral hepatitis, organ transplantation, therapeutic endoscopy)
   • Critically assess controversies in the management of gastrointestinal disorders, integrating the available best evidence and best practices
   • Demonstrate sound knowledge of surgical and interventional radiology procedures for the diagnosis and treatment of gastrointestinal disease
   • Demonstrate medical expertise in situations other than patient care (e.g. presentations, medico-legal cases)
   • Discuss the performance (accuracy/efficacy), risks and complications of gastrointestinal tests and procedures, with recognition of current controversies and alternative approaches
2. Assess and investigate patients with common gastrointestinal conditions:
   • Identify and explore issues to be addressed in a patient encounter effectively
   • Select medically appropriate investigative methods in a resource-effective and ethical manner, including:
     • Laboratory investigations (bloodwork)
     • Imaging modalities (ultrasound, CT, MRI, angiogram, ERCP, EUS, capsule endoscopy)
     • Biopsies of the gastrointestinal tract and liver
     • Diagnostic and therapeutic endoscopy of the upper and lower gastrointestinal tract
   • Demonstrate effective problem-solving skills and judgment to address patient problems, including interpreting available data and integrating information to generate extensive differential diagnosis for presenting problems and comprehensive management plans for gastrointestinal diseases
3. Demonstrate effective, appropriate and timely consultation of another health professional as needed, recognizing the limits of their expertise
4. Recognize and appropriately respond to relevant ethical issues arising in the investigation and care of patients with common gastrointestinal conditions involving the digestive system, liver and pancreas
5. Demonstrate the ability to perform advanced diagnostic and therapeutic endoscopy under supervision, including:
   • Colonoscopy and polypectomy
   • Endoscopic hemostasis (including injection, thermal therapy, clips and band ligation)
   • Luminal dilation
   • Foreign body removal
   • Percutaneous endoscopic gastrostomy
   • Identification and interpretation of endoscopic findings with confidence, including those that are uncommon or elusive (Dieulafoy lesions, eosinophilic esophagitis, celiac disease, gastric antral vascular ectasia, solitary rectal ulcers, discrimination of Crohn's disease and ulcerative colitis)

Communicator

Key Competencies: Physicians are able to

1. Develop rapport, trust, and ethical therapeutic relationships with patients and families
2. Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues, and other professionals
3. Convey relevant information and explanations accurately to patients and families, colleagues and other professionals
4. Develop a common understanding on issues, problems and plans with patients, families, and other professionals to develop a shared plan of care
5. Convey effective oral and written information about a medical encounter

Specific Requirements: Gastroenterology residents are able to

1. Establish effective relationship with patients and their families in order to obtain a meaningful history, conduct a relevant physical examination, and to properly manage a patient’s medical problem without the immediate supervision of the consultant
2. Convey information about diagnosis, prognosis, risks/benefits of tests and treatment options to patients and families, and referring physicians accurately and effectively without the immediate supervision of the consultant
3. Communicate and cooperative effectively with allied health professionals and medical colleagues in the care of individual patients without the immediate supervision of the consultant
4. Demonstrate effective consultation skills in presenting well-documented assessment and recommendations in written and/or verbal form with minimal support or revision by the consultant, including:
   1. Procedural reports
   2. Consultation letters, progress notes and discharge summaries

Collaborator

Key Competencies: Physicians are able to

1. Participate effectively and appropriately in an interprofessional health care team
2. Work with other health professionals effectively to prevent, negotiate, and resolve interprofessional conflict

Specific Requirements: Gastroenterology residents are able to

1. Demonstrate confidence in leading a consultation service as a junior attending by interacting directly and effectively with other physicians, and developing a management plan for patients in collaboration with various members of an interdisciplinary team within and between hospitals, other health care facilities and collaborative groups
2. Collaborate with the inpatient team at the Juravinski Site in the safe transfer of patients with acute GI conditions requiring admission
3. Work with other members of the health care team to prevent and resolve conflicts

ManagerKey Competencies: Physicians are able to

1. Participate in activities that contribute to the effectiveness of their health care organizations and systems
2. Manage their practice and career effectively
3. Allocate finite health care resources appropriately
4. Serve in administration and leadership roles, as appropriate

Specific Requirements: Gastroenterology residents are able to

1. Understand the administrative aspects of an inpatient consultation-based hospital service and outpatient practice
2. Understand the operational aspects of an endoscopy unit, such as planning, budgeting, and evaluation
3. Ensure timeliness and appropriateness of referrals (triaging of referrals on the basis of apparent urgency from the inpatient services) independently
4. Demonstrate understanding of cost/benefit ratios of diagnostic and therapeutic interventions, cost containment and efficacy as they relate to quality assurance
5. Demonstrate time management skills necessary to balance the leadership role in the care of patients, participation in outpatient activities, teaching junior residents and students, and personal time.

Health Advocate

Key Competencies: Physicians are able to

1. Respond to individual patient health needs and issues as part of patient care
2. Respond to the health needs of the communities that they serve
3. Identify the determinants of health for the populations that they serve
4. Promote the health of individual patients, communities, and populations

Specific Requirements: Gastroenterology residents are able to

1. Demonstrate an understanding of the health care needs of patients with gastrointestinal diseases in an inpatient setting
2. Identify non-medical factors (e.g. ethnic, cultural, socioeconomic, psychosocial, life-style induced factors) that may influence the health and discharge planning of the patients
3. Identify vulnerable or marginalized populations within those served, including but not limited to candidates for HBV vaccine, HCV screening amongst high risk populations and respond appropriately
4. Understand the importance of patient education in the management of many common GI conditions and facilitate such learning when possible
5. Identify opportunities for advocacy, health promotion and disease prevention with the individual patients that they serve
6. Understand the role of a gastroenterologist in advocating for patients’ access to care through private insurers, hospital / provincial formularies and wait lists
7. Understand current public policies that affect gastrointestinal health
8. Identify key controversies in the Canadian health care system that affect gastrointestinal illness and advocate for policy that reduces the burden of illness, including biologic medications for inflammatory bowel disease, medications for viral hepatitis and wire capsule endoscopy for obscure GI bleeding
9. Understand the advocacy roles of professional society, patient groups and private organizations in reducing the burden of gastrointestinal disease
10. Understand the cost-benefit relationship of emerging therapies for chronic gastrointestinal disorders (e.g. inflammatory bowel disease, viral hepatitis)
11. Appreciate the possibility of conflict inherent in their role as a health advocate for a patient or community with that of a manager or gatekeeper

Scholar

Key Competencies: Physicians are able to

1. Maintain and enhance professional activities through ongoing learning
2. Critically evaluate medical information and its sources, and apply this appropriately to practice decisions
3. Facilitate the learning of patients, families, students, residents, other health professionals, the public and others
4. Contribute to the development, dissemination, and translation of new knowledge and practices

Specific Requirements: Gastroenterology residents are able to

1. Integrate advanced critical appraisal skills to the medical literature
2. Demonstrate knowledge of new advances in the management of gastrointestinal disorders including but not limited to organ transplantation, therapeutic endoscopy, endoscopic ultrasound and capsule endoscopy
3. Identify collaboratively the learning needs of others and desired learning outcomes of others, (e.g. junior residents, nurses, allied health professionals) and select effective teaching strategies and content to facilitate others’ learning
4. Develop, implement and monitor a personal continuing education strategyand personal practice audit

Professional

Key Competencies: Physicians are able to

1. Demonstrate a commitment to their patients, profession, and society through ethical practice
2. Demonstrate a commitment to their patients, profession and society through participation in profession-led regulation
3. Demonstrate a commitment to physician health and sustainable practice

Specific Requirements: Gastroenterology residents are able to

1. Balance personal and professional priorities to ensure personal health and a sustainable practice
2. Deliver highest quality care with honesty, integrity and compassion
3. Exhibit appropriate personal and interpersonal professional behavior
4. Be courteous and punctual
5. Follow-up on patients evaluated and arrange additional investigations, as appropriate for patient problems
6. Evaluate one’s own abilities, knowledge, skills and limitations of professional competence
7. Demonstrate strategies to maintain and advance professional competence, recognize and respond to others’ unprofessional behaviours in practice

OVERVIEW

The overall goal of the Hepatology curriculum is to train gastroenterologists who are competent to manage the broad spectrum of liver-related problems encountered in a typical Gastroenterology practice. To obtain the core knowledge required for the Hepatology curriculum, residents will be required to attend lectures during academic half day on Hepatology topics, as well as complete selected readings. The clinical experience will be provided by a rotation in outpatient clinic dedicated to Hepatology patients and problems, and through interaction with Hepatology physicians.

Residents will acquire a broad knowledge of the physiology of the liver and a thorough knowledge of the management of patients with hepatobiliary diseases obtained through teaching rounds, outpatient clinic experience, lectures and personal reading / research. The curriculum will ensure exposure to the following aspects of Hepatology:

1. Basic science knowledge relevant to Hepatology including genetic markers of liver disease, immunology, virology, and other pathophysiological mechanisms of liver injury; the basic biology and pathophysiology of the liver and biliary systems
2. Knowledge and skills in the diagnosis and management of common and uncommon disorders of the liver, and the management of patients with end stage liver disease
3. Selection and management of liver transplant patients
4. Skills in the performance of diagnostic and therapeutic paracentesis
5. An appreciation of the indications and use of a number of diagnostic and therapeutic procedures that are needed to manage hepatobiliary disorders

It is anticipated that all Gastroenterology fellows in the McMaster University Gastroenterology Training Program will be a participant. To allow early exposure to Hepatology and to help with career choice, a one-month rotation is mandatory for First Year residents. In addition, Second Year residents are encouraged to obtain additional training in Hepatology during their elective months and during the outpatient rotation.

Dr. Marco Puglia is the Hepatology Curriculum Coordinator.

Responsibilities of the Resident

Outpatient Experience
Rotation schedule is prepared by the Hepatology Curriculum Coordinator on a monthly basis. Residents are expected to attend each assigned clinic and endoscopy list, to be punctual, and to complete procedure notes and consultation notes on all patients seen in the clinic in a timely fashion. Clinical supervisors must be informed of vacation / professional leave 4 weeks prior to the start date of the rotation. In addition, clinical supervisors must be informed when residents are unable to attend clinic or endoscopy lists due to post-call reasons. Residents are expected to develop, implement and monitor a personal continuing education strategy. To facilitate this objective, at least one half day is set aside per week for self-directed learning of topics and diseases encountered in the clinics.

Rotation Schedule
	AM	PM
Monday	Clinic (Puglia)	Endoscopy (Puglia)
Tuesday	Clinic (Witt-Sullivan)	Reading day
Wednesday	Academic Half Day	Endoscopy (Tsoi)
Thursday	Clinic (Witt-Sullivan)	Endoscopy
Friday	Paracentesis / Liver biopsy	Clinic (Tsoi)

* Multi-disciplinary hepatobiliary rounds (optional) on Friday 7-9 am

Educational and Scholarly activities
Educational activities, which are a priority for the GI resident, include both scheduled rounds and other academic sessions. The resident is expected to attend the Gastroenterology Residents’ academic half-day, including the Farncombe noon rounds, on a weekly basis. In addition, the resident is expected to identify a topic of interest to review with the attending physician on a weekly basis.

Residents are encouraged to gain exposure through participation in activities at the Hamilton Hepatology Clinical Research Unit. They are invited to collaborate with staff hepatology supervisors in available research opportunities, and in successful cases present in local, national and international conferences.

Evaluation of the Resident

Residents are encouraged to seek informal verbal feedback throughout the Hepatology outpatient experience concerning their proficiency at managing clinical problems and performing endoscopic procedures / paracentesis. A formal evaluation session with the resident will take place at the end of the rotation. Input is sought from other members of the clinic team who have worked with the resident (e.g. nurses, nurse practitioners, other allied health professionals). Based on all feedback received, at the end of the rotation, a formal web-based CanMEDS compliant ITER is compiled by the supervisor. Final evaluations are discussed with the resident.

Evaluation of the Rotation

Residents are encouraged to provide feedback on how the rotation and teaching are structured. As with all rotations, an anonymous rotation evaluation is handled by the One 45 WebEval System. Each teaching faculty is evaluated separately in a similar manner. The Residency Program Committee meets semi-annually to compile a collective rotation and faculty evaluation, respecting anonymity. This has been important to maintaining feedback.

Rotation-Specific Objectives

In addition to the general objectives outlined above, rotation-specific goals and objectives for the First Year of Training in Adult Gastroenterology at McMaster University are listed below.

Medical Expert

Key Competencies: Physicians are able to

1. Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal, ethical and patient-centered medical care
2. Establish and maintain clinical knowledge, skills and attitudes appropriate to Gastroenterology
3. Perform a complete and appropriate assessment of a patient
4. Use preventive and therapeutic interventions effectively
5. Demonstrate proficient and appropriate use of procedural skills, both diagnostic and therapeutic
6. Seek appropriate consultation from other health professionals, recognizing the limits of their expertise

Specific Requirements: Gastroenterology residents are able to

1. Demonstrate knowledge in the following general areas:
   • An approach to patients with abnormal liver enzymes, both transaminitis and cholestatic enzyme abnormalities
   • An approach to the management of common hepatobiliary disorders seen in an outpatient setting. This will include:
     • Viral hepatitis (A, B, C, D, E, Epstein-Barr Virus) with or without HIV coinfection
     • Alcoholic liver disease and alcoholic hepatitis
     • Non-Alcoholic Fatty Liver Disease (NAFLD) and Non-Alcoholic Steatohepatitis (NASH)
     • Autoimmune hepatitis, Primary Biliary Cirrhosis (PBC), Primary Sclerosing Cholangitis (PSC) and overlap syndrome
     • Inherited Liver Disease – hemochromatosis, Wilson’s Disease, Alpha-1 antitrypsin disease
     • Liver mass, both benign and malignant causes
     • Portal hypertension, compensated and decompensated liver cirrhosis
     • Assessment for liver transplantation
     • Post-liver transplantation complications
   • Epidemiology, pathophysiology, methods of diagnosis, management and prognosis of common hepatobiliary conditions
   • Pharmacology of drugs commonly used in Hepatology
   • The role of liver imaging modalities including computed tomography, magnetic resonance-based techniques (magnetic resonance imaging, magnetic resonance angiography, magnetic resonance cholangiography), hepatic angiography, and ultrasound (including Doppler evaluation of hepatic vasculature) in the evaluation of hepatic conditions
   • Surgical and interventional radiologic procedures employed in relation to hepatobiliary disorders and their complications
2. Assess and investigate patients with common gastrointestinal conditions:
   • Establish a professional relationship and interact with patients
   • Take a history that is relevant, concise and accurate to context
   • Perform a focused physical exam that is relevant and accurate
   • Select medically appropriate investigative methods in a resource-effective and ethical manner, including:
     • Laboratory investigations (bloodwork)
     • Imaging modalities (ultrasound, CT, MRI, ERCP, EUS)
     • Biopsies of the gastrointestinal tract and liver
     • Diagnostic and therapeutic endoscopy of the upper and lower gastrointestinal tract
   • Use clinical databases appropriately to formulate problems and to correctly develop investigation and management plans
3. Understand and appropriately respond to relevant ethical issues arising in the investigation and care of patients with common hepatobiliary conditions
4. Demonstrate the ability to perform basic diagnostic endoscopy under supervision in the elective setting, including:
   • Upper gastrointestinal endoscopy with biopsy
   • Upper gastrointestinal endoscopy with banding ligation of varices
   • Flexible sigmoidoscopy with biopsy
5. Demonstrate proficiency at diagnostic and therapeutic paracentesis

Communicator

Key Competencies: Physicians are able to

1. Develop rapport, trust, and ethical therapeutic relationships with patients and families
2. Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues, and other professionals
3. Convey relevant information and explanations accurately to patients and families, colleagues and other professionals
4. Develop a common understanding on issues, problems and plans with patients, families, and other professionals to develop a shared plan of care
5. Convey effective oral and written information about a medical encounter

Specific Requirements: Gastroenterology residents are able to

1. Establish effective relationship with patients and their families in order to obtain a meaningful history, conduct a relevant physical examination, and to properly manage a patient’s medical problem
2. Convey information about diagnosis, prognosis, risks/benefits of tests and treatment options to patients and families, and referring physicians accurately and effectively under supervision
3. Communicate effectively with clinic staff and discuss appropriate information with all members of the health care team
4. Effectively present verbal reports of clinical encounters and plans
5. Compose succinct, accurate and comprehensive consultation letter or procedure note with appropriate support from the supervising consultant

Collaborator

Key Competencies: Physicians are able to

1. Participate effectively and appropriately in an interprofessional health care team
2. Work with other health professionals effectively to prevent, negotiate, and resolve interprofessional conflict

Specific Requirements: Gastroenterology residents are able to

1. Contribute clinically useful management options on patients referred for consultation, including ordering and arranging for specific testing or procedures, administering required therapy, and conveying the results of the management options to referring physicians. This process involves integrating information from multiple sources to construct a clear diagnosis which is then used to guide the patient’s therapy. This may require integrating the results of haematological investigations, radiologic tests, endoscopic procedures with histopathological interpretation.
2. Develop awareness of a multidisciplinary approach in the management of hepatobiliary diseases
3. Consult and collaborate with hepatobiliary surgery, radiology, pathology, clinic staff, endoscopy unit staff, and other health care professionals, and contribute effectively to the collaborative investigation and management of patients
4. Develop skills in managing patients in collaboration with another medical institution such as a liver transplant centre

Manager

Key Competencies: Physicians are able to

1. Participate in activities that contribute to the effectiveness of their health care organizations and systems
2. Manage their practice and career effectively
3. Allocate finite health care resources appropriately
4. Serve in administration and leadership roles, as appropriate

Specific Requirements: Gastroenterology residents are able to

1. Set priorities and manage time to balance patient care, practice requirements, outside activities and personal life
2. Institute effective and efficient management plans for patients with hepatobiliary disease by utilizing the available resources in an outpatient setting
3. Understand resource allocations in liver disease especially in liver transplantation
4. Aware of community resources available to assist Hepatology patients
5. Demonstrate good time management in an outpatient setting by assessing patients accurately, comprehensively and efficiently with timely diction of consultation notes and / or procedure notes

Health Advocate

Key Competencies: Physicians are able to

1. Respond to individual patient health needs and issues as part of patient care
2. Respond to the health needs of the communities that they serve
3. Identify the determinants of health for the populations that they serve
4. Promote the health of individual patients, communities, and populations

Specific Requirements: Gastroenterology residents are able to

1. Demonstrate an understanding of the health care needs of patients with hepatobiliary diseases in an outpatient setting
2. Identify opportunities for advocacy, health promotion and disease prevention with the individual patients that they serve, including helping patients obtain Limited Use medications, preparing documents for patients (insurance, disability, application for medications) that describe and outline the nature of the patient’s problem and the recommended treatments, arranging appropriate vaccinations, prophylactic antibiotics for spontaneous bacterial peritonitis, and the use of screening and surveillance tests (hepatocellular carcinoma, portal hypertension)
3. Understand the role of a gastroenterologist in advocating for patients’ access to care through private insurers, provincial formularies and wait lists
4. Appreciate complexity behind government funding process for financial support towards medications in treatment of viral hepatitis
5. Develop an awareness of the process in the evaluation of candidacy of patients for liver transplantation

Scholar

Key Competencies: Physicians are able to

1. Maintain and enhance professional activities through ongoing learning
2. Critically evaluate medical information and its sources, and apply this appropriately to practice decisions
3. Facilitate the learning of patients, families, students, residents, other health professionals, the public and others
4. Contribute to the development, dissemination, and translation of new knowledge and practices

Specific Requirements: Gastroenterology residents are able to

1. Develop, implement and monitor a personal continuing education strategy. To facilitate this objective, at least one half day is set aside per week for self-directed learning of topics and diseases encountered in the clinics.
2. Demonstrate efficiency and competence in searching, appraising and applying medical literature to address a clinical question
3. Understand the role of research in advancing the understanding of hepatobiliary disease

Professional

Key Competencies: Physicians are able to

1. Demonstrate a commitment to their patients, profession, and society through ethical practice
2. Demonstrate a commitment to their patients, profession and society through participation in profession-led regulation
3. Demonstrate a commitment to physician health and sustainable practice

Specific Requirements: Gastroenterology residents are able to

1. Deliver highest quality care with honesty, integrity and compassion
2. Exhibit appropriate personal and interpersonal professional behavior
3. Be courteous and punctual
4. Follow-up on patients evaluated and arrange additional investigations, as appropriate for patient problems
5. Evaluate one’s own abilities, knowledge, skills and limitations of professional competence
6. Demonstrate strategies to maintain and advance professional competence

OVERVIEW

The Functional GI Laboratory is located at the McMaster University Medical Center under the Directorship of Dr. Bercik. Motility, 24-hour pH-metry and combined pH-metry/impedance studies are conducted by specially trained nurses daily from Monday to Thursday, under the supervision of Drs. Bercik and Collins. Motility studies are performed using state of the art high-resolution manometry system, for both upper and lower GI tract examinations.

The overall goal of the Motility Curriculum is to acquire practical knowledge and skills in the diagnosis and management of GI motor disorders. The specific objectives include:

1. To become familiar with the equipment and competent in the techniques used to measure esophageal motility, pH and electrical impedance, including Bernstein and bread provocation tests
2. To become competent in the analysis and interpretation of esophageal motility tracings and pH recordings
3. To become competent in the analysis and interpretation of pH and pH/impedance recordings
4. To become familiar with the equipment and competent in the techniques used to measure anorectal motility
5. To become competent in the analysis and interpretation of anorectal motility recordings
6. To become familiar with the biofeedback training program
7. To become competent in devising appropriate management strategies in patients with motility disorders

Dr. Premysl Bercik is the Coordinator for the Motility Curriculum.

Motility Curriculum

The Motility Curriculum includes the following components:

1. Motility Rotation (4-week block):
   • Observation of esophageal pH and impedance studies
   • Observation of esophageal manometry studies
   • Observation of ano-rectal manometry studies
   • Observation of biofeedback training
   • Hands-on experience with the interpretation of manometry, pH and impedance tests
   • Clinics dedicated to motility and functional disorders
2. Three academic half-day lectures focused on:
   • esophageal pH-metry and impedance tests
   • esophageal manometry and provocation tests
   • anorectal manometry and biofeedback.

The Motility Rotation can be incorporated into an Outpatient Rotation or an Elective Block in the Second Year.

Second Year residents can obtain additional experience in GI motility by participating in on-going clinical trials using novel techniques of videofluoroscopy image analysis and magnet tracking to assess gastroduodenal and small intestinal motility.

Responsibilities of the Resident

Rotation schedule is prepared by the Chief Residents on a monthly basis. However, the rotation schedule should be confirmed with the Motility Curriculum Coordinator 4 weeks prior to the start date of the rotation. Residents are expected to attend each assigned Motility Lab session, clinic and endoscopy list, to be punctual, and to complete procedure notes and consultation notes on all patients in a timely fashion. Clinical supervisors must be informed of vacation / professional leave 4 weeks prior to the start date of the rotation. In addition, clinical supervisors must be informed when residents are unable to attend clinic or endoscopy lists due to post-call reasons. Residents are expected to develop, implement and monitor a personal continuing education strategy. To facilitate this objective, at least one half day is set aside per week for self-directed learning of topics and diseases encountered in the clinics.

Residents are expected to attend Motility Lab sessions on Monday morning, Wed afternoon and Thursday morning. Tuesday afternoon is devoted to analysis of motility and pH recordings under the supervision of Dr. Bercik or Dr. Collins. Residents are also expected to assess patients in Dr. Bercik’s and Dr. Collins’ clinic which have a focus on motility and functional disorders on Tuesday morning. Residents will also have the opportunity to assess patients with complex motility disorders (second opinion referrals) on Friday morning.

Rotation Schedule
	AM	PM
Monday	Motility Lab	Endoscopy
Tuesday	Clinic (Bercik / Collins)	Analysis of motility and pH recordings
Wednesday	Academic Half Day	Motility Lab
Thursday	Motility Lab	Endoscopy (Bercik)
Friday	Complex Motility Clinic	Reading day

Evaluation of the Resident

Residents are encouraged to seek informal verbal feedback throughout the Motility Rotation concerning their proficiency at interpreting functional GI investigations and managing clinical problems related to functional bowel / motility disorders. A formal evaluation session with the resident will take place at the end of the rotation. Input is sought from other members of the clinic team who have worked with the resident (e.g. motility nurse, other allied health professionals). Based on all feedback received, at the end of the rotation, a formal web-based CanMEDS compliant ITER is compiled by the supervisor. Final evaluations are discussed with the resident.

Evaluation of the Rotation

Residents are encouraged to provide feedback on how the rotation and teaching are structured. As with all rotations, an anonymous rotation evaluation is handled by the One 45 WebEval System. Each teaching faculty is evaluated separately in a similar manner. The Residency Program Committee meets semi-annually to compile a collective rotation and faculty evaluation, respecting anonymity. This has been important to maintaining feedback.

Rotation-Specific Objectives

Specific goals and objectives of the Motility Curriculum in CanMEDs format are as follows:

Medical Expert

Key Competencies: Physicians are able to

1. Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal, ethical and patient-centered medical care
2. Establish and maintain clinical knowledge, skills and attitudes appropriate to Gastroenterology
3. Perform a complete and appropriate assessment of a patient
4. Use preventive and therapeutic interventions effectively
5. Demonstrate proficient and appropriate use of procedural skills, both diagnostic and therapeutic
6. Seek appropriate consultation from other health professionals, recognizing the limits of their expertise

Specific Requirements: Gastroenterology residents are able to

1. Demonstrate knowledge in the following general areas:
   • An approach to the diagnosis and management of patients with common motility disorders. This will include:
     • Esophageal motility disorders (e.g. achalasia)
     • GERD and refractory GERD
     • Non-cardiac chest pain
     • Gastroparesis
     • Multi-system diseases and their effect on GI motility (e.g. scleroderma, diabetes)
     • Chronic constipation
     • Irritable bowel syndrome
     • Fecal incontinence
   • Pharmacology of drugs commonly used in patients with motility disorders
   • Detailed knowledge of anatomy, physiology and pathology of the digestive system, with special emphasis on esophagus, stomach and anorectum, focusing on motility, viscerosensitivity and acid secretion
2. Assess and investigate patients with common motility disorders:
   • Establish a professional relationship and interact with patients
   • Perform a complete history and physical exam that is relevant, comprehensive and appropriate with particular emphasis on areas specific to patients with motility disorders.
   • Diagnose motor disorders of the esophagus and anorectum using high-resolution manometry, pH-metry, combined pH-metry/impedance and provocation tests.
   • Design effective treatment strategies in patients with motility disorders and acid secretion abnormalities.
   • Select medically appropriate investigative methods in a resource-effective and ethical manner, including:
     • Laboratory investigations (bloodwork)
     • Imaging modalities (ultrasound, CT, MRI)
     • Manometry, pH-metry and provocation tests
     • Upper GI endoscopy and colonoscopy
   • Use clinical databases appropriately to formulate problems and to correctly develop investigation and management plans
3. Understand and appropriately respond to relevant ethical issues arising in the investigation and care of patients with common motility disorders
4. Demonstrate the ability to interpret esophageal manometry and pH-metry:
   • Recognize common patterns of esophageal motility disorders seen with esophageal manometry such as: achalasia, nutcracker esophagus, diffuse esophageal spasm and ineffective peristalsis
   • Interpret 24-hour esophageal pH and impedance studies and correlate the result to clinical outcomes

Communicator

Key Competencies: Physicians are able to

1. Develop rapport, trust, and ethical therapeutic relationships with patients and families
2. Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues, and other professionals
3. Convey relevant information and explanations accurately to patients and families, colleagues and other professionals
4. Develop a common understanding on issues, problems and plans with patients, families, and other professionals to develop a shared plan of care
5. Convey effective oral and written information about a medical encounter

Specific Requirements: Gastroenterology residents are able to

1. Establish effective relationship with patients and their families in order to obtain a meaningful history, conduct a relevant physical examination, and to properly manage a patient’s medical problem based on clinical correlation with manometry or pH-metry results
2. Convey information about diagnosis, prognosis, risks/benefits of tests and treatment options to patients and families, and referring physicians accurately and effectively under supervision
3. Communicate effectively with clinic staff and discuss appropriate information with all members of the health care team
4. Effectively present verbal reports of clinical encounters and plans
5. Compose succinct, accurate and comprehensive consultation letter or specialty test reports with appropriate support from the supervising consultant

Collaborator

Key Competencies: Physicians are able to

1. Participate effectively and appropriately in an interprofessional health care team
2. Work with other health professionals effectively to prevent, negotiate, and resolve interprofessional conflict

Specific Requirements: Gastroenterology residents are able to

1. Appreciate the operation of a GI Motility Lab, and the contribution from its members: nurses and physicians
2. Establish effective collaborations in clinical care, both within and between institutions
3. Resolve conflicts with and between other members of the health care team

Manager

Key Competencies: Physicians are able to

1. Participate in activities that contribute to the effectiveness of their health care organizations and systems
2. Manage their practice and career effectively
3. Allocate finite health care resources appropriately
4. Serve in administration and leadership roles, as appropriate

Specific Requirements: Gastroenterology residents are able to

1. Understand the role and limitation of the GI Motility Lab in the assessment and diagnosis of common motility disorders
2. Set priorities and manage time to balance patient care, practice requirements, outside activities and personal life
3. Institute effective and efficient management plans for patients with motility disorders by utilizing the available resources in an outpatient setting
4. Demonstrate good time management in an outpatient setting by assessing patients accurately, comprehensively and efficiently with timely diction of consultation notes and / or subspecialty test reports

Health Advocate

Key Competencies: Physicians are able to

1. Respond to individual patient health needs and issues as part of patient care
2. Respond to the health needs of the communities that they serve
3. Identify the determinants of health for the populations that they serve
4. Promote the health of individual patients, communities, and populations

Specific Requirements: Gastroenterology residents are able to

1. Understand the health determinants that may contribute to the symptoms and presentation of patients with GI motility disorders
2. Identify opportunities for advocacy, health promotion and disease prevention with the individual patients that they serve, including helping patients obtain Limited Use medications, preparing documents for patients (insurance, disability, application for medications) that describe and outline the nature of the patient’s problem and the recommended treatments, and the use of screening and surveillance tests
3. Understand the role of a gastroenterologist in advocating for patients’ access to care through private insurers, provincial formularies and wait lists
4. Understand the cost-benefit relationship of therapies for motility disorders

Scholar

Key Competencies: Physicians are able to

1. Maintain and enhance professional activities through ongoing learning
2. Critically evaluate medical information and its sources, and apply this appropriately to practice decisions
3. Facilitate the learning of patients, families, students, residents, other health professionals, the public and others
4. Contribute to the development, dissemination, and translation of new knowledge and practices

Specific Requirements: Gastroenterology residents are able to

1. Develop, implement and monitor a personal continuing education strategy. To facilitate this objective, at least one half day is set aside per week for self-directed learning of topics and diseases encountered in the clinics.
2. Demonstrate efficiency and competence in searching, appraising and applying medical literature to address a clinical question
3. Understand the role of research in advancing the understanding of motility and functional disorders

Professional

Key Competencies: Physicians are able to

1. Demonstrate a commitment to their patients, profession, and society through ethical practice
2. Demonstrate a commitment to their patients, profession and society through participation in profession-led regulation
3. Demonstrate a commitment to physician health and sustainable practice

Specific Requirements: Gastroenterology residents are able to

1. Deliver highest quality care with honesty, integrity and compassion
2. Exhibit appropriate personal and interpersonal professional behavior
3. Be courteous and punctual
4. Follow-up on patients evaluated and arrange additional investigations, as appropriate for patient problems
5. Evaluate one’s own abilities, knowledge, skills and limitations of professional competence
6. Demonstrate strategies to maintain and advance professional competence

OVERVIEW

The recognition and management of malnutrition, including nutritional deficiencies associated with gastrointestinal and hepatopancreaticobiliary dysfunction as well as the gastrointestinal luminal, hepatic and pancreatic consequences of overweight and obesity are key elements of Gastroenterology practice. There is a general expectation, on the part of health care professionals and patients, that gastroenterologists are, or should be expert in the area of nutrition and nutrition is one of the topics highlighted in the Royal College curriculum for subspecialty Gastroenterology training programs. Despite this, there is evidence that practising gastroenterologists do not consider that they have had adequate training in the field of nutrition, either to provide comprehensive nutritional care for their patients with gastrointestinal diseases or to advise other health care professionals with respect to nutritional care (Singh H, Duerksen DR. Can J Gastroenterol 2006;20:527-30).

In Canada, the Royal College of Physicians and Surgeons of Canada (RCPSC) requires training in nutrition in GI residency programs and, in the U.S., a consortium of Gastroenterology associations has designated nutrition training of GI fellows as a mandatory component of their training programs (Heimburger DC. J Clin Gastroenterol 2002;34:505-8)

The overall goal of the Clinical Nutrition Curriculum is to acquire practical knowledge and skills in the major clinical nutrition domains relevant to gastroenterologists. These include:

1. The management of patients with gastrointestinal disorders (e.g. inflammatory bowel disease, dysmotility, celiac disease and structural abnormalities of the gastrointestinal tract) associated with malnutrition
2. The placement of feeding tubes (e.g. gastrostomy or jejunostomy tubes, endoscopically or radiologically) in patients to provide access for enteral nutrition
3. The management of nutritional support for patients (e.g. with short bowel syndrome) requiring short- and long-term total parenteral nutrition, in hospital and in the community
4. The management of obesity, non-alcoholic fatty liver disease and the sequelae of anti-obesity therapy

Dr. David Armstrong is the Coordinator for the Clinical Nutrition Curriculum.

Clinical Nutrition Curriculum

The Clinical Nutrition Curriculum includes the following components:

1. Clinical Nutrition Rotation (4-week block):
   • Weekly Nutrition Ward Rounds on a Monday afternoon (1330 h -1600 h):
     • Inpatient Nutrition rounds (Juravinski Site)
     • Nutrition Topic Review presented by the Resident
   • Weekly Ambulatory Care Nutrition Clinics on a Thursday morning (0900 h – 1200 h)
     • 09:00 – 10:00 Digestive Diseases Program Dietician (Suzanne Hansen, RD)
     • 10:00 – 12:00 Home Parenteral Nutrition Clinic (Stella Stevens RN; Suzanne Hansen RD; David Armstrong MD)
       • Outpatient Home Parenteral Nutrition Rounds: including review of current test result and clinical status for 25 patients managed by the HHS HPN Team
       • Outpatient HPN patient evaluation: 1-2 patients weekly
   • Weekly Inpatient Consultations for patients referred by inpatient services for evaluation of nutritional compromise (David Armstrong MD, Jodie Hoard RD)
   • Opportunity to participate in the weekly Adult Cystic Fibrosis Clinic (3Z) at the MUMC site (Wednesday afternoon, 13:00 to 16:30) and gain an understanding of the nutritional, gastrointestinal and hepatic sequelae of cystic fibrosis
2. Four academic half-day lectures (2 per year) focused on:
   • Nutritional assessment with particular reference to patients with GI diseases
   • Management of nutritionally compromised individuals by enteral nutrition
   • Management of nutritionally compromised individuals by parenteral nutrition
   • Management of nutritional issues related to inflammatory bowel disease, celiac disease, cystic fibrosis, liver disease, obesity, bariatric surgery, short bowel syndrome and eating disorders
3. One introductory session on the principles of enteral and parenteral nutrition at the start of each academic year. This will be run by one of the registered Digestive Diseases Program dieticians (Suzanne Hansen RD)
4. There will be clinical research opportunities that should be reviewed with the Program Director, the Research Coordinator and the Clinical Nutrition Curriculum Coordinator at the start of the year.

The Clinical Nutrition Rotation can be incorporated into an Outpatient Rotation or an Elective Block in the Second Year.

At completion of the Nutrition Curriculum, the Gastroenterology resident will:

1. Have an understanding of normal and stress metabolism
2. Be proficient in nutritional assessments
3. Be able to evaluate the risks and benefits of specialized nutrition support
4. Understand the principles of determining caloric requirements by calculation and indirect calorimetry
5. Be able to design formulae for parenteral or enteral nutrition
6. Be proficient in monitoring for and managing the complications of nutrition support, central catheters, enteral tubes
7. Be proficient in the outpatient management of TPN, obesity, celiac disease, and other nutritional problems

Responsibilities of the Resident

Rotation schedule is prepared by the Chief Residents on a monthly basis. However, the rotation schedule should be confirmed with the Nutrition Curriculum Coordinator 4 weeks prior to the start date of the rotation. Residents are expected to attend each assigned clinic and endoscopy list, to be punctual, and to complete procedure notes and consultation notes on all patients seen in the clinic in a timely fashion. Clinical supervisors must be informed of vacation / professional leave 4 weeks prior to the start date of the rotation. In addition, clinical supervisors must be informed when residents are unable to attend clinic or endoscopy lists due to post-call reasons. Residents are expected to develop, implement and monitor a personal continuing education strategy. To facilitate this objective, at least one half day is set aside per week for self-directed learning of topics and diseases encountered in the clinics.

Rotation Schedule
	AM	PM
Monday	Endoscopy	Nutrition Ward Rounds (JH)
Tuesday	Endoscopy	Dr. Armstrong Clinic (2F)
Wednesday	Academic Half Day	Cystic Fibrosis Clinic
Thursday	Nutrition Clinic (2F)	Dr. Armstrong Clinic (2F)
Friday	Reading day

Evaluation of the Resident

Residents are encouraged to seek informal verbal feedback throughout the Clinical Nutrition Rotation concerning their proficiency at diagnosing and managing clinical problems related to nutritional disorders. A formal evaluation session with the resident will take place at the end of the rotation. Input is sought from other members of the clinic team who have worked with the resident (e.g. motility nurse, other allied health professionals). Based on all feedback received, at the end of the rotation, a formal web-based CanMEDS compliant ITER is compiled by the supervisor. Final evaluations are discussed with the resident.

Evaluation of the Rotation

Residents are encouraged to provide feedback on how the rotation and teaching are structured. As with all rotations, an anonymous rotation evaluation is handled by the One 45 WebEval System. Each teaching faculty is evaluated separately in a similar manner. The Residency Program Committee meets semi-annually to compile a collective rotation and faculty evaluation, respecting anonymity. This has been important to maintaining feedback.

Rotation-Specific Objectives

Specific goals and objectives of the Clinical Nutrition Curriculum in CanMEDs format are as follows:

Medical Expert

Key Competencies: Physicians are able to

1. Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal, ethical and patient-centered medical care
2. Establish and maintain clinical knowledge, skills and attitudes appropriate to Gastroenterology
3. Perform a complete and appropriate assessment of a patient
4. Use preventive and therapeutic interventions effectively
5. Demonstrate proficient and appropriate use of procedural skills, both diagnostic and therapeutic
6. Seek appropriate consultation from other health professionals, recognizing the limits of their expertise

Specific Requirements: Gastroenterology residents are able to

1. Develop knowledge in the following general areas via case-based learning, interactive discussion, or self-directed learning:
   • Nutrients:
     • Absorption
     • Digestion
     • Requirements: macronutrients micronutrients, water
     • Deficiency
     • Toxicity
   • Diet and Activity:
     • Canada Food Guide to Health Eating
     • Diets, including vegetarianism, fads
     • Activity guidelines
   • Nutritional Assessment:
     • History and Physical; SGA
     • Laboratory evaluation
     • Anthropometry
     • Indirect calorimetry
   • Nutritional Therapy
     • Diet - e.g. gluten free diet, high fibre diet etc
     • Enteral nutrition – access / requirements/ products / complications
     • Parenteral nutrition – access / requirements / prescription / complications
     • Refeeding syndrome
     • Home nutrition support
   • An approach to the management of nutrition in disease states. This will include:
     • IBD
     • Chronic liver disease
     • Celiac disease
     • Pancreatitis
     • Allergy
     • Intestinal failure / short bowel syndrome
     • Eating disorders
     • Osteoporosis
     • Critical care
   • Nutrition and the lifecycle:
     • Growth and development
     • Pregnancy
     • Aging
     • Ethical considerations
   • Bariatric Medicine:
     • Physiology / gut hormones
     • Diet / medical / surgical therapy
     • Endoscopic therapy
     • NAFLD / NASH
   • Anatomy, physiology and pathology of the digestive system, including the pancreas and liver; with respect to intake and absorption of macronutrients and micronutrients
   • The principles of gastrointestinal surgery including the effect of operations on the gastrointestinal tract on patients’ nutritional status
   • Indications, contraindications and complications of enteral and total parenteral nutrition (e.g. refeeding syndromes, feeding tube complications, line sepsis and other metabolic problems)
   • Current methodologies for assessing nutritional status including biochemical parameters, subjective global assessment and the use of the metabolic cart
   • Various enteral products currently on the market, distinguishing characteristics of each and advantages / disadvantages of each preparation in various clinical situations
   • Controversial areas in the area of nutrition including hepatic encephalopathy, pre-operative feeding and terminal cancer
   • New advances in the management of nutritional disorders (e.g. organ transplantation, endoscopic feeding tube placement, growth factors, specialized nutritional supplements)
2. Assess and investigate patients with nutritional compromise:
   • Establish a professional relationship and interact with patients
   • Perform a complete history and physical exam that is relevant, comprehensive and appropriate with particular emphasis on areas specific to patients with nutritional compromise
   • Select medically appropriate investigative methods in a resource-effective and ethical manner, including:
     • Laboratory investigations (bloodwork)
     • Imaging modalities (ultrasound, CT, MRI)
     • Tests commonly employed in GI function laboratories (breath tests, motility studies)
     • Upper GI endoscopy and colonoscopy
   • Use clinical databases appropriately to formulate problems and to correctly develop investigation and management plans
3. Understand and appropriately respond to relevant ethical issues arising in the investigation and care of patients with common motility disorders
4. Demonstrate the ability to perform advanced diagnostic and therapeutic endoscopy under supervision, including:
   • Percutaneous endoscopic gastrostomy (PEG)
   • PEG tube exchange

Communicator

Key Competencies: Physicians are able to

1. Develop rapport, trust, and ethical therapeutic relationships with patients and families
2. Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues, and other professionals
3. Convey relevant information and explanations accurately to patients and families, colleagues and other professionals
4. Develop a common understanding on issues, problems and plans with patients, families, and other professionals to develop a shared plan of care
5. Convey effective oral and written information about a medical encounter

Specific Requirements: Gastroenterology residents are able to

1. Establish effective relationship with patients and their families in order to obtain a meaningful history, conduct a relevant physical examination, and to properly manage a patient’s medical problem
2. Convey information about diagnosis, prognosis, risks/benefits of tests and treatment options to patients and families and referring physicians accurately and effectively under supervision
3. Communicate effectively with clinic staff and discuss appropriate information with all members of the health care team
4. Effectively present verbal reports of clinical encounters and plans
5. Compose succinct, accurate and comprehensive consultation letters, procedure reports and specialty test reports with appropriate support from the supervising consultant

Collaborator

Key Competencies: Physicians are able to

1. Participate effectively and appropriately in an interprofessional health care team
2. Work with other health professionals effectively to prevent, negotiate, and resolve interprofessional conflict

Specific Requirements: Gastroenterology residents are able to

1. Appreciate the vital and diverse contributions from each of the nutrition care team members including physicians, specialized nurses and dieticians
2. Develop a care plan for a patient, including investigation, treatment and continuing care, in collaboration with the members of the interdisciplinary nutrition care team
3. Participate in an interdisciplinary nutrition care team meeting, demonstrating the ability to accept, consider and respect the opinions of other team members, while contributing expertise in the field of clinical nutrition and Gastroenterology
4. Establish effective collaborations in clinical care, both within and between institutions

Manager

Key Competencies: Physicians are able to

1. Participate in activities that contribute to the effectiveness of their health care organizations and systems
2. Manage their practice and career effectively
3. Allocate finite health care resources appropriately
4. Serve in administration and leadership roles, as appropriate

Specific Requirements: Gastroenterology residents are able to

1. Set priorities and manage time to balance patient care, practice requirements, outside activities and personal life
2. Institute cost-effective management plans for patients with nutritional compromise by utilizing the available resources in both outpatient and inpatient settings
3. Demonstrate good time management by assessing patients accurately, comprehensively and efficiently with timely dictation of consultation notes, procedure notes and / or subspecialty test reports

Health Advocate

Key Competencies: Physicians are able to

1. Respond to individual patient health needs and issues as part of patient care
2. Respond to the health needs of the communities that they serve
3. Identify the determinants of health for the populations that they serve
4. Promote the health of individual patients, communities, and populations

Specific Requirements: Gastroenterology residents are able to

1. Understand the causes, consequences and prevalence of malnutrition in hospital inpatients and long-term health care facility residents
2. Understand the funding and challenges of long-term nutritional therapy in Ontario
3. Understand the determinants of health that may present as obstacles for patients with nutritional compromise to remain in the ambulatory setting
4. Identify opportunities for advocacy, health promotion and disease prevention with the individual patients that they serve, including helping patients obtain Limited Use medications, preparing documents for patients (insurance, disability, application for medications or nutrition) that describe and outline the nature of the patient’s problem and the recommended treatments, and the use of screening and surveillance tests
5. Understand the role of a gastroenterologist in advocating for patients’ access to care through private insurers, provincial formularies and wait lists
6. Work with specialty societies and other associations to identify “at risk” groups (e.g. candidates for nutritional support) and apply available knowledge about prevention to “at risk” groups. Contribute “group data” for better understanding of health problems within the population (e.g. Canadian CNS Home PN Registry, Canadian Malnutrition Task Force [CMTF])

Scholar

Key Competencies: Physicians are able to

1. Maintain and enhance professional activities through ongoing learning
2. Critically evaluate medical information and its sources, and apply this appropriately to practice decisions
3. Facilitate the learning of patients, families, students, residents, other health professionals, the public and others
4. Contribute to the development, dissemination, and translation of new knowledge and practices

Specific Requirements: Gastroenterology residents are able to

1. Develop, implement and monitor a personal continuing education strategy. To facilitate this objective, at least one half day is set aside per week for self-directed learning of topics and diseases encountered in the clinics.
2. Demonstrate efficiency and competence in searching, appraising and applying medical literature to address a clinical question
3. Understand the role of research in advancing the understanding of nutritional disorders
4. Demonstrate a willingness to teach others including patients, caregivers, students, trainees from other disciplines and allied health care professionals

Professional

Key Competencies: Physicians are able to

1. Demonstrate a commitment to their patients, profession, and society through ethical practice
2. Demonstrate a commitment to their patients, profession and society through participation in profession-led regulation
3. Demonstrate a commitment to physician health and sustainable practice

Specific Requirements: Gastroenterology residents are able to

1. Deliver highest quality care with honesty, integrity and compassion
2. Exhibit appropriate personal and interpersonal professional behavior
3. Be courteous and punctual
4. Follow-up on patients evaluated and arrange additional investigations, as appropriate for patient problems
5. Evaluate one’s own abilities, knowledge, skills and limitations of professional competence
6. Demonstrate strategies to maintain and advance professional competence
7. Recognize the roles, in clinical nutrition practice, of ethical issues such as consent, advanced directives, confidentiality, end-of-life care, conflict of interest, resource allocation and research ethics

OVERVIEW

Health care reforms have significantly changed the practice of medicine, resulting in a continuing expansion of medical care delivery through community-based programs. The classical teaching hospital may deal with a filtered patient population that may not reflect the ultimate practice pattern of the graduate. The introduction of community experiences to our training program curriculum serves to address these needs within the current teaching system. In Canada, the Royal College of Physicians and Surgeons of Canada (RCPSC) mandates community-based learning experiences as either stand along rotations (equivalent to one block or four weeks) or mandatory half day clinics outside of the academic health sciences centre that would constitute an equivalent experience.

The community Gastroenterology experience will encompass and expand upon the core training elements employed by the Gastroenterology residency training program at McMaster University. The main focus of this rotation will be to address the CanMEDS directed role in the context of community based Gastroenterology. The primary purposes of this rotation are to:

1. Offer residents an opportunity to experience practice in an area where they may subsequently wish to settle and may also enable them to tailor their subsequent training rotations to meet the needs required in a future area of practice
2. Provide opportunities for learning which are not available in the conventional teaching environment
3. Provide opportunities for residents to practice autonomy with independent decision-making with limitations of technological resources / medical resource personnel that are more readily available in tertiary care environments. Self-learning for the resident would be emphasized, and local physicians and mentors serve as role models

The rotation is carried out in Oakville, ON, supervised by the GI practice group (Drs. N. Arya, D. Bair and J. Pham), where GI consultation care is given to residents in the local and surrounding communities of Oakville. Oakville has a catchment population over 150,000 people. The Gastroenterology practice is very diverse and consists of inpatient hospital service, outpatient clinics and as well as outpatient endoscopy. Residents will have the opportunity to be exposed to a wide range of therapeutic endoscopy procedures that include endoscopy, colonoscopy, ERCP, ampullectomies, Zenker's diverticulectomies, endoscopic mucosal resections, a full metal stenting program and diagnostic and therapeutic endoscopic ultrasound.

During this four week rotation, second year Gastroenterology trainee will be working directly with established community-based GI physicians in ambulatory clinics and inpatient hospital settings, and the performance of endoscopic procedures in relation to these consultations. This rotation will consist of 2 or 3 weeks of ambulatory GI clinics and 1 or 2 weeks of inpatient hospital service. During the ambulatory blocks, there will be three and a half days of clinics and one and a half day of endoscopy. While on inpatient service, residents will perform endoscopy on their patients and outpatient endoscopy lists when possible.

Alternatives to Rotation in Oakville

It is highly encouraged that residents undertake their community GI rotation in Oakville as the rotation goals and objectives are structured and tailored to the Second Year GI residents. However, residents are free to identify and choose other community based settings for this rotation in keeping with their individual training objectives, subject to approval by the Program Director and Residency Program Committee. Residents must identify a supervisor responsible for monitoring and evaluating his / her performance. If an alternative community site is chosen for this rotation, an elective form with CanMEDS based goals and objectives of this experience will need to be formalized and submitted to the Program Director and the rotation supervisor for review 4 weeks prior to the start of this rotation.

Residents on this rotation are not exempted from on-call duties.

Responsibilities of the Resident

Inpatient and Outpatient Experience
The community rotation is 4 weeks in duration and includes patient care activities in both an inpatient and outpatient setting, as well as educational and scholarly activities outside a teaching hospital. This rotation is only for Second Year GI residents. Residents should contact Dr. J. Pham (Community GI Rotation Coordinator, 905 849 7426) 4 weeks prior to the start of the rotation to obtain hospital privileges and to confirm schedule of activities.

Educational and Scholarly activities
Educational activities, which are a priority for the GI resident, include both scheduled rounds and other academic sessions. The resident is expected to attend the Gastroenterology Residents’ academic half-day, including the Farncombe noon rounds, on a weekly basis. In addition, the resident is expected to identify a practice management topic of interest to review with the attending physician on a weekly basis.

Trainees are welcome to attend the local monthly journal club in Oakville that includes the surgical and radiology teams.

Evaluation of the Resident

An orientation session (with Dr. J. Pham) will take place during the first week of the rotation to discuss the goals and description of this rotation with the resident. The specific objectives of the resident will be discussed and an attempt made to integrate these objectives into the overall objectives of the rotation.

Residents are encouraged to seek informal verbal feedback throughout the rotation concerning their proficiency at managing clinical problems and performing endoscopic procedures. A formal evaluation session with the resident will take place at the end of the rotation with the Rotation Coordinator (Dr. J. Pham) at the end of the 4-week rotation. Input is sought from other members of the clinic team who have worked with the resident (e.g. gastroenterologists, nurses, nurse practitioners, other allied health professionals). The Rotation Coordinator should be informed a few days prior to the end of the rotation to collate comments from all supervisors and health professionals. Based on all feedback received, at the end of the rotation, a formal web-based CanMEDS compliant ITER is compiled by the supervisors. Final evaluations are discussed with the resident.

Evaluation of the Rotation

Residents are encouraged to provide feedback on how the rotation and teaching are structured. If issues arise during the rotation, the resident is encouraged to bring these to the attention of the rotation supervisor and the Site Coordinator. A mechanism for dealing with any shortcomings will then be discussed with the resident and subsequently at the Residency Program Committee meeting. As with all rotations, an anonymous rotation evaluation is handled by the One 45 WebEval System. Each teaching faculty is evaluated separately in a similar manner. The Residency Program Committee meets semi-annually to compile a collective rotation and faculty evaluation, respecting anonymity. This has been important to maintaining feedback.

Rotation-Specific Objectives

The Community GI Rotation centres on consolidating and extending clinical skills acquired during the first year, and allows the resident to gain confidence as a consultant in Gastroenterology in a community-based setting. The overall goals of this experience are to develop consultancy and time management skills required to practice Gastroenterology, as well as to allow the resident experience in community-based medicine. The resident is expected to fulfil all of the CanMEDS roles described in the first year. In addition, the second year resident is expected to assimilate knowledge gained in the first year to function as a consultant gastroenterologist in a community-based setting.

In addition to the general objectives outlined above, rotation-specific goals and objectives for the Second Year of Training in Adult Gastroenterology at McMaster University are listed below.

Medical Expert

Key Competencies: Physicians are able to

1. Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal, ethical and patient-centered medical care
2. Establish and maintain clinical knowledge, skills and attitudes appropriate to Gastroenterology
3. Perform a complete and appropriate assessment of a patient
4. Use preventive and therapeutic interventions effectively
5. Demonstrate proficient and appropriate use of procedural skills, both diagnostic and therapeutic
6. Seek appropriate consultation from other health professionals, recognizing the limits of their expertise

Specific Requirements: Gastroenterology residents are able to

1. Demonstrate knowledge in the following general areas, including the ability to:
   • Understand the spectrum and limitations of practice in a community setting based on resources and geography
   • Appreciate the structure of health care in a community setting including:
     • Access to quaternary care, stabilization and investigation of patients for transfer
     • Function effectively within a multi-disciplinary setting
     • Resource allocation and health care infrastructure
     • Practice management
   • Demonstrate a confident approach to the management of common GI disorders seen in both an outpatient and inpatient setting, with a specific focus on community health related issues and practices. This will include acute GI bleeding, acute/chronic diarrhea, inflammatory bowel disease, motility and functional bowel disease, chronic and end-stage liver disease, acute liver disease, obscure GI bleeding, gastrointestinal cancers, malnutrition, pancreatitis, gallstone disease, and complications of endoscopy.
2. Assess and investigate patients with common gastrointestinal conditions:
   • Identify and explore issues to be addressed in a patient encounter effectively
   • Select medically appropriate investigative methods in a resource-effective and ethical manner in a community-based setting, including:
     • Laboratory investigations (bloodwork)
     • Imaging modalities (ultrasound, CT, MRI, angiogram, ERCP, EUS, capsule endoscopy)
     • Biopsies of the gastrointestinal tract and liver
     • Diagnostic and therapeutic endoscopy of the upper and lower gastrointestinal tract
   • Demonstrate effective problem-solving skills and judgment to address patient problems, including interpreting available data and integrating information to generate extensive differential diagnosis for presenting problems and comprehensive management plans for gastrointestinal diseases
3. Demonstrate effective, appropriate and timely consultation of another health professional as needed, recognizing the limits of their expertise
4. Recognize and appropriately respond to relevant ethical issues arising in the investigation and care of patients with common gastrointestinal conditions involving the digestive system, liver and pancreas
5. Demonstrate the ability to perform advanced diagnostic and therapeutic endoscopy under supervision, including:
   • Colonoscopy and polypectomy
   • Endoscopic hemostasis (including injection, thermal therapy, clips and band ligation)
   • Luminal dilation
   • Foreign body removal
   • Percutaneous endoscopic gastrostomy
   • Identification and interpretation of endoscopic findings with confidence, including those that are uncommon or elusive (Dieulafoy lesions, eosinophilic esophagitis, celiac disease, gastric antral vascular ectasia, solitary rectal ulcers, discrimination of Crohn's disease and ulcerative colitis)

Communicator

Key Competencies: Physicians are able to

1. Develop rapport, trust, and ethical therapeutic relationships with patients and families
2. Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues, and other professionals
3. Convey relevant information and explanations accurately to patients and families, colleagues and other professionals
4. Develop a common understanding on issues, problems and plans with patients, families, and other professionals to develop a shared plan of care
5. Convey effective oral and written information about a medical encounter

Specific Requirements: Gastroenterology residents are able to

1. Establish effective relationship with patients and their families in order to obtain a meaningful history, conduct a relevant physical examination, and to properly manage a patient’s medical problem without the immediate supervision of the consultant
2. Convey information about diagnosis, prognosis, risks/benefits of tests and treatment options to patients and families, and referring physicians accurately and effectively without the immediate supervision of the consultant
3. Communicate and cooperative effectively with allied health professionals and medical colleagues in the care of individual patients without the immediate supervision of the consultant
4. Demonstrate effective consultation skills in presenting well-documented assessment and recommendations in written and/or verbal form with minimal support or revision by the consultant, including:
   1. Procedural reports
   2. Consultation letters, progress notes and discharge summaries

Collaborator

Key Competencies: Physicians are able to

1. Participate effectively and appropriately in an interprofessional health care team
2. Work with other health professionals effectively to prevent, negotiate, and resolve interprofessional conflict

Specific Requirements: Gastroenterology residents are able to

1. Demonstrate an ability to collaborate with health care professionals by interacting directly and effectively with other physicians, and developing a management plan for patients in collaboration with various members of an interdisciplinary team within and between hospitals, other health care facilities and collaborative groups
2. Understand the type of collaboration between specialists and general practitioners in a community setting
3. Demonstrate a respectful attitude towards other colleagues and members of an interprofessional team
4. Understand how provincial and hospital governance influence the ability to provide health care in the community setting

Manager

Key Competencies: Physicians are able to

1. Participate in activities that contribute to the effectiveness of their health care organizations and systems
2. Manage their practice and career effectively
3. Allocate finite health care resources appropriately
4. Serve in administration and leadership roles, as appropriate

Specific Requirements: Gastroenterology residents are able to

1. Investigate and manage patients with GI disorders in a cost effective manner, while ensuring the optimal patient care and outcome
2. Recognize limitation of resources in a community setting, and develop judgment for when transfer to a larger centre is necessary for optimal patient care
3. Demonstrate time management skills necessary to balance inpatient consultations, outpatient procedure, clinic and educational opportunities
4. Demonstrate the ability to balance personal and professional activities and use their time to optimize patient care and continuing professional development
5. Understand office administration, practice management and billing
6. Understand the operational and administrative aspects of an inpatient hospital service and a private endoscopy centre in a community setting
7. The community rotation provides an excellent arena to teach and discuss practice management along with other managerial skills. Topics for review in this area include:
   • Negotiation skills
   • Committee responsibility
   • How to get references
   • Practice efficiency
   • Managing length of stay and waitlist
8. Appreciate the differences in patient population and their management between quaternary care and community care in a tertiary centre

Health Advocate

Key Competencies: Physicians are able to

1. Respond to individual patient health needs and issues as part of patient care
2. Respond to the health needs of the communities that they serve
3. Identify the determinants of health for the populations that they serve
4. Promote the health of individual patients, communities, and populations

Specific Requirements: Gastroenterology residents are able to

1. Understand the advocacy role of a community gastroenterologist in provision of high quality care to citizens of the community where GI consultation is provided by a single group of specialists
2. Develop an appreciation of the health determinants that may influence patient adherence and outcome in a community setting
3. Appreciate a balance between cost and benefit of investigations and therapies of GI disorders in a community setting
4. Identify opportunities for advocacy, health promotion and disease prevention with the individual patients and communities that they serve

Scholar

Key Competencies: Physicians are able to

1. Maintain and enhance professional activities through ongoing learning
2. Critically evaluate medical information and its sources, and apply this appropriately to practice decisions
3. Facilitate the learning of patients, families, students, residents, other health professionals, the public and others
4. Contribute to the development, dissemination, and translation of new knowledge and practices

Specific Requirements: Gastroenterology residents are able to

1. Demonstrate the ability to assess, appraise, acquire and contribute to lifelong learning (local talks, journal clubs, conferences, online resources)
2. Recognize the need for a broad spectrum of knowledge when practicing in the community; as well as a strategy for Continuing Professional Development
3. Understand the contribution of the consultant in the lifelong learning of the general practitioners and other health providers

Professional

Key Competencies: Physicians are able to

1. Demonstrate a commitment to their patients, profession, and society through ethical practice
2. Demonstrate a commitment to their patients, profession and society through participation in profession-led regulation
3. Demonstrate a commitment to physician health and sustainable practice

Specific Requirements: Gastroenterology residents are able to

1. Balance personal and professional priorities to ensure personal health and a sustainable practice
2. Deliver highest quality care with honesty, integrity and compassion
3. Exhibit appropriate personal and interpersonal professional behavior
4. Be courteous and punctual
5. Follow-up on patients evaluated and arrange additional investigations, as appropriate for patient problems
6. Evaluate one’s own abilities, knowledge, skills and limitations of professional competence
7. Demonstrate strategies to maintain and advance professional competence
8. Understand the importance of quality assurance in endoscopy with the identification of quality indicators and methods to collect, analyze, and report endoscopy data in a community setting

OVERVIEW

The Pediatric Gastroenterology Rotation at McMaster University Medical Centre is intended for Second Year Gastroenterology Residents. It is designed to meet the objectives of the Royal College of Physicians and Surgeons and to provide an experience that will facilitate the resident’s education in becoming a competent consultant in Gastroenterology. Increasingly, adult Gastroenterologists are expected to participate in a limited scope of care for pediatric patients when, in underserved areas, Pediatric Gastroenterology consultation is not available, or to assist pediatric colleagues with complex endoscopic procedures more common in adult patients.

This 2-week rotation will include outpatient consultative Pediatric Gastroenterology exposure, as well as ongoing outpatient clinical care. There are also opportunities to participate in inpatient Pediatric Gastroenterology activities relevant to the learning goals and objectives of the Adult Gastroenterology residents. In addition, Second Year residents are encouraged to obtain additional exposure to Pediatric Gastroenterology during their elective months and during the outpatient rotation. During this 2-week rotation, the Adult Gastroenterology resident will be expected to participate primarily in the care of Pediatric GI ambulatory consultation with the availability of daily clinics. The consultation service is broad-based with GI, nutritional and Hepatology consults, with focused clinics for IBD, Hepatology, Celiac disease, constipation, and Cyclic Vomiting Syndrome. The objectives outlined below represent topics that should be covered and discussed in the context of pathophysiology, clinical presentation and management. Many of the conditions are similar to Adult Gastroenterology (inflammatory bowel disease, celiac disease, cystic fibrosis, functional abdominal pain, gastroesophageal reflux disease, functional GI disorders, chronic liver disease), but the presentation, management and natural history may vary in patients under 18 years of age. There is also an opportunity to observe pediatric endoscopy, and participate if pediatric GI residents are not assigned to the list.

The goal of this limited rotation is NOT proficiency in Pediatric Gastroenterology but to understand the conditions unique to pediatrics, pediatric diseases which will impact adult life, and the similarities and differences in disorders found in both Adult and Pediatric Gastroenterology. The use of medications, radiological, and endoscopic investigations in children will be discussed. Through these activities, the resident will gain a pediatric perspective and an increased awareness of the important distinctions between Adult and Pediatric Gastroenterology including the overall approach to the evaluation of pediatric patients of varying ages and their families; the spectrum of disease in children; the need to adapt diagnostic tests and interventions to the age-specific needs of the pediatric patient; and the attention to therapeutics in the pediatric age groups, especially with regard to the mode of delivery, side effect profiles and long-term implications. In addition, this experience will increase understanding of the differences in practice, enhance collaboration and improve transition of care.

Responsibilities of the Resident

Outpatient Experience
Rotation schedule is prepared by the Pediatric Program Director on a monthly basis. The schedule will need to be confirmed prior to the start of the rotation. Residents meet with the Pediatric GI Division’s Educational Resource Person on the first day. Residents are expected to attend each assigned clinic, to be punctual, and to complete consultation notes on all patients seen in the clinic in a timely fashion. Clinical supervisors must be informed of vacation / professional leave 4 weeks prior to the start date of the rotation. In addition, clinical supervisors must be informed when residents are unable to attend clinic due to post-call reasons. Residents are expected to develop, implement and monitor a personal continuing education strategy. To facilitate this objective, at least one half day is set aside per week for self-directed learning of topics and diseases encountered in the clinics.

 

Rotation Schedule
	AM	PM
Monday	Zachos (Constipation Clinic)	Brill (GI/Hepatology)
Tuesday	Sherlock	Issenman (IBD Clinic)
Wednesday	Academic Half Day	Adult / Pediatric Endoscopy / Celiac / CVS
Thursday	Brill (GI/IBD)	Issenman (GI Clinic)
Friday	Reading day / observe inpatient service

* Please contact Andrea Brydges (brydgea@mcmaster.ca), Administrative Assistant, Paediatric Gastroenterology & Nutrition, prior to the start of this rotation to confirm meeting time with the Educational Resource Person.

Educational and Scholarly activities
Educational activities, which are a priority for the GI resident, include both scheduled rounds and other academic sessions. The resident is expected to attend the Gastroenterology Residents’ academic half-day, including the Farncombe noon rounds, on a weekly basis. In addition, the resident is expected to actively participate in the Pediatric Teaching rounds / seminars on Monday from 1200 to 1300. During these educational sessions, essential topics in Pediatric Gastroenterology will be discussed. The resident is expected to present a topic of interest or a journal article during this session. Pathology rounds are held every Tuesday from 1200 to 1300 at McMaster Site.

Evaluation of the Resident

Residents are encouraged to seek informal verbal feedback throughout the Pediatric Gastroenterology outpatient experience concerning their proficiency at managing clinical problems. A formal evaluation session with the resident will take place at the end of the rotation. Input is sought from other members of the clinic team who have worked with the resident (e.g. nurses, nurse practitioners, other allied health professionals). Based on all feedback received, at the end of the rotation, a formal web-based CanMEDS compliant ITER is compiled by the supervisor. Final evaluations are discussed with the resident.

Evaluation of the Rotation

Residents are encouraged to provide feedback on how the rotation and teaching are structured. As with all rotations, an anonymous rotation evaluation is handled by the One 45 WebEval System. Each teaching faculty is evaluated separately in a similar manner. The Residency Program Committee meets semi-annually to compile a collective rotation and faculty evaluation, respecting anonymity. This has been important to maintaining feedback.

Rotation-Specific Objectives

In addition to the general objectives outlined above, rotation-specific goals and objectives for the Second Year of Training in Adult Gastroenterology at McMaster University are listed below.

Medical Expert

Key Competencies: Physicians are able to

1. Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal, ethical and patient-centered medical care
2. Establish and maintain clinical knowledge, skills and attitudes appropriate to Gastroenterology
3. Perform a complete and appropriate assessment of a patient
4. Use preventive and therapeutic interventions effectively
5. Demonstrate proficient and appropriate use of procedural skills, both diagnostic and therapeutic
6. Seek appropriate consultation from other health professionals, recognizing the limits of their expertise

Specific Requirements: Gastroenterology residents are able to

1. Demonstrate knowledge in the following general areas:
   • The effect of age on the pathophysiology of gastrointestinal disease and response to treatment
   • The unique aspects of Pediatric Gastroenterology and an awareness of the clinical problems of Pediatric Gastroenterology
   • Epidemiology, pathophysiology, methods of diagnosis, management and prognosis of common gastrointestinal conditions involving the digestive system, liver and pancreas in pediatric patients
   • Pharmacology of drugs commonly used in Pediatric Gastroenterology
   • Indications, contraindications, limitations, complications, techniques and interpretation of results of the common diagnostic and therapeutic procedures performed on the digestive tract in pediatric patients. This will include upper GI endoscopy, sigmoidoscopy, colonoscopy, barium studies, ultrasound, CT, MRI, radioisotope scan, ERCP, EUS, capsule endoscopy, pHmetry and liver biopsy.
   • An approach to the management of common gastrointestinal disorders seen in pediatric patients in an outpatient setting. This will include dyspepsia, constipation, maldigestion and malabsorption, celiac disease, cystic fibrosis, pancreatic and gallstone disease, functional GI disorders, inflammatory bowel disease, congenital hepatobiliary syndromes, chronic liver disease and portal hypertension.
   • An approach to the nutritional assessment techniques and nutritional disorders in pediatric patients
2. Assess and investigate patients with common gastrointestinal conditions in a manner appropriate for the patient’s age, including the ability to:
   • Establish a professional relationship and interact with patients and their care-givers in order to obtain a relevant history
   • Take a history that is relevant, concise and accurate to context
   • Perform a focused physical exam that is relevant and accurate, demonstrating sensitivity to patient’s needs, modified according to patient’s age
   • Select medically appropriate investigative methods in a resource-effective and ethical manner, including:
     • Laboratory investigations bloodwork)
     • Imaging modalities (barium studies, ultrasound, CT, MRI, radioisotope scan, ERCP, EUS, capsule endoscopy)
     • Tests commonly employed in GI function laboratories (breath tests, motility studies)
     • Biopsies of the gastrointestinal tract and liver
     • Diagnostic and therapeutic endoscopy of the upper and lower gastrointestinal tract
   • Use clinical databases appropriately to formulate problems and to correctly develop investigation and management plans
3. Understand and appropriately respond to relevant ethical issues arising in the investigation and care of pediatric patients with common gastrointestinal conditions involving the digestive system, liver and pancreas, including the appropriate treatment of patients whose families hold religious or other beliefs that preclude the use of “standard medical treatments”

Communicator

Key Competencies: Physicians are able to

1. Develop rapport, trust, and ethical therapeutic relationships with patients and families
2. Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues, and other professionals
3. Convey relevant information and explanations accurately to patients and families, colleagues and other professionals
4. Develop a common understanding on issues, problems and plans with patients, families, and other professionals to develop a shared plan of care
5. Convey effective oral and written information about a medical encounter

Specific Requirements: Gastroenterology residents are able to

1. Establish effective relationships with patients, their parents, legal guardians or other caregivers in order to obtain a meaningful history and to conduct a relevant physical examination
2. Convey information about diagnosis, prognosis, risks/benefits of tests and treatment options to patients and families, and referring physicians accurately and effectively under supervision
3. Communicate effectively with clinic staff and discuss appropriate information with all members of the health care team
4. Effectively present verbal reports of clinical encounters and plans
5. Compose succinct, accurate and comprehensive consultation letter or follow-up note
6. Understand the psychosocial aspects of caring for children with chronic disorders, and their families
7. Understand the informed consent process and ability to apply this to obtain informed consent for diagnostic procedures and therapy in paediatric patients

Collaborator

Key Competencies: Physicians are able to

1. Participate effectively and appropriately in an interprofessional health care team
2. Work with other health professionals effectively to prevent, negotiate, and resolve interprofessional conflict

Specific Requirements: Gastroenterology residents are able to

1. Contribute clinically useful management options on patients referred for consultation, including ordering and arranging for specific testing or procedures, administering required therapy, and conveying the results of the management options to referring physicians. This process involves integrating information from multiple sources to construct a clear diagnosis which is then used to guide the patient’s therapy. This may require integrating the results of endoscopic procedures with histopathological interpretation, radiologic tests, and haematological investigations.
2. Consult and collaborate with paediatric health care professionals including paediatricians, paediatric nurses, paediatric surgeons, and paediatric anesthesiologists, clinic staff and other health care professionals, and contribute effectively to the collaborative investigation and management of Paediatric patients

Manager

Key Competencies: Physicians are able to

1. Participate in activities that contribute to the effectiveness of their health care organizations and systems
2. Manage their practice and career effectively
3. Allocate finite health care resources appropriately
4. Serve in administration and leadership roles, as appropriate

Specific Requirements: Gastroenterology residents are able to

1. Set priorities and manage time to balance patient care, practice requirements, outside activities and personal life
2. Institute effective and efficient management plans for paediatric patients with gastrointestinal disease by utilizing the available resources in an outpatient setting
3. Demonstrate good time management in an outpatient setting by assessing patients accurately, comprehensively and efficiently with timely diction of consultation notes and / or procedure notes
4. Demonstrate knowledge of the different roles and responsibilities of patients, caregivers, physicians, nurses, clerical staff and allied health professionals in the outpatient management of gastrointestinal conditions
5. Appreciate the various factors involved in transition of care from paediatric to adult practitioners

Health Advocate

Key Competencies: Physicians are able to

1. Respond to individual patient health needs and issues as part of patient care
2. Respond to the health needs of the communities that they serve
3. Identify the determinants of health for the populations that they serve
4. Promote the health of individual patients, communities, and populations

Specific Requirements: Gastroenterology residents are able to

1. Demonstrate an understanding of the health care needs of paediatric patients with gastrointestinal diseases in an outpatient setting
2. Demonstrate an appropriate sensitivity to age related issues
3. Identify opportunities for advocacy, health promotion and disease prevention with the individual patients that they serve, including helping patients obtain Limited Use medications, preparing documents for patients (insurance, disability, application for biologic medications) that describe and outline the nature of the patient’s problem and the recommended treatments, arranging appropriate vaccinations)
4. Understand the role of a gastroenterologist in advocating for patients’ access to care through private insurers, provincial formularies and wait lists
5. Aware of ancillary resources to assist with delivery of care including but not limited to dietary, social services, psychiatric counselling and support groups (e.g. Crohn’s and Colitis Foundation, etc)

Scholar

Key Competencies: Physicians are able to

1. Maintain and enhance professional activities through ongoing learning
2. Critically evaluate medical information and its sources, and apply this appropriately to practice decisions
3. Facilitate the learning of patients, families, students, residents, other health professionals, the public and others
4. Contribute to the development, dissemination, and translation of new knowledge and practices

Specific Requirements: Gastroenterology residents are able to

1. Develop, implement and monitor a personal continuing education strategy. To facilitate this objective, at least one half day is set aside per week for self-directed learning of topics and diseases encountered in the clinics.
2. Demonstrate efficiency and competence in searching, appraising and applying medical literature to address a clinical question, particularly as it applies to treatments of gastrointestinal disorders of children and adolescents, and for procedures, where randomized trials are difficult or impossible
3. Understand the role of research in advancing the understanding of gastrointestinal disease

Professional

Key Competencies: Physicians are able to

1. Demonstrate a commitment to their patients, profession, and society through ethical practice
2. Demonstrate a commitment to their patients, profession and society through participation in profession-led regulation
3. Demonstrate a commitment to physician health and sustainable practice

Specific Requirements: Gastroenterology residents are able to

1. Deliver highest quality care with honesty, integrity and compassion
2. Exhibit appropriate personal and interpersonal professional behavior
3. Be courteous and punctual
4. Follow-up on patients evaluated and arrange additional investigations, as appropriate for patient problems
5. Evaluate one’s own abilities, knowledge, skills and limitations of professional competence
6. Demonstrate strategies to maintain and advance professional competence
7. Understand the professional obligations to the patient and parents when caring of patients below the age of consent compared to adult patients

OVERVIEW

Endoscopy training in the Adult Gastroenterology Training Program takes place at four sites: the McMaster, the Juravinski and the General Sites of Hamilton Health Sciences, and St. Joseph’s Hospital. Experience on-call is acquired at all three acute care sites in Hamilton. Training in endoscopy occurs continuously throughout the two years of the fellowship, at whatever site the trainee is based for his/her rotation. All residents receive orientation to the Endoscopy Unit in the first month of residency. This includes instruction on patient preparation, safety, antibiotic prophylaxis, equipment maintenance, and disinfection of instruments. In addition to the endoscopic procedure, appropriate patient care is expected to include thorough explanation of the procedure, review of appropriateness of the indication, assessment of contraindications, explanation of risks, informed consent, appropriate conscious sedation, recovery, discharge planning and communication of findings and management plans to patients, families and referring health professionals. Endoscopy is provided as part of a comprehensive Gastroenterology service in cooperation with physicians, surgeons, radiologists, pathologists and allied health personnel.

FACILITIES

Endoscopy units at the four teaching hospitals in Hamilton perform approximately 20,000 gastrointestinal endoscopic procedures each year. A full range of endoscopic procedures is provided to assess and manage a broad spectrum of medical and surgical disorders. Each endoscopy unit is furnished with modern PentaxTM endoscopy equipment and access to fluoroscopy for ERCP (all sites), argon plasma coagulation (Juravinski, McMaster and St. Joseph’s Sites), laser (St. Joseph’s Site) and endoscopic ultrasound (McMaster Site).

The endoscopy suite at the McMaster Site offers four video-equipped endoscopy rooms with state-of-the art Pentax equipment for both adult and pediatric endoscopy. A fluoroscopy suite with radiologist supervision is available. The unit is staffed by endoscopy nurses well-trained in adult and pediatric endoscopy. Endoscopic ultrasound is provided at this site. Additionally, the unit is equipped for enteroscopy. Endoscopy reports are generated immediately post-procedure using EndoPro software with digital image capture. Capsule endoscopy is available on-site. In addition, the site offers computerized video simulations with the SymbionixTM endoscopy simulator.

The endoscopy suite at the Juravinski Site offers two video equipped rooms with full access to fluoroscopy suites and EndoPro software.

The endoscopy suite at the St. Joseph’s site has 5 fully equipped rooms with Pentax video endoscopic instruments. It also boasts interventional laser facilities. In addition, the site offers full endoscopic training facilities using computerized video simulations in collaboration with the Centre for Minimal Access Surgery.

Trainees’ initial exposure to endoscopy after joining the training program is with the Symbionix^TM endoscopy simulator, housed at the McMaster Site. Trainees are expected complete a defined curriculum of simulator scenarios successfully before beginning to perform endoscopy under supervision on patients.

TRAINING EXPECTATIONS

Trainees attend a minimum of one endoscopy session each week over their two years of training. Generally, at least 500 procedures are completed under direct supervision. Because therapeutic endoscopy is considered more hazardous, it is taught only after satisfactory basic training in diagnostic endoscopy is complete. During all endoscopic training, the complementary roles of histology, radiology and surgery are emphasized.

Competence at diagnostic upper gastrointestinal endoscopy is achieved well before the end of the first year. During the first year, residents also become competent at flexible sigmoidoscopy and are introduced to colonoscopy. During the second year of training, the resident focuses on therapeutic aspects of upper endoscopy and becomes competent at colonoscopy, including polypectomy. Training in urgent endoscopy, including interventions for acute gastrointestinal bleeding, is acquired largely through participation in regional call rota. All emergency endoscopies are performed under direct supervision of the on-call consultant.

Competence at upper gastrointestinal endoscopy is expected to include diagnostic assessment, biopsy, brushing, injection therapies, thermal coaptive therapies (e.g. heater probe, BiCAP), mechanical hemostatic techniques (eg. hemo-clip), injection sclerotherapy, variceal band ligation, argon plasma coagulation, foreign body removal, polypectomy, bougie and balloon dilatation, and percutaneous endoscopic gastrostomy. Competence at lower gastrointestinal endoscopy is expected to include diagnostic assessment including terminal ileal intubation, biopsy, polypectomy, injection therapy, thermal coaptive therapies, mechanical hemostatic techniques, and balloon dilation. Endoscopy unit personnel provide training in equipment set-up, maintenance, cleaning and disinfection. This is also reviewed in detail at the introductory endoscopy course.

Trainees in the core two-year program are offered exposure to ERCP and EUS, but competence in diagnostic / therapeutic ERCP and EUS is not an objective of the program. Core trainees are expected to gain a thorough understanding of the technique, indications, contraindications, complications and interpretation of related radiography, and to gain early experience with intubation of a side-viewing endoscope.

Trainees interested in therapeutic biliary endoscopy (including endoscopic sphincterotomy and biliary stent placement) or endoscopic ultrasound are encouraged to consider a third year of advanced endoscopic training. Trainees in the core program may undertake electives in biliary endoscopy upon identifying an appropriate supervisor. However, priority to assist at ERCP is given to fellows in their third year. Third-year training in advanced endoscopy could also include experience in laser endoscopy, pediatric endoscopy, enteroscopy, endoscopic mucosal resection and intra-operative endoscopy.

Summary of Endoscopy Objectives

Competence at Upper Endoscopy
Diagnostic (including biopsy and brushing)
Injection (including sclerotherapy)
Coaptive therapy (including heater probe, BiCAP)
Hemoclip application
Dilation (bougie and balloon)
Argon plasma coagulation
Variceal ligation
Foreign body removal
Polypectomy
Percutaneous endoscopic gastrostomy

Competence in Colonoscopy
Diagnostic (including terminal ileal intubation, biopsy)
Polypectomy
Argon plasma coagulation
Balloon dilation
Injection
Coaptive therapy (including heater probe, BiCAP)
Hemoclip application

Training in GI endoscopy has largely been based on hands-on acquisition of experience in patients rather than on a structured training program. Unlike most diagnostic modalities, endoscopies evolved amidst a number of specialties, being performed by gastroenterologists, surgeons, and radiologists and as a result, clear training requirements and provision differed. There are currently no guidelines regarding how endoscopists should be trained. Many national endoscopy societies have produced guidelines that include aspects of endoscopy that should be learned and have recommended minimal competency procedural thresholds. Yet none have addressed the issue of how to teach endoscopic skills in a structured way. The traditional model of “see one, do one, teach one” is probably not an adequate method of conveying the necessary information for successful, safe endoscopy. A well-organized, structured training is essential if we are to ensure that procedures are performed in a safe and effective manner. In addition, such a program would serve to improve and standardize the training and practice of endoscopy, and ultimately improve the quality and safety of endoscopic procedures.

A structured pre-endoscopy training curriculum should ideally include introductory lectures and courses on the cognitive aspects of competency of endoscopy including informed consent, safety and sedation, indications and complications of endoscopy, unit management, endoscopy and accessory design, and their operation. Once the cognitive aspects of competency has been taught and assessed, teaching of psychomotor skills necessary for endoscopy can be addressed. These skills can be taught by the use of simulation which has been shown to decrease the time needed to improve the performance of trainees significantly especially in the early training period. Once the psychomotor skills are mastered, the trainees can then achieve proficiency by practice on real patients under supervision. Underpinning the acquisition of cognitive and psychomotor skills is the ability to identify and correctly interpret pathologies. This component of endoscopy training can be taught by reviewing video clips or endoscopic pictures of pathologies.

With the goal of formalizing a structured pre-endoscopy training curriculum, the First Year GI Residents Endoscopy Training Course was first introduced in 2005 at McMaster University. It is an intensive 2-day course which incorporates didactic lectures, small group discussions, hands-on training on simulation and dinner event with debate by course faculty at McMaster University. This annual course has been endorsed by many GI training programs across the country and has been very well received by trainees. This is now, attended by 35 to 40 first year Adult and Pediatric GI residents and surgical residents, and the course has included faculty from across the country. It is important to highlight that all faculty trainers for the simulation sessions have received formal training as endoscopic trainers through Train-the-Trainers (TTT) programs.

The steering committee of this course includes: David Armstrong, Frances Tse, Lawrence Hookey, Don MacIntosh, Mark Borgaonkar, David Morgan, John Marshall and John Anderson (UK National Endoscopy Training Lead).

Specific goals and objectives

Medical Expert

Understand the importance of integration of all CanMEDS roles to provide optimal, ethical and patient-centered medical care in endoscopy:

1. Identify performance, quality and safety indicators in endoscopy in accordance with the Canadian Association of Gastroenterology (CAG) Consensus Guidelines on Safety and Quality Indicators in Endoscopy
2. Appropriate use and care of equipment used in endoscopic procedures
3. Recognize the indications, interpretations, limitations and complications of endoscopic procedures including endoscopy, colonoscopy, flexible sigmoidoscopy and advanced procedures (endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, capsule endoscopy) in a resource-effective and ethical manner
4. Recognize the hazards of endoscopic procedures for the endoscopist, assistants and patient and the measures appropriate to minimize such hazards
5. Recognize the importance of pre-procedural care to optimize patient safety and quality of endoscopic procedures including antibiotic prophylaxis, routine and special needs for sedation, anticoagulation management, and colonoscopy preparation
6. Understand the principles of informed consent for endoscopic procedures with thorough explanation of the procedure, review of appropriateness of the indication, assessment of contraindications, explanation of risks and alternatives
7. Identify and appropriately respond to relevant ethical issues arising in patient care during endoscopy
8. Understand the principles of management of gastrointestinal emergencies including, but not limited to: upper GI bleeding, lower GI bleeding, biliary obstruction / cholangitis, and foreign body impaction
9. Understand the basic principles and equipments required for therapeutic procedures including luminal dilatation, polypectomy, endoscopic hemostasis, and foreign body removal
10. Effective, appropriate and timely application of preventive and therapeutic interventions relevant to endoscopy, including, but not limited to: screening colonoscopy, upper endoscopy for Barrett’s esophagus and portal hypertension
11. Appropriate post-procedural care pertaining to recovery and discharge planning

Communicator

1. Recognize that being a good communicator is a core clinical skill for endoscopists, and that effective physician-patient communication can foster patient satisfaction, physician satisfaction, adherence and improved clinical outcomes

1. Recognize the importance of incorporating patient’s beliefs, concerns, and expectations in clinical encounter pertaining to endoscopy
2. Understand the importance of documentation and dissemination of information related to procedures performed and their outcomes
3. Understand the importance of communication of findings and management plans to patients, families and referring health professionals

Collaborator

1. Understand the role of the gastroenterologist within the endoscopy unit to optimize patient care
2. Understand the importance of maintaining a respectful and professional attitude towards other colleagues and members of the endoscopy unit to prevent, negotiate and resolve inter-professional conflict

Manager

1. Understand the collaborative role of the gastroenterologist within the endoscopy unit
2. Describe the principles behind the operation of a safe and effective endoscopy unit including infection control and sedation
3. Understand the importance of participation in systemic quality process evaluation and improvement, such as procedural quality and patient safety initiatives
4. Understand the principles of budgeting and financing of an endoscopy unit

Health Advocate

1. Describe in broad terms the key issues currently under debate regarding changes in the Canadian health care system, indicating how these changes may affect the delivery of endoscopic services and health outcomes and how gastroenterologists can advocate to decrease the burden of illness at a community or society level.
2. Demonstrate an understanding of the role of screening tests in reducing mortality from colorectal cancer
3. Identify barriers to access to care and resources for colorectal cancer screening
4. Appreciate the possibility of conflict inherent in their role as health advocate for a patient or community with that of manager or gatekeeper

Scholar

1. Describe the principles and strategies for maintenance of competence in endoscopy
2. Recognize the importance of personal practice audit in the evaluation of performance and quality indicators in endoscopy

Professional

1. Recognize the professional role of a gastroenterologist in delivering the highest quality care and maintenance of competence in endoscopy
2. Demonstrate a commitment to patients, profession and society through participation in CAG and local quality initiatives in endoscopy

Competence in performing endoscopy is an essential component of a Gastroenterology trainee’s professional development, and yet the standards that both facilitate and confirm the achievement of competency are poorly defined. Increasingly, objective assessment of performance is recognized as a critical assessment parameter in determining endoscopic competence accurately. Furthermore, the ASGE training guidelines mandated that each trainee’s acquisition of technical and cognitive skills be monitored on a regular basis. Most training programs do so by the use of procedure logs or subjective evaluation by proctors. Unfortunately, performance of a minimum number of procedures, while a prerequisite for skill acquisition, does not guarantee competence. Furthermore, subjective observation is neither valid nor reliable. Tracking quality indicators for trainees may provide more reliable outcome data to improve educational programs and establish training requirements. As such, the objective of the RPAGE program is to measure specific endoscopic quality indicators for trainees to determine if outcome can be used to assess the quality of procedure training and contribute to more objective means of establishing uniform training requirements among programs.

The Resident Practice Audit Program Gastro-Enterology (RPAGE) is an innovative program that was developed by the Division of Gastroenterology at McMaster University (Dr. Ted Xenodemetropoulos, Dr. Frances Tse, Dr. David Armstrong) in collaboration with the Canadian Association of Gastroenterology (CAG). The RPAGE is a natural and logical extension of the Practice Audit in Gastroenterology (PAGE) program for practicing Canadian endoscopists. Over the last 6 – 7 years, the PAGE program has developed into a powerful, real time instrument for practice audit, continuing professional development and quality improvement, recognized by the Royal College of Physicians and Surgeons of Canada with their 2011 Innovations in Accreditation Award.

The RPAGE program is designed to provide trainees with a point-of-care, peer-comparator practice audit tool. With the help of the endoscopic trainers, all trainees enter details of each procedure they complete in real-time. Anonymized trainee, patient and practice data are collected using touchscreen smartphones or desktop computer with automated data upload for data analysis and review by participants. The program allows trainees to objectively record key endoscopic quality indicators (e.g. gastroscope and colonoscope insertion and withdrawal times, segments of procedure performed independently or with assistance, bowel preparation quality, sedation, immediate complications and polypectomy, biopsy rates). There is also an evaluation tool built in the program that allows trainees to have their endoscopic performance objectively evaluated by their trainers on a regular basis. The RPAGE program will allow trainees to review their own performance and compare this with their peers, promoting the identification of learning needs and objectives, as well as the basis for the development of targeted education programs. The Program Director can review procedure volumes, endoscopic quality indicators and evaluation results on a regular basis.

To assess the usability of the RPAGE program, pilot testing is currently undertaken at McMaster University. The project was presented to the Program Directors at the Canadian Digestive Disease Week in 2012 and was met with great enthusiasm. The plan is to gradually roll out the fully functioning RPAGE program to other GI training programs (adult and pediatric) across the country by the end of 2012. It is anticipated that this program will foster the ability for trainees and programs to benchmark themselves and provide impetus for quality improvement in endoscopy training.

MEDICAL ETHICS

Each rotation incorporates informal teaching in ethics around clinical cases and scenarios. Formal teaching in ethics also occurs during Multidisciplinary Academic Half-Days organized by the Postgraduate Medical Education Office. These are scheduled five times per year, and are attended by all core and subspecialty trainees in internal medicine, including residents in the GI Training Program. Ethics Grand Rounds are co-organized by the Hamilton Health Sciences Clinical Ethics Committee and McMaster University Faculty of Health Sciences on a monthly basis. In addition, several sessions of the GI Academic Half Day are devoted to topics relevant to medical ethics. Every three months, one case discussion at the GI Academic Half-Day is devoted to a Morbidity and Mortality format. Here, an adverse treatment outcome or procedure complication is discussed, with review of ethical issues related to consent and disclosure. The ethical issues surrounding the use of diagnostic and therapeutic endoscopy are reviewed in the annual First Year GI Residents’ Endoscopy Training Course. All trainees are encouraged to access the Royal College of Physicians and Surgeons of Canada Bioethics Education Project online.

For research ethics, trainees are encouraged to access the McMaster University’s web-based tutorial that reviews the implications of Ontario’s Health Information Protection Act legislation and the National Institutes of Health web-based tutorial on Protecting Human Research Participants (PHRP) course.

QUALITY ASSURANCE

Gastroenterology residents acquire experience and skills in quality assurance through various aspects of their training. Orientation to the regional endoscopy units addresses the appropriate use and maintenance of endoscopy equipment and the proper function of an endoscopy unit. Trainees are introduced to the principles underlying quality assurance in endoscopy including the Global Rating Scale (an endoscopy quality assurance program) and key performance indicators (e.g. cecal intubation rate, adenoma detection rate) during the First Year Residents’ Endoscopy Training Course. The Resident Practice Audit Gastro-Enterology (RPAGE) program provides our trainees with a powerful, real time peer-comparator practice audit tool for continuing professional development and quality improvement in endoscopy training. The concepts of quality assurance in endoscopy are reinforced during residency by the RPAGE program and through review of performance of local endoscopy units with the Global Rating Scale during the Hamilton Association of Gastroenterology meetings. Many clinical research projects undertaken by trainees include detailed review of local practices and outcomes relative to national standards and/or published guidelines. At pathology rounds, biopsy and autopsy results are discussed in the context of clinical diagnoses and overall case management. At M & M rounds, adverse outcomes are discussed and possible improvements in the delivery of care are reviewed. Quality assurance is also a component of the weekly Journal Club, where new evidence is assessed and evaluated, and current practices are reconsidered. Finally, quality assurance is a common component of discussions on clinical ward rounds at all sites.

OVERVIEW

Gastrointestinal research at McMaster University has enjoyed considerable success for over 25 years due to the close collaboration between clinicians and basic scientists. Indeed, McMaster has often ranked within the top 5 institutions in the world in the number of abstracts submitted to international meetings such as Digestive Diseases Week. Many of our successful papers have been authored by Gastroenterology trainees. Many of the Faculty of the GI division are internationally renowned researchers and have published groundbreaking research in wide range of subjects. GI faculty have published approximately 400 peer reviewed papers and obtained over $78 million in funding from industry and grant agencies in the last 5 years. Research published by GI faculty has received over 24,000 citations with 47 papers each receiving over 100 citations.

The GI Training Program is particularly strong in its ability to offer training in research. Three blocks in the first year (and up to 3 more blocks in the second year) are designated to research activities. It is intended that the resident work on a viable project with an experienced supervisor, optimizing the chance that an abstract and paper will result. Residents are encouraged to submit their work to national (e.g. Canadian Digestive Diseases Week), international (e.g. American Gastroenterological Association) or local (e.g. McMaster Resident Research Day, Farncombe Family Digestive Health Research Institute Research Day) meetings.

The Training Program believes that exposure to research is an integral and important part of clinical training. Faculty members perform research in a wide variety of basic and clinical areas, and both clinical and basic research projects are feasible. Basic research is performed within the Farncombe Family Digestive Health Research Institute, and several members of the GI Division are Full Members of the Farncombe Institute. Clinical research may include retrospective clinical studies, case reviews, prospective clinical studies or even intervention trials. Furthermore, the Upper Gastrointestinal and Pancreatic Diseases Cochrane Review Group is based at McMaster University under the leadership of Dr. Paul Moayyedi and Dr. Grigorios Leontiadis. Residents are encouraged to take advantage of the expertise in systematic reviews and meta-analyses of the Cochrane Collaboration in conducting their research projects.

Research Curriculum

The research curriculum comprises three aspects:

1. Research methodology workshops which consist of a series of academic half-day lectures focused on 1) introduction to research, trial design & biostatistics (Dr. P. Moayyedi); 2) introduction to meta-analysis (Dr. G. Leontiadis); 3) presentation skills (speakers training program); and 4) how to get your manuscript published (Dr. S. Collins).
2. Protected research blocks allowing trainees to initiate and complete a research project during the 2 years of training. Three blocks in the first year (and up to 3 more blocks in the second year) are designated to research activities. It is intended that the resident work on a viable project with an experienced supervisor, optimizing the chance that an abstract and paper will result.

   Residents entering the GI Training Program are required to identify a Research Mentor and a research project within the first few months of training. A list of basic science and clinical research projects prepared by our faculty are available to trainees in the beginning of the academic year. Research projects and mentors are reviewed and approved by the Research Coordinator (Dr. Premysl Bercik). Residents are then asked to present their research question and/or research protocol at Farncombe Noon Rounds early in the academic year. The research proposal will state the question, hypothesis, objectives, design and proposed outcome measures of the study. The nature and scope of the project should allow the resident to generate an abstract for national or international meetings. Throughout their training, residents are also encouraged to identify unique and rare clinical cases that can yield case reports and/or literature reviews for publication. Residents are encouraged to submit their work to national (e.g. Canadian Digestive Diseases Week), international (e.g. American Gastroenterological Association) or local (e.g. McMaster Resident Research Day, IDRP Research Day) meetings.

3. Evaluation of research training performance (See Evaluation of the Resident)

Responsibilities of the Resident

The overall goals of the Research Rotation are:

1. To identify an area of research interest and a mentor
2. To review the relevant literature and to distill from it a scientific question that can be answered using facilities available in an appropriate time period
3. To organize and conduct a series of experiments to answer the research question
4. To analyze and interpret data
5. To present the data in oral and written format to a group of peers. This requires both submission of an abstract to a national, international or local meeting and preparation of a manuscript suitable for journal submission.

Evaluation of the Resident

At the end of the first year, each resident must review his/her project with the Research Coordinator. Residents who demonstrate sufficient interest and productivity will be offered up to three blocks of research time in their second year to continue their work and/or begin new projects. Successful completion of the research training component requires each of the following:

1. Attendance at the research methodology workshops
2. Presentation of proposal, interim and/or completed research data at the Farncombe Noon Rounds
3. Successful evaluation of each research block is undertaken by the Research Mentor and the Research Coordinator. Input is sought from other members of the research team who have worked with the resident. Based on all feedback received, at the end of the rotation, a formal web-based CanMEDS compliant ITER is compiled by the Research Mentor. Final evaluations are discussed with the resident. Successful evaluation is defined as a grade of “Meets Expectations” or higher in each evaluated category. Each 4-week research block is evaluated in a similar fashion to clinical rotations using the Research Block Evaluation Form by the Research Mentor. If the trainee receives a grade of less than “Meet Expectations”, he or she is encouraged to meet with the Research Mentor and the Research Coordinator to discuss a course of action to improve future performance. As long as improvement in performance is documented at the end of the project, a passing grade will be given.
4. Attendance at 1 outpatient endoscopy list and 1 outpatient clinic list per week.

Completion of each of these requirements will result in a “PASS” of the Research Component of the Final in-Training Evaluation Report (FITER).

Evaluation of the Rotation

Residents are encouraged to provide feedback on how the rotation and teaching are structured. If issues arise during the rotation, the resident is encouraged to bring these to the attention of the Research Coordinator. A mechanism for dealing with any shortcomings will then be discussed with the resident and the Research Mentor, and subsequently at the Residency Program Committee meeting. As with all rotations, an anonymous rotation evaluation is handled by the One 45 WebEval System. Each teaching faculty is evaluated separately in a similar manner. The Residency Program Committee meets semi-annually to compile a collective rotation and faculty evaluation, respecting anonymity. This has been important to maintaining feedback.

GOALS AND OBJECTIVES

The Adult GI Training Program at McMaster University incorporates research training as part of the requirement of the Royal College of Physician and Surgeons of Canada. Specific goals and objectives of the research rotation in CanMEDS format are as follows:

Medical Expert

Specific Requirements: Gastroenterology residents are able to

1. Critically appraise the background literature of the research project
2. Demonstrate an understanding of the basic principles of research design, methodology, biostatistics, and clinical epidemiology
3. Demonstrate in-depth knowledge of the research topic of interest

Communicator

Specific Requirements: Gastroenterology residents are able to

1. Demonstrate skills in conveying and discussing scientific research on gastrointestinal diseases to scientific communities through posters, abstracts, teaching slides manuscripts, grant applications, or other scientific communications
2. Communicate and collaborate effectively with research team members to conduct the research

Collaborator

Specific Requirements: Gastroenterology residents are able to

1. Identify, consult and collaborate with appropriate experts to conduct the research

Manager

Specific Requirements: Gastroenterology residents are able to

1. independently identify an area of research interest and a research mentor in order to engage in the scholarship of scientific inquiry and dissemination
2. Independently utilize available resources and regularly meet with an identified research mentor
3. Demonstrate effective time management in research setting
4. Demonstrate leadership and administrative abilities, where appropriate, in leading a research team

Health Advocate

Specific Requirements: Gastroenterology residents are able to

1. Recognize the contributions of scientific research in improving the health of patients and communities

Scholar

Specific Requirements: Gastroenterology residents are able to

1. Pose a research question (clinical, basic or population health)
2. Develop a proposal to solve the research question:
   • conduct an appropriate literature search based on the question
   • propose a methodological approach to solve the question
3. Carry out the research outlined in the proposal
4. Critically analyze and disseminate the results of the research
5. Identify areas for further research

Professional

Specific Requirements: Gastroenterology residents are able to

1. Uphold ethical and professional expectations of research consistent with institutional review board guidelines, including maintenance of meticulous data and conduct of ethically sound human or animal subjects research
2. Demonstrate personal responsibility for setting research goals and working with mentors to set and achieve research timeline objectives
3. Participate as possible in specialty organizations that promote scholarly activity and continuous professional development
4. Publish accurate and reliable research results, with attention to appropriate authorship attribution criteria
5. Disclose potential financial conflicts of interest (including speaker fees, consultative relationships, investments, etc.) as appropriate when engaging in and disseminating research results

BASIC RESEARCH ACTIVITY (FARNCOMBE FAMILY DIGESTIVE HEALTH RESEARCH INSTITUTE)

The Farncombe Family Digestive Health Research Institute is an integrated group of clinical and basic scientists dedicated to understanding the impact of digestive health and nutrition on disease across the life span. The institute is focused on developing new strategies for the diagnosis, treatment and prevention of intestinal diseases such as Crohn’s disease and ulcerative colitis. However, the focus of research in the institute is not limited to digestive disease; rather, it includes diseases of many other organ systems that may be caused and/or profoundly influenced by digestive health.

Facilitated by an extraordinary $15 million donation from the Farncombe family, the institute was established as an outgrowth of McMaster University’s Intestinal Diseases Research Program (IDRP), originally founded in 1983. The Farncombe Family’s generous contribution has allowed by the establishment of endowed chairs and infrastructure capital, which will ensure the long-term success of the institute and enhance its role as an innovative training environment.

For more than 20 years, McMaster’s Intestinal Diseases Research Program has garnered an international reputation as one of the top 10 gastrointestinal research groups in the world. The growth in research funding, faculty awards and the expansion into a Research Institute is a testament to the critical role McMaster researchers are playing in the study of digestive disorders.

Mission

The mandate of Farncombe Family Digestive Health Research Institute encompasses its leadership role in research, innovation and training as it relates to intestinal diseases. The mission of the Farncombe Family Digestive Health Research Institute:

1. Understand the causes of chronic gastrointestinal diseases that are prevalent in society, and to develop new strategies for their diagnosis, treatment and prevention.
2. Provide a productive and innovative training environment.
3. Maintain excellence in research at an international level.

There are 14 full members of the Farncombe Family Digestive Health Research Institute. These members conduct their primary research within the Institute’s facilities. There are 13 associate members who conduct collaborative research with the institute’s members. The Farncombe Institute includes Canada’s only gnotobiotic laboratory and houses a metagenomics platform that includes a Roche 454 rapid DNA sequencer. There is a clinical research center within the institute that conducts clinical trials, meta-analyses, epidemiological studies in affiliated hospitals as well as on a national and international basis. The institute has a large complement of technical staff, graduate students and research fellows as well as administrative staff.

Research Themes

The Farncombe Family Digestive Health Research Institute conducts research under the following themes:

• Inflammation, infection and mucosal immunology (including the pharmacology of inflammation)
• Molecular microbiology
• Gut-Brain Interactions and the relationship of gastrointestinal diseases with emotional stress, anxiety and depression, including the exploitation of models of behavioral illness
• Gastrointestinal physiology (including motility, pain perception, entero-endocrine cell function and mucosal barrier function)
• Abnormal responses to food (including gliadin sensitivity and other food intolerances)
• Developmental neurobiology
• Hepatic blood flow and vascular adhesion molecule expression in sepsis and multi-organ failure
• Clinical, Epidemiological and Health Services Research

The above-described themes represent overlapping areas of research interests, with most institute researchers working in more than one area. This forms the basis of the institute’s integrated research program on gut function in health and disease.

Specific Areas of Research

• The role of resident bacteria in the development of the immune system and its reactivity; allergic and autoimmune disease; hygiene hypothesis of diseases of developed countries.
• Pathogenesis of chronic inflammatory disorders including celiac disease
• Role of pathogenic bacteria in functional gastrointestinal disorders (post-infective IBS) including epidemiological studies and patient phenotyping and genotyping (e.g. in Walkerton residents).
• The role of resident bacteria in inflammatory and functional gastrointestinal diseases and the accompanying psychiatric co-morbidity; rationalization of probiotic use in these and other disorders
• Assessments of brain-gut interactions including established models of primary behavioural disorders and behavioral phenotyping.
• Immuno-physiology and host defense in the context of intestinal infection/inflammation
• Physiology of enteroendocrine cells
• Myogenic and neural control of intestinal smooth muscle, in particular the electrophysiology of smooth muscle cells and interstitial cells of Cajal (ICC)
• Pathophysiology of gut motor abnormalities
• Interaction between immune cells, in particular resident immune cells, ICC smooth muscle and enteric nerves
• Sensory and autonomic neuroscience and information processing in enteric neuronal networks
• Leukocyte recruitment to bring inflammatory cells to the site of infection or injury in the liver
• Adhesion molecules for leucocytes in the liver

OVERVIEW

The objectives of the elective experience are to provide flexibility and opportunities to explore career possibilities, to gain experience in aspects of medicine beyond the core curriculum, and to study certain areas in greater depth. Knowledge, skills and attitudes are further developed in a self-directed choice of area across the curriculum.

Trainees are provided between one and four months for elective experience. Trainees are free to identify and choose specific electives in keeping with their individual training objectives, subject to approval by the Program Director and Residency Program Committee. It is expected that electives will be undertaken in Hamilton, barring exceptional circumstance where the trainee demonstrates that the regional facilities are insufficient to meet his/her training objectives. For each elective, trainees must identify a supervisor responsible for monitoring his/her experience and evaluating his/her performance. Both the resident and the supervisor are responsible for ensuring a clear, mutual understanding of the learning activities designed to meet the objectives of the elective.

A completed and signed Elective Request Form must be submitted to the Program Director at least four weeks prior to beginning an elective. Using this form, the trainee is expected to provide: (1) a summary of the elective experience; (2) a statement of goals and objectives for the elective experience; and (3) a schedule of activities and responsibilities to be undertaken during the elective. This document must be signed by the Program Director, the elective supervisor and the trainee. The goals and objectives of elective rotations must address the CanMEDS physician roles identified by the Royal College. Elective evaluations will address both the CanMEDS roles and the elective-specific objectives identified by the trainee. The trainee may choose to undertake two electives in parallel, if neither provides full-time activity.

The following list suggests some appropriate electives and potential supervisors:

            Hepatology (Drs. Puglia, Witt-Sullivan, Tsoi)
            Gastrointestinal motility (Drs. Bercik, Collins)
            Clinical nutrition (Dr. Armstrong)
            Inflammatory bowel disease (Drs. Marshall, Halder)
            Colorectal Surgery (Drs. Kelly, Stephens, Forbes)
            Gastrointestinal oncology (Drs. Zbuk, Wong)
            Gastrointestinal radiology (Drs. Vora, Midia)
            Gastrointestinal anatomical pathology (Dr. Ramsay)
            Psychiatry (Dr. Anglin)
            Pain management (Drs. Buckley)
            Pediatric Gastroenterology (Drs. Issenman, Brill, Ratcliffe, Zachos)
            Laser endoscopy (Dr. Morgan)
            Biliary endoscopy (Drs. Lumb, Seaton, Tse)
            Endoscopic ultrasound (Dr. Tse)
            Swallowing disorders (Dr. Mazzadi)

Responsibilities of the Resident

Rotation schedule is prepared by the resident and the clinical supervisor for the elective. The schedule will need to be approved by the Program Director prior to the start of the rotation. Residents are expected to attend each assigned activity, to be punctual, and to complete written documentations on all patients seen in a timely fashion. Clinical supervisors must be informed of vacation / professional leave 4 weeks prior to the start date of the rotation. In addition, clinical supervisors must be informed when residents are unable to attend assigned activities due to post-call reasons. Residents are expected to develop, implement and monitor a personal continuing education strategy. To facilitate this objective, at least one half day is set aside per week for self-directed learning of topics and diseases encountered during the elective. Residents on elective experience are not exempted from on-call duties.

Evaluation of the Resident

Residents are encouraged to seek informal verbal feedback throughout the elective concerning their performance. A formal evaluation session with the resident will take place at the end of the rotation. Input is sought from other members of the health care team who have worked with the resident (e.g. nurses, other allied health professionals). Based on all feedback received, at the end of the rotation, a formal web-based CanMEDS compliant ITER is compiled by the supervisor. Final evaluations are discussed with the resident.

Evaluation of the Rotation

Residents are encouraged to provide feedback on how the rotation and teaching are structured. As with all rotations, an anonymous rotation evaluation is handled by the One 45 WebEval System. Each teaching faculty is evaluated separately in a similar manner. The Residency Program Committee meets semi-annually to compile a collective rotation and faculty evaluation, respecting anonymity. This has been important to maintaining feedback.

GOALS AND OBJECTIVES

The broad goals of the elective rotation are noted below. The following CanMEDS competencies apply to all clinical elective experiences and are listed on the evaluation form for the elective:

Medical Expert

Key Competencies: Physicians are able to

1. Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal, ethical and patient-centered medical care
2. Establish and maintain clinical knowledge, skills and attitudes appropriate to Gastroenterology
3. Perform a complete and appropriate assessment of a patient
4. Use preventive and therapeutic interventions effectively
5. Demonstrate proficient and appropriate use of procedural skills, both diagnostic and therapeutic
6. Seek appropriate consultation from other health professionals, recognizing the limits of their expertise

Communicator

Key Competencies: Physicians are able to

1. Develop rapport, trust, and ethical therapeutic relationships with patients and families
2. Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues, and other professionals
3. Convey relevant information and explanations accurately to patients and families, colleagues and other professionals
4. Develop a common understanding on issues, problems and plans with patients, families, and other professionals to develop a shared plan of care
5. Convey effective oral and written information about a medical encounter

Collaborator

Key Competencies: Physicians are able to

1. Participate effectively and appropriately in an interprofessional health care team
2. Work with other health professionals effectively to prevent, negotiate, and resolve interprofessional conflict

Manager

Key Competencies: Physicians are able to

1. Participate in activities that contribute to the effectiveness of their health care organizations and systems
2. Manage their practice and career effectively
3. Allocate finite health care resources appropriately
4. Serve in administration and leadership roles, as appropriate

Health Advocate

Key Competencies: Physicians are able to

1. Respond to individual patient health needs and issues as part of patient care
2. Respond to the health needs of the communities that they serve
3. Identify the determinants of health for the populations that they serve
4. Promote the health of individual patients, communities, and populations

Scholar

Key Competencies: Physicians are able to

1. Maintain and enhance professional activities through ongoing learning
2. Critically evaluate medical information and its sources, and apply this appropriately to practice decisions
3. Facilitate the learning of patients, families, students, residents, other health professionals, the public and others
4. Contribute to the development, dissemination, and translation of new knowledge and practices

Professional

Key Competencies: Physicians are able to

1. Demonstrate a commitment to their patients, profession, and society through ethical practice
2. Demonstrate a commitment to their patients, profession and society through participation in profession-led regulation
3. Demonstrate a commitment to physician health and sustainable practice

Criteria Specific to Elective

In addition, specific objectives are to be agreed BEFORE the beginning of the elective by the resident and the supervisor: at least two major specific objectives are to be listed in the space provided on the Evaluation Form.

OVERVIEW

The goal of the Adult Gastroenterology Training Program is to produce subspecialists in Gastroenterology who can work independently in any clinical setting. Trainees are also expected to sit the subspecialty exams of The Royal College of Physicians of Canada, and to fulfil all CANMEDS role competencies. Their progress through the program is monitored in order to meet these objectives.

The McMaster University Gastroenterology Residency Training Program maintains a collegial atmosphere in which feedback is frequently exchanged between residents and faculty in order to promote excellence in resident education and resident performance. We want to ensure that every resident successfully achieves or exceeds rotation objectives and that every rotation meets or exceeds resident learning objectives. The evaluation process is instrumental in meeting these goals.

EVALUATION PROCESS

Faculty are expected to follow the official policy and procedures of the Postgraduate Medical Education (PGME) Office for the evaluation of residents’ performance. Appeal processes are defined by the PGME Office. The Evaluation Policy in its entirety is available on the PGME website: //fhs.mcmaster.ca/postgrad/documents/ResidentEvaluation1.pdf.

1. At the beginning of the Rotation, the site coordinator / supervisor and the Resident should meet to discuss objectives and how the Resident will be evaluated, and in particular, should discuss the following:
   1. Delineate the Resident’s role during the rotation;
   2. Outline the duties and responsibilities expected of the Resident;
   3. Outline the goals and objectives of the rotation;
   4. Explain the structure and inter-relationships of the health care team; and
   5. Advise the Resident on what evaluation tools will be used in the evaluation process, how the ITER is completed and the timing of evaluations (including on-going informal feedback and the ITER)
2. During the Rotation, there should be regular informal face-to-face feedback to the Resident (on a weekly basis). The Resident is responsible for scheduling a face-to-face (formative) evaluation at the mid-point of their rotation, so the Resident has an opportunity to address any deficiencies that may have been identified.
3. At the end of the Rotation, the Clinical Supervisor should draw on feedback of other members of the health care team and any other evaluation forms utilized (e.g. Evaluation of Written Consultation Dictation in Ambulatory Care) to complete the ITER and then discuss the evaluation and the ITER with the Resident prior to the end of the Rotation. If the supervisor is not able to meet these deadlines and has not met with the Resident within 10 working days after the Rotation, the Clinical Supervisor should submit the ITER and send any supporting document to the Program Director.
4. It is expected that the Resident will review the evaluation within 20 working days from the end of the Rotation on the One45 WebEval System.

All evaluations are site-, year-, and rotation-specific based on the CanMEDS competencies. Within each domain and for each goal and objective on the ITER, there may be several levels of competence identified. However, the overall (summative) evaluation on the ITER should indicate one of the following designations:

Satisfactory	Resident has successfully met the goals and objectives of the rotation
Provisional Satisfactory	Resident has demonstrated significant deficiencies in one or more of the RCSC competenciesidentified in the rotation objectives, or any other requirement of the rotation, and that while such deficiencies require remediation,they are not so severe to necessitate the Resident repeating the entire rotation. The Clinical Supervisor believes that the Resident can satisfy the deficient rotation objective(s) or requirement(s) during other rotations. These deficiencies often relate to non-Medical Expert CanMEDS domains.
Unsatisfactory	Resident has demonstrated significant deficiencies in one or more of the RCPSC competenciesidentified in the rotation objectives, or any other requirement, and the Clinical Supervisor believes that the rotation objective(s) or requirement(s)can only be reasonably met by remediation and having the Resident repeat the entire rotation. These deficiencies often relate to Medical Expert CanMEDS domains.
Incomplete	“Incomplete” indicates that the Clinical Supervisor has beenunable to properly and fully evaluate the Resident because the Resident’s time spent on the rotation was insufficient, for whatever reason, e.g. illness, extenuating circumstances etc.As the rotation is incomplete, time will have to be made up to fulfil the requirements of the rotation.A designation of “incomplete” may be appropriate where the Resident has not spent at least 50% of the required time on the rotation. Even where a designation of “incomplete” is indicated, the Clinical Supervisor should complete the ITER in order to document the Resident’s time spent in the rotation and the Resident’s performance during that limited time.

Rotation In-Training Evaluation Reports (ITERS)
The ITER is the main modality of assessing resident knowledge and observed performance according to CanMEDS competencies. Residents are evaluated at the end of each rotation with a rotation-specific and year-specific ITER that encompasses all of the CanMEDS domains and follows each rotation description in this syllabus. Our program uses the one-45 computer-based evaluation system. Once completed, residents can review their ITERs electronically, provided they have no outstanding rotation evaluations to complete.

Mock Examinations
In preparation for the Royal College of Physicians and Surgeons Examination in Gastroenterology, trainees undergo a mock OSCE and written exam twice per year (November and May). This exam is intended to follow the format of the Royal College Examination in Adult Gastroenterology. The OSCE consists of several stations that test history taking, physical examination, endoscopic / histopathologic / radiologic interpretation, and clinical management of a wide variety of gastroenterologic problems. The stations are designed to assess all CanMEDS roles. Individualized instruction and feedback are provided after each station as part of formative feedback that helps learners become aware of any gaps that exist between their goals and their current knowledge, understanding, or skill and guides them through actions necessary to obtain the goals. OSCE stations are generated by the OSCE Coordinating Committee and reviewed by the OSCE Coordinator and the Program Director before being implemented. Written exams are prepared by 2 faculty members (1 luminal and 1 hepatology) and submitted to the Written Exam Coordinator for review and approval prior to implementation. This experience is invaluable preparation for the Royal College of Physicians and Surgeons of Canada licensing examinations, and also facilitates organized thinking around problems and ethical dilemmas in Gastroenterology. The results of these tests are reviewed and used as formative assessment tools to guide future learning objectives.

Resident Practice Audit Gastro-Enterology
Residents are responsible for maintaining a Procedural Skill Competency Log via the Resident Practice Audit Gastro-Enterology (RPAGE) Program. The RPAGE is designed to provide trainees with a point-of-care, peer-comparator practice audit tool. The purpose of the RPAGE program is to monitor and document the trainee’s progress and development in endoscopic skills. With the help of the endoscopic trainers, all trainees enter details of each procedure they complete in real-time. Anonymized trainee, patient and practice data are collected using touchscreen smartphones or desktop computer with automated data upload for data analysis and review by participants. The program allows trainees to objectively record key endoscopic quality indicators. There is also an evaluation tool built in the program that allows trainees to have their endoscopic performance objectively evaluated by their trainers on a regular basis. The RPAGE program allows trainees to review their own performance and compare this with their peers, promoting the identification of learning needs and objectives, as well as the basis for the development of targeted education programs. The Program Director can review procedure volumes, endoscopic quality indicators and evaluation results on a regular basis.

Progress Review
Each resident meets with the Program Director semi-annually to review progress, career goals, fellowship plans and other issues. Evaluations of all rotations are reviewed with residents at the semi-annual meetings. Particular areas of weaknesses and strengths are brought to the attention of the Site Coordinator and Mentor, to generate discussion among faculty and the resident involved. In this plan, plans for remedial help and supervision can be initiated promptly.

The clinical faculty also meet as a group once each year to discuss trainees’ performance on the wards, in the emergency department, in clinics, in endoscopy, and on the mock OSCE/written examinations. For each resident, completed online evaluations are reviewed and summarized by the Program Director. A broad and open discussion is initiated for each resident to counterbalance discrepant evaluations by individual faculty members. The discussion complements the online evaluations from each rotation, and generates a formal appraisal of each trainee’s strengths and weaknesses that is used to inform the FITER. These are then submitted to the Postgraduate Medical Education Office and then forwarded to the Royal College. Feedback from this meeting is also reviewed with the individual resident during the semi-annual meeting with the Program Director.

Final In-Training Evaluation Report
At the end of training, a final evaluation form (FITER) is prepared by the Program Director, with assistance from all faculty members and the Residency Training Program Committee. The FITER is forwarded to the Royal College and is used specifically in cases of borderline Royal College Examination results.

Allied Health Profession Evaluation of Resident
Evaluations from the health care team can provide feedback useful in guiding residents’ professional growth. Feedback from allied health professionals on residents’ competencies of interpersonal and communication skills and professionalism are obtained by means of a multi-source evaluation twice each year. These evaluations are very useful for formative feedback in residents’ professional development.

Peer Evaluation and Self-Assessment
360-degree assessment is a way of providing feedback about progress by placing the persons to be evaluated at the “hub of the wheel”. To provide a full-circle view of resident skills and abilities of interpersonal and communication skills, a self-assessment and a peer 360-degree evaluation form will be obtained twice per year. These evaluations encourage reflection and promote development of a self-improvement plan.

Evaluation of Written Consultation Dictation
To assess and improve the ability of residents to communicate effectively with referring physicians, written evaluation is formally evaluated during every ambulatory rotation by means of a Written Consultation Dictation Evaluation Form. It is the expectation that the resident on clinic block will review one consultation letter with an attending staff and have the evaluation form completed for each clinic rotation.

Rotation Evaluati on

Residents are encouraged to complete confidential Rotation Evaluations at the end of each rotation using the web-based evaluation system. The Residency Program Committee (RPC) reviews individual rotations and the rotation evaluations formally twice per year, but also on an ad hoc basis at its regular meetings in order to make adjustments as necessary. To maintain anonymity, only cumulative evaluation summaries are prepared for review by the Program Director and the RPC. Residents are free to bring concerns about rotations to the Program Director directly, and to table concerns for formal discussion by the RPC.

Faculty Evaluation

Residents are encouraged to complete a confidential faculty evaluation in respect of each member of the clinical teaching faculty with responsibility for the resident via the web-based evaluation system. Evaluation and feedback is expected to reflect the four broad domains of influence which the clinical faculty have with the residents: supervision; teaching; evaluation; and professional behaviour. At 6 month intervals, the Program Director receives and reviews cumulative summary evaluations for every individual faculty member, and each faculty member receives his/her summary evaluation as feedback. The average score obtained by their colleagues is also given. The summaries of all evaluations are forwarded to the Division Chief and to the Site Coordinators and Service Chiefs. These summaries are brought to the RPC for discussion at least once per year. Any concerns are reviewed by the Program Director and the Division Chief. These are then discussed with the individual faculty and the Service Chief at the hospital site. Depending on the nature of the concern, various measures are taken. This may simply require a discussion with the individual faculty concerned with on-going monitoring. If the concerns are more serious, changes would be made to the resident rotations to remove the residents from being taught by the individual faculty member. This would involve discussions with the Postgraduate Medical Education (PGME) Office, the Division Chief and the Department Chair according to the PGME policy.

PROMOTION PROCESS

Evaluations are reviewed with the Resident at his / her semi-annual meetings with the Program Director. Particular areas of weakness are brought to the attention of the Site Coordinator and the respective Mentor, to generate discussion among faculty and the Resident involved. In this way, plans for remedial help and supervision can be initiated promptly. Career counselling is also discussed. Resident progress is reported to the Residency Program Committee.

In the second half of each academic year, a special meeting of the Residency Program Committee is convened to discuss resident performance. Resident representatives do not attend this meeting, but all faculty members (including those who are not members of the Residency Program Committee) are invited to attend. For each resident, completed online evaluations are reviewed and summarized by the Program Director. A broad and open discussion is initiated for each resident to counterbalance discrepant evaluations by individual faculty members. Promotion of a Resident to the next academic level occurs if all rotation periods during the academic year have been completed with satisfactory evaluations. The Committee discussion forms the basis for the Program Director’s completion of FITER reports. These are then submitted to the Postgraduate medical Education Office and then forwarded to the College. Feedback from this special meeting is also reviewed with the individual resident by the Program Director.

APPEAL PROCESS

Only ITERs rated as “Unsatisfactory” or “Provisional Satisfactory” can be appealed. An appeal of an ITER can be made only on the basis that the Clinical Supervisor failed to follow the process set out in the Evaluation Policy by the PGME office, or on the basis that there are extraordinary mitigating personal circumstances that ought to be considered. All appeals must be made within 15 days after the Resident being sent the ITER.

The first level of appeal is made to the Program (Level 1). At the Program level, there is an emphasis on informal resolution.

1. The first stage is an informal stage in which the Resident must discuss the ITER with the Clinical Supervisor who completed it and identify whatever additional information the Resident believes should be considered (e.g. external factors which influenced the Resident’s performance; identification of other individuals who could add an additional perspective on the Resident’s performance).
2. Within 15 working days of the informal discussion between the Resident and the Clinical Supervisor, the Clinical Supervisor must either a) revise the ITER in which event the revised ITER becomes the official ITER, replacing the earlier one; or b) advise the Resident in writing that the ITER will remain unchanged.
3. If the Resident is not satisfied with the review by the Clinical Supervisor, the Resident may proceed to the formal stage of the appeal process by notifying the Program Director in writing of his or her intention to do so. The notice must be delivered no later than 5 working days following receipt of the Clinical Supervisor’s decision. The appeal must document the perceived error in process.
4. Upon receipt of written notice from the Resident, the Program Director will forward the appeal to the Residency Program Committee (RPC). The Program Director and the RPC will give the Resident an opportunity to meet with them and provide oral submissions and any additional documentation (i.e. evaluations, correspondence) relevant to the issues under appeal no later than 10 working days following receipt of the written notice. The Resident may be accompanied by a colleague, however ordinarily any oral submissions or presentations must be made by the Resident him/herself. The RPC will review all of the relevant documentation and meet with the Clinical Supervisor and other individuals if it deems necessary before making a decision.
5. The RPC will issue a decision in writing with reasons and a copy will be provided to the PGME office.
   1. If the RPC decides that the evaluation was inaccurate or unfair, it may require that the evaluation be corrected or it may remove the evaluation from the file and allow a further period of evaluation under such terms as the RPC may require.
   2. If the RPC decides that there are compelling extenuating or compassionate circumstances that warrant an additional period of assessment and evaluation, it will permit the Resident to undergo an additional evaluation under such terms as the RPC may require.
   3. If the RPC concludes that the ITER was accurate and fair, the ITER should remain in the file and that there will be no additional assessment or evaluation.

If the issue is not resolved at the Program Level (Level 1), it can be directed to the PGME Office, which is Level 2. The PGME office will convene a meeting of the Appeal Review Board. Level 3 is the final level of appeal and at this point the Dean, Faculty of Health Sciences will strike a Tribunal, whose decision is final. The PGME Appeal Policy in its entirety is available on the PGME website.

The mission of our Residency Program is to help each individual Resident achieve their personal career goals and to develop a foundation for a rewarding career in Gastroenterology.

Career planning is performed throughout the residency training. Broad career goals are first identified when applicants are interviewed for admission, and are reviewed upon entry to the Gastroenterology Training Program by the Program Director. Where feasible, career expectations are incorporated into the individual’s objectives for residency and considered when choosing elective rotations. Career expectations are reviewed formally at semi-annual meetings between each Resident and the Program Director, and especially at the end of the first year. This allows the Program Director time to council individual Residents based on their interests (including discussion of various fellowships) and allows the Program Director to adjust the annual rotation schedules as necessary. In addition, career counselling is performed on an informal basis during each rotation. The program maintains flexibility in scheduling rotations, and provides elective experience in the Second Year to meet all career planning choices. Each Resident’s career plans are also discussed when the Residency Program Committee and regional faculty meet to review resident performance.

A formal mentorship program is in place. Each Resident is assigned a Mentor upon entry to the Program. The Mentor is expected to know the resident well, and to be in a position to offer personal insight into his / her aspirations and concerns. One responsibility of the Mentor is to provide career counselling. Where possible, Mentors are selected to match the resident’s career interests. However, the Mentor is also expected to direct the resident to others for advice in areas outside his / her expertise. If a Resident has expressed an interest in an academic career, the Research Supervisor becomes another important source of counselling.

A Resident Career Night is held every 2 years to develop Second Year Residents’ understanding of how their education can be put into practice. First Year Residents are also invited to attend. Practicing gastroenterologists from the community and also from academic centres are invited to offer advice, guidance and support, and answer residents’ questions based on real-life experience. The seminar is designed to expose the Residents to career options and information. Topics covered include: hospital medicine, how to set up private outpatient clinics and endoscopy units, life after residency and fellowship, job search, networking, and what to look for in an employment contract.

In addition, the following centralized resources are available to all residents:

1. Canadian Medical Association (CMA) Practice Management Curriculum Seminar – A full-day of interactive seminars on Practice Management are offered by the Postgraduate Medical Education Office and the Practice Solutions, a subsidiary of the Canadian Medical Association to senior specialty residents (PGY 5) and their significant others regarding negotiations, financial management, setting up a practice, incorporation and related topics. The seminars address the key challenges residents will face in setting up their practice, such as contract negotiation, financial wellness, and practice management. Residents are relieved of all service responsibilities to attend these seminars.
2. Practice Ontario is a new career-planning service for McMaster University Postgraduate Medical Residents who want to explore practice opportunities across Ontario that match personal and professional interests. This initiative is a joint venture between McMaster’s Faculty of Medicine Postgraduate Medical Education Office and HealthForce Ontario Marketing and Recruitment Agency (HFO MRA). HFO MRA is an agency of the provincial Ministry of Health and Long Term Care. Practice U is an online resource that provides practical, career-focused information sourced from experts throughout Ontario’s healthcare sector. McMaster postgraduate trainees can connect with a personal career advisor called Community Partnership Coordinator (CPC) from HFO MRA to explore locum and permanent practice opportunities throughout Ontario – from urban to rural settings. Each CPC is a regional expert with a wide network of professional connections in Ontario’s health-care sector. The CPC can also assist with resume preparation and arrange visits to, and interviews with, potential employers. These services are free and offered either by phone, email, or face-to-face consultation.
3. HealthForceOntario Job Database HFOJobs is a recruitment tool launched by the HFO MRA. It provides physicians in training and in practice with up-to-date information on employment opportunities (locum and permanent positions) available in Ontario. Communities and health care organizations and employers within these communities can register to create and manage customized websites to advertise and market job opportunities and to provide community information to physicians and their families. The HFOJobs Portal for Physicians allows Residents to search and view current practice and educational opportunities and community information as well as build their CV and set job alerts.
4. PAIRO Resident Placement Program (PRPP). After a confidential interview with PAIRO and Community Development Officers (CDOs), the Resident will be provided with a list of potential communities that will suit the Resident’s needs and goals, along with the appropriate contact information. Spouses / partners are also invited to attend.
5. COMPASS is an electronic newsletter designed for Residents making their transition to practice. This newsletter provides Residents with important information on health care in Ontario, career-planning tips for making a smooth transition from residency to practice, links to HFO  MRA, as well as training and learning opportunities.
6. Human Solutions – Employee & Family Assistance Program (EFAP) offers a broad range of services to Residents and their family members. Plan Smart Services are designed to provide life balance solutions. These services include consultation with a specialist, as well as a package of valuable support and resource material. Among the many services provided, Human Solutions offers complete career planning services and career development counselling to support Residents’ personal and professional career objectives through analysis of their interests, values and motivations. Feedback and coaching is provided and a plan is developed to assist Residents to take the steps toward defining and achieving their career aspirations.
7. Health Professional Recruitment Tours (HPRT) - The HPRT is an annual job fair that provides an opportunity for residents to meet and make contacts with community representatives from underserviced areas across Ontario. The tour provides the chance for residents to talk with representatives from over 90 communities about their unique career and lifestyle offerings.

In summary, career planning and counselling is provided on an ongoing basis throughout the residency through the sources identified above.

The Gastroenterology Training Program makes every effort to provide a friendly and supportive environment for its residents. However, there are a variety of support systems available to residents to provide assistance with stress and / or personal problems.

Support within the Gastroenterology Residency Program

1. Peer support through the resident group has been helpful in reviewing aspects of the program and/or resident development related to issues of stress. A Resident Buddy System is designed to provide first year incoming residents with peer support. Each incoming PGY 4 resident is paired with a PGY 5 resident. Resident buddies help with advice on making the transition from Internal Medicine to Gastroenterology residency, including information about the city, the program, and clinical service / call system.
2. The Program Director attempts to build a close relationship with the trainees and residents are made aware that the Program Director will make all reasonable efforts to ameliorate stressful personal, health, and work-related situations – including intervening in situations in which there is personal conflict between the resident and other faculty members.
3. A Mentorship Program is designed to provide residents with faculty support and guidance as they navigate their residency training. Each trainee is assigned a mentor who will be available to discuss problems ranging from personal (e.g. stress) to professional (e.g. career choices). The mentor is expected to develop a special relationship with the trainee over the duration of his or her stay in the program, meet individually with the resident on a regular basis, provide general counselling on professional matters, monitor the well-being of the individual and his/her family, and identify and address any signs of difficulty.
4. The External Program Ombudsperson is available to offer confidential, informal, and independent information and advice; as well as, provide intervention and referrals for residents. The Ombudsperson acts as an advocate for Gastroenterology residents on equity and fairness in mediating program-related conflicts. All matters dealt with are held in strictest confidence.

Support through Postgraduate Medical Education and McMaster University

Support is available through the Postgraduate Medical Education Office and information about resident support systems is distributed at registration (Housestaff Support Systems) and is available on the Postgraduate Medical Education Office website.

1. Human Solutions – Employee & Family Assistance Program (EFAP) offers a broad range of services for Residents and their dependent family members including:

• Plan Smart Services which are designed to provide life balance solutions. These services include consultation with a specialist, as well as package of valuable support and resource material. Topics covered include: eldercare, childcare, pre-retirement planning, financial planning, legal advisory, career counselling, e-learning courses for a range of life and leadership skills.
• Health Management Services which are designed to provide a range of relevant and timely health related information. The online health library offers a wide variety of relevant articles and up-to-date information supported by the Canadian Medical Association. The online Health Planning tools can assist residents in setting and reaching health-related goals such as proper nutrition, exercise, and overall personal well-being. Nutritional counselling that includes one-on-one support and customized information is available.
• Counselling that focuses on addressing specific problems, working with a highly trained professional. All clinicians are either Master level counsellors or PhD Psychologists. Counselling areas include, but are not limited to: communication, family dynamics, marriage dynamics, anxiety disorders, mood disorders, clinical assessment, learning and motivation, child and adolescent development, parenting, addictions, and personality development.

2. The Postgraduate Medical Education Office, in conjunction with the Department of Psychiatry, facilitates confidential professional counselling services for residents, if required. Residents reluctant to use local services are assisted with arrangements for help in other communities.
3. In conjunction with the Department of Family Medicine, the Postgraduate Medical Education Office will assist residents in finding a family physician to help with long-term personal or stress related issues.
4. A social worker (Valarie Spironello, valarie@choosewellness.ca) who specializes in life work balance and wellness can assist residents in using a mindfulness approach to improve wellness in body, mind and spirit. Visits are confidential and are covered under the Resident Benefit Plan as per the PAIRO agreement.
5. The University Office of Human Rights and Equity Services is available to assist with issues surrounding sexual or non-sexual harassment, discrimination and complaint resolution. The Faculty of Health Sciences Advisor, Professionalism (Robin Edwards, 905-525-9140 ext. 22417), is also available to consult residents on behavioural issues and matters of professionalism.

Support outside the Academic Environment

Support services are available through:

1. The Professional Association of Interns and Residents of Ontario (PAIRO) Helpline (1-866-HELP-DOC) is a 100% confidential service that is available 24 hours a day for residents and their families. The PAIRO – Physician at Risk Committee also organizes one session per year of the Postgraduate Medical Education Office’s Multidisciplinary Academic Half-Days, which deals with issues surrounding resident well-being. 
2. The Ontario Medical Association Physician Health Program (1-800-851-6606) is a confidential program for physicians and their families at risk of or suffering from stress, burnout, mental health and substance use to physicians and their families with expedited referral to third party providers.
3. Distress Centre of Hamilton (905-525-8611) provides a 24 hour telephone service for individuals with varying degrees of crisis.
4. The Salvation Army Suicide Prevention Services provides a 24 hour telephone support (905-522-1477), intervention, and referrals for individuals experiencing varying degrees of crisis.

Issues of Harassment

Harassment and intimidation includes but is not limited to unfair work demands or workload abuse, discrimination, verbal abuse, physical abuse, sexual abuse, and reprisal for having lodged or being a witness in a harassment or intimidation complaint. The Gastroenterology Residency Program and McMaster University have zero tolerance for harassment. Both the Postgraduate Medical Education Office and the Internal Medicine Residency Program Office at McMaster University have policies and procedures to deal with intimidation, harassment, and abuse. Residents should deal with these issues in that way that makes them most comfortable – complaints may be informal (unwritten) or formal (written). No one shall be compelled to proceed with a complaint. Reprisal of the complainant for involvement in this process will not be tolerated. Confidentiality of the identity of the complainant and the respondent will be protected.

Residents have the option of discussing their concerns with the individual involved in the incident, a friend or colleague (including the Chief Resident), the family physician, the Clinical Supervisor, the Site Coordinator, the Program Director, the Mentor, the External Program Ombudsperson, and/or the Assistant Dean, Postgraduate Education. If the incident involves human rights (e.g. based on sex, sexual orientation, race, religion, age, skin color, etc), the resident can also directly discuss the issue with the University Office of Human Rights and Equity Services.

If a formal complaint is submitted to the Residency Program Director, Division Director, or Postgraduate Education, University counsel will be sought in consultation with the Program Director, Division Director, and Assistant Dean, as appropriate. If the incident falls within the University definition of human rights related harassment, the University Office of Human Rights and Equity Services will be consulted. The complaint should be made in a timely fashion (no later than 12 months from the date of the harassment. The complaint should include dates, names of individuals involved, and a full description of the event. The respondent will be notified that a complaint has been filed and, with the permission of the complainant and respondent, a meeting will be scheduled with the Assistant Dean, Postgraduate Education and/or Program Director and/or Clinical Supervisor and appropriate University counsel. The group will attempt to arrive at a negotiated process. However, if the group reaches the conclusion that no resolution is possible, both the complainant and respondent will be informed in writing within 5 working days of that determination. If the complainant and/or respondent are not satisfied with the decision of the group, a request may be made in writing for a formal hearing. This request will be forwarded to the Board of Governors.

If the reported incident is patient related, it must be reported to the College of Physicians and Surgeons of Ontario.

1. Introduction

Resident education must occur in a physically safe environment (Royal College of Physicians and Surgeons of Canada, standard A.2.5; College of Family Physicians of Canada). The university also recognizes that safe working environment for trainees is beneficial to resident education and patient care, and that there are ethical and moral reasons for maintaining such a working environment.

The purpose of this document is to provide a policy regarding workplace safety for postgraduate trainees in Gastroenterology at McMaster University and to demonstrate the commitment of the residency training program in providing and maintaining healthy and safe working and learning environment for all postgraduate trainees. This is achieved by observing best practices which meet or exceed the standards to comply with legislative requirements as contained in the Ontario Occupational Health and Safety Act, Environmental Protection Act, Nuclear Safety and Control Act and other statutes, their regulations, and the policy and procedures established by the University.

It is expected that the postgraduate trainee, the residency training program, the Postgraduate Medical Education (PGME) Office will work together with the affiliated teaching hospitals and community training sites to ensure the personal safety of all postgraduate trainees.

This policy complies with the Royal College accreditation standards A2.5 and B1.3.9 and does not supersede any University wide or PGME Policy that is already established. In this policy, “Safety” relates to the residents’ physical, emotional and professional wellbeing.

2. Scope

This policy covers resident safety in the areas of travel, patient encounters, including house calls, after-hours consultations in isolated departments and patient transfers (Royal College Standard B1.3.9). This policy should allow resident discretion and judgment regarding their personal safety and ensure residents are appropriately supervised during all clinical encounters.

These policies apply only during residents’ activities that are related to the execution of residency duties.

3. Program Specific Policies

3.1 The Resident Safety Policy needs input and acceptance from the residents through the residency education committee.

3.2 Residents need to provide rotation and faculty evaluations to help direct or establish concerns of resident safety.

3.3 The residency program administration and the Program Director need to act promptly to verify safety issues and take due action to rectify the problem.

3.4 Critical incidents involving residents must be recorded, and appropriate debriefing should occur in a timely fashion.

4. Responsibility of the Resident

TRAVEL

4.1 Residents traveling for clinical or other academic duties by private vehicle should maintain their vehicle adequately and travel with appropriate supplies and contact information. Cell phone use or text messaging while driving is not recommended.

4.2 If the resident has determined that it is unsafe to travel (i.e. due to extreme weather concerns), the resident may elect not to attend clinic / endoscopy lists, inpatient service, or academic half day. However, they must inform their clinical supervisors as soon as possible in a professional manner.

4.3 Residents are encouraged to discuss safety procedures at rural or remote locations with their supervisors as soon as possible after arriving. Emergency contact information should be recorded and carried.

4.4 Residents should ensure adequate rest after call duties before traveling home from the site of clinical duties. Call rooms are available at each training site to accommodate residents for rest before travel. Residents should discuss such arrangements with the site coordinator or attending physician.

4.5 Residents who are called in for clinical duties after 6 pm and before 6 am, and feel unsafe to drive post call should opt to take a taxi for transportation. Reimbursement for taxi charges will be provided upon presentation of appropriate receipts. 

4.6 Residents are not required to attend academic half day if they are greater than 50 km away from the academic half day location nor are they required to attend on post call days. Should residents feel well rested despite being post call, they are encouraged and welcome to attend academic sessions. If not attending due to post call, residents must inform the Program Assistant (Cindy Potter) of this reason for absence.

PHYSICAL SAFETY

4.7 Residents must participate in required safety sessions including Workplace Hazardous Materials Information and Safety (WHMIS), Fire safety, and abide by the Safety codes of the designated area where s/he is training.

4.8 Residents must observe universal precautions and isolation procedures. If necessary, a refresher or literature will be provided on universal precaution procedures.

4.9 Residents should familiarize themselves with the occupational and safety office. This includes familiarity with policies and procedures in reporting contact with contaminated fluids, needles, TB exposure or risk, etc.

4.10 Residents should keep their immunizations and TB skin testing up to date. Overseas travel immunizations and advice should be organized well in advance when traveling abroad for electives or meetings. Since the residency training program does not mandate overseas electives, the resident is expected to coordinate and finance these services.

4.11 Residents should not assess violent or psychotic patients without the backup of security or a supervisor and also an awareness of accessible exits.

4.12 Residents should not work alone at after-hours clinics, make unaccompanied home visits, perform air transport, or arrange to meet patients after hours without on-site support. This does not apply if a patient is being seen in the emergency room or on a hospital ward. A supervisor must always be present if the resident is assessing a patient in an ambulatory setting after hours.

4.13 If the resident feels that his/her own personal safety is threatened, s/he should seek immediate assistance and remove themselves from the situation in a professional manner. The resident should be aware of the contact for security at participating training sites. The resident should ensure that their immediate supervisor and/or Program Director, has been notified, as appropriate. The resident can also bring their safety concerns to the attention of the PGME office (905 525 9140 Ext. 22118) during regular work hours, particularly if the Program Director is not available. If an issue arises after regular office hours, where the clinical supervisor and/or Program Director may not be available, contact Security of the institution where the trainee is based.

4.14 Residents doing home call and arriving after hours should be aware of their environment before leaving their car and have a cellphone available to contact security if it is deemed an escort is required. If residents feel potential threat to their safety, residents should not exit their cars and leave accordingly. In the rare event this occurs, residents should notify the clinical supervisors on call.

4.15 Residents must complete the Field Trips and Electives Planning and Approval process when planning to do an elective outside of North America to ensure compliance with standards and best practices for the safety of all trainees. International electives must occur in a stable political environment with a qualified preceptor to provide appropriate supervision. Additionally, there must be a Canadian Consulate in that country.

4.16 Residents must use caution with respect to confidential personal and patient information, and exercise good judgment and professional behavior when using social media.

4.17 If an injury occurs while working, the injury must be reported as follows:

• During daytime hours, while working at one of the Hamilton teaching hospitals, the trainee should go to the Employee Health Office at any of the teaching hospitals. An incident form will be provided by the Employee Health Office to the trainee. Trainees are encouraged to submit a copy of the incident form to the Program Director and the PGME Office for records.
• During after hours, while working at one of the Hamilton teaching hospitals or if working at a training site outside of the Hamilton area, the trainee should go to the nearest emergency room and identify themselves as a resident and request to be seen on an urgent basis. The trainee must complete, within 24 hours, an Injury / Incident Report available in the local emergency room. The form should be submitted to the hospital where the injury took place, the Program Director and the PGME office for record

PSYCHOLOGICAL SAFETY

4.18 Residents are encouraged to report incidents of intimidation, harassment and discrimination to the Program Director. Any incidents or issues brought forth to the Program Director will remain confidential and residents have the right to confidential psychological and counseling services.

4.19 Residents are encouraged to comment on the rotation evaluations professional issues encountered by staff and residents.

PROFESSIONAL SAFETY

4.20 Residents must not be expected to participate in any situation that would go against their professional responsibilities, ethics, or moral beliefs.

4.21 Residents must have adequate contact with their clinical supervisors for help during critical incidents.

4.22 CMPA provides legal advice and insurance for residents who have acquired coverage.

5. Responsibility of the Program

5.1 It is the responsibility of the residency training program and the PGME to ensure that appropriate safety sessions are available to all trainees. In addition to WHMIS, the residency training program must ensure that there is an initial, specialty, site-specific orientation available to the trainee.
5.2 It is the responsibility of the residency training program to ensure that individual clinics or practice settings develop a site specific protocol in the event that personal safety is breached. The protocol should include the following:

• Identify potential risks to the trainee
• Include how the trainee would alert the supervisor if they felt at risk during an encounter, identification of potentially problematic patients at the beginning of the encounter, so they could be monitored.
• A supervisor or co-worker must be present:
  • While the trainee is seeing a patient after hours in clinic. This would not apply if the patient is being seen in an emergency room.
  • At the end of office hours if the trainee is still with patients.

5.3 It is the responsibility of the residency training program to ensure (via the site coordinators for each site) that each training site remains compliant with the program policy.

5.4 It is the responsibility of the residency training program to ensure a safe learning environment that is free from intimidation, harassment and discrimination. The residency training program will not tolerate such behaviors.

ON-CALL

The objective of resident involvement in the call process is to develop skills in the efficient assessment and triage of patients in the Emergency Room while under supervision by GI attending staff. As part of this training, GI residents participate in home call and assessment will sometimes occur over the phone by communicating with a junior resident rotating through the GI service. In situations of diagnostic or therapeutic uncertainty, patients may require direct assessment by the GI resident in person. The frequency of call is designed to provide optimal and adequate exposure to urgent clinical problems and endoscopic procedures. In both years of the program, the resident is on-call approximately one night per week and one in four weekends.

Attending staff on-call remains available for advice either by phone or in person. Attending staff needs to be informed of all patients who have been seen or assessed by the GI resident. The timing of this notification depends on the resident’s stage of training, and subject to the judgment of the resident. Graduated responsibility applies as the resident’s knowledge and skills mature. Routine and uncomplicated consultations can usually be discussed with staff early on the next working day. Attending staff should be informed in a timely fashion in the following circumstances:

1. Patients who require urgent after-hours endoscopy
2. Patients who have complex management and triage issues, which the GI resident does not feel capable of handling without further advice
3. Seriously ill patients
4. Patient death

Several things to note:

1. Patients who are being discharged from the Emergency Room need to have a satisfactory follow-up plan in place. This must be discussed with attending staff prior to discharge.
2. The GI resident should not be functioning simply as a conduit of information between the junior medicine resident and the GI staff. All consults seen by the junior medicine resident are to be reviewed with the GI resident first either in person or over the phone. If the GI resident is not certain about appropriate course of management, the patient will need to be assessed by the GI resident in person before contacting the GI staff.
3. Signover of GI admissions and consults should occur between 1630 h to 1700 h the afternoon before call starts and between 0800 h to 0830 h the following morning (or on Monday morning after weekend call). Patient lists should be updated in Citrix on a daily basis.
4. After-hours consultations from inpatient services are the GI Resident’s responsibility.
5. Request and consult for ERCP procedures need to be vetted first by the on-call team, which will then contact the ERCP staff (Drs. Lumb, Seaton, Tse).
6. The operators are instructed to direct calls from the emergency department and inpatient services to the GI resident. Calls from outside referring doctors will be directed to the GI staff. This allows efficient assessment and triage of patients in the emergency room while under supervision by GI attending staff.
7. Residents must be relieved of ALL clinical and academic responsibilities post call (home by 24 + 2 hours) when they are called into the hospital to perform duties between midnight and before 6 am or when they are called into the hospital to perform duties for at least 4 consecutive hours with at least one hour of which extends past midnight.
8. Residents on home call may be reimbursed up to $70 per month for taxi charges if:
   • The resident does not have a parking pass
   • The resident is called in for clinical duties after 6 pm and before 6 am

The travel allowance will be provided upon presentation of appropriate receipts and credit card statements

9. Back-up weekend call schedules are prepared by the Chief Residents with each call schedule and are only circulated internally among GI residents and staff. The expectation is that normally the residents on weekend call will help each other out with coverage issues and the GI staff can provide back-up as necessary. Back-up residents are expected to be available by pagers between 0800 h to 0900 h each weekend day or holiday (e.g. Saturday, Sunday, long weekend Monday). Back-up residents are only activated when both residents on-call have been called into the hospital to perform duties between midnight and before 6 am or when they are called into the hospital to perform duties for at least 4 consecutive hours with at least one hour of which extends past midnight. It is the responsibility of the on-call residents to activate the back-up resident between 0800 h to 0900 h when necessary after discussion with each other. The GI staff should also be notified about the activation of the back-up resident. The back-up resident and the GI staff will then provide coverage for all sites until 1700 h when both residents return to call after adequate rest.

LEAVE

Vacation

The Postgraduate Medical Education Committee has drawn up guidelines relating to vacations in keeping with the terms of the PAIRO-CAHO Agreements:

1. Residents are entitled to 4 weeks of paid vacation per year. Vacation time must be taken within the academic year July to June. A week of vacation is defined as 5 working days plus 2 weekend days (20 working days).
2. Requests for vacation shall be submitted at least 4 weeks before the proposed commencement of the vacation and not later than March 1. As an exception, each resident taking a certification examination in June shall have until April 15 to make a written request for one week of his/her vacation entitlement.
3. The Resident is to submit a request on medportal. Approval will need to be obtained first from the Chief Residents who is responsible for the resident call schedule, followed by the Clinical Supervisor, the Site Coordinator and the Program Director in this sequence.
4. The PAIRO-CAHO agreement states that, “All vacation requests must be confirmed or alternative times agreed to within two weeks of the request being made.” This being recognized, it may not always be possible to confirm the request within two weeks. In these instances, the expectation would be that the Resident receives communication regarding the request within the two week period. For example, the Resident would receive an email stating that the request had been received and is then provided with a time when s/he can expect the approval. It is important that timely communication between all parties take place, in order that the Resident receives timely confirmation of the vacation request.
5. Vacations may be taken by housestaff at any time; the timing of vacation may be delayed where necessary, having regard to the professional and patient responsibilities of the hospital department for the time the vacation is requested.
6. All housestaff are entitled to the following recognized holidays:

New Year’s Day	Thanksgiving Day
Family Day	Christmas Day
Victoria Day	Boxing Day
Canada Day	New Year’s Day
August Civic Holiday	Floating Holiday
Labour Day	Please refer to Medportal for the dates of each holiday

If a resident works on a recognized holiday, s/he is entitled to a paid day off in lieu at a mutually convenient time within 90 days.

7. Over the Christmas-New Year’s break, each resident is allowed five consecutive days off during the 12 day period encompassing Christmas Day and New Year’s Day. These 5 days account for Christmas Day, New Year’s Day, Boxing Day and two weekend days. The residents will determine amongst themselves the division of holiday time, with overview by the Chief Residents. Residents do not get additional lieu days for working on any of the statutory holidays during the period.
8. If a resident observes religious holidays that are not specifically listed in the PAIRO-CAHO Collective Agreement, our program will try to accommodate the religious practice to the point of undue hardship (“undue hardship” may include a number of factors, such as patient safety, the hospital’s service requirements, and the resident’s educational / training requirements). It is the resident’s responsibility to request accommodation. Any requests for time off to observe religious holidays must be submitted as vacation requests through medportal and are subject to the same mechanism of approval.
9. Vacation entitlements do not carry over from one year to the next.
10. Housestaff may arrange for their vacation to be taken in one continuous period or in one or more segments of at least one week in duration provide professional and patient responsibilities are met. If a trainee is requesting a vacation block of > 10 days, this request should be made well in advance, before the rotation schedules are drawn up for each academic year. In essence, any vacation block of > 10 days should be requested prior to the start of the academic year in order to enable the program to accommodate such requests wherever possible. It should be recognized that missing > 2 weeks in a 4-week mandatory rotation could impact on the resident’s program and should be discussed with the Program Director.

Professional Leave

1. In addition to vacation entitlement, residents are entitled to additional paid leave (up to a maximum of seven working days per year) to attend educational events, such as medical conferences approved by the Program Director provided that professional and patient responsibilities are met to the satisfaction of the hospital department head.
2. Residents are also entitled to paid leave for the purpose of taking any Canadian or American professional certification exam. This leave time shall include the date(s) of the exam and reasonable travel time to and from the exam site. This leave is in addition to other vacation or leave time.
3. Professional leave will take priority over vacation leave, and priority will be given to residents presenting papers.

Leave of Absence
Interruptions in training which require a leave of absence may be granted by the Postgraduate Dean on recommendation of the Program Director. In order to request a leave of absence from the program, the Resident should complete a Request for Leave of Absence Form that can be obtained from the PGME website. This form is then submitted to the Program Director for approval and then forwarded to the Postgraduate Medical Education Office. Additional information regarding maternity leave, parental leave, and sick leave entitlements are available through the Postgraduate Medical Education Office website.

It is understood that residents will return to a residency program following the leave of absence and that residents are expected to maintain a standard of conduct in keeping with the standards of the residency program, the university and the medical profession at large. It is anticipated that the required time lost or rotations missed must be made up with equivalent extra time in residency upon the residents return to the program. Normally all residents will be required to complete all mandatory / elective components of the program.

All leaves are reported to the College of Physicians and Surgeons of Ontario by the Postgraduate Medical Education office.

Medical Leave

1. A doctor’s note must be provided to the Program Director prior to taking a scheduled medical leave.
2. The Postgraduate Medical Education Office must be notified of all leaves of absence.
3. Ministry of Health funded residents on medical leave will receive full pay for 6 months and after 6 months are eligible to apply for Long Term Disability.
4. To maintain your residency appointment with the University, the resident or his/her delegate will provide a report to the Postgraduate Dean on the resident’s status every 3 months.
5. The Postgraduate Medical Education Office requires that a medical letter from the resident’s physician stating that the trainee is fit to resume training prior to return from medical leave (normally, a doctor’s’ note is not required for leaves of less than 2 weeks duration, provided the leave is not recurrent).

Compassionate/Personal Leave

1. The resident must complete the leave form and attach a letter of support from the Program Director.
2. The Postgraduate Medical Education Office normally does not need to be informed about leaves of less than 2 weeks. This is unpaid leave.

Maternity/Paternity Leave

1. The total amount of time off for a maternity/parental leave is 52 weeks (2 weeks paid EI waiting period, 15 weeks of Maternity Leave, and 35 weeks of Parental Leave).
2. Maternity benefits are paid to the birth mother. The mother can start collecting benefits up to 8 weeks prior to the expected birth. Parental benefits can be claimed by one parent or shared between the two parents but will not exceed a combined maximum of 35 weeks. Parental leave cannot be taken until the birth of the baby.
3. EI will pay a maximum of 50 weeks at a basic benefit rate of 55% of average insured earning up to a maximum payment of $468 per week.
4. For 25 weeks only, Hamilton Health Sciences will top-op salary to 75% of resident earnings based on what is received from EI. To receive top-op.
5. The resident’s Record of Employment can be either mailed to the resident or arrangements can be made to pick up.
6. The resident should apply to EI as soon as work is stopped (1-800-206-7218 or www.hrdc-drhc.gc.ca under Employment Insurance).

OVERVIEW

Moonlighting is defined as residents registered in postgraduate medical education programs leading to certification with the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada who provide clinical services for remuneration outside of the residency program. Moonlighting has been more recently called “restricted registration for residents”.

POLICES ON MOONLIGHTING

The Ontario Faculties of Medicine does not support resident moonlighting. Moonlighting compromises postgraduate programs and undermines the educational environment. McMaster Postgraduate Medical Education (PGME) supports this policy. It is recognized that McMaster PGME cannot restrict, from a practical point of view, those residents with an independent practice certificate from participating in this practice, but this activity must not interfere with the training program and the Program Director should be informed by the resident of this activity so that s/he can monitor its effect on the resident as well as the program.

It is recognized that there is a manpower problem within health care in Ontario but it is not under the mandate of McMaster PGME to solve this problem. The McMaster Postgraduate Medical Education Program wishes to maintain an environment in which there is:

1. a positive balance between education and service
2. a strong academic focus in our training programs
3. no confusion regarding the resident’s role in the clinical setting

The Royal College of Physicians and Surgeons of Canada neither condemns nor condones the practice of moonlighting during residency training. However, it does suggest that the following principles be considered if this practice does occur:

1. Moonlighting must not be coercive (i.e. a requirement of the residency program).
2. The moonlighting workload must not interfere with the ability of the resident to achieve the educational goals and objectives of the residency program (i.e. the Program Director should be informed when a resident chooses to moonlight and must monitor resident performance to ensure that neither learning nor patient safety are compromised because of increased fatigue).
3. If residents do moonlight, it should not occur on the same unit or service to which they are currently assigned as a resident.
4. Confirmation of licensing, credentialing, and appropriate liability coverage is the responsibility of the employer, not the Residency Training Program.

Restricted Registration

There is a process whereby residents are able to practice medicine with a certificate of Restricted Registration. “Restricted Registration” is a certificate offered by the College of Physicians and Surgeons of Ontario (CPSO) to Residents who meet agreed on criteria.

The Council of Ontario Faculties of Medicine have defined “Restricted Registration”, another term for Limited Licensure, as “Residents registered in postgraduate medical education programs leading to certification with the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada who provide clinical services for remuneration outside of the residency program.”

Responsibilities of the Resident

The following criteria must be met before approval for participation in the Restricted Registration Program will be granted:

1. Abide by the terms and conditions of the PAIRO/CAHO Collective Agreement (i.e. not work more than the hours / shifts anticipated by the contract)
2. Have obtained / will obtain the necessary CMPA coverage for Restricted Registration (CMPA Code 14 – Residents for Moonlighting)
3. Restrict activities to the scope of services and sites indicated by the registration
4. Practice only within the scope of training received to date
5. Not allow the Restricted Registration activities to interfere with the requirements and responsibilities of his/her training program (including not undertaking activities during residency work hours including on-call periods that are defined by the program). “Moonlighting” activities cannot interfere with Program call requirements.

Restricted Registration activities cannot interfere with the educational requirements of the Program.Therefore, for each rotation in the preceding 12 months, there can be no provisional or unsatisfactory evaluations. Residents must at least “meet expectations” in all criteria and have at least 50% “exceeds expectations” in all criteria in all CanMEDS domains. Residents must also be in good standing overall in the Program. This includes satisfactory attendance at mandatory educational events and satisfactory progress with respect to their research projects. If the Resident does not maintain good academic standing or if the Restricted Registration activities negatively impact on his/her academic and/or clinical obligations in his/her residency program, the Program Director and Postgraduate Dean reserves the right to withdraw their approval for the Restricted Registration, and/or inform the College requesting that the Restricted Registration be terminated.

Failure to comply with the terms of the agreement (abiding by the Collective Agreement, obtaining necessary CMPA coverage, and working within the scope of the Restricted Registration) may constitute unprofessional conduct and may warrant further action by the CPSO under the Act or Rules.

For details, please refer to Restricted Registration Program for Ontario Medical Residents website.