IBD Curriculum

University of Chicago

Contributing Authors: Russell Cohen, Sunanda Kane

Update: 3/10/06

Educational Goals:

Fellow Year One

  • Learn the epidemiological theories that are currently believed to play a role in the identification of persons at risk for developing IBD.
  • Differentiate disease characteristics specific for ulcerative colitis and Crohn’s disease.
  • Learn the various immune mechanisms believed to be responsible for the IBD disease processes.
  • Differentiate the various first-line therapies currently available for the treatment of IBD, and understand when to use them.
  • Identify and understand the therapeutic options for patients failing first line therapies, or for patients with moderate to severe disease.
  • Learn how to work up patients presenting with symptoms suggestive of possible IBD.
  • Understand the role for various endoscopic and radiographic diagnostic procedures in IBD.
  • Understand the differential for gastrointestinal symptoms in an IBD patient.
  • Learn to interpret serological testing for IBD subtypes.
  • Gain exposure to the endoscopic evaluation of the IBD patient.
  • Gain exposure to the radiographic evaluation of the IBD patient.
  • Learn outpatient management of IBD.
  • Learn inpatient management of IBD.
  • Differentiate the various surgical approaches to patients with fistulizing and structuring Crohn’s disease.
  • Understand the multi-step surgical procedures involved in the surgical treatment of ulcerative colitis with formation of an ileal pouch-anal anastomosis.
  • Understand the various extraintestinal manifestations of IBD.
  • Identify risk factors for neoplasia in IBD patients.
  • Understand colorectal cancer surveillance in patients with colitis.
  • Feel comfortable with triaging patients over the phone on call.

Second Year Fellow

  • Learn the current genetic markers and subtypes for IBD patients.
  • Evaluate patients for possible inclusion in experimental clinical therapeutic trials.
  • Demonstrate an understanding of the unique quality of life issues regarding young patients with chronic diseases.
  • Understand the economic considerations when treating patients with long-standing, chronic, relapsing diseases.
  • Demonstrate confidence in evaluation and treatment of severe fulminant ulcerative colitis.
  • Identify the various extraintestinal manifestations of IBD.
  • Identify pediatric manifestations of IBD.
  • Demonstrate ability in the approach to the IBD patient contemplating pregnancy, the pregnant patient, and the post-partum patient.
  • Perform appropriate colorectal cancer surveillance in patients with chronic colitis.
  • Understand the evaluation and treatment of the post-operative patients with diarrhea.
  • Demonstrate the ability to discuss with patients the risk and benefits of post-operative prevention of Crohn’s disease relapse.
  • Manage effectively patients with intestinal malabsorption.
  • Understand treatment regimens for acute and chronic pouchitis.

Overview of the Rotation:

Most GI fellows are typically assigned 2-3 months of IBD rotation in their first year, and 0-2 months in their second year. Unlike most institutions, the University of Chicago had a dedicated inpatient IBD service; at the current time, this is a fellow-run service. In addition, the IBD service provides medical management advice and follow-up to the post-operative IBD patients who are on the inpatient surgical service, as well as consultations for patients with IBD on other inpatient services. One IBD attending is typically assigned as the “Inpatient IBD Attending of the Month”; it is not unusual to have medical residents or students on elective rotations as well.

The IBD rotation involves outpatient clinic and endoscopy experiences on a daily basis. The fellows rotate through the outpatient clinics of most of the IBD faculty, and are also expected to see urgent patients scheduled in clinic. There are no “private patients” here that exclude fellow coverage. An IBD attending should be available for overview on all cases. Additional outpatient exposure occurs in the IBD Surgical Clinic, and with patients undergoing infusions of infliximab or iron therapy.

Endoscopy experiences in IBD patients while on the IBD rotation typically involve the inpatient cases, or outpatient cases from the fellow’s continuity clinic. The fellow’s involvement in these cases is determined in part by their previous endoscopic training and comfort level with endoscopy.

The IBD fellow is expected to participate in numerous educational conferences during their rotation. A multi-disciplinary IBD Pathology Conference is held twice monthly, and an IBD Clinical Research Conference monthly. Fellows typically present interesting or complicated patients at the weekly GI Clinical Conference, and are encouraged to review recent studies in the weekly Fellows’ Journal Club.

Due to our unique patient population and volume, fellows are encouraged to partake in research studies, case reports, reviews, and coauthor articles or chapters with the IBD faculty while on the service. Many of these activities require a commitment to complete the work on a timely basis; if not during the rotation, then shortly afterwards.

Core Competencies and Curriculum:

Teaching Methods / Clinical Encounters

All fellows will be exposed to a variety of teaching methods and clinical encounters while on the IBD Service:

  • Didactic lectures from IBD attendings.
  • Clinical presentations to IBD team
  • Clinical case presentations to GI Faculty
  • Hands-on interactions and delivery of care to patients in the outpatient IBD clinic
  • Hands-on interactions and delivery of care to patients in the outpatient surgical IBD clinic
  • Direct inpatient care of medical IBD patients
  • Consultative care of medical patients for IBD-related issues
  • Consultative care of surgical IBD patients
  • Endoscopic evaluation of IBD patients
  • Radiographic evaluation of IBD patients
  • Pathological evaluation of specimens from IBD patients
  • Fellow Board Review
  • Fellow Journal Club
  • Interactions with Clinical Trial Staff
  • Interactions with patient support staff, such as ostomy nurses, dieticians, physical therapists

Patient Characteristics / Disease Mix:

  • Crohn’s disease
  • Initial evaluation
  • Diagnostic workup
  • Disease severity grading
  • Therapeutic options
  • Surgical options
  • Management of disease-related complications
  • Ulcerative colitis
  • Initial evaluation
  • Diagnostic workup
  • Disease severity grading
  • Therapeutic options
  • Surgical options
  • Management of disease-related complications
  • Indeterminate colitis
  • Initial evaluation
  • Diagnostic workup
  • Therapeutic options
  • Microscopic colitidies
  • Collagenous colitis
  • Initial evaluation
  • Diagnostic workup
  • Therapeutic options
  • Lymphocytic colitis
  • Initial evaluation
  • Diagnostic workup
  • Therapeutic options
  • Eosinophilic colitis
  • Initial evaluation
  • Diagnostic workup
  • Therapeutic options
  • Ulcerative enteritis
  • Initial evaluation
  • Diagnostic workup
  • Therapeutic options

Procedures and Skills:

Fellows will have the opportunity to participate in various gastrointestinal procedures while rotating through the IBD service; the degree of participation will be dependent upon their prior experience in endoscopy and advanced procedures. All procedures are supervised by an attending physician. Most procedures will be on inpatients; fellows with outpatient continuity clinics will be expected to perform procedures on their patients as well.

Procedures :

  • Upper endoscopy
  • Colonoscopy
  • Enteroscopy
  • Ileoscopy / colonoscopy through a stoma
  • Pouchoscopy
  • In some cases, Fellows will gain exposure as an observer or assistant to double-balloon enteroscopy, ERCP, endoscopic ultrasound, therapeutic endoscopic dilations, and surgical management of IBD.

Skills:

  • Physical examination
  • Interpretation of laboratory tests.
  • Including specialized IBD testing:
  • TPMT, 6TGN, 6MMP
  • ASCA, ANCA, ompC, flagellin
  • Infliximab and HACA levels
  • Interpretation of radiographic tests
  • Interpretation of histological samples
  • Interpretation of endoscopic findings
  • Interpretation of video capsule studies

Faculty Supervision:

All faculty members are full-time faculty at the University of Chicago. All endoscopic procedures performed in the Section of Gastroenterology require supervision of qualified GI faculty for the entire procedure. The core IBD faculty (currently 6 members) provide supervision for all outpatient clinic patient interactions. One of the core faculty serves as the monthly inpatient attending, and conducts daily rounds on the IBD inpatient and consultation services.

Methods of Evaluation:

  • Daily feedback from IBD faculty during inpatient and outpatient settings.
  • Monthly web-based Fellow Evaluation Forms.
  • Semi-annual meetings with Fellowship Director
  • Endoscopy log (computerized)

Attitudes and Behaviors:

  • Patient Care
  • Adequate performance of history and physical
  • Demonstrate compassion and empathy for patients, and emphasize the continued integrity of each patient
  • Daily rounds
  • Attending observation of interaction of Fellow with patient and family members
  • Medical Knowledge
  • Understanding of necessary tests required to diagnose and evaluate new patients, and manage established patients
  • Develop competence in management of complications from IBD and its therapies
  • Ability to interpret laboratory, radiographic, endoscopic and pathologic results
  • Practice-based learning and improvement
  • Utilization of the medical literature to guide recommendations to patients and inpatient treatment strategies
  • Review relevant pathology, radiography, and endoscopy with attendings
  • Interpersonal Skills and communication
  • Develop communication skills with patients and families conveying relevant information, prognosis and treatment options
  • Act as a team player with social services, ostomy nurse specialists, nutritionists, and relevant consultants
  • Develop communication skills with referring physicians
  • Professionalism
  • Demonstrate integrity, respect, compassion and empathy for patients
  • Demonstrate timeliness, respect toward duties and respect for other team members
  • Systems-based practice
  • Incorporation of multi-disciplinary team in the care of patients, including surgeons, pathologists, radiologists and stoma therapists
  • Discussion of appropriate resource utilization including third party payor issues of coverage for biologic therapies and for surgical interventions
  • Assessment of length of stay and adequate resource utilization for the geographic bed assignments for inflammatory bowel disease patients

Resources

  • All fellows currently receive a personal copy of the following textbook:
  • Cohen RD, ed. Inflammatory Bowel Disease: Diagnosis and Therapeutics. Totowa, New Jersey: Humana Press, 2003.
  • Copies of leading GI textbooks in fellows’ work areas.
  • Teaching Slide Sets available for fellows’ use
  • Electronic Resources
  • Up-To-Date
  • Crerar Library Science Electronic Journal Access
  • Department of Medicine Electronic Medical Information Databases

Conferences

  • Gastroenterology Section
  • GI Fellows’ Teaching Conference
  • IBD Pathology Multi-Disciplinary Conference
  • Liver Pathology Multi-Disciplinary Conference
  • GI Research Conference
  • GI Clinical Conference
  • GI Fellows’ Board Review
  • Housestaff Lecture Series
  • Department of Medicine
  • Grand Rounds
  • Morning Report
  • Housestaff Lecture Series
  • Special Lecture Series
  • National Conferences*
  • American Gastroenterological Association
  • AmericanCollege of Gastroenterology
  • Crohn’s and Colitis Foundation National Conference
  • American Association for the Study of Liver Diseases
  • North American Conference for GI Fellows
  • Healthcare Outcomes Research Workshop
  • Evidence Based Medicine Workshop
  • GI Fellows Clinical Forum
  • AGA Academic Skills Workshop

* attendance requires accepted abstract, approval from Section Chief, and in some cases, applicant must be selected to attend.

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