Mission

Our primary mission within the training program is to provide a well-rounded educational experience in the broad fields of Gastroenterology and Hepatology.  We are a multifaceted training program that provides fellows with tailored experiences to be leaders in clinical and academic Gastroenterology. The program provides the opportunity for fellows to work and learn in a variety of diverse and unique environments while keeping the Three Aims of the program in mind – Care of the Community, Clinical and Scholastic Excellence, and Professionalism.

Vision

The fellowship program is singularly focused on assisting fellows in achieving excellence that is uncompromising and unconditional through varied clinical experiences, patient ownership, and academic productivity. Through close relationships with committed faculty and staff challenges faced by fellows both generalizable to all training fellowships and unique to a military training program will be overcome in order to provide for the needs of the military health system wherever graduates are called to serve.

Aims

The program has three Aims:  Care of the Community, Clinical and Scholastic Excellence, and Professionalism.

Care of the Military and Civilian Community

Graduates of the program are well prepared to begin the practice of Gastroenterology and Hepatology in any environment with the additional capabilities expected of those serving in the armed forces. Fellows will gain a patient-based educational experience that emphasizes diseases and problems common to gastroenterology and hepatology. 

Clinical and Scholastic Excellence

Our mission is to train superb expert gastroenterologists, scholars, researchers, and irreproachable physician officers who care for patients as family. A NMCSD gastroenterology trained fellow is capable of pursuing careers in clinical practice, academic medicine, research, or health care administration.  Outstanding performance as a GI consultant and scholar is the product of mastery of gastroenterology and hepatology, endoscopy, and scholarly discovery.  Through self-learning and personal drive, one-on-one mentorship, and clinical coaching, our fellows learn the prerequisite skills necessary for excellence.

Professionalism

Our patients’ confidence in us is fundamental to our effectiveness as health care providers.  Everything we do must be done on the foundation of professionalism.  If we fail to gain our patient’s respect as professionals, they will not trust our judgement, jeopardizing their care and recovery.  Professionalism boils down to six elements: discipline, honor, courage, commitment, competency, skill, and emotional intelligence, all of which to some degree will be fostered together as a team.  Through a culture of clear expectations and collegiality amongst all intraprofessional team members throughout the department, fellows will demonstrate how to serve in a professional manner and expect professional interactions from their teammates.

Program Goals

It is expected that each physician studying gastroenterology at NMCSD will acquire the ability to:

• Identify and treat uncommon and rare conditions in gastroenterology and hepatology.
• The skills to manage patients with diseases and problems common to gastroenterology.
• The ability to provide acute and comprehensive care to the seriously ill adult in both the inpatient and outpatient settings.
• Provide accurate, comprehensive, timely, and effective consultative services to anyone calling for gastrointestinal and hepatic specialty care, guidance, or opinion.
• Utilized therapeutic and diagnostic endoscopy with competence as deemed by the NMCSD GI clinical competency committee utilizing published standards by ACGME and the three GI scientific societies: American Society for Gastrointestinal Endoscopy, American College of Gastroenterology, and the American Gastroenterological Association

Intensive participation in basic and clinical science conferences is a core part of the NMCSD GI fellowship. Fellows are responsible for attending the majority of them, the only extenuating circumstances being emergent patient care or leave/TAD.

Core Curriculum Conference (mandatory)

Staff and fellows meet to specifically review and discuss in-depth selected inpatient and outpatient cases, regarding pathophysiology, clinical presentation, and management controversies as presented by fellows. Thoroughness of literature review, appropriateness of work-up and management, cost effective issues will all be discussed. Also, laboratory tests, X-rays, and endoscopic pictures will be presented in “short case” format.

GI/Liver pathology Review (mandatory)

Every 2-3 months the GI Staff and fellows meet with NMCSD GI pathologist to review biopsy and pathology specimens submitted by the GI division.

Radiology Conference

Every 2-3 months during the Thursday academic schedule. Clinical presentations related to the full range of radiologic exams of each part of the GI tract.

NMCSD Internal Medicine Morning Report & “Attending Rounds” (Highly Encouraged)

Daily from 12 - 12:30 p.m. This is a general internal medicine conference directed to residents and is presented in a case-based format.

NMCSD Internal Medicine Faculty Lecture Series, AKA “Noon Conference” (Recommended based on Topic Relevance)

Daily from 12:30-1 p.m. in the DMS Conference Room. This is a general internal medicine conference oriented towards the internal medicine residents. GI related topics will be presented on a rotating basis and fellows will be responsible for several of these during the year (one to two lectures/year for the fellows).

• Research at NMCSD
• Inpatient transplant hepatology at Scripps Green
• IBD at University of California San Diego (UCSD)
• Advanced endoscopically training at various sites
• Gastrointestinal motility

Outpatient Gastroenterology Service

This is a one calendar month rotation with a specific emphasis on caring for outpatients with gastrointestinal illnesses. Generally, 1st year fellows are assigned to this rotation with occasional assignments to 2nd and 3rd year fellows. Fellows serve as the initial point of contact for emergency, today, and urgent (72-hr) outpatient gastroenterology consultations.

Opportunities for professional growth unique to a military physician are found throughout the program both in formal and informal settings. Duty status determinations, disability evaluation referrals, along with general leadership skill development through orchestration of multi-setting patient care encounters will challenge all fellows to enhance their systems-based practice skills and are formally taught through collaboration with the judge advocate and Veterans’ Affairs program managers. This helps to focus trainees on skillset development that will be critical on day one after training when tasked to providing recommendations regarding the status of a particular service member which a GI condition which may affect their ability to service in austere settings.

Gastroenterology Fellows are required to maintain Basic Life Support (BLS) and Advanced Life Support (ALS) or Advanced Cardiac Life Support (ACLS) throughout their fellowship training.

Fellows are encouraged to utilize the endoscopy simulator in the initial instruction of residents and medical students on the fundamentals of endoscopy. This should be accomplished prior to permitting residents to perform supervised flexible sigmoidoscopy.

Experiential leadership opportunities occur on a daily basis for fellows manage teams to conduct complex medical care across multiple settings, requiring the development of skills in time management, emotional intelligence, interpersonal communication, conflict resolution and change management. Through internally developed curricular content, opportunistic debriefing, and institutional faculty development, skills are formally embedded into academic program.

This is a one calendar month rotation with a specific emphasis performing research and scholarly activity. Fellows will take part in research and scholarly activities throughout all three years of fellowship training and will have a minimum of 3 protected months to perform this (with additional months given on an elective basis). The research program provides a meaningful, supervised research experience with protected time both in blocks and concurrent with all of the clinical rotations. Fellows will choose or be assigned a research staff or mentor in order to facilitate introduction to research. Fellows will learn the design and interpretation of research studies, the responsible use of informed consent, and research methodology and interpretation of data. This is typically done through a structured online curriculum (CITI). Research/scholarly projects will generally include preparing case reports for publication and presentation, preparing clinical or bench research protocols for IRB submission, conducting clinical or bench research, analyzing data, and preparation/submission of research manuscripts for publication. This will be supplemented by presentations regarding research methods and ongoing research at monthly research conferences. Ongoing establishment of relationships with the research department within NMCSD at large will assist in re-establishing deeper research opportunities and mentorship, which for some trainees may be related to educational curricula or training.

Gastroenterology is a rapidly developing specialty. The wealth of International Conferences held annually is a testament to this fact. Fellows will receive command funding for one major conference per fiscal year.

An exhaustive list of conferences to choose from is beyond the scope of this document. The three main conferences that members of the GI Department at NMCSD typically attend are:

1. Digestive Disease Week “DDW” – Held annually for 4 days in May in a different major city each year. This is the premier GI conference collectively sponsored by the AGA, ASGE, AASLD and SSAT.
2. American College of Gastroenterology “ACG” - Held annually for 4½ days in October in a different major city each year. This meeting is usually the best venue for submission of case series and case reports.
3. American Association for the Study of Liver Diseases (“AASLD” or “The Liver Meeting”) - Held annually for 4½ days in October in a different major city each year (typically alternating between east and wests coasts). Fellows with an interest in Hepatology should attend this conference at least once during training.

Other conferences that are available to attend, either on a “no cost” basis, or if presenting original work include: The American College of Physicians (ACP) annual meeting, The Navy Chapter of the ACP Associates meeting and many others.

All fellows must propose and delineate the steps of a quality improvement project to address a perceived area of deficiency within the fellowship or department, utilizing any one of a number of frameworks to design to proposal (A3, PDSA, 4DX). Recent initiatives within the department have included bowel prep optimization, broader intradisciplinary collaboration with primary care providers for colon cancer screening, improving efficiency related to direct access colonoscopy for colon cancer screening, and cost avoidance for referrals for infusion centers for IBD patients (using newly approved injectable and oral therapies). Additional quality assurance opportunities include quarterly conferences dedicated to systems-based practice improvement within the department. A structured online curriculum related to quality improvement through the Institute of Healthcare Improvement (IHI) is recommended for first year fellows to complete.

Fellows are encouraged to take advantage of the minimal costs of belonging to several of the national GI organizations. Applications and letters of recommendation are readily available from the Program Director or Chief of GI. Any other involvement in military or Internal Medicine societies is encouraged, time permitting.

• Scripps Clinic and Scripps Green Hospital
• Sharp Rees-Stealy Medical Group
• Southern California Kaiser Permanente Medical Group
• University of California San Diego - Gastroenterology Division 

• Rotation opportunities are readily available for active Internal Medicine residents from NMCSD.  These opportunities are typically conducted on the inpatient service and punctuated with a lecture during weekly Socratic academic sessions with the entire fellowship.
• Resident rotators from outside institutions will be considered on a case-base-case basis, should the request arise.
• Rotation opportunities are also available for medical students.  Please visit our Medical Student Rotation informational page to see a listing of available medical student rotations offered at NMCSD.

Interviews for Gastroenterology Fellowship positions are conducted individually on an as-requested basis and are not scheduled on any particular date and time.  Should you desire an interview, please contact the Gastroenterology Program Leadership at dha.san-diego.San-Diego-NMC.list.nmcsd-gastro@health.mil.

Program graduates take the Gastroenterology Certification Exam. This exam is offered annually.  To become fully board certified, applicants are eligible to take board certification exam four months following graduation. To be eligible to take specialty board exams, graduates must complete all pre-requisites required by the American Board of Internal Medicine (ABIM) by 31^st of October.  The Gastroenterology Certification Exam is open for registration December through June and the examination is scheduled in November. For additional information, please visit the ABIM website at: Gastroenterology Policies | ABIM.org. 

Fellows will have opportunities to teach rotating residents and medical students during academics throughout their Gastroenterology Fellowship.

Fellows have the opportunity to apply for Assistant Professorship at the Uniformed Service University of Health Sciences.

• Advanced Endoscopy
• Advanced Transplant Hepatology

The program has dual pathways for mentorship for fellows, both to assist them in their professional development within GI, as well as to allow them to serve as mentors for junior trainees through a structured mentorship program though the Department of Medicine. Beyond local mentorship with active duty faculty, the program is structured to allow broad, longitudinal mentoring relationship between fellows and outside faculty and local centers, in addition to pursue involvement in multiple medical society organizations which provide opportunities for national recognition and professional growth through mentorship from outside institutions.

On a quarterly basis, academic conference will be replaced by a wellness-half day for the fellows to be off site and engaged in team-building activities at the discretion of the chief fellow. One of such day, this will double as an off-site fellowship retreat to assist in communication regarding desired updates or alterations to the fellowship.