GI Fellows Research Articles

A 12-Year North American Longitudinal Study of Gender Equity and Equality in Gastroenterology

A 12-Year North American Longitudinal Study of Gender Equity and Equality in Gastroenterology

Gender and Other Factors Associated with Endoscopy Volume Among U.S. Gastroenterology Fellows

Gastroenterology (GI) fellows' ability to perform procedures are evaluated by the level of competency in the cognitive and technical components of procedures in Accreditation Council for Graduate Medical Education-accredited fellowship programs.1 However, competency in endoscopic procedures correlates with the number of procedures performed.2 The American Society for Gastrointestinal Endoscopy has recommended that a minimum of 130 esophagogastroduodenoscopies (EGDs) and 275 colonoscopies be performed before procedural competency can be assessed.3 Few studies have examined program or trainee-related factors, such as trainee gender, that may influence procedural volume. In other procedural subspecialties, a gender gap exists in trainee procedural volumes, with female residents performing fewer surgical cases than males.4,5 However, whether gender-related disparities exist in endoscopy volume among GI trainees is unknown. The primary aim of this study was to determine the impact of GI fellow gender on endoscopic procedural volume during training. Secondary aims were to determine if fellow career choice or other training program-related factors, such as program size, location, or setting, affect procedure volume during fellowship.

S3389 Identifying Barriers to Vaccination in Veteran Patients With Advanced Liver Disease

Introduction: Patients with advanced fibrosis and cirrhosis are at high risk for vaccine-preventable conditions such as Hepatitis A/B. Despite Center for Disease Control (CDC) recommendations, many patients with liver disease remain unvaccinated. The goal of our project was twofold: (1) to identify barriers to vaccination at a Veterans Affairs Medical Center (VAMC), and (2) to formulate process improvement strategies to improve vaccination rates among our veterans. Methods: An ad-hoc multidisciplinary quality improvement team was assembled to evaluate and improve upon vaccination efforts in the VAMC Gastroenterology (GI) and Liver clinics. Data was collected through a 10-item questionnaire consisting of multiple choice, free response, and Likert scale questions that was distributed electronically to clinic providers. Results: Twenty providers participated in the survey: 8 attendings (40%), 9 GI fellows (45%), 1 nurse practitioner (5%), 1 physician assistant (5%), and 1 pharmacist (5%). Six providers (30%) reported almost always addressing vaccination status with patients during an encounter in clinic. Data also revealed that 50% of providers rarely or never undergo post vaccination serological testing (Figure 1). Thirteen (65%) providers currently have a note template related to vaccinations, but 19 providers (95%) reported an interest in implementing a standardized template. A majority of providers believed that the most effective and opportune time to address vaccinations during an encounter was during patient intake with the clinic nurse (13, 65%) as opposed to during the encounter with the provider (4, 20%) or during check-in with the medical support assistant (3, 15%). Moreover, there was variability amongst providers in prioritizing vaccinations during patient encounters (Table). Qualitative data was obtained regarding perceived barriers to vaccination. Common themes elicited were lack of time (65%), patients declining vaccinations (55%), and overlap of responsibility with primary care providers (35%). Providers also expressed difficulty determining vaccination history for patients. Conclusion: Significant room for improvement remains in vaccination rates of VAMC patients. Addressing opportunities and barriers such as provider education, standardizing a template for vaccination status and immunity in provider documentation, and engaging veterans during clinic intake could prove to be beneficial interventions improving the rates of vaccination in the future.Figure 1.: Addressing Vaccination Status and Post-Vaccination Serological Testing During Patient Encounters.Table 1.: Priority of Addressing Vaccinations During Clinic Encounters.

S1362 Fast Track for Tube Delivery

Introduction: Due to increased morbidity and mortality of inadvertent blind feeding tube placements, we implemented an enteral nutrition inpatient pilot at our tertiary care facility. We created a “tubes service” in an effort to provide more timely nutrition in a safe manner to improve quality of care. We aimed to reduce risk of adverse events as well as to provide more timely nutrition safely by also minimizing radiation from x-ray. Methods: We piloted the enteral nutrition platform with GI fellow placement of NG/post pyloric feeding tubes under direct visualization without use of endoscopy for failed blind bedside NG placements. A data collection form was created to measure results (Figure1a). We incorporated the Resource Intensive Care (RIC) Nurses onto our team. GI provided an in-service for critical care staff on the enteral nutrition platform. The RIC Nurse service went live after each nurse was deemed competent based on a competency evaluation developed by the GI lead physician (Figure1b). Collaboration with IT Services for use of this platform to capture images of proper placement was confirmed for medical record documentation and for reduction of x-ray usage. GI will support failed attempts endoscopically. Results: GI fellows placed 50 tubes with no adverse events from February 2020 - December 2020. This number excludes 3 months of the initial pandemic period and excluded COVID 1 patients. Average time from consult to placement was 9 hours compared to reported time from consult to blind placement averaging ∼21 hours. From March -April 2021, 16 (100%) tubes were placed successfully in the ICUs by our dedicated RIC nurse team. One attempt was hindered due to hiatal hernia. Average times from consult to placement averaged 4 hours. Conclusion: Bedside placement of feeding tubes with built-in camera technology allows for a safer, more effective, and more efficient method for delivery of enteral nutrition for inpatients. A cost/ benefit analysis shows a potential $840.20 in savings per patient with decreased need for x-rays, decreased risk of adverse events, earlier time to feeding and decreased length of stay. Out of 66 successful placements, it is an estimated total potential savings of $55,453. We will expand this service to other hospitals within our large health system to include COVID1 patients moving forward..

Trying: On Teaching Empathy.

Trying: On Teaching Empathy.

S1364 Web-Based Culinary Medicine Curriculum for GI Fellows Improves Dietary Counseling Confidence

S1364 Web-Based Culinary Medicine Curriculum for GI Fellows Improves Dietary Counseling Confidence

S1319 The Impact of the COVID-19 Pandemic on Graduating Gastroenterology Trainees and Perceptions of Program Directors

Introduction: Re-allocation of resources and closure of endoscopy units during the COVID-19 pandemic may have lasting impacts on graduating gastroenterology (GI) fellows who rely on their final year in training to refine their skills. We aimed to assess the impact of the pandemic on graduating GI fellows and the perceptions of their program directors (PDs). Methods: We conducted a national survey study of graduating fellows (3rd and 4th year) and program directors (PDs). An initial trainee and a PD survey were administered in 5/2020; a 6-month follow-up trainee survey was administered in 11/2020. The surveys aimed to determine the impact of COVID-19 on: (1) employment; (2) CME; (3) telehealth; (4) clinical practice; and (6) confidence/competency. Initial and follow-up trainee surveys and trainee and PD surveys were compared. Bivariate analyses were performed using either Chi-square or Fisher exact tests. Results: 105 and 43 graduating GI fellows completed the initial and follow-up surveys. 107 PDs were surveyed. 15.2 % of trainees had a change in their employment due to the pandemic. Popular educational resources used were ACG Education Universe (39.1%) and ACG Virtual Grand Rounds (55.4%). A large proportion of fellows were not likely to attend an in-person national conference prior to and 6 months after graduation (34.3 % vs 44.2%, P = 0.58). The risk of COVID-19 transmission was an important factor in the decision to attend a national GI conference both prior to and 6 months after graduation (41.0% vs 46.5%, P = 0.94). For telehealth, lack of training and reimbursement were factors that affected a fellow’s decision to use telehealth. The likelihood of ordering non-invasive testing for common GI complaints decreased significantly with time (P < 0.01). A considerable proportion of fellows believed they needed additional endoscopic training as a result of the pandemic, however, this proportion declined 6 months after graduation (43.8% vs 25.6%, P = 0.04). Compared with trainees, the minority of PD’s believed that graduating fellows needed additional training in endoscopic procedures as a result of the pandemic (43.8 vs 4.7%, P =< 0.001). Conclusion: The COVID-19 pandemic has impacted the employment, educational resources, confidence, telehealth and clinical practice of our graduating GI fellows. Despite the COVID-19 pandemic, PDs were confident in their graduating fellow’s technical abilities and graduating fellows gained confidence in endoscopic skills over time.Table 1.: Impact of the COVID-19 pandemic on graduating GI fellows and perceptions of program directors.

S1306 Virtual Pivot: Gastroenterology Fellows’ Perception of a Teleconferencing Platform to Conduct Objective Structured Clinical Examinations

Introduction: The objective structured clinical examination (OSCE) has been shown to not only assess but also improve the performance of trainees. Our group has previously demonstrated the benefits of OSCEs to assess gastroenterology (GI) fellows. We have successfully assessed performance across numerous milestones. Typically, OSCEs are held in person, however the COVID-19 pandemic has precipitated the need for virtual learning. We accordingly transitioned to a virtual zoom OSCE (Z-OSCE) and evaluated trainees’ perception of this program. Methods: Fourteen first- and second-year GI fellows from five programs across multiple states participated in a four-station virtual OSCE on Zoom. Afterwards, participants answered a survey to share their perspectives and provide feedback. Learners were asked to rate the usefulness of the virtual OSCE and compare it to other in-person and virtual educational modalities. These questions were rated on a 10-point Likert scale (Figure 1). Additionally, free-text responses regarding any aspect of the OSCE were evaluated for comments on the virtual format. Results: In comparing the usefulness of the virtual OSCE to other in-person modalities, trainees rated it a mean of 7.15 (range 5-10), and 31% of respondents rated it a 9 or 10. Trainees rated the virtual OSCE compared to other virtual learning modalities a mean of 8.15 (range 5-10), and 43% rated it 9 or 10. When asked whether they would recommend this OSCE as a training tool, the trainees gave a mean recommendation of 7.77 (range 5-10), and 38% gave a 9 or 10. General feedback regarding the nature of the OSCE noted the virtual format worked well, orientation to the format was important and could be improved by providing it in an email beforehand. Conclusion: Virtual learning has been necessary during the COVID-19 pandemic, and it is crucial to evaluate the value of the novel Z-OSCE. Participants found the virtual OSCE may be more useful than in-person learning modalities and it compared favorably to other virtual learning modalities. One benefit of this modality was the easier inclusion of fellows from geographically disparate areas negating the need to travel for this program, a benefit given lack of universal access to simulation using standardized patients. To improve future exams, orientation prior to the day of the OSCE may improve trainees’ experiences.Figure 1.: Ten-point Likert scale evaluating learner feedback on the virtual OSCE.

Local COVID-19 Epicenter in Detroit Metropolitan Area Causing Profound and Pervasive Reorganization of Clinical, Educational, Research, and Financial Programs of a Large Academic Gastroenterology Division with a GI Fellowship and Primary Medical School Affiliation.

AimTo report revolutionary reorganization of academic gastroenterology division from COVID-19 pandemic surge at metropolitan Detroit epicenter from 0 infected patients on March 9, 2020, to > 300 infected patients in hospital census in April 2020 and > 200 infected patients in April 2021.SettingGI Division, William Beaumont Hospital, Royal Oak, has 36 GI clinical faculty; performs > 23,000 endoscopies annually; fully accredited GI fellowship since 1973; employs > 400 house staff annually since 1995; tertiary academic hospital; predominantly voluntary attendings; and primary teaching hospital, Oakland-University-Medical-School.MethodsThis was a prospective study. Expert opinion. Personal experience includes Hospital GI chief > 14 years until 2020; GI fellowship program director, several hospitals > 20 years; author of > 300 publications in peer-reviewed GI journals; committee-member, Food-and-Drug-Administration-GI-Advisory Committee > 5 years; and key hospital/medical school committee memberships. Computerized PubMed literature review was performed on hospital changes and pandemic. Study was exempted/approved by Hospital IRB, April 14, 2020.ResultsDivision reorganized patient care to add clinical capacity and minimize risks to staff of contracting COVID-19 infection. Affiliated medical school changes included: changing “live” to virtual lectures; canceling medical student GI electives; exempting medical students from treating COVID-19-infected patients; and graduating medical students on time despite partly missing clinical electives. Division was reorganized by changing “live” GI lectures to virtual lectures; four GI fellows temporarily reassigned as medical attendings supervising COVID-19-infected patients; temporarily mandated intubation of COVID-19-infected patients for esophagogastroduodenoscopy; postponing elective GI endoscopies; and reducing average number of endoscopies from 100 to 4 per weekday during pandemic peak! GI clinic visits reduced by half (postponing non-urgent visits), and physical visits replaced by virtual visits. Economic pandemic impact included temporary, hospital deficit subsequently relieved by federal grants; hospital employee terminations/furloughs; and severe temporary decline in GI practitioner’s income during surge. Hospital temporarily enhanced security and gradually ameliorated facemask shortage. GI program director contacted GI fellows twice weekly to ameliorate pandemic-induced stress. Divisional parties held virtually. GI fellowship applicants interviewed virtually. Graduate medical education changes included weekly committee meetings to monitor pandemic-induced changes; program managers working from home; canceling ACGME annual fellowship survey, changing ACGME physical to virtual site visits; and changing national conventions from physical to virtual.ConclusionReports profound and pervasive GI divisional changes to maximize clinical resources devoted to COVID-19-infected patients and minimize risks of transmitting infection.

Impact of COVID-19 on Gastroenterology Fellowship Training

The coronavirus disease 2019 (COVID-19) outbreak caused numerous social and cultural changes, but few studies focused on their effects on gastroenterology (GI) fellowship training. This study evaluated the impact of COVID-19 on GI fellowship training. A web-based questionnaire was sent out to GI fellows in Korea between 15 February and 15 March 2021. The questionnaire included questions regarding the characteristics of GI fellows, perception of COVID-19 outbreak, impact of COVID-19 outbreak, and telemedicine on the education of a GI fellowship. Among 111 answers, 94 respondents were analyzed. The GI fellows were provided with sufficient information about the COVID-19 outbreak (74.7%), well educated, and provided with personal protective equipment use (74.7% and 83.9%, respectively). On the other hand, outpatient schedule and volume decreased in 25.5% and 37.8% of respondents, respectively. Moreover, endoscopy sessions and volume decreased in 51.1% and 65.6% of respondents, respectively. As a result, 78.9% of respondents were concerned that the COVID-19 outbreak adversely affected their education. Telemedicine utilization was introduced during the COVID-19 outbreak, but only 20.0% and 10.6% of respondents agreed that telemedicine has benefits from the patient's and doctor's perspectives, respectively. In addition, only 25.9% of respondents were willing to continue telemedicine if adequately reimbursed, and 68.2% of respondents were concerned that it adversely affected their education. The COVID-19 outbreak has adversely affected GI fellowship training in Korea for outpatient clinics, gastrointestinal endoscopy, educational conferences, and telemedicine. This study highlights that GI fellowship training needs more attention in the COVID-19 outbreak.

The Role of Training Institutions and Academic Societies for the Training and Education of GI Fellows

The training and education of GI fellows are crucial issues for the training institutions and academic societies. Current circumstances about GI fellows are changing rapidly according to shortage of training period of the internal medicine residency program and growing up of multimedia and web-based education system. Recently, the education board of Korean Society of Gastroenterology revised the educational objectives considering 2 years program of GI fellows. We also need to develop a concrete education program through cooperation with related organizations including the training institutions and academic societies. All of these efforts should be made with the goal of making a good gastroenterologist, not just making an endoscopist.

Training in advanced bilio-pancreatic endoscopy.

As the clinical applications of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) take more and more root in everyday practice and these endoscopic procedures become increasingly more complex and interventional with a higher chance for complications, the demand for expert biliopancreatic endoscopists continues to increase. In response to this growing need, specific postgraduate fellowships have been developed, however the standardization of training programs and the assessment of the achieved competence still remains an open debate. ERCP and EUS competency often requires training beyond the scope of a standard GI fellowship program, which lasts at least 1-2 years, and there are some differences in the way to face the issues of advanced biliopancreatic endoscopy training between Europe, America and the Asian regions. Today there is no role for the self-teaching of ERCP and EUS through trial and error without supervision and, in the near future, it is necessary to critically revise current training guidelines, to establish a standardized curriculum for advanced biliopancreatic endoscopists and to implement universally validated skill assessment tools, able to ensure constant and targeted feedback to trainees.

A94 BARRIERS TO ADVANCEMENT ALONG THE GASTROENTEROLOGY CAREER PATHWAY: A RESIDENT PERSPECTIVE

Abstract Background GI residency training programs in Canada are comprised of approximately 30% females. Survey data from procedural specialities reveal gender related differences relating to work-life balance, parental obligations, access to role models, and workplace gender discrimination. Aims To determine gender specific differences affecting the choice of GI as a sub-specialty and the experience of GI as a career during residency and fellowship. Methods A 91-question mixed methods survey was electronically disseminated in two recruitment waves to PGY4-6 gastroenterology residents and fellows across Canada between May 7th-July 1st, 2020. The survey consisted of nine groups of questions aimed at understanding personal, professional, financial, and training characteristics. Comparisons were made between self-identified male and female genders. Wilcoxon (Mann Whitney U test) was used for continuous variables while chi-squared test and fisher’s exact test was applied for categorical variables using SAS software. Qualitative thematic analysis was applied for short answer responses with two independent reviewers. Results A total of 122 residents were surveyed with a response rate of 36% (44/122).There were 17 PGY4s, 15 PGY5s, and 12 PGY6s. Females comprised 41% (18/44) of respondents. Women were statistically more likely to take on a predominant caregiver role for children (p=0.012) and state that having children would slow their career advancement (p=0.046). Men were more likely to state that it is preferable to have children during residency (p=0.036) and that their partner’s preference factored into their subspecialty training choice (p=0.009) than women. Male PGY4/5 trainees were more likely to select therapeutic endoscopy for advanced training (p=0.033). No statistical difference was found regarding aspirations for administrative/leadership positions, desired future income, practice setting, academic pursuits, and perspectives on compromising marriage for career. Qualitative analysis suggests non-gender specific challenges related to achieving work-life balance, securing a desired location of practice, and obtaining financial stability are common resident and fellow concerns. Conclusions Our study is the first of its kind within the field of gastroenterology to focus on GI residents and fellows’ experiences within Canadian training programs. Our results show that there exist gender related differences in relation to work-life balance and career advancement. Women may benefit from supports to cope with increased caregiver demands in order to allow them to meet career goals which are similar to their male peers. Funding Agencies None

Gastroenterology Fellowship Applicants’ Perspectives on GI Program Preferences

Gastroenterology fellowship continues to be highly competitive among internal medicine subspecialties. Recruiting excellent applicants is also important for GI fellowship program directors. We aim to examine factors that influence GI fellowship applicants' perspectives about a fellowship program. The authors conducted an anonymous online survey of applicants focusing on program characteristics including location, faculty, research/clinical opportunities, website, and interview day experience. Anonymous survey responses were recorded regarding program characteristics, and subsequent candidate preferences were evaluated for factors influencing their decision. Candidates were also asked to evaluate their interview experience and share other comments about the program. Though GI fellowship applicants have varying preferences regarding the ideal training program, some opinions converged. The study of these trends can inform program directors regarding areas for improvement that in turn can help attract the best applicants.

Novel Modifications for a Virtual Interview Visit to Simulate the Traditional, Live, Site Visit for GI Fellowship Applicants for an Academic GI Fellowship Program Due to the COVID-19 Pandemic

Novel Modifications for a Virtual Interview Visit to Simulate the Traditional, Live, Site Visit for GI Fellowship Applicants for an Academic GI Fellowship Program Due to the COVID-19 Pandemic

Addressing Gender Disparity: Increase in Female Leadership Increases Gender Equality in Program Director and Fellow Ranks.

Women make up 15% of the total number of practicing gastroenterology (GI) physicians in the US. Despite this disparity, only 33% of the current GI fellows are female. Increasing female GIs is a major goal of all four GI societies. It is known that gender disparity exists in the field of gastroenterology, and women are underrepresented in the leadership ranks and trainee level at academic programs. Whether an increase in female leadership in academic medicine is associated with an increase in female program directors and trainees is unknown. The aim of this study was to assess this relationship in GI. Data were collected via a standardized protocol from all 173 US gastroenterology fellowship programs up until October 2018 from program websites and supplemented by online surveys completed by program coordinators. Any missing information was collected by calling the program coordinators. Data were collected on gender and academic rank of the program director, associate program director, division chief, chair of medicine, program size, academic center affiliation, number, and academic rank of female faculty and geographic region. The association was assessed using a Chi-square test or independent samples t test. In leadership positions, men were listed as comprising 86% of chairs, 82% of division chiefs, 76% of program directors and 63% of associate program directors. Forty-three percent of programs did not have female representation at any leadership level. The presence of a female program director or female associate program director was associated with an increase in the number of female fellows (4.03 vs 3.20; p = 0.076; 4.26 vs 3.36; p = 0.041), respectively. Overall, the presence of a female in any leadership position led to an increase in the number of female fellows (4.04 females vs 2.87 females; p = 0.007) enrolled in a program. If a GI division chief was male, the program director was more likely to be male as well (81% male vs. 18.8% female). Conversely, having a female division chief was likely to lead to a more equitable program director representation, 54% female to 48% male (p value < 0.0001, OR 5.03 95% CI 2.04-12.3). Furthermore, if either the internal medicine department chair or GI chief was female, the proportion of female program directors increased to 41% as compared to 19% if both were male (p value < 0.0001, OR 2.99 95% CI 1.34-6.6). Women are significantly underrepresented in the number of practicing gastroenterologists, at all levels of leadership in GI fellowship programs, and at the fellow level. Increasing the number of women in fellowship leadership positions is associated with an increase in female program directors and trainees. Per our knowledge, this is the first study to examine the relationship between female leadership in fellowship programs and the gender of trainees. Increasing female representation in leadership positions would not only address current gender disparity, but it may also increase the number of female future GI trainees.

Navigating Through Right Career Choice After Gastroenterology and Hepatology Fellowship.

Navigating Through Right Career Choice After Gastroenterology and Hepatology Fellowship.

C.O.V.I.D.: A Survival Guide for GI Fellowship Training During the COVID-19 Pandemic

C.O.V.I.D.: A Survival Guide for GI Fellowship Training During the COVID-19 Pandemic

Assessing perspectives on artificial intelligence applications to gastroenterology

Assessing perspectives on artificial intelligence applications to gastroenterology

Impact of COVID-19 Pandemic on Training: Global Perceptions of Gastroenterology and Hepatology Fellows in the USA.

BackgroundThe COVID-19 pandemic has impacted numerous facets of healthcare workers’ lives. There have also been significant changes in Gastroenterology (GI) fellowship training as a result of the challenges presented by the pandemic.AimsWe conducted a national survey of Gastroenterology fellows to evaluate fellows’ perceptions, changes in clinical duties, and education during the pandemic.MethodsA survey was sent to Gastroenterology (GI) fellows in the USA. Information regarding redeployment, fellow restriction in endoscopy, outpatient clinics and inpatient consults, impact on educational activities, and available wellness resources was obtained. Fellows’ level of agreement with adjustments to clinical duties was also assessed.ResultsOne hundred and seventy-seven Gastroenterology fellows responded, and 29.4% were redeployed to non-GI services during the pandemic. COVID-19 impacted all aspects of GI fellowship training in the USA (endoscopy, outpatient clinics, inpatient consults, educational activities). Fellows’ level of agreement in changes to various aspects of fellowship varied. 72.5% of respondents reported that their programs provided them with increased wellness resources to cope with the additional stress during the pandemic. For respondents with children, 17.6% reported no support with childcare.ConclusionsOur results show that the COVID-19 pandemic has impacted GI fellowship training in the USA in multiple domains, including gastrointestinal endoscopy, inpatient consults, outpatient clinics, and educational conferences. Our study highlights the importance of considering and incorporating fellows’ viewpoints, as changes are made in response to the ongoing pandemic.Electronic supplementary materialThe online version of this article (10.1007/s10620-020-06655-y) contains supplementary material, which is available to authorized users.