This residency program is for 2 years.

Program length of training does not exceed the Royal College or College of Family Physicians of Canada standard.

The Program:

The program operates in and is supported by 2 closely integrated teaching hospitals, the Kingston General Hospital (KGH) and the Hotel Dieu Hospital (HDH). These institutions are located in the central part of the city, separated by about 700 meters. All of the acute inpatient care is delivered at KGH. HDH provides all ambulatory care. Trainees spend about a third of the time at KGH. All specialty care in the city is provided by the academic members of the Division. There are no locally based private practice gastroenterology clinicians. A home TPN program under GI leadership has recently been developed which will provide added educational opportunities.

Acute Inpatient Experience – KGH

KGH is a 450 bed, tertiary care general hospital with all medical and surgical services except liver, lung and cardiac transplantation, though patients post liver transplant are followed in clinic. It is a regional gastroenterology resource for a population of about 750,000. Facilities include a busy emergency department, a large multi-functional ICU, coronary care and neurological intensive care specialty units and renal dialysis. Renal and bone marrow transplant programs are in routine operation. Traditional contrast imaging is supported by MRI as well as CT, ultrasound and radioisotope scanning. An active interventional radiology group offers, among others, acute angiography for bleeds, TIPS for varices, transjugular liver biopsy and portal pressure measurements, percutaneous ethanol injections, RFA and transarterial chemoembolization for hepatocellular cancer and a full range of interventional biliary procedures.

Gastroenterology maintains a dedicated inpatient CTU that lists at 5 beds. The case mix includes patients undergoing special procedures( TACE, POEMS, ESD), inflammatory bowel disease patients, patients with unstable GI bleeding, and liver failure cases. A well-equipped endoscopy suite with dedicated endoscopy nursing staff provides all endoscopic services 24 hours a day. The GI inpatient service is staffed by one attending from the teaching staff (alternate every 2 weeks), as well as the GI fellow plus or minus the help of rotating residents on elective.

The KGH experience is designed to provide trainees with supervised opportunities to evaluate and manage sick GI patients requiring hospital-based care and to develop additional skills critical to the efficient use of hospital resources. The GI Consult resident assigned, in 4 week blocks, to the inpatient service evolves to act as a junior attending as progressive competence is demonstrated. In addition to overseeing the 5 CTU beds, KGH ward resident performs all of the endoscopy procedures on the inpatient cases as well as attending HCC rounds and TPN service sessions. These include all the consultation endoscopies as well as the GI CTU cases.

KGH also provides a large number of inpatient medical and surgical GI consultations (5-7 cases daily on average). The majority of the consultations are seen by the GI resident assigned to the consult service. The consults are regularly supervised by a member of the teaching Faculty alternating every 2 weeks. The GI consult resident has one 1/2 day of weekly outpatient endoscopy time.

A resident’s room with computer access is provided.

Ambulatory Experience – HDH

Approximately 2/3 of the training time is spent at HDH in ambulatory care which inherently provides a longitudinal experience. This includes up to 8 half-day clinics (general, urgent, liver, hepatitis, motility and IBD) and 2 procedure half days weekly. The objectives of ambulatory training are to provide supervised exposure to both common and unusual ambulatory GI problems and to instruct trainees in the organization and operation of an ambulatory endoscopy facility.

HDH operations are designed to facilitate efficient patient-centered care. There is excellent well-staffed clinic space and a fully functioning ambulatory endoscopy unit staffed by dedicated endoscopy nurses. A multifunctional GI function lab offers a range of breath tests, high-resolution esophageal manometry, anorectal manometry, ambulatory pH-impedance testing, and video capsule endoscopy. An added benefit in the ambulatory area is the immediate geographic proximity of the clinic, the endoscopy suite, the GI function lab as well as the translational research core lab and reseach offices on the same floor. Currently the GI residents use HDH as home base. A resident’s room with computer access is provided.

Endoscopy:

The program provides instruction in all aspects of endoscopic intervention. Although a trainee’s graded responsibility and independence increases with increasing levels of stage-specific competence, all procedures are performed with the responsible attending physician present in the endoscopy unit. Procedures include upper endoscopy, colonoscopy and sigmoidoscopy. Therapeutic interventions include injection (saline/epi, sclerosant), banding, bipolar coagulation, argon plasma coagulation, polypectomy, clipping, endoloops, chromoendoscopy, endoscopic mucosal resection (freehand and cap) and endoluminal dilation. The caseload easily enables trainees to exceed thresholds for the achievement of competence.

Second year trainees who plan to pursue advanced therapeutic endoscopy fellowship training and who have made satisfactory progress and are in good standing in all domains may be offered the opportunity to undertake a longitudinal training experience in ERCP. These trainees usually participate in/perform about 50 cases under supervision. Interventions include sphincterotomy, balloon and basket stone extractions and biliary stent placement. Although achieving competence with this level of training is not expected, it provides a good understanding of the procedure and a foundational skills for trainees who will be pursuing advanced training in therapeutic endoscopy.

The program also provides an Endoscopic Ultrasound service including FNA, biopsy capability, pseudocyst drainage, and celiac neurolysis. Trainees may wish to become familiar with this modality but the program does not provide instruction in the 2-year program to enable trainees to become competent in this procedure.

New since 2020, the second year(Core stage) residents have a 4-week endoscopy rotation in preparation for the transition to practice stage. There has been very positive feedback from the GI residents so far about this experience.

Motility:

The program provides basic and advanced training in motility testing. Both esophageal and anorectal motility testing is readily available. Trainees learn the execution and interpretation of these testing methods. Interested trainees may develop skills sufficient to enable them to establish motility testing facilities in practice though a formal motility fellowship is encouraged. The resident is assigned to motility studies for ½ day a week and interacts closely with the Motility Fellow when present.

Structured Educational Activities:

The program includes several protected structured activities which constitute the academic half day. These include a weekly critical appraisal journal club (1 hour), pathology round (1 hour), and clinical round (1 hour). Weekly case-based learning or visiting professor talks (1 hour) are also included in the academic half day curriculum which has been extended to cover a 2 year curriculum. A bootcamp is run in the summer for new residents as part of the transition to specialty/discipline experience. We participate in the Canadian Association of Gastroenterology Basic Science National Teleconference Series (1.5 hours/month) and GI residents run a Directed Independent Learning review of core GI physiology and principles in preparation for the RCPSC GI exam. A monthly informational journal club runs from September to May (2 hours). GI residents attend twice monthly Hepatocellular carcinoma rounds as well as sessions with TPN pharmacists and dieticians to hone skills in prescription and the management of patients on TPN.

Trainees are allowed up to 3 months of elective activity. Trainees have no responsibilities to the program (call schedule) during the elective block. Selection is the responsibility of the trainee. The Program Director is available for consultation and guidance. Trainees may do the electives on-site or remotely but in each case the elective must be approved by the Program Director. RCPSC style evaluations are expected in all cases.

A 1 month mandatory community GI elective is also carried out in Peterborough in the the second year. One month of GI pathology is now part of the first year experience for all.

In addition to the radiology teaching that occurs daily on a case by case basis, trainees complete a one month radiology block in the second half of their first year. This focuses on luminal studies and cross sectional imaging.

Research:

Trainees are expected to undertake a research project in either basic science or clinical research, as well as a quality assurance/improvement project. Each trainee is encouraged to submit this research to the Canadian Association of Gastroenterology resident training course( GRIT) and Canadian Digestive Diseases Week. To encourage focused and productive research, trainees in good standing are allotted the option to take four weeks of dedicated research time during their second year of training for completion of their work and manuscript preparation.

Evaluation:

The program has transitioned to a CBME-based model of evaluation as part of the exciting process occurring at Queen’s at this time.

Because the program is small (4-6 trainees) and all the teachers are full time academic staff, evaluation occurs easily throughout training thus having made the transition to CBME a logical and achievable step. Each trainee is assigned an academic adviser with whom they meet quarterly and who will help coach them and monitor their learning trajectory across the different stages as they develop competence in their Entrustable Professional Activities (EPAs). The program director meets with trainees every 3-months unless a problem is identified requiring more timely intervention. As per tradition, informal feedback is continuous and will now be captured in field notes in the clinical setting. Trainees are evaluated on their teaching and leadership skills as well as their knowledge bases and clinical skills. The program employs the RCPSC Goals and Objectives in Gastroenterology as the blueprint for evaluations according to the CanMeds philosophy. EPA’s under the new CBME framework are assessed by Field notes, Supervisor forms for direct and indirect observations as well as Procedure forms. Their timely completion is facilitated by WiFi in both hospitals, as well as desktop terminals in all team review rooms. These are all captured and loaded into the learners portfolio on the Elentra platform and can be reviewed by the learner for purposes of self-assessment as well as with their academic adviser. Advisers report to the Competence Committee which decides when the requirements for stage completion are met.

In addition, there is an OSCE in the spring of each year, 360°feedback twice a year, presentation skills assessments and a yearly formative AGA practice multiple choice written exam.

Surgical Support:

The program enjoys excellent collaboration with the Division of General Surgery. Surgical special interests include esophageal diseases (1 surgeon), bariatric surgery(1 surgeon), tertiary hepatobiliary surgery (2 surgeons), colorectal surgery (2 surgeons) as well as general surgery. Co-management of GI bleeds, complex hepatic tumors and difficult IBD cases is commonplace. One surgeon is a regular supervisor in the ERCP training activities.

Pathology Support:

Interpretation and teaching are provided by GI specially trained pathologists. These individuals organize and run the weekly pathology round which is a highly acclaimed part of our training program curriculum.

Gastrointestinal Oncology:

The program is integrated with the Kingston Regional Cancer Center based at KGH. Trainees are encouraged to attend a weekly multidisciplinary GI oncology round (1 hour) attended by the medical oncologists, radiation oncologists, GI pathologist, surgical oncologists and representative attending staff. This is a clinically oriented round focusing on 3 to 5 cases of mutual interest. As similar hepatocellular carcinoma multidisciplinary round exists.