Pediatric Gastroenterology Inpatient (Service Line) Rotation
John Kerner, M.D.
Professor of Pediatrics
Department of Pediatrics
Division of Gastroenterology, Hepatology and Nutrition
Stanford University Medical School of Medicine
750 Welch Road 116
Palo Alto, CA 94304
Phone: 650.723.5070
jkerner@stanfordmed.org
Introduction
The pediatric gastroenterology inpatient rotation provides an opportunity for the resident to develop an understanding of the pathophysiology, clinical manifestations, and management of complex common and unusual disorders of the gastrointestinal tract, liver, and pancreas. Emphasis will be placed on the performance of a detailed and focused history and physical examination and the interpretation of laboratory, imaging studies, and G-I procedures (e.g., upper endoscopy, colonoscopy). Following completion of the rotation, residents will be able to initiate initial evaluation and management of these complex patients.
Goals
To develop the knowledge, skills, and attitudes to acquire competency in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice applicable to the pediatrician dealing with common gastrointestinal problems.
Objectives
I. To develop the knowledge and skills needed to recognize and manage the following complex pediatric gastrointestinal problems.
A. The Inpatient Management of
- Inflammatory Bowel Disease
- Gastroesophageal Reflux
- Motility Disorders (e.g., Intestinal Pseudo-obstruction)
- Acute Pancreatitis/pancreatic exocrine insufficiency
- Peptic Ulcer Disease
- Congenital Anomalies of the G-I Tract
- Short Bowel Syndrome
- Chronic Hepatitis
- Liver Failure (both acute and chronic)
- Post Liver Transplant Complications
- Rejection
- Infections in Immunocompromised Patients
- Lymphoproliferative Disease
B. The Inpatient Work-Up of:
- Failure to Thrive
- Chronic Diarrhea
- Conjugated Hyperbilirubinemia
- Acute Gastrointestinal Bleeding
C. Nutritional Support in Pediatrics
Methods Used to Evaluate Completion of Objectives:
Resident performance (including knowledge base, diagnostic skills, and ability to formulate a plan of management) is evaluated during the inpatient experience and by a written examination modeled after the ABP certifying examination.
Additional “Tools” for Evaluation of Competencies:
- Each resident will give an oral presentation either on an “AAP Top Ten List” topic or a journal article of particular relevance or a relevant case presentation with discussion.
(Faculty evaluation of the presentation will be added to the resident’s portfolio.)
- Each resident will keep a journal recording a running list of the diagnoses of all inpatients and outpatients seen so the faculty can help assure there is a broad exposure to Pediatric G-I cases over the course of the rotation.
Schedule
Monday |
Tuesday |
Wednesday |
Thursday |
Friday |
|---|---|---|---|---|
8-9:30 a G-I/Liver Meeting 750 Welch Rd. 116 |
8-8:30 am Morning Report |
8-8:30 am Morning Report |
8-8:30 am Morning Report |
8-9 am Grand Rounds |
| 9:30 am – noon G-I Clinic |
Inpatient Consults/Directed Reading | Inpatient Consults/Directed Reading 10 am – 12 noon Nutrition Support Rounds (3 East Conference Room) |
9 am – noon G-I Clinic |
9 am – 12 noon Pediatric Obesity Clinic. Mt. View Commons |
| Noon Conference | Noon Conference | Noon Conference | Noon Conference | 12:15 pm – 1 pm G-I Teaching Seminar |
1 pm – 5 pm G-I Clinic |
1 pm – 5 pm G-I Clinic |
G-I Clinic (SCVMC)* |
1pm – 5 pm G-I Clinic 1st and 3rd Thursday of each month: 1:30 pm – 5:30 pm G-I Clinic (PAMF)** |
1:30 pm – 5 pm G-I Clinic |
* Attending: Dr. Manuel Garcia/Dr. Missy Hurwitz
** Attending:Dr. Dorsey Bass
References
Each resident will receive a folder including:
- A CD with current articles on all aspects of pediatric G-I, liver, nutrition, and transplantation.
- Listing of all faculty and ancillary staff, including phone and pager numbers.
- A review article on Failure to Thrive and on Parenteral Nutrition.
- A Pediatric Formula Guide, a pediatric nutrition handbook and supplementary information on formulas available at LPCH.
Faculty Preceptors
| John Kerner, M.D. | Ken Cox, M.D |
| Manuel Garcia, M.D. | William Berquist , M.D. |
| Dorsey Bass , M.D. | Ricardo Castillo, M.D. |
| Eric Sibley , M.D. | Missy Hurwitz , M.D. |
For the inpatient service, one of the above attendings will be responsible for GI inpatients and all consults; Liver Transplant patients, Small Bowel Transplant patients, or combined Liver-Small Bowel Transplant patients will be covered by a separate attending. There will be 1-2 fellows on inpatient service, depending on the schedule (if there are 2, they will parallel the patient load of each attending).
General Expectations
The PL-1 and PL-2 or PL-3 assigned to G-I/Liver Transplant will be responsible for the day-to-day management of all medical patients followed by either the G-I service or the Liver Transplant Service (except those followed in the PICU and except for any liver or liver/small bowel transplant patients followed by the Pediatric Liver Nurse Practitioner). They will both participate in outpatient G-I and liver clinics, with the intern primarily responsible for the inpatients.
Interns (PL-1’s)
A. Primary physician for all medical patients on the G-I or Liver Transplant Service except as stated above.
B. Responsibilities
- Write up history, physical, and treatment plan on all service admissions in consultation with the PL-2 or PL-3 and G-I or Liver Transplant Attending.
- Write all of the orders on G-I and Liver Transplant medical patients.
- Arranging for all special diagnostic tests.
- Maintenance of charts, including daily progress notes, growth charts, and lab results on all patients. In general, progress notes should be written at the earliest after morning rounds, but preferably later in the day when results of laboratory tests, cultures, radiologic studies, etc. are available. If a significant change in the patient’s status, requiring a change in management occurs after the daily progress note is written, an addendum must be written.
- Keeping parents and patients apprised of progress, lab results, new developments, etc.
- Discharge summaries must be dictated on all patients within 48 hours of discharge. Face sheets must be completed at the time of discharge.
- As the primary physician, the intern is responsible for knowing each of his/her patients in detail including past medical history and relevant psychosocial history.
Rounds
- Interns will be responsible for presenting their patients in detail at Work Rounds in the morning and briefly presenting a review of the status and treatment plan of everyone of the intern’s patients to the on-call residents on Evening Sign-Out Rounds.
- Interns will be expected to have rounded on their inpatients prior to morning work rounds so they will be able to present an up-to-date clinical summary and appropriate latest labwork. Presentation should be succinct: reviewing each patient in appropriate detail by active problems with a presentation of assessment and plan for each problem. New patient admissions will be presented formally and in detail.
- Additional teaching rounds will be arranged between the Attending, Fellow, and Housestaff.
Outpatient Clinic
- Arrangements will be attempted to enable the intern to attend at least ½ day of G-I or Liver Transplant Clinic if the PL-3 is able to cover the inpatient service.
Supervisory Resident (PL2’s or PL3’s)
- Direct supervision of the PL-1 for all medical inpatients on the G-I or liver transplant service (except as stated before)
- An admission history and physical is to be dictated on each medical patient on the services above.
- Supervising proper maintenance of the patients’ charts on the above services.
- The PL-2 or PL-3 will lead morning Work Rounds, focusing on all active problems for each patient.
- The PL-2 or PL-3 will perform G-I consultations as requested by the G-I Attending.
- The PL-2 or PL-3 will attempt to attend 2-3 half-days of G-I or Liver Transplant Clinic if patient care responsibilities allow the resident to leave the inpatient service.
- The PL-2 or PL-3 will cover the G-I and Liver Transplant medical inpatients once a week to enable the PL-1 to attend a half-day of G-I or Liver Transplant Clinic.
The G-I and Liver Transplant Division will recognize the important release times for residents:
A. Morning Report
- Noon Conference
- Continuity Clinic
- Evening Rounds
| PL-1 | PL-2 or PL-3 | |
| Inpatient: | Pre-round on all patients before Work Rounds | Supervise PL-1 |
| Daily progress notes | Dictate H&P on all new patients | |
| Hand written H&P on all new patients | Perform G-I consults as requested by G-I Attending | |
| Write all patient care orders | ||
Clinic: |
Attend 1 half-day of G-I/Liver Transplant Clinic | Attend 2-3 half-days of G-I/Liver Transplant Clinic |
