Sita S. Chokhavatia

Informed Consent in the Older Adult: OSCEs for Assessing Fellows’ ACGME and Geriatric Gastroenterology Competencies

OBJECTIVES:The American Gastroenterological Association fellowship curriculum identifies geriatric components for gastroenterology (GI) training; however, few tools are available for this purpose. Using an objective structured clinical examination (OSCE), we aimed to assess ACGME competencies of communication, professionalism, and geriatric-specific patient care among GI fellows.METHODS:We developed an informed-consent case involving a geriatric patient who needs surveillance colonoscopy. We used a validated faculty skills checklist to rate fellows across three competency domains. Fifteen fellows from four GI training programs participated.RESULTS:Although the fellows excelled at communication and professionalism, only 51% excelled at geriatric-specific patient-care skills. Fellows were least likely to demonstrate collaboration with the patient, to assess patient understanding, and to explain the limits of the test. Communication and geriatric-specific skills were correlated.CONCLUSIONS:OSCEs are a feasible method for assessing geriatric-related ACGME competencies for fellows. The results highlight the need for curriculum development.

Teaching the competencies: using observed structured clinical examinations for faculty development.

OBJECTIVES:Gastroenterology (GI) training programs must develop the teaching skills of their faculty and provide feedback to their fellows. Many faculty feel uncomfortable offering feedback or identifying specific areas for improvement to the fellows. We developed an Observed Structured Clinical Exam (OSCE) to assess fellows’ skills and provided faculty with specific criteria to rate the fellows’ performance. We propose that OSCEs can serve as tools for faculty development in delivering effective feedback.METHODS:Faculty completed a Web-based training module and received written guidelines on giving feedback. Four OSCE stations were completed by each fellow with faculty using standardized checklists to assess the fellows’ skills. Afterwards, faculty rated each program component and assessed their comfort level with feedback.RESULTS:Eight faculty members and 10 fellows from 5 GI training programs in NYC participated. 100% of the faculty agreed that feedback is an important learning tool, should include the learner’s self-assessment, and that feedback skills could improve with practice. Compared to faculty skills prior to the program, 87.5% of the faculty agreed that they focused more on specific behaviors and 75% agreed that giving negative feedback was now easier.CONCLUSIONS:OSCEs can serve as practicums for faculty development in giving constructive feedback.

Observing handoffs and telephone management in GI fellowship training.

OBJECTIVES:Gastroenterology (GI) training programs are mandated to teach fellows interpersonal communication and professionalism as basic competencies. We sought to assess important skill sets used by our fellows but not formally observed or measured: handoffs, telephone management, and note writing. We designed an Observed Standardized Clinical Examination (OSCE) form and provided the faculty with checklists to rate fellows’ performance on specific criteria.METHODS:We created two new scenarios: a handoff between a tired overnight senior fellow on call and a more junior fellow, and a telephone management case of an ulcerative colitis flare. Fellows wrote a progress notes documenting the encounters. To add educational value, we gave the participants references about handoff communication. Four OSCE stations—handoff communication, telephone management, informed consent, and delivering bad news—were completed by fellows and observed by faculty.RESULTS:Eight faculty members and eight fellows from four GI training programs participated. All the fellows agreed that handoffs can be important learning opportunities and can be improved if they are structured, and that handoff skills can improve with practice.CONCLUSIONS:OSCEs can serve as practicums for assessing complex skill sets such as handoff communication and telephone management.

Treatment of Acute Colonic Pseudo-Obstruction With Tegaserod

Acute colonic pseudo-obstruction is characterized by symptoms, signs and radiologic appearance of large bowel obstruction in the absence of a true mechanical obstruction. Several pharmacologic treatments have been proposed. We present a case of a patient with Guillain-Barré syndrome complicated by acute colonic pseudo-obstruction, who had a clinical response to tegaserod, a partial 5-hydroxytryptamine type-4 agonist. 5-Hydroxytryptamine type 4 agonists may be an option in the treatment of acute colonic pseudo-obstruction.

Gastrointestinal Dysmotility in the Elderly

The number of persons 60 years and older has increased 3-fold between 1950 and 2000. Aging alone does not greatly impact the gastrointestinal (GI) tract. Digestive dysfunction, including esophageal reflux, achalasia, dysphagia, dyspepsia, delayed gastric emptying, constipation, fecal incontinence, and fecal impaction, is a result of the highly prevalent comorbid conditions and the medications with which those conditions are treated. A multidisciplinary approach with the expertise of a geriatrician, gastroenterologist, neurologist, speech pathologist, and physical therapist ensures a comprehensive functional and neurological assessment of the older patient. Radiographic and endoscopic evaluation may be warranted in the evaluation of the symptomatic older patient with consideration given to the risks and benefits of the test being used. Treatment of the digestive dysfunction is aimed at improving health-related quality of life if cure cannot be achieved. Promotion of healthy aging, treatment of comorbid conditions, and avoidance of polypharmacy may prevent some of these digestive disorders. The age-related changes in GI motility, clinical presentation of GI dysmotility, and therapeutic principles in the symptomatic older patient are reviewed here.