Clinic

In clinic, residents are encouraged to review the medical chart of the upcoming patient and any pertinent imaging. Discuss with your attendings how he/she prefers to organize the day. Some will encourage you to go in and see the patient before them and gather the medical history and formulate an idea of what you think is going on; others may prefer that you see the patient simultaneously with them, as they often have long-term relationships with these patients and know them very well. It is imperative to develop a knowledge of the advantages and limitations of the various endoscopic procedures, as this will make you a better consultant for gastroenterologists and hepatologists and will allow you to consult endoscopists when patients would be better served by their services instead.

Diagnostic Imaging

The resident’s core diagnostic radiology skills will be very useful and frequently called upon throughout this rotation. The attendings typically review the imaging and report. However, they may turn to you as an experienced radiologist. In the clinic setting, new patients frequently present to the clinic with only outside imaging available; this is an excellent opportunity for you to showcase your expertise and help the clinician understand the findings on the CT or MRI. This is a great time to learn and build upon your CT and MRI abdominal imaging knowledge, as these patients often have complicated medical conditions that require advanced imaging. Furthermore, this experience will improve your clinical judgment as you observe how clinicians decide when an imaging study is indicated or needed, how they respond to radiologists interpretations, and how our reports affect patient management and their course in the hospital.

Relevance to Interventional Radiology

The resident will further develop their clinical knowledge and judgment, which will assist in their progression toward becoming a practicing clinical interventionalist. Patients with acute and chronic hepatic dysfunction will often require the services of interventional radiology. As part of the referring team, the IR resident has the opportunity to observe how patients requiring these procedures present and to assist in managing them fully during the peri-procedural and post-procedural period. This rotation is also an excellent opportunity to enhance your knowledge of the indications and limitations of the common interventional radiology procedures this patient population typically requires (see below). You will also gain a better understanding of the role of a consulting physician by observing how your team functions as consultants for patients on other services.

Frequently requested interventional radiology procedures:

  • Transjugular liver biopsy and portosystemic pressure measurements
  • Transjugular Intrahepatic Portosystemic Shunt (TIPS) placement /revision: both for bleeding and for refractory ascites
  • Visceral angiography and embolization for gastrointestinal hemorrhage
  • Treatment of post-transplant biliary and vascular complications
  • Balloon-Occluded Retrograde Obliteration (BRTO) for gastric varices
  • Percutaneous transhepatic cholangiogram (PTC) and biliary drainage catheter placement (PTBD)
  • Rendezvous procedure for endoscopic stent placement
  • Percutaneous metallic biliary stenting (usually for malignancy)
  • Image-guided large-volume and (in difficult patients) diagnostic paracentesis
  • Percutaneous cholecystostomy
  • Treatment of HCC: TACE, Y-90, Ablation
  • IVC filter placement and retrieval
  • G/J-tube placement / exchange

Specific Rotation Goals and Objectives

  • History and physical examination
    • Practice and refine the physical exam and medical history skills learned during internship year (PGY-1)
  • Clinical Knowledge
    • Gastrointestinal tract anatomy
    • Know anatomic location and relations of the esophagus and stomach, liver and biliary tree, pancreas, small and colonic bowel
    • Know the physiology of the liver and biliary tree, and pathophysiology of bile production and formation of biliary lithiasis
    • Develop a better understanding of the presentation of patients experiencing liver dysfunction, from the ambulatory setting through fulminant liver failure and transplantation.
    • Identify the physical exam findings in acute and chronic liver failure and portal hypertension.
    • Understand the diagnosis, work-up and treatment of the following:
      • Acute Liver Failure (NASH, Viral, drug- and toxin-induced, vascular (ischemic and venous), autoimmune)
      • Cirrhosis (Alcoholic, NAFLD, Viral, PBC, PSC, vascular)
      • ATN, Hepatorenal Syndrome
      • Hepatopulmonary Syndrome
      • Viral Hepatitis (Life cycle of HBV and HCV, new treatments)
    • Know the medications implicated in acute liver failure and the medications that should be avoided or doses adjusted in the setting of liver dysfunction.
    • Understand the relationship between the many liver diseases and hepatocellular carcinoma (HCC). Know the guidelines for serologic and imaging screening.
    • Know the following scoring systems: MELD, MILAN, Child-Pugh, BCLC
    • Understand the workup and points system for hepatic transplantation.
    • Know the indications for and amount of albumin supplementation during paracentesis. Know how to calculate SAAG and what it is used for.
    • Enhance your knowledge of the imaging presentation of hepatic disease and malignancy. These patients will have US, CT and/or MRI and this is an excellent opportunity to cement your understanding of the strengths and weaknesses of these modalities and how they are complementary
  • Procedural goals:
    • Potential procedures that you may be able to perform or participate in include:
      • EGD (surveillance and for acute issues)
      • ERCP and duct tissue sampling
      • EUS and EUS-guided FNA
      • Sphincterotomy and biliary stone removal
      • Variceal cauterization and band ligation
      • Endoscopic biliary and pancreatic stent placement and replacement
      • Endoscopic gastrostomy tube placement
      • Endoscopic pseudocyst gastrostomy

Systems Based Practice

  • Take on new patients and consultations with the goal of assigning team resources to address them in an appropriate and timely manner
  • Be able to coordinate care within the team over multiple patients and multiple problems of varying urgency (i.e. be able to triage effectively)
  • Coordinate hospital and physician resources in regards to transferring patients who are critically ill from other institutions
  • Complete full consult notes and progress notes every day on the patients that you are covering in a detailed and accurate format that is easily translatable to other services
  • Be an active, effective and efficient team member by effectively transferring care between duty hours completely and responsibly

Practice-Based Learning and Improvement

  • Shows appropriate use of consultation with medical and non-medical services, including special diagnostic studies
  • Uses evidence from the medical literature to answer clinical questions
  • Identifies areas for potential improvement in personal delivery of care
  • Maintains a positive attitude towards learning, including attendance and participation on patient rounds and conferences, and evidence of reading or other methods of gaining knowledge
  • Participates actively in teaching others, including students, residents, and faculty
  • Serve as a radiology advisor/liaison to the team when called upon
  • Educate the team regarding imaging utilization, radiation concerns and
  • Develop the clinical skills necessary to successfully manage a patient throughout the peri-procedural course, to help facilitate improved non-procedural interventional radiology patient care during your career.

Patient Care

  • Review past and current imaging on all patients you are involved with.
  • Perform procedures within the level of your knowledge under supervision.
  • Assist in the admission and discharge of patients when appropriate.
  • Assist in consults when appropriate.

Interpersonal and Communications Skills

  • Presents a patient effectively and efficiently
  • Communicates with patients and concerned others effectively
  • Writes accurate and complete entries in the medical record
  • Works constructively as part of a team
  • Exchanges information effectively and efficiently during rounds that reflects pertinent issues and problems, current therapeutic plans, and expected complications and issues
  • Establish therapeutic and empathetic relationships with patients and their families

Professionalism

  • Remember you are a guest in another specialties’ practice. Be prompt, present
  • Take on progressive amounts of responsibilities during your rotation and live up
  • Dress code: White coat and business casual attire is expected in the outpatient clinic. Scrubs under white coat may be acceptable on the floor depending on your attending. Scrubs alone are acceptable during procedures.