The inpatient and outpatient clinical rotations at Cedars-Sinai provide fellows with exposure to patients with a variety of gastrointestinal, pancreaticobiliary and liver diseases that meet competency requirements of the Accreditation Council for Graduate Medical Education (ACGME).
The core training includes a minimum of 20 months of dedicated clinical rotations in inpatient general gastrointestinal, inflammatory bowel disease (IBD) and hepatology; and outpatient rotations in motility, IBD and pancreaticobiliary disorders. Electives and research months provide additional opportunities in areas of particular interest to the fellow. In addition, fellows will have a weekly continuity clinic throughout the fellowship.
A typical training schedule consists of the following:
Year 1 (PGY-4)
- GI/IBD consultation service (nine months)
- Hepatology (one month)
- IBD outpatient (one month)
- Outpatient GI or endoscopy (one month)
Year 2 (PGY-5)
- GI /IBD consultation service (two months)
- Hepatology (three months)
- GI outpatient (two months)
- Endoscopy (one month)
- Research (two months)
- Motility outpatient (one month)
- Nutrition/endoscopy (one month)
Year 3 (PGY-6)
- GI /IBD consultation service (one month)
- Hepatology (two months)
- IBD outpatient (one month)
- Pancreaticobiliary outpatient (one month)
- Motility (one month)
- Research (three months)
- Elective (three months)
Inpatient Consultation Service
- Gastroenterology Consultation Service: Fellows work closely with gastroenterology faculty to evaluate and manage patients with acute gastrointestinal and pancreaticobiliary diseases who have been hospitalized for medical, surgical, obstetric and other primary services. As a result of having specialized faculty and serving as a major referral center in the area, fellows serve as consultants on common GI cases such as gastrointestinal bleeding, nausea and vomiting, and abdominal pain; as well as for motility disorders and functional bowel disease. In addition, the fellow is responsible for general pancreaticobiliary consults. Fellows are also encouraged to perform endoscopic procedures on patients for whom they performed consultations.
- Inflammatory Bowel Disease Service: Fellows work with dedicated faculty in inflammatory bowel disease to help provide comprehensive diagnoses and treatments to our complex IBD patient population. The IBD inpatient service — an outgrowth of our world-renown IBD center and cutting-edge research — provides the fellow a unique opportunity to learn the "art of medicine" when dealing with highly complex patients. Fellows will be involved in a multidisciplinary approach, often working alongside colorectal surgeons, pain management specialists and clinical social workers. Fellows are responsible for presenting complicated cases at a weekly, multidisciplinary IBD case conference; and for participating in unique psychosocial seminars.
Fellows work with the faculty's transplant hepatologists and a dedicated nurse practitioner to evaluate, work up and manage inpatients with any of a variety of liver diseases. The fellow will be involved with general hepatology consults, compensated and decompensated liver disease, and patients awaiting liver transplantation as well as post-transplant management. Fellows will be exposed to the entire spectrum of viral hepatitis, alcoholic liver disease, nonalcoholic fatty liver disease, autoimmune hepatitis, and drug-induced liver disease. Fellows have the unique opportunity to consult and manage post-transplant patients on the transplant service and become familiar in acute and chronic rejection and managing immunosuppressive therapy.
Inflammatory Bowel Disease Clinic
Fellows evaluate new referrals and perform follow-up examinations with established patients in several half-day clinics each week at the IBD clinic. Fellows work alongside IBD specialists to learn the highly complex outpatient management of intestinal and extra-intestinal IBD. The experience includes decision-making in IBD therapies, medication management, lab monitoring and colonoscopy surveillance. Fellows learn the complexity and the wide variation of management between patients in our high-volume, high-complexity IBD clinic.
GI Motility Clinic
Fellows work alongside faculty with specialization in motility disorders to evaluate patients in the GI motility clinic. Fellows are exposed to a large number of patients with a wide variety of dysmotility disorders, including achalasia, gastroparesis, small bowel dysmotility, functional bowel disease, small intestinal bacterial overgrowth, colonic inertia and pelvic floor disorders. Fellows learn to perform and interpret high-resolution esophageal manometry, lactulose breath testing and pH monitors, among other tests, during their time in the motility program. Fellows are encouraged to perform endoscopic procedures on the patients for whom they performed consultations.
Fellows will participate in evaluating patients alongside our interventional gastroenterologists and pancreatologists in the ambulatory setting. Fellows will gain exposure to patients with chronic pancreatitis, sphincter of Oddi dysfunction, and pancreatic and biliary malignancies, among other conditions. This rotation will also allow fellows the opportunity to learn how to interpret small bowel endoscopy and determine the type of interventional endoscopy procedure indicated, if any, based on findings.
Fellows rotate at high-volume centers partnered with the Cedars-Sinai Gastroenterology Fellowship (Kaiser Permanente and Los Angeles County + USC Medical Center), with the primary goal of working under direct supervision of faculty to gain proficiency in diagnostic endoscopy and therapeutics. Diagnostic upper endoscopy and colonoscopy are emphasized first, followed by therapies such as hemostasis, esophageal dilation, polypectomy and banding. Fellows should also become proficient in percutaneous endoscopic gastrostomy. The fellow is also expected to learn the principles of anesthesia, including conscious sedation and monitored anesthesia care. The fellow's time is dedicated primarily to endoscopic procedures during this time.
Fellows spend an outpatient-clinic rotation focused on clinical gastroenterology as practiced at a community-based, academically oriented center. The rotation consists of five half-day endoscopy sessions with Cedars-Sinai Medical Group faculty and five half-day shifts in a clinic with a focus on community-based gastroenterology and consultations. The Cedars-Sinai Medical Group program offers a unique opportunity for a general gastroenterology experience and community-based education. We feel the opportunity to have our fellows work in a high-volume gastroenterology division and to work with busy clinicians and private practitioners on basic clinical gastroenterology is valuable real-world experience.
This multidisciplinary rotation is designed to provide fellows with an education in the diagnosis and management of nutritional clinical issues. Under the guidance of the gastroenterology staff, nutritional nursing staff and renal staff, education in the diagnosis and management of malabsorption and diarrheal diseases is provided in an inpatient and outpatient setting. Training is provided to all fellows at a basic level and for those who wish to specialize in nutrition at an advanced level, including total parenteral nutrition. Training is under the direct supervision of an attending gastroenterologist.
Part of the mission of the fellowship program is to train fellows in clinical investigation and to contribute to each fellow's scholarly and academic development. As such, all fellows are expected to identify a clinical mentor early in their fellowship and pursue a defined research project. Each fellow will have five to six months of dedicated time to engage in scholarly activity. This time is intended for the fellow to become familiar with the research process by selecting clinical questions, developing a protocol, obtaining IRB approval, collecting data, and participating in statistical analysis — all of which is intended to generate academic productivity. Fellows are encouraged to submit and present their research projects at local and national conferences.
A unique aspect of Cedars-Sinai is its wide spectrum of research endeavors, which include a significant amount of basic science and translational research. When adjusted for the number of faculty, Cedars-Sinai is one of the top GI divisions nationwide in receiving federal funding to support basic research projects. Cedars-Sinai has scores of laboratories on its campus dedicated to basic research. The new Advanced Health Sciences Pavilion is an 11-story, 820,000-square-foot, state-of-the-art facility that brings clinical practice and translation research together under one roof. These extensive resources offer our fellows the opportunity to engage in basic research across a variety of disciplines, including GI, immunology, liver immunology, alcoholic liver disease, non-alcoholic steatohepatitis, liver cancer, colon cancer, pancreatic injury and cancer.
Training for a Career in Biomedical Research
Our division also offers an opportunity that combines a traditional clinical training program with an intense and goal-directed research training program that totals four years in length, with the option of a fifth year.
The purpose of this program is to prepare trainees to become highly skilled in biomedical research areas that will enhance the field and to obtain positions in leading academic medical centers. The program includes opportunities for mentored research in a full range of disease areas and disciplines relevant to gastrointestinal, liver and pancreatic disorders, including laboratory-based disease mechanism investigations, health outcomes, quality assurance and epidemiology. Cedars-Sinai faculty members are national and international leaders in these areas. In addition, a program of didactic learning and seminars is tailored to the needs of the individual trainee. All trainees undergo training in ethics and are enrolled in a workshop on grant writing skills.
Conferences and Didactics
Various conferences and didactic lectures complement the fellow's education in patient care while also integrating core topics in the principles of gastroenterology and hepatology:
- Journal Club: weekly on Tuesday
- Core Topics Didactic Lecture Series: weekly on Tuesday
- Basic/Board Review Lecture: weekly on Monday
- IBD Case Conference: weekly on Wednesday
- GI Grand Rounds: weekly on Thursday
- Morbidity and Mortality Conference: every three months on a Thursday
- Pancreatitis Case Conference: weekly on Thursday
- Liver Pathology Conference: weekly on Tuesday
- GI Pathology Conference: bi-weekly on Wednesday
- Capsule Endoscopy Review: bi-weekly on Thursday
- Hepatobiliary-Pancreatic Case Conference: monthly on a Tuesday
- Psychosocial Seminar: monthly on a Wednesday
- Esophageal Case Conference: monthly on a Thursday