Pichamol Jirapinyo, Christopher Thompson
How to Incorporate Bariatric Training Into Fellowship Programs
This document provides proposed objectives, curriculum content, training models, available resources and assessment of competence for obesity medicine and endoscopy training within gastroenterology fellowship programs. © 2019 by the AGA Institute
As gastroenterologists become more active in the care of patients with obesity, fellowship programs should be ready to provide an intellectual environment for trainees to acquire the knowledge, skills, clinical judgment, and professional attributes that are essential to the practice of obesity medicine. This article addresses the process of incorporating bariatric training into gastroenterology fellowship programs. This article is based largely on expert opinion and is intended to start a discussion regarding the introduction of obesity and obesity management into gastroenterology fellowship programs as well as to serve as a general guide for training programs moving forward.
Bariatric training for gastroenterology fellows may be divided into 2 levels. Level 1 represents basic training in obesity medicine that should be provided to all trainees. Level 2 represents advanced training for fellows who are interested in specializing in obesity medicine and include those who plan on practicing obesity medicine with or without bariatric endoscopy.
Bariatric training in gastroenterology fellowship can take a variety of forms. Various models and resources will likely be required to achieve these goals. Tables 1 and 2 illustrate the suggested bariatric content for the gastroenterology core curriculum, and the levels 1 and 2 sections detail a proposal for delivery of this content.
Jirapinyo P, Thompson CC. How to Incorporate Bariatric Training Into Your Fellowship Program. Gastroenterology. 2019;157(1):9-13.
TABLE 1. Suggested Obesity-Related Gastroenterology Core Curriculum Content
TABLE 2. Currently available obesity medications, primary EBMTs, and complications of bariatric surgery
The fellowship programs should provide all trainees with a general understanding of the following topics.
Obesity and Its Pathophysiology
Trainees should understand the definition, classification, and social impact of obesity. The pathophysiology of obesity and its related comorbidities should be emphasized. Additionally, trainees should learn to recognize and manage gastrointestinal diseases that are more common in patients with obesity.
Principles of Obesity Management
Trainees should develop a basic understanding of lifestyle modification, pharmacotherapy, and endoscopic and surgical interventions for the treatment of obesity and its comorbidities, and should know when to appropriately refer patients for each treatment modality. The importance of an interdisciplinary team strategy should also be emphasized.
Endoscopy in Patients with Obesity with or without Previous Bariatric Surgery
Trainees should understand challenges related to sedation and airway management in patients with obesity. Goals of endoscopy before bariatric surgery should also be emphasized. Additionally, they should understand and be able to recognize surgical anatomy for bariatric procedures and be able to diagnose and manage common complications.
Ethics and Professionalism
Trainees should learn to be mindful of obesity-related psychosocial issues and be able to obtain weight-related history in a neutral and non-stigmatizing way. Careful attention should be given to selecting and using weight-friendly equipment.
Level 2 trainees should achieve all level 1 goals in addition to the following.
Comprehensive Medical Evaluation for Patients with Obesity
Trainees should be able to obtain a complete weight-related history and physical examination. They should also be competent in the evaluation of secondary causes of obesity and related nutritional deficiencies. Additionally, they should be capable of performing a thorough prebariatric surgical evaluation, including preoperative endoscopy as indicated.
Competence in Lifestyle and Medical Management of Obesity
Trainees should be able to advise patients on specific diet plans and exercise programs with appropriate intensity. Eating disorders and relevant psychiatric conditions should also be addressed. Trainees should be familiar with medications that promote weight gain and know alternative medications to suggest to the prescribing physicians. Comprehensive knowledge of and ability to prescribe weight loss medications (US Food and Drug Administration–approved and off label) should also be achieved.
Understanding the Cognitive Aspects of and Achieving Technical Proficiency in Endoscopic Bariatric and Metabolic Therapies
Trainees should have a comprehensive understanding of the US Food and Drug Administration–approved and investigational endoscopic bariatric and metabolic therapies (EBMTs). Patient selection, risk–benefit profile, adverse events and their management should also be emphasized. Additionally, the sedation plan, pre-procedural assessment, and post-procedural instructions should be a part of the bariatric curriculum. Furthermore, programs may offer a variety of procedures, including various primary EBMTs and specific complication management techniques. If a program does not perform a certain class of procedure, access to relevant content experts should be arranged.
American Boards of Obesity Medicine Certification
For level 2 trainees who plan on subspecializing in bariatrics, programs should be prepared to provide a path that allows them to become board certified in obesity medicine. As of 2018, there are 54 gastroenterologists who are board certified in obesity medicine, representing 2% of all ABOM diplomates. This number is however expected to increase.
Didactic Lectures and Selected Readings
To obtain the core knowledge required for all trainees, didactic lectures and selected readings should be integrated as part of the fellowship curriculum. At institutions where experts in obesity medicine, bariatric endoscopy, or bariatric surgery are available, these lectures should be given by the experts and topics should include the medical, endoscopic, and surgical management of obesity. Additionally, several readings and guidelines on obesity medicine are available and should be included as part of training.
Online Training Modules
Fellows can acquire additional knowledge in bariatric medicine through online training modules. For institutions that are able to provide a comprehensive curriculum through didactic lectures, this training model may be optional. Additionally, these modules may be selectively implemented depending on available resources at individual programs. Current online training modules include the Obesity Medicine Academy which is the academy’s online learning platform including >200 on-demand presentations related to obesity medicine, and various American Society for Gastrointestinal Endoscopy training videos.
Clinical Shadowing Experience
All trainees should have clinical exposure to all areas listed. These clinical experiences can be obtained by rotating on inpatient and outpatient nutrition and bariatric surgery services. Clinical shadowing in a weight loss clinic and a bariatric endoscopy clinic (if available) should also be offered. For institutions that have bariatric endoscopists, an endoscopy rotation to expose trainees to postbariatric surgery anatomy and endoscopic management of complications should be provided.
Level 2 training should be obtained at institutions where faculty have expertise in obesity medicine and bariatric endoscopy if available. Achievement of competence in level 2 training requires an average of 12 months of clinical and research training in obesity medicine, which can be provided either as a separate fourth-year fellowship or as part of the third-year gastroenterology fellowship for certain programs. In addition to the listed teaching materials required for level 1 trainees, level 2 trainees should be exposed to the following.
An interdisciplinary case conference focusing on bariatrics should be available at the institutions that provide level 2 training. Experts from various disciplines including nutrition, social worker, psychology, endocrinology, gastroenterology and surgery should be part of the conference. Fellows should participate by presenting interesting cases, as well as landmark and recently published articles and research projects.
Level 2 trainees should have an opportunity to rotate through several subspecialty clinics, including nutrition, lifestyle coaching, obesity medicine, bariatric endoscopy, and bariatric surgery. This training may be done concurrently or sequentially. Trainees should actively participate during these rotations with a goal of being able to independently provide counseling on lifestyle intervention, prescribing weight loss medications, and performing procedures by the time of graduation. A few sessions to observe bariatric surgery should also be considered to further enhance trainees’ understanding of anatomy and surgical technique.
Trainees should start by learning principles of diagnostic endoscopy in patients with obesity and those with previous bariatric surgery, including the diagnosis of marginal ulceration, fistulas, and stenosis. Simple therapeutic procedures such as argon plasma coagulation for the treatment of weight regain and balloon dilation of stenosis may then be considered. Next, trainees may progress to less complex primary EBMTs, such as aspiration therapy and intragastric balloons. Before learning more complex procedures including endoscopic suturing and plication, trainees should learn to assist and become comfortable with the devices, accessories, and steps involved in each procedure.
Hands-on Simulator Training
Hands-on simulator training should be highly considered for a subset of Level 2 trainees who aspire to perform bariatric endoscopy in clinical practice. This includes mechanical and ex vivo simulators developed primarily for training of more complex procedures such as endoscopic suturing and plication. Company- and device-specific simulators are also becoming available. It is recommended that trainees learn and practice using the device and accessories in the simulator before initiation of their first human case.
Courses Outside Institution
There are several courses that focus on obesity medicine with a few focusing primarily on bariatric endoscopy with hands-on and/or live case demonstration.11 Additionally, an increasing number of interventional endoscopy courses have started to incorporate a day of bariatric endoscopy training which includes both didactic lectures and hands-on session.
Externship at Bariatric Center of Excellence
For programs that lack expertise in any of these areas, trainees should be encouraged to do externship rotations to achieve comprehensive training. These externship rotations may also be structured to count toward the 18-month clinical Accreditation Council for Graduate Medical Education (ACGME) requirement.
Obesity Medicine and/or Bariatric Endoscopy Fellowship
Currently, there are several obesity medicine fellowship programs, all of which require completion of an ACGME-accredited residency program and range from 1 to 3 years. Additionally, trainees may choose to pursue a 1-year bariatric endoscopy fellowship. These programs typically take fourth-year fellows; however, training may also be accomplished within select 3-year gastroenterology fellowship program. Additionally, many fourth-year advanced endoscopy fellowships are increasingly, including bariatric endoscopy as part of their curricula. However, with many diverse objectives these programs often do not have time to incorporate a comprehensive interdisciplinary structure that is critical to learning obesity medicine.
There are currently 2 pathways for trainees to become board eligible for ABOM examination. First, trainees may spend >500 hours (equivalent to 2.5 full-time months) on clinical rotations managing patients with obesity and/or obesity-related conditions. Second, they may earn 60 continuing medical education credits with 30 credits being earned from attending one of the following conferences—Obesity Medicine Association Spring Conference, Columbia University/Weil Cornell Obesity Conference, Harvard Blackburn Course in Obesity Medicine, Obesity Medicine Association Fall Conference and Obesity Week—and the remainder 30 credits from participating in home-based continuing medical education activities or live meetings where obesity is the specific educational focus.
ASSESSMENT OF COMPETENCE
Knowledge of obesity medicine and bariatric endoscopy should be assessed as part of the overall evaluation of trainees in gastroenterology during and after the fellowship. Questions relating to obesity medicine and bariatric endoscopy should be included on the gastroenterology board examination and should reflect a general knowledge of this content. Assessment of competency for Level 2 goals may be more appropriately achieved through non-ACGME pathways including ABOM certification and programs being put forth by Society of American Gastrointestinal and Endoscopic Surgeons and the ABE.
© 2019 by the AGA Institute