DM Gastroenterology

Curriculum

DM Gastroenterology

Index

Goals
Objectives
Syllabus
Teaching programme
Schedule of Posting
Research Project
Assessment
Job responsibilities
Suggested books and journals
Model Test Papers

Curriculum

DM Gastroenterology

The infrastructure and faculty of the department of gastroenterology will be as per MCI guidelines

1. Goals

The goal of DM course is to produce a competent Gastroenterologist who:

Recognizes the health needs of adults and carries out professional obligations in keeping with principles of National Health Policy and professional ethics;
Has acquired the competencies pertaining to gastroenterology that are required to be practiced in the community and at all levels of health care system;
Has acquired skills in effectively communicating with the patients, family and the community;
Is aware of the contemporary advances and developments in medical sciences.
Acquires a spirit of scientific enquiry and is oriented to principles of research methodology; and
Has acquired skills in educating medical and paramedical professionals.

2. Objectives

At the end of the DM course in Gastroenterology, the student should be able to:

Recognize the key importance of medical problems in the context of the health priority of the country;
Practice the specialty of gastroenterology in keeping with the principles of professional ethics;
Identify social, economic, environmental, biological and emotional determinants of adult gastroenterology diseases and know the therapeutic, rehabilitative, preventive and promotion measures to provide holistic care to all patients;
Take detailed history, perform full physical examination and make a clinical diagnosis;
Perform and interpret relevant investigations (Imaging and Laboratory);
Perform and interpret important diagnostic procedures;
Diagnose gastroenterological illnesses in adults based on the analysis of history, physical examination and investigative work up;
Plan and deliver comprehensive treatment for illness in adults using principles of rational drug therapy;
Plan and advise measures for the prevention of gastroenterological diseases;
Plan rehabilitation of adults suffering from chronic illness, and those with special needs;
Manage gastroenterological emergencies efficiently;
Demonstrate skills in documentation of case details, and of morbidity and mortality data relevant to the assigned situation;
Demonstrate empathy and humane approach towards patients and their families and respect their sensibilities;
Demonstrate communication skills of a high order in explaining management and prognosis, providing counseling and giving health education messages to patients, families and communities.
Develop skills as a self-directed learner, recognize continuing educational needs; use appropriate learning resources, and critically analyze relevant published literature in order to practice evidence-based medicine;
Demonstrate competence in basic concepts of research methodology and epidemiology;
Facilitate learning of medical/nursing students, practicing physicians, para-medical health workers and other providers as a teacher-trainer;
Play the assigned role in the implementation of national health programs, effectively and responsibly;
Organize and supervise the desired managerial and leadership skills;
Function as a productive member of a team engaged in health care, research and education.

3. Syllabus

3.1 Theory

The syllabus should include the cardinal manifestations, definition, epidemiology, etiopathogenesis, genetics, clinical presentation, complications, differential diagnosis, investigations, treatment and prevention and prognosis of all gastroenterological diseases. In addition the candidate should be well versed with all the common and important pediatric gastroentrological diseases. It should also cover the recent advances that have occurred in the field of gastroentrology.

Biology of the gastrointestinal tract and liver

Gastrointestinal Hormones and Neurotransmitters
Cellular Communication, Neural Regulation of the Gastrointestinal Tract, Peptide
Hormones of the Gastrointestinal Tract, Other Chemical Messengers of the
Gastrointestinal tract, Signal Transduction, Regulation of Gastrointestinal Growth by
Hormones and Transmitters, Regulation of Gastrointestinal Hormones by Intraluminal Releasing Factors,Gastrointestinal Peptide That regulate Satiety and Hunger, Enteroinsular Axis
Mucosal Immunology and Mechanisms of Gastrointestinal Inflammation Mucosal Immune Responses, Inflammatory Responses
Cellular Growth and Neoplasia
Mechanisms of Normal Cell Homeostasis, Tumor Development: Multistep
Formation and Clonal Expansion, Neoplasia – Asociated Genes, Oncogenic
Signaling Pathways, Environmental Mutagenesis, Biological Features of Tumor
Metastasis, Summary of Molecular Mechanisme of Gastrointestinal Cancers,
Molecular Medicine: Current and Future Approaches in Gastrointestinal Oncology

Approach to patients with symptoms and signs

Acute Abdominal Pain

Anatomic Basis of Pain, Stimulants of Pain, Types of Pain, An Approach to the

Patient with Acute Abdominal Pain, Pharmacologic Management of the Acute Abdomen

Chronic Abdominal Pain

Definition and Classification of Functional Abdominal Pain Syndrome, Epidemiology and Impact on Health care Systems, Pathophysiology, Clinical features, Diagnosis and Differential Diagnosis Treatment

Symptoms of Esophageal Disease

Dysphagia, Odynophagia, Globus Sensation, Hiccups, Chest Pain of Esophageal Origin, Heartburn and Regurgitation, Extraesophageal Symptoms of Gastroesophageal Reflux Disease

Dyspepsia

Definition, Epiemiology, Cause of Organic dyspepsia, Functional (Nonulcer) Dyspepsia, Approach to Uninvestigated Dyspepsia, Treatment of Functional Dyspepsia

Nausea and Vomiting

Pathophysiology, Clinical Characteristics of Vomiting, Causes, Diagnostic Evaluation, Complications, Treatment

Diarrhea

Definition, Pathophysiology, Clinical Classification, Differential Diagnosis, Evaluation of the Patient with Diarrhea Treatment, Selected Diarrheal Syndromes

Intestinal Gas

Volume and Composition of Intestinal Gas, Sources of intestinal Gas, Propulsion of Gas Through the Intestinal Tract, Clinical Gas Problems

Fecal Incontinence

Prevalence, Mechanisms of Continence and Fecal Incontinence, Differential Diagnosis Fecal Incontinence, Evaluation of the Patient with fecal Incontinence, Treatment, Management of Specific Situations

Constipation: Definition and Presenting Symptoms, Epidemiology, Risk Factors,

Classification of Constipation, Colonic Anatomy and function, Pathophysiology of

Constipation, Disorders of the Anorectum and Pelvic Floor, Constipation with

Systemic Disorders, Constipation with Nervous System Disease, Constipation

Secondary to Structural Disorders of the Colon, Rectum, Anus, and Pelvic Floor,

Medications Associated with Constipation, Psychological Disorders as Causes of or Aggravating Factor in Constipation, Clinical Assessment, Diagnostic Tests, Medical Treatment

Gastrointestinal Bleeding: Clinical Manifestations, Acute Upper Gastrointestinal

Bleeding, Acute Lower Gastrointestinal Bleeding, Occult and Obscure Bleeding

Jaundice : Determinants of Serum Bilirubin Concentration, Differential Diagnostic of Jaundice, Diagnostic Approach to the Patient with Jaundice, Therapeutic Options

Nutrition

Nutritional Assessment and Management of the Malnourished Patient

Basic Nutritional Concepts, Micronutrients, Starvation, Malnutrition, When Is Aggressive Nutritional Support Indicated for the Hospitalized Patient?, Refeeding

Syndrome, Management of Severe Malabsorption: A Nutritional Perspective

Nutrition in Gastrointestinal Disease

Nutritional Assessment, Nutrients, Nutrition in Specific Disease States, Nutrition Therapy

Eating Disorders

Epidemiology, Etiology and Course, Diagnosis and Evaluation, Gastrointestinal Abnormalities Associated with Eating Disorders, Management of Eating Disorders in the Adult, Medical Management of Gastrointestinal Symptoms of Patient with Eating Disorders

Obesity

Definition and prevalence Etiology, Gastrointestinal Complications, NonGastrointestinal Complications, Treatment

Food Allergies

Background, Definitions, and Prevalence, Pathogenesis, Clinical Features, Diagnosis, Therapy and Natural History

Esophagus

Anatomy, Histology, Embryology, and Developmental Anomalies of the Esophagus,Anatomy and Histology, Embryology, Development Anomalies
Esophageal Motor and Sensory Function and Motor Disorders of the Esophagus

Motor and Sensory Innervation, Coordinated Esophageal Motor Activity, Pathogenesis and Categorization of Motor Disorders, Diagnosis, Disorder of the UES and Cervica Esophageal Region, Achalasia, Other Hypermotility Disorders of the Distal Esophagus and LES (Spastic Disorders), Esophageal Hypomotility Disorders

Gastroesophageal Reflux Diseases and Its Complications

Epidemiology, Health Care Impact, Pathogenesis, Clinical Features, Differential

Diagnosis, Associated Conditions, Diagnosis, Clinical Course, Complications,

Treatment of uncomplicated disease, Treatment of complications

Esophageal Disorders Caused by Medications, Trauma, and infection

Medication-Induced Esophageal Injury, Esophageal Injury from Nasogastric and other Nonendoscopic Tubes, Esophageal Injury from Penetrating or Blunt Trauma, Esophageal Infections in the Immunocompetent Host

Tumors of the Esophagus

Malignant Epithelial Tumors, Other Malignant Epithelial Tumors, Benign Epithelial Tumors, Malignant Nonepithelial Tumors, Benign Nonepithelial Tumors

Stomach and duodenum

Anatomy, Histology, Embryology, and Developmental Anomalies of the Stomach and Duodenum

Anatomy of the Stomach, Anatomy of the Duodenum, Congenital Anomalies of the Stomach and Duodenum

Gastric Motor and Sensory Function and Motor Disorders of the Stomach Gastric Motor and Sensory Physiology, Clinical Assesment of Gastric Motor and

Sensory Function and Dysfunction, Gastric Motor Disorders, Treatment

Gastric Secretion

Physiology, Quantitative Aspect of Acid Secretion in Humans, Mucus/Bicarbonate

Secretion, Secretion of Other Electrolytes(K+,Na+,CI-), Pepsinogens and other Gastric Aspartic proteases, Human Gastric lipase, Intrinsic factor, Gastric Secretion in Disease, Gastric Antisecretory drugs

Helicobacter pylori

Epidemiology, Virulence Factors, Acute Infection, Chronic Infection, Diagnosis, Treatment, Immunization (Prevention)

Gastric and Gastropathies
Classification, Chronic, Nonspecific Gastritides, Infection Gastritides, Granulomatous
Gastritides, Distinctive Gastritides, Miscellaneous forms of Gastritis, Reactive
Gastropathies (Acute Erosive Gastritis), Hyperplastic Gastropathies, Differential
Diagnosis of Gastritis and Gastropathy, Treatment and Prevention of Gastritis and Gastropathy
Peptic Ulcer Disease
Pathophysiology of Peptic Ulceration, Epidemiology, Clinical Features of
Uncomplicated Peptic Ulcer Disease, Diagnostic Tests, Complication of Peptic Ulcer
Disease, Cameron Ulcers (Linear Gastric Erosions in Hiatal Hernias)
Treatment of Peptic Ulcer Disease
History, Antisecretory and Acid-Neutralizing Agents, Ulcers Associated with Helicobacter pylori infection, Peptic Ulcer Associated with Nonsteroidal Antiinflammatory Drugs, Refractory Peptic Ulcers, Stress-Related Mucosal Injury, Treatment of Complications of Peptic Ulcer Disease
Tumors of the Stomach
Adenocarcinoma, Gastric Lymphoma, Gastric Carcinoid Tumors, Gastrointestinal Stromal Tumors, Miscellaneous Tumors

Pancreas

Anatomy, Histology, Embryology, and Development Anomalies of the Pancreas Anatomy, Histology and Ultrastrcture, Embryology, Signaling and Growth Factors, Developmental Anomalies
Pancreatic Secretion

Functional Anatomy, Composition of Exocrine Secretions, Functions of the major Digestive Ezymes, Disgestive Enzyme synthesis and Transport, Celluler regulation of Enzyme Secretion, Organ Physiology, Pancreatic secretory Function tests

Hereditary, Familial, and Genetic Disorders of the Pancreas and Pancreatic

Disorders in Childhood

Definitions and Terminology, Models of Pancreatitis as a Complex Disorder, Major
Gene Mutations Causing Pancreatic Disease, Modifier Genes in Pancreatic Disease,
Pancreatic Disorders in Childhood, Genetic Disorders Affecting Pancreas in
Childhood, Rare Syndromes, Familial Metabolic Syndromes Associated with Recurrent Acute and Chronic Pancreatitis
Acute Pancreatitis
Epidemiology, Definitions, Natural History, Pathology, Pathogenesis,
Pathophysiology, Predisposing Conditions, Clinical Features, Laboratory, Diagnosis, Radiologic Diagnosis, Differential Diagnosis, Predictors of Severity, Treatment, Complications
Chronic Pancreatitis

Definition, Epidemiology, Pathology, Pathology, Pathophysiology, Etiology, Clinical features, Physical Examination, Diagnosis, Treatment, Complications

Pancreatic Cancer, Cystic Pancreatic Neoplasms, and Other Nonendocrine

Pancreatic Tumors

Pancreatic cancer, Cystic tumors of the Pancreas, Other Nonendocrine, Pancreatic Tumors

Biliary tract

Anatomy, Histology, Embryology, Developmental Anomalies, and Pediatric Disorders of the Biliary Tract
Development of the Liver and Biliary Tract, Anatomy of the Biliary Tract and Gallbladder, Congenital Anomalies of the Gallbladder, Overview of Disorders of the Biliary Tract in Children, Pediatric Disorders of the Bile Ducts, Pediatric Disorders of the Gallbladder
Biliary Tract Motor Function and Dysfunction
Anatomy and Physiology, Gallbladder Dyskinesia, Sphincter of Oddi Dysfunction,
Sphincter of Oddi Dysfunction in Pancreatitis, Failure of Respones to Biliary
Sphincterotomy in Sphincter of Oddi Dysfuntion
Bile Secretion and the Enterohepatic Circulation
Bile Acid Synthesis and Metabolism, The Enterohepatic Circulation, Hepatic Bile
Acid Transport and Bile Secretion, Intestinal and Renal Bile Acid Transport,
Disorders of the Enterohepatic Circulation, Bile Acid Therapy, Sequestrants, and Transport Inhibitors
Gallstone Disease
Epidemiology, Composition, Risk Factors, Pathogenesis, and Natural History of Gallstones, Clinical features, Uncommon Complications,
Treatment of Gallstone Disease
Medical Treatment, Surgical Treatment, Choice of Treatment, Indications for
Treatment, Treatment of Choledocholithiasis, Bile duct Stricture,
Postcholecystectomy Syndrome, Gallstones, Cholecystctomy, and Cancer
Acalculous Cholecystitis, Cholesterolosis, Adenomyomatosis, and Polyps of the

Gallbladder

Acalculous Biliary Pain, Acute Acalculous Cholecystitis, Cholesterolosis of the
Gallbladder, Adenomyomatosis of the Gallbladder, Polyps of the Gallbladder
Sclerosing Cholangitis and Recurrent pyogenic Cholangitis

Primary Sclerosing Cholangitis, Recurrent Pyogenic Cholangitis

Tumors of the Gallbladder, Bile Ducts, and Ampulla

Gallbladder Tumors, Tumors of the Extrahepatic Biliary Tree, Tumors of the Ampulla of Vater

Endoscopic and Radiologic Treatment of Biliary Disease

General Principles, Procedural Techniques, Treatment of Specific Conditions

Liver

Anatomy, histology, Embryology, and Developmental Anomalies of the liver Surface Anatomy, Segmental Anatomy, Large Vessels of the liver, Lymph Vessels, Nerve Supply, Biliary System, Microanatomy
Liver Physiology and Energy Metabolism
Liver Cell types and Organization, Integration of the Functions of the Different Cell
Types, Regeneration and Apoptosis of Liver Cells, Protein Synthesis and
Degradation in the Liver Cells, Hepatic Nutrient Metabolism
Liver Chemistry and Function tests

Biochemical Markers of Hepatic Injury, Patterns and Severity of Hepatic Injury, Predictors of Hepatic Injury, Additional Tests

Hemochromatosis

Causes of Iron Overload, Pathophysilogy, Clinical Features, Diagnosis, Treatment and Prognosis, Family Screening

Wilson Disease

The Copper Pathway, The Basic Molecular defect, Clinical Features, Pathology, Diagnosis, Treatment, Prognosis

Other Inherited Metabolic Disorders of the Liver
Clinical Features of Metabolic Liver Disease, α1-Antitrypsin deficiency, Glycogen Storage Diseases, Congenital Disorders of Glycosylation, Porphyrias, Tyrosinemias,

Urea Cycle Defects, Bile AcidSynthesis and Transport defects, Cystic Fibrosis,

Mitochondrial Liver Diseases

Hepatitis A

Virology, Epidemiology, Pathogenesis, Clinical Features, Diagnosis, Prevention and Treatment

Hepatitis B and D

Virology, Epidemiology, Pathogenesis, Clinical Features, Diagnosis, Prevention and Treatment

Hepatitis C

Virology, Epidemiology, Pathogenesis, Clinical Feature, Diagnosis, Histopathologic

Finding and Role of Liver Biopsy, Natural History, Prevention, Treatment

Hepatitis E

Virology, Epidemiology, Pathogenesis, Clinical Features, Diagnosis, Treatment and Prevention

Hepatitis caused by Other Viruses

Hepatitis G and GB Agent Infection, TT Virus Infection, Sanban, Yonban, and SEN

Viruses and TTV-Like Mini-Virus Infections, Systemic Viral Infections That May Involve the Liver

Bacterial, Parasitic, and Fungal Infections of the Liver, Including Liver Abscess Bacterial Infections Involving or Affecting the Liver, Parasitic Infections, Fungal infections, Liver Abscess
Vascular Diseases of the Liver
Budd- Chiari Syndrome, Sinusoidal Obstruction Syndrome (Veno-occlusive
Disease), Portal Vein Thrombosis, Ischemic hepatitis, Congestive hepatopathy,
Peliosis hepatitis, Hepatic Artery Aneurysm, Atherosclerosis
Alcoholic liver Disease
Epidemiology, Spectrum of Disease, Diagnosis of Alcohol Abuse, Diagnosis of Alcoholic Liver Disease, Clinical Challenges, Confaunders that may influence progression of Alcoholic Liver Disease, Pathogenesis, Prognosis, Treatment
Nonalcoholic Fatty Liver Disease
Nonalcoholic Fatty Liver and Steatohepatitis, Focal Fatty Liver, Liver Disease
Caused by Drugs, Definitions and Importance, Epidemiology, Pathophysiology, Clinicopathologic Features of Drug- induced liver Disease, A Practical and management, Dose- Dependent Hepatotoicity, Drug-Induced, Acute hepatitis, Druginduced Granulomatous Hepatitis, Drug- Induced Chronic hepatitis, Drug-Induced Acute Cholestasis, Drug-Induced Chronic Cholestasis, Drug-Induced
Steatohepatitis, Hepatic Fibrosis, and Cirrhosis, Drug-Induced Vascular Toxicity
Liver Disease Caused by Anesthetics, Toxins, and Herbal Preparations Anesthetic Agents, Chemicals, Metals, Adulterated cooking Oils and

Contaminated Foods, Drugs of Abuse, Botanical and Environmental Hepatotoxins, Vitamins and Herbal Preparations

Autoimmune Hepatitis

Diagnosis Criteria, Pathogenesis, Classification, Variant Forms, Autoimmune, Hepatitis and Chronic hepatitis C, Epidemiology, Prognostic Indices, Clinical features, Treatment, Liver Transplantation, Future Directions

Primary Biliary Cirrhosis

Epidemiology, Pathogenesis, Clinical Features, Diagnosis, Natural History, Treatment, Complication of Chronic Cholestasis, Liver Transplantation, Autoimmune Cholangitis (AMA-Negative Primary Biliary Cirrhosis).

Portal Hypertension and Gastrointestinal Bleeding

Normal Portal Circulation, Hemodynamic Principles of portal Hypertension,

Measurement of Portal Hypertension, Detection of varices, Cause of portal Hypertension, Clinical Assessment of patients with portal hypertension-related bleeding, Treatment of portal hypertension-related Bleeding, Management of Specific lesions

Ascites and Spontaneous Bacterial peritonitis

Pathogenesis of Ascites, Clinical Features, Diagnosis, Differential Diagnosis, Complications, Treatment of Ascites, Prognosis

Hepatic Encephalopathy, Hepatopulmonary Syndromes, Hepatorenal Syndome, and Other Complications of Liver Disease

Hepatic Encephalopathy, Hepatopulmonary Syndromes, Hepatorenal Syndome, Endocrine Dysfunction, Coagulation Disorders

Acute Liver Failure

Definition, Etiology, Clinical Features, Predictors of Outcome, Treatment, Liver Transplantation, Investigational Approaches

Hepatic Tumors and Cysts

Hepatic Tumors, Tumor-Like Hepatic Lesions, Hepatic Cysts, Approach to the Patient with a Hepatic Mass Lesion

Liver Transplantation
Indications, Listing Criteria and Policies of the United Network for Organ Sharing,
Absolute and Relative Contraindications, Transplantation Evaluation and Listing,
Disease-Specific Indications, Surgical Aspects of Liver Transplantation, Immunosuppression, Postoperative Course, Long-Term management

Small and large intestine

Anatomy, Histology, Embryology, and Development Anomalies of the Small and

Large Intestine

Anatomy, Embryology, Abnormalities in Normal embryologic Development

Small Intestinal Motor and Sensory Function and Dysfunction
Anatomy, Structural Elements and Their Role in Small intestinal motor and Sensory
Function, Integrative Control of Motility, Mechanisms underlying Abnormal Motor and
Sensory Function, Evaluation of Small Intestinal Motility, Clinical Measurement of
Small Intestinal Motility, Normal Small Intestinal Motility, Clinical Consequences of
Diordered Small Intestinal Motor Function, Approach to Patients with Possible Small Intsetinal Motor Dysfunction
Colonic Motor and Sensory function and Dysfunction
Anatomy and Basic Control Mechanisms, Innervation of the Colon, Relationships among cellular Events, Pressure, and Flow, Regulation of Colonic Filling, Transport, and defection, Anorectal motility, Modulators of Colonic Motility, Disorders of Colonic Motility
Intestinal Water and Electrolyte Transport
Features of the Intestinal Mucosa Essential for Water and Electrolyte Transport, Mucosal Components Involved in the Regulation and Modulation of intestinal Water and Electrolyte transport, Neurohumoral regulation of Intestinal Secretion and Absorption, Mucosal water and Electrolyte transport Processes, Changes in water and electrolyte transport in disease.
Digestion and Absorption of Nutrients and vitamins
Digestion and Absorption of Nutrients: An Overview, Fat, Carbohydrate, Protein,
Vitamins, Minerals, Trace Elements, Adaptation to Changes in need or Load, The
Neonatal Intestine, Diet-Gene Interctions, Bariatric Surgry: Effect on Digestion and Absorption
Etiology and Pathophysiology
Etiology and Pathophysiology, Clinical Features and Evaluation, Anatomic
Investigations, Noninvasive Evaluation of Gastrointestinal Absorptive and Digestive
Function, Malabsorption in Specific Disease States, General Approach to the Management of Malabsorption
Enteric Bacterial Flora and Bacterial Overgrowth
Composition and Molecular Analysis of the Enteric Flora, Host-Flora Interaction,
Metabolic Activity of the Flora, Small Intestinal Bacterial Overgrowth
Short Bowel Syndrome
Etiology, Incidence and Prevalence, Pathophysiology, Medical Management,
Complications, Surgical Management, Pharmacologic Enhancement of Bowel Adaptation, Survival and Quality of Life
Celiac Sqrue and Refractory Sprue
Definitions, History, Epidemiology, Pathology, Clinical Feature, Diagnostic Studies,
Differential Diagnosis, Disease Associated with Celiac Sqrue, Treatment,
Complications, Refractory Sprue, Prognosis, Future Therapies
Tropical Malabsorption and Tropical Diarrhea

Specific Causes of Tropical Malabsorption, Nonspecific Tropical Malabsorption

Whipple’s Disease
History, Epidemiology, Microbiology, Genomics, Pathogenesis and Immunology,
Clinical Features, Pathology, Diagnosis, Differential Diagnosis, Treatment and Prognosis, Future Prospects
Infectious Enteritis and Proctocolitis and Bactreial Food Poisoning
Susceptibility to Intestinal Infection, Classification of Bacterial Diarrhea, Diagnosis of Infectious Diarrheal Disease, Toxigenic Pathogens, Invasive Pathogens, Viral
Pathogens, Special Situations, Dysentery versus Ulcerative Colitis, Treatment of
Tuberculosis of Gastrointestinal Tract, Bacterial Food Poisoning, Fish Poisoning
Antibiotic-Associated Diarrhea, Pseudomembranous Enterocolitis, Clostridium difficile-Associated Diarrhea and Colitis, Antibiotic-Associated Diarrhea, Pseudomembranous Enterocolitis, Clostridium difficile-Associated Diarrhea and Colitis
Intestinal Protozoa

Entamoeba Histolytica, Other Intestinal Amebae, Giardia Lamblia, Dientamoeba fragilis, Blastocystis hominis, Cryptosporidium Species, Cyclospora cayetanensis,

Isospora belli, Microsporidia, Trypanosoma cruzi(American Trypanosomiasis or Chagas Disaeas)

Intestinal Worms

Nematodes, Cestodes, Trematodes

Crohn’s Disease
History, Epidemiology, Etiology and Pathogenesis, Pathology, Clinical Features,
Differential Diagnosis, Establishing the Diagnosis and Evaluation of Disease,
Treatment, Crohn’s Disease in the life Cycle, Prognosis
Ulcerative Colitis
Epidemiology, Etiology and Pathogensis, Pathology,Clinical Features, Natural
History and Prognosis, Diagnosis, Assessment of Disease Activity, Medical Therapy, Surgical Therapy, Management of Specific Complications, Extraintestinal Manifestations
Ileostomy, Colostomy, and Pouches
Pathophysiologic Consequences of Proctocolectomy, Clinical Consequences of
Proctocolectomy, Compliactions and Management of the Conventional Brooke
Ileostomy, Continent Ileostomy, Ileal Pouch-Anal Anastomosis, Abdominal
Colectomy and ilieorectal Anastomosis, Colostomy in the Management of
Inflammatory, Bowel Disease, Summary of Risk-Benefit Analysis
Intestinal Ischemia
Anatomy of the Splanchnic circulation, Pathophysiology and Pathology, Acute Mesenteric Ischemia, Mesenteric Venous Thrombosis, Focal Segmental Ischemia of the Small Intestine, Colon Ischemia, Chronic Mesenteric Ischemia, Vasculitis and Angiopathy of the Splanchnic Circulation
Ulcers of the Small and Large Intestine Isolated Ulcers, Diffuse Ulcerations
Appendicitis
Historical Notes, Epidemiology, Anatomy and Embryology, Pathology, Pathogenesis, Diagnosis, Complications, Treatment, Treatment Outcomes,

Miscellaneous Topics

Diverticular Disease of the Colon

Epidemiology, Pathologic Anatomy, Etiology and Pathogenesis, Uncomplicated Diverticulosis, Diverticular Hemorrhage

Irritable Bowel Syndrome

Definitions, Clinical Features, Epidemiology, Pathophysiology, Diagnosis, Management, Prognosis

Intestinal obstruction and Ileus

Small Intestinal Obstruction, Colonic Obstruction Ileus

Acute and Chronic Pseudo-obstruction

Epidemiology, Neural Control of Small Intestinal and Coloic Motility, Chronic Intestinal Pseudo-obstruction, Acute Colonic Pseudo-obstruction, Colonic Pseudoobstruction and Megacolon, Chronic Colonic Pseudo-obstruction

Small Intestinal Neoplasms

Epidemiology, Pathology, Etiology and Risk Factors, Diagnosis, Treatment

Colonic Polyps and Polyposis Syndromes

Colonic Polyps, Gastrointestinal Polyposis Syndromes

Malignant Neoplasms of the Large Intestine
Epidemiology of Colorectal Cancer, Etiology and Clues about Causation, of
Colorectal Cancer, Familial Colon Cancer, Predisposing Factors for Colorectal
Cancer, Pathology, Natural History, and Staging, Prognosis, Clinical Manifestation,
Diagnosis and Screening, Treatment, Other malignant Colonic Tumors
Other Disease of Colon and Rectum
Lymphocytic and Collagenous Colitis, Diversion Colitis, Nonspecific Colonic Ulcers,
Dieulofoys-Type Colonic Ulceration, Cathartic Colon, Pseudomelanosis Coli,
Chemical Colitis, Pneumatosis Coli, Malakoplakia, Colitis Cystica Profunda, Neutropenic Enterocolitis, Endometriosis
Disease of the Anorectum
Anatomy, Examination of the Anus and rectum, Hemorrhoids, Anal Fissure,
Abscesses and Fistulas, Special Fistulas, Anal Warts, Pruritus Ani, Anal Stenosis,
Unexplained Anal pain, Hidradenitis Suppurativa, Pilonidal Disease, Rectal Foreign Body

Psychosocial factors

A Biopsychosocial Understanding of Gastrointestinal Illness and Disease Case Study: A Typical Patient in a Gastroenterology Practice, The Biomedical

Model, The Biopsychosocial Model

Palliative Medicine in Patient with Advanced Gastrointestinal and hepatic Disease Definitions, Common Themes in Palliative Medicine
Complementary and Alternative Medicine Therapies in gastrointestinal and Hepatic

Disease

Definition and Epidemiology, Types of Therapies, Demography, Rationale for use, Gastrointestinal Disorders Addressed by CAM Therapies

Topics involving multiple organs

Oral Disease and Oral-Cutaneous Manifestations of Gastrointestinal and Liver

Disease

Disorders of Mouth and Tongue, Mucocutaneous Candidasis, Mucocutaneous
Features of HIV Infection, Mucocutaneous Ulcerative Disease, Vesiculobullous Diseases, Lichen Planus, Cutaneous Manifestations of Intestinal Disease, Vascular and Connective Tissue Disorders, Cutaneous Manifestations of Gastrointestinal Malignancies, Cutaneous Manifestations of Liver Disease, Parastitic Diseases of the
Intestine and Skin, Dermatitis Herpetiformis and Celiac Sprue, Vitamin Deficiencies
Diverticula of the Pharynx, Esophagus, Stomach, and Small Intestine Zenker’s Diverticulum, Esophageal Diverticula, Esophageal intramural

Pseudodiverticula, Gastric Diverticula, Duodenal Diverticula, Jejunal Diverticula

Abdominal Hernias and Gastric Volvulus
Disphragmatic Hernias, Gastric Volvulus, Inguinal and Femoral Hernias(Groin
Hernias), Other Ventral Hernias, Pelvic and Perineal Hernias, Lumber Hernias, Internal Hernias
Foreign Bodies and Bezoars

Foreign Bodies, Bezoars

Caustic Injury to the Upper Gastrointestinal Tract

Caustic Agents, Button (Disk) Battery Ingestion

Abdominal Abscesses and Gastrointestinal Fistulas

Abdominal Abscesses, Gastrointsetinal Fistulas

Eosinophilic Disorders of the Gastrointestinal Tract

Eosinophil: Role in Health and Disease, Clinical Entities, Evaluation, Differential Diagnosis, Management

Protein-Losing Gastroentropathy

Definition and Normal Physiology, Pathophysiology, Clinical Manifestations, Disease Associated with Protein-Losing Gastroenteropathy, Diagnosis, Treatment and Prognosis

Gastrointestinal Lymphomas: Background, General Principles of lymphoma Management, Gastric Lymphomas, Small Intestinal Lymphomas, Others Sites, Immunodeficiency-Related Lymphomas
Gastrointestinal Stromal Tumors

Incidence, Location, Clinical Presentation, Pathology and Molecular Pathobiology, Diagnosis, Treatment, Special Considerations

Gastrointestinal Carcinoid Tumors and the Carcinoid Syndrome

Clinical Presentation, Pathology, Classification, The Carcinoid Syndrome, Metastatic Carcinoid Tumors

Endocrine Tumors of the Pancreas and Gastrointestinal Tract
General Aspects, Multiple Endocrine Neoplasia, Other Inherited Syndromes,
Insulinomas, Gastrinomas, Glucagonomas, VIPomas, Somatostatinomas,
GRFomas, PPomas/Nonfunctioning Pancreatic Endocrine Tmors(PETs), Other
PETs, Tumor Localization, Management of Metastatic PETs
Gastrointestinal Consequences of Infection with Human Immunodeficiency Virus
Diarrhea, Odynophagia and Dyspagia, Abdominal Pain, Anorectal Disease,
Gastrointestinal Bleeding, Heptomegaly and Abnormal Liver Tests
Gastrointestinal and Hepatic Complications of Solid Organ and Hematopoietic Cell

Transplantation

Complications of Solid Organ Transplantation, Complications of Hematopoietic Cell Transplantation

Gastrointestinal and Hepatic Manifestations of Systemic Disease
Rheumatologic and Collagen Vascular Diseases, Oncologic and Hematologic
Disease, Endocrine Diseases, Disorders of Lipid Metabolism, Renal Disease,
Neurologic Diseases, Pulmonary Disease and Problem in Patients Who Require Critical Care, Cardiovascular Diseases, Infiltrative Diseases, Nodular Disorders of the Liver
Vascular Lesions of the Gastrointestinal Tract
Vascular Lesions, Abdominal Aortic Aneurysm, Mycotic Aneurysms, Paraprosthetic
Enteric and Aortoenteric Fistula, Superior Mesenteric Artery Syndrome, Celiac Axis Compression Syndrome
Surgical Peritonitis and Other Diseases of the Peritoneum, Mesentery, Omentum, and Diaphragm
Anatomy and Physiology, Surgical Peritonitis, Peritonitis of Other Causes, Peritoneal
Tumors, Diseases of the Mesentery and Omentum, Diseases of the Diaphragm, Laparoscopy in the Evaluation of Peritoneal Disease
Gastrointestinal and Hepatic Disorders in the Pregnant Patient
Gastrointestinal and Hepatic Function in Normal Pregnancy, Gastrointestinal
Disorders and Pregnancy, Hepatic Disorders Unique to Pregnancy, Common Liver Diseases and Pregnancy
Radiation Injury to the Gastrointestinal Tract
Radiation Physics, Biological Effects of Radiation, Mechanisms of Radiation-Induced
Damage to the Gastrointestinal Mucosa, Radiation-Induced Esophagitis, Radiation-
Induced Gastritis, Radiation –Induced Enteritis, Management and Prevention of Radiation-Induced Gastrointestinal Tract Injury
Complications of Gastrointestinal Endoscopy
Complications of Sedation, Infectious Complications, Bleeding Complications, Other
General Complications, Timing and Severity of Complication, Medicolegal Complications, Complications of Upper Endoscopy, Complications of Colonoscopy and Sigmoidoscopy, Complications of ERCP, Complications of Endoscopic Ultrasonography

Recent advances

Recent advances in Gastroenterology
Recent advances in Hepatology
Recent advances in Endoscopy

3.2. Practical

History, examination and writing of records:

History taking should include the back ground information, presenting complaints and history of present illness, history of previous illness, family history, social and occupational history and treatment history.

Detailed physical examination should include general examination and systemic examination (Chest, Cardio-vascular system, Abdomen, Central nervous system, locomotor system and joints), with detailed examination of the abdomen.

Skills in writing up notes, maintaining problem oriented records, progress notes, and presentation of cases during ward rounds, planning investigations and making a treatment plan should be taught.

Bedside procedures & Investigations:

Therapeutic skills: Venepuncture and establishment of vascular access, Administration of fluids, blood, blood components and parenteral nutrition, Nasogastric feeding, Urethral catheterization, Administration of oxygen, Cardiopulmonary resuscitation, Endotracheal intubation.

Upper GI Endoscopic, Colonoscopic and ERCP Procedures:

Endoscopic Ultrasound, Motility Study, Double Balloon Enteroscopy etc

3.3. Clinical Teaching

Residents should have the practical knowledge and clinical skills to evaluate and manage the various medical and gastrointestinal disorders. Clinical work should be closely guided and supervised by Consultants. If a particular clinical teaching material is not available in the institution, then the resident should be posted in another institution for acquiring the practical knowledge and skills.

Gastroenterology Teaching

Clinical

OPD: A Resident should work up common cases and discuss with the consultant.
WARD: A Resident should gain competency in diagnostic case work up and day to day management of the following cases:
Acute viral hepatitis and its complications, chronic hepatitis, cirrhosis of liver and its complications, management of hepatic encephalopathy, upper and lower gastrointestinal bleed (assessment/monitoring/indications for transfusion), acute abdomen (peritonitis, intestinal obstruction, pancreatitis etc), liver abscess, inflammatory bowel disease, malabsorption, intestinal tuberculosis and its complications, malignant lesions of liver, gall bladder, stomach, pancreas and intestines etc. Investigations

The Resident should have acquired the theoretical/practical knowledge about following investigations:

Interpretation of plain X-ray of the abdomen, barium swallow, barium meal, barium enema, abdominal ultrasound and CT scan of the abdomen.
Pattern of liver biopsy in common diseases (e.g. chronic hepatitis, cirrhosis of the liver etc.).
Indication for upper GI Endoscopy, Sigmoidoscopy, Colonoscopy, Endoscopic Sclerotherapy and Banding, Enteroscopy.
ERCP and MRCP- indications and interpretations.
Capsule Endoscopy- indications and interpretations.
GI Motility studies- indications and interpretations.
Fibroscan- indications and interpretations.

Endoscopic Ultrasound- indications and interpretations.

Procedures

The Resident should have acquired practical knowledge of/and should be able to carry out the following:

Per rectal examination and proctoscopy.
Nasogastric intubation.
Ascitic tap.
Liver biopsy.
FNAC of abdominal masses (under ultrasound guidance).
Needle aspiration from liver abscess (under ultrasound guidance).
Upper GI Endoscopy
Sigmoidoscopy
Colonoscopy
Side viewing Endoscopy

MINIMUM PROCEDURES TO BE CARRIED OUT BY A GASTROENTEROLOGY

	RESIDENT
Procedure	Performance Criteria	Number of Procedures
Esophago-gastroduodenoscopy (EGD)	Esophageal intubation Pyloric intubation	300
Colonoscopy	Navigation through sigmoid colon Intubation of splenic flexure Intubation of the hepatic flexure Intubation of cecum Retroflexion in the rectum	100
Sigmoidoscopy	Navigation Through the sigmoid colon Visualization of the splenic flexure Retroflexion in the rectum	100
Endoscopic retrograde	Duodenal Intubation	20
Cholangiopancreatography Visualization of Papilla (ERCP)		20
Liver Biopsy Safety & adequate understanding of the procedure		20

4. Teaching Program

4.1 General Principles

Acquisition of practical competencies being the keystone of postgraduate medical education, postgraduate training is skills oriented.
Learning in postgraduate program is essentially self-directed and primarily emanating from clinical and academic work. The formal sessions are merely meant to supplement this core effort.

4.2 Teaching Sessions

The teaching methodology consists of bedside discussions, ward rounds, case presentations, clinical grand rounds, statistical meetings, journal club, lectures and seminars. Along with these activities, trainees should take part in inter-departmental meetings i.e clinico-pathological and clinico-radiological meetings that are organized regularly.

Trainees are expected to be fully conversant with the use of computers and be able to use databases like the Medline, Pubmed etc.

They should be familiar with concept of evidence based medicine and the use of guidelines available for managing various diseases.

4.3 Teaching Schedule

Following is the suggested weekly teaching programme in the Department of Gastroenterology:

Sr. No. Description	Frequency
1. Case Presentation & Discussion	Once a week
2. Seminar	Once in two weeks
3. Journal Club	Once in two weeks
4. Grand Round presentations	Once a month
5. Emergency case discussions	Once a week
6. Statistical & Mortality Meet	Once a month
7. Clinico–Pathological meet	Once a month
8. Clinico–Radiological meet	Once a month
9. Clinico-Surgical meet	Once a month
10. Faculty lecture teaching	Once a month

Each unit should have regular teaching rounds for residents posted in that unit. The rounds should include bedside case discussions, file rounds (documentation of case history and examination, progress notes, round discussions, investigations and management plan), interesting and difficult case unit discussions.
Central hospital teaching sessions will be conducted regularly and DM residents would present interesting cases, seminars and take part in clinico-pathological case discussions.

4.4 Conferences and Papers

A resident must attend at least one conference per year.

One paper must be presented in at least 3 years.

5. Schedule of Posting

The residents should be posted in the gastroenterology ward, emergency (casualty) and gastroenterology intensive care unit during the three year course. They should also undergo rotation in allied specialties. The following should be the training program in the department:

Gastroenterology Ward - 2 years
Endoscopy Lab - 4 months
Gastroenterology ICU - 3 months
Emergency Ward - 3 months
Gastro-intestinal Surgery - 15 days
Pathology - 15 days
Microbiology - 15 days
Radiology - 15 days

Log Book:

All the work done during the course will be recorded by the candidate in the log book duly signed by the consultant.

6. Research Project:

Every candidate shall carry out work on an assigned research project under the guidance of a recognized postgraduate teacher, the project shall be written and submitted in the from of a Project.
Every candidate shall submit project plan to university within time frame set by university
Thesis shall be submitted to the University within 9 months of joining the course.

The student will (i) identify a relevant research problem, (ii) conduct a critical review of literature, (iii) formulate a hypothesis, (iv) determine the most suitable study design, (v) state the objectives of the study, (vi) prepare a study protocol, (viii) undertake a study according to the protocol, (viii) analyze and interpret research data, and draw conclusion, (ix) write a research paper.

7. Assessment

All the PG residents are assessed daily for their academic activities and also periodically.

7.1. General Principles

The assessment is valid, objective and reliable
It covers cognitive, psychomotor and affective domains.
Formative, continuing and summative (final) assessment is also conducted in theory as well as practical. In addition, research project is also assessed separately.

7.2. Formative Assessment

The formative assessment is continuous as well as end of term.
The former is based on the feedback from the consultants concerned.
Formative assessment will provide feedback to the candidate about his/her performance and help to improve in the areas they lack.
Record of internal assessment should be presented to the board of examiners for consideration at the time of final examination.

7.3. Internal Assessment

The performance of the resident during the training period should be monitored throughout the course and duly recorded in the log books as evidence of the ability and daily work of the student. Marks should be allotted out of 100 as followed.

Sr. No. Items Marks

Personal Attributes 20
Clinical Work 20
Academic activities 20
End of term theory examination 20
End of term practical examination 20

7.3.1 Personal attributes:

Behavior and Emotional Stability: Dependable, disciplined, dedicated, stable in emergency situations, shows positive approach.

Motivation and Initiative: Takes on responsibility, innovative, enterprising, does not shirk duties or leave any work pending.

Honesty and Integrity: Truthful, admits mistakes, does not cook up information, has ethical conduct, exhibits good moral values, loyal to the institution.

Interpersonal Skills and Leadership Quality: Has compassionate attitude towards patients and attendants, gets on well with colleagues and paramedical staff, is respectful to seniors, has good communication skills.

7.3.2 Clinical Work:

Availability: Punctual, available continuously on duty, responds promptly on calls and takes proper permission for leave.

Diligence: Dedicated, hardworking, does not shirk duties, leaves no work pending, does not sit idle, competent in clinical case work up and management.

Academic ability: Intelligent, shows sound knowledge and skills, participates adequately in academic activities, and performs well in oral presentation and departmental tests.

Clinical Performance: Proficient in clinical presentations and case discussion during rounds and OPD work up. Preparing Documents of the case history/examination and progress notes in the file (daily notes, round discussion, investigations and management) Skill of performing bed side procedures and handling emergencies.

7.3.3 Academic Activity: Performance during presentation at Journal club/ Seminar/ Case discussion/Stat meeting and other academic sessions. Proficiency in skills as mentioned in job responsibilities.

7.3.4 End of term theory examination conducted at end of 1^st, 2^nd year and after 2 years 9 months

7.3.5 End of term practical/oral examinations after 2 years 9 months.

Marks for personal attributes and clinical work should be given annually by all the consultants under whom the resident was posted during the year. Average of the three years should be put as the final marks out of 20.

Marks for academic activity should be given by the all consultants who have attended the session presented by the resident.

The Internal assessment should be presented to the Board of examiners for due consideration at the time of Final Examinations.

7.4. Summative Assessment

Ratio of marks in theory and practical will be equal.
The pass percentage will be 50%.
Candidate will have to pass theory and practical examinations separately.

A. Theory examination

Paper Title Marks

Paper -I Basic Sciences as related to Gastroenterology 100

Paper-II Clinical Gastroenterology 100

Paper-III Investigative Gastroenterology 100

Paper-IV Recent advances in Gastroenterology 100

Total 400

B. Practical & Viva-Voce Examination

S. No Marks

Long Case (1) 100
Short Cases (2) 75 marks each 150
Procedure 50
Grand Viva including Instruments/Radiology/Pathology 100

Total 400

8. Job Responsibilities

Outdoor Patient (OPD) Responsibilities

The working of the residents in the OPD should be fully supervised.
They should evaluate each patient and write the observations on the OPD card with date and signature.
Investigations should be ordered as and when necessary using prescribed forms.
Residents should discuss all the cases with the consultant and formulate a management plan.
Patient requiring admission according to resident’s assessment should be shown to the consultant on duty.
Patient requiring immediate medical attention should be sent to the casualty services with details of the clinical problem clearly written on the card.
Patient should be clearly explained as to the nature of the illness, the treatment advice and the investigations to be done.
Resident should specify the date and time when the patient has to return for follow up.

In-Patient Responsibilities

Each resident should be responsible and accountable for all the patients admitted under his care. The following are the general guidelines for the functioning of the residents in the ward;
Detailed work up of the case and case sheet maintenance;
He/She should record a proper history and document the various symptoms. Perform a proper patient examination using standard methodology. He should develop skills to ensure patient comfort/consent for examination. Based on the above evaluation he/she should be able to formulate a differential diagnosis and prepare a management plan.
Should develop skills for recording of medical notes, investigations and be able to properly document the consultant round notes.
To organize his/her investigations and ensure collection of reports.
Bedside procedures for therapeutic or diagnostic purpose.
Presentation of a precise and comprehensive overview of the patient in clinical rounds to facilitate discussion with senior residents and consultants.
To evaluate the patient twice daily (and more frequently if necessary) and maintain a progress report in the case file.
To establish rapport with the patient for communication regarding the nature of illness and further plan management.
To write instructions about patient’s treatment clearly in the instruction book along with time, date and the bed number with legible signature of the resident.
All treatment alterations should be done by the residents with the advice of the concerned consultants and senior residents of the unit.

Admission day

Following guidelines should be observed by the resident during admission day.

Resident should work up the patient in detail and be ready with the preliminary necessary investigations reports for the evening discussion with the consultant on duty.
After the evening round the resident should make changes in the treatment and plan out the investigations for the next day in advance.

Doctor on Duty

Duty days for each Resident should be allotted according to the duty roster.
The resident on duty for the day should know about all sick patients in the wards and relevant problems of all other patients, so that he could face an emergency situation effectively.
In the morning, detailed over (written and verbal) should be given to the next resident on duty. This practice should be rigidly observed.
If a patient is critically ill, discussion about management should be done with the consultant at any time.
The doctor on duty should be available in the ward through out the duty hours.

Care of Sick Patients

Care of sick patients in the ward should have precedence over all other routine work for the doctor on duty.
Patients in critical condition should be meticulously monitored and records maintained.
If patient merits ICU care then it must be discussed with the senior residents and consultants for transfer to ICU.

Resuscitation skills

At the time of joining the residency programme, the resuscitation skills should be demonstrated to the residents and practical training provided at various work stations.
Residents should be fully competent in providing basic and advanced cardiac life support.
They should be fully aware of all advanced cardiac support algorithms and be aware of the use of common resuscitative drugs and equipment like defibrillators and external cardiac pacemakers.
The resident should be able to lead a cardiac arrest management team.

Discharge of the Patient

Patient should be informed about his/her discharge one day in advance and discharge cards should be prepared 1 day prior to the planned discharge.
The discharge card should include the salient points in history and examination, complete diagnosis, important management decisions, hospital course and procedures done during hospital stay and the final advice to the patient.
Consultants and DM Residents should check the particulars of the discharge card and counter sign it.
Patient should be briefed regarding the date, time and location of OPD for the follow up visit.

In Case of Death

In case it is anticipated that a particular patient is in a serious condition, relatives should be informed about the critical condition of the patient beforehand.
Residents should be expected to develop appropriate skills for breaking bad news and bereavements.
Follow up death summary should be written in the file and face sheet notes must be filled up and the sister in charge should be requested to send the body to the mortuary with respect and dignity from where the patient’s relatives can be handed over the body.
In case of a medico legal case, death certificate has to be prepared in triplicate and the body handed over to the mortuary and the local police authorities should be informed.
Autopsy should be attempted for all patients who have died in the hospital especially if the patient died of an undiagnosed illness.

Bedside Procedures

The following guidelines should be observed strictly:
Be aware of the indications and contraindications for the procedure and record it in the case sheet. Rule out contraindications like low platelet count, prolonged prothrombin time, etc.
Plan the procedure during routine working hours, unless it is an emergency. Explain the procedure with its complications to the patient and his/her relative and obtain written informed consent on a proper form. Perform the procedure under strict aseptic precautions using standard techniques. Emergency tray should be ready during the procedure.
Make a brief note on the case sheet with the date, time, nature of the procedure and immediate complications, if any.
Monitor the patient and watch for complications(s).

Medico-Legal Responsibilities of the Residents

All the residents are given education regarding medico-legal responsibilities at the time of admission in a short workshop.
They must be aware of the formalities and steps involved in making the correct death certificates, mortuary slips, medico-legal entries, requisition for autopsy etc.
They should be fully aware of the ethical angle of their responsibilities and should learn how to take legally valid consent for different hospital procedures & therapies.
They should ensure confidentiality at every stage.