Upper Gastrointestinal Physiology 2 —
Training activity: 1

Details

Review and triage patient referrals under supervision, and determine suitability for upper gastrointestinal physiology investigations

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

• What does success look like?
  • Identify what is expected of you in relation to effectively planning and preparing to undertake upper gastrointestinal (GI) physiology investigations by accurately triaging patient referrals.
  • Consider how the learning outcomes apply, specifically in relation to performing high-resolution oesophageal manometry and pH-impedance monitoring, practicing professionally within the multidisciplinary team (MDT), and identifying situations where physiological measurements are affected by pharmacological interactions.
  • Discuss with your training officer to gain clarity of what is expected of you in relation to the relevant referral criteria, logistical expectations for patient flow, and integrating necessary safety protocols.
• What is your prior experience of this activity?
  • Think about what you already know about the referral criteria for upper GI physiology investigations and reviewing relevant patient history and previous investigation results.
  • Consider possible challenges you might face during the activity, such as handling complex cases or pharmacological interactions that might affect investigation suitability.
  • Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example if pharmacological interactions might affect investigation suitability or if the patient presents with ambiguous or complex symptoms.
  • Acknowledge how you feel about reviewing and triaging patient referrals in the context of this training activity.
• What do you anticipate you will learn from the experience?
  • Consider the specific skills you want to develop, such as efficiently evaluating referrals and determining investigation suitability.
  • Identify the specific insights you hope to gain into the typical patient pathways and presentations that lead to these referrals, and the scope and limitations of different upper GI physiology investigations.
• What additional considerations do you need to make?
  • Consult actions identified following previous experiences of reviewing guidelines or protocols related to referral triage.
  • Identify important information you need to consider before embarking on the activity, such as reviewing knowledge regarding pharmacological interactions that might affect investigation suitability or results.

In action

• Is anything unexpected occurring?
  • Are you noticing anything surprising or different from what you anticipate whilst triaging patient referrals and determining suitability?
  • Are you encountering situations such as:
    • The patient’s referral symptoms suggest urgent ‘red flag’ pathology (e.g., severe weight loss or acute dysphagia) that requires immediate escalation rather than routine triage?
    • The patient’s medication list indicates a complex pharmacological interaction that may confound the physiological measurement, challenging the standard triage pathway?
    • The clinical information is highly ambiguous, making it difficult to determine which upper GI investigation is most suitable?
• How are you reacting to the unexpected development?
  • How is this impacting your actions? For example, are you responding to the situation appropriately?
  • Are you adapting or changing your approach to evaluating investigation suitability or patient prioritisation?
  • Consider the steps you are taking in the moment, such as:
    • Immediately halting the routine triage process to consult the Training Officer regarding escalation protocols for unexpected urgent symptoms.
    • Proactively reviewing academic content on pharmacological interactions to determine if the test must be performed off-medication or if the results will be affected.
  • How are you feeling in that moment? For instance, are you finding it difficult to resolve the pharmacological conflict? Is it affecting your confidence in accurately assessing patient suitability for the planned investigation?
• What is the conclusion or outcome?
  • Identify how you are working within your scope of practice. For example, are you successfully resolving the conflict between the referral reason and standard criteria by consulting departmental guidelines? Or are you needing support because a complex pharmacological interaction or acute symptom requires senior medical review before a triaging decision can be finalised?
  • What are you learning as a result of the unexpected development? For example, are you mastering a more efficient strategy for identifying high-risk referrals? Or gaining insight into the criticality of medication review in physiological testing?

On action

• What happened?
  • Begin by summarising the key steps you took when reviewing and triaging patient referrals to determine their suitability for upper gastrointestinal (GI) investigations.
  • Consider specific events, actions, or interactions which felt important, such as the criteria you used, or were guided to use, when triaging the referrals, or how you evaluated the relevance of patient history and previous investigation results.
  • Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately halting the routine triage process to consult the Training Officer regarding unexpected urgent symptoms or pharmacological issues.
  • How did you feel during this experience, e.g., were you confident in efficiently evaluating referrals or stressed by handling complex cases?
• How has this experience contributed to your developing practice?
  • Identify what learning you can take from this experience regarding planning and preparing upper GI investigations.
  • What strengths did you demonstrate, e.g., efficiently evaluating referral criteria?
  • What skills and/or knowledge gaps were evident, e.g., unfamiliarity with the potential impact of complex pharmacological interactions on test suitability?
  • Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved?
  • Has your practice improved in understanding suitability criteria for different upper GI investigations?
  • Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding handling referrals with ambiguous symptoms or complex pharmacological histories, and how you reacted to this.
• What will you take from the experience moving forward?
  • Identify the actions you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to consolidating your understanding of suitability criteria and the patient pathway.
  • What will you do differently next time you approach referral triaging, for instance, by proactively reviewing academic content related to pharmacological interactions that might confound physiological measurements?
  • Do you need to practise any aspect of the activity further, such as reviewing case examples of complex referrals or key learning outcomes related to determining investigation suitability?

Beyond action

• Have you revisited the experiences?
  • How have your subsequent experiences of performing complex investigations or presenting cases since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, an instance where a subsequent complex case required immediate changes to the recommendation due to pharmacological interference forced you to re-evaluate the meticulousness of the initial medication and symptoms check during your first attempt at this training activity.
  • Considering what you understand about the critical nature of pharmacology, patient pathways, and MDT requirements now, were the actions or considerations you identified after your initial reflection on this training activity sufficient?
  • How have you since implemented or adapted improvements in your triage workflow based on further learning and experiences? For example, how you proactively reviewed and integrated a structured approach to identifying “red flag” symptoms that necessitate urgent escalation, demonstrating you have adapted improvements based on further learning.
  • Has discussing complex or ambiguous referrals or the impact of insufficient triage on workflow with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a case where medication cessation was overlooked refined your understanding of the critical nature of applying specific suitability criteria during the triage process.
• How have these experiences impacted upon current practice?
  • How has the learning from this initial training activity, in combination with subsequent interpretation and MDT experiences, contributed to your overall confidence and competence in efficiently evaluating referrals and applying pharmacological knowledge, particularly in preparing for assessments like Case-Based Discussions (CBDs)? For example, how your accumulated ability in evaluating investigation suitability now enables you to confidently discuss the rationale for selecting a specific upper GI investigation during a CBD assessment.
  • How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to initial patient assessment? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely seek advice from the Training Officer or specialist clinician immediately when pharmacological interactions or highly ambiguous symptoms compromise the fundamental suitability of the patient for routine testing.

Relevant learning outcomes

#	Outcome
# 1	Outcome Perform high-resolution oesophageal manometry in the complex patient, including a full range of adjunctive tests as appropriate.
# 2	Outcome Perform combined oesophageal pH-impedance monitoring in adult patients presenting with a wide range of conditions.
# 5	Outcome Practice professionally within the multidisciplinary team.
# 8	Outcome Identify situations where physiological measurements are affected by pharmacological interactions and the impact this may have on test results.