Gut 1996; 38: 459-470 SPECIAL REPORT A national training programme for gastroenterology and hepatology M J G Farthing, R P Walt, R N Allan, C H J Swan, I T Gilmore, C N Mallinson, J R Bennett, C J Hawkey, W R Burnham, A I Morris, C J Tibbs, T E Bowling, C Cobb, S Catnach, C Farrell, A Towle The British Society of Gastroenterology, Training Working Party, St Andrews Place, London in association with The King's Fund Development Centre, London M J G Farthing R P Walt R N Allan C H J Swan I T Gilmore C N Mallinson J R Bennett C J Hawkey W R Bumham A I Morris C J Tibbs T E Bowling C Cobb S Catnach C Farrell A Towle Correspondence to: Professor M J G Farthing, Digestive Diseases Research Centre, The Medical College of Saint Bartholomew's Hospital, Charterhouse Square, London EC 1M 6BQ. Accepted for publication 6 December 1995 1. Gastroenterology and hepatology: the future Gastroenterologists, like many hospital specialists, are facing major changes in the way in which they work with general practitioners and develop hospital based gastroenterology and hepatology services. These changes will no doubt continue to evolve as the emphasis on primary care increases and the need for hospital specialists to provide rapid access to day care services expands. The development of new technologies such as advanced therapeutic endoscopy are putting increasing demands on gastroenterologists, while at the same time most continue to make a major contribution to general and emergency medicine services in their hospitals. The expansion and continued evolution of gastroenterology services in the United Kingdom has prompted the council of the British Society of Gastroenterology to set up a working party to consider how future service needs will drive this evolutionary process and to anticipate the training needs of the gastroenterologist and hepatologist of the future. To assist this process, a sample of 10% of consultant gastroenterologists were questioned about their current workload and how they might wish to change their job plans in the future (Appendix I). In parallel with this, the working party considered the training requirements for the future, made proposals for a curriculum, its implementation, and methods of assessment. The working party was made aware of the results of the survey towards the end of its deliberations and took these into account during the writing of this report. The work of the training working party was facilitated by Christine Farrell (director, clinical change programme) and Angela Towle (project manager for medical education) of the King's Fund Centre, London. 2. Trends in healthcare that may influence the practice of medical gastroenterology and hepatology The working party made a fundamental assumption that medical gastroenterology and hepatology in the future will differ from the way in which it is currently practised. The working party attempted first to identify ways in which practice may change and then sug- gested adjustments to training programmes to satisfy future needs. A number of factors were identified that are presently under change or recently changed, which will influence both training and practice. 2.1 The changing emphasis in primary care Current health policies are attempting to move much secondary care into primary care. Fund holding general practitioners wish to ensure that their patients get the most cost effective secondary care and are already requesting changes in the practice of gastroenterology and hepatology. 2.1.1 Rapid access services must be developed to provide 'one stop' diagnosis in district general hospitals. 2.1.2 Outpatient consultant opinions will be sought more often and easy, prompt access to consultants will be expected. Therapeutic decisions made by consultants may be modified by primary care physicians. 2.1.3 In rural areas, access to diagnostic facilities will need to be improved, which may involve outreach clinics, ultrasound, and endoscopy. The exact extent of the shift of care towards primary care will determine how much change is required. In some areas it seems that there will be little change while in others important redistribution is likely. Consultants need to be trained in the development of local management guidelines and with these could oversee treatment for a number of chronic gastrointestinal disorders in general practice. The emphasis will be on outpatient consulta- tion. 2.2 New technology and technologists The endoscopic revolution from gastro- cameras to video endoscopy has occurred in less than 30 years. It would not have been pre- dicted that cholecystectomy could be per- formed laparoscopically or that endoscopic stent insertion for the treatment of extrahepatic cholestasis would reduce requirements for hospital beds. Digitised video images can now be transmitted transatlantically and it is 459 on 11 December 2018 by guest. Protected by copyright. http://gut.bmj.com/ Gut: first published as 10.1136/gut.38.3.459 on 1 March 1996. Downloaded from
Transcript
Gut 1996; 38: 459-470
SPECIAL REPORT
A national training programme forgastroenterology and hepatology
M J G Farthing, R P Walt, R N Allan, C H J Swan, I T Gilmore, C N Mallinson,J R Bennett, C J Hawkey, W R Burnham, A I Morris, C J Tibbs, T E Bowling, C Cobb,S Catnach, C Farrell, A Towle
The British Society ofGastroenterology,Training WorkingParty, St AndrewsPlace, London inassociation with TheKing's FundDevelopment Centre,LondonM J G FarthingR P WaltRN AllanC H J SwanI T GilmoreC N MallinsonJ R BennettC J HawkeyW R BumhamA I MorrisC J TibbsT E BowlingC CobbS CatnachC FarrellA Towle
Correspondence to:Professor M J G Farthing,Digestive Diseases ResearchCentre, The Medical Collegeof Saint Bartholomew'sHospital, CharterhouseSquare, London EC1M6BQ.
Accepted for publication6 December 1995
1. Gastroenterology and hepatology: thefutureGastroenterologists, like many hospitalspecialists, are facing major changes in the wayin which they work with general practitionersand develop hospital based gastroenterologyand hepatology services. These changes will nodoubt continue to evolve as the emphasis onprimary care increases and the need forhospital specialists to provide rapid access today care services expands. The development ofnew technologies such as advanced therapeuticendoscopy are putting increasing demands ongastroenterologists, while at the same timemost continue to make a major contribution togeneral and emergency medicine services intheir hospitals.The expansion and continued evolution of
gastroenterology services in the UnitedKingdom has prompted the council ofthe British Society of Gastroenterology to setup a working party to consider how futureservice needs will drive this evolutionaryprocess and to anticipate the training needs ofthe gastroenterologist and hepatologist ofthe future. To assist this process, a sample of10% of consultant gastroenterologists werequestioned about their current workload andhow they might wish to change their job plansin the future (Appendix I). In parallel withthis, the working party considered the trainingrequirements for the future, made proposalsfor a curriculum, its implementation, andmethods of assessment. The working partywas made aware of the results of the surveytowards the end of its deliberations and tookthese into account during the writing of thisreport.The work of the training working party was
facilitated by Christine Farrell (director,clinical change programme) and Angela Towle(project manager for medical education) of theKing's Fund Centre, London.
2. Trends in healthcare that mayinfluence the practice ofmedicalgastroenterology and hepatologyThe working party made a fundamentalassumption that medical gastroenterology andhepatology in the future will differ from theway in which it is currently practised. The
working party attempted first to identify waysin which practice may change and then sug-gested adjustments to training programmes tosatisfy future needs. A number of factors wereidentified that are presently under change orrecently changed, which will influence bothtraining and practice.
2.1 The changing emphasis in primary careCurrent health policies are attempting to movemuch secondary care into primary care. Fundholding general practitioners wish to ensurethat their patients get the most cost effectivesecondary care and are already requestingchanges in the practice of gastroenterology andhepatology.2.1.1 Rapid access services must be developedto provide 'one stop' diagnosis in districtgeneral hospitals.2.1.2 Outpatient consultant opinions will besought more often and easy, prompt access toconsultants will be expected. Therapeuticdecisions made by consultants may bemodified by primary care physicians.2.1.3 In rural areas, access to diagnosticfacilities will need to be improved, which mayinvolve outreach clinics, ultrasound, andendoscopy.The exact extent of the shift of care towards
primary care will determine how muchchange is required. In some areas it seemsthat there will be little change while in othersimportant redistribution is likely. Consultantsneed to be trained in the development of localmanagement guidelines and with these couldoversee treatment for a number of chronicgastrointestinal disorders in general practice.The emphasis will be on outpatient consulta-tion.
2.2 New technology and technologistsThe endoscopic revolution from gastro-cameras to video endoscopy has occurred inless than 30 years. It would not have been pre-dicted that cholecystectomy could be per-formed laparoscopically or that endoscopicstent insertion for the treatment of extrahepaticcholestasis would reduce requirements forhospital beds. Digitised video images can nowbe transmitted transatlantically and it is
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probable that endoscopic advice may berequired by telephone using such systems.Communication with general practitionersmay follow similar lines with tele-clinics or'hands-off outpatients.
Endoscopists are likely to be trained from anon-medical pool in the foreseeable future inattempts to improve service, reduce costs, andprovide more outpatient time for consultants.A greater proportion of the endoscopy prac-tised by gastroenterologists is likely to be moretherapeutic and time consuming, but time maybe made available by reducing the diagnosticload.
Screening for colonic cancer is likely todevelop in one form or another. A non-invasivescreening tool (genetic/molecular) will prob-ably become available and will re-focus theneed for colonoscopy, but until such timecolonoscopy will continue to be a growth area.Time and personnel need to be made availablefor this.
2.3 Audit and evidence based outcomesPresent outcome audit is rudimentary, butpressure is being applied by the Royal Collegesto audit and purchasers are going to directresources to the most effective units.Consultants need to be involved in developingthe right measures and identifying theproblems (case-mix, racial, social, andenvironmental), which in turn affect outcomemeasures. This activity will be time consumingand personnel will be required. Training inaudit technology is needed.
2.4 Subspecialisation and the implications forsecondary and tertiary careFewer but larger hospitals are likely to remainafter the present round of reorganisations andpurchasing authorities are likely to merge.These hospitals will have more consultantswith a greater outpatient and investigative rolebut may have fewer beds. In such an environ-ment gastroenterological groupings are likelyto include individuals who specialise in certaingastrointestinal areas - liver, inflammatorybowel disease, nutrition, etc. Internal manage-ment guidelines will be just as important as ingeneral practice. The opportunity will exist forsurgeons, pathologists, radiologists, specialistnurses, and technicians to work in multi-specialty teams with gastroenterologists andhepatologists.
There is increasing demand to re-groupcertain conditions, for example gastrointestinalcancer. In this case a specialist gastrointestinaloncologist may be needed to work in associa-tion with a gastroenterologist who will providecontinuing care.
2.5 Increasing requirements for general andemergency medicineThere is an increasing number of hospitalemergency admissions and gastroenterologistshave traditionally participated fully in thereceipt of such cases. The need will remain but
gastroenterologists' time will be erodedthrough provision of increasing outpatient andendoscopic services. Most gastroenterologistsaccept that they will continue to participate inthe general medical service but some will prob-ably opt out. Thus there will be a need toensure that most trainees have adequateexperience in general medicine and to identifytraining schemes for subspecialist gastro-enterologists.
2.6 DemographyAn increasing elderly population with experi-ence of high tech medicine will pressuriseagainst agism. Colon cancer surveillance pro-grammes for example may not be agerestricted. Patients with gastrointestinal dis-orders will have multiple conditions andgastroenterologists will be expected to be ableto deal with them. Endoscopic gastrostomyfeeding could become standard practice inmany conditions of the elderly associated withpoor appetite.
2.7 Postgraduate training and researchReduction in junior doctors' hours is widelysupported but will probably have a detri-mental effect on the aspect of training thatcomes from direct consultant supervision.Patient care may deteriorate through lack ofcontinuity when provided solely by consul-tants because of inadequate replacement oflost hours. The pressure will divide loyaltiesto gastroenterology (predominantly out-patient and easily controlled) and generalmedicine (mostly inpatient and uncontrol-lable). Solutions could be more prolongedtraining, which goes against The RoyalCollege of Physicians recommendations andEuropean Commission and governmentdirectives, or massive consultant expansionincluding part time posts, with more hands-on general medical involvement.An important and expanding managerial
role has already developed in gastroenterology,with consultants often managing teams ofendoscopists, nurses, stomacare nurses, andadministrative staff. Consultants require train-ing in this area. As training becomes for-malised, consultants will need support andopportunities for improving their own skills asa trainer. The need for continuing medicaleducation will include these areas in additionto those of medical and gastroenterologicalclinical practice.The research emphasis will tend to be into
the health services: health provision, identifica-tion of needs, outcomes, and cost effective-ness. This assumption is borne out by the'health services research initiatives'. Basicscience research had traditionally played a partin the training of many gastroenterologists.The importance of some formal training inresearch methods may subsume the previousemphasis on attaining a higher degree throughresearch for some, while a few will havethe opportunity for extended basic researchtraining.
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3. Structure and process of trainiing inmedical gastroenterology and hepatology
3. 1 Objectives3.1.1 To provide a comprehensive and struc-tured higher medical training programme ingastroenterology for those who have completedgeneral professional training to equip them forspecialist practice in gastroenterology.3.1.2 To enable trainees to reach agreed stan-dards of quality and satisfy the assessmentprocess.3.1.3 To encourage flexibility in content andduration (full time or part time) so that thosewho show special aptitude for teaching,research or detailed subspecialist work maypursue this, subject to sufficient career oppor-tunities after completion of training.
At present the government devolves respon-sibility for setting and maintaining standards oftraining for junior medical staff to the RoyalColleges. The three Royal Colleges ofPhysicians discharge this responsibilitythrough the Joint Committee on HigherMedical Training (JCHMT), which in turnlooks to individual Specialty AdvisoryCommittees (SACs) for approval of trainingprogrammes and accreditation of trainees whohave satisfactorily completed such pro-grammes.The SACs draw their membership from
both the Colleges and from the specialistsocieties; hence the SAC in gastroenterologyhas three members from the BSG and threefrom the Colleges, acknowledging the impor-tance of the specialist society in this function ofsetting training standards. At local level, post-graduate deans, in consultation with collegeregional advisers, have responsibility for assess-ing higher trainees annually and overseeingtheir programmes.
In recognition of the increasing complexitiesand demands that accompany the more struc-tured 'post-Calman' training programmes, theJCHMT wishes to strengthen the regional net-work by putting in place for each specialty suchas gastroenterology a regional programmedirector, nominated by the postgraduate deanand approved by the JCHMT. This fits in wellwith the independent conclusions reached inthis document for the supervision and assess-ment of trainees.
3.2 Structure of training postsTo cater for the varied needs of individualtrainees, a modular training structure is pro-posed with a Core module and a series of Optionmodules (see 4.2.1 and 4.2.2). This structurewill allow trainees to develop their own interestswithin the subject while ensuring that they havea broad background in both gastroenterologyand general medicine. It is anticipated that dualcertification in gastroenterology and generalmedicine will require a five year training course.Training will aim to provide dually accreditedtrainees who would be pluripotential, fulfillingfuture teaching hospital, district generalhospital, and academic needs. Flexibility is thekey to this arrangement.
3.2.1 Core: Core training in gastroenterologywould be two and a half years in generalmedicine and gastroenterology concurrently.Trainees would also be expected to complete afurther 30 months in Option modules in gastro-enterology/hepatology. Training would there-fore be completed in five years giving dualaccreditation in general medicine and gastro-enterology.3.2.2 Options: proposed optional subjects arelisted in Section 4.2.2. Depending upon theoption, it is anticipated that three to six monthswill be required to reach competence in a givenoption. Trainees wishing to specialise in a par-ticular aspect of gastroenterology or hepa-tology will be able to choose to spend longer inthat field to achieve excellence. In manyinstances this will be for a year. However, thosewishing to specialise as clinical academics,hepatologists or advanced endoscopists maychoose to spend the entire 30 months availablefor options training in research, hepatology orendoscopy.Some of the Option modules may be pro-
vided by other disciplines and surgeons,radiologists and pathologists may participate inthose modules.
Training in the option modules will gener-ally take place during the working day.Trainees will be required in addition to joingeneral medical rotas for out of hours work.This will be important to ensure: (a) thatoption module training does not compromisehospital rotas; (b) that concurrent training ingeneral medicine and gastroenterology cantake place.To facilitate the organisation of a weekly
time table the options may be taken as wholetime (four days per week), half time (two daysper week) or quarter time (one day per week).Throughout the Core training period the
trainee will be expected to undertake self-directed study to ensure that the theoreticalaspects of the subject are learnt. Self-directedlearning should be supplemented by regionallybased teaching programmes.
Entry to the training programmeEntry to the specialist registrar grade in gastro-enterology will be by open competition andinterview before a properly constitutedadvisory appointments committee for eachgroup of training hospitals. The advisoryappointments committee should considerapplicants for both full time and part timetraining. Candidates will have the MRCP(UK)and have completed general professionaltraining.
3.3 Regional programme directorThere will normally be one programme direc-tor for each region (as defined by the areacovered by a regional postgraduate dean) whowill be responsible for implementation of thecurriculum and delivery of a planned, progres-sive programme of training and educationthrough agreed standards of quality andquantity.
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The regional programme director will beappointed by the postgraduate dean with theadvice of the trainers. S/he will be responsibleto the postgraduate dean and maintain linkswith the Royal College regional adviser.The programme director will have the fol-
lowing responsibilities:(a) To plan a programme of training contain-ing both core and appropriate options in con-junction with the trainee and the localeducational supervisors. The programmedirector should ensure that the training pro-vided is likely to meet the needs of mosthospitals to maximise the chances of appoint-ment to a consultant post at the end of thetraining programme. Links with the manpowercoordinator of the British Society of Gastro-enterology and Royal College of Physiciansgastroenterology committee will be essential toensure that this goal is achieved.(b) The training programme will almostinevitably involve rotation between hospitals,which will require supervision by the pro-gramme director.(c) The programme director should ensurethat the experience in each post fulfils thestated requirements for that period of training(module).(d) The programme director will need to liaisewith the trainee, trainer or local educationsupervisor, and other bodies in the event ofproblems with the trainee or the training post.(e) The programme director will arrange andfacilitate the assessment of each trainee atappropriate intervals - probably yearly.
In view of the responsibilities of the regionalprogramme director in decisions, coordinatingand assessing training in gastroenterology andhepatology it is anticipated that two sessionswill be required each week to complete thetask, and a source(s) of funding will need to beidentified to support this activity.
3.4 TrainerThe trainer will be one of the consultant staffon the firm or in the department to which thetrainee is attached and will usually have day today contact with the trainee. The trainer willplan a weekly programme, agreed with theregional programme director and the trainee,which will provide an appropriate balancebetween training and service commitments.Training commitments will include time foracademic meetings, audit, self-directed learn-ing, research, study leave, and supervisedservice. The trainer will also arrange for regularassessments of the trainee (see section 5).
3.5 TraineesThe trainee should agree and implement aweekly time table with the local trainer and theregional programme director. The traineeshould ensure that there is a formal meetingwith the trainer every three months and thatany problems with training are identified andresolved in good time. The trainee should keepa record of practical procedures in a personaltraining record and ensure that the experience
from the post will fulfil the stated requirementsfor that period of training. Any problems thatare not resolved locally should be reportedpromptly to the regional programme directoror failing this, the Specialist Advisory Com-mittee. Trainees should see and sign anyformal reports or assessments about theirtraining.
3.6 Alternatives to full time training (flexibletraining)There is increasing demand for periods of lessthan full time training in all medical specialties.All training programmes in medical gastro-enterology/hepatology must have posts avail-able for trainees wishing to work part time atany stage in the programme. These traineesmust apply through a specifically designatedofficer appointed by each regional post-graduate dean to oversee part time training.Competition for posts on regional part timetraining programmes must be alongside fulltime applicants and appointments made by thesame advisory appointments committee,although a separate committee may be neededif no appointments to full time regional traineeposts are made within six months of applica-tion for a part time post. A part time traineewill be required to work a minimum of halftime but may work further hours up to full timebut all Option modules should be available on aless than full time basis. Part time traineesshould have equal access to each of the Coreand Option modules of a training scheme as fulltime trainees and the same commitment fromtrainees and regional programme directors. Itwould be expected that flexible trainees willhave a regular on call commitment.The frequency of assessments for trainees
will depend on the numbers of hours worked.The progress of their training will be con-sidered in terms of the numbers of hours com-mitted to each Core or Option module unlessthis can be defined in terms of numbers ofprocedures (for example, endoscopy) or theacquisition of a precise skill (for example,imaging).
3.7 OutcomeTrainees completing the training programmewhether full time or part time, would be quali-fied to practise general and emergencymedicine and general gastroenterology/hepa-tology. In addition, the programme is suffi-ciently flexible to permit further specialisationwithin the field of gastroenterology andhepatology, allowing the development ofindividuals with a major commitment to: (a)academic gastroenterology/laboratory science;(b) hepatology; (c) advanced endoscopy.
3.8 Recommendations3.8.1 Regional programme directors in gastro-enterology/hepatology should be appointedunder the auspices of postgraduate deans andin conjunction with trainers.3.8.2 It is anticipated that two sessions each
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week will be required to devise and oversee aregional programme and thus sources of fund-ing to support regional programme directorswill need to be identified.3.8.3 The funding of part time posts will haveto be clarified in relation to the funding of allcareer grade medical gastroenterology/hepa-tology posts.
4. A curriculum for training in medicalgastroenterology and hepatology
4.1 Aims4.1.1 To produce gastroenterologists who areclinically skilled and sufficiently competent toprovide a general gastroenterological andhepatological service.4.1.2 The training programme should haveflexibility to encourage a degree of specialisa-tion and choice commensurate with careeraims and service needs, and enable the traineeto face the changing needs of gastroenterologyin the NHS.4.1.3 The training should encourage a criticaland analytical approach to effective clinicalmanagement and a positive approach to healthservice management, teaching, and research.
4.2 The curriculumThe curriculum should be divided into Coreand Option modules. The Core of the curri-culum will provide education in the theoreticalbasis of, and training in, the clinical care ofpatients with common gastroenterological con-ditions in the inpatient and outpatient setting.Such training will include basic diagnostic andtherapeutic endoscopic and investigationalskills, in harmony with European trends andconsistent with the relevant EEC Directive13/93.
4.2.1 Core
4.2.1.1 Scientific basisDuring specialist training the trainee shouldacquire sound scientific and theoretical know-ledge of the normal structure and function ofthe gastrointestinal tract as well as knowledgeof the aetiology, pathogenesis, natural history,clinical presentation, investigation, and.-treat-ment of diseases of the gastrointestinal tract,including the hepatobiliary system and pan-creas. Such knowledge includes histo-pathology, haematology, microbiology andparasitology, chemical pathology, immun-ology, genetics, molecular biology, epidemi-ology, and statistics. An understanding ofmedical demography and health careeconomics is required.
4.2.1.2 Clinical knowledgeThe trainee will be expected to have a broadbased education in most areas of gastro-enterology. Knowledge of the indications andcontraindications for, and the complicationsof, various imaging, investigational, and
surgical techniques together with understand-ing of their limitations will be essential in avariety of clinical settings.
All training will fulfil the requirements of theSpecialist Advisory Committee in Gastro-enterology and the Joint Committee on HigherMedical Training.4.2.1.2.1 General and emergency medicine.4.2.1.2.2 Core gastroenterology (to includethe inpatient and outpatient management ofthe following): (a) inflammatory bowel disease;(b) hepatobiliary disease (acute and chronicliver disease, jaundice and alcohol relateddisorders); (c) functional bowel disorders;(d) malabsorption and pancreatic disease;(e) gastrointestinal infections and AIDS;(f) oesophageal and gastroduodenal disease;(g) oncology (oesophageal, gastric, pancreatic,and colon cancer); (h) gastrointestinal emer-gencies (acute abdomen, bleeding, fulminantcolitis, cholangitis); (i) nutritional support; (j)gastroenterological manifestations of systemicdisease.
4.2.1.3 Clinical care and expertiseTrainees should have supervised practicalexperience in the clinical care of patients in theabove groups, both as inpatients and out-patients. The clinical management of patientsin the primary care setting and at home shouldbe understood. Clinical experience must begained mainly in substantive posts with appro-priate development of clinical responsibility.Teaching by direct supervision of clinical workand attendance at multidisciplinary meetingsmust be an integral part of the trainingprogramme. Pharmacological, psychological,dietetic, and surgical treatments available forthe above conditions will need to be under-stood and experience gained in their use.
4.2.2.1.4 Competence/skills requiredTo treat patients with these conditions trainingwill be required in the following skills:(a) Diagnosis and treatment;(b) Basic diagnostic endoscopy. This shouldinclude rigid sigmoidoscopy, oesophagogastro-duodenoscopy and colonoscopy, and possiblyexposure to endoscopic retrograde cholangio-pancreatography. Principles of disinfection,safety, and sedation;(c) Basic endoscopic therapeutic techniques.This should include stricture dilatation, injec-tion or banding of varices, or both, haemostatictechniques and polypectomy. The indications,contraindications, and complications of theseprocedures should be understood;(d) Communication skills. Trainees shouldacquire an attitude to, knowledge of, and skillin doctor/patient communication and the man-agement of communication in hospital andbeyond. This should include basic communi-cation skills, information giving, negotiating,writing comprehensible prepared material,participating in hospital-wide communicationinitiatives and working in a multidisciplinaryteam;(e) Cancer care. This should include palliative
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care and palliative techniques, pain relief,terminal care, informing patients, psychologi-cal support, counselling, management ofbereavement and ethics;(f) Non-endoscopic techniques. This shouldinclude liver biopsy, paracentesis, and know-ledge of other investigative techniques used ingastroenterology and hepatology;(g) Management training. This should includeexperience of audit, information technology,Health Service management, contracting, andmarketing.
4.2.2 Option modulesThe trainee will be required to undertake avariety of advanced option modules (clinicaland research) after discussion with the regionaltraining supervisor. Some of the options will befull time whereas others will be part time andpermit training in both Core and Option to runconcurrently.
All options will include training in the teach-ing of patients, nurses, medical students, anddoctors relevant to that module.(a) Advanced gastroenterology (experience inspecialist units such as inflammatory boweldisease, or coloproctology, or oesophagealdisease).(b) Advanced hepatology (management offulminant hepatic failure, transplantation,specialist hepatitis referral centre).(c) Physiological measurement (oesophagealmanometry and pH measurements, gastric andpancreatic function testing, anorectal physio-logical studies).(d) Nutrition (assessment of requirements,catheter placement, nutrition team servicemanagement).(e) Paediatric and adolescent liaison gastro-enterology (to acquire experience in gastro-enterological conditions that start in childhoodand continue into adulthood).(f) Advanced therapeutic endoscopy (ERCP,or laser therapy, or photodynamic therapy, ormanagement of strictures and fistulas, orenteroscopy).(g) Imaging (ultrasound, endoscopic ultra-sound, computed tomography, magneticresonance imaging, nuclear medicine).(h) Cancer care (drug therapeutic regimens,radiotherapy, combined modality treatment,and brachytherapy of all common gastro-intestinal and hepatic malignancies).(i) Palliative care (pain relief, hospice care,terminal care, palliative endoscopic tech-niques).(j) Communicable disease (advanced AIDS,intestinal infection, hepatitis, tropical disease,parasitology, special experience with Helico-bacter pylon).(k) Psychological medicine (basic liaison psy-chiatry; the knowledge of psychiatric disease inhospital patients and the nature and manage-ment of physical symptoms with no organicbasis. Eating and drinking disorders, factitiousdisease).(1) Research: basic (experimental design, basictechniques, statistical planning, criticalappraisal).
(m) Research: advanced I (cellular/molecularbiology), II (whole organism pathophysiology),or III (clinical trials/epidemiology).(n) The interface between primary and secon-dary care in gastroenterology.(o) Teaching and presentation skills (includ-ing training in presentation, educationalmethods, audiovisual techniques, media man-agement, information technology).(p) Health service management (audit, infor-mation technology, budgeting, contracting,negotiating skills, personnel management,marketing).(q) Elective free option (for example, 'pure'epidemiology, genetics, microbiology).
4.3 Practical experienceThe Core curriculum will run during the first30 months of specialist training. Trainees willin addition be required to undertake severalOption modules during their training to meettheir own educational and clinical interests, aswell as their career aims.The number of Option modules available in
each region will vary, and arrangements willneed to be made to permit as much choice aspossible. The total number of Option modulesshould remain flexible and dependent oncareer intentions. It is anticipated that in manycases the Option modules and Core curriculumwill run simultaneously.The number of practical procedures that are
undertaken by the trainee will be in line withthat advised by the Joint Advisory Group onEndoscopic Training.
4.4 Recommendations4.4.1 Training in gastroenterology and hepa-tology should be a basic five year programmewith the option of an additional year to permitflexibility in clinical training and research.4.4.2 The training programme should consistof a compulsory Core component and broadrange of Option modules to enable trainees tostructure their training towards a variety ofcareer outcomes.4.4.3 The Core will consist of 30 months'training in gastroenterology and hepatologyconcurrently with general and emergencymedicine. Options will require a further 30months, each having a minimum duration ofthree and a maximum of 12 months wholetime equivalents and a further optional oneyear may be taken for research.4.4.4 The training programme will producebroadly trained gastroenterologists/ hepatolo-gists but in addition will enable some traineesto gain special expertise to pursue careers inacademic gastroenterology (including clinicaland basic science), advanced hepatology, andadvanced endoscopy.4.4.5 The British Society of Gastroenterologyshould develop a syllabus for the training pro-gramme to cover the theoretical basis of thepractice of gastroenterology/hepatology.4.4.6 Approaches to implementing thissyllabus should be investigated with considera-tion given to both self-directed learning (for
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example, by the development of interactivecomputer based learning programmes) and bythe development of a regionally based teachingprogramme to complement for former.
5. Methods ofassessment
5.1 Training unit and the trainerCurrent Guidelines and Practice by TheSpecialist Advisory Committee of UnitAssessment will be adhered to. A unit will bedeemed suitable if:(a) there are a minimum of two consultantgastroenterologists or, if only one, adequatecover arrangements, so that day to day practicecan realistically be supervised;(b) there should be at least one half of thework undertaking supervised clinical responsi-bilities such as endoscopy lists, ward rounds,and outpatient clinics;(c) it is able to provide facilities to permit thebest standards of specialist practice, includingfacilities for appropriate clinical investigationand management;(d) there are adequate opportunities to gainclinical experience as indicated by outpatientand daycase attendances and completed con-sultant inpatient episodes;(e) there are adequate library facilities andother forms of academic support;(f) adequate study leave is provided in theform of day release and for longer trainingcourses within or outside the region.
Currently, the specialist advisory committeeundertake unit assessments every five years. Inaddition to these the postgraduate dean orrepresentative and the regional programmedirector, who will be a gastroenterologist/hepa-tologist, will validate the unit and trainer on anannual basis. The postgraduate dean may electthe regional programme director to be hisrepresentative. These annual assessments willneed to ensure:(a) The unit and trainer are fulfilling therequirements of the core curriculum and anyoption modules they may be covering.(b) The trainee is receiving trainer assessmentand adequate supervision on a day to day basis.At these annual assessments the trainee will begiven the opportunity to give unbiased feed-back on trainer and unit, which will subse-quently be fed back to the trainer by theregional programme director or the regionalpostgraduate dean, or both.
It will be the responsibility of the post-graduate dean to ensure that the trainer isadequately prepared to be a trainer. Provisionof training courses for trainers may berequired.
5.2 Trainee Assessment
5.2.1 LocalOn arrival in post there will be a 'formative'first appraisal assessment by the trainer whichwill:(a) Determine educational needs with respectto the Core curriculum for Option modules
offered by the particular training unit. The per-sonal training record will be used to assess thetrainee's progress and to identify gaps inexperience. The needs of a first year traineewill be different from a third or fourth yeartrainee. Difficulties in achieving training goalswill be identified.(b) Set future training goals on the basis ofneed. Goals will be set and agreed uponbetween trainer and trainee, documented, andsigned by both. This will be an informalprocess.A second 'summative' appraisal interview
with the trainer will take place either one yearlater or at the end of the post, if this is shorter.The summative appraisal will:(a) determine the extent to which trainee goalshave been achieved;(b) examine the personal training recordwith the trainer signing the trainee up for thevarious skills attained;(c) assess trainee competence includingstrengths and weaknesses;(d) set new goals.A written record of the experience and train-
ing of each trainee must be maintained andagreed by both trainer and trainee, in advanceof the annual assessment organised by thepostgraduate dean. This will form part of areport containing also an assessment by thetrainer of the trainee's technical ability on anagreed scale. The report will also show thetrainee's ability to work as a member of amultidisciplinary team and their ability torelate to and communicate with patients andother staff at all levels. The aim should be toensure that the trainee is developing theseand other skills (for example, management)essential for consultant practice in the NHS.
In addition to this formal assessment at locallevel, informal continuous assessment willcontinue on a day to day basis during:(a) At least one consultant led ward round perweek.(b) Outpatient clinics, in which the trainermight join the trainee during consultations ona monthly basis.(c) Endoscopic training suggested by theSpecialist Advisory Committee guidelines(Appendix II).(d) Regular multidisciplinary meetings (radio-logy, histopathology, etc) and journal reviewsessions.
5.2.2 RegionalTrainees will be assessed annually at an inter-view organised by the postgraduate dean withthe college regional adviser as chairman. Othermembers would normally include the regionalprogramme director, another consultant ingastroenterology not directly connected withthe training scheme or unit, and a consultantphysician from another specialty where thetraining also involves general (internal)medicine.The trainer will also be asked to evaluate the
competence of the trainee. As a result of thisassessment a written report would be prepared,signed by the trainer, trainee, and regional
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postgraduate dean/regional adviser. A copywill be kept by each as well as one sent to theJCHMT. At the penultimate annual assess-ment, the panel will include a gastroenterolo-gist from outside the region nominated by theJCHMT. This assessment would permit iden-tification and correction of problems with theaim of avoiding an adverse final assessment.
If the trainer or the regional programmedirector feel that the trainee is failing in anyrespect, or the trainee wishes to opt out of thetraining programme, it will be the responsi-bility of the regional programme director toorganise appropriate career counselling. At thisannual interview the trainee will have theopportunity to give feedback on the unit andtrainer.At the end of training, a final summative
appraisal will be undertaken in a similar formatand the report sent to the JCHMT and CCSTto enable certification.A final 'exit' examination for trainees at the
end of the training period was felt undesirablebut that standards could be maintained bycontinuous self-assessment by the trainees andby the trainers.
5.2.3 Appeals procedureIf there is a dispute between trainer and traineeon the description of experience, training orperformance, arbitration will be coordinatedby the postgraduate dean and the SAC. If thefinal assessment is unsatisfactory, an appealmechanism independent of the JCHMT andpostgraduate deans should come into play.The British Society of Gastroenterology maywish to assist this process.
6. SummaryThe council of the British Society of Gastro-enterology commissioned this report from aworking party set up to examine future trainingin gastroenterology. The need for re-examina-tion of training was driven by two considera-tions - the rapid changes in healthcareorganisation in Britain, and by acceleratingtechnological progress in diagnosis and treat-ment of gastrointestinal conditions.The predominant organisational changes are
the trend towards increasing primary care sup-ported by ready access for general practitionersto diagnostic tests; outreach clinics by consul-tants and prompt access to appropriate, costeffective secondary care; yet higher levels ofemergency acute admissions. The agingpopulation and the necessity to provide tech-nologically appropriate care for them is animportant demographic trend.
Technologically it seems likely that changewill be even more rapid over the next 30 yearsthan it has been in the past 30 years; this makesprediction difficult, but undoubtedly endo-scopic techniques - both diagnostic and thera-peutic - will increase in number and safety.
6.1 Patterns of trainingThe training pattern proposed is based on a
more structured core of scientific educationthan now, partly achieved by 'distance learn-ing' techniques, with periods of self-assess-ment. This core scientific knowledge will bethe basis for clinical experience in approvedunits, with as much emphasis on consultativeskills as on technical achievement. Appropriateexposure to general internal medicine (includ-ing acute admissions) as well as Core gastro-enterology will be assured. Training will besupervised, recorded, and appraised.
In addition to this essential Core, there willbe a number of Option modules coveringadvanced areas of clinical gastroenterology,endoscopy, psychology and epidemiology,research, etc. Every trainee will undertakeseveral such modules, the pattern being deter-mined by agreement between the trainee andsupervisor.
6.2 Structure of trainingThe training programme has been designed tofit in with the reduced hours of work/traininglikely to be acceptable in the future. Coregastroenterology training would run concur-rently with general medicine for 30 monthsduring training. A trainee would be expected tohave completed a further 30 months' trainingin Option modules before applying for consul-tant posts.The necessary organisation of this complex
scheme would be the responsibility of aregional programme director under super-vision of the regional postgraduate dean. Therewould be local educational supervisors(trainers) and regular feedback sessionsbetween them.To ensure that this compressed training pro-
gramme will have the right outcome, the unitsproviding training and the trainers will needregular assessment (by the SAC every fiveyears and the regional postgraduate dean andregional programme director annually). Thetrainee will also be assessed annually by localtrainers and by the regional postgraduate deanor regional programme director. On all theseoccasions a written report will be preparedwith copies kept by trainer and trainee.
6.3 OutcomesThe final product will be three types of gastro-enterologist. The trainee with a minimumnumber of hours in a broad range of moduleswould be a 'general physician/gastroenterolo-gist'. Others would be 'specialists' with a broadgeneral training, but with more specialist train-ing in a smaller number of modules in areassuch as nutrition, oncology, management.Finally there would be 'super-specialists' whowould have spent most of their modular optiontraining in one area such as research, hepato-logy or advanced endoscopy.The days of clinical apprenticeship - 'pick-
ing it up as you go along' - are over. Trainingin the future must be at once faster, yet morecomprehensive; stimulating yet better super-vised. The changes envisaged make consider-able demands on future trainees, but require
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A national training programme for gastroenterology and hepatology
even greater changes in attitude, expectation,and training ability from existing consultants.These will not easily be achieved along with themany other rapid changes demanded of seniorprofessionals, but the force for such change isirresistible.This working party report was accepted by the training com-mittee of the British Society of Gastroenterology and approvedby the council of the British Society of Gastroenterology inDecember 1995.
Members ofthe training working partyM J G Farthing (chairman), secretary, British Society ofGastroenterology; R P Walt, secretary, BSG; R N Allan, RoyalCollege of Physicians gastroenterology committee; C H J Swan,I T Gilmore, specialist advisory committee in gastroenterology;C N Mallinson, European board of gastroenterology of theEUMS; J R Bennett, BSG clinical services committee;C J Hawkey, BSG education committee; W R Burnham, BSGmanpower office; A I Morris, BSG endoscopy training officer;C J Tibbs, T E Bowling, association of gastroenterologists intraining; C Cobb, S Catnach, co-opted as representatives offlexible training in gastroenterology; C Farrell, director, clinicalchange programme, King's Fund Development Centre;A Towle, project manager, medical education, Kings' FundDevelopment Centre.
Appendix I
King's Fund Centre
Gastroenterologists: present and future needs
1. The sampleQuestionnaires were sent to 69 gastroenterologists inthe United Kingdom. This represents a 10% sample ofall the physician gastroenterologists on the BritishSociety of Gastroenterologists' (BSG) membership list.The response rate was 77%. Time prevented a followup letter to increase this response.
2. Profile of respondents
AgeA quarter (26%) of the respondents were aged 40 or
below; a third (34%) were between 41 and 50; justunder a third (31%) were between 51 and 59; and 9%were 60 and over. All but two were men. Everyone inthe sample had reached consultant level before the ageof 40, with 70% appointed by the age of 35.
Hospital typeFour of 10 (40%) were working in teaching hospitals;the rest in district general hospitals.
Replies were received from gastroenterologists in allregions.
3. Components ofworkTable I shows how respondents divided timebetween the different aspect of their jobs. Nearly twothirds (63%) of the sample spent either 10% or 20%of their time on general medicine. A similarproportion (66%) spent up to 30% of their time on
gastroenterological work. Nine of 10 (93%) spent upto 30% of their time on endoscopy. Only one in five(21%) spent any time on nutrition. Four fifths (79%)spent up to half their time on management duties.
TABLE II Changes to time spent on general medicine
Number %
Stop all general medicine 12 41Reduce % 12 41Stay with current % 2 3Increase 0/, 2 3Doesn't do general medicine 1 2Total 29 100
TABLE III Respondents wish to spend more or less time onspecific aspects of their currentjobs
Wish to spend Wish to spendJ7ob components more time on (9%o) less time on (%/)
General medicine 4 45Gastroenterology 28 2Endoscopy 9 17Nutrition 19 2Management 4 30Teaching 11 11Research 45 0Private practice 7 13No desire to change 43 43No response 2 2
Number=53 (totals do not add to 100% because more thanone choice was available).
Four of five consultants (79%) did some privatepractice, with three quarters (79%) of these spending10% of their time on it.Over half the respondents (59%) engaged in
research with most spending 10% of their time on it.
4. Desire for changeTwenty three respondents (43%) said that they werecontent with the way their current activities weredisposed; and one other person did not reply to thisquestion. These 24 people are excluded from thefollowing analysis, which records the changes that the29 malcontents wished to make.
General medicineAlmost all the people who wished for change wantedeither to stop doing general medicine altogether or toreduce the amount of time they spent on it; 41% ineach case. Most of those who wished to reduce thetime, wanted to reduce it from 20% to 10%, althoughthere were three who were doing more than 20%general medicine who wished to reduce the time spentto 20%. Two respondents wanted to increase theamount of time spent on general medicine by 10%.Table II shows the exact proportions.
GastroenterologyThe majority wish to remove or reduce time spent ongeneral medicine was primarily to allow people tospend more time on other activities not alwaysgastrointestinal. In this case, 11 (38%) respondentswanted to keep the same proportion of time forgastroenterology, usually at 30%. Fifteen people(52%) wanted to increase the amount of time theyspent on it by 10% or 20%. One person wanted toreduce the time by half to 15%.
TABLE I Proportion ofsample spending time on different aspects of theirjobs
General% Of medicine Gastroenterology Endoscopy Nutrition Management Teaching Research Privatetime spent % % % % % % % practice
Regional Health Authority:..........................................................................................How many gastroenterologists work in your hospital/trust?(a) Actual number(b) Full-time equivalent number
(c) Level of staff: consultant(s)senior registrar(s)Other: .....................................................................
8. What proportion of your work time do you spend on the following?Please circle the actual or nearest proportion.General medicineGastroenterologyEndoscopyNutritionManagementTeaching/trainingResearchPrivate practice
9. Are you content with this allocation of time? Yes n No n(a) If No, what proportion of your work time would you prefer to spend on each of thefollowing? Please circle appropriate figures.General medicineGastroenterologyEndoscopyNutritionManagementTeaching/trainingResearchPrivate practice
(b) Please explain briefly, the reasons why you would prefer to allocate your time in a
different way.
10. Career developmentAre there any skills related to your current jobwhich you do not have but would like to acquire?(a) If yes, please write in which skills you would like to acquire.
11. Are there any skills unrelated to your currentjob, which would be useful to you in your future career?
Yes FL No Fl
Yes No l
12. If yes, please write in which skills you would like to acquire.
13. Thinking about the likely developments in gastroenterological medicine during the next ten
years, which of the following skills do you think it will be essential for postgraduate traineesto acquire?
Number in priority order (1- 12) skills listed below
Diagnostic and therapeutic upper GI endoscopy ......
Diagnostic and therapeutic colonoscopy ......
Diagnostic and therapeutic ERCP ......
Computer skills (endoscopy databases, etc) ......
Diagnostic ultra sound ......
Oesophageal manometry ......
Nutritional support ......
Liver biopsy ......
Communication/psycho-social skills ......
Management and term working skills ......
Teaching skills ......
Research and evaluation skills ......
Thank you for your helpPlease return this questionnaire direct to: Christine Farrell, at The King's Fund Centre, 126Albert Street, London NW1 7NF
EndoscopyThose who wanted to change the proportion of timethey spent on endoscopy (14 in all) either wished toincrease it (5) or reduce it (9). Those who wanted toincrease the time spent on endoscopy were usuallyspending sizeable proportions of their time on it andnone of them wanted to reduce it to less than 20% or30%. Satisfaction with endoscopy seemed to behighest when the proportion of time spent on it was30%.
NutritionTable I showed that only one in five respondentsspent any time on nutrition. This seemed to be theway people liked it as only 11 respondents wished tochange it. Ten of these 11 people wanted to spend upto 10% more of their time on nutrition up to amaximum of 20%. One person who was spending10% of his time on it wanted to stop doing italtogether.
ManagementAltogether 18 people wanted to change the amount oftime they spent on management. Most of them (16)wanted to reduce the amount of time. For 10 of these,this wish must have been unrealistic as they wanted tostop managing altogether. The two people who wantedto increase the amount of time, wanted only smallincreases of 5% and 1 0%. The last of these was notcurrently doing any!
Teaching and trainingTwelve people wished to change the proportion oftime they spent teaching. Of these, six wanted to doless and six wanted to do more - usually smallamounts (5% or 10%) both ways.
ResearchNobody wanted to spend less time doing research but24 respondents wanted more time to spend on it. Theincrease they wanted was usually from 10% to 20%,although in one case it was from 20% to 30%.
Private practiceEleven people wished to reorganise their privatepractice allocations. Six respondents wanted to stopdoing it altogether: two wanted to increase it from10% to 20%; and two from zero to 10%.
In summary, where people were discontented withthe time they spent on the individual components oftheir jobs, it was primarily connected to the amount oftime spent on general medicine and their wish to devotemore time either to research or gastroenterology. TableIII shows the relative size of the shifts people wished tomake. To put these shifts into perspective, the Tableincludes all respondents.
5. Career developmentThe range of skills related to current jobs thatrespondents felt they did not have and would like toacquire was broad and diverse. Forty per cent said theydid not have any requirements. Of the 60% who did feelthey lacked some skills, seven wanted to acquiremanagement skills. Twelve wanted ultrasound or endo-scopic ultrasound skills, or both; five wanted computingand information technology skills; five wanted biliarymanometry skills; four wanted therapeutic ERCP skills;and three wished to acquire skills related to nutrition.Other skills listed by individuals included: teaching,research, laser endoscopy, vasical banding (?),knowledge of molecular biology, colonoscopy, and liverhistopathology.
Fewer respondents (34%) felt the need to acquirenew skills for their future careers. Of those who did,eight thought management and financial skillswould be useful, and another three people wanted toacquire negotiating skills related to contracting. Sixpeople thought teaching, research and audit skillswould be useful. Three people wanted computingand information technology skills and one personthought the acquisition of leisure skills would beuseful!
6.
7.
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Set out in this way, the Table shows little except that diagnostic and therapeutic (D+T) upper gastrointestinal endoscopy skills are given top priority by three offour respondents. However, if the ranked items are divided into top six and bottom six proportions then added up, a clearer picture emerges. NR=not ranked.
TABLE V Postgraduate trainees essential skills - top six and bottom six ranked items
D+ T Computerupper and
Skills gastrointestinal information Diagnostic Liverendoscopy Colonoscopy ERCP technology ultrasound Manometry Nutrition biopsy Communication Management Teaching Research
Working from the top and bottom, these proportions can be used to produce a rank order of skills considered essential to postgraduate training. How useful this is,will be for the group to decide.
0/
23456789101112
Diagnostic and therapeutic gastrointestinal endoscopyColonoscopyERCPCommunicationsTeachingManagementLiver biopsyComputing and information technologyResearchNutritionDiagnostic ultrasoundManometry
(94)(88)(86)(58)(54)(50)(48)(46)(55)(63)(76)(82)
6. Essential skills for postgraduate trainees in thefutureRespondents were asked to indicate and rank inpriority order, the skills that future traineegastroenterologists should acquire. Table IV showstheir response. Several (eight) people said that this wasa pointless exercise but almost everyone completed thetask (polite!). A few people ranked a number of itemsas equal first, or sixth, etc but this does not seriouslyaffect the results.
Appendix II
SAC guidelines - Gastroenterology
Entry requirementsApplicants for Higher Medical Training (HMT)should have completed a minimum of two yearsgeneral professional training (GPT) in approved postsand obtained the MRCP (UK) or (I). A period ofexperience in gastroenterology at SHO grade isconsidered desirable, before entry to HMT, althoughnot essential. GPT should provide a minimum of 24months involved with direct patient care at least 12months of which should be concerned with acuteunselected medical intake. Non-British/Irish graduateswithout the MRCP who compete for HMT posts mustprovide evidence of appropriate knowledge, training,and experience, particularly in the care of acutemedical conditions.
Duration and organisation of trainingThe duration of HMT in gastroenterology is four
years. One of those four years must be in general(internal) medicine (G(I)M), as this training isessential for the practice of gastroenterology. Thosewho wish to obtain dual certification to include G(I)Mwill require at least a fifth year in training. HMT willprovide experience in both teaching hospital(s) orother major centres with academic activity andDGH(s). The programme to which the trainee isappointed will have named consultant trainers for eachslot in the programme. In addition, one consultantwithin the same region will act as programme directorto the trainee and will be appointed jointly by thepostgraduate deans and the JCHMT.A written record of training will be maintained by
the trainee, to be countersigned by the relevant trainerannually; it will remain the property of the trainee butmust be produced at the annual assessment and for thefinal SAC decision on certification.
ResearchResearch experience is encouraged and supported bythe SAC and could count for up to a year of HMT ifrelevant to gastroenterology and undertaken in adepartment where the trainee has some clinicalcommitment. The SAC would be in a position tojudge this. It will remain essential to acquire the fullbalance of clinical training.
AssessmentAssessment of trainees will be based upon the standardformat of annual review. The recommendation of thepostgraduate dean on the award of a CCST will besubmitted to the JCHMT who retain the finalresponsibility for advising the GMC.
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General description of trainingThis will provide a balance of training in gastro-enterology between district and university hospitalsand in specialist units. There will be exposure toemergencies and a balance of outpatient and inpatientwork, the detail of which is included in thecurriculum below. There should be emphasisthroughout on the importance of close cooperationwith gastroenterology colleagues in other disciplines,especially surgery, radiology, and pathology and withgeneral (internal) medicine. Trainees should acquiresome experience in management skills, especially withreference to running a gastroenterology service.
Training in practical skillsAcquisition of skills as an endoscopist is essentialfor training as a gastroenterologist but should beacknowledged as only part of that training. It is not arequirement for certification that a trainee becomescompetent in every single diagnostic and therapeuticprocedure, particularly at the expense of experience inthe overall management of patients. Whereverendoscopy is taught, it should be as part of an overallgastroenterology service with cooperation betweenphysician, surgeon, radiologist, and pathologist. Whileabdominal ultrasound is traditionally performed byradiologists in the UK, the SAC acknowledges thatpractical ultrasonography is a mandatory part oftraining for gastroenterology physicians in many partsof Europe. To bring any UK certificate into line withEuropean Diploma requirements, we recommendsome supervised training in ultrasonography.
Curiculum
(a) GeneralWhile not every aspect of training can be prescribed, itshould include wide experience in the diagnosis andmanagement of common gastrointestinal disorderssuch as acute and chronic gastrointestinal bleeding,peptic ulcers, oesophageal disease, infections,neoplasia, inflammatory bowel disease, jaundice,malabsorption, and pancreatic disease. The traineeshould be familiar with the principles of enteral andparenteral nutrition. There should be extensiveexposure to liver disease, both acute and chronic, withemphasis on the spectrum of alcohol related disorders.Trainees should become familiar with the indicationsfor screening for gastrointestinal malignancy andinteract with oncologists for the treatment andpalliation of gastrointestinal cancers. There should bean understanding of gastrointestinal disease as foundin the elderly. Wide outpatient experience must beobtained and familiarity gained with the managementof functional bowel disorders. Throughout trainingthere must be regular and close liaison withgastrointestinal surgeons in the joint management ofpatients and links with interested radiologists andhistopathologists. There must be evidence ofexperience of the relevance of other pathologicaldisciplines to gastroenterology, including micro-biology, clinical chemistry, and haematology. Exposureto the management of patients with HIV infectionshould be sought. There must be evidence ofcontinuing inpatients responsibility for patients withgastrointestinal disorders and a commitment to themanagement of emergencies.
Trainees should have the opportunity to gainparticular added experience in specialised services suchas liver transplantation, gastrointestinal motility,paediatric gastroenterology, AIDS, home parenteral
nutrition, and the management of fulminant hepaticfailure, but it is not considered essential that theyshould have wide experience in all of these.
(b) rlactical skillsOesophagogastroduodenoscopy (OGD) - the unit shouldbe performing more than 1000 examinations per year.The trainee should attend at least weekly for sixmonths and perform at least 150-200 diagnosticexaminations under a degree of supervision, andthen undertake further examinations, when judgedcompetent, with a degree of independence in selectedcases, to a total minimum of 300 examinations.Therapeutic endoscopy of the upper gastrointestinaltract requires further specific training undersupervision, requiring 30 variceal injections andother haemostatic techniques. The trainee shouldhave knowledge of the indications for the techniqueof endoscopic placement of feeding gastrostomytubes.Colonoscopy - as with OGD, training in service is mostimportant. Training units must undertake at least 200procedures per year to allow adequate opportunitiesfor training. Trainees should assist at a minimum of 50colonoscopies and complete a further 50 undersupervision. The ability to perform polypectomycorrectly and understand the principles of diathermy isessential. Experience in fibreoptic sigmoidoscopy doesnot imply expertise with a colonoscope. Rigidsigmoidoscopy remains an essential skill and exposureto a minimum of 100 procedures is recommended.ERCP - before starting ERCP a sound experience ofOGD is essential. To provide adequate experiencetraining centres should undertake at least 200procedures per year. There should be liaison withradiologists skilled in imaging and interventionaltechniques. Joint meetings of different disciplinesshould be held to discuss cases. The experience toachieve competence will vary, but a high percentage ofsuccessful pancreatic and biliary diagnosticcannulation is essential before procedures areperformed independently. A minimum experience islikely to be 150 cases. Ability to interpret theradiological findings is essential. If the trainee is toproceed to an independent ERCP practice, aftermastering diagnostic ERCP, it is essential to proceedto a competence in papillotomy for stone extractionand in stent insertion.Liver biopsy - all trainees should be thoroughly familiarwith the indications, methods, and risks ofpercutaneous liver biopsy including that performedunder ultrasound control, and should have practicalexperience of a minimum of 50 procedures.Intubation techniques - exposure to the principles andpractice of intubation for oesophageal motility, 24hour pH monitoring, and acid output tests should besought.Abdominal ultrasonography - supervised experience of aminimum of 300 examinations is recommended toalign with European Diploma requirements.Courses - trainees should attend courses in basic andtherapeutic endoscopy, approved by the British Societyof Gastroenterology. Topics covered will includepatient care, cleaning, maintenance and disinfection ofinstruments, electrical hazards, recognition andmanagement of complications, and therapeuticprocedures such as stricture dilatation and varicealinjection. The general administration and managementof an endoscopy service will be covered. Furthercourses on colonoscopy and ERCP should be attendedas appropriate for the trainee.
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