Post Graduate Education in Gastroenterology

Alejandro Piscoya, MD Professor of Medicine, Universidad Peruana de Ciencias Aplicadas (UPC) Gastroenterologist, Hospital Nacional Cayetano Heredia, Lima - Perú Member of the Editorial Board, Revista de Gastroenterología del Perú

Medical education has become a major field all over the world; professors now need to improve their teaching skills by learning new ways to  teach and assess students ¹. As such, competency based medical education is now the standard in undergraduate studies and nearly every school in the USA and Europe and some in the less developed countries have developed their curriculums using competencies.

Assessment remains an important issue since there are still no standards on how to perform research and whether there are new techniques needed to evaluate our students. There are several assessment techniques such as simulation, Mini-Cex and formative or summative assessment that may be used together to allow students to fulfill the requirements of their studies ¹.

Postgraduate studies in general have moved towards the competency-based model. Most recently, the Blue Book of the European Board of Gastroenterology & Hepatology (EBGH) in 2012 ² provided a list of basic competencies (Table 1). The recent implementation of the Next Accreditation System (NAS) has been launched by the Accreditation Council for Graduate Medical Education (ACGME) this year in the USA ³. The major gastroenterological societies have joined effort to fulfil the requirement of the ACGME and to create a large set of tools, the EPA (Entrustable Professional Activities) that will be completed by all postgraduate students from now on ⁴ (Table 2). Canada has the Canmeds Program that can be applied to most specialties, including core and specific competencies; they have a specific set for Gastroenterology ⁵.

Table 1. The Blue Book Basic Competencies in Gastroenterology & Hepatology (2012)

Functional and Motility Disorders of the GI Tract Oro-Oesophageal Disorders Stomach & Duodenum Pancreatic disorders Biliary tract disorders Liver Small intestine Large intestine Inflammatory bowel disease Radiation and chemotherapy induced enteropathies Anorectal disease Conditions involving systemic diseases, genetic disease, multiple organs and the elderly Nutrition Fundamental Clinical and General Skills and Knowledge for Endoscopy Specific Endoscopy Skills

 

Table 2. EPAs for Gastroenterology - USA (2014)

Manage common acid peptic related problems Manage common functional gastrointestinal disorders Manage common gastrointestinal motility disorders Manage liver diseases Manage complications of cirrhosis Perform upper and lower endoscopic evaluation of the luminal gastrointestinal tract for screening, diagnosis, and intervention Perform endoscopic procedures for the evaluation and management of gastrointestinal bleeding Manage biliary disorders Manage pancreatic diseases Manage common GI infections in non-immunosuppressed and immunocompromised populations Identify and manage patients with noninfectious GI luminal disease Manage common GI and liver malignancies, and associated extraintestinal cancers Assess nutritional status and develop and implement nutritional therapies in health and disease

We have, however, little information on the rest of the world. In 2007, the WGO released its Standards in Gastroenterology Training that gathered information from all over the world and gave a framework of recommendations ⁶. This is an ongoing effort; standards should be  reviewed on the light of recent research, and the WGO may need to perform its own research in order to improve the guidelines and tailor the functioning of their educational programs. One approach may be the analysis of the different documents provided in order to update the current standards. Also some regional or member societies may change the importance of the competencies and perhaps add some more according to the most common pathologies in their area.

One of the WGO’s two major educational programs, The Train the Trainers (TTT) course ⁷, provides tools for faculty development where competencies are quite important. There are several aspects of group teaching, skills teaching, assessment and Evidence Based Medicine taught in a unique way, giving faculty from all over the world a first impression of what is needed. Sometimes this course serves as a catalyst to change existing programs and continues as the trained faculty replicate the course or by sharing what they have learned with other faculty with new studies on how to teach. The other educational program, the WGO’s Training Centers ⁸, are where high quality endoscopy training is provided. An interesting effort is the collaboration with several societies in the USA and Europe in order to provide professors and mentors for several Training Centers. It is worth mentioning that the Ankara Training Center in Turkey ⁹ has developed a mentorship program with the AGA that will provide some competencies other than the endoscopic skills for their trainees. Most of basic techniques are covered in the TTT programs and the development of the TTT in Spanish had provided a new opportunity for some non-English speaking members; this idea may be replicated in other languages to make this available for a larger group.

Endoscopic skills are part of the competencies but a special consideration is the lack of quality standards for the different procedures, not only the common procedures such as gastroscopy or colonoscopy but also because of the development of several new procedures like endoscopic ultrasound and endoscopic mucosal resection require a good training program for the gastroenterologist to become proficient. The quality standards begin with numbers provided by the different societies, mostly without large research to back them up, so they are usually quite different from one another (Table 3) ¹⁰.

Table 3. Requirements of procedure for trainees
	WGO (2007)	ASGE (2012)	EBG (2012)	BSG (2004)	Peru (2002)
Upper Endoscopy	100	130	200	200	50
Control of nonvariceal UGI bleeding	20	25	30	-	-
Control of variceal UGI bleeding	15	20	-	-	-
Colonoscopy	100	200	200	200	50
Polypectomy	20	30	50	-	20
Upper Endoscopy	10	15	15	-	20

In the past few years there have been some initiatives to improve quality measures. A series of instruments have been designed to evaluate the quality of colonoscopy. This started with only cecal intubation rates but then polyp detection rates and patient comfort were added. The UK has published its first large colonoscopy audit last year and they also have a Joint Advisory Group on GI Endoscopy ¹¹ which has recently  provided information from their e-portfolio of trainees that say they achieved their learning curves at a larger numbers than the one set from their national society ¹². There are some instruments to measure colonoscopy assessment like the Mayo Colonoscopy Skills Assessment Tool or the Gastrointestinal Endoscopy Competency Assessment Tool from Toronto ^{13, 14}. All these are ongoing efforts on establishing ways to evaluate procedure skills, and the WGO may play a role in giving standards for most countries, especially in those countries that may not be able to perform their own research.

Critical appraisal, statistics and knowledge translation are very important and probably could be taught better. There is much research showing that many different groups of physicians lack the understanding of basic statistics. This may impact patient care if misinterpretation affects understanding patients needing screening and the risks of both screening and performing different invasive and non-invasive tests ¹⁵.

In summary, the WGO has provided several tools to improve gastroenterology training worldwide and continues to help improve training among its members, but it also has a unique position to perform research such as systematic reviews on educational programs such as  assessment tools in order to set global standards in several issues. It may also develop programs on medical education training in  gastroenterology and perform research among its members in order to inform how gastroenterology is being taught all over the world, and whether there are special needs in their educational programs. There are several opportunities for collaboration that may help improve  postgraduate education in gastroenterology.

References

1. Dent J, Harden R. New horizons in medical education. In: Dent J, Harden R, editors. A practical guide for medical teachers. Fourth ed. London: Churchill Livingstone Elsevier; 2014. p. 3-7.
2. The European Section and Board of Gastroenterology and Hepatology. The EB Gastrohep Training Programme. The Blue Book. 2012. 
3. ASGE. Entrustable professional activities for gastroenterology fellowship training. GIE 2014;80(1):16-27.
4. AASLD, ACG, AGA, ANMS, ASGE, NASPGHAN. EPA Toolbox. Available at: http://www.ownyourfellowship.org/?page_id=46. Accessed Aug, 2014.
5. Royal College of Physicians & Surgeons of Canada. Objectives of Training in the Subspecialty of Gastroenterology. 2011; Available at: http://www.royalcollege.ca/cs/groups/public/documents/document/y2vk/mdaw/~edisp/tztest3rcpsced000899.pdf. Accessed Aug, 2014.
6. Fosman E SR. Standards in gastroenterology training: a comprehensive guide to basic standards in gastroenterology. World Gastroenterology Organisation 2007.
7. WGO. Train the Trainers. Available at: http://www.worldgastroenterology.org/train-the-trainers.html. Accessed Aug, 2014.
8. WGO. Training Centers. Available at: http://www.worldgastroenterology.org/training-centers.html. Accessed Aug, 2014.
9. Yurdaydin C, Boyacioglu S, Tozun N. Collaboration destined for success: The WGO-AGA-TSG Ankara Training Center. 2013; Available at: https://www.gastro.org/journals-publications/aga-perspectives/octobernovember-2013/international-corner-agas-impactaround-the-world. Accessed Aug, 2014.
10. Comité Nacional de Residentado Médico (CONAREME). Estándares Mínimos de Formación para el Programa de Segunda Especialización en Gastroenterología. 2002.
11. Joint Advisory Group on Gastrointestinal Endoscopy. Guidelines for the training, appraisal and assessment of trainees in gastrointestinal endoscopy. 2004.
12. Ward S, Mohammed M, Walt R, Valori R, Ismail T, Dunckley P. An analysis of the learning curve to achieve competency at colonoscopy using the JETS database. Gut 2014;0:1-9.
13. Sedlack R. The Mayo Colonoscopy Skills Assessment Tool: validation of a unique instrument to assess colonoscopy skills in trainees. GIE 2010;72:1125-33.
14. ASGE Training Committee, Sedlack RE, Coyle WJ, Obstein KL, Al-Haddad MA, Bakis G, Christie JA, Davila RE, Degregorio B, Dimaio CJ, Enestvedt BK, Jorgensen J, Mullady DK, Rajan L. ASGE’s assessment of competency in endoscopy evaluation tools for colonoscopy and EGD. Gastrointest Endosc 2013; In press.
15. Wegwart O, Gigerenzer G. Statistical Illiteracy in Doctors. In: Gigerenzer G, Muir Gray JA, editors. Better Doctros, Better Patients, Better Decisions - Envisioning Health Care 2020 Cambridge, Massachussets: The MIT Press; 2011. p. 137-51.