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Gastrointestinal endoscopy in Italy
2. SEGAL I, DUBB AA, aU TiM L, ET AL: Duodenal ulcer and working class morbidity in an African population in South Africa. Br. Med /1:469,1978 3. au TIM L, SEGAL I, LAWSON HH: Chronic calcifying pancreatitis at 8aragwanath Hospital. S Afr / Med Sci (Suppl.) 73, XI, 1977 4. ISAACSON C, SELZER G, KAYE V, ET AL: Cancer in the urban blacks of South Africa. S Afr Cancer Bull 22:49, 1978 5. SEGAL I, au TIM L: The witchdoctor and the bowel. S Afr Med / 56:308, 1979 6. SEGAL I, au TIM L, HAMILTON DG, ET AL: Ritual enema-induced colitis. Dis Colon Rectum 22:195, 1979
Gastrointestinal endoscopy in Italy Massimo Crespi, MD G. Casale, MD Gastrointestinal endoscopy in Italy is in a developing and improving state as endoscopic facilities spread throughout the country. In 1978, 500 questionnaires were sent to all those who were known to have purchased endoscopic instruments. There were only 172 completed questionnaires, including 126 evaluable responses. The remaining "ghost instruments" were considered to be unused. This discrepancy is the result of the policy followed by the public health authorities not to deny the purchase of an instrument considered to be a symbol of technological advancement. Appropriately trained personnel are often not available to use these instruments. Endoscopic facilities are shared by internists and surgeons. Only recently has the postgraduate teaching of endoscopy been incorporated into gastroenterology programs. Emergency endoscopy, although declared as part of their activities by many centers, is, in fact, routinely available in few. In the majority of centers, barium roentgenograms are used prior to endoscopy. However, this habit is undergoing modification, especially for upper gastrointestinal endoscopy. Twelve major centers, including our own, perform endoscopy mostly on an outpatient basis, even for such maneuvers as colonic or gastric polypectomy. Thirty-six leading centers perform more than 1000 endoscopic examinations a year. Consent by the patient for the procedure is seldom requested in our country or is restricted to a verbal agreement without any legal meaning. This happy situation is largely due to a low incidence of malpractice suits. There is still a great degree of variability in the diagnostic work-up of patients depending on the appreciation by the general practitioner of the value of gastrointestinal endoscopy. Information on the results of modern fiberoptic endoscopy is still lacking among older doctors, who consider endoscopy as something akin to a surgical procedure. The situation is obviously much better in those areas in which an endoscopic center has been in operation for several years. The Italian Society of Digestive Endoscopy (SlED) From fnstituto "Regeno Elena," Rome, Italy.
260
7. LEIMAN G, au TIM L, SEGAL I: Diagnosis of upper gastrointestinal lesions by endoscopy, cytology and biopsy. S Afr Med /55:619, 1979 8. SEGAL I, SOLOMON A, au TIM L, ET AL: Giant duodenal ulcer syndrome. S Afr Med / 52:724, 1977 9. BREMNER CG, ACKERMAN LV: Polyps and carcinoma of the large bowel in the African Bantu. Cancer 26(5):991,1970 10. SEGAL I, au TIM L, TRAPPLER D: Value of the flexible sigmoidofibrescope in the diagnosis of diarrheal disease. S Afr Med / 60:293, 1981
was founded in 1965 by a handful of enthusiastic gastroenterologists and surgeons and has rapidly expanded its membership to the present level of more than 600. SlED accepts membership from nonpracticing endoscopists and is therefore also a forum for those interested in endoscopy. A national congress is held every 2 years and a minor symposium every year. These may be independent or may be linked to major gastroenterological events. The Society does not provide specific training courses or programs, nor has it the privilege of licensing endoscopists. Only universities are legally permitted to issue such licenses. Only university postgraduate schools offer a specific program for gastrointestinal endoscopy. Others in which endoscopy is taught in the framework of gastroenterology deliver mainly a theoretical education. The number of student admissions may be as high as 30 to 40 a year per school. An internship and specific licensing are not required to practice endoscopy. The opportunity to perform some or all of the gastrointestinal endoscopic procedures is provided by some leading endoscopic centers. While most prospective endoscopists reach a high level of technical ability, others visit one or more centers "just to have a look," only to emerge as "endoscopists" a few weeks later because they were "trained in the center of__ ." This kind of behavior is highly damaging to the quality of medical practice and the reputation of endoscopy. Obviously, it is of potential economic benefit for these practitioners and for the instrument manufacturers. 51 ED is now publishing the official journal of the Society, founded in 1978 by Drs. Cheli, Crespi, Fratton, and Mirelli. It appears every three months in Italian or English and is named Giornale Italiano di Endoscopia. It accepts articles by foreign endoscopists. Many initiatives in the field of research or in the systematic approach to major health problems have been taken by active members of SlED. Examples are the Italian Task Force on Colorectal Cancer (GOICC), the follow-up of colonic polyps with invasive cancer excised at endoscopy, the national registry of familial polyposis cases, the cooperative group screening and epidemiology of premalignant lesions of the stomach, the endoscopic surveys in high incidence areas for esophageal cancer (Iran and China), the implementation of an endoscopic center in Mogadishu (50maliland), and endoscopic-histological correlations in duodenitis. GASTROINTESTINAL ENDOSCOPY
Of relevance is the participation of Italian endoscopists in international bodies. The European Society for Gastrointestinal Endoscopy (ESGE) presently has two Italians in leading positions: R. Cheli (Genova) as President and M. Crespi (Roma) as Scientific Secretary. The bulk of endoscopy in Italy is provided tree of charge in the framework of the public health service. These are reimbursed at very low fees, approximately 6 to 8 U.S. dollars! There is great pressure to obtain examinations outside of the normal waiting lists because of the discrepancy between demand and availability in areas in which an "endoscopic consciousness" is already established. This demand can be met
only by private practice. The part-time contract of most doctors is with the hospitals, and the low numbers of health providers for the public make private work in Italy very lucrative. Prices for upper gastrointestinal endoscopy range from 300 to 600 U.S. dollars, reaching even 1000 or more for ERCP or endoscopic polypectomy. In conclusion, we can say that the overall picture for endoscopy is bright, but education and information at the level of the general practitioner are needed. Training and development of young endoscopists deserve much more attention by the health authorities.
Endoscopy in the Peoples' Republic of China
cal-surgical hospital that is one of the teaching hospitals in Shanghai, a city of 11 million people. Our host at this hospital, Dr. Wong Tsan-Zunn,2 spoke excellent English and acted as our interpreter during the clinical discussions and lectures. The morning was spent touring the hospital and reviewing case material in a conference with 30 to 40 Chinese physicians. All of the endoscopic procedures currently being performed in the United States with the exception of sclerotherapy are established at this hospital. The majority of their instruments are of japanese design; however, we had the opportunity to see an endoscope that was made in the Peoples' Republic of China. It appeared to be of high quality with good optics. We did not have an opportunity to use it in a patient examination. ERCP is well established at this institution and endoscopic sphincterotomy is beginning to be performed. The second medical facility we visited was the hospital of the commune near Shanghai. This was statted by two physicians and a traditional medical doctor. The senior physician had apparently been trained and served with the Peoples' Liberation Army for 8 years prior to his assignment at this hospital. The level and background of his training was not entirely clear. Facilities at this hospital were below what would be seen at a small community hospital in the United States. It was designed for emergency care and the treatment of minor ailments. Although the standard of medical facilities in the countryside of China is below the level of that in the United States, the provision of health to all areas is truly remarkable when it is considered that, prior to 1949, vast areas of the country and huge numbers of Chinese had no health care at all. The use of acupuncture both in Shanghai and Beijing is widespread and is used primarily for the treatment of chronic problems or acute pain when the primary disease process is treated by Western methods. None of the physicians whom we met in China seemed to have any hypothesis as to its mode of action. Both in Shanghai and Beijing, the hospitals had used acupuncture to perform surgery but were no longer using it because of a rather high failure rate (20
Stephen E. Silvis, MD During late March and early April of 1982, five members of the Executive Committee of the American Society for Gastrointestinal Endoscopy and their wives toured China. Members of the group included Dr. and Mrs. jerome Waye, Dr. and Mrs. joseph Geenen, Dr. and Mrs. Melvin Schapiro, Dr. and Mrs. Francis Tedesco, my wife, Marilyn, and myself. We had an opportunity to visit three medical facilities and four cities during our 16-day stay. Before the endoscopic experience in China can be appreciated, the overall organization of Chinese medicine must be understood. 1 Essentially, all of the hospitals and other medical facilities are run by the government, but a small number of physicians have established private clinics. There is an interesting mixture of medical practices. Traditional doctors (trained in the ancient Chinese system of herbology, acupuncture, and moxibustion) have been integrated into the medical care system. This has occurred at all levels from the district or commune clinics to the university hospitals. There is considerable variation in training of the Chinese physicians. Some have had rather short, intensive medical training following either a nursing education or training equivalent to that of American military corpsmen. Others have educations equivalent to that of physicians in the United States and may have had a number of years of postgraduate training in a special area. The "barefoot doctors" have been extensively publicized, but we did not meet with any of them on this visit. They function mainly in the countryside and primarily in the areas of first aid, primary treatment, immunization, and health education, especially that related to birth control. Patients are assigned to an area clinic and must attend this clinic if they want free medical care. Patients who pay for their care may attend any hospital they wish. We visited the Huadong Hospital, a general mediFrom Veterans Administration Hospital and the University of Minnesota, Minneapolis, Minnesota. VOLUME 28, NO. 4, 1982
261
Gastrointestinal endoscopy in Italy Massimo Crespi, MD G. Casale, MD Gastrointestinal endoscopy in Italy is in a developing and improving state as endoscopic facilities spread throughout the country. In 1978, 500 questionnaires were sent to all those who were known to have purchased endoscopic instruments. There were only 172 completed questionnaires, including 126 evaluable responses. The remaining "ghost instruments" were considered to be unused. This discrepancy is the result of the policy followed by the public health authorities not to deny the purchase of an instrument considered to be a symbol of technological advancement. Appropriately trained personnel are often not available to use these instruments. Endoscopic facilities are shared by internists and surgeons. Only recently has the postgraduate teaching of endoscopy been incorporated into gastroenterology programs. Emergency endoscopy, although declared as part of their activities by many centers, is, in fact, routinely available in few. In the majority of centers, barium roentgenograms are used prior to endoscopy. However, this habit is undergoing modification, especially for upper gastrointestinal endoscopy. Twelve major centers, including our own, perform endoscopy mostly on an outpatient basis, even for such maneuvers as colonic or gastric polypectomy. Thirty-six leading centers perform more than 1000 endoscopic examinations a year. Consent by the patient for the procedure is seldom requested in our country or is restricted to a verbal agreement without any legal meaning. This happy situation is largely due to a low incidence of malpractice suits. There is still a great degree of variability in the diagnostic work-up of patients depending on the appreciation by the general practitioner of the value of gastrointestinal endoscopy. Information on the results of modern fiberoptic endoscopy is still lacking among older doctors, who consider endoscopy as something akin to a surgical procedure. The situation is obviously much better in those areas in which an endoscopic center has been in operation for several years. The Italian Society of Digestive Endoscopy (SlED) From fnstituto "Regeno Elena," Rome, Italy.
260
7. LEIMAN G, au TIM L, SEGAL I: Diagnosis of upper gastrointestinal lesions by endoscopy, cytology and biopsy. S Afr Med /55:619, 1979 8. SEGAL I, SOLOMON A, au TIM L, ET AL: Giant duodenal ulcer syndrome. S Afr Med / 52:724, 1977 9. BREMNER CG, ACKERMAN LV: Polyps and carcinoma of the large bowel in the African Bantu. Cancer 26(5):991,1970 10. SEGAL I, au TIM L, TRAPPLER D: Value of the flexible sigmoidofibrescope in the diagnosis of diarrheal disease. S Afr Med / 60:293, 1981
was founded in 1965 by a handful of enthusiastic gastroenterologists and surgeons and has rapidly expanded its membership to the present level of more than 600. SlED accepts membership from nonpracticing endoscopists and is therefore also a forum for those interested in endoscopy. A national congress is held every 2 years and a minor symposium every year. These may be independent or may be linked to major gastroenterological events. The Society does not provide specific training courses or programs, nor has it the privilege of licensing endoscopists. Only universities are legally permitted to issue such licenses. Only university postgraduate schools offer a specific program for gastrointestinal endoscopy. Others in which endoscopy is taught in the framework of gastroenterology deliver mainly a theoretical education. The number of student admissions may be as high as 30 to 40 a year per school. An internship and specific licensing are not required to practice endoscopy. The opportunity to perform some or all of the gastrointestinal endoscopic procedures is provided by some leading endoscopic centers. While most prospective endoscopists reach a high level of technical ability, others visit one or more centers "just to have a look," only to emerge as "endoscopists" a few weeks later because they were "trained in the center of__ ." This kind of behavior is highly damaging to the quality of medical practice and the reputation of endoscopy. Obviously, it is of potential economic benefit for these practitioners and for the instrument manufacturers. 51 ED is now publishing the official journal of the Society, founded in 1978 by Drs. Cheli, Crespi, Fratton, and Mirelli. It appears every three months in Italian or English and is named Giornale Italiano di Endoscopia. It accepts articles by foreign endoscopists. Many initiatives in the field of research or in the systematic approach to major health problems have been taken by active members of SlED. Examples are the Italian Task Force on Colorectal Cancer (GOICC), the follow-up of colonic polyps with invasive cancer excised at endoscopy, the national registry of familial polyposis cases, the cooperative group screening and epidemiology of premalignant lesions of the stomach, the endoscopic surveys in high incidence areas for esophageal cancer (Iran and China), the implementation of an endoscopic center in Mogadishu (50maliland), and endoscopic-histological correlations in duodenitis. GASTROINTESTINAL ENDOSCOPY
Of relevance is the participation of Italian endoscopists in international bodies. The European Society for Gastrointestinal Endoscopy (ESGE) presently has two Italians in leading positions: R. Cheli (Genova) as President and M. Crespi (Roma) as Scientific Secretary. The bulk of endoscopy in Italy is provided tree of charge in the framework of the public health service. These are reimbursed at very low fees, approximately 6 to 8 U.S. dollars! There is great pressure to obtain examinations outside of the normal waiting lists because of the discrepancy between demand and availability in areas in which an "endoscopic consciousness" is already established. This demand can be met
only by private practice. The part-time contract of most doctors is with the hospitals, and the low numbers of health providers for the public make private work in Italy very lucrative. Prices for upper gastrointestinal endoscopy range from 300 to 600 U.S. dollars, reaching even 1000 or more for ERCP or endoscopic polypectomy. In conclusion, we can say that the overall picture for endoscopy is bright, but education and information at the level of the general practitioner are needed. Training and development of young endoscopists deserve much more attention by the health authorities.
Endoscopy in the Peoples' Republic of China
cal-surgical hospital that is one of the teaching hospitals in Shanghai, a city of 11 million people. Our host at this hospital, Dr. Wong Tsan-Zunn,2 spoke excellent English and acted as our interpreter during the clinical discussions and lectures. The morning was spent touring the hospital and reviewing case material in a conference with 30 to 40 Chinese physicians. All of the endoscopic procedures currently being performed in the United States with the exception of sclerotherapy are established at this hospital. The majority of their instruments are of japanese design; however, we had the opportunity to see an endoscope that was made in the Peoples' Republic of China. It appeared to be of high quality with good optics. We did not have an opportunity to use it in a patient examination. ERCP is well established at this institution and endoscopic sphincterotomy is beginning to be performed. The second medical facility we visited was the hospital of the commune near Shanghai. This was statted by two physicians and a traditional medical doctor. The senior physician had apparently been trained and served with the Peoples' Liberation Army for 8 years prior to his assignment at this hospital. The level and background of his training was not entirely clear. Facilities at this hospital were below what would be seen at a small community hospital in the United States. It was designed for emergency care and the treatment of minor ailments. Although the standard of medical facilities in the countryside of China is below the level of that in the United States, the provision of health to all areas is truly remarkable when it is considered that, prior to 1949, vast areas of the country and huge numbers of Chinese had no health care at all. The use of acupuncture both in Shanghai and Beijing is widespread and is used primarily for the treatment of chronic problems or acute pain when the primary disease process is treated by Western methods. None of the physicians whom we met in China seemed to have any hypothesis as to its mode of action. Both in Shanghai and Beijing, the hospitals had used acupuncture to perform surgery but were no longer using it because of a rather high failure rate (20
Stephen E. Silvis, MD During late March and early April of 1982, five members of the Executive Committee of the American Society for Gastrointestinal Endoscopy and their wives toured China. Members of the group included Dr. and Mrs. jerome Waye, Dr. and Mrs. joseph Geenen, Dr. and Mrs. Melvin Schapiro, Dr. and Mrs. Francis Tedesco, my wife, Marilyn, and myself. We had an opportunity to visit three medical facilities and four cities during our 16-day stay. Before the endoscopic experience in China can be appreciated, the overall organization of Chinese medicine must be understood. 1 Essentially, all of the hospitals and other medical facilities are run by the government, but a small number of physicians have established private clinics. There is an interesting mixture of medical practices. Traditional doctors (trained in the ancient Chinese system of herbology, acupuncture, and moxibustion) have been integrated into the medical care system. This has occurred at all levels from the district or commune clinics to the university hospitals. There is considerable variation in training of the Chinese physicians. Some have had rather short, intensive medical training following either a nursing education or training equivalent to that of American military corpsmen. Others have educations equivalent to that of physicians in the United States and may have had a number of years of postgraduate training in a special area. The "barefoot doctors" have been extensively publicized, but we did not meet with any of them on this visit. They function mainly in the countryside and primarily in the areas of first aid, primary treatment, immunization, and health education, especially that related to birth control. Patients are assigned to an area clinic and must attend this clinic if they want free medical care. Patients who pay for their care may attend any hospital they wish. We visited the Huadong Hospital, a general mediFrom Veterans Administration Hospital and the University of Minnesota, Minneapolis, Minnesota. VOLUME 28, NO. 4, 1982
261