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So you want to be a gastroenterologist?
Careers
So you want to be a gastroenterologist?
Training pathways General Gastroenterology including Acute Medicine to Level 2 General Gastroenterology including Acute Medicine to level 2 + Hepatology 2 years General Gastroenterology alone without Acute Medicine General Gastroenterology + Hepatology 2 years without Acute Medicine General Gastroenterology including Acute Medicine + 1 year Specialised Endoscopy*
Andrew Steel
Gastroenterology is a branch of internal medicine which deals with a wide variety of gastrointestinal and hepatic diseases. On the one hand, we may be seeing fit, asymptomatic individuals with a significant family history of colorectal cancer, who require appropriate advice and investigations, or, on the other hand, we may be involved in the care of a patient with fulminate hepatic failure in an intensive care setting, who requires urgent hepatic transplantation. The majority of gastroenterologists in the UK will work in a district general hospital (DGH) and contribute to the general medical workload, as well as providing specialist input in the management and diagnosis of gastrointestinal and hepatological diseases. Specialist training presently follows a period of foundation training, during which time the foundation programme competencies will have been achieved. The first two years are usually in either core medical training (CMT) or in acute care common stem training (ACCS (M)), during which time the trainee will have achieved level 1 acute medicine competencies and a knowledge-based assessment (KBA), usually MRCP part 1 or equivalent. Gastroenterological exposure up to this stage is not essential but considered desirable. The majority of trainees will then enter a training programme which will last five years and result in a Certificate of Completion of Training (CCT) in gastroenterology, with recognition of level 2 competency in acute medicine. This level of training will enable the trainee not only to work as a gastroenterologist but also to contribute to the acute medical take within their hospital. Although this is presently the usual training pathway, other routes are possible (Table 1). During training, a number of assessments are carried out, including mini-CEX (mini-Clinical Examination Exercise), DOPS (Direct Observation of Procedural Skills), and MSF (multi-source feedback). Prior to CCT, the trainee will have completed the MRCP examination and will also have completed a KBA in gastroenterology. The KBA is in the form of an MCQ examination and will be offered to candidates in the summer of 2008. To be able to manage and diagnose a wide range of gastrointestinal (GI) and hepatic diseases, the general gastroenterologist needs various endoscopic skills. There needs to be a basic proficiency in therapeutic and diagnostic upper GI endoscopy
Total 5 years Total 4 years Total 4 years Total 5 years
*This pathway is still in the process of being developed.
Table 1
and flexible sigmoidoscopy. Subspeciality expertise may follow on from this fundamental training, in areas such as colonoscopy, endoscopic cholangiopancreatiography (ERCP) and endoscopic ultrasound. It is likely that the majority of gastroenterologists will continue to carry out colonoscopy, while only those actively involved in hepatology will continue in ERCPs. The development of newer techniques such as CT colonography and capsule endoscopy will have an, as yet undetermined, effect on endoscopic workload. Other areas that will be available to trainees include nutrition and gastrointestinal physiology. The aim of the specialist training years is to produce a gastroenterologist using a curriculum developed by the Speciality Advisory Committee in Gastroenterology, which has input from the Joint Committee on Higher Education (JRCPTB), the British Society of Gastroenterology (BSG), the Chairman of the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) and a trainee. This curriculum will be continually reviewed in light of developments in technique and service needs. Endoscopic training is an essential element in the speciality training years. The responsibility for the endoscopic components of the curriculum and the assessment of competence has been devolved to the JAG. The JAG has greatly influenced the improvement in endoscopy training in this country since its formation in 1998. It has defined its remit and focuses on issues of competence and training. These include the following. • Endoscopy training courses – agreeing curricula and setting standards. • Appraisal and assessment of trainees – delivered through the introduction of formalized, valid and documented processes. • The accreditation and re-accreditation of endoscopy units – delivered through co-operative visits under the aegis currently of the bowel cancer-screening programme. Re-accreditation will take place on a five-yearly basis. • The certification of trainers’ and trainees’ competence. Most gastroenterologists will spend the majority of their consultant career working within a DGH. Most will be working with at least one colleague within the speciality. The majority will have some commitment to general medicine as well. There will be an inpatient workload with a case mix including acute medical cases and a combination of gastroenterological/hepatic cases.
Andrew Steel FRCP is a Consultant Physician at Kettering General Hospital NHS Trust, UK. He is also the Director of Medical Education within the Trust. He is a member of the Gastroenterology KBA Standard Setting Group of the Royal College of Physicians. He has a special interest in dyspepsia and Helicobacter Pylori. Conflicts of interest: none declared.
THE FOUNDATION YEARS 4:7
Total 5 years
297
© 2008 Elsevier Ltd. All rights reserved.
Careers
Their acute on-call will be shared with other physicians within the DGH. However, with changes in practice this may well alter; in particular, if cardiologists take up primary coronary intervention, they may be relieved of acute medical on-call. Similarly, if gastroenterologists are to be expected to provide an acute GI bleed service 24/7, they may be forced to relinquish their acute medical on-call. Besides the ward commitment, gastroenterology is practised in the outpatient department and the endoscopy suites. Normally there will be two outpatient sessions each week. These will in general be of about three hours duration and will include a mixture of new referrals and follow-up patients; the ratio will vary and may be dictated by local managers. The patients will be mainly gastroenterological or hepatological but a general medical portion may be included. The clinics will usually have junior doctor support, may also include medical students and so possibly will contain a large educational commitment. Increasingly the clinics may also include specialist nurses in a variety of subspecialties, such as inflammatory bowel disease, hepatitis C and gastrointestinal tract (GIT) malignancies. Some of these nurse specialists may indeed have their own clinical load and work independently for a part of their week. Most gastroenterologists will have two endoscopy lists a week. These may be a combination of upper and lower GIT endoscopy, or they may be dedicated to either the upper or lower GIT. All gastroenterologists should be competent in diagnostic and therapeutic endoscopy both at gastroscopy and flexible sigmoidoscopy. The majority will have comparable skills at colonoscopy. Those with more of a hepatobiliary leaning will be
THE FOUNDATION YEARS 4:7
trained and competent at diagnostic and therapeutic endoscopic retrograde cholangiopancreatiography (ERCP). Some consultants may become trained and proficient at both transabdominal ultrasonography and endoscopic ultrasound. A minority of consultants, almost certainly working in tertiary referral centres, will become trained in advanced endoscopic techniques and become skilled in submucosal resections and so on. These recent advances in therapeutic endoscopy are at the forefront of developments. Other advances, for example capsule endoscopy, will have an impact upon the way in which gastroenterological services are provided to our patients in the future. Another area in which gastroenterologists are often involved is as part of a nutrition team. This team usually consists of a doctor, dietician, clinical nurse specialist, and pharmacist, with strong support from clinical laboratory services. The team provides advice and support across all aspects of nutrition, from sip feeding to total parental nutrition in complex cases. I would hope that this brief insight into working as a gastroenterologist has been informative; the main message would be that the speciality is varied, involves working in teams across professional boundaries and has many challenges but is exciting and stimulating. ◆
Useful links • www.JRCPTB.org.uk • www.thejag.org.uk • www.bsg.org.uk
298
© 2008 Elsevier Ltd. All rights reserved.
So you want to be a gastroenterologist?
Training pathways General Gastroenterology including Acute Medicine to Level 2 General Gastroenterology including Acute Medicine to level 2 + Hepatology 2 years General Gastroenterology alone without Acute Medicine General Gastroenterology + Hepatology 2 years without Acute Medicine General Gastroenterology including Acute Medicine + 1 year Specialised Endoscopy*
Andrew Steel
Gastroenterology is a branch of internal medicine which deals with a wide variety of gastrointestinal and hepatic diseases. On the one hand, we may be seeing fit, asymptomatic individuals with a significant family history of colorectal cancer, who require appropriate advice and investigations, or, on the other hand, we may be involved in the care of a patient with fulminate hepatic failure in an intensive care setting, who requires urgent hepatic transplantation. The majority of gastroenterologists in the UK will work in a district general hospital (DGH) and contribute to the general medical workload, as well as providing specialist input in the management and diagnosis of gastrointestinal and hepatological diseases. Specialist training presently follows a period of foundation training, during which time the foundation programme competencies will have been achieved. The first two years are usually in either core medical training (CMT) or in acute care common stem training (ACCS (M)), during which time the trainee will have achieved level 1 acute medicine competencies and a knowledge-based assessment (KBA), usually MRCP part 1 or equivalent. Gastroenterological exposure up to this stage is not essential but considered desirable. The majority of trainees will then enter a training programme which will last five years and result in a Certificate of Completion of Training (CCT) in gastroenterology, with recognition of level 2 competency in acute medicine. This level of training will enable the trainee not only to work as a gastroenterologist but also to contribute to the acute medical take within their hospital. Although this is presently the usual training pathway, other routes are possible (Table 1). During training, a number of assessments are carried out, including mini-CEX (mini-Clinical Examination Exercise), DOPS (Direct Observation of Procedural Skills), and MSF (multi-source feedback). Prior to CCT, the trainee will have completed the MRCP examination and will also have completed a KBA in gastroenterology. The KBA is in the form of an MCQ examination and will be offered to candidates in the summer of 2008. To be able to manage and diagnose a wide range of gastrointestinal (GI) and hepatic diseases, the general gastroenterologist needs various endoscopic skills. There needs to be a basic proficiency in therapeutic and diagnostic upper GI endoscopy
Total 5 years Total 4 years Total 4 years Total 5 years
*This pathway is still in the process of being developed.
Table 1
and flexible sigmoidoscopy. Subspeciality expertise may follow on from this fundamental training, in areas such as colonoscopy, endoscopic cholangiopancreatiography (ERCP) and endoscopic ultrasound. It is likely that the majority of gastroenterologists will continue to carry out colonoscopy, while only those actively involved in hepatology will continue in ERCPs. The development of newer techniques such as CT colonography and capsule endoscopy will have an, as yet undetermined, effect on endoscopic workload. Other areas that will be available to trainees include nutrition and gastrointestinal physiology. The aim of the specialist training years is to produce a gastroenterologist using a curriculum developed by the Speciality Advisory Committee in Gastroenterology, which has input from the Joint Committee on Higher Education (JRCPTB), the British Society of Gastroenterology (BSG), the Chairman of the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) and a trainee. This curriculum will be continually reviewed in light of developments in technique and service needs. Endoscopic training is an essential element in the speciality training years. The responsibility for the endoscopic components of the curriculum and the assessment of competence has been devolved to the JAG. The JAG has greatly influenced the improvement in endoscopy training in this country since its formation in 1998. It has defined its remit and focuses on issues of competence and training. These include the following. • Endoscopy training courses – agreeing curricula and setting standards. • Appraisal and assessment of trainees – delivered through the introduction of formalized, valid and documented processes. • The accreditation and re-accreditation of endoscopy units – delivered through co-operative visits under the aegis currently of the bowel cancer-screening programme. Re-accreditation will take place on a five-yearly basis. • The certification of trainers’ and trainees’ competence. Most gastroenterologists will spend the majority of their consultant career working within a DGH. Most will be working with at least one colleague within the speciality. The majority will have some commitment to general medicine as well. There will be an inpatient workload with a case mix including acute medical cases and a combination of gastroenterological/hepatic cases.
Andrew Steel FRCP is a Consultant Physician at Kettering General Hospital NHS Trust, UK. He is also the Director of Medical Education within the Trust. He is a member of the Gastroenterology KBA Standard Setting Group of the Royal College of Physicians. He has a special interest in dyspepsia and Helicobacter Pylori. Conflicts of interest: none declared.
THE FOUNDATION YEARS 4:7
Total 5 years
297
© 2008 Elsevier Ltd. All rights reserved.
Careers
Their acute on-call will be shared with other physicians within the DGH. However, with changes in practice this may well alter; in particular, if cardiologists take up primary coronary intervention, they may be relieved of acute medical on-call. Similarly, if gastroenterologists are to be expected to provide an acute GI bleed service 24/7, they may be forced to relinquish their acute medical on-call. Besides the ward commitment, gastroenterology is practised in the outpatient department and the endoscopy suites. Normally there will be two outpatient sessions each week. These will in general be of about three hours duration and will include a mixture of new referrals and follow-up patients; the ratio will vary and may be dictated by local managers. The patients will be mainly gastroenterological or hepatological but a general medical portion may be included. The clinics will usually have junior doctor support, may also include medical students and so possibly will contain a large educational commitment. Increasingly the clinics may also include specialist nurses in a variety of subspecialties, such as inflammatory bowel disease, hepatitis C and gastrointestinal tract (GIT) malignancies. Some of these nurse specialists may indeed have their own clinical load and work independently for a part of their week. Most gastroenterologists will have two endoscopy lists a week. These may be a combination of upper and lower GIT endoscopy, or they may be dedicated to either the upper or lower GIT. All gastroenterologists should be competent in diagnostic and therapeutic endoscopy both at gastroscopy and flexible sigmoidoscopy. The majority will have comparable skills at colonoscopy. Those with more of a hepatobiliary leaning will be
THE FOUNDATION YEARS 4:7
trained and competent at diagnostic and therapeutic endoscopic retrograde cholangiopancreatiography (ERCP). Some consultants may become trained and proficient at both transabdominal ultrasonography and endoscopic ultrasound. A minority of consultants, almost certainly working in tertiary referral centres, will become trained in advanced endoscopic techniques and become skilled in submucosal resections and so on. These recent advances in therapeutic endoscopy are at the forefront of developments. Other advances, for example capsule endoscopy, will have an impact upon the way in which gastroenterological services are provided to our patients in the future. Another area in which gastroenterologists are often involved is as part of a nutrition team. This team usually consists of a doctor, dietician, clinical nurse specialist, and pharmacist, with strong support from clinical laboratory services. The team provides advice and support across all aspects of nutrition, from sip feeding to total parental nutrition in complex cases. I would hope that this brief insight into working as a gastroenterologist has been informative; the main message would be that the speciality is varied, involves working in teams across professional boundaries and has many challenges but is exciting and stimulating. ◆
Useful links • www.JRCPTB.org.uk • www.thejag.org.uk • www.bsg.org.uk
298
© 2008 Elsevier Ltd. All rights reserved.