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Third tier certification: additional training for “specialized” endoscopic expertise
lowing percutaneous endoscopic gastrostomy: a prospective study. Gastrointest Endosc 1986;32:397-9. 6. Ponsky JL, Gauderer MW, Stellato TA, Aszodi A. Percutaneous approaches to enteral alimentation. Am J Surg 1985;149:102-5. 7. Mindelzun RE. McCort JJ. Acute abdomen: radiology. In: Margulis AR, Burhenne HJ, ed. Alimentary tract radiology, 3rd ed. St. Louis: CV Mosby, 1983:392-6.
From the Rostrum
Third tier certification: additional training for "specialized" endoscopic expertise The complexity and sophistication of present day medical training stems, in a large part, from a continuum of advances in new technology and its clinical application. The archtype of this situation exists in medical and surgical subspecialties that perform gastrointestinal endoscopic procedures. Today's GI trainee must deal with a burgeoning number of clinically useful diagnostic and therapeutic procedures. It comes as no surprise, therefore, that concerns have arisen about the adequacy of training in many of these procedures, particularly when the total learning experience of the postgraduate GI clinical fellowship is only 2 years. Recently, the American Board of Internal Medicine and its Subspecialty Board on Gastroenterology have extended the evaluation of essential clinical skills in gastroenterology to include procedural skills. Procedural skills are defined as "the learned manual skills necessary to perform diagnostic and therapeutic procedures within the domain of the gastroenterologist." It was felt that the Board's Subspecialty Certificate in GI training was being used by many for clinical privileges to perform the procedures of the subspecialty despite the fact that these skills had never been systematically documented during fellowship training. Subsequently, the Board decided that procedural skills "should be directly observed and carefully assessed" during training to formally certify the GI trainee in specific procedural competence. In an expansion of the overall assessment of clinical competence, program directors in gastroenterology are now being asked to verify certain procedural skills of the postgraduate trainee as a new requirement for certification. At the completion of 2 years of clinical training, all GI fellows who are candidates for certification must now present satisfactory skills in the indications, contraindications, per292
formance, and interpretation of the following technical procedures: esophagogastroduodenoscopy examination, including tissue biopsy; colonoscopy, including biopsy and polypectomy; dilation procedures for· esophageal disease; peroral small intestinal biopsy; and percutaneous aspiration liver biopsy. The question of obtaining procedural skills in other GI technical procedures, e.g., endoscopic retrograde cholangiopancreatography (ERCP), is not mandated by the Board. These additional (procedural) skills will be determined "by type of practice, personal preference, availability of other skilled professionals and local delineation of privileges," although the trainee must be familiar with the indications, contraindications, and interpretation of the results of these additional procedures. Currently, the majority of academic endoscopic training programs try to offer some degree of familiarity with most of the procedures required in today's practice of gastroenterology. This exposure may not be adequate enough for the trainee to ensure appropriate experience and competence to do all procedures, however. What are the possible solutions to this dilemma for the trainee and program director? A. All postgraduate GI fellows do not have to be certified as competent in each and every technical procedure. The time has arrived when we must realize that every trainee does not have to do every gastrointestinal technical procedure by the time fellowship is completed, or whenever. There are limits to the resources, patient population, and endoscopic expertise available at anyone endoscopic training center. In the near future, only a portion of talented trainees will be certified in certain highly specialized GI technical procedures. The GI fellowship is not an exclusive endoscopic experience. There is only so much time during the 2 clinical years for the broad, diversified, intellectual learning experience necessary for the practice of gastroenterology. The GI trainee will have to be content with "competence" in some technical procedures and "familiarity" in others at the completion of his 2-year pr.ogram. B. Additional training for specialized endoscopic expertise: tier III certification. At the present time, highly specialized endoscopic techniques require additional training during an extra year of intensive on-job experience at several wellknown centers. Additional time to develop appropriate procedural skills is not a new concept to GI training programs. GI endoscopic program directors do not wish to emulate the ancient craft guilds, but the basic philosophy is well accepted. It takes time and experience to develop a skilled craftsman. Perhaps the best current example of this attitude involves developing competence in therapeutic ERCP procedures. For example, at the Medical College of Wisconsin, a third year of specialized training is required for therapeutic ERCP. Endoscopic treatment of pancreaticobiliary duct disorders demands considerable operator experience and practice. The prerequisites for performing endoscopic sphincterotomy in our unit are fairly rigorous. The GI fellow has to have performed at least 100 (preferably 150) diagnostic ERCP studies with a success rate for selective duct cannulation of 85% or better. It is important for the trainee in therapeutic ERCP to be exposed to the wide variety of problems and complications related to pancreaticobiliary tract disease, to observe and participate in the interaction between the interventional GASTROINTESTINAL ENDOSCOPY
Table 1. Division of GI procedural competence into three tiers or levels of postgraduate training Level of training" 1st tier
2nd tier
3rd tier
"One tier program.
Procedural competence Diagnostic: Esophagogastroduodenoscopy, flexible fiberoptic sigmoidoscopy, tissue/liver biopsy Dilation: simple esophageal stricture Diagnostic: Colonoscopy, endoscopic cholangiopancreatography, esophageal manometry Therapeutic: Polypectomy, electrocautery and heat probe, sclerotherapy, percutaneous endoscopic gastrostomy, infrared coagulation Diagnostic: Laparoscopy, sphincter of Oddi manometry Therapeutic: Endoscopic cholangiopancreatography (sphincterotomy, stent placement, balloon distention); laser therapy; esophageal stent placement Dilation: brusque (achalasia)
1 year of supervised training in an accredited
radiologist, the surgeon, and the endoscopist, and to have experienced supervision and direction during these times. Experience with endoscopic guide wire insertion, stent management, balloon dilation of strictures, and sphincter of Oddi manometric recording requires significant exposure to a specialized referral pI pulation and an endoscopic team familiar with the myriad of complex devices now available for use with these therapeutic procedures. The technology explosion in our subspecialty area necessitates a concentrated exposure for the trainee to a working environment wherein the physicians and nurse-technicians constantly interact and redirect their therapeutic options and instrumentation commensurate with the complexity of clinical findings and the difficulty of the procedure. There are ot':ler endoscopic procedures that may necessitate a third ti(~r of training for the GI postgraduate fellow before competency is acquired, e.g., advanced laparoscopy, endoscopic ~aser therapy, or esophageal prosthetic insertions. Tiers and procedural competence. Table 1 is an attempt to divide GI procedural competence among three tiers or levels of postgraduate training (one tier = 1 year of supervised training in an accredited GI postgraduate training program). The complexity or learning curve of these procedures ~ncreases directly with the tier rank. The trainee's antic ipated growth in endoscopic skills and clinical experienCf. should parallel this. f.Jbviously, there is some overlap between the first and VOLUME 34, NO.3, 1988
second tier in some academic programs. A third tier of training to assure competence in sophisticated therapeutic procedures will become a reality for all GI training programs in the near future. You can pack only so much training and experience into 2 years.
REFERENCE 1. Benson JA, Cohen S. Evaluation of procedural skills in gastroenterologists (editorial). Gastroenterology 1987;92:254-7.
Abstracts ENDOSCOPY AROUND THE WORLD
Editor for Abstracts, Charles J. Lightdale, MD Panel of Reviewers Jamie S. Barkin Stanley B. Benjamin Lawrence J. Brandt Edward L. Cattau Sarkis J. Chobanian Peter B. Cotton Javier Elizondo Kenneth A. Forde Lionello Gandolfi David Y. Graham Richard H. Hunt Dennis M. Jensen Seibi Kobayashi Richard A. Kozarek
Glen A. Lehman Finlay Macrae Zdenek Maratka Mark H. Mellow Patrice A. Michaletz Jay A. Noble H. Juergen Nord Jeffrey L. Ponsky Paul Rozen Melvin Schapiro Walter L. Trudeau G. N. J. Tytgat Richard A. Wright
Usefulness of manometric assessment of varices in maintenance sclerotherapy: a controlled trial HOSKINS JW, ROBINSON P, JOHNSON AG Gastroenterology 93:846-851, 1987
Hoskins and colleagues report a prospective controlled trial of 68 patients undergoing maintenance sclerotherapy with 5% ethanolamine, 35 of whom had variceal patency assessed manometrically and 33 by visual means. A patent venous channel was defined after direct varix puncture as having a low pressure «45 mm Hg) that fluctuated with respiration. Thrombosed vessels, extraluminal punctures, or punctures into the esophageal wall, in turn, were associated with a rapid pressure rise (>100 mm Hg) unassociated with respiratory-induced pressure variations. The authors report that during a mean follow-up period of 13 months, there was a statistically significant difference in variceal bleeding episodes (1 vs. 14, P < 0.002), ulceration (2 vs. 9; p < 0.05), and obliteration (11 vs. 2; P < 0.01). Not only were objective results improved using manometry to define patency, but the authors claimed a 25 % error rate in assessing patency by visual means. 293
From the Rostrum
Third tier certification: additional training for "specialized" endoscopic expertise The complexity and sophistication of present day medical training stems, in a large part, from a continuum of advances in new technology and its clinical application. The archtype of this situation exists in medical and surgical subspecialties that perform gastrointestinal endoscopic procedures. Today's GI trainee must deal with a burgeoning number of clinically useful diagnostic and therapeutic procedures. It comes as no surprise, therefore, that concerns have arisen about the adequacy of training in many of these procedures, particularly when the total learning experience of the postgraduate GI clinical fellowship is only 2 years. Recently, the American Board of Internal Medicine and its Subspecialty Board on Gastroenterology have extended the evaluation of essential clinical skills in gastroenterology to include procedural skills. Procedural skills are defined as "the learned manual skills necessary to perform diagnostic and therapeutic procedures within the domain of the gastroenterologist." It was felt that the Board's Subspecialty Certificate in GI training was being used by many for clinical privileges to perform the procedures of the subspecialty despite the fact that these skills had never been systematically documented during fellowship training. Subsequently, the Board decided that procedural skills "should be directly observed and carefully assessed" during training to formally certify the GI trainee in specific procedural competence. In an expansion of the overall assessment of clinical competence, program directors in gastroenterology are now being asked to verify certain procedural skills of the postgraduate trainee as a new requirement for certification. At the completion of 2 years of clinical training, all GI fellows who are candidates for certification must now present satisfactory skills in the indications, contraindications, per292
formance, and interpretation of the following technical procedures: esophagogastroduodenoscopy examination, including tissue biopsy; colonoscopy, including biopsy and polypectomy; dilation procedures for· esophageal disease; peroral small intestinal biopsy; and percutaneous aspiration liver biopsy. The question of obtaining procedural skills in other GI technical procedures, e.g., endoscopic retrograde cholangiopancreatography (ERCP), is not mandated by the Board. These additional (procedural) skills will be determined "by type of practice, personal preference, availability of other skilled professionals and local delineation of privileges," although the trainee must be familiar with the indications, contraindications, and interpretation of the results of these additional procedures. Currently, the majority of academic endoscopic training programs try to offer some degree of familiarity with most of the procedures required in today's practice of gastroenterology. This exposure may not be adequate enough for the trainee to ensure appropriate experience and competence to do all procedures, however. What are the possible solutions to this dilemma for the trainee and program director? A. All postgraduate GI fellows do not have to be certified as competent in each and every technical procedure. The time has arrived when we must realize that every trainee does not have to do every gastrointestinal technical procedure by the time fellowship is completed, or whenever. There are limits to the resources, patient population, and endoscopic expertise available at anyone endoscopic training center. In the near future, only a portion of talented trainees will be certified in certain highly specialized GI technical procedures. The GI fellowship is not an exclusive endoscopic experience. There is only so much time during the 2 clinical years for the broad, diversified, intellectual learning experience necessary for the practice of gastroenterology. The GI trainee will have to be content with "competence" in some technical procedures and "familiarity" in others at the completion of his 2-year pr.ogram. B. Additional training for specialized endoscopic expertise: tier III certification. At the present time, highly specialized endoscopic techniques require additional training during an extra year of intensive on-job experience at several wellknown centers. Additional time to develop appropriate procedural skills is not a new concept to GI training programs. GI endoscopic program directors do not wish to emulate the ancient craft guilds, but the basic philosophy is well accepted. It takes time and experience to develop a skilled craftsman. Perhaps the best current example of this attitude involves developing competence in therapeutic ERCP procedures. For example, at the Medical College of Wisconsin, a third year of specialized training is required for therapeutic ERCP. Endoscopic treatment of pancreaticobiliary duct disorders demands considerable operator experience and practice. The prerequisites for performing endoscopic sphincterotomy in our unit are fairly rigorous. The GI fellow has to have performed at least 100 (preferably 150) diagnostic ERCP studies with a success rate for selective duct cannulation of 85% or better. It is important for the trainee in therapeutic ERCP to be exposed to the wide variety of problems and complications related to pancreaticobiliary tract disease, to observe and participate in the interaction between the interventional GASTROINTESTINAL ENDOSCOPY
Table 1. Division of GI procedural competence into three tiers or levels of postgraduate training Level of training" 1st tier
2nd tier
3rd tier
"One tier program.
Procedural competence Diagnostic: Esophagogastroduodenoscopy, flexible fiberoptic sigmoidoscopy, tissue/liver biopsy Dilation: simple esophageal stricture Diagnostic: Colonoscopy, endoscopic cholangiopancreatography, esophageal manometry Therapeutic: Polypectomy, electrocautery and heat probe, sclerotherapy, percutaneous endoscopic gastrostomy, infrared coagulation Diagnostic: Laparoscopy, sphincter of Oddi manometry Therapeutic: Endoscopic cholangiopancreatography (sphincterotomy, stent placement, balloon distention); laser therapy; esophageal stent placement Dilation: brusque (achalasia)
1 year of supervised training in an accredited
radiologist, the surgeon, and the endoscopist, and to have experienced supervision and direction during these times. Experience with endoscopic guide wire insertion, stent management, balloon dilation of strictures, and sphincter of Oddi manometric recording requires significant exposure to a specialized referral pI pulation and an endoscopic team familiar with the myriad of complex devices now available for use with these therapeutic procedures. The technology explosion in our subspecialty area necessitates a concentrated exposure for the trainee to a working environment wherein the physicians and nurse-technicians constantly interact and redirect their therapeutic options and instrumentation commensurate with the complexity of clinical findings and the difficulty of the procedure. There are ot':ler endoscopic procedures that may necessitate a third ti(~r of training for the GI postgraduate fellow before competency is acquired, e.g., advanced laparoscopy, endoscopic ~aser therapy, or esophageal prosthetic insertions. Tiers and procedural competence. Table 1 is an attempt to divide GI procedural competence among three tiers or levels of postgraduate training (one tier = 1 year of supervised training in an accredited GI postgraduate training program). The complexity or learning curve of these procedures ~ncreases directly with the tier rank. The trainee's antic ipated growth in endoscopic skills and clinical experienCf. should parallel this. f.Jbviously, there is some overlap between the first and VOLUME 34, NO.3, 1988
second tier in some academic programs. A third tier of training to assure competence in sophisticated therapeutic procedures will become a reality for all GI training programs in the near future. You can pack only so much training and experience into 2 years.
REFERENCE 1. Benson JA, Cohen S. Evaluation of procedural skills in gastroenterologists (editorial). Gastroenterology 1987;92:254-7.
Abstracts ENDOSCOPY AROUND THE WORLD
Editor for Abstracts, Charles J. Lightdale, MD Panel of Reviewers Jamie S. Barkin Stanley B. Benjamin Lawrence J. Brandt Edward L. Cattau Sarkis J. Chobanian Peter B. Cotton Javier Elizondo Kenneth A. Forde Lionello Gandolfi David Y. Graham Richard H. Hunt Dennis M. Jensen Seibi Kobayashi Richard A. Kozarek
Glen A. Lehman Finlay Macrae Zdenek Maratka Mark H. Mellow Patrice A. Michaletz Jay A. Noble H. Juergen Nord Jeffrey L. Ponsky Paul Rozen Melvin Schapiro Walter L. Trudeau G. N. J. Tytgat Richard A. Wright
Usefulness of manometric assessment of varices in maintenance sclerotherapy: a controlled trial HOSKINS JW, ROBINSON P, JOHNSON AG Gastroenterology 93:846-851, 1987
Hoskins and colleagues report a prospective controlled trial of 68 patients undergoing maintenance sclerotherapy with 5% ethanolamine, 35 of whom had variceal patency assessed manometrically and 33 by visual means. A patent venous channel was defined after direct varix puncture as having a low pressure «45 mm Hg) that fluctuated with respiration. Thrombosed vessels, extraluminal punctures, or punctures into the esophageal wall, in turn, were associated with a rapid pressure rise (>100 mm Hg) unassociated with respiratory-induced pressure variations. The authors report that during a mean follow-up period of 13 months, there was a statistically significant difference in variceal bleeding episodes (1 vs. 14, P < 0.002), ulceration (2 vs. 9; p < 0.05), and obliteration (11 vs. 2; P < 0.01). Not only were objective results improved using manometry to define patency, but the authors claimed a 25 % error rate in assessing patency by visual means. 293