|Year : 2014 | Volume
| Issue : 4 | Page : 135-138
Endoscopy training: Indian perspective
MK Goenka, DN Reddy, R Kochhar, Prateek Sharma
Governing Council Members of Society of Gastrointestinal Endoscopy of India
|Date of Web Publication||3-Feb-2015|
M K Goenka
Director & Head, Institute of Gastrosciences, 58 Canal Circular Road, Kolkata - 700 054, India
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Goenka M K, Reddy D N, Kochhar R, Sharma P. Endoscopy training: Indian perspective. J Dig Endosc 2014;5:135-8
| Introduction|| |
Importance of Gastrointestinal (g.i.) Endoscopy in Gastroenterology practice, both for routine day to day care as well as for advanced and sophisticated management, cannot be over-emphasized. It is expected that anybody practicing gastroenterology and hepatology today, should be well versed with both diagnostic and therapeutic g.i. endoscopy. Important component of adequate endoscopy training however, goes much beyond performing and completing an endoscopy. A comprehensive training should include:
- Ability to recommend or choose an endoscopic option considering indication, contraindications, as well as other alternative nonendoscopic options (such as radiology, surgery, etc.)
- Carrying out safe and complete endoscopic procedure in a reasonable time
- Proper assessment of endoscopic findings and evaluation in the context of other available information and investigations
- Ability to prevent, recognize and manage complications arising out of endoscopic procedures
- Understand safe and effective sedation and need for monitoring during and after the procedure
- Ability to know one's limitation and threshold for stopping a procedure at appropriate time.
However, there are many issues that concern us in present day Indian scenario:
- Inconsistent and nonuniform training of trainees during their postgraduate courses that is, DM or DNB in Gastroenterology. There is no clear guideline from authority about aim of endoscopy training, methods adopted for such training as well type and number of procedures expected from the trainees (supervised and independent) during their training period
- There are short, unstructured courses available to nongastroenterologists at private hospitals as well as teaching institutes (government as well as nongovernment). This results in improper and inadequate training to these physicians. In addition, there are endoscopist who have learned endoscopy by just observing some procedures at endoscopy centers or during an endoscopy workshop
- There is a poor ratio of trained or so called "trained endoscopist" vis a vis population at large. This is particularly true for some states of India and is more true for smaller cites and rural areas.
| Role of Society|| |
Society of Gastrointestinal Endoscopy of India (SGEI) is a professional organization of Indian G.I. Endoscopists with an aim to propagate, standardize and educate GI Endoscopy. SGEI therefore, considers it to be its duty to address this complex issue in the form of a position paper. This would initiate debate on this burning subject and in due course of time, society will be in a position to issue guidelines.
| Levels of Training|| |
We feel, there can be three levels of endoscopy training, which could be imparted to Indian physicians:
- Level 1 or Primary level: Limited to upper GI (UGI) endoscopy, sigmoidoscopy and a few simple interventions such as biopsies, injection hemostasis or band ligation
- Level 2 or Basic level: Including UGI endoscopy, lower G1 (LGI) endoscopy, capsule endoscopy and basic Endoscopic retrograde cholangiopancreatography (ERCP) with some therapeutic procedures but excluding endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), endoscopic ultrasound (EUS) and complex ERCP therapeutic procedures
- Level 3 or Advanced level: Including advanced technique related to ERCP (such as drainage of walled-off pancreatic necrosis, minor papilla cannulation, cholangioscopy, hilar tumor management), EUS (including fine needle aspiration cytology [FNAC] and fluid aspirations), balloon assisted enteroscopy (diagnostic and therapeutic), EMR and ESD.
This could be imparted to any skilled physician with interest in learning endoscopy. We feel a post graduate physician or surgeon (MD/MS or DNB in medicine or surgery) will be best suited for such training.
Training must be in a structured fashion and for a minimum of 6 months. This could be at teaching institute or in private SGEI accredited hospitals with availability of qualified, experienced, interested endoscopists and equipment for teaching.
Since, the period of training will be short and trainees may not have observed many procedures, availability of training models (plastic or digital) will be a pre-requisite to ensure such training for safety of patients. Training should include lectures on equipment, techniques, and normal as well abnormal endoscopic findings together with close observation and access to videos and atlases. A brief understanding of disinfection of endoscope and accessories is also mandatory and the same should be practiced at least 10 times under supervision. [Table 1] gives the list of minimum number of procedures, which a trainee must perform before he/she is assessed for competency for level 1.
A logbook must be maintained during training and mentor should certify the competency at end of training. Number of procedures performed for learning should include procedures performed unassisted but under supervision. Log book should, however, mention all procedures performed inclusive of assisted procedures as well as unsuccessful procedures. Indication, time taken and complications (if any) should also be recorded. Upper GI Endoscopy could be assessed for esophageal intubation, pyloric intubation, D2 entry, and retroflexion. Level 1 trained people should be clearly warned about consequences of overstepping their limits of performing endoscopy. Certificate provided by the supervisor or mentor should clearly state the procedures that the trainee has been trained and has acquired competency in. It is also recommended that trainee subsequently attends workshops and courses to continuously update their skills and knowledge.
This should be imparted primarily to students enrolling themselves for DM and DNB in Gastroenterology as well as MCh/DNB in GI surgery. Alternatively a 2 year fellowship can be started at accredited institutes with proper infrastructure.
Training should be at centers licensed by Medical Council of India to impart DM (Gastroenterology) or MCh (Surgical Gastroenterology) or by National Board of Examinations to impart DNB in Medical or Surgical Gastroenterology. In addition, reputed private set ups accredited by SGEI for the purpose can train for a 2 year fellowship. All these centers should have infrastructure and faculty with availability of radiology, pathology and lab services. It is mandatory that centers should have both elective and emergency services as well as intensive therapeutic units.
Training should again be very structured with well set out goals and methodology. Physicians should not only be trained about techniques of endoscopy but also judicious use of technology and management of complications. Physicians at the end of training should be able to use the endoscopic procedures at its appropriate place in the algorithm for diagnosis and treatment of various g.i. diseases. While models, simulators, and video library could form initial part of their training; close observation and discussion with faculty followed by hands-on training-under supervision will be main learning process. It will also be essential for them to learn maintenance as well as disinfection and reprocessing of endoscopes and accessories. At least 20 sessions of endoscopy cleaning should be performed under supervision of expert endoscopist or technician, and this should be recorded in log book. Sedation (including propofol) and monitoring during procedures should also be a part of their syllabus. Log book as mentioned above should be maintained. Log book should also include complications resulting from endoscopy. [Table 2] gives the list of minimum number of procedures, which a trainee must perform before he/she is assessed for competency for level 2.
|Table 2: Minimum no. of procedures for competence assessment for level 2|
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While the number mentioned is based on some guidelines issued by various societies, it is somewhat arbitrary.
We feel present systems at most institutes and universities do not allow proper evaluation of trainees at the end of the course. Besides a periodic assessment by faculty of the institute, there should be a critical assessment of logbook. Most importantly during their exit examination, enough weightage should be given to endoscopy skills including (a) knowledge of indication, contraindication and complication, (b) practical evaluation of technical aspect e.g. colonoscopic procedure can be assessed by intubation at splenic flexure, reaching cecum, entering ileum etc., (c) interpretation of endoscopic findings. It is expected that cecal intubation rate should be ≥90% in last 40 cases prior to completion of training in colonoscopy (excluding cases with severe colitis or obstructive lesion, where cecal intubation is not possible or not indicated). Other aspects to be assessed include consent process, monitoring, management changes based on endoscopy findings. Final evaluation should always be done by external examination along with internal faculty. Trainee, not up to the mark should be reassessed after a gap of 4-6 months.
This level of training should only be imparted to qualified Gastroenterologists or Gastrointestinal surgeons who have already been successfully trained during DM or DNB in medical gastroenterology, DNB or Mch in surgical gastroenterology or basic fellowship in GI endoscopy (Level 2). Training should be for a minimum of 1 year.
This training can be imparted at advanced centers that could be governmental or autonomous institutes as well as SGEI accredited nongovernmental organizations with adequate infrastructure and faculty. Center should have at least two faculty performing
these advanced procedures on a regular basis.
It is expected that these trainees have learned all aspects of level 2 training, and if there is any deficit, it should be taken care of. Main stress in this level of training however, will be on advanced ERCP (such as Hilar tumor, pancreatic endotherapy, cholangioscopy, drainage of WOPN etc.,) EUS (including FNAC and therapeutic), EMR, ESD, POEM as well balloon assisted enteroscopy. They should also understand pancreatico biliary anatomy as seen at ERCP and at EUS (cross-sectional anatomy) as well as radiation safety and oncological staging. Log book as mentioned should be maintained. [Table 3] gives the list of minimum number of procedures, which a trainee must perform before he/she is assessed for competency for level 3.
|Table 3: Minimum no. of procedures for competence assessment for level 3|
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Training will not be only for achieving competence in advanced procedure, but also to learn art of teaching and carrying out research in the field of endoscopy.
Evaluation should be as for level 2. Technical assessment for ERCP should include cannulation of desired duct, sphincterotomy, stone extraction, hilar stenting, pancreatic stenting. EUS assessment should include intubation of esophagus, crossing pylorus, imaging the desired organ, performing a successful FNAC and proper tumor staging. SGEI if involved in evaluation process may be able to certify the trainee.
| Conclusion|| |
We feel the above format may not be an ideal one, but it is a practical approach considering the existing scenario of our education set up and our demand to supply ratio. We also strongly believe that our own perspective about this issue may change over next decade. However, what we are suggesting now, is one we can actually achieve in present time. No attempt has yet been made to recommend training guidelines specific for pediatric endoscopic practice.
| Society of Gastrointestinal Endoscopy of India (SGEI) Governing Council members are listed as follows|| |
Pankaj Dhawan (Mumbai), SA Zargar (Srinagar), S P Misra (Allahabad), Mahesh K. Goenka (Kolkata), Vipulroy Rathod (Mumbai), P. K. Sethy (Kolkata), Uday C Ghosal (Lucknow), Vijay K Rai (Kolkata), Mohammed Ali (Chennai), Satish Midha (Ranchi), Saroj K Sinha (Chandigarh), Rajesh Puri (Delhi), Manoj Kumar (Patna), Haribhakti Seba Das (Bhubaneswar), Vinod Dixit (Varanasi), Manu Tandon (Hyderabad), G V Rao (Hyderabad), S P Singh (Bhubaneswar).
| Bibliography|| |
- ASGE Training Committee, Adler DG, Bakis G, Coyle WJ, DeGregorio B, Dua KS, et al. Principles of training in GI endoscopy. Gastrointest Endosc 2012;75:231-5.
- Azad JS, Verma D, Kapadia AS, Adler DG. Can U.S. GI fellowship programs meet American Society for Gastrointestinal Endoscopy recommendations for training in EUS? A survey of U.S. GI fellowship program directors. Gastrointest Endosc 2006;64:235-41.
- Chak A, Cooper GS, Blades EW, Canto M, Sivak MV Jr. Prospective assessment of colonoscopic intubation skills in trainees. Gastrointest Endosc 1996;44:54-7.
- Cotton PB, Eisen G, Romagnuolo J, Vargo J, Baron T, Tarnasky P, et al. Grading the complexity of endoscopic procedures: Results of an ASGE working party. Gastrointest Endosc 2011;73:868-74.
- Cass OW. Training to competence in gastrointestinal endoscopy: A plea for continuous measuring of objective end points. Endoscopy 1999;31:751-4.
- Faigel DO, Cotton PB, World Organization of Digestive Endoscopy. The London OMED position statement for credentialing and quality assurance in digestive endoscopy. Endoscopy 2009;41:1069-74.
- Hochberger J, Maiss J, Magdeburg B, Cohen J, Hahn EG. Training simulators and education in gastrointestinal endoscopy: Current status and perspectives in 2001. Endoscopy 2001;33:541-9.
- Hawes R, Lehman GA, Hast J, O'Connor KW, Crabb DW, Lui A, et al. Training resident physicians in fiberoptic sigmoidoscopy. How many supervised examinations are required to achieve competence? Am J Med 1986;80:465-70.
- Heller SJ, Tokar JL. Current status of advanced gastrointestinal endoscopy training fellowships in the United States. Adv Med Educ Pract 2011;2:25-34.
- Hawes RH. Advanced endoscopy and endosurgical procedures: Do we need a new subspecialty? Gastrointest Endosc Clin N Am 2007;17:635-9, ix.
- Vennes JA, Ament CH, Boyce HW Jr, Cotton PB, Jensen DM, Ravich WJ, et al. Principles of training in gastrointestinal endoscopy. Gastrointest Endosc 1999;49:845-9.
- Koch AD, Ekkelenkamp VE, Haringsma J, Schoon EJ, de Man RA, Kuipers EJ. Simulated colonoscopy training leads to improved performance during patient-based assessment. Gastrointest Endosc 2014; S0016-5107(14)02193-2.
- MacSween HM. Canadian Association of Gastroenterology Practice Guideline for granting of privileges to perform gastrointestinal endoscopy. Can J Gastroenterol 1997;11:429-32.
- Martinek J, Suchanek S, Stefanova M, Rotnaglova B, Zavada F, Strosova A, et al. Training on an ex vivo animal model improves endoscopic skills: A randomized, single-blind study. Gastrointest Endosc 2011;74:367-73.
- Rodney WM, Weber JR, Swedberg JA, Gelb DM, Coleman WH, Hocutt JE Jr, et al. Esophagogastroduodenoscopy by family physicians phase II: A national multisite study of 2,500 procedures. Fam Pract Res J 1993;13:121-31.
- Sharma VK, Coppola AG Jr, Raufman JP. A survey of credentialing practices of gastrointestinal endoscopy centers in the United States. J Clin Gastroenterol 2005;39:501-7.
- Sedlack RE. Training to competency in colonoscopy: Assessing and defining competency standards. Gastrointest Endosc 2011;74:
- Soma T, Sakamoto Y, Matsuoka Y, Nakano T, Kamiuttanai M, Akiyama M. Short-term training of upper gastrointestinal endoscopy for resident doctors in Sotogahama Central Hospital in Aomori, Japan. Adv Med Educ Pract 2013;4:127-31.
- Walker T, Deutchman M, Ingram B, Walker E, Westfall JM. Endoscopy training in primary care: Innovative training program to increase access to endoscopy in primary care. Fam Med 2012;44:171-7.
- Wexner SD, Litwin D, Cohen J, Earle D, Ferzli G, Flaherty J, et al. Principles of privileging and credentialing for endoscopy and colonoscopy. Gastrointest Endosc 2002;55:145-8.
- Xiong X, Barkun AN, Waschke K, Martel M, Canadian Gastroenterology Training Program Directors. Current status of core and advanced adult gastrointestinal endoscopy training in Canada: Survey of existing accredited programs. Can J Gastroenterol 2013;27:267-72.
[Table 1], [Table 2], [Table 3]