Paediatric endoscopy has a broad spectrum of levels depending on the resources available, the experience of the trainers, the availability of cases, and most importantly the availability of a cogent structure for that training with a worldwide consensus on syllabus, curriculum, and methods of assessment. The latter is a major need for endoscopists who have already some experience and have a routine practice, as well as for those approaching initial training. Priorities to optimise training include achieving consensus throughout the world on the content of a training programme in paediatric endoscopy and how to reach this. A major point is to agree upon a tool and a method of policing this process, namely how to ensure that training is being delivered effectively and that the end product, the trainee, is adequately prepared to operate effectively in a general setting. In addition, periodic validation of skills should parallel the continuing progresses in the techniques and the indications to perform them in rapidly evolving scenarios. Federation of International Societies of Pediatric, Gastroenterology, Hepatology, and Nutrition societies should agree upon a syllabus, a major tool needed to achieve uniformity of excellence in the training process and availability of training. They should approach national and international bodies for funding towards development of training courses and fellowships for trainees in paediatric endoscopy. Furthermore, “training the trainer” should be a strategy to achieve excellence combined with effectiveness. Training mannequins, and the formalisation of training completion, should also be considered. This whole approach should have no international boundaries or limitations.
SUMMARY OF THE PROBLEM
We predicate the importance of this position statement on the following immutable driving force: endoscopy should be available to all of the children in the world to aim for excellence of care in all cultures and countries. As an aim that is incontrovertible, it should be conducted by those with the requisite skills. It is undeniable that its application may, in hard terms, save economies money through prevention of malnutrition and identification of treatable conditions such as celiac disease, and help in the amelioration of issues in the developing world such as variceal bleeding. Clearly, the importance of endoscopy in children's care cannot be refuted and consensus in its application is needed; however, if we ascribe to this value, then it is our responsibility as a community of paediatric gastroenterology practitioners to ensure the quality of delivery of such a service.
It has become increasingly apparent in recent years that the landscape of paediatric endoscopy training varies widely, not only between differing health systems and countries, who nevertheless in principle may aspire to identical standards of training excellence, but even between apparently comparable “training” endoscopy units within individual countries. These issues are critical for our next generation of trainees in this procedural specialty that remains unique in paediatric medicine.
We as endoscopy trainers, and as those representative of a generation who have had variable training ourselves, have an acute responsibility to get it right for our trainees going forward. This is an opportunity that should not be missed and, we believe, asks to be seized.
In 2012, there exists no international agreement on, or coordination of, overall endoscopy training, and in paediatrics this is no different, and is reflected in the lack of a cogent strategy for this. Furthermore, there is no adherence to, or indeed discussion of, a common policy of what constitutes the basics for effective training. This should include:
- Training standards and how to deliver these effectively
- Standards of competency for those finishing training
- How to train the trainers
- Perhaps most important, the ongoing peer-review of colleagues’ ability, that is, ongoing assessment and revalidation of capability.
Until recently, little prospective data existed regarding training and the rates of skill acquisition in either paediatric or adult endoscopy training. As a consequence, recommendations in paediatrics of the minimum numbers of supervised procedures required for competence in training have often been based on anecdote and personal opinion. Some prospectively collected data exist in adult endoscopy (1,2), and although this is often inconsistent, it forms the basis for training requirements that have been used historically. During the last 10 years, changes in paediatric endoscopy training guidelines have occurred in the absence of a prospectively gathered evidence base to support them. In 1997, the North American Society of Pediatric Gastroenterology recommended a minimum of 50 colonoscopies. This was revised to 100 in 1999 and also included recommendations for therapeutic procedures such as snare polypectomies (20), balloon dilatation of strictures (15), and management of bleeding gastrointestinal (GI) lesions (20) (3–5); however, a requirement for an absolute number of procedures does not take into consideration potential differences between individuals in terms of both technical scope-handling skill acquisition rate and lesion recognition. Anecdotally, it has been suggested that there may be significant differences between trainees in their progression in endoscopic skill acquisition. Although this would seem likely and has been demonstrated in other surgical specialities and with virtual models (6,7), only one attempt to prospectively investigate this exists as yet within paediatric endoscopy (8).
It has been suggested that endoscopy simulators have the ability to differentiate between beginners and experts in endoscopy, supporting the validity of the model (7). Simulators have been used in 1 paediatric study and have revealed significant efficacy in the speed of skill acquisition of trainees that were exposed to simulator training prepatient, both in terms of depth of insertion and ileoscopy, and also in terms of lesion recognition success that was presumed to be an effect of a greater focus on lesions once the trainee had less need for concentration on the correct endoscope manipulation (8).
Furthermore, the standard of trainers deserves attention, and periodic accreditation of those acting as trainers, as exists in other specialities, should be an important aim.
This document represents an attempt across all of the societies of FISPGHAN to bring together a cogent and applicable strategy for the future standardisation of training in paediatric endoscopy across the landscape of worldwide training structures.
RESEARCH AND EDUCATION
Observational or interventional research in this field is sparse, and the use of structured or virtual model-based training regimens is not mainstream. As an integral part of GI practice, and with the recognition that ours is almost unique in paediatric medicine as an interventional specialty, it is surprising and regrettable that so little exists in this area of essential medical education. For too long the mantra has been “see one, do one, teach one,” and in the 21st century we believe that this is no longer good enough. Part of the problem is defined by the lack of actual observational or objective knowledge of the problem: its dimensions; its depth; and its history. Investment in defining the size of the issue and the potential efficacy of strategies to deal with it are urgently needed. Of course this must occur across the world encompassing different endoscopic training environments, but we feel that this should not be allowed to be an obstacle to the goal of a worldwide training structure and a definition of minimum standards of such.
GOALS (PRIORITIES) FOR INTERVENTIONS
- Structured hands-on courses. These should occur in 4 areas and timelines:
- Pretraining and in specific areas of endoscopy specific to the eventual outcome of the trainee; for example, diagnostic upper GI endoscopy, ileocolonoscopy, and interventional endoscopy
- Specific add-on skills, for example, wireless capsule endoscopy, enteroscopy, and endoultrasound
- “Training the trainer” courses, with every trainer having attended such a course, and an individual in each training unit identified to deliver this function effectively
- Animal model–based endotherapeutic courses mid-way or towards end of training.
- It would be ideal, as we suggest below, that these would form the base of a collaborative worldwide process of training, with an agreed minimum algorithm for paediatric endoscopy training based on an agreed curriculum/syllabus with a stratified skill approach, that is, with varied outcome goals dependent on the future aims of the trainee, for example, pure diagnostic simple therapeutic, or advanced skill base.
- Assessment by direct observation of practical skills (DOPS) basis. It is clear that trainer review (peer review for trained individuals) of ability in endoscopy is the only way forward. Practical issues include manpower, finance, and impartiality, but these should not dissuade us to strive towards acquisition of excellence of practical technique. It would be envisaged that DOPS would occur at the beginning of training (formative), at the end (summative), and for those trained (ongoing) potentially periodically, for example, on a 5-year interval basis.
- Interchange between units worldwide. There remains no doubt that the variability of facilities, experience, and training opportunities that exist between countries and differing medical systems pose difficulties for some trainees in obtaining the ideal of excellence of training as espoused above. It would be integral to a worldwide vision of endoscopy training in paediatrics that a fluid transfer of trainees between units would be possible, with funding perhaps allowed by the mother country for limited and focussed periods of time.
PLANS TO ACHIEVE GOALS
- Structured hands-on courses. One proposal, which is the most practical, is that one or more units are identified in each country or region and that these units would provide endoscopic courses on a format that is proscribed by the FISPGHAN Working Group on Endoscopy; this would be the most useful tool in coordinating the goal towards uniformity of excellence in training. The goals, structure, and delivery of such courses are already well defined and would be easily translatable culturally, linguistically, and technologically.
- e-Learning and paediatric-specific texts. Lesion definition and recognition with online learning tools are in the process of development. Interaction with the groups forming such tools would be ideal, but otherwise a fund from the bodies forming FISPGHAN to construct such a resource would be a cost-effective way of providing training. An online examination tool could easily assist in assessment and feed in to the trainee's portfolio. Standard paediatric endoscopy and endoscopy training texts have been published and should be read by trainees (9–11).
- Meetings specific to endoscopy. This is already happening with North American Society of Paediatric Gastroenterology, Hepatology, and Nutrition and European Society of Paediatric Gastroenterology, Hepatology, and Nutrition Summer Schools, and is to be encouraged and amplified.
- Online training logs. Again, this is already occurring and should be rolled out worldwide to feed in to uniformity of training standards. The JAG Endoscopy Training Site, where JAG stands for Joint Advisory Group on Training Standards (for endoscopy) Web site (www.jets.nhs.uk) is an example of how this may be accomplished, and this is mandatory now for all UK endoscopy trainees. It is populated by DOPS training forms filled in by trainers contemporaneously during an endoscopic procedure carried out by a trainee.
- Assessment of units and their ability to provide appropriate levels of training. This is self-explanatory, occurs already, and with a tool such as a global rating score (GRS) can be extremely effective as a powerful lever in persuasion of hospitals and other institutions to deliver appropriate training in a conducive endoscopic training environment.
- Adoption of a worldwide “curriculum” for trainees. An example, adopted by the British Society of Paediatric Gastroenterology Heptatology, and Nutrition, the British Association of Paediatric Surgeons, and now the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition of such a curriculum, is to be found in Appendix 1 (http://links.lww.com/MPG/A179). It can be seen that this allows for trans-specialty training including surgeons and others, and it is envisaged that these other disciplines would be encouraged to engage in a uniform training process as outlined in this article. In addition, it defines differing levels of training competence defined by the trainee's objective endpoint. This approach has gained momentum in the UK, for instance, within and between differing training structures, that is, medical and surgical paediatric trainees.
The above goals require finance, and in a most practical way, a number of options exist including, but not limited to, national governments providing specific training health service-led systems, for example, the National Health Service in the UK, Paediatric Gastroenterology Society–funded training, WHO funding for developing countries, charity funding such as the Bill and Melinda Gates Foundation and others, EU Commission, and grant-awarding bodies for specific research-led training projects, all driven by heightening awareness of the general public regarding the importance of their children receiving excellence of care, which is clearly contingent on excellence of training of the doctors who will deliver endoscopy to the next and subsequent generations.
Engagement with national regulatory bodies of training; national societies; international groups represented within FISPGHAN; individuals in our discipline; financing bodies such as governments, WHO, international charitable, and philanthropic organisations; parent- and patient-led lobby groups; and endoscopy companies.
It should not be forgotten that in some developed-world cities, there is a paediatric endoscopist for every 100,000 to 200,000 inhabitants, but that in places such as Bangladesh with a population of approximately 150 million, there are only 2 or 3. This is an example of the inequity of health provision, and, although not unique, indicates that we have the opportunity, and more important, the imperative, to set this balance right. Training is everything towards excellence of care.
There remains no doubt that the validity of, delivery of, policing of, and ability to effectively provide excellence of paediatric endoscopy training vary greatly across the globe. In this context, this document aims to provide our colleagues with an ideal: We believe that children deserve the best in skills from their practitioner, and to attain such skills their training needs to be of a far greater standard and uniformity than has hitherto been available worldwide.
The present article proposes a possible road map that may start to provide a potential solution to this vital area that is long overdue attention. Enthusiastic support and signing up to this structure from all members and societies alike are vital if we are to succeed in the foreseeable future, and we believe that failure to engage at personal, national, societal, and international levels is not an option. FISPGHAN offers us an opportunity to open this dialogue towards a common aim for the next generation.
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