Original Articles: Gastroenterology
See “Novel Methods for Training Future Pediatric Gastroenterologists” by Kadzielski and Winter on page 2 and “Challenge of Meeting Fellowship Procedural Guidelines in Therapeutic Endoscopy and Liver Biopsy” by Lentze on page 3.
In 1999 the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) established the number of specialized gastrointestinal (GI) procedures required to achieve competency during a 3-year pediatric gastroenterology fellowship (1). These guidelines were based predominantly on adult procedural experiences. There are no data in the literature to indicate that meeting these competency standards is feasible during a pediatric GI fellowship. The 1999 guidelines distinguish which procedures are considered routine, complex, or advanced and label them as level 1, 2, or 3, respectively. Level 1 procedures are considered routine and minimums should be achieved during the course of training. Level 2 and 3 procedures are considered advanced and it is recognized that additional training after fellowship may be required to reach competency thresholds (2).
Our study was conducted to assess the maximal number of opportunities for therapeutic endoscopy procedures, liver biopsies, and percutaneous endoscopic gastrostomy (PEG) placements available to pediatric GI fellows during a typical 3-year training period. During the course of our study, NASPGHAN published updated training guidelines (2); thus, our results were analyzed to incorporate the new recommendations (2,3).
Discordance between present training guidelines and actual experiences by pediatric GI fellows was first suggested by Lightdale et al (3), who surveyed 59 (65%) of the upper-level fellows in North America and found that only 10% were meeting the recommendations for colonoscopies and polypectomies, 54% for upper endoscopies, and 41% for liver biopsies. Another self-reported questionnaire administered by Qualia et al (4) in 2007 to 66% of third-year North American fellows found that only 52% had exceeded the threshold of 100 colonoscopies and only 44% met the threshold of 20 liver biopsies.
Data were collected from 12 pediatric GI fellowship programs in the United States. Procedures completed in the years 2009–2011 were obtained using CPT codes and query of endoscopy databases. Programs were characterized as small if they graduated 1 fellow per year, medium-sized with 2 fellows per year, and large if they graduated ≥3 fellows per year. Different-size programs were included to attempt to ascertain whether there was a difference in opportunities for procedures based on size alone. All of the participating centers completed a questionnaire regarding ancillary opportunities for endoscopic training, including rotations with adult endoscopists, access to endoscopy courses, and simulation. The maximal opportunity for procedures was based on the total procedures performed by the institution during a 3-year period divided by the total number of fellows in the program.
A total of 12 centers participated in the study, 2 small, 7 medium, and 3 large. The study sample represents 81 of 296 (27%) of all fellows enrolled in pediatric GI training programs between 2009 and 2011. We found significant variability in pediatric endoscopic training opportunities in specialized GI procedures, PEG placements, and liver biopsies (Table 1). Under the 1999 guidelines, no center met the recommendations for control of nonvariceal bleeding and polypectomies (Table 2, Figures 1 and 2). Fewer than one-third of programs provided enough opportunities to meet the guidelines for sclerotherapy/band ligation and stricture dilation. One of the biggest differences between the 2013 and the 1999 procedure guidelines is a decrease in the number needed for training in polypectomy from 20 to 10. This change made it feasible for 67% of programs to offer enough polypectomy experience to reach the competency numbers versus 0% based on the 1999 threshold. Although the new guidelines decreased the threshold needed to reach competency standards in control of bleeding techniques from 35 to 15 procedures, the percentage of centers able to offer enough opportunities to reach that goal remained at 17% (Table 2, Figures 3 and 4). Most centers were reaching the procedural thresholds for foreign-body retrieval based on the 1999 guidelines (75%), but because of an increase in the threshold from 5 to 10, the number of centers offering enough foreign-body removal procedures decreased to 58%. Opportunities for PEG placements were adequate if the GI department participated in the procedure, but in 42% of the centers, PEG placement was performed by pediatric surgery or interventional radiology alone. The percentage of centers meeting the guidelines for liver biopsy increased marginally from 67% to 75% after the new guidelines lowered the threshold from 20 to 15. Similar to PEG placements, this is another procedure that is being increasingly outsourced to interventional radiology. On average, fellows were more likely to meet the guidelines if they were trained at a small center over a medium-size or a large center; however, the numbers were too small for statistical analysis. The raw procedural numbers were significantly higher at larger centers, but the opportunity was decreased because of the increased number of fellows competing for those procedures (Table 3). Supplemental endoscopy training is provided by 92% of the training programs, mostly in the form of optional adult endoscopy rotations (58%) and/or participation in hands-on endoscopy courses (33%), followed by simulator training (25%) (Table 4).
In this study, we demonstrate that achieving the procedural targets recommended by NASPGHAN may be difficult in most pediatric GI fellowship programs. None of the centers met all of the thresholds under the 1999 NASPGHAN guidelines. Even with the recent changes in the numbers needed to reach competency, only 1 center offered enough opportunities to meet all of the thresholds.
Procedures that require the use of nonvariceal hemostatic techniques were exceedingly rare in all of the pediatric training programs. This is further highlighted by the fact that even after a 43% reduction in competency threshold, the number of programs reaching the guidelines did not change. These techniques include use of hemostatic clips, submucosal injections, electrocautery, and argon-laser coagulation. It is likely that pediatric GI fellows may graduate from training programs never having used some of these modalities. Without supplemental training, none of the programs were able to provide sufficient opportunities to meet the NASPGHAN guidelines for control of nonvariceal bleeding. Under the 2013 guidelines, control of variceal and nonvariceal bleeding categories were combined for the purposes of competency thresholds (2). The new guidelines also reclassified control of variceal and nonvariceal bleeding from a level 2 to a level 1 procedure, stressing that expertise in hemostasis should be achieved during fellowship (2). Given that only 17% of the centers surveyed were able to reach the minimum threshold under the 1999 and 2013 guidelines, experiences outside of the pediatric setting or ex vivo learning will be imperative. A standard ex vivo course can also offer the opportunity to teach individual hemostasis techniques. Even though it is not mandated by the guidelines, obtaining competency in both variceal banding and sclerotherapy, along with various nonvariceal hemostatic techniques, is important in a pediatric setting in which patient size may place limitations on equipment that can be used.
Because acquisition of skills from clinical experience is likely to be insufficient, trainees may need to resort to other modalities. Presently, 92% of participating programs already offer ancillary training opportunities; however, given taxing training schedules, these modalities may not be used if made optional (5). Rotation with adult gastroenterologists can supplement pediatric experience and was already established in 58% of the programs as an optional elective (Table 4). If reaching the NASPGHAN competency guidelines was a prerequisite for graduation from fellowship, rotating with adult endoscopists would likely be the most effective way to obtain the procedural numbers. To address whether adding pediatric trainees would impede adult GI fellows’ ability to reach American Society for Gastrointestinal Endoscopy (ASGE) defined competence thresholds, we obtained procedural numbers using CPT codes in 1 adult academic institution. Procedure numbers were only collected for procedures performed at the main university hospital, which accounted for 2 years and 8 months of training. Each adult GI fellow had an opportunity to participate in 271 polypectomy cases, 40 procedures for control of nonvariceal bleeding, 70 cases of stricture dilation, and 28 band ligations/sclerotherapy procedures (data not shown). All of the procedural numbers far surpassed threshold criteria, with the exception of stricture dilation/band ligation techniques, which were close to the cutoff values. In this one institution, the adult special procedure opportunities were more than sufficient to accommodate multiple pediatric GI fellows; however, this may vary between centers depending on the size of the institution and number of trainees.
Computer simulators have been shown to be effective for acquisition of colonoscopy skills but have not been evaluated for therapeutic endoscopic techniques (6). Future research efforts will need to address the effectiveness of simulation training in this arena. Alternately, hands-on use of ex vivo animal models has become an accepted standard in endoscopy training and has been shown to be superior to lecture-based learning (1,4). Numerous studies have shown significant improvement in skill acquisition in hemostasis, clip application, variceal banding, and stricture dilation techniques after completion of hands-on courses (7–9). There is some evidence to suggest that hands-on training can have a sustained effect on skills when evaluated 7 to 9 months after training (10), but the effect is procedure dependent and may require repeated educational sessions (11). A pediatric ASGE/NASPGHAN hands-on endoscopy course is offered annually in Chicago, Illinois, but is presently underused by trainees. During the study period, only 19 of 296 (9%) fellows were able to participate in the course, possibly because of funding limitations. Another hands-on course organized at the annual NASPGHAN meeting offers opportunity for training, but because of space and time limitations, most participants rotate through only 1 or 2 stations. In 2012, only 68 of 363 (17%) fellows were able to participate in this course. Despite the higher-volume clinical training opportunities in adult GI programs, a subsidized hands-on endoscopy course has been established for first-year adult GI fellows and according to the ASGE draws approximately 320 fellows each year. Incorporating endoscopic training into one of the yearly pediatric GI fellows’ training meetings or subsidizing attendance for the ASGE/NASPGHAN endoscopy course may be an effective way to increase ancillary training opportunities in pediatric endoscopy. Given that this modality has been shown to be effective for skill acquisition, newer guidelines may consider accepting ex vivo hands-on procedure experience toward achieving competency thresholds. Establishing a standardized logging system or audit of procedural volumes may increase the incentives for programs to make ancillary procedural training part of the fellowship curriculum.
There are some limitations to our study. Acquisition of procedural data using CPT codes and billing can only be regarded as estimates because these standards vary between institutions. We attempted to standardize this by including all available GI procedural billing codes. The data presented do not account for the possibility of multiple opportunities per case, such as retrieval of >1 polyp or control of bleeding with ≥2 modalities. In addition, only 27% of the pediatric GI fellows were represented in this study, albeit from different-size programs. Despite these limitations, the opportunities for these procedures are so limited that meeting the guidelines would still pose a challenge at most institutions even if underestimated.
Reaching the recommended NASPGHAN threshold for procedural numbers is difficult in the pediatric GI clinical setting even with the new 2013 guidelines. Training in therapeutic endoscopy, PEG placement, and liver biopsy in pediatric GI fellowships should be supplemented using all possible options, including rotations with adult GI providers and hands-on endoscopy courses. Conversely, moving toward qualitative outcome measures compared with quantitative measures may be more appropriate in the long run.
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Keywords:© 2014 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,
competency; endoscopic procedures; fellowship; liver biopsy; pediatric gastroenterology training