'See one, try one, and carry on practising endoscopy' is no longer acceptable in 1999. The long-awaited recommendations of the Joint Advisory Group (JAG) on gastrointestinal endoscopy training have set standards for all trainee endoscopists physicians, surgeons, GPs, radiologists and nurse practitioners.
They start by setting the minimum standards for the units approved for training. All endoscopists are encouraged to register with the JAG not only those passing through higher medical and surgical training.
The recommendations set down that sessional endoscopists must be trained in units approved by the JAG (training to include the management of sedation and its complications). Training should be part of an overall gastroenterology service with interdisciplinary cooperation; in-service experience is to be supplemented by attendance at approved courses. Trainees are to maintain their own logbook of experience (summary forms are included in the JAG document).
Recommended numbers of procedures are the subject of review, and skills acquired during training are to be regarded as minimum requirements and should be reinforced by attending advanced courses; there must be a commitment to CME. Specifically, GPs will be required to train in units approved by the JAG.
The present recommendations are effective until 1 January 2001. Training units must fulfil the following criteria: upper GI endoscopy (OGD), minimum 1000 procedures per year, must have high quality video-endoscopic equipment with televisual display and image recording facilities, and fluoroscopy available; colonoscopy, 400 procedures per year, standard of equipment as for upper GI; flexible sigmoidoscopy, 200 procedures per year; ERCP and therapeutic ERCP, 250 procedures per annum.
Numbers of procedures currently required for the endoscopist in training are: OGD, 200 procedures under supervision and a further 100 with advice available (total 300 minimum); colonoscopy, assist in 50, perform 50 under supervision, minimum 25 poly-pectomies; flexible sigmoidoscopy 50 under supervision, plus 50 with advice available (will not imply competence in colonoscopy); ERCP 100 procedures under supervision, endoscopic sphincterotomy and insertion of stents in at least 25.
Review of the set criteria is inevitable. Some units may be unable to meet all the training criteria but may have to function for lack of viable alternatives and the need to meet the investigation workload. Training needs to be done at defined training lists; patient turn-around time is probably doubled. Numbers of procedures required from trainees may take inordinate time in some areas. Some endoscopists, e.g. GPs in rural areas, may be forced to train, at least in part, outside approved units.
The monitoring of this process will be time-consuming and is going to do nothing for current waiting times for procedures. But the setting out of proper standards is to be welcomed and a consequence will be increased availability of appropriate CME, currently unavailable to most GP endoscopists. The establishment of a Diploma in Endoscopy is also being considered.
A further priority for endoscopy units should be appropriate terms of service for sessional endoscopists, particularly GPs and nurse endoscopists. The steady attrition rate of GPs from the ranks of expert endoscopists is due to poor terms of service, notably the inappropriate clinical assistant grade, and a pay scale equivalent to half the BMA recommended rate for locum sessional cover in general practice. This loss of skilled manpower is a waste and needs to be urgently addressed.
- The JAG was commissioned by the Royal Colleges and is chaired by Dr Charles Swan (representing the Joint Committee on Higher Medical Training JCHMT). Other members included representatives from the RCGP (Dr Jeremy Barnes), JCHST, RCR, BSG and RCN.
- The document Recommendations for Training in Gastrointestinal Endoscopy 1999 is available from the Joint Advisory Group on Gastrointestinal Endoscopy, JCHMT, 5 St Andrew's Place, Regent's Park, London NW1 4LB.