Research, plans to spend several million dollars to create practice guidelines and to assess the effectiveness of different approaches to the diagnosis and management of medical problems to determine which most effectively achieve beneficial outcomes. It will be up to us to ensure that the patient's outcome, not government's, insurers', and investors' bottom line, remains the primary concern. It was Oregon's application of traditional cost-effectiveness theory that produced a prioritized list of health care services for Medicaid reimbursement in which dental tooth capping took precedence over a life-saving appendectomy for acute appendicitis or surgery for ectopic pregnancy, despite the virtually 100% effectiveness of these procedures in treating otherwise generally fatal conditions. To economists, the goal is to maximize health benefits within society without regard for individual welfare. The obvious absurdities sent the Oregon Health Services Commission back to the drawing board to factor in the powerful human proclivity to rescue endangered life, dubbed the "Rule of Rescue" by Jonsen, who also recognized the difficulties it posed for resource allocation planning. Moreover, although the Rule of Rescue may be most compelling in the context of lifesaving interventions, it is also a factor whenever a patient is in need of treatment that may be costly but is clearly most effective for that individual. Our obligations will be: (1) to ensure that quality does take precedence over cost in the care of our patients; (2) to monitor outcomes and effectiveness research closely to be sure that the premises upon which it is based are valid; and (3) to continue to lead in practice guideline development and assume leadership in the evaluation of their effectiveness and impact on medical practice. There were times this year when I felt like the little Dutch boy with his finger in the hole in the dike. Confucius was wrong though. I have not been lonesome. I feel like I know most of the 5000 members of AISIGIE from the letters I have sent to you, the hundreds that I have received personally, and the copies of correspondence to HCFA and Congress that members have sent to me. I have shared your anger and frustration as well as your gratitude for the successes we have achieved. Your communications have helped to bolster my resolve to continue the battle. Now, Dr. John Bond, your assignment, should you choose to accept it, is to continue to lead the fight in all these spheres with your usual flare and determination. Thank you all for your support. Barbara B. Frank, MD Haverford, Pennsylvania
VOLUME 38, NO.5, 1992
From the Rostrum
Advanced endoscopic training: teaching us older dogs some new tricks The primary responsibility of the governing board of a professional medical society is, of course, to respond to the stated needs of its membership. Recognizing all of the highly successful current and recent A/S/G/E projects and programs, we must confess that one of the most frequently cited priorities of our members has not yet been successfully addressed-how can A/S/G/E members obtain hands-on training to perform endoscopic procedures which either were not taught during formal training, or were developed after graduation from formal training? A correlative of this question is how can members obtain hands-on training with an experienced teacher to improve their performance of basic endoscopic procedures they already perform? The A/S/G/E has been a leader among professional gastrointestinal societies in establishing standards for training and credentialing. The bottom line appropriately has been the greatest benefit for patients with digestive disorders. As these standards and guidelines have been promulgated, however, many conscientious and skilled endoscopists have been caught between the completion of their fellowship training and the rapid development of new, highly technical advances in our specialty. Our training standards rightfully declare that acquiring competence in new techniques, or major extensions of established procedures, requires not only didactic course instruction, but also hands-on training under the supervision of a skilled and experienced teacher. What we haven't yet solved, however, is the frequently asked question, "Okay, but where do I go to get such required training?" An informal query of training programs conducted by 631
Jack Vennes in 1982 first identified the demand for specialized postgraduate endoscopic training of practicing gastroenterologists. In 1983, under the direction of Barbara Frank, a comprehensive "manpower survey" of A/S/G/E members was conducted.! This survey identified the desire for advanced training of practicing endoscopists as the single highest priority of the membership. As stated in the survey report, "Almost 78% of respondents thought that the A/S/ G/E should emphasize advanced/refresher training for practitioners who wished to become competent in procedures not offered during their training period. This training should involve more than short courses; block-time or mini-residency training with hands-on experience is desired." The Postgraduate Education Committee, chaired by Jay Noble, was asked to explore the feasibility of setting up mini-sabbaticals in existing training programs which would provide the needed training. They conducted a survey of all gastroenterology programs which indicated that 74% believed that a retraining program of 1 to 4 months was reasonable. Of the 60 program directors who responded positively, most indicated an initial willingness to accept qualified A/S/G/E members for hands-on training. Spurred on by this favorable response, the committee promptly sent follow-up letters requesting actual commitments for this training. Disappointingly, only one center subsequently agreed to accept a trainee, and this program stipulated that candidates must be graduates of their own fellowship program who had been in practice less than 5 years. Reluctantly, the Governing Board agreed with the recommendation of the Postgraduate Education Committee not to pursue this issue further at that time. A long-range planning workshop in January 1990 once again emphasized the need to "establish programs for postgraduate hands-on training in endoscopic procedures for A/ S/G/E members."2 Our previous unsuccessful attempts to establish mini-residencies within existing academic programs were attributed to their limited clinical capacity which was already saturated by the training requirements of regular gastrointestinal fellows. At this point, a leader with imagination and foresight, James L. Borland, Jr. had an idea. If it is impractical to bring practitioner-students to an endoscopic teacher, why not arrange to have the teacher visit the student's practice to accomplish needed hands-on instruction. Furthermore, if many academic endoscopists are too busy teaching their own gastrointestinal fellows, let's also recruit teachers from the private practice community for this training. Several examples were identified where this approach has been employed successfully for a number of years. Intrigued by this concept, the Governing Board established the Ad Hoc Committee on Advanced Training (soon dubbed the Retread Committee) with Dr. Borland as chairman. After a year of intense productive work, and with the input from the Society's Standards of Practice Committee and the Committee on Training, a detailed plan was developed which was reviewed and approved by the board in May 1992. After a few final problems are worked out, we plan to formally launch this program in early 1993. The retraining program was named Guideline for Enhancement of Endoscopic Skills: A Program for A/S/G/E Members to Learn New, or Enhance Existing Endoscopic Skills. The program is a multi-step process designed to ensure a working knowledge of cognitive and technical as632
pects of a specific endoscopic procedure. The basic elements of the program include the following: 1. A review of pertinent literature and available audiovisual aids relevant to the procedure to be learned. 2. Attendance at an A/S/G/E approved didactic postgraduate course which contains material relevant to the procedure. 3. Arrangement with an A/S/G/E approved teacher who will organize and conduct supervised, hands-on training. 4. One or more visits by the student to the teacher's unit to become familiar with the specific methods of the procedure and review additional background material as necessary. 5. Successful completion of an established number of procedures under the direct supervision of the teacher; in most instances, the teacher will travel to the student's unit and conduct this hands-on instruction using patients in the student's medical facility. 6. Parts of this program may be deleted or abbreviated, when appropriate, for training in minor skills or for enhancement of existing skills. 7. Variations of this process, approved by both teacher and student are acceptable as long as they do not reduce the quality of the learning experience; for example, in some instances the entire hands-on instruction might be accomplished by having the student travel to the teacher's unit. Both students and teachers must be experienced endoscopists who are members of the A/S/G/E. Each applicant for training will be asked to document existing endoscopic skills and experience appropriate to the desired additional training. Using this information, a prospective teacher will estimate the number of cases likely to be required to attain competence in the procedure in question. In addition, prior to hands-on instruction all necessary arrangements must be completed regarding appropriate medical liability coverage, licensure, hospital privileges, patient care responsibility including management of complications and follow-up, availability of assistants and equipment, and reasonable remuneration for the teacher's time and effort. Teachers will be solicited through training directors, the Council of Regional Endoscopic Societies, and from a general mailing to the membership announcing the program. Appropriate criteria for prospective teachers include demonstrated skill and experience in the procedure to be taught and demonstrated interest and/or experience in teaching. Interested members will submit their credentials to the A/S/G/E Committee on Training, which will generate a list of approved teachers. The society will then serve mainly as a clearinghouse facilitating contact of member candidates desiring training with its cadre of approved teachers. It is important to stress that this advanced training program is not intended to provide formal certification of competence in a given procedure. The program is designed to facilitate and formalize a process whereby an individual with basic endoscopic skills may learn new skills or enhance existing skills in an effective educational environment, and obtain documentation of completion of a structured teaching program. Whereas the goal of the program is attainment of competence in a given procedure, the A/S/G/E does not guarantee that this objective will be satisfied in all cases. Once a mutually satisfactory arrangement has been established between teacher and student, the A/S/G/E will not GASTROINTESTINAL ENDOSCOPY
take an active role in the specific design or control of the individual teaching experience. The Society's Committee on Training will, however, monitor the program carefully to ensure general conformance with these guidelines, assess the level of participation, and evaluate the effectiveness of the training. Following recruitment of an adequate number of teachers, applications for member candidates interested in obtaining advanced training will be available from the A/S/G/E office. Applicants will be provided a copy of the program guideline, appropriate application forms, and a list of teachers in their area specifying the procedures each are prepared to teach. The last, and most essential ingredient which will ultimately determine the success or failure of this program, is the level of commitment of members of the A/S/G/E. Both teachers and students must be willing to enter into a good faith contract in sufficient numbers to make the effort worthwhile. Some creativity, flexibility, mutual trust, hard work, and an element of selflessness will be required if we're to make this experiment succeed. The common goal we all strive for is one of the main purposes of the A/S/G/E as stated in our constitution, "to establish and maintain the highest standards of practice for the diagnostic and therapeutic use of gastrointestinal endoscopic methods" and "to assist all those involved with health care as it relates to gastrointestinal endoscopy."3
REFERENCES 1. Frank BB. The 1983 A/S/G/E membership survey. Gastrointest Endosc 1984;30:206-12. 2. Borland JL Jr. The next 50. Gastrointest Endosc 1990;36: 416-7. 3. American Society for Gastrointestinal Endoscopy Constitution, A/S/G/E Membership Roster, Constitution and By-Laws, 131 Elm Street, Manchester, MA, June 1991.
Letters to the Ed itor Viral esophagitis: the endoscopic appearance To the Editor: I enjoyed reading the excellent article by McBane and Gross describing the clinical syndrome, endoscopic findings, and diagnosis of herpes virus (HSV) esophagitis in 23 patients.! As pointed out in the Discussion, the authors found a "typical" endoscopic appearance in 4 of 23 cases. However, they have not described the typical endoscopic findings of their 4 patients and how they differed from 16 patients with endoscopic findings "suggestive" of HSV infection. I believe, it is most likely due to the retrospective nature of their study. The typical endoscopic appearance in HSV esophagitis is the presence of discrete vesicles. In the absence of discrete vesicles, there is no typical endoscopic appearance, and apparently only one of their four patients had endoscopically typical HSV esophagitis. We have previously described five immunocompromised patients with viral esophVOLUME 38, NO.5, 1992
agitis. 2 All patients had ulcers and four patients had vesicles at endoscopy. McDonald et al. 3 have found a high incidence of viral esophagitis in 46 patients after bone marrow transplantation with equal distribution of HSV and cytomegalovirus esophagitis. Only one of their patients with HSV infection had discrete vesicles noted during endoscopic examination. They described three stages of HSV esophagitis: an early stage with vesicles, an intermediate stage with erosions and ulcers, and a late stage with mucosal necrosis. 3, 4 I share their opinion that the finding of vesicles should strongly suggest HSV infection, since neither cytomegalovirus nor fungal organisms appear to cause vesicular lesions. I would like to make few additional comments: 1. Vesicles probably are the only typical endoscopic findings of HSV esophagitis. During this early vesicular stage, biopsies and cultures may be negative for HSV as shown in our study.2 McBane and Gross! found positive culture or biopsies in all patients. I suspect this to be due to the late stage of infection. 2. It is likely that the vesicles were seen in only a fraction of patients reported by McBane and Gross! and by McDonald et al. 3 because endoscopy was performed after longstanding symptoms. In our study,2 the mean duration of odynophagia was 6.8 days (range, 4 to 10 days). The authors do not mention the duration of symptoms in their patient population. 3. Early endoscopy plays an important role in immunocompromised patients with esophageal symptoms, especially odynophagia. As shown in our study,2 if vesicles are found at early endoscopy, the diagnosis of viral esophagitis may be presumed and treatment with acyclovir may be initiated immediately even before biopsy and culture results are available. All of our patients had rapid improvement of odynophagia within 1 to 5 days and complete resolution within 3 to 7 days with acyclovir therapy. It would be interesting to know the results of acyclovir treatment in the patients reported by McBane and Gross.! Shailesh C. Kadakia, MD Department of Medicine Gastroenterology Service Brooke Army Medical Center San Antonio, Texas
REFERENCES 1. McBane RD, Gross JB. Herpes esophagitis: clinical syndrome, endoscopic appearance, and diagnosis in 23 patients. Gastrointest Endosc 1991;37:600-3. 2. Kadakia SC, Oliver GA, Peura DA. Acyclovir in endoscopically presumed viral esophagitis. Gastrointest Endosc 1987;33:33-5. 3. McDonald GB, Sharma P, Hackman RC, Meyers JD, Thomas ED. Esophageal infection in immunosuppressed patients after bone marrow transplantation. Gastroenterology 1985;88: 1111-7. 4. McDonald GB. Esophageal disease caused by infection, systemic illness, and trauma. In: Sleisenger MH, Fordtran JS, eds. Gastrointestinal disease. Philadelphia: WB Saunders, 1989:640-56.
The opinions and assertions contained herein are the private views of the authors and are not to be construed as reflecting the views of the Department of the Army or the Department of Defense.