GASTROENTEROLOGY
1992;103:1127-1132
.,'
AMERICAN
GASTROENTEROLOGICAL
ASSOCIATION
AGA Governing Board Policy Statement on Training and Education he President of the American Gastroenterological Association, Sidney Cohen, and the Governing Board met to develop a long-range agenda for the Training and Education Committee. The three areas identified as subjects for discussion were (a) recertification, (b) fellowship training, and(c) new technologies in education. Several experts were asked to speak as consultants in each of the areas, and with their advice, the following policies have been established.
T
Recertification The current description of the recertification process is based on the guidelines set by the American Board of Internal Medicine (ABIM) in their publication “Recertification: Overview of the New ABIM Program.“’ Certificates in critical care medicine (1982) and geriatric medicine (1988) have been time-limited since their inception. While diplomates certified before 1990 will not jeopardize their status if they do not seek recertification, diplomates with time-limited certificates must be successful in recertification to maintain their certification status in internal medicine, its subspecialties, or added qualifications. Those diplomates certified in or after 1990 who do not seek recertification or who are unsuccessful in the recertification process (as defined below) will no longer be listed as board certified when their time-limited certificates lapse. Entry into the recertification process can occur at any time after the initial certification or the last recertification. However, the process of recertification must be completed within 10 years; candidates who fail the examination three times will lose their eligibility for recertification. Recertification involves three distinct phases. The first phase is a clinical competence assessment. ABIM will require peer assessment of clinical performance at the local level and proof of an unchallenged, unrestricted license to practice medicine. The ABIM plans to use local privileging and credentialing processes within hospitals and other health care organizations to verify the clinical competence of a candidate. Specifically, the Board will require verification of satisfactory clinical skills and judgment, provision of quality medical care, humanistic qualities, professional attitudes and behavior, and
moral and ethical behavior in the clinical setting. The methods and standards to be applied to this phase of recertification are under development by the Board. The second phase requires candidates to successfully complete a self-evaluation, which is planned as a series of short tests arranged in a modular, self-administered, open-book format. Candidates will select modules from a menu prepared by the Board. The questions are designed to assess the candidate’s strengths and weaknesses in the areas of medical knowledge, synthesis, and clinical judgment. The self-evaluation component can be taken over several years and is not linked directly to any specific education vehicle. No continuing medical education credits will be given and no syllabus is provided. Candidates will, however, receive feedback on their performance. The candidate will only be allowed to enter the third and final phase of the process after verification of clinical competence and the establishment of unrestricted licensure and completion of the self-evaluation process. The third component is a final examination, which will be of modular design to ensure flexibility and provide multiple content areas that relate to clinical practice. The examination will be scored using an absolute criterion-referenced standard. Although the complete program will not be implemented until 1995, an interim process has been initiated for those wishing to volunteer for earlier recertification. This process will require unrestricted licensure, satisfactory local credentialing, and the successful passing of an examination. The ABIM states that recertification is dedicated to promoting clinical excellence within the specialty of internal medicine. Its goals are to (a) improve the quality of patient care, (b) set high standards of clinical competence within internal medicine subspecialties and areas of added qualifications, and (c) foster the continuing scholarship required for professional excellence over a lifetime of practice. Although the AGA Governing Board obviously endorses these goals, it has concerns as to whether the process as outlined will indeed achieve the stated objectives. The Governing Board of the AGA acknowledges the value of the process and realizes that
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public perception of and confidence in the medical community may be enhanced by these measures. However, the AGA has major concerns about the process as outlined by the ABIM and further amplified in the recent position paper published in the Annals of Internal Medicine.’ These concerns apply, in particular, to the process of recertification as it relates to subspecialties, and the AGA Governing Board believes that the extensive experience that resides within our association could be utilized by the ABIM during the design of this process. The Governing Board believes the AGA’s response to recertification should be multifaceted. The AGA needs to reevaluate the educational opportunities it provides to its membership to ensure that they are optimal for those members undergoing recertification. In particular, the AGA will introduce or modify existing teaching programs to make them more useful to members involved in the recertification process. The Training and Education Committee will develop a core curriculum for the AGA fall course to make it a useful learning vehicle for those undergoing recertification and for those taking their subspecialty boards for the first time. Novel teaching techniques such as Lifetime television, interactive patient management courses, and videocassettes are just some of the new teaching vehicles the AGA has under consideration or evaluation. The AGA, together with other gastroenterology societies, is working in an advisory capacity on an American College of Physicians’ project that will result in the publication of a Gastroenterology Subspecialty Medical Knowledge Self-Assessment Program (MKSAP). The release of the final program is anticipated in early 1993, well in advance of the first compulsory recertification examination. One of the components of the recertification process that gives the AGA greatest concern is the issue of peer assessment at the local level. The AGA believes that this is currently a difficult and subjective process with both real and potential legal, moral, political, and financial implications to the association’s members. The AGA also believes the potential misuse of local peer assessment as a tool to limit the practice of another physician is real. The AGA would recommend that recertification be limited to an objective and measurable test of knowledge. The AGA holds that decisions that affect the livelihood of any professional should not be based on “opinion” but rather on measurable indices. Because the AGA sees the potential for abuse in this component of the recertification process, such an important issue should not be introduced without a well-defined appeal process for the applicant who is refused recertification based on the local peer-review process. The AGA is also concerned that recertification may at
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some future date be linked to such delicate issues as credentialing, reimbursement, hospital privileges, etc. The Governing Board has asked the Patient Care Committee to work with the Training and Education Committee to develop objective measures of clinical competence that could also serve as guidelines for hospital credentialing in gastroenterology. It is also hoped that the ABIM will use the available expertise within the AGA to develop this important component of this difficult process. The AGA also feels that it should not be necessary for the practicing gastroenterologist to take two examinations, one to be recertified in internal medicine and another in gastroenterology. Under the proposal initially outlined by the ABIM, the candidate must take both examinations if he or she is to be dual-certified. The candidate will get some credit for any overlapping modules in the self-evaluation program or examination. Candidates can be recertified in the subspecialty without necessarily being recertified in internal medicine under the rules proposed by the ABIM. However, candidates taking this approach will no longer be deemed diplomates of internal medicine when their internal medicine certificate expires. The consequences of such a decision to the future practice of a gastroenterologist remain unclear. The AGA will ask the ABIM to consider introducing additional general medicine modules to the self-assessment examination and to the final examination itself so that the candidate can be recertified in internal medicine and gastroenterology after taking one examination. Alternatively, the AGA would propose that the subspecialist be allowed to obtain recertification in gastroenterology with internal medicine added as an “additional qualification” and thus not lose the internal medicine certification. This is not to say that the practice of internal medicine is not of importance to the practicing gastroenterologist. This recommendation takes into consideration the fact that a significant number of our members spend the majority of their time in the practice of gastroenterology, and internal medicine may only form a small component of their practice or only be involved as such general issues relate to gastroenterology. The AGA would not want to preclude gastroenterologists with large internal medicine components to their practices from having the opportunity to take the recertification examinations in both internal medicine and gastroenterology. Rather, we see this choice as a reflection of the variation in physicians’ practice habits. The AGA believes this approach is quite compatible with the statement made by the ABIM task force on recertification that “the recertification process would need to be flexible enough to meet the needs of a diverse population of physicians whose practices differ in response to individual de-
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October 1992
sires, skills and local needs.” Given these concerns, the AGA will petition the ABIM to seek an advisory role in the design of an alternative path that would allow dual certification in internal medicine and gastroenterology. Although the ABIM is addressing these issues, local peer review remains a major concern. It is not clear who will perform the review or who will fill in the proposed ABIM clinical competence evaluation form. The AGA sees the potential for abuse within this system, particularly if physicians are asked to evaluate other physicians with whom they are in direct competition. The process of evaluation suggested by the ABIM has close parallels to the current evaluation used by training directors when they evaluate fellows before their sitting the boards. In the AGA’s opinion, these evaluation processes are not analogous given the differing natural biases and goals of the evaluators. The ABIM has also included local hospital privileging and credentialing as part of the peer-review process. However, the AGA feels strongly that these processes are not standardized and most certainly not uniformly handled from institution to institution. As such, the Governing Board has charged the Patient Care Committee to work with the Training and Education Committee to develop guidelines for credentialing in gastroenterology* The AGA accepts that the ABIM has a well-developed process of developing the examination questions and does not seek to influence the selection of examination questions by the Gastroenterology Subspecialty Board. It merely encourages the ABIM to use the extensive expertise available within the ranks of the AGA in developing and refining the recertification process as it relates to the practice of gastroenterology. The AGA has opened a dialogue with the ABIM over these concerns and is encouraged by the receptive response of the ABIM to these issues. Fellowship
Training
Some dramatic changes have occurred in fellowship training over the last two decades. First, gastroenterology training in the 1960s and 1970s had a significantly smaller clinical service component because of the very limited use of endoscopy. Second, although salaries of trainees were low 20 years ago, this was offset by the fact that debts from college and medical school were disproportionately smaller. Third, the training of fellows for careers in clinical care and basic science research was not as divergent or distinct as it is now. Last, 20 years ago there was a steady stream of individuals well trained in basic science research methods who were entering gastroenterology fellowship programs from the National In-
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stitutes of Health (NIH); this source of well-trained laboratory-based fellows has all but dried up. In contrast, in the 1990s there are numerous factors that make it difficult for trainees to enter academic careers in gastroenterology. Trainees are now entering gastroenterology training programs with huge debts incurred while in medical school; according to figures released by the American Association of Medical Colleges, the estimated median debt for medical school graduates is $45,000. The large differential between salaries of gastroenterologists in practice vs. basic scientists in research exacerbates the problems of debt payment for those fellows interested in research careers. Because repayment of these debts can no longer be postponed beyond fellowship, junior faculty are encumbered with major financial obligations that they often cannot meet with their starting academic salaries. Furthermore, the uncertainties of future salary support, which is often tied to grant support, is a further deterrent to many fellows entering or staying in academics. The trainee’s anxieties and concerns about career choices are further exacerbated by established researchers who have lost their funding and freely vocalize their frustrations with the system. The AGA must consider increasing its support of the training and career development of young academic gastroenterologists. In most cases, at least 5 years of basic science research training is required to attain the status of independent investigator. Funding for young people in this critical interim period should be a major concern and a topic of discussion and action by the Training and Education Committee. The Training and Education Committee suggests that to alleviate the difficulties that many gastroenterology trainees encounter in entering academics, specific programs should be designed to ease the adverse effects of current levels of trainee debt; examples include the encouragement of loan repayment or salary supplementation plans under the auspices of the universities themselves, the NIH, or groups such as the AGA. The Training and Education Committee should also consider sponsoring publications aimed specifically at gastroenterology trainees describing potential funding sources or containing general advice on career development. Courses for training directors should be organized on such issues as management of fellowship programs, junior faculty career development, financial issues pertinent to gastroenterology trainees, etc. The AGA should also open a dialogue and explore the development of joint programs in these areas with other gastroenterology societies. One major issue related to clinical training is whether the length of gastroenterology fellowship
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training should be extended from 2 years to 3 years. There is a general feeling that 2 years of training is inadequate and that a large number of the leading programs have already initiated 3-year fellowship programs for all trainees. The ABIM would hesitate to mandate 3 years of training for gastroenterology board eligibility but would be more likely to respond to a demonstration of the need based on a consensus of the major gastroenterology organizations and the approval of the directors of the gastroenterology training programs. A number of other issues are obviously related to the question of length of training but stand on their own in requiring further consideration, evaluation, and discussion. The time is appropriate to consider formalized third-tier training in specialized disciplines such as hepatology, nutrition, and therapeutic endoscopy. This could lead to the AGA petitioning the ABIM to recognize advanced training in hepatology and therapeutic endoscopy as an “added qualification” attached to the current gastroenterology subspecialty boards. The concept of separate training requirements and board examination in hepatology totally divorced from gastroenterology is strongly opposed by the Governing Board. Such a move could have significant implications for AGA members who currently handle gastroenterology and hepatology cases in their practice. For example, a separate board in hepatology might eventually preclude gastroenterologists without boards in hepatology from seeing or being reimbursed for consultations on patients with routine liver diseases. However, given the dramatic change in the practice of hepatology engendered by the introduction of liver transplantation, the AGA sees the need for additional training for physicians wishing to take care of complex cases of severe liver disease. It would seem appropriate to approach specialized training in therapeutic endoscopy or nutritional support in the same manner. If the AGA did support the 3-year fellowship concept, the Training and Education Committee would need to consider the effect of this change on personnel. For example, if the present number of positions offered per year were reduced to keep overall numbers of fellows in training constant, it would theoretically result in a reduction in the number of fellows completing training per year. It may also be necessary to consider a reduction in the requirement for internal medicine training (from 3 years to 2 years) for individuals entering a 3-year subspecialty training program. Other concerns relate to how program directors would fund the third year of training and how the concept of third-tier training would fit if a 3-year fellowship program were mandated for all fellows.
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Another area of concern is how to determine standards for procedural training, including the number of procedures required before a trainee can be said to be competent. Furthermore, a delineation of the types of procedures required of all gastroenterology trainees needs to be made and, by inference, a delineation of procedures that require specialized training over and above that given in a general gastroenterology fellowship. The Governing Board of the AGA thought this issue would be most appropriately discussed by all four gastroenterology societies, who would then issue a joint statement on agreed standards. There is a general consensus that the AGA should be involved in developing guidelines to be used by training directors when they define adequate training and judge procedural competence of fellows. The issues of procedure credentialing and privileges and the training of established gastroenterologists in new procedures has been raised. It is the recommendation of the Governing Board that these two issues continue to be the responsibility of the Patient Care Committee. The Governing Board has also discussed whether some form of research should be mandated of all trainees and whether incorporation of training in clinical research methods, e.g., biostatistics, epidemiology, study design, and outcomes assessment, should become a component of core training for all fellows. Whatever their career choice, this option would allow graduates to critically review new publications and assess the relevance of new findings to the practice of gastroenterology. The Training and Education Committee is working on a policy statement concerning fellowship training. In the area of fellowship matches, the Governing Board states that subspecialty matches in medicine are still viable in gastroenterology, cardiology, and pulmonary medicine, subspecialties that were in greatest demand by the applicant pool. These subspecialties differ from other nonprocedural subspecialties in that there are usually more applicants than positions available. Despite this fact, not all gastroenterology programs are in the match, and there is a perception that not all programs that are in the match are playing by the rules. As a result, the match is in jeopardy. Most Governing Board members favor preservation of the match and a consideration of ways to close loopholes and endorse compliance. Proposals vary from strong endorsement of the match by the AGA to sanctions against nonparticipants. The latter might take the form of a notation of nonparticipation in the AGA program listing in the August issues of GASTROENTEROLOGY. The Governing Board has set priorities for the
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Training and Education Committee related to both research and clinical training. In the area of research training, it is the AGA’s opinion that first a dialogue should be initiated that would lead to the development of a training program directors’ meeting under the auspices of all four gastroenterology societies, i.e., the AGA, the American Society for Gastrointestinal Endoscopy, the American College of Gastroenterology, and the American Association for the Study of Liver Diseases, Second, guidelines should be published that would advise gastroenterology fellows on academic careers and sources of funding, and third, the Training and Education Committee should explore and evaluate loan-repayment and salary-supplementation plans. In the area of clinical training, it was decided that the Training and Education Committee should present a policy paper to the Governing Board that describes the design and format of the ideal fellowship program. Factors that need evaluation include the length of fellowship training; the development of standards for training in procedures, including the types of procedures required for all trainees and the numbers of procedures before competence can be considered acceptable; third-tier training and “added” qualifications; the concept of training in hepatology outside a conventional gastroenterology fellowship; the development of a core curriculum; and the development of tracts built around the core component that will prepare trainees for careers in clinical and basic research, therapeutic endoscopy, nutrition, hepatology, etc. New Technologies
in Education
Developing technology has the potential to revolutionize presentations given at AGA-sponsored scientific meetings and courses. Computer graphics have greatly increased the range of options for slide presentations while decreasing cost and production time. The technology is currently available to produce hard copies of slides at the time of a presentation that would be immediately available for distribution to the audience. New high-definition projection devices that incorporate zoom features allow speakers to highlight one component of a slide while computer-based multimedia presentations allow integration of slides and video simultaneously. Computer-generated, digitally enhanced three-dimensional imaging, coupled with high-definition television, allows virtual-reality presentations that are ideal teaching vehicles. Current technology already allows for sophisticated, interactive, and instantaneous communication between the audience and the speaker. For example, the use of computerbased touch pads will allow audience participation
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during presentation of patient-management problems. Specific issues relate to the application of these new communication technologies by the AGA. The results of a recent survey of 2000 AGA members in which they were asked to delineate learning needs and the future teaching modalities they would like to see the AGA introduce can now be summarized. The majority of members surveyed thought that AGA slide lecture series, such as those produced by the Undergraduate Teaching Project and Clinical Teaching Project, were most useful to them. There was general interest in the AGA developing more self-learning packages, including single-topic video tapes; the most desired topics for future tapes included Crohn’s disease, nutrition, and motor disorders of the gastrointestinal tract. However, it was important that the cost of such tapes be kept below $50 for a single educational videotape and that any home teaching program developed by the AGA be coupled to continuing medical education credits. The membership felt that private industry could sponsor such educational endeavors but that the tapes should not be considered advertising vehicles for industry. Production can be costly, and the whole process can be very time-consuming for those individuals involved in producing such tapes. However, successful educational programs using the video format would attract industry and foundation support in a form that would be acceptable to the membership, e.g., an educational grant without conditions. Although advertising on tapes would not be acceptable, an acknowledgement of support accompanied by the sponsoring company logo would be. Purchase of such educational tapes by industry with free distribution by the purchaser to AGA members would be another mechanism to reduce the financial burden on members. The Governing Board felt that serious consideration should be given to television broadcasting as one vehicle for educating the membership. Given the expense of such an endeavor, it is felt that sponsorship (under conditions similar to those described above) would be required to help offset the costs. Any new educational modality chosen by the AGA would need to use high-quality production techniques. Several production options are possible. For example, the AGA could prepare television programs and tapes using the expertise currently available within the society itself or it could develop these new programs as coventures with another society or sponsor. The use of a university-based biomedical media department might be a viable option if the department had prior experience with similar projects. However, in all likelihood use of a professional
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company would be necessary to ensure the success of these ventures. During the planning stages, further consideration needs to be given to the audience, including the targeting of nonmembers or the international market. A two-tier pricing system should then be introduced in which members would be charged less than nonmembers. With regard to video technology, the AGA is in favor of using this means to educate both physicians and patients. Such ventures would be purely informational or a component of a self-instruction program. One potential for the AGA would be the production of a video journal club that would include six articles per issue either for distribution through a CD-ROM or a video disc. Alternatively, such a project could be produced as a television program on a health cable network. Other possibilities include the production of videotapes of AGA courses or Digestive Disease Week (DDW) presentations that would be made available to members. Patient education could be achieved in a number of ways, e.g., patient-oriented books or video tape programs produced under the auspices of the AGA. Any topic chosen for video production should be suited to production in a visual format. Alternatives would be the production of educational programs through cable television or AGA support of a patientrelated information hotline. Although it is essential that the AGA control the content and the speakers for such programs, outside sponsorship could be needed to defray the substantial costs of such programs. Given the costs of these endeavors, it would be important to assess the desires and interests of the members to ensure that their educational needs were met. While the Training and Education Committee has responsibility for physician education, the Governing Board feels that patient education should remain the primary responsibility of the Patient Care Committee. Increased communication between these two committees in the form of joint working subcommittees will be needed. The Training and Education Committee will explore how these new technologies could best be adapted for DDW and the postgraduate courses. Possibilities include video posters and interactive audience participation using computer tables for the courses, but their advantages and disadvantages will have to be assessed. The Training and Education Committee, in consultation with others, will prepare
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a policy statement and coordinate the application the new technologies to specific AGA programs.
of
Conclusion The dramatic changes in health care in the United States, coupled with the technological advances made in the field of gastroenterology, force a reevaluation of our current methods of training and education of gastroenterologists. The impact of recertification on the educational needs of our membership will be significant as are the ramifications of such issues as “local peer review,” separate boards in hepatology, third-tier certification, credentialing, etc. The Governing Board has charged the Training and Education Committee to become more proactive in issues that relate to the training of fellows and the education of practicing gastroenterologists. The large number of issues that the Training and Education Committee has been asked to address will necessitate a restructuring of the Committee itself. The Training and Education Committee has been split into two working subcommittees, one to deal with issues that relate to training (Subcommittee Chairman, Dr. James Grendell) and the other issues that relate to education (Subcommittee Chairman, Dr. Richard McDermott). This new structure will enable the Training and Education Committee to develop policy statements that will be presented to the Governing Board for their approval and that will better serve members of the AGA. IAN L. TAYLOR, M.D., PH.D. Chairman, Training and Education
Committee
JAMES GRENDELL, M.D. Chairman, Training Subcommittee SIDNEY COHEN, M.D. President (1991)
References 1. Recertification: Overview of the new ABIM Program. American Board of Internal Medicine Publication 1990. 2. Glassock RJ, Benson JA, Copeland RB, Godwin HA, Johanson WG, Point W, Pupp RL, Scherr L, Stein JH, Taunton D. Timelimited certification and recertification: The program of the American Board of Internal Medicine. Ann Intern Med 1991;114:59-62.
Address requests for reprints to: Ian L. Taylor, M.D., Ph.D., Department of Gastroenterology, Duke University Medical Center, P.O. Box 3913, Durham, North Carolina 27710. 0 1992 by the American Gastroenterological Association
1992;103:1127-1132
.,'
AMERICAN
GASTROENTEROLOGICAL
ASSOCIATION
AGA Governing Board Policy Statement on Training and Education he President of the American Gastroenterological Association, Sidney Cohen, and the Governing Board met to develop a long-range agenda for the Training and Education Committee. The three areas identified as subjects for discussion were (a) recertification, (b) fellowship training, and(c) new technologies in education. Several experts were asked to speak as consultants in each of the areas, and with their advice, the following policies have been established.
T
Recertification The current description of the recertification process is based on the guidelines set by the American Board of Internal Medicine (ABIM) in their publication “Recertification: Overview of the New ABIM Program.“’ Certificates in critical care medicine (1982) and geriatric medicine (1988) have been time-limited since their inception. While diplomates certified before 1990 will not jeopardize their status if they do not seek recertification, diplomates with time-limited certificates must be successful in recertification to maintain their certification status in internal medicine, its subspecialties, or added qualifications. Those diplomates certified in or after 1990 who do not seek recertification or who are unsuccessful in the recertification process (as defined below) will no longer be listed as board certified when their time-limited certificates lapse. Entry into the recertification process can occur at any time after the initial certification or the last recertification. However, the process of recertification must be completed within 10 years; candidates who fail the examination three times will lose their eligibility for recertification. Recertification involves three distinct phases. The first phase is a clinical competence assessment. ABIM will require peer assessment of clinical performance at the local level and proof of an unchallenged, unrestricted license to practice medicine. The ABIM plans to use local privileging and credentialing processes within hospitals and other health care organizations to verify the clinical competence of a candidate. Specifically, the Board will require verification of satisfactory clinical skills and judgment, provision of quality medical care, humanistic qualities, professional attitudes and behavior, and
moral and ethical behavior in the clinical setting. The methods and standards to be applied to this phase of recertification are under development by the Board. The second phase requires candidates to successfully complete a self-evaluation, which is planned as a series of short tests arranged in a modular, self-administered, open-book format. Candidates will select modules from a menu prepared by the Board. The questions are designed to assess the candidate’s strengths and weaknesses in the areas of medical knowledge, synthesis, and clinical judgment. The self-evaluation component can be taken over several years and is not linked directly to any specific education vehicle. No continuing medical education credits will be given and no syllabus is provided. Candidates will, however, receive feedback on their performance. The candidate will only be allowed to enter the third and final phase of the process after verification of clinical competence and the establishment of unrestricted licensure and completion of the self-evaluation process. The third component is a final examination, which will be of modular design to ensure flexibility and provide multiple content areas that relate to clinical practice. The examination will be scored using an absolute criterion-referenced standard. Although the complete program will not be implemented until 1995, an interim process has been initiated for those wishing to volunteer for earlier recertification. This process will require unrestricted licensure, satisfactory local credentialing, and the successful passing of an examination. The ABIM states that recertification is dedicated to promoting clinical excellence within the specialty of internal medicine. Its goals are to (a) improve the quality of patient care, (b) set high standards of clinical competence within internal medicine subspecialties and areas of added qualifications, and (c) foster the continuing scholarship required for professional excellence over a lifetime of practice. Although the AGA Governing Board obviously endorses these goals, it has concerns as to whether the process as outlined will indeed achieve the stated objectives. The Governing Board of the AGA acknowledges the value of the process and realizes that
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public perception of and confidence in the medical community may be enhanced by these measures. However, the AGA has major concerns about the process as outlined by the ABIM and further amplified in the recent position paper published in the Annals of Internal Medicine.’ These concerns apply, in particular, to the process of recertification as it relates to subspecialties, and the AGA Governing Board believes that the extensive experience that resides within our association could be utilized by the ABIM during the design of this process. The Governing Board believes the AGA’s response to recertification should be multifaceted. The AGA needs to reevaluate the educational opportunities it provides to its membership to ensure that they are optimal for those members undergoing recertification. In particular, the AGA will introduce or modify existing teaching programs to make them more useful to members involved in the recertification process. The Training and Education Committee will develop a core curriculum for the AGA fall course to make it a useful learning vehicle for those undergoing recertification and for those taking their subspecialty boards for the first time. Novel teaching techniques such as Lifetime television, interactive patient management courses, and videocassettes are just some of the new teaching vehicles the AGA has under consideration or evaluation. The AGA, together with other gastroenterology societies, is working in an advisory capacity on an American College of Physicians’ project that will result in the publication of a Gastroenterology Subspecialty Medical Knowledge Self-Assessment Program (MKSAP). The release of the final program is anticipated in early 1993, well in advance of the first compulsory recertification examination. One of the components of the recertification process that gives the AGA greatest concern is the issue of peer assessment at the local level. The AGA believes that this is currently a difficult and subjective process with both real and potential legal, moral, political, and financial implications to the association’s members. The AGA also believes the potential misuse of local peer assessment as a tool to limit the practice of another physician is real. The AGA would recommend that recertification be limited to an objective and measurable test of knowledge. The AGA holds that decisions that affect the livelihood of any professional should not be based on “opinion” but rather on measurable indices. Because the AGA sees the potential for abuse in this component of the recertification process, such an important issue should not be introduced without a well-defined appeal process for the applicant who is refused recertification based on the local peer-review process. The AGA is also concerned that recertification may at
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some future date be linked to such delicate issues as credentialing, reimbursement, hospital privileges, etc. The Governing Board has asked the Patient Care Committee to work with the Training and Education Committee to develop objective measures of clinical competence that could also serve as guidelines for hospital credentialing in gastroenterology. It is also hoped that the ABIM will use the available expertise within the AGA to develop this important component of this difficult process. The AGA also feels that it should not be necessary for the practicing gastroenterologist to take two examinations, one to be recertified in internal medicine and another in gastroenterology. Under the proposal initially outlined by the ABIM, the candidate must take both examinations if he or she is to be dual-certified. The candidate will get some credit for any overlapping modules in the self-evaluation program or examination. Candidates can be recertified in the subspecialty without necessarily being recertified in internal medicine under the rules proposed by the ABIM. However, candidates taking this approach will no longer be deemed diplomates of internal medicine when their internal medicine certificate expires. The consequences of such a decision to the future practice of a gastroenterologist remain unclear. The AGA will ask the ABIM to consider introducing additional general medicine modules to the self-assessment examination and to the final examination itself so that the candidate can be recertified in internal medicine and gastroenterology after taking one examination. Alternatively, the AGA would propose that the subspecialist be allowed to obtain recertification in gastroenterology with internal medicine added as an “additional qualification” and thus not lose the internal medicine certification. This is not to say that the practice of internal medicine is not of importance to the practicing gastroenterologist. This recommendation takes into consideration the fact that a significant number of our members spend the majority of their time in the practice of gastroenterology, and internal medicine may only form a small component of their practice or only be involved as such general issues relate to gastroenterology. The AGA would not want to preclude gastroenterologists with large internal medicine components to their practices from having the opportunity to take the recertification examinations in both internal medicine and gastroenterology. Rather, we see this choice as a reflection of the variation in physicians’ practice habits. The AGA believes this approach is quite compatible with the statement made by the ABIM task force on recertification that “the recertification process would need to be flexible enough to meet the needs of a diverse population of physicians whose practices differ in response to individual de-
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sires, skills and local needs.” Given these concerns, the AGA will petition the ABIM to seek an advisory role in the design of an alternative path that would allow dual certification in internal medicine and gastroenterology. Although the ABIM is addressing these issues, local peer review remains a major concern. It is not clear who will perform the review or who will fill in the proposed ABIM clinical competence evaluation form. The AGA sees the potential for abuse within this system, particularly if physicians are asked to evaluate other physicians with whom they are in direct competition. The process of evaluation suggested by the ABIM has close parallels to the current evaluation used by training directors when they evaluate fellows before their sitting the boards. In the AGA’s opinion, these evaluation processes are not analogous given the differing natural biases and goals of the evaluators. The ABIM has also included local hospital privileging and credentialing as part of the peer-review process. However, the AGA feels strongly that these processes are not standardized and most certainly not uniformly handled from institution to institution. As such, the Governing Board has charged the Patient Care Committee to work with the Training and Education Committee to develop guidelines for credentialing in gastroenterology* The AGA accepts that the ABIM has a well-developed process of developing the examination questions and does not seek to influence the selection of examination questions by the Gastroenterology Subspecialty Board. It merely encourages the ABIM to use the extensive expertise available within the ranks of the AGA in developing and refining the recertification process as it relates to the practice of gastroenterology. The AGA has opened a dialogue with the ABIM over these concerns and is encouraged by the receptive response of the ABIM to these issues. Fellowship
Training
Some dramatic changes have occurred in fellowship training over the last two decades. First, gastroenterology training in the 1960s and 1970s had a significantly smaller clinical service component because of the very limited use of endoscopy. Second, although salaries of trainees were low 20 years ago, this was offset by the fact that debts from college and medical school were disproportionately smaller. Third, the training of fellows for careers in clinical care and basic science research was not as divergent or distinct as it is now. Last, 20 years ago there was a steady stream of individuals well trained in basic science research methods who were entering gastroenterology fellowship programs from the National In-
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stitutes of Health (NIH); this source of well-trained laboratory-based fellows has all but dried up. In contrast, in the 1990s there are numerous factors that make it difficult for trainees to enter academic careers in gastroenterology. Trainees are now entering gastroenterology training programs with huge debts incurred while in medical school; according to figures released by the American Association of Medical Colleges, the estimated median debt for medical school graduates is $45,000. The large differential between salaries of gastroenterologists in practice vs. basic scientists in research exacerbates the problems of debt payment for those fellows interested in research careers. Because repayment of these debts can no longer be postponed beyond fellowship, junior faculty are encumbered with major financial obligations that they often cannot meet with their starting academic salaries. Furthermore, the uncertainties of future salary support, which is often tied to grant support, is a further deterrent to many fellows entering or staying in academics. The trainee’s anxieties and concerns about career choices are further exacerbated by established researchers who have lost their funding and freely vocalize their frustrations with the system. The AGA must consider increasing its support of the training and career development of young academic gastroenterologists. In most cases, at least 5 years of basic science research training is required to attain the status of independent investigator. Funding for young people in this critical interim period should be a major concern and a topic of discussion and action by the Training and Education Committee. The Training and Education Committee suggests that to alleviate the difficulties that many gastroenterology trainees encounter in entering academics, specific programs should be designed to ease the adverse effects of current levels of trainee debt; examples include the encouragement of loan repayment or salary supplementation plans under the auspices of the universities themselves, the NIH, or groups such as the AGA. The Training and Education Committee should also consider sponsoring publications aimed specifically at gastroenterology trainees describing potential funding sources or containing general advice on career development. Courses for training directors should be organized on such issues as management of fellowship programs, junior faculty career development, financial issues pertinent to gastroenterology trainees, etc. The AGA should also open a dialogue and explore the development of joint programs in these areas with other gastroenterology societies. One major issue related to clinical training is whether the length of gastroenterology fellowship
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training should be extended from 2 years to 3 years. There is a general feeling that 2 years of training is inadequate and that a large number of the leading programs have already initiated 3-year fellowship programs for all trainees. The ABIM would hesitate to mandate 3 years of training for gastroenterology board eligibility but would be more likely to respond to a demonstration of the need based on a consensus of the major gastroenterology organizations and the approval of the directors of the gastroenterology training programs. A number of other issues are obviously related to the question of length of training but stand on their own in requiring further consideration, evaluation, and discussion. The time is appropriate to consider formalized third-tier training in specialized disciplines such as hepatology, nutrition, and therapeutic endoscopy. This could lead to the AGA petitioning the ABIM to recognize advanced training in hepatology and therapeutic endoscopy as an “added qualification” attached to the current gastroenterology subspecialty boards. The concept of separate training requirements and board examination in hepatology totally divorced from gastroenterology is strongly opposed by the Governing Board. Such a move could have significant implications for AGA members who currently handle gastroenterology and hepatology cases in their practice. For example, a separate board in hepatology might eventually preclude gastroenterologists without boards in hepatology from seeing or being reimbursed for consultations on patients with routine liver diseases. However, given the dramatic change in the practice of hepatology engendered by the introduction of liver transplantation, the AGA sees the need for additional training for physicians wishing to take care of complex cases of severe liver disease. It would seem appropriate to approach specialized training in therapeutic endoscopy or nutritional support in the same manner. If the AGA did support the 3-year fellowship concept, the Training and Education Committee would need to consider the effect of this change on personnel. For example, if the present number of positions offered per year were reduced to keep overall numbers of fellows in training constant, it would theoretically result in a reduction in the number of fellows completing training per year. It may also be necessary to consider a reduction in the requirement for internal medicine training (from 3 years to 2 years) for individuals entering a 3-year subspecialty training program. Other concerns relate to how program directors would fund the third year of training and how the concept of third-tier training would fit if a 3-year fellowship program were mandated for all fellows.
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Another area of concern is how to determine standards for procedural training, including the number of procedures required before a trainee can be said to be competent. Furthermore, a delineation of the types of procedures required of all gastroenterology trainees needs to be made and, by inference, a delineation of procedures that require specialized training over and above that given in a general gastroenterology fellowship. The Governing Board of the AGA thought this issue would be most appropriately discussed by all four gastroenterology societies, who would then issue a joint statement on agreed standards. There is a general consensus that the AGA should be involved in developing guidelines to be used by training directors when they define adequate training and judge procedural competence of fellows. The issues of procedure credentialing and privileges and the training of established gastroenterologists in new procedures has been raised. It is the recommendation of the Governing Board that these two issues continue to be the responsibility of the Patient Care Committee. The Governing Board has also discussed whether some form of research should be mandated of all trainees and whether incorporation of training in clinical research methods, e.g., biostatistics, epidemiology, study design, and outcomes assessment, should become a component of core training for all fellows. Whatever their career choice, this option would allow graduates to critically review new publications and assess the relevance of new findings to the practice of gastroenterology. The Training and Education Committee is working on a policy statement concerning fellowship training. In the area of fellowship matches, the Governing Board states that subspecialty matches in medicine are still viable in gastroenterology, cardiology, and pulmonary medicine, subspecialties that were in greatest demand by the applicant pool. These subspecialties differ from other nonprocedural subspecialties in that there are usually more applicants than positions available. Despite this fact, not all gastroenterology programs are in the match, and there is a perception that not all programs that are in the match are playing by the rules. As a result, the match is in jeopardy. Most Governing Board members favor preservation of the match and a consideration of ways to close loopholes and endorse compliance. Proposals vary from strong endorsement of the match by the AGA to sanctions against nonparticipants. The latter might take the form of a notation of nonparticipation in the AGA program listing in the August issues of GASTROENTEROLOGY. The Governing Board has set priorities for the
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Training and Education Committee related to both research and clinical training. In the area of research training, it is the AGA’s opinion that first a dialogue should be initiated that would lead to the development of a training program directors’ meeting under the auspices of all four gastroenterology societies, i.e., the AGA, the American Society for Gastrointestinal Endoscopy, the American College of Gastroenterology, and the American Association for the Study of Liver Diseases, Second, guidelines should be published that would advise gastroenterology fellows on academic careers and sources of funding, and third, the Training and Education Committee should explore and evaluate loan-repayment and salary-supplementation plans. In the area of clinical training, it was decided that the Training and Education Committee should present a policy paper to the Governing Board that describes the design and format of the ideal fellowship program. Factors that need evaluation include the length of fellowship training; the development of standards for training in procedures, including the types of procedures required for all trainees and the numbers of procedures before competence can be considered acceptable; third-tier training and “added” qualifications; the concept of training in hepatology outside a conventional gastroenterology fellowship; the development of a core curriculum; and the development of tracts built around the core component that will prepare trainees for careers in clinical and basic research, therapeutic endoscopy, nutrition, hepatology, etc. New Technologies
in Education
Developing technology has the potential to revolutionize presentations given at AGA-sponsored scientific meetings and courses. Computer graphics have greatly increased the range of options for slide presentations while decreasing cost and production time. The technology is currently available to produce hard copies of slides at the time of a presentation that would be immediately available for distribution to the audience. New high-definition projection devices that incorporate zoom features allow speakers to highlight one component of a slide while computer-based multimedia presentations allow integration of slides and video simultaneously. Computer-generated, digitally enhanced three-dimensional imaging, coupled with high-definition television, allows virtual-reality presentations that are ideal teaching vehicles. Current technology already allows for sophisticated, interactive, and instantaneous communication between the audience and the speaker. For example, the use of computerbased touch pads will allow audience participation
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during presentation of patient-management problems. Specific issues relate to the application of these new communication technologies by the AGA. The results of a recent survey of 2000 AGA members in which they were asked to delineate learning needs and the future teaching modalities they would like to see the AGA introduce can now be summarized. The majority of members surveyed thought that AGA slide lecture series, such as those produced by the Undergraduate Teaching Project and Clinical Teaching Project, were most useful to them. There was general interest in the AGA developing more self-learning packages, including single-topic video tapes; the most desired topics for future tapes included Crohn’s disease, nutrition, and motor disorders of the gastrointestinal tract. However, it was important that the cost of such tapes be kept below $50 for a single educational videotape and that any home teaching program developed by the AGA be coupled to continuing medical education credits. The membership felt that private industry could sponsor such educational endeavors but that the tapes should not be considered advertising vehicles for industry. Production can be costly, and the whole process can be very time-consuming for those individuals involved in producing such tapes. However, successful educational programs using the video format would attract industry and foundation support in a form that would be acceptable to the membership, e.g., an educational grant without conditions. Although advertising on tapes would not be acceptable, an acknowledgement of support accompanied by the sponsoring company logo would be. Purchase of such educational tapes by industry with free distribution by the purchaser to AGA members would be another mechanism to reduce the financial burden on members. The Governing Board felt that serious consideration should be given to television broadcasting as one vehicle for educating the membership. Given the expense of such an endeavor, it is felt that sponsorship (under conditions similar to those described above) would be required to help offset the costs. Any new educational modality chosen by the AGA would need to use high-quality production techniques. Several production options are possible. For example, the AGA could prepare television programs and tapes using the expertise currently available within the society itself or it could develop these new programs as coventures with another society or sponsor. The use of a university-based biomedical media department might be a viable option if the department had prior experience with similar projects. However, in all likelihood use of a professional
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company would be necessary to ensure the success of these ventures. During the planning stages, further consideration needs to be given to the audience, including the targeting of nonmembers or the international market. A two-tier pricing system should then be introduced in which members would be charged less than nonmembers. With regard to video technology, the AGA is in favor of using this means to educate both physicians and patients. Such ventures would be purely informational or a component of a self-instruction program. One potential for the AGA would be the production of a video journal club that would include six articles per issue either for distribution through a CD-ROM or a video disc. Alternatively, such a project could be produced as a television program on a health cable network. Other possibilities include the production of videotapes of AGA courses or Digestive Disease Week (DDW) presentations that would be made available to members. Patient education could be achieved in a number of ways, e.g., patient-oriented books or video tape programs produced under the auspices of the AGA. Any topic chosen for video production should be suited to production in a visual format. Alternatives would be the production of educational programs through cable television or AGA support of a patientrelated information hotline. Although it is essential that the AGA control the content and the speakers for such programs, outside sponsorship could be needed to defray the substantial costs of such programs. Given the costs of these endeavors, it would be important to assess the desires and interests of the members to ensure that their educational needs were met. While the Training and Education Committee has responsibility for physician education, the Governing Board feels that patient education should remain the primary responsibility of the Patient Care Committee. Increased communication between these two committees in the form of joint working subcommittees will be needed. The Training and Education Committee will explore how these new technologies could best be adapted for DDW and the postgraduate courses. Possibilities include video posters and interactive audience participation using computer tables for the courses, but their advantages and disadvantages will have to be assessed. The Training and Education Committee, in consultation with others, will prepare
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a policy statement and coordinate the application the new technologies to specific AGA programs.
of
Conclusion The dramatic changes in health care in the United States, coupled with the technological advances made in the field of gastroenterology, force a reevaluation of our current methods of training and education of gastroenterologists. The impact of recertification on the educational needs of our membership will be significant as are the ramifications of such issues as “local peer review,” separate boards in hepatology, third-tier certification, credentialing, etc. The Governing Board has charged the Training and Education Committee to become more proactive in issues that relate to the training of fellows and the education of practicing gastroenterologists. The large number of issues that the Training and Education Committee has been asked to address will necessitate a restructuring of the Committee itself. The Training and Education Committee has been split into two working subcommittees, one to deal with issues that relate to training (Subcommittee Chairman, Dr. James Grendell) and the other issues that relate to education (Subcommittee Chairman, Dr. Richard McDermott). This new structure will enable the Training and Education Committee to develop policy statements that will be presented to the Governing Board for their approval and that will better serve members of the AGA. IAN L. TAYLOR, M.D., PH.D. Chairman, Training and Education
Committee
JAMES GRENDELL, M.D. Chairman, Training Subcommittee SIDNEY COHEN, M.D. President (1991)
References 1. Recertification: Overview of the new ABIM Program. American Board of Internal Medicine Publication 1990. 2. Glassock RJ, Benson JA, Copeland RB, Godwin HA, Johanson WG, Point W, Pupp RL, Scherr L, Stein JH, Taunton D. Timelimited certification and recertification: The program of the American Board of Internal Medicine. Ann Intern Med 1991;114:59-62.
Address requests for reprints to: Ian L. Taylor, M.D., Ph.D., Department of Gastroenterology, Duke University Medical Center, P.O. Box 3913, Durham, North Carolina 27710. 0 1992 by the American Gastroenterological Association
