SHORT COMMUNICATION
Present Standard in Pediatric Gastroenterology Fellowship Training in the Interpretation of Capsule Endoscopy Nadia M. Hijaz, Seth S. Septer, and Thomas M. Attard
See ‘‘Training in Video Capsule Endoscopy: A Call for Curriculum Development’’ by Sauer and Erdman on page 381.
What Is Known
ABSTRACT Consensuses on fellowship training in wireless capsule endoscopy (WCE) interpretation have been published for adult gastroenterology (GI) but not in pediatric GI training. A questionnaire has been sent to 64 pediatric and 45 adult GI fellowship programs to compare their present training approach. Adult GI programs reported having a formal GI capsule endoscopy module in 38% and required to attend hands-on course in 27% as compared with 4% and 8% in pediatric programs, respectively. A more formalized approach to WCE training may be required for credentialing pediatric trainees to be aligned with expectations in adult GI programs. Key Words: adult gastroenterology fellowship, capsule endoscopy, pediatric gastroenterology fellowships, training
(JPGN 2015;61: 421–423)
P
ediatric gastroenterologists increasingly are expected to be proficient in the interpretation of wireless capsule endoscopy (WCE) in children. Although consensus positions on fellowship training in WCE interpretation have been published for adult gastroenterology (GI) by the American Society for Gastrointestinal Endoscopy (ASGE) and the European Society of Gastrointestinal Endoscopy (1,2), no analogous consensus is in place for pediatric trainees (3). The educational requirements presently in place for pediatric fellows’ training vary by program presenting an opportunity for an evidence-based approach in formulating a consensus on training requirements in the future. The goal of this study was to define the present practice and formal structures in place for training pediatric GI fellows in reading and interpreting WCE studies in the United States and Canada and to compare the present training approach in
Received July 11, 2014; accepted April 14, 2015. From the Division of Pediatric Gastroenterology, Children’s Mercy Hospitals and Clinics, Kansas City, MO. Address correspondence and reprint requests to Nadia Hijaz, Division of Pediatric Gastroenterology, Children’s Mercy Hospital and Clinics, 2401 Gillham Rd, Kansas City, MO 64108 (e-mail: [email protected]). The authors report no conflicts of interest. Copyright # 2015 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition DOI: 10.1097/MPG.0000000000000829
JPGN
Volume 61, Number 4, October 2015
American Society for Gastrointestinal Endoscopy and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Guidelines recommend formal training and a minimum number of wireless capsule endoscopy readings to achieve competency.
What Is New
A total of 38% of adult fellowships have formal wireless capsule endoscopy training module and 27% require a formal video capsule endoscopy course. Of pediatric fellowships, 4% have formal wireless capsule endoscopy training module and 8% require a formal video capsule endoscopy course. A more formalized approach to video capsule endoscopy training is suggested for pediatric training programs.
pediatric GI fellowship with that obtained in adult fellowship programs.
METHODS Participants and Procedures A self-created 5-item questionnaire allowing dichotomous response was sent in an e-mail to the available fellowship directors. Several resources—North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), Fellowship and Residency Electronic Interactive Database Access System, American Gastroenterological Association, American College of Gastroenterology (ACG), and Accreditation Council for Graduate Medical Education—were used to obtain the most present database of contact information for the diverse programs and was sent to 64 pediatric GI fellowship program directors (PDs) and 45 adult GI fellowship PDs.
Measure A 5-item questionnaire (Fig. 1) was developed to assess the key components of WCE training (Table 1) and was based on the guidelines for credentialing physicians (Table 2) to perform WCE studies in adults, which were published by the ASGE in 2005. Responses were categorized and scored as either ‘‘yes’’ or ‘‘no,’’ indicating the present presence or absence of that key element in their program’s training.
421
Copyright 2015 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Hijaz et al
JPGN
Volume 61, Number 4, October 2015
70
Positive response, %
60 50 40 Pediatric GI FTP 30
Adult GI FTP
20 10 0 Q1
Q2
Q3
Q4
Q5
Questionnaire item FIGURE 1. Positive answers to the questionnaire questions in pediatric and adult GI fellowship training programs. Q1: Do you have a formal GI capsule endoscopy module? Q2: Are your trainees required to attend hands-on course during their training? Q3: Are your trainees required to read a specific number of CE studies as part of their training requirements? Q4: Do you have a formal requirement for your trainees to present a journal club or other formal didactic presentation on CE as part of their training? Q5: Do you have a requirement for teaching staff to present a formal lecture on CE as part of the fellowship training? CE ¼ capsule endoscopy; FTP ¼ fellowship training programs; GI ¼ gastroenterology.
Data Reduction/Analysis Fisher exact tests were used to compare pediatric and adult program responses on individual items. Significance was determined at P < 0.05.
RESULTS
66% of the adult programs and 8% of the pediatric programs (P < 0.005), a specific number of WCE studies were required to be read as part of training (range 10–25 studies). Presentation at journal club or another type of formal didactic presentation about WCE was required in 6% of the adult programs and 12% of the pediatric programs (P ¼ not significant [ns]). The faculty was
The response rate for this survey was 80% (36/45) and 39% (25/64) for adult and pediatric PDs, respectively. Of the respondents, 38% of adult programs reported having a formal GI capsule endoscopy module as part of the training program, compared with 4% of the pediatric programs (P < 0.005). Trainees were required to attend a hands-on course as a part of their training in 27% of the adult programs and 8% of the pediatric programs (P < 0.01). The WCE module in ACG Universe (http://universe.gi.org/contentlist. asp?eventtype=44) was most often cited as a useful resource. In
TABLE 2. Principles of initial credentialing in capsule endoscopy
TABLE 1. Training requirements for capsule endoscopy before competency can be assessed
3.
1.
2.
3.
Completion of a gastrointestinal endoscopy training program that included training in the recognition and management of small intestinal diseases (for small intestine capsule endoscopy) Be competent and have privileges to perform EGD, colonoscopy, and (for small intestine capsule endoscopy) enteroscopy Familiarity with the hardware and software systems One of the following a. Formal training in capsule endoscopy during GI fellowship b. Completion of a hands-on course with a minimum of 8-h CME credit, endorsed by a national or international GI or surgical society and review of the first 10 capsule studies by a credentialed capsule endoscopist
ASGE ¼ American Society for Gastrointestinal Endoscopy; CME ¼ continuing medical education; EGD ¼ esophagogastroduodenoscopy; GI ¼ gastroenterology. Adapted from (1).
422
1. 2.
Credentials for capsule endoscopy should be determined independently from other endoscopic procedures Appropriate documentation should be required in the determination of competence in capsule endoscopy. This may include the completion of a formal training program (residency or fellowship) or documentation of sufficient training in other settings, which include diagnosis and therapy of diseases of the small intestine. Documentation of continued competence should be required for the renewal of capsule endoscopy privileges. Endoscopists wishing to perform capsule endoscopy a. must understand the indications, the contraindications, and the risks of capsule endoscopy and be able to accurately identify and interpret capsule endoscopy findings b. should have sound general medical or surgical training and be able to integrate capsule endoscopy into the overall clinical evaluation of appropriately selected patients c. must have completed 24 mo of a standard GI fellowship (or equivalent), with training in the recognition and the management of small intestinal diseases (for small bowel capsule endoscopy) d. must have documented competence and privileges to perform EGD; colonoscopy; and, for small bowel capsule endoscopy, enteroscopy e. must be familiar with the hardware and the software necessary to perform and interpret the capsule endoscopy images and be able to document capsule endoscopy findings and communicate with referring physicians
ASGE ¼ American Society for Gastrointestinal Endoscopy; GI ¼ gastroenterology. Adapted from (1).
www.jpgn.org
Copyright 2015 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
JPGN
Volume 61, Number 4, October 2015
required to present 1 formal lecture about WCE in 31% of the adult programs and 33% of the pediatric programs (P ¼ ns). In addition to answering the 5 survey items, several PDs made spontaneous qualitative comments of note. Comments by PDs generally reflected a desire to develop a more formal structure for trainees. Several adult PDs indicated that the number of WCE studies required to complete training in their program was 25 to 30. Only rarely, in pediatric programs, did PDs state that present unstructured training involving direct mentoring as cases increase is sufficient to ensure competency in WCE interpretation.
DISCUSSION Present training in the interpretation of WCE in pediatric GI programs is variable and relatively unstructured as reflected in our survey responses. In our survey, pediatric and adult programs appear comparable in offering 1 formal didactic lecture on WCE. In contrast, a larger proportion of adult GI training programs emphasize WCE training as part of the formal curriculum, require trainees to attend a hands-on course or online webinars as part of their training. These courses or webinars seem to be more feasible in adult fellowship programs because most of the hands-on courses in WCE training are provided and focus toward educating adult programs for the purpose of discussing bleeding of unknown origin or rare vascular lesions, which are typically less of a concern in pediatric programs. This makes these courses less directed toward pediatric pathology and less interesting for pediatric trainees. It is becoming increasingly important to include WCE exposure during GI training at a level analogous to that in adults’ programs. NASPGHAN and ASGE Guidelines state that the minimum number of capsule endoscopy required to achieve competency is 20 for WCE interpretations and 5 for deployments of WCE. (4) ASGE requires either formal established training in reading of WCE or having the trainee attend an 8-hour WCE-directed course and read 10 of the WCE studies. Based on these guidelines, our survey shows that very few pediatric programs would meet these requirements as
Present Standard in Pediatric Gastroenterology Fellowship Training in the Interpretation of Capsule Endoscopy Nadia M. Hijaz, Seth S. Septer, and Thomas M. Attard
See ‘‘Training in Video Capsule Endoscopy: A Call for Curriculum Development’’ by Sauer and Erdman on page 381.
What Is Known
ABSTRACT Consensuses on fellowship training in wireless capsule endoscopy (WCE) interpretation have been published for adult gastroenterology (GI) but not in pediatric GI training. A questionnaire has been sent to 64 pediatric and 45 adult GI fellowship programs to compare their present training approach. Adult GI programs reported having a formal GI capsule endoscopy module in 38% and required to attend hands-on course in 27% as compared with 4% and 8% in pediatric programs, respectively. A more formalized approach to WCE training may be required for credentialing pediatric trainees to be aligned with expectations in adult GI programs. Key Words: adult gastroenterology fellowship, capsule endoscopy, pediatric gastroenterology fellowships, training
(JPGN 2015;61: 421–423)
P
ediatric gastroenterologists increasingly are expected to be proficient in the interpretation of wireless capsule endoscopy (WCE) in children. Although consensus positions on fellowship training in WCE interpretation have been published for adult gastroenterology (GI) by the American Society for Gastrointestinal Endoscopy (ASGE) and the European Society of Gastrointestinal Endoscopy (1,2), no analogous consensus is in place for pediatric trainees (3). The educational requirements presently in place for pediatric fellows’ training vary by program presenting an opportunity for an evidence-based approach in formulating a consensus on training requirements in the future. The goal of this study was to define the present practice and formal structures in place for training pediatric GI fellows in reading and interpreting WCE studies in the United States and Canada and to compare the present training approach in
Received July 11, 2014; accepted April 14, 2015. From the Division of Pediatric Gastroenterology, Children’s Mercy Hospitals and Clinics, Kansas City, MO. Address correspondence and reprint requests to Nadia Hijaz, Division of Pediatric Gastroenterology, Children’s Mercy Hospital and Clinics, 2401 Gillham Rd, Kansas City, MO 64108 (e-mail: [email protected]). The authors report no conflicts of interest. Copyright # 2015 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition DOI: 10.1097/MPG.0000000000000829
JPGN
Volume 61, Number 4, October 2015
American Society for Gastrointestinal Endoscopy and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Guidelines recommend formal training and a minimum number of wireless capsule endoscopy readings to achieve competency.
What Is New
A total of 38% of adult fellowships have formal wireless capsule endoscopy training module and 27% require a formal video capsule endoscopy course. Of pediatric fellowships, 4% have formal wireless capsule endoscopy training module and 8% require a formal video capsule endoscopy course. A more formalized approach to video capsule endoscopy training is suggested for pediatric training programs.
pediatric GI fellowship with that obtained in adult fellowship programs.
METHODS Participants and Procedures A self-created 5-item questionnaire allowing dichotomous response was sent in an e-mail to the available fellowship directors. Several resources—North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), Fellowship and Residency Electronic Interactive Database Access System, American Gastroenterological Association, American College of Gastroenterology (ACG), and Accreditation Council for Graduate Medical Education—were used to obtain the most present database of contact information for the diverse programs and was sent to 64 pediatric GI fellowship program directors (PDs) and 45 adult GI fellowship PDs.
Measure A 5-item questionnaire (Fig. 1) was developed to assess the key components of WCE training (Table 1) and was based on the guidelines for credentialing physicians (Table 2) to perform WCE studies in adults, which were published by the ASGE in 2005. Responses were categorized and scored as either ‘‘yes’’ or ‘‘no,’’ indicating the present presence or absence of that key element in their program’s training.
421
Copyright 2015 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Hijaz et al
JPGN
Volume 61, Number 4, October 2015
70
Positive response, %
60 50 40 Pediatric GI FTP 30
Adult GI FTP
20 10 0 Q1
Q2
Q3
Q4
Q5
Questionnaire item FIGURE 1. Positive answers to the questionnaire questions in pediatric and adult GI fellowship training programs. Q1: Do you have a formal GI capsule endoscopy module? Q2: Are your trainees required to attend hands-on course during their training? Q3: Are your trainees required to read a specific number of CE studies as part of their training requirements? Q4: Do you have a formal requirement for your trainees to present a journal club or other formal didactic presentation on CE as part of their training? Q5: Do you have a requirement for teaching staff to present a formal lecture on CE as part of the fellowship training? CE ¼ capsule endoscopy; FTP ¼ fellowship training programs; GI ¼ gastroenterology.
Data Reduction/Analysis Fisher exact tests were used to compare pediatric and adult program responses on individual items. Significance was determined at P < 0.05.
RESULTS
66% of the adult programs and 8% of the pediatric programs (P < 0.005), a specific number of WCE studies were required to be read as part of training (range 10–25 studies). Presentation at journal club or another type of formal didactic presentation about WCE was required in 6% of the adult programs and 12% of the pediatric programs (P ¼ not significant [ns]). The faculty was
The response rate for this survey was 80% (36/45) and 39% (25/64) for adult and pediatric PDs, respectively. Of the respondents, 38% of adult programs reported having a formal GI capsule endoscopy module as part of the training program, compared with 4% of the pediatric programs (P < 0.005). Trainees were required to attend a hands-on course as a part of their training in 27% of the adult programs and 8% of the pediatric programs (P < 0.01). The WCE module in ACG Universe (http://universe.gi.org/contentlist. asp?eventtype=44) was most often cited as a useful resource. In
TABLE 2. Principles of initial credentialing in capsule endoscopy
TABLE 1. Training requirements for capsule endoscopy before competency can be assessed
3.
1.
2.
3.
Completion of a gastrointestinal endoscopy training program that included training in the recognition and management of small intestinal diseases (for small intestine capsule endoscopy) Be competent and have privileges to perform EGD, colonoscopy, and (for small intestine capsule endoscopy) enteroscopy Familiarity with the hardware and software systems One of the following a. Formal training in capsule endoscopy during GI fellowship b. Completion of a hands-on course with a minimum of 8-h CME credit, endorsed by a national or international GI or surgical society and review of the first 10 capsule studies by a credentialed capsule endoscopist
ASGE ¼ American Society for Gastrointestinal Endoscopy; CME ¼ continuing medical education; EGD ¼ esophagogastroduodenoscopy; GI ¼ gastroenterology. Adapted from (1).
422
1. 2.
Credentials for capsule endoscopy should be determined independently from other endoscopic procedures Appropriate documentation should be required in the determination of competence in capsule endoscopy. This may include the completion of a formal training program (residency or fellowship) or documentation of sufficient training in other settings, which include diagnosis and therapy of diseases of the small intestine. Documentation of continued competence should be required for the renewal of capsule endoscopy privileges. Endoscopists wishing to perform capsule endoscopy a. must understand the indications, the contraindications, and the risks of capsule endoscopy and be able to accurately identify and interpret capsule endoscopy findings b. should have sound general medical or surgical training and be able to integrate capsule endoscopy into the overall clinical evaluation of appropriately selected patients c. must have completed 24 mo of a standard GI fellowship (or equivalent), with training in the recognition and the management of small intestinal diseases (for small bowel capsule endoscopy) d. must have documented competence and privileges to perform EGD; colonoscopy; and, for small bowel capsule endoscopy, enteroscopy e. must be familiar with the hardware and the software necessary to perform and interpret the capsule endoscopy images and be able to document capsule endoscopy findings and communicate with referring physicians
ASGE ¼ American Society for Gastrointestinal Endoscopy; GI ¼ gastroenterology. Adapted from (1).
www.jpgn.org
Copyright 2015 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
JPGN
Volume 61, Number 4, October 2015
required to present 1 formal lecture about WCE in 31% of the adult programs and 33% of the pediatric programs (P ¼ ns). In addition to answering the 5 survey items, several PDs made spontaneous qualitative comments of note. Comments by PDs generally reflected a desire to develop a more formal structure for trainees. Several adult PDs indicated that the number of WCE studies required to complete training in their program was 25 to 30. Only rarely, in pediatric programs, did PDs state that present unstructured training involving direct mentoring as cases increase is sufficient to ensure competency in WCE interpretation.
DISCUSSION Present training in the interpretation of WCE in pediatric GI programs is variable and relatively unstructured as reflected in our survey responses. In our survey, pediatric and adult programs appear comparable in offering 1 formal didactic lecture on WCE. In contrast, a larger proportion of adult GI training programs emphasize WCE training as part of the formal curriculum, require trainees to attend a hands-on course or online webinars as part of their training. These courses or webinars seem to be more feasible in adult fellowship programs because most of the hands-on courses in WCE training are provided and focus toward educating adult programs for the purpose of discussing bleeding of unknown origin or rare vascular lesions, which are typically less of a concern in pediatric programs. This makes these courses less directed toward pediatric pathology and less interesting for pediatric trainees. It is becoming increasingly important to include WCE exposure during GI training at a level analogous to that in adults’ programs. NASPGHAN and ASGE Guidelines state that the minimum number of capsule endoscopy required to achieve competency is 20 for WCE interpretations and 5 for deployments of WCE. (4) ASGE requires either formal established training in reading of WCE or having the trainee attend an 8-hour WCE-directed course and read 10 of the WCE studies. Based on these guidelines, our survey shows that very few pediatric programs would meet these requirements as
