10.1055/a-1093-0877Education and training are key for quality and patient safety. Serious issues regarding
gastrointestinal endoscopy quality have been demonstrated in several studies, mainly
related to missed lesions, adverse events (AEs), and poor patient experiences [1]
[2]. To improve the quality of endoscopy procedures, the European Society of Gastrointestinal
Endoscopy (ESGE) has during the last decade developed recommendations for quality
targets and quality performance indicators (KPI) [3].
Educational efforts are urgently needed to achieve these goals as implemented by the
well-established Joint Advisor Group Endoscopy Training System (JETS) in the United
Kingdom(UK) [4]. There are strong indications that their system based on “train the trainer” programs
and formal training courses for junior doctors have had an important positive impact
on the quality of endoscopic procedures in the UK [5].
In this issue of Endoscopy International Open, Maida et al. present a comprehensive
survey including 16 European countries. In several of the countries there are fundamental
weaknesses in the current training of junior doctors [6]. Unfortunately, with a study response rate of less than 30 % combined with few respondents
from each country, there exists a notable risk of bias in the reported results. Nevertheless,
the authors’ findings raise serious concerns regarding the quality of training, and
emphasize the need to increase focus, and improve gastrointestinal endoscopy training
to ensure patient safety. The study results most likely reveal the consequence of
long-lasting ignorance by many organizations and leadership of the importance of training,
despite ESGE’s efforts and recommended targets for the services [7]. The focus on training is of particular importance to ensure that existing or planned
expensive colorectal cancer screening programs in European countries will not be compromised.
The questions in the survey by Maida et al are based on the curriculum recommended
by The European Section and Board of Gastroenterology and Hepatology stated in the
“the Blue book,” for which the main goal is to define, secure and assess the standards
of training in gastroenterology and hepatology. It covers the core elements of competence-based
medical education; theoretical knowledge, practical and clinical skills, communication
and interpersonal skills, ethics, professionalism, patient safety, and quality improvement.
The recommended curriculum also involves training in complex high-risk endoscopic
procedures such as endoscopic submucosal dissection, endoscopic retrograde cholangiopancreatography
(ERCP), and endoscopic ultrasound (EUS).
The survey reveals important gaps between countries in endoscopy training and shows
that some countries are successful in achieving the training goals. Detailed knowledge
about the success factors in the latter countries would probably be helpful for less
successful countries. However, one should keep in mind that the survey assessed targets
limited to numbers of procedures and not acquired competency. More details regarding
achieved KPIs is necessary to assess the effectiveness of the training system.
Well-structured training frameworks and high-quality supervision of trainees are vital
to achieve the required competencies for gastroenterologists. In the current survey,
such variables are not evaluated but need to be included in the future. They include
trainer curriculum and competency, the existence of continuous workplace assessments
with objective tools, and the existence of training lists under direct observation.
These variables might also be helpful in revealing root causes for suboptimal training
that can be acted upon.
Supervision and direct observation are key to assess an endoscopists’ skills and provide
relevant feedback to enhance learning to achieve the required KPIs. These assessments
need to be documented by each trainee in conjunction with his/her trainer. It is encouraging
that three out of four trainees recorded their activities, although aiming for a goal
of 100 % is important. However, the details of these recordings and whether they included
assessments is unclear. Consequently, in the future, surveys need to assess the content
and quality of these recordings.
Basic skills in endoscopy include polypectomy and endoscopic mucosal resection of
lesions less than 20 mm and the competency to treat subsequent AEs like bleeding and
small perforations. These skills are also essential to achieve before undertaking
training on more complex procedures. In the survey, most of the trainees had performed
too few basic interventions to achieve full competency and it is alarming that nevertheless,
most of them perceive themselves as very or fully competent in endoscopy, confirming
the limited value of self-assessment.
The survey demonstrates a very low adherence to recommended training in advanced procedures
like ERCP and EUS. That might be related to the demography of countries in which these
procedures are performed only in a limited number of hospitals, and not necessarily
indicative of a limitation in training, but could rather be based on a conscious decision
to prevent harm to patients. Hence, non-adherence to the Blue book’s recommendations
needs to be interpreted in accordance with the individual countries’ requirements
to provide good health services.
In conclusion the survey, although suffering validity issues, has important results
that call for an urgent initiative to improve training in Europe.
To increase the impact and validity of future surveys, limiting the survey to one
core topic at a time (e. g. training in endoscopy combined with a substantial effort
via the national gastroenterology associations to recruit relevant trainees) could
increase the response rate. That would also make it possible to compare and suggest
interventions to improve training in specific countries.
One should also bear in mind that important endoscopy educational initiatives are
launched in several countries frequently related to implementation of colorectal cancer
screening programs. More knowledge about how to perform high-quality endoscopy training
to obtain quality targets might be helpful in garnering sufficient funding for sustainable
existing and new endoscopy training systems.
I would encourage the authors to continue their important effort in improving gastrointestinal
training and repeat surveys related to training in the future to get more valid results
that will make it possible to push the leadership and organizations to improve their
training facilities.
