Twitter debate: should upper gastrointestinal bleeding training and certification be formalised?

Introduction

With recent recommendations from the Joint Advisory Group (JAG) in Gastrointestinal Endoscopy for training and certification in oesophagogastroscopy,¹ flexible sigmoidoscopy² and colonoscopy,³ this #FGDebate discussed a controversial topic on whether training and certification for upper gastrointestinal bleeding should also be formalised. We were joined by an expert panel consisting of AJM and AMV who are both consultant gastroenterologists with an interest in interventional endoscopy and senior authors of the British Society of Gastroenterology (BSG)-led multisociety consensus care bundle for the early clinical management of acute upper gastrointestinal bleeding (AUGIB).⁴ This article will summarise and expand on the main discussion points generated from the #FGDebate.

The rationale for a formal certification process

AUGIB is a common medical emergency in the UK with an estimated incidence of 134 per 100 000 individuals, roughly equating to one acute presentation every 6 min and approximately 25 000 annual inpatient hospital admissions.⁵ Mortality rate following AUGIB remains high at approximately 10% with several nationwide audits revealing suboptimal quality of care.^{6 7} The 2015 UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD) audit again demonstrated the suboptimal care for those with AUGIB, including poor or unacceptable endoscopic management in 12% of patients.⁸ Gastroenterologists in the UK are typically expected to undertake periendoscopic and endoscopic management of AUGIB. Despite no formal recommendation from the NCEPOD report on training, the latest curriculum for gastroenterology training published in 2022 highlights the importance for trainees to be able to independently manage patients with AUGIB by the end of their training.⁹ However, trainees still do not require a formal demonstration of competency for endoscopic haemostasis training for AUGIB. They are only able to record formative direct observation of procedural skills (DOPS) (figure 1) and are not required to complete a summative DOPS as part of a sign-off process for AUGIB.¹⁰

Figure 1.

JAG’s formative DOPS for upper gastrointestinal bleeds.¹⁰ DOPS, direct observation of procedural skills; GI, gastrointestinal; JAG, Joint Advisory Group.

The current haemostasis training is based on a traditional apprenticeship model whereby training is locally agreed among trainees, trainers and endoscopy units. A recent retrospective analysis of the JAG Endoscopy Training System e-portfolio, which provided haemostasis experience of gastroenterology trainees prior to attainment of Certificate of Completion of Training (CCT), demonstrated that exposure to haemostasis procedures was relatively low (median 42 procedures) in particular with respect to sclerotherapy (figure 2).¹¹ Partly because of locally agreed training pathways, the same study demonstrated significant variation in exposure to haemostasis procedures according to registered deanery (figure 3).¹¹ It is, therefore, not surprising that gastroenterology trainees’ surveys demonstrated that they do not feel adequately prepared and competent at haemostasis procedures.^{12 13} The current haemostasis training is dissimilar to the rigorous nationally agreed pathways and key performance indicators for training in diagnostic oesophagogastroscopy,¹ flexible sigmoidoscopy² and colonoscopy.³ Finally, although there is currently no evidence that a formal certification process will improve mortality rate in patients with AUGIB, the inclusion of evidence-based key performance indicators, such as those used in diagnostic colonoscopy,¹⁴ to assess trainees’ performance is likely be beneficial. For all these reasons, 55% of the 56 individuals who took part in our poll during this #FGDebate believed that a formal certification process is required.

Figure 2.

Volume of modality-specific haemostasis procedures reported by gastroenterologists prior to completion of training.¹¹ AUGIB, acute upper gastrointestinal bleeding.

Figure 3.

Haemostasis procedures according to registered deanery.¹¹ CCT, Certificate of Completion of Training; N/A, data unavailable

What might a formal training pathway and certification process look like?

A formal training pathway may have a blend of formal didactic teaching, simulation training, experiential learning and postcertification support. TheBSG and JAG have developed a pilot haemostasis course that could be used to deconstruct and learn new haemostasis techniques in a simulated environment. This course has been shown to increase confidence in both understanding and delivery of haemostatic techniques among trainees.¹⁵ During our #FGDebate, some trainees raised concerned that the cost of such a course may be a barrier to its uptake but should this be mandated by JAG and the Joint Royal Colleges of Physician Training Board, one would expect that it would be funded by the deanery. Haemostasis training can be delivered in all acute hospitals accepting patients with AUGIB with trainees spending a minimum period of time on an AUGIB out of hours rota. Formative DOPS could be undertaken in the workplace to improve structured feedback for trainees (figure 4).¹⁶ Summative DOPS can then be carried out to assess competence prior to allowing trainees to manage AUGIB under indirect supervision. Finally, those who are newly certified should be offered a period of support with access to a mentor to discuss and reflect on cases encountered in their practice.

Figure 4.

The AUGIB DOPS to improve training in in AUGIB management.¹⁶ AUGIB, acute upper gastrointestinal bleeding; DOPS, direct observation of procedural skills.

Barriers implementing a formal certification

While a formal assessment of competence is likely to improve patient care, there are concerns as to whether trainees in the UK will be able to meet all the potential stringent requirements for certification. With the demand for service provision, especially for general internal medicine, gastroenterology trainees are already struggling to achieve competency in colonoscopy,¹⁷ which is now a requirement for attainment of CCT.⁹ Second, the shape of training report recommended changes to postgraduate training meaning that gastroenterology trainees only spend 4 years, rather than 5, in higher specialty training.¹⁸ This is a 20% reduction in time allocated for training and exposure to management of patients with AUGIB. During our #FGDebate, some trainees also raised concerns that they already have to go to work on their rest days and annual leave in order to meet the mandatory curriculum requirements and felt that adding another mandatory requirement to their curriculum may be too onerous. This raised the question of whether a formal certification process should be a requirement for CCT or whether a certification should be achieved post-CCT. This means that new consultants may need regular access to therapeutic lists or have to be doubled up on an AUGIB out of hours rota for further training and certification. On the other hand, our expert panel were of the opinion that a mandatory requirement for CCT may mean that training programme directors and endoscopy units will have a duty to provide protected regular training time. Following this discussion, we asked the audience how easy they thought such a system can be implemented in their region. Of the 43 responses, nearly 90% of individuals thought it would be difficult or very difficult to implement but we were unable to examine the reasons for these as they beyond the scope of this #FGDebate.

Conclusion

In summary, this #FGDebate explored the rationale for a formalised pathway for training and certification for the endoscopic management of AUGIB but it remains unclear as to whether trainees, trainers, endoscopy units, training programme directors and JAG will be to circumvent all the challenges discussed. Patients with AUGIB might have a reasonable expectation that the clinician managing their bleeding episode, particularly as part of an out of hours emergency service, should be able to demonstrate competence. We believe that all stakeholders should be consulted prior to implementing a formal certification process.

Ethics statements

Patient consent for publication

Not applicable.