Introduction
Limited data exist regarding the status of inflammatory bowel disease (IBD) training during gastroenterology (GI) fellowship. A survey of GI fellows in 2016 showed that only 28% were satisfied with their level of IBD exposure during training, and up to 43% were unsure or believed that outpatient IBD training was inadequate.1 Since then, the management of patients with IBD has become even more complex with the expansion of the treatment pipeline.2–7 The treatment goals and targets have also evolved significantly with the introduction of the STRIDE II consensus statements.8 All these factors make it challenging for general GI fellows to obtain competency and confidence in managing IBD during a 3-year fellowship. We aimed to assess the current status of IBD training among GI fellows in the United States.
Methods
We performed a multicenter survey of US GI fellows in 17 fellowship programs from December 2021 to April 2022. The survey was voluntary, anonymous, and distributed electronically prior to a planned didactic session or via email. The study was deemed exempt by the Yale University Institutional Review Board (IRB 2000031661).
The survey included questions on 20 IBD core domains derived from previously proposed IBD core competencies and entrustable professional activities (EPA)1,9 (see Supplemental Material). Questions were reviewed and edited by 4 gastroenterologists specializing in IBD (L.M., F.R., J.G., D.P.). Questions evaluated fellows’ confidence levels in IBD management with a Likert scale of 1 to 4 (1, not confident at all; 2, slightly confident [still need a lot of supervision]; 3, moderately confident [still need occasional supervision]; 4 extremely confident [ready to do this independently]). The survey assessed the IBD training received (none, “on the fly,” work rounds, didactic or conference, or self-directed [ie, national conferences, webinars, independent reading]) and the amount of additional training desired (none, a little [1 hour], a moderate amount [2-3 hours], or a lot [>3 hours]). Fellows were asked to rank their preferred learning methods for IBD-related topics.
Confidence was dichotomized into “low confidence” defined as not at all to slightly confident and “high confidence” defined as moderately to extremely confident. Data were analyzed as frequencies and percentages. We evaluated factors associated with confidence in the 5 lowest ranking domains. Continuous variables were analyzed using unpaired Student t tests. Categorical variables were analyzed using Pearson χ2 tests. A P value <.05 was considered statistically significant. JMP (SAS Institute Inc., Cary, North Carolina, U.S.) was used for data analysis.
Results
A total of 113 of 175 fellows (65%) responded to the survey. Responders were evenly distributed between first-, second-, and third-year fellows (36.8%, 28.7%, 33.3%, respectively). Most fellows (85%) were training at academic institutions, with 55.2% having an IBD center. Only 8.0% of fellows planned to do a dedicated IBD fellowship, and 13.8% were planning a career in IBD.
Most respondents (81.1%) reported low confidence in managing the pregnant patient with IBD, and 78.9% reported low confidence in managing pouch disorders (Figure 1). Among third-year fellows, ≥50% reported low confidence in managing the pregnant patient with IBD, pouch disorders, extraintestinal manifestations (EIMs), postoperative Crohn’s disease (CD), and counseling patients on small molecule medications (Figure 2).
Figure 1.
GI fellows’ level of confidence across 20 core IBD domains.
Figure 2.
Low confidence among third-year vs. first- and second-year GI fellows.
Having a dedicated outpatient IBD rotation was significantly associated with high confidence in managing the pregnant patient with IBD (87.5% vs 40.9%; P = .007), managing pouch disorders (78.9% vs 41.2%; P = .004), managing EIMs (71.4% vs 42.4%; P = .021), and managing postoperative CD (70.8% vs 41.3%; P = .014). Receiving more than 4 didactic IBD sessions per year was significantly associated with high confidence in managing the pregnant patient with IBD (100% vs 63.6%; P = .002) and managing postoperative CD (92.3% vs 62.3%; P = .004). Training institution type (academic vs community vs university-affiliated) was not associated with confidence in the 5 lowest ranking domains (all P > .05).
Many respondents reported no IBD specific training in managing elderly patients (23.0%), EIMs (12.6%), and diet/nutrition counseling (12.5%). Most fellows (64.4%-68.9%) desired a moderate to a lot more training (≥2 hours) in therapeutic drug monitoring, managing patients failing first-line biologic therapy, counseling patients on biologics/small molecules, managing elderly patients, perianal CD, EIMs, and pouch disorders. Recorded web-based lectures were the preferred learning strategy by 25.7%, followed by live case-based lectures (23%), virtual live didactic sessions (23%), and in-person didactic sessions (18%). Inflammatory Bowel Disease away rotations were preferred in only 5% of respondents.
Discussion
In our study, most GI fellows reported low confidence in many basic domains of IBD management. Although third-year fellows reported higher confidence, half or more of third-year fellows still reported low confidence in important IBD management domains. Having a dedicated outpatient IBD rotation and receiving more than 4 IBD didactic sessions per year were associated with improved confidence. Furthermore, most fellows desired moderate to a lot more training in IBD management.
Despite efforts to enhance IBD training during fellowship with online webinars sponsored by national GI societies, local-regional workshops, and national meetings, multiple gaps in IBD training among GI fellows in the United States still persist.9 Advanced IBD fellowships only fill a small gap, as they can only accommodate a minority of fellows and require an extra year of training which is not universally desired by GI fellows. A highly successful IBD away rotation program is available through the Crohn’s and Colitis Foundation to address training gaps.10 This program is limited by the number of available positions, funding, and required time commitment, and according to our survey, only 5% of fellows ranked an away rotation as their preferred learning strategy. Recently, Malter et al proposed an updated set of IBD EPA for GI fellows that helps form the basis of a standardized IBD curriculum.9
In our study, having a dedicated outpatient IBD rotation was associated with improved fellows’ confidence in management of IBD. A significant proportion of the required 18 months of clinical experience in GI fellowships, however, is spent in the inpatient setting. A recent survey study showed that GI fellows felt that attendings in the inpatient setting spent less time teaching and providing feedback compared with the attendings’ perception of what was provided.11 Outpatient training offers different patient care and learning perspectives for chronic conditions such as IBD. Thus, programs may wish to consider increasing outpatient rotations to include more training directed to IBD care.
The strengths of our study include a high response rate, large sample size, diverse GI training programs, and optimal timing of survey administration past the middle of the academic year. Limitations include lack of fellows’ knowledge and skill assessment and program directors’ input regarding barriers to IBD curriculum implementation.
Our study highlights that many GI fellows lack confidence and training in key domains of IBD management. This lack of training may have negative implications on the quality of IBD care provided to patients. A focused and sustainable curriculum for GI fellows addressing identified knowledge gaps in IBD management is warranted.
Contributor Information
Badr Al-Bawardy, Section of Digestive Disease, Yale School of Medicine, New Haven, CT, USA; Department of Internal Medicine, Division of Gastroenterology and Hepatology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
Lisa Malter, Department of Medicine, Division of Gastroenterology, New York University Langone Medical Center, NY, USA.
Adam C Ehrlich, Section of Gastroenterology, Temple University Lewis Katz School of Medicine, Philadelphia, PA, USA.
Florian Rieder, Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
Jill K J Gaidos, Section of Digestive Disease, Yale School of Medicine, New Haven, CT, USA.
Deborah Proctor, Section of Digestive Disease, Yale School of Medicine, New Haven, CT, USA.
Donna M Windish, Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.
Author Contributions
B.A-B.: Conception, study design, statistical analysis, manuscript draft, manuscript revisions, final approval
L.M.: Study design, survey review, manuscript review and revisions
A.C.E.: Study design, manuscript review and revisions
F.R.: Survey review. manuscript review and revisions
J.K.J.G.: Survey review. manuscript review and revisions
D.D.P.: Survey review, manuscript review and revisions
D.M.W.: Study design, survey review, manuscript review and revisions
Funding
None.
Conflicts of Interest
B.A-B.: Speaker honoraria from AbbVie, Takeda, Bristol-Meyers Squibb. Advisory board for Bristol-Meyers Squibb. Medical education grant from Takeda
L.M.: Medical education grants from AbbVie, Janssen, Pfizer, Takeda. Advisory board for AbbVie, Bristol-Meyers Squibb, Janssen, Merck, and Takeda.
A.C.D: Advisory boards for Pfizer, BMS, and Eli Lilly.
F.L.: consultant to Agomab, Allergan, AbbVie, Boehringer-Ingelheim, Celgene, Cowen, Genentech, Gilead, Gossamer, Guidepoint, Helmsley, Index Pharma, Jannsen, Koutif, Metacrine, Morphic, Pfizer, Pliant, Prometheus Biosciences, Receptos, RedX, Roche, Samsung, Takeda, Techlab, Thetis, UCB, and 89Bio.
J.K.J.G.: Speaker honoraria from AbbVie. Advisory Board for Bristol-Myers Squibb
D.P.: Consultant for AbbVie, Celgene, Paraxel
D.M.W.: none.
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