Training to Competence in Gastrointestinal Endoscopy: A Plea for Continuous Measuring of Objective End Points

Introduction

Apprentice is derived from the Latin apprehendere, meaning “to seize”. Physicians have seized the skills needed to perform procedures in the same way that apprentices have learned since the days of the mediaeval guilds: by watching someone work. We have known for hundreds of years that some apprentices are skilled well before others. Similarly, some apprentices have better hand-eye coordination, others, a better fund of knowledge. How have we distinguished between them? The opinion of the master or mentor has been supreme.

It has been the same way in gastrointestinal endoscopy until the rise of consumer interest in healthcare and payer interest in costs. A gastroenterologist would receive privileges at a hospital on the basis of a letter from his training program director. But, in the last quarter of the twentieth century, patients, their lawyers, third-party payers, and hospitals began to ask, “Show us that you are really qualified!” Surgeons have a long tradition of keeping a logbook of their procedures, but such a practice was a new thing for gastroenterologists. Nonetheless, beginning in the 1980s, trainees were formally required to keep track of every procedure that they carried out [1].

At the same time, medical societies began to ask, “How much training is enough?” In the absence of data, expert opinion was sought. The Federation of Digestive Disease Societies recommended 50 - 100 procedures for competence in esophagogastroduodenoscopy (EGD) and colonoscopy [2]. Wington et al. obtained estimates of the numbers of procedures thought necessary to achieve competence, from internists [3], internal medicine residency directors [4], and gastroenterologists [5]. The first two groups thought a median of 25 EGDs or colonoscopies were sufficient, while the gastroenterologists thought a median of 75 EGDs and 88 colonoscopies were needed. The American Board of Internal Medicine surveyed gastroenterology fellowship directors and found that a median of 85 EGDs and 75 colonoscopies were expected [6].

References

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