200 upper GI endoscopies "appropriate" requirement for competency

Reuters Health Information: 200 upper GI endoscopies "appropriate" requirement for competency

200 upper GI endoscopies "appropriate" requirement for competency

Last Updated: 2016-04-08

By Will Boggs MD

NEW YORK (Reuters Health) - The requirement of 200 esophago-gastro-duodenoscopies (EGDs) to achieve competency, as defined by the unassisted ability to pass the endoscope into the second part of the duodenum, seems reasonable, according to an analysis of the U.K. national training database.

"Some trainees (especially surgical) find it difficult to accumulate the necessary experience to achieve this number and have therefore questioned this standard," Dr. Stephen T. Ward from the University of Birmingham in the U.K. told Reuters Health by email. "This study provides objective evidence that 200 appears appropriate in order to ascertain the necessary skills and complete one's learning curve."

The number of EGDs deemed necessary to establish competency ranges from 130 procedures in the USA to 150 in Canada to 200 in the U.K. and Australia. There are few studies to support any of these targets.

Dr. Ward's team used data from the Joint Advisory Group (JAG) endoscopy training system (JETS) to analyze the learning curve to achieve competency in EGD completion.

They defined EGD completion as passage of the endoscope by a trainee to the second part of the duodenum (D2) without physical assistance, the same definition used by JAG to define a complete procedure.

By moving average analysis, the 95% EGD completion rate was achieved after an average 187 procedures, the researchers report in Gut, online March 14.

Similarly, by learning curve cumulative summation analysis, >90% of trainees achieved competency after 200 procedures.

The total number of procedures performed by a trainee, trainee specialty, trainee age, and lower GI endoscopy experience, especially colonoscopy, were independently associated with EGD completion.

"The ability to perform endoscopy independently to the high standard that patients deserve requires experience of a greater number of procedures than previously thought," Dr. Ward said. "Furthermore, this study only assesses the technical ability to complete the procedure and perform a successful J-maneuver."

"As standards in endoscopy continue to improve, assessment of other parameters, such as trainee ability to recognize pathology, will be required to gain a license for independent practice," he said.

Dr. Ward added, "I believe that endoscopy trainees are no different wherever they are in the world. I wouldn't expect trainees in the U.S. to have a naturally shorter or longer learning curve than trainees in the U.K. It is possible that trainees in some countries undergo periods of immersion training, which could potentially shorten the number of procedures required, but there is little evidence to suggest that this would be the case for EGDs."

Dr. Rajesh N. Keswani from Northwestern University in Chicago, who has also studied endoscopy learning curves, told Reuters Health by email, "It is surprising that it takes a fairly large number of procedures to achieve what could be considered a very generous definition of competency."

"Specifically," he said, "there is a great deal more to performing a high-quality EGD than simply reaching the second portion of the duodenum. Recognizing subtle pathology, performing adequate biopsies of relevant pathology, management of strictures, and recognition of abnormalities at the gastroesophageal junction are among the many other skills that are required to achieve competency in EGD. It is unknown, but I suspect that these take far more EGD exposure to achieve competency, i.e., many more than 200 EGDs."

"I think we need to be cognizant of how we define competency before we focus solely on 'assessing it,'" Dr. Keswani said. "Regardless, the authors emphasize that competency should not be measured by a procedure number - rather, by an objective assessment of endoscopist skill by the trainer."

SOURCE: http://bit.ly/1SECoJq

Gut 2016.

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