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Abstract
Introduction Trainees report inadequate exposure and training barriers in acute upper gastrointestinal bleed (AUGIB) endoscopic management. This UK-wide survey evaluated the experiences of trainees and trainers in AUGIB endoscopy training.
Methods A questionnaire was distributed to UK upper GI endoscopy trainees and trainers in 2022–2023.
Results We received responses from 137 trainees (23%) and 115 trainers (76%). Trainees reported higher exposure to diagnostic oesophagogastroduodenoscopies (OGDs) than AUGIB endoscopy (median 300, IQR 203–441 vs 15, IQR 2.5–35.5 lifetime procedures), with variations among grades and regions. Among trainees, 55% were specialist trainee (ST)3–5 and 28% ST6–7; 73% had Joint Advisory Group (JAG) certification for OGDs, and 32% attended a JAG-approved haemostasis course. For ST6–7 trainees, the highest lifetime procedure counts were for band ligation (median 20, IQR 8.5–39) and injection therapy (median 10, IQR 6.5–29.5); the lowest counts were for glue, over-the-scope clip and Danis stent (median 0). ≤41% of ST6–7 trainees felt confident in independent haemostatic procedures. Most trainees (68%) and trainers (64%) reported difficulties in AUGIB endoscopy training. Key barriers included lack of structured training (94% trainees), not being part of the AUGIB on-call rota (78% trainees and 72% trainers) and intensive acute-take commitments (75% trainees and 85% trainers). Suggested improvements included mandatory AUGIB on-call rota participation (89% trainees and 85% trainers), access to JAG-approved haemostasis courses (85% trainees and 84% trainers), simulation-based training (83% trainees and 72% trainers) and reduced acute-take commitments (80% trainees and trainers).
Conclusion This survey highlights limited exposure to haemostasis procedures and low perceived competence among UK trainees. Addressing these challenges provides an opportunity for targeted improvements, ensuring a more comprehensive training experience.
- ENDOSCOPY
- GASTROINTESTINAL BLEEDING
- BLEEDING
Data availability statement
Data are available upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Training for acute upper gastrointestinal bleed (AUGIB) endoscopy is variable across regions, is often unstructured, and trainees frequently report insufficient exposure to necessary procedures.
WHAT THIS STUDY ADDS
This study provides detailed insights into the specific barriers faced by trainees and trainers, highlighting the significant gaps in current training models and the need for structured, standardised training pathways.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The findings advocate for policy changes to include mandatory participation in AUGIB rotas, formal certification and structured training programmes, which could enhance competency among trainees and improve patient outcomes in gastrointestinal bleeding management.
Introduction
Upper gastrointestinal (GI) endoscopy, including the endoscopic management of acute upper GI bleed (AUGIB), is an essential skill for gastroenterologists. However, trainees have reported inadequate exposure to AUGIB endoscopic management and face barriers to training and gaining experience.1 The current gastroenterology curriculum outlines an expectation for trainees to be competent in performing endoscopic management of AUGIB independently by the end of their training.2 However, many gastroenterology trainees are concerned that this level of competence may not be achieved with the current training models.3
AUGIB training is highly variable between regions, often taking the form of ad-hoc teaching and opportunistic access to inpatient lists.4 5 Unlike diagnostic endoscopy, which has moved towards more structured training with objective assessment and certification, there is currently no formal certification system or training pathway for AUGIB endoscopy and haemostasis procedures.6 7 This inconsistency challenges the delivery of comprehensive and standardised training in AUGIB management.
Assessment of current AUGIB endoscopy training from both the trainer and trainee perspectives is essential to guide further improvements in delivering training. This survey aims to evaluate the experiences of both UK trainees and trainers in AUGIB endoscopy training, identify barriers and suggest potential areas for improvement.
Methods
Study design and setting
This prospective questionnaire survey was conducted among UK upper GI endoscopy trainees and trainers at hospitals participating in the 2022 UK AUGIB audit.8 The objective was to evaluate the experiences and training in AUGIB endoscopy to identify barriers and areas for improvement.
Participants
Trainees (specialist trainee (ST) year 3 and above): gastroenterology, surgical and acute medicine trainees performing or training in upper GI endoscopy.
Trainers: named training leads for gastroenterology/endoscopy at each participating hospital (one per hospital site).
Questionnaire development
Two separate questionnaires were developed (online supplemental appendix 1):
Supplemental material
1. Trainee Questionnaire consisted of 20 questions in four sections.
Demographics and training information: included questions on specialty, training grade and additional acute take commitments. Training grades collected ranged from ST year 3–7, with ST3 referring to the first year of gastroenterology training and ST7 as the final year.
Procedural experience: data on diagnostic oesophagogastroduodenoscopy (OGD) and therapeutic AUGIB procedure counts from the Joint Advisory Group (JAG) endoscopy training system (JETS) e-portfolio. Trainees provided cumulative lifetime and last postprocedure counts.
Perceived competence: self-assessed competence in individual AUGIB procedures.
Barriers and improvements: used a Likert-scale format to gather information on barriers to training and potential improvements.
2. Trainer Questionnaire: This included six questions divided into three sections:
Demographics and training environment: number of trainees, exposure to AUGIB training and training provisions.
Barriers and improvements: used a Likert-scale format to gather information on barriers to training and potential improvements from a trainer's perspective.
Survey distribution and data collection
Trainee questionnaires were initially distributed as paper versions and then electronically (JotForm) due to limited responses, resulting in more submissions.9 Detailed instructions were provided to avoid duplicates, and data consistency was checked. Trainer questionnaires were emailed and returned electronically.
Study outcomes
Primary outcome: variation in diagnostic and therapeutic AUGIB OGD exposure across regions and grades.
Secondary outcomes: comparison of procedure counts, perceived competence in haemostatic procedures and opinions on training barriers and improvements.
Statistical analysis
Analyses were conducted using Excel and Python. Descriptive statistics summarised the data, including median and IQR for procedure counts. Spearman’s correlation coefficient assessed correlations between diagnostic and AUGIB procedures. Further analysis calculated the ratio of AUGIB to diagnostic procedures to measure relative exposure. The χ2 tests examined the association between attending a JAG-approved haemostasis course and perceived competence. Missing values were excluded.
Ethical considerations
The survey was part of the UK AUGIB 2022 audit, registered locally at participating hospitals. Participation was voluntary, and responses were anonymised. The study protocol is available online: https://osf.io/zet8r/. The study’s reporting adheres to the Checklist for Reporting Results of Internet E-Surveys statement (see online supplemental appendix 2).10
Results
General characteristics
The survey received 137 trainee and 115 trainer responses. Trainers reported 589 trainees performing endoscopy, with a median of four trainees per site (IQR 2–7). The response rate was 76% (115/152) for trainers and 23% (137/589) for trainees. The denominator for calculating trainee response rates was based on the number of trainees reported by the trainers.
Among the trainees, 90% (123) were gastroenterology trainees, 4% (5) were surgical trainees, 1% (2) were acute medicine trainees, and 5% (7) were from other specialties. Training grades included: 55% (75) ST3–5, 28% (39) ST6–7 and 16% (22) were currently out of the programme. Additionally, 12% (17) were training less than full time. Trainees from all UK training regions were represented (online supplemental table 1). Regarding certification, 73% (100) of trainees had JAG certification for diagnostic OGD, that is, considered competent to perform OGDs independently, and 32% (44) had attended a JAG-approved haemostasis course.
Supplemental material
AUGIB Rota participation
Of the trainees, 20% (27) were on the AUGIB rota, with varying frequencies: 33% (9) weekly, 37% (10) fortnightly, 15% (4) monthly and 15% (4) less than once a month. The distribution across training levels showed that 22% (6) were out of the programme, 22% (6) were ST3–4, 33% (9) were ST5–6 and 19% (5) were ST7 or above. Trainees from 12 out of 17 training regions reported being part of the AUGIB on-call rota. 77% (105) of trainees had additional on-call commitments, with 88% (91) participating in regular acute general internal medicine on-call.
Trainer data
Training environments varied: 54% (59) of trainers provided training through semielective inpatient lists, mostly on weekdays (93%) and occasionally on weekends (7%). Additionally, 28% (31) described training as ad hoc, and 4% (4) reported no specific AUGIB training regimen. Sites with trainees on the AUGIB rota (14%) ensured daily access to inpatient lists with consultant supervision.
Procedural experience
The median number of lifetime diagnostic endoscopy procedures performed by trainees was 300 (IQR 203–441), compared with a median of 15 for lifetime AUGIB-related endoscopy procedures (IQR 2.5–35.5). In the trainees’ last post, the median number of diagnostic endoscopy procedures was 96 (IQR 34–150), compared with a median of 5 (IQR 0–15) for AUGIB-related procedures.
Variability in procedures as per training region
There was variability in diagnostic OGD and AUGIB procedure counts across different regions (figure 1) Linear regression analysis showed a strong positive correlation between lifetime diagnostic OGDs and AUGIB procedures (Spearman r=0.88, p<0.0001) (online supplemental figure 1) and a moderate positive correlation between last postdiagnostic OGDs and AUGIB procedures (Spearman r=0.58, p=0.015) (online supplemental figure 2).
Lifetime and last postdiagnostic and AUGIB procedures (median, IQR). The x-axis represents different regions, with the total number of responses from each region indicated in brackets. AUGIB, acute upper gastrointestinal bleed.
To further explore limited exposure to AUGIB procedures compared with diagnostic procedures, we calculated the ratio of AUGIB procedures to diagnostic procedures for each region (online supplemental figure 3). Median ratios were less than 0.10 for lifetime procedures and less than 0.20 for the last postprocedures.
Variability in procedures as per grade
Online supplemental table 2 and figure 2 show the distribution of lifetime diagnostic and AUGIB procedures by training grade (ST3–7). Median diagnostic procedures increase from 81 at ST3 to 538 at ST7, while AUGIB procedures rise from 0 at ST3 to 40 at ST7. Linear regression showed an excellent fit for diagnostic procedures (R²=0.99) and a strong fit for AUGIB procedures (R² = 0.93), with yearly exposure increasing by around 110 diagnostic and 11 AUGIB procedures (figure 2).
Lifetime diagnostic and AUGIB oesophagogastroduodenoscopy procedures by grade with trend lines and median values. AUGIB, acute upper gastrointestinal bleed; ST, specialist trainees.
Competence and exposure to haemostasis procedures
Competence and exposure to haemostasis procedures varied widely by therapy type. Less common procedures like Danis stent, over-the-scope clip (OTSC), glue injection and Sengstaken tube had a median of 0, while more frequent procedures showed greater variability: variceal band ligation (VBL) (median 6, IQR 1–20), injection therapy (median 4, IQR 0–10) and haemostatic clipping (median 2, IQR 0–10) (online supplemental figure 4).
Procedure exposure increased with training level. ST3–5 trainees had lower medians: VBL (2, IQR 0–7), injection therapy (1, IQR 0–5) and clipping (1, IQR 0–3). ST6–7 trainees showed higher medians: VBL (20, IQR 8.5–39), injection therapy (10, IQR 6.5–29.5) and clipping (12, IQR 5–23). Procedures like Danis stent, OTSC, glue injection and Sengstaken tube consistently showed low medians across both groups (figure 3).
Box and Whisker plot of lifetime procedure counts for haemostatic procedures by training grade (ST3–5 vs ST6–7). The red and blue lines represent the median and IQR, respectively. ST, specialist trainees.
Overall perceived competence in AUGIB procedures varied, with the highest independence reported for VBL (18%), injection therapy (18%) and haemostatic clipping (18%). Conversely, glue injection (2%), OTSCs (1%) and Danis stents (0%) had the lowest perceived independence. Many trainees reported being in training or having no experience with most procedures, particularly OTSC (67%), Danis stents (61%) and glue injection (55%) (online supplemental figure 5).
Among ST3–5 trainees, independence was low for most procedures, with VBL (6%) and clipping (8%) being the highest (online supplemental figure 6). ST6–7 trainees reported greater independence: VBL (39%), injection therapy (41%) and clipping (37%), but low competence for glue injection (4%), OTSC (2%) and Danis stents (0%) (online supplemental figure 7).
Trainees who attended a JAG-approved haemostasis course were significantly more likely to feel independent in VBL, injection therapy, thermal devices and clipping compared with those who did not attend the course (p<0.05).
Barriers to AUGIB training and suggested improvements
Trainees and trainers identified barriers to effective training in AUGIB management (figure 4). Among trainees, 68% (93) reported difficulty in gaining experience, with significant barriers including a lack of structured training opportunities (94%), not being part of the AUGIB on-call rota (78%), and intensive acute take commitments (75%). Additional barriers included the lack of formal certification in AUGIB (66%) and procedures being performed primarily by consultants (60%). Personal inexperience or lack of confidence was reported by 40%.
Barriers and suggested improvements in trainee and trainer responses.
Trainers reported similar difficulties, with 64% (72) acknowledging challenges in providing training. Key barriers included intensive acute take commitments (85%), trainees not being part of the AUGIB on-call rota (72%) and a lack of clear guidance on formal certification (68%). Resource constraints to provide structured training (55%), organisational barriers (38%) and a need for additional resources such as courses or e-learning (39%) were also highlighted.
All trainees (137) and trainers (115) were asked to rate suggested improvements for AUGIB training in the UK. Trainees suggested several improvements, such as mandatory participation in AUGIB procedures (89%), access to JAG-approved haemostasis courses (85%) and simulation-based training (83%). Other suggestions included reducing acute take commitments for senior trainees (80%) and mandatory JAG certification in AUGIB management (66%). Establishing predefined minimum procedure requirements for the JETS portfolio was supported by 59%.
Trainers’ suggestions aligned with those of trainees, advocating mandatory participation in the AUGIB on-call rota (85%), increased access to JAG-approved haemostasis courses (84%) and simulation-based training (72%). They also suggested reducing acute take commitments (80%) and setting predefined procedure requirements (76%). Mandatory JAG certification in AUGIB management was supported by 71%.
Discussion
This survey highlights a disparity between exposure to AUGIB endoscopy versus diagnostic procedures among trainees. AUGIB procedural counts are consistently lower across all training regions and grades, reflecting systemic issues in current training models. Overall, less than 20% of trainees (and ≤41% of ST6–7 trainees) report independent practice in haemostatic procedures, indicating insufficient exposure and training. While many trainees are certified to perform diagnostic OGDs, they are rarely involved in AUGIB endoscopy and haemostasis procedures, likely due to the absence of a defined certification pathway.
Key barriers identified include lack of structured training, AUGIB on-call rota exclusion, intensive acute take commitments and no formal AUGIB certification. Addressing these barriers is crucial for improving training experiences. Both trainees and trainers suggested improvements. These included mandatory participation in AUGIB rotas, access to JAG-approved haemostasis courses, simulation-based training, reducing acute take commitments for senior trainees, mandatory JAG certification in AUGIB management, and establishing predefined minimum procedure requirements for the JETS portfolio. JAG’s rigorous training pathways for diagnostic endoscopy have established a model that promotes excellence in quality standards for endoscopy in the UK and has had global influence.11 However, similar standards are lacking for AUGIB certification.
The analysis reveals significant differences in exposure to diagnostic OGDs and AUGIB procedures across training grades (ST3–7). Although diagnostic OGD experience increases steadily with each grade, AUGIB experience does not follow this trend, highlighting a gap in the training curriculum. A previous UK study reported a reduction in the number of AUGIB procedures performed by trainees, from 76% in 1996 to 15% in 2015 (p<0.001) and highlighted a lack of exposure to complex and challenging cases.4
Less commonly performed procedures, such as Danis stents, OTSCs, glue injection and Sengstaken tubes, showed limited exposure, which is concerning given the need for proficiency in a range of procedures. More commonly performed procedures, like VBL, injection therapy and thermal device usage, show higher medians but substantial variability, indicating room for improvement.
A recent study on the learning curve for endoscopic haemostasis in AUGIB management found that trainee endoscopists need an average of 20 supervised procedures to achieve competence in basic haemostatic techniques, with more extensive experience required for advanced procedures like OTSC placement.7 While senior trainees meet the VBL threshold, wide variability in other procedures highlights the need for consistent, structured training across all haemostatic techniques in AUGIB management. The limited AUGIB endoscopy exposure among trainees, especially with the reduced training time to 4 years under the Shape of Training in the UK, could lead to less effective management of GI bleeding and impact patient outcomes as the trainees advance to consultant roles.12 Training in these procedures is essential to maintain care standards. The lifetime ratio of AUGIB procedures to diagnostic procedures is less than 0.10 (online supplemental figure 3). The 2022 UK audit reported that one in three inpatient endoscopies for AUGIB required endotherapy, underscoring the need for a benchmark for the number of procedures trainees must perform along with completing courses to demonstrate competency.13 This benchmark would ensure trainees are adequately prepared to work independently as consultants.
Enhanced training programmes providing comprehensive exposure to a wider array of procedures are necessary. Structured training opportunities, including hands-on workshops and simulation-based learning, could address these gaps. Integrating less common but critical procedures into regular training curricula could ensure all trainees achieve a minimum competency level, improving patient care in AUGIB management.
About a third of the participants reported having attended the JAG-approved haemostasis course developed as part of the BSG Endoscopy Quality Improvement initiative.14 A previous study from Yorkshire reported significant improvement in the knowledge, procedural skills and confidence of 22 delegates in managing AUGIB post a haemostasis course (p<0.001).15 In our survey, trainees who attended the JAG-approved haemostasis course were significantly more likely to feel independent in procedural competencies. However, potential confounders such as training grade and other factors may influence perceived independence. Future studies with robust data may clarify the impact of these courses on trainee competence.
Identifying key performance indicators to be achieved with set milestones during training progression would hold training programme directors accountable for ensuring adequate training. Additionally, mandating attendance at a JAG AUGIB haemostasis course and setting personalised development plans at each stage of training would benefit trainees and trainers alike. Training centres should be expected to provide access to appropriate AUGIB training as part of their JAG accreditation.
Introducing an ‘immersion’ in therapeutic endoscopy for senior trainees, including on-call duties, could ensure comprehensive AUGIB procedure exposure, though implementation may vary. While balancing acute take commitments, it remains essential to provide senior trainees access to AUGIB training lists during working hours and emergency on-call AUGIB rotas to improve training quality and outcomes. Our survey found that only one in five trainees were on the AUGIB rota, revealing a gap in exposure. Being on a rota often means supervised exposure rather than structured training, but it still provides essential experience in triage, haemostatic techniques and decision-making during emergencies. While senior trainees are usually expected to join, junior trainees also participate in some regions, offering early exposure and skill development under supervision.
One of the strengths of this study is its comprehensive approach, capturing data from trainees and trainers across various UK regions, providing a broad perspective on the current state of AUGIB training. However, the study has limitations, including a relatively low trainee response rate, possibly due to the detailed information sought and survey fatigue during the COVID-19 pandemic. Additionally, responses from more junior trainees in certain regions may skew the results, underscoring the need for graduated training across all grades. The lower trainee response rate (23% vs 76% for trainers) may introduce response bias, limiting the generalisability of our trainee findings. Future studies could use National Endoscopy Database data to validate self-reported counts and improve accuracy. However, our study’s national scope and dual perspectives offer valuable insights for enhancing AUGIB training.
Despite these limitations, the findings align with previous studies highlighting regional variability in training experiences and the need for standardised certification pathways.1 5 The use of medians in this study, given the non-normal distribution of experiences, effectively illustrates the wide variability in procedural exposure among trainees, supporting the call for standardised certification.1 16 While UK-based, the study has international relevance, as similar endoscopy training challenges exist elsewhere.17 The global scarcity of standardised haemostasis training programmes underscores the novelty of our study and the need for consistent training that could serve as a model internationally. Policy changes mandating structured training and certification pathways, along with dedicated funding, are crucial to ensure consistent competency and sustain high-quality, accessible programmes.
In conclusion, this survey demonstrates profound deficiencies in AUGIB endoscopy training within the UK, highlighting limited exposure to haemostasis procedures and low perceived competence. Recognising these challenges provides an opportunity for targeted improvements, ensuring a more comprehensive and robust training experience moving forward. Implementing the suggested changes could enhance the training process, preparing trainees better for their future roles as consultants and ultimately improving patient outcomes.
Supplemental material
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Acknowledgments
All participating hospitals, trainees and trainers providing data for this. UK AUGIB audit steering committee
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
GBN and AM are joint first authors.
Collaborators UK 2022 Acute Upper GI bleed (AUGIB) audit steering committee Paul Davies: National Comparative Audit of Blood Transfusion NHS Blood and Transplant, UK. Paula Dhiman: Center for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK. Lise Estcourt: NHS Blood and Transplant, Oxford University Hospitals NHS Trust, Oxford, UK. Vipul Jairath: Department of Medicine, Division of Gastroenterology, Schulich school of Medicine, Western University; Department of Epidemiology and Biostatistics, Western University, London, ON, Canada. Bhaskar Kumar: Norfolk and Norwich University Hospital, Norwich, UK. Mike F Murphy: NHS Blood and Transplant, Oxford University Hospitals NHS Trust, Oxford, UK. Raman Uberoi: Department of Interventional Radiology, Oxford University Hospitals, Oxford, UK.
Contributors GBN made equal contributions to the conceptualisation, supported data curation, led the formal analysis and was involved in writing the original draft, review and editing process. AM provided assistance in data analysis, data interpretation, and contributed to writing the original draft. JGC made equal contributions to data curation and participant recruitment. AD supported participant recruitment with assistance from all authors and provided overall supervision for the project. All authors, including ER, JGC, JAL, KO, AJM, ST, SH, AJS and AD, provided critical inputs, reviewed, and edited the manuscript. GBN and AD are guarantors of this article on behalf of all co-authors.
Funding This work was supported by funding from NHS Blood and Transplant, and the British Society of Gastroenterology for the 2022 UK acute upper gastrointestinal bleeding audit. GBN is funded by National Institute for Health and Care Research (Grant number 302607) for a doctoral research fellowship.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.