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Abstract
Background Physician training in the UK is undergoing considerable change due to the implementation of recommendations made in the Shape of Training Review. In particular, higher specialty training (HST), including gastroenterology, will be shortened from 5 to 4 years. This will also incorporate general internal medicine (GIM) training. There is concern among gastroenterologists regarding how high-quality gastroenterology training will be delivered in 4 years.
Methods The 2018 British Society of Gastroenterology (BSG) trainees’ survey results were used to examine the potential impact of a 4-year HST period on achieving key competencies in gastroenterology.
Results 291 (49.4%) gastroenterology trainees responded. Satisfaction with gastroenterology training was high (79.6% respondents), and self-reported confidence in hepatology training was also high (84% senior respondents). However, only half (51.1%) of the respondents achieved complete colonoscopy certification by their final year of training. Comparison with the 2014 BSG trainees’ survey demonstrated that the number of endoscopy procedures achieved by trainees has reduced in sigmoidoscopy (p=0.006) and colonoscopy (p<0.001). The proportion of time spent in GIM training has increased since the last survey, with 81.8% of the respondents spending more than 25% of their time in GIM. GIM training was reported to be a key barrier to adequate gastroenterology and endoscopy training.
Conclusion These data indicate significant barriers to delivering gastroenterology and endoscopy training within the current 5-year programme. Novel strategies will be required to improve the rate of progression in endoscopy training, in particular if high-quality gastroenterology HST training is to be delivered in 4 years.
- endoscopy
- colonoscopy
- nutrition
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Introduction
Higher specialty training (HST) in gastroenterology in the UK currently takes a minimum of 5 years. During this period, trainees attain a broad range of clinical and technical skills, while balancing the service provision of a general medical rota. Many trainees will also undertake further training in subspecialist areas of gastroenterology, including hepatology, inflammatory bowel disease and nutrition. The 2014 British Society of Gastroenterology (BSG) trainees’ survey1 revealed that general internal medicine (GIM)-related activities are a significant barrier to the acquisition of endoscopic skills.
Demand for endoscopy services is rising,2 3 with a 44% increase in endoscopic procedures predicted between 2015 and 2020.4 This increase in demand is due to several factors, including 2-week wait gastrointestinal cancer exclusion pathways and the development of the National Bowel Cancer Screening Programme (BCSP).5 The planned replacement of faecal occult blood testing with faecal immunochemical testing is expected to considerably increase BCSP colonoscopy demand.6 Gastroenterologists make up 40% of the endoscopic workforce in the UK2 and, despite other strategies to increase endoscopy capacity with nurse endoscopists and non-clinical endoscopists, more gastroenterologist-delivered endoscopy capacity will be required to meet demand. Colonoscopy is not currently a mandatory requirement for gastroenterology training, and trainees pursuing a hepatology subspecialty interest may opt out of training. However, the Joint Royal College of Physicians Training Board (JRCPTB) recognise that most trainees choose to accredit in colonoscopy, and the 2013 curriculum states that sufficient resources must be available to facilitate this.7
Another anticipated area of increased demand is in the management of patients with liver disease. Since 1970, mortality from liver disease has risen by 400% in the UK8; furthermore, mortality in isolation underestimates the burden of liver disease.9 A deficiency of consultant gastroenterologists with sufficient hepatology experience has been suggested as a contributory factor to this mortality.8 The National Liver Plan10 advises there should be at least one hepatologist in every trust. The current gastroenterology curriculum recommends a minimum of 1-year hepatology training for all gastroenterologists (with at least 6 months in a level 2 or 3 centre), with a further year of specialist training for those pursuing subspecialty accreditation in hepatology.
The Shape of Training (SoT) report11 recommended changes to postgraduate training to produce doctors who can manage patients with multisystem disease. This will be achieved by changing training pathways to produce ‘more broadly trained’ doctors with experience of wide-ranging presentations, symptoms and diagnoses. In response, the JRCPTB has redesigned the medical training pathway to extend prespecialty training (previously core medical training (CMT)) to 3 years (internal medicine training (IMT)). Following this, trainees will enter a 4-year HST programme. This reduction in training time has the potential to impact on the attainment of specialist competencies and skills.
We present the findings of the 2018 BSG trainees’ survey, examining the potential impact of the proposed SoT changes on the ability to meet the training needs of gastroenterology trainees in the context of future service demands.
Methods
The BSG trainees’ survey runs on a 4-year cycle, with the previous survey performed in 2014. Survey questions were written by the authors based on prior iterations of the survey, then reviewed and agreed by BSG trainees’ section members. A web-based survey tool (SurveyMonkey) was used for data collection. Email invitations to complete the survey were sent to all higher specialty gastroenterology trainees in the UK using established trainee databases, and advertised on Twitter through the BSG trainee section account. The survey was open to respondents for 6 weeks from March to May 2018. Endoscopy data entered by survey participants were self-reported.
Endoscopy data for the 2014 and 2018 survey cohorts were analysed in Excel (Microsoft) and Prism V.7 (GraphPad Software). Where respondents had written a range for number of endoscopic procedures, the lower value was used. Where statistical tests were used, normality testing with D’Agostino and Pearson or Shapiro-Wilk test was performed, and the appropriate parametric or non-parametric test applied.
Results
Demographics
291 gastroenterology trainees responded to the questionnaire out of 609 gastroenterology trainees nationally (47.8%).12 The majority were male (61.5%), matching the national composition of gastroenterology trainees (60.0% male). All training grades were represented (table 1), and there were respondents from all deaneries.
Respondents’ demographics
General satisfaction with training quality
Of the respondents, 79.6% were satisfied or very satisfied with their overall training in gastroenterology, similar to 2014 (82.9%). Most respondents were satisfied or very satisfied with training in inflammatory bowel disease (81.7%), hepatology (71.0%) and basic endoscopy (70.6%). Fewer respondents reported being satisfied or very satisfied with training in nutrition (54.5%), functional gastrointestinal disorders (49.8%) and advanced endoscopy (29.4%). Only 28.4% of the respondents believed GIM training to be of good quality, with trainees citing service demands (78.2%) and workload pressure (58.4%) as reasons that training was compromised.
Endoscopic procedural experience in 2018 BSG trainee surveys
Self-reported data on Joint Advisory Group (JAG) certification status and the number of endoscopic procedures performed were available for 234 and 277 respondents from the 2014 and 2018 surveys, respectively (tables 2 and 3). Academic clinical fellows, research fellows and locum appointments to training were not included in the analysis unless their grade of training was clear.
JAG accreditation for endoscopic procedural competency by stage of training (2018 survey data)
Endoscopic procedure experience by stage of training and year of survey
Almost all trainees obtained provisional JAG accreditation in oesophagogastroduodenoscopy (OGD) by specialty training level 5 (ST5) (94.3%). The number of procedures performed by respondents varied widely, with a median of 300 (IQR 250–356) procedures for ST4 respondents and a median of 670 (IQR 500–1250) for ST7 respondents (figure 1A). As expected, progress with colonoscopy was slower, with 17.1% of respondents achieving provisional accreditation by ST5, 54.1% by ST6 and 84.8% by ST7. Progress to complete accreditation was lower, with only 13.5% of ST6 respondents and 51.1% of ST7 respondents achieving this, consistent with the considerable number of ST6 and ST7 trainees who had performed fewer than 300 procedures (figure 1C, D). The number of flexible sigmoidoscopies performed by ST7 respondents was low (median 200, IQR 100–300).
Number of endoscopic procedures for respondents by stage of training. The number of procedures performed by respondents from the 2018 survey, categorised by stage of training, for (A) OGD, (B) flexible sigmoidoscopy and (C) colonoscopy is shown. Both box and whiskers plots (median, IQR, range) and scatter plots are displayed. For OGD (A) and colonoscopy (C), the dotted line indicates 200 and 300 procedures, respectively, the minimum requirement for JAG accreditation. (D) The proportion of respondents who have achieved JAG accreditation for OGD and colonoscopy at each stage of training. JAG, Joint Advisory Group; OGD, oesophagogastroduodenoscopy; ST, specialty training.
Comparison of endoscopic procedural experience between 2014 and 2018 BSG trainee surveys
Endoscopic procedural experience of respondents of different grades was compared between the 2014 and 2018 survey results. The numbers of OGDs, sigmoidoscopies and colonoscopies were numerically lower in the 2018 survey than the 2014 survey, with significantly lower numbers of OGDs for ST6 and ST7 respondents (figure 2A–C).
Comparison of the number of endoscopic procedures for respondents by stage of training between the 2014 and 2018 surveys. The number of procedures performed by respondents from the 2014 (blue) and 2018 (red) surveys, categorised by stage of training, for (A) OGD, (B) flexible sigmoidoscopy and (C) colonoscopy is shown. Scatter plots with median and IQR are displayed. The dotted lines indicate the minimum requirement for complete JAG accreditation (200 for OGD and sigmoidoscopy, 300 for colonoscopy). **P<0.01 (Mann-Whitney test). (D) The proportion of respondents completing the minimum required numbers of procedures for OGD (200, solid line), flexible sigmoidoscopy (200, dotted line) and colonoscopy (300, dashed line) is shown for the 2014 survey (blue) and 2018 survey (red). P value statistics from two-way analysis of variance with Sidak’s multiple comparisons test. JAG, Joint Advisory Group; OGD, oesophagogastroduodenoscopy; ST, specialty training.
The JAG criteria for provisional and complete accreditation in endoscopy have changed in recent years with a requirement for an increased number of direct observation of procedure skills (DOPS) assessments, and this was therefore not compared between the two surveys. The majority of trainees did not feel that the increased DOPS requirement had adversely affected their ability to achieve accreditation (69.2%).
The proportion of respondents completing the minimum number of procedures required for accreditation was compared for each stage of training between the two surveys. The proportion of respondents who had performed more than 300 colonoscopies or more than 200 sigmoidoscopies was significantly lower in the 2018 survey at all stages of training (p=0.0059 and p=0.0007, respectively, two-way analysis of variance with Sidak’s multiple comparisons test), while progression to 200 OGDs was similar (figure 2D). The total number of colonoscopies performed by senior trainees (ST6 and ST7) expressing a hepatology subspecialty interest was significantly lower than trainees who identified themselves as general gastroenterologists or had an alternative subspecialty interest (mean 263 vs 469 procedures, p=0.0042).
Perceptions of endoscopy training
Only 66.4% of trainees had regular endoscopy training lists at least weekly. Of the trainees, 57.5% reported using annual leave or ‘zero’ days to gain additional endoscopy training.
The impact of GIM training and other service commitments were considered to be the most significant barriers to endoscopy training, and the proportion of trainees expressing this view has increased since the 2014 survey (71.8% vs 64.2%). Other difficulties encountered in endoscopy training were insufficient number of dedicated training lists (57.4%) and training lists not tailored to the trainee’s needs (too many procedures or wrong case load) (48.0%).
Respondents were asked about their experience of working with trainee nurse endoscopists (TNEs). Of the respondents, 74.6% had TNEs in their endoscopy unit, and 45.9% stated that the presence of TNEs had had a negative effect on their endoscopy training, while 14.3% reported it had had a positive impact. The negative impact was perceived to be due to reduced availability of dedicated training lists and ad hoc training opportunities. Positive impact included nurse endoscopists training gastroenterology trainees, or TNEs and gastroenterology trainees collaborating to maximise training opportunities.
Hepatology training
Of the respondents, 69.4% stated that subspecialist hepatology training was available within their deanery. Among senior trainees, the majority had transplant unit exposure (57.1%) and experience at a unit providing care for complex liver disease (74.4%) (table 4). All trainees had exposure to general and specialist hepatology clinics, with the exception of non-alcoholic fatty liver disease (NAFLD) clinics, to which only 58% of senior trainees had exposure.
Hepatology exposure
The majority of senior trainees were confident that they had adequate hepatology training (84%). ST6 and ST7 trainees who had spent longer than 3 months in a level 2 or 3 liver unit were more likely to describe themselves as ‘confident’ or ‘very confident’ in their hepatology skills than trainees who had spent less than 3 months in a unit (97.7% vs 74.4%). Trainees who self-selected as intending to provide specialist hepatology care as a consultant had lower levels of exposure and lower self-reported confidence in their hepatology experience.
GIM impact
The vast majority of trainees (97.2%) dual-accredit in GIM, although 23.8% were out of programme at the time of the survey. Of the trainees, 34.6% reported spending 30% of their time doing GIM, followed by 19.2% spending 40% of their time. The proportion of time committed to GIM has increased since the same question was asked on the 2014 survey1 (figure 3).
Respondents (%) reporting differing proportions of time spent on general internal medicine (GIM) training in the 2014 and 2018 surveys. The proportion of respondents who reported spending greater than 25% of their time on GIM training is also shown.
Of the respondents, 63.8% stated that GIM currently has a negative impact on their training, compared with 14.2% who described the impact as positive. Only 27.4% of ST6 and ST7 respondents stated an intention to continue GIM as a consultant, and 50.0% have actively decided not to continue GIM, with the remainder undecided.
Of the respondents (n=103) who did not wish to continue GIM as a consultant, 68% felt GIM had a negative impact on their gastroenterology training. Despite this, 50.5% believed it to be useful to them as a consultant, compared with only 20.3% who did not. Of this cohort, 57.3% would stop GIM training given the opportunity, compared with 23.3% who would continue and 19.4% who were undecided.
Discussion
Data from the 2018 BSG trainees’ survey in 2018 demonstrate that trainees at all levels are performing fewer endoscopies compared with their counterparts in 2014. Trainees report a contemporaneous increase in the proportion of their training time spent performing general medical duties, and the demands of GIM are viewed as the most significant barrier to accessing endoscopy training. The current structure of early physician training will undergo significant changes in response to SoT. A key change is the transformation of CMT to IMT. This will result in a reduction in higher specialist gastroenterology training to 4 years. The development of the new higher specialty curriculum in gastroenterology is still ongoing.
Endoscopy training in the UK is typically undertaken in a sequential manner, with colonoscopy training commenced only once competence in gastroscopy is achieved.1 Outcomes from the 2018 survey indicate that only half of all trainees are achieving full colonoscopy certification after 5 years of gastroenterology training. After 4 years, only 13.5% had achieved full certification. This demonstrates that the fifth year of training (currently ST7) is critical for achieving the competence required to practise independent colonoscopy. By compressing HST into 4 years, we anticipate a reduction in colonoscopy capacity from new consultants, which is especially concerning at a time when demand for colonoscopy is increasing substantially. New strategies for more rapid endoscopic training will be needed to ensure the new consultant workforce is able to meet the demands of the population, and to address the imbalance between training and projected workload. This could include ‘immersion training’ in which a dedicated period of focused endoscopy training can lead to acquisition of competence in weeks or months,13 or embarking on colonoscopy training from the outset of HST.
TNEs represent a vital part of the endoscopic workforce in an era of increased demand.4 However, their increasing presence in endoscopy units is having a negative impact on some trainees’ access to regular training lists. Trainees cited a perceived loyalty of units to TNEs, who had often been long-standing staff members, and cited increased competition for training lists. Consideration is required from individual units to balance the needs of these groups, although many trainees had experienced good practice where collaboration had benefited all. Changes to the assessment requirements for JAG certification were not felt by most trainees to be an obstacle to gaining accreditation.
The configuration of hepatology training following the SoT reform has not yet been finalised. However, current training in hepatology appears to be of good quality, with a majority reporting exposure to the main aetiologies of liver disease and time in subspecialist units. The only area of concern was NAFLD exposure, which was reported by only 40% of ST6 trainees, but 71% of ST7 trainees. As NAFLD is a rapidly growing cause of liver disease, training in screening, diagnosis, effective lifestyle advice and more advanced therapeutics is important to address.
Among ST6 trainees 73.7% reported being ‘confident’ or ‘very confident’ that they had adequate hepatology training, and this proportion was higher in those who had spent at least 3 months in a level 2 or 3 liver unit. This suggests that overall hepatology competencies could reasonably be acquired within 4 years alongside general gastroenterology, especially if trainees with a hepatology interest are identified at an early juncture and can therefore tailor their curriculum requirements. Hepatology trainees are performing fewer colonoscopies than their counterparts, which may represent a positive decision not to invest training time in accrediting in lower gastrointestinal endoscopy.
The interaction between GIM and gastroenterology training is an important theme of the survey responses. Even among those who actively do not plan to perform GIM duties as a consultant, 80% believed that training in GIM was useful to them in their future practice as a consultant, suggesting an appreciation of the broad-based skills GIM training affords. However, 68% believe it has a negative impact on training in gastroenterology. Furthermore only 28.4% believed the quality of training they received in GIM was adequate, citing service pressures and heavy workload.
SoT proposals11 currently suggest up to 25% (12 of 48 months) of training time will be spent performing GIM, allowing a maximum of 36 months of gastroenterology training, in line with many international training programmes.14 At present, 81.8% of trainees report spending more than 25% of training in GIM, an increase since 2014. A key goal of SoT is to enhance the generalist skills of the future consultant workforce to better care for an ageing and increasingly comorbid population.11 However, future training programmes must balance this with the need for excellent specialist training to develop the future gastroenterology workforce required by our patients. It is unclear how the GIM requirement will be delivered following SoT, and is likely to vary across the UK. Endoscopy training typically occurs inhours, and over half of trainees report using their annual leave or ‘zero’ days to attend additional training lists. Changes in the working patterns dictated by the 2016 junior doctors contract15 place strict safeguards for time off in lieu after on-call shifts, and rota patterns will have to be carefully modelled to ensure gastroenterology trainees are not unduly affected in missing weekday endoscopy training.
Several strategies could mitigate the impact of GIM on gastroenterology training. While a reduction in the GIM commitment would be contradictory to the principles of SoT, ensuring that this is limited to an appropriate fixed proportion of time over a specialist training programme would protect gastroenterology training time, and mitigate against disparities between trusts and regions. This study indicates that measures to support endoscopy training are of particular importance. Development of fast-track programmes (similar to those available to nurse endoscopists) or deep immersion periods, as discussed earlier, could play a valuable role.16
However, it is likely that trainees will seek out opportunities to gain additional specialist training through periods out of programme and post-HST fellowships. This does not address the problem of increased GIM commitment but would allow trainees to develop the skill set that their future job roles require. Unfortunately, this would represent an informal prolongation of training.
This study has limitations, as the data are derived from a self-reported questionnaire. The response rate (47.8%) was high for a survey of this type, with the gender mix of respondents representative of gastroenterology trainees nationally, from all grades and all geographical regions. Trainees’ self-reported experience of clinical exposure may not be a true reflection of their competence in those domains, and the responses may represent bias towards trainees with strong views on their training quality. Subjective assessment of time spent in GIM activities was required, and rota patterns will vary nationally. We anticipate that self-reported numbers of endoscopy procedures are likely to be accurate, as trainees typically have a record of these data in their JAG endoscopy training system (JETS) ePortfolio.
Conclusion
The results of this large national survey come at a time of significant change in HST in gastroenterology. These data suggest that, although 4 years may be adequate time to train in hepatology, many trainees require 5 years to adequately train in endoscopy based on current JAG requirements. New approaches are urgently required to improve access to endoscopy training if the future workforce is to meet projected colonoscopy demands. Strategies for limiting the impact of GIM training on gastroenterology exposure, as well as pilot programmes for novel training models, are now required.
Significance of this study
What is already known on this topic
The proposed Shape of Training Review proposes a reduction in higher specialty training in the UK to 4 years.
This represents a significant change, and the impact on gastroenterology training is uncertain.
What this study adds
The 2018 British Society of Gastroenterology trainees’ survey highlights areas of good practice, but raises concerns in acquisition of endoscopic competence.
The proposed reduction in higher specialty training time will further increase the pressure on endoscopy training.
How might it impact on clinical practice in the foreseeable future
The data will aid planning to mitigate the impact of the changes to higher specialty training, ensuring that the new consultant workforce have the required skills to meet population demand for endoscopy provision and subspecialty skills.
Acknowledgments
The authors would like to thank the members of the 2018 British Society of Gastroenterology Trainees’ Committee who contributed to the design of the survey and distributed it to trainees across the UK.
Footnotes
JC, MF, PH and LM contributed equally.
Collaborators British Society of Gastroenterology Trainees’ Committee.
Contributors JC, MF, PH and LM, in addition to the representatives of the BSG Trainees’ Section, were involved in the planning and design of the survey. JC wrote and administered the survey. JC, MF and PH performed the data analyses. MF and PH created the figures and tables. JC, MF, PH and LM wrote and edited the manuscript, and approved the final version.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests The authors hold positions as regional representatives on the BSG Trainees’ Committee, and MF is co-chair of the Royal College of Physicians London Trainees’ Committee.
Patient consent Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
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