Feb. 24, 2011
The American Board of Surgery (ABS) has reviewed the recent position paper issued jointly by four gastrointestinal (GI) societies*, alleging that the numbers used by the ABS as a standard for resident training in endoscopy do not confer competence, while placing an undue burden on gastroenterologists. The position paper is erroneous and misleading on multiple points, beginning with the fact that the ABS does not maintain that any numerical standard defines competence in any procedure. The ABS consistently maintains that hospital privileging must be predicated on a broader base of evaluation, including specialty certification, prior training and experience, and current outcomes in actual clinical performance. It is well known that counting the numbers of cases is an inadequate surrogate for measuring safety and competence during training or afterwards.
The official ASGE position on this is similar to that of the ABS: The ASGE statement entitled Methods of Granting Hospital Privileges to Perform Gastrointestinal Endoscopy clearly states, "performance of an arbitrary number of procedures does not guarantee competency." It goes on to emphasize "the need to use objective criteria of skill, rather than an arbitrary number of procedures performed, when granting privileges to physicians for endoscopic procedures."1
Endoscopy is a field that was developed by surgeons, to which surgeons have made, and continue to make, major contributions. These include the development of endoscopic treatment of variceal bleeding; endoscopic control of upper gastrointestinal bleeding; endoscopic polypectomy; endoscopic tattoo for location of colon cancers; endoscopic retrograde cholangiopancreatography; endoscopic placement of biliary stents; and endoscopic placement of feeding tubes. Surgeons, who are intimately familiar with the anatomy of the GI tract through performing open and laparoscopic operations, and with the two dimensional representation of a three dimensional structure from their extensive experience with laparoscopy, could be considered to have significant advantages over gastroenterologists in developing proficiency in endoscopy, since gastroenterologists lack this breadth of experience.
Essential endoscopy services are provided by surgeons around the world. In the United States gastroenterologists are rarely available in rural and underserved areas; in such areas surgeons may be the only providers of indispensable endoscopic services. The development of highly limiting credentialing criteria may substantially restrict access to care and result in a substantial disservice to public health. This is amplified by the increasing demand for colonoscopy as screening programs are becoming more prevalent.
Managing the continuity of disease, including complications of procedures, is important to good quality care. Given that many of the diseases identified at endoscopy are ultimately treated surgically, a surgeon's involvement in the early diagnosis and management is often optimal, to assure continuity of care. Surgical expertise is frequently required to evaluate and manage complications of endoscopy, especially those that are catastrophic or life-threatening.
The quality of the literature devoted to the effect of numbers on competence in upper and lower GI endoscopy is highly variable as to groups studied, methods of assessment, and end points. Most studies involve small numbers and lack statistical power. The largest (by an order of magnitude) and most thoroughly analyzed study, by Wexner et al,2 evaluated 13,580 lower GI endoscopies performed by surgeons, and found that complications, ability to reach the cecum in >90% of cases, and total procedure times of <30 minutes were all achieved at an experience level of 50 cases, with modest improvement at volumes beyond that. Pediatric gastroenterologists have arrived at a similar number of 50 cases to define competency in colonoscopy for their trainees.3
In clinical practice, while there are few credible studies, the largest of these,4 in 14,064 patients who had colonoscopy within three years prior to a diagnosis of a colorectal cancer, showed equivalent performance of colonoscopy by surgeons relative to gastroenterologists in regard to missed lesions. A study of specific metrics of performance in 5,237 colonoscopies performed by general surgeons, colorectal surgeons, and gastroenterologists found no differences among them.5 Clearly someone who has performed 500 endoscopies will be more facile than someone who has performed 50, but the crucial question in defining training standards is the level at which safety and basic competence are achieved, not expert performance. This is the intent of the standards established by the Residency Review Committee for Surgery for surgical residency programs and endorsed by the ABS. It is also important to recognize that residency program requirements are not intended to prevent trainees from performing more endoscopic procedures than the minimum.
Given the available data there is no credible basis for the position paper published by the GI societies. We are concerned that an excessively high number of procedures to define competence will be misrepresented as a quality measure and restrict entry of appropriately trained surgeons to the field. For many years gastroenterology faculty have collaborated with departments of surgery and general surgery residency programs to provide excellent training in endoscopic skills. We are appreciative of these efforts and believe that all have benefitted from these educational partnerships; continued collaboration will improve the outcomes of endoscopic training of gastroenterologists and surgeons. If the concerns of the GI societies are indeed focused on quality training then we would welcome a joint effort to use our combined resources to improve training and establish better outcome measures for endoscopic training.
The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), as a surgical organization with a particular focus on surgical endoscopy and education, is committed to the concept that physicians should make every effort to establish measures of competence. To this end they are in the final stages of developing the Fundamentals of Endoscopic Surgery (FES) training course, and a validated global rating scale called GAGES (Global Assessment of Gastrointestinal Endoscopic Skills)6 to be used in the clinical setting. The ABS is committed to working with SAGES to complete FES and establish more objective standards for the training and assessment of endoscopic skills. We would encourage the participation of gastroenterologists in this effort. Clearly our patients will be best served by establishing validated quality indicators for proficiency, and working together to train endoscopists to this level of competence using these more objective standards.
The American Board of Surgery is an independent, nonprofit organization founded in 1937 for the purpose of certifying surgeons who have met a defined standard of education, training and knowledge. The ABS offers board certification in general surgery, vascular surgery, pediatric surgery, surgical critical care, surgery of the hand, and hospice and palliative medicine. It is one of the 24 member boards of the American Board of Medical Specialties.