Assessment of ERCP training and competency in the UK: current practice and future possibilities

UoM administered thesis: Doctor of Medicine

  • Authors:
  • Katherine Mcwhirter

Abstract

ERCP is a technically challenging therapeutic procedure, and is the endoscopic intervention with highest risk of morbidity and mortality. Currently, training and independent practice are relatively unmonitored. There is no nationally recommended curriculum structure and so training is organised at independently at deanery level. Performance in training and independent practice is difficult to monitor due to lack of validated key performance indicators. A survey of trainees was performed within the local deanery, and a second wider survey of UK gastroenterology trainees, asking about their experience of ERCP training, and any barriers found to training. A further survey was issued to independent ERCP endoscopists in the local deanery. This revealed that all units adhered to BSG recommendations of requirements for a high quality service. The UK wide survey revealed a wide variation in the structure of training and both regional and UK surveys showed the expectation that further training beyond speciality training would be required before confidence to practice independently could be achieved. A training framework is proposed that could potentially address common training issues. The second facet of study comprised investigation of a novel means of grading ERCP complexity, with the intention of making outcome measures more meaningful both in training and in service. Using ampullary appearance as a discriminating factor, we found that an ERCP undertaken in the presence of a non-prominent ampulla was more likely to be successful, in terms of achieving cannulation. Although not reaching statistical significance, there appeared a disproportionate number of complications within this group. We propose that both these findings may relate to the underlying ductal anatomy. Finally, a comparison of our grading scale was performed, using ampullary appearance, compared to other suggested grading scales (ASGE, Morriston, HOUSE) . This showed that our scale showed a similar ability to predict cannulation and therapeutic success, but was equally unable to anticipate complication occurrence. It is suggested that ERCP training should be co-ordinated to ensure that an appropriate number of trainees receive the necessary exposure in terms of caseload and variety. This snapshot of practice within a single deanery would suggest that high quality practice exists in which to train. In addition, we propose that ERCP complexity grading would be of use in tracking training progress, although the optimum means in which to do this remains to be established.

Details

Original languageEnglish
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Award date1 Aug 2019