With expanding numbers of pediatric GI trainees, it is even more concerning that training centers have had difficulty providing adequate experience for their trainees. In a recent study (JPGN 2014; 58: 27-33), not one of 12 centers was able to meet the threshold for all of the procedures.
The authors provide NASPGHAN procedural competency guidelines in Table 2. The 2013 guidelines lowered the threshold for almost all procedures in comparison to the 1999 guidelines. One notable exception was foreign bodies which was increased to 10. Then, the authors examined the frequency of procedures actually performed between 2009-2011.
Key findings (with the lower thresholds)
- Polypectomy (threshold, n=10) 67% of programs meeting 2013 NASPGHAN guidelines
- Control of nonvariceal bleeding/Sclerotherpy/Variceal band ligation (threshold, n=15) 17% of programs meeting 2013 NASPGHAN guidelines. Mean number per fellow of nonvariceal bleeding cases was 2 procedures. Mean number per fellow of banding/sclerotherapy was 7 procedures. With the 1999 guidelines, the threshold had been 35 for these procedures combined.
- Esophageal, pyloric and duodenal stricture dilatation (threshold, n=15) 42% of programs meeting 2013 NASPGHAN guidelines
- PEG (threshold, n=10) 42% of programs meeting 2013 NASPGHAN guidelines (training not available at 42% of these institutions)
- Percutaneous liver biopsy (threshold, n=15) 67% of programs meeting 2013 NASPGHAN guidelines
- Foreign-body removal (threshold, n=10) 58% of programs meeting 2013 NASPGHAN guidelines
It is noted that the 2013 guidelines “reclassified control of variceal and nonvariceal bleeding from a level 2 to a level 1 procedure, stressing that expertise in hemostasis should be achieved during fellowship.” “Without supplemental training, none of these programs, which are likely representative of most programs, were able to provide sufficient opportunities to meet the NASPGHAN guidelines.” Besides spending more time working with adult gastroenterologists, other potential ways to gain more experience includes simulators and hands-on training courses.
Take-home message: Pediatric gastroenterology training centers are not providing enough procedural experience and need to make rotating with adult gastroenterologists mandatory. It is unfair to trainees and vulnerable patients to consider their training complete with these obvious deficiencies.
When families ask the newly trained pediatric gastroenterologist how many cases like this that they have completed, how will they feel if the honest answer is two?
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