General Surgeons and the Provision of Quality Endoscopy Services in Canada
Minutes
February 7th, 2014
Osgoode Room, Toronto Hilton, Toronto, ON
Present:
Elijah Dixon (Chair)
Cassandre Boland (CAGS)
Nori Bradley (CAGS Residents’ Committee)
Chris de Gara (CAGS)
Jim Ellsmere (CAGS MIS Committee)
Tony Gomes (CAGS)
Jamie Gregor (CAG)
Paul Hardy (CAGS - AB)
Michael Harrington (CAGS - SK)
Stephen Hiscock (CAGS - BC)
Lawrence Hookey (CAG)
Jolanda Karpinski (RCPSC)
Stephen Kelly (CSCRS)
Jasmin Lidington (CAGS)
Angus MacIver (CAGS - ON)
Andy McFadden (CSSO)
Robin McLeod (CCO)
Mark O’Driscoll (CAGS – NL)
Allan Okrainec (CAGS MIS Committee)
Linda Rabeneck (CCO)
Phil Smith (CAGS - NS)
Steve Schwaitzberg (SAGES)
Jill Tinmouth (CCO)
David Urbach (CAGS)
Chris Vinden (OAGS)
Melina Vassiliou (CAGS)
Mark Walsh (CAGS PG-ED Committee)
Garth Warnock (CAGS)
Les Wasilewski (CAGS - NS)
Debrah Wirtzfeld (CAGS)
Brent Zabolotny (CAGS - MB)
1)
Welcome and Introductions - E. Dixon
Dr. Elijah Dixon called the meeting to order at 1:00 PM Eastern. He gave a brief overview of the
agenda and of the objectives for the meeting, which included defining competence and
identifying the current major issues facing endoscopists in Canada. Dr. Dixon thanked all those
present and asked each attendee to introduce themselves.
2)
Endoscopy in Canada and Current Issues for the General Surgeon - C. de Gara
Dr. Chris de Gara first presented a slide on declaration of conflict of interest, followed by a
presentation with references to available literature on endoscopy data gathered through various
studies. He began with an overview of who does endoscopy in Canada which illustrated the
distribution between surgeons, who provide most endoscopic services in rural areas versus their
gastroenterologist counterparts who provide most endoscopic services in urban centres.
Dr. de Gara questioned if General Surgery graduates were competent to perform endoscopy upon
graduation, as the data suggested some were not performing enough to reach 100 procedures. He
went on to present data from various studies on cecal intubation rates, withdrawal times,
frequency of polyp removal, and location of where the procedure took place, which cast doubt on
any true measures of competence due to the wide discrepancies in numbers from one study to
another. He concluded that a tremendous amount of work is still needed in order to decide what
constitute agreed-upon measures of competence in Canada.
3)
Quality of Colonoscopy: Evidence and the Cancer Care Ontario Perspective - J. Tinmouth
Dr. Jill Tinmouth spoke on the Cancer Care Ontario (CCO) experience with the development of
the guideline on colonoscopy that addresses endoscopy quality in ON. She explained that the
guideline committee used the Program in Evidence-Based Care (PEBC); a review process used to
develop this guideline that was evidence-based. She went on to explain the findings they came
to and the evidence that supported them to create the guideline on quality colonoscopy in
Ontario, such as:
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General surgeons are exposed to endoscopy training over 6 months in residency, where
gastroenterologists must complete a two year subspecialty training program.
At end of training, residents who have achieved competency should achieve 85% cecal
intubation and 300 scopes
Completion of more than 200 colonoscopies yearly and 95% intubation rate ongoing as
an endoscopist in practice
In review, withdrawal time was omitted from the final guideline.
Low volume surgeons have the highest failure to reach the cecum rate.
Low volume surgeons live in urban areas and not rural
There was some discussion on what is the right measurement and if adenoma detection rates
should be measured. Dr. Tinmouth explained that the adenoma detection rate was an indicator
of people looking well during the procedure.
5)
Endoscopy in Canada the General Surgery Resident Perspective - N. Bradley
Dr. Nori Bradley presented a study she had undertaken with the CAGS Residents’ Committee
about training and preparedness for entry into practice. The study results were from an
electronic survey sent to all general surgery residents which had a 34% response rate. Of the
respondents, 70% would like to perform endoscopy in their future practice and 93% took a core
block of endoscopy, 65% have access to simulators, but 53% had only optional or rare use of a
simulator. 34% said a simulator was helpful for endoscopic and procedural skills, but 20% did not
use it at all, and just over 50% have a couple of hours on it. Most new graduates were not
comfortable doing upper GI procedures and overall, new graduates appeared to feel unprepared
for independent practice. Endoscopy training varied significantly across the country and the
CAGS Residents’ Committee would support a national approach to help residents achieve a
standardized level of competence.
6)
Metrics/Measures of Competence - M. Vassiliou
Dr. Melina Vassiliou said that she had participated on a taskforce put forth by the Society of
American Gastrointestinal and Endoscopic Surgeons (SAGES) to assess a measurement tool for
endoscopy competence. The taskforce assessed a measurement tool called GAGES, which stood
for ‘Global Assessment of Gastrointestinal Endoscopic Skills’. The definition of competence that
the GAGES taskforce used was: “Having the minimal technical aptitude and skills required to
safely perform a procedure”, and those skills and aptitude required have an element of
subjectivity, and therefore the standard of competence varied from one individual to another,
and was also in constant evolution, just as science and technology was in constant evolution.
Dr. Vassiliou presented the GAGES findings that used a global rating scale of five items for upper
endoscopy and colonoscopy. They found that after 50 cases, scores plateaued for upper GI
endoscopy and after 75-100 they plateaued for lower GI colonoscopy when measuring basic
skills. She then presented the Direct Observation of Procedural Skills (DOPS), which was the
measurement tool used across the board in the UK. It consisted of four domains, mixing skills
and judgment with one to four levels on a likert scale. Some drawbacks of the tool were that the
degree of case difficulty is hard to judge appropriately and surprisingly the tool had a negative
correlation with case numbers as they increased, which caused an element of doubt.
Dr. Vassiliou described another measurement tool called the Mayo Colonoscopy Skills
Assessment Tool (MCSAT), which measured a split between motor skills and cognitive skills for a
more integrated picture of competence. The pass mark or competency point was where the
expert and learner line intersected on the graph. This was a challenge to reproduce on an
ongoing basis. Dr. Vassiliou said that endoscopy simulators are also a challenge to use
effectively because they are inadequate at reproducing lifelike circumstances of patient
responses and real life environment, therefore they did not measure performance that well.
Dr. Vassiliou concluded her presentation by stating that competence is in continuous evolution,
therefore it is dangerous to just measure it at one point in time, which would create a danger of
over-standardization. She also stated that measuring competence for new graduates has levels
of complexity, because human beings only have the ability to pay attention to so many things at
once. Quality endoscopy requires an accumulation of skills that come together over time and
free up mental working space so one can pay attention to other components like polyp removal,
and the danger of only paying attention to technical skills creates a lack of attention to the other
cognitive components.
7)
Acquisition and Measurement of Competency: American College of Surgeons (ACS) /
Society of American Gastrointestinal & Endoscopic Surgeons (SAGES) Perspective - S.
Schwaitzberg
Dr. Steve Schwaitzberg gave a presentation in his capacity as Past-President of SAGES, where
similar environmental factors converged within the area of endoscopy, specifically colonoscopy,
as those that were taking place now in Canada. He stated that whether a general surgeon
performed 85 cases or not, most new surgeons are uncomfortable with many tasks at entry into
practice, and that SAGES believes in training to a measure of performance, which means practice
until one can do it.
Dr. Schwaitzberg said that in response to a letter from the American Society for Gastrointestinal
Endoscopy (ASGE), stating surgeons were not equipped well enough to perform endoscopy, the
American Board of Surgery (ABS) reached out to SAGES and asked for the development of an
endoscopy curriculum because, to the surprise of US gastroenterologists, the number one case
type reported to ABS is endoscopy. This created a problematic situation for the ASGE, because
how could an entire specialty be expected to retreat from its number one procedure? That is
when a common curriculum for qualification in endoscopic skills was developed that was multidisciplinary and collaborative from both GI and surgical worlds. Although the ASGE was part of
this process, the new President did not endorse the curriculum because he did not want to risk
disenfranchising his members.
Dr. Schwaitzberg said that through the development of the endoscopy curriculum, the definition
they worked on for a surgical endoscopist included some of the following components: intubate
upper and lower, recognize pathology, biopsy, polypectomy (and manage complications), GAGES
tool, FES certification, Pathology recognition (complex topics). He stated that a more advanced
endoscopist definition, or Advanced Endoscopic Curriculum included: five year program,
identified milestones before completion, and a fulfilled need for teachers, simulators, etc. The
ideal endoscopist of the future may be some sort of GI-Surgeon hybrid, like a GI Interventionalist.
Dr. Schwaitzberg commented that competency is taught and is the minimum standard, but
mastery has to be sought. Discussion followed about how narrow that gap between these has
to be for society, which assumes there is a relatively small gap. Junior surgeons do not perform
as well as senior surgeons, which is true for every proceduralist and in this sense, experience is
irreplaceable. In terms of training, there was a commitment in the US that a surgeon going into
practice offered the same quality in endoscopic procedures as a gastroenterologist going into
practice and agreement on the same common standard to move forward. Along with that
commitment came an understanding that all training in the endoscopic suite served the same
need, regardless of the specialty of the trainee.
8)
Acquisition & Measurement of Competency: Joint Advisory Group and other options A. Gomes
Dr. Tony Gomes said he had concerns about the preparedness of young surgical graduates
performing endoscopy, and therefore Dr. Dixon had asked him to participate in this discussion.
He went on to explain the Joint Advisory Group (JAG) on GI and endoscopy that accredits
endoscopy units in the UK, as an example of a system where endoscopists are certified. This
certification process came about due to a lack of standardization in facilities and training of
endoscopy, and was supported by a bowel screening program in the UK. JAG uses a global rating
scale to assess training and service delivery and it is becoming the de facto standard in
endoscopy there.
JETS is the training system that JAG developed in order to credential endoscopists. It consists of
a basic skills course that lasts three days and is a mix of teaching, simulation, demonstrations,
and cases with a trainer on video. After 200 procedures a trainee will do four summative cases
and then receive an assessment by an assessor, followed by more steps and a total of 300
colonoscopies have to be completed before full certification. There is also an E-portfolio online
that has to be completed. Endoscopy units are mandated to provide adequate training to all
trainees regardless of specialty, however there are problems for surgical trainees due to training
time constraints.
9)
Issues/Roadblocks and Going Forward - J. Ellsmere
Dr. Jim Ellsmere gave a presentation about the importance of quality endoscopic services from
general surgeons and gastroenterologists, and that the establishment of certain safety standards
and practices would answer a currently unmet need. He asked if regional centres needed
endoscopists and if the person providing endoscopic services should provide other services as
well? He felt that general surgery is in need of a review altogether with a full re-branding that
should be incumbent with a closer study of the delivery of services across Canada. Going
forward, Dr. Ellsmere supported the forming of a CAGS Endoscopy Taskforce, while working with
gastroenterologists to improve endoscopic services, and continuing to discuss the rebranding of
general surgery. He also suggested publishing a training curriculum including assessment, and
publishing a practice audit strategies document.
10)
Plenary Discussion on Next Steps
Discussion indicated the following:
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11)
Many felt there needed to be a more engaged participation in the establishment of
quality measures for endoscopy, and perhaps a formalized, accredited approach.
There was interest in the CAG train the trainers program that had helped and educated
many surgeons in practice immensely, and it was felt that more general surgeons should
participate, who could then effectively train residents.
There was a need to address the definition of competence as presented earlier by Dr.
Vassiliou, and the need to acknowledge the difference between competence and
mastery.
There was a request to stop outsourcing the training of general surgeons and take back
the number one procedure in general surgery. This should be done with consideration
for the SAGES curriculum. It was suggested that training is the most easily remedied area
to look at and might also be the best point to start to work collaboratively with GIs.
There was a suggestion for the Endoscopy Taskforce to look at where residents are being
sent to learn endoscopy. The rural community might not support a resident at surgery,
but there is a ton of endoscopy work for learning.
CAGS can invent the solution and Royal College will buy in, which will likely be easier and
faster than waiting for the Royal College to find a solution.
Wrap-up - E. Dixon
Dr. Dixon thanked everyone for coming to the meeting which had been an outstanding
discussion with valuable insight and excellent ideas. The next steps would be to synthesize the
information gathered and disseminate to others, then create the Endoscopy Taskforce based on
the suggestions and ideas gathered. He asked that anyone with an interest in participating on
the taskforce to let him know. He adjourned the meeting at 4:45 PM Eastern.