ACPGBI AGENDA

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ACPGBI AGENDA

• Andrew Shorthouse

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ACPGBI Agenda

• Getting good value?
• Colonoscopy surgeons under threat?
• Training and certification of colorectal surgeons
• Research and Audit
• Research Foundation
• ACPGBI as a major stakeholder
• e.g Revised Colorectal Measures for the Manual
  for Cancer Services 2004

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Documents in Production

• Revision CRC Guidelines
• Resources for Coloproctology revision
• Significant influence as stakeholder for
• BSG Strategy for Delivery of GI Services
• Revised Colorectal Measures The Manual For
  Cancer Services2004

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Ownership share with ESCP
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Relating to the Membership

• Bridging the gap between the Executive and grass
  roots membership
• ACPGBI has a good track record of support
• ACPGBI syllabus
• CME courses and annual meeting

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Relating to the Membership

• Bridging the gap between the Executive and grass
  roots membership
• ACPGBI has a good track record of support

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Professional Development and Training
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CPDACPGBI Annual Meeting Sage Gateshead July
3-6 2006

• CME update
• Live international laparoscopic surgery
• 14 multidisciplinary symposia
• State of the Art lectures
• Free papers Wednesday afternoon only
• No wasted half day!
• Wonderful venue

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ACPGBI Annual Meeting Sage Gateshead July 3-6 2006

• CME update
• CR07 results
• EAUS workshop
• Nurses and Dukes club symposia
• Significant contribution by Europeans

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Relating to the Membership

• Identify membership concerns which impact on
  practise
• Mail shots, chapter reps, chapter visits,
  informal correspondence
• Rapid response and feedback
• Develop consensus and act e.g colonoscopy

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Colonoscopy
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Colonoscopy

• Screening and quality measures
• GRS for endoscopy units
• Competence of endoscopists
• Dominated by gastroenterologists
• Marginalisation of surgeons
• Threat to colorectal surgeons if driving test
  rolled out to diagnostic practise
• Accreditation for Screening Endoscopists
• Poor quality colonoscopy in UK

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Colonoscopy

• Job plans may preclude screening
• Accreditation process favours physicians
• Surgeons need to do colonoscopy
• Numbers
• On-table colonoscopy eg bleeding, laparoscopy
• Know what youre operating on!
• Physicians proactive in screening some catching
  up to do
• Initiative with invasive colonoscopy

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Colonoscopy

• Initial concern raised by a member to PRCS
• Taken up by ACPGBI
• Dialogue with Roland Valori, National Endoscopy
  Lead
• Multi-agency ownership of endoscopy
• No elite corps
• Surgeons participation in screening
• Some QA criteria redefined

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Colonoscopy QA Criteria

• gt150 colonoscopies per year
• 90 completion rate on intention to treat basis
• Perforation rate lt11000 (!)
• Evidence that sedation used is within recommended
  guidelines
• Detailed submission of 50 consecutive cases with
  relevant histology to determine the adenoma
  detection rate (lt15 detection may result from
  case mix)

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ACPGBI Colonoscopy Committee

• Increase JAG representation
• Establish colonoscopy framework consistent with
  National Standards to credential colorectal
  surgeons
• Seek current colonoscopy practice by
  questionnaire
• Colonoscopy courses for established consultants
  to hone skills
• Establish EMR database with BSG participation

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Collaboration with Physicians

• ACPGBI now more actively involved
• united approach to endoscopy development
• screening
• symptomatic cancer management
• national endoscopy team involvement
• BSG endoscopy committee
• training
• representation at BSG improved

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Colonoscopy Accreditation

• Trainee certificate of competence
• Performance measures
• completion rate for a defined number of
  procedures
• Implicit in this is a need to have done a certain
  number of procedures
• Revalidation of existing colonoscopists
• Performance measures rather than minimum numbers
• caecal intubation
• polyp detection
• Sedation
• Supporting reference

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Colonoscopy

• Collect prospective data
• Keep documentation up to date using JAG compliant
  forms
• Endoscopists signed off locally for access to
  endoscopy units
• Implications for access to colonoscopy in the
  private sector
• Envisage most colonoscopists will gradually
  embrace accreditation process
• Get weaving!

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Specialist Training
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Specialist Training

• Defining a colorectal surgeon
• Minimum number of index procedures, including
  anterior resection
• Colonoscopy (to be defined)
• 6 modules colorectal surgery
• At least 4 in recognised specialist training
  units in final 2 years
• Procedure and workplace based assessments
• Mandatory training course attendance
• Development of specialist exit examination

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Specialist Training

• Conflicting pressures
• Provide specialist DGH service locally
• Distinct colorectal and benign upper GI elective
• Large laparoscopic component
• Provide general GI emergency service
• A minority of smaller remote hospitals may want
  general visceral surgeon
• Need for highly specialised regional services
• Breast surgeons withdrawing from take
• Ensure efficient, attractive career structure
  within constraints of MMC and EWTD

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Specialist Training

• ACPGBI position
• More clearly defined, directional training
  required with MMC and EWTD
• Specialist colorectal training in flexible CCT
• 6 modules (3 yrs) in recognised training units
• 1 year in upper GI surgery
• General GI emergency rota (excluding vascular)
• Clear process of colorectal certification
• Optional post-CCT fellowships for those wishing
  to be highly specialised

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Recommendations from ACPGBI, AUGIS and ALS
Presidents

• Is there a role for a more general type of GI
  Specialist in addition to the colorectal and
  upper GI specialist?

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Recommendations from ACPGBI, AUGIS and ALS
(colorectal upper GI)

• Modular training
• Minimum 6 modules in relevant specialty
• 2 modules in complementary GI training post
• Minimum final 4 modules in recognised specialist
  training unit
• Minimum 2 earlier modules in specialty

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Recommendations from ACPGBI, AUGIS and ALS ( GI
Specialist)

• Separate category of specialist GI surgeon
• Smaller hospitals
• Working with teams of upper or lower GI surgeons
  in larger hospitals
• Training to include
• Hemicolectomy (?), cholecystectomy, anti-reflux
  surgery, most uncomplicated laparoscopic
  procedures

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Recommendations from ACPGBI, AUGIS and ALS
(General GI Specialist)

• Separate category of specialist GI surgeon
• Minimum 4 modules each of upper and lower GI
  surgery
• At least one module in HPB
• OGD and colonoscopy training
• No requirement for post CCT fellowship year
• Laparoscopic training
• Sufficient exposure to open surgery
• Bariatric experience

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Recommendations from ACPGBI, AUGIS and ALS

• Complex level 3 procedures eg rectal cancer, IBD,
  complex upper GI should be referred to
  appropriate colorectal or upper GI specialist
• Defined laparoscopic training structure
• All participate in general emergency rota
  throughout training
• Abdominal and thoracic trauma training
• Recognised courses

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Recommendations from ACPGBI, AUGIS and ALS

• Post CCT fellowships
• Not a prerequisite for all
• Insufficient training posts
• Optional for minority who wish to be
  super-specialised
• Mentorship
• All newly appointed specialists should be
  formally mentored during first 5 yrs

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M62

• Nigel Scott and Jim Hill
• 1996 11th year
• Hugely successful!
• State of the Art in just 2 days
• 100 delegates and 25 faculty
• Have a great meeting!

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A Vision of Specialist and General
Gastrointestinal Surgical Training in the United
Kingdom

• Professor Andrew Shorthouse
• Northern General Hospital Sheffield

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Seamless Training Program
F1 F2 Foundation Years
Selection
Early General Surgery (2 yrs)
MRCS (core specialty)
General Surgery Specialty Training
Subspecialty Module (4yrs)
FRCS (core specialty)
CCT
Advanced Specialty Training (2yrs)
Specialty exam
SAC Gen Surg Proposal March 2004
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A Vision of GI Specialist Training

• Routine UGI work, laparoscopic, bariatric,
  antreflux and straightforward biliary work
• Smaller hospitals wont do bariatric work
• Routine colonic and proctology
• Upper and lower GI endoscopy distinction
  between upper and lower GI specialist
• Specialist GI surgeon must be able to do do both
  OGD and colonoscopy
• Doesnt need post CCT
• 4 and 4 modules at any time
• No complex level 3 work in OG/HBP/CR (complex
  fistula/pouch/rectal cancer

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A Vision of GI Specialist Training

• Electing at the beginning of specialist training
• More surgeon availability makes it easier to
  subspecialise
• OG and HPB final 2 years in specialist unit and
  one other year. One colorectal (2 modules)
• Emergency GI surgery will be done by specialist
  OG/HPB/CR or specialist GI surgeon
• Formal jointly badged training courses in upper,
  lower GI and laparoscopic surgery (digestive lap
  surgery)

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A Vision of GI Specialist Training

• Appropriate training in emergency surgery
  ATLS/CRISP/RCS course (includes laparoscopy)
• Formula in training to allow for GI surgeon to
  gain experience in eg thoracic trauma
• Laparoscopic upper GI and CR should be done under
  auspices of relevant specialist associations

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Specialist Training

• ACPGBI position
• More clearly defined, directional training within
  MMC and EWTD
• Specialist colorectal training in flexible CCT
• 6 modules (3 yrs) in recognised training units
• 1 year in upper GI surgery
• General GI emergency rota (excluding vascular)
• Clear process of colorectal certification
• Optional post-CCT fellowships for those wishing
  to be highly specialised

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Specialist Training

• ACPGBI position presented to ASGBI
• Joint statement in preparation for Specialist
  Associations, Senate and PMETB

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Association of Coloproctology of Great Britain
and Ireland

• Current issues

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Specialist Training ACPGBI Position Statement

• Fears about rigid 4 years specialist training
  arising from MMC and EWTD
• Delivery of certified specialists only achievable
  within flexible CCT
• GI general training followed by specialist
  training in final 2 yrs
• Ideally, certification for all colorectal
  surgeons, however specialised

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Specialist Training ACPGBI Position Statement

• Important to recognise the training needs of
  majority of colorectal specialists in general
  hospitals, from those who will super-specialise
• Post CCT fellowship year optional
• Could this model of flexible specialist training
  be adapted to other specialties?
• Seek agreed template for General Surgery training
  via ASGBI Specialty Presidents

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Specialist Training

• ACPGBI position presented to ASGBI
• Joint statement in preparation for Specialist
  Associations, Senate and PMETB

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A Vision of
Specialist and Generalist Gastrointestinal
Surgical Training in the UK
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Surgical Gastroenterology

• Government policy and reforms
• Better defined, directional training and career
  structure
• Most patients wish to be treated close to home
• Ready access to specialist services
• Secondary care 3 tiers
• Smaller hospitals
• Combined Trusts and large DGHs
• Large tertiary referral centres

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Surgical Gastroenterology Today

• Teams of upper GI and colorectal surgeons
• Catalysed by reorganisation of cancer services
• Centralisation of upper GI cancer
• Driven by government
• Case volume relates to outcomes
• Colorectal Cancer
• Units function well at more local level
• Prevalence of disease
• Outcomes and case volume less well defined

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Future Challenges

• Provision of high quality service
• Shorter training
• Manpower limitations
• Specialist care needed at local and regional
  level
• Progressive specialisation in elective work
• GI emergency service to be maintained

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Future Challenges

• Most trainees focussed towards specialist career
• Compensating for EWTD and MMC
• Paradox of expertise required across spectrum of
  GI emergency care
• Includes abdominal and thoracic trauma

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Acute Cover

• Problematic
• Breast surgeons
• Fewer performing major upper GI resections
  because of COG guidance
• Ideal would be parallel upper/colorectal teams
• Insufficient manpower
• Expansion to achieve would dilute elective work
• Must continue to share emergency general workload

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Acute Cover

• Increasing specialisation threatens competency
  managing complex emergencies when cross covering
• By CCT, competence expected for all GI surgical
  emergencies

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Concept of the Specialist GI Surgeon

• Specialist GI Surgeon novel approach
• Alternative and complementary to pure upper and
  lower GI specialists
• Designated specialist
• Broader, more general GI training
• Equipped to work side by side with more
  specialised colleagues

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Concept of the Specialist GI Surgeon

• Possibly preferred by smaller hospitals
• Attractive to tertiary referral centres
• Challenged by target pressures
• High volume and less specialised work
• Significant laparoscopic component

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Concept of the Specialist GI Surgeon who does
the cancers?

• Elective upper GI cancer devolved
• Where does colorectal cancer fit?
• Colorectal trainees
• Final two years in recognised specialist units
• At least one other year in a colorectal post
• TME training
• Index procedures accrued

proficiency
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Concept of the Specialist GI Surgeon

• Precludes the more general GI specialist?
• Not fulfilled relevant training criteria
• Rectal cancer
• Colon cancer?
• Should all CRC be the sole domain of the
  colorectal specialist?
• Specialist GI surgeons need to manage emergency
  colorectal and gastric cancer

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Concept of the Specialist GI Surgeon

• Some cases demanding and wont wait
• May not be specialist backup
• Choice to transfer or operate
• Some logic in devolving elective colon cancer
• Keep the left sided cancers or just the rectals?
• Occasional exposure to emergency upper GI
  malignancies with no elective experience

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Concept of the Specialist GI Surgeon

• ACPGBI and AUGIS view
• All cancer management by the relevant specialist
• Uneasy philosophical conflict between
• Progressive upper and lower GI specialisation,
  partition of cancer management, separate MDTs
• More generalist approach with incumbent
  difficulties maintaining competence across
  breadth of surgery

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Training Specialist Upper GI and Colorectal
Surgeons

• Modular
• Final 2-3 years in specialist training units
• Rationalisation of regional training schemes
• Colorectal and upper GI trainees
• Sufficient general GI training for acute take
• Excluding vascular
• Higher level of expertise in respective elective
  and emergency area of special interest
• Variably large laparoscopic component

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Post CCT Fellowships

• Counterproductive if rigid prescription for all
• Newly appointed specialists will develop in post
• Option for those wanting to be more specialised
• Need to differentiate needs of
• Majority who will become specialists in general
  hospitals around UK from
• Aspiring super-specialists

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Training the Specialist Upper and Lower GI
Surgeon

• Modular
• Equal amount of upper and lower GI surgery
• Continuing emphasis on emergency surgery
• Final two years upper and lower shared
• More limited elective portfolio from EWTD
• Flexible timescale to CCT
• Full range of level 2 colorectal and upper GI
  procedures
• Spectrum of GI emergencies

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Laparoscopy

• Large laparoscopic commitment for most surgeons
• Core skills course (F2 and 3)
• Intermediate skills course (early ST years)
• Advanced courses planned eg colorectal
• Laparoscopic fellowships (ACPGBI and ALS)
• Preceptorship schemes

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Exit Examination and Certification

• Future exit exams should be taken by all
  colorectal and upper GI specialists, however
  specialised they aim to be
• Adapt to needs of specialist GI surgeon

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Specialist Training

• ICE remains a problem
• No specialist recognition
• Specialist curriculum developed by ACPGBI
• Procedure based assessment tools evolving
• Validation exercise to start (big job)
• Needs to be educationally valid and PMETB
  compliant
• More weight if other specialties adopt

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Specialty Training

• ACPGBI well prepared for change
• Coloproctology curriculum and operative
  competency form developed
• Accepted unconditionally by JCHST
• Defines requirements for training, assessment,
  exit examinations, certification and
  revalidation
• Breakdown of selected procedures into stages
  for PBA - under development

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Certification for Specialist Status

• Mode of certification not yet decided
• Series of in-training assessments
• Portfolio of subspecialty work
• Final assessment - scientific knowledge, case
  scenarios, and viva
• Exit examination for specialist status?
• Conflict!
• No specialist badging
• Portfolio of specialist MCQs needs to be
  developed
• EBSQ?

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MMC Unresolved Issues

• ACPGBI well positioned to steer colorectal and
  general surgery development
• Vascular surgery split with own SAC
• Breast and endocrine stopping emergency takes
• Dialogue with upper GI surgeons
• How to train surgeons for GI general take, in
  parallel with training of colorectal and upper GI
  specialists
• Concept of visceral GI surgeon

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Specialist Training

• Conflicting pressures
• Provide specialist DGH service locally
• Distinct colorectal and benign upper GI elective
• Large laparoscopic component
• Provide general GI emergency service
• A minority of smaller remote hospitals may want
  general visceral surgeon
• Need for highly specialised regional services
• Breast surgeons abrogating responsibility
• Ensure efficient, attractive career structure
  within constraints of MMC and EWTD

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Specialist Training

• Need to define a colorectal surgeon
• Minimum number of index procedures, including
  anterior resection
• Colonoscopy Competency assessment based upon
  performance measure over x consecutive cases, as
  yet not determined (JAG to issue guidance)
• 6 modules colorectal surgery
• At least 4 in recognised specialist training
  units in final 2 years
• Procedure and workplace based assessments
• Mandatory training course attendance
• Development of specialist exit examination

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Colonoscopy Credentialing

• Measures of competency preferable to absolute
  numbers
• E.g. completion rate for the last x
  procedures?  
• JAG shortly to arrive at consensus

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Specialist Training

• ICE remains a problem
• No specialist recognition
• Specialist curriculum developed by ACPGBI
• Procedure based assessment tools evolving
• Validation exercise to start (big job)
• Needs to be educationally valid and PMETB
  compliant
• More weight if other specialties adopt

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Specialist Training

• Decision to proceed with process to establish
  formal assessment in coloproctology
• Eligibility criteria
• 3 years colorectal training, two of which should
  be on recognised training units
• Case numbers
• Work place based assessment
• Written examination
• Oral examination for candidates successful in
  first two parts

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Specialist Training

• Writing educational justification for proposed
  examination
• Feasibility issues being addressed
• Issue of a formal register for existing
  consultants more difficult
• EBSQ recognised by EU but not individual national
  education authorities