Colorectal Surgery Training & Certification: Enhancing Competence and Collaboration

1. ACPGBI AGENDA Andrew Shorthouse

2. 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

4. 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

5. Ownership share with ESCP

6. 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

7. Relating to the Membership • Bridging the gap between the Executive and grass roots membership • ACPGBI has a good track record of support

8. Professional Development and Training

9. 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

10. ACPGBI Annual Meeting Sage Gateshead July 3-6 2006 • CME update • CR07 results • EAUS workshop • Nurses’ and Dukes’ club symposia • Significant contribution by Europeans

11. 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

12. Colonoscopy

13. 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

14. Colonoscopy • Job plans may preclude screening • Accreditation process favours physicians • Surgeons need to do colonoscopy • Numbers • On-table colonoscopy eg bleeding, laparoscopy • Know what you’re operating on! • Physicians proactive in screening – some catching up to do • Initiative with “invasive colonoscopy”

15. 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

16. Colonoscopy QA Criteria • >150 colonoscopies per year • 90% completion rate on intention to treat basis • Perforation rate <1:1000 (!) • Evidence that sedation used is within recommended guidelines • Detailed submission of 50 consecutive cases with relevant histology to determine the adenoma detection rate (<15% detection may result from case mix)

17. 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

18. 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

19. 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

20. 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!

21. Specialist Training

22. 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

23. 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

24. 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?

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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!

33. A Vision of Specialist and General Gastrointestinal Surgical Training in the United Kingdom Professor Andrew Shorthouse Northern General Hospital Sheffield

34. 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

35. A Vision of GI Specialist Training • Routine UGI work, laparoscopic, bariatric, antreflux and straightforward biliary work • Smaller hospitals won’t 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 • Doesn’t need post CCT • 4 and 4 modules at any time • No complex level 3 work in OG/HBP/CR (complex fistula/pouch/rectal cancer

36. 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)

37. 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

38. 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

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

40. Association of Coloproctology of Great Britain and Ireland Current issues

41. 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

42. 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

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

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

45. 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

46. 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

47. 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

48. 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

49. 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

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