Health Education England, working across the East of England - Gastroenterology ST Training Scheme:
Welcome to the Health Education England, working across the East of England Gastroenterology Training Programme. Here are some notes to help you find your way around the Training Programme.
Core experience and special options
The Training Scheme will follow the national guidelines for training in Gastroenterology and Hepatology developed by the British Society of Gastroenterology and SAC (http://www.jrcptb.org.uk/specialties/gastroenterology-includes-sub-specialty-hepatology) and subsequently confirmed by the Gastroenterology SAC, JRCPBT and PMETB. All posts will include experience in the following "Core Topics":
a. Inflammatory bowel disease
b. Hepatobiliary disease
c. Functional bowel disease
d. Malabsorption and pancreatic disease
e. Gastrointestinal infection
f. Oesophageal and gastroduodenal disease
g. Oncology (oesophageal, gastric, pancreatic, colonic cancer)
h. Gastrointestinal emergencies (acute abdomen, GI bleeding, fulminant colitis, cholangitis)
i. Nutritional support
j. Gastrointestinal manifestations of systemic disease
Optional modules will be available in many posts, some of which will run concurrently with core training, but others will require a full time secondment. National guidelines recommend the following modules and all can be obtained within this region;
1. Advanced gastroenterology (Inflammatory Bowel Disease, oesophageal disease)
2. Advanced hepatology (FHF, liver transplantation)
3. Physiological measurements (oesophageal manometry)
4. Nutrition (assessment, catheter placement, nutrition team service, management)
5. Paediatric and adolescent liaison gastroenterology (conditions starting in childhood continuing into adulthood)
6. Advanced therapeutic endoscopy (ERCP, EUS, laser therapy, management of strictures, fistulas, enteroscopy)
7. Imaging (ultrasound, endoscopic ultrasound, CT, MRI, Nuclear Medicine)
8. Cancer care (drug therapeutic regimens, radiotherapy, combined modality treatments)
9. Palliative care (pain relief, hospice care, palliative endoscopic therapy)
10. Communicable diseases (intestinal infection, hepatitis, tropical diseases, parasitology, special experience with Helicobacter pylori)
11. Psychological medicine (basic liaison psychiatry; knowledge of psychiatric disease in hospital patients. Eating disorders, factitious disease.
13. Teaching/Presentation skills
14. Health Service Management
15. Small bowel transplantation
Clinical skills to be acquired:
The training scheme will concentrate on teaching the following clinical skills recommended in the Gastroenterology curriculum:
i. Basic diagnostic endoscopy (rigid sigmoidoscopy, OGD, colonoscopy; principles of disinfection, safety, sedation)
ii. Endoscopic therapeutic techniques (stricture dilatation, injection/ banding of varices, haemostatic techniques, polypectomy; indications, risks and benefits of therapies)
iii. Communication skills
iv. Cancer Care
v. Non-endoscopic techniques (paracentesis)
The posts on the rotation are in the locations listed below. Most posts provide training in all core aspects and skills as outlines in the gastroenterology curriculum. The exact rotation and choice of optional training for each trainee is determined after discussions at the annual ARCP interviews.
Norfolk and Norwich
Luton and Dunstable
In addition to time each week set aside in their timetable for personal study there are expected to be 30 educational sessions (half-day) per year. These will be made up of activities at different levels including;
• Trust: Local Grand Rounds, Journal clubs and Postgraduate meetings
• Regional: Regional training days will be held several times a year. East Anglian Gut Club meetings also occur twice yearly. Attendance at all these regional meetings is a compulsory part of the Training scheme.
• National/ International: British Society of Gastroenterology (BSG) and British Association for the Study of the Liver (BASL) meetings. It is strongly recommended that all trainees attend these as well as other International meetings (UEGW, EASL, AGA, AASLD, BAPEN and ESPEN). Study leave to attend these meetings will be given by all trainees' Educational Supervisors. Unfortunately, the Deanery's study leave budget will not cover all study leave expenses.
• Courses: Basic gastroscopy and colonoscopy courses are required as part of JAG accreditation for diagnostic procedure. Norwich is the regional training centre and provides the courses at a subsidised rate. It is recommended to attend a course on management (usually done in final years) as well as teaching.
Each year all trainees will be assessed at their ARCP, looking at both gastroenterology and GIM components (if dual accrediting). This will initially be a review of the evidence presented in your e-portfolio and following this you will meet with a group usually including the following individuals:
• Regional Dean/Dean's Representative
• Chairman of Training Committee
• Program Director/Regional College Advisor
• A local Gastroenterologist (involved in the rotations but not the trainee's Trainer)
There may also need to be an external assessor from another region or from the Gastroenterology SAC. A written assessment (supervisor report) of the trainee from their current Educational Supervisor will be available at this interview, the aim of which is to confirm the adequacy of training to date and progression through the training programme. A written confirmation of the outcome/conclusions of this meeting will be sent to each trainee. The trainee may appeal against any decision taken at this meeting. These ARCP reviews usually take place in September. This also provides a forum for you to discuss your training. You will have at least six weeks notification of the ARCP but it is the trainee's responsibility to present the evidence.
Furthermore, at the end of each annual assessment a plan will have been drawn up between the trainee, the Training Programme Director (acting for the Regional Dean) and the Educational Supervisor delineating which aspects of the training will be delivered in the forthcoming year, and details of any future rotation to other training centres or secondment for 'optional modules of training'.
During these interviews an assessment of the training adequacy and educational component of each training post will also be made following a report by each trainee. A written report will then be sent to each Educational Supervisor after this assessment.
Ongoing assessment will take the form of work-based assessments (currently mini-CEX, multi-source feedback, DOPS and case-based discussion).
The decision aid for ARCPs is given on the JRCPT website.
All STs, at each centre, should have the opportunity to have an induction/orientation program into the Hospital/Trust's activities along the guidelines recommended by the King's Fund. This will either involve lectures or an information pack to include such topics as Health and Safety, Security, Fire Drill etc., as well as the Hospital/Trust's computerised Pathology requesting/ results service and Radiology systems. It is important that STs are introduced to all other areas that they will encounter including Clinics and Endoscopy Suites. All Eastern Region STs should undergo formal introduction and induction in endoscopy, each time they start in new unit. There is a specific proforma to guide this. This is appended.
A period of research is recommended for every trainee, although it is not essential and many trainees complete training without any out of programme research. With suitable notice to the Dean and Programme Director, time out from their clinical training will usually be available. Trainees intending to take time out for research must discuss this beforehand with the TPD and are encouraged to discuss this with Dr Rebecca Fitzgerald the academic representative or Professor Alastair Watson UEA, Norwich. It is necessary to have secured funding and have a developed academic and job plan before approval for time out of programme is granted. At least three months notification needs to be given prior to taking time out of programme. You cannot give notice of your desire to leave the programme until you have received approval from the TPD, postgraduate Dean and the SAC this may take some months. This emphasizes the importance of discussing your plans with the TPD at an early stage. Research time out of programme cannot be accredited towards your CCT.
Current PMETB regulations state that no more than three years can be taken out of programme.
Time out of programme for other reasons such a clinical or endoscopic experience is encouraged and supported, again at least three months notice is required. Clinical experience outside the programme may be counted towards the CCT, but prospective approval is required from the SAC and PMETB.
All gastroenterology trainees will follow the training scheme and assessments as outlined by the Joint Advisory Group (www.thejag.org.uk). Formal assessments and JAG certification should be performed before any trainee does independent lists. All trainees are required to show competence in upper GI endoscopy and flexible-sigmoidoscopy. Diagnostic Colonoscopy is an optional skill, but it is strongly recommended that only those with subspecialty accreditation in Hepatology are not required to demonstrate competence in colonoscopy.
Training in ERCP and endoscopic ultrasound is currently being rationalised on a national basis. It is not possible or desirable for all trainees to train in these modalities. Selection for training will be based on educational needs and endoscopic aptitude. ERCP or EUS training should not begin until year 3 of training. Those who are training in ERCP are encouraged to undertake the regional endoscopy ATP and need to liaise with TPD regarding training needs to be placed in units with adequate ERCP exposure.
All trainees will spend at least six months in a post with a significant specialized exposure to liver diseases. This may be in the teaching hospitals or one of the larger district hospitals which have be locally recognised for providing this module. The TPD will co-ordinate the posts.
It is possible to gain sub-speciality accreditation in hepatology. For this, trainees must spend a total of 24 months in liver posts, up to six months of this may be in a peripheral hospital with a liver interest and 12 months must be spent in one of the nationally advertised hepatology posts. Entry to these is competitive.
All trainees will spend at least six months in a post with recognised exposure to and teaching in nutritional support. These posts usually combine this with some general gastroenterology and are in both the Teaching Hospitals and the peripheral hospitals.
There is an active trainees section of the British Society of Gastroenterology and you are strongly encouraged to join.
At least 10 each year for every procedure you are training in.
At least four each year for those procedures you are doing unsupervised/been signed off as competent on, as formative assessments to show continued competence. It would be wise to get these done in the first two weeks of new posts when all trainees should be observed anyway.
In addition to these four, you should include DOPS on those procedures over an above standard diagnostic endoscopy, such as treatment of bleeding, dilatation, stenting etc. I would suggest you continue to get this done as DOPS even once signed off for therapeutic as they are relatively rare occurances.
For endoscopy the JAG forms should be used. See the JAG website, new versions being released now.
DOPS are also required for PEGs, liver biopsy and paracentesis and any other practical procedure you can think off. Use the Royal College forms for non-endoscopy.
Paracentesis and PEGs are required for CCT. See the curriculum and JAG guidelines, Technically liver biopsy is a hard requirement for hepatology subspeciality accreditation, although we realise less unguided biopsies are perfomed and this is the one area where some flexibility is being allowed.
Those of you that didn't bring DOPS to the last RITA, need to bring at least two years' worth.
Although work-placed assessments in general are only mandatory for those "in programme," JAG assessments including DOPS should continue to be performed by all those doing endoscopy in any forum, including research posts.
Mini-CEX/case based discussion:
Five at least every year — you should aim to cover the different facets/domains of the curriculum each year.
One from upper GI
One from small bowel / nutrition
One from colonic disease
One from hepatobiliary
Using a variety of settings (not all outpatients) and don't repeat your favourite condition every year.
I realise this variety will be difficult for those of you doing a very focused post, but try and get some variety and if you miss something one year you should cover it next year. Over the period of your training you should aim to cover the whole curriculum with these assessments, this may mean that you require more than the minimal gastroenterology mini-CEX numbers.
This also means that you need to bring all your mini-CEX to the RITAs. So that it is possible to establish the spread of competence across the curriculum. Thus for instance, your small bowel/nutrition ones should encompass different aspects of this section and not all on coeliac disease or iron-deficiency anaemia and should include some nutritional support.
Those of you that didn't bring mini-CEX to the last RITA, need to bring at least two two years' worth.
Mini-CEX has been compulsory since 2006, so even those of you that are on the old curriculum should have accumulated > 12 of these by the RITAs in January 2009.
If you are taking time out of programme, you still need to the same total number of work-based assessments; this means that some of you will have significant catching up to do on return to clinical training.
1 every year. This is an Eastern Deanery Gastroenterology requirement, more regularly than the JRCPT minimum, but is very good practice and will hold you in good stead come application for consultant posts.
Although you can choose the people involved this must include:
Your educational supervisor
Another consultant you work for
One medical secretary
One endoscopy unit nurse
One ward nurse
One specialist nurse
One outpatient nurse
There should be 12 — 20 raters in total in each MSF.
If you move posts mid-year, you need to ensure that you get reports from both trainers. If you come out of programme mid-year, you need to make sure you get a report from the clinical post. Even if you only spend a few months in any training post you should make sure you get a trainer's report for this period. These are CCT requirements and some SpRs have had to chase these reports from now retired consultants some six years after they worked for the relevant consultants. There is new Eastern Deanery trainer's report proforma now active.