acpgbi agenda andrew shorthouse. acpgbi agenda getting good value?getting good value? colonoscopy...

ACPGBI AGENDAACPGBI AGENDA

Andrew ShorthouseAndrew Shorthouse

ACPGBI AgendaACPGBI Agenda• Getting good value?Getting good value?

• Colonoscopy – surgeons under threat? Colonoscopy – surgeons under threat?

• Training and certification of colorectal surgeonsTraining and certification of colorectal surgeons

• Research and AuditResearch and Audit

• Research FoundationResearch Foundation

• ACPGBI as a major stakeholderACPGBI as a major stakeholder e.g Revised Colorectal Measures for the Manual for e.g Revised Colorectal Measures for the Manual for

Cancer Services 2004Cancer Services 2004

Documents in ProductionDocuments in Production

• Revision CRC GuidelinesRevision CRC Guidelines

• Resources for Coloproctology revisionResources for Coloproctology revision

• Significant influence as stakeholder forSignificant influence as stakeholder for– BSG StraBSG Strategy for Delivery of GI Servicestegy for Delivery of GI Services– Revised Colorectal Measures: The Manual For Revised Colorectal Measures: The Manual For

Cancer Services2004 Cancer Services2004

Ownership share with ESCPOwnership share with ESCP

Relating to the MembershipRelating to the Membership

• Bridging the gap between the Executive Bridging the gap between the Executive and grass roots membershipand grass roots membership

• ACPGBI has a good track record of ACPGBI has a good track record of support support – ACPGBI syllabusACPGBI syllabus– CME: courses and annual meetingCME: courses and annual meeting


• Bridging the gap between the Executive Bridging the gap between the Executive and grass roots membershipand grass roots membership

• ACPGBI has a good track record of ACPGBI has a good track record of supportsupport

Professional Development and TrainingProfessional Development and Training

CPDCPDACPGBI Annual Meeting Sage Gateshead July 3-6 ACPGBI Annual Meeting Sage Gateshead July 3-6 20062006

• CME updateCME update

• Live international laparoscopic surgery Live international laparoscopic surgery

• 14 multidisciplinary symposia14 multidisciplinary symposia

• State of the Art lecturesState of the Art lectures

• Free papers Wednesday afternoon onlyFree papers Wednesday afternoon only

• No wasted half day!No wasted half day!

• Wonderful venueWonderful venue

ACPGBI Annual Meeting Sage ACPGBI Annual Meeting Sage Gateshead July 3-6 2006Gateshead July 3-6 2006

• CME updateCME update

• CR07 resultsCR07 results

• EAUS workshopEAUS workshop

• Nurses’ and Dukes’ club symposiaNurses’ and Dukes’ club symposia

• Significant contribution by EuropeansSignificant contribution by Europeans


• Identify membership concerns which Identify membership concerns which impact on practiseimpact on practise– Mail shots, chapter reps, chapter visits, Mail shots, chapter reps, chapter visits,

informal correspondenceinformal correspondence– Rapid response and feedbackRapid response and feedback– Develop consensus and act e.g colonoscopyDevelop consensus and act e.g colonoscopy

ColonoscopyColonoscopy


• Screening and quality measuresScreening and quality measures– GRS for endoscopy unitsGRS for endoscopy units– Competence of endoscopistsCompetence of endoscopists

• Dominated by gastroenterologistsDominated by gastroenterologists• Marginalisation of surgeonsMarginalisation of surgeons• Threat to colorectal surgeons if “driving test” rolled out Threat to colorectal surgeons if “driving test” rolled out

to diagnostic practiseto diagnostic practise• ““Accreditation for Screening Endoscopists”Accreditation for Screening Endoscopists”• Poor quality colonoscopy in UKPoor quality colonoscopy in UK


• Job plans may preclude screeningJob plans may preclude screening• Accreditation process favours physiciansAccreditation process favours physicians• Surgeons need to do colonoscopySurgeons need to do colonoscopy

– NumbersNumbers– On-table colonoscopy eg bleeding, laparoscopyOn-table colonoscopy eg bleeding, laparoscopy– Know what you’re operating on!Know what you’re operating on!

• Physicians proactive in screening – some catching up Physicians proactive in screening – some catching up to doto do

• Initiative with “invasive colonoscopy”Initiative with “invasive colonoscopy”


• Initial concern raised by a member to Initial concern raised by a member to PRCSPRCS

• Taken up by ACPGBITaken up by ACPGBI• Dialogue with Roland Valori, National Dialogue with Roland Valori, National

Endoscopy LeadEndoscopy Lead– Multi-agency ownership of endoscopyMulti-agency ownership of endoscopy– No elite corpsNo elite corps– Surgeons participation in screeningSurgeons participation in screening– Some QA criteria redefinedSome QA criteria redefined

Colonoscopy QA CriteriaColonoscopy QA Criteria

– >150 colonoscopies per year>150 colonoscopies per year– 90% completion rate on intention to treat basis90% completion rate on intention to treat basis– Perforation rate <1:1000 (!)Perforation rate <1:1000 (!)– Evidence that sedation used is within Evidence that sedation used is within

recommended guidelinesrecommended guidelines– Detailed submission of 50 consecutive cases with Detailed submission of 50 consecutive cases with

relevant histology to determine the adenoma relevant histology to determine the adenoma detection rate (<15% detection may result from detection rate (<15% detection may result from case mix)case mix)

ACPGBI Colonoscopy CommitteeACPGBI Colonoscopy Committee

• Increase JAG representation Increase JAG representation • Establish colonoscopy framework consistent with Establish colonoscopy framework consistent with

National Standards to credential colorectal surgeonsNational Standards to credential colorectal surgeons• Seek current colonoscopy practice by questionnaireSeek current colonoscopy practice by questionnaire• Colonoscopy courses for established consultants to Colonoscopy courses for established consultants to

hone skillshone skills• Establish EMR database with BSG participationEstablish EMR database with BSG participation

Collaboration with PhysiciansCollaboration with Physicians

• ACPGBI now more actively involved ACPGBI now more actively involved – united approach to endoscopy developmentunited approach to endoscopy development

• screeningscreening• symptomatic cancer managementsymptomatic cancer management• national endoscopy team involvement national endoscopy team involvement • BSG endoscopy committeeBSG endoscopy committee• trainingtraining

– representation at BSG improvedrepresentation at BSG improved

Colonoscopy AccreditationColonoscopy Accreditation

• Trainee certificate of competenceTrainee certificate of competence• Performance measures Performance measures

– completion rate for a defined number of procedurescompletion rate for a defined number of procedures– Implicit in this is a need to have done a certain number of Implicit in this is a need to have done a certain number of

procedures procedures

• Revalidation of existing colonoscopistsRevalidation of existing colonoscopists• Performance measures rather than minimum numbers Performance measures rather than minimum numbers

– caecal intubation caecal intubation – polyp detection polyp detection – SedationSedation

• Supporting reference Supporting reference

ColonoscopyColonoscopy• Collect prospective data Collect prospective data • Keep documentation up to date using JAG Keep documentation up to date using JAG

compliant formscompliant forms• Endoscopists signed off locally for access to Endoscopists signed off locally for access to

endoscopy unitsendoscopy units• Implications for access to colonoscopy in the Implications for access to colonoscopy in the

private sectorprivate sector• Envisage most colonoscopists will gradually Envisage most colonoscopists will gradually

embrace accreditation processembrace accreditation process

Get weaving!Get weaving!

Specialist TrainingSpecialist Training


• Defining a colorectal surgeonDefining a colorectal surgeon– Minimum number of index procedures, Minimum number of index procedures,

including anterior resectionincluding anterior resection– Colonoscopy (to be defined)Colonoscopy (to be defined)– 6 modules colorectal surgery6 modules colorectal surgery– At least 4 in recognised specialist training At least 4 in recognised specialist training

units in final 2 yearsunits in final 2 years– Procedure and workplace based assessmentsProcedure and workplace based assessments– Mandatory training course attendanceMandatory training course attendance– Development of specialist exit examinationDevelopment of specialist exit examination


• Conflicting pressuresConflicting pressures– Provide specialist DGH service locallyProvide specialist DGH service locally

• Distinct colorectal and benign upper GI electiveDistinct colorectal and benign upper GI elective• Large laparoscopic componentLarge laparoscopic component

– Provide general GI emergency serviceProvide general GI emergency service– A minority of smaller remote hospitals may A minority of smaller remote hospitals may

want general visceral surgeonwant general visceral surgeon– Need for highly specialised regional servicesNeed for highly specialised regional services– Breast surgeons withdrawing from takeBreast surgeons withdrawing from take– Ensure efficient, attractive career structure Ensure efficient, attractive career structure

within constraints of MMC and EWTDwithin constraints of MMC and EWTD

Recommendations Recommendations from ACPGBI, AUGIS from ACPGBI, AUGIS and ALS Presidentsand ALS Presidents

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

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

• Modular trainingModular training

• Minimum 6 modules in relevant specialtyMinimum 6 modules in relevant specialty

• 2 modules in complementary GI training post2 modules in complementary GI training post

• Minimum final 4 modules in recognised Minimum final 4 modules in recognised specialist training unitspecialist training unit

• Minimum 2 earlier modules in specialty Minimum 2 earlier modules in specialty

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

• Separate category of specialist GI surgeonSeparate category of specialist GI surgeon– Smaller hospitalsSmaller hospitals– Working with teams of upper or lower GI surgeons Working with teams of upper or lower GI surgeons

in larger hospitalsin larger hospitals

• Training to includeTraining to include– Hemicolectomy (?), cholecystectomy, anti-reflux Hemicolectomy (?), cholecystectomy, anti-reflux

surgery, most uncomplicated laparoscopic surgery, most uncomplicated laparoscopic proceduresprocedures

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

• Separate category of specialist GI surgeonSeparate category of specialist GI surgeon– Minimum 4 modules each of upper and lower GI Minimum 4 modules each of upper and lower GI

surgerysurgery– At least one module in HPBAt least one module in HPB– OGD and colonoscopy trainingOGD and colonoscopy training– No requirement for post CCT fellowship yearNo requirement for post CCT fellowship year– Laparoscopic trainingLaparoscopic training– Sufficient exposure to open surgerySufficient exposure to open surgery– Bariatric experienceBariatric experience

Recommendations from ACPGBI, Recommendations from ACPGBI, AUGIS and ALSAUGIS and ALS

• Complex level 3 procedures eg rectal cancer, Complex level 3 procedures eg rectal cancer, IBD, complex upper GI should be referred to IBD, complex upper GI should be referred to appropriate colorectal or upper GI specialistappropriate colorectal or upper GI specialist

• Defined laparoscopic training structureDefined laparoscopic training structure

• All participate in general emergency rota All participate in general emergency rota throughout trainingthroughout training

• Abdominal and thoracic trauma trainingAbdominal and thoracic trauma training

• Recognised coursesRecognised courses

Recommendations from ACPGBI, Recommendations from ACPGBI, AUGIS and ALSAUGIS and ALS

• Post CCT fellowshipsPost CCT fellowships– Not a prerequisite for allNot a prerequisite for all– Insufficient training postsInsufficient training posts– Optional for minority who wish to be super-Optional for minority who wish to be super-

specialisedspecialised

• MentorshipMentorship– All newly appointed specialists should be formally All newly appointed specialists should be formally

mentored during first 5 yrsmentored during first 5 yrs

M62M62

• Nigel Scott and Jim HillNigel Scott and Jim Hill

• 1996 111996 11thth year year

• Hugely successful!Hugely successful!

• State of the Art in just 2 daysState of the Art in just 2 days

• 100 delegates and 25 faculty100 delegates and 25 faculty

• Have a great meeting!Have a great meeting!

A Vision of Specialist A Vision of Specialist and General and General

Gastrointestinal Gastrointestinal Surgical Training in Surgical Training in the United Kingdomthe United Kingdom

Professor Andrew ShorthouseProfessor Andrew ShorthouseNorthern General Hospital SheffieldNorthern General Hospital Sheffield

Seamless Training Program

F1 & F2 Foundation YearsF1 & F2 Foundation Years

Early General Surgery (2 yrs)Early General Surgery (2 yrs)

General Surgery Specialty Training General Surgery Specialty Training + Subspecialty Module (4yrs)+ Subspecialty Module (4yrs)

Advanced Specialty Training (2yrs)Advanced Specialty Training (2yrs)

SelectionSelection

MRCS (core + specialty)MRCS (core + specialty)

FRCS (core + specialty)FRCS (core + specialty)

Specialty examSpecialty examSAC Gen Surg Proposal March 2004SAC Gen Surg Proposal March 2004

CCTCCT

A Vision of GI Specialist TrainingA Vision of GI Specialist Training• Routine UGI work, laparoscopic, bariatric, Routine UGI work, laparoscopic, bariatric,

antreflux and straightforward biliary workantreflux and straightforward biliary work• Smaller hospitals won’t do bariatric workSmaller hospitals won’t do bariatric work• Routine colonic and proctologyRoutine colonic and proctology• Upper and lower GI endoscopy = distinction Upper and lower GI endoscopy = distinction

between upper and lower GI specialistbetween upper and lower GI specialist• Specialist GI surgeonSpecialist GI surgeon must be able to do do must be able to do do

both OGD and colonoscopyboth OGD and colonoscopy– Doesn’t need post CCTDoesn’t need post CCT– 4 and 4 modules at any time4 and 4 modules at any time– No complex level 3 work in OG/HBP/CR (complex No complex level 3 work in OG/HBP/CR (complex

fistula/pouch/rectal cancerfistula/pouch/rectal cancer

A Vision of GI Specialist TrainingA Vision of GI Specialist Training

• Electing at the beginning of specialist trainingElecting at the beginning of specialist training• More surgeon availability makes it easier to More surgeon availability makes it easier to

subspecialisesubspecialise• OG and HPB final 2 years in specialist unit and OG and HPB final 2 years in specialist unit and

one other year. One colorectal (2 modules)one other year. One colorectal (2 modules)• Emergency GI surgery will be done by Emergency GI surgery will be done by

specialist OG/HPB/CR or specialist GI surgeonspecialist OG/HPB/CR or specialist GI surgeon• Formal jointly badged training courses in upper, Formal jointly badged training courses in upper,

lower GI and laparoscopic surgery (digestive lower GI and laparoscopic surgery (digestive lap surgery)lap surgery)

A Vision of GI Specialist TrainingA Vision of GI Specialist Training

• Appropriate training in emergency surgery Appropriate training in emergency surgery ATLS/CRISP/RCS course (includes ATLS/CRISP/RCS course (includes laparoscopy)laparoscopy)

• Formula in training to allow for GI surgeon to Formula in training to allow for GI surgeon to gain experience in eg thoracic traumagain experience in eg thoracic trauma

• Laparoscopic upper GI and CR should be done Laparoscopic upper GI and CR should be done under auspices of relevant specialist under auspices of relevant specialist associationsassociations


• ACPGBI position ACPGBI position – More clearly defined, directional training within More clearly defined, directional training within

MMC and EWTDMMC and EWTD– Specialist colorectal training in Specialist colorectal training in flexibleflexible CCT CCT– 6 modules (3 yrs) in recognised training units6 modules (3 yrs) in recognised training units– 1 year in upper GI surgery1 year in upper GI surgery– General GI emergency rota (excluding vascular)General GI emergency rota (excluding vascular)– Clear process of colorectal certificationClear process of colorectal certification– Optional post-CCT fellowships for those wishing Optional post-CCT fellowships for those wishing

to be highly specialisedto be highly specialised


• ACPGBI position presented to ASGBIACPGBI position presented to ASGBI• Joint statement in preparation for Joint statement in preparation for

Specialist Associations, Senate and Specialist Associations, Senate and PMETBPMETB

Association of Coloproctology of Great Britain and Ireland

Current issues

Specialist Training – ACPGBI Specialist Training – ACPGBI Position StatementPosition Statement

Fears about rigid 4 years specialist training Fears about rigid 4 years specialist training arising from MMC and EWTDarising from MMC and EWTD

• Delivery of certified specialists only achievable Delivery of certified specialists only achievable within within flexibleflexible CCT CCT

• GI general training followed by specialist GI general training followed by specialist training in final 2 yrs training in final 2 yrs

• Ideally, certification for all colorectal surgeons, Ideally, certification for all colorectal surgeons, however specialisedhowever specialised

Specialist Training – ACPGBI Specialist Training – ACPGBI Position StatementPosition Statement

• Important to recognise the training needs of Important to recognise the training needs of majority of colorectal specialists in general majority of colorectal specialists in general hospitals, from those who will super-specialisehospitals, from those who will super-specialise

• Post CCT fellowship year optionalPost CCT fellowship year optional

• Could this model of flexible specialist training Could this model of flexible specialist training be adapted to other specialties?be adapted to other specialties?

• Seek agreed template for General Surgery Seek agreed template for General Surgery training via ASGBI Specialty Presidentstraining via ASGBI Specialty Presidents


• ACPGBI position presented to ASGBIACPGBI position presented to ASGBI• Joint statement in preparation for Joint statement in preparation for

Specialist Associations, Senate and Specialist Associations, Senate and PMETBPMETB

A Vision of A Vision of Specialist and Generalist Specialist and Generalist

Gastrointestinal Gastrointestinal Surgical Training in the UKSurgical Training in the UK

Surgical GastroenterologySurgical Gastroenterology

• Government policy and reformsGovernment policy and reforms– Better defined, directional training and career Better defined, directional training and career

structurestructure

• Most patients wish to be treated close to homeMost patients wish to be treated close to home

• Ready access to specialist servicesReady access to specialist services

• Secondary care – 3 tiersSecondary care – 3 tiers– Smaller hospitalsSmaller hospitals– Combined Trusts and large DGHsCombined Trusts and large DGHs– Large tertiary referral centresLarge tertiary referral centres

Surgical Gastroenterology TodaySurgical Gastroenterology Today

• Teams of upper GI and colorectal surgeonsTeams of upper GI and colorectal surgeons

• Catalysed by reorganisation of cancer servicesCatalysed by reorganisation of cancer services

• Centralisation of upper GI cancerCentralisation of upper GI cancer– Driven by governmentDriven by government– Case volume relates to outcomesCase volume relates to outcomes

• Colorectal CancerColorectal Cancer– Units function well at more local levelUnits function well at more local level– Prevalence of diseasePrevalence of disease– Outcomes and case volume less well defined Outcomes and case volume less well defined

Future ChallengesFuture Challenges

• Provision of high quality serviceProvision of high quality service

• Shorter trainingShorter training

• Manpower limitationsManpower limitations

• Specialist care needed at local and regional Specialist care needed at local and regional levellevel

• Progressive specialisation in elective workProgressive specialisation in elective work

• GI emergency service to be maintainedGI emergency service to be maintained

Future ChallengesFuture Challenges

• Most trainees focussed towards specialist Most trainees focussed towards specialist careercareer

• Compensating for EWTD and MMCCompensating for EWTD and MMC

• Paradox of expertise required across spectrum Paradox of expertise required across spectrum of GI emergency careof GI emergency care

• Includes abdominal and thoracic traumaIncludes abdominal and thoracic trauma

Acute CoverAcute Cover

• ProblematicProblematic– Breast surgeonsBreast surgeons– Fewer performing major upper GI resections Fewer performing major upper GI resections

because of COG guidancebecause of COG guidance

• Ideal would be parallel upper/colorectal teamsIdeal would be parallel upper/colorectal teams

• Insufficient manpowerInsufficient manpower

• Expansion to achieve would dilute elective workExpansion to achieve would dilute elective work

• Must continue to share emergency general Must continue to share emergency general workloadworkload

Acute CoverAcute Cover

• Increasing specialisation threatens competency Increasing specialisation threatens competency managing complex emergencies when cross managing complex emergencies when cross coveringcovering

• By CCT, competence expected for all GI By CCT, competence expected for all GI surgical emergenciessurgical emergencies

Concept of the Specialist GI SurgeonConcept of the Specialist GI Surgeon

• Specialist GI Surgeon novel approachSpecialist GI Surgeon novel approach

• Alternative and complementary to pure upper Alternative and complementary to pure upper and lower GI specialistsand lower GI specialists

• Designated specialistDesignated specialist

• Broader, more general GI trainingBroader, more general GI training

• Equipped to work side by side with more Equipped to work side by side with more specialised colleaguesspecialised colleagues


• Possibly preferred by smaller hospitalsPossibly preferred by smaller hospitals

• Attractive to tertiary referral centresAttractive to tertiary referral centres– Challenged by target pressuresChallenged by target pressures– High volume and less specialised workHigh volume and less specialised work– Significant laparoscopic componentSignificant laparoscopic component

Concept of the Specialist GI Surgeon – Concept of the Specialist GI Surgeon – who does the cancers?who does the cancers?

• Elective upper GI cancer devolvedElective upper GI cancer devolved

• Where does colorectal cancer fit?Where does colorectal cancer fit?

• Colorectal traineesColorectal trainees– Final two years in recognised specialist unitsFinal two years in recognised specialist units– At least one other year in a colorectal postAt least one other year in a colorectal post– TME trainingTME training– Index procedures accruedIndex procedures accrued

proficiencyproficiency


• Precludes the more general GI specialist?Precludes the more general GI specialist?

• Not fulfilled relevant training criteriaNot fulfilled relevant training criteria– Rectal cancerRectal cancer– Colon cancer?Colon cancer?

• Should all CRC be the sole domain of the Should all CRC be the sole domain of the colorectal specialist?colorectal specialist?

• Specialist GI surgeons need to manage Specialist GI surgeons need to manage emergency colorectal and gastric canceremergency colorectal and gastric cancer


• Some cases demanding and won’t waitSome cases demanding and won’t wait

• May not be specialist backupMay not be specialist backup

• Choice to transfer or operateChoice to transfer or operate

• Some logic in devolving elective colon cancerSome logic in devolving elective colon cancer

• Keep the left sided cancers or just the rectals?Keep the left sided cancers or just the rectals?

• Occasional exposure to emergency upper GI Occasional exposure to emergency upper GI malignancies with no elective experiencemalignancies with no elective experience


• ACPGBI and AUGIS viewACPGBI and AUGIS view– All All cancer management by the relevant specialistcancer management by the relevant specialist

• Uneasy philosophical conflict between:Uneasy philosophical conflict between:– Progressive upper and lower GI specialisation, Progressive upper and lower GI specialisation,

partition of cancer management, separate MDTspartition of cancer management, separate MDTs– More generalist approach with incumbent difficulties More generalist approach with incumbent difficulties

maintaining competence across breadth of surgerymaintaining competence across breadth of surgery

Training: Specialist Upper GI and Training: Specialist Upper GI and Colorectal SurgeonsColorectal Surgeons• ModularModular

• Final 2-3 years in specialist training unitsFinal 2-3 years in specialist training units

• Rationalisation of regional training schemesRationalisation of regional training schemes

• Colorectal and upper GI trainees:Colorectal and upper GI trainees:– Sufficient general GI training for acute takeSufficient general GI training for acute take– Excluding vascularExcluding vascular– Higher level of expertise in respective elective and Higher level of expertise in respective elective and

emergency area of special interestemergency area of special interest– Variably large laparoscopic componentVariably large laparoscopic component

Post CCT FellowshipsPost CCT Fellowships

• Counterproductive if rigid prescription for allCounterproductive if rigid prescription for all

• Newly appointed specialists will develop in postNewly appointed specialists will develop in post

• Option for those wanting to be more specialisedOption for those wanting to be more specialised

• Need to differentiate needs of Need to differentiate needs of – Majority who will become specialists in general Majority who will become specialists in general

hospitals around UK from:hospitals around UK from:– Aspiring super-specialistsAspiring super-specialists

Training: the Specialist Upper and Training: the Specialist Upper and Lower GI SurgeonLower GI Surgeon• ModularModular

• Equal amount of upper and lower GI surgeryEqual amount of upper and lower GI surgery

• Continuing emphasis on emergency surgeryContinuing emphasis on emergency surgery

• Final two years upper and lower shared Final two years upper and lower shared

• More limited elective portfolio from EWTDMore limited elective portfolio from EWTD

• Flexible timescale to CCTFlexible timescale to CCT– Full range of level 2 colorectal and upper GI Full range of level 2 colorectal and upper GI

proceduresprocedures– Spectrum of GI emergenciesSpectrum of GI emergencies

LaparoscopyLaparoscopy

• Large laparoscopic commitment for most Large laparoscopic commitment for most surgeonssurgeons

• Core skills course (F2 and 3)Core skills course (F2 and 3)

• Intermediate skills course (early ST years)Intermediate skills course (early ST years)

• Advanced courses planned eg colorectalAdvanced courses planned eg colorectal

• Laparoscopic fellowships (ACPGBI and ALS)Laparoscopic fellowships (ACPGBI and ALS)

• Preceptorship schemesPreceptorship schemes

Exit Examination and CertificationExit Examination and Certification

• Future exit exams should be taken by all Future exit exams should be taken by all colorectal and upper GI specialists, however colorectal and upper GI specialists, however specialised they aim to bespecialised they aim to be

• Adapt to needs of specialist GI surgeonAdapt to needs of specialist GI surgeon


• ICE remains a problemICE remains a problem– No specialist recognitionNo specialist recognition– Specialist curriculum developed by ACPGBISpecialist curriculum developed by ACPGBI– Procedure based assessment tools evolvingProcedure based assessment tools evolving– Validation exercise to start (big job) Validation exercise to start (big job) – Needs to be educationally valid and PMETB Needs to be educationally valid and PMETB

compliantcompliant– More weight if other specialties adoptMore weight if other specialties adopt

Specialty TrainingSpecialty Training

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

Certification for Specialist StatusCertification for Specialist Status

• Mode of certification not yet decidedMode of certification not yet decided• Series of in-training assessmentsSeries of in-training assessments• Portfolio of subspecialty workPortfolio of subspecialty work• Final assessment - scientific knowledge, case Final assessment - scientific knowledge, case

scenarios, and vivascenarios, and viva

• Exit examination for specialist status?Exit examination for specialist status? – Conflict!Conflict!– No specialist badgingNo specialist badging– Portfolio of specialist MCQs needs to be developedPortfolio of specialist MCQs needs to be developed– EBSQ?EBSQ?

MMC: Unresolved IssuesMMC: Unresolved Issues

• ACPGBI well positioned to steer colorectal and ACPGBI well positioned to steer colorectal and general surgery development general surgery development

• Vascular surgery split with own SACVascular surgery split with own SAC• Breast and endocrine stopping emergency takesBreast and endocrine stopping emergency takes• Dialogue with upper GI surgeons Dialogue with upper GI surgeons

– How to train surgeons for GI general take, in parallel How to train surgeons for GI general take, in parallel with training of colorectal and upper GI specialistswith training of colorectal and upper GI specialists

– Concept of visceral GI surgeonConcept of visceral GI surgeon


• Conflicting pressuresConflicting pressures– Provide specialist DGH service locallyProvide specialist DGH service locally

• Distinct colorectal and benign upper GI electiveDistinct colorectal and benign upper GI elective• Large laparoscopic componentLarge laparoscopic component

– Provide general GI emergency serviceProvide general GI emergency service– A minority of smaller remote hospitals may A minority of smaller remote hospitals may

want general visceral surgeonwant general visceral surgeon– Need for highly specialised regional servicesNeed for highly specialised regional services– Breast surgeons abrogating responsibilityBreast surgeons abrogating responsibility– Ensure efficient, attractive career structure Ensure efficient, attractive career structure

within constraints of MMC and EWTDwithin constraints of MMC and EWTD


• Need to define a colorectal surgeonNeed to define a colorectal surgeon– Minimum number of index procedures, including Minimum number of index procedures, including

anterior resectionanterior resection– Colonoscopy: Competency assessment based upon Colonoscopy: Competency assessment based upon

performance measure over x consecutive cases, as performance measure over x consecutive cases, as yet not determined (JAG to issue guidance)yet not determined (JAG to issue guidance)

– 6 modules colorectal surgery6 modules colorectal surgery– At least 4 in recognised specialist training units in final At least 4 in recognised specialist training units in final

2 years2 years– Procedure and workplace based assessmentsProcedure and workplace based assessments– Mandatory training course attendanceMandatory training course attendance– Development of specialist exit examinationDevelopment of specialist exit examination

Colonoscopy CredentialingColonoscopy Credentialing

• Measures of competency preferable to absolute Measures of competency preferable to absolute numbersnumbers

• E.g. completion rate for the last x E.g. completion rate for the last x procedures? procedures?

• JAG shortly to arrive at consensusJAG shortly to arrive at consensus


• ICE remains a problemICE remains a problem– No specialist recognitionNo specialist recognition– Specialist curriculum developed by ACPGBISpecialist curriculum developed by ACPGBI– Procedure based assessment tools evolvingProcedure based assessment tools evolving– Validation exercise to start (big job) Validation exercise to start (big job) – Needs to be educationally valid and PMETB Needs to be educationally valid and PMETB

compliantcompliant– More weight if other specialties adoptMore weight if other specialties adopt


• Decision to proceed with process to Decision to proceed with process to establish formal assessment in establish formal assessment in coloproctologycoloproctology– Eligibility criteriaEligibility criteria

• 3 years colorectal training, two of which should be 3 years colorectal training, two of which should be on recognised training unitson recognised training units

• Case numbersCase numbers• Work place based assessmentWork place based assessment

– Written examinationWritten examination– Oral examination for candidates successful in Oral examination for candidates successful in

first two parts first two parts


• Writing educational justification for Writing educational justification for proposed examinationproposed examination

• Feasibility issues being addressedFeasibility issues being addressed

• Issue of a formal register for existing Issue of a formal register for existing consultants more difficultconsultants more difficult

• EBSQ recognised by EU but not individual EBSQ recognised by EU but not individual national education authoritiesnational education authorities