Pediatric Ileocolonoscopy Training: Acquisition of Endoscopic Skill Must Be Nurtured and Objectively Assessed Within a Formalized Pediatric Framework

Not for the first time, and almost certainly not for the last, the adult gastrointestinal endoscopy literature has not only reported low rates of ileal intubation but also questioned the necessity of ileal histology. Yoong and Heymann, in their May 2006 article in Surgical Endoscopy, carried out a retrospective analysis of more than 2000 colonoscopies (1). The terminal ileum was intubated in just 16.1% of patients. In only 4% of those who had ileoscopies performed were abnormal findings on histologic studies noted. There are many studies detailing the increased yield of ileocolonoscopy versus colonoscopy or radiological contrast studies, and also the benefit of taking biopsy specimens from normal-looking ileal mucosa in the assessment and diagnosis of pediatric Crohn disease (2,3). It is consequently clear that ileal intubation, when not restricted by strictures, is mandatory in the assessment of pediatric inflammatory bowel disease. These studies support the view that by the completion of their endoscopy training, our trainees should be able to competently and safely intubate the terminal ileum to provide the most comprehensive assessment of the lower gastrointestinal tract. It would seem that anything less than this is substandard training and the opportunity to promote a standard of clinical/endoscopic excellence in future trainees will be diluted. Although one must recognize that the different pathologies being sought in adults with gastrointestinal symptoms will inevitably require different approaches—rigid sigmoidoscopy and lack of necessity for ileal intubation in the assessment of potential colorectal malignancies being the most striking—these sorts of publications question the role of adult gastroenterologists in the assessment of pediatric patients and may raise doubts surrounding their role in the education of pediatric endoscopy trainees. Successful pancolonoscopy and ileoscopy has been examined by many authors, including Israel et al (4), who concluded that “trainees can acquire the skills necessary to perform this challenging procedure in children when they are closely supervised and guided in a dedicated pediatric gastroenterology program.” This would suggest the need for much more formalized and structured pediatric endoscopy for trainees within our specialty, which are run and supervised by pediatric endoscopy trainers with appropriate skills and training ability. This must, of course, acknowledge that innovative techniques carried out mainly in adult gastroenterology may only be initially learned in that setting. Most pediatric gastroenterology training bodies recognize endoscopy training as a part of the wider training of a pediatric gastroenterologist or hepatologist. There is ongoing debate in an era when the range of modalities of treatment that can be administered endoscopically is increasing in regard to how many of these procedures should be part of standard training requirements. This is particularly true of procedures that are needed less commonly and those for which there may be a relatively prolonged learning period, such as endoscopic retrograde cholangiopancreatography. It may well be that these need to be carried out in only a few institutions where experience and knowledge can be consolidated, thereby potentially improving outcomes. In general, training requirements have been based around a requirement for a minimum number of supervised procedures. Pediatric guidelines have often been created or revised to include changes in the range and number of procedures required in the absence of prospectively acquired data looking at the rates of skill acquisition (5). There seems to be little doubt that a minimum number of completed endoscopic procedures will continue to be required, but this is an insufficient assessment tool. Among adult gastroenterology trainees, it appears that rates of skill acquisition vary among individuals in training (6). Prospectively acquired data from the Royal Free Hospital, where each pediatric trainee's endoscopic performance was assessed contemporaneously by the supervising physician, would seem to be in agreement with these findings (7). It would therefore seem appropriate to consider the need for objective assessment of competence of pediatric gastroenterologists in training with a universally accepted document. It would also seem sensible to consider the need for periodic assessment of the trainers and creation/recognition of accredited endoscopic training centers. In adult practice, evidence is accumulating recognizing the benefit of virtual endoscopy in hastening the acquisition of endoscopic skill (8). These findings have been replicated in work carried out at the Royal Free Hospital looking at rates of skill acquisition in ileocolonoscopy in 2 cohorts of pediatric trainees, with 1 cohort having prior exposure to virtual endoscopy (7). We as pediatric gastroenterologists should strive for the ideal of an individual with specific gastrointestinal training in children being the provider of care to the child. However, until we organize our training (and this includes retraining of those already trained, but who are performing in a manner recognized as substandard), we will not be able to make a cogent argument against the continued involvement of our adult counterparts in this arena. Pediatric gastrointestinal endoscopy has taken major strides forward recently, and training programs must keep abreast of these changes. Standardization of competency assessment, as well as independent assessment of the competency of the trainer plus a minimum requirement for procedures, seems logical. Another integral component of the ideal training journey for a trainee is exposure to basic skills training courses at the outset of training using virtual models and then live subjects. Although observational courses have a place, skill acquisition will be helped by hands-on courses. Practical skill attainment must be learned in parallel to lesion recognition. All of these arguments are underpinned by the requirement for a trainee to be adequately assessed by a competent trainer who will keep a contemporaneous and trainer-assessed account of every procedure, which could be entered into a log book. This would logically lead to an exit qualification from training specific for pediatric endoscopic skill at one or more different levels of procedure complexity. Consequently, it is a logical extension of this discussion that, in due course, a “driving test” for those already trained and those undergoing training will become a mandatory part of clinical lives to ensure excellence of endoscopic provision for children. It may also be argued that, depending on trainee assessment during endoscopic training, competency and assessed skill may inform as to the degree of service and technical ability that might be provided by a particular individual once they attain independent practitioner status, and indeed in the United Kingdom, the Joint Advisory board of Gastrointestinal endoscopic training (www.thejag.org.uk) has specific requirements for training at 2 different levels for pediatric endoscopists.