Endoscopy training in Canada in general surgery residency programs: ways forward.

As former residency directors and endoscopists interested in teaching and quality improvement, we applaud the article written by Bradley and colleagues (DOI: 10.1503/cjs.008514) for their work on this topic. We agree that endoscopy training is an essential component of general surgical training and the challenges that they have put forward are achievable. We would like to offer potential solutions. As noted by Bradley and colleagues, there is variability across the country in terms of resident exposure to endoscopy. Unfortunately, procedure volumes are not always recorded and quality outcome measures, such as colonoscopy completion rates and adenoma detection rates, are rarely tracked. This must change. One method to record procedure volumes and quality outcomes data would be to use a synoptic reporting program that has been modified to account for resident involvement. Some in the surgical community resist setting minimum endoscopy procedure volumes for trainees. A recent British study, which used a modified synoptic reporting system involving more than 36 000 patients and 297 trainees, found that only 41% of the trainees achieved a colonoscopy completion rate of 90% after 200 colonoscopies.1 This result is consistent with the recommendation by Cancer Care Ontario of a minimum of 300 cases to achieve competency.2 Given that a general surgical residency is 5 years long, we feel that this number is achievable through increased use of community surgery rotations. Many of us were never taught how to teach flexible endoscopy aside from role modelling. To improve and standardize training, we feel that the Canadian Association of General Surgeons (CAGS)–sponsored Skills Enhancement for Endoscopy (SEE) program should be adopted. This program includes a Colonoscopy Skills Enhancement (CSE) course and a Train the Endoscopy Trainer (TET) course.3 The CSE course improves skill in all aspects of colonoscopy. For example, in a recent randomized trial, endoscopists who took this course had a significant improvement in their adenoma detection rate.4 The TET course is designed to improve teaching skills for endoscopists who teach endoscopy. We have taken both courses and firmly believe that they deliver on their objectives. Ideally, all faculty members who train residents in flexible endoscopy should take the CSE course, and at least 2 faculty members from each training program should become certified trainers. In the interim, senior surgical residents should also be required to take the CSE course. To increase our trainees’ exposure to emergent and therapeutic upper gastrointestinal endoscopy, we feel that there needs to be increased collaboration with the gastroenterology specialty. In many large teaching centres, surgeons are not involved in the management of emergency cases. The result is that many trainees to do not get adequate exposure to these cases. One approach to solving this problem is to have our trainees rotate through a gastroenterology consultation service with the expectation of participating in the daytime service as well as after-hours call. It has been recognized that there is variation in the quality of endoscopy services across the country.5 As our patients deserve high-quality endoscopy services, CAGS must play a central role in improving the training of our residents.