training in eus: our challenge
DESCRIPTION
II Encuentro Latinoamericano CLEUS- Dr Bertrand NapoleonTRANSCRIPT
Training in EUS : our challenge
B Napoléon, Ecuador 2010
Challenges of development
Without planned teaching two risks are present :
1) not enough endosonographers
confidential technique only used in rare university hospital and big cities no future
2) too many endosonographers
large diffusion but low quality level no future
But EUS is difficult and time consuming to learn
Impact of EUS training ?
- Accuracy of EUS staging for esophageal cancer improved for T staging from 64 % to 90 % but not for N staging
- Short training (2 months) improved FNA accuracy in pancreatic masses from 33 % to 91 %
- Significant increase in sensitivity after 30 cases (>80 %) for FNA in pancreatic masses ….
Schlick T Surg Endosc 1999; Harewood Gastrointest Endosc 2002Mertz H Gastrointest Endosc 2004; Eloubeidi Gastrointest Endosc 2005
Value of EUS proportional to the training ASGE guidelines
How many procedures …?
Competence in EUS 2001 ASGE 2008 survey of guidelines advanced fellows
Muc/submuc lesions 75 90 (50-100)Pancreatico-biliary exam 75 100 (50-150)EUS-FNA 50 70 (25-100)
- Experience : 200-250 procedures/y (close to ERCP)- Training : ≥ 6 mths in a center doing > 300 EUS/y
Ainsworth Endoscopy 2002; Sivak Gastrointest Endosc 2002, Rosenthal Gastrointest Endosc 2008
How organizing teaching in a country : french experience
First EUS in France : 1987 - Pr Lambert : Lyon / Pr Paolaggi Paris
French Club of Digestive EUS (CFED) 1992(Drs Palazzo, Roseau, Souquet, Napoleon, Pujol)
Once a year : national congress congress mixed with Belgian Club of EUS
University diploma 1994
What diploma in 1994 ?
French particularities :
- important private activity (> 50% of endoscopy done in private practice)
- No limit for gastroenterologist : everyone may do every endoscopy without the necessity of a specific university diploma
- Only limit : when sued you need to prove your competence …but EUS is not risky…
What diploma in 1994 ?Problems :
- adapted either for residents and for senior
- necessity to be attractive (no need of certification)
The choice was national, originating from the clubCombining the two best approaches of teaching :- university approach : theoretical courses, exam,
original research…- post-graduate course approach : clinical practice
Organisation
One National university diploma in Paris (1994) :Organizing commitee with experts from different
hospitals and from private practice :
Selection of 20 to 30 trainees per year (endoscopists)
Selection of centers for clinical practice Organisation of course (2 to 3 weeks per
year) Certification, qualification
What work for the trainee ?
- 2 years- 2 weeks/ year of theoretical course- 20 one-day session / year of clinical practice- original thesis report- examination with :
- anonymous theoretical work- selected EUS videotapes case studies
Who were the teachers ?
Gastroenterologists wellknown for their competence, interest, experience in the field of EUS
CompagnonageNo remuneration
Pathologists, surgeons, radiologists
Evaluation of the diploma in 2000- More useful for the trainee :Theoretical courses, videosession, clinical practice- Would want : simulator, video library- 91 % would recommend the diploma
Evaluation of EUS activity after diploma:- 22% no activity or < 5/monthMain reasons : economic, number of indications- 23% between 5 and 10/ month- 55% > 10 /month
How is EUS in France in 2008
What experience ?
What training ?
Evolution of diploma
2008 : what experience
217 centers (360 users) 1 / 275000 inhabitants- throughout national territory- 66% private pratice / 33% hospital
70000 EUS/year 10% puncture63% BP, 25% Anorectal, 13% Oesogast
Questionnaire to the CFED members : 176 answers / 360 users
> 200
51-200 < 50
2008 what experience
< 50
51-200
201 to 500
>500
Diagnosis EUS/year Puncture EUS/year
every year
2-3 / 5 y
< 1/5 y
Participation of French Club meeting (live/conventionnal)
2008 : what training
Questionnaire to the CFED members :
How did you learn ? - 33% diploma- 49% compagnonage- 17% alone
When did you learn ?- 1/3 as resident, - 2/3 as gastroenterologist
New diploma (Paris Marseille)- Over one year - At least 2 years after GI fellowship- With EUS equipment available- Speaking/understanding French
- Theoretical formation emphasizing the role of EUS images (DVD, videotape…) : 3 wks
- Symbionix simulator and animal model : 1 wk- Participation to EUS meetings
2008 : evolution of diploma
Learning interventional EUS on animal model (pig)
One day session, sub group of < 6 fellowsFaculty laboratory (experimental surgical room)
Marc Barthet,Hôpital Nord,Marseille, France
Learning interventional EUS on animal model (pig)
Session program :- to follow anatomical structures : mesenteric, portal and celiac vessels, pancreatic gland, bile duct- to perform FNA on lymph nodes in the liver hilum- to perform celiac neurolysis
Evaluation : pre and post test Significant improvement - to follow anatomical structures - to perform : lymph node FNA (time and precision), celiac neurolysis (time)
Participation to meetings
Participation to the Francophone annual congress of EUS (alternatively theoretical session, live)
Participation to live demo of EUS which will be held in Marseille every year
In Europe :One specific live course about EUS in
Amsterdam (P Fockens) every yearEUS as a part of endoscopic live demo
(VidéoDigest, courses, UEGW …)
EUS is a difficult and time-consuming learning technique
In a country, the mean level of the endosonographers and the repartition throughout the territory are as important as the presence of international experts
Conclusion
EUS can not be developed without an efficient teaching = motivated experts
Different modalities of teaching must be developed
- University credentialing (only 30% of cases in France)
- Phantoms, DVD, books, live demo …- Compagnonage +++
Conclusion
Thanks to Gilles Roseau, Marc Barthet and Jean-Michel Godchauxfor giving me some results