• ENDOSCOPY

We read with interest the paper by Ekkelenkamp et al, who found that the early use of validated simulators during endoscopy training expedites the learning of procedural skills. Authors propose the structured employment of simulators within endoscopy training curricula.1

Endoscopic learning represents an essential component of gastroenterology training and would surely benefit from the application of virtual reality techniques.

Nevertheless, beyond the necessity of high-tech gadgets, other basic educational needs of gastroenterology trainees appear to remain unmet in Europe to date.

In 2002, Bisschops et al compared the training programmes of 10 different European countries, finding marked dissimilarities in several aspects of gastroenterology training, including duration, workload, earnings and programmes. In particular, the teaching of some fundamental techniques (eg, abdominal ultrasound) was not provided by all Training Centres. Furthermore, the average number of endoscopic procedures was different among the included countries, and the overall endoscopy training appeared to be inadequate in at least four of them. Additionally, a third of last-year trainees were not confident of their competence in endoscopy.2 Seven years later, Telleman et al confirmed the discrepancies among European (and also non-European) countries in terms of curriculum duration, compulsoriness of entrance and final exams, and required minimum number of endoscopic and ultrasonographic procedures.3

Additionally, gender imbalance towards interest in advanced endoscopy training appears to represent, still in the 21th Century, another relevant issue, despite the absence of pertinent reports from Europe.4

Disparities in the education of trainees will lead to differences in the quality of their competences, with deleterious consequences for the European healthcare system.

One of the key objectives of the European Board of Gastroenterology and Hepatology (EBGH) is to define, secure and assess the European standards of training in gastroenterology and hepatology. In 2012, the EBGH released the latest version of the Blue Book, which includes the competences of the European specialists in gastroenterology and hepatology. Gastroenterologists who satisfy the training criteria are awarded the European Diploma of Gastroenterology. Furthermore, the EBGH certifies Training Centres in Countries of the European Union of Medical Specialists who meet certain criteria.5 Nevertheless, when we analyse the timeline and the geographical location of accredited Training Centres,4 the work made by EBGH appears to be partially lost in translation at present.

As shown in figure 1, the number of newly accredited Training Centres has decreased over the years by about a third, from 38 Centres between 1995 and 1999 to only 12 Centres between 2010 and 2013.

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Figure 1

Newly accredited European Union of Medical Specialists Training Centres approved by the European Board of Gastroenterology & Hepatology over the years (updated to November 2013).

Furthermore, looking at the geographical position of accredited Centres, two considerations stand out (figure 2). First, an overall prevalence of northern Centres over southern ones is easily evident. Nevertheless, after we separated Centres accredited from 1995 to 2004 from those accredited after 2004, we appreciated a south-north gradient (assessed by linear regression) in the prevalence of recently certified Centres. The latter phenomenon may be explained by the desire for Europeanisation of the non-European countries and the ambition to grow of the less prosperous ones, as well as by the efforts made by the United European Gastroenterology to engage them in the harmonisation of European gastroenterology.

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Figure 2

Map of accredited European Union of Medical Specialists Training Centres approved by the European Board of Gastroenterology & Hepatology (updated to November 2013).

What lies ahead for European gastroenterology education? Future directions should include economic, political and organisational measures to allow and ensure the adherence of each Training Centre to the rules of EBGH. One of the aims of the United European Gastroenterology Strategic Plan for 2015–2018 is to reduce disparities across Europe as well as to improve education and training, also through the partnership with pertinent European corporations. This objective is really challenging, and a close collaboration among societies and people involved in digestive diseases is necessary to make it achievable.