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ERCP training
  1. Barnsley DGH Trust, Gawber Road
  2. Barnsley, South Yorkshire S75 2EP, UK
  3. dwwbullimore{at}

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Editor,—The leading article “ERCP training —time for change” by Hellier and Morris (OpenUrlFREE Full Text) addresses important issues. Views as to how endoscopic retrograde cholangiopancreatography (ERCP) training should change may vary considerably between those in the average district general hospital (DGH) serving 220 000–250 000, and those in larger units, frequently serving populations of around 500 000.

Firstly, those without ERCP training but additional skills elsewhere will soon find themselves a favoured species. What price a skilled ultrasonographer? Advertising recently for a third consultant gastroenterologist to join two who undertook ERCP, we specified that ERCP was a skill not required. We felt an additional ERCP practitioner would dilute experience and eventually skill. Many DGH trusts are in a similar position with two consultants already in post who can provide sufficient ERCP cover and they do not want a third.

Secondly, the quality of training is largely dependent on two factors: the skill of the trainer, both in relation to ERCP and as an educationalist, and the case exposure available to the trainee. Frequently in a DGH there is only one trainee and case exposure is high. In a larger centre, while the number of ERCPs undertaken may be twice as great, there are frequently 3–5 trainees wanting to gain experience and “hands on” case experience is unavoidably less.

I am sure that I am not alone in finding that some attached SpRs have improved rapidly when exposed to a regular weekly list, an exposure that they were unable to achieve at their main teaching centre where teaching was otherwise excellent, simply because of pressure of the number of trainees on lists.

If the final decision is that units undertaking less than an arbitrary number of procedures (currently 250) are not to train SpRs, there are obvious consequences for training beyond further loading of the teaching centres which are already overstretched. It means that if an SpR is attached to a DGH at a late stage of training, when she is competent to undertake procedures independently, as judged by the main teaching centre, she will be unable to consolidate her skill at the DGH during the attachment. This is because it would be unwise from the clinical governance and medicolegal standpoint for a consultant or trust to allow anyone still defined as being a “trainee” near an ERCP if the unit is not a Joint Advisory Group (JAG) approved training centre.

The top centres in the country have practitioners the skill of which we all admire but few of us working elsewhere could ever approach. They provide excellent live demonstration teaching days and at times informal and friendly one to one advice from which we greatly benefit. Attendance at such live demonstration days should be a required component of all trainees' training and regularly considered for CPD by trainers.

Finally, my recent experience of SpR applicants for a consultant post had its illuminating aspects. The stated experience of some was such that they had apparently undertaken ERCPs independently on the equivalent entire average clinical load for a DGH for a three year period and this was for a post where ERCP was not required. I did wonder how trainers were maintaining any skill at all.