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The future of ERCP training in the UK
  1. I A MURRAY,
  3. R HEELEY,
  1. Department of Gastroenterology
  2. Northern General Hospitals NHS Trust
  3. Herries Road, Sheffield S5 7AU, UK
  1. Dr M T Donnelly, Department of Gastroenterology, Northern General Hospitals NHS Trust, Herries Road, Sheffield S5 7AU, UK.mark.donnelly{at}
  1. M D HELLIER, Chairman—Specialist Advisory Committee in Gastroenterology to JCHMT
  1. Department of Gastroenterology
  2. Princess Margaret Hospital, Okus Road
  3. Swindon, Wiltshire SN1 4 JU, UK
  1. A I MORRIS, Chairman—Joint Advisory Group in Endoscopy (JAG)
  1. Department of Gastroenterology
  2. Princess Margaret Hospital, Okus Road
  3. Swindon, Wiltshire SN1 4 JU, UK

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Editor,—We read with great interest the leading article by Hellier and Morris (

) regarding the future of endoscopic retrograde cholangiopancreatography (ERCP) training in the UK. They discuss the importance of restricting training in ERCP to some trainees and training only in centres that are accredited for training by the Joint Advisory Group (JAG) in Endoscopy. JAG, at the request of the Conference of Royal Colleges, produced endoscopy training guidelines.1 For ERCP training, these state that a centre should be performing a minimum of 250 procedures per annum (with specialist centres performing 500 per annum). They should also have regular meetings to discuss radiological findings with a radiologist with special interest in ERCP.

While we certainly agree with the importance of ensuring satisfactory training, we are concerned that the guidelines base competence for training in ERCP solely on the number of procedures carried out in individual centres. We have noted that larger centres often have several practitioners performing ERCP and several trainees learning. To determine the likely impact of the JAG recommendations on ERCP training and whether trainees were likely to have greater individual exposure to procedures in larger units, we performed a questionnaire based study, which was mailed to all acute UK hospitals. A total of 178 of 292 units replied (61%) to a single mailing (anonymous questionnaire), of whom 151 (84.8%) were performing ERCPs. Forty teaching hospitals (THs 75.5%) and 74 district general hospitals (DGHs 61.6%) offered ERCP training.

The service was mainly consultant based (92.1% of lists being consultant led). Gastroenterologists (68.0%), surgeons (29.2%), and radiologists (2.8%) performed ERCPs. The number of procedures performed per annum in DGHs was 40–800 (mean 228) and in THs 60–2000 (mean 336), 57.2% of which were therapeutic. Of those performing more than 250 procedures per annum, 82.1% of DGHs and 77.3% of THs held regular radiology meetings to discuss findings. Of those performing less than 250 procedures per annum, 72.9% of DGHs and 75.0% of THs held radiology meetings.

Each centre trained up to six trainees per annum, most training one or two. The average number of procedures which trainees could perform per annum was 176 (48–431) in DGHs and 144 (range 54–311) in THs. This was dependent more on the number of trainees per centre than on the type of hospital in which the training was performed with the exception of three centres which train six or seven trainees and perform 600–2000 procedures per annum (summarised in fig 1): 32.5% of DGHs and 50% of THs had or planned to apply for JAG accreditation for ERCP training. At present, only 68 units nationally are accredited for ERCP training. Despite this, 86.5% of DGHs and 90% of THs planned to continue with ERCP training.

Figure 1

Relationship between number of procedures performed in centres per annum and average “hands on” endoscopic retrograde cholangiopancreatography (ERCP) experience of trainees. Results shown are mean (SEM).

Like the authors of this article and others preceding it,2 3 we believe that ERCP for every trainee is neither achievable nor desirable. We would urge that the revised JAG criteria should include guidelines to the number of trainees who may be trained in each centre according to the number of procedures performed. Otherwise the opportunity to train in smaller centres perhaps performing 200 procedures per annum but training a single trainee will be lost. Attention should also be paid to both the technical competence of the trainers and their ability to impart their knowledge.



Editor,—We read with interest the letter and enclosed results of a survey on endoscopic retrograde cholangiopancreatography (ERCP) training. We, like the authors, have been concerned since the initial Joint Advisory Group (JAG) training document that to a large extent competence is judged by numbers rather than other measures of endoscopy skills. Indeed, reliance on numbers has been the cause of most of the correspondence that JAG has received following the publication of the initial training document. However, at that time and to a large extent at present, there are few satisfactory measures of competence to replace numbers and time. The authors state in their letter “that only centres that are accredited for training by JAG will be permitted to continue endoscopy training”. Strictly speaking this is not true. Lack of recognition of a unit for training would mean that any training that takes place in that unit would not be recognised by the statutory bodies but this would not prohibit the units from training. They also state that “the guidelines base competence for training in ERCP solely on the number of procedures carried out in the individual centres”. The training does actually require a little more than numbers, for example the training document states that “endoscopists cannot be considered competent in ERCP until they are able to cannulate the desired duct in over 90% of cases and provide biliary drainage. Trainees should carry out at least 100 procedures under supervision and be achieving a high percentage of success before performing the procedure independently”. Nevertheless, the general message is accepted that we must be looking at quality rather than quantity.

Although it is clear that good opportunities do exist for gaining training in units undertaking smaller numbers of procedures, it is difficult to define a precise number that takes into account the needs of the individual trainee in getting the required experience and the numbers required for the trainer to maintain competence.

In the new JAG document, which we hope to publish in the next month, the emphasis has moved away from numbers to other means of assessing competence. We are still of the opinion that those units with lower throughputs should combine with larger units to provide training as part of a regionally organised training scheme. Trainees are already organised regionally and decisions as to who will undertake ERCP training will be made in consultation with the regional training director. Several hospitals have already applied for, and been granted, ERCP training status on the basis of a combined training unit. A total of 174 units have now registered with JAG, of whom 115 have been approved for ERCP training.

The new JAG document makes it clear that trainers should undergo training on endoscopy specific skills courses that have already been piloted by the Raven Department of Education at the RCS. In future, it will be essential for re-accreditation of units that trainers will have gone on such courses.

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