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