Journal of the Canadian Association of Gastroenterology, 2018, XX(X), 1–5 doi: 10.1093/jcag/gwy024 Original Article Original Article 1 1 2 Brian P.H. Chan, MD, FRCPC , Michael Fine, MD, FRCPC , Seth Shaffer , MD, FRCPC , Khurram J. Khan, MS, MD, FRCPC 1 2 Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Section of Gastroenterology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada Correspondence: Khurram J. Khan, Division of Gastroenterology, Department of Medicine, St. Joseph’s Healthcare, 50 Charlton Avenue East, Martha Wing, Room H421, Hamilton, Ontario L8N 4A6, e-mail: firstname.lastname@example.org. ABSTRACT Background: Gastroenterology training in Canada is guided by the Royal College of Physicians and Surgeons of Canada. Resident perspectives on training and the degree of heterogeneity across training programs have not been previously surveyed. Aim: This study aims to evaluate the current Canadian adult gastroenterology training experience from a resident perspective and provide insight into the heterogeneity among training programs. Method: A survey designed by three current gastroenterology residents was distributed to trainees ae tt nding the Gastroenterology Residents-in-Training course at Canadian Digestive Diseases Week 2018. Categorical data from the survey was analyzed in table format. Other continuous data was con- verted to dichotomous data and analyzed in groups of small and large programs, the large program defined as greater than six trainees. Results: The overall response rate was 45 of 56 (80%), representing 13 of 14 accredited training sites. Mandatory rotations and core procedures varied widely across respondents, with only inpatient training consistent across all sites. Small programs had a higher call burden (P=0.039), but staff were more likely to be available to cover call if the resident coverage was unavailable (P=0.002). There were nonsignificant trends in small programs in the inability to take a post-call day (P=0.07) and a resident perception of being well trained (P=0.07). Conclusions: There is heterogeneity across programs in mandatory rotations and core procedures. With the upcoming shift to competency-based medical education, it is an opportune time to re-evalu- ate and perhaps standardize how gastroenterology training is delivered in Canada. Keywords: Medical education; curriculum; residency; fellowship; gastroenterology. Previous studies in GI training have all primarily focused on INTRODUCTION breadth and volume of exposure in endoscopy (1–4). Evaluation There are 14 accredited adult gastroenterology (GI) train- of endoscopy training in Canada was reported in 2013 (3), ing programs in Canada. Training standards and objec- but limited other information regarding training was assessed. tives are governed by the Royal College of Physicians and A survey of European GI training assessed by trainees found Surgeons of Canada (RCPSC), which also administers cer- major differences in duration of training, workload, call burden, tification examinations. The RCPSC has a multiyear plan and endoscopic procedures between and within countries (1). to transition all specialties to Competency-Based Medical In 2011, revised duty hour reforms (DHR) were implemented Education (CBME) with a Competency by Design (CBD) by the Accreditation Council for Graduate Medical Education model. Each training program determines how objectives (ACGME) in the United States. Meta-analysis has shown that are achieved. © The Author(s) 2018. Published by Oxford University Press on behalf of the Canadian Association of Gastroenterology. 1 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact email@example.com Downloaded from https://academic.oup.com/jcag/advance-article-abstract/doi/10.1093/jcag/gwy024/5003402 by Ed 'DeepDyve' Gillespie user on 07 June 2018 2 Journal of the Canadian Association of Gastroenterology, 2018, Vol. XX, No. XX DHR improves resident well-being, although effects on edu- sample from all programs. Within each program, it was under- cation and patient safety remain unclear (5). In Canada, sim- stood that each resident could have a unique experience, and ilar DHR have not been implemented widely; however, they this variability would be reflected if multiple responses per remain an active area of discussion. school were obtained. Significant changes are forthcoming in the Canadian medical Categorical data from the survey was analyzed in table format education landscape. Gastroenterology training has not previ- based on program grouping. Data was presented in aggregate ously been evaluated regarding work load, duty hours, program to protect respondents and programs from identification, given size or subspecialty exposure on the effects and satisfaction the small population of GI training in Canada. All the contin- of training. These factors are all increasingly important with uous data was converted to dichotomous data, given the small the upcoming transition to CBME. The current study aims to numbers in the survey for statistical analysis purposes. The evaluate the Canadian GI training experience from a resident midpoint was the cut-point for converting the ordinal data to perspective using surveys and provide insight into the hetero- dichotomous. For the questions with a five-point Likert scale, geneity among training programs. the data was dichotomized with “agree” and “strongly agree” taken as positive, and “neutral”, “disagree” and “strongly dis- agree” taken as negative. Ae ft r considering options to analyze METHODS and interpret our data, a post hoc decision was made to look Survey Design and Development at program size and identify if this was associated with on-call The survey was developed by three current GI residents. The list burden and perception of program satisfaction. of survey questions was developed in an iterative fashion, and Using IBM SPSS statistics version 20 (Armonk, NY), a Chi- the final survey had agreement among all authors. To improve square test was employed to compare programs with less than the likelihood of response rate, the survey was limited to 35 six residents to programs with six or more residents. A Fisher questions, designed to be completed in five minutes. The survey exact test was used if any value in the Chi-square was less than was tested in a pilot study, which was distributed to all current or equal to five. A two-sided significance of 0.05 was used to GI Chief Residents in Canada (6). No questions were added assess statistical significance. Further testing for correlation of to the pilot study, but several were removed, which focused on variables was not performed. community staff involvement, accommodations for the Internal Medicine RCPSC exam and the burden of academic activity RESULTS outside of clinical duties. There were 56 adult GI residents at GRIT, and we received 45 Survey sections included program demographics, program completed responses, for an 80% response rate. Thirteen train- structure, on-call responsibilities, subspecialty procedures, ing programs were represented, and one school in Quebec was academic activities and a global assessment. Questions were not represented from the surveys collected. presented as multiple choice ordinal responses or a five-point Likert scale. All responses were anonymized. The survey instru- Program Demographics ment is available in the Appendix. Nine programs had less than or equal to six trainees (n=28), Study Recruitment while four programs had greater than six trainees (n=17) across both core years of training. This included both Canadian The survey was distributed at the Gastroenterology Residents- Medical Graduates and International Medical Graduates. Seven in-Training course (GRIT) at Canadian Digestive Diseases programs had less than or equal to two hospital sites, while six Week (CDDW) 2018. Sixty-seven residents ae tt nded GRIT: had greater than two sites. Gastroenterology was an admit- 56 adult GI and 11 pediatric GI. Surveys were distributed to ting service at 10 programs, although the number of admitted all participants, and any pediatric responses were discarded. patients had wide intra-rater variability. The mean number of No remuneration was provided for completing the survey. gastroenterology and hepatology academic staff per program Responses were collected at GRIT. For participants who failed was 25 (range 7–60), corresponding to an average of four aca- to return the survey, multiple ae tt mpts via personal contact demic staff to each resident (range 2–10). were made to collect results until the end of CDDW (72 hours post-GRIT), which was the end of the survey collection period. Program Structure Statistical Analysis Mandatory rotations varied widely across respondents, with Responses were collected from the surveys and entered in a only inpatient service being constant across all programs Microsoft Excel sheet (Microsoft Corporation, Redmond, (Figure 1). Outside of esophagogastroduodenoscopy and Washington). The data was categorized by the program to which colonoscopy, procedures also varied widely across respondents, the residents belonged, to ensure that we had a reasonable with percutaneous gastrostomy tube placement being the most Downloaded from https://academic.oup.com/jcag/advance-article-abstract/doi/10.1093/jcag/gwy024/5003402 by Ed 'DeepDyve' Gillespie user on 07 June 2018 Journal of the Canadian Association of Gastroenterology, 2018, Vol. XX, No. XX 3 Figure 1. Mandatory rotations across Canadian gastroenterology training. common (Figure 2). Endoscopic retrograde cholangiopan- creatography (ERCP; three programs) and endoscopic ultra- sound (EUS; one program) remain sparsely offered as part of core training. All programs provided financial support to ae tt nd academic conferences. Seven programs provided greater than $1500, while six provided less than or equal to $1500 in con- ference funding. Program Size and Call Burden Programs were grouped into large (greater than six trainees) and small (six trainees or fewer) for the purposes of statistical analysis and comparison (Table 1). Using a call volume of greater than or Figure 2. Training in subspecialty procedures received during manda- equal to six calls per month, residents in smaller programs had a tory rotations across Canadian gastroenterology training. US, ultrasound; statistically significant higher call volume (P =0.039). Compared ERCP, endoscopic retrograde cholangiopancreatography; EUS, endo- to large programs, smaller programs had staff coverage available scopic ultrasound; PEG, percutaneous endoscopic gastrostomy. as first call, if residents were not available to cover call (P =0.002). majority of programs had six or fewer residents, with a median There was a trend in smaller programs that residents perceived of six. In ACGME-accredited programs, there is an average of they were unable to take a post-call day if required, although this 9.2, but training in the United States is three years, making the was not statistically significant (P =0.07). There was no statistical number of trainees per year similar (4). The mean ratio of four difference between groups in frequency of call-backs to hospital academic staff per resident is much higher than the reported (P=0.28), call-backs to hospital ae ft r 10 pm (P =0.99) and the ratio in Europe, at 4:3 (1). Faculty to student ratio is widely amount of sleep achieved while on call (P=0.72). used in higher education but has not been studied in relation to resident outcomes. However, full-time equivalent paid faculty Program Size and Satisfaction to position ratio (FTP) has been correlated with improved suc- There were no significant differences between program size and cess at licensing examinations in pediatrics and internal medi- satisfaction (Table 1). There was a trend towards a resident per - cine (7, 8). The FTP is preferred over resident to faculty ratio, ception of being well-trained at the end of the training period as a small program may be at a disadvantage using this measure in smaller programs (P=0.07). Otherwise, there was no statis- alone, but this was not evaluated in our survey. tical difference in staff support (P=0.14), career counselling Smaller programs were found to have a higher call burden (P=0.35) or program satisfaction (P=0.45) between large and but more staff support for call if residents were unavailable to small programs. do call. This is intuitive as fewer trainees available to support the GI service may result in a higher workload. Call is an inev- DISCUSSION itable aspect of the practice of medicine but a high-call bur- We present the first study to look at the Canadian GI training den has been a noted deterrent to recruitment (9). There was experience from a trainee perspective. There was a wide range also a trend towards residents in smaller programs perceiving of number of core trainees across the two years of training; the they would be well-trained at the end of their training. Medical Downloaded from https://academic.oup.com/jcag/advance-article-abstract/doi/10.1093/jcag/gwy024/5003402 by Ed 'DeepDyve' Gillespie user on 07 June 2018 4 Journal of the Canadian Association of Gastroenterology, 2018, Vol. XX, No. XX Table 1. Comparison of survey results between small and large programs on call burden and program satisfaction Survey Question Small Programs Large Programs P value % (n) % (n) Call volume greater than or equal to six shifts per month. 92.9 (26) 64.7 (11) 0.039 Call backs to hospital more than 50% of shifts. 17.9 (5) 35.3 (6) 0.28 Call backs to hospital ae ft r 10 pm, more than 50% of shifts. 10.7 (3) 11.8 (2) 0.99 Do staff cover as first call if residents are not available? 71.4 (20) 23.5 (4) 0.002 Greater than or equal to six hours of sleep while on call. 21.4 (6) 29.4 (5) 0.72 *Ability to take post-call days. 21.4 (6) 47.1 (8) 0.07 *Staff support while on call. 96.4 (27) 82.4 (14) 0.14 *Adequate career counselling. 46.4 (13) 29.4 (5) 0.35 *Overall program satisfaction. 85.7 (24) 76.5 (13) 0.45 *Belief of being well trained at the completion of residency. 85.7 (24) 58.8 (10) 0.07 *Denotes a five-point Likert scale question. For analysis, this data was dichotomized with “strongly agree”, and “agree”, taken as positive, and “neutral”, “disagree”, and “strongly disagree”, taken as negative. education requires patient exposure and heterogeneity of cases, to therapeutic procedures. Although a survey conducted from which a higher workload may provide. However, it has also been 2010 showed ERCP and EUS exposure was not a priority for shown that an overemphasis on clinical service comes at the Canadian residents in choosing a GI training program (21), expense of educational opportunities and may be detrimental this attitude may have changed as practice has changed, and to overall learning (10–13). In GI, this is of even greater con- Canadian training programs may be behind our contemporar- cern, as procedural skills must also be developed. ies in this shift. Service to education ratio has been widely discussed as it per- Our study has several limitations. There are relatively few GI tains to resident work hours. In 2003 and 2011, the ACGME training programs in Canada, and despite an 80% response rate, put in place regulations to limit the work week to 80 hours for this only represents 45 participants, and 52% of all adult GI res- all trainees, inclusive of call and moonlighting, and maximum idents in Canada. In addition, all study participants ae tt nded 16-hour shifts for first year residents. Similarly in 2012, Quebec GRIT, which may represent a select population of residents instituted a maximum 16-hour duty schedule for in-house calls who may be more interested in research and similar academic (14). The merit of this policy continues to be debated in the activities. The study instrument was a survey which has inher - literature. Post-DHR studies have shown improvement (15, ent limitations. It was open to both first- and second-year GI 16), no change (17), and worse performance (18) in certifica - trainees, who have different training experiences. Recall bias tion and in-training examination scores but an improvement in remains a large concern, and there was intra-rater variability resident well-being (5). There are no GI specific studies, but within schools. All the methods for statistical analysis were for- procedural specialties have favoured DHR significantly less mulated post hoc, which may lead to some analysis bias. than internal medicine (19). In addition, residents at advanced Program directors (PD) were not included in the survey stages of training favoured DHR less than their junior coun- because the focus of our study was resident-experience spe- terparts (20). These findings are not entirely applicable to the cific. It is well documented that PD and trainee perceptions Canadian GI training experience but do speak to a need to bal- vary widely, with PDs often having a superior opinion of the ance service requirements and clinical training opportunities. program (22–26). A comparison by Patel et al. on endoscopy The transition to CBD provides an ideal juncture to re-examine training in the United States showed that PDs rated their quality our approach to training, service requirements, skill acquisi- of endoscopy training and teachers, as well as quality of feed- tion, and resident well-being. back, significantly higher than trainees (4). A comparison of PD There was variability in the mandatory rotations and core responses to residents would be interesting as a future study to procedures across training programs. The RCPSC defines compare differences in perception. minimum training requirements but does not provide a list of mandatory procedures. EUS and ERCP are not requirements CONCLUSION of core training in Canada. Only one program provided EUS training, while three provided ERCP training. This is in contrast Our survey highlights aspects of current gastroenterology train- to Europe, where ERCP is included in core training (1), and in ing in Canada. There is heterogeneity across programs in rota - many US training sites, where the third year provides exposure tions and procedural exposure. Smaller programs were found to Downloaded from https://academic.oup.com/jcag/advance-article-abstract/doi/10.1093/jcag/gwy024/5003402 by Ed 'DeepDyve' Gillespie user on 07 June 2018 Journal of the Canadian Association of Gastroenterology, 2018, Vol. XX, No. XX 5 9. Jhaveri KD, Sparks MA, Shah HH, et al. W hy not nephrology? A survey of US internal have a higher call burden but had more staff support if residents medicine subspecialty fellows. Am J Kidney Dis 2013;61(4):540–6. were unavailable to do call. As the Canadian medical education 10. Haney EM, Nicolaidis C, Hunter A, Chan BK, Cooney TG, Bowen JL. Relationship between resident workload and self-perceived learning on inpatient medicine wards: landscape transitions to CBME, this survey provides important A longitudinal study. BMC Med Educ 2006;6(1):35. information for academic committees reviewing gastroenterol - 11. a Th narajasingam U, McDonald FS, Halvorsen AJ, et al. Service census caps and unit- ogy training curriculums. based admissions: Resident workload, conference ae tt ndance, duty hour compliance, and patient safety. Mayo Clin Proc 2012;87(4):320–7. 12. Haferbecker D, Fakeye O, Medina SP, Fieldston ES. Perceptions of educational Supplementary data experience and inpatient workload among pediatric residents. Hosp Pediatr 2013;3(3):276–84. Supplementary data are available at Journal of the Canadian Association 13. Delva MD, Kirby JR, Knapper CK, Birtwhistle RV. Postal survey of approaches to of Gastroenterology online. learning among Ontario physicians: Implications for continuing medical education. BMJ 2002;325(7374):1218. 14. Dussault C, Saad N, Carrier J. 16-hour call duty schedules: The Quebec experience. Acknowledgements BMC Med Educ 2014;14(Suppl 1):S10. 15. Durkin ET, McDonald R , Munoz A, Mahvi D. The impact of work hour restrictions on All authors were involved in study design, data collection, and man- surgical resident education. J Surg Educ 2008;65(1):54–60. 16. Jain G, Dzara K , Mazhar MN, Punwani M. Do regulated resident working hours affect uscript production. KJK performed statistical analysis. Preliminary medical graduate education? Trends in the American psychiatry board pass rates pre- data from this project was presented as a poster at Canadian and post-2003 duty hours regulations. Psychiatr Bull 2014;38(6):299–302. Digestive Diseases Week 2018 under the title, “State of the Nation: 17. Rajaram R , Chung JW, Jones AT, et al. Association of the 2011 ACGME resident duty hour reform with general surgery patient outcomes and with resident examination Gastroenterology Training in Canada”. The authors have no funding or performance. JAMA 2014;312(22):2374. conflicts of interest to declare. 18. Ahmed N, Devitt KS, Keshet I, et al. A systematic review of the effects of resident duty hour restrictions in surgery: Impact on resident wellness, training, and patient out- comes. Ann Surg 2014;259(6):1041–53. References 19. Tierney WS, Elkin RL, Nielsen CD. Quantitative and qualitative perceptions of the 2011 residency duty hour restrictions: A multicenter, multispecialty cross-sectional 1. Bisschops R , Wilmer A, Tack J. A survey on gastroenterology training in Europe. Gut study. BMC Med Educ 2015;15(1):57. 2002;50(5). 20. Sandefur BJ, Shewmaker DM, Lohse CM, Rose SH, Colletti JE. Perceptions of the 2. Wells CW, Inglis S, Barton R . Trainees in gastroenterology views on teaching in clini- 2011 ACGME duty hour requirements among residents in all core programs at a large cal gastroenterology and endoscopy. Med Teach 2009;31(2):138–44. academic medical center. BMC Med Educ 2017;17(1):199. 3. Xiong X, Barkun AN, Waschke K , Martel M; the Canadian Gastroenterology Training 21. Khan K , Levstik M. Ranking in Canadian gastroenterology residency match: W hat do Program Directors. Current status of core and advanced adult gastrointestinal endos- residents and program directors want? Can J Gastroenterol 2010;24(6):369–72. copy training in Canada: Survey of existing accredited programs. Can J Gastroenterol 22. Rose JS, Waibel BH, Schenarts PJ. Disparity between resident and faculty surgeons’ 2013;27(5):267–72. perceptions of preoperative preparation, intraoperative teaching, and postoperative 4. Patel SG, Keswani R , Elta G, et al. Status of competency-based medical education in feedback. J Surg Educ 2011;68(6):459–64. endoscopy training: A nationwide survey of US ACGME-accredited gastroenterology training programs. Am J Gastroenterol 2015;110(7):956–62. 23. Sender Liberman A, Liberman M, Steinert Y, McLeod P, Meterissian S. Surgery res- 5. Lin H, Lin E, Auditore S, Fanning J. A narrative review of high-quality literature on the idents and ae tt nding surgeons have different perceptions of feedback. Med Teach effects of resident duty hours reforms. Acad Med 2016;91(1):140–50. 2005;27(5):470–2. 6. Chan BP, Fine M, Shaffer S. A206 State of The Nation: Adult gastroenterology training 24. Pugh CM, DaRosa DA, Glenn D, Bell RH. A comparison of faculty and resi- in Canada. J Can Assoc Gastroenterol 2018;1(suppl_2):305–305. dent perception of resident learning needs in the operating room. J Surg Educ 7. Atsawarungruangkit A. Relationship of residency program characteristics with pass 2007;64(5):250–5. rate of the American Board of Internal Medicine certifying exam. Med Educ Online 25. Silcox LC, Ashbury TL, VanDenKerkhof EG, Milne B. Residents’ and program direc- 2015;20:28631. tors’ attitudes toward research during anesthesiology training: A Canadian perspec - 8. Atsawarungruangkit A. Residency program characteristics that are associated with tive. Anesth Analg 2006;102(3):859–64. pass rate of the American Board of Pediatrics certifying exam. Adv Med Educ Pract 26. Buschbacher R, Braddom RL. Resident versus program director perceptions about 2015;6:517–24. PM&R research training. Am J Phys Med Rehabil 1995;74(2):90–100. Downloaded from https://academic.oup.com/jcag/advance-article-abstract/doi/10.1093/jcag/gwy024/5003402 by Ed 'DeepDyve' Gillespie user on 07 June 2018
Journal of the Canadian Association of Gastroenterology – Oxford University Press
Published: May 24, 2018
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