Gastroenterology: new subspecialtiesBMJ 2007; 334 doi: https://doi.org/10.1136/bmj.334.7584.s16 (Published 13 January 2007) Cite this as: BMJ 2007;334:s16
- Janusz Jankowski, senior research fellow and consultant gastroenterologist
Jane Collier, John de Caestecker, and Janusz Jankowski explain what's out there
Extra national training numbers have been awarded to trusts to help meet the requirements of the European Working Time Directive (EWTD). This expansion is likely to continue with the Royal College of Physicians' recommendation that there should be six whole time equivalent gastroenterologists per 250 000 of the population.
Most consultant posts are in tubal gut gastroenterology but an increasing number focus on hepatology and pancreatobiliary disease. Endoscopic ultrasound, therapeutic endoscopy, and nutrition have developed considerably over the past decade and subspecialisation continues to grow in these areas (box 1).
Improvements in cancer prevention, screening, surveillance, nutrition, and therapeutic interventions such as PEG (percutaneous endoscopic gastrostomy) tubes, stents, and endoscopic mucosal resections have encouraged more clinicians to specialise in gastrointestinal (GI) oncology. The interaction of surgery, radiology, pathology, biochemistry, specialist nurses, oncologists, and dietitians make gastroenterologists ideally suited to the multidisciplinary management of their patients. Unfortunately, in recent years, trying to see patients with suspected GI cancer within two weeks has, in some regions, overwhelmed the clinical and endoscopic capacity of gastroenterologists.
Twenty four hour consultant cover for gastroenterological emergencies, such as acute upper GI bleeding, will probably be introduced following the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report on interventional endoscopy deaths. More colonoscopists are needed to deliver national colon cancer screening over the next three years in England. This will probably make it more difficult for gastroenterologists to practise in general internal medicine as well as their own specialty. Subspecialisation will become commonplace.
Hearts and brains
How will this impact on the training of specialist registrars (SpRs)? The first post-F2 (foundation year 2) trainees will enter “seamless” training programmes in the second half of 2007. Recruitment to gastroenterology will probably entail two years of basic medical training followed by four years of specialty training. Membership of the Royal College of Physicians may not be needed for entering specialty training. Alternatively, there may be a six year period of training, as with cardiology and neurology, which will incorporate both general internal medicine and gastroenterology.
Box 1: Main subspecialty interests in gastroenterology
Inflammatory bowel disease
Functional bowel disease
Gastrointestinal cancer and its prevention
Medicolegal issues in medicine
Inherited cancer syndromes
From 2006 onwards foundation year trainees and SpRs will be assessed by the miniclinical evaluation exercise (miniCEX) and DOPS (direct observation of procedural skills), which, together with the 360° appraisals, will form part of the yearly RITA (record of in-training assessment) process. A proposed core curriculum might include basic upper GI endoscopy, flexible sigmoidoscopy and colonoscopy, and a general GI training over two years.
A general GI clinic and endoscopy list would continue into the final two years but would be streamed into subspecialisation modules: “luminal” gastroenterology, hepatology, or specialised endoscopy. There may be further specialisation such as neurogastroenterology, GI physiology, or advanced inflammatory bowel disease. ERCP (endoscopic retrograde cholangiopancreatography) training would only be offered to those showing an aptitude for, and an interest in, endoscopy. This might be an option also for trainees in hepatology who have the appropriate eye-hand coordination skills.
Motivated and talented
The future of the clinical academic postfoundation programme is under review, led by the newly constituted Clinical Research Collaboration UK. The British Society of Gastroenterology wants to attract motivated and talented individuals to an academic career so the new proposals should facilitate this type of tailored approach.
Mine's a JAG
Endoscopy trainees must attend a joint intercollegiate advisory group on GI endoscopy (JAG)-approved course in basic endoscopic theory and practice, and subsequently an approved colonoscopy training course. Certification of completed training will depend on attending JAG courses, completion of a satisfactory minimum number of procedures and formal assessment by the DOPS procedures. An image registry for lesion recognition will very shortly supplement this process, probably through a web-based quiz.
Hepatology can be practised in liver transplant centres, non-transplant teaching hospitals, and district general hospitals. An increasing number of district general hospitals are appointing gastroenterologists with a subspecialty interest in hepatology to manage patients with chronic liver disease. The seven liver transplant centres in the United Kingdom are in London (Royal Free/University College London and Kings College Hospital), Birmingham, Leeds, Cambridge, Newcastle upon Tyne, and Edinburgh. Care after liver transplant is now undertaken jointly with regional and local hepatologists.
Doctors can apply for a certificate of completion of training in gastroenterology with subspecialty recognition in hepatology. To achieve this they have to complete one year of training within the four year single specialty or five year dual specialty (general medicine and gastroenterology) training programme. More than 15 posts across the country have been approved for the stand alone one year national training number in hepatology. The posts are normally taken up during the third or fourth year of the gastroenterology training scheme and can be in a different deanery. At least six months should be spent working in a liver transplant unit at some point during the gastroenterology and hepatology training programme.
The number of clinicians with independent fellowships from organisations such as the Medical Research Council, the Wellcome Trust, and Cancer Research UK continues to drop. Only a few academic centres throughout the UK, such as London, Oxford, Cambridge, and Nottingham can support large training programmes. Our first study on SpRs considering academic GI medicine showed that 88% sought jobs in district general hospitals or a teaching hospital job with no research component; 8% sought a teaching hospital job with a minor research commitment; and only 4% wanted a post with mainly academic duties. Their main argument against academic medicine is the lack of training opportunities in applied clinical research when compared to basic laboratory science. Many trainees feel academic gastroenterology has little clinical relevance. Other reasons given were too many demands outside clinical duties, and teaching commitments.
Most non-academic recruits to gastroenterology are not keen to teach because they feel the new contract requires programmed clinical activities. Several academic gastroenterology positions are not filled each year—10% at chair level, 15% at senior lecturer/reader level, and 20% at lecturer level. In recent years, the development of translational medicine in gastroenterology has successfully bridged the gap between basic science and clinical practice. For example, the Aspirin Esomeprazole Chemoprevention Trial (AspECT) aims to prevent the development of gastrointestinal cancers with the use of aspirin and proton pump inhibitors. This large trial has allowed 100 centres to tackle important clinical questions together and address basic science issues such as the location of stem cells and the role of inflammation in cancer.
Career choices in gastroenterology
GI physiology/functional bowel specialist
Problems with academic gastroenterology
Few undergraduates doing intercalated BSc (less than 10% of students)
Few major GI academic units (currently only 10 nationally)
Few academics with track records of training
Many pressures for young doctors
Few funding sources for clinically related work
Obstacles in funding and academic careers
Few career development grades
From bed to bench and back
Gastroenterology continues to evolve. Specialties such as GI oncology may be offered. Many posts are available for training, but most offer too few research opportunities. Despite this, excellent clinical training programmes can be found throughout the UK. There are good prospects for a career in clinical or academic gastroenterology. Training is being redesigned in basic gastroenterology and endoscopy, encouraging development of one or more subspecialties in the final two years. Research is now evolving alongside clinical training, offering opportunities from bed to bench and back again.