Letter: enhancing training opportunities for upper GI bleeding in Sheffield—a UK transferable model?

Abstract

Editors, We read with great interest the recent paper by Chaudhary et al that noted the casefatality from upper gastrointestinal bleeding (UGIB) in Scotland has fallen over the past 16 years (30day mortality from 10% to 7.9%).1 However, it is unclear whether this improvement is due to senior involvement and what effect trainees involvement has on mortality. Future speciality gastroenterology training in the United Kingdom will be shortened to 4 years (previously a 5year training scheme). This potentially reduces the exposure trainees have to undertaking therapeutic gastroscopy in patients with UGIB, before having to undertake such procedures independently as a consultant. Clough et al demonstrated the significant impact that the new 4year Shape of Training programme could have on gastroenterology trainees.2 The standard of training quality that will be delivered to trainees and the ability to achieve required practical clinical competencies are key concerns. Increasing or enhancing the exposure for trainees to UGIB has only previously been demonstrated in Japan and in a sample size of two trainees.3 In 2017 our UK tertiary centre hospital introduced three targeted interventions to improve training opportunities for trainees with tailored endoscopy lists, an immersive 6week training block, and extra ad hoc lists. Our retrospective review over a 17month period (January 2018May 2019) investigated all patients presenting with UGIB following these initiatives and compared this to a previous study assessing training in the same centre in 2011.4 In total, there were 1059 patients (mean age 62 years, SD ± 19 years, 75% as inpatients) presenting with UGIB. Trainees (n = 23) performed a greater proportion of all endoscopies in 2018 than in 2011 (22.9% vs 15%, respectively) with no difference in mortality compared to consultants (P = 0.72). On average, trainees were in specialty training year (ST) 6, but 41.4% of endoscopies were carried out by ST7 trainees. The allcause mortality was 6.7%. Of those, only 15.5% were due to UGIB; the most common cause of death was sepsis (21.4%). Mortality was not associated with year of training (P = 0.146) or with time of endoscopy (morning, afternoon or out of hours; P = 0.840). In 0.6% of cases, bleeding could not be controlled endoscopically and these patients subsequently required surgery. At our centre, Gastroenterology trainees now perform more endoscopies for UGIB than previously due to new initiatives; crucially, this is without increased patient mortality. We believe that this model is transferable across the United Kingdom. This model may enable trainees to gain experience with UGIB and address their concerns with regards to attaining competency during training.