Training in EUS: our challenge

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II Encuentro Latinoamericano CLEUS- Dr Bertrand Napoleon

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  • EUS activity : 200 requested for accurate dc
  • Training in EUS: our challenge

    1. 1. Training in EUS : our challenge B Napoléon, Ecuador 2010
    2. 2. Challenges of development <ul><li>Without planned teaching two risks are present : </li></ul><ul><li>not enough endosonographers </li></ul><ul><li> confidential technique only used in rare university hospital and big cities  no future </li></ul><ul><li>too many endosonographers </li></ul><ul><li> large diffusion but low quality level  no future </li></ul><ul><li>But EUS is difficult and time consuming to learn </li></ul>
    3. 3. 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 2002 Mertz H Gastrointest Endosc 2004; Eloubeidi Gastrointest Endosc 2005 Value of EUS proportional to the training  ASGE guidelines
    4. 4. 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
    5. 5. How organizing teaching in a country : french experience <ul><li>First EUS in France : 1987 </li></ul><ul><li>- Pr Lambert : Lyon / Pr Paolaggi Paris </li></ul><ul><li>French Club of Digestive EUS (CFED) 1992 </li></ul><ul><li>(Drs Palazzo, Roseau, Souquet, Napoleon, Pujol) </li></ul><ul><li>Once a year : national congress </li></ul><ul><li>congress mixed with Belgian Club of EUS </li></ul><ul><li>University diploma 1994 </li></ul>
    6. 6. What diploma in 1994 ? <ul><li>French particularities : </li></ul><ul><li>important private activity (> 50% of endoscopy done in private practice) </li></ul><ul><li>No limit for gastroenterologist : everyone may do every endoscopy without the necessity of a specific university diploma </li></ul><ul><li>Only limit : when sued you need to prove your competence …but EUS is not risky… </li></ul>
    7. 7. What diploma in 1994 ? <ul><li>Problems : </li></ul><ul><li>- adapted either for residents and for senior </li></ul><ul><li>- necessity to be attractive (no need of certification) </li></ul><ul><li>The choice was national, originating from the club </li></ul><ul><li>Combining the two best approaches of teaching : </li></ul><ul><li>university approach : theoretical courses, exam, original research… </li></ul><ul><li>post-graduate course approach : clinical practice </li></ul>
    8. 8. Organisation <ul><li>One National university diploma in Paris (1994) : </li></ul><ul><li>Organizing commitee with experts from different hospitals and from private practice : </li></ul><ul><ul><li> Selection of 20 to 30 trainees per year (endoscopists) </li></ul></ul><ul><ul><li> Selection of centers for clinical practice </li></ul></ul><ul><ul><li> Organisation of course (2 to 3 weeks per year) </li></ul></ul><ul><ul><li> Certification, qualification </li></ul></ul>
    9. 9. What work for the trainee ? <ul><li>2 years </li></ul><ul><li>2 weeks/ year of theoretical course </li></ul><ul><li>20 one-day session / year of clinical practice </li></ul><ul><li>original thesis report </li></ul><ul><li>examination with : </li></ul><ul><ul><li>anonymous theoretical work </li></ul></ul><ul><ul><li>selected EUS videotapes case studies </li></ul></ul>
    10. 10. Who were the teachers ? Gastroenterologists wellknown for their competence, interest, experience in the field of EUS Compagnonage No remuneration Pathologists, surgeons, radiologists
    11. 11. Evaluation of the diploma in 2000 <ul><li>More useful for the trainee : </li></ul><ul><li>Theoretical courses, videosession, clinical practice </li></ul><ul><li>- Would want : simulator, video library </li></ul><ul><li>91 % would recommend the diploma </li></ul><ul><li>Evaluation of EUS activity after diploma: </li></ul><ul><li>- 22%  no activity or < 5/month </li></ul><ul><li>Main reasons : economic, number of indications </li></ul><ul><li>- 23%  between 5 and 10/ month </li></ul><ul><li>- 55%  > 10 /month </li></ul>
    12. 12. How is EUS in France in 2008 <ul><li>What experience ? </li></ul><ul><li>What training ? </li></ul><ul><li>Evolution of diploma </li></ul>
    13. 13. 2008 : what experience <ul><li>217 centers (360 users)  1 / 275000 inhabitants </li></ul><ul><li>- throughout national territory </li></ul><ul><li>- 66% private pratice / 33% hospital </li></ul><ul><li>70000 EUS/year 10% puncture </li></ul><ul><li>63% BP, 25% Anorectal, 13% Oesogast </li></ul><ul><li>Questionnaire to the CFED members : </li></ul><ul><li>176 answers / 360 users </li></ul>
    14. 14. 2008 what experience Diagnosis EUS/year Puncture EUS/year Participation of French Club meeting (live/conventionnal)
    15. 15. 2008 : what training <ul><li>Questionnaire to the CFED members : </li></ul><ul><li>How did you learn ? </li></ul><ul><li>- 33% diploma </li></ul><ul><li>- 49% compagnonage </li></ul><ul><li>- 17% alone </li></ul><ul><li>When did you learn ? </li></ul><ul><li>- 1/3 as resident, </li></ul><ul><li>- 2/3 as gastroenterologist </li></ul>
    16. 16. <ul><li>New diploma (Paris  Marseille) </li></ul><ul><li>Over one year </li></ul><ul><li>At least 2 years after GI fellowship </li></ul><ul><li>With EUS equipment available </li></ul><ul><li>Speaking/understanding French </li></ul><ul><li>Theoretical formation emphasizing the role of EUS images (DVD, videotape…) : 3 wks </li></ul><ul><li>Symbionix simulator and animal model : 1 wk </li></ul><ul><li>Participation to EUS meetings </li></ul>2008 : evolution of diploma
    17. 17. Learning interventional EUS on animal model (pig) One day session, sub group of < 6 fellows Faculty laboratory (experimental surgical room) Marc Barthet, Hôpital Nord,Marseille, France
    18. 18. 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)
    19. 19. 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 year EUS as a part of endoscopic live demo (VidéoDigest, courses, UEGW …)
    20. 20. <ul><li>EUS is a difficult and time-consuming learning technique </li></ul><ul><li>In a country, the mean level of the endosonographers and the repartition throughout the territory are as important as the presence of international experts </li></ul>Conclusion
    21. 21. <ul><li>EUS can not be developed without an efficient teaching = motivated experts </li></ul><ul><li>Different modalities of teaching must be developed </li></ul><ul><li>- University credentialing (only 30% of cases in France) </li></ul><ul><li>- Phantoms, DVD, books, live demo … </li></ul><ul><li>- Compagnonage +++ </li></ul>Conclusion
    22. 22. Thanks to Gilles Roseau, Marc Barthet and Jean-Michel Godchaux for giving me some results

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