GI Fellows Research Articles

Endoscopic approaches to enteral feeding and nutrition core curriculum

Endoscopic approaches to enteral feeding and nutrition core curriculum

Su1567 Time to Splenic Flexure Intubation Competency Predicts Time to Cecal Intubation Competency in GI Fellows

Su1567 Time to Splenic Flexure Intubation Competency Predicts Time to Cecal Intubation Competency in GI Fellows

Mo1498 Learning Curve in Diagnosing Dysplasia in Barrett's Esophagus (BE) Using Probe-Based Confocal LASER Endomicroscopy (pCLE): Results From a Randomized Controlled Trial

Mo1498 Learning Curve in Diagnosing Dysplasia in Barrett’s Esophagus (BE) Using Probe-Based Confocal LASER Endomicroscopy (pCLE): Results From a Randomized Controlled Trial Prashanth Vennalaganti*, Kavous Pakseresht, Benjamin R. Alsop, Sharad C. Mathur, Sravanthi Parasa, Benjamin Hornung, Neil Gupta, Prateek Sharma Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, MO; Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, KS; Gastroenterology, Loyola University Medical Center, Chicago, IL Background: With the advent of multiple novel techniques, optimal methods to teach advanced imaging techniques like pCLE have not yet been developed. There are limited data regarding the learning curve for trainees for using pCLE in diagnosing BE associated neoplasia. Aim: To determine the learning curve of medical trainees in diagnosing BE associated neoplasia using pCLE. Methods: Videos from a previously conducted multicenter trial evaluating the utility of pCLE in BE were used for this study. Study participants (GI fellows and medical students) with no previous pCLE experience were randomized to either in-class didactic or selfdirected teaching groups stratified by level of training. A standardized power point presentation was developed explaining the technology, the disease state and using previously published validated criteria for diagnosing dysplasia in BE: 1)epithelial surface: saw-toothed 2)goblet cells: sparse 3)glands: not equidistant 4)glands: unequal in size and shape 5)cells: enlarged 6)cells: pleomorphic. For in-class didactic group, an expert in pCLE conducted a classroom teaching session with an opportunity for interaction. Every study participant in the self-directed teaching group was provided with the same teaching power point but with recorded audio explaining the pCLE features to distinguish dysplastic and non-dysplastic BE. Following this initial training, all participants completed 1st set of 20 pCLE videos (pre-feedback) after which they reviewed correct responses with either the expert (in-class didactic group) or on audio power point (self teaching group). Finally, all participants completed next set of 40 videos (post-feedback) and marked their level of confidence in video interpretation for all assessments. Fisher’s exact test was used to calculate statistical differences between groups. Results:60 pCLE videos (nondysplastic BE 40 and dysplastic 20) were assessed by 18 study participants (10 GI fellows and 8 students). The overall accuracy of the entire group significantly improved from 73% to 79% post feedback (pZ0.04) (Table). This improvement was driven by overall improvement post feedback for the in-class didactic group (from 74% to 84%; p!0.01). Students had improvement in the proportion of predictions with high confidence (from 47% to 54.4% p 0.1) while fellows improved their pCLE accuracy in high-confidence predictions (from 82% to 91%, p 0.02) (Table). Finally, accuracy improved with years in endoscopy training (72.08% Students, 77.08% FY1, 82% FY2 and 85% FY3, p 0.003). Conclusions: Trainees taught by an in-class, didactic teaching session (overall 1 hour) had a shorter learning curve and achieved higher accuracies compared to self-directed learning group for the use of pCLE to diagnose BE associated neoplasia. In-class didactic teaching sessions should be the preferred method to teach pCLE for use in BE.

Interview From Anywhere: Feasibility and Utility of Web-Based Videoconference Interviews in the Gastroenterology Fellowship Selection Process

Traditional personal interviews are subject to limitations imposed by geographic, financial, and scheduling constraints. Web-based videoconferencing (WVC) has the potential to simplify the interview process. This study was intended to evaluate the feasibility and utility of WVC using standard tablets/computers with videoconferencing capability in gastroenterology (GI) fellowship interviews. At a single institution, 16 GI fellowship applicants participated in WVC with one interviewer, who was present at a remote location 750 miles away. In addition, each of the candidates underwent traditional interviews with four faculty members at the program site. All study interviewees used an iPad2 (Apple, iOS 5.1; Apple) with a videoconferencing application (Facetime). The interviewer (SRD) used Facetime on a MacBook Pro (Apple, Mac OS X 10.7.3). Each candidate completed a voluntary paper survey after completion of all assigned faculty interviews. The average age of the candidates was 30 years (range, 27-37 years). Fourteen candidates were native English speakers. Candidates expressed a high level of satisfaction, with 13 candidates (81%) stating that their WVC experience met or exceeded their expectations, and 87% of candidates stating that WVC should be an option in fellowship interviews. In addition, 25% of candidates felt that their WVC experience was equivalent to or better than their traditional interview experience on the same day. WVC can be an effective and useful tool in the fellowship interview process. It affords candidates increased flexibility, cost saving, convenience, and provides an option for participating in the selection process at more programs. For the programs and faculty, WVC has a potential to be an effective screening tool, can help minimize loss of clinical revenue and can also be an acceptable alternative to in-person interviews.

Does training and experience influence the accuracy of computed tomography colonography interpretation?

To evaluate the effect of experience on the accuracy rate of computed tomography colonography (CTC) interpretation and patient preferences/satisfaction for CTC and colonoscopy. A prospective, non-randomized, observational study performed in a single, tertiary care center involving 90 adults who underwent CTC followed by colonoscopy on the same day. CTC was interpreted by an abdominal imaging radiologist and then a colonoscopy was performed utilizing segmental un-blinding and re-examination as required. A radiology resident and two gastroenterology (GI) fellows blinded to the results also interpreted the CTC datasets independently. Accuracy rates and trend changes were determined for each reader to assess for a learning curve. Among 90 patients (57% male) aged 55 ± 8.9 years, 39 polyps ≥ 6 mm were detected in 20 patients and 13 polyps > 9 mm in 10 patients. Accuracy rates were 88.9% (≥ 6 mm) and 93.3% (> 9 mm) for the GI Radiologist, 89.8% (≥ 6 mm) and 98.9% (> 9 mm) for the Radiology Resident and 86.7% and 95.6% (≥ 6 mm) and 87.8% and 94.4% (> 9 mm) for each of the GI fellows respectively. The reader's accuracy rate did not change significantly with the percentage change rate ranging between -1.7 to 0.9 (P = 0.12 to 0.56). Patients considered colonoscopy more satisfactory than CTC (30% vs 4%, P < 0.0001), they felt less anxiety during colonoscopy (36% vs 7%, P < 0.0001), they experienced less pain or discomfort during colonoscopy compared to CTC (69% vs 4%, P < 0.0001) and colonoscopy was preferred by 77% of the participants as a repeat screening test for the future. No statistically significant learning curve was identified in CTC interpretation suggesting that further study is required to identify the necessary training to adequately interpret CTC scans.

P-088 Assessing the Utility of a Pocket-Sized Inflammatory Bowel Disease Educational Resource Designed for Gastroenterology Fellows

Inconsistencies in adherence to evidence-based medicine practice guidelines and quality indicators for inflammatory bowel disease (IBD) have been a recognized limitation in the quality of care afforded to IBD patients. We designed an Objective Structured Clinical Examination (OSCE) to assess many of the core competencies and to provide GI fellows with a simulated, case-based learning experience in the management of IBD patients. To supplement this experience, we provided GI fellows with an easily accessible educational resource in the form of a pocket-sized guide to highlight key evidence-based concepts in IBD education stressed in the OSCE. We assessed the utility of the NYU Gastroenterology Fellowship Training Program Pocket Guide’s usefulness, functionality, utilization, and the GI fellows’ satisfaction with this educational resource. The NYU Gastroenterology Fellowship Training Program’s OSCE course included 4 real life IBD clinical scenarios. Five New York City GI training programs and 12 second-year GI fellows participated. Following the OSCE, each fellow was given a pocket guide entitled “NYU Gastroenterology Fellowship Training Program Pocket Guide: Key Concepts in Managing Patients with Inflammatory Bowel Disease.” In addition, the pocket guide was given to the remaining 8 NYU GI fellows who did not participate in the OSCE. The white coat pocket-sized guide is comprised of 5 front and back laminated pages, with approximately 2 pages devoted to each OSCE case. Three months following the distribution of the pocket guide, 20 fellows were invited to participate in an online survey about the pocket guide in general as an education tool, and about its specific elements, and the fellows’ answers were collected. Sixteen of 20 (80%) fellows responded to the survey. Nearly 94% (15/16) of responders found the pocket guide to be a useful supplement to their fellowship IBD training, and 100% agreed that the guide would have been a useful reference tool to have at the start of GI fellowship training. Fifty percent (8/16) of fellows reported consulting the IBD pocket guide for the care of 20% or more of their IBD patients. Nearly 70% (11/16) would have found the pocket guide most useful as a smartphone application instead of a pocket-sized laminated guide. When assessing the usefulness of the specific key concepts detailed in the guide, the majority of fellows (≥50%, ≥8/16) agreed that the information improved their care of IBD patients. This IBD pocket guide serves as an educational resource that fulfills physicians’ need to easy access to evidence-based medicine and quality indicators to help guide clinical decision-making in the care of IBD patients. The majority of GI fellow participants agreed that the care for their IBD patients improved with the use of the guide as a resource. The large majority of fellows found the guide to be a useful and vital educational tool to aid in the employment of evidence-based medicine when caring for their IBD patients. Most would have preferred a smartphone application instead of a physical pocket guide.

Navigating a Successful Course Through GI Fellowship: A Year-by-Year Perspective

The sense of accomplishment you felt as a resident newly-matched into your chosen field of gastroenterology gradually morphs into a combination of excitement, anticipation, and indeed a healthy amount of trepidation, as you inch closer to the start of your fellowship. But fear not. While fellowship is no doubt a character-building experience, presenting unique challenges, it can be effectively navigated with a deliberate approach. This article is intended to serve as a roadmap to guide you in successfully completing your gastroenterology fellowship.

Lower Rates of Cecal Intubation by GI Fellows Are Associated with Performing a Disproportionally Higher Percentage of Inpatient Colonoscopies: A Retrospective Chart Review

Purpose: An expectation of cecal intubation rates for gastroenterology fellows at graduation has been set at 85% based on a recent study done by Sedlack (GI Endoscopy, 2011). The goal of this study was to investigate whether or not the proportion of inpatients to outpatients impacted the overall cecal intubation rate. Methods: A retrospective chart review was done on all colonoscopies (n=8645) performed by GI staff regardless of fellow involvement at our facility from July 2010-June 2012. This was done by interrogating the Oracle-based database used by Provation (Minneapolis, MN). Colonoscopies were then assigned to inpatient and outpatient subgroups. Cecal intubation rates were measured based on whether the endoscopist successfully reached the cecum. For those colonoscopies that failed to reach the cecum, the reasons for cecal intubation failure were noted and tallied. The percentage of inpatient vs. outpatient cases was also quantitated for GI fellow involvement and compared to the entire GI department as a whole. Results: Cecal intubation rates were found to be significantly lower among inpatient (88%) vs. outpatient colonoscopies (98%; p<0.0001). The top three reasons for failing to reach the cecum among inpatient colonoscopies were poor bowel prep, significant colitis, and colonic obstruction. Furthermore, GI fellows were involved with a disproportionally higher percentage of inpatient colonoscopies (41%) when compared to the entire GI department as a whole (8%; p<0.0001). Conclusion: Lower cecal intubation rates among GI fellows are likely due to the fact that they perform a disproportionately higher percentage of inpatient colonoscopies. These procedures may be technically more difficult for fellows to reach the cecum, especially in the setting of poor bowel prep, signifi cant colitis, and colonic obstruction. Thus, the expectation of cecal intubation rates for GI fellows should be interpreted in light of the proportion of inpatient to outpatient procedures they perform at their institution.

Limited Formal Training in Optically-enhanced Endoscopy: A Single Center Survey Analysis

Purpose: Colonoscopy is the gold standard screening modality for colorectal cancer but miss rates up to 25% have been reported. Novel technologies assist real-time polyp histology evaluation such as confocal endomicroscopy and endocytoscopy along with the contemporary NBI, I-Scan and FICE functions. The aim of this survey was to investigate trainee fellow exposure and demand of novel optically-enhanced endoscopy (OEE) techniques. Methods: A 10-question web-based survey was distributed to 34 gastroenterologists (17 fellows and 17 attendings) at a university-based gastroenterology program. Each of the survey participants have experience in performing screening colonoscopy and polyp evaluation but variable experiences with OEE. Results: We received a 74% overall response rate which included 15 fellows and 9 attending physicians. The GI trainee response rate was 94% and the attending response rate was 53%. The trainees comprised six physicians in their first year, four in their second year, and six in their third year. Overall, 68% of the survey participants reported a cecal intubation rate >90%, and in 88% an estimated cecal withdrawal times greater than 6 minutes. Forty percent of the survey reported high confidence in classifying polyps as hyperplastic or adenomatous. A total of 68% reported limited formal training with OEE either during GI training or as part of continued medical education. An overall 80% of respondents felt formal training in these modalities would be useful; since only 40% currently utilize these techniques in polyp evaluation. Predictably, attendings characterized polyp histology with a higher confidence than fellows (78% vs. 19%). Only 31% of the trainee fellows reported significant formal exposure to OEE but 63% use these technologies to assist polyp evaluation. These values were similar for attending physicians with one-third reporting formal training in OEE and nearly two-thirds utilizing these technologies in polyp evaluation. Overall, 75% of fellows reported formal training in these technologies would be useful in their training and 89% of the experienced attending physicians stated that formal training in these technologies would be useful. Conclusion: A majority of GI trainees and GI attendings surveyed reported limited formal training in OEE techniques and believe that formal training in these technologies would be useful during GI fellowship. The limitations of this study include its single institution, survey-based format, and lack of correlation between self-reported polyp characterization confidence and technology utilization rates with actual clinical encounters. Further studies are needed to explore the learning curve for novel endoscopic technologies and the role of these technologies in GI fellowship training.Table: Table. Survey demographics and response rate

Assessing Physician-Patient Communication and Shared Decision-making Skills in IBD Patient Care: ACG/AstraZeneca Fellow Award: Presidential Poster

Purpose: A paradigm of shared decision-making (SDM) is increasingly recognized as an effective strategy for information exchange, but is not formally evaluated in gastroenterology fellowship training. Given its management complexities, the field of inflammatory bowel disease (IBD) represents fertile ground for the evaluation of an SDM strategy to patient care. We assessed this clinical skillset in gastroenterology (GI) fellows through the use of novel objective structured clinical examinations (OSCEs). Methods: Twelve second-year GI fellows from five GI fellowship programs participated in a four-station OSCE. Previously validated OSCE checklists were used to assess the GI fellows' performance in IBD-specific cases, two of which will be discussed here. In the first case (“New Diagnosis” or “ND case”), the goal of the GI fellow was to educate a patient on her recent diagnosis of ulcerative colitis and to navigate a complex conversation about her risk of colon cancer. In the second case (“SDM case”), the objective was to evaluate a patient with Crohn's disease who would benefit from combination therapy with infliximab and azathioprine. Each station was videotaped and observed live by faculty gastroenterologists. Checklists were scored independently by the physician-observer and the standardized patient (SP), who both provided feedback to the fellow immediately following each case. Post-OSCE, fellows attended a debriefing session on patient communication, and were surveyed to assess their perspective on the exam's educational value. Results: For the ND case, the majority of fellows received high ratings for patient interaction (11/12, 91.7%), appropriate non-verbal behavior (8/12, 66.7%), and providing clear explanations and information (11/12, 91.7%). However, 10/12 (83.3%) did not assess the SP's comprehension of the concept of endoscopic surveillance of dysplasia, and only 4/12 (33.3%) educated the patient on alarm symptoms that would require urgent consultation. In the SDM case, 8/12 (66.6%) did not completely elicit the SP's preferences regarding treatment, although 9/12 (75%) shared the treatment decision with the SP. The vast majority recognized patient factors that are considered high-risk for complications (11/12, 91.7%) and discussed mucosal healing as an endpoint (9/12, 75%). The fellows rated the OSCE experience highly, regarding its educational value, and noted improvement in their IBD-specific knowledge after the exercise. Conclusion: To our knowledge, this is the first OSCE designed specifically for assessing SDM in IBD patient care. OSCEs are a particularly valuable educational tool for the evaluation of interpersonal and communicative competency in the field of IBD.

Mission Impossible: Predicting ERCP Procedure Times to Facilitate Quality Improvement

Purpose: ERCP procedure length remains quite variable, ranging from minutes to hours, given the heterogeneity of procedural indications and inherent technical difficulty. ERCPs are typically scheduled in block time without taking into consideration indication, patient anatomy, or other clinical factors. At times, the procedure may be longer or shorter than the allotted time. We aimed to retrospectively evaluate the utility of a priori prediction of ERCP procedural length with an overall goal to improve the scheduling efficiency and capacity of our therapeutic endoscopy unit. Methods: Our endoscopy database was utilized to identify patients who underwent ERCP procedures from January 1, 2012 to February 1, 2012 at a tertiary care medical center. Clinical and procedural data were reviewed. A brief summary was generated by a medical resident for each patient, which outlined recent clinical history and ERCP indication. Additional procedural information was provided regarding GI fellow assistance, sphincterotomy status, failure or success of previous ERCPs, and presence of surgically-altered anatomy or stents. A 2nd-year GI fellow and a staff therapeutic endoscopist with >20 years of ERCP experience attempted to retrospectively predict procedural length (0-30 min, 31-60 min, 61-90 min, >90 min) in each case blinded to other details about the case. Predictions were then compared to actual procedural length using the kappa statistic. Results: ONe consecutive ERCP procedures (51 men; mean age 62±15 years) were included. Indications for ERCP included a biliary etiology in 83 cases. The remaining cases were divided equally between pancreatic (N=10) and various other indications (N=7). Fellows participated in 70 procedures. Median ERCP time was 43 minutes (IQR 28-63). ERCP times were classified by blocks of time (min): 0-30 (n=28), 31-60 (n=44), 61-90 (n=16), >90 (n=12). Time blocks were accurately predicted in 40% cases by the 2nd year GI fellow and in (31%) cases by the staff endoscopist. When compared to actual ERCP times, both the fellow's and staff endoscopist predicted times had poor kappa agreement (κ=0.15 and κ=0.02, respectively). The kappa between fellow and staff was also poor (κ=0.08) with an overall agreement of 35%. Neither fellow nor consultant predicted correctly in 41% cases with both overestimating in 23/41 (56%), both underestimating in 13/41 (32%), and one overestimating/one underestimating in 5/41 (12%). Conclusion: Accurate prediction of ERCP procedure length appears to be very challenging. Inaccurate prediction is likely multifactorial with the inherent technical difficulty and unpredictability of ERCP being major limiting factors. Prospective studies with a priori prediction of ERCP length are needed to confirm our findings.

Characterizing the Learning Curve and Accuracy of Wireless Capsule Endoscopy Interpretation amongst Digestive Healthcare Practitioners: Presidential Poster

Purpose: Trainees and mid-level providers are often used as first-line readers of wireless capsule endoscopy (WCE) studies to earmark images that are subsequently reviewed by an attending gastroenterologist. This study is intended to prospectively evaluate the accuracy and learning curve of WCE trainees without prior WCE experience (GI fellow, CRNP fellow, and senior GI nurse). Methods: Each trainee individually reviewed and interpreted 48 full-length de-identified WCE studies. Significant findings, the time required to interpret each study, and the confidence of the interpretation were recorded. The results were compared to a WCE expert. After every 10 studies, each trainee reviewed findings with the expert. The first 10 studies were considered the training period, the next 19 studies considered study period 1, and last 19 studies considered study period 2. Reading times were compared using Wilcoxon rank-sum tests. Results: The median time for interpretation improved significantly from the training period to the first study period for each trainee, but was only different from study period 1 to 2 for the RN (Table 1). Pharmacokinetic modeling of the median reading time compared to the WCE expert demonstrates that the GI fellow and CRNP fellow plateau in reading speed during the study, suggesting that additional studies are unlikely to improve reading efficiency (Figure 1).The GI nurse never plateaus during the study. Confidence improved for all trainees during the study. However, during the final study period, the GI fellow reported higher confidence levels than the CRNP fellow, who reported higher confidence than the GI nurse. The GI nurse was still only “moderately confident” for half the studies during study period 2. The MD fellow was found to have a higher sensitivity, specificity and accuracy compared to other trainees (Table 2).Table 1: Median reading time (in minutes) for each interpreter.Figure: PK modeling of median difference in reading time compared to the WCE expert.Table 2: Sensitivity, specificity, and acccuracy of WCE trainees after a training period of 10 studiesConclusion: A minimum of 25 WCE studies, with each study read in its entirety, appears to be sufficient for trainees enrolled in a GI fellowship program who are actively performing endoscopy. Physician extenders and nurses appear to require interpretation of more than 25 WCE studies before adequate proficiency is achieved.

The 1:00 AM Consult: Assessing Communication with Primary Providers as a Clinical Skill in Gastroenterology Fellowship Training

Purpose: Interacting with a patient's care team in all situations, including the overnight emergency consult, is a core skill for all specialty physicians. We developed a night-call objective structured clinical examination (OSCE) emphasizing the ACGME's core competencies of interpersonal communication, professionalism, and systems-based practice to assess the competency of GI fellows in this area with the intent of informing future training curriculums. Methods: In the “overnight call” case, a new intern in the medical ICU calls a consult at 1:00 AM to evaluate a patient with a massive upper gastrointestinal bleed. Earlier, on admission, the patient received a suboptimal upper endoscopy with a plan for repeat endoscopy in the morning, but the patient decompensates overnight and the intern pleads for help. The goals for the fellow were to calm the intern and obtain complete information about the patient before making an informed decision. Twelve fellows from four programs participated and were observed by an attending physician. Feedback was provided to the fellow by the faculty observer and the standardized intern completed previously validated behaviorally anchored checklists rating the fellow's performance. The fellows were rated on a three point scale for each task: not done (the fellow did not perform the task), partly done (the fellow attempted to perform the task but was unsuccessful) and well done (the fellow addressed the task and was successful). Results: Half of the fellows successfully calmed the intern while 58% (7/12) of fellows acknowledged the intern's emotions appropriately. While 58% (7/12) of fellows obtained findings from the prior endoscopic procedure, only 17% (2/12) assessed the quality and completeness of the procedure, 8% (1/12) asked about scheduled follow-up events, and none (0/12) asked for the rationale for the follow-up plans. While all of the fellows provided a clear plan of action, only 33% (4/12) asked questions to assess if the intern understood the plan. None of the fellows collaborated with the intern to identify possible next steps in diagnosis/treatment or appreciated the intern's contributions to clinical problem solving. Conclusion: OSCEs provide a structured opportunity to assess the ability of fellows to achieve an urgent therapeutic plan and relationship with fellow trainees who serve in different patient care roles. All fellows were able to provide clear plans of action, but few involved the intern in clinical problem solving or checked for intern comprehension. These results point to deficiencies and potential areas of improvement in provider communication and professional collaboration curriculum for fellowship training.

Cecal Intubation Rate Is a Better Milestone Parameter Than Polyp Detection Rate in Fellowship Endoscopy Training

Purpose: To compare known colonoscopy quality parameters, cecal intubation rate (CIR), polyp detection rate (PDR), and withdrawal time (WT) with year of fellowship training. Methods: We conducted a quality improvement project to assess the impact of the level of training on three measures of colonoscopy quality. We included only those patients who were undergoing initial screening colonoscopy. Data collected was from 11 GI fellows on a semi-annual basis over the course of 3 years. Data points for each level of training were 9 for first years, 8 for second years and 8 for third years. The quality indicators examined were PDR, CIR and WT >6 minutes. Statistical Products and Service Solutions 20 (SPSS) was used for statistical analysis. The Kruskal-Wallis test was used to analyze the nonparametric interval variables. Results: 821 screening colonoscopies were analyzed (483 by first year, 224 by second year and 114 by third year fellows). For first year fellows, the average PDR was 49% and the average CIR was 88%. For second year fellows, the average PDR was 52% and the average CIR was 98%. For third year fellows, the average PDR was 62% and the average CIR was 100%. Withdrawal time was always greater than six minutes for all exams recorded. The CIR showed a statistically significant increase (p=0.009) for the second and third year fellows (mean rank of 14.38 and 17.00, respectively) compared to the first year fellows (mean rank =8.22). There was no statistically significant difference in PDR among any years of training (p=0.256). Conclusion: Our study showed no improvement in PDR during fellowship. Prior studies on PDR have been inconclusive. PDR can be influenced by multiple factors including other health care providers present in the room (attendings and nurses) and innate individual characteristics. Hence, in an endoscopy training environment, PDR may be a less robust parameter of fellowship evaulation. Some prior studies have even shown that trainees may improve PDR of attendings. Polyp detection rate perhaps is better suited for evaluating quality in established practitioners. Our study demonstrated that CIR is a better milestone for level of endoscopy training. We, therefore, suggest including CIR in any endoscopy training evaluation.Table. Results

Narcotics Improve EGD-assisted Capsule Endoscopy Completion Rate? A Single-center Retrospective Study

Purpose: To determine the agents, co-morbidities, and intestinal anatomical abnormalities that contribute to the improved capsule endoscopy (CE) completion rates (CR) starting at 2010 to present in a Veteran's Administration single-center tertiary care medical center. Methods: A retrospective analysis of 53 patients undergoing CE, aged 26-88 years, median age 65 years, >97% male, from 2007 through 2013. CR defined as capsule completing the transit to the cecum. Small bowel transit time (SBTT) defined as the capsule's total time in the small intestine. Results: In our study of 53 patients undergoing CE, the most common indications were obscure gastrointestinal bleed (38%), iron-deficiency anemia (34%), diarrhea (16%), abdominal pain (10%) and suspected Crohn's disease (10%). The three most common findings were angioectasia (33.3%), ulcerations (23.8%) and active bleeding (16.7%). Significant improvement in outpatient EGD-assisted CE was detected starting from 2010 to the present compared to previous years (94% vs. 60%, p=0.034). EGD-assist CE showed a significantly improved CR compared to conventional CE without endoscopy assisted CE placement (94% vs. 38%, p=0.018, 2010-present). Patients who underwent conventional CE and failed to have complete capsule transit consisted of a marked diabetic population (57% vs. 0%, p=0.015). The significantly improved CR amongst the EGD-assisted CE in 2010 to present showed a population which used significantly increased opiates (50% vs. 0%, p=0.0015) compared to years prior. Among the patients from all years who successfully completed capsule transit to the cecum, there was a marked use of narcotic agents (35% vs. 0%, p=0.0024) compared to those whose capsules did not complete their transit to the cecum. Amongst patients who had successful CR there was a trend towards shorter SBTT in the patient population taking narcotics, though the trend was not statistically significant (201 vs. 223 min, p=0.44). Other factors including promotility (i.e., metoclopramide), and bowel cleansing regimen (GoLYTELY®), co-morbidities such as Crohn's disease, and anatomical abnormalities were not found to have statistical significance contributing to the improved CR from 2010 to the present. Conclusion: Long known for contributing to intestinal hypo-motility, we report opiate use markedly improved CR with evidence that SBTT may be shortened in patients undergoing EGD-assisted CE in the clinical setting. In contrast, conventional CE remained inferior to endoscopy-assisted CE with lower CR. Future prospective studies are needed to further understand this novel and intriguing relationship. Disclosure - Dr. Jackson, VA GI physician Dr. Basseri, VA GI fellow.

GI Fellowship Training Programs

American Journal of Gastroenterology: July 2013 - Volume 108 - Issue 7 - p 1184-1213 doi: 10.1038/ajg.2013.182

A Nationwide Survey of Gastroenterologists and Their Acquisition of Knowledge

The Gastroenterology (GI) Core Curriculum is a culmination of efforts from the American Association for the Study of Liver Diseases, the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy to develop a review of knowledge and skills for those training in a gastrointestinal subspecialty. Fellows are expected to conduct scholarly activity, attend seminars, and read textbooks and syllabus materials. While efforts to standardize education across the nation are welcomed, we sought to ascertain the learning preferences of GI fellows and attending physicians. A national online survey was e-mailed to directors of US adult GI programs, who were also asked to invite their colleagues and fellows to participate. While majorities of both fellows and attendings affirmed regular attendance at national conferences, more attendings affirmed that their knowledge was improved by their participation. Asked how they acquire knowledge best, 45 fellows and 67 attendings responded; 42% of attendings favored journal articles, and 40% of fellows favored conferences. More attendings than fellows felt that writing a manuscript and belonging to a GI society improved knowledge. We believe the Gastroenterology Core Curriculum provides trainees with essential tools for becoming an autonomous gastroenterologist who can appreciate various learning modalities.

P-0267 - Knowledge and Practice Pattern of Gastroenterology Attendings and Fellows in Screening High Risk Patients for Colon Cancer

Background: Individuals with a positive family history of colon cancer have an increased risk of colorectal cancer (CRC). Risk stratification is essential to effective implementation of colorectal cancer (CRC) screening strategies. For patients with single first-degree relative with CRC excluding hereditary non polyposis colorectal cancer (HNPCC)diagnosed after age 60, the ACG recommends screening to start at age 50 and if negative repeat colonoscopies every 10 years. The objectives of this study were to assess the current practice patterns of practicing gastroenterologists and gastroenterology (GI) fellows regarding screening patients with family history of colon cancer and compare these practices to the 2008 ACG guidelines. Methods: We conducted a survey of GI fellows and practicing gastroenterologists who attended the 2012 William M. Steinberg Board Review in Gastroenterology. The attendees at this course are from all of the United States and Puerto Rico. The survey instrument asked the following questions: 1- You see a 30 year old woman in your practice whose father had colon cancer at age 70. At what age do you advise beginning screening? And 2- if the colonoscopy is negative, how many years later do you advise a repeat procedure. In addition, physicians were asked if they were aware of 2008 ACG screening guidelines for individuals with family histories of CRC. We used The Cochran-Armitage test for trend to see the linear trend between the groups Results: 225 of the 399 attendees (56.4%) completed the survey. Of the 225 responders, 64 identified as GI fellows and 161 as practicing GI physicians. Practicing GI’s were stratified in to 3 categories based on the number of years in practice (0-10 yrs {n= 71}, 11-20 yrs {N = 58} and >20 yrs {N = 31}). 97% of the fellows, 78% of 1-10 yr GI’s, 87% of 11-20 yr GI’s and 84% of >20 yr GI’s stated they were aware of the 2008 ACG guidelines (p = 0.146). For question one above 78% of the fellows, 64% of 1-10 yr GI’s, 67% 11-20 yr GI’s and 62% of >20 yr GI physicians stated they would start screening at age 50 (p value =0.124) and the rest answered they would start screening before the age of 50. When asked when to repeat the screening (question 2) - 62% of the fellows, 46% of 1-10 yr GI’s, 51% of 1-20 yr GI’s and 31.1% of >20 yr GI’s stated they would repeat at 10 years (P value = 0.013) and the rest preferred to repeat screening before 10 years (most responded at 5 years). Conclusion: Fellows and practicing GI physicians have equal awareness of the 2008 ACG guidelines. Both fellows and GI physician practices are in line with the guidelines when it comes to the age at which screening should start. However, practicing physicians tend to advise re-scoping at shorter intervals than GI fellows and this trend is more pronounced the longer a GI physician is in practice.

Mo1073 Nutritional Knowledge of Gastroenterology Fellows in the United States

Introduction: The aim of this study is to determine current nutritional knowledge and identify the perceived effectiveness of nutrition education among gastroenterology (GI) fellows. Methods: A survey was created to collect demographic data, perceived nutritional knowledge, and a 20 question multiple choice examination (MCE) testing components of nutrition specific to GI. Adult GI fellowship coordinators at the 162 U.S. accredited adult fellowship programs were sent an email asking them to forward an internet link to their 1 st through 3 rd year GI Fellows where fellows could anonymously complete the survey. Results: The survey was attempted by 137 fellows with 119 fellows fully completing it. The majority of fellows (86.6%) wanted more nutrition focused education. Fellows perceived themselves as having the least knowledge in micro/macronutrients and providing nutritional support to patients. Fellows perceived themselves as having the strongest knowledge in technical skills to manage nutritional issues. The mean total score for MCE was 39.45% (standard deviation (SD) = 15.56). Fellows had the highest mean score in the questions related to nutritional support (50.67%, SD = 21.55). The lowest mean score was on the subset of questions related to obesity (26.08%, SD = 13.01). Mean scores in other areas of nutrition included: nutrition assessment 46.45% (SD = 14.18), micro/macronutrients 34.07 % (SD = 18.92), and nutrition in GI diseases 43.35% (SD = 23.88). Discussion: GI fellows believe their knowledge of nutrition is suboptimal and objective evaluation of nutrition knowledge confirms this belief. Formal nutrition education should be developed in the context of GI fellowship education.

The Learning Curve of Gastric Intestinal Metaplasia Interpretation on the Images Obtained by Probe-Based Confocal Laser Endomicroscopy

Background. Reading the results of gastric intestinal metaplasia (GIM) with probe-based confocal laser endomicroscopy (pCLE) by the expert was excellent. There is a lack of study on the learning curve for GIM interpretation. Therefore, we conducted a study to explore the learning curve in the beginners. Material and Method. Five GI fellows who had no experience in GIM interpretation had been trained with a set of 10 pCLE video clips of GIM and non-GIM until they were able to interpret correctly. Then they were asked to interpret another 80 video clips of GIM and non-GIM. The sensitivity, specificity, accuracy, PPV, NPV, and interobserver agreement on each session were analyzed. Results. Within 2 sessions, all beginners can achieve 80% accuracy with substantial to almost perfect level of interobserver agreement. The sensitivities and specificities among all interpreters were not different statistically. Four out of five interpreters can maintain their high quality of reading skill. Conclusion. After a short session of training on GIM interpretation of pCLE images, the beginners can achieve a high level of reading accuracy with at least substantial level of interobserver agreement. Once they achieve the high reading accuracy, almost all can maintain their high quality of reading skill.