Example 1: Edmund Godfrey.
Once I decided I wanted to embark on EUS training I approached a radiology consultant who was known for EUS locally. He acted as a mentor and was an important advocate in gaining access to endoscopy training lists. Although I was unable to get space on OGD training lists at my local hospital, he negotiated for me to spend a day a week at the regional endoscopy training centre.
With two lists per week I was able to get signed off with the JAG in diagnostic upper GI endoscopy in less than a year. This training took place towards the end of my third year, and required the support of the Radiology Training Programme Director, given the inevitable loss of training/service time in the department. Having an advocate to help negotiate this is very important.
After getting over the initial hurdle of OGD training I attended on average two EUS lists a week as well as the relevant MDT meetings (HPB and upper GI) for the rest of my SpR training. When I first started working as a consultant I attended a colleague’s EUS list during my SPA time. This additional time spent gaining experience with an expert was invaluable.
1. You need an advocate, most likely a radiologist who is doing endoscopy. This would ideally be someone local but doesn’t have to be. If you are unsure who to ask, approach a member of the BSGAR endoscopy committee.
2. Talk to your Training Programme Director as early as possible, you will need their support.
3. Be prepared to travel, but if you have to, try to organise two lists in a day to make most efficient use of your time.
Example 2: Dush Shetty
I decided to sub-specialise in GI radiology early on and was first exposed to EUS in my second year of training, at that time endoscopy and EUS was not something I was definitely going to pursue. In my third year, having completed my FRCR 2A modules I once again had the chance to work with a GI radiologist who performed both interventional endoscopy and EUS, it was working with him that inspired me train in EUS. The best advice I was given at that stage was to formally complete my JAG accreditation in basic upper GI endoscopy, this was vital basic training for the endoscopic skills required at EUS. I did this by attending two lists a week, one with a nurse endosocpist. I completed my 200+ procedures and summative DOPS in just over 1 year. During this time I continued to attend the EUS lists and was slowly allowed to do more and more; starting with basic scope handling progressing to lesion localisation, intubation and eventually simple FNA work. Attendance at oesophago-gastric and HPB MDTs is absolutely vital in order to fully understand the role EUS plays and the often specific information the clinicians want.
When it comes to training lists I found working with a nurse endoscopist an invaluable resource to get my OGD numbers. I also attended bleeder lists with gastroenterologists- be prepared to step back if there happens to be a gastroenterology trainee also present.
Post CCT I arranged a dedicated EUS fellowship at a tertiary referral centre to complete my training prior to starting as a consultant.
1. Get formal JAG accreditation in diagnostic upper GI endoscopy.
2. Nurse endoscopists are an invaluable resource to get your numbers.
3. The importance of MDT participation cannot be overstated.
4. A degree of long-term planning is important- having worked hard to acquire this important skill, try to make sure there is a potential job where your skills will be used and not wasted.
How to get trained in endoscopy as a radiologist:
Example 3: Amy Clayton
I already had some experience of endoscopy as a Surgical SHO prior to my radiology training but was required to complete the foundation course and register with JAG before being allowed to continue endoscopic practice according to the new JAG guidance. I obtained registration and completed the course within my first month as an ST1 radiology trainee as I had already decided I wanted to perform interventional endoscopic procedures as a radiologist. I approached a radiology consultant in the training scheme’s base hospital who performed both ERCP and EUS, he became both my endoscopic mentor and champion. He not only gave me excellent advice and support but also spoke to the programme director on my behalf convincing them that I should be allowed to pursue my interest from an early stage. Initially he secured half a day a week for me to pursue endoscopic training. This was the easy part, because obtaining a regular list proved extremely difficult. As a radiology trainee I took every opportunity to attend lists whenever there was a gastroenterology or surgical trainee absent but this was sporadic as I was unable to secure my own training list initially. I finally found a radiologist in a local DGH who undertook a weekly upper GI endoscopy list as well as being an ERCPist. I started attending this list regularly parallel to attending ERCP lists and learning how to use a duodenoscope.
I subspecialised in GI and Head and Neck Radiology in my final two years. The DGH radiologist retired and I continued an upper GI training list with a nurse endoscopist at the same hospital. I eventually became JAG accredited just prior to my CCT. I wanted more ERCP experience before commencing my independent list, therefore as a Consultant I continued 1.5 ERCP training lists a week during my SPA time. I am now in a position where I run my own ERCP lists. In the early stages it has been useful to maintain the support and interaction of a new mentor who is available for the first 6 months during most of my lists should I need advice or practical help.
As you all have probably gathered my training has not been straightforward; there have been many obstacles but I worked hard with the support of all my trainers and was determined to overcome them. Sharing my experiences will hopefully be beneficial to those contemplating or starting their training to enter the privileged position of performing endoscopic intervention. On the back of my experiences we are trialling a new fast track approach in the South Wales Training Scheme whereby JAG accreditation is obtained within 6 months post FRCR 2A exams and EUS and ERCP is concentrated upon thereafter.
1. Find a mentor and express an interest early to your programme director if you know that you want to pursue endoscopic intervention.
2. It is important to enter into endoscopic training with the knowledge that it will take considerable time commitment, hard work and perseverance.
3. Attending meetings such as WAGE (Welsh Association for Gastroenterology and Endoscopy) will facilitate dialogue with other endoscopists and gain vital contacts for training.
4. Training in endoscopic intervention does not preclude following two sub specialty interests alongside endoscopy.