Stricter national standards are required for credentialing of endoscopic-retrograde-cholangiopancreatography in the United States

Abstract

Endoscopic-retrograde-cholangiopancreatography (ERCP) is now a vital modality with primarily therapeutic and occasionally solely diagnostic utility for numerous biliary/pancreatic disorders. It has a significantly steeper learning curve than that for other standard gastrointestinal (GI) endoscopies, such as esophagogastroduodenoscopy or colonoscopy, due to greater technical difficulty and higher risk of complications. Yet, GI fellows have limited exposure to ERCP during standard-three-year-GI-fellowships because ERCP is much less frequently performed than esophagogastroduodenoscopy/colonoscopy. This led to adding an optional year of training in therapeutic endoscopy. Yet many graduates from standard three-year-fellowships without advanced training intensely pursue independent/unsupervised ERCP privileges despite inadequate numbers of performed ERCPs and unacceptably low rates of successful selective cannulation of desired (biliary or pancreatic) duct. Hospital credentialing committees have traditionally performed ERCP credentialing, but this practice has led to widespread flouting of recommended guidelines ( e.g ., planned privileging of applicant with 20% successful cannulation rate, or after performing only 7 ERCPs); and intense politicking of committee members by applicants, their practice groups, and potential competitors. Consequently, some gastroenterologists upon completing standard fellowships train and learn ERCP “on the job” during independent/unsupervised practice, which can result in bad outcomes: high rates of failed bile duct cannulation. This severe clinical problem is indicated by publication of ≥ 12 ERCP competency studies/guidelines during last 5 years. However, lack of mandatory, quantitative, ERCP credentialing criteria has permitted neglect of recommended guidelines. This work comprehensively reviews literature on ERCP credentialing; reviews rationales for proposed guidelines; reports problems with current system; and proposes novel criteria for competency. This work advocates for mandatory, national, written, minimum, quantitative, standards, including cognitive skills (possibly assessed by a nationwide examination), and technical skills, assessed by number performed (≥ 200-250 ERCPs), types of ERCPs, success rate (approximately ≥ 90% cannulation of desired duct), and letters of recommendation by program director/ERCP mentor. Mandatory criteria should ideally not be monitored by a hospital committee subjected to intense politicking by applicants, their employers, and sometimes even competitors, but an independent national entity, like the National Board of Medical Examiners/American Board of Internal Medicine.

Increased ERCP volume improves cholangiogram interpretation: a new performance measure for ERCP training?

“…The relative difficulty of ERCP procedures may vary depending on patient characteristics, biliary anatomy, procedural indication, and intervention. 7 , 13 According to one grading system, ERCP procedures for small-to-medium sized biliary stones are less difficult to identify than extrahepatic strictures. 7 , 14 This is congruent with the findings of the present study.…”

“…3 The shift in ERCP training has led to the development of guidelines that define competency for this procedure. [4][5][6][7] The American Society of Gastrointestinal Endoscopy (ASGE) recommends 200 ERCPs per trainee, with selective cannulation rates of the common bile duct > 80-90% in a native papilla as a surrogate marker of trainee competence. 8 Alternatively, the British Society of Gastroenterology (BSG) recommends successful cannulation of the target duct, common bile duct (CBD) stone clearance, and stent/cytology of extrahepatic strictures as key performance indicators (KPIs) and a minimum of 75 procedures per year to maintain competence, although one should aspire to complete more than 100.…”

Soft Liver Phantom with a Hollow Biliary System

“… 20 , 24 However, the interventional procedures are difficult due to the following reasons: (1) high risk of complications, for example, the biliary infection, bile leaks, hemobilia, and pancreatitis; (2) high level of technical expertise and professional knowledge are needed to perform the interventional procedures; (3) few training opportunities available, which mostly existed in academic medical center or tertiary hospitals. 3 As shown in the previous studies, a threshold of 180–200 ERCPs were recommended to achieve the competency. 9 However, there are insufficient number of ERCP procedures for the fellowship training in most training centers.…”

The status of training in new technologies in advanced endoscopy: from defining competence to credentialing and privileging

“…It is the responsibility of each institution to develop and maintain their own guidelines regarding this process, which potentially introduces conflict of interest; hospital credentialing committees may be subject to external pressure from the applicants, their employers, and even competitors. 58 Many hospitals may be pressured to offer a broad range of endoscopic procedures due to economic incentives. Similarly, the pursuit for endoscopic innovation and the distinction of being the "first" hospital to offer a novel procedure may unintentionally influence and circumvent the safeguard training and credentialing requirements necessary for such processes.…”