Introduction

Two years into the pandemic, the trainee editors at Frontline Gastroenterology reflected on the strain that COVID-19 had placed on training and the wider healthcare system in the UK. Repeated lockdowns, redeployments and the necessary prioritisation of service delivery over formal training had left gastroenterology trainees stuck in a repeating cycle, analogous to the film ‘Groundhog Day’.1 We believe a perceived lack of control during that time and the resulting ‘learnt helplessness’ could have negatively affected the mental well-being of trainees.2 Indeed, 33% of trainees previously reported a deterioration in their morale.3 Even more worryingly, they ranked fifth most at risk of burn-out among all medical specialties.3

As we transition into a period of recovery, we find ourselves in a transformed training and working landscape. A newly shortened 4-year curriculum for gastroenterology training has been mandated by the General Medical Council following the Shape of Training (SoT) report. Virtual consultations are now embedded in outpatient services and outsourcing of diagnostic endoscopy has been implemented to tackle waiting list backlogs.4 Regionally, endoscopy academies are emerging to offer immersive training and facilitate acquisition of Joint Advisory Group accreditations.5

Navigating through these changes, and burdened with COVID-19-related setbacks, trainees are now under more pressure than ever to try and achieve their required competencies within a shorter time frame. Even prior to the pandemic, 63.8% of trainees viewed general internal medicine (GIM) commitments as an obstacle to specialty training.6 There are concerns that the new curriculum will further impair their ability to achieve high-quality training as specialists.7 The 2021 British Society of Gastroenterology (BSG) Workforce Report recommended a 7%–9% yearly expansion in consultant numbers to meet the expected growing demand for services.8 Delivering this will be a challenge, even more so when a potential increase in post-certificate of completion of training (CCT) training and anticipated less than full time (LTFT) consultant working patterns are taken into account.

This is a watershed moment for our specialty. We, therefore, aimed to assess the current state of gastroenterology training in the UK and the perceived impact of the new curriculum.

Results

In total, 40.3% (266/660) of gastroenterology and hepatology trainees responded to the survey (table 1).

Table 1

Demographic data of survey respondents

The new curriculum

Only 10% (23/229) of respondents felt they would be ready to be a consultant after 4 years of training, compared with 15.8% in 2020. While >90% of respondents anticipated achieving the two capabilities in practice (CiPs) related to the care of inpatients and outpatients (>119/219), far lower levels of confidence were reported in achieving the remaining CiPs (figure 1). Currently, inflammatory bowel disease and hepatology are the only two subspecialties to which respondents report having consistently good or sufficient exposure (figure 2).

Figure 1

Anticipated achievement of CiPs with a 4-year training programme. GI, gastrointestinal.

Figure 2

Subspecialty exposure. ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasound; GI, gastrointestinal.

The vast majority of respondents (98.7%, 226/229) dual-accredit in GIM, which is now mandated. Although it’s stipulated that a quarter or less of training time should be spent in GIM, GIM comprised a quarter to a half of training time for 44.4% (114/257) of respondents and over half of training time for 26.5% (68/257) of respondents.10 GIM training had a negative or somewhat negative impact on specialty training for 71.6% (144/201) of respondents, up from 65.8% in 2020.8 A significant majority (80.9%, 172/225) felt that mandatory non-specialty GIM clinics negatively or very negatively impact their specialty training, while only 19.9% (45/226) felt they improved their GIM training. Interestingly, only 18% (70/87) of ST6–ST7 respondents plan to pursue a consultant post with GIM commitments.

Respondents suggested that a median 80% (IQR 70%–80%) of training time should be ring-fenced for gastroenterology in order to achieve curriculum competencies and sufficient subspecialty exposure. Most respondents (64.3%, 146/227) would prefer GIM training to be undertaken in blocks rather than interspersed throughout their annual rota. The vast majority (95.5%, 191/200) either cannot take annual leave during GIM on-call commitments, or must move these on-calls into gastroenterology training time to do so.

Endoscopy

Dedicated training lists have returned to prepandemic levels completely for 40% (90/225) of respondents and partially for 48% (108/225). Before the introduction of single-stage colonoscopy certification, only 36.1% (13/36) of ST7s held provisional and 22.2% (8/36) full certification in colonoscopy (figure 3). Of respondents interested in hepatology, 69.1% (76/110) wanted to pursue colonoscopy training, despite the new curriculum no longer mandating this. 72.6% (98/135) of ST3–5s had certification in oesophagogastroduodenoscopy.

Figure 3

Joint Advisory Group certification rates by year of training.

Of all respondents, 16.2% (32/235) were part of a ‘bleed rota’ and 49.4% (49/235) relied on occasional ad-hoc exposure in-hours. Most (92.3%, 217/235) wanted to spend at least 1 year on an out-of-hours on-call ‘bleed rota’. Only 69.4% (25/36) of ST7s felt they would be capable of endoscopically managing variceal bleeding as a newly qualified consultant and 63.9% (23/36) felt they would be able to site a Sengstaken-Blakemore tube.

Teaching

Respondents received 4 hours (IQR 4–8 hours) of departmental, regional or national teaching monthly, with 45% (100/218) suggesting this was insufficient. Teaching quality was rated as ‘good or excellent’ by 43.1% (94/218) of respondents and ‘generally good but with room for improvement’ by 39.5% (86/218). Regarding subspecialty teaching, nutrition was felt to be under-represented by 58.6% (109/186) of respondents, followed by advanced endoscopy for endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic ultrasound (EUS) (48.4%, 90/218), advanced lower gastrointestinal endoscopy (47.3%, 88/218), functional bowel disorders (44.6%, 83/218) and pancreatobiliary (44%, 82/218).

Virtual platforms facilitated increased engagement in educational activities during the pandemic for the majority (72.6%, 99/219). Moving forward, 81% (171/211) expressed a preference for departmental teaching to be face to face and 59.2% (159/201) felt similarly about regional teaching. Overall, respondents mostly preferred teaching to be split between mostly regional (48.2%, 105/218), some departmental (65.7%, 142/216) and some national (71.4%, 155/217) settings.

Collaborative work

More than half (53.6%, 120/224) of respondents contributed to a collaborative project outside of their local department during the pandemic (eg, a regional or national audit). 40.2% (90/224) were trainee research network members, while an additional 35.3% (79/224) would be interested in becoming members in future.

Training pathways and future workforce planning

In total, 11.3% (30/266) of respondents were OOP. Reasons for pursuing this pathway included subspecialist interest development (77.8%, 23/30), curriculum vitae enhancement (69.1%, 21/30), work–life balance (39.7%, 12/30) and concerns about burn-out (30.2%, 9/30). Currently, 19% (50/263) of respondents work LTFT. Almost half (48%, 24/50) chose this pathway for improved work–life balance, whereas 24% (12/50) did so due to concerns about burn-out. Looking towards the future, 34.8% (63/181) of full-time respondents are considering going LTFT, mostly due to work–life balance (68.9%, 51/74), family and friends (44.6%, 33/74) and concerns about burn-out (41.9%, 31/74).

Respondents have become less confident that they will develop the required expertise in their subspecialist interest compared with 2020 (42.3% vs 55.6%, respectively). Almost half (47%, 117/249) plan to undertake a post-CCT fellowship to remedy this (online supplemental graph 4). As a result of the pandemic, more than half of respondents (52.5%, 104/198) reported needing to make up for missed training opportunities with post-CCT fellowships (26.3%, 52/198), time OOP (15.2%, 30/198) or extended training (12.1%, 22/198). Among respondents interested in hepatology, 62.5% (65/104) perceived barriers with the application for an advanced training post (ATP), citing concerns regarding caring responsibilities and geographical relocation.

Overall, 44% (109/248) of respondents would prefer to work LTFT as a consultant compared with 32% in 2020. Female respondents indicated a greater preference compared with their male counterparts (64.9% vs 29.9%, p<0.001) and this gender difference persisted even for female respondents without caring responsibilities. 57.4% (143/249) of respondents would be willing to move to another region for a consultant post.

Discussion

This is the largest survey of UK gastroenterology and hepatology trainees since the introduction of the new curriculum. It covers a pivotal period, including recovery from the COVID-19 pandemic and training changes implemented following the SoT report. There is a decreased response rate from 2020 (40.3% vs 51%), despite identical dissemination methods. This could be attributed to growing ‘survey fatigue’ and represent a potential sampling bias, however, the survey was made available for as long as possible to minimise this. The reduced response rate may well also reflect a sense of futility among trainees whose previously raised concerns (including feedback regarding SoT implementation) were not addressed. Trainee engagement in future surveys may partly rest on an impact of raised concerns about training being demonstrated.

Endoscopy training

The ramifications of lost endoscopy training opportunities during the pandemic are clear. Rates of ST7s completing colonoscopy certification in 2022 have fallen by almost two-thirds since 2018.11 Given this will be a mandatory requirement for CCT for a significant proportion of trainees under the new curriculum, this must be addressed as a matter of urgency. A shift towards immersion training via endoscopy academies has been a welcome initiative and may help mitigate this setback through increased and consecutive procedure exposure. Our results have starkly demonstrated what competencies (or lack thereof) can be expected from a time-pressured traditional training model. Therefore, prioritising funding and trainer provision for academies is imperative to avoid further impairment of endoscopy training within the new 4-year curriculum. Access must be equitable across deaneries and ‘best practice’ models should be widely adopted in order to safeguard the skills of our future workforce.

The ability to endoscopically manage acute upper gastrointestinal bleeding is a requisite consultant skill.12 Our results are concerning in this regard, with almost one-third of ST7 respondents reporting insufficient experience and confidence in this area. There is a dearth of structured ‘in-hours’ training and only 16.2% (32/235) of all respondents participate in a formal on-call ‘bleed rota’. Although ‘in-hours’ training is preferable, out-of-hours experience fosters decision-making skills and remains a desirable option, with over 92% (217/235) of respondents wanting to spend at least 1 year on an on-call ‘bleed rota’. We believe training programme leads should aspire to facilitate this where possible, with support from consultant colleagues.13 Improved access to skills courses can also maximise hands-on training, including rarer haemostatic techniques which may otherwise not be encountered during training.14

The pressures of GIM

In a curriculum mandating dual accreditation, a fine balance needs to be upheld between both specialties. To equip gastroenterologists of the future to manage an ageing and increasingly complex patient population, a GIM-dedicated year (IMT3) now replaces ST3 of specialty training, up to 25% of training time is earmarked for GIM and twenty non-specialist clinics must be achieved. However, our survey reveals the immense strain this places on gastroenterology training. 71.6% (144/201) of respondents stated GIM negatively impacted on their specialty training and 26.5% (68/257) self-reported that in reality more than half of their training time was spent in GIM. To more accurately monitor this working pattern, we strongly recommend the introduction of a training time calculator which can be used in real time to collect data prospectively.15 The split can be used as a key performance indicator of the new curriculum and correlated with the attainment of core competencies.16 Dedicated blocks of GIM training would reduce the interference of post on-call days off with training lists and ward continuity, therefore offering a potential solution to redress the imbalance. Indeed, this was the preference of almost two thirds (64.3%, 146/227) of respondents.

Subspecialty exposure and complex pathways

A significant proportion of respondents (47%, 117/249) are planning to pursue some form of post-CCT training. This is an expected consequence of a newly abbreviated curriculum. However, our results suggest the current training pathway is failing to provide trainees with sufficient subspecialty exposure to make informed career decisions. For example, over a half of respondents (54.2%, 135/249) have no exposure to interventions such as ERCP or EUS. We advocate that trainees need improved exposure to such subspecialty areas to guard against gaps in future service provision. Our survey also highlights the discrepancy between the 45% (112/246) of respondents wishing to subspecialise as hepatologists and the limited availability of hepatology ATPs. This may, in part, be addressed by the proposed revisions to recruitment.17

It was notable that in a number of survey areas respondents are consistent in their responses between early and later stages of training. This includes reporting high demand for post-CCT training, low confidence in subspecialty interest development and low desire to pursue GIM as a consultant. This suggests the training programme does little to address concerns established early in training, perhaps representing a missed opportunity. If this remains the case, such areas of concern will inevitably impact on future workforce planning.

Protecting against burn-out

The risk of burn-out has featured heavily in the analysis of the pandemic’s impact across the NHS workforce.18 It similarly features throughout this survey as a motivator for undertaking OOP pathways and LTFT working patterns. Interestingly, more respondents expressed a desire to work LTFT as consultants than are working LTFT currently, which perhaps represents a degree of premeditated mitigation for anticipated burn-out. Regardless of the underlying reason, the implications for workforce planning are significant.

Within training, consistent provision of high-quality teaching, mentorship programmes and opportunities for engagement with research and innovation all represent protective factors against burn-out and low morale. We have highlighted a desire for balanced provision of local, regional and national teaching and a return to face-to-face teaching at least at a local level. Importantly, not only must trainees have protected time to attend this teaching, but trainers must be adequately resourced to provide it effectively. The collaborative work afforded by trainee research networks may also play an important part in the fostering of team-working, subspecialty interests, future research interests and improved cohesion as a specialty.19 We have demonstrated a high level of interest from respondents in participating in trainee research networks, which currently exist outside of the formal curriculum. They might also address new guidance around the assessment of trainee quality improvement competencies within the curriculum.20

The benefits of mentorship are well documented and this will be increasingly integral in the fight against burn-out.21 Currently, trainees must seek out a mentor independently or apply for a place within a specific programme.22 There is a strong argument that all trainees could benefit from facilitated engagement with a mentor at an early stage in their training, though once again such initiatives require sufficient resourcing.

Conclusion

Gastroenterology training has been adversely affected by the COVID-19 pandemic. Moving forward within the new curriculum, trainees are faced with the added pressures of shortened training time and the ongoing issue of detrimentally disproportionate GIM commitments. This raises concerns over trainees’ ability to develop the specialist expertise expected of them as consultants in a variety of domains, including endoscopy and subspecialty areas. We have discussed a number of solutions to this and highlighted that critical further adjustments to training are required in order for the new curriculum to succeed. By adapting and improving in response to trainee feedback, we can achieve the right balance between delivering effective service provision and the robust specialty training needed for excellence in patient care, all while protecting our valuable workforce.