Research, plans to spend several million dollars tocreate practice guidelines and to assess the effective­ness of different approaches to the diagnosis andmanagement of medical problems to determine whichmost effectively achieve beneficial outcomes. It will beup to us to ensure that the patient's outcome, notgovernment's, insurers', and investors' bottom line,remains the primary concern.

It was Oregon's application of traditional cost-effec­tiveness theory that produced a prioritized list ofhealth care services for Medicaid reimbursement inwhich dental tooth capping took precedence over alife-saving appendectomy for acute appendicitis orsurgery for ectopic pregnancy, despite the virtually100% effectiveness of these procedures in treatingotherwise generally fatal conditions. To economists,the goal is to maximize health benefits within societywithout regard for individual welfare. The obviousabsurdities sent the Oregon Health Services Commis­sion back to the drawing board to factor in the pow­erful human proclivity to rescue endangered life,dubbed the "Rule of Rescue" by Jonsen, who alsorecognized the difficulties it posed for resource allo­cation planning.

Moreover, although the Rule of Rescue may be mostcompelling in the context of lifesaving interventions,it is also a factor whenever a patient is in need oftreatment that may be costly but is clearly mosteffective for that individual. Our obligations will be:(1) to ensure that quality does take precedence overcost in the care of our patients; (2) to monitor out­comes and effectiveness research closely to be surethat the premises upon which it is based are valid; and(3) to continue to lead in practice guideline develop­ment and assume leadership in the evaluation of theireffectiveness and impact on medical practice.

There were times this year when I felt like the littleDutch boy with his finger in the hole in the dike.Confucius was wrong though. I have not been lone­some. I feel like I know most of the 5000 members ofAISIGIE from the letters I have sent to you, thehundreds that I have received personally, and thecopies of correspondence to HCFA and Congress thatmembers have sent to me.

I have shared your anger and frustration as well asyour gratitude for the successes we have achieved.Your communications have helped to bolster my re­solve to continue the battle.

Now, Dr. John Bond, your assignment, should youchoose to accept it, is to continue to lead the fight inall these spheres with your usual flare and determi­nation.

Thank you all for your support.

Barbara B. Frank, MDHaverford, Pennsylvania

VOLUME 38, NO.5, 1992

From the Rostrum

Advanced endoscopic training: teachingus older dogs some new tricks

The primary responsibility of the governing board of aprofessional medical society is, of course, to respond to thestated needs of its membership. Recognizing all of the highlysuccessful current and recent A/S/G/E projects and pro­grams, we must confess that one of the most frequently citedpriorities of our members has not yet been successfullyaddressed-how can A/S/G/E members obtain hands-ontraining to perform endoscopic procedures which either werenot taught during formal training, or were developed aftergraduation from formal training? A correlative of this ques­tion is how can members obtain hands-on training with anexperienced teacher to improve their performance of basicendoscopic procedures they already perform?

The A/S/G/E has been a leader among professional gas­trointestinal societies in establishing standards for trainingand credentialing. The bottom line appropriately has beenthe greatest benefit for patients with digestive disorders. Asthese standards and guidelines have been promulgated, how­ever, many conscientious and skilled endoscopists have beencaught between the completion of their fellowship trainingand the rapid development of new, highly technical advancesin our specialty. Our training standards rightfully declarethat acquiring competence in new techniques, or majorextensions of established procedures, requires not only di­dactic course instruction, but also hands-on training underthe supervision of a skilled and experienced teacher. Whatwe haven't yet solved, however, is the frequently askedquestion, "Okay, but where do I go to get such requiredtraining?"

An informal query of training programs conducted by

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Jack Vennes in 1982 first identified the demand for special­ized postgraduate endoscopic training ofpracticing gastroen­terologists. In 1983, under the direction of Barbara Frank,a comprehensive "manpower survey" of A/S/G/E memberswas conducted.! This survey identified the desire for ad­vanced training of practicing endoscopists as the singlehighest priority of the membership. As stated in the surveyreport, "Almost 78% of respondents thought that the A/S/G/E should emphasize advanced/refresher training for prac­titioners who wished to become competent in procedures notoffered during their training period. This training shouldinvolve more than short courses; block-time or mini-resi­dency training with hands-on experience is desired."

The Postgraduate Education Committee, chaired by JayNoble, was asked to explore the feasibility of setting upmini-sabbaticals in existing training programs which wouldprovide the needed training. They conducted a survey of allgastroenterology programs which indicated that 74% be­lieved that a retraining program of 1 to 4 months wasreasonable. Of the 60 program directors who respondedpositively, most indicated an initial willingness to acceptqualified A/S/G/E members for hands-on training. Spurredon by this favorable response, the committee promptly sentfollow-up letters requesting actual commitments for thistraining. Disappointingly, only one center subsequentlyagreed to accept a trainee, and this program stipulated thatcandidates must be graduates of their own fellowship pro­gram who had been in practice less than 5 years. Reluctantly,the Governing Board agreed with the recommendation ofthe Postgraduate Education Committee not to pursue thisissue further at that time.

A long-range planning workshop in January 1990 onceagain emphasized the need to "establish programs for post­graduate hands-on training in endoscopic procedures for A/S/G/E members."2 Our previous unsuccessful attempts toestablish mini-residencies within existing academic pro­grams were attributed to their limited clinical capacity whichwas already saturated by the training requirements of regu­lar gastrointestinal fellows. At this point, a leader withimagination and foresight, James L. Borland, Jr. had anidea. If it is impractical to bring practitioner-students to anendoscopic teacher, why not arrange to have the teachervisit the student's practice to accomplish needed hands-oninstruction. Furthermore, if many academic endoscopistsare too busy teaching their own gastrointestinal fellows, let'salso recruit teachers from the private practice communityfor this training. Several examples were identified wherethis approach has been employed successfully for a numberof years. Intrigued by this concept, the Governing Boardestablished the Ad Hoc Committee on Advanced Training(soon dubbed the Retread Committee) with Dr. Borland aschairman. After a year of intense productive work, and withthe input from the Society's Standards of Practice Commit­tee and the Committee on Training, a detailed plan wasdeveloped which was reviewed and approved by the boardin May 1992. After a few final problems are worked out, weplan to formally launch this program in early 1993.

The retraining program was named Guideline for En­hancement of Endoscopic Skills: A Program for A/S/G/EMembers to Learn New, or Enhance Existing EndoscopicSkills. The program is a multi-step process designed toensure a working knowledge of cognitive and technical as-

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pects of a specific endoscopic procedure. The basic elementsof the program include the following:

1. A review of pertinent literature and available audiovis­ual aids relevant to the procedure to be learned.

2. Attendance at an A/S/G/E approved didactic post­graduate course which contains material relevant to theprocedure.

3. Arrangement with an A/S/G/E approved teacher whowill organize and conduct supervised, hands-on training.

4. One or more visits by the student to the teacher's unitto become familiar with the specific methods of the proce­dure and review additional background material as neces­sary.

5. Successful completion of an established number ofprocedures under the direct supervision of the teacher; inmost instances, the teacher will travel to the student's unitand conduct this hands-on instruction using patients in thestudent's medical facility.

6. Parts of this program may be deleted or abbreviated,when appropriate, for training in minor skills or for enhance­ment of existing skills.

7. Variations of this process, approved by both teacherand student are acceptable as long as they do not reduce thequality of the learning experience; for example, in someinstances the entire hands-on instruction might be accom­plished by having the student travel to the teacher's unit.

Both students and teachers must be experienced endos­copists who are members of the A/S/G/E. Each applicantfor training will be asked to document existing endoscopicskills and experience appropriate to the desired additionaltraining. Using this information, a prospective teacher willestimate the number of cases likely to be required to attaincompetence in the procedure in question. In addition, priorto hands-on instruction all necessary arrangements must becompleted regarding appropriate medical liability coverage,licensure, hospital privileges, patient care responsibility in­cluding management of complications and follow-up, avail­ability of assistants and equipment, and reasonable remu­neration for the teacher's time and effort.

Teachers will be solicited through training directors, theCouncil of Regional Endoscopic Societies, and from a gen­eral mailing to the membership announcing the program.Appropriate criteria for prospective teachers include dem­onstrated skill and experience in the procedure to be taughtand demonstrated interest and/or experience in teaching.

Interested members will submit their credentials to theA/S/G/E Committee on Training, which will generate a listof approved teachers. The society will then serve mainly asa clearinghouse facilitating contact of member candidatesdesiring training with its cadre of approved teachers.

It is important to stress that this advanced training pro­gram is not intended to provide formal certification ofcompetence in a given procedure. The program is designedto facilitate and formalize a process whereby an individualwith basic endoscopic skills may learn new skills or enhanceexisting skills in an effective educational environment, andobtain documentation of completion of a structured teachingprogram. Whereas the goal of the program is attainment ofcompetence in a given procedure, the A/S/G/E does notguarantee that this objective will be satisfied in all cases.Once a mutually satisfactory arrangement has been estab­lished between teacher and student, the A/S/G/E will not

GASTROINTESTINAL ENDOSCOPY

take an active role in the specific design or control of theindividual teaching experience. The Society's Committee onTraining will, however, monitor the program carefully toensure general conformance with these guidelines, assess thelevel of participation, and evaluate the effectiveness of thetraining.

Following recruitment of an adequate number of teachers,applications for member candidates interested in obtainingadvanced training will be available from the A/S/G/E office.Applicants will be provided a copy of the program guideline,appropriate application forms, and a list of teachers in theirarea specifying the procedures each are prepared to teach.

The last, and most essential ingredient which will ulti­mately determine the success or failure of this program, isthe level of commitment of members of the A/S/G/E. Bothteachers and students must be willing to enter into a goodfaith contract in sufficient numbers to make the effortworthwhile. Some creativity, flexibility, mutual trust, hardwork, and an element of selflessness will be required if we'reto make this experiment succeed. The common goal we allstrive for is one of the main purposes of the A/S/G/E asstated in our constitution, "to establish and maintain thehighest standards of practice for the diagnostic and thera­peutic use of gastrointestinal endoscopic methods" and "toassist all those involved with health care as it relates togastrointestinal endoscopy."3

REFERENCES1. Frank BB. The 1983 A/S/G/E membership survey. Gastrointest

Endosc 1984;30:206-12.2. Borland JL Jr. The next 50. Gastrointest Endosc 1990;36:

416-7.3. American Society for Gastrointestinal Endoscopy Constitution,

A/S/G/E Membership Roster, Constitution and By-Laws, 131Elm Street, Manchester, MA, June 1991.

Letters to the Ed itor

Viral esophagitis: the endoscopicappearance

To the Editor:

I enjoyed reading the excellent article by McBane andGross describing the clinical syndrome, endoscopic findings,and diagnosis of herpes virus (HSV) esophagitis in 23 pa­tients.! As pointed out in the Discussion, the authors founda "typical" endoscopic appearance in 4 of 23 cases. However,they have not described the typical endoscopic findings oftheir 4 patients and how they differed from 16 patients withendoscopic findings "suggestive" of HSV infection. I believe,it is most likely due to the retrospective nature of theirstudy. The typical endoscopic appearance in HSV esopha­gitis is the presence of discrete vesicles. In the absence ofdiscrete vesicles, there is no typical endoscopic appearance,and apparently only one of their four patients had endo­scopically typical HSV esophagitis. We have previously de­scribed five immunocompromised patients with viral esoph-

VOLUME 38, NO.5, 1992

agitis. 2 All patients had ulcers and four patients had vesiclesat endoscopy. McDonald et al.3have found a high incidenceof viral esophagitis in 46 patients after bone marrow trans­plantation with equal distribution of HSV and cytomegalovi­rus esophagitis. Only one of their patients with HSV infec­tion had discrete vesicles noted during endoscopic exami­nation. They described three stages of HSV esophagitis: anearly stage with vesicles, an intermediate stage with erosionsand ulcers, and a late stage with mucosal necrosis.3, 4 I sharetheir opinion that the finding of vesicles should stronglysuggest HSV infection, since neither cytomegalovirus norfungal organisms appear to cause vesicular lesions.

I would like to make few additional comments:1. Vesicles probably are the only typical endoscopic find­

ings of HSV esophagitis. During this early vesicular stage,biopsies and cultures may be negative for HSV as shown inour study.2 McBane and Gross! found positive culture orbiopsies in all patients. I suspect this to be due to the latestage of infection.

2. It is likely that the vesicles were seen in only a fractionof patients reported by McBane and Gross! and by Mc­Donald et al.3because endoscopy was performed after long­standing symptoms. In our study,2 the mean duration ofodynophagia was 6.8 days (range, 4 to 10 days). The authorsdo not mention the duration of symptoms in their patientpopulation.

3. Early endoscopy plays an important role in immuno­compromised patients with esophageal symptoms, especiallyodynophagia. As shown in our study,2 if vesicles are foundat early endoscopy, the diagnosis of viral esophagitis may bepresumed and treatment with acyclovir may be initiatedimmediately even before biopsy and culture results are avail­able. All of our patients had rapid improvement of odyno­phagia within 1 to 5 days and complete resolution within 3to 7 days with acyclovir therapy. It would be interesting toknow the results of acyclovir treatment in the patientsreported by McBane and Gross.!

Shailesh C. Kadakia, MDDepartment of Medicine

Gastroenterology ServiceBrooke Army Medical Center

San Antonio, Texas

REFERENCES1. McBane RD, Gross JB. Herpes esophagitis: clinical syndrome,

endoscopic appearance, and diagnosis in 23 patients. Gastroin­test Endosc 1991;37:600-3.

2. Kadakia SC, Oliver GA, Peura DA. Acyclovir in endoscopicallypresumed viral esophagitis. Gastrointest Endosc 1987;33:33-5.

3. McDonald GB, Sharma P, Hackman RC, Meyers JD, ThomasED. Esophageal infection in immunosuppressed patients afterbone marrow transplantation. Gastroenterology 1985;88:1111-7.

4. McDonald GB. Esophageal disease caused by infection, sys­temic illness, and trauma. In: Sleisenger MH, Fordtran JS, eds.Gastrointestinal disease. Philadelphia: WB Saunders,1989:640-56.

The opinions and assertions contained herein are the private viewsof the authors and are not to be construed as reflecting the viewsof the Department of the Army or the Department of Defense.

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