Does Integrated Practice Guideline Testing in Gastroenterology Fellowship Training Improve Fellows' Education?

INTRODUCTION

Currently, 3 major American societies have published guidelines and recommendations for clinical practice in the field of gastroenterology (GI): the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy (ASGE).^1-14 Although these societies have been publishing these guidelines since 1996, many of these documents have been produced in the past 10 years. Practitioners in the GI field support these guidelines because they are derived from evidence-based medicine or are recommendations from a consensus of experts in the field and are intended to assist providers in delivering optimal care. While the validity and importance of these guidelines are not disputed, most of the top-ranked training programs do not incorporate guideline review into their formal didactic curricula. We contacted the top 10 GI fellowship training programs—as ranked by 2012 U.S. News & World Report¹⁵—and found that only 1 of the 10 centers currently employs formal guideline review and testing.

The ASGE currently lists more than 70 guideline papers under its standards of practice that are available to training and practicing gastroenterologists. We designed an integrated guideline review that used formal testing of 14 current ASGE guidelines deemed essential for GI fellowship training to determine if this review format would improve fellows' knowledge and provide an avenue to objectively evaluate their knowledge.

RESULTS

The 4 fellows in the experimental group, who were unaware of which guidelines would be reviewed, increased the number of correctly answered questions from 61% on the pretest to 81% on the posttest (Figure 1), resulting in a 33% improvement in correctly answered questions after the guideline review. The 2 fellows comprising the control group who initially reviewed each article and generated their own unique questions while being blinded to the other writer's questions also improved their test scores from 88% to 94%, a 7% improvement in correctly answered questions (Figure 2).

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Figure 1.

Change in correct answers for the experimental group before and after the guideline review.

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Figure 2.

Change in correct answers for the control group before and after the guideline review.

The educational merit survey with the 7 questions described above in the Methods section resulted in a cumulative optimal score of 200 out of the possible 210 points. This score correlates to 95.24% of the possible perfect score. Interestingly, all 6 fellows gave a 5 out of 5 possible points to the final statement regarding improving patient safety and providing optimal care. This result demonstrated the subjective significance of formal guideline review during fellowship training for the surveyed fellows.

DISCUSSION

With the movement to electronic medical records, advancements in clinical research and evidence-based medicine, increased focus on patient safety, and the push to meet the goals of physician quality reporting systems, physicians need to ensure that their knowledge of the standards of practice published for their fields is up to date. Unfortunately, only 10% of the top GI fellowship training programs has formally incorporated a review of current guidelines into the academic curricula. Although these guidelines are available to any practicing physician and to the public at large and can be independently reviewed as needed, we believe that practice guidelines should be somehow incorporated into the formal postgraduate training curriculum. Guideline reviews are the backbone of clinical practice and tend to be a reference for the standard of care.

After participating in a structured 14-week curriculum, the 4 fellows in the experimental group uniformly improved their scores between the pretests and the posttests and achieved a greater level of comfort in implementing the recommendations from the guidelines in their own patient care. The 2 control fellows, who initially reviewed the articles and generated the questions, also improved their scores after the weekly formal review. The experimental group demonstrated a greater improvement than the control group in their posttest scores. We believe these results show that repetition is one of the keys to knowledge retention and a benefit of integrated practice guidelines testing.

Future studies designed to prove statistical significance in test performance after formal guideline review must include an additional control group denied access to the guidelines being reviewed. We felt that a 14-week period of denying fellows access to the guidelines in this study presented us with an unacceptable ethical dilemma because doing so would have delayed fellowship education and possibly compromised patient care in the interim.

This review curriculum also revealed that not all of the guidelines were being followed by either the fellows or the mentoring staff physicians. This finding might be explained by the fact that these guidelines are continuously evolving (with most recommendations having been published in the past decade) and that some of the guidelines include expert opinion rather than true standards of care.

CONCLUSION

This project reminded us that the art and practice of medicine require continuous refreshing of our knowledge base and that a curriculum incorporating current guidelines will encourage both training and mentoring physicians to improve patient safety and provide quality care.