Published online Jul 21, 2019. doi: 10.3748/wjg.v25.i27.3468
Peer-review started: February 27, 2019
First decision: May 9, 2019
Revised: May 16, 2019
Accepted: June 23, 2019
Article in press: June 23, 2019
Published online: July 21, 2019
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.
Core tip: An additional, optional year of endoscopic-retrograde-cholangiopancreatography (ERCP) training was added because of limited ERCP exposure during standard-three-year-gastrointestinal-fellowships and its greater endoscopic technical difficulty. Yet, many graduates from standard-three-year-fellowships intensely pursue ERCP privileges despite inadequate numbers of ERCPs, or low successful duct cannulation rates. Hospital credentialing committees have sometimes disregarded recommended ERCP credentialing guidelines. Consequently, some gastroenterologists learn ERCP “on the job”, after completing standard GI fellowships, during unsupervised practice. National, mandatory, standards for ERCP are advocated, including number (≥ 200-250) of performed ERCPs, and ≥ 85%-90% successful cannulation rate. An independent entity should oversee ERCP credentialing to prevent politicking within hospital committees.