Young GI angle: Subspecialising in gastroenterology: Needs, challenges and opportunities
In the UK, the Joint advisory group on GI endoscopy (JAG) established in 1994 works across three domains: endoscopist training, endoscopy service accreditation and accreditation of screening endoscopists. At present, they provide certification to trainees in diagnostic upper GI endoscopy, colonoscopy and flexible sigmoidoscopy, with plans to expand the certification process to include Endoscopic Retrograde Cholangio‐Pancreatography (ERCP), EUS and therapeutic upper GI endoscopy. However, there are currently no formal certification or formal assessment tools for accreditation in advanced endoscopy modalities including ERCP, Endoscopic Ultrasound (EUS), Radiofrequency Ablation, Endoscopic Submucosal Dissection, Advanced Endoscopic Mucosal Resection of complex level 3 or 4 colonic polyps and Per Oral Endoscopic Myotomy. Overall, the implementation of JAG endoscopy training courses and endoscopy training portfolios have demonstrated an overall reduction in reported complication rates, improvement in standards of teaching and increased trainee satisfaction with training in diagnostic upper and lower GI. , In contrast, in advanced endoscopy training where standardised courses and accreditation processes are lacking, only 29.4% of trainees felt satisfied/very satisfied in their current training within advanced endoscopy. At present, there are no defined criteria identifying which centres can provide advanced endoscopy fellowships. Furthermore, there are no unified curricula or defined accreditation criteria for advanced endoscopic procedures. Frequently of concern to trainees is the absence of guidelines or standards pertaining to the application process of advanced fellowships. The BSG has collated a list of some of the available endoscopy fellowships available within the UK to increase transparency around the availability of advanced endoscopy training. However, the duration of fellowship, types of procedures, number of procedures and experience offered varies significantly. A recent survey found that training programs among European advanced endoscopy fellowships were highly variable. Most ERCP/EUS training fellows are male (70%), which suggests that the application processes are biased. The study also found that a formal curriculum is in place at only 54% of centres, with 65.7% of centres assessing competency at differing timings during the fellowship. Validated assessment tools are currently only being used in 33% of centres. For members, the European Society of Gastrointestinal Endoscopy offers a fellowship grant programme for the development of advanced techniques separated into two modules. First, a 4‐week period of observational training with experts with successful completion of this allowing candidates to apply for grant funding for module 2, which offers hands on training for 3 months within an accredited unit. 

The need for gastroenterologists with a specialist interest in IBD is partly due to the increased prevalence of the disease. However, this is also due to the breadth of advances within the field, such as our understanding of pathophysiology, the novel agents used in the management of disease and IBD specific interventions such as chromoendoscopy for detecting dysplasia. There is a need for skilled clinical endoscopists able to detect subtle changes that guide the escalation and de‐escalation of therapy. There is a high demand for clinical expertise to manage complex diseases and provide services such as paediatric transition clinics, IBD in pregnancy and joint IBD surgical clinics. In the UK, higher speciality training has been shortened to 4 years. A review of the BSG training survey has highlighted that only half of the trainees have achieved complete colonoscopy certification prior to their final year. If trainees' ability to achieve core skills early within their training is hampered, the opportunity to develop advanced IBD competencies will be diminished. The BSG officially endorses fellowships and has strict standards for centres and fellows alike. The European Crohn's and Colitis Organisation offers a number of fellowships, grants and travel awards designed to ‘encourage young physicians in their career and to promote innovative scientific research in IBD Europe.’ 

Hepatology has long been a subspeciality area that offers advanced fellowships focussed on medical management of liver transplantation. However, it is now recognised that core hepatology training should be delivered to all gastroenterologists reflecting the service demands of general gastroenterology. Within the UK, this is delivered with a minimum 6‐month rotation during a 4 years training programme at a liver centre meeting specific predefined criteria identified as a tier 2 liver centre. , Additional sub‐speciality accreditation can be achieved by spending additional training time within a tier 2 and a liver transplant centre (tier 3). Within gastroenterology training in the United Kingdom, there exists an advanced training programme for hepatology where trainees can competitively apply to nationally advertised training posts offering additional hepatology training. Trainees in these yearlong posts acquire standardised skills in an advanced curriculum by having an additional 12 months of core and advanced hepatology. This standardised model offers a robust advanced training programme to accredit general hepatologists. 

Nutrition as a subspecialist area has often been overlooked; in a survey of trainees developed by the BSG, only 54.4% of respondents would feel satisfied or very satisfied with their training in nutrition compared to 81.7% in IBD, 71.0% in hepatology and 70.6% in basic endoscopy. , A current challenge in delivering training in nutrition is that only 80% of all hospitals in the UK currently have a nutrition support team with only 48% having a full MDT provision (nutrition nurse, a dietician, a doctor and a pharmacist). There is a wide regional variation in provision of nutrition training and this in turn has an adverse effect on training opportunities with a survey showing that a quarter of UK trainees were unlikely to get formal nutrition training. This sentiment is echoed across Europe. There are numerous international and national nutrition courses, and the European Society for Clinical Nutrition and Metabolism (ESPEN) organises an annual course alternating across locations in Europe, aimed at providing an ‘overview of the nutritional consequences and metabolic challenges posed by acute and chronic diseases.’ The British Society of Parenteral and Enteral nutrition (BAPEN) also organises a regional meeting annually and endorses regional meetings that meet educational standards. Advanced fellowships in nutrition are available; however, unlike their hepatology, IBD and advanced endoscopy counterparts, there is no unified directory of centres that offer this and at present it is difficult to ascertain what competencies a trainee can expect to develop during their fellowship. Further work at a national training level is required to define criteria for centres that provide complex nutritional training and develop a detailed curriculum for gastroenterology trainees subspecialising in nutrition. , 

