Structured training and assessment in ERCP has become essential for the Calman era.

Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most diYcult endoscopic procedures to learn. It has a significant complication rate even when undertaken by experienced practitioners. During the procedure, patients have a right to expect a competent practitioner to be in charge as complications may result in cholangitis, bleeding, pancreatitis, duodenal and biliary perforation, and consequent death. However, in the United Kingdom, there are no guidelines either for the training required by these doctors or the assessment of proficiency. This issue has become increasingly important. The use of ERCP has increased with the advent of laparoscopic cholecystectomy 3 and the minimal access management of gallstones. Developments such as magnetic resonance imaging (MRI) are likely to reduce the number of purely diagnostic ERCPs needed, leaving only the more diYcult therapeutic procedures to be done using this method. It has become increasingly obvious that competence in ERCP reduces complications, maximises therapeutic potential and reduces costs incurred in unsuccessful and repeated procedures. Finally, time available for ERCP training within the confines of specialist registrar training schemes has decreased. In the past, recommendations (mainly from the USA) have emphasised the number of procedures that a trainee needs to master in order to achieve competence. Often, these recommendations represent a pragmatic, consensus view of the number of procedures a trainee could realistically expect to perform under supervision, rather than the number actually needed to achieve a definitive level of success—for example, an 80% cannulation rate of the desired duct. A survey of the American College of Physicians suggests that 50 ERCPs are suYcient and guidelines from American Society of Gastrointestinal Endoscopy (ASGE) propose that 35 ERCPs are enough. In practice, it seems that as the number of endoscopic procedures performed by trainees increase, 10 there is a concomitant rise in the number of procedures perceived as necessary to attain a high level of proficiency. Arbitrary guidelines based on a statutory number of procedures are not a practical measure of the level of competence achieved and the assessment process needs to be more objective if the use of ERCP is to be controlled and optimised. The need for formal guidelines has recently been acknowledged by the ASGE in its recommendations for level 3 Advanced Training and Certification in gastrointestinal endoscopy. Although they still suggest a threshold number of procedures (100), they recommend that the ability to cannulate the common bile duct deeply 80% of the time is used as a further assessment measure. A recent prospective evaluation estimated that it took around 180– 200 ERCPs to achieve this level of proficiency 13 and an additional period of training has been suggested as one way of ensuring that such skills are acquired. Similarly, we feel that the current ad hoc apprenticeship in the UK, with its assumed level of competence, needs to be formalised into a training and assessment process with a standardised form of accreditation. In the past decade we have trained both physicians and surgeons in ERCP in a unit which undertakes more than 500 ERCPs annually, and we have run two ERCP teaching courses each year for the past five years. Based on our experience, in this paper we examine the current problems for both the trainee and trainer, and attempt to formulate pragmatic criteria for training today.