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Saudi J Gastroenterol
Saudi J Gastroenterol
SJG
Saudi J Gastroenterol
Saudi Journal of Gastroenterology : Official Journal of the Saudi Gastroenterology Association
1319-3767
1998-4049
Wolters Kluwer - Medknow India

38841910
SJG-30-260
10.4103/sjg.sjg_19_24
Original Article
Inflammatory bowel disease training assessment of gastroenterology fellows in Saudi Arabia
AlDhneem Hassan 1
AlMutairdi Abdulelah 23
Attamimi Mashary 2
Mosli Mahmoud 4
AlAmeel Turki 5
Al-Bawardy Badr 236
1 College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
2 Department of Internal Medicine, Division of Gastroenterology and Hepatology, King Faisal Specialist Hospital, Riyadh, Saudi Arabia
3 College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
4 Department of Internal Medicine, King Abdulaziz University, Inflammatory Bowel Disease Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
5 Department of Medicine, King Fahad Specialist Hospital, Dammam, Saudi Arabia
6 Department of Internal Medicine, Section of Digestive Diseases, Yale School of Medicine New Haven, CT, USA
Address for correspondence: Dr. Badr Al-Bawardy, Department of Internal Medicine, Division of Gastroenterology and Hepatology, King Faisal Specialist Hospital and Research Center, P. O. Box 3354, Riyadh 11211, Saudi Arabia. E-mail: badr.albawardy@yale.edu
Jul-Aug 2024
06 6 2024
30 4 260265
14 1 2024
21 4 2024
05 5 2024
Copyright: © 2024 Saudi Journal of Gastroenterology
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Background:

Recent advancement and complexity in the management of inflammatory bowel disease (IBD) has made it challenging for gastroenterology (GI) fellows to obtain competency and confidence in managing the complex IBD patient. We aimed to evaluate the confidence and training in IBD among GI fellows in Saudi Arabia.

Methods:

We conducted an electronic, voluntary, and anonymous multicenter survey study of GI fellows in Saudi Arabia, from 1/5/2023 to 1/9/2023. The survey evaluated the fellows’ confidence level in IBD management, methods of training received, and the amount of additional training desired in 20 core IBD domains. GI fellows’ preferred learning method was also evaluated.

Results:

A total of 65 GI fellows responded to the survey. In the entire cohort, >50% of fellows reported low confidence in 7 out of 20 IBD management domains, which included 71% in managing j-pouch disorders, 67% in managing the elderly/frail patient with IBD, 60% in managing extraintestinal manifestations, 57% in recommending preventative health services, and 54% in counseling patients on small molecules. Receiving >4 IBD didactic sessions per year was significantly associated with high confidence in managing j-pouch disorders (44.4% vs 13.3%, P = 0.05) and managing the elderly/frail patient with IBD (86.7% vs 50.0%, P = 0.03). Doing an external rotation to expand IBD knowledge was associated with high confidence in managing the elderly/frail patient with IBD (100% vs 26.7%, P = 0.01).

Conclusion:

Many GI fellows lacked confidence and training in key domains of IBD management. Enhancing IBD exposure with didactics and external rotations improved fellows’ confidence in specific domains.

Inflammatory bowel disease
medical education
training
==== Body
pmcINTRODUCTION

Inflammatory bowel diseases (IBDs) such as Crohn’s disease (CD) and ulcerative colitis (UC) result in relapsing and remitting chronic intestinal inflammation. The worldwide incidence of IBD is increasing, and the prevalence in Western countries is also on the rise.[1] The highest prevalence of IBD is approximately 3 million people in the United States (US).[12] In the Arab region, the incidence of IBD has been growing over the past few decades. The incidence of IBD in the Arab region is estimated to be 2.33 and 1.46 per 100,000 persons per year for UC and CD, respectively.[3] Accurate data regarding the epidemiology of IBD in Saudi Arabia are lacking, but it is estimated that there is an increase in the incidence and prevalence of IBD in the region.[24] With the increasing incidence of IBD in Saudi Arabia, it is expected that there will be an increase in accompanying patterns seen in Western countries such as an elderly population with IBD and j-pouch disorders.[5]

The management of IBD has become more complex in recent years with the ever-expanding armamentarium of approved therapeutic agents and the paradigm shift in treatment goals and targets.[67] In addition, the pipeline of new and emerging therapies in IBD continues to increase.[89] Based on this, it has become challenging for gastroenterology (GI) fellows in training to be competent in IBD management. Moreover, the GI fellows’ exposure to IBD may vary depending on the institution or geographic location. In the US, multiple large studies have demonstrated significant variations in care patterns between different practice types with better outcomes such as steroid-free remission rates and quality of life scores in CD patients followed at academic centers.[1011]

A survey study conducted in the US of 43 GI fellowship program directors and 160 GI fellows was published in 2016.[12] This showed that only 28% of GI fellows were satisfied with their level of IBD exposure during training and up to 43% were unsure or believed that outpatient IBD training was inadequate.[12] In a recent study we conducted among 113 US GI fellows, we found that a significant proportion of fellows lacked confidence in essential domains of IBD management and desired a lot more training than what is being received currently.[13] There are no published data regarding the GI fellows’ IBD training and educational gaps in Saudi Arabia. In this study, we aimed to evaluate the confidence, training received, and desire for more training in the field of IBD among GI fellows in Saudi Arabia.

MATERIALS AND METHODS

We conducted a national electronic survey of GI fellows’ IBD training in Saudi Arabia, from 1/5/2023 to 1/9/2023. The survey was voluntary, anonymous, and distributed to the fellows electronically through the fellowship program directors. The survey was distributed electronically through email and text messaging. Multiple regular reminders were sent to program directors to encourage their fellows to complete the survey. The study was deemed exempt by King Faisal Specialist Hospital and Research Center Institutional Review Board.

The survey covered 20 IBD core domains derived from previously proposed IBD core competencies and entrustable professional activities.[1214] The survey was developed and reviewed by four IBD specialists and utilized in assessing the training of GI fellows in the US [Supplement].[13] The survey evaluated confidence, training received, desire for additional training, and preferred learning method. Confidence levels in IBD management were surveyed using a Likert scale of 1–4 [1: not confident at all, 2: slightly confident (still need a lot of supervision), 3: moderately confident (still need occasional supervision), and 4: extremely confident (ready to do this independently)]. Confidence was dichotomized into “low confidence” defined as not at all to slightly confident and “high confidence” defined as moderately to extremely confident.

The fellows were surveyed on the amount and type of IBD training received [none, “on the fly”, work rounds, didactic or conference, self-directed (i.e., national conferences, webinars, independent reading)] and amount of additional training desired [none, a little (1 hour), a moderate amount (2–3 hours), a lot (>3 hours)]. The GI fellows were asked to rank their preferred learning methods for IBD-related topics.

We analyzed data as frequencies and percentages. We then evaluated predictive risk factors associated with low confidence in the five lowest-ranking domains. We utilized the unpaired Student’s t-test for continuous variables and Pearson’s Chi-square tests for categorical variables. A P value <0.05 was considered statistically significant. JMP (SAS Institute Inc., Cary, North Carolina, U.S.) was used for data analysis.

RESULTS

A total of 65 fellows responded to the survey. First-year GI fellows made up 48.5% of the cohort, while 21.2% were second-year fellows and 30.3% were third-year fellows. The majority of the respondents were male, at 78.1%. The respondents represented multiple geographic areas within Saudi Arabia, with 61% getting training in the central region, 21% in the eastern region, 12% in the western region, 3% in the southern region, and 3% in other (nonspecified) regions. Most respondents (60.6%) were part of single-center programs rather than joint training programs. Only 9% of GI fellows had an external rotation outside their respective institution to increase IBD exposure. Attending a national or international IBD conference during fellowship was reported by 48.5% of GI fellows. A total of 81.8% of GI fellows reported having an IBD specialist on faculty [Table 1].

Table 1 Characteristics of gastroenterology fellows who responded to the survey

Questions/Characteristics	n (%)*	
Fellowship Year		
 1st year	16 (48.5%)	
 2nd year	7 (21.2%)	
 3rd year	10 (30.3%)	
 4th year (not IBD)		
Location of Training Institution		
 Central Region	20 (60.6%)	
 Eastern Region	7 (21.2%)	
 Western Region	4 (12.1%)	
 Southern Region	1 (3.0%)	
 Other (not specified)	1 (3.0%)	
Trained in a Joint GI Fellowship Program		
 Yes	13 (39.4%)	
 No	20 (60.6%)	
External IBD Rotation		
 Yes	3 (9.1%)	
 No	30 (30.3%)	
Number of IBD Didactic Sessions/Year		
 1	1 (3.0%)	
 2	4 (12.1%)	
 3	6 (18.2%)	
 4	3 (9.1%)	
 >4	15 (45.5%)	
 No didactics	4 (12.1%)	
Availability of an IBD Specialist on Faculty		
 Yes	27 (81.8%)	
 No	6 (18.2%)	
 Unsure	0	
Planning a Career in IBD		
 Yes	8 (24.2%)	
 No	10 (30.3%)	
 Unsure	15 (45.5%)	
Applying/Enrolling in an Advanced 4th year IBD Fellowship		
 Yes	8 (24.2%)	
 No	13 (39.4%)	
 Unsure	12 (36.4%)	
Attended an IBD Conference During GI Fellowship		
 Yes	16 (48.5%)	
 No	17 (51.5%)	
*Missing data in 32 of 65

In the entire cohort, >50% of fellows reported low confidence in 7 out of 20 IBD management domains. A total of 71% (30/42) reported low confidence in managing j-pouch disorders including pouchitis, 67% (28/42) reported low confidence in managing the elderly/frail patient with IBD, 60% (25/42) reported low confidence in managing extraintestinal manifestations, 57% (24/42) reported low confidence in recommending preventative health services, 54% (22/41) reported low confidence in counseling patients on small molecules, and 52% (22/42) reported low confidence in managing a pregnant patient with IBD and counseling on diet and nutrition [Figure 1].

Figure 1 GI fellows’ level of confidence across 20 core IBD domains

We evaluated factors associated with confidence in the five lowest-ranking domains: managing j-pouch disorders, managing the elderly/frail patient with IBD, managing extraintestinal manifestations, recommending preventative health services, and counseling patients on small molecules. Receiving more than 4 IBD didactic sessions per year was significantly associated with high confidence in managing j-pouch disorders (44.4% vs 13.3%, P = 0.05) and managing the elderly/frail patient with IBD (86.7% vs 50.0%, P = 0.03). Being part of a joint (rather than single-center) program was associated with high confidence in managing the elderly/frail patient with IBD (53.9% vs 20%, P = 0.04) and counseling patients on small molecules (76.9% vs 30%, P = 0.008). Doing an external rotation to expand IBD knowledge was associated with high confidence in managing the elderly/frail patient with IBD (100% vs 26.7%, P = 0.01).

A total of 22.9% (11/48) of GI fellows reported receiving no training in managing the elderly/frail patient with IBD, 16% (8/50) reported no training on counseling patients on small molecules and on managing j-pouch disorders, 13.2% (7/53) reported no training on recommending preventative health services, and 12.7% (7/55) reported no training on counseling patients on diet and nutrition. More than 50% of GI fellows desired a moderate to a lot more training (≥2 hours) in 18 of 20 domains (excluding managing the hospitalized patient with UC and endoscopic scoring of UC). Fellows desired moderate to a lot more training (≥2 hours) in managing j-pouch disorders (88.6%; 31/35), counseling patients on small molecules (74.3%; 26/35), managing postoperative CD (74.3%; 26/35), managing a pregnant patient with IBD (71.4%; 25/35), and managing perianal CD (71.4%; 25/35) [Figure 2].

Figure 2 Amount of additional IBD training desired by GI fellows

In terms of the preferred learning method, GI fellows ranked virtual live sessions as the preferred method most frequently at 40.9% (9/22), followed by in-person live sessions at 18.2% (4/22) and web-based lecture that can be referenced repeatedly at 18.2% (4/22). Only 24.2% (8/33) of GI fellows planned to do a dedicated IBD fellowship.

DISCUSSION

Our study was conducted to evaluate the educational gaps and needs in IBD management among GI fellows in Saudi Arabia. Several valuable findings were identified from this study. For instance, many GI fellows reported low confidence in multiple domains of IBD management. In addition and among the five lowest-confidence domains, we identified certain factors that are associated with improved confidence in these domains, such as a higher number of IBD didactic sessions (>4 per year) and being part of a joint training program or the ability to do external rotations. We have also found that >50% of fellows desired a lot more training in 18 of the 20 IBD domains that were surveyed and noted that a virtual live session was ranked as the preferred learning method most frequently.

The prevalence of IBD is expanding worldwide, and the incidence rate is particularly increasing in Saudi Arabia.[123] In addition, the field of IBD has been rapidly progressing with the evolving treatment targets and expanding therapeutic armamentarium.[689] The increase in incidence and prevalence along with the growing complexity of IBD management poses a challenge in training GI fellows to become competent and confident in the management of patients with IBD.

The literature evaluating the status of IBD training among GI fellows is scarce. A survey study of 43 GI fellowship program directors and 160 GI fellows in the US was published in 2016.[12] In this study, only 28% of GI fellows were satisfied with their level of IBD exposure during training and up to 43% were unsure or believed that outpatient IBD training was inadequate.[12] In the aforementioned study, <50% of fellows felt confident in the 7 IBD domains: management of j-pouch complications, managing extraintestinal manifestations, managing a pregnant patient with IBD, tailoring therapy for postoperative CD, endoscopic assessment of IBD, managing perianal CD, and ostomy management. Similarly, our study found that ≥50% of GI fellows reported low confidence in seven IBD domains. A more recent assessment of IBD training among GI fellows was performed via a multicenter US study and was published in 2023.[13] In this survey study of 113 GI fellows, the 5 lowest-IBD confidence domains were managing a pregnant patient with IBD, managing pouchitis/pouch disorders, managing extraintestinal manifestations, counseling patients on small molecules, and managing postoperative CD. A national survey of GI fellows in Canada found that only a third of GI fellows were fully satisfied with the level of IBD exposure and <50% were confident in 11 out 22 IBD core domains.[15] In our current study, we found that fellows had low confidence in similar IBD domains as reported by the previous studies in the US (managing j-pouch disorders including pouchitis, managing extraintestinal manifestations, managing a pregnant patient with IBD). We also found overlapping core domains in which fellows reported low confidence in between our study and the national survey from Canada, such as managing j-pouch disorders and managing the pregnant patient with IBD.[15] This highlights a consistent and universal group of topics that need to be emphasized more during GI fellowship.

In our current study, we have identified multiple factors associated with improved confidence in some of the lowest-ranking IBD domains. For example, receiving >4 IBD didactic sessions/year was significantly associated with improved confidence in managing j-pouch disorders and managing IBD in the elderly. Similarly in the study by Cohen et al.[12] in 2016 and on multivariate logistic regression analysis, having at least monthly IBD didactics predicted satisfaction with IBD exposure (OR 4.1, 95% CI 1.9–9). The survey study of US GI fellows in 2023 also found a similar impact of the volume of IBD didactic sessions and confidence.[13] In that study, receiving >4 didactic IBD sessions/year was significantly associated with high confidence in managing the pregnant patient with IBD (100% vs 63.6%; P = .002) and managing postoperative CD (92.3% vs 62.3%; P = .004).[13] This suggests that a longitudinal and higher volume of IBD didactic sessions is likely to improve confidence in managing particular domains of IBD.

We have identified a couple of factors that were significantly associated with improved confidence in specific IBD domains. For example, being part of a joint program was associated with high confidence compared to single-center programs in managing the elderly/frail patient with IBD and counseling patients on small molecules. In addition, doing an IBD external rotation was significantly associated with higher confidence in managing the elderly/frail patient with IBD. The improved confidence in IBD management with these two factors is likely a reflection of clinical exposure in relatively higher volume centers. Clinical exposure to patients with IBD is essential for training.

Our study highlights gaps in IBD training among GI fellows in Saudi Arabia. We have demonstrated that a significant proportion of fellows lack confidence in key domains of IBD management. We have also shown that many GI fellows desired a lot more training in IBD than is currently received. Multiple potential solutions to bridge the gap in IBD education among GI fellows in Saudi Arabia can be considered. A dedicated 1-year IBD fellowship can improve clinical exposure, confidence, and competency in management of IBD.[1617] However, IBD fellowships fill only a minor gap in IBD training as they can only accommodate a relatively small pool of GI fellows and require a full year of extra training which is not desired by most GI fellows. In fact, in our survey, only 24.2% of fellows stated that they were planning to do an IBD fellowship. Other potential solutions include offering an away IBD-dedicated rotation at high-volume centers or generating and maintaining a national IBD curriculum for GI fellows that can be delivered longitudinally in a virtual environment.

The strengths of our study include providing a national representation of GI fellows’ experience in IBD training. The study is also strengthened by identifying specific domains or topics in IBD management on which efforts can be made for improvement. The limitations of the study include inherent limitations of survey studies such as incomplete data and the limited response rate. We were also unable to calculate the exact response rate to the survey.

In conclusion, we found that many GI fellows in Saudi Arabia lacked confidence and desired a lot more training in essential domains of IBD management. This training gap may potentially affect the quality of care delivered to patients with IBD. Dedicated longitudinal solutions are needed to bridge this gap and improve IBD training in Saudi Arabia.

Financial support and sponsorship

Nil.

Conflicts of interest

Dr. Abdulelah AlMutairdi: Speaker fees: AbbVie, Takeda, Bristol-Myers Squibb. Advisory board: AbbVie, Takeda, Bristol-Myers Squibb, Pfizer.

Dr. Mahomud Mosli: Speaker for Janssen, Abbvie, Pfizer, Takeda, Hikma, Ferring, Sandoz, and Organon; he also served as an advisory board member for AbbVie, Hikma, Janssen, Pfizer, Takeda, Amgen, Bristol-Myers Squibb, Novartis, Ferring, Organon, Sanofi, Sandoz, and Falk.

Dr. Turki AlAmeel: Speaker fees: AbbVie, Takeda, Bristol-Myers Squibb, Janssen Pharmaceuticals, Hikma, Sandoz, Amgen. Advisory board: AbbVie, Takeda, Bristol-Myers Squibb, Lilly, Ferring, NewBridge.

Dr. Badr Al-Bawardy: Speaker fees: AbbVie, Takeda, Bristol-Myers Squibb, Janssen Pharmaceuticals. Advisory board: Bristol-Myers Squibb, Pfizer.

SUPPLEMENT
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