WEO Newsletter

Digestive EndoscopyVolume 35, Issue 4 p. 552-558 WEO NewsletterFree Access WEO Newsletter First published: 11 May 2023 https://doi.org/10.1111/den.14556AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL WEO Newsletter Editor: Nalini M Guda MD, FASGE, AGAF, FACG, FJGES Global health: Impact of United States-based clinical observations in gastroenterology to enhance medical knowledge Stella-Maris Chinma Egboh,1 Nkengeh Tazinkeng,2,3 Evaristus S. Chukwudike,4 Akwi W. Asombang2,3 Department of Internal Medicine/Gastroenterology Unit, Federal Medical Centre, Yenagoa, Nigeria Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA Pan-African Organization for Health, Education and Research (POHER), Manchester, MO, USA Gastroenterology/Hepatology Unit, Department of Internal Medicine, University of Calabar Teaching Hospital, Calabar, Nigeria Corresponding: Akwi W. Asombang, Division of Gastroenterology, Massachusetts General Hospital, 15 Parkman Street, Wang 5, Boston, MA 02114, USA. Email: [email protected] INTRODUCTION The field of gastroenterology is globally dynamic but there exist racial and ethnic disparities.1 Recent advances in gastrointestinal endoscopy, educational opportunities, translational clinical research, and mentorship programs can be widely impactful and sustainable if low- and middle-income countries are significantly included in these endeavors. In the United States, recognized gastroenterology organizations and societies provide grants for their international members and minority groups to obtain training in North America in an attempt to ameliorate the existing geographical health disparities. International clinical observerships are exchange programs that enable physicians to spend time at a host institution outside their own locality, expanding their knowledge in a particular medical field through observing innovative clinical, diagnostic, and procedural techniques. Observers may also learn from lectures, seminars, and other interdisciplinary conferences in the hospital. This promotes a collaborative environment for the exchange of ideas, and enhances technical, intercultural and interdisciplinary competencies.2 Despite the obvious benefits of International observership programs, they can entail challenges, including adaptation to cultural differences, linguistic barriers, dietary variations, lack of social support, and changes in self-identity; these could lead to a culture shock that adversely affects the trainee's mental health.3, 4 As the quest for international experience evolves, it is imperative that trainees are aware of these cultural barriers. There are benefits of global health education in gastroenterology for both the recipients and sponsors. The diversity in patient characteristics and disease patterns, attributed to increasing globalization, international migration, and medical tourism,5 could lead to an outbreak of emerging and re-emerging infectious diseases, posing a health threat to the most developed countries of the world.6 Bilateral exchange of knowledge, through international observership, can assist physicians in developed countries to understand the strategies for the prevention and control of these diseases, while simultaneously designing a path for mentorship and networking of global health professionals in low- and middle-income countries to create the best standard of care and eliminate inequalities in global health.7, 8 Partnership and collaboration arising from international training can ultimately foster the building of local healthcare systems, thereby ameliorating the persistent health disparities. We describe the experience of three trainees, supported by different organizations, who participated in diverse global health electives at large academic centers in the USA. ASGE ENDOSCOPIC TRAINING AWARD: DR STELLA-MARIS CHINMA EGBOH The American Society for Gastrointestinal Endoscopy (ASGE) Endoscopic Training Award, provides advanced fellows or junior faculty with the opportunity to advance their GI training through gaining international experience with recognized GI groups or endoscopists.8 Dr Egboh had the privilege of undergoing a three-month training at the Massachusetts General Hospital (MGH), Boston, sponsored by ASGE under the supervision of Dr Akwi Asombang, Dr Brenna Casey, Dr Brian Jacobson, Dr Jonah Cohen, Dr Kumar Krishnan, and Dr Brad Kuo. The objectives of the ASGE training were to: (i) compare the inflow in the endoscopy unit of the MGH with the existing standard in Nigeria; (ii) understand the indications, contraindications, patient preparations, techniques, complications, and post-procedural follow-up of the patients at MGH; and (iii) identify the geographical differences in care and suggest possible solutions to diminish the existing gap. It was a well-structured program that included clinical rotations at the advanced endoscopy unit, general gastroenterology clinic and center for neurointestinal health. Dr Egboh observed various advanced endoscopic procedures, as summarized in Table 1, and practiced some techniques on simulators. She attended didactic virtual conferences including research seminars, basic translational research club meetings, GI grand rounds, and didactic sessions on GI motility. This training enabled her to acquire in-depth knowledge of the value of clinical research in medicine and the concept of patient-centered care as a quality indicator in GI endoscopy. She gained further insight into the role of the electronic medical record in clinical care and research, and into the use of medical interpreter services as a bridge in the communication gap between patients and health care provider. Table 1. Summary of the advanced endoscopy procedures observed during clinical rotations Procedure observed Egboh (ASGE) Chukwudike (ACG) Tazinkeng (Berenson scholar) ERCP 88 83 105 Ampullectomy 4 0 6 Biliary stenting 39 51 65 Sphincterotomy + balloon dilation of the common bile duct 15 29 48 SpyGlass cholangioscopy 2 3 5 Stone removal 20 26 60 Brushing 8 6 10 Endoscopic ultrasound -directed transgastric ERCP (EDGE) 0 0 2 Endoscopic ultrasound (EUS) 31 48 50 Necrosectomy 3 1 2 EUS-guided gastrojejunostomy 2 1 3 Fine-needle aspiration 8 5 20 Fine-needle biopsy 2 3 5 Esophagogastroduodenoscopy (EGD) 190 248 205 Capsule endoscopy 6 15 4 Variceal band ligation 7 11 0 Hemoclip 15 25 15 Hemospray 0 2 0 Gastrojejunal tube insertion 3 1 0 Suturing of a gastrocutaneous fistula 3 0 2 Esophageal balloon dilation 5 8 10 Bougie dilation of the esophagus 2 20 8 Stenting (esophageal cancer) 7 3 5 Botox injection 0 4 3 Foreign-body removal 0 3 1 Snare polypectomy 7 46 8 Endoscopic mucosal resection (EMR) 10 18 10 Endoscopic submucosal dissection 2 1 2 Peroral endoscopic myotomy (POEM) 6 0 3 Gastric POEM (G-POEM) 1 0 2 24 h pH monitoring/Bravo 4 21 10 EndoFLIP 6 0 4 EsoFLIP 0 0 3 Translumobsacral neuromodulation 1 0 0 Ablative therapy (radiofrequency ablation [RFA]) 4 10 15 Argon plasma coagulation 2 15 5 Balloon enteroscopy 1 7 2 Manometry High resolution esophageal manometry (HREM) 5 12 5 Anorectal manometry 5 2 0 Balloon expulsion test 5 1 0 Colonoscopy 110 269 128 EMR 12 24 42 Snare polypectomy 20 85 58 Fecal microbiota transplantation 1 6 0 AMERICAN COLLEGE OF GASTROENTEROLOGY INTERNATIONAL TRAINING GRANT: DR EVARISTUS S. CHUKWUDIKE The ACG International GI Training Grant, a program initiated in 1995, provides partial financial support to physicians outside of the United States and Canada to receive clinical research training or education in gastroenterology and hepatology in selected medical training centers in North America.9 The funding is provided so that an individual can acquire or develop new cognitive knowledge or technical skill, with the aim of improving patient care in the applicant's geographic area.9 Dr Chukwudike spent six months of the observership fellowship training program at Brown University and Rhode Island Hospital in Providence, United States, under the supervision of Dr Steven Moss and Dr Akwi Asombang. The objectives and experience of Dr Chukwudike's ACG international training were: To observe and understand the patient flow and resource utilization in a resource-rich setting compared to those in low–middle-income countries, with a focus on inpatient consults and endoscopy. Smoothing the flow of patients in and out of hospitals helps to reduce overcrowding and avoid delays that are characteristic of most hospitals in low- and middle-income countries. Numerous physical constraints, ranging through human resource shortages (low ratio of health workers to population), inadequate infrastructural development, poor documentation, inefficient communication skills, and a poorly trained workforce, acting together with poverty, scarcity, and deprivation, impede the effective delivery of healthcare in resource-poor countries of sub-Saharan Africa compared to resource-rich countries. These factors synergistically militate against efficient healthcare delivery. The ACG observership training offered the opportunity to compare patient flow in resource-rich settings, especially inpatient consults and endoscopic procedures, taking note of the barriers to setting up efficient healthcare in resource-limited settings. The knowledge acquired from this training has helped Dr Chukwudike scale up approaches to improve the utilization of healthcare resources in his home institution in Nigeria. To observe interventional endoscopic procedures, namely endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP), with emphasis on preprocedural, intraprocedural, and post-procedural evaluation. There is only one endoscopic center where ERCP is continuously performed in Nigeria, a constraint on the training of interventional gastroenterologists. There are no health facilities that offer endoscopic ultrasound in Nigeria. The ACG International GI Training award offered the opportunity to observe the preprocedural, intraprocedural, and post-procedural evaluation of patients in relation to endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). This has increased Dr Chukwudike's interest in seeking opportunities to train in these vital areas of gastroenterology practice. To strengthen the collaboration with Dr Steven Moss on Helicobacter pylori research- with a focus on studying H. pylori antibiotic resistance patterns and eradication rates in Nigeria. There is rising concern about worldwide H. pylori resistance to previously efficacious antibiotics. In developing countries like Nigeria, it has been shown that some antibiotic resistance rates can reach up to 100%, a significant reason for eradication failure.10-12 Despite the alarming H. pylori antibiotic resistance and suboptimal eradication rates, there is a paucity of epidemiological and all-encompassing studies on the status of those rates. During the ACG international training, Dr Chukwudike co-authored an article titled “Management of Helicobacter pylori in Africa: The challenges and peculiarities.”10 As part of the mentorship leading up to and during the clinical observership, Dr Chukwudike presented two abstracts, titled ‘Helicobacter pylori eradication rates and antibiotic resistance patterns in Nigeria, West Africa: A systematic review11 at the ACG 2021 Annual Scientific Meeting, and “Helicobacter pylori antimicrobial resistance and eradication rates in Africa: A systematic review”12 at the 2022 Digestive Disease Week (DDW). During the training, Dr Chukwudike attended the general gastroenterology consultations at the specialists' and fellows' clinics, the esophageal motility clinic, and the Clostridium (Clostridioides) difficile clinic, inpatient rounds, and endoscopic procedures. Endoscopic activities comprised basic and advanced procedures, including esophagogastroduodenoscopy (EGD), colonoscopy, endoscopic biopsies, endoscopic radiofrequency ablation and cryoablation for Barrett's esophagus, esophageal variceal ligation, endoscopic esophageal dilation (balloon and Savary), argon plasma coagulation of arteriovenous malformations (AVMs), hemostatic bipolar probe cauterization of bleeding vessels, foreign-body retrieval, single-balloon/spiral enteroscopy, mapping for intestinal metaplasia, insertion of a wireless catheter for ambulatory pH monitoring, capsule endoscopy, percutaneous endoscopic gastrostomy (PEG) tube insertion, polypectomy techniques for small and large polyps, clip and snare deployment, epinephrine injection, retrieval of large polyps with retrieval nets, deployment of hemospray, spyglass cholangioscopy, endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), and manometry (see Table 1). Dr Chukwudike also participated in the gastroenterology weekly academic seminars and presented a topic titled “Overview of Gastroenterology Training Program in Nigeria.” BERENSON INTERNATIONAL SCHOLARSHIP IN ENDOSCOPY: DR NKENGEH TAZINKENG The Berenson International Scholarship in Advanced Endoscopy at Beth Israel Deaconess Medical Center (BIDMC) and Harvard Medical School supports international physicians from developing nations wishing to spend two months in Boston observing complex endoscopy procedures, participating in multidisciplinary pancreaticobiliary conferences, and attending weekly didactic sessions at BIDMC and Harvard Medical School. The BIDMC has a strong teaching program in its gastroenterology department with a focus on therapeutic endoscopy. Dr Tazinkeng spent 10 weeks training under the supervision of four advanced endoscopy attendings (Douglas Pleskow, Tyler Berzin, Moamen Gabr, and Mandeep Sawhney) and three advanced endoscopy fellows (Sultan Mahmood, Igbinedion Samuel, and Erik Holzwanger). The objectives of Dr Tazinkeng's training were to: (i) understand the indications, contraindications, patient preparation, techniques, complications, and post-procedural follow-up of the patients at the advanced endoscopy suite at BIDMC; and (ii) identify the geographical differences in disease epidemiology, presentation, and care. The advanced endoscopy suite at BIDMC has a central working space for the attendings and fellows, and three rooms with well-equipped technology for complex procedures such as complex ERCP with cholangioscopy, therapeutic EUS, radiofrequency ablation and cryotherapy for Barrett's esophagus, endoscopic mucosal resection, biliary and luminal stenting, and single-balloon enteroscopy. Rotating at one of the main referral hospitals for complex endoscopic procedures in the USA, Dr Tazinkeng was privileged to observe the endoscopic management of a vast multitude of upper and lower gastrointestinal diseases, as shown in Table 1, most of which he had never seen prior to his experience at BIDMC. While shadowing the advanced endoscopy fellows, he also witnessed the use of certified medical translator services for foreign nationals. He had the opportunity to write up cases and videos for publication, under the supervision of the advanced fellows and attendings. His experience at BIDMC introduced him to the wide scope of diagnostic and therapeutic endoscopy, in addition to improving his understanding of the differences in standards of care between healthcare in the USA and his home country, Cameroon. This will serve as a driving force to actively engage in global health programs geared toward advancing endoscopy services in Cameroon and Africa at large. CONCLUSION The ASGE endoscopic training grant has enhanced Dr Egboh's academic and career progression by igniting more interest and opportunities for further training. This progression is beneficial to her home country, Nigeria, where endoscopic services are underutilized. The ACG grant award offered Dr Chukwudike the opportunity to improve his clinical, endoscopic, and research skills with a focus on cascading these skills in Africa. The training enabled him to interact and network with the international community of gastroenterologists, courtesy of his training directors' efforts. The Berenson International scholarship served as a step toward Dr Tazinkeng's career progression and a conceptual revolution in patient management. With a stronger desire and commitment to advancing endoscopy in their home countries, the lessons learned will continue to help the awardees to develop both their careers in gastroenterology and the provision of standard care for their communities. RECOMMENDATIONS We recommend an increase in the number of awards given each year to recipients, considering the benefits of the program and strategic re-integration of the trainees into their home institutions through mentoring and collaborations. There should be an expansion of global gastroenterology health programs aimed at training specialists in low- and middle-income countries. Image 1 Dr Egboh's ASGE experience. Image 2 Dr Chukwudike's ACG experience. Image 3 Dr Tazinkeng's Berenson experience. REFERENCES 1Rahal HK, Tabibian JH, Issaka RB et al. Diversity, equity, and inclusion in gastroenterology and hepatology: A survey of where we stand. Gastrointest Endosc 2022; 96: 887– 97. 2Vicente CR, Jacobs F, de Carvalho DS et al. The joint initiative for teaching and learning on global health challenges and one health experience on implementing an online collaborative course. One Health 2022; 15: 100409. 3Bhugra D, Becker MA. Migration, cultural bereavement and cultural identity. World Psychiatry 2005; 4: 18– 24. 4Xia J. Analysis of impact of culture shock on individual psychology. Int J Psychol Stud 2009; 1: 97. 5Mogaka JJ, Mashamba-Thompson TP, Tsoka-Gwegweni JM, Mupara LM. Effects of medical tourism on health systems in Africa. African J Hospitality Tourism Leisure 2017; 6: 1– 25. 6Spernovasilis N, Tsiodras S, Poulakou G. Emerging and re-emerging infectious diseases: Humankind's companions and competitors. Microorganisms 2022; 10: 98. 7Hamid M, Rasheed MA. A new path to mentorship for emerging global health leaders in low-income and middle-income countries. Lancet Glob Health 2022; 10: e946– 8. 8 ASGE. Available from: https://www.asge.org/home/about-asge/grants-awards 9 American College of Gastroenterology. Available from: https://gi.org/trainees/gi-training-grants/ 10Chukwudike ES, Moss SF, Asombang AW. Management of Helicobacter pylori infection in Africa. The challenges and peculiarities. e-wgn. 2022; 27. Available from: https://www.worldgastroenterology.org/publications/e-wgn/e-wgn-expert-point-of-view-articles-collection/management-of-helicobacter-pylori-infection-in-africa-the-challenges-and-peculiarities 11Chukwudike ES, Asombang AW, Sawyer K et al. Helicobacter pylori (H. pylori) eradication rates and antibiotic resistance pattern in Nigeria, West Africa: A systematic review. Am J Gastroenterol 2021; 116: S647. 12Chukwudike ES, Asombang AW, Sawyer K et al. Helicobacter pylori antimicrobial resistance and eradication rates in Africa: A systematic review. Gastroenterology 2022; 162: S-874– 5. Keep in touch! The WEO events calendar WEO upcoming events WEO Course: Improving the outcomes of pancreaticobiliary endoscopy May 28, 2023 – Abu Dhabi, United Arab Emirates. WEO webinars Save the date for the following webinars: Video Capsule Endoscopy in Children June 10, 2023 – Virtual WEO partner events International Digestive Endoscopy Network 2023 (IDEN 2023) June 8–10, 2023 – Seoul, South Korea EDDW 21 July 10–13, 2023 – Cairo, Egypt WEO endorsed events 40th Gastroenterology and Endotherapy European Workshop (GEEW) June 25–27, 2023 – Brussels, Belgium (hybrid) For a full list of upcoming events and WEO Centers of Excellence live courses, please see www.worldendo.org/events. Volume35, Issue4May 2023Pages 552-558 ReferencesRelatedInformation

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