MUSC Advanced Endoscopy Fellowship 2011: Dr Michael Chapman

Thank you to the BSG, Peter Cotton and support from Boston Scientific for the opportunity to visit the excellent Digestive Disease Centre at the Medical University of South Carolina (MUSC) in Charleston, USA.

Peter Cotton and the team had arranged a full programme for the 10 day visit allowing us to get a taste of US health care (academic, private and Veterans Affair systems), advanced endoscopy (mostly ERCP), EUS and GI training schemes. Every day, arrangements had been made for us to visit new people and departments, all of whom were incredibly welcoming, open and helpful. The unit at MUSC is a new purpose built unit with 9 endoscopy rooms with full time dedicated ERCP and EUS rooms, exactly the type of unit we all aspire to have back home in the UK. The team were very generous with their hospitality allowing us to enjoy some informal evenings with good company and southern cuisine. Also, we quite enjoyed being driven around by Peter Cotton in his golf buggies whilst visiting his local private island residence! It was interesting that overall there were far more similarities than differences between the US and NHS systems. In particular, the private or insurance funded activity in the US was in reality very similar to the way our own units function with regards coding forms, tariffs and costings made in a similar way to the commissioner-provider system in the UK. The case mix, techniques and skills for ERCP were similar to those in the larger tertiary referrals pancreatobiliary units in the UK. Pancreatic stenting is widely used and advocated at MUSC, something that is still being debated in many UK centres. The use of EUS has clearly vastly outgrown our limited practice of this discipline in the UK. Indications for EUS procedures were ‘softer’ than those used in the UK but probably appropriate sensible indications, highlighting the poor provision for EUS in the NHS.

An interesting noteworthy difference was the very high use of propofol sedation or anaesthesia, a subject that has been discussed at length amongst BSG members for some time. Propofol clearly facilitates a still and comfortable environment for both physician and patient, probably making procedures easier to perform well. Also, the good ‘sedation’ and patient comfort allowed trainees to spend considerable time during each procedure improving their skills in what is clearly an excellent focused training programme for US gastroenterology residents and fellows. However, the use of propofol sedation delivered by anaesthetic teams did often result in long delays between cases with some lack of control by gastroenterologists of their endoscopy lists- something we need to be conscious of when considering propofol sedation in our own practice in the UK.

However, above all, I felt the most striking difference from the NHS was the staff attitudes and high levels of job satisfaction driven by schemes such as the ‘MUSC Excellence Program’. Almost without exception, all clinical, administrative and support staff could not have been more friendly and helpful with a ‘can do’ attitude and comments such as “nothing is impossible” being the cultural norm throughout. Developing such a culture in the NHS would be one of the most valuable changes we should adopt. Thank you to all involved.