The consequences of limited training in disorders of gut‐brain interaction: Results from a national survey of gastroenterology trainees in the United Kingdom

Despite their high prevalence and burden, disorders of gut‐brain interaction (DGBI) are undertaught and underrepresented in medical curricula. We evaluated the exposure of UK gastroenterology trainees to DGBI and their comfort managing these conditions.


| INTRODUC TI ON
Disorders of gut-brain interaction (DGBI) are among the most common conditions seen by gastroenterologists, with an estimated national prevalence of 37%, with a similar prevalence across the four nations of the UK. 1,2Not only are DGBI common, but they are also costly with an annual cost per patient of up to €2487 (£2123). 3od communication between physicians and patients with any medical condition has been shown to be important for increasing satisfaction 4 and ensuring positive health outcomes. 5This is particularly important for DGBI 6 with several studies highlighting the importance of structure, 7 empathy 8 and positivity during consultations 9 as well as, more negatively, when patients perceive that their physician does not adequately explain their DGBI 10 or is dismissive. 11spite the high prevalence of DGBI in the community and the importance of strong and structured communication when managing patients with DGBI, it is, unfortunately, the case that there is very little emphasis on DGBI in the past 12 or current 13 versions of the UK gastroenterology postgraduate training curriculum.This is also the case internationally in countries such as the United States. 14There is also emerging evidence that DGBI are underrepresented in undergraduate medical curricula, 1,15 further compounding the situation.
In 2022 Luo et al published a paper that sought to investigate the attitudes and experiences of gastroenterology trainees in the USA toward training and management of DGBI. 14Among other findings, they showed many trainees often felt "burnt out" after interacting with patients with DGBI, and that some senior clinicians and other trainees often had dismissive attitudes toward patients with DGBI. 14ditionally, only 51.7% of trainees were comfortable initiating and 27.1% titrating gut-brain neuromodulators. 14No study of a similar nature has been performed in the UK where the structure, duration and accreditation process for gastroenterology training differs from that in the USA.UK training includes parallel internal medicine commitments and competency requirements throughout gastroenterology training, during a longer program, typically spread out over 5 years.
To address this large gap in knowledge, we aimed to assess UK gastroenterology trainees' access to DGBI training, attitudes toward DGBIs, access to DGBI-related services and potential barriers that impair their management of patients with DGBI.

| Survey participants
An invitation email containing an explanation of the survey, its aims

| Survey design
An anonymous, online, 16-question survey was constructed using Qualtrics XM.The survey was based on a USA survey developed by Luo et al 14  The attitude to DGBI section included questions about trainee attitudes toward diagnosing DGBI, initiating and titrating gut-brain neuromodulators and referral for specialist psychological input.This section also included questions assessing the attitudes co-trainees and consultants have toward patients with DGBI.The last section assessed trainee perceptions of barriers that impact their ability to manage patients with DGBI.

| Data analysis
All survey data were subjected to initial arithmetic analysis before being presented as proportions and percentages.Following this, comparisons were made between the responses of senior (ST6 and ST7) and junior gastroenterology trainees (ST3, ST4, and ST5) using the chi-squared test.ST6-7 trainees were classed as "senior" trainees while ST3-5 were classified as "junior" trainees based on the cut-off at ST5 between early and late-stage gastroenterology training in the new gastroenterology curriculum. 13To enable an

| RE SULTS
One hundred twelve (21.4% of gastroenterology training post holders in the UK) participated.The survey response rate was 112/141 (79.4%) of those who accessed/ opened the survey hyperlink.All 112 participated and completed sufficient questions (≥9 of the 16 questions) to be included in the analysis.Most participants (102/112, 91%) completed the survey in its entirety.

| Demographics
Of trainee respondents, 37.5% were female, 61.6% were male and 0.9% preferred not to indicate their gender.

| Opportunities for DGBI training
Overall, 49.1% of trainees had attended formal lectures on DGBI, 22.3% of all trainees had attended dedicated DGBI clinics, 8.9% of all trainees had received training in DGBI communication skills, and 17.9% of all trainees stated they had received other forms of formal DGBI training.With regards to observation, 52.8% of trainees had never been observed during encounters with patients with DGBI, whereas 32.1% had been observed one to four times, 7.6% had been observed five to nine times, and 7.6% had been observed over ten times.

| DGBI management
Overall, 36.2% of trainees were comfortable or very comfortable making a diagnosis of a DGBI (Figure 1).Regarding comfort in communicating DGBI diagnoses to patients, 39.4% of all trainees expressed being comfortable or very comfortable.35.8% of all trainees were comfortable or very comfortable initiating neuromodulators with 21.2% expressing the same level of comfort titrating their dose.
Twenty-one percent of trainees were comfortable or very comfortable prescribing second-line agents for IBS with predominant constipation and diarrhea.
With regards to recognizing when an onward referral is appropriate for second-and third-line interventions and integrated multidisciplinary care approaches for DGBI, 19.0% of trainees were comfortable or very comfortable knowing when to refer a patient with a DGBI to a psychologist while 32.7% felt the same as regards a referral to a dietician.

| Perceptions of managing patients with DGBI
In terms of perceptions of trainees, 38.7% of trainees reported that their co-trainees and 21.0% of their consultants, often or very often exhibited dismissive attitudes toward patients with DGBI (Figure 2).

Regular positive communication encounters between consultants
and their patients with DGBI were observed by 28.3% (often or very often).Frequent frustration and burnout (either often or very often) were reported by 29.5% of trainees surveyed after their encounters with patients with DGBI.

| Access to DGBI-related services
Over the course of their training, 7.8% of trainees reported often having access to a gastrointestinal psychologist, 73.5% of trainees often had access to a dietician and 22.6% of trainees often had access to biofeedback (Figure 3).

| Trainee barriers to DGBI management
Overall, 45.1% indicated that often or very often, a lack of access to skilled clinicians was a barrier when it came to managing patients with DGBI (Figure 4).The lack of a DGBI multidisciplinary team (MDT) was either often or very often reported as a barrier by 56.9% of those surveyed.Time constraints were reported as an important barrier by 63.7% (often or very often), while 31.4% often or very often felt patients' cultural beliefs acted as a barrier to their DGBI management.

| Seniority
The survey population included 59.8% 'junior' trainees in their ST3 Responses to the study questions were compared between 'junior' (ST3-5: 59.8%) and 'senior' (ST6-7: 40.2%) trainees.While senior trainees were more likely to have attended DGBI lectures and clinics than juniors, there were no significant differences in self-reported competencies with DGBI diagnostic and management skills (Table 1).

| Subspecialty interest
Regarding subspecialty interest, 50% of trainees indicated they had a subspecialty interest in luminal gastroenterology while 22.3% F I G U R E 1 UK trainee reported percentage comfort levels with the diagnosis and management of DGBI.

F I G U R E 2 UK trainee observations and attitudes on DGBI clinical practice -data expressed as percentages.
indicated hepatology and the remaining 27.7% were undecided.

Responses between trainees interested in luminal subspecialization
(50%) and those that did not express a luminal subspecialty interest (50%) were compared (Table 2).Despite most trainees with a luminal interest not having attended DGBI lectures, DGBI clinics, and most not receiving communication skills training, trainees without an interest in luminal gastroenterology were even less likely to access these training opportunities and were more likely to express a preference not to see patients with DGBI (Table 2).There was no significant difference in the self-reported competency of diagnosing and managing DGBI between those with and without a luminal subspecialty interest.

| Size of training program
Overall, 44.6% of participants stated they were from training programs with >25 trainees, 30.4% were from programs with 15-25 trainees, while 14.3% were from programs with <15 trainees.10.7% were unsure of the total number of trainees within their program.Data were merged to create two groups large (>25 trainees) and small programs (<25 trainees).Training opportunities, trainee perceived competencies and attitudes did not significantly vary by program size (Table 3).were merged to make the group S.W.NI (7.4%).While there were some inter-regional differences in training opportunities, trainee self-reported competencies and attitudes to DGBI did not vary between regions (Table 4).

| DISCUSS ION
This study is the first within the UK and Europe and the largest regarding proportional response to assess the attitudes and expe- Across all questions in all survey sections, the UK trainee DGBI experiential picture was worse than the previously reported equivalent experience of trainees in the USA, 14 highlighting the need for a nationwide multifaceted change in DGBI teaching, supervision, and assessment of competency.Across all categories of DGBI diagnosis and management, there were no differences in comfort levels between "junior" and "senior" trainees, indicating that despite increased time in training there was no corresponding increase in self-reported core DGBI competency.In the two categories where there were significant changes between the experience of "junior" and "senior" trainees, attending DGBI lectures and specialist clinics, there remained a considerable proportion of senior trainees who were relatively inexperienced.

| Training opportunities
Importantly, there were significant differences between trainee subspecialty interest, access to training and attitudes toward pa-

| DGBI management
Perhaps unsurprisingly, given the limited opportunities for UK gastroenterology trainees to gather DGBI experience, trainees, reported low levels of comfort managing aspects of DGBI across all management questions.Additionally, there were no differences between self-reported comfort levels between more "junior" and "senior" trainees, between trainees from large or smaller programs, between trainees with and without a declared luminal subspecialty interest, and between different regions of the UK.Across every comparable category, UK trainees expressed lower levels of comfort than in the comparable USA trainee survey. 14ainee attitudes as regards DGBI management can be partially compared to the attitudes of fully trained gastroenterologists due to the findings of a large recently published USA study of prescribing practices. 20This showed while around three-quarters of fully trained gastroenterologists were comfortable using neuromodulators, only 40% of them stated they felt they were highly competent in doing so. 20Furthermore, those who expressed that they were highly competent were more likely to work in DGBI specialist clinics and prescribe neuromodulators as part of their practice. 20These findings reflect those of our study and show that increased DGBI exposure strongly and positively influences management practices.
This implies that if gastroenterology training programs were optimized to provide robust DGBI supervision and teaching, we could expect a corresponding increase in trainee confidence in DGBI management and by extension, a reduction in the proportion of trained gastroenterologists who are uncomfortable using evidence-based second-line treatments such as neuromodulators.

| Perceptions of patients with DGBI
Close to a third of trainees often or very often reported feeling frustrated or burnt-out following interactions with patients with DGBI.
The proportion of trainees with these feelings declined with increasing seniority, with "junior" trainees more likely to express burnout than more "senior" trainees.In a similar vein, despite close to 40% of all UK trainees stating they would prefer not to review DGBI patients often or very often, fewer "senior" than junior trainees stated this was the case.This suggests that with increasing seniority and clinical experience comes an increased understanding of patients with DGBI.Additionally, when the attitudes of luminal trainees were compared to non-luminal trainees, it was observed that non-luminal trainees were significantly more likely luminal trainees to express that they would often rather not review patients with DGBIs.
Again, this may be indicative of differing levels of interest and understanding of the relevance of neurogastroenterology between those interested in luminal and non-luminal sub-specialties.
Of concern, close to 40% of UK trainees frequently expressed dismissive attitudes toward patients with DGBI, which possibly indicates a culture of relative antipathy toward patients with DGBI in the gastroenterology trainee body.Studies have shown that organizational culture is heritable and formed by the attitudes and behaviors of senior staff. 21Hence, trainee attitudes toward DGBI patients may be a reflection of the perceived dismissive attitudes of consultant gastroenterologists shown in the survey.

| Barriers to DGBI management
Integrated multidisciplinary care for DGBI management, with ready access to psychologists, dieticians, and biofeedback, is increasingly becoming the standard of care worldwide.However, our survey suggests that access to specialist DGBI services is poor and variable for UK trainees.This limited access may contribute to some of the difficulties trainees experience trying to obtain the requisite experience.
Over 40% of UK trainees stated that a lack of access to skilled consultants served as a barrier to their management of patients with DGBI.This may explain some of the apparent cultural antipathy among consultants and as a consequence their trainees, towards patients with DGBI.The fact that trainees feel a large proportion of their consultants are not skilled in DGBI may reflect a lack of DGBI exposure in the consultant body, consequent lack of confidence regarding management, and resultant antipathy.Studies have shown that a lack of perceived knowledge of a subject 22 or the perception of difficulty 23 can result in anxiety, reduced confidence, and avoidance. 23nally, almost a third of UK trainees surveyed indicated that patient attitudes and cultural beliefs were frequently a barrier to treatment.Cultural barriers have been described as adversely affecting the outcomes of patients with DGBI. 24[26] However, should stigma be overcome, often via the employment of patient-centered, empathetic communication, acceptance of DGBI management strategies and patient outcomes can be improved with the resultant elimination of intergroup differences. 27

| Limitations
Despite the useful information obtained from our survey, there remain limitations that should be kept in mind when considering its findings.First, all voluntary surveys are prone to selection bias and concerns about the generalizability of their findings.However, our survey obtained the views of 21.4% of UK gastroenterology clinical training posts, a higher trainee response rate than in the earlier USA trainee survey, 14 which should help mitigate these factors.A slight caveat to this is the fact that response numbers from Scotland, Wales and Northern Ireland were low and there was some variation in the number of participants in different regions.While it is true that the majority of the UK population lives in England, the disproportionate number of English responses needs to be kept in mind.
Also, our data is UK specific, and while similar trends were seen in the previous USA survey, 14 similar studies should be carried out in other countries around the world to determine if this is a global issue, rather than a UK or USA specific problem.grams should be developed and delivered on a national scale.As the problems identified are national in their scope, a comprehensive national approach is required to address them and is likely to be more successful than local interventions.More broadly, attempts can be made to raise trainees' awareness of neurogastroenterology as an attractive patient-centered subspecialty 28 as a means of addressing the large societal burden of DGBI.While not all training centers will have access to a dedicated DGBI team and specialist clinic, these resources will be available when rotating through regional tertiary centers and identifying and signposting these opportunities with regions to attend a specialist clinic could be made mandatory.

| Potential solutions
Additionally, these findings make a case for a change to be made

| Conclusion
This study has identified deficiencies in the current UK training curriculum, and the need to formalize core DGBI training and core clinical competencies.There is a need for new, innovative strategies, to deliver DGBI skills training on a national scale to prepare future generations of gastroenterologists for the demands of independent practice and to optimize patient outcomes.
and a survey link was sent to all gastroenterology training program directors in all Local Education Training Boards (LETBs) in England, and in all postgraduate deaneries in Scotland, Wales and Northern Ireland.All gastroenterology trainees in the UK were eligible for inclusion in the study.Data were collected for a 6-month period from September 2022 to February 2023.As the survey data were anonymous, and did not include any patient data, formal ethical approval was not required, and this was verified with the University of Manchester research ethics tool.
to assess the attitudes of gastroenterology trainees in the USA to DGBI.However, the survey was modified for use in a UK setting.The survey was divided into five broad sections: demographics, access to training, attitudes toward DGBI, access to DGBI-related services, and barriers to DGBI management.In more detail, the demographics section of the survey included questions about gender, stage of training (ST3-ST7), gastroenterology subspecialty interest and LETB/training program.Questions in the access to training section included access to: DGBI lectures, DGBI specialist clinics and DGBI communication training.K E Y W O R D S attitudes, DGBI, disorders of gut-brain interaction, gastroenterology training, neurogastroenterology and motility Key points • Despite their high prevalence in the UK, trainee gastroenterologists at all stages of training receive limited training in disorders of gut-brain interaction (DGBI).• Most trainees have not attended a specialist DGBI clinic, seldom receive DGBI communication skills training, and almost half have never been observed by a trainer during a DGBI consultation.• Consequently, most trainees are not comfortable with making and communicating a DGBI diagnosis, and most are uncomfortable initiating second-line DGBI treatments including medications, dietician, and clinical psychology referrals.• This study has identified deficiencies in the current training curriculum, and the need to formalize DGBI training and clinical competencies.There is a need for new, innovative strategies to deliver DGBI skills training on a national scale, to prepare future generations of gastroenterologists for independent practice and to optimize patient outcomes.
analysis of geographical variations in DGBI training experiences across the 12 LETB/deaneries in England, responses were divided into the following groups: North of England (Northwest, Yorkshire and Humber and North East), Midlands (East and West Midlands), South of England (Kent Surrey Sussex, Wessex, Peninsula, Severn, Thames Valley/Oxford, London and The East of England).Responses were pooled for the other nations of the UK (Northern Ireland, Scotland and Wales), each of which forms a single postgraduate training deanery.

F
I G U R E 3 Access to DGBI-related services.F I G U R E 4 UK trainees opinions on perceived barriers to DGBI management -data expressed as percentages.
Trainee responses were received from each of the four nations of the UK and each training program/training board.Data from individual training boards and programs were merged to make four analyzable groups (The North of England [43.9%],The Midlands [23.3%] and The South of England [26.3%]).Due to small numbers, responses from Scotland (1.8%), Wales (1.8%) and Northern Ireland (3.8%) riences of trainee gastroenterologists to DGBI training and management.The data are likely to be representative, as the survey captured the views of over 20% of the 523 gastroenterology clinical training posts in the UK, 16 and are comprehensive, as they include representation from trainees of every training grade and trainees in each of the training programs/postgraduate education boards across the four nations of the UK.Across the board, our survey reveals low levels of UK trainee DGBI teaching and training opportunities.The data have also provided insight into the barriers faced by trainees when it comes to DGBI management which, unfortunately, appears to result in a lack of confidence in diagnosing and managing patients with DGBI.
These data have shown that only a minority of UK trainees attend structured DGBI training opportunities.Substantial proportions of trainees have never attended DGBI lectures, clinics, or communication skills training, and over half of all trainees have never been observed by a consultant while interacting with patients with DGBI.Communication skills training was the least well-attended form of training, which is concerning as studies have shown the importance of well-structured positive communication when consulting with patients with DGBI. 9 Furthermore, as patient satisfaction, compliance and outcomes are positively impacted by improved communication skills, 5,17 patients with DGBI are not well served by the current situation.
Despite a high UK national prevalence, DGBI have little prominence in the UK gastroenterology training curricula. 12,13Consequently, there are very few specific DGBI-based requirements that need to be met prior to the completion of training.Without targets there is the risk local education training boards and training programs will not feel obliged to insist upon supervised DGBI exposure and structured teaching, potentially leading to large interindividual variations in experience and hence competence.This is highlighted by our survey which has demonstrated that current exposure to DGBI training currently appears to be ad hoc and influenced by trainee preferences and sub-specialty interests, rather than being a core aspect of gastroenterology training for arguably the most common disorders encountered by gastroenterologists, regardless of their future subspecialization.Potential solutions include the introduction of a UK national training requirement for a set number of yearly DGBI: workplacebased assessments, clinics and lectures.Furthermore, trainees should attend at least one workshop on DGBI prescribing and communication skills during the course of their training, and these pro- in the future to the UK gastroenterology training curriculum with an emphasis on apprenticeship-based training,29 along the lines of the suggested NGM curriculum described in the jointly constructed position paper by the European and American NGM Associations,30 with prominence of DGBI and neurogastroenterology guidelines and topics in gastroenterology exit examinations prior to certification of specialist training.

Junior trainees Senior trainees χ 2 p-value (Difference between groups) Have you…
TA B L E 1 Comparison of training opportunities, comfort levels with diagnosis and management and attitudes to DGBI by seniority of trainee.

Luminal trainees Non-luminal trainees χ 2 p-value (Difference between groups) Have you…
1,2h DGBI.Significantly more luminally interested gastroenterology trainees attended DGBI clinics and accessed DGBI communication skills training.In a similar vein, a smaller proportion of trainees with an interest in luminal gastroenterology stated that TA B L E 2 Comparison of training opportunities, comfort levels with diagnosis and management and attitudes to DGBI by subspecialty interest.theyhadnosupervisedDGBI patient interactions.As there are no additional DGBI curriculum requirements for luminal trainees degrams would have within them a greater number of sizable teaching hospitals housing DGBI specialists, and by extension, training opportunities.While there was some variability by UK region in trainee respondents' attendance at specialist clinics, communication skills teaching, and observed DGBI consultations, at least half of the trainees in each UK region did not access these opportunities.cies that need to be achieved, including endoscopic training, there is understandably difficulty in ensuring all specialty and subspecialty areas are given the prominence they deserve.However, producing gastroenterologists experienced in DGBI is important, due to the high UK prevalence of DGBI1,2and the fact that well-managed

>25 Trainees in program <25 Trainees in program χ 2 p-value (Difference between groups) Have you…
Comparison of training opportunities, comfort levels with diagnosis and management and attitudes to DGBI by size of program.
TA B L E 3 20

.NI χ 2 p-value (Difference between groups) Have you…
Comparison of training opportunities, comfort levels with diagnosis and management and attitudes to DGBI by UK regions.
TA B L E 4