Endoscopy in Korea has become increasingly important in colorectal diseases especially after the establishment of the National Cancer Screening Program in 2004 [1]. In 2016, there were 2,750,839 colonoscopy procedures held in Korea accounting for 134.9 billion KRW (Korean won) (111 million USD) in total fees [2]. Most of colorectal cancers in Korea are now being screened via colonoscopy which now is the third leading cause of malignancies in Korea where there were 26,978 newly diagnosed cases in 2014 [3]. Colonoscopy proficiency is therefore becoming crucial especially for surgeons practicing in colorectal diseases.

Equally important is the education of new surgical residents in colonoscopy procedures. Currently, the Korean Surgical Society requires all residents to attend a 1-day training session program performing gastroscopy and colonoscopy on a simulator model during their residency [4]. Each endoscopic session lasts 120 minutes. However, this amount is far behind the sufficient level to achieve proficiency and thus much focus lies on each teaching hospital to incorporate some form of colonoscopy education for the residents. Currently, there is no standardized training program, regulations or guidelines regarding the proficiency of colonoscopy for surgical residents and most training is done according to each institution's ability.

The aim of this study was to access the status of colonoscopy training for surgical residents in Korea and collect the opinions among experts on the direction for future colonoscopy education. We also investigated the status of surgeons themselves who are performing colonoscopies in their own institutions.

A questionnaire was developed by the Korean Surgical Skill Study Group, a subgroup of the Korean Surgical Research Foundation dedicated to enhancing the skills and training of surgeons in Korea, containing 24 items (Table 1). The format was finalized during a management committee meeting held in November 11, 2014. This survey was conducted electronically by sending out e-mails to 310 colorectal surgeons in 84 training hospitals across the country between December 2014 and March 2015.

The questions were generally grouped into 4 categories; personal status (Q1–3), current practice pattern of performing colonoscopy (Q4–9), resident education for colonoscopy (Q10–19), and professional opinions regarding colonoscopy education (Q20–24). The full format was written in Korean. We asked each respondent their sex (male/female, Q1), years in practice (Q2), and affiliation in terms of health care delivery (Q3). We further asked the status of colonoscopy at their institution in terms of volume (Q4, Q6), proportion done by surgeons (Q5), indications in which surgeons perform colonoscopies (Q7, Q8: multiple choice), and obstacles faced (lack of support from other departments or hospital management) when surgeons are performing colonoscopies themselves (Q9). After asking the trainee status at each institution (Q10), we asked the participants whether they incorporated colonoscopy education programs (Q11), the format of which education is given (Q12), satisfactory level (Q13), and time and volume of which the residents will perform colonoscopies (Q14–18). We also asked whether they faced any administrative or political obstacles when surgical residents were performing colonoscopies at each institution (Q19). We finally asked their professional opinion as to whether there should be a stricter goal in colonoscopy education for professional qualification of residency (Q20, 21), and the time and volume of a trainee to perform colonoscopy independently and safely (Q22–24). Frequencies of each answer were analyzed for each question with respect to each individual and/or institution.

One hundred fifteen staff surgeons (115 of 310, 37%) in 84 institutions returned fully completed questionnaires. 100 respondents (87.0%) were male. Most of the responding surgeons were working at tertiary hospitals (97 of 115, 84.3%) and had experience as a colorectal surgeon for more than 5 years (96, 83.5%)

Historically, colonoscopy was introduced to Korea in the 1970's and was initially performed by surgeons and internists alike [56]. However, while gastroenterologists further developed colonoscopy as one of their cornerstones of medical training, surgeons generally overlooked colonoscopy with many eventually abandoning the procedure, thus resulting in a gap in colonoscopy training. In recent years, colonoscopy proficiency has become a key element in a surgeons' practice due to the increased prevalence of benign and malignant colorectal diseases including colorectal cancer, inflammatory bowel diseases, ischemic colitis and anorectal diseases. This is clearly evident in primary care units where 47% (1,187,007 of 2,750,839 in 2016) of the total colonoscopies are being performed in the nation and at least an estimated 30% are being done by surgeons [26]. Considering this, it would be equally important to equip and educate surgical residents to prepare them with the necessary skills to use after their training.

The importance for colonoscopy education was early recognized in the United States and incorporated to their surgical training program. The American Board of Surgery has required endoscopic training since 1980 [7]. The Society of American Gastrointestinal Endoscopic Surgeons [8] recently changed their recommendation from the number of procedures to a generalized qualification to be assessed by qualified instructors. Similarly, the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties have made a toolbox to determine competence [9]. There have been countless measures over the years judging the competency and proficiency of colonoscopy for surgeons and surgical residents alike and polices have changed accordingly [1011121314].

Based on our results there is a consensus on the importance of colonoscopy education during residency but most (78.2%) were unsatisfied with the current situation where colonoscopy training for surgical residents is not done at all or done with nonstandardized methods. The main reason for this is surgeons at teaching hospitals are not performing sufficient numbers of colonoscopies. In our survey cohort, 67.0% were performing less than 10 cases a month where two-thirds were doing none. A 2012 survey done on 22 secondary and tertiary hospitals where surgeons performed colonoscopies, of the 118,416 cases done, only 7,976 (6.7%) were done in tertiary centers and in fact, the largest three hospitals did 87.3% (6,960 of 7,976 cases) of the cases [6]. This concentration was also noted in secondary hospitals where 86.0% (95,000 of 110,000) were done in the 6 largest hospitals all of which were specialist hospitals dedicated to colorectal diseases. Lack of colonoscopy cases naturally leads to under-education. This is consistent with the results in our survey cohort where the institutions said to have an official training program were also performing more colonoscopies from the institutions that were not. The top 3 surgeons performing the largest cases per month were also from these institutions.

There were two main reasons for the lack of colonoscopy procedures performed by surgeons in teaching hospitals. First and foremost is the lack of time to incorporate colonoscopy sessions into their busy schedules. Surgeons in teaching hospitals already have a busy 54.7 average hour a week schedules rotating between clinical duties, education, and research [15]. The challenging work environment of surgeons generally have prevented putting education, especially of new procedures not familiar to their practice out of sight. Second is the conflict between other departments already performing endoscopy sessions as a mainstay. In our results, many of the procedures done by surgeons were on their own surgical patients, mostly for follow-up or evaluation before surgery. Colonoscopy for general screening purposes was generally reserved for the gastroenterologists, and as shown in the survey, there is much resistance for surgeons. This resistance can also be witnessed in the most prestigious academic journals as well [16].

However, despite these shortcomings, progress is needed. To apply for specialist qualification exams, the Korean Surgical Society states a minimum requisite of surgical procedures either performed and/or assisted by a resident. This is to assure a certain standard among different training institutions. In our study, when asked if there needed to be a similar goal stated in terms of colonoscopy procedures, most viewed positive toward a more objective approach. Many viewed at least 50 cases to be the adequate minimum during residency for their education. This is debatable along with the result of 91.3% saying at least 50 cases are needed to perform colonoscopy independently and safely. Previous literatures regarding the learning curve of colonoscopy and required cases to achieve proficiency have generally been higher [1718] with many not only focusing on the absolute threshold but rather the objective quality of the colonoscopy itself for credential guidelines [1920]. Thus, it must be noted, that these numbers are not based on solid evidence but a collective of respondents' opinions; many who lack the experience of performing colonoscopy themselves and/or training of colonoscopy to residents. Nonetheless, if a certain objective goal is identified, it is much easier to have more discussions regarding measures for actual ‘proficiency’. Another thing to consider is, to achieve this goal, much support is needed not only from the surgical society but also from individual institutions as well, where setting a higher goal would likely be more difficult to accomplish. Twenty percent (20%) were worried for the difficult logistics that will occur when such objective goals are suddenly implemented into the residency program. The discrepancy among institutions must also be considered when enforcing a firm policy.

Our study has many limitations. Response rate was 37% and the survey for actual procedures being done was highly based on the surgeon's ability to recall and not on solid numbers. This bias may have potentially affected the results. However, the overall message where surgical residents are generally being undertrained for colonoscopy and the necessity for improvement is unchanged. Although the survey was conducted in 2014, the requirement for specialist qualification in terms of colonoscopy has been unaltered and still to this day, there is no composite goal for endoscopic proficiency.

In conclusion, this survey shows colonoscopy education for surgical residents is still insufficient in Korea and that most surgeons feel that regular colonoscopy training is needed during the surgical residency period. There needs to be efforts to standardize the education program as well as various institutional and academic societal supports to achieve this goal.