Training activity information
Details
Perform, analyse and interpret a range of complex pH-impedance traces for patients, choosing at least three from the following conditions:
- Barrett’s oesophagus
- Reflux following treatment for achalasia
- Supragastric belching
- Oesophageal diverticulum
- Pharyngeal pouch
- Suspected acid-generating gastric inlet patch
- Connective tissue disorders
Type
Entrustable training activity (ETA)
Evidence requirements
Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion.
Reflection at multiple timepoints on the trainee learning journey for this activity.
Reflective practice guidance
The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.
Before action
- What does success look like?
- Identify what is expected of you in relation to performing combined oesophageal pH-impedance monitoring and critically analysing and interpreting complex data from a range of listed conditions.
- Consider how the learning outcomes apply, specifically in relation to producing reports and making recommendations, practicing professionally within the MDT, and considering pharmacological influences.
- Discuss with your training officer to gain clarity of what is expected of you in relation to the interpretation of reflux following surgical interventions (e.g., post-treatment for achalasia) and the appropriate management of pharmacological factors.
- What is your prior experience of this activity?
- Think about what you already know about the typical pH-impedance findings in complex conditions (e.g., Barrett’s oesophagus, supragastric belching), and how pharmacological agents can influence pH and impedance data.
- Consider possible challenges you might face during the activity, such as interpreting complex traces from post-surgical patients, correlating atypical symptoms with findings, or managing significant artefacts.
- Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example if patterns deviate significantly from typical presentations or involve complex pharmacological history.
- Acknowledge how you feel about interpreting potentially ambiguous data from complex, multi-systemic disorders (e.g., connective tissue disorders).
- What do you anticipate you will learn from the experience?
- Consider the specific skills you want to develop, such as efficiently analysing complex pH-impedance traces, and identifying patterns complicated by other factors (e.g., surgical interventions or co-morbidities).
- Identify the specific insights you hope to gain into how pH-impedance data informs diagnosis and management decisions for these complex conditions.
- What additional considerations do you need to make?
- Consult actions identified following previous experiences of reviewing literature or case studies related to pH-impedance findings in the specific complex conditions.
- Identify important information you need to consider before embarking on the activity, such as preparing by considering the potential impact of patient history, co-morbidities, and medication on the pH-impedance results.
In action
- Is anything unexpected occurring?
- Are you noticing anything surprising or different from what you anticipate whilst performing or analysing the pH-impedance study for a complex patient?
- Are you encountering situations such as:
- A patient with known Barrett’s oesophagus shows significant non-acid reflux despite being on maximal acid suppression, complicating interpretation?
- The patient is post-treatment for achalasia, and the trace suggests high volumes of liquid reflux, but the patient reports minimal symptoms?
- The trace shows frequent events highly suggestive of supragastric belching, but the patient denies the symptom during history taking?
- How are you reacting to the unexpected development?
- How is this impacting your actions? For example, are you responding to the situation appropriately?
- Are you adapting or changing your approach to patient coaching, probe placement, or analysis criteria selection?
- Consider the steps you are taking in the moment, such as:
- Immediately re-checking the probe placement depth to ensure correct anatomical coverage, especially for suspected pharyngeal pouch cases.
- Halting the analysis to meticulously verify the timing and classification of the confusing reflux events (e.g., non-acid vs. liquid reflux) against academic criteria.
- How are you feeling in that moment? For instance, are you finding it difficult to apply standard analysis criteria to patients who have undergone surgery? Is it affecting your confidence in accurately identifying the pathophysiological mechanism?
- What is the conclusion or outcome?
- Identify how you are working within your scope of practice. For example, are you successfully differentiating between supragastric belching and true gastroesophageal reflux based on pattern recognition? Or are you needing support because the combination of previous surgery (e.g., post-achalasia treatment) and complex pharmacological history requires senior clinical input for reliable interpretation?
- What are you learning as a result of the unexpected development? For example, are you mastering advanced analysis techniques for identifying complex features like belching or rumination? Or gaining insight into the difficulties of interpreting physiological measurements in the context of prior surgical interventions?
On action
- What happened?
- Begin by summarising the key steps you took when performing, analysing, and interpreting complex pH-impedance studies (e.g., for Barrett’s oesophagus, Reflux following treatment for achalasia, etc.).
- Consider specific events, actions, or interactions which felt important, such as how you instructed the patient regarding diet and medication, or how you classified reflux events (non-acid, weakly acid) in a case of Barrett’s oesophagus.
- Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately adjusting patient instructions or troubleshooting trace quality when technical issues complicated the analysis.
- How did you feel during this experience, e.g., did you feel focused on applying criteria or challenged by the ambiguity of findings in post-surgical patients?
- How has this experience contributed to your developing practice?
- Identify what learning you can take from this experience regarding performing and interpreting complex pH-impedance monitoring.
- What strengths did you demonstrate, e.g., meticulous analysis of non-acid reflux patterns?
- What skills and/or knowledge gaps were evident, e.g., difficulty confidently interpreting baseline impedance in the context of connective tissue disorders or managing complex pharmacological factors?
- Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved?
- Has your practice improved in analysing and interpreting data for a wide range of complex conditions?
- Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding interpreting findings complicated by previous surgical intervention or pharmacological effects, and how you reacted to this.
- What will you take from the experience moving forward?
- Identify the actions you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to refining your analysis and interpretation of complex pH-impedance traces.
- What will you do differently next time you approach complex pH-impedance studies, for instance, by proactively reviewing the known effects of surgical procedures (e.g., achalasia treatment) on impedance patterns?
- Do you need to practise any aspect of the activity further, such as differentiating between supragastric belching and gastroesophageal reflux or key learning outcomes related to performing combined oesophageal pH-impedance monitoring?
Beyond action
- Have you revisited the experiences?
- How have your subsequent experiences of analysing atypical reflux studies or drafting reports since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, interpreting a study for a patient with Barrett’s oesophagus forced you to re-evaluate the diligence of classifying weakly acid and non-acid reflux events during your first attempt at this training activity.
- Considering what you understand about specific disease manifestations (e.g., supragastric belching, post-surgical reflux), data interpretation, and clinical correlation now, were the actions or considerations you identified after your initial reflection on this training activity sufficient?
- How have you since implemented or adapted improvements in your analysis and interpretation methodology based on further learning and experiences? For example, how you proactively reviewed and integrated academic content on the specific characteristics of reflux following treatment for achalasia, demonstrating you have adapted improvements based on further learning.
- Has discussing complex trace features (e.g., in connective tissue disorders) or the management of pharmacological influences with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a misinterpretation of supragastric belching refined your understanding of the critical nature of accurate feature identification in complex traces.
- How have these experiences impacted upon current practice?
- How has the learning from this initial training activity, in combination with performing the full range of upper GI investigations and professional practice, contributed to your overall confidence and ability in performing and interpreting complex pH-impedance monitoring, particularly in preparing for assessments like Case-Based Discussions (CBDs)? For example, how your accumulated ability in identifying specific patterns related to Barrett’s oesophagus or post-surgical reflux now enables you to confidently discuss complex pH-impedance findings during a CBD assessment.
- How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to managing procedural variability?
- How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely seek advice from the Training Officer or specialist consultant immediately when interpreting findings complicated by complex pharmacological regimes or highly rare conditions (e.g., pharyngeal pouch, oesophageal diverticulum) that deviate significantly from expected patterns.
Relevant learning outcomes
| # | Outcome |
|---|---|
| # 2 |
Outcome
Perform combined oesophageal pH-impedance monitoring in adult patients presenting with a wide range of conditions. |
| # 3 |
Outcome
Analyse and interpret the data producing complete reports for both high-resolution oesophageal manometry and oesophageal pH-impedance monitoring, making recommendations for subsequent management/treatment. |
| # 5 |
Outcome
Practice professionally within the multidisciplinary team. |
| # 6 |
Outcome
Employ effective communication skills to present information to a variety of audiences including patients, carers and healthcare professional colleagues. |
| # 8 |
Outcome
Identify situations where physiological measurements are affected by pharmacological interactions and the impact this may have on test results. |