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“Drivers ed” with a road test for the capsule endoscopist
EDITORIAL
“Drivers ed” with a road test for the capsule endoscopist If we informally polled GI fellows from various programs around the country in regard to their experiences with capsule endoscopy (CE), most would say that their only training requirement was to have at least 20 cases read and signed-off (by an attending physician) before graduation. In addition, aside from those saved selected images that the trainee deems to be important, very infrequently are most fellows sitting down with a supervising physician and reviewing the capsule study in its totality. Indications and contraindications of performing CE are learned passively, as fellows progress through their dayto-day ward rounds with attending physicians on GI consult services. By completion of fellowship, most are credentialed and granted privileges for CE at their new places of work, assuming that 20 studies have been performed and that the fellow has knowledge of how to operate the software and document a report. In 2005, the American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee published its first official guidelines for credentialing and granting privileges in CE.1 In this report, the training requirements for CE that must be completed before competency can be assessed are as follows: (1) completion of a GI endoscopy training program that includes the recognition and management of small intestine diseases, (2) hospital privileges to competently perform EGD, colonoscopy, and push enteroscopy, (3) familiarity with the CE hardware and software systems, (4) either formal training in CE during GI fellowship or completion of a hands-on course with a minimum of 8 hours of continuing medical education credit. Unfortunately, at the time of publication of this 2005 report, and still today in 2013, formal training in CE during GI fellowship is defined only loosely, without any standardization among training programs across the country. In fact, the 2005 ASGE guidelines go on to state that “specific measures for competency.should be rapidly adopted in credentialing processes as they are developed” and that “formal training during GI fellowship must include both didactic tutoring and an adequate case volume, so that the trainee attains a level of competence similar to that of the mentor.” In this month’s issue of Gastrointestinal Endoscopy, Rajan et al2 from the Mayo Clinic nicely fulfill those
mandates put forth by the ASGE Standards of Practice Committee 6 years ago. They report their experience with using a formalized assessment tool for teaching CE to GI trainees within their own fellowship program.2 Based on the 2005 ASGE guidelines, the authors of the study developed the Capsule Competency Test, (CapCT). The CapCT includes 3 sections, with a total of 32 test items and a maximum score of 100 points. Section 1 is a series of multiple-choice questions regarding the indications for and contraindications to performing CE (maximum score Z 24). Section 2 is a quiz consisting of 8 cases with brief video clips and still images (maximum score Z 40). Section 3 is a full review of a real CE case,
We have not yet developed any semblance of a formalized CE training program or assessment tool for graduating trainees to demonstrate their competency.
Copyright ª 2013 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2013.06.006
including accurate identification of procedural findings, appropriate documentation, and development of a patient management plan (maximum score Z 36). Fellows had differing levels of experience in EGD, colonoscopy, and push enteroscopy but were allowed to take the CapCT once they completed 5 supervised CE interpretations. A CapCT score R82% was defined as achieving competency (ie, R90% of the mean CapCT score by a group of 8 experienced staff capsule endoscopists). In total, 39 GI fellows completed this training curriculum with various levels of experience in reading CE studies before taking the CapCT. For trainees with!10 previously interpreted CE studies, the mean CapCT test score was 79% (not competent). For those with experience in 11 to 20 prior CE studies, the mean score was also 79% (not competent). For fellows with 21 to 35 prior CE studies, the mean score was 85% (achieving competency) (P ! .001). Furthermore, there was a significant difference in mean scores between the expert staff and fellows interpreting %20 cases (P ! .001). No correlation was found, however, between the trainee scores and their prior endoscopy experience. Overall, Rajan et al2 concluded that a structured assessment tool such as the CapCT can be used to define competency in CE interpretation and that GI fellows preferably should
www.giejournal.org
Volume 78, No. 4 : 2013 GASTROINTESTINAL ENDOSCOPY 623
Editorial
Buscaglia
complete O27 cases (the mean number of cases in the 21-35 group) before competency can be assessed. I commend the authors of this study for tackling an important issue surrounding the training of our gastroenterology fellows and not-so-distant-future colleagues. CE continues to play an integral role in the management of patients with small intestine disorders. For over a decade, however, we have not yet developed any semblance of a formalized CE training program or assessment tool for graduating trainees to demonstrate their competency. Instead, we assume that if fellows can perform endoscopy and are familiar with the CE software system, then they are capable of performing CEs in their future practicesdassuming the correct number of procedures have been signed-off on by their fellowship program directors. The CapCT by Rajan et al2 represents initial success in developing the first formalized training curriculum with a standardized test in the arena of CE interpretation. Why is a standardized test, such as the CapCT, important? Well, it is important that we speak the same language because it helps enable us to more effectively communicate with one another and thus accomplish our intended goals. Here, our goal is to competently train GI fellows with the skills necessary to begin reading and interpreting CE studies on their own. As trainers, we want assurance that each trainee exits fellowship with at least a standard level of CE competency, so they have the ability to independently expand their knowledge and skill sets and thus practice CE with a high level of accuracy and precision. A tool such as the CapCT allows trainers to create a starting line for the trainees. That is, competency on the CapCT (or future iteration of this tool) tells the rest of the GI endoscopy community that pre-set requirements have been achieved and that the trainee is ready to begin independent CE interpretations. Just like the driver who needs to pass a road test before obtaining a license to drive, so too does the trainee who wishes to practice CE. But before widespread use or adoption of the CapCT into other GI training programs, a few important points should be considered, because the study by Rajan et al2 has some limitations. The CapCTdalbeit novel and potentially extremely useful to our fielddis not a validated assessment tool. It was designed from a single center’s training experience with a competency cut-off value modeled from the mean score of 8 expert capsule endoscopists. It was not tested among other expert capsule endoscopists before implementation, and the overall number of fellows assessed was fairly small. As such, the generalizability of some of the important data yielded from the study may be lacking.
In order for us to move to the next level with the CapCT, the test should be more heavily scrutinized by additional expert capsule endoscopists. The proposed competency cut-off value should be confirmed by more experienced test takers, and the number and types of cases presented for the trainees should be expanded and diversified. Last, an attempt should be undertaken to reproduce similar findings in a larger number of trainees at various institutions. Using novel electronic tools previously described by Postgate et al,3 such as computerbased learning programs for CE, may allow this type of multicentered study approach to be readily performed. Once this has been accomplished, and any necessary modifications to the CapCT have been made, it may be able to serve as our field’s first and only “road test” to credentialing and granting privileges in CE for GI fellows looking to start their careers. In conclusion, the CapCT by Rajan et al2 finally sheds light on a more structured and standardized method for credentialing graduating GI fellows in independent CE interpretation. The authors should be commended for their efforts and hopefully stimulated to further validate this tool so that it may be shared and used among trainers and trainees across the entire GI endoscopy community.
624 GASTROINTESTINAL ENDOSCOPY Volume 78, No. 4 : 2013
www.giejournal.org
DISCLOSURE The author disclosed no financial relationships relevant to this publication. Jonathan M. Buscaglia, MD, FASGE Department of Medicine Stony Brook University Medicine Stony Brook, New York, USA Abbreviations: ASGE, American Society for Gastrointestinal Endoscopy; CE, capsule endoscopy; CapCT, Capsule Competency Test.
REFERENCES 1. Faigel DO, Baron TH, Adler DG, et al. ASGE guideline: guidelines for credentialing and granting privileges for capsule endoscopy. Gastrointest Endosc 2005;61:503-5. 2. Rajan E, Iyer PG, Oxentenko AS, et al. Training in small-bowel capsule endoscopy: assessing and defining competency. Gastrointest Endosc 2013;78:617-22. 3. Postgate A, Haycock A, Thomas-Gibson S, et al. Computer-aided learning in capsule endoscopy leads to improvement in lesion recognition ability. Gastrointest Endosc 2009;70:310-6.
“Drivers ed” with a road test for the capsule endoscopist If we informally polled GI fellows from various programs around the country in regard to their experiences with capsule endoscopy (CE), most would say that their only training requirement was to have at least 20 cases read and signed-off (by an attending physician) before graduation. In addition, aside from those saved selected images that the trainee deems to be important, very infrequently are most fellows sitting down with a supervising physician and reviewing the capsule study in its totality. Indications and contraindications of performing CE are learned passively, as fellows progress through their dayto-day ward rounds with attending physicians on GI consult services. By completion of fellowship, most are credentialed and granted privileges for CE at their new places of work, assuming that 20 studies have been performed and that the fellow has knowledge of how to operate the software and document a report. In 2005, the American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee published its first official guidelines for credentialing and granting privileges in CE.1 In this report, the training requirements for CE that must be completed before competency can be assessed are as follows: (1) completion of a GI endoscopy training program that includes the recognition and management of small intestine diseases, (2) hospital privileges to competently perform EGD, colonoscopy, and push enteroscopy, (3) familiarity with the CE hardware and software systems, (4) either formal training in CE during GI fellowship or completion of a hands-on course with a minimum of 8 hours of continuing medical education credit. Unfortunately, at the time of publication of this 2005 report, and still today in 2013, formal training in CE during GI fellowship is defined only loosely, without any standardization among training programs across the country. In fact, the 2005 ASGE guidelines go on to state that “specific measures for competency.should be rapidly adopted in credentialing processes as they are developed” and that “formal training during GI fellowship must include both didactic tutoring and an adequate case volume, so that the trainee attains a level of competence similar to that of the mentor.” In this month’s issue of Gastrointestinal Endoscopy, Rajan et al2 from the Mayo Clinic nicely fulfill those
mandates put forth by the ASGE Standards of Practice Committee 6 years ago. They report their experience with using a formalized assessment tool for teaching CE to GI trainees within their own fellowship program.2 Based on the 2005 ASGE guidelines, the authors of the study developed the Capsule Competency Test, (CapCT). The CapCT includes 3 sections, with a total of 32 test items and a maximum score of 100 points. Section 1 is a series of multiple-choice questions regarding the indications for and contraindications to performing CE (maximum score Z 24). Section 2 is a quiz consisting of 8 cases with brief video clips and still images (maximum score Z 40). Section 3 is a full review of a real CE case,
We have not yet developed any semblance of a formalized CE training program or assessment tool for graduating trainees to demonstrate their competency.
Copyright ª 2013 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2013.06.006
including accurate identification of procedural findings, appropriate documentation, and development of a patient management plan (maximum score Z 36). Fellows had differing levels of experience in EGD, colonoscopy, and push enteroscopy but were allowed to take the CapCT once they completed 5 supervised CE interpretations. A CapCT score R82% was defined as achieving competency (ie, R90% of the mean CapCT score by a group of 8 experienced staff capsule endoscopists). In total, 39 GI fellows completed this training curriculum with various levels of experience in reading CE studies before taking the CapCT. For trainees with!10 previously interpreted CE studies, the mean CapCT test score was 79% (not competent). For those with experience in 11 to 20 prior CE studies, the mean score was also 79% (not competent). For fellows with 21 to 35 prior CE studies, the mean score was 85% (achieving competency) (P ! .001). Furthermore, there was a significant difference in mean scores between the expert staff and fellows interpreting %20 cases (P ! .001). No correlation was found, however, between the trainee scores and their prior endoscopy experience. Overall, Rajan et al2 concluded that a structured assessment tool such as the CapCT can be used to define competency in CE interpretation and that GI fellows preferably should
www.giejournal.org
Volume 78, No. 4 : 2013 GASTROINTESTINAL ENDOSCOPY 623
Editorial
Buscaglia
complete O27 cases (the mean number of cases in the 21-35 group) before competency can be assessed. I commend the authors of this study for tackling an important issue surrounding the training of our gastroenterology fellows and not-so-distant-future colleagues. CE continues to play an integral role in the management of patients with small intestine disorders. For over a decade, however, we have not yet developed any semblance of a formalized CE training program or assessment tool for graduating trainees to demonstrate their competency. Instead, we assume that if fellows can perform endoscopy and are familiar with the CE software system, then they are capable of performing CEs in their future practicesdassuming the correct number of procedures have been signed-off on by their fellowship program directors. The CapCT by Rajan et al2 represents initial success in developing the first formalized training curriculum with a standardized test in the arena of CE interpretation. Why is a standardized test, such as the CapCT, important? Well, it is important that we speak the same language because it helps enable us to more effectively communicate with one another and thus accomplish our intended goals. Here, our goal is to competently train GI fellows with the skills necessary to begin reading and interpreting CE studies on their own. As trainers, we want assurance that each trainee exits fellowship with at least a standard level of CE competency, so they have the ability to independently expand their knowledge and skill sets and thus practice CE with a high level of accuracy and precision. A tool such as the CapCT allows trainers to create a starting line for the trainees. That is, competency on the CapCT (or future iteration of this tool) tells the rest of the GI endoscopy community that pre-set requirements have been achieved and that the trainee is ready to begin independent CE interpretations. Just like the driver who needs to pass a road test before obtaining a license to drive, so too does the trainee who wishes to practice CE. But before widespread use or adoption of the CapCT into other GI training programs, a few important points should be considered, because the study by Rajan et al2 has some limitations. The CapCTdalbeit novel and potentially extremely useful to our fielddis not a validated assessment tool. It was designed from a single center’s training experience with a competency cut-off value modeled from the mean score of 8 expert capsule endoscopists. It was not tested among other expert capsule endoscopists before implementation, and the overall number of fellows assessed was fairly small. As such, the generalizability of some of the important data yielded from the study may be lacking.
In order for us to move to the next level with the CapCT, the test should be more heavily scrutinized by additional expert capsule endoscopists. The proposed competency cut-off value should be confirmed by more experienced test takers, and the number and types of cases presented for the trainees should be expanded and diversified. Last, an attempt should be undertaken to reproduce similar findings in a larger number of trainees at various institutions. Using novel electronic tools previously described by Postgate et al,3 such as computerbased learning programs for CE, may allow this type of multicentered study approach to be readily performed. Once this has been accomplished, and any necessary modifications to the CapCT have been made, it may be able to serve as our field’s first and only “road test” to credentialing and granting privileges in CE for GI fellows looking to start their careers. In conclusion, the CapCT by Rajan et al2 finally sheds light on a more structured and standardized method for credentialing graduating GI fellows in independent CE interpretation. The authors should be commended for their efforts and hopefully stimulated to further validate this tool so that it may be shared and used among trainers and trainees across the entire GI endoscopy community.
624 GASTROINTESTINAL ENDOSCOPY Volume 78, No. 4 : 2013
www.giejournal.org
DISCLOSURE The author disclosed no financial relationships relevant to this publication. Jonathan M. Buscaglia, MD, FASGE Department of Medicine Stony Brook University Medicine Stony Brook, New York, USA Abbreviations: ASGE, American Society for Gastrointestinal Endoscopy; CE, capsule endoscopy; CapCT, Capsule Competency Test.
REFERENCES 1. Faigel DO, Baron TH, Adler DG, et al. ASGE guideline: guidelines for credentialing and granting privileges for capsule endoscopy. Gastrointest Endosc 2005;61:503-5. 2. Rajan E, Iyer PG, Oxentenko AS, et al. Training in small-bowel capsule endoscopy: assessing and defining competency. Gastrointest Endosc 2013;78:617-22. 3. Postgate A, Haycock A, Thomas-Gibson S, et al. Computer-aided learning in capsule endoscopy leads to improvement in lesion recognition ability. Gastrointest Endosc 2009;70:310-6.