Endoscopic simulation for training

GASTROINTESTINAL ENDOSCOPY Editor CHARLES J. L1GHTDALE, MD Associate Editors STEPHEN E. SILVIS, MD JEROME D. WAYE, MD ROBERT C. KURTZ, MD Editorial Assistant REINA L1GHTDALE Associate Editor For Abstracts JAMES S. BARTHEL, MD Editors Emeritus WILLIAM S. HAUBRICH, MD BERNARD M. SCHUMAN, MD Address all editorial correspondence to the Editor Memorial Sloan-Kettering Cancer Center 1275 York Ave., P.O. Box 67 New York, New York 10021 Editorial Board JOSEPH E. GEENEN, MD Chairman LAWRENCE BRANDT, MD JOHN P. CELLO, MD THOMAS DENT, MD KENNETH A. FORDE, MD PAUL A. KANTROWITZ, MD ROBERT G. STRICKLAND, MD ROBERT W. SUMMERS, MD SIDNEY j. WINAWER, MD International Editors MEINHARD CLASSEN, MD Munich, Germany MICHEL CREMER, MD Brussels, Belgium L10NELLO GANDOLFI, MD Bologna, Italy MOISES GUELRUD, MD Caracas, Venezuela KEIICHI KAWAI, MD Kyoto, Japan ZDENEK MARATKA, MD Prague, Czechoslovakia PAUL ROZEN, MD Tel-Aviv, Israel GUIDO TYTGAT, MD Amsterdam, The Netherlands CHRISTOPHER WILLIAMS, MD London, England 462

Editorials Endoscopic simulation for training Endoscopic training is traditionally a hands-on apprenticeship. The American Society for Gastrointestinal Endoscopy and American College of Physicians have set minimal guidelines for the training and performance of basic endoscopic procedures. 1 Disparity in the cognitive levels of endoscopists has been found by the Gastrointestinal Endoscopy Self-Assessment Program. 2 Similar disparities almost certainly exist in performance skills. Formalization of training methods is seldom achievable because of the diversity of patients and differences in user aptitude. The training of primary care physicians in flexible sigmoidoscopy is becoming more difficult because of the need for an adequate number of patients, limitations in exposure to pathology, and the gradual disappearance of the "clinic" patient from medical school experience. Training in advanced endoscopic procedures is difficult because of the need to achieve adequate case numbers in a population of patients with rare diseases. The student of endoscopy is faced with the function of instrument controls, the spatial environment of the bowel, the recognition of pathology, and concern for patient safety. The use of latex models has not proven to be an effective learning device. The effectiveness of endoscopic teaching methods are difficult to assess because of the small number of physicians being trained in anyone program. The learning of sigmoidoscopy by larger numbers of medical personnel can provide some insight into the learning process. The more procedures done in a preceptorship the greater the degree of competence. Hawes et al. 3 found a noticeable variation among users in the number of procedures required to be competent. Speer et al. 4 felt that a small number of examinations did not allow residents to observe enough variations in pathology to feel comfortable. These studies point to the need to recognize differences in user aptitude and to provide sufficient and varied cases for learning. An area unaddressed in the studies is the reliability of evaluation methodology in measuring competence. Simulators can provide realistic training experience, and at the most sophisticated levels actually substitute for real world experience. Witness the aircraft simulators used to train pilots by the United States Air Force and commercial airlines. Aircraft simulators are used to train pilots on new aircraft and to maintain pilot competence in specific aircraft once they have been trained. In the case of skill maintenance, 1 hour spent "flying" the simulator appears to be equivalent to 1 hour of flying the actual aircraft. GASTROINTESTINAL ENDOSCOPY

Simulators support learning both in cognitive and psychomotor skills. Although they are designed to support whole-task training, their flexibility allows them to be used for part or highly critical aspects of a procedure. They also can have several advantages over real life endoscopic learning. Scheduling of their use is not dependent on availability of the instructor or confined to normal work hours. They do not expose patients to additional hazards or discomfort. Environmental control, to a degree, is impossible to achieve in the real world. A patient with easy or difficult anatomy or with a specific pathology can be selected for the user. The patient can be stable or have medical difficulties such as shortness of breath that require nursing interaction. The user can be taught to recognize equipment problems. Learning enhancement can be achievable by presenting greater variability of pathology in a smaller number of cases. And finally, objective measurement of a performance task may be possible. The merging of computer and videodisc technology makes the development of an endoscopic simulator possible. A computer-assisted endoscopic training program for gastroscopy has been developed,5 and an endoscopic simulator prototype has been built that allows significantly greater freedom of movement, but is still limited by a fixed number of paths. 6 Tasks may be distinguished as being either verbal or motor. Verbal tasks include the cognitive processes of rule learning, judgment, and problem solving. Motor tasks may be either fine or gross, simple or complex, and discrete or continuous. Motor-perceptual skills can be made up of several separate factors. Important for endoscopy may be the concepts of tactile discrimination, spatial response speed, wrist-finger speed, and that manual dexterity is separate from finger dexterity. Simulators are composed of a visual and tactile subsystem. The presence of instantaneous or real time simulation (e.g., when the tip of the endoscope is moved, the view changes instantly) is important as visual delays are disruptive. In addition to real time response, the simulator will have to match the visual resolution of fiberoptics or video endoscopy and possess a tactile system that includes an endoscopic handle. Experience in other simulator environments has shown that complete fidelity is never required. Instructional feedback must be provided (e.g., "You are against the wall," "Don't advance when the lumen is collapsed," "The lesion located here is suspicious"). Feedback must be sufficient and relatively unobtrusive, but not overwhelming. Simulators must be able to measure a user's performance. Key factors will involve adequacy and safety of the examination along with the recognition of pathology. An endoscopic simulator could be utilized as a learnVOLUME 35, NO.5, 1989

ing device, a tool for certification, and a means to maintain competence in infrequently performed procedures. The success of any simulator will depend on the ability of the user to transfer his skills to the real patient. The measurement of transference will allow evaluation of training schedules, the role of aptitude in learning endoscopy, and the degree of difficulty needed in simulator programs. Progress in endoscopic simulation will have to come from multidisciplinary teams of gastroenterologists, computer programmers, bioengineers, and instructional designers in order to fulfill its fullest potential. Christopher J. Barde, MD Division of Gastroenterology Dayton V.A. Medical Center Wright State University Dayton, Ohio

REFERENCES 1. Health and Public Policy Committee, American College of

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Physicians. Clinical competence in colonoscopy. Ann Intern Med 1987;107:772-4. Morrissey JF. The self assessment examination: its role in evaluation and what we have learned from it. AISIGIE Training Director's Workshop, Dallas, Texas, January 1988. Hawes R, Lehman G, Hast J, et a!. Training resident physicians in fiberoptic sigmoidoscopy. How many supervised examinations are required to achieve competence? Am J Med 1986;80:465-8. Speer AG, Eaves ER, Gijsbers AJ, et a!. Training in sigmoidoscopy. Med J Aust 1984;141:223-5. Beer-Gabel M, Delmotte S, Brunet F. Computer assisted training in gastroscopy [Abstract). Gastroenterology 1988;94:A30. Barde CJ, White MD. Concept prototype of an endoscopic simulator. Proceedings of Fourth Conference in Learning Technology in the Health Care Sciences. Warrenton, VA: Society for Applied Learning Technology, 1989:16-7.

A salute to Dutch gastroenterology Congratulations to the Netherlands Society of Gastroenterology on their 75th anniversary, celebrated at the Holland Digestive Disease Week this year. An international gathering, coordinated by Guido N. J. Tytgat, brought experts from around the world to a superb meeting in Amsterdam at a time that may well come to be recognized as a golden age of gastroenterology research and development in the Netherlands. Led by the group at the Academic Medical Center, Dutch gastroenterologists are among the leaders in our field today. Particularly in endoscopy, we all receive the benefits of the tremendous energy and achievements of our Dutch colleagues. We salute them, and wish them continued success in the future. Charles J. Lightdale, MD New York, New York 463