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Learning curve for endoscopy training: Is it all about numbers?
Accepted Manuscript Learning curve for endoscopy training: is it all about numbers? Nauzer Forbes, MD, Rachid Mohamed, MD, Maitreyi Raman, MD, MSc
PII:
S1521-6918(16)30013-0
DOI:
10.1016/j.bpg.2016.04.003
Reference:
YBEGA 1424
To appear in:
Best Practice & Research Clinical Gastroenterology
Received Date: 9 February 2016 Revised Date:
22 March 2016
Accepted Date: 7 April 2016
Please cite this article as: Forbes N, Mohamed R, Raman M, Learning curve for endoscopy training: is it all about numbers?, Best Practice & Research Clinical Gastroenterology (2016), doi: 10.1016/ j.bpg.2016.04.003. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Learning curve for endoscopy training: is it all about numbers?
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Nauzer Forbes MD1, Rachid Mohamed MD2, Maitreyi Raman MD, MSc2,* 1
Advanced Therapeutic Endoscopy Training Program, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada 2 Department of Medicine, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
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*Corresponding author: Tel +1 403-592-5020, Fax 403-592-5020, Email [email protected]
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Abstract Endoscopy training is an important component of postgraduate gastroenterology
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and general surgery programs. Proficiency in endoscopy requires the development of several tangible and intangible skills. Much attention has traditionally been paid to
establishing a threshold, or minimum procedural volume during the training period,
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which is necessary for a trainee to achieve competence in endoscopy by the conclusion of his or her program. However, despite several attempts to characterize this target, it has
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become clear in recent years that training programs need to consider other factors rather than relying on this measure as the sole marker of trainee competency. Here, we present a review of general concepts in endoscopy skills acquisition that affect the learning curve, the evolving definition of competency as it relates to procedural volume, the role of
endoscopy training.
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simulation in endoscopy training, and the concept of massed versus spaced delivery of
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Keywords (MeSH Index)
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endoscopy education learning simulation training clinical competence
Word Count 4491
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Skills Acquisition and Cognitive Load The pursuit of competence and excellence in the acquisition of skills is dependent
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upon a blend of innate biological capability, dedicated instructors and many hours of
training. The process of skills acquisition has been well-described and involves three
major phases. The novice phase involves intense concentration to completely understand
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the activity and minimize mistakes. The second phase is an evolution to a more fluid and less cognitively arduous step in which trainees begin to perform at an acceptable level.
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The final phase involves a process of automation in which the skill is precisely and smoothly performed with little or no conscious cognitive involvement [1]. Specifically, with relevance to colonoscopy, a common diagnostic procedure performed world-wide, a novice endoscopist must attend to a myriad of sensory stimuli, including stimuli form the
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endoscopic image on the monitor, verbal stimuli form the patient, nurse and preceptor, and stimuli from proprioception from the endoscope. These stimuli are all potential sources of cognitive load. These external stimuli exist in addition to the demands
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involved in performing the procedure itself. Technical demands on the trainee include the process of straightening the scope or loop reduction, a technique critical to the safe and
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successful completion of colonoscopy. Additional procedural skills required to complete a diagnostic colonoscopy include applying knowledge regarding appropriate positioning of the patient to advance the scope successfully, identifying landmarks of completion, such as the ileo-cecal valve and cecal base, and recognizing pathology. Collectively, these inputs may all contribute to increase cognitive load for the novice trainee.
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Using a validated tool (National Aeronautics and Space Administration Task Load Index, NASA-TLX) to estimate cognitive load in GI endoscopy, Mohamed et al. [1] showed through factor analysis that the bulk of cognitive load experienced by trainees
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during colonoscopy arises from two main sources. The first is related to exertion
(combination of the effort and physical demand) and the second is related to the trainee’s perception of self-efficacy (subjective interpretation of performance). In this study, the
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evolution of exertion and self-efficacy during the initial training procedures of novice
endoscopists was mapped to the volume of procedures completed. For both colonoscopy
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and upper endoscopy, there was a steady decline in self-perceived exertion over the 3month training period. For colonoscopy, there was a progressive increase in self-reported self-efficacy over the first 29 procedures, followed by a drop in self-efficacy scores over the next 25 procedures. These findings were compared to the self-efficacy scores of
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expert gastroenterologists and were much lower than their expert cohort’s. The findings were slightly different for gastroscopy. For upper endoscopies, a rapid acquisition of skills was observed in addition to a rapidly increasing perception of self-efficacy over the
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first 9 procedures that quickly reached a plateau and stabilized. The findings from this study point to the occurrence of sensitive periods for the novice endoscopist that may be
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strategically managed by the expert preceptor by recognizing the need to minimize additional cognitive load for the trainee, including extra verbal communication. In addition, cognitive load may be further reduced by using standardized language to reflect simple directives such as “tip deflection”, “torque direction”, “insufflation”, “aspiration” so as to provide guidance while not overloading the trainee.
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Defining Competency Trainees in gastrointestinal endoscopy are required to demonstrate competency at the end of their program. Competency is defined by the American Society for
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Gastrointestinal Endoscopy (ASGE) as the “minimal level of skills, knowledge, and/or expertise derived through training and experience that is necessary to safely and
proficiently perform a procedure” [2]. Formal studies are lacking among GI and surgical
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programs that outline the characteristics of colonoscopy education. However, it is likely that a large degree of variability exists in the educational approaches taken towards
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teaching endoscopy trainees. Historically, educational pedagogy focused on “see one, do one and teach one”, whereas current skills pedagogy has been rooted in incorporating didactic, cognitive inputs with hands-on instruction [3]. One group demonstrated that even among trainees from GI fellowship programs, potential deficiencies may exist in the
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approach to teaching colonoscopy. Munroe [4] found an adenoma miss rate of 27% amongst GI trainees. In addition, the study investigators highlighted that there was a 2.2fold decrease in the risk of missing an adenoma with each 10-fold increase in trainee
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experience. Based on these study findings, the authors concluded that a trainee would have to perform 450 procedures to attain less than 25% adenoma miss rate, a number that
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many GI fellows may never reach in the course of their training. In an online survey of colonoscopy quality indicators, GI fellows received a mean
score of only 55% in their ability to correctly identify established quality benchmarks, with only 42% and 44% of trainees being able to correctly identify cecal intubation rate (CIR) and adenoma detection rate as quality indicators, respectively [5]. Conceivably, a sound knowledge base regarding expectations and benchmarks of quality would increase
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trainee vigilance and result in improved endoscopic performance. Feedback from GI trainees highlights the need for standardization in colonoscopy education. A survey of over 160 trainees in the UK found that only 36% felt that they were fully trained in
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colonoscopy. Interestingly, a faculty preceptor was in the room only 30% of the time to provide formal instruction and feedback [6]. Additional effective teaching strategies
proposed by trainees included a systematic approach towards endoscopic techniques,
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excellent supervision and discussion based training, attending a course on quality and
smaller procedural schedules to allow for training time [6]. Collectively, objective study
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findings and subjective needs assessment from trainees point to the need for reforming our current approach toward teaching colonoscopy.
The learning curve for GI endoscopy should include competency milestones. Competency in colonoscopy can be assessed across a number of domains including cecal
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intubation rates, adenoma detection rates, patient comfort, and appropriate sedation [7]. In addition, there exists several validated tools to assess competence in endoscopy (8,9). The Global Assessment of Gastrointestinal Endoscopic Skills (GAGES) score was
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developed by experts in endoscopy and education to objectively assess important endoscopic skills [8]. The GAGES-C score addresses five crucial colonoscopy skill
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domains: 1) scope navigation, which involves tip deflection, torque, advancement and/or withdrawal; 2) use of strategies including patient positioning, abdominal pressure, insufflation, suctioning and loop reduction; 3) ability to maintain a clear endoscopic field; 4) instrumentation, including the capacity to direct and repeatedly target instruments; and 5) overall quality of the examination, including patient comfort, efficiency, and completeness of mucosal evaluation [8]. Another colonoscopy skills assessment
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instrument, the Mayo Colonoscopy Skills Assessment Tool (MCSAT), has been validated for the evaluation of the colonoscopy learning curve [9]. This tool has a similar structure to the GAGES-C, but also incorporates elements of sedation, pathology recognition, and
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potential interventional skills, in addition to providing global cognitive and technical
assessments and quantifying the degree of trainee involvement in the overall procedure [9]. Despite its many strengths with regard to assessment of trainees, the MCSAT has
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important limitations; namely, it does not assess other parameters important to the
endoscopist, such as adenoma or polyp detection rates [10]. The Rotterdam Assessment
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Form for Colonoscopy (RAF-C) has also been described as a tool that facilitates both the navigation and the documentation of the colonoscopy learning curve, creating a feedback loop to ultimately improve proficiency through repeated assessments [11]. Studies have typically measured competency in upper endoscopy in two ways:
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intubation of the esophagus, and adequate scores on the GAGES Upper Endoscopy (GAGES-UE) tool [13]. The GAGES-UE assessment similarly evaluates five domains critical to performance of a successful endoscopy: 1) intubation of the esophagus, which
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requires an understanding of issues related to sedation as well as patient anatomy; 2) scope navigation, which involves tip deflection, torque, advancement and/or
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withdrawal; 3) ability to maintain a clear endoscopic field; 4) instrumentation; and 5) overall examination quality [8].
Minimum Procedural Volume: Is it all About Numbers?
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GI endoscopy training has conventionally focused on a minimum threshold for procedural volume during the training period as a means to achieve competency. The American Board of Surgery has recommended that a minimum number of 50
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colonoscopies be performed during training whereas the UK JAG stipulates 200
[7,14,15]. The number of colonoscopies required to achieve a cecal intubation rate of
90% has been the subject of previous studies, with discordant results. Some groups have
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reported that this can be achieved after 150 procedures, while other authors have
suggested a requirement for a minimum of 275 procedures [11,16–18]. This discordance
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may have arisen as a consequence of variable trainee numbers ranging between 8 and 41 participants. Recently, the largest study investigating the colonoscopy learning curve to date was completed, and it included all gastroenterology-training centers in the UK [7]. Results from that study showed that the cohort collectively required an average of 233
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procedures to achieve a mean cecal intubation rate of 90%. Specifically, 41% of trainees were competent after 200 procedures and 76% competent after 250 procedures. Only a minority of trainees reached the desired cecal intubation targets after 100 procedures.
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Other studies have also concluded that the 100 colonoscopy mark was insufficient in terms of trainees reaching a CIR of greater than 90% [19,20]. A recent meta-analysis
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summarized studies that assessed minimum procedure volumes [13]. It was found, unsurprisingly, that all such studies confirmed a relationship between trainee experience and performance. The study also concluded that a minimum threshold of 275–280 colonoscopies during GI training was the most agreed upon range based on studies of the highest available quality [11,13,18]. In terms of upper endoscopy, high-quality evidence is scarce, relatively speaking. Vassiliou et al., the same group that validated the GAGES
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tool, also observed a plateau in the GAGES-UE score after trainees performed 50 upper endoscopies [21]. Other studies have found more modest estimates of trainee progress, reporting a success rate of esophageal intubation of only 80% after 100 procedures [19].
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Despite these data, a paradigm shift has taken place in recent years, whereby
gastroenterology programs are no longer focused solely on a poorly-defined ‘critical mass’ of procedures as the ultimate goal for their endoscopy trainees. Instead, more
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emphasis is being placed on competency-based evaluation and promotion, which includes the assessment of important quality indicators. In fact, the ASGE Committee on Training
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has stated that “minimal threshold numbers represent a benchmark before which a trainee’s competency should not even be assessed,” and that true proficiency is not achieved until much later [22]. As such, the ASGE has developed a modified evidencebased tool for assessment of competency in endoscopy (ACE) specific to colonoscopy
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[23,10]. This tool is designed for continuous documentation and reporting of basic endoscopic procedures during training. Formative procedural feedback can be provided using validated assessment tools such as the direct observation of procedural skills
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(DOPS). This allows longitudinal, structural and objective feedback to be provided to a trainee throughout his or her training period [24]. A competency-based training model,
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rather than reliance on a minimum threshold alone, makes good pedagogical sense for a number of reasons. Importantly, certain endoscopic skill subsets are not reliably learned by the end of training regardless of procedural volume. A recent study surveyed trainees in US gastroenterology programs and found that almost all trainees met ASGE guidelinerecommended minimum procedural volumes for colonoscopy (100%) and upper endoscopy (98%). However, despite the cohort meeting overall minimum basic
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endoscopic volumes, only the minority of trainees met minimum recommended thresholds for treatment of variceal hemorrhage (40%) and esophageal dilation (43%), as examples (25).
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Importantly, competency and thresholds are defined heterogeneously across
different subspecialty training programs (namely, those for gastroenterology and general surgery). Overall, it would be prudent for programs to consider a more complete
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approach to evaluating trainee competency during the training period. This should likely include a mechanism for continuous documentation of trainee procedures throughout
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fellowship, with frequent re-evaluation by the program director, both ensuring adequate procedural volumes and appropriate case exposure. Importantly, training programs ought to increasingly consider general GI quality benchmarks and apply these to the trainee as well [26]. A recent survey reported that only 30% and 28% of GI training programs in the
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US make use of skills assessment tools or quality metrics, respectively [27]. This proves that, despite a growing knowledge of the above concepts, most programs still rely on a misguided view of ‘minimum procedural volume’ to measure competency at the end of
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training. As the old dogma of endoscopy training fades, new and enlightened endoscopy
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training curricula ought to take its place.
The Role of Simulation The advances in technology availability have resulted in innovations in
simulation. Simulation-based training provides an opportunity for the trainee to develop cognitive and technical skills in a safe and pressure-free learning environment. Several studies have demonstrated a potential benefit to the use of simulation during the early
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phases of endoscopy training. One group compared simulation- vs. non-simulationtrained fellows with regard to subjective and objective measures of competence including cecal intubation, and the ability to correctly identify cecal landmarks [28]. During the
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first 80 live procedures, the simulator-trained group had higher objective and subjective levels of competence. However, after 120 live cases, this relative advantage was no
longer observed, and both groups still required 160 live cases to attain 90% competence
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[28]. In another simulator-based study, simulator-exposed GI fellows scored better on all performance measures than non-exposed fellows; however, differences between groups
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dissipated once greater than 30 live procedures were performed [29]. A meta-analysis nicely summarized findings that showed a significant benefit when simulation was compared to no training at the beginning of fellowship, but that advantage was less robust when it was compared against usual training on live-patients [30].
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The optimal manner in which to deliver simulation-based training in endoscopy has yet to be determined. Prior studies have demonstrated that simply providing trainees with simulators does not ensure their effective use [31] and that expert feedback provided
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to trainees enhances acquisition of basic endoscopic skills [32]. It is now recognized that colonoscopy requires a complex skill set beyond technical skills. Literature indicates that
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non-technical skills have considerable influence on the performance of endoscopists and are thus an important contributor to patient safety [33] and to the quality of the procedure. Despite these findings, competency standards and education continue to predominantly focus on the development of technical skills [34]. Recently, a comprehensive curriculum that addresses the simulation-based technical, cognitive and integrative skills of colonoscopy was compared to the efficacy of a simulator-based self-regulated learning
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program [35]. Specifically, self-regulated learning is an educational strategy whereby trainees direct their knowledge acquisition using proactive strategies that plan goals, organize learning behaviors, self-monitor progress and promote self-assessment [36].
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Participants in the simulator-based comprehensive group outperformed participants in the self-regulated group during the first 2 live colonoscopies. In addition, the structured
comprehensive group demonstrated significantly better knowledge and colonoscopy-
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specific performance, communication and global performance.
All things considered, we can conclude that simulation is an important tool to
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enhance the performance and learning curve in colonoscopy acquisition skills. In addition, blending simulation-based training with non-technical learning strategies such as communication, clinical knowledge and direct feedback may further accelerate
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learning.
Optimizing Endoscopy Training Schedules Data are scarce in terms of defining an optimal training schedule for GI trainees
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learning basic endoscopy. In general, knowledge and skill acquisition can take place in one of two ways. Massed learning involves longer training durations, with few inter-
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training intervals as opposed to spaced learning which involves longer inter-training intervals. For example some training programs may dedicate endoscopy ‘blocks’ which are typically front-loaded at the onset of training, followed in the middle of training by potentially extended research rotations, during which endoscopy is performed at a minimum, or on an ad-hoc basis. Conversely, some programs offer a longitudinal
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endoscopy experience for trainees, whereby some degree of endoscopy exposure is maintained regardless of the rotation.
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Though the mechanisms are poorly understood, it has been established that spaced learning is superior to massed learning in terms of memory formation [37]. A similar
effect has been shown in terms of the acquisition of motor skills [38]. Data exist from the
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surgical literature comparing the two methods. One study showed that a distributed, spaced, learning method resulted in surgical trainees being 18.7% faster in their
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performance of basic endoscopic surgery skills compared to a control group submitted to a massed training method [39]. Jorgensen et al. studied whether breaks in GI endoscopy training affect performance. In an observational study of 24 GI trainees performing over 6000 colonoscopies, it was noted that there may be a slight decrease in a trainee’s
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performance as defined by their CIR after prolonged breaks in endoscopy training, with performance decreasing marginally after every subsequent 4-week break [40]. As described earlier, CIR is only one means of measuring trainee performance, and thus, this
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single study ought to be interpreted cautiously. In summary, it is unclear at this time which strategy is superior, or indeed, if there
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is a clearly superior strategy. Further studies are crucial in determining whether a spaced or massed model is optimal for building and maintaining competency among GI trainees.
Maintenance of Competency Competency in colonoscopy and upper endoscopy should never be viewed as a static outcome. An endoscopist must continue to work and develop technical and
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cognitive skills in order to continually maintain target levels of CIR and adenoma detection rate (ADR) for example. This is perhaps particularly valid in a field where technology is constantly changing and measures of quality continue to evolve. Report
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cards outlining an endoscopist’s quality outcomes (CIR, ADR, patient comfort, etc.) are becoming increasingly popular as means of feedback on performance. What is lacking is consistent formative feedback to staff endoscopists that would facilitate skill
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enhancement. There are opportunities for endoscopists to seek out observation-based feedback in settings such as ‘Train the Trainer’ workshops [41], but these are
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unfortunately available to and used by only a minority. The DOPS evaluation tool [24] has been validated in staff or senior endoscopists, and is one tool that can be used for assessment of competence.
We are moving toward a larger emphasis on quality outcomes in endoscopy with
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novel concepts such as “pay for performance” and open-access to endoscopist report cards being considered. This should be viewed as an opportunity for endoscopists to continue their learning beyond their structured training period and encourage reviews of
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Summary
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competence with the goal of skill enhancement.
Achieving competence and excellence in endoscopy requires several hours of
training in order to develop numerous tangible and intangible skills. The concept of trainee competency in GI endoscopy is in a state of evolution. Traditional apprenticeship models that have customarily been based on achieving minimum procedural volumes are becoming obsolete in relation to competency approaches that apply evidence-based
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endoscopic benchmarks to trainees. Using accepted endoscopy quality and outcome criteria to provide feedback to trainees within reasonable expectations can conceivably improve performance and ease the transition to independent practice. The development
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and validation of multi-faceted endoscopy curricula are vital, and further research is needed to elucidate the properties of an ideal training program. Ideally, endoscopy training regimens should include a robust mechanism for ongoing procedural
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documentation, assessment and feedback. Simulation is an important component that can potentially improve the rate of colonoscopy acquisition skills by accelerating the initial
training remains unclear.
Practice Points
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Endoscopy skills acquisition involves numerous internal and external stimuli for the trainee; an understanding of cognitive load can help the learning curve Competency in colonoscopy is challenging to define; for trainees, a target cecal intubation rate (CIR) of ≥90% is reasonable by the end of their program Simulation can help improve the initial endoscopy learning curve Minimum procedural volume is only one of several important parameters that training programs must consider for their endoscopy trainees
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•
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learning curve. At this juncture, the optimal manner schedule of delivery of endoscopy
Research Agenda
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Further research in endoscopy simulation is needed, especially as high-fidelity simulation technology becomes available The optimal scheduling and delivery of endoscopy training (massed versus spaced) needs to be defined Endoscopy training curricula need to be developed and validated, as do instruments for documentation of progress and incorporation of feedback during training
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Conflict of Interest None.
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PII:
S1521-6918(16)30013-0
DOI:
10.1016/j.bpg.2016.04.003
Reference:
YBEGA 1424
To appear in:
Best Practice & Research Clinical Gastroenterology
Received Date: 9 February 2016 Revised Date:
22 March 2016
Accepted Date: 7 April 2016
Please cite this article as: Forbes N, Mohamed R, Raman M, Learning curve for endoscopy training: is it all about numbers?, Best Practice & Research Clinical Gastroenterology (2016), doi: 10.1016/ j.bpg.2016.04.003. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Learning curve for endoscopy training: is it all about numbers?
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Nauzer Forbes MD1, Rachid Mohamed MD2, Maitreyi Raman MD, MSc2,* 1
Advanced Therapeutic Endoscopy Training Program, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada 2 Department of Medicine, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
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*Corresponding author: Tel +1 403-592-5020, Fax 403-592-5020, Email [email protected]
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Abstract Endoscopy training is an important component of postgraduate gastroenterology
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and general surgery programs. Proficiency in endoscopy requires the development of several tangible and intangible skills. Much attention has traditionally been paid to
establishing a threshold, or minimum procedural volume during the training period,
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which is necessary for a trainee to achieve competence in endoscopy by the conclusion of his or her program. However, despite several attempts to characterize this target, it has
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become clear in recent years that training programs need to consider other factors rather than relying on this measure as the sole marker of trainee competency. Here, we present a review of general concepts in endoscopy skills acquisition that affect the learning curve, the evolving definition of competency as it relates to procedural volume, the role of
endoscopy training.
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simulation in endoscopy training, and the concept of massed versus spaced delivery of
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Keywords (MeSH Index)
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endoscopy education learning simulation training clinical competence
Word Count 4491
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Skills Acquisition and Cognitive Load The pursuit of competence and excellence in the acquisition of skills is dependent
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upon a blend of innate biological capability, dedicated instructors and many hours of
training. The process of skills acquisition has been well-described and involves three
major phases. The novice phase involves intense concentration to completely understand
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the activity and minimize mistakes. The second phase is an evolution to a more fluid and less cognitively arduous step in which trainees begin to perform at an acceptable level.
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The final phase involves a process of automation in which the skill is precisely and smoothly performed with little or no conscious cognitive involvement [1]. Specifically, with relevance to colonoscopy, a common diagnostic procedure performed world-wide, a novice endoscopist must attend to a myriad of sensory stimuli, including stimuli form the
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endoscopic image on the monitor, verbal stimuli form the patient, nurse and preceptor, and stimuli from proprioception from the endoscope. These stimuli are all potential sources of cognitive load. These external stimuli exist in addition to the demands
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involved in performing the procedure itself. Technical demands on the trainee include the process of straightening the scope or loop reduction, a technique critical to the safe and
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successful completion of colonoscopy. Additional procedural skills required to complete a diagnostic colonoscopy include applying knowledge regarding appropriate positioning of the patient to advance the scope successfully, identifying landmarks of completion, such as the ileo-cecal valve and cecal base, and recognizing pathology. Collectively, these inputs may all contribute to increase cognitive load for the novice trainee.
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Using a validated tool (National Aeronautics and Space Administration Task Load Index, NASA-TLX) to estimate cognitive load in GI endoscopy, Mohamed et al. [1] showed through factor analysis that the bulk of cognitive load experienced by trainees
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during colonoscopy arises from two main sources. The first is related to exertion
(combination of the effort and physical demand) and the second is related to the trainee’s perception of self-efficacy (subjective interpretation of performance). In this study, the
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evolution of exertion and self-efficacy during the initial training procedures of novice
endoscopists was mapped to the volume of procedures completed. For both colonoscopy
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and upper endoscopy, there was a steady decline in self-perceived exertion over the 3month training period. For colonoscopy, there was a progressive increase in self-reported self-efficacy over the first 29 procedures, followed by a drop in self-efficacy scores over the next 25 procedures. These findings were compared to the self-efficacy scores of
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expert gastroenterologists and were much lower than their expert cohort’s. The findings were slightly different for gastroscopy. For upper endoscopies, a rapid acquisition of skills was observed in addition to a rapidly increasing perception of self-efficacy over the
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first 9 procedures that quickly reached a plateau and stabilized. The findings from this study point to the occurrence of sensitive periods for the novice endoscopist that may be
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strategically managed by the expert preceptor by recognizing the need to minimize additional cognitive load for the trainee, including extra verbal communication. In addition, cognitive load may be further reduced by using standardized language to reflect simple directives such as “tip deflection”, “torque direction”, “insufflation”, “aspiration” so as to provide guidance while not overloading the trainee.
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Defining Competency Trainees in gastrointestinal endoscopy are required to demonstrate competency at the end of their program. Competency is defined by the American Society for
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Gastrointestinal Endoscopy (ASGE) as the “minimal level of skills, knowledge, and/or expertise derived through training and experience that is necessary to safely and
proficiently perform a procedure” [2]. Formal studies are lacking among GI and surgical
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programs that outline the characteristics of colonoscopy education. However, it is likely that a large degree of variability exists in the educational approaches taken towards
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teaching endoscopy trainees. Historically, educational pedagogy focused on “see one, do one and teach one”, whereas current skills pedagogy has been rooted in incorporating didactic, cognitive inputs with hands-on instruction [3]. One group demonstrated that even among trainees from GI fellowship programs, potential deficiencies may exist in the
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approach to teaching colonoscopy. Munroe [4] found an adenoma miss rate of 27% amongst GI trainees. In addition, the study investigators highlighted that there was a 2.2fold decrease in the risk of missing an adenoma with each 10-fold increase in trainee
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experience. Based on these study findings, the authors concluded that a trainee would have to perform 450 procedures to attain less than 25% adenoma miss rate, a number that
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many GI fellows may never reach in the course of their training. In an online survey of colonoscopy quality indicators, GI fellows received a mean
score of only 55% in their ability to correctly identify established quality benchmarks, with only 42% and 44% of trainees being able to correctly identify cecal intubation rate (CIR) and adenoma detection rate as quality indicators, respectively [5]. Conceivably, a sound knowledge base regarding expectations and benchmarks of quality would increase
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trainee vigilance and result in improved endoscopic performance. Feedback from GI trainees highlights the need for standardization in colonoscopy education. A survey of over 160 trainees in the UK found that only 36% felt that they were fully trained in
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colonoscopy. Interestingly, a faculty preceptor was in the room only 30% of the time to provide formal instruction and feedback [6]. Additional effective teaching strategies
proposed by trainees included a systematic approach towards endoscopic techniques,
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excellent supervision and discussion based training, attending a course on quality and
smaller procedural schedules to allow for training time [6]. Collectively, objective study
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findings and subjective needs assessment from trainees point to the need for reforming our current approach toward teaching colonoscopy.
The learning curve for GI endoscopy should include competency milestones. Competency in colonoscopy can be assessed across a number of domains including cecal
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intubation rates, adenoma detection rates, patient comfort, and appropriate sedation [7]. In addition, there exists several validated tools to assess competence in endoscopy (8,9). The Global Assessment of Gastrointestinal Endoscopic Skills (GAGES) score was
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developed by experts in endoscopy and education to objectively assess important endoscopic skills [8]. The GAGES-C score addresses five crucial colonoscopy skill
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domains: 1) scope navigation, which involves tip deflection, torque, advancement and/or withdrawal; 2) use of strategies including patient positioning, abdominal pressure, insufflation, suctioning and loop reduction; 3) ability to maintain a clear endoscopic field; 4) instrumentation, including the capacity to direct and repeatedly target instruments; and 5) overall quality of the examination, including patient comfort, efficiency, and completeness of mucosal evaluation [8]. Another colonoscopy skills assessment
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instrument, the Mayo Colonoscopy Skills Assessment Tool (MCSAT), has been validated for the evaluation of the colonoscopy learning curve [9]. This tool has a similar structure to the GAGES-C, but also incorporates elements of sedation, pathology recognition, and
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potential interventional skills, in addition to providing global cognitive and technical
assessments and quantifying the degree of trainee involvement in the overall procedure [9]. Despite its many strengths with regard to assessment of trainees, the MCSAT has
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important limitations; namely, it does not assess other parameters important to the
endoscopist, such as adenoma or polyp detection rates [10]. The Rotterdam Assessment
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Form for Colonoscopy (RAF-C) has also been described as a tool that facilitates both the navigation and the documentation of the colonoscopy learning curve, creating a feedback loop to ultimately improve proficiency through repeated assessments [11]. Studies have typically measured competency in upper endoscopy in two ways:
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intubation of the esophagus, and adequate scores on the GAGES Upper Endoscopy (GAGES-UE) tool [13]. The GAGES-UE assessment similarly evaluates five domains critical to performance of a successful endoscopy: 1) intubation of the esophagus, which
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requires an understanding of issues related to sedation as well as patient anatomy; 2) scope navigation, which involves tip deflection, torque, advancement and/or
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withdrawal; 3) ability to maintain a clear endoscopic field; 4) instrumentation; and 5) overall examination quality [8].
Minimum Procedural Volume: Is it all About Numbers?
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GI endoscopy training has conventionally focused on a minimum threshold for procedural volume during the training period as a means to achieve competency. The American Board of Surgery has recommended that a minimum number of 50
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colonoscopies be performed during training whereas the UK JAG stipulates 200
[7,14,15]. The number of colonoscopies required to achieve a cecal intubation rate of
90% has been the subject of previous studies, with discordant results. Some groups have
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reported that this can be achieved after 150 procedures, while other authors have
suggested a requirement for a minimum of 275 procedures [11,16–18]. This discordance
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may have arisen as a consequence of variable trainee numbers ranging between 8 and 41 participants. Recently, the largest study investigating the colonoscopy learning curve to date was completed, and it included all gastroenterology-training centers in the UK [7]. Results from that study showed that the cohort collectively required an average of 233
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procedures to achieve a mean cecal intubation rate of 90%. Specifically, 41% of trainees were competent after 200 procedures and 76% competent after 250 procedures. Only a minority of trainees reached the desired cecal intubation targets after 100 procedures.
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Other studies have also concluded that the 100 colonoscopy mark was insufficient in terms of trainees reaching a CIR of greater than 90% [19,20]. A recent meta-analysis
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summarized studies that assessed minimum procedure volumes [13]. It was found, unsurprisingly, that all such studies confirmed a relationship between trainee experience and performance. The study also concluded that a minimum threshold of 275–280 colonoscopies during GI training was the most agreed upon range based on studies of the highest available quality [11,13,18]. In terms of upper endoscopy, high-quality evidence is scarce, relatively speaking. Vassiliou et al., the same group that validated the GAGES
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tool, also observed a plateau in the GAGES-UE score after trainees performed 50 upper endoscopies [21]. Other studies have found more modest estimates of trainee progress, reporting a success rate of esophageal intubation of only 80% after 100 procedures [19].
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Despite these data, a paradigm shift has taken place in recent years, whereby
gastroenterology programs are no longer focused solely on a poorly-defined ‘critical mass’ of procedures as the ultimate goal for their endoscopy trainees. Instead, more
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emphasis is being placed on competency-based evaluation and promotion, which includes the assessment of important quality indicators. In fact, the ASGE Committee on Training
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has stated that “minimal threshold numbers represent a benchmark before which a trainee’s competency should not even be assessed,” and that true proficiency is not achieved until much later [22]. As such, the ASGE has developed a modified evidencebased tool for assessment of competency in endoscopy (ACE) specific to colonoscopy
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[23,10]. This tool is designed for continuous documentation and reporting of basic endoscopic procedures during training. Formative procedural feedback can be provided using validated assessment tools such as the direct observation of procedural skills
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(DOPS). This allows longitudinal, structural and objective feedback to be provided to a trainee throughout his or her training period [24]. A competency-based training model,
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rather than reliance on a minimum threshold alone, makes good pedagogical sense for a number of reasons. Importantly, certain endoscopic skill subsets are not reliably learned by the end of training regardless of procedural volume. A recent study surveyed trainees in US gastroenterology programs and found that almost all trainees met ASGE guidelinerecommended minimum procedural volumes for colonoscopy (100%) and upper endoscopy (98%). However, despite the cohort meeting overall minimum basic
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endoscopic volumes, only the minority of trainees met minimum recommended thresholds for treatment of variceal hemorrhage (40%) and esophageal dilation (43%), as examples (25).
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Importantly, competency and thresholds are defined heterogeneously across
different subspecialty training programs (namely, those for gastroenterology and general surgery). Overall, it would be prudent for programs to consider a more complete
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approach to evaluating trainee competency during the training period. This should likely include a mechanism for continuous documentation of trainee procedures throughout
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fellowship, with frequent re-evaluation by the program director, both ensuring adequate procedural volumes and appropriate case exposure. Importantly, training programs ought to increasingly consider general GI quality benchmarks and apply these to the trainee as well [26]. A recent survey reported that only 30% and 28% of GI training programs in the
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US make use of skills assessment tools or quality metrics, respectively [27]. This proves that, despite a growing knowledge of the above concepts, most programs still rely on a misguided view of ‘minimum procedural volume’ to measure competency at the end of
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training. As the old dogma of endoscopy training fades, new and enlightened endoscopy
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training curricula ought to take its place.
The Role of Simulation The advances in technology availability have resulted in innovations in
simulation. Simulation-based training provides an opportunity for the trainee to develop cognitive and technical skills in a safe and pressure-free learning environment. Several studies have demonstrated a potential benefit to the use of simulation during the early
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phases of endoscopy training. One group compared simulation- vs. non-simulationtrained fellows with regard to subjective and objective measures of competence including cecal intubation, and the ability to correctly identify cecal landmarks [28]. During the
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first 80 live procedures, the simulator-trained group had higher objective and subjective levels of competence. However, after 120 live cases, this relative advantage was no
longer observed, and both groups still required 160 live cases to attain 90% competence
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[28]. In another simulator-based study, simulator-exposed GI fellows scored better on all performance measures than non-exposed fellows; however, differences between groups
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dissipated once greater than 30 live procedures were performed [29]. A meta-analysis nicely summarized findings that showed a significant benefit when simulation was compared to no training at the beginning of fellowship, but that advantage was less robust when it was compared against usual training on live-patients [30].
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The optimal manner in which to deliver simulation-based training in endoscopy has yet to be determined. Prior studies have demonstrated that simply providing trainees with simulators does not ensure their effective use [31] and that expert feedback provided
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to trainees enhances acquisition of basic endoscopic skills [32]. It is now recognized that colonoscopy requires a complex skill set beyond technical skills. Literature indicates that
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non-technical skills have considerable influence on the performance of endoscopists and are thus an important contributor to patient safety [33] and to the quality of the procedure. Despite these findings, competency standards and education continue to predominantly focus on the development of technical skills [34]. Recently, a comprehensive curriculum that addresses the simulation-based technical, cognitive and integrative skills of colonoscopy was compared to the efficacy of a simulator-based self-regulated learning
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program [35]. Specifically, self-regulated learning is an educational strategy whereby trainees direct their knowledge acquisition using proactive strategies that plan goals, organize learning behaviors, self-monitor progress and promote self-assessment [36].
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Participants in the simulator-based comprehensive group outperformed participants in the self-regulated group during the first 2 live colonoscopies. In addition, the structured
comprehensive group demonstrated significantly better knowledge and colonoscopy-
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specific performance, communication and global performance.
All things considered, we can conclude that simulation is an important tool to
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enhance the performance and learning curve in colonoscopy acquisition skills. In addition, blending simulation-based training with non-technical learning strategies such as communication, clinical knowledge and direct feedback may further accelerate
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learning.
Optimizing Endoscopy Training Schedules Data are scarce in terms of defining an optimal training schedule for GI trainees
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learning basic endoscopy. In general, knowledge and skill acquisition can take place in one of two ways. Massed learning involves longer training durations, with few inter-
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training intervals as opposed to spaced learning which involves longer inter-training intervals. For example some training programs may dedicate endoscopy ‘blocks’ which are typically front-loaded at the onset of training, followed in the middle of training by potentially extended research rotations, during which endoscopy is performed at a minimum, or on an ad-hoc basis. Conversely, some programs offer a longitudinal
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endoscopy experience for trainees, whereby some degree of endoscopy exposure is maintained regardless of the rotation.
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Though the mechanisms are poorly understood, it has been established that spaced learning is superior to massed learning in terms of memory formation [37]. A similar
effect has been shown in terms of the acquisition of motor skills [38]. Data exist from the
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surgical literature comparing the two methods. One study showed that a distributed, spaced, learning method resulted in surgical trainees being 18.7% faster in their
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performance of basic endoscopic surgery skills compared to a control group submitted to a massed training method [39]. Jorgensen et al. studied whether breaks in GI endoscopy training affect performance. In an observational study of 24 GI trainees performing over 6000 colonoscopies, it was noted that there may be a slight decrease in a trainee’s
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performance as defined by their CIR after prolonged breaks in endoscopy training, with performance decreasing marginally after every subsequent 4-week break [40]. As described earlier, CIR is only one means of measuring trainee performance, and thus, this
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single study ought to be interpreted cautiously. In summary, it is unclear at this time which strategy is superior, or indeed, if there
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is a clearly superior strategy. Further studies are crucial in determining whether a spaced or massed model is optimal for building and maintaining competency among GI trainees.
Maintenance of Competency Competency in colonoscopy and upper endoscopy should never be viewed as a static outcome. An endoscopist must continue to work and develop technical and
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cognitive skills in order to continually maintain target levels of CIR and adenoma detection rate (ADR) for example. This is perhaps particularly valid in a field where technology is constantly changing and measures of quality continue to evolve. Report
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cards outlining an endoscopist’s quality outcomes (CIR, ADR, patient comfort, etc.) are becoming increasingly popular as means of feedback on performance. What is lacking is consistent formative feedback to staff endoscopists that would facilitate skill
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enhancement. There are opportunities for endoscopists to seek out observation-based feedback in settings such as ‘Train the Trainer’ workshops [41], but these are
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unfortunately available to and used by only a minority. The DOPS evaluation tool [24] has been validated in staff or senior endoscopists, and is one tool that can be used for assessment of competence.
We are moving toward a larger emphasis on quality outcomes in endoscopy with
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novel concepts such as “pay for performance” and open-access to endoscopist report cards being considered. This should be viewed as an opportunity for endoscopists to continue their learning beyond their structured training period and encourage reviews of
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Summary
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competence with the goal of skill enhancement.
Achieving competence and excellence in endoscopy requires several hours of
training in order to develop numerous tangible and intangible skills. The concept of trainee competency in GI endoscopy is in a state of evolution. Traditional apprenticeship models that have customarily been based on achieving minimum procedural volumes are becoming obsolete in relation to competency approaches that apply evidence-based
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endoscopic benchmarks to trainees. Using accepted endoscopy quality and outcome criteria to provide feedback to trainees within reasonable expectations can conceivably improve performance and ease the transition to independent practice. The development
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and validation of multi-faceted endoscopy curricula are vital, and further research is needed to elucidate the properties of an ideal training program. Ideally, endoscopy training regimens should include a robust mechanism for ongoing procedural
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documentation, assessment and feedback. Simulation is an important component that can potentially improve the rate of colonoscopy acquisition skills by accelerating the initial
training remains unclear.
Practice Points
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Endoscopy skills acquisition involves numerous internal and external stimuli for the trainee; an understanding of cognitive load can help the learning curve Competency in colonoscopy is challenging to define; for trainees, a target cecal intubation rate (CIR) of ≥90% is reasonable by the end of their program Simulation can help improve the initial endoscopy learning curve Minimum procedural volume is only one of several important parameters that training programs must consider for their endoscopy trainees
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•
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learning curve. At this juncture, the optimal manner schedule of delivery of endoscopy
Research Agenda
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Further research in endoscopy simulation is needed, especially as high-fidelity simulation technology becomes available The optimal scheduling and delivery of endoscopy training (massed versus spaced) needs to be defined Endoscopy training curricula need to be developed and validated, as do instruments for documentation of progress and incorporation of feedback during training
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Conflict of Interest None.
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