Resident Training in Flexible Gastrointestinal Endoscopy: A Review of Current Issues and Options

2007 APDS SPRING MEETING

Resident Training in Flexible Gastrointestinal Endoscopy: A Review of Current Issues and Options James G. Bittner IV, MD,a Jeffrey M. Marks, MD,b Brian J. Dunkin, MD,c William O. Richards, MD,d Raymond P. Onders, MD,b and John D. Mellinger, MDa a

Department of Surgery, Medical College of Georgia School of Medicine, Augusta, Georgia, bDepartment of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, cDepartment of Surgery, The Methodist Hospital, Houston, Texas, and dDepartment of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee COMPETENCY: Medical Knowledge, Interpersonal and

Communication Skills, Practice Based Learning and Improvement, Systems Based Practice

INTRODUCTION The Residency Review Committee for Surgery (RRC-S) recently mandated a 293% increase in required flexible gastrointestinal endoscopy experience for general surgery residents. Despite this heightened accreditation emphasis, resident exposure to flexible endoscopy remains erratic even in volume-adequate settings. A successful endoscopy training program requires planning, educator and resident buy-in, and proper training tools. So, how does the program director in surgery change the curriculum to prepare trainees for successful completion of the program? Steps toward a more uniform and appropriate training experience should include addressing current Accreditation Council for Graduate Medical Education (ACGME) policies, efficiently using available resources, including simulators, and instituting a validated, standardized endoscopy curriculum incorporating recommendations from surgery and gastrointestinal societies. Trainees also may benefit from structured experiences with rural surgeons or other high-volume endoscopy providers. Incorporation of multidisciplinary initiatives focused on expanding and standardizing endoscopy training also may be helpful. Such initiatives include development of standardized national curricula and proficiency-oriented skills assessment. Another burgeoning initiative is natural orifice translumenal endoscopic surgery (NOTES), which lends itself to novel technology de-

Correspondence: Inquiries to John D. Mellinger, MD, Professor of Surgery, Chief, Section of Gastrointestinal Surgery, Program Director, General Surgery Residency, Department of Surgery, Medical College of Georgia School of Medicine, 1120 15th Street, Augusta, GA 30912; fax: (706) 721-0972l; e-mail: [email protected]

sign, expansion and application of fundamental endoscopic skills, multidisciplinary training and research models, plus outcomes assessment. Along with reviewing the aforementioned issues, this article articulates the perspective that flexible endoscopy is an integral part of general surgery and that alimentary tract surgery will involve increasing utilization of endoscopic techniques in the future. If gastrointestinal surgeons are to provide integrated and current patient care, it will be necessary to incorporate intralumenal and potentially translumenal endoscopic techniques as they evolve. This article details the available strategies to prepare general surgery residents for the scope of contemporary practice.

SURGICAL ENDOSCOPY MINIMUM REQUIREMENTS AND RECOMMENDATIONS In February 2006, the RRC-S increased the required experience in flexible endoscopy during general surgery residency training. The 2009 graduates must complete 85 total gastrointestinal endoscopy cases, composed of 35 upper endoscopic procedures and 50 colonoscopies.1 Although a noteworthy increase from previous endoscopy requirements, completion of the obligatory case minimum does not necessarily ensure procedural competence. Ongoing monitoring of graduate procedural experience is followed by some organizations to guide changes in requirements or recommendations. For example, over a 12-year period (1994-2005), endoscopy volumes reported by applicants for American Board of Colon and Rectal Surgeons (ABCRS) certification changed significantly. The median number of colonoscopies increased from 209 to 264 per resident with a simultaneous decrease in flexible sigmoidoscopy (135.5 to 39) over the same period, reflecting an increased role of colonos-

Journal of Surgical Education • © 2007 Association of Program Directors in Surgery Published by Elsevier Inc. All rights reserved.

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TABLE 1. Flexible Endoscopy Requirements, Recommendations, and Case Volumes ACGME* Requirements

Recommended Case Volumes

Procedure

2006

2009

ASGE§

ABCRS储

SAGES¶

AAFP**

EGD†† PEG‡‡ FS§§ CLN储储 Totals

29 Total

35 0 0 50 85

130 15 30 140 315

0 0 25 138 163

25 0 25 50 100

0 0 0 0 0

29

Average Case Volumes National MCG 20 5.3 6.3 30.1 61.7

MCG† Range

27.7 16 9.5 35.7 88.9

5-49 1-35 0-28 4-72

P Value‡ 0.010 0.031 0.048 0.409 0.0236

*Accreditation Council for Graduate Medical Education.1,8 †Medical College of Georgia. ‡Student’s t test comparing 2001-2006 National and MCG mean numbers of cases performed (alpha ⫽ 0.05). §American Society for Gastrointestinal Endoscopy.4 储American Board of Colon and Rectal Surgery.5 ¶Society of American Gastrointestinal Endoscopic Surgeons.6 **American Academy of Family Physicians.7 ††Esophagogastroduodenoscopy. ‡‡Percutaneous endoscopic gastrostomy. §§Flexible sigmoidoscopy. 储储Colonoscopy.

copy for cancer screening. Prospective monitoring allows the ABCRS to adjust case requirements to reflect these evolving practice patterns.2 The ABCRS median numbers are much lower than the average number of colonoscopies performed annually by members of the American Society of Colon and Rectal Surgeons according to a survey of 778 practitioners. The survey respondents performed a mean of 458.3 colonoscopies during 1 year and 55% felt there should be a greater emphasis on colonoscopy during training and certification.3 One crucial aspect of successful endoscopy training is the clinical volume, particularly in light of the new RRC-S requirements. The flexible endoscopy experience at the Medical College of Georgia School of Medicine (MCG) is significantly greater than the national average and close to the case volume recommended by SAGES (Table 1).1,4-8 At MCG all surgery residents are taught by surgeons trained in advanced endoscopy and no formal endoscopy rotation exists. Residents garner clinical experience during operative procedures, general and gastrointestinal surgery rotations, and ad hoc opportunities. These data represent one academic institutional experience where both gastroenterologists and surgeons perform diagnostic and therapeutic endoscopy within the same facility. It also highlights the fact that resident exposure to endoscopy is vari-

able even in volume-adequate settings. The absence of a formalized rotation still may yield acceptable endoscopy experience, as illustrated by the MCG self-study. However, the teaching of flexible endoscopy to general surgery residents lacks consistency and as such requires a formalized curriculum.9 Another concern for training programs under the current system is preparing adequately the graduate to practice successfully in a community or rural practice. According to the American Board of Surgery (ABS) and recent retrospective research, rural general surgeons sitting for the recertification examination perform a greater variety of cases than urban surgeons.10,11 A recent national survey demonstrated that rural surgeons felt less prepared for practice after residency and perceived a need for more surgical endoscopy training compared with their urban counterparts. The desire of rural surgeons for more endoscopy training correlates with their substantially higher average annual volumes of endoscopy performed (Table 2).10 Community surgeons also incorporate a significant volume of endoscopy into their practices. A retrospective review investigated the total number (n ⫽ 1154) and economic impact of gastrointestinal endoscopies performed by a group of 5 community general surgeons. Over the 6-month study period, 54% of all procedures performed were endoscopies generating 43% of the

TABLE 2. National Survey of Rural and Urban General Surgeons* Outcomes

Rural† Surgeons (n ⴝ 390)

Urban Surgeons (n ⴝ 145)

P Value

Mean age Time in practice Intention to change practice in ⬍ 5 years Mean annual endoscopy volume Felt well prepared for current practice Feel more endoscopy training needed

53.7 years 14.2 years 33% 219.7 80.4% 62%

53.1 years 14.7 years 33% 76.5 93.1% 45.8%

— — — 0.0001 0.0009 0.0009

*Heneghan et al.10 †Population ⬍ 50,000. 400

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TABLE 3. Relationship of Surgeon Experience Level to Colonoscopy Outcomes* Prior Experience Level (cases) Colonoscopies (n ⴝ 13,580)

<50

50-99

100-200

201-500

>1000

Number completed (%) Median time to completion (minutes) Complications (%)

75.9 23 0.23

91.3 21 0

92 25 0.11

92.5 25 0.07

93.5 17 0.18

Annual Experience Level (cases) Colonoscopies (n ⴝ 13,580)

<50

50-99

100-200

201-500

>500

Number completed (%) Median time to completion (minutes) Complications (%)

86.7 25 0.16

88.4 21 0.21

92.3 20 0.29

94.2 17 0.15

96.6 15 0.12

*Wexner et al.14

total charges. The authors concluded that achieving significant case volumes by referral was possible in a community setting and that endoscopy can contribute substantially to financial productivity for community surgeons.12 In the February 2007 Bulletin of the American College of Surgeons (ACS), Hughes details his perspective on rural surgery and operative log for the last year, including 531 total procedures of which 279 (53%) were endoscopy cases. His next most frequent operation was cholecystectomy (8%). These data may indicate a shift in the community and rural surgeons’ most common procedure compared with previous years.13 According to Wexner et al,14 surgeons with annual endoscopy volumes similar to Hughes might expect to complete the procedure with expert results (Table 3). However, investigators concluded that surgeons with significantly less experience can perform lower gastrointestinal endoscopy with acceptable complication rates although procedure time and completion rate may be affected negatively.14 These results support the concept that no minimum case number can be mandated to assure safe colonoscopy but may indicate additional markers for credentialing. Similarly, Cass et al evaluated prospectively the acquisition of technical competency for 135 gastroenterology fellows. Results demonstrate fewer successful intubations of the esophagus, pylorus, and cecum and less recognition of abnormalities for those below 50 endoscopies. For trainees to achieve 90% competence across all objective and subjective endpoints, at least 130 EGD and 140 colonoscopy cases were necessary,15 supporting the ASGE recommended case minimums. Despite variable data and recommendations of ASGE and SAGES, a recent survey of endoscopy centers in the United States revealed that at least 48% of responding centers do not require a certain number of endoscopy cases to grant privileges.16 Although ASGE and SAGES strive to recommend guidelines appropriate for their represented disciplines, ultimately they cannot control their members when compliance with recommendations and credentialing processes are considered. In fact, it seems most entities do not apply these recommendations in their credentialing practices.16,17

Although disparity occurs in the minimum number of cases to achieve competence, it is imperative that surgical educators and societies promote consistency in endoscopy education. One step toward more uniform training might be prospective monitoring of graduate physician endoscopy volumes that mirror evolving practice patterns, allowing for ongoing assessment of residency requirements. Making use of the clinical variety and volume present in rural settings may benefit trainees and foster relationships between academic and rural surgeons. Since a significant percentage of U.S. endoscopy centers do not seem to require recommended case minimums to grant privileges, it intensifies the need for training programs to prepare adequately residency graduates for safe clinical practice.

TEACHING SURGICAL ENDOSCOPY The development of comprehensive cognitive and technical skills curricula that includes upper and lower gastrointestinal endoscopy is ongoing at the national level. The Surgical Council on Resident Education (SCORE) recently defined the scope of general surgery cognitive training. SCORE, which brings together major regulatory, professional, and surgical education organizations, is involved actively in assessment of technical competence, simulation in surgery education, professional development, and the practicing surgeon’s view of residency training.18 The Surgical Skills Curriculum Task Force initiated the development of a technical skills curriculum aimed at the insufficient clinical experience of applicants for ABS certification. This Task Force is a joint effort between the Association for Program Directors in Surgery (APDS) and the ACS with the purpose of improving resident technical skills performance and providing a means of standardized skills assessment. The Fundamentals of Endoscopic Surgery (FES) curriculum initiative from SAGES incorporates the goals set forth by SCORE and the Task Force to establish a validated, standardized tool for endoscopic basic skills training and evaluation. The FES curriculum will be composed of a high-stakes cognitive examination plus simulator-based basic skills training (Marks JM, per-

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sonal communication, May 2, 2007). A future initiative of these entities is to determine effective and accurate methods to assess technical competency for practice safety and professionals.18 According to a 2000 survey of program directors in general surgery, approximately 60% of training programs in the United States claimed to include formal endoscopy rotations, but only 33.3% were lead by fellowship trained instructors.19 Of those programs with established endoscopy rotations, the curriculum components included endoscopy lectures (36%), animal laboratories (71%), instructional videos (57%), and endoscopic models (34%). In the current training model, surgery residents cannot receive credit for intraoperative endoscopy, rely solely on clinical volume for experience, and garner technical skills from real-world practice. These types of inconsistent endoscopy training experiences must be standardized to educate trainees about the conditions and diseases endorsed by SCORE and train technical skills to levels of competence. Several strategies for improving the current educational experience include the institution of ACGME policy changes, formal endoscopy rotations, national cognitive and technical skills curricula based on adult learning theory, and simulatorbased training. For lower volume centers and programs without a formal endoscopy experience, a critical change might be the inclusion of intraoperative endoscopy cases in resident operative logs. Intraoperative endoscopy exhibits significant utility during certain laparoscopic procedures.20 Unfortunately, the ACGME states that only 1 resident may take credit as surgeon for each operation and only for 1 procedure in a multiprocedure operation.8 It also precludes a junior resident from logging the intraoperative EGD because only 1 trainee may take credit for a procedure on the same patient during the same day. One approach to increase the number of “countable” endoscopy cases would be to address the current refusal by the ACGME to count intraoperative endoscopy as a separate procedure for a second surgeon. Their policy fails to consider the current practice in surgery. Intraoperative endoscopy in most settings is a procedure that must be performed by a surgeon outside the sterile field. Certainly, if a gastroenterology fellow performs intraoperative endoscopy, the ACGME expects the fellow to count the procedural experience. The same should be true for general surgery residents. Furthermore, surgical residents must recognize differences in endoscopic anatomy evident during intraoperative procedures but not commonly observed during nonoperative endoscopy. Capturing this important skill in the intraoperative setting is incredibly important for our trainees. A formal endoscopy rotation and curriculum offering a solid foundation might include having second-year and/or third-year surgery residents rotate for 1 month under the mentorship of multidisciplinary endoscopy educators. The didactics of the rotation should comprise aspects of endoscopy-related conditions, such as gastroesophageal reflux disease, Barrett’s metaplasia, adenomatous polyps, hemorrhoids, gastrointestinal bleeding, among others. The basic procedural objectives might 402

include safe intubation of the esophagus and cecum, systematic examination and accurate identification of mucosal pathology, demonstration of adequate tissue sampling techniques, and the cognitive components of therapeutic interventions. During this period, the resident would complete standardized curricula such as the APDS skills curriculum or the FES curriculum as they become available. The aim of the junior-level rotation is to evaluate basic technical ability and prepare the trainee for advanced therapeutic endoscopy training. Senior residents could use their junior endoscopy rotation as a foundation for advanced procedural training. Again, a rotation with didactic and procedural components may benefit these trainees. The instructional aspect would incorporate indications, techniques, and complications associated with advanced elective and acute therapeutic endoscopy. Important material for review might include acute and recurrent gastrointestinal hemorrhage secondary to arteriovenous malformations, varices, and peptic ulcer disease as well as the appropriate use of mucosal resection, dilation, and stenting. In addition, intraoperative opportunities such as Heller myotomy or paraesophageal hernia repair should be included either during the rotation or as opportunities present. In this day of rapidly advancing endoscopic surgery, any exposure to novel endolumenal procedures for gastroesophageal reflux, mucosal resection, endolumenal bariatric surgery, or transgastric surgery will enhance the overall clinical experience and may augment resident interest in postgraduate surgical endoscopy fellowship training.21 The conclusion of the rotation would incorporate verbal and written objective feedback from faculty mentors regarding performance. A distributed surgical endoscopy curriculum is paramount to the successful education of future trainees. For example, a controlled trial randomized 38 junior surgery residents to either massed (1 day) or distributed (weekly) practice of a simulated microvascular anastomosis. Moulten et al22 assessed performance before training, immediately after training, 1-month posttraining, and finally tested resident performance of a microvascular anastomosis on a live, anesthetized rat. Both groups improved their performance, but the retention among the distributed group was significantly better with respect to time, number of hand movements, and expert global ratings. The distributed group also performed better on the rat anastomosis in all measures suggesting distributed practice improves surgical skills retention. Extrapolating this data to the training of surgical endoscopy may mean that distributed technical practice during formal rotations is likely to improve skills retention based on established objective metrics and expert global assessment. With the completion of the FES program or similar curricula plus continued surgical education research, resultant objective metrics will help establish an appropriate evaluation tool for surgical endoscopy training. As institutional and national surgical skills curricula take shape, surgical educators must keep in mind the principles of adult learning. Based on adult learner characteristics, an endoscopy skills curriculum should be practical, goal-oriented, and

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directly relevant to better connect new concepts or skills to the individual’s existing knowledge or experience. Once a curriculum is established, surgical educators will be responsible for addressing the 4 critical elements of adult learning: motivation, reinforcement, retention, and transference. Motivation of surgery residents to learn endoscopy often is based on external expectations, cognitive interest, and personal advancement. Barriers against resident participation may be lack of time, confidence or interest, and lack of information about opportunities to learn. Educators should provide motivation to learn via several means: Establish an atmosphere conducive to learning, create an appropriate level of concern directly related to task importance, and set a level of difficulty that will challenge participants without excessive frustration. To encourage correct modes of performance, reinforcement is a necessary part of the learning process. Instructors need to use it on a frequent and regular basis early on to help trainees retain learned information and skills. Transference, the ability to use the previously taught information or skill in a new setting, is most likely to occur when residents associate simulated endoscopy skills training with aspects of the real procedure. In motivated individuals who receive quality feedback, the use of standardized curricula might result in a high degree of original learning and subsequent retention. In the end, one of the most powerful messages to effect change in surgical training programs is the presence of surgical faculty who actually model the practice component of gastrointestinal endoscopy.

ROLE OF ENDOSCOPY SIMULATORS IN TRAINING Simulator-based gastrointestinal endoscopy training continues to mature as a valuable method of educating and potentially credentialing residents, fellows, and skilled endoscopists.23,24 For this technology to take its place in current and future residency curricula, instructors must move beyond antiquated teaching traditions that often result in educational and clinical disparity among trainees. Instead, program directors and teaching staff should consider simulation as a platform to introduce new skills, maintain proficiency, and possibly evaluate competency in a safe, stress-reduced learning environment. Of course, the specific role of endoscopy simulators within a comprehensive training program should be based on reliable validation and educational outcomes research and serve as a means to augment rather than replace clinical experience.25 The gastrointestinal endoscopy simulator market is dominated by 2 companies that offer high-fidelity virtual reality simulators, although low-fidelity, less-expensive models are being used successfully (Dunnington GL, personal communication, January 15, 2007). Currently available systems ranging in price from $50,000 to $100,000 include the GI Mentor II (Simbionix USA Corp., Cleveland, Ohio) and the Endoscopy AccuTouch System (Immersion Corp., San Jose, California). Table 4 compares simulator components, modules, metrics, and feedback, which is important in the early train-

TABLE 4. Comparison of Virtual Reality Gastrointestinal Endoscopy Simulators Components

GI Mentor II*

AccuTouch†

Platform Endoscopes Graphics

Reversible mannequin Pentax 3D recreation 3D map Master tool (simulates 10 devices)

Interface devices Proxy 3D recreation 3D map Master tool (simulates 3 devices)

Instruments

Modules

GI Mentor II

AccuTouch

CyberScopy Bronchoscopy Upper GI Endoscopy Flexible Sigmoidoscopy Lower GI Endoscopy Emergency Bleeding ERCP‡ Endoscopic Ultrasound

2 scenarios — 20 cases 10 cases 20 cases 10 cases 20 cases 30 cases

— 12 cases 6 cases Tutorial 18 cases — 6 cases —

Feedback

GI Mentor II

AccuTouch

Visual Auditory Haptic Summative Paradoxical Motion

X X X X X

X X X X —

Selected Metrics

GI Mentor II

AccuTouch

Time total Time with clear view Time to reach duodenum Time to esophageal intubation Efficiency of screening Tracheal intubation Excessive sedation Patient discomfort % mucosa visualized Retroflexion performed Loop formation Pathology type/location Pathology missed Pathology/polyp retrieved Biopsies taken Electrocautery specifics Bleeding Pain Perforation Air aspirated on exit Captured images

X X X

X X X

—

X

X — — X X X X X

— X X X X X X X

X X

— X

X X X X X X X

X X X X X — X

*Simbionix USA, Corp (Cleveland, Ohio). †Immersion Medical Corp (Gaithersburg, Maryland). ‡Endoscopic retrograde cholangiopancreatography.

ing phase of skill acquisition.26 Since traditional methods of endoscopy training may extend procedural time by as much as 40%,27 investigators validated the ability of virtual endos-

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TABLE 5. Studies of Virtual Reality Gastrointestinal Endoscopy Simulator Validity Simulator GI Mentor*

AccuTouch‡

Procedure

Study (Reference)

Validity Type

35

Colonoscopy

Bar-Meir

Face

Colonoscopy

Aabakken et al36

Face

Colonoscopy

Eversbusch and Grantcharov32

Face/Construct

Colonoscopy

Clark et al37

None

Colonoscopy

Felsher et al38

Face/Construct

Colonoscopy

Grancharov et al39

Face/Construct

Colonoscopy

Cohen et al40

Predictive/Transfer

EGD†/Colonoscopy

Ferlitsch et al41

Construct

EGD

Moorthy et al42

Face/Construct/Reliability

EndoBubble

Ritter et al28

Construct/Reliability

EndoBubble

Adamsen et al43

Predictive

Colonoscopy

Mahmood and Darzi46

Face/Construct

Colonoscopy

Sedlack and Kolars47

Predictive

FS§

Datta et al48

Face/Construct

FS

Gerson and Van Dam31

None

FS

Sedlack et al49

None

Outcomes Hands-on simulator evaluation Hands-on simulator evaluation Skill levels differentiated and learning curves defined Resident simulator performance improves over 2 years Expert distinguished from novice and intermediate levels Expert distinguished from novice and intermediate levels Simulator training shows improved objective competency Novice simulator group reached expert level Metrics and global rating scale reliably differentiate skill levels Intermediate level outperformed novice in psychomotor skills Psychomotor skill correlates with time, economy of movement Expert distinguished from novice and intermediate levels Simulator-based training superior to bedside training Expert distinguished from novice and intermediate levels Bedside training alone superior to simulatorbased training No skill difference between simulator and bedside training

*Simbionix USA Corp (Cleveland, Ohio). †Esophagogastroduodenoscopy. ‡Immersion Medical Corp (Gaithersburg, Maryland). §Flexible sigmoidoscopy.

copy simulators to accelerate the learning curve for novice endoscopists.28-32 Currently, the GI Mentor II simulator exhibits face, construct, and predictive validity based on comparative trials (Table 5).28,32,35-43 Using this simulator, educators can design and implement individualized training programs as well as offer personalized feedback for every scenario completed by the trainee. Users progress through tutorials at different speeds based on solely their ability to exhibit competence for the task.32-34,44 The endoscopic ultrasound module available only 404

on the GI Mentor II exhibits particular promise according to the members of The First International Conference on Endoscopy Simulation.45 To date, the AccuTouch system demonstrates face and construct validity and a training advantage for colonoscopy.31,46-50 This system permits performance of simulated bronchoscopy, which may aid inexperienced anesthesiology residents in fiberoptic intubation.51 Another major impetus toward simulation-based endoscopy training is the cost associated with current methods of procedural teaching. When the direct cost of training each general

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surgery resident is considered and this value is extrapolated to a national scale, the economic impact is staggering, which may be due in part to the prolonged time necessary for residents to learn endoscopic procedures in a high-stakes environment.24 For example, in 1 academic institution, the average time to complete PEG tube insertion under operative conditions was 26 minutes longer when performed with a general surgery resident compared with faculty alone.52 Another review of the CORI database compared duration and reimbursement rates of procedures (EGD and colonoscopy) performed in private practices, academic institutions, and Veterans Affairs medical centers with and without gastroenterology fellows. The investigators concluded that training fellows prolongs procedure time by 10% to 37% and that the subsequent reduction in reimbursement at teaching centers causes financial strain.27 Prolonged procedure times over a 5-year training program add almost $50,000 to the total cost of training each resident.53 Such a significant time and financial burden may be lessened with the appropriate use of simulator-based, curriculum-driven endoscopy training programs. Simulator use may be tailored to individual abilities and level of experience with the intention of shortening the learning curve and decreasing the patient risk associated with early stages of training. Current literature reveals that novice learners perform basic lower gastrointestinal endoscopy procedures more readily when trained on a computer-based simulator compared with those trained by traditional standards40,47 except perhaps for sigmoidoscopy.31 Also, patients who undergo colonoscopy by a computer simulation-trained novice experience less discomfort. These trends seem to apply for the first 30 colonoscopies, after which any difference in outcomes is negligible.47 Similarly, upper gastrointestinal endoscopy simulator training for novices is beneficial with regard to development of psychomotor skills and fundamental abilities. Ritter and colleagues noted that the GI Mentor II simulator differentiates between the abstract psychomotor skills of novice and intermediate trainees with a high level of consistency and reliability as well as correlate fundamental perceptual and visuospatial abilities with duration of required endoscopy simulator training. It suggests that baseline perceptual, visuospatial, and psychomotor abilities contribute to variability in endoscopic skills acquisition.28,44,54 So endoscopy simulators may be used to identify learners who have not mastered minimal levels of competence before they practice on patients and who require additional or individualized training. Both computer and ex vivo simulation are useful for teaching advanced endoscopic procedures, including control of gastrointestinal hemorrhage, ERCP, and EUS, all of which may be difficult to learn under stressed clinical conditions. Gastrointestinal hemorrhage management can be a tense event during which most residents and fellows do not receive adequate hands-on training. Often the attending physician must intervene to prevent additional bleeding and complications. This high-stakes environment with little time for adequate training lends itself to simulator-based learning. The computer simulation currently available offers modules for gastrointestinal

hemorrhage but has not been studied extensively.25,34,55 Certain simulation systems provide ERCP and EUS capabilities; unfortunately, few validation and no clinical studies specifically investigating these modalities exist. The most widely used ERCP and EUS high-fidelity simulator is the GI Mentor II, but ex vivo porcine models may be more realistic and easier to use in some instances.56-58 However, the anatomic models do have limitations, since trainees cannot be exposed to a variety of pathology. As such designing a standardized endoscopic training curriculum using ex vivo models becomes problematic. Despite the absence of data for ERCP and EUS simulator-based training, the ASGE curriculum for gastroenterology fellows incorporates standardized instruction and introductory hands-on training using ex vivo models and computer-based simulation for ERCP and EUS.59-61 Although advances in simulation have resulted in vastly improved virtual environments, prospective, randomized controlled trials have yet to determine all the absolute indications for simulation in endoscopy training. The literature supports the idea that endoscopy simulators may be most useful for introducing novice learners to basic endoscopy techniques and for comparative trials to traditional teaching paradigms. To date, studies suggesting clear indications for simulators in endoscopy include animal-based simulators for control of gastrointestinal bleeding62-64 and computer-based simulators for novice and intermediate trainees learning colonoscopy.40,47,55 A recent multicenter, randomized controlled trial defined the benefits of GI Mentor II simulator training on the acquisition of colonoscopy competence in new gastroenterology fellows at academic medical centers. Investigators compared objective and subjective competency and patient discomfort during real colonoscopy between simulator and unsupervised training groups. The simulator group completed 10 hours on the GI Mentor II before performing any real colonoscopy procedures. The unsupervised group performed real colonoscopies under normal training conditions. Proctors recorded a global subjective score and objective data, including trainee procedure number, ability to reach the transverse colon and cecum without assistance, and ability to identify abnormalities. They concluded that additional indications for gastrointestinal endoscopy simulators may be to improve patient comfort, serve as an objective measure of skill acquisition, and possibly ascertain competence.40 More experienced trainees may find computer-based simulators useful for advanced skills development. Since the GI Mentor II demonstrates validity,32,35-42 the use of this or similar virtual endoscopy simulators might be applicable to trained endoscopists in the setting of a short course experience. According to the ASGE, when properly designed, short courses may introduce new techniques to those with a background in basic endoscopy.65 Simulator use in this setting provides an opportunity to challenge the senior-level residents with difficult therapeutic cases that would otherwise require an animate laboratory.66

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RECOMMENDATIONS FOR SIMULATOR USE IN ENDOSCOPY TRAINING Program directors should consider incorporation of endoscopy simulators as an important component of a standardized endoscopy curriculum and effective tool for resident training.23 One crucial element of simulator-based training is subjective and objective feedback. Of course, feedback is necessary to improve learner performance in formulating a clinical diagnosis, patient encounters, psychomotor skills acquisition, and procedural training.52,54,67-69 For example, individuals receiving both computer-based training and instructor feedback showed greater improvement in knot-tying performance scores compared with those with computer training alone. Computerbased endoscopy simulators incorporate video replay, but this type of feedback alone may not suffice. Instead, supplemental instructor cuing to direct the trainee’s focus during video replay provides greater benefit.70 Specific to feedback in endoscopy training, investigators found no improvement in performance among subjects (novice to expert) using a colonoscopy simulator when feedback was not provided.42 This literature highlights the fact that “screen time” alone does not facilitate optimal educational outcomes. According to the residents that use them, simulators can improve basic surgical skills and augment clinical experience when used voluntarily; however, participation should be mandatory for simulator-based training to be an effective and efficient part of a residency curriculum.71 Additional recommendations for improving resident endoscopy education through appropriate simulator use and feedback include tailoring our educational methods to fit individual student learning styles and rates of progress. It likely will contribute to individualized, variable residency training periods. It is important to maintain a computerized log of trainee progress with objective data regarding instrument accuracy, motion, and forces to facilitate objective and uniform measures of procedural competency. Standardizing clinical content and providing a controllable, secure learning environment with the opportunity for extensive repetitive practice without patient consequence may improve overall patient care. In the current training environment, developing rare or “sentinel” virtual clinical scenarios infrequently encountered through traditional training methods will increase the breadth of experience. Depending entirely on clinical experience to learn advanced endoscopy results in residency graduates with highly variable skills.72 Of 252 general surgery residency programs in the United States surveyed (2002-2003); the RRC-S cited 73 programs. The most common citation (49%) was for operative insufficiencies relating to required category deficits, poor balance of cases among trainees, and breadth of experience.73 Simulator training ensures that all residents have a standardized opportunity to apply learned technical skills across a broad range of situations. Active faculty participation in resident education is paramount if an endoscopy training program is going to prosper. Faculty buy-in plays a crucial role in fostering simulator-based 406

education because residents must be permitted to temporarily get out of their clinical duties for protected, mandated skills training. An adjunct to faculty involvement is the surgical educator who would contribute to overall resident skills acquisition. This individual would facilitate the proper application of simulation equipment, educate trainees and physicians, and assist with research projects. Furthermore, a surgical educator would offset faculty time expenditures and allow for implementation of a full surgical simulation curriculum in a cost-effective manner. A safe, structured virtual education and surgical simulation laboratory built to provide residents a secure environment for independent training regardless of the time of day promotes utility.

CONCLUSION Developments in gastrointestinal surgery dictate an expanded educational emphasis on flexible endoscopy in the surgical curriculum. Specific strategies to expand resident endoscopic experience offer the real potential to produce a generation of surgeons optimally equipped to deal with patients’ needs in the evolving landscape of minimally invasive care. Those who embrace cooperation for the benefit of their patients and trainees will be in a position to lead the burgeoning field of endoscopic surgery. One way to foster this joint venture is to implement multidisciplinary endoscopy teaching and research teams composed of surgeons and gastroenterologists.74 With standardized, cognitive and technical skills curricula, dedicated faculty devoted to the discipline of endoscopy, and appropriate use of simulation and other methods as they mature into validated educational tools, trainees of today will be prepared to lead in pioneering the exciting field of surgical endoscopy tomorrow.

ACKNOWLEDGMENT The authors extend their sincere appreciation to the Society of American Gastrointestinal and Endoscopic Surgeons resident education and flexible endoscopy committees for their support of the educational workshop presented at the 2007 Association of Program Directors in Surgery annual meeting, Washington, D.C.

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Force on Ensuring Competence in Endoscopy. Methods

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of granting hospital privileges to perform gastrointestinal endoscopy. Gastrointest Endosc. 2002;55:780-783. 5. American Board of Colon and Rectal Surgery. Operative

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