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See one, simulate one, do one, teach one—the value of hands-on simulator training in interventional endoscopy
Techniques in Gastrointestinal Endoscopy (2011) 13, 111-112
Techniques in GASTROINTESTINAL ENDOSCOPY www.techgiendoscopy.com
See one, simulate one, do one, teach one—the value of hands-on simulator training in interventional endoscopy As to diseases make a habit of two things—to help, or at least, to do no harm. —Hippocrates, Epidemics The Felder–Silverman model describes different types of learning styles based on perceptual modalities, information processing, and personality patterns. Visual learners remember best what they see: pictures, diagrams, flow charts, timelines, films, and demonstrations. Verbal learners comprehend information better through written and spoken explanations. Active learners tend to retain and best understand information by doing something active, by discussing or applying the topic, or by explaining it to others. Reflective learners prefer to acquire information silently by themselves. Sensing learners tend to like learning factual data, whereas intuitive learners often prefer discovering possibilities and relationships. Sequential learners follow logical stepwise paths to solutions, whereas global learners need to see the big picture before learning details. In general, information is better retained and memorized when presented visually and verbally.1 Hands-on simulation provides the possibility of accommodating all different types of learning styles by operating visual, verbal, and tactile channels and through interactive tutor–trainee communication. Thus, hands-on training resembles the most effective way of transmitting information in particular procedural skills with a knowledge-based background. Gastroenterology fellows typically acquire skills in interventional endoscopy by performing live cases under the supervision of their proctor. However, this mode of education is limited by the ability to learn in a calm, controlled environment and the opportunity to obtain feedback from an instructor. In critical situations, patient instability may require the supervising attending to take over the procedure. The frequency of exposure to various procedures may also vary significantly from one training institution to another. With the development of realistic simulator technology, intensive hands-on instruction in therapeutic endoscopy offers a new educational option to overcome these limitations. Additionally, with the expanding applications of endoscopic procedures, simulation optimizes exposure and expertise. Knowledge-based teaching cannot replace the performance of actual procedures with real-time personal feedback from
an experienced tutor. This is especially applicable when new techniques are practiced for the first time.2 In the current and upcoming issues of Techniques of Gastrointestinal Endoscopy, world-renowned investigators in gastrointestinal endoscopy training, present a series of interesting articles updating the status of simulation for teaching interventional endoscopy. Specifically, the role of simulation is analyzed in diagnostic endoscopy, therapeutic endoscopy, endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, and transluminal endoscopic surgery. The status of simulation and its role in training internationally are updated, and technical aspects of simulator validation and metrics to establish competency are also highlighted. Over the years, specialized medical societies have introduced guidelines and recommendations for establishing minimal quality requirements for the unsupervised performance of the various endoscopic techniques.3-5 However, structured practical training programs and teaching curricula for gastrointestinal endoscopy have not been well defined, validated, or widely adopted.6 In the field of surgery, virtual-reality simulators have been demonstrated to improve the performance of residents when performing laparoscopic surgery. Studies have reported that simulator-trained surgical residents are faster and less likely to fail and make fewer errors compared with non-simulator-trained residents.7,8 In the field of endoscopy, simulator-based training is rapidly evolving. Computer simulators may play an important role in the early phase of endoscopic training, especially for the first steps in colonoscopy.9-20 For the close-to-reality training of complex therapeutic interventions, computer simulators have now been developed to mimic real-life scenarios with customizable training programs. Ex vivo specimens are also frequently used to simulate endoscopic procedures worldwide. Because of ethical concerns and the poor simulation of pathology involved using live animals, ex vivo models provide an excellent alternative. The ex vivo model offers the opportunity to practice interventional endoscopic procedures using commercially available devices in a realistic environment but without the risk of patient or animal harm and without time limitations. The benefit from simulation is likely a combination of
112
Techniques in Gastrointestinal Endoscopy, Vol 13, No 2, April 2011
private time spent on the model, expert instruction, and formal skills evaluation with opportunity for feedback.10,21 It is important to emphasize that the success of the simulator is dependent on the knowledge, experience, and teaching skills of trainers knowing how to maximize the use of the models. Fortunately, evidence shows that it does not take much for practicing endoscopists to gain adeptness and skill at using the models. A pilot study, which evaluated how quickly and effectively new trainers are able to gain simulator proficiency, determined that after a 6-hour train-thetrainer workshop, the newly simulator-trained endoscopists were able to effectively conduct independent workshops for gastroenterology fellows in 4 hemostasis techniques. Fellows under the direction of the new teachers made significant progress on the models. The hemostasis skills acquisition of the fellows participating in this study were of similar magnitude to that achieved in prior trials using more experienced trainers. Furthermore, the fellows consistently rated the teaching skills of the new trainers highly.22 If interest in hands-on simulation for credentialing and recredentialing in therapeutic endoscopy continues to grow, then the question that remains is, “How can it be achieved?” With the growing use of ex vivo models, there are growing opportunities. The American Society for Gastrointestinal Endoscopy (ASGE) Interactive Training and Technology (ITT) Center is a pivotal institution providing hands-on ex vivo training on a national level (http://www.asge.org). It has been suggested to further expand this training method by establishing centers of excellence on local levels. This decentralization of the ITT model may enhance the availability of ex vivo training to gastroenterologists.23 Additionally, the Society for American Gastrointestinal and Endoscopic Surgeons (SAGES) has developed a program to determine knowledge and skills in endoscopy termed Fundamentals in Endoscopic Surgery (http://www.fesprogram.org). The program utilizes Webbased didactics and hands-on simulators that can be used for training and assessing knowledge, judgment, and technical skills. Growth of such centers and programs from ASGE and SAGES can help measure aptitude and may set benchmarks for credentialing and recredentialing. In summary, interventional endoscopy will become more and more invasive in the future, which will further increase the demand for realistic simulator training. Comparable to flight simulator training, standard endoscopy techniques, particularly new endolumenal or translumenal procedures, may require the acquisition of skills in a simulator before they can be performed safely in patients. Computer simulators are helpful to train basic skills in standard endoscopic techniques and are becoming customizable for specific endoscopic encounters. Ex vivo hands-on simulator training provides the realistic simulation of interventional techniques with the opportunity to use commercially available devices and even prototypes. These modes of training have the potential to help patients by improving outcome and limiting patient harm. Finally, simulators may objectively assess various skill sets, ultimately guiding the way to better measurements of trainee proficiency.
Kai Matthes, MD Shyam J. Thakkar, MD Guest Editors
References 1. Felder RM, Silverman LK: Learning and teaching styles in engineering education. Engr Educ 78:674-681, 1988 2. Deviere J, Hochberger J, Neuhaus H, et al: Recommendations of the ESGE workshop on ethical, clinical, and economic dilemmas arising from the implementation of new techniques. First European Symposium on Ethics in Gastroenterology and Digestive Endoscopy, Kos, Greece, June 2003. Endoscopy 35:768-771, 2003 3. Borland JL Jr: Retraining in endoscopy. Gastrointest Endosc Clin N Am 5:363-372, 1995 4. Statements and guidelines developed by the Standards of Training and Practice Committee of the ASGE. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 34:1S-40S, 1988 5. Principles of training in gastrointestinal endoscopy. From the ASGE. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 49:845-853, 1999 6. Bisschops R, Wilmer A, Tack J: A survey on gastroenterology training in Europe. Gut 50:724-729, 2002 7. Seymour NE, Gallagher AG, Roman SA, et al: Virtual reality training improves operating room performance: Results of a randomized, double-blinded study. Ann Surg 236:458-463, 2002 [discussion: 463-464] 8. Grantcharov TP, Kristiansen VB, Bendix J, et al: Randomized clinical trial of virtual reality simulation for laparoscopic skills training. Br J Surg 91:146-150, 2004 9. Sedlack RE, Kolars JC: Computer simulator training enhances the competency of gastroenterology fellows at colonoscopy: Results of a pilot study. Am J Gastroenterol 99:33-37, 2004 10. Dunkin BJ: Flexible endoscopy simulators. Semin Laparosc Surg 10:29-35, 2003 11. MacDonald J, Ketchum J, Williams RG, et al: A lay person versus a trained endoscopist: Can the PreOp endoscopy simulator detect a difference? Surg Endosc 17:896-898, 2003 12. Ladas SD, Malfertheiner P, Axon A: An introductory course for training in endoscopy. Dig Dis 20:242-245, 2002 13. Bar-Meir S: A new endoscopic simulator. Endoscopy 32:898-900, 2000 14. Aabakken L, Adamsen S, Kruse A: Performance of a colonoscopy simulator: Experience from a hands-on endoscopy course. Endoscopy 32:911-913, 2000 15. Ferlitsch A, Glauninger P, Gupper A, et al: Evaluation of a virtual endoscopy simulator for training in gastrointestinal endoscopy. Endoscopy 34:698-702, 2002 16. Datta V, Mandalia M, Mackay S, et al: The PreOp flexible sigmoidoscopy trainer. Validation and early evaluation of a virtual reality based system. Surg Endosc 16:1459-1463, 2002 17. Gerson LB, Van Dam J: The future of simulators in GI endoscopy: An unlikely possibility or a virtual reality? Gastrointest Endosc 55:608611, 2002 18. Williams CB, Saunders BP, Bladen JS: Development of colonoscopy teaching simulation. Endoscopy 32:901-905, 2000 19. Noar MD, Soehendra N: Endoscopy simulation training devices. Endoscopy 24:159-166, 1992 20. Baillie J, Jowell P, Evangelou H, et al: Teaching by endoscopy simulation. Endoscopy 23:239-240, 1991 21. Waye JD, Leicester RJ: Teaching endoscopy in the new millennium. Gastrointest Endosc 54:671-673, 2001 22. Matthes K, Cohen J, Kochman ML, et al: Efficacy and costs of a one-day hands-on EASIE endoscopy simulator train-the-trainer workshop. Gastrointest Endosc 62:921-927, 2005 23. Vargo JJ: See one, do one, teach one. Gastrointest Endosc, 2008 67:419-221
Techniques in GASTROINTESTINAL ENDOSCOPY www.techgiendoscopy.com
See one, simulate one, do one, teach one—the value of hands-on simulator training in interventional endoscopy As to diseases make a habit of two things—to help, or at least, to do no harm. —Hippocrates, Epidemics The Felder–Silverman model describes different types of learning styles based on perceptual modalities, information processing, and personality patterns. Visual learners remember best what they see: pictures, diagrams, flow charts, timelines, films, and demonstrations. Verbal learners comprehend information better through written and spoken explanations. Active learners tend to retain and best understand information by doing something active, by discussing or applying the topic, or by explaining it to others. Reflective learners prefer to acquire information silently by themselves. Sensing learners tend to like learning factual data, whereas intuitive learners often prefer discovering possibilities and relationships. Sequential learners follow logical stepwise paths to solutions, whereas global learners need to see the big picture before learning details. In general, information is better retained and memorized when presented visually and verbally.1 Hands-on simulation provides the possibility of accommodating all different types of learning styles by operating visual, verbal, and tactile channels and through interactive tutor–trainee communication. Thus, hands-on training resembles the most effective way of transmitting information in particular procedural skills with a knowledge-based background. Gastroenterology fellows typically acquire skills in interventional endoscopy by performing live cases under the supervision of their proctor. However, this mode of education is limited by the ability to learn in a calm, controlled environment and the opportunity to obtain feedback from an instructor. In critical situations, patient instability may require the supervising attending to take over the procedure. The frequency of exposure to various procedures may also vary significantly from one training institution to another. With the development of realistic simulator technology, intensive hands-on instruction in therapeutic endoscopy offers a new educational option to overcome these limitations. Additionally, with the expanding applications of endoscopic procedures, simulation optimizes exposure and expertise. Knowledge-based teaching cannot replace the performance of actual procedures with real-time personal feedback from
an experienced tutor. This is especially applicable when new techniques are practiced for the first time.2 In the current and upcoming issues of Techniques of Gastrointestinal Endoscopy, world-renowned investigators in gastrointestinal endoscopy training, present a series of interesting articles updating the status of simulation for teaching interventional endoscopy. Specifically, the role of simulation is analyzed in diagnostic endoscopy, therapeutic endoscopy, endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, and transluminal endoscopic surgery. The status of simulation and its role in training internationally are updated, and technical aspects of simulator validation and metrics to establish competency are also highlighted. Over the years, specialized medical societies have introduced guidelines and recommendations for establishing minimal quality requirements for the unsupervised performance of the various endoscopic techniques.3-5 However, structured practical training programs and teaching curricula for gastrointestinal endoscopy have not been well defined, validated, or widely adopted.6 In the field of surgery, virtual-reality simulators have been demonstrated to improve the performance of residents when performing laparoscopic surgery. Studies have reported that simulator-trained surgical residents are faster and less likely to fail and make fewer errors compared with non-simulator-trained residents.7,8 In the field of endoscopy, simulator-based training is rapidly evolving. Computer simulators may play an important role in the early phase of endoscopic training, especially for the first steps in colonoscopy.9-20 For the close-to-reality training of complex therapeutic interventions, computer simulators have now been developed to mimic real-life scenarios with customizable training programs. Ex vivo specimens are also frequently used to simulate endoscopic procedures worldwide. Because of ethical concerns and the poor simulation of pathology involved using live animals, ex vivo models provide an excellent alternative. The ex vivo model offers the opportunity to practice interventional endoscopic procedures using commercially available devices in a realistic environment but without the risk of patient or animal harm and without time limitations. The benefit from simulation is likely a combination of
112
Techniques in Gastrointestinal Endoscopy, Vol 13, No 2, April 2011
private time spent on the model, expert instruction, and formal skills evaluation with opportunity for feedback.10,21 It is important to emphasize that the success of the simulator is dependent on the knowledge, experience, and teaching skills of trainers knowing how to maximize the use of the models. Fortunately, evidence shows that it does not take much for practicing endoscopists to gain adeptness and skill at using the models. A pilot study, which evaluated how quickly and effectively new trainers are able to gain simulator proficiency, determined that after a 6-hour train-thetrainer workshop, the newly simulator-trained endoscopists were able to effectively conduct independent workshops for gastroenterology fellows in 4 hemostasis techniques. Fellows under the direction of the new teachers made significant progress on the models. The hemostasis skills acquisition of the fellows participating in this study were of similar magnitude to that achieved in prior trials using more experienced trainers. Furthermore, the fellows consistently rated the teaching skills of the new trainers highly.22 If interest in hands-on simulation for credentialing and recredentialing in therapeutic endoscopy continues to grow, then the question that remains is, “How can it be achieved?” With the growing use of ex vivo models, there are growing opportunities. The American Society for Gastrointestinal Endoscopy (ASGE) Interactive Training and Technology (ITT) Center is a pivotal institution providing hands-on ex vivo training on a national level (http://www.asge.org). It has been suggested to further expand this training method by establishing centers of excellence on local levels. This decentralization of the ITT model may enhance the availability of ex vivo training to gastroenterologists.23 Additionally, the Society for American Gastrointestinal and Endoscopic Surgeons (SAGES) has developed a program to determine knowledge and skills in endoscopy termed Fundamentals in Endoscopic Surgery (http://www.fesprogram.org). The program utilizes Webbased didactics and hands-on simulators that can be used for training and assessing knowledge, judgment, and technical skills. Growth of such centers and programs from ASGE and SAGES can help measure aptitude and may set benchmarks for credentialing and recredentialing. In summary, interventional endoscopy will become more and more invasive in the future, which will further increase the demand for realistic simulator training. Comparable to flight simulator training, standard endoscopy techniques, particularly new endolumenal or translumenal procedures, may require the acquisition of skills in a simulator before they can be performed safely in patients. Computer simulators are helpful to train basic skills in standard endoscopic techniques and are becoming customizable for specific endoscopic encounters. Ex vivo hands-on simulator training provides the realistic simulation of interventional techniques with the opportunity to use commercially available devices and even prototypes. These modes of training have the potential to help patients by improving outcome and limiting patient harm. Finally, simulators may objectively assess various skill sets, ultimately guiding the way to better measurements of trainee proficiency.
Kai Matthes, MD Shyam J. Thakkar, MD Guest Editors
References 1. Felder RM, Silverman LK: Learning and teaching styles in engineering education. Engr Educ 78:674-681, 1988 2. Deviere J, Hochberger J, Neuhaus H, et al: Recommendations of the ESGE workshop on ethical, clinical, and economic dilemmas arising from the implementation of new techniques. First European Symposium on Ethics in Gastroenterology and Digestive Endoscopy, Kos, Greece, June 2003. Endoscopy 35:768-771, 2003 3. Borland JL Jr: Retraining in endoscopy. Gastrointest Endosc Clin N Am 5:363-372, 1995 4. Statements and guidelines developed by the Standards of Training and Practice Committee of the ASGE. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 34:1S-40S, 1988 5. Principles of training in gastrointestinal endoscopy. From the ASGE. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 49:845-853, 1999 6. Bisschops R, Wilmer A, Tack J: A survey on gastroenterology training in Europe. Gut 50:724-729, 2002 7. Seymour NE, Gallagher AG, Roman SA, et al: Virtual reality training improves operating room performance: Results of a randomized, double-blinded study. Ann Surg 236:458-463, 2002 [discussion: 463-464] 8. Grantcharov TP, Kristiansen VB, Bendix J, et al: Randomized clinical trial of virtual reality simulation for laparoscopic skills training. Br J Surg 91:146-150, 2004 9. Sedlack RE, Kolars JC: Computer simulator training enhances the competency of gastroenterology fellows at colonoscopy: Results of a pilot study. Am J Gastroenterol 99:33-37, 2004 10. Dunkin BJ: Flexible endoscopy simulators. Semin Laparosc Surg 10:29-35, 2003 11. MacDonald J, Ketchum J, Williams RG, et al: A lay person versus a trained endoscopist: Can the PreOp endoscopy simulator detect a difference? Surg Endosc 17:896-898, 2003 12. Ladas SD, Malfertheiner P, Axon A: An introductory course for training in endoscopy. Dig Dis 20:242-245, 2002 13. Bar-Meir S: A new endoscopic simulator. Endoscopy 32:898-900, 2000 14. Aabakken L, Adamsen S, Kruse A: Performance of a colonoscopy simulator: Experience from a hands-on endoscopy course. Endoscopy 32:911-913, 2000 15. Ferlitsch A, Glauninger P, Gupper A, et al: Evaluation of a virtual endoscopy simulator for training in gastrointestinal endoscopy. Endoscopy 34:698-702, 2002 16. Datta V, Mandalia M, Mackay S, et al: The PreOp flexible sigmoidoscopy trainer. Validation and early evaluation of a virtual reality based system. Surg Endosc 16:1459-1463, 2002 17. Gerson LB, Van Dam J: The future of simulators in GI endoscopy: An unlikely possibility or a virtual reality? Gastrointest Endosc 55:608611, 2002 18. Williams CB, Saunders BP, Bladen JS: Development of colonoscopy teaching simulation. Endoscopy 32:901-905, 2000 19. Noar MD, Soehendra N: Endoscopy simulation training devices. Endoscopy 24:159-166, 1992 20. Baillie J, Jowell P, Evangelou H, et al: Teaching by endoscopy simulation. Endoscopy 23:239-240, 1991 21. Waye JD, Leicester RJ: Teaching endoscopy in the new millennium. Gastrointest Endosc 54:671-673, 2001 22. Matthes K, Cohen J, Kochman ML, et al: Efficacy and costs of a one-day hands-on EASIE endoscopy simulator train-the-trainer workshop. Gastrointest Endosc 62:921-927, 2005 23. Vargo JJ: See one, do one, teach one. Gastrointest Endosc, 2008 67:419-221