Advances and Challenges in Endoscopic Training
2018; Elsevier BV; Volume: 154; Issue: 7 Linguagem: Inglês
10.1053/j.gastro.2017.11.293
ISSN1528-0012
Autores Tópico(s)Pancreatic and Hepatic Oncology Research
ResumoOne of the challenges of the current era is ensuring that endoscopic training is accomplished effectively in the face of multiple competing demands. As health care delivery evolves, with rising patient complexity and increasing productivity requirements, there is mounting pressure on the time available for training in the clinical setting. The practice of endoscopy itself continues to expand to include increasingly complex procedures (eg, therapeutic endoscopic ultrasound, endoscopic submucosal dissection, and peroral endoscopic myotomy) that require dedicated endoscopy training. The rapid pace of progress in the field of endoscopy means that the demand for endoscopy training is not limited to the formal period of training, but instead spans the spectrum to include physicians already in practice. In light of recent advances in our understanding of endoscopy training, this review will serve to highlight the current state of affairs with respect to endoscopic training and how we can consider approaching these challenges. One of the challenges of the current era is ensuring that endoscopic training is accomplished effectively in the face of multiple competing demands. As health care delivery evolves, with rising patient complexity and increasing productivity requirements, there is mounting pressure on the time available for training in the clinical setting. The practice of endoscopy itself continues to expand to include increasingly complex procedures (eg, therapeutic endoscopic ultrasound, endoscopic submucosal dissection, and peroral endoscopic myotomy) that require dedicated endoscopy training. The rapid pace of progress in the field of endoscopy means that the demand for endoscopy training is not limited to the formal period of training, but instead spans the spectrum to include physicians already in practice. In light of recent advances in our understanding of endoscopy training, this review will serve to highlight the current state of affairs with respect to endoscopic training and how we can consider approaching these challenges. Walter CoyleView Large Image Figure ViewerDownload Hi-res image Download (PPT) Endoscopic training in routine procedures, such as upper endoscopy and colonoscopy, generally occurs during the course of a residency program, typically either gastroenterology fellowship or general surgery residency. The overall composition and structure of each training program is overseen by national accreditation bodies that set core curricular guidelines and are responsible for formal knowledge assessment at the end of training. In general, the requirements set forth by these accreditation bodies with respect to endoscopy training have been very limited in their scope. In the United States, for example, core curricular guidelines have only suggested minimum endoscopy volumes before assessing competence for upper and lower endoscopy.1American Association for the Study of Liver Diseases, American College of Gastroenterology, AGA Institute, American Society for Gastrointestinal Endoscopy A journey toward excellence: training future gastroenterologists—the gastroenterology core curriculum, third edition.Am J Gastroenterol. 2007; 102: 921-927Crossref PubMed Scopus (27) Google Scholar The curricular requirements for advanced endoscopic procedures are less stringent and, in practice, the exposure to these procedures varies from program to program. In the current training paradigm, each program is left to determine the specifics of endoscopy training. This responsibility falls upon the local program directors, along with their associated faculty, who typically have not been formally trained how to teach endoscopy. Trainees learn endoscopy from one or more practicing endoscopists during the course of managing patients in the clinical setting. This apprenticeship model has the advantage of work-based training, but it is recognized that the training experience requires a delicate balance between patient care and learners' needs, leading to potential variability of the clinical/learning experience.2Irby D.M. Cooke M. O'Brien B.C. Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010.Acad Med. 2010; 85: 220-227Crossref PubMed Scopus (584) Google Scholar Numerous other factors, including the demands of clinical care, local culture, organization of clinical rotations, and different patient populations encountered in programs can also lead to varied training experiences. The lack of formal training for clinicians in teaching is an important limitation as well. Although it is a common assumption that competence in endoscopy confers an ability to teach it, experience in endoscopy is not an automatic surrogate marker for skill in teaching. Residents are also often exposed to multiple teachers, which can limit the development of longitudinal relationships with endoscopy trainers, who themselves are under increasing demands on their time. With these factors in mind, it is clear that there is potential room for improvement in endoscopy training at the residency level. Subsequent to completing accredited residency training, additional endoscopic training is typically accomplished in the form of fellowships that last an additional year or longer, depending on the program. This type of training can be dedicated to subspecialization in endoscopy, such as endoscopic retrograde cholangiopancreatography or endoscopic ultrasound training. These programs are not formally accredited, which means that there is no mandated curriculum or standardized evaluation and less regulatory oversight than exists in residency and general fellowship programs. The length and structure of these fellowships can vary significantly from program to program. As is the case with general training programs, the attending staff involved in teaching are not mandated to have undergone formal training in how to teach. The main advantage at the fellowship level is the amount of accumulated experience required to reach this level of training. Overall, the same issues mentioned at the residency level are expected to occur in fellowship programs. Once an endoscopist is already in practice, it can be a major challenge to return for an additional year or fellowship program. Opportunities for endoscopic training, particularly hands-on training, outside of these programs are highly sought after by physicians in practice. The majority of these opportunities for physicians in practice arise via courses held by professional endoscopy societies or endoscopy- or device-related companies. Short-duration courses are thought to be less than ideal, given the lack of evaluation, feedback, and ongoing practice opportunities, but they are often the only option available. Given the rapid advances in endoscopic practice, the needs of the practicing clinician for training are likely to increase with time, and practical solutions are sorely needed. Responding to the challenges of our current endoscopic training system will require efforts at all levels of training in endoscopy. At the level of accreditation, a fundamental shift in medical education is gradually occurring at all levels of residency training away from the current time-based residency programs toward competency-based medical education (CBME). CBME has been defined as an outcomes-based approach to the design, implementation, assessment, and evaluation of medical education programs, using an organizing framework of competencies.3Frank J.R. Snell L. ten Cate O. et al.Competency-based medical education: theory to practice.Med Teach. 2010; 32: 638-645Crossref PubMed Scopus (1376) Google Scholar It has been gaining in popularity in medical education literature due to a focus on outcomes, an emphasis on abilities, a de-emphasis on time-based training, and the promotion of learner-centeredness. This transition has already occurred in the United States and is about to begin in Canada for gastroenterology and surgery. One of the main limitations of this transition has been that the competencies defined are fairly high level and generic—they are not specific to endoscopy. A nationwide survey of US Accreditation Council for Graduate Medical Education–accredited gastroenterology training programs in 2015 demonstrated that although the majority of program directors and trainees believed that measuring specific metrics is important in determining endoscopy competence, most programs relied on procedure volume and subjective attending evaluations to determine overall competence.4Patel S.G. Keswani R. Elta G. et al.Status of competency-based medical education in endoscopy training: a nationwide survey of US ACGME-accredited gastroenterology training programs.Am J Gastroenterol. 2015; 110: 959-962Crossref Scopus (58) Google Scholar It is clear that implementing CBME in endoscopy requires clarification of training milestones, instructional methods, and assessment tools in order to successfully transition to this framework—in other words a new formal endoscopy curriculum is needed. Table 1 illustrates the current state and ideal state for endoscopic training. Most programs are beyond the current state, however. The ideal state is not obtainable in every category but should be the goal of all training programs.Table 1Spectrum of Endoscopic Training in Training ProgramsVariableCurrent stateIdeal stateCurriculumAd hocApprenticeship modelFormal curriculum, competency-basedTrainers/facultyNo formal training in teachingFormal training (eg, train the trainer courses)Procedure volumeStrong emphasisOutcome-basedTime in trainingFixed/mandatedMilestone-basedSimulation: novice phaseRecommendedIntegrated into formal curriculumSimulation: intermediate to advanced learnerVoluntaryIntegrated into formal curriculumEvaluationsRequired/genericRequired/specificOutcomesAssessed near endContinuous assessment Open table in a new tab The lack of a comprehensive teaching curriculum for endoscopy training has been one of the major hurdles limiting the transition to the new CBME model. This has also made it impossible to study the impact of different curricula on quality and speed of skill acquisition in endoscopy. Recently, however, several innovative programs have included principles of CBME training specific to endoscopy (structured curricula with feedback and assessment methods) that provide insights into endoscopy training. The national training programs in the United Kingdom and Canada, for example, have both introduced formal training of endoscopy trainers in Train the Endoscopy Trainer courses.5Waschke K.A. Anderson J. Macintosh D. et al.Training the gastrointestinal endoscopy trainer.Best Pract Res Clin Gastroenterol. 2016; 30: 409-410Crossref PubMed Scopus (43) Google Scholar After completing the Train the Endoscopy Trainer programs, each trainer can then participate as faculty in colonoscopy skills improvement programs. In these skills improvement programs, both endoscopic and non-technical skills are addressed, including room setup, scope handling, intubation and withdrawal technique, loop recognition, and resolution with live endoscopy. Courses have been exported to multiple countries by those programs, with the goal of developing local expertise in endoscopy training. The impact of this hands-on training course for colonoscopists was shown by a randomized trial at a screening center in Poland that demonstrated improved quality measures (adenoma detection rate, proximal adenoma detection rate, and non-polypoid lesion detection rate) after the course when compared with simple audit and feedback.6Kaminski M.F. Anderson J. Valori R. et al.Leadership training to improve adenoma detection rate in screening colonoscopy: a randomized trial.Gut. 2016; 65: 616-624Crossref PubMed Scopus (119) Google Scholar This effect is particularly encouraging, given the short duration of the course and the sustained effect on colonoscopy performance over 1.5 years. The main strength of these courses lies in the formal training of trainers, the use of a structured curriculum, and effective feedback and assessment methods. Table 2 illustrates the current state vs an ideal state in which endoscopic learning continues in a self-directed lifelong fashion. Many of these concepts are difficult to implement or represent a radical change from the present, with potential for unintended consequences and, therefore, we recommend that they be kept voluntary or at least private, such as endoscopic report cards, until such time that our educational system has evolved closer to the ideal state.Table 2Endoscopic Learning by PractitionersVariableCurrent stateIdeal stateLearning new proceduresDifficulty learning new proceduresCoordinated approach with online CME/learning management systems/assessment-based programQuality measuresGovernment-driven (mandated)Learner-centered (lifelong self-directed learning)SimulationNoneRefresher coursesOutcomes assessmentVoluntaryProcess improvementEndoscopic report cardsNoneComparison with peers in order to assist in detection of unperceived learning needsaEndoscopic self- reporting encouraged.New techniquesSelected coursesExpanded optionsCME, continuing medical education.a Endoscopic self- reporting encouraged. Open table in a new tab CME, continuing medical education. The American Society of Gastrointestinal Endoscopy's STAR (Skills, Training, Assessment and Reinforcement) program is another program that includes formative feedback and assessment with CBME principles.7ASGE Update.Gastrointest Endosc. 2016; 84: 15AAbstract Full Text PDF Google Scholar This certificate-based program combines an online curriculum with assessment, live course with hands-on training featuring ongoing formative evaluation and feedback, and a post-course skills assessment and knowledge assessment. The strength of this program lies again in a well-developed curriculum (in this case, for advanced endoscopic procedures: upper and lower mucosal resection, Barrett's endotherapy, endoscopic suturing) with formal training of trainers and the use of regular feedback and assessment. Implementing elements of these successful programs within residency and fellowship programs could be a way of bridging the past apprenticeship model with the new CBME model. It is clear from the aforementioned examples that formal training in endoscopic teaching can have an impact on improving training at physicians already in practice, and it should improve training at any level. Endoscopy is considered to be a complex skill that is comprised of multiple elements; cognitive, psychomotor, and attitudinal components. This complexity likely accounts in part for the current endoscopy training infrastructure, as performing endoscopy at a high skill level requires attention to all of these areas. An additional process that may account for some of the difficulty faced by endoscopy trainers is termed automaticity.8Logan G.D. Toward an instance theory of automatization.Psychol Rev. 1988; 95: 492-527Crossref Scopus (2417) Google Scholar When a skill is developed and no longer requires conscious thought for efficient performance this is termed automaticity. The advantage conferred by this psychological process is speed and fluidity of movement. Anyone who remembers learning to ride a bicycle can recall when automaticity occurred in that setting. The disadvantage to automaticity is that the behavior is no longer under conscious control, and therefore explaining the components can be impossible. For this reason, many endoscopists may be skilled at endoscopy, but find it easier to take a scope out of a learner's hands in order to show what to do, rather than being able to describe the necessary steps. The ability to be able to decompose a task into smaller part tasks is believed to be a useful step in the acquisition of new skills. Understanding a task and all of its components and being able to consciously describe them is a necessary skill for endoscopy trainers. This is termed conscious competence and should be a goal of every endoscopy trainer. Without this element, all subsequent aspects of training are a significant challenge. The planning of training is an essential first step in improving endoscopy training that does not require the presence of a formal curriculum. In the current paradigm in which training occurs in the clinical setting, learning opportunities can be maximized if active planning is done by the trainer beforehand. Picture the following scenarios, for example, a resident or fellow in their first week of endoscopy training, an intermediate level resident who can perform basic upper endoscopy but is struggling to reach the cecum once they pass the splenic flexure, or the advanced endoscopy fellow who is trying to improve their cannulation rate. In each example, it is important to consider who the trainee is, what their prior knowledge and experience may be, and what areas of training may be most useful to them given the scenario in question. With experience, this process becomes second nature. Before meeting each of these trainees, it is essential to have given thought to the learning objectives of the encounter, how to assess each session, what materials are needed and how much time is likely needed. Depending on the scenario, this may vary substantially. Once a training session is planned out and about to begin, a very useful approach before starting any training session is to ask the trainee what they think the focus of training should be from their perspective. This allows the trainer to evaluate what the trainees' motivation and priorities are. Although learners may be unable to answer at times, particularly trainees with no prior experience with this process, trying to determine the learner's goals is critical, as most learners and trainers typically have very different agendas at the start of training. Before starting any training session, both agendas should be aligned with respect to the teaching outcome. For example, if the learner believes that their priority is learning advanced polypectomy technique, but the trainer thinks the highest yield will be loop recognition and resolution, this needs to be actively resolved before continuing. Finally, expectations and ground rules should be addressed at this point, particularly with respect to patient safety issues, such as when to stop a procedure or when the scope should be passed to the trainer. We will now address each scenario in turn to elaborate additional elements that can be integrated into endoscopy training. In this scenario, the learner is typically inexperienced and unaware of how much there is to learn about endoscopy. Learners at this level typically view problems at a superficial level and perceive things very differently from highly skilled endoscopists. When designing training for this level, the trainer should provide highly structured training. As with all levels of learners, learning objectives should be stated beforehand, clearly defined and be accompanied by explicit feedback and regular formative assessment. With clear, measurable end points, these objectives afford the learner opportunities for repetition and error correction, which are both considered to be important elements of effective practice. It is clear from colonoscopy assessment studies, for example, that learners develop colonoscopy skill by progressing through phases of development, rather than attaining competence at a predefined threshold number of procedures.9Ekkelenkamp V.E. Koch A.D. de Man R.A. et al.Training and competence in GI endoscopy: a systematic review.Gut. 2016; 65: 607-615Crossref PubMed Scopus (114) Google Scholar As learners' endoscopy skill develops, these objectives can evolve, with the learner gradually developing the ability to self-assess and set their own objectives. At the novice level, it is useful to begin endoscopy training with a formal orientation process. This process can include peer to peer instruction as residents or fellows of an intermediate or advanced higher level are typically intimately knowledgeable with the novices' needs (eg, for preparing the on-call endoscopy cart for emergencies) as it is very recent in their minds. This can also assist clinical staff with workload pressures at the start of training. With proper mentoring, this can also be used as a way to further develop the endoscopy training skills of the residents and fellows. At this level of training, there has been significant interest and literature in the area of endoscopy simulators, which will be examined next. Unlike the flight industry, medical specialties have been slow to adopt and utilize simulation as part of training, credentialing, or privileging.10Zanchetti D.J. Schueler S.A. Jacobson B.C. et al.Effective teaching of endoscopy: a qualitative study of the perceptions of gastroenterology fellows and attending gastroenterologists.Gastroenterol Rep. 2016; 210: 125-130Crossref Scopus (14) Google Scholar There are multiple reasons, but the most important seem to be cost, inadequacy of the simulators, and tenacious adherence to the apprenticeship model of teaching. Multiple studies in many of the surgical and medical specialties in the past decade have shown that simulators can improve skill, use of medical devices, and shorten the length of procedures.11Dawe S. Windsor J. Broeders J. et al.A systematic review of surgical skills transfer after simulation-based training: laparoscopic cholecystectomy and endoscopy.Ann Surg. 2014; 259: 236-248Crossref PubMed Scopus (151) Google Scholar Most of these studies have focused on novice learners and shown improved performance, particularly in the first few clinical cases.12Blackburn S.C. Griffin S.J. Role of simulation in training the next generation of endoscopists.World J Gastrointest Endosc. 2014; 6: 234-239Crossref PubMed Google Scholar Few studies have been done to demonstrate that simulation can be used to assess the skill level and competency of a practicing physician.13Walsh C.M. Sherlock M.E. Ling S.C. et al.Virtual reality simulation training for health professions trainees in gastrointestinal endoscopy.Cochrane Database Syst Rev. 2012 Jun 13; : CD008237PubMed Google Scholar This is surprising because it is the standard in the air industry for civilian and military pilots to be reassessed and retrained in simulators throughout their lifetime.14Lee A. Flight Simulation: Virtual Environments in Aviation. Taylor and Francis, New York2016Google Scholar In gastroenterology, simulation for practicing physicians has been used mostly for hands-on learning of a new skill, such as radiofrequency ablation, endoscopic mucosal resection, and mucosal clipping and suturing.15van der Wiel S.E. Kuttner Magalhaes R. Rocha Goncalves C.R. et al.Simulator training in gastrointestinal endoscopy—from basic training to advanced endoscopic procedures.Best Pract Res Clin Gastroenterol. 2016; 30: 375-387Crossref PubMed Scopus (43) Google Scholar The simulators have mostly been animal hybrid models, such as porcine stomachs and bovine colons. There is a wide variety of simulators available for endoscopic training and we will discuss the various models. The box model or the part task simulator is the most basic and inexpensive of the simulators.16Thompson C.C. Jirapinyo P. Kumar N. et al.Development and initial validation of an endoscopic part-task training box.Endoscopy. 2014; 46: 735-744Crossref PubMed Scopus (29) Google Scholar Instead of attempting to reproduce actual endoscopic experience, these devices focus on specific tasks that can be learned and practiced. Endoscopy is broken down into its component parts, such as tip control, torque, insertion, and reduction. Familiarity and experience handling a scope are achieved outside a clinical or organic model. Recent studies have shown that these devices significantly and rapidly improve novice skills with endoscopic devices, which translates over to clinical skill in the early endoscopic learning period.17Jirapinyo P. Abidi W. Zaki T. et al.Preclinical endoscopic training using a part-task simulator: learning curve assessment and determination of threshold score for advancement to clinical endoscopy.Gastrointest Endosc. 2016; 83: AB114Abstract Full Text Full Text PDF Google Scholar These devices are relatively inexpensive and are especially useful when coupled with other methods of simulation. An unexplored role for these devices would be retraining and assessment of practicing clinicians who develop disability from injury or stroke. Live animal models provide the ideal tool and have been used in the training of surgeons, research, and during courses in Advanced Trauma and Life Support.18Hall R.B. Randomized objective comparison of live tissue training versus simulators for emergency procedures.Am Surg. 2011; 77: 561-565Crossref PubMed Google Scholar These models are quite expensive, require veterinary support, housing facilities, and are generally not reusable. Separate endoscopy equipment must be maintained when using animals. Ethical considerations must also be addressed when using live animals.19Garrett J.R. The Ethics of Animal Research: Exploring the Controversy. The MIT Press, Cambridge, MA2012Crossref Google Scholar Composite or hybrid models have been used more recently.20Ahn J.Y. Lee J.S. Lee G.H. et al.The efficacy of a newly designed, easy-to-manufacture training simulator for endoscopic biopsy of the stomach.Gut Liver. 2016; 10: 764-772Crossref PubMed Scopus (9) Google Scholar In these models, the part of an animal is used in a holding tray or other mechanical device. Other attachments and reusable tools are usually added, depending on what is being learned. These devices have been used to train novice learners and teach more advanced skills, like endoscopic retrograde cholangiopancreatography or stent placement. The advantage of these tools is that the composite parts can be reused and there is a stable supply of animal parts from the food industry. Most learners prefer these models.21Ende A. Zopf Y. Konturek P. et al.Strategies for training in diagnostic upper endoscopy: a prospective randomized trial.Gastrointest Endosc. 2011; 75: 254-260Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar The devitalized tissue, however, does not perform as well as live tissue and can make techniques like banding, submucosal injection, and endoscopic mucosal resection more difficult and unrealistic. Virtual simulators have been in development for many years and there are several major endoscopic simulator manufacturers.22Harpham-Lockyer L. Laskaratos F.M. Berlingieri P. et al.Role of virtual reality simulation in endoscopy training.World J Gastrointest Endosc. 2015; 7: 1287-1294Crossref PubMed Google Scholar Various studies have shown significant improvement in skills and speed by learners. No significant clinical outcomes and safety have been demonstrated when these devices have been studied. The positive effect is most profound in the initial clinical cases with novice endoscopists.23Koch A. Ekkelenkamp V. Haringsma J. et al.Simulated colonoscopy training leads to improved performance during patient-based assessment.Gastrointest Endosc. 2015; 81: 630-636Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 24Ferlitsch A. Schoefl R. Puespoek A. et al.Effect of virtual endoscopy simulator training on performance of upper gastrointestinal endoscopy in patients: a randomized controlled trial.Endoscopy. 2010; 42: 1049-1056Crossref PubMed Scopus (54) Google Scholar These devices are expensive but can be used repeatedly and no dedicated endoscopic equipment is required. The main problem has been the inability to replicate the experience in a live human. The haptic limitations continue to be a problem, but the quality of the devices is improving over time. The newest simulation tool to be developed are 3-dimensional printed organs.25Dhir V. Itoi T. Fockens P. et al.Novel ex vivo model for hands-on teaching of and training in EUS-guided biliary drainage: creation of "Mumbai EUS" stereolithography/3D printing bile duct prototype.Gastrointest Endosc. 2015; 81: 440-446Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 26Holt B.A. Hearn G. Hawes R. et al.Development and evaluation of a 3D printed endoscopic ampullectomy training model.Gastrointest Endosc. 2015; 81: 1470-1475Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar The use of plastic or other polymers still limits the realism and haptic sense of these models, but the organs can be copied and lesions printed into the simulated tissue. As 3-dimensional printing matures and live cells are inserted into printed lattices and matrices, we may finally be able to reproduce organs with the feel and realism of human tissue. The expense of these models may also be an issue. There is a common theme in studies with any gastrointestinal simulation. Active mentoring by a skilled endoscopist improves results.27Grover S. Garg A. Scaffidi M. et al.Impact of a simulation training curriculum on technical and nontechnical skills in colonoscopy: a randomized trial.Gastrointest Endosc. 2015; 82: 1072-1079Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar Leaving learners alone with simulation can create poor habits and behaviors. Engaged instructors can immediately correct poor scope handling, identify ergonomic risk factors, and provide timely feedback. Simulation should also be progressive in difficulty to optimize the learner's development. Adult learning theory supports a progressive increase in level of difficulty matched to the learne
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