Portal de Periódicos da CAPES

Training in EUS and ERCP: standardizing methods to assess competence

2018; Elsevier BV; Volume: 87; Issue: 6 Linguagem: Inglês

10.1016/j.gie.2018.02.009

1097-6779

Sachin Wani, Rajesh N. Keswani, Bret T. Petersen, Steven A. Edmundowicz, Catharine M. Walsh, Christopher Huang, Jonathan Cohen, Gregory A. Coté,

Esophageal and GI Pathology

Postgraduate interventional endoscopy fellowships were created in response to the burgeoning portfolio of therapeutic endoscopy.1Moffatt D.C. Yu B.N. Yie W. et al.Trends in utilization of diagnostic and therapeutic ERCP and cholecystectomy over the past 25 years: a population-based study.Gastrointest Endosc. 2014; 79: 615-622Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 2Hogan W.J. Third tier certification: additional training for “specialized” endoscopic expertise.Gastrointest Endosc. 1988; 34: 292-293Abstract Full Text PDF Google Scholar Many programs recognized that comprehensive training in ERCP and EUS could not be achieved within the 3-year curriculum of an Accreditation Council for Graduate Medical Education (ACGME)–accredited fellowship in gastroenterology, hepatology, and nutrition. Although these postgraduate fellowships initially focused on ERCP and/or EUS, these postgraduate fellowships have evolved to include various combinations of training in ERCP and EUS, complex endoscopic resection (eg, large polyp EMR and endoscopic submucosal dissection [ESD]), endoluminal stent placement, advanced closure techniques, and bariatric endoscopy. Although the breadth of training has increased, the duration of these training programs has remained the same or been shortened. Given the myriad procedures that trainees must learn and the central role of EUS and ERCP in these training programs, assessing competence in these advanced endoscopic procedures is vital. To achieve this goal, the use of validated, task-specific, skills-assessment tools is of paramount importance. The goals of this American Society for Gastrointestinal Endoscopy (ASGE) document are to (1) present the rationale and methods to assess competence in performing EUS and ERCP, (2) describe an evidence-based tool for the assessment of competence in EUS and ERCP, and (3) outline a means of tracking and assessing procedures that align with the competency-based medical education ACGME guidelines. Advanced endoscopy training traditionally has been based on an apprenticeship model. At the end of this training period, in lieu of a formal assessment of competence, volume is often used as a surrogate for competence. It is instructive to understand how the various volume thresholds (to ensure procedural competence) were established. Initially, minimum ERCP volume recommendations were determined by expert opinion. This resulted in early guidelines recommending as few as 35 supervised ERCPs for cognitive and technical competence.3Health and Public Policy Committee, American College of Physicians. Clinical competence in diagnostic endoscopic retrograde cholangiopancreatography.Ann Intern Med. 1988; 108: 142-144Crossref PubMed Scopus (30) Google Scholar Two of the first studies that attempted to correlate volume with competence were published in 1996.4Watkins J.L. Etzkorn K.P. Wiley T.E. et al.Assessment of technical competence during ERCP training.Gastrointest Endosc. 1996; 44: 411-415Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 5Jowell P.S. Baillie J. Branch M.S. et al.Quantitative assessment of procedural competence: a prospective study of training in endoscopic retrograde cholangiopancreatography.Ann Intern Med. 1996; 125: 983-989Crossref PubMed Scopus (241) Google Scholar In 1 study of 20 trainees,4Watkins J.L. Etzkorn K.P. Wiley T.E. et al.Assessment of technical competence during ERCP training.Gastrointest Endosc. 1996; 44: 411-415Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar the authors found that, even after 100 procedures, trainees did not consistently achieve a cannulation rate of >85%. Thus, the authors concluded that >100 ERCPs were needed to achieve competence in diagnostic ERCP; this recommendation was echoed in the contemporaneous ASGE Gastroenterology Core Curriculum. In a second study, Jowell et al5Jowell P.S. Baillie J. Branch M.S. et al.Quantitative assessment of procedural competence: a prospective study of training in endoscopic retrograde cholangiopancreatography.Ann Intern Med. 1996; 125: 983-989Crossref PubMed Scopus (241) Google Scholar assessed competence in a variety of ERCP-related skills including cannulation, stent insertion, and sphincterotomy. The authors similarly found that deep biliary cannulation was not reliably achieved by all trainees, but the data suggested that trainees who performed at least 180 ERCPs achieved competence in this specific skill. Subsequent ASGE and National Institutes of Health consensus guidelines published in 2002 recommended that competence be assessed—but cannot be assured—after 200 ERCP procedures and 150 EUS procedures.6Eisen G.M. Baron T.H. Dominitz J.A. et al.Methods of granting hospital privileges to perform gastrointestinal endoscopy.Gastrointest Endosc. 2002; 55: 780-783Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar, 7NIH state-of-the-science statement on endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy.NIH Consens State Sci Statements. 2002; 19: 1-26Google Scholar No measure to assess competence was offered. A recent systematic review of the literature on ERCP training showed that trainee competence was achieved across a wide range of procedure volumes (overall, 70-400; selective duct cannulation, 79-300; common bile duct cannulation rate, 160-400; and native papilla common bile duct cannulation, 350-400).8Shahidi N. Ou G. Telford J. et al.When trainees reach competency in performing ERCP: a systematic review.Gastrointest Endosc. 2015; 81: 1337-1342Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar, 9Verma D. Gostout C.J. Petersen B.T. et al.Establishing a true assessment of endoscopic competence in ERCP during training and beyond: a single-operator learning curve for deep biliary cannulation in patients with native papillary anatomy.Gastrointest Endosc. 2007; 65: 394-400Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar There is little information on ERCP training of trainees who are not gastroenterologists.10Vitale G.C. Zavaleta C.M. Vitale D.S. et al.Training surgeons in endoscopic retrograde cholangiopancreatography.Surg Endosc. 2006; 20: 149-152Crossref PubMed Scopus (33) Google Scholar Based on recent quality indicators in ERCP that established a threshold of 90% for cannulation of ducts of interest in native papilla cases,11Adler D.G. Lieb 2nd, J.G. Cohen J. et al.Quality indicators for ERCP.Gastrointest Endosc. 2015; 81: 54-66Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar it should be noted that the benchmark used in previous studies to define success in terms of cannulation rates (80%) may have been set too low. There are few historical data on volumes required for trainees to achieve EUS competence. Early volume recommendations appeared to be based on expert opinion.6Eisen G.M. Baron T.H. Dominitz J.A. et al.Methods of granting hospital privileges to perform gastrointestinal endoscopy.Gastrointest Endosc. 2002; 55: 780-783Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar In part, this is most likely because of the inability to identify a universally applicable endpoint relevant to EUS. Because cannulation is central to all ERCP procedures, selective cannulation rate has always been an attractive primary endpoint. A comparable metric in EUS is less clear: successful identification and characterization of the lesion of interest? adequate cellularity from FNA or biopsy? Given the myriad indications and unique challenges associated with EUS for different pathologies, 1 or both of these questions cannot be assigned to EUS procedures unambiguously. These data highlight the fact that procedure volume thresholds—or a 1 size fits all metric—are inadequate to assure competence. Task-specific, direct observational assessment tools with strong evidence of validity and reliability are needed. Societal endoscopy credentialing guidelines have relied on the described limited available data to generate minimum procedure volumes wherein competence might be obtained (Tables 1 and 2). However, most current guidelines specify competence thresholds as opposed to absolute procedure volume requirements as a means to determine competence in EUS and ERCP, with thresholds varying between guidelines.12Polkowski M. Larghi A. Weynand B. et al.Learning, techniques, and complications of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Guideline.Endoscopy. 2012; 44: 190-206Crossref PubMed Scopus (241) Google Scholar, 13Faulx A.L. Lightdale J.R. Acosta R.D. et al.ASGE Standards of Practice CommitteeGuidelines for privileging, credentialing, and proctoring to perform GI endoscopy.Gastrointest Endosc. 2017; 85: 273-281Abstract Full Text Full Text PDF PubMed Scopus (108) Google Scholar, 14Conjoint Committee for Recognition of Training in Gastrointestinal Endoscopy (on behalf of the Royal Australasian College of Surgeons, the Gastroenterological Society of Australia and the Royal Australasian College of Physicians), 2008. Available at: http://www.conjoint.org.au/. Accessed July, 2017.Google Scholar, 15British Society of Gastroenterology. Guidelines for the training, appraisal and assessment of trainees in gastrointestinal endoscopy and for the assessment of units for registration and re-registration 2004. Available at: http://www.bsg.org.uk/training/general/training-programmes.html. Accessed July, 2017.Google Scholar, 16British Society of Gastroenterology. ERCP: The way forward, a Standards framework (June 2014). Available at: http://www.bsg.org.uk/clinical/news/ercp-%E2%80%93-the-way-forward-a-standards-framework.html. Accessed June 10, 2015.Google Scholar, 17Jorgensen J. Kubiliun N. Law J.K. et al.ASGE Training CommitteeEndoscopic retrograde cholangiopancreatography (ERCP): core curriculum.Gastrointest Endosc. 2016; 83: 279-289Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 18Springer J. Enns R. Romagnuolo J. et al.Canadian credentialing guidelines for endoscopic retrograde cholangiopancreatography.Can J Gastroenterol. 2008; 22: 547-551Crossref PubMed Scopus (21) Google Scholar A competence threshold is a minimum number of supervised procedures that a trainee is required to perform before competence can be assessed; an assessment of competence then requires direct observation and the use of objective criteria. The most recent document on privileging and credentialing in endoscopy by the ASGE suggests that at least 225 hands-on EUS cases and 200 supervised independent ERCP procedures (including 80 independent sphincterotomies and 60 biliary stent placements) should be performed before learner competence is assessed.13Faulx A.L. Lightdale J.R. Acosta R.D. et al.ASGE Standards of Practice CommitteeGuidelines for privileging, credentialing, and proctoring to perform GI endoscopy.Gastrointest Endosc. 2017; 85: 273-281Abstract Full Text Full Text PDF PubMed Scopus (108) Google Scholar It should be noted that these guidelines are not validated, and these thresholds do not account for the variable rates at which trainees learn and acquire endoscopic skills.19Wani S. Hall M. Wang A.Y. et al.Variation in learning curves and competence for ERCP among advanced endoscopy trainees by using cumulative sum analysis.Gastrointest Endosc. 2016; 83: 711-719 e11Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar, 20Northup P.G. Argo C.K. Muir A.J. et al.Procedural competency of gastroenterology trainees: from apprenticeship to milestones.Gastroenterology. 2013; 144: 677-680Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 21Eisen G.M. Dominitz J.A. Faigel D.O. et al.Guidelines for advanced endoscopic training.Gastrointest Endosc. 2001; 53: 846-848Abstract Full Text Full Text PDF PubMed Google Scholar Thus, these recommended volume thresholds generally have been accompanied by the caveat that a minimum volume of procedures cannot ensure competence. The thresholds remain valuable to guide training programs as to the minimum case volume they need to offer trainees and when they can realistically begin to make summative skill assessment of trainees based on objective criteria.Table 1Guidelines for assessment of EUS competence∗These numbers represent the minimum number of cases needed to be completed before competence can be assessed.ASGE(United States)FOCUS(Canada)ESGE(Europe)BSG(United Kingdom)Year of publication2017201620122011Total no. of supervised cases225250NR250Pancreaticobiliary indicationNR100NR150 (75 pancreatic cancer)Luminal indication (mucosal)NR25 Rectal EUSNR80 (10 Rectal EUS)Subepithelial lesionNRNRNR20EUS-guided FNANR50 (10 CPB, CPN)50 (30 pancreatic)75 (45 pancreatic)ASGE, American Society for Gastrointestinal Endoscopy; FOCUS, Forum on Canadian Endoscopic Ultrasound; ESGE, European Society of Gastrointestinal Endoscopy; BSG, British Society of Gastroenterology; NR, not reported; CPB, celiac plexus block; CPN, celiac plexus neurolysis.∗ These numbers represent the minimum number of cases needed to be completed before competence can be assessed. Open table in a new tab Table 2Guidelines for assessment of competence in ERCP∗These numbers represent the minimum number of cases needed to be completed before competence can be assessed.Society guidelinesThresholds for assessment of competenceAmerican Society for Gastrointestinal Endoscopy200 supervised ERCPs; at least 80 independent sphincterotomies and 60 biliary stent placementsGastroenterological Society of Australia and Canadian Association of Gastroenterology200 unassisted ERCPs with native papillary sphincters, 80 independent sphincterotomies, and 60 stentsBritish Society of GastroenterologyAt least 300 ERCPs, with a cannulation rate of >80% (last 50 cases); must be competent in sphincterotomy, stone extraction, and stent placement∗ These numbers represent the minimum number of cases needed to be completed before competence can be assessed. Open table in a new tab ASGE, American Society for Gastrointestinal Endoscopy; FOCUS, Forum on Canadian Endoscopic Ultrasound; ESGE, European Society of Gastrointestinal Endoscopy; BSG, British Society of Gastroenterology; NR, not reported; CPB, celiac plexus block; CPN, celiac plexus neurolysis. We recognize that reliance solely on minimum procedure volumes has a number of limitations because it would require several assumptions regarding training, specifically (1) all trainees learn at the same speed; (2) trainees learn all skills at the same speed; (3) all trainers are equivalent educators; (4) trainees are exposed to procedures of similar complexity and with comparable opportunities for supervised, hands-on learning; and (5) trainees acquire cognitive endoscopy skills at the same rate as technical skills. Because these assumptions are clearly unrealistic, it is imperative that we use more rigorous methodologies to assess competence. Based on these limitations, there has been a greater emphasis on learning curves. One of the largest studies assessing competence in cannulation for 15 trainees was prospectively performed in the Netherlands.22Ekkelenkamp V.E. Koch A.D. Rauws E.A. et al.Competence development in ERCP: the learning curve of novice trainees.Endoscopy. 2014; 46: 949-955Crossref PubMed Scopus (47) Google Scholar This demonstrated that trainees acquire competence in ERCP skills at variable rates based on the skill assessed. Specifically, this study recognized that trainees achieve competence in native papilla cannulation much later than other ERCP skills. Thus, competence assessment must account for the variable rates at which specific milestones are achieved. Results of a recent prospective multicenter study highlighted the learning curves in ERCP among advanced endoscopy trainees using a standardized assessment tool and cumulative sum (CUSUM) analysis.19Wani S. Hall M. Wang A.Y. et al.Variation in learning curves and competence for ERCP among advanced endoscopy trainees by using cumulative sum analysis.Gastrointest Endosc. 2016; 83: 711-719 e11Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar This study demonstrated significant variability in the number of ERCPs performed during training and in the learning curves for cognitive and technical aspects of ERCP. We have previously demonstrated substantial variability in the number of procedures required to achieve competence in EUS and that a specific case load does not ensure trainee competence.23Wani S. Hall M. Keswani R.N. et al.Variation in aptitude of trainees in endoscopic ultrasonography, based on cumulative sum analysis.Clin Gastroenterol Hepatol. 2015; 13: 1318-1325 e2Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar These findings parallel a growing movement in medical education. There is an increasing emphasis on standardizing competence assessments and demonstrating readiness for independent practice, as medical training in North America transitions from an apprenticeship model to competency-based medical education. The ACGME has replaced its reporting system with the Next Accreditation System, which is a continuous assessment reporting system focused on ensuring that specific milestones are reached throughout training, that competence is achieved by all trainees, and that these assessments are documented by training programs. There has been an evolution in the definition of competence itself. ERCP competence traditionally has been defined as the ability to cannulate the duct of choice (selective cannulation). However, this important first step does not ensure procedural success and thus is an incomplete measure of competence. In contrast, successfully completing the entirety of a procedure is a more comprehensive measure of competence. Similarly, the trainer could use a global assessment of competence wherein he or she assesses trainee competence via a single question assessing technical and cognitive skill. Although these single composite competence measures are useful, their impact during training is limited, because they do not provide specific and directed feedback. Ideally, evaluation would assess performance on individual skills (eg, successful cannulation, stone extraction, stent placement) as well as the global assessment of competence.24Wani S. Cote G.A. Keswani R. et al.Learning curves for EUS by using cumulative sum analysis: implications for American Society for Gastrointestinal Endoscopy recommendations for training.Gastrointest Endosc. 2013; 77: 558-565Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar Thus, the development of validated competence assessment tools is essential for both ERCP and EUS training. In sum, a rigorous assessment of competence cannot rely on procedure volume. A minimum number of cases performed under supervision remains a necessary but insufficient step in the acquisition of competence. Instead, milestones such as native papilla cannulation success rates must be identified, assessment tools with strong validity evidence must be developed, and trainees must be assessed in a continuous fashion throughout fellowship. Furthermore, an ideal training program also would provide continuous feedback to trainees regarding which skills are lagging, so that trainees may seek additional educational opportunities. ACGME requirements for advanced endoscopy training during an accredited 3-year fellowship are minimal: (1) there must be at least 1 key faculty member participating in advanced endoscopy procedures; (2) advanced endoscopy volumes must comply with ASGE guidelines; (3) fellows must receive adequate instruction in and exposure to these procedures so they can request them appropriately in clinical practice; and (4) hands-on exposure for fellows is not required (http://www.acgme.org/Portals/0/PDFs/FAQ/144_Gastroenterology_FAQ.pdf). In contrast, no similar criteria exist to define what must be present (ie, number of faculty members, numbers of advanced procedures performed) in a dedicated advanced endoscopy fellowship. Data regarding the number of advanced endoscopy applicants, programs, and training content before 2012 are sparse. In an effort to standardize the process for applicants and programs, the ASGE established a match for advanced endoscopy fellowship programs in 2012 (www.asgematch.com). Since that time, the annual number of participating advanced endoscopy programs has been about 60, and the number of applicants has been about 110, resulting in program match rates of >90% and applicant match rates of <60%. Roughly 1 in 3 fellows graduating from an accredited ACGME fellowship program applies for an advanced endoscopy training position, despite the fact that these procedures comprise 200 ERCPs in order to receive credentials in their facilities.28Cotton P.B. Feussner D. Dufault D. et al.A survey of credentialing for ERCP in the United States.Gastrointest Endosc. 2017; 86: 866-869Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Results from a recent, large, multicenter, prospective study showed that the median number of EUS examinations performed during advanced endoscopy training was 300 (range 155-650), with the vast majority of procedures being performed for pancreaticobiliary indications.29Wani S. Keswani R. Hall M. et al.A prospective multicenter study evaluating learning curves and competence in endoscopic ultrasound and endoscopic retrograde cholangiopancreatography among advanced endoscopy trainees: the Rapid Assessment of Trainee Endoscopy Skills (RATES) study.Clin Gastroenterol Hepatol. 2017; 15: 1758-1767Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar The median number of ERCP examinations performed per trainee was 350 (range 125-500), and the median number of ERCP examinations performed in patients with native papillae was 51 (range 32-79). The majority of examinations were performed for biliary indications and met the grade 1 ASGE degree of difficulty. The overall mean time allowed for cannulation in cases with a native papilla was 5.7 minutes, and for cases in which trainees failed cannulation it was 6.2 minutes. Overall, advanced endoscopy trainees have limited exposure to ERCPs for pancreatic indications, those requiring advanced cannulation techniques (eg, freehand needle-knife sphincterotomy) and interventional EUS procedures. Given the technical complexity of ERCP, EUS, and other advanced endoscopic procedures, training has typically focused on technical aspects, such as cannulation and the diagnostic yield of FNA. Conceptually, competence in advanced endoscopy should be considered in 3 broad competence domains: (1) technical (psychomotor), (2) cognitive (knowledge and recognition), and (3) integrative (expertise and behavior).30Walsh C. In-training gastrointestinal endoscopy competency assessment tools: types of tools, validation and impact.Best Pract Res Clin Gastroenterol. 2016; 30: 357-374Crossref PubMed Scopus (31) Google Scholar Until recently, no instrument designed for ERCP, EUS, or any other advanced endoscopic procedure had incorporated all of these competence domains. In the United Kingdom, the Joint Advisory Group (JAG) has developed the direct observation of procedural skills (DOPS) program in colonoscopy and upper endoscopy. For colonoscopy, the DOPS instrument is used to assess performance in four domains: (1) assessment, consent, and communication; (2) safety and sedation; (3) endoscopic skills during insertion and withdrawal (the principal domain for assessing technical competence); and (4) diagnostic and therapeutic ability. These concepts can be transferred easily to ERCP and EUS, although these procedures are highly variable in their spectrum of indications and required maneuvers. EUS is particularly hampered by its poor interobserver variability, even among experts. Finally, the risks of ERCP often preclude adequate (even this requires definition) hands-on time—especially during cannulation. Competence does not happen; it develops over time. As such, the ACGME Next Accreditation System requires training programs to continuously monitor trainee development from not yet assessable to ready for unsupervised practice (the target) or beyond (aspirational). There is a critical need for instruments specific to ERCP and EUS that incorporate the core competencies of the ACGME and include key technical aspects for each procedure. Additionally, endoscopy trainers must learn how to perform these assessments systematically and consistently. Given the risks specific to ERCP, EUS-guided FNA (EUS-FNA), and EUS-directed therapies, additional considerations include the use of simulators and careful patient triage throughout the training process (for example, a trainee’s first attempt to cannulate a native papilla should not be a patient with complete pancreas divisum requiring minor papillary access). The ASGE recommends that advanced endoscopy programs consider using the EUS and ERCP Skills Assessment Tool (TEESAT) (Fig. 1), a competence assessment tool for EUS and ERCP with strong validity evidence.19Wani S. Hall M. Wang A.Y. et al.Variation in learning curves and competence for ERCP among advanced endoscopy trainees by using cumulative sum analysis.Gastrointest Endosc. 2016; 83: 711-719 e11Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar, 23Wani S. Hall M. Keswani R.N. et al.Variation in aptitude of trainees in endoscopic ultrasonography, based on cumulative sum analysis.Clin Gastroenterol Hepatol. 2015; 13: 1318-1325 e2Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar, 24Wani S. Cote G.A. Keswani R. et al.Learning curves for EUS by using cumulative sum analysis: implications for American Society for Gastrointestinal Endoscopy recommendations for training.Gastrointest Endosc. 2013; 77: 558-565Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar, 29Wani S. Keswani R. Hall M. et al.A prospective multicenter study evaluating learning curves and competence in endoscopic ultrasound and endoscopic retrograde cholangiopancreatography among advanced endoscopy trainees: the Rapid Assessment of Trainee Endoscopy Skills (RATES) study.Clin Gastroenterol Hepatol. 2017; 15: 1758-1767Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 31Cotton P.B. Eisen G. Romagnuolo J. et al.Grading the complexity of endoscopic procedures: results of an ASGE working party.Gastrointest Endosc. 2011; 73: 868-874Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar This tool facilitates assessment and grading of technical and cognitive skills and development of global assessments in a balanced manner. It should be used in a continuous fashion throughout fellowship training but not consecutive examinations. This tool uses a 4-point scoring system: (1) (novice) unable to complete the task and requiring the trainer to take over, (2) (intermediate) achieves the task with multiple verbal instructions or hands-on assistance, (3) (advanced) achieves the task with minimal verbal instruction, and (4) (superior) achieves the task independently. Setting these anchors for specific skills and behaviors is critical to ensure that the grading process is reproducible from one assessor to the next. In addition, this tool includes a global rating scale (4-point scale) used to provide an overall assessment of the trainee: (1) learning basic technical and cognitive aspects but requires significant assistance and coaching, (2) acquired basic technical and cognitive skills but requires limited hands-on assistance and/or significant coaching, (3)