The Endoscopic Training Triangle: Advancing from Focus on Skills to Competence-Based Training

The development of, research into, and implementation of learning strategies in medicine have evolved almost in parallel with the technological development of modern gastrointestinal endoscopy in recent decades. With the increasing numbers of accessories and procedural options available, the main focus has obviously been on manual skills in handling endoscopes and on conducting procedures safely and effectively.

Research has therefore mainly focused on estimating the number of supervised procedures necessary to achieve procedural competence (often defined as a 90 % success rate) in flexible sigmoidoscopy [1], gastroscopy and colonoscopy [2] [3], endoscopic retrograde cholangiopancreatography (ERCP) [4] [5], and more recently endoscopic ultrasonography (EUS) [6] [7] [8]. In these studies, the numbers proved to be much higher than assumed, and for endoscopists with less than 5 years’ experience in colonoscopy at least 200 annual colonoscopies are required to maintain adequate competence [6]. As a consequence, national and international societies have developed evidence-based guidelines and policies on training, accreditation, and retraining.

At the same time, the recent development of simulators [9] [10] and innovative devices and technologies, such as the variable-stiffness colonoscope [11] [12] and the real-time magnetic colonoscope imaging system [13] has been shown in randomized studies to have an impact on trainees’ performance. This is fortunate, since the number of colonoscopies available for trainees may decline in the years to come with the spread of computed-tomographic colonography, as happened with ERCP after the implementation of magnetic resonance cholangiopancreatography (MRCP).

In medicine, rapid decisions frequently have to be made without all the necessary information desirable being available. A model developed in the field of experimental nuclear engineering, which to a certain extent can be considered comparable to medicine in this respect, suggested that the first stage in practical learning in such an environment is the acquisition of skills, and that an individual can be competent in these skills before the full knowledge relating to the skill has been acquired - the skills then being applied using a series of rules [14]. It has also been theorized that with time, practical experience increases and is augmented by knowledge, leading eventually to the highest level of knowledge-based practice. This model is applicable to endoscopic procedural skills, and reflects what many of us have experienced in recent decades. However, a trial-and-error approach exposes patients to avoidable risks.

Recent research has emphasized the need to establish a broader theoretical foundation for clinical practice on the part of endoscopists, at least in Europe. As published in this issue of Endoscopy, the European Panel on the Appropriateness of Gastrointestinal Endoscopy investigated the appropriateness of colonoscopies in 5381 consecutive patients in 21 centers in 11 European countries. While the endoscopists themselves found that 219 colonoscopies (4 %) were inappropriate, the panel using validated criteria found that 1463 (26 %) were inappropriate. Furthermore, the colonoscopists themselves considered that indications were crucial (necessary) in 58 %, while the panel found that this was the case in only 21 % [15]. For ERCP, an analysis of complicated and fatal cases found that in a considerable number of these, the indications for the procedure were at best dubious, and among other findings, the series revealed faulty sphincterotomy technique leading to perforation and death [16]. These are examples of the types of issues that are highlighted in postgraduate courses and meetings, where trained endoscopists have an opportunity to receive regular updates on indications, techniques, etc.

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