SPED Statement: Training in Gastrointestinal Endoscopy

A. Models and modulable factors in endoscopy training

Gastrointestinal endoscopy (GIE) depends on the operator’s competence. The acquisition of the technical dexterity and the cognitive integrative skills needed for its performance rely on several factors, and ultimately on the success of the GI endoscopy learning/training process.

The traditional master apprentice model demands a difficult balance between the patient’s interests and trainee’s needs. Moreover, with the increasing productivity requirements, there is mounting pressure on the time available for training in the clinical setting. On the other hand, the rising complexity of patients and endoscopic procedures dictates the need for a more dedicated GIE training, that goes beyond the formal Gastroenterology residency, with advanced training and recertification of practicing endoscopists [1].

The search of the best GIE training program is an international hot topic. Training being one of SPED’s cornerstones, it was decided to sumarize the currently available evidence based knowledge and other scientific societies orientations, in a set of recommendations regarding GIE training as a “SPED statement”. This document is also important in order to understand the ongoing interventions by SPED School

Several topics will not be addressed in this document: advanced training in ERCP, EUS and enteroscopy; advanced training and recertification of practicing endoscopists; training of non-medical endoscopy staff.

For organizational reasons this item “Training in Gastrointestinal Endoscopy” will be divided in this position statment (A. Models and factors modulable in endoscopy training) and in another one (B. Competence and assessment in endoscopy).

SPED recommends that:

1. GIE training in Portugal should be in line with the international medical education. The current paradigm is a progressive transition from the subjective, number/time based master apprentice model to a structured simulator and patient based training with an objective competence based assessment [1] [2] [3]. This shift is already taking place in some scientific societies, who defined structured training programs and credentialing criteria – Joint Advisory Group on GI Endoscopy (JAG – UK) [4], ASGE e ASGE’s-STAR (EUA) [5], Conjoint Committee for Recognition of Training in GI Endoscopy (Austrália).

2. Basic training (upper endoscopy and colonoscopy) should be initiated in a validated virtual reality simulator (e. g. Simbionix GI Mentor II). This approach improves the novice’s technical skills and accelerates the learning curve, while minimizing patient’s risk and discomfort. Simulator based training is complementary and does not replace patient based training [6] [7], although its optimal integration on the training program is not yet defined. The described benefit ceases when a minimum duration/volume of training, or certain goals, are achieved [8] [9].

3. Training new procedures should first take place in a simulation based setting (model – mechanic, 3 D, ex vivo, in vivo - dependent on the specific procedure and training stage). Despite the limited scientific data available on the impact of some of these models in clinical practice, a potential benefit is assumed. Mechanical and ex vivo models can be used for the introduction of endoscopic resection techniques (polypectomy and EMR) and hemostatic therapy whilst the in vivo models are more suitable for the training of advanced procedures (EMR, ESD, stenting, POEM) [10] [11]. There is also some evidence that hands-on intensive courses have a positive impact on performance [5] [12].

4. Simulation based training must be structured in increasing complexity. When comparing self administered training with a structured simulation based training (theory sessions, simulation training and trainer feed-back) there is evidence of a significant positive impact in the performance of the later group in patients [13]. Moreover, a structured learning program comprising increasingly complex exercises has an even bigger impact that is also more durable [14].

5. Cognitive and behavior learning should complement technical hands-on training. Competence in endoscopy incorporates technical, cognitive and integrative skills. The later is essential for embedding the formers in order to execute quality endoscopy in different scenarios. All learning programs and hands-on training courses usually include cognitive learning (anatomy, lesion recognition, procedure indications, contraindications, alternatives, adverse events, equipment, specific preparation, etc). In fact there is evidence that interactive theoretical learning (including e-learning) improve lesion recognition and performance, accelerating competence acquisition [15] [16]. We also believe that the integrative and behavioral skills should be addressed in these hands-on training moments and in specific sessions (communication, decision making, team work, leadership skills, etc) [3].

6. The trainer should provide performance feed-back. Feed-back can be defined as specific information about the comparison between trainee’s observed performance and a standard. The quality, quantity, timing, and manner in which it is given are determinants. There is strong evidence about he role of efective feed-back on the learning results of the trainee in both simulation and patient based training [13] [17] [18].

7. Conditions should be created for trainers’ training, in order to ensure the quality of training process (communication, techniques, structure and evaluation of the sessions, must be uniform). This methodology is used in the above mentioned training programs that include procedure specific “train-the-trainers” sessions. An experienced endoscopist (unconscious competence – automaticity) may not be an adequate trainer because a conscious competence is needed in order to preform the task decomposition and to transmit its components. [1]. Trainee information overload while performing a certain task may be detrimental for his performance, the trainer should modulate the information, minimizing distractions and optimizing the trainee’s cognitive load [18] [19].

8. While the proposed change in training methodology is supposed to be applied to all training levels it should start at the core learning of GIE in the Gastroenterology residency. Core learning (basic GIE) includes upper endoscopy, colonoscopy, polypectomy, hemostatic techniques and management of adverse events (bleeding and perforation); advanced GIE comprises EMR, ESD, endoluminal stenting, ablative procedures, diverticulotomy, POEM, endoscopic suturing, etc (some demand a specific subspecialization period and certification). So as to change the present training/learning process to a competence based one, the Gastroenterology residency curriculum should be carefully reassessed in order to clarify each procedure training objectives/goals, methodology, and assessement.

On behalf of SPED’s Education Committee
Rolanda C, Vilas-Boas F, Eliseu L

• References

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