Training and competence assessment in GI endoscopy: a systematic review.

INTRODUCTION: Training procedural skills in GI endoscopy once focused on threshold numbers. As threshold numbers poorly reflect individual competence, the focus gradually shifts towards a more individual approach. Tools to assess and document individual learning progress are being developed and incorporated in dedicated training curricula. However, there is a lack of consensus and training guidelines differ worldwide, which reflects uncertainties on optimal set-up of a training programme. AIMS: The primary aim of this systematic review was to evaluate the currently available literature for the use of training and assessment methods in GI endoscopy. Second, we aimed to identify the role of simulator-based training as well as the value of continuous competence assessment in patient-based training. Third, we aimed to propose a structured training curriculum based on the presented evidence. METHODS: A literature search was carried out in the available medical and educational literature databases. The results were systematically reviewed and studies were included using a predefined protocol with independent assessment by two reviewers and a final consensus round. RESULTS: The literature search yielded 5846 studies. Ninety-four relevant studies on simulators, assessment methods, learning curves and training programmes for GI endoscopy met the inclusion criteria. Twenty-seven studies on simulator validation were included. Good validity was demonstrated for four simulators. Twenty-three studies reported on simulator training and learning curves, including 17 randomised control trials. Increased performance on a virtual reality (VR) simulator was shown in all studies. Improved performance in patient-based assessment was demonstrated in 14 studies. Four studies reported on the use of simulators for assessment of competence levels. Current simulators lack the discriminative power to determine competence levels in patient-based endoscopy. Eight out of 14 studies on colonoscopy, endoscopic retrograde cholangiopancreatography and endosonography reported on learning curves in patient-based endoscopy and proved the value of this approach for measuring performance. Ten studies explored the numbers needed to gain competence, but the proposed thresholds varied widely between them. Five out of nine studies describing the development and evaluation of assessment tools for GI endoscopy provided insight into the performance of endoscopists. Five out of seven studies proved that intense training programmes result in good performance. CONCLUSIONS: The use of validated VR simulators in the early training setting accelerates the learning of practical skills. Learning curves are valuable for the continuous assessment of performance and are more relevant than threshold numbers. Future research will strengthen these conclusions by evaluating simulation-based as well as patient-based training in GI endoscopy. A complete curriculum with the assessment of competence throughout training needs to be developed for all GI endoscopy procedures.

Simulated colonoscopy training leads to improved performance during patient-based assessment.

BACKGROUND: Virtual reality (VR) endoscopy simulators are increasingly being used in the training of novice endoscopists. There are, however, insufficient data regarding the effect of simulator training on the early learning curve of novice endoscopists. OBJECTIVE: The aim of this study was to assess the clinical performance of novice endoscopists during colonoscopy after intensive and prolonged training on a VR endoscopy simulator. DESIGN: Prospective study. SETTING: Single university medical center. PATIENTS: Patient-based assessment (PBA) of performance was carried out on patients routinely scheduled for colonoscopy. INTERVENTIONS: Eighteen trainees without any endoscopic experience were included in the study. They were divided into 2 groups. The simulator-training program consisted of either 50 (group I) or 100 (group II) VR colonoscopies. After 10, 30, and 50 (group I) and after 20, 60, and 100 (group II) VR colonoscopies, trainees underwent both simulator-based assessment and PBA. MAIN OUTCOME MEASUREMENTS: Cecal intubation time, colonic insertion depth, and cecal intubation rate. RESULTS: Eighteen novices participated in the study. All completed VR training and assessments. The mean cecal intubation time on the SBA decreased from a baseline of 9.50 minutes to 2.20 minutes at completion of the training (P = .002). Colonic insertion depth during PBA improved from 29.4 cm to 63.7 cm (P < .001). The learning effect of simulator training ceased after 60 colonoscopies. LIMITATIONS: Single-center study, no formal sample size calculation. CONCLUSIONS: VR training by using a colonoscopy simulator leads to a significant improvement in performance with the simulator itself and, more importantly, to significantly improved performances during patient-based colonoscopy. This study demonstrates the rationale for intensive simulator training in the early learning curve of novices performing colonoscopy.

Quality evaluation through self-assessment: a novel method to gain insight into ERCP performance.

BACKGROUND: The American Society for Gastrointestinal Endoscopy Committee on Outcomes Research has recommended monitoring nine endoscopic retrograde cholangiopancreatography (ERCP)-specific quality indicators for quality assurance in ERCP. With the development of a self-assessment tool for ERCP (Rotterdam Assessment Form for ERCP-RAF-E), key indicators can easily be assessed. OBJECTIVE: The aim of this study was to test in daily practice an easy-to-use form for assessment of procedural quality in ERCP and to determine ERCP quality outcomes in a tertiary referral hospital. DESIGN: This was a prospective study carried out in a tertiary referral hospital. In January 2008, a quality self-assessment programme was started. Five qualified endoscopists participated in this study. All ERCPs were appraised using RAF-E. Primary parameters were common bile duct (CBD) cannulation rate and procedural success. The indication was classified and procedural difficulty was graded; success rates of therapeutic interventions were measured for all different difficulty degrees. RESULTS: A total number of 1691 ERCPs were performed. 1515 (89.6%) of these were appraised using RAF-E. Median CBD cannulation success rate was 94.1%. Successful sphincterotomy was accomplished in almost all patients (median 100%; range 98.2-100%). Stent placement was successful in 97.8% and complete stone extraction, if indicated, was achieved in 86.8%. CONCLUSIONS: Quality indicators for ERCP can be measured using the Rotterdam self-assessment programme for ERCP. Outcome data in ERCPs obtained with this RAF-E provide insight into the quality of individual as well as group performance and can be used to assess and set standards for quality control in ERCP.