North of 100 and south of 500: where does the “sweet spot” of colonoscopic competence lie?
Article Outline
Those who speak most of progress measure it by quantity and not by quality.
—George Santayana
Competence should not be considered a static concept during training or throughout a career.
Competence is defined as the possession of a required skill, knowledge, qualification, or capacity. From an endoscopic standpoint, competence is the attainment of technical and cognitive milestones that enables the performance of a particular procedure at an acceptable standard. We, as educators, know competence when we see it. However, the journey to this educational summit has been strewn with a surprising lack of science. In this issue of Gastrointestinal Endoscopy, Spier et al1 tackle the vexing issue surrounding procedural competence in colonoscopy. In their study, competence was defined as the ability to perform ≥90% of colonoscopies independently during a month-long observation period. They have shown us again that the threshold for assessing competence is not an immutable, hallowed number. When the threshold of 140 colonoscopies, which has been published as the minimum number of procedures to have been completed before assessing competence, was used, no trainees exhibited a cecal intubation rate of ≥90%. It was not until 500 colonoscopies were performed that all trainees achieved this goal. Procedural times continued to improve throughout the 3 years of GI training fellowship. There was no comparison of attending performance to determine whether the skills of the third-year fellows were equivalent to those of their teacher. Interestingly, the adenoma detection rate was the same among first-, second-, and third-year fellows.
There is a question we must ask ourselves at this juncture: is a procedural threshold for colonoscopy competence of approximately 500 that far fetched? A brief history of the colonoscopic competence threshold is in order. By using expert opinion, the American Society for Gastrointestinal Endoscopy Standards of Training Committee placed the threshold at 100 procedures.2 Cass et al3 smartly navigated through this ceiling when they found that the cecal intubation rate was only 80% at the 100-procedure level. Defining a 30-minute time limit for cecal intubation as success and using two 7-month evaluation periods during the 2 years of fellowship training, Marshall4 found that fellows achieved cecal intubation at various rates. First-year fellows with a median of 149 colonoscopies achieved a cecal intubation rate of 54% (range 25%-86%). With a median of 328 procedures over the 2-year period, only 2 out of 6 fellows achieved a cecal intubation rate of >90%. Cass et al5 then conducted a multicenter study involving 14 fellowship programs and 135 fellows. Competence was defined as cecal intubation, the identification of abnormalities, and a subjective grade of competency. Trainees required a minimum of 140 colonoscopies to meet all of the competency criteria 90% of the time. Parry and Williams6 found that achieving a consistent cecal intubation rate of 90% required 200 procedures and that further improvement was seen above this level. In a prospective analysis of 13,580 colonoscopies, Wexner et al7 concluded that a minimum of 50 colonoscopies was needed to achieve competency. In this author's opinion, this study suffers from ascertainment bias, as the attribution of success or failure is quite vague. Chak et al8 compared the colonoscopic abilities of first-year fellows with second-year fellows. Ninety-two percent of the colonoscopies performed by first-year fellows required the assistance of an attending gastroenterologist. The second-year fellows who had performed an average of 123 colonoscopies reached the cecum 84% of the time and required 14.5 minutes. These fellows also required assistance in 36.3% of the procedures. In contrast, the cecal intubation rate of the attending physicians was 94.3%, with a cecal intubation time of 10.5 minutes.
What does this encapsulated history of colonoscopic competence tell us? First, the definition of competence has fortunately evolved past the numbers-based concept of cecal intubation to include cognitive and quality outcome components. Second, the minimum numerical threshold to assess competence has continued to inch higher. This should come as no surprise, because many of the studies indicated that learning continued with increasing procedural volumes.5, 6 Third, the data pertain only to diagnostic colonoscopy. Issues surrounding competence for therapeutic procedures such as polypectomy are even more undifferentiated.
Can we realize a boost along the colonoscopic learning curve by implementing simulator training? Multiple validation studies have shown the ability of simulators to discern between experts and novices.9, 10 A randomized, multicenter study by Cohen et al11 found that 10 hours of simulator training led to an improvement in objective competence for colonoscopies that were performed early in the learning process. The traditionally trained group eventually caught up with their simulator-training–enriched colleagues. It should be noted that the threshold for competence was the same between groups (160 colonoscopies), and there was no difference in subjective assessment of patient discomfort.
Is a cecal intubation rate of >90% too lenient? Some experts feel that colonoscopists should be able to intubate the cecum in >95% of cases in which the indication is screening in a healthy adult.12 An overlooked element of endoscopic training is the use of feedback. Harewood et al13 found that the use of systematic feedback after the procedure could improve cecal intubation and polyp detection when compared with controls. With the current pressures on medical practice, we must be mindful not to shortchange our trainees but to provide them with high-quality mentoring.
Competence should not be considered a static concept during training or throughout a career. We still do not know whether decrements in skill sets occur after even brief interruptions in endoscopic training during a fellowship or with time. Do decrements occur? We know that the complication rate for endoscopic sphincterotomy increases if experienced endoscopists perform fewer than one per week.14 Recently, a tool for the assessment of endoscopic skills, known as the global assessment for GI endoscopic skills, has been developed. This tool carries with it the promise of having a universal validation tool for upper endoscopy and colonoscopy. The tool has passed the initial stages of validation, and we look forward to further studies in the future.15
In summary, Spier et al1 have confirmed the concept that many more procedures are required before the assessment of competence in colonoscopy. Intriguingly, adenoma detection did not require the same volume of procedures. This speaks to different rates of learning not only among different trainees but also for different technical and cognitive aspects for a single fellow. The development of a validated competence assessment tool coupled with a national training database is needed to more accurately define the training landscape. We look forward to continued advancements in how we assess and maintain competence. George Santayana's words ring true: quality in teaching and competence assessment should always supersede quantity.
Disclosure
The author disclosed the following financial relationships relevant to this publication: The author has a consultant relationship with Ethicon EndoSurgery, Cincinnati, OH, and Olympus America, Center Valley, PA.
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PII: S0016-5107(09)02536-X
doi:10.1016/j.gie.2009.09.027
© 2010 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.
