Teaching endoscopy in the new millennium

Dr. Leicester: Unlike most diagnostic modalities, endoscopies grew up between a number of specialties, being performed by gastroenterologists, surgeons, and radiologists and as a result, clear training requirements and provision differed. Recently there have been moves in many countries to expand the endoscopic services by employment of nurse endoscopists. However, no guidelines exist regarding how endoscopists should be trained. At a meeting of international experts in endoscopy (Endoscopy Masters Forum, Orlando, January 2001, Florida), no consensus was reached regarding the best method of teaching. Most of the respondents agreed that there should be a basic theory of endoscopy delivered in lectures, but training beyond this stage then largely centered on demonstration of the technique, followed by practice, and augmented by various visual aids. Fifty percent of the experts felt that simulators should play a role in training, particularly in the early stages, but overall, most endoscopy training programs resembled the time-honored apprenticeship model, with formal education lacking because many believed there was little time to conduct formal training sessions.

Many national endoscopy societies have produced guidelines on which aspects of endoscopy should be learned and have recommended numbers of endoscopies to be carried out under supervision. Yet until recently none had addressed the issue of how to teach the skills of endoscopy in a structured way.

Two audits of the availability and quality of endoscopy in the United Kingdom conducted by The British Society of Gastroenterology revealed a lack of formal training and a disturbing lack of knowledge of certain essential subjects, such as safety and sedation. The colonoscopy audit revealed that only 30% of endoscopists had attended any kind of endoscopy course, and the degree of supervision of trainees fell far short of the recommendations of the national advisory committee on endoscopy training. Although the complication rate from the procedure was lower than that in other reported series, the completion rate for colonoscopy was less than 70%.

In order to address the issue, a team of experts drawn from the Royal Colleges and specialist associations began the design of a national program of skills training in endoscopy. Based within the Raven Department of Education at the Royal College of Surgeons of England, the whole educational task was reviewed and curricula were developed, exploring new methods of teaching that convey knowledge and skills in the most effective manner.

The process of curricula development begins with setting clear aims and objectives that concentrate on teaching the core knowledge of all aspects of endoscopy, including informed consent, safety and sedation, indications and complications of endoscopy, unit management, endoscope and accessory design, and their operation. Once the core knowledge has been adequately taught and assessed, teaching of psychomotor skills necessary for endoscopy can be addressed. The traditional model of “see one, do one, teach one” is not an adequate method of conveying the necessary information for successful, safe endoscopy. The teaching of psychomotor skills needs to be broken down into simple steps, which, for example in colonoscopy, comprise instrument handling, torque steering, loop recognition, and loop resolution. Once the skills have been defined, the most appropriate medium for teaching needs to be identified, whether it be models, simulators, live endoscopy, or a combination of these. In order to teach a psychomotor skill, the teacher must be able to clearly identify each step of the particular skill and break this down into no more than 3 or 4 steps. Each step is then demonstrated and explained to the student until the procedure is fully understood, at which time the student carries out the skill and practices it before progressing to the next skill. In this way, the individual components are built up until the necessary combination of skills is easily repeated and combined to achieve safe, effective endoscopy. In order to teach the skills effectively, all tutors must teach the same skills in the same way. Once these skills are mastered, the student can then achieve proficiency by practice under supervision. Underpinning the acquisition of cognitive (knowledge) and psychomotor skills are the affective and interpersonal elements of learning in which the knowledge and skill are put into context, allowing understanding and correct interpretation of the knowledge and skill, together with the necessary communication and teamwork required to make an effective endoscopist.

Teaching the core knowledge should be approached in an interesting and stimulating manner by using a variety of teaching methods, such as small group discussions and the use of appropriate audiovisual materials. The basic requirement to achieve effective teaching is the training of teachers in methods of adult education and skills teaching because most endoscopists have never had the opportunity to learn and develop teaching skills. In the UK national training program, regional centers are being developed to run basic skills courses in all endoscopic modalities. Currently, colonoscopy and basic foundation courses have been completed, the former being mainly patient-based and the latter classroom and model-based. In those courses in which live endoscopy is used, the performance of each endoscopy is videotaped and the tapes and procedure are critiqued, somewhat in the manner of sports training, highlighting the good points and concentrating on areas for improvement. All tutors have undergone a 2-day course in how to teach, and they concentrate on teaching one simple, safe way to perform the procedure, thus avoiding the confusion of teaching different techniques. Once the student has mastered the basic technique, further skills can be acquired during the residency program in his or her own hospital. In order to facilitate this, all endoscopy supervisors are encouraged to attend the regional center for a “train the trainers” course, in which not only teaching skills are taught, but the basic techniques used during the trainees courses are practiced in order to achieve uniformity of skills teaching.

Clearly, appropriate assessments need to be built into the courses and continuing assessments should be based on objective criteria carried out at regular intervals during the trainees' educational program. Such assessments allow the trainer to concentrate on further skills teaching in deficient areas.

If the use of endoscopy is to be maximized as a diagnostic and therapeutic procedure, adequate structured training is required to make the procedure safe and effective. All of this takes time and it is important that healthcare providers recognize the need to allocate time and resources to education and to balance this with service requirements. Long-term, appropriately educated skilled endoscopists have the potential to make significant improvements to the management and prevention of GI disease while minimizing the cost and potential harm to the patient.