Endoscopy Around the World: Perspectives| Volume 54, ISSUE 5, P671-673, November 2001

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Teaching endoscopy in the new millennium

      Dr. Waye: At a meeting of international experts in endoscopy (Endoscopy Masters Forum, Orlando, Florida, January 2001), some of the participants were requested to answer a survey concerning training programs. The survey respondents were as follows:
      • H. Worth Boyce (USA)
      • Sidney Chung (Hong Kong)
      • Guido Costamagna (Italy)
      • Peter Cotton (USA)
      • Jacques Deviere (Belgium)
      • Paul Fockens (The Netherlands)
      • Rikiya Fujita (Japan)
      • Joseph Geenen (USA)
      • Christopher Gostout (USA)
      • Robert Hawes (USA)
      • Aksel Kruse (Denmark)
      • Roger Leicester (England)
      • Charles Lightdale (USA)
      • Thierry Ponchon (France)
      • Jean-Francois Rey (France)
      • Nib Soehendra (Germany)
      • Jacques Van Dam (USA)
      • Kenjiro Yasuda (Japan)
      The number of fellows in the various training programs ranged from 2 to 20 with an average of 7. The length of the training program varied from 1 to 4 years, with an average of 2.5 years. The number of endoscopies per year in the different units ranges from 4000 to 33,000, with an average of 12,000 and a median of 9000. Each program has approximately 8 teachers of endoscopy. In half of the programs everybody in the department rotates through the teaching sessions, and in the other half teachers are specifically selected based on their ability and commitment to teaching. Nine of 15 respondents felt that it was worthwhile beginning the teaching of endoscopy basics with gastroscopy as the first procedure to learn, but 6 experts felt that both colonoscopy and gastroscopy should be taught from the very beginning, on the basis of doing whatever is scheduled. In 11 programs, every endoscopic examination is supervised by an endoscopic instructor; in 1 program the trainee performs cases without further supervision after 3 months; in another program after 100 cases have been completed; and in 4 programs the trainee can perform cases alone based on having performed cases with competency.
      Ten of 16 teaching units use simulators in their training program. Two use plastic models, 2 use the Erlangen/Hochberger model (an eviscerated pig intestine with implanted “blood vessels,” which can be used for practice in such procedures as hemostasis, polypectomy, mucosectomy, stent placement, and papillotomy) and 2 use the Symbionix computer-based simulator (Tel-Hashomer, Israel) (with the simulated ability to perform biopsy, stop bleeding, and perform papillotomy and colonoscopy with polypectomy).
      Eight of the respondents felt that large live courses have limited usefulness, whereas 4 felt they were quite beneficial. Among the comments were that large live courses are not a substitute for hands-on training and that they are only for “experienced endoscopists.” One respondent thought that edited videos are better teaching tools than large live courses. Many respondents were concerned that large live courses may not provide good patient care because experts are brought in who are not familiar with the unit, the cases, or the nurses and assistants. One of the comments concerning quality of patient care was that the best patient care is achieved when doctors perform their own cases in their own institutions.
      In answer to the question of “how can the trained endoscopist learn a new technique,” a varied set of answers were obtained. Among the answers were:
      • Take live courses; it is better than nothing at all.
      • Go visit someone and watch how they do it.
      • Use CD-ROMs, simulators, animal models, and then supervised hands-on training.
      One respondent felt that an “internet-based tutorial” was the best method of training, but this editor was not familiar with any such tutorials on learning new techniques. It was felt that the current apprentice system is old-fashioned and that one could learn by going to an expert and either watching or being permitted to actually do hands-on endoscopy. Last, it was thought that various models or simulators may be of some benefit.
      The experts were requested to structure, in any manner they wished, a basic training program to introduce trainees to endoscopy. Nine of 12 respondents felt that one should first give lectures, then demonstrate techniques, and then have the fellow observe several procedures before getting started. One of 12 felt that lectures were not worthwhile. Eight of 12 felt that videos, CD-ROMs, and books were helpful adjuncts to expose the trainees before actual procedures, although 1 of 12 respondents felt that videos were not worthwhile. Six of 12 felt that simulators were of some benefit and should be used early in the training programs. One respondent felt that the trainees should observe a few procedures, withdraw the instrument after it had been passed by the instructor, and then go ahead and perform an endoscopy. One expert felt that the best way to expose a trainee to endoscopic techniques was to just have him “do it,” albeit under close supervision.
      It is obvious that there is not a unified approach to teaching endoscopy to trainees. Although the current “apprentice” one-on-one training has not changed from the days of Schindler, it represents the best method at present to teach endoscopy. It is evident that in most hospitals the performance of endoscopy is a necessary part of rendering patient care, whether the fellows are on their last day of training or on their first. Cases must be done, and patients must be served. There is actually very little time for lectures, watching videotapes, or observing others perform procedures. The reality of the need to perform procedures dictates the “just go do it” attitude of many endoscopy instructors who do not have the luxury of time to provide such introductory protocols.


      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.