Evaluating learning curves and competence in colorectal EMR among advanced endoscopy fellows: a pilot multicenter prospective trial using cumulative sum analysis

Published:September 19, 2020DOI:

      Background and Aims

      Data on colorectal EMR (C-EMR) training are lacking. We aimed to evaluate C-EMR training among advanced endoscopy fellows (AEFs) by using a standardized assessment tool (STAT).


      This multicenter prospective study used a STAT to grade AEF training in C-EMR during their 12-month fellowship. Cumulative sum analysis was used to establish learning curves and competence for cognitive and technical components of C-EMR and overall performance. Sensitivity analysis was performed by varying failure rates. AEFs completed a self-assessment questionnaire to assess their comfort level with performing C-EMR at the completion of their fellowship.


      Six AEFs (189 C-EMRs; mean per AEF, 31.5 ± 18.5) were included. Mean polyp size was 24.3 ± 12.6 mm, and mean procedure time was 22.6 ± 16.1 minutes. Learning curve analyses revealed that less than 50% of AEFs achieved competence for key cognitive and technical C-EMR endpoints. All 6 AEFs reported feeling comfortable performing C-EMR independently at the end of their training, although only 2 of them achieved competence in their overall performance. The minimum threshold to achieve competence in these 2 AEFs was 25 C-EMRs.


      A relatively low proportion of AEFs achieved competence on key cognitive and technical aspects of C-EMR during their 12-month fellowship. The relatively low number of C-EMRs performed by AEFs may be insufficient to achieve competence, in spite of their self-reported readiness for independent practice. These pilot data serve as an initial framework for competence threshold, and suggest the need for validated tools for formal C-EMR training assessment.


      AEF (advanced endoscopy fellow), ASGE (American Society for Gastrointestinal Endoscopy), C-EMR (colorectal EMR), CUSUM (cumulative sum), EMR-STAT (EMR standardized assessment tool)
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      Linked Article

      • Validated training tools are needed for assessing competency in colorectal endoscopic mucosal resection
        Gastrointestinal EndoscopyVol. 93Issue 3
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          We read with great interest the study by Yang et al1 evaluating competency in the performance of colorectal EMR (C-EMR) among 6 advanced endoscopy fellows (AEFs). The competency outcome measured was defined by a novel EMR standardized assessment tool (EMR-STAT), and the study’s primary finding was that a small percentage of the studied trainees achieved competence in the technical and cognitive aspects of C-EMR. Given the lack of published studies on C-EMR training, we laud the authors for carrying out this study.
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