final_principles of training in endoscopy 2012 feb issue

7/28/2019 FINAL_Principles of Training in Endoscopy 2012 Feb Issue

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REPORT ON TRAINING

Principles of training in GI endoscopy

This document, prepared by the American Society for

Gastrointestinal Endoscopy Committee on Training, was

undertaken to provide general guidelines for endoscopy

training and written primarily for individuals involved in

teaching endoscopic procedures to fellows/trainees. This

updates the previous Principles of Training document.1

Research in objective evaluation of procedural skills makes

revision of the guidelines at this time highly appropriate.

OBJECTIVES

Upon completion of training in GI endoscopy, traineesshould be prepared to (1) appropriately recommend en-doscopic procedures as indicated by the findings ofconsultative evaluation, with explicit understanding ofaccepted specific indications, contraindications, anddiagnostic/therapeutic alternatives; (2) perform proce-dures safely, completely, and expeditiously, includingpossessing a thorough understanding of the principles ofconscious sedation/analgesia techniques, the use ofanesthesia-assisted sedation where appropriate, and pre-procedure clinical assessment and patient monitoring; (3)correctly interpret endoscopic findings and integrate them

into medical or endoscopic therapy; (4) identify risk fac-tors for each procedure, understand how to minimizeeach, and recognize and appropriately manage complica-tions when they occur; (5) acknowledge the limitations ofendoscopic procedures and personal skills and knowwhen to request help; and (6) understand the principles ofquality measurement and improvement.

TRAINING PROGRAMS

InstitutionsTraining in GI endoscopy should take place within the

context of a global clinical training program in the fields ofadult or pediatric gastroenterology or general surgery.These training programs must be recognized by the Ac-creditation Council for Graduate Medical Education or theAmerican Osteopathic Association and should exist withininstitutions where they are supported by the presence ofaccredited training programs in internal medicine, pediat-

rics, general surgery, radiology (including interventiontraining), and pathology.

Supporting curriculumCompetence in technical skills requires the foundation

of didactic learning that occurs within the comprehensivetraining of a specialist in GI and liver disease. In particular,the endoscopic trainee must participate in a program ofdirected reading and teaching conferences that conveysthe following: (1) the indications, limitations, and contra-indications of endoscopic procedures; (2) procedure com-plications and their management; (3) the principles of safe

sedation/analgesia techniques and patient monitoring andwhen to consider alternate forms of anesthesia; (4) medi-cal, radiological, and surgical alternatives to endoscopictherapy; (5) issues of informed consent, advanced direc-tives, and medical ethics as pertains to GI endoscopy (as inthe evaluation of gastrostomy and cancer palliation candi-dates); (6) skills for critical assessment of new techniquesand endoscopic scientific literature; (7) incorporating en-doscopic findings into overall patient management; (8)preparation of endoscopy reports and communicationwith referring providers and other members of the careteam; and (9) quality measurement and continuous quality

improvement.

The endoscopy training directorEach training program should have an expert endosco-

pist and teacher who is designated as the endoscopytraining director and will (1) monitor on a regular basiseach trainees acquisition of appropriate technical andcognitive skills, including maintenance of personal logs/records documenting trainees numerical procedural ex-perience (including indications, findings, and compli-cations) and success in achieving defined objective per-formance standards, as discussed in the following; (2)

incorporate endoscopic teaching resources (textbooks, at-lases, videotapes, electronic media) into the training pro-gram; (3) periodically review and update training method-ology and quality of training within the program; (4)review evaluation forms from trainers with the trainee andallow for feedback from the trainee on the trainers and theprogram; and (5) review and update the training curricu-lum on an ongoing basis.

Endoscopic facultyThe endoscopic faculty should include experienced en-

doscopists and teachers with demonstrated expertise in

Copyright 2012 by the American Society for Gastrointestinal Endoscopy

0016-5107/$36.00

doi:10.1016/j.gie.2011.09.008

Communication

from the ASGE

Training

Committee

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the procedures being taught. Faculty should (1) have time(and institutional financial support) dedicated to teaching;(2) be responsible for didactic instruction and supervisionof trainees; (3) regularly attend GI continuing medicaleducation sessions as well as interdisciplinary meetingswith surgeons, radiologists, and pathologists; (4) be ofadequate numberthe ratio of teachers to trainees shouldbe approximately or greater than one; (5) communicatewith the training director and/or each trainee should havea designated faculty supervisor; and (6) show active pro-motion of research or advancement of clinical practice thatincludes publications and participation in educational ac-tivities on local, regional, national, and internationallevels.

The training processSuccessful trainees in GI endoscopy acquire their skills

through a program of hands-on experiential training underthe mentorship of expert endoscopic trainers that occursover a prolonged period of time, such as that represented

by a gastroenterology fellowship or surgical residency.Cognitive learning from outside reading, conferences, andinstruction in the disciplines comprising the broad field ofGI medicine is critical to this process and, through theefforts of both trainer and trainee, is intimately integratedwith the technical aspects of procedural instruction andpatient management.

Training follows a natural progression as trainees ac-crue more technical expertise and confidence. Initially, atrainee may observe a procedure, followed by first at-tempting only the diagnostic or less technically demand-ing aspects of a procedure. At this stage, under constant

supervision, trainees will learn key principles of anatomyand scope manipulation and practice basic techniquessuch as esophageal and pyloric intubation and retroflexionof the scope tip. They will also practice sedation tech-niques, begin to learn basic recognition of normal andabnormal endoscopic findings, learn integration of find-ings into a plan of treatment, and develop skills for writingand appropriate documentation of endoscopic findings.

As experience grows, the trainee will progress to per-forming the entire procedure and attempting therapeuticinterventions. Trainees must appreciate the seamless inte-gration of diagnosis and therapy that is the hallmark of

modern endoscopic practice. Examples include the deliv-ery of hemostatic therapy during endoscopy in a bleedingpatient and the performance of polypectomy duringscreening colonoscopy.

The trainee is expected to progress through stages ofdecreasing supervision, extending from the initial phase ofcomplete supervision through a period of partial supervi-sion, in which the trainee is deemed competent to performa procedure with reasonable safety and patient comfort. Inthe latter phase, the trainer is available to view pertinentfindings and assist when problems arise. The rate of skillacquisition will vary among trainees and for a single

trainee between different procedures, because of differ-ences in manual dexterity, volume of procedures, traineejudgment, and quality of instruction. Ultimately, thetrainee should reach a stage in which he or she is deemedcompetent by the endoscopic training director to performa specific procedure without supervision. The current eco-nomic constraints placed on most academic training insti-tutions will, however, likely mandate that supervision bemaintained for most if not all procedures regardless of thetrainees proficiency.

Standard proceduresThe amount of time and experience required to learn

the effective and safe performance of endoscopic exami-nations varies considerably among trainees and from oneprocedure to another. Competence in one procedure doesnot equate to competence in other procedures. In mostcenters, training begins with procedures that are easier tomaster and progresses to more challenging procedures.ERCP and EUS training is expected to follow experience in

less complex and technically demanding examinations.The American Society for Gastrointestinal Endoscopy thusupholds a distinction between two types of procedures,standard and advanced.

Standard procedures are commonly performed and arereadily available to most patients. These procedures arepart of the core of diagnostic and therapeutic capabilityexpected of physicians performing endoscopy. Most train-ees can expect to master these procedures during a 3-yeargastroenterology fellowship period (including a minimumcore period of 18 months of clinical training). Standardprocedures include EGD, flexible sigmoidoscopy, colono-

scopy, capsule endoscopy, mucosal biopsy, polypectomy,dilation of peptic strictures of the esophagus, percutane-ous liver biopsy, and PEG. Although the delivery of endo-scopic hemostasis (injection and cautery techniques,esophageal variceal sclerotherapy, and band ligation) re-quires considerable endoscopic expertise, mastery ofthese techniques is essential for every endoscopist per-forming endoscopy in bleeding patients and are thus in-cluded among standard procedures.

Advanced proceduresAdvanced procedures are more complex and techni-

cally demanding to perform and often carry a relativelyhigher risk of complications. These examinations, whichoften include complicated and high-risk diagnostic andtherapeutic components, are required less frequently thanstandard procedures, and, thus, the number of individualstrained to perform them should be smaller than the num-ber trained in standard procedures. Advanced proceduresinclude ERCP and all associated interventions, EUS, pneu-matic dilation for achalasia, dilation of complex esopha-geal strictures (eg, lye and radiation strictures), stent place-ment, Barretts esophagus ablation therapies, EMR, deepenteroscopy, and endoscopic tumor ablation.

Training in GI endoscopy

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The learning of advanced procedures is founded on athorough mastery of standard procedures and often re-quires an additional year of training beyond the standard3-year fellowship. Guidelines for training programs in ad-vanced endoscopy were published by the American Soci-ety for Gastrointestinal Endoscopy in 1994.2 Not all train-ees should pursue such advanced training because ofvariations in individual skill and the manpower needs ofthe health care system. Likewise, not all programs shouldoffer advanced training; such training should be concen-trated in those programs that have an adequate combina-tion of patient volume and faculty expertise.

In certain circumstances, select advanced proceduresmay be mastered during a standard 3-year training pro-gram when adequate patient volume and trainee aptitudeare present. In general, however, good medical practiceand the current health care climate both mandate the idealof concentrating advancing techniques in a relatively smallnumber of highly trained individuals. Training in ad-vanced techniques should be undertaken only if there is a

reasonable expectation that the trainee will be able toachieve proficiency in the procedure and be prepared forunsupervised function by the end of the training period.Providing brief exposure to an advanced procedure suchas ERCP during standard fellowship with the expectationthat the trainee will subsequently complete training inpractice is no longer appropriate.

Evaluation of trainee competenceThe evaluation of a trainees progress in endoscopic

skill acquisition continues throughout the duration of thetraining program. The endoscopy training director super-

vises the process, but all trainers must participate. In keep-ing with accreditation guidelines, there must be a writtenevaluation policy that is known by the trainee and in-cludes provisions for frequent and regular structured feed-back as well as evaluation of the program and trainers bythe trainee. Ultimate assessment of trainee achievementrests with the expert opinion of the endoscopy trainingdirector, based on both subjective and objective measures.

Components of trainee competenceEvaluation encompasses both cognitive and technical

abilities. In-service evaluations in both areas should be

used. Trainee log books and records of procedural num-bers should be provided by the trainee to the trainingdirector as a raw record of trainee experience. The utilityof objective performance standards is discussed in thefollowing. Careful subjective evaluation also must bemade of trainees endoscopic interpretive skills, abilities toincorporate endoscopic findings into overall patient care,responses to incorporate endoscopic findings into overallpatient care, responses to complications, adherence tosafe patient monitoring and sedation practices, and thequality of their preprocedure and postprocedure patientteaching.

Technical evaluation/performance standardsThe use of threshold procedure numbers at which com-

petence may be globally assessed provides only a roughbenchmark for guiding trainee evaluation. Few studies ofthe rate at which proficiency is attained have been per-formed, but available data suggest that at least 25 to 30flexible sigmoidoscopies,3 130 upper endoscopies, and

200 colonoscopies are required at a minimum before thetrainee can be assessed for competence.4 Similarly, 180 to200 ERCPs are needed before trainees can routinelyachieve selective duct cannulation.5 Available data oncompetency in EUS suggest that 100 examinations areneeded for acceptable accuracy in the T-staging of esoph-ageal carcinoma6; most experts agree that pancreatobiliaryEUS demands more experience than esophageal EUS,7

whereas 40 to 50 cases may provide adequate preparationfor the accurate evaluation of submucosal lesions.8 Itshould be stressed that these minimal threshold numbersrepresent a benchmark before which a trainees compe-

tency should not even be assessed. Most trainees willachieve competence much later. Training programs mustbe able to meet and exceed these procedural volumes foreach trainee.

For colonoscopy, 140 procedures had been previouslycited as a minimum experience before competency couldbe assessed. This number was based on data limited tocecal intubation rates and based on expert opinion ofcompetency thresholds (90%) for this metric. However,using these same limited metrics, Spier et al9 found thateven after 140 colonoscopies, no trainee exhibited proce-dural competency, yet by 500 procedures, all fellows had

achieved procedural competency benchmarks.10

To betterdefine where within this range competency occurs, a morecomprehensive definition of competency was required. Arecently reported colonoscopy skills assessment form bySedlack11 provides a means to assess a broader range ofboth cognitive and motor skills for colonoscopy. With theuse of this form, learning curves and competency thresh-olds for each of these core skills have been defined, andthey suggest that competence is not achieved by the av-erage trainee until she or he has performed roughly 275colonoscopies.4,12 Trainees, however, develop skills atwidely varying rates. Data from studies by Sedlack11 and

Chung et al12

show that a fraction of trainees can achievecompetency as early as 175 to 200 procedures, whereasothers achieve competency as late as 400 procedures.Absolute or threshold numbers may thus be misleadingand should be used with caution in the evaluation ofindividual trainees. What this illustrates is that the recom-mended threshold numbers mentioned earlier for eachtype of procedure should be used only as a guide incurricula planning. The achievement of competenceshould be based on a separate assessment, either on aperiodic or continuous basis, of a broad range of definedskills. It also should be stressed that the rate of skill




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acquisition for a given trainee may vary among differentprocedures; hence, competence in one procedure doesnot imply competence in other procedures.13

To enhance the quality of trainee evaluation and endo-scopic training through the use of experience-based crite-ria, the American Society for Gastrointestinal Endoscopyrecommends that program directors also incorporate themonitoring of specific technical skills (such as indepen-dent cecal intubation) and interpretive/diagnostic skill(polyp or adenoma detection) into the global assessmentof trainees in a continuous manner or on a periodic basisat specified intervals of training. Such monitoring may beachieved through a variety of methods, including the fol-lowing: (1) incorporating the reporting of performancedata into electronic endoscopic report generation, (2) re-cording of performance data by supervising endoscopictrainers, (3) selective observation of trainees by a desig-nated evaluator, and (4) self-reporting of performanceparameters in trainee logs. Performance data for eachtrainee should be collected and tracked by the training

director, who can then observe and document trends ineach trainees development. Programs may elect, for ex-ample, to monitor a few performance metrics on a contin-uous basis or multiple parameters intermittently.

Although this monitoring effort entails an additionaltime investment by the faculty trainers, it will enhance theaccurate measurement of each trainees progress and read-iness for successively more complex procedures and lev-els of training. Expert endoscopists are generally expectedto perform at a 95% to 100% technical success level, andcurrent research supports establishing a standard of 80% to90% technical success before trainees are deemed compe-

tent in a specific skill.14-17 In a given program, small vari-ations in the standard of expected proficiency that is setfrom one procedure to the next may be appropriate, es-pecially among procedures of varying complexity; how-ever, the expected performance level should be uniformamong all trainees.

For any given procedure, training institutions should beable to provide trainees with a sufficient volume of pro-cedures to achieve technical competence as defined bythese standards. Adherence to objective assessment willhelp to guide programs in deciding which trainees aregood candidates for advanced endoscopic training, how

many trainees should be instructed in a given procedure,and for which procedures the program can provide asufficient volume of cases to ensure adequate training.

Ongoing competence, credentialing, andcertification

A certification of procedural competence will be pro-vided by the endoscopy training director. Privileging toperform procedures in the clinical setting after trainingoccurs falls under the purview of individual hospital cre-dentialing committees. There are no established standardsfor monitoring ongoing procedural competence after the

completion of training. Although most trainees will be-come more adept with additional experience after train-ing, maintenance of expert performance cannot be as-sumed. The objective performance criteria applied here asminimum standards for trainees should serve as usefulbenchmarks for hospital credentialing authorities address-ing this issue, in conjunction with evaluation of otherfactors such as case complexity, complications, and out-come. Acquisition and maintenance of documented levelsof competency in the skills conveyed through a globaltraining program in gastroenterology and GI endoscopyhave important and positive implications for both the costand quality of patient care.18

Retraining and alternative pathway trainingAs new technologies and techniques emerge, there is a

natural desire among established practitioners to enhanceand expand their own capabilities. It is rarely feasible fortraining programs to accommodate the retraining needs of

past trainees. Such individuals may need to consider theoption of pursuing advanced endoscopic training fellow-ship positions. Although most endoscopic training occursin gastroenterology fellowships or surgical residency train-ing programs, some practitioners may seek training inother settings. In previous position statements, the Amer-ican Society for Gastrointestinal Endoscopy has definedthe criteria that such alternative pathway endoscopic train-ing programs must fulfill, emphasizing that training shouldbe comprehensive and provide a working knowledge ofthe pathophysiology, diagnosis, and management of di-gestive diseases for which endoscopic procedures areindicated.19

DISCLOSURE

All authors disclosed no financial relationships relevant

to this publication.

REFERENCES

1. Principles of training in gastrointestinalendoscopy. Manchester (Mass):

The American Society for Gastrointestinal Endoscopy; 1991.

2. Guidelines for advanced endoscopic training. Manchester (Mass): The

American Society for Gastrointestinal Endoscopy; 1994.3. Hawes R, Lehman GA, Hast J, et al. Training resident physicians in fiber-

optic flexible sigmoidoscopy: How many supervised examinations are

required to achieve competence? Am J Med 1986;80:465-70.

4. Sedlack RE. Training to competency in colonoscopy: assessing and de-

fining competency standards. Gastrointest Endosc 2011;74:355-66.

5. Jowell PS, Baillie J, Branch MS, et al. Quantitative assessment of proce-

dural competence: a prospective study of training in endoscopic retro-

grade cholangiopancreatography. Ann Intern Med 1996;125:983-9.

6. Fockens P, Vanden Brande JH, Van Dullemen HM, et al. Endosono-

graphic T-staging of esophageal carcinoma: a learning curve. Gastroin-

test Endosc 1996;44:58-62.

7. Hoffman BJ, Hawes RH. Endoscopic ultrasound and clinical compe-

tence. Gastrointest Endosc Clin North Am 1995;5:879-84.


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8. Van Dam J, Brady PG, Freeman M, et al. Guidelines for training in elec-

tronic ultrasound: guidelines for clinical application. Gastrointest En-

dosc 1999;49:829-33.

9. Spier BJ, Benson M, Pfau PR, et al. Colonoscopy training in gastroenter-

ology fellowships: determining competence.GastrointestEndosc 2010;

71:319-24.

10. VargoJJ.North of100 and south of500:where does thesweet spotof

colonoscopy competence lie? Gastrointest Endosc 2010;71:325-6.

11. Sedlack RE.The Mayo ColonoscopySkillsAssessment Tool: validation of

a unique instrument to assess colonoscopy skills in trainees. Gastroin-

test Endosc 2010;72:1125-33.

12. Chung JI, Kim N, Um MS, et al. Learning curves for colonoscopy: a pro-

spective evaluation of gastroenterology fellows at a single center. Gut

2010;4:31-5.

13. Wigton RS.Measuringproceduralskills(editorial).Ann InternMed 1996;

125:1003-4.

14. Cass OW, Freeman ML, Peine CJ, et al. Objective evaluation of endos-

copy skills during training. Ann Intern Med 1993;118:40-4.

15. Alternative pathways to training in gastrointestinal endoscopy. Man-

chester (Mass): The American Society for Gastrointestinal Endoscopy;

1995.

16. RexK, CutlerCS, Lemmel GT,et al.Colonoscopic missratesof adenomas

determined by back-to-back colonoscopies. Gastroenterology 1997;

112:24-8.

17. Chak A, Cooper GS, Blades EW, et al. Prospective assessment of colono-

scopic intubation skills in trainees. Gastrointest Endosc 1996;44:54-7.

18. Zeroske JR, Wadsworth TM, Sargant M, et al. Comparison of GI hemor-

rhage (DRG 174) cost per case and length of stay when performed by

gastroenterology vs. internal medicine departments. Am J Gastroen-

terol 1995;90:1669A.

19. Joint Statement. Principles of privileging and credentialing for endos-

copy and colonoscopy. Gastrointest Endosc 2002;55:145-8.

Prepared by:

ASGE Training Committee

Douglas G. Adler, MD

Gennadiy Bakis, MD

Walter J. Coyle, MD

Barry DeGregorio, MD

Kulwinder S. Dua, MD

Linda S. Lee, MD

Lee McHenry, Jr., MD

Shireen A. Pais, MD

Elizabeth Rajan, MD

Robert E. Sedlack, MD

Vanessa M. Shami, MD

Ashley L. Faulx, MD, Chair

This document was updated by the training committees 2010 to 2011



final_principles of training in endoscopy 2012 feb issue

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