Successful Training in Gastrointestinal Endoscopy. Группа авторов

apparent to the pioneer generation of flexible fiberoptic endoscopy. As early as 1962, the then recently renamed ASGE conducted a symposium entitled “Teaching Methods in Gastrointestinal Endoscopy” in New York City [3]. Two years later, the ASGE formed a committee to examine the requirements for training endoscopists; the conclusions established training as a priority and created a framework that guided formal endoscopy training for many years to follow. Three items were required: (1) full training in medicine or surgery, (2) special training specifically in gastrointestinal (GI) endoscopy under the supervision of an appropriately skilled teacher, and (3) performance of an adequate number of procedures. Soon to follow was the first annual postgraduate training course.

These efforts at a national level have been complemented by a proliferation of local and regional efforts to promote training with local courses and lectures aimed to supplement the one‐on‐one supervised instruction of trainees in the endoscopy laboratory as well as keep practicing endoscopists up on all of the latest techniques and advances. In 1973, Jim Eddy, Jerry Waye, Hiromi Shinya, Sid Winawer, Paul Sherlock, Henry Colcher, David Zimmon, and Richard McCray met at the Yale Club in New York to discuss how they might disseminate their knowledge and excitement about colonoscopy and polypectomy to practicing gastroenterologists. The result was the formation of the New York Society for Gastrointestinal Endoscopy (NYSGE) and shortly thereafter, an annual endoscopy course initially designated, “A Day in the Colon.” In this case, a regional society was founded for the sole purpose of promoting training. The evolving role of societies in training is the subject of Chapter 38 in this book. However, it is important to recognize that from the national to the local level, the endoscopic societies have provided the dedication, organization, and resources to innovate and advance the field of training.

Supervised performance of actual endoscopies remains the predominant mode of endoscopy education today. Such apprenticeship‐type relationships between mentor and mentee have evolved greatly from the autocratic and unidirectional flow of information characteristic of similar learning environments dating back to the Middle Ages (Figure 1.1). Recognition and adoption of key concepts such as the benefits of learning in a reduced stress environment, the need for constructive feedback and interactive dialog, and the importance of gradually increasing autonomy of the trainee as skills progress are among the concepts that would make current trainee learning environments quite foreign to medical apprentices of earlier eras.

In the United States today, most instruction in the techniques of gastrointestinal endoscopy is accomplished in the setting of formalized training programs of 3 years duration, with additional training available for selected “advanced” procedures such as ERCP and EUS. Proctored teaching of endoscopic techniques within such highly structured environments has been the “traditional” training method in gastrointestinal endoscopy. Endoscopic skills are developed concurrently with the immersion of the trainee in a complete curriculum that encompasses the range of normal and abnormal functioning of the digestive system, GI anatomy, and pathology. Trainees learn the indications for endoscopy, diagnostic and therapeutic capabilities of endoscopy, technical endoscopic skills, and application of therapeutic endoscopic intervention all in the context of intensive active supervised participation in consultative gastroenterology, for both outpatients and hospitalized individuals. While many physical aspects of endoscope manipulation and even lesion recognition can be taught to individuals not versed in the science and art of caring for patients with gastrointestinal complaints and disorders, to date, patients and practitioners alike have recognized the value and requirement that endoscopy be performed by individuals trained in such a comprehensive fashion, something that in this day can only be achieved in formal gastroenterology and surgical training programs. For this reason, this remains a first principle of published ASGE training guidelines [4, 5].

Figure 1.1 An example of a typical apprenticeship contract in colonial America, circa 1750.

      Within these training programs, didactic information about endoscopy is included in the curriculum to an extent, but much of the actual endoscopic training remains directly imparted from instructor to student in the course of the performance of actual procedures on actual patients. Such hands‐on supervision allows for increasing independence on the part of the trainee, as the teacher constantly assesses both technical and cognitive progress [6, 7]. In this process, the endoscopy teacher must give the trainee sufficient time to develop skills while protecting the patient’s safety at all times, and must be able to give appropriate feedback [8, 9]. This process is both time and labor intensive. Additionally, sufficient case volume is necessary to allow for development of necessary skills through repetitive deliberate practice, and enough variation in pathology needs to be present to allow the development of cognitive skills to go along with advances in technical expertise [10, 11]. Mere possession of clinical judgment and endoscopic proficiency do not guarantee that an individual is qualified to be a good endoscopic teacher. The importance of having instructors who know how to teach and the constraints that limit the time such mentors have to devote to teaching can pose significant challenges for this “traditional method” of endoscopy training—challenges which some of the newer complementary teaching tools discussed later in this chapter were developed to address. While many of the chapters in this book refer to the importance and characteristics of good mentors, very little investigation has yet been conducted to understand how to best train the trainers to teach endoscopy. This topic is addressed in detail in Chapter 4.

      What must be learned?

      Guidelines for training in gastrointestinal endoscopy have been published and widely disseminated [4, 5]. Skill sets that trainees must acquire to successfully perform endoscopic procedures have been outlined [12–16] and include the following:

      1 Understanding of the indications and contraindications for endoscopic procedures and risk factors for complications.

      2 Knowledge of the endoscopic equipment and accessories and how to set up this equipment for use.

      3 Familiarity with the endoscope control dials and buttons.

      4 Dexterity in controlling the scope range of motion using the dials and torque applied to the endoscope shaft.

      5 Hand–eye coordination to produce deliberate, precise manipulation of the endoscope within the lumen and of accessories.

      6 Communication with nursing and technical staff regarding required assistance during the procedure.

      7 Knowledge of normal anatomic landmarks and possible abnormal pathologies that might be encountered.

      8 Interpretive skills to correctly identify abnormalities that are detected.

      9 Judgment of how to manage appropriately those lesions that are encountered.

      10 Familiarity with patient monitoring and the administration of moderate sedation.

      11 Awareness of how to recognize and manage adverse events.

      12 Understanding of risks and benefits of intended procedures and the ability to obtain informed consent.

      13 Documentation of findings.

      14 Communication of results to patients and other physicians.

Standards and end points of current endoscopic training

      Since the early establishment that training in endoscopy was a high‐priority activity among academic endoscopy centers and GI societies, a great deal of effort has been devoted to assess the efficacy of training, determine learning curves for various procedures, and explore new methods for imparting proficiency. A number of important guidelines on the subject have incorporated much of this data and expert opinion on the subject