Teaching Colonoscopy: from Novice to Competence

Abstract

Training procedural skills in gastrointestinal endoscopy once focused on threshold numbers. However, as threshold numbers poorly reflect individual competence, the focus gradually shifts towards a more individual approach. Tools to assess and document individual learning progress are being developed and incorporated in dedicated training curricula. However, there is a lack of consensus and training guidelines differ worldwide, which reflects uncertainties on optimal set-up of a training program. The primary aim of this systematic review was to evaluate the currently available literature for the use of training and assessment methods in GI endoscopy. Secondly, we aimed to identify the role of simulator-based training as well as the value of continuous competence assessment in patient-based training. Thirdly, we aimed to propose a structured training curriculum based on the presented evidence. A literature search was carried out in the available medical and educational literature databases. The results were systematically reviewed and studies were included using a predefined protocol with independent assessment by two reviewers and a final consensus round. The literature search yielded 5846 studies. Ninety-four relevant studies on simulators, assessment methods, learning curves and training programs for gastrointestinal endoscopy met the inclusion criteria. Twenty-seven studies on simulator validation were included. Good validity was demonstrated for four simulators. Twenty-three studies reported on simulator training and learning curves, including 17 RCT’s. Increased performance on a virtual reality simulator was shown in all studies. Improved performance in patient-based assessment was demonstrated in 14 studies. Four studies reported on the use of simulators for assessment of competence levels. Simulator-based performance did not reflect competence in patientbased endoscopy. Eight out of fourteen studies on colonoscopy, ERCP and EUS reported on learning curves in patient-based endoscopy and proved the value of this approach for measuring performance. Ten studies explored the numbers needed to gain competence, but the proposed thresholds varied widely between them. Five out of nine studies describing the development and evaluation of assessment tools for gastrointestinal endoscopy provided insight in performance of endoscopists. Five out of seven studies proved that intense training programs result in good performance. The use of validated virtual reality simulators in the early training setting accelerates learning of practical skills. Learning curves are valuable for continuous assessment of performance and are more relevant than threshold numbers. Future research will strengthen these conclusions by evaluating simulation-based as well as patient-based training in gastrointestinal endoscopy. A complete curriculum with assessment of competence throughout training needs to be developed for all gastrointestinal endoscopy procedures.