Successful Training in Gastrointestinal Endoscopy. Группа авторов

and by direct mentored experience. The development of such cognitive skills should occur at the same time that the trainee learns to carefully inspect the entire mucosa, as these skills are complementary and dependent on one another.

The technical requirements of inspection differ somewhat depending on the nature of the procedure. In upper endoscopy, for example, the papilla and medial wall of the duodenum are common blind spots without careful and deliberate inspection, and may not always be easily obtained during EGD. In EUS or ERCP, the oblique viewing nature of the endoscope provides particular limitations and careful attention must be paid. In EUS imaging, the ultrasound view has very specific requirements to ensure that adequate imaging of specific structures has occurred. Depending on the indication for the procedure, repositioning of the patient, addition of fluid in the lumen, removing mucous, using chromoendoscopy, or narrow‐band imaging may be particularly useful. For enteroscopy or colonoscopy, inspection is a crucial aspect that has been highlighted by recent trials of adenoma detection. Slow withdrawal of the endoscope must be achieved, while at the same time using frequent movement of the tip of the endoscope to ensure that the entire circumference of the mucosa is inspected. Proper insufflation is helpful in effacing the mucosa, making polyps more easily identified. In several areas, repositioning of the patient may also be useful. Care must be taken to avoid rapid expulsion of the scope as this may occur when the tip of the endoscope is not anchored in place. To avoid unintended sudden changes in endoscope position, careful attention to both the endoscopic image and sensation in the right hand is necessary. Scope readvancement may be required if a region of the wall is not seen on first pass. Flexures and folds in the colon may create potential blind spots in colonoscopy for instance, or in the case of EUS, there are known blind spots in the stomach or regions that are outside of the limit of the ultrasound image. The endoscopist must always be aware of these locations and ensure that they are properly evaluated. Complete examination of specific areas within the GI tract, such as the distal rectum and anorectal junction, requires the endoscopist to be able to retroflex the endoscope in the rectum. This may also be required for complex polypectomy or other therapeutic maneuvers elsewhere in the GI tract. In the upper GI tract, for example, complete inspection of the stomach requires the endoscopist to be able to retroflex the scope to provide a complete view of the cardia and fundus. Retroflexion requires the endoscopist to understand the concept of paradoxical movement; as the retroflexed scope is withdrawn, the tip gets closer to the esophagogastric junction. Once the scope is retroflexed, the endoscopist can more accurately view the entire lesser curvature with a good view of the incisura angularis and the proximal lesser curvature. The hiatal opening can be viewed from below, and lesions in the cardia and fundus can be accurately evaluated. The combination of retroflexion, withdrawal of the scope, and rotation are required to fully evaluate the stomach.

      Assessment of mucosal inspection can be done in terms of the percent of mucosal surface evaluated. This is best done using virtual reality simulators, where these metrics are readily obtained electronically. A skilled endoscopist can achieve this more efficiently than a novice, but it must be emphasized that quick endoscopy that does not provide complete mucosal inspection is a poor trade‐off. At the present time, documentation of imaging quality in lower GI procedures typically involves photo or video documentation of specific landmarks such as the terminal ileum, ileocecal valve, and appendiceal orifice. In addition, aspects such as bowel preparation and residual bodily fluids may impair visualization of subtle lesions, and trainees should be encouraged to evaluate and document their presence. In endoscopic ultrasound, training should give consideration to the evaluation and documentation of the adequacy of examination on an intent‐to‐image basis.

Instrumentation

      A fundamental skill that should be in the skill set of any GI endoscopist is to be able to use instrumentation placed through the accessory channel to accomplish biopsy, snare a polyp, perform an injection, or apply energy for tissue destruction or hemostasis. Virtually, all GI endoscopes have a working channel through which instruments can be introduced. Although side‐viewing endoscopes are used in ERCP, or linear EUSs have an elevator that can be used to deflect the angle of accessories that exit the scope tip, most upper and lower endoscopes do not have a separate deflector for the instrument channel, hence control of the instrument must be achieved by orienting the working channel properly using the combination of tip deflection and torque of the scope to provide the best working angle between the instrument and the target. The endoscopist must be able to maintain a stable endoscopic position and clear view at all times when performing therapeutic procedures. At times, it may be helpful to have an assistant hold the endoscope in place while advancing the instrument, particularly if a stable position is hard to maintain.

      Accurate targeting is a learned skill that can be practiced and evaluated. Metrics to evaluate targeting include time required to instrument the “lesion” once the target mucosa has been visualized, accuracy of placement of the instrument relative to the target, and number of attempts to direct the instrument to the target. This is relevant to a number of procedures such as biopsy in EGD, fine‐needle aspiration in EUS, cannulation in ERCP, and polypectomy in colonoscopy. Again, mastery of these tasks requires sufficient skill in scope handling and navigation, as well as an understanding of the cognitive aspects, such as indications for the intervention, potential complications, alternatives, and so on. This final stage of training is typically only reserved for advanced trainees who have successfully demonstrated proficiency in the fundamental earlier stages.

Simulators and task deconstruction

      Simulators can be beneficial in helping to train specific endoscopic‐related skills [17]. Simulators should be selected based on the educational goals as opposed to available technology, such that the capabilities and focus of the simulator match the learning task. For example, portable, inexpensive part‐task trainers are particularly useful for teaching navigation‐related tasks such as tip control and retroflexion (Video 2.2) [18–21]. Alternatively, ex vivo animal tissue models can be used to train more advanced techniques such as those related to hemostasis (e.g., hemoclip application, injection). Hybrid simulations, which link a simulated patient (i.e., an actor) with a virtual reality or inanimate simulator, can be used for focused teaching on endoscopic nontechnical skills such as communication, teamwork and situational awareness. In this way, simulators can be used to teach and/or reinforce various tasks depending on how they are used and integrated within a curriculum. As mentioned, a “progressive” learning strategy, which involves planned and gradual increases in the difficulty and complexity of tasks as learners’ abilities improve, can be used by educators to help guide the selection of simulators for educational programs. A stepwise progression enables trainees to build upon previously attained skills by engaging in activities of increasing difficulty without being cognitively overloaded [16]. As with clinical training, instruction and feedback are crucial to facilitate learning [22].

      In developing new simulators, task deconstruction is important to ensure key tasks are integrated within the model and focused on as points of instruction [3]. Similarly, it aids in formulating simulator‐derived metrics that can serve as objective performance feedback for trainees.

Summary

      The training of endoscopic skill is an important component of residency training that has not been the focus of extensive study. In this chapter, we have attempted to illustrate that although performing endoscopy involves highly complex psychomotor skills, a structured approach to training using deconstruction of relevant skill sets can be a useful starting point to designing training. Although current training programs are no doubt producing competent endoscopists, and many have learned endoscopy on their own in the past, observations from a variety of perspectives have demonstrated that there is room for improvement. A careful examination of current training methods using a framework for both endoscopy and training, such as that described in this chapter as a starting point, can assist endoscopy trainers in providing efficient, timely, and comprehensive training to future endoscopists.

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