The next component of the preparation phase is an assessment of the trainee’s skill level. It is particularly important for a trainer to elucidate a trainee’s level of competence if the trainee–trainer pair have not met previously or if a long period of time has elapsed since their last training session, so that the trainee is not pushed beyond their limits or what is safe for the patient. The trainer should briefly assess the trainee’s current skill level through directed discussion with the trainee and, if possible, through review of an e‐portfolio, procedural log, prior feedback, and/or assessments. While a formal assessment is generally not possible, the trainer can ask a few directed questions to get a sense of the trainee’s skill level, their previous experience, and areas of difficulty. An example dialogue between the trainer–trainee pair could include questions such as: “Tell me about your previous experience with colonoscopy?,” “What skills have you been working on?” or “What difficulties have you encountered recently in performing colonoscopy?” Directed questioning can help the trainer better assess the skill level of the trainee, challenge any assumptions the trainer had going into the encounter, and generate a learning agenda.
Alignment of agendas between the trainer and trainee is an important component of the preparation phase. The trainer and trainee will both have an agenda or goals they hope to achieve during the training session, which may be the same or different. If the trainer and trainee’s agendas differ, and the trainer does not take the trainee’s goals into account, the training session may be compromised, as it will not be as meaningful or as well received by the trainee. It is important for the trainer to elicit the trainee’s agenda through an open discussion, be flexible, and try to come to a consensus on the goals for the session, which should take into account both the trainer and trainee’s agendas [25]. Alignment of agendas helps to ensure the trainee and trainer are aware of and appreciate one another’s perspectives and also have a shared understanding of the goals for the teaching encounter [4]. This then facilitates the development of two to three focused learning objectives which should be established collaboratively in advance of the training session. Tools and frameworks designed to enhance the quality of learning objectives, such as SMART (specific, measurable, achievable, realistic and timely), may be used to help formulate objectives that clearly describe the knowledge, skills, and behaviors the trainee should be able to demonstrate by the end of the teaching encounter [29]. Well‐defined and mutually agreed upon learning objectives are essential in that they provide a target with which trainees can focus their learning efforts and trainers can focus their observation and feedback to maximize training effectiveness. It is important that the goals are realistic and achievable. Early in training, trainees may be unaware of their deficits (i.e., unconsciously incompetent) and the trainer will likely need to play a greater role in setting the agenda and learning objectives. However, as a trainee’s skills improve, they should be encouraged to critically reflect on their performance and take increasing responsibility for identifying targets for improvement and setting learning objectives [30, 31].
Figure 4.3 Set‐up of an endoscopy suite during training to optimize the trainer’s view of the patient’s face, the monitor, and the trainee’s hands.
Finally, it is important for the trainer to maintain a sense of control over the procedure, trainee, and environment during a teaching encounter, as patient safety must not be compromised for the sake of training. Essential to this are ground rules or agreed upon parameters for teaching during the procedure [25]. The ground rules, which will vary across trainees and cases, outline the roles and responsibilities of the trainee and trainer during the teaching session, make clear the time allocated for training, and provide pre‐defined criteria for trainer interventions (i.e., stopping or taking over the procedure) that can be expected by the trainee. Establishing ground rules helps to ensure patient safety, reinforces the trainer’s control of the session, and establishes the trainer as the team leader.
The learning objectives and ground rules form the basis of an educational contract, which is an agreement between the trainer and trainee as to how the teaching encounter will be structured and conducted. It is important that decisions are made ahead of the training encounter so that the trainer and trainee’s expectations are both realistic and aligned. An effective educational contract enables the trainee to focus on their skills development while ensuring that the trainer maintains control over the training encounter.
Training
The training encounter refers to the time from the point the trainee starts the procedure until they complete it, or the training encounter is terminated. During this component, there are several evidence‐based educational principles that can be applied by trainers to enhance learning. Performance enhancing instruction, or formative feedback provided during the learning encounter, is a key motivator for trainees and one of the most important determinants of endoscopy skill acquisition [32, 33]. During the procedure, instruction should be based on direct observation of performance, should be informative, and when possible, should focus on the agreed upon learning objectives for the training session. The use of learning objectives, instructional feedback, and correction to enhance performance forms the basis for deliberate practice, a foundational element for the development of expertise [34]. To guide their observations and feedback, trainers can use endoscopy assessment tools with strong evidence of validity for use during training [35], such as the Assessment of Competence in Endoscopy (ACE) tool [36], the Gastrointestinal Endoscopy Competency Assessment Tool (GiECAT) [37, 38], or the JAG’s Direct Observation of Performance Skills (DOPS) tool for colonoscopy [39]. Such tools help to highlight key areas that are required for skillful endoscopy performance and are discussed in more detail in Chapter 39 of this volume.
Feedback should be tailored to the skill level of the trainee. The process of skill acquisition has been described as a sequential process involving three major phases: cognitive, associative, and autonomous [40]. In the cognitive phase, the trainee is focused on developing a mental understanding of the procedure and considerable cognitive effort is required. While skill acquisition is rapid, performance is inconsistent, inefficient, and error filled. Feedback during this phase is often more directive (i.e., specific instruction on how to do or not to do something) and is best focused on how the procedure is performed correctly and identifying and rectifying common errors to improve the trainee’s understanding of the procedure [4]. Instructions should be clear, concise, and focused on distinct skills (e.g., torque steering, loop resolution) so that the trainee is not overwhelmed [41].
During the associative phase, performance becomes more fluid, efficient, and reliable with fewer mistakes. Additionally, less cognitive activity is required. Instruction and feedback during this phase should be more facilitative, focusing on helping the trainee to reflect on what happened. The trainer should analyze the trainee’s performance, recognize areas of strength, and identify errors and corresponding corrective actions [42, 43]. In the final autonomous phase, the procedure is performed skillfully, consistently, and efficiently. Performance is largely automatic with little conscious awareness devoted to skill execution. Instruction is best focused on helping the trainee build their conscious awareness so that they can deconstruct their automated actions, and explicitly explain what is occurring and what to do.
Decision training focuses on having the trainee pinpoint critical challenges during the procedure, identify solutions, and choose the best approach. It