Barton et al12 described in 2012 the value of the Direct Observation of Procedural Skills (DOPS) method developed by an expert group of colonoscopists and clinical educators in the United Kingdom. Colonoscopists wishing to participate in the British National Health Service National Bowel Cancer Screening Programme (BCSP) were assessed. Assessments from 147 candidates and 28 assessors were analyzed. Candidates had to prove experience in a minimum of 500 colonoscopies with a self-reported cecal intubation rate of ≥ 90% and a polyp detection rate of ≥ 20%. The assessment had high reliability using generalizability theory (G) with G = 0.81 and correlated highly with a global expert assessment. Both, candidates and assessors, believed that the DOPS was a valid assessment of competence.
Anderson13 recently described how DOPS evaluation has been successfully integrated for trainees as well as for independent endoscopists into the “UK National Bowel Cancer Screening Programme.” The Joint Advisory Group (JAG) sets the standards for endoscopy training and the accreditation of endoscopy units as base training units.14,15 A Global Rating Scale web-based system is used for continuous assessment of performance and DOPS is regularly applied in order to monitor continuously individual performances. An individual web-based logbook and e-portfolio of each endoscopist is created via a national database system that is the base for credentialing and certification. Feedback of data to individuals helps in benchmarking and identification of those with suboptimal performance and a need for extra training and close audits. The system has recently been extended to upper GI endoscopy and other techniques.16
1.2.2 Training in Endoscopic Retrograde Cholangiopancreatography
Proficiency in all aspects of endoscopic retrograde cholangiopancreatography (ERCP) requires several years of practical training and continuous refinement of knowledge and skills.8 With the advent of noninvasive tests such as magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS), ERCP is an almost purely therapeutic procedure. This is creating a new challenge in the training of young endoscopists, as ERCP procedures are becoming more complex and are concentrated in large- or mid-volume endoscopy centers.17,18
In most fellowship training programs, traditional ERCP training follows education in diagnostic gastroscopy and colonoscopy and is often begun when the trainee has been introduced to polypectomy, hemostasis, or EUS training as part of a “learning pyramid” (
Jowell et al19 found that a minimum of 180 to 200 ERCPs are needed to be performed before a trainee could attain competency in ERCP.19 (
Fig. 1.1 Procedure time by experience. (Reproduced with permission from Sedlack et al 2016.11)
Fig. 1.2 Polyp detection and miss rates by experience. (Reproduced with permission from Sedlack et al 2016.11)
Fig. 1.3 The “learning pyramid” as an example of stepwise clinical training in interventional endoscopy. (Adapted from Hochberger et al 2010.1)
Fig. 1.4 The probability (with 95% confidence intervals) of achieving an acceptable score for cholangiography (a), pancreatography (b), deep pancreatic cannulation (c), and deep biliary cannulation (d) during training of fellows in endoscopic retrograde cholangiopancreatography (ERCP), as reported by Jowell et al19 for 17 gastroenterology fellows during 1,450 ERCP procedures.
Now that most ERCPs are performed for therapeutic purposes, it is a matter of controversy whether cannulation is the next technique for the trainee to learn after he or she is able to maneuver the duodenoscope competently to the papilla. For example, it is well known that for routine stent exchanges in the setting of a prior sphincterotomy, fewer procedures (n = 60) are needed to obtain competence than is the case with cannulation of a native papilla (n = 180–200), and it is also known that stent exchanges are associated with a lower risk profile compared to cannulation. Patients with benign biliary strictures, chronic obstructive pancreatitis, and recurrent bile duct stones in the setting of prior sphincterotomy are also associated with lower risk during training.
The ASGE published their latest core curriculum for training in ERCP in 2016.8,23 Trainees who elect to perform ERCP should have completed at least 18 months of standard gastroenterology training, followed by at least 12 months of ERCP training.
Schutz and Abbott24 developed an ERCP grading scale based on procedural difficulty using benchmarks such as cannulation rates to gauge competency. A modification of this score was adopted by the ASGE as part of their quality-assessment document. Absolute numbers of procedures partially performed by a fellow may not realistically reflect competence.25 Where possible, trainee logbook records should specify particular skills completed by the fellow (cannulation, sphincterotomy, stent placement, tissue sampling), and should also indicate cases that the trainee completed without assistance. The ASGE guidelines state that most fellows require at least 180 ERCP cases before competency can be assessed, with at least half being therapeutic.8 Although not all of the trainees may ultimately perform ERCP after the completion of their training, all fellows should at least develop an understanding of the diagnostic and therapeutic role of the procedure, including indications, contraindications, and possible complications.26
The decision by a program director as to whether to train one or more fellows each year to achieve sufficient competence will depend in some measure on the volume of ERCPs performed at the institution and the availability of experts in ERCP (
1.2.3 Complementary E-learning and Video Courses
Live endoscopy courses, interactive teaching programs, and video materials can help trainees to recognize pathology better and to understand the appropriate application of therapeutic techniques.27