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and to achieve reliable skills assessment on a simulator.

At present, computer simulators appear to have much to offer trainees in terms of showing diverse pathology and teaching beginners hand–eye coordination and endoscope handling. Unique aspects of this type of training are simulation of contractions, feedback on comfort, opportunity for self‐instruction without constant expert supervision, quantification of skills, and offsite skills assessment by instructors. Current available models appear less useful for more experienced endoscopists, although capabilities are expanding rapidly. At present, the therapeutic modules for the GI Mentor II simulator are best suited for introductory orientation only to polypectomy, hemostasis, and ERCP.

      Computerized technology offers the potential to incorporate didactic lessons, specific questions for the endoscopist concerning accessory setup and generator settings, and opportunities for self‐assessment quizzes to complement the hands‐on technical experience. However, to date, such potential advances have not yet been incorporated into the existing simulators.

      The major obstacle to expanded use of these simulators remains the cost and logistics of making them accessible to trainees. At costs ranging from $50,000 to 70,000, most individual departments cannot afford to purchase computer simulators.

The future of simulators in endoscopy training

What will be the next steps in the evolution of endoscopy simulators? A number of scenarios can be envisioned. Some potential developments envisioned in 2010 are described in Table 1.1, which interestingly shows ideas for future applications of simulators that were proposed in the first edition of this chapter, and now updated with remarks in red showing the progress or in some cases, lack of progress, in these areas over the past decade. Regardless of exactly how this field evolves in the coming years, it is fairly certain that simulators will play an increasing role in teaching and training in gastrointestinal endoscopy.

On November 19 and 20, 2017, the ASGE hosted an EndoVators Summit, partially supported by grant from the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health at the ASGE Institute for Training and Technology in Downers Grove, Illinois. The purpose of the summit was to define the role and value of simulators in the future of endoscopic training and to reach consensus regarding priority areas for simulation‐related education and research and simulator development. Over 70 thought leaders in simulation research, simulator development, and endoscopic education and training and key decision makers from industry gathered to review the current state of endoscopic simulation and the role it could play in endoscopic training. A White Paper published in 2019 [62] summarized the day’s events and the findings.

Table 1.1 Anticipated expanded applications of endoscopy simulation in 2010 and current status in 2020.

Computer simulators may be used to test innate hand–eye coordination skills of fellowship applicants. This has not yet happened.

More training programs may offer static mannequins to allow novices to practice rudimentary maneuvers with controls on endoscopes and for manual dexterity training prior to handling endoscopes on real patients. While supported by the ACGME guidelines for training programs to incorporate simulators in GI training [63], despite the relatively low cost, this compelling development has not yet occurred.

GI training programs with sufficient resources may provide access to hospital‐based virtual reality simulators, designed to offer training in many GI and non‐GI procedures. Hospitals can purchase these for training and credentialing of practitioners in many fields and training of technical assistants for these procedures. Multiuse simulators could justify the cost. Sim centers have proliferated, largely driven by surgical departments.

The large capital outlay for these simulators could be obviated by regional web‐based virtual reality servers. These might allow hospitals and training programs to subscribe and then “perform” specific procedures on “dummy” terminals at remote sites via cloud computing without purchasing the entire computer and software packages. A decade after the first edition of this book, educators still grapple with this cost and access issue. The debate remains over the ultra‐high tech expensive and high‐fidelity simulator that closely mimics all aspects of procedure versus less‐expensive lower tech models that allow for specific skill component teaching and practice. Dramatic increases in computing power and virtual reality technology may solve this cost barrier to scalable computer simulation. However, this may need to wait until the third edition of this book to be achieved.

Interactive quizzes of pathology recognition and correct management decisions based on findings may be integrated into future simulator training along with the hands‐on practice of technical skills. Alternatively, an Internet‐based tutorial could serve as an introduction to pathology. Training in cognitive skills acquisition, including use of web‐based learning tools was regarded as a high priority in the 2019 NIH‐sponsored simulator summit. This remains an unrealized goal though it is likely achievable in the near future.

Simulators and simulator‐based workshops might allow skill assessments, which would indicate when trainees were ready to proceed to perform supervised real cases and ultimately independent endoscopic procedures. The move to competency‐based education has driven greater incorporation of objective skills assessments during hands‐on workshops along with feedback. Examples of this appear subsequently in Chapters 37 and 38.

With validated simulator‐based skills assessment, it is conceivable that no procedures would be allowed on human subjects until simulated training has occurred and satisfactory performance measured. No simulator‐based assessment has yet been demonstrated to have predictive validity for outcomes measured on real cases. Assessment of skill is discussed in detail in Chapter 39. Simulator training prior to proctored experience on real patients now has many advocates, though there remain access and cost obstacles to widespread adoption and eventual requirement.

Therapeutic workshops using ex vivo animal models will proliferate further and become increasingly available at multiple regional locations for trainees and practicing gastroenterologists hoping to learn new skills or polish old ones. This has fully taken hold with opportunities at many local venues as well as the larger meetings.

GI trainees will be required to attend one such workshop during the first year of fellowship and recommended to attend another early in the third year. Third year opportunities are emerging, but so far these are sporadic and far from scaling to parallel the widespread reach of first year hands‐on training course attendance.

A cadre of endoscopy instructors could be trained to run such workshops, including individuals from every region of the country. Train‐the‐trainer efforts have expanded especially in the United Kingdom and Canada with regards to colonoscopy, though the focus has not been on how to use simulators to maximum effect. There still has been no effort to standardize “simulator‐based instruction methods” among a large group of instructors.

Possibly, practicing endoscopists will be required in the future to attend such workshops at defined intervals, possibly every 5 years, to maintain privileges for therapeutic endoscopy. There remains no validated maintenance of skill instruction program, though the NIH emphasized the need for research on this topic [62]. Nor has there yet been consensus or driver pushing for retooling or upskilling in the United States for practicing endoscopists. Objective performance measure tracking has gained traction, and poor performers in colonoscopy outcome such as adenoma detection rate (ADR) have led to efforts to provide remediation.

      The goal was to provide a working roadmap for the developers of simulators and for the investigators whose goal is it to define the optimal use of endoscopy‐related simulation. Moreover, the attendees

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