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This model stipulates that feedback should be delivered as part of a “learning conversation” [53] or “facilitated discussion” during which the trainer first Asks the trainee for their view and reflection of the training encounter and explores issues that the trainee identifies. Subsequently, during a Conversation, the trainer should reinforce good techniques and behaviors. Additionally, they can raise issues that the trainee did not mention and explore them further. It is important for the trainer to confirm where there is congruence between the trainer and the trainee’s perspectives and correct misperceptions and knowledge deficiencies [31]. Finally, the trainer should conclude with a quick review of what was achieved in relation to the pre‐defined learning objectives and then outline one to two key Take‐home messages or specific suggestions for improvement that relate to the learning objectives. This information can then be used to develop a plan for improvement and help set learning goals for future training sessions so as to iteratively modify training expectations to build trainee competence. The trainer should aim to foster skills development by increasing a trainees’ self‐awareness, and ability to monitor and self‐regulate their learning and sense of personal responsibility. The endoscopic trainer should achieve this through the use of questioning, active listening and, where appropriate, respectfully challenging trainee viewpoints in a supportive, and learner‐centered manner [58]. A well‐managed learning conversation includes explicit feedback and leaves the trainee feeling valued and cognizant of their next steps.

      Summary

      Each step in the Preparation–Training–Wrap‐up framework should be tailored to the trainee and the training session since individuals learn in different ways and at different paces. Although this framework applies to a single training session, it is important to conceptualize training over the longer term, such that the take‐home messages from one training session become the goals of the next session, and each training session is integrated within an overarching curriculum [23]. Additionally, communication among various trainers within a program or institution is essential to ensure continuity and consistency in training.

Training aids

      Over the last decade, there have been several technical advances in the provision of endoscopic training, notably magnetic endoscopic imagers, and endoscopic simulators. Trainers can take advantage of these tools to enhance learning.

      Magnetic imagers

Magnetic endoscopic imaging provides the trainer and trainee with a three‐dimensional display of the endoscope configuration within the patient (Figure 4.5). This is particularly useful during colonoscopy, where the visual representation of loops can be used to teach loop recognition and loop reduction techniques [59]. Use of magnetic endoscopic imaging with trainee endoscopists has been assessed in only one randomized controlled trial where its usage was associated with a lower risk of procedure failure, reduced cecal intubation time, higher cecal intubation rate, decreased duration of looping, fewer loop reductions, and more effective use of external pressure [60]. Additionally, its use is not associated with cognitive overload in trainees [61]. Studies in practicing endoscopists have shown that use of magnetic imagers facilitates colonoscopy completion, insertion time, lesion localization and improves patient comfort [62–64]. The unpublished experience from the Canadian SEE Program has been that the use of magnetic imagers is extremely beneficial in fostering conscious competence among trainers as it enables them to link their “feel” to the image on the screen to develop a better understanding of the procedure.

      Currently, two imagers are available commercially: the ScopeGuide from Olympus Medical Systems and SCOPEPILOT form Pentax Medical. Prior to employing this technology in training, trainers should be comfortable in using it themselves and interpreting the images. While its use is integrated within many existing endoscopy “train‐the‐trainer” programs, a focused curriculum to educate trainers on its use during training does not yet exist. Future studies are required to examine whether longitudinal use of magnetic endoscopic imaging during training can accelerate trainee learning curves and to determine the optimal manner in which to integrate this technology into endoscopy training.

      Endoscopic simulators

      Many of the principles of effective endoscopic training outlined above also apply to training within the simulated setting. The history of the development and use of simulators in training is reviewed in detail in Chapter 1, and specific applications are detailed elsewhere in Part II of this textbook which addresses particular endoscopic procedures.

      Simulators are important, especially for more novice trainees, as they afford trainees opportunities for deliberate practice, a critical factor in the acquisition of skills and expertise [34, 65, 66]. Deliberate practice encompasses repetitive performance of structured activities, coupled with informative feedback, which promotes monitoring and error correction to improve performance in a specific domain [34, 65]. For deliberate practice to be most effective, the trainee has to be challenged with tasks of appropriate difficulty that increase in pace with trainee skill development [47]. Additionally, it requires the provision of focused feedback from a trainer. Studies have shown that there is no improvement in endoscopy skill acquisition in the simulated setting without feedback, and the absence of feedback may, in fact, foster the development of “bad habits” [67, 68]. Additionally, studies have shown that instructor‐derived feedback has a distinct advantage in improving endoscopy skill acquisition as compared with simulator‐generated feedback [32, 33]. As in the clinical setting, to avoid overburdening the trainee, feedback should focus on well‐defined and achievable goals, and include specific suggestions for improvement. The simulated setting is unique, however, in that it provides an ideal environment for trainees to work through errors independently without compromising patient safety. Withholding feedback until the end of a simulated endoscopic task has been shown to be more beneficial as compared to continuous feedback, likely because it enables trainees to better engage in real‐time problem‐solving without becoming cognitively overloaded [45]. Similar to the clinical setting, it is important for trainers to tailor their feedback to the trainee, their learning style and level of skill development.

Simulators are advantageous in that they permit trainers to employ teaching strategies that are not possible within the clinical setting as they would compromise patient safety. For example, simulators can be used to teach around troubleshooting difficult and unexpected situations such as perforation and they enable trainers to demonstrate incorrect technique as a counterexample to illustrate concepts and explore trainee misconceptions. Prior to using simulation as a training modality, it is important for trainers to gain experience with the models they plan to employ and familiarize themselves with relevant pedagogical principles to maximize their potential benefits. Courses have been developed to help trainers gain experience with endoscopy simulation and guide them in the appropriate pedagogical utilization of this educational technology, such as the World Endoscopy Organization’s Program for Endoscopic Teachers (https://www.worldendo.org/education/program‐for‐endoscopic‐teachers‐pet/). As with all training sessions, trainers need to plan and structure their teaching using simulators. It is important to recognize that there are a wide variety of simulators available to teach endoscopy. Both low‐ and high‐fidelity simulators can be used effectively, as the pedagogical goal should be the main determinant of simulator selection, as opposed to technological capabilities [47, 69].

Figure 4.5 This image shows a common loop visualized with the assistance of a magnetic endoscopic

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