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Figure 5.14 Sample case from GI Mentor™.

      In a randomized study, novice fellows were assigned to either 10 hours of preclinical training on the former Simbionix simulator or to no simulator training. Each trainee then performed EGDs in 20 subjects. The trainees who received simulator training demonstrated more complete procedure rates and required less instructor assistance [27]. Another study using the former Simbionix simulator randomized half of the medical residents to 5 hours of simulator‐based training in EGD and demonstrated that this group had higher skill level for performance parameters measured during subsequent live EGD cases [28]. A recent systematic review concluded that virtual endoscopy simulator training was more effective than bedside teaching or other interventions for novice endoscopists: the percentage of independently completed EGDs was 88% with simulator training compared to 70% in the non‐simulator training group [29].

      Animal models

      The primary animal model used has been the Erlangen Endo‐Trainer (ECE Ltd., Erlangen, Germany) or the compact Erlanger Active Simulator for Interventional Endoscopy (EASIE) simulator. Both models feature a rotatable plastic torso in which organ packages can be placed for training. In the compact EASIE model, a roller pump has been used to drive an artificial blood circulation through major organ arteries and simulate spurting arterial bleeding. Initial comparison of both models used during endoscopic courses showed no difference in trainee preferences between the two models [30]. Subsequent analyses of data generated from training courses showed that trainees all improved in endoscopic skills [31] and that the usage of the EASIE simulator improved skills over bedside training alone [32]. In a multicenter study enrolling novices in endoscopy, a 1‐week course with the Erlangen Endo‐Trainer was associated with significant improvements in the tested endoscopic parameters, but no control group was used [33]. In a subsequent study where fellows were randomized to education only versus simulator training in EGD with the Erlangen Endo‐Trainer, the learning curve for the simulator‐trained group after 9 months of fellowship was significantly higher compared to the group receiving education alone [34].

Assessment of performance

      Evaluation of each trainee's endoscopic skill is commonly done by applying ACGME's core competencies and using their Next Accreditation System that focuses on milestone attainment [35]. However, it is also important that trainees receive timely and routine feedback on their endoscopy skills from their attendings throughout the training period. Assessment of performance in upper endoscopy should include the following cognitive and motor skills [3,35]:

      The training program director should monitor procedure logs to ensure that the minimal threshold of 130 EGDs is achieved and surpassed [3,35]. Periodic evaluations of trainees should also be submitted to the program director and/or clinical competency committee for review to assess skill proficiency and appropriate clinical judgment as determined by faculty proctors.

Conclusions

      Proper training in upper endoscopy is essential for residents or fellows in an endoscopic training program. Trainees should become proficient in both cognitive and procedural aspects of endoscopy. This includes understanding when a procedure is indicated, recognizing landmarks and pathology, performing the procedure safely and thoroughly, and translating endoscopic findings into a management plan for the patient. Skills in therapeutic endoscopy, particularly in the management of endoscopic hemostasis, are important, and thresholds exist for the determination of competence for each therapeutic modality. Simulation in EGD is available through computer and animal models; both models have shown that trainees improve endoscopic skill sets with simulation compared to no simulation, but further studies are needed to determine if simulation alone can reduce or even ultimately replace bedside training.

Videos

      Video 5.1 Handling the endoscope

      Video 5.2 Esophageal intubation

      Video 5.3 Retroflexion in the stomach

      Video 5.4 Advancing into the duodenum

      Video 5.5 Endoscopic biopsy

References