Abstract
Junior perspective: Ivo Boskoski
The dream of every gastrointestinal (GI) fellow who is training in endoscopy is to become an expert endoscopist in all endoscopic techniques. In the past two decades, there has been an ‘endoscopic revolution’, with many new procedures that are becoming more and more complex and therapeutic. Today’s GI fellows are not limited to performing simple upper and lower GI procedures, but instead have an increasing interest in the dissection of large lesions, treatment of achalasia, palliation of malignancies of the GI tract, treatment of bilio-pancreatic disorders, endoscopic suturing and many other procedures. As all procedures are becoming more complex, training represents an increasingly important endeavour.
Training is essential for learning and improving your endoscopic technique. But how should you train and, more importantly, how should competence be evaluated? Moreover, how should simulation be integrated into training programmes? For instance, almost one-half of the gastroenterology training programs in the USA provide fellows with access to endoscopic simulation, but only 15% of the programmes require that trainees use simulators. 1 As the issue concerns the evaluation of competence, many different tests have been developed, with Direct Observation of Procedural Skills more dedicated to endoscopy. 2 Trainees differ from each other in terms of cognitive and procedural skills in upper and lower endoscopy. The question that arises is how do we decide what technique is best suited to a certain fellow? What we already know is that high-level cognitive and procedural skills in upper endoscopy and colonoscopy are required in order to achieve competence in any advanced endoscopic procedure including endoscopic retrograde cholangio-pancreatography (ERCP), therapeutic Endoscopic Ultrasound (EUS), dissection and endoscopic suturing.
Competence development in endoscopy is a process that should go through structured training programmes supervised by experienced endoscopists. The main question, or more precisely, the main problem here is how to access ‘structured training programmes’ and, even more importantly, for free? In Europe, there are many European Society of Gastrointestinal Endoscopy (ESGE) endorsed centres that offer basic and advanced training in GI endoscopy. Furthermore, training can be intended for a whole procedure or a part of it. Training on patients, especially for novices, is becoming an important issue that is increasingly common. This is a serious problem in terms of informed consent, legal issues and complication rates etc. In addition to this, some senior endoscopists are not comfortable sharing the scope with a fellow or, at the first difficulty, they will ask for the scope back. This can happen very often for complex procedures such as ERCP. Based on this, it is probably due to a fear of the senior endoscopists that severe complications might occur. How do we solve this? Endoscopy simulators have the capacity to accelerate the learning curve of entire techniques or part of them, and they are extremely important in the training process. Ex vivo animal tissues, mechanical simulators, virtual reality models or a combination of all three have the potential to enhance the existing practice of teaching endoscopy. The importance of endoscopy simulators in competence development has already been proven. It is extremely important that endoscopy simulators are used as part of structured training programmes and, at a certain stage, in combination with training on patients and under the direct supervision of expert endoscopists.
The fascinating world of endoscopy has been ultimately enriched by endoscopy robots. 3 The good news is that these robots do not require very skilled endoscopists. For instance, an endoscopic submucosal dissection (ESD) of the rectum could be done in a very short time by a fellow that knows the bases of the procedure. This is a completely new field, and nobody knows what the impact on endoscopists and patients will be, but the only fact is that robots will surely bring democracy in endoscopy.
Senior perspective: Pierre Deprez
Improving endoscopic technique depends on several factors: motivation from the trainee, teaching skills and competence from the trainer, sufficient local resources and time. What should be the trainers be aware off? First, deliverers of adult learning and teaching should remember Benjamin Franklin’s words ‘Involve me and I learn’. This will of course be especially true for acquiring endoscopy skills. The trainer must be committed, prepared and of course skilled himself. Involving a young fellow in advanced endoscopy might be quite stressful for the senior trainer, particularly if it concerns his own patients. He will need patience, to allow time to learn, foster mutual respect in his relationship with his fellow, be encouraging and supportive, challenge ideas, clarify difficult concepts and provide positive feedback.
The training programme should be structured, with levels of competence and skills, and objectives identified. Resources should be provided to the trainee in terms of space, tools and time to learn, scopes and devices (allowing him to use the best scopes, for example with magnification in the case of EMR-ESD) and enough cases. A skilled endoscopist is not always a good teacher. There are programmes available (WGO-Train the trainers) to increase awareness of teaching skills.
What do the trainers want from a fellow? Appropriate knowledge has to be acquired first through lectures, reading, watching movies (all passive learning methods) about the pathology involved, the indications for endoscopy, and the technical specificities of scopes and devices that will be used. 4 Too often we see fellows jumping on the scope without a clear understanding of the aim, indication, and limits of an EUS or ERCP examination. Watching live demonstrations may similarly put fellows in danger, since performance is sometimes put forward. I do agree that including simulators or ex vivo models should be fully integrated in a structured programme. 5
An important quality for a fellow (or a trained endoscopist) is the faculty to act as a conscious or unconscious ‘sponge’ to acquire new competences and ideas, and for that purpose it is of interest to visit other centres/countries with different practices (and models). Since its launch in the mid-1990s, the ESGE fellowship grant programme has become an established educational cornerstone offering two types of grants: to visit expert units to experience day-to-day life, and to spend longer stays with more in-depth learning and hands-on training.
Learning endoscopy is a step-by-step process. 6 Before starting interventional endoscopy, diagnosis is crucial and too often fellows are blind to the beauty of description, imaging and filming, although we now have access to high-definition endoscopy, EUS and miniaturized scopes. EMR and ESD cannot be successful without proper recognition of lesions, and delineation or margins, and ERCP will always be more efficient with a good understanding of MRCP and previous EUS images.
Curriculums for training do exist (ERCP and EUS, for example) or will be soon published to improve the quality of digestive endoscopy (for example the ESGE ESD curriculum).7,8 But not all fellows should embark on advanced therapeutic endoscopy. There is no need for that: cases are limited and should be gathered in expert technique centres. Also, fellows should be aware of the increased levels of stress and burnout related to an interventional career choice. 9 The most effective pathway therefore seems to be the building of an individual teaching programme together with the future employer to discuss needs, the number of cases necessary to maintain the competence acquired and the resources that will be provided by the institution. Too many of our fellows are unable to continue to perform the techniques they learn due to local financial or political limitations.
Finally, being a better endoscopist does not only mean a sufficient medical knowledge, and cognitive and technical skills, but also a positive attitude and good relationships with the patients, nursing staff, anaesthesiology team and care providers. Empathy for the patient will be the final touch in becoming a better endoscopist! The endoscopist must understand the patient’s needs, discuss the endoscopic approach and the alternatives with him, explain the limits and of course the possible complications that may occur, and refrain being a simple expert technician.