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Barsuk JH, Cohen ER, Patel RV, Keswani RN, Aadam AA, Wayne DB, Cameron KA, Komanduri S. Effect of Polypectomy Simulation-Based Mastery Learning on Skill Retention Among Practicing Endoscopists. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2024; 99:317-324. [PMID: 37934830 PMCID: PMC10922268 DOI: 10.1097/acm.0000000000005538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
PURPOSE Practicing endoscopists frequently perform and teach screening colonoscopies and polypectomies, but there is no standardized method to train and assess physicians who perform polypectomy procedures. The authors created a polypectomy simulation-based mastery learning (SBML) curriculum and hypothesized that completion of the curriculum would lead to immediate improvement in polypectomy skills and skill retention at 6 and 12 months after training. METHOD The authors performed a pretest-posttest cohort study with endoscopists who completed SBML and were randomized to follow-up at 6 or 12 months from May 2021 to August 2022. Participants underwent SBML training, including a pretest, a video lecture, deliberate practice, and a posttest. All learners were required to meet or exceed a minimum passing standard on a 17-item skills checklist before completing training and were randomized to follow-up at 6 or 12 months. The authors compared simulated polypectomy skills performance on the checklist from pretest to posttest and posttest to 6- or 12-month follow-up test. RESULTS Twenty-four of 30 eligible participants (80.0%) completed the SBML intervention, and 20 of 24 (83.3%) completed follow-up testing. The minimum passing standard was set at 93% of checklist items correct. The pretest passing rate was 4 of 24 participants (16.7%) compared with 24 of 24 participants (100%) at posttest ( P < .001). There were no significant differences in passing rates from posttest to combined 6- and 12-month posttest in which 18 of 20 participants (90.0%) passed. CONCLUSIONS Before training and despite years of clinical experience, practicing endoscopists demonstrated poor performance of polypectomy skills. SBML was an effective method for practicing endoscopists to acquire and maintain polypectomy skills during a 6- to 12-month period.
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Zhao AY, Gimpaya N, Angeli Fujiyoshi MR, Fujiyoshi Y, Khan R, Lisondra J, Walsh CM, Grover SC. How to make cost-effective polyp simulators for high-fidelity simulation-based training in postpolypectomy bleeding management and EMR. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2023; 8:520-526. [PMID: 38155828 PMCID: PMC10751457 DOI: 10.1016/j.vgie.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
Video 1Demonstration of manufacturing instructions and features of the postpolypectomy bleeding and conventional and underwater EMR simulators.
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Affiliation(s)
- Ally Y Zhao
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Nikko Gimpaya
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada
| | | | - Yusuke Fujiyoshi
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Rishad Khan
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - James Lisondra
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Catharine M Walsh
- Division of Gastroenterology, Hepatology, and Nutrition and the Research and Learning Institutes, Hospital for Sick Children, Department of Paediatrics and the Wilson Centre, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Samir C Grover
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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3
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Holme Ø. Are we ready for the cold snare revolution? Endoscopy 2023; 55:938-939. [PMID: 36827990 DOI: 10.1055/a-2025-0997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Affiliation(s)
- Øyvind Holme
- Institute of Health and Society, University of Oslo, Oslo, Norway
- Sorlandet Hospital, Department of Medicine, Kristiansand, Norway
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4
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Mouchli M, Bierle L, Reddy S, Walsh C, Mir A, Yeaton P, Chitnavis V. Does completing advanced endoscopy fellowship improve outcomes after endoscopic mucosal resection? Minerva Gastroenterol (Torino) 2023; 69:344-350. [PMID: 33793165 DOI: 10.23736/s2724-5985.21.02782-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND It was reported that about 60% of the physicians in the USA believed that their Gastroenterology fellowship poorly prepared them for large polyp resection. The aim of this study was to compare endoscopic mucosal resection (EMR) efficacy and complication rates between skilled general gastroenterologists who perform high volume of EMR and advanced endoscopists. METHODS We identified 140 patients with documented large colonic polyps treated by 4 providers using EMR technique at Carilion Clinic, in Roanoke, Virginia, USA between 01/01/2014-12/31/2017, with follow-up through 10-2018. Information on demographics, clinical and pathological features of high-risk polyps (i.e., size, histology, site, and degree of dysplasia), timing of surveillance endoscopies, tools used during resection, and skills of performing endoscopist's were extracted. The cumulative risks of polyp recurrence after first resection using EMR technique were estimated using Kaplan-Meier curves. RESULTS One hundred and forty patients were identified (mean age, 64.1±11.2 years; 47.1% males). Fifty-five polyps (39.3%) were removed by 2 skilled gastroenterologists and 85 (60.7%) were removed by advanced endoscopists. Most of the polyps resected were located in the right colon (63.6%) and roughly half of the polyps were removed in piecemeal fashion. At follow-up endoscopy, the advanced endoscopy group had lower polyp recurrence rates. The median recurrence after polypectomy was significantly different between the groups (0.88 and 1.03 years for skilled gastroenterologists who did not complete and completed EMR hands-on workshops; respectively vs. 3.99 years for the advanced endoscopist who did not complete EMR hands-on workshop, P=0.03). CONCLUSIONS There is a need for additional EMR training since polyp recurrence was significantly different between the groups despite high rates of piecemeal resection in the advanced endoscopy groups.
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Affiliation(s)
- Mohamad Mouchli
- Department of Hepatology and Gastroenterology, Cleveland Clinic Foundation, Cleveland, OH, USA -
| | - Lindsey Bierle
- Department of Internal Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Shravani Reddy
- Department of Internal Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Christopher Walsh
- Department of Internal Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Adil Mir
- Department of Internal Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Paul Yeaton
- Department of Hepatology and Gastroenterology, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Vikas Chitnavis
- Department of Hepatology and Gastroenterology, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
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5
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Siau K, Pelitari S, Green S, McKaig B, Rajendran A, Feeney M, Thoufeeq M, Anderson J, Ravindran V, Hagan P, Cripps N, Beales ILP, Church K, Church NI, Ratcliffe E, Din S, Pullan RD, Powell S, Regan C, Ngu WS, Wood E, Mills S, Hawkes N, Dunckley P, Iacucci M, Thomas-Gibson S, Wells C, Murugananthan A. JAG consensus statements for training and certification in flexible sigmoidoscopy. Frontline Gastroenterol 2023; 14:181-200. [PMID: 37056324 PMCID: PMC10086722 DOI: 10.1136/flgastro-2022-102259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 10/04/2022] [Indexed: 01/28/2023] Open
Abstract
IntroductionJoint Advisory Group (JAG) certification in endoscopy is awarded when trainees attain minimum competency standards for independent practice. A national evidence-based review was undertaken to update standards for training and certification in flexible sigmoidoscopy (FS).MethodsA modified Delphi process was conducted between 2019 and 2020 with multisociety representation from experts and trainees. Following literature review and Grading of Recommendations, Assessment, Development and Evaluations appraisal, recommendation statements on FS training and certification were formulated and subjected to anonymous voting to obtain consensus. Accepted statements were peer-reviewed by national stakeholders for incorporation into the JAG FS certification pathway.ResultsIn total, 41 recommendation statements were generated under the domains of: definition of competence (13), acquisition of competence (17), assessment of competence (7) and postcertification support (4). The consensus process led to revised criteria for colonoscopy certification, comprising: (A) achieving key performance indicators defined within British Society of Gastroenterology standards (ie, rectal retroversion >90%, polyp retrieval rate >90%, patient comfort <10% with moderate-severe discomfort); (B) minimum procedure count ≥175; (C) performing 15+ procedures over the preceding 3 months; (D) attendance of the JAG Basic Skills in Lower gastrointestinal Endoscopy course; (E) satisfying requirements for formative direct observation of procedural skill (DOPS) and direct observation of polypectomy skill (SMSA level 1); (F) evidence of reflective practice as documented on the JAG Endoscopy Training System reflection tool and (G) successful performance in summative DOPS.ConclusionThe UK standards for training and certification in FS have been updated to support training, uphold standards in FS and polypectomy, and provide support to the newly independent practitioner.
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Affiliation(s)
- Keith Siau
- Department of Gastroenterology, Royal Cornwall Hospital, Truro, UK
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Stavroula Pelitari
- Department of Gastroenterology, Royal Free London NHS Foundation Trust, London, UK
| | - Susi Green
- Department of Gastroenterology, University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - Brian McKaig
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Arun Rajendran
- Department of Gastroenterology, Hillingdon Hospitals NHS Foundation Trust, Uxbridge, UK
| | - Mark Feeney
- Department of Gastroenterology, Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - Mo Thoufeeq
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John Anderson
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
| | - Vathsan Ravindran
- Department of Gastroenterology, St Mark's Hospital and Academic Institute Wolfson Unit for Endoscopy, Harrow, UK
| | - Paul Hagan
- Endoscopy, Royal Derby Hospital, Derby, UK
| | - Neil Cripps
- Colorectal Surgery, University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - Ian L P Beales
- University of East Anglia, Norwich, UK
- Department of Gastroenterology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | | | | | - Elizabeth Ratcliffe
- Department of Gastroenterology, Wrightington Wigan and Leigh NHS Foundation Trust, Wigan, UK
- Division of Diabetes, Endocrinology and Gastroenterology Faculty of Biology, Medicine and Health School of Medical Sciences, The University of Manchester, Manchester, UK
| | - Said Din
- Department of Gastroenterology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Rupert D Pullan
- Colorectal Surgery, Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - Sharon Powell
- Endoscopy, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Catherine Regan
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Wee Sing Ngu
- Colorectal Surgery, City Hospitals Sunderland NHS Foundation Trust, South Shields, UK
| | - Eleanor Wood
- Gastroenterology, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Sarah Mills
- Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
- Imperial College London, London, UK
| | - Neil Hawkes
- Department of Gastroenterology, Royal Glamorgan Hospital, Llantrisant, UK
| | - Paul Dunckley
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Marietta Iacucci
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
- Department of Gastroenterology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Siwan Thomas-Gibson
- Imperial College London, London, UK
- St Mark's Hospital and Academic Institute Wolfson Unit for Endoscopy, Harrow, UK
| | - Christopher Wells
- Department of Gastroenterology, North Tees and Hartlepool NHS Foundation Trust, Hartlepool, UK
| | - Aravinth Murugananthan
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
- Faculty of Health, Education and Life Sciences, Birmingham City University, Birmingham, UK
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6
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Siau K, Pelitari S, Green S, McKaig B, Rajendran A, Feeney M, Thoufeeq M, Anderson J, Ravindran V, Hagan P, Cripps N, Beales ILP, Church K, Church NI, Ratcliffe E, Din S, Pullan RD, Powell S, Regan C, Ngu WS, Wood E, Mills S, Hawkes N, Dunckley P, Iacucci M, Thomas-Gibson S, Wells C, Murugananthan A. JAG consensus statements for training and certification in colonoscopy. Frontline Gastroenterol 2023; 14:201-221. [PMID: 37056319 PMCID: PMC10086724 DOI: 10.1136/flgastro-2022-102260] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 10/04/2022] [Indexed: 01/28/2023] Open
Abstract
IntroductionIn the UK, endoscopy certification is awarded when trainees attain minimum competency standards for independent practice. A national evidence-based review was undertaken to update and develop standards and recommendations for colonoscopy training and certification.MethodsUnder the oversight of the Joint Advisory Group (JAG), a modified Delphi process was conducted between 2019 and 2020 with multisociety expert representation. Following literature review and Grading of Recommendations, Assessment, Development and Evaluations appraisal, recommendation statements on colonoscopy training and certification were formulated and subjected to anonymous voting to obtain consensus. Accepted statements were peer reviewed by JAG and relevant stakeholders for incorporation into the updated colonoscopy certification pathway.ResultsIn total, 45 recommendation statements were generated under the domains of: definition of competence (13), acquisition of competence (20), assessment of competence (8) and postcertification support (4). The consensus process led to revised criteria for colonoscopy certification, comprising: (1) achieving key performance indicators defined within British Society of Gastroenterology standards (ie, unassisted caecal intubation rate >90%, rectal retroversion >90%, polyp detection rate >15%+, polyp retrieval rate >90%, patient comfort <10% with moderate–severe discomfort); (2) minimum procedure count 280+; (3) performing 15+ procedures over the preceding 3 months; (4) attendance of the JAG Basic Skills in Colonoscopy course; (5) terminal ileal intubation rates of 60%+ in inflammatory bowel disease; (6) satisfying requirements for formative direct observation of procedure skills (DOPS) and direct observation of polypectomy skills (Size, Morphology, Site, Access (SMSA) level 2); (7) evidence of reflective practice as documented on the JAG Endoscopy Training System reflection tool; (8) successful performance in summative DOPS.ConclusionThe UK standards for training and certification in colonoscopy have been updated, culminating in a single-stage certification process with emphasis on polypectomy competency (SMSA Level 2+). These standards are intended to support training, improve standards of colonoscopy and polypectomy, and provide support to the newly independent practitioner.
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Affiliation(s)
- Keith Siau
- Department of Gastroenterology, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
- University of Birmingham College of Medical and Dental Sciences, Birmingham, Birmingham, UK
| | - Stavroula Pelitari
- Department of Gastroenterology, Royal Free London NHS Foundation Trust, London, London, UK
| | - Susi Green
- Department of Gastroenterology, University Hospitals Sussex NHS Foundation Trust, Worthing, West Sussex, UK
| | - Brian McKaig
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, Wolverhampton, UK
| | - Arun Rajendran
- Department of Gastroenterology, Hillingdon Hospitals NHS Foundation Trust, Uxbridge, Greater London, UK
| | - Mark Feeney
- Department of Gastroenterology, Torbay and South Devon NHS Foundation Trust, Torquay, Torbay, UK
| | - Mo Thoufeeq
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, Sheffield, UK
| | - John Anderson
- Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, Gloucestershire, UK
| | - Vathsan Ravindran
- Gastroenterology, St Mark's Hospital and Academic Institute Wolfson Unit for Endoscopy, Harrow, London, UK
| | - Paul Hagan
- Endoscopy, Royal Derby Hospital, Derby, UK
| | - Neil Cripps
- Colorectal Surgery, University Hospitals Sussex NHS Foundation Trust, Worthing, West Sussex, UK
| | - Ian L P Beales
- Department of Gastroenterology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
- University of East Anglia, Norwich, Norfolk, UK
| | | | - Nicholas I Church
- Department of Gastroenterology, NHS Lothian, Edinburgh, Edinburgh, UK
| | - Elizabeth Ratcliffe
- Faculty of Medical and Human Sciences, The University of Manchester, Manchester, Manchester, UK
- Wrightington Wigan and Leigh NHS Foundation Trust, Wigan, Wigan, UK
| | - Said Din
- Department of Gastroenterology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Rupert D Pullan
- Colorectal Surgery, Torbay and South Devon NHS Foundation Trust, Torquay, Torbay, UK
| | - Sharon Powell
- Endoscopy, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, Wolverhampton, UK
| | - Catherine Regan
- Endoscopy, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, Wolverhampton, UK
| | - Wee Sing Ngu
- Colorectal Surgery, City Hospitals Sunderland NHS Foundation Trust, South Shields, Tyne and Wear, UK
| | - Eleanor Wood
- Department of Gastroenterology, Homerton University Hospital NHS Foundation Trust, London, London, UK
| | - Sarah Mills
- Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
- Imperial College London, London, UK
| | - Neil Hawkes
- Department of Gastroenterology, Royal Glamorgan Hospital, Llantrisant, UK
| | - Paul Dunckley
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, Gloucestershire, UK
| | - Marietta Iacucci
- University of Birmingham College of Medical and Dental Sciences, Birmingham, Birmingham, UK
- Department of Gastroenterology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
| | - Siwan Thomas-Gibson
- Imperial College London, London, UK
- St Mark's Hospital and Academic Institute Wolfson Unit for Endoscopy, Harrow, London, UK
| | - Christopher Wells
- Department of Gastroenterology, North Tees and Hartlepool NHS Foundation Trust, Hartlepool, Hartlepool, UK
| | - Aravinth Murugananthan
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, Wolverhampton, UK
- Faculty of Health, Education and Life Sciences, Birmingham City University, Birmingham, UK
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Lam AY, Duloy AM, Keswani RN. Quality Indicators for the Detection and Removal of Colorectal Polyps and Interventions to Improve Them. Gastrointest Endosc Clin N Am 2022; 32:329-349. [PMID: 35361339 DOI: 10.1016/j.giec.2021.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Modifiable risk factors for postcolonoscopy colorectal cancer include suboptimal lesion detection (missed neoplasms) and inadequate lesion removal (incomplete polypectomy) during colonoscopy. Competent detection and removal of colorectal polyps are thus fundamental to ensuring adequate colonoscopy quality. Several well-researched quality metrics for polyp detection have been implemented into clinical practice, chief among these the adenoma detection rate. Less data are available on quality indicators for polyp removal, which currently include complete resection rates and skills assessment tools. This review summarizes the available literature on quality indicators for the detection and removal of colorectal polyps, as well as interventions to improve them.
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Affiliation(s)
- Angela Y Lam
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, 2350 Geary Boulevard, San Francisco, CA 94115, USA
| | - Anna M Duloy
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, 1635 Aurora Court, Aurora, CO 80045, USA
| | - Rajesh N Keswani
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, 676 North Street, Clair, Suite 1400, Chicago, IL 60611, USA.
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8
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Patel RV, Barsuk JH, Cohen ER, Wani SB, Rastogi A, McGaghie WC, Wayne DB, Keswani RN, Komanduri S. Simulation-based training improves polypectomy skills among practicing endoscopists. Endosc Int Open 2021; 9:E1633-E1639. [PMID: 34790525 PMCID: PMC8589541 DOI: 10.1055/a-1525-5620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 06/04/2021] [Indexed: 11/01/2022] Open
Abstract
Background and study aims Practicing endoscopists have variable polypectomy skills during colonoscopy and limited training opportunities for improvement. Simulation-based training enhances procedural skill, but its impact on polypectomy is unclear. We developed a simulation-based polypectomy intervention to improve polypectomy competency. Methods All faculty endoscopists at our tertiary care center who perform colonoscopy with polypectomy were recruited for a simulation-based intervention assessing sessile and stalked polypectomy. Endoscopists removed five polyps in a simulation environment at pretest followed by a training intervention including a video, practice, and one-on-one feedback. Within 1-4 weeks, endoscopists removed five new simulated polyps at post-test. We used the Direct Observation of Polypectomy Skills (DOPyS) checklist for assessment, evaluating individual polypectomy skills, and global competency (scale: 1-4). Competency was defined as an average global competency score of ≥ 3. Results 83 % (29/35) of eligible endoscopists participated and 95 % (276/290) of planned polypectomies were completed. Only 17 % (5/29) of endoscopists had average global competency scores that were competent at pretest compared with 52 % (15/29) at post-test ( P = 0.01). Of all completed polypectomies, the competent polypectomy rate significantly improved from pretest to post-test (55 % vs. 71 %; P < 0.01). This improvement was significant for sessile polypectomy (37 % vs. 65 %; P < 0.01) but not for stalked polypectomy (82 % vs. 80 %; P = 0.70). Conclusions Simulation-based training improved polypectomy skills among practicing endoscopists. Further studies are needed to assess the translation of simulation-based education to clinical practice.
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Affiliation(s)
- Ronak V. Patel
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Jeffrey H. Barsuk
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States,Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Elaine R. Cohen
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Sachin B. Wani
- Division of Gastroenterology and Hepatology, University of Colorado, Aurora, Colorado, United States
| | - Amit Rastogi
- Division of Gastroenterology, Hepatology, and Motility, The University of Kansas, Kansas City, Kansas, United States
| | - William C. McGaghie
- Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Diane B. Wayne
- Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Rajesh N. Keswani
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
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Pedersen IB, Bretthauer M, Kalager M, Løberg M, Hoff G, Matapour S, Hugin S, Frigstad SO, Seip B, Kleist BA, Løvdal L, Botteri E, Holme Ø. Incomplete endoscopic resection of colorectal polyps: a prospective quality assurance study. Endoscopy 2021; 53:383-391. [PMID: 32961579 DOI: 10.1055/a-1243-0379] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic screening with polypectomy has been shown to reduce colorectal cancer incidence in randomized trials. Incomplete polyp removal and subsequent development of post-colonoscopy cancers may attenuate the effect of screening. This study aimed to quantify the extent of incomplete polyp removal. METHODS We included patients aged 50-75 years with nonpedunculated polyps ≥ 5 mm removed during colonoscopy at four hospitals in Norway. To evaluate completeness of polyp removal, biopsies from the resection margins were obtained after polypectomy. Logistic regression models were fitted to identify factors explaining incomplete resection. RESULTS 246 patients with 339 polyps underwent polypectomy between January 2015 and June 2017. A total of 12 polyps were excluded due to biopsy electrocautery damage, and 327 polyps in 246 patients (mean age 67 years [range 42-83]; 52 % male) were included in the analysis. Overall, 54 polyps (15.9 %) in 54 patients were incompletely resected. Histological diagnosis of the polyp (sessile serrated lesions vs. adenoma, odds ratio [OR] 10.9, 95 % confidence interval [CI] 3.9-30.1) and polyp location (proximal vs. distal colon, OR 2.8, 95 %CI 1.0-7.7) were independent risk factors for incomplete removal of polyps 5-19 mm. Board-certified endoscopists were not associated with lower rates of incomplete resection compared with trainees (14.0 % vs. 14.2 %), OR 1.0 (95 %CI 0.5-2.1). CONCLUSION Incomplete polyp resection was frequent after polypectomy in routine clinical practice. Serrated histology and proximal location were independent risk factors for incomplete resection. The performance of board-certified gastroenterologists was not superior to that of trainees.
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Affiliation(s)
- Ina B Pedersen
- Department of Medicine, Sorlandet Hospital Kristiansand, Kristiansand, Norway.,Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway
| | - Michael Bretthauer
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway.,Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Mette Kalager
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway.,Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Magnus Løberg
- Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway.,Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Geir Hoff
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway.,Department of Medicine, Telemark Hospital Skien, Skien, Norway
| | - Senaria Matapour
- Department of Medicine, Vestre Viken Hospital Trust, Gjettum, Norway
| | - Silje Hugin
- Department of Medicine, Vestre Viken Hospital Trust, Gjettum, Norway
| | - Svein O Frigstad
- Department of Medicine, Vestre Viken Hospital Trust, Gjettum, Norway
| | - Birgitte Seip
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway.,Department of Medicine, Vestfold Hospital Trust, Tønsberg, Norway
| | - Britta A Kleist
- Department of Pathology, Sorlandet Hospital Kristiansand, Norway
| | - Leif Løvdal
- Department of Pathology, Sorlandet Hospital Kristiansand, Norway
| | - Edoardo Botteri
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
| | - Øyvind Holme
- Department of Medicine, Sorlandet Hospital Kristiansand, Kristiansand, Norway.,Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway.,Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.,Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
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Frimberger E, Klare P, Haller B, Elnegouly M, Bajbouj M, Schmid RM, von Delius S, Abdelhafez M. Preliminary assessment of two novel mechanical colonoscopic polypectomy simulators: Description, evaluation and validation. Endosc Int Open 2020; 8:E1522-E1529. [PMID: 33043124 PMCID: PMC7541194 DOI: 10.1055/a-1186-8420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 03/02/2020] [Indexed: 12/15/2022] Open
Abstract
Background and study aims Colonoscopic polypectomy is an essential endoscopic skill. The simulators available for training are limited and based on raw porcine colons. Animal intestines are inconvenient and offer limited advantages for polypectomy training. These limitations are avoided by two novel mechanical simulators - the magnetic system based simulator (MSPS) and the simulator for polypectomy with high frequency current (HFPS) - described here. They are equipped to demonstrate self-repair of polyps after making a cut and hybrid polyps. The aim of this study was to describe and establish face, content, and construct validity of the two simulators and to assess their perceived utility as training and assessment tools. Methods Ten novice, seven intermediate, and 10 advanced endoscopists participated in this study. Each one performed two polypectomies in MSPS and then one polypectomy and polyp retrieval in HFPS. The median times were compared among the three groups to preliminarily assess construct validity as a primary outcome. To establish face validity, the novices and intermediates completed a questionnaire about the credibility of each simulator after finishing the tasks. For content validity, the experts completed a questionnaire grading different aspects of the simulators' realism and their usefulness for training. Results All 27 participants completed the modules. Median times needed to complete the tasks in both simulators differed significantly between the participants with different levels of experience ( P < 0.05). Both MSPS and HFPS received favorable scores regarding face and content validity. No technical problems were encountered. Conclusion This study provides preliminary validation for MSPS and HFPS as useful training tools in a preclinical setting as well as during colonoscopy training. Moreover, we demonstrated the construct validity of both simulators, which confirms their use as a skill assessment tool during a colonoscopy training program.
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Affiliation(s)
| | - Peter Klare
- Klinik und Poliklinik für Innere Medizin, Munich, Germany
| | - Bernhard Haller
- Institut für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Mayada Elnegouly
- Klinik und Poliklinik für Innere Medizin, Munich, Germany,Department of infectious diseases and endemic Hepatology and Gastroenterology, Kasr Alainy Hospital, Cairo University, Cairo, Egypt
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11
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Kaminski MF, Robertson DJ, Senore C, Rex DK. Optimizing the Quality of Colorectal Cancer Screening Worldwide. Gastroenterology 2020; 158:404-417. [PMID: 31759062 DOI: 10.1053/j.gastro.2019.11.026] [Citation(s) in RCA: 98] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 11/04/2019] [Accepted: 11/14/2019] [Indexed: 12/14/2022]
Abstract
Screening, followed by colonoscopic polypectomy (or surgery for malignant lesions), prevents incident colorectal cancer and mortality. However, there are variations in effective application of nearly every aspect of the screening process. Screening is a multistep process, and failure in any single step could result in unnecessary morbidity and mortality. Awareness of variations in operator- and system-dependent performance has led to detailed, comprehensive recommendations in the United States and Europe on how colonoscopy screening should be performed and measured. Likewise, guidance has been provided on quality assurance for nonprimary colonoscopy-based screening programs, including strategies to maximize adherence. Quality improvement is now a validated science, and there is clear evidence that higher quality prevents incident cancer and cancer death. Quality must be addressed at the levels of the system, provider, and individuals, to maximize the benefits of screening for any population. We review the important aspects of measuring and improving the quality of colorectal cancer screening.
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Affiliation(s)
- Michael F Kaminski
- Department of Gastroenterological Oncology, the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland; Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland; Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Douglas J Robertson
- Department of Veterans Affairs Medical Center, White River Junction, Vermont; The Geisel School of Medicine at Dartmouth and The Dartmouth Institute, Hanover, New Hampshire
| | - Carlo Senore
- Epidemiology and Screening Unit-CPO, University Hospital Città della Salute e della Scienza, Turin, Italy
| | - Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana.
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Duloy AM, Keswani RN. Assessing the Quality of Polypectomy and Teaching Polypectomy. Gastrointest Endosc Clin N Am 2019; 29:587-601. [PMID: 31445684 DOI: 10.1016/j.giec.2019.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Ineffective polypectomy technique may lead to incomplete polyp resection, high complication rates, interval colorectal cancer, and costly referral to surgery. Despite its central importance to endoscopy, training in polypectomy is not standardized nor has the most effective training approach been defined. Polypectomy competence is rarely reported and quality metrics for this skill are lacking. Use of tools and measurements to assess polypectomy outcomes is low. There is a need for standardization of training and remediation in polypectomy; defining standards of competent polypectomy and how it is feasibly measured; and integration of polypectomy quality metrics into training programs and the accreditation process.
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Affiliation(s)
- Anna M Duloy
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, 1635, Aurora CT, Aurora, CO 80045, USA
| | - Rajesh N Keswani
- Department of Gastroenterology and Hepatology, Northwestern University, 676 North Street Clair, Suite 1400, Chicago, IL 60611, USA.
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13
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Duloy AM, Kaltenbach TR, Wood M, Gregory DL, Keswani RN. Colon polypectomy report card improves polypectomy competency: results of a prospective quality improvement study (with video). Gastrointest Endosc 2019; 89:1212-1221. [PMID: 30825535 DOI: 10.1016/j.gie.2019.02.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 02/06/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Polypectomy competency varies significantly among providers. Poor polypectomy technique may lead to interval cancer and/or adverse events. Our aim was to determine the effect of a polypectomy skills report card on subsequent polypectomy performance. METHODS We conducted a 3-phase, prospective, single-blinded study. In phase 1 ("baseline"), we graded 10 polypectomies per endoscopist using the Direct Observation of Polypectomy Skills (DOPyS) tool (scores 1-4); mean overall scores ≥3 are competent. In phase 2 ("pre-report card"), we selected 10 additional polypectomies per endoscopist. We subsequently gave endoscopists a report card with baseline scores and instructional videos demonstrating optimal polypectomy technique. In phase 3 ("post-report card"), 10 additional polypectomies per endoscopist were selected. Raters, blinded to study phase, graded 10 pre- and 10 post-report card polypectomies per endoscopist. We compared mean DOPyS scores and rate of competent polypectomy in the pre- and post-report card phases. RESULTS We graded 110 pre- and 110 post-report card polypectomies performed by 11 endoscopists. The mean DOPyS score increased between the pre- and post-report card phases (2.7 ± .9 vs 3.0 ± .8, P = .01); this improvement was seen for diminutive (P < .0001) but not for small-to-large polyps. Rate of competent polypectomy significantly improved from the pre- to post-report card phase (56% vs 69%, P = .04); this improvement was seen for diminutive (57% vs 81%, P = .001) but not for small-to-large polyps (55% vs 36%, P = .2). CONCLUSIONS Report cards with educational videos effectively improved polypectomy technique, primarily because of improvements in resecting diminutive polyps. The improved competency and decreased piecemeal resection may reduce the risk of polyp recurrence. Further education is needed to improve larger polyp resection.
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Affiliation(s)
- Anna M Duloy
- Department of Gastroenterology and Hepatology, University of Colorado, Aurora, Colorado, USA
| | - Tonya R Kaltenbach
- Department of Gastroenterology, University of California, San Francisco, San Francisco, California, USA
| | - Mariah Wood
- Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Dyanna L Gregory
- Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Rajesh N Keswani
- Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
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14
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Siau K, Green JT, Hawkes ND, Broughton R, Feeney M, Dunckley P, Barton JR, Stebbing J, Thomas-Gibson S. Impact of the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) on endoscopy services in the UK and beyond. Frontline Gastroenterol 2019; 10:93-106. [PMID: 31210174 PMCID: PMC6540274 DOI: 10.1136/flgastro-2018-100969] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 09/18/2018] [Accepted: 09/24/2018] [Indexed: 02/04/2023] Open
Abstract
The Joint Advisory Group on Gastrointestinal Endoscopy (JAG) was initially established in 1994 to standardise endoscopy training across specialties. Over the last two decades, the position of JAG has evolved to meet its current role of quality assuring all aspects of endoscopy in the UK to provide the highest quality, patient-centred care. Drivers such as changes to healthcare agenda, national audits, advances in research and technology and the advent of population-based cancer screening have underpinned this shift in priority. Over this period, JAG has spearheaded various quality assurance initiatives with support from national stakeholders. These have led to the achievement of notable milestones in endoscopy quality assurance, particularly in the three major areas of: (1) endoscopy training, (2) accreditation of endoscopy services (including the Global Rating Scale), and (3) accreditation of screening endoscopists. These developments have changed the landscape of UK practice, serving as a model to promote excellence in endoscopy. This review provides a summary of JAG initiatives and assesses the impact of JAG on training and endoscopy services within the UK and beyond.
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Affiliation(s)
- Keith Siau
- Endoscopy Unit, Dudley Group NHS Foundation Trust, Dudley, UK
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - John T Green
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Neil D Hawkes
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, Cwm Taf University Health Board, Llantrisant, UK
| | - Raphael Broughton
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
| | - Mark Feeney
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, South Devon Healthcare NHS Foundation Trust, Torquay, UK
| | - Paul Dunckley
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, Gloucestershire Royal Hospital, Gloucester, UK
| | - John Roger Barton
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Newcastle University Medicine Malaysia, Nusajaya, Johor, Malaysia
| | - John Stebbing
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of GI Surgery, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Siwan Thomas-Gibson
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Wolfson Unit for Endoscopy, St Marks Hospital, Harrow, UK
- Imperial College London, London, UK
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Abstract
PURPOSE OF THE REVIEW Progress towards the goal of high-quality endoscopy across health economies has been founded on high-quality structured training programmes linked to credentialing practice and ongoing performance monitoring. This review appraises the recent literature on training interventions, which may benefit performance and competency acquisition in novice endoscopy trainees. RECENT FINDINGS Increasing data on the learning curves for different endoscopic procedures has highlighted variations in performance amongst trainees. These differences may be dependent on the trainee, trainer and training programme. Evidence of the benefit of knowledge-based training, simulation training, hands-on courses and clinical training is available to inform the planning of ideal training pathway elements. The validation of performance assessment measures and global competency tools now also provides evidence on the effectiveness of training programmes to influence the learning curve. The impact of technological advances and intelligent metrics from national databases is also predicted to drive improvements and efficiencies in training programme design and monitoring of post-training outcomes. Training in endoscopy may be augmented through a series of pre-training and in-training interventions. In conjunction with performance metrics, these evidence-based interventions could be implemented into training pathways to optimise and quality assure training in endoscopy.
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Affiliation(s)
- Keith Siau
- Department of Gastroenterology, Dudley Group Hospitals NHS Foundation Trust, Dudley, UK. .,Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK.
| | - Neil D Hawkes
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK.,Department of Gastroenterology, Cwm Taf University Health Board, Llantrisant, UK
| | - Paul Dunckley
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK.,Department of Gastroenterology, Gloucestershire Royal Hospital, Gloucester, UK
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Biswas S, Alrubaiy L, China L, Lockett M, Ellis A, Hawkes N. Trends in UK endoscopy training in the BSG trainees' national survey and strategic planning for the future. Frontline Gastroenterol 2018; 9:200-207. [PMID: 30046424 PMCID: PMC6056087 DOI: 10.1136/flgastro-2017-100848] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 07/26/2017] [Accepted: 08/19/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Improvements in the structure of endoscopy training programmes resulting in certification from the Joint Advisory Group in Gastrointestinal Endoscopy have been acknowledged to improve training experience and contribute to enhanced colonoscopy performance. OBJECTIVES The 2016 British Society of Gastroenterology trainees' survey of endoscopy training explored the delivery of endoscopy training - access to lists; level of supervision and trainee's progression through diagnostic, core therapy and subspecialty training. In addition, the barriers to endoscopy training progress and utility of training tools were examined. METHODS A web-based survey (Survey Monkey) was sent to all higher specialty gastroenterology trainees. RESULTS There were some improvements in relation to earlier surveys; 85% of trainees were satisfied with the level of supervision of their training. But there were ongoing problems; 12.5% of trainees had no access to a regular training list, and 53% of final year trainees had yet to achieve full certification in colonoscopy. 9% of final year trainees did not feel confident in endoscopic management of upper GI bleeds. CONCLUSIONS The survey findings provide a challenge to those agencies tasked with supporting endoscopy training in the UK. Acknowledging the findings of the survey, the paper provides a strategic response with reference to increased service pressures, reduced overall training time in specialty training programmes and the requirement to support general medical and surgical on-call commitments. It describes the steps required to improve training on the ground: delivering additional training tools and learning resources, and introducing certification standards for therapeutic modalities in parallel with goals for improving the quality of endoscopy in the UK.
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Affiliation(s)
- Sujata Biswas
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Laith Alrubaiy
- Department of Gastroenterology, Swansea University Medical School, Swansea, UK
| | - Louise China
- Division of Medicine, University College London, London, UK
| | | | - Melanie Lockett
- Department of Gastroenterology, North Bristol NHS Trust, Bristol, UK
| | - Antony Ellis
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Neil Hawkes
- Department of Gastroenterology, Royal Glamorgan Hospital, Llantrisant, UK
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17
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Sonnenberg A. When to let the fellow do the procedure. United European Gastroenterol J 2017; 5:954-958. [PMID: 29163960 PMCID: PMC5676551 DOI: 10.1177/2050640617696401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 02/06/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND AIMS In complex endoscopies, the initial attempt is often associated with the highest success and subsequent attempts to achieve the same outcome have a higher failure rate. An attending physician needs to decide how the ultimate success may become compromised by letting a fellow start the procedure. A decision analysis is aimed to shed light on this issue. METHODS A formula is derived to calculate the point in time when to switch the instrument between an attending and fellow physician. This time point is determined by the ratio of benefit to the patient over benefit to the fellow, the difference in probability of achieving success by an attending versus a fellow, and the decline in probability of success during consecutive procedural attempts. RESULTS The attending should undertake the first attempts at doing the procedure, if the fellow is inexperienced and the difference in success rate between attending and fellow is still large, if the procedure is risky, and if the benefit of a successful outcome outweighs the benefit of a teaching experience to the fellow. Vice versa, fellows should take the lead, if they have become well trained and the difference in their procedural success rate compared with the attendings' has grown relatively small. The fellow should also be trusted to lead in all instances where the risk to the patient is small. CONCLUSIONS Such rules can serve as general guidance when to pass the endoscope to a fellow physician. Medical decision analysis is helpful to enlighten complex situations during training of fellows.
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Affiliation(s)
- Amnon Sonnenberg
- The Portland VA Medical Center and the Division of Gastroenterology/Hepatology, Oregon Health & Science University, Portland, OR, USA
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