Evaluation of a virtual endoscopy simulator for training in gastrointestinal endoscopy

The standardized training and assessment system for magnetically controlled capsule gastroscopy (with video)

BACKGROUND AND AIM

To explore the feasibility of a standardized training and assessment system for magnetically controlled capsule gastroscopy (MCCG).

METHODS

The results of 90 trainees who underwent the standardized training and assessment system of the MCCG at the First Affiliated Hospital of Xi'an Jiaotong University from May 2020 to November 2023 was retrospectively analyzed. The trainees were divided into three groups according to their medical backgrounds: doctor, nurse, and non-medical groups. The training and assessment system adopted the '7 + 2' mode, seven days of training plus two days of theoretical and operational assessment. The passing rates of theoretical, operational, and total assessment were the primary outcomes. Satisfaction and mastery of the MCCG was checked.

RESULTS

Ninety trainees were assessed; theoretical assessment's passing rates in the three groups were 100%. The operational and total assessment passing rates were 100% (25/25), 97.92% (47/48), and 94.12% (16/17), for the doctor, nurse, and non-doctor groups respectively, with no significant difference (χ2 = 1.741, p = 0.419). No bleeding or perforation occurred during the procedure. Approximately, 96.00% (24/25), 95.83% (46/48), and 94.12% (16/17) of the doctor, nurse and non-medical groups anonymously expressed great satisfaction, respectively, without statistically significant difference (χ2 = 0.565, p = 1.000). The average follow-up time was 4-36 months, and 87 trainees (96.67%) had mastered the operation of the MCCG in daily work.

CONCLUSIONS

Standardized training and assessment of magnetically controlled capsule endoscopists is effective and feasible. Additionally, a strict assessment system and long-term communication and learning can improve teaching effects.

Virtual reality tools for training in gastrointestinal endoscopy: A systematic review

BACKGROUND

Virtual reality (VR) has emerged as an innovative technology in endoscopy training, providing a simulated environment that closely resembles real-life scenarios and offering trainees a valuable platform to acquire and enhance their endoscopic skills. This systematic review will critically evaluate the effectiveness and feasibility of VR-based training compared to traditional methods.

AIM

To evaluate the effectiveness and feasibility of VR-based training compared to traditional methods. By examining the current state of the field, this review seeks to identify gaps, challenges, and opportunities for further research and implemen-tation of VR in endoscopic training.

METHODS

The study is a systematic review, following the guidelines for reporting systematic reviews set out by the PRISMA statement. A comprehensive search command was designed and implemented and run in September 2023 to identify relevant studies available, from electronic databases such as PubMed, Scopus, Cochrane, and Google Scholar. The results were systematically reviewed.

RESULTS

Sixteen articles were included in the final analysis. The total number of participants was 523. Five studies focused on both upper endoscopy and colonoscopy training, two on upper endoscopy training only, eight on colon-oscopy training only, and one on sigmoidoscopy training only. Gastro-intestinal Mentor virtual endoscopy simulator was commonly used. Fifteen reported positive results, indicating that VR-based training was feasible and acceptable for endoscopy learners. VR technology helped the trainees enhance their skills in manipulating the endoscope, reducing the procedure time or increasing the technical accuracy, in VR scenarios and real patients. Some studies show that the patient discomfort level decreased significantly. However, some studies show there were no significant differences in patient discomfort and pain scores between VR group and other groups.

CONCLUSION

VR training is effective for endoscopy training. There are several well-designed randomized controlled trials with large sample sizes, proving the potential of this innovative tool. Thus, VR should be more widely adopted in endoscopy training. Furthermore, combining VR training with conventional methods could be a promising approach that should be implemented in training.

Green endoscopy: British Society of Gastroenterology (BSG), Joint Accreditation Group (JAG) and Centre for Sustainable Health (CSH) joint consensus on practical measures for environmental sustainability in endoscopy

GI endoscopy is highly resource-intensive with a significant contribution to greenhouse gas (GHG) emissions and waste generation. Sustainable endoscopy in the context of climate change is now the focus of mainstream discussions between endoscopy providers, units and professional societies. In addition to broader global challenges, there are some specific measures relevant to endoscopy units and their practices, which could significantly reduce environmental impact. Awareness of these issues and guidance on practical interventions to mitigate the carbon footprint of GI endoscopy are lacking. In this consensus, we discuss practical measures to reduce the impact of endoscopy on the environment applicable to endoscopy units and practitioners. Adoption of these measures will facilitate and promote new practices and the evolution of a more sustainable specialty.

Simulation-based mastery learning in gastrointestinal endoscopy training

Simulation-based mastery learning (SBML) is an emerging form of competency-based training that has been proposed as the next standard method for procedural task training, including that in gastrointestinal endoscopy. Current basic gastrointestinal endoscopy training relies on the number of procedures performed, and it has been criticized for its lack of objective standards that result in variable skills among trainees and its association with patient safety risk. Thus, incorporating simulators into a competency-based curriculum seems ideal for gastrointestinal endoscopy training. The curriculum for SBML in gastrointestinal endoscopy is currently being developed and has promising potential to translate into the clinical performance. Unlike the present apprenticeship model of "see one, do one, teach one," SBML integrates a competency-based curriculum with specific learning objectives alongside simulation-based training. This allows trainees to practice essential skills repeatedly, receive feedback from experts, and gradually develop their abilities to achieve mastery. Moreover, trainees and trainers need to understand the learning targets of the program so that trainees can focus their learning on the necessary skills and trainers can provide structured feedback based on the expected outcomes. In addition to learning targets, an assessment plan is essential to provide trainees with future directions for their improvement and ensure patient safety by issuing a passing standard. Finally, the SBML program should be planned and managed by a specific team and conducted within a developed and tested curriculum. This review discusses the current state of gastrointestinal endoscopy training and the role of SBML in that field.

Gastroenterology in the Metaverse: The dawn of a new era?

2021 is known as the first Year of the Metaverse, and around the world, internet giants are eager to devote themselves to it. In this review, we will introduce the concept, current development, and application of the Metaverse and the use of the current basic technologies in the medical field, such as virtual reality and telemedicine. We also probe into the new model of gastroenterology in the future era of the Metaverse.

Impact of Computer-Assisted System on the Learning Curve and Quality in Esophagogastroduodenoscopy: Randomized Controlled Trial

Background and Aims: To investigate the impact of the computer-assisted system on esophagogastroduodenoscopy (EGD) training for novice trainees in a prospective randomized controlled trial. Methods: We have constructed a computer-aided system (CAD) using retrospective images based on deep learning which could automatically monitor the 26 anatomical landmarks of the upper digestive tract and document standard photos. Six novice trainees were allocated and grouped into the CAD group and control group. Each of them took the training course, pre and post-test, and EGD examination scored by two experts. The CAD group was trained with the assistance of the CAD system and the control group without. Results: Both groups achieved great improvements in EGD skills. The CAD group received a higher examination grading score in the EGD examination (72.83 ± 16.12 vs. 67.26 ± 15.64, p = 0.039), especially in the mucosa observation (26.40 ± 6.13 vs. 24.11 ± 6.21, p = 0.020) and quality of collected images (7.29 ± 1.09 vs. 6.70 ± 1.05). The CAD showed a lower blind spot rate (2.19 ± 2.28 vs. 3.92 ± 3.30, p = 0.008) compared with the control group. Conclusion: The artificial intelligence assistant system displayed assistant capacity on standard EGD training, and assisted trainees in achieving a learning curve with high operation quality, which has great potential for application. Clinical Trial Registration: This trial is registered at https:/clinicaltrials.gov/, number NCT04682821.

Development of Simulator Guidelines for Resident Assessment in Flexible Endoscopy

Virtual reality (VR) simulators may hold a role in the assessment of trainee abilities independent of their role as instructional instruments. Thus, we piloted a course in flexible endoscopy to surgical trainees who had met Accreditation Council for Graduate Medical Education endoscopy requirements to establish the relationship between metrics produced by a VR endoscopic simulator and trainee ability. After a didactic session, we provided faculty instruction to senior residents for Case 1 upper endoscopy and colonoscopy modules on the CAE Endoscopy VR. Course conclusion was defined as a trainee meeting all proficiency standards in basic endoscopic procedures on the simulator. Simulator metrics and course evaluation comprised data. Eleven and eight residents participated in the colonoscopy and upper endoscopy courses, respectively. Average time to reach proficiency standards for esophagogastroduodenoscopy was 6 and 13 minutes for colonoscopy after a median of one (range, one to two) and one (range, one to four) task repetitions, respectively. Faculty instruction averaged 7.5 minutes of instruction per repetition. A subjective course evaluation demonstrated that the course improved learners’ knowledge of the subject and comfort with endoscopic equipment. Within a VR-based curriculum, experienced residents rapidly achieved task proficiency. The resultant scores may be used as simulator guidelines for resident assessment and readiness to perform flexible endoscopy.

Impact of a simulation-based induction programme in gastroscopy on trainee outcomes and learning curves

BACKGROUND

Pre-clinical simulation-based training (SBT) in endoscopy has been shown to augment trainee performance in the short-term, but longer-term data are lacking.

AIM

To assess the impact of a two-day gastroscopy induction course combining theory and SBT (Structured PRogramme of INduction and Training – SPRINT) on trainee outcomes over a 16-mo period.

METHODS

This prospective case-control study compared outcomes between novice SPRINT attendees and controls matched from a United Kingdom training database. Study outcomes comprised: (1) Unassisted D2 intubation rates; (2) Procedural discomfort scores; (3) Sedation practice; (4) Time to 200 procedures; and (5) Time to certification.

RESULTS

Total 15 cases and 24 controls were included, with mean procedure counts of 10 and 3 (P = 0.739) pre-SPRINT. Post-SPRINT, no significant differences between the groups were detected in long-term D2 intubation rates (P = 0.332) or discomfort scores (P = 0.090). However, the cases had a significantly higher rate of unsedated procedures than controls post-SPRINT (58% vs 44%, P = 0.018), which was maintained over the subsequent 200 procedures. Cases tended to perform procedures at a greater frequency than controls in the post-SPRINT period (median: 16.2 vs 13.8 per mo, P = 0.051), resulting in a significantly greater proportion of cases achieving gastroscopy certification by the end of follow up (75% vs 36%, P = 0.017).

CONCLUSION

In this pilot study, attendees of the SPRINT cohort tended to perform more procedures and achieved gastroscopy certification earlier than controls. These data support the role for wider evaluation of pre-clinical induction involving SBT.

Effectiveness of echocardiography simulation training for paediatric cardiology fellows in CHD

Simulation is used in many aspects of medical training but less so for echocardiography instruction in paediatric cardiology. We report our experience with the introduction of simulator-based echocardiography training at Weill Cornell Medicine for paediatric cardiology fellows of the New York-Presbyterian Hospital of Columbia University and Weill Cornell Medicine. Knowledge of CHD and echocardiographic performance improved following simulation-based training. Simulator training in echocardiography can be an effective addition to standard training for paediatric cardiology trainees.

Factors defining expertise in screening colonoscopy

BACKGROUND AND STUDY AIMS

 There is very little literature defining characteristics of expert endoscopists. It is hypothesised that previously undetermined human factors may correlate with high performance in screening colonoscopists. The aim of this study was to determine factors contributing towards expertise in screening colonoscopy.

MATERIALS AND METHODS

 A focus group was used to hypothesise skills considered to be relevant to high performance in colonoscopy. The skills were then ranked in order of importance by an independent group of screening colonoscopists for both diagnostic and therapeutic colonoscopy. Twenty screening colonoscopists subsequently participated in individual semi-structured interviews to explore participants' views of expertise and the factors contributing to it. Data extracted from the interview transcripts were used to identify the thematic framework associated with expertise.

RESULTS

The 5 initial highest-ranked themes were low complication rates, high adenoma detection rates, interpersonal skills with staff, communication skills, and manner with patients. Interviewees considered technical skills (20/20), previous experience of colonoscopy (19/20), judgment/decision-making (18/20), communication (18/20), teamwork (15/20), resources (11/20) and leadership (8/20) to be the most important themes related to expertise.

CONCLUSIONS

 Both technical and non-technical abilities are considered essential components of expertise by experienced colonoscopists. Further research into targeted interventions to improve the rate of acquisition of these skills in training endoscopists may be useful in improving performance.

Development of a Haptic Interface for Natural Orifice Translumenal Endoscopic Surgery Simulation

Natural orifice translumenal endoscopic surgery (NOTES) is a minimally invasive procedure, which utilizes the body's natural orifices to gain access to the peritoneal cavity. The NOTES procedure is designed to minimize external scarring and patient trauma, however flexible endoscopy based pure NOTES procedures require critical scope handling skills. The delicate nature of the NOTES procedure requires extensive training. Thus, to improve access to training while reducing risk to patients, we have designed and developed the VTEST, a virtual reality NOTES simulator. As part of the simulator, a novel decoupled 2-DOF haptic device was developed to provide realistic force feedback to the user in training. A series of experiments were performed to determine the behavioral characteristics of the device. The device was found capable of rendering up to 5.62N and 0.190 Nm of continuous force and torque in the translational and rotational DOF, respectively. The device possesses 18.1 and 5.7 Hz of force bandwidth in the translational and rotational DOF, respectively. A feedforward friction compensator was also successfully implemented to minimize the negative impact of friction during the interaction with the device. In this work, we have presented the detailed development and evaluation of the haptic device for the VTEST.

Simulator training in gastrointestinal endoscopy - From basic training to advanced endoscopic procedures

Simulator-based gastrointestinal endoscopy training has gained acceptance over the last decades and has been extensively studied. Several types of simulators have been validated and it has been demonstrated that the use of simulators in the early training setting accelerates the learning curve in acquiring basic skills. Current GI endoscopy simulators lack the degree of realism that would be necessary to provide training to achieve full competency or to be applicable in certification. Virtual Reality and mechanical simulators are commonly used in basic flexible endoscopy training, whereas ex vivo and in vivo models are used in training the most advanced endoscopic procedures. Validated models for the training of more routine therapeutic interventions like polypectomy, EMR, stenting and haemostasis are lacking or scarce and developments in these areas should be encouraged.

Training and competence assessment in GI endoscopy: a systematic review

INTRODUCTION

Training procedural skills in GI endoscopy once focused on threshold numbers. As threshold numbers poorly reflect individual competence, the focus gradually shifts towards a more individual approach. Tools to assess and document individual learning progress are being developed and incorporated in dedicated training curricula. However, there is a lack of consensus and training guidelines differ worldwide, which reflects uncertainties on optimal set-up of a training programme.

AIMS

The primary aim of this systematic review was to evaluate the currently available literature for the use of training and assessment methods in GI endoscopy. Second, we aimed to identify the role of simulator-based training as well as the value of continuous competence assessment in patient-based training. Third, we aimed to propose a structured training curriculum based on the presented evidence.

METHODS

A literature search was carried out in the available medical and educational literature databases. The results were systematically reviewed and studies were included using a predefined protocol with independent assessment by two reviewers and a final consensus round.

RESULTS

The literature search yielded 5846 studies. Ninety-four relevant studies on simulators, assessment methods, learning curves and training programmes for GI endoscopy met the inclusion criteria. Twenty-seven studies on simulator validation were included. Good validity was demonstrated for four simulators. Twenty-three studies reported on simulator training and learning curves, including 17 randomised control trials. Increased performance on a virtual reality (VR) simulator was shown in all studies. Improved performance in patient-based assessment was demonstrated in 14 studies. Four studies reported on the use of simulators for assessment of competence levels. Current simulators lack the discriminative power to determine competence levels in patient-based endoscopy. Eight out of 14 studies on colonoscopy, endoscopic retrograde cholangiopancreatography and endosonography reported on learning curves in patient-based endoscopy and proved the value of this approach for measuring performance. Ten studies explored the numbers needed to gain competence, but the proposed thresholds varied widely between them. Five out of nine studies describing the development and evaluation of assessment tools for GI endoscopy provided insight into the performance of endoscopists. Five out of seven studies proved that intense training programmes result in good performance.

CONCLUSIONS

The use of validated VR simulators in the early training setting accelerates the learning of practical skills. Learning curves are valuable for the continuous assessment of performance and are more relevant than threshold numbers. Future research will strengthen these conclusions by evaluating simulation-based as well as patient-based training in GI endoscopy. A complete curriculum with the assessment of competence throughout training needs to be developed for all GI endoscopy procedures.

Can a Computerized Simulator Assess Skill Level and Improvement in Performance of ERCP?

BACKGROUND

Endoscopic retrograde cholangiography (ERCP) is a challenging procedure with considerable risk. Computerized simulators are valuable in training for flexible endoscopy, but little data exist for their use in ERCP training.

AIM

To determine a simulator's ability to assess the level of ERCP skill and its responsiveness over time to increasing trainee experience.

MATERIALS AND METHODS

In this prospective parallel-arm cohort study, six novice gastroenterology fellows and four gastroenterology faculty with expertise in ERCP completed four simulated baseline cases and the same four cases at a later date. This study took place at a surgical skills center at an academic tertiary referral center. The primary outcome was the total time to complete the ERCP procedure.

RESULTS

For the baseline session, experts had a shorter total procedure time than novices (444.0 vs. 616.9 s; least squares mean; p = 0.026). There was no significant difference between experts and novices in the difference of total procedure time between session 1 and session 2 (-200.3 vs. -164.4; least squares mean; p = 0.402).

CONCLUSIONS

The simulator was able to differentiate experts from novices for the primary outcome of total procedure time. The simulator was not responsive to an increase in trainee experience over time.

Role of virtual reality simulation in endoscopy training

Recent advancements in virtual reality graphics and models have allowed virtual reality simulators to be incorporated into a variety of endoscopic training programmes. Use of virtual reality simulators in training programmes is thought to improve skill acquisition amongst trainees which is reflected in improved patient comfort and safety. Several studies have already been carried out to ascertain the impact that usage of virtual reality simulators may have upon trainee learning curves and how this may translate to patient comfort. This article reviews the available literature in this area of medical education which is particularly relevant to all parties involved in endoscopy training and curriculum development. Assessment of the available evidence for an optimal exposure time with virtual reality simulators and the long-term benefits of their use are also discussed.

Performance of different categories of operators in simulated diagnostic colonoscopy

The possible involvement, although limited to the diagnostic phase of the procedure, of nonmedical staff (particularly endoscopy nurses) in lower digestive endoscopy has recently been suggested. Computer-based simulators have demonstrated objective evaluation of technical skills in digestive endoscopy. The aim of this study was to evaluate basic colonoscopy skills of endoscopy nurses (naive operators), as compared with junior physician staff and senior endoscopists, through a virtual reality colonoscopy simulator. In this single-center, prospective, nonrandomized study, 3 groups of digestive endoscopy operators (endoscopy nurses, junior doctors [<150 previous colonoscopies], expert doctors [>500 previous colonoscopies and >200/year]) completed six diagnostic cases generated by an endoscopic simulator (AccuTouch, Immersion Medical, Gaithersburg, MD). The performance parameters, collected by the simulator, were compared between groups. Five parameters have been considered for statistical analysis: time spent to reach the cecum; pain of any degree; severe/extreme pain; amount of insufflated air; percentage of visualized mucosa. Statistical analysis to compare the three groups has been performed by means of Wilcoxon test for two independent samples and by means of Kruskal-Wallis test for three independent samples (p < .05). Sixteen operators have been studied (six endoscopy nurses, five junior doctors, and five senior doctors); 96 colonoscopic procedures have been evaluated. Statistically significant differences between experts and naive operators were observed regarding time to reach the cecum and induction of severe/extreme pain, with both Kruskal-Wallis and Wilcoxon test (p < .05); all other comparisons did not reach statistical significance. Although, as expected, expert doctors exceeded both junior doctors and naive operators in some relevant quality parameters of simulated diagnostic colonoscopies, the results obtained by less expert performers--and particularly by nursing staff--appear satisfactory as in regards to most of the considered quality parameters and suggest a potential value of this device in effectively teaching basic lower digestive endoscopy to beginners in a relatively short time.

System characterization of a novel haptic interface for natural orifice translumenal endoscopic surgery simulation

Natural orifice translumenal endoscopic surgery (NOTES) is a minimally invasive procedure, which utilizes the body's natural orifices to gain access to the peritoneal cavity. The VTEST(©) is a virtual reality NOTES simulator developed at the CeMSIM at RPI to train surgeons in NOTES. A novel 2 DOF decoupled haptic device was designed and built for this simulator. The haptic device can render 5.62 N and 190.05 N-mm of continuous force and torque respectively. In this work we have evaluated the haptic interface and developed a model to accurately describe the system behavior, to further incorporate into an impedance type controller for realistic haptic rendering in the VTEST(©).

Characterization of force and torque interactions during a simulated transgastric appendectomy procedure

We have developed an instrumented endoscope grip handle equipped with a six-axis load cell and measured forces and torques during a simulated transgastric natural orifice translumenal endoscopic surgery appendectomy procedure performed in an EASIE-R ex vivo simulator. The data were collected from ten participating surgeons of varying degrees of expertise which was analyzed to compute a set of six force and torque parameters for each coordinate axis for each of the nine tasks of the appendectomy procedure. The mean push/pull force was found to be 3.64 N (σ = 3.54 N) in the push direction and the mean torque was 3.3 N · mm (σ = 38.6 N · mm) in the counterclockwise direction about the push/pull axis. Most interestingly, the force and torque data about the nondominant x and z axes showed a statistically significant difference (p < 0.05) between the expert and novice groups for five of the nine tasks. These data may be useful in developing surgical platforms especially new haptic devices and simulation systems for emerging natural orifice procedures.

Current status of endoscopic simulation in gastroenterology fellowship training programs

BACKGROUND AND AIMS

Recent guidelines have encouraged gastroenterology and surgical training programs to integrate simulation into their core endoscopic curricula. However, the role that simulation currently has within training programs is unknown. This study aims to assess the current status of simulation among gastroenterology fellowship programs.

METHODS

DESIGN

This questionnaire study consisted of 38 fields divided into two sections. The first section queried program directors' experience on simulation and assessed the current status of simulation at their institution. The second portion surveyed their opinion on the potential role of simulation on the training curriculum.

SETTING

The study was conducted at the 2013 American Gastroenterological Association Training Directors' Workshop in Phoenix, Arizona.

PARTICIPANTS

The participants were program directors from Accreditation Council for Graduate Medical Education accredited gastroenterology training programs, who attended the workshop.

RESULTS

The questionnaire was returned by 69 of 97 program directors (response rate of 71%). 42% of programs had an endoscopic simulator. Computerized simulators (61.5%) were the most common, followed by mechanical (30.8%) and animal tissue (7.7%) simulators, respectively. Eleven programs (15%) required fellows to use simulation prior to clinical cases. Only one program has a minimum number of hours fellows have to participate in simulation training. Current simulators are deemed as easy to use (76%) and good educational tools (65%). Problems are cost (72%) and accessibility (69%). The majority of program directors believe that there is a need for endoscopic simulator training, with only 8% disagreeing. Additionally, a majority believe there is a role for simulation prior to initiation of clinical cases with 15% disagreeing.

CONCLUSION

Gastroenterology fellowship program directors widely recognize the importance of simulation. Nevertheless, simulation is used by only 42% of programs and only 15% of programs require that trainees use simulation prior to clinical cases. No programs currently use simulation as part of the evaluation process.

Effects of simulation-based training in gastrointestinal endoscopy: a systematic review and meta-analysis

BACKGROUND & AIMS

Simulation-based training (SBT) in gastrointestinal endoscopy has been increasingly adopted by gastroenterology fellowship programs. However, the effectiveness of SBT in enhancing trainee skills remains unclear. We performed a systematic review with a meta-analysis of published literature on SBT in gastrointestinal endoscopy.

METHODS

We performed a systematic search of multiple electronic databases for all original studies that evaluated SBT in gastrointestinal endoscopy in comparison with no intervention or alternative instructional approaches. Outcomes included skills (in a test setting), behaviors (in clinical practice), and effects on patients. We pooled effect size (ES) using random-effects meta-analysis.

RESULTS

From 10,903 articles, we identified 39 articles, including 21 randomized trials of SBT, enrolling 1181 participants. Compared with no intervention (n = 32 studies), SBT significantly improved endoscopic process skills in a test setting (ES, 0.79; n = 22), process behaviors in clinical practice (ES, 0.49; n = 8), time to procedure completion in both a test setting (ES, 0.79; n = 16) and clinical practice (ES, 0.75; n = 5), and patient outcomes (procedural completion and risk of major complications; ES, 0.45; n = 10). Only 5 studies evaluated the comparative effectiveness of different SBT approaches; which provided inconclusive evidence regarding feedback and simulation modalities.

CONCLUSIONS

Simulation-based education in gastrointestinal endoscopy is associated with improved performance in a test setting and in clinical practice, and improved patient outcomes compared with no intervention. Comparative effectiveness studies of different simulation modalities are limited.

Repeated versus varied case selection in pediatric resident simulation

BACKGROUND

Repeated exposure to pediatric emergency scenarios improves technical skills, but it is unclear whether repeated exposure to specific cases affects medical decision making in varied cases.

OBJECTIVE

We sought to determine whether repeated exposure to 1 scenario would translate to improved performance and decision making in varied scenarios.

METHODS

Senior pediatrics residents participated in 3 scenarios with scripted debriefing. Residents were randomized to repeated practice (RP) scenarios or mixed (MIX) scenarios. RP residents completed pulseless electrical activity (PEA) with different stems (Case 1, 2, 3). MIX residents completed PEA (Case 1), seizure (Case 2), and ventricular tachycardia (Case 3) scenarios. Four months later, participants returned to complete 3 more cases: PEA (Case 4), seizure (Case 5), and critical coarctation (Case 6).

RESULTS

Twenty-three residents participated in the study and were randomized to either the RP or the MIX group. The RP group showed statistically significant improvement in time to start chest compressions, whereas the MIX group showed no improvement. Use of a backboard improved significantly in Case 4 for the RP group but not for the MIX group. Similarly, time to check glucose in the seizure scenario was significantly better in the MIX group that had previous exposure to a seizure scenario. No differences in performance were noted between groups in Case 6, which was new to both groups.

CONCLUSIONS

Results of this study indicate that whereas repeated exposure may improve decision-making skills in similar scenarios, it may not translate to improved medical decision making in other scenarios.

The effect of virtual endoscopy simulator training on novices: a systematic review

BACKGROUND

Advances in virtual endoscopy simulators have paralleled an interest in medical simulation for gastrointestinal endoscopy training.

OBJECTIVE

The primary objective was to determine whether the virtual endoscopy simulator training could improve the performance of novices.

DESIGN

A systematic review.

SETTING

Randomized controlled trials (RCTs) that compared virtual endoscopy simulator training with bedside teaching or any other intervention for novices were collected.

PATIENTS

Novice endoscopists.

INTERVENTIONS

The PRISMA statement was followed during the course of the research. The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and ScienceDirect were searched (up to July 2013). Data extraction and assessment were independently performed.

MAIN OUTCOME MEASUREMENTS

Independent procedure completion, total procedure time and required assistance.

RESULTS

Fifteen studies (n = 354) were eligible for inclusion: 9 studies designed for colonoscopy training, 6 for gastroscopy training. For gastroscopy training, procedure completed independently was reported in 87.7% of participants in simulator training group compared to 70.0% of participants in control group (1 study; 22 participants; RR 1.25; 95% CI 1.13-1.39; P<0.0001). For colonoscopy training, procedure completed independently was reported in 89.3% of participants in simulator training group compared to 88.9% of participants in control group (7 study; 163 participants; RR 1.10; 95% CI 0.88-1.37; P = 0.41; I(2) = 85%).

LIMITATIONS

The included studies are quite in-homogeneous with respect to training schedule and procedure.

CONCLUSIONS

Virtual endoscopy simulator training might be effective for gastroscopy, but so far no data is available to support this for colonoscopy.

The effect of model fidelity on colonoscopic skills acquisition. A randomized controlled study

INTRODUCTION

Colonoscopic simulators offer the opportunity for skill acquisition in the preclinical setting. Currently available simulators vary widely with respect to level of fidelity and technological sophistication. Despite the belief that more realistic is better, there is a paucity of evidence regarding the relative effectiveness of simulator fidelity (high vs low) on the acquisition of basic colonoscopic skills. We hypothesized that novice learners can acquire basic colonoscopic skills using simulators, however fidelity of the simulator does not make a difference.

METHODS

We randomly assigned novice third-year and fourth-year medical students to practice on either a low-fidelity or high-fidelity colonoscopy model. The low-fidelity model used is described in the module 16 of the American College of Surgeons/Association of Program Directors in Surgery surgical skills curriculum for residents, Phase 1: basic or core skills and tasks < http://elearning.facs.org/mod/resource/view.php?1d=450 >. The high-fidelity model was the AccuTouch colonoscopy simulator, Immersion Medical (AccuTouch CS) that has 6 different simulated scenarios for diagnostic colonoscopy (level 1-6). Both groups had 16 students and were given standard instruction by an expert with respect to the procedure and instrument handling on both models. Both groups were pretested and posttested on level 1 of the AccuTouch CS. The high-fidelity group practiced on level 2 and 4 of the AccuTouch CS, whereas the low-fidelity group practiced on the low-fidelity model for 2 sessions of 1 hour each. The computer-based evaluation parameters available on the AccuTouch CS were used to compare performances.

RESULTS

Both groups had similar demographics. There were no significant differences in the baseline performances of either group. Each group demonstrated significant improvement for insertion time and percentage of mucosa visualized. However, there were no significant differences between the groups on posttesting on any of the measured parameters.

CONCLUSIONS

Colonoscopic skill training on a low-fidelity model appears to be as effective as high-fidelity model training for basic endoscopic skill acquisition for novice learners.

Predictive mechanisms in the control of contour following

In haptic exploration, when running a fingertip along a surface, the control system may attempt to anticipate upcoming changes in curvature in order to maintain a consistent level of contact force. Such predictive mechanisms are well known in the visual system, but have yet to be studied in the somatosensory system. Thus, the present experiment was designed to reveal human capabilities for different types of haptic prediction. A robot arm with a large 3D workspace was attached to the index fingertip and was programmed to produce virtual surfaces with curvatures that varied within and across trials. With eyes closed, subjects moved the fingertip around elliptical hoops with flattened regions or Limaçon shapes, where the curvature varied continuously. Subjects anticipated the corner of the flattened region rather poorly, but for the Limaçon shapes, they varied finger speed with upcoming curvature according to the two-thirds power law. Furthermore, although the Limaçon shapes were randomly presented in various 3D orientations, modulation of contact force also indicated good anticipation of upcoming changes in curvature. The results demonstrate that it is difficult to haptically anticipate the spatial location of an abrupt change in curvature, but smooth changes in curvature may be facilitated by anticipatory predictions.

Poor discriminatory function for endoscopic skills on a computer-based simulator

BACKGROUND

Computer-based endoscopy simulators may enable trainees to learn and develop technical skills before performing on patients. Simulators require validation as adequate models of live endoscopy before being used for training or assessment purposes.

OBJECTIVE

To evaluate content and criterion validity of the CAE EndoscopyVR Simulator colonoscopy and EGD modules as predictors of clinical endoscopic skills.

DESIGN

Prospective, observational, non-randomized, parallel cohort study.

SETTING

Single academic center with accredited gastroenterology training program.

PARTICIPANTS

Five novice first-year gastroenterology fellows and 6 expert gastroenterology attending physicians.

INTERVENTION

Participants performed 18 simulated colonoscopies and 6 simulated EGDs. The simulator recorded objective performance parameters. Participants then completed feedback surveys.

MAIN OUTCOME MEASUREMENTS

The 57 objective performance parameters measured by the endoscopy simulator were compared between the two study groups. Novice and expert survey responses were analyzed.

RESULTS

Significant differences between novice and expert performance were detected in only 19 of 57 (33%) performance metrics. Eight of these 19 (42%) were time-related metrics, such as total procedure time, time to anatomic landmarks, and time spent in contact with GI mucosa. Of 49 non-time related measures, the few additional statistically significant differences between novices and experts involved air insufflation, sedation management, endoscope force, and patient comfort. These findings are of uncertain clinical significance. Survey data found multiple aspects of the simulation to be unrealistic compared with human endoscopy.

LIMITATIONS

Small sample size.

CONCLUSION

The CAE EndoscopyVR Simulator displays poor content and criterion validity and is thereby incapable of predicting skill during in vivo endoscopy.

Towards continuous improvement of endoscopy standards: validation of a colonoscopy assessment form

AIM

The assessment of procedural colonoscopy skills is important and topical. The aim of this study was to develop and validate a competency-based colonoscopy assessment form that would be easy to use, suitable for the assessment of junior and senior endoscopists and potentially a useful instrument to detect differences in performance standards following different training interventions.

METHOD

A standardized assessment form was developed incorporating a checklist with dichotomous yes/no responses and a global assessment section incorporating several different elements. This form was used prospectively to evaluate colonoscopy cases during the period of the study in several university teaching hospitals. Results were analysed using ANOVA with Bonferroni corrections for post hoc analysis.

RESULTS

Eighty-one procedures were assessed, performed by eight consultant and 19 trainee endoscopists. There were no serious errors. When divided into three groups based on previous experience (novice, intermediate and expert) the assessment form demonstrated statistically significant differences between all three groups (P<0.05). When separate elements were taken into account, the global assessment section was a better discriminator of skill level than the checklist.

CONCLUSION

This form is a valid, easy-to-use assessment method. We intend to use it to assess the value of simulator training in trainee endoscopists. It also has the potential to be a useful training tool when feedback is given to the trainee.

Evaluation of hands-on training in colonoscopy: is a computer-based simulator useful?

BACKGROUND AND AIMS

The advantages of using a computer-based simulator during colonoscopy training are debated. We aimed to explore its usefulness in objectively measuring trainees' competence in colonoscopy.

METHODS

Twelve colonoscopy trainees (fully trained in upper GI endoscopy) were evaluated using a computer-based simulator (GI-Mentor, Symbionix) before and during hands-on training (i.e. after 60 colonoscopies); the controls were 15 experts (>90% of caecal intubation). Both trainees and experts performed two "screening" simulations (easy and difficult) in a randomised order, and the time to reach the caecum and withdrawal time was assessed.

RESULTS

The percentage of caecal intubation progressively increased during hands-on training. All of the trainees intubated the caecum during the easy and difficult simulations, both before and during hands-on training. The median time (interquartile range) to reach the caecum upon easy simulation was the only variable influenced by hands-on training: 2.7 min (2.1-3.2) before and 1.9 min (1.6-2) during training (p<0.01). Withdrawal time was ≥6 min in the case of five trainees before training, and three during hands-on training. Computer-based simulator performance did not correlate with hands-on training performance.

CONCLUSIONS

The computer-based simulator was not found to be useful in evaluating competence during hands-on training in colonoscopy.

Objective assessment of learning curves for the Voxel-Man TempoSurg temporal bone surgery computer simulator

Introduction:

Simulators are becoming an increasingly important part of surgical training. Temporal bone surgery is one area in which simulators, such as the Voxel-Man TempoSurg simulator, are likely to play a significant role in training. We present learning curve data from novice trainees using this simulator to learn cortical mastoidectomy, exposure of the sigmoid sinus, and exposure of the short process of the incus.

Methods:

We measured the time taken to perform the procedures, the volume of reference bone removed, and the structures damaged during dissection.

Results:

We found improvement in a number of parameters over the course of the study. The overall scores, structural damage scores and time taken improved, to differing degrees, for each task. The volume of reference bone removed remained constant.

Conclusion:

These results indicate that the trainees' efficiency improved as they became more proficient at removing a given volume of reference bone.

Computer simulators: the present and near future of training in digestive endoscopy

The available data concerning recently marketed computer simulators for training in digestive endoscopy suggest that they could play a role in the pre-clinical phase of training, thus potentially leading to a shorter learning curve and better performance in the endoscopy room during the early phase of hands-on training. Technical improvements are still needed before such simulators can be used for the retraining of experienced endoscopists and for training in the use of newly developed devices dedicated to therapeutic endoscopy.

Strategies for training in diagnostic upper endoscopy: a prospective, randomized trial

BACKGROUND

Training simulators have been used for decades with success; however, a standardized educational strategy for diagnostic EGD is still lacking.

OBJECTIVE

Development of a training strategy for diagnostic upper endoscopy.

STUDY DESIGN

Prospective, randomized trial.

SETTINGS

A total of 28 medical and surgical residents without endoscopic experience were enrolled. Basic skills evaluations were performed following a structured program involving theoretical lectures and a hands-on course in diagnostic EGD. Subsequently, stratified randomization to clinical plus simulator training (group 1, n = 10), clinical training only (group 2, n = 9), or simulator training only (group 3, n = 9) was performed. Ten sessions of simulator training were conducted for groups 1 and 3 during the 4-month program. Group 2 underwent standard training in endoscopy without supplemental simulator training. The final evaluation was performed on the simulator and by observation of 3 clinical cases. Skills and procedural times were recorded by blinded and unblinded evaluators.

MAIN OUTCOME MEASUREMENTS

Time to reach the duodenum, pylorus, or esophagus.

RESULTS

All trainees demonstrated a significant reduction in procedure time during a simple manual skills test (P < .05) and significantly better skills scores (P = .006, P = .042 and P = .017) in the simulator independent of the training strategy. Group 1 showed shorter times to intubate the esophagus (61 ± 26 seconds vs 85 ± 30 seconds and 95 ± 36 seconds) and the pylorus (183 ± 65 seconds vs 207 ± 61 seconds and 247 ± 66 seconds) during the clinical evaluation. Blinded assessment of EGD skills showed significantly better results for group 1 compared with group 3. Blinded and unblinded evaluations were not statistically different.

LIMITATIONS

Small sample size.

CONCLUSIONS

Structured simulator training supplementing clinical training in upper endoscopy appears to be superior to clinical training alone. Simulator training alone does not seem to be sufficient to improve endoscopic skills.

Basic requirements of gastroenterologists to treat upper gastrointestinal bleeding: competency and sedation issues

This article reviews the components of adequate training required for a gastroenterologist to treat upper gastrointestinal bleeding (UGIB). The current status of endoscopic simulators is critically reviewed to determine whether these should be part of the UGIB armamentarium in the training of individuals and whether credentialing could be accomplished through this method of instruction. Finally, the author discusses the appropriate use of sedation in patients with UGIB.

Use of a continuing medical education course to improve fellows' knowledge and skills in esophageal disorders

Advanced esophageal endoscopic procedures such as stricture dilation, hemostasis tools, and stent placement as well as high-resolution manometry (HRM) interpretation are necessary skills for gastroenterology fellows to obtain during their training. Becoming proficient in these skills may be challenging in light of higher complication rates compared with diagnostic procedures and infrequent opportunities to practice these skills. Our aim was to determine if intensive training during a continuing medical education (CME) course boosts the knowledge and skills of gastroenterology fellows in esophageal diagnostic test interpretation and performance of therapeutic procedures. This was a pretest-posttest design without a control group of a simulation-based, educational intervention in esophageal stricture balloon dilation and HRM interpretation. The participants were 24 gastroenterology fellows from 21 accredited US training programs. This was an intensive CME course held in Las Vegas, Nevada from August 7 to August 9, 2009. The research procedure had two phases. First, the subjects were measured at baseline (pretest) for their knowledge and procedural skill. Second, the fellows received 6 hours of education sessions featuring didactic content, instruction in HRM indications and interpretation, and deliberate practice using an esophageal stricture dilation model. After the intervention, all of the fellows were retested (posttest). A 17-item checklist was developed for the esophageal balloon dilation procedure using relevant sources, expert opinion, and rigorous step-by-step procedures. Nineteen representative HRM swallow studies were obtained from Northwestern's motility lab and formed the pretest and posttest in HRM interpretation. Mean scores on the dilation checklist improved 81% from 39.4% (standard deviation [SD]= 33.4%) at pretest to 71.3% (SD = 29.5%) after simulation training (P < 0.001). HRM mean examination scores increased from 27.2% (SD = 16.4%) to 46.5% (SD = 15.8%), representing a 71% improvement (P < 0.001). Pearson's correlations indicated there was no correlation between pretest performance, medical knowledge measured by United States Medical Licensing Examination examinations, prior clinical experience, or procedural self-confidence and posttest performance of esophageal dilation or HRM interpretation. The education program was rated highly. This study demonstrated that a CME course significantly enhanced the technical skills and knowledge of gastroenterology fellows in esophageal balloon dilation and HRM interpretation. CME courses such as this may be a valuable adjunct to standard fellowship training in gastroenterology.

Do basic psychomotor skills transfer between different image-based procedures?

Background

Surgical techniques that draw from multiple types of image-based procedures (IBP) are increasing, such as Natural Orifice Transluminal Endoscopic Surgery, fusing laparoscopy and flexible endoscopy. However, little is known about the relation between psychomotor skills for performing different types of IBP. For example, do basic psychomotor colonoscopy and laparoscopy skills interact?

Methods

Following a cross-over study design, 29 naïve endoscopists were trained on the Simbionix GI Mentor and the SimSurgery SEP simulators. Group C (n = 15) commenced with a laparoscopy session, followed by four colonoscopy sessions and a second laparoscopy session. Group L (n = 14) started with a colonoscopy session, followed by four laparoscopy sessions and a second colonoscopy session.

Results

No significant differences were found between the performances of group L and group C in their first training sessions on either technique. With additional colonoscopy training, group C outperformed group L in the second laparoscopy training session on the camera navigation task.

Conclusions

Overall, training in the basic colonoscopy tasks does not affect performance of basic laparoscopy tasks (and vice versa). However, to limited extent, training of basic psychomotor skills for colonoscopy do appear to contribute to the performance of angled laparoscope navigation tasks. Thus, training and assessment of IBP type-specific skills should focus on each type of tasks independently. Future research should further investigate the influence of psychometric abilities on the performance of IBP and the transfer of skills for physicians who are experienced in one IBP type and would like to become proficient in another type of IBP.

Fellow perceptions of training using computer-based endoscopy simulators

BACKGROUND

Integrating procedural training by using computer-based endoscopic simulators (CBES) into gastroenterology fellowships may facilitate technical skill development, while posing no additional risk to patients.

OBJECTIVE

The aim of our study was to survey pediatric gastroenterology fellows about their experiences with and perceptions of CBES as compared with actual procedures, prior to and after exposure to both types of endoscopic learning.

DESIGN AND SETTING

All first-year trainees at Children's Hospital Boston (2003-2008) were invited to complete a written, pretraining questionnaire and then perform at least 10 each of CBES endoscopies and colonoscopies prior to performing actual procedures. Fellows completed a written, posttraining questionnaire after 4 months.

MAIN OUTCOME MEASUREMENTS

Survey responses.

RESULTS

All 25 first-year fellows (12 male, median age 30 years) over the 5-year period participated. Four months into their fellowships, fellows reported simulation to be helpful in increasing procedural skill and confidence. The number of sessions on the simulator was associated with reported increased colonoscopic skill and confidence (P = .032 and P = .007, respectively). All fellows reported it difficult to incorporate CBES into their work schedules. Only 28% of fellows reported performing 20 total CBES procedures, with most simulation sessions reportedly lasting less than 30 minutes. All participants rated faculty instruction with CBES as very helpful.

LIMITATIONS

This was a single-site study of pediatric trainees and may be limited in generalizability.

CONCLUSION

A few short sessions with CBES may be perceived as useful for endoscopic skill acquisition by pediatric gastroenterology trainees. Further exploration into how to assimilate CBES into busy gastroenterology training programs may be warranted.