Training to Competence in Gastrointestinal Endoscopy: A Plea for Continuous Measuring of Objective End Points

 

 Buy Article Permissions and Reprints

Introduction

Apprentice is derived from the Latin apprehendere, meaning “to seize”. Physicians have seized the skills needed to perform procedures in the same way that apprentices have learned since the days of the mediaeval guilds: by watching someone work. We have known for hundreds of years that some apprentices are skilled well before others. Similarly, some apprentices have better hand-eye coordination, others, a better fund of knowledge. How have we distinguished between them? The opinion of the master or mentor has been supreme.

It has been the same way in gastrointestinal endoscopy until the rise of consumer interest in healthcare and payer interest in costs. A gastroenterologist would receive privileges at a hospital on the basis of a letter from his training program director. But, in the last quarter of the twentieth century, patients, their lawyers, third-party payers, and hospitals began to ask, “Show us that you are really qualified!” Surgeons have a long tradition of keeping a logbook of their procedures, but such a practice was a new thing for gastroenterologists. Nonetheless, beginning in the 1980s, trainees were formally required to keep track of every procedure that they carried out [1].

At the same time, medical societies began to ask, “How much training is enough?” In the absence of data, expert opinion was sought. The Federation of Digestive Disease Societies recommended 50 - 100 procedures for competence in esophagogastroduodenoscopy (EGD) and colonoscopy [2]. Wington et al. obtained estimates of the numbers of procedures thought necessary to achieve competence, from internists [3], internal medicine residency directors [4], and gastroenterologists [5]. The first two groups thought a median of 25 EGDs or colonoscopies were sufficient, while the gastroenterologists thought a median of 75 EGDs and 88 colonoscopies were needed. The American Board of Internal Medicine surveyed gastroenterology fellowship directors and found that a median of 85 EGDs and 75 colonoscopies were expected [6].

References

• 1 American Society for Gastrointestinal Endoscopy. Trainee evaluation form.  Manchester, Massachusetts; American Society for Gastrointestinal Endoscopy, 1982
• 2 Federation of Digestive Disease Societes. Guidelines for training in endoscopy.  Manchester, Massachusetts; Federation of Digestive Disease Societies, 1981
• 3 Wington R S, Nicolas J OA, Blank L L. Procedural skills of the general internist: a survey of 2500 physicians.  Ann Intern Med. 1989;  111 1023-1034
  PubMedGoogle Scholar
• 4 Wington R S, Blank L L, Nicolas J OA, Tape T G. Procedural skills training in internal medicine residencies.  Ann Intern Med. 1989;  111 932-938
  PubMedGoogle Scholar
• 5 Wington R S, Blank L L, Monsour H, Nicolas J OA. Procedural skills of practicing gastroenterologists. A national survey of 700 members of the American College of Physicians.  Ann Intern Med. 1990;  113 540-546
  PubMedGoogle Scholar
• 6 American Board of Internal Medicine. Results of procedure survey of gastroenterology program directors. Am Board Intern Med Newsletter, Spring/Summer 1990: 4-5
• 7 Parry B A, Williams S M. Competency and the colonoscopist: a learning curve.  Aust NZ J Surg. 1991;  61 419-422
  CrossrefPubMedGoogle Scholar
• 8 Godreau C J. Office-based colonoscopy in a family practice.  Fam Pract Res J. 1992;  12 313-320
  PubMedGoogle Scholar
• 9 Rodney W M, Dabov G, Cronin C. Evolving colonoscopy skills in a rural family practice: the first 293 cases.  Fam Pract Res J. 1993;  13 43-52
  PubMedGoogle Scholar
• 10 Cass O W, Freeman M L, Peine C J, et al. Objective evaluation of endoscopy skills during training.  Ann Intern Med. 1993;  118 40-44
  PubMedGoogle Scholar
• 11 Cass O W, et al. Acquisition of competency in endoscopic skills during training: a multicenter study.  Gastrointest Endosc. 1996;  43 308
  PubMedGoogle Scholar
• 12 Church J N. Learning colonoscopy: the need for patience (patients).  Am J Gastroenterol. 1993;  88 1569
  PubMedGoogle Scholar
• 13 Church J N. Training. In: Church JN. Endoscopy of the colon, rectum and anus.  New York; Igaku Shoin, 1995: 214-225
  Google Scholar
• 14 Marshall J B. Technical proficiency of trainees performing colonoscopy: a learning curve.  Gastrointest Endosc. 1995;  42 287-291
  CrossrefPubMedGoogle Scholar
• 15 Chak A, Copper G S, Blades E W, et al. Prospective assessment of colonoscopic intubation skills in trainees.  Gastrointest Endosc. 1996;  44 54-57
  PubMedGoogle Scholar
• 16 Hopper W, Kyker K A, Rodney W M. Colonoscopy by a family physician: a 9-year experience of 1048 procedures.  J Fam Pract. 1996;  43 561-566
  PubMedGoogle Scholar
• 17 Tassios P S, Ladus S D, Grammenos I, et al. Acquisition of competence in colonoscopy: the learning curve of trainees.  Endoscopy. 1999;  31 702-706
  Article in Thieme ConnectPubMedGoogle Scholar
• 18 Haseman J H, Lemmel G T, Rahmani E Y, Rex D K. Failure of colonoscopy to detect colorectal cancer.  Gastrointest Endosc. 1997;  45 451-455
  CrossrefPubMedGoogle Scholar
• 19 Anonymous. Methods of granting hospital privileges to perform gastrointestinal endoscopy. American Society for Gastrointestinal Endoscopy Standards of Training and Practice Committee.  Gastrointest Endosc. 1992;  38 765-767
  PubMedGoogle Scholar
• 20 Farthing M JG, Walt R P, Allan R N, et al. A national training programme for gastroenterology and hepatology.  Gut. 1966;  38 459-470
  PubMedGoogle Scholar
• 21 Conjoint Committee for Recognition of Training in Gastrointestinal Endoscopy. Information for supervisors: changes to endoscopic training.  Sydney; The Conjoint Committee for Recognition of Training in Gastrointestinal Endoscopy, 1997
  Google Scholar
• 22 European Union of Medical Specialists. European Board of Gastroenterology. Chapter 6.  Charter on training of medical specialists in the EU. Requirements for the specialty gastroenterology.  Brussels; European Union of Medical Specialists. European Board of Gastroenterology, 20 Avenue de la Couronne, 20-1050 Bruxelles, Belgium, http://www.uems.be/gastro-e.htm, 1995
  Google Scholar
• 23 Jones D B, Chapuis P. What is adequate training and competence in gastrointestinal endoscopy?.  Med J Aust. 1999;  170 274-276
  PubMedGoogle Scholar
• 24 Cass O W. Objective evaluation of competence: technical skills in gastrointestinal endoscopy.  Endoscopy. 1995;  27 86-89
  PubMedGoogle Scholar
• 25 Plumeri P A. Legal issues.  Gastrointest Endosc. 1995;  41 647-651
  PubMedGoogle Scholar
• 26 Williams C B. Endoscopy teaching: time to get serious.  Gastrointest Endosc. 1998;  47 429-430
  PubMedGoogle Scholar
• 27 Davidoff F. Training to competence - so crazy it might just work.  ACP Observer. 1995;  October 9
  PubMedGoogle Scholar
• 28 Gallagher A G, McClure N, McGuigan J, et al. An ergonomic analysis of the fulcrum effect in the acquisition of endoscopic skills.  Endoscopy. 1998;  30 617-620
  PubMedGoogle Scholar
• 29 Cotton P B. So who needs teaching?.  Gastrointest Endosc. 1974;  21 9-12
  PubMedGoogle Scholar

O. W. CassM.D. F.A.C.P. F.A.C.G. 

Dept. of Medicine

Hennepin County Medical Center

701 Park Avenue South

Minneapolis, MN 55415

USA

Phone: + 1-612-904-4299

Email: cassx001@tc.umn.edu