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CC BY-NC-ND 4.0 · Endosc Int Open 2022; 10(09): E1174-E1180
DOI: 10.1055/a-1795-9037
Original article

Learning curves in ERCP during advanced endoscopy training: a Canadian multicenter prospective study

Usman Khan
 1   Division of General Surgery, Department of Surgery, University of Toronto
,
Rishad Khan
 2   Department of Medicine, University of Toronto
,
Eric Benchimol
 3   Division of Gastroenterology, Hepatology, and Nutrition, the Hospital for Sick Children, University of Toronto
,
Misbah Salim
 4   Division of Gastroenterology, University Health Network, University of Toronto
,
Jennifer Telford
 5   Division of Gastroenterology and Hepatology, Department of Medicine, University of British Columbia
,
Robert Enns
 5   Division of Gastroenterology and Hepatology, Department of Medicine, University of British Columbia
,
Rachid Mohamed
 6   Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary
,
Nauzer Forbes
 6   Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary
,
Gurpal Sandha
 7   Division of Gastroenterology and Hepatology, University of Alberta Hospital, University of Alberta
,
Ali Kohansal
 8   Division of Digestive Care and Endoscopy, Department of Medicine, Dalhousie University
,
Jeffrey Mosko
 9   Division of Gastroenterology, St. Michael’s Hospital, University of Toronto
,
Avijit Chatterjee
10   Division of Gastroenterology and Hepatology, The Ottawa Hospital, University of Ottawa
,
Gary May
 9   Division of Gastroenterology, St. Michael’s Hospital, University of Toronto
,
Kevin Waschke
11   Division of Gastroenterology, McGill University Health Centre, McGill University
,
Alan Barkun
11   Division of Gastroenterology, McGill University Health Centre, McGill University
,
Paul D. James
 4   Division of Gastroenterology, University Health Network, University of Toronto
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Abstract

Background and study aims Growing emphasis on quality and patient safety has supported the shift toward competency-based medical education for advanced endoscopy trainees (AETs). In this study, we aimed to examine Canadian AETs learning curves and achievement of competence using an ERCP assessment tool with strong evidence of validity.

Methods This prospective study was conducted at five institutions across Canada from 2017–2018. Data on every fifth procedure performed by trainees were collected using the United Kingdom Joint Advisory Joint Advisory Group of Gastrointestinal Endoscopy (JAG) ERCP Direct Observation of Procedural Skills (DOPS) tool, which includes a four-point rating scale for 27 items. Cumulative sum (CUSUM) analysis was used to create learning curves for overall supervision ratings and ERCP DOPS items by plotting scores for procedures performed during training.

Results Eleven trainees who were evaluated for 261 procedures comprised our sample. The median number of evaluations by site was 49 (Interquartile range (IQR) 31–76) and by trainee was 15 (IQR 11–45). The overall cannulation rate by trainees was 82 % (241/261), and the native papilla cannulation rate was 78 % (149/191). All trainees achieved competence in the “overall supervision” domain of the ERCP DOPS by the end of their fellowship. Trainees achieved competency in all individual domains, except for tissue sampling and sphincteroplasty.

Conclusions Canadian AETs are graduating from fellowship programs with acceptable levels of competence for overall ERCP performance and for the most specific tasks. Learning curves may help identify areas of deficiency that may require supplementary training, such as tissue sampling.

Supplementary material



Publication History

Received: 27 July 2021

Accepted after revision: 13 December 2021

Article published online:
14 September 2022

© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

Comment to this article:

Endoscopy International Open – recently publishedEndoscopy 2022; 54(10): 1020-1020
DOI: 10.1055/a-1852-8518

 

  • References

  • 1 Mounzer R, Wani S. ERCP Training. Baron TH, Kozarek RA, Carr-Locke DL. ERCP. 3rd ed. Elsevier; 2019: 68-79
    CrossrefGoogle Scholar
  • 2 Holmboe ES, Sherbino J, Long DM. et al. The role of assessment in competency-based medical education. Med Teacher 2010; 32: 676-682
    CrossrefPubMedGoogle Scholar
  • 3 Yang D, Wagh MS, Draganov PV. The status of training in new technologies in advanced endoscopy: from defining competence to credentialing and privileging. Gastrointest Endosc 2020; 92: 1016-1025
    CrossrefPubMedGoogle Scholar
  • 4 Wani S, Keswani RN, Petersen B. et al. Training in EUS and ERCP: standardizing methods to assess competence. Gastrointest Endosc 2018; 87: 1371-1382
    CrossrefPubMedGoogle Scholar
  • 5 Verma D, Gostout CJ, Petersen BT. et al. Establishing a true assessment of endoscopic competence in ERCP during training and beyond: a single-operator learning curve for deep biliary cannulation in patients with native papillary anatomy. Gastrointestinal endoscopy 2007; 65: 394-400
    CrossrefPubMedGoogle Scholar
  • 6 Wani S, Hall M, Wang AY. et al. Variation in learning curves and competence for ERCP among advanced endoscopy trainees by using cumulative sum analysis. Gastrointest Endosc 2016; 83: 711-719
    CrossrefPubMedGoogle Scholar
  • 7 Ekkelenkamp VE, Koch AD, Rauws EAJ. et al. Competence development in ERCP: The learning curve of novice trainees. Endoscopy 2014; 46: 949-955
    Article in Thieme ConnectPubMedGoogle Scholar
  • 8 Dumonceau J-M, Kapral C, Aabakken L. et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2020; 52: 127-149
    Google Scholar
  • 9 Springer J, Enns R, Romagnuolo J. et al. Canadian credentialing guidelines for endoscopic retrograde cholangiopancreatography. Can J Gastroenterol 2008; 22: 247-251
    CrossrefPubMedGoogle Scholar
  • 10 Jorgensen J, Kubiliun N, Law JK. et al. Endoscopic retrograde cholangiopancreatography (ERCP): core curriculum. Gastrointest Endosc 2016; 83: 279-289
    CrossrefPubMedGoogle Scholar
  • 11 Siau K, Dunckley P, Feeney M. et al. ERCP assessment tool: evidence of validity and competency development during training. Endosc 2019; 51: 1017-1026
    Article in Thieme ConnectPubMedGoogle Scholar
  • 12 Wani S, Keswani R, Hall M. et al. A prospective multicenter study evaluating learning curves and competence in endoscopic ultrasound and endoscopic retrograde cholangiopancreatography among advanced endoscopy trainees: The Rapid Assessment of Trainee Endoscopy Skills Study. Clin Gastroenterol Hepatol 2017; 15: 1758-1767.e11
    CrossrefPubMedGoogle Scholar
  • 13 Cotton PB, Eisen G, Romagnuolo J. et al. Grading the complexity of endoscopic procedures: results of an ASGE working party. Gastrointest Endosc 2011; 73: 868-874
    Google Scholar
  • 14 Bolsin S, Colson M. The use of the Cusum technique in the assessment of trainee competence in new procedures. International Journal for Quality in Health Care 2000; 12: 433-438
    CrossrefPubMedGoogle Scholar
  • 15 Patel SG, Rastogi A, Austin G. et al. Gastroenterology trainees can easily learn histologic characterization of diminutive colorectal polyps with narrow band imaging. Clin Gastroenterol Hepatol 2013; 11: 997-1003
    CrossrefPubMedGoogle Scholar
  • 16 Smith S, Tallentire V. The right tool for the right job: the importance of CUSUM in self‐assessment. Anaesth 2011; 66: 747
    CrossrefPubMedGoogle Scholar
  • 17 Lee Y-K, Ha Y-C, Hwang D-S. et al. Learning curve of basic hip arthroscopy technique: CUSUM analysis. Knee Surg Sports Traumatol Arthrosc 2013; 21: 1940-1944
    CrossrefPubMedGoogle Scholar
  • 18 Wani S, Han S, Simon V. et al. Setting minimum standards for training in EUS and ERCP: results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees. Gastrointest Endosc 2019; 89: 1160-1168.e9
    CrossrefPubMedGoogle Scholar
  • 19 Salowi MA, Choong Y-F, Goh P-P. et al. CUSUM: a dynamic tool for monitoring competency in cataract surgery performance. Br J Opthal 2010; 94: 445-449
    CrossrefPubMedGoogle Scholar
  • 20 Han S, Obuch JC, Duloy AM. et al. A prospective multicenter study evaluating endoscopy competence among gastroenterology trainees in the era of the next accreditation system. Academic Medicine 2020; 95: 283-292
    CrossrefPubMedGoogle Scholar
  • 21 Wilkinson M, Charnley R, Morris J. ERCP -- The way forward. A standards framework. British Society of Gastroenterology. https://www.bsg.org.uk/clinical-resource/ercp-the-way-forward-a-standards-framework/
    PubMedGoogle Scholar
  • 22 Adler DG, Lieb JG, Cohen J. et al. Quality indicators for ERCP. Gastrointest Endosc 2015; 81: 54-66
    CrossrefPubMedGoogle Scholar
  • 23 Waller HM, Connor SJ. Cumulative sum (Cusum) analysis provides an objective measure of competency during training in endoscopic retrograde cholangio-pancreatography (ERCP). HPB 2009; 11: 565-569
    CrossrefPubMedGoogle Scholar
  • 24 Wani S, Keswani RN, Han S. et al. Competence in endoscopic ultrasound and endoscopic retrograde cholangiopancreatography, from training through independent practice. Gastroenterology 2018; 155: 1483-1494
    Google Scholar
  • 25 Matharoo M, Haycock A, Sevdalis N. et al. A prospective study of patient safety incidents in gastrointestinal endoscopy. Endosc Int Open 2017; 5: E83-E89
    Google Scholar
  • 26 Cullinane M, Gray AJG, Hargraves CMK. et al. Scoping our practice: The 2004 report of the National Confidential Enquiry into Patient Outcome and Death. National Confidential Enquiry into Patient Outcome and Death. https://www.ncepod.org.uk/2004sop.html
    PubMedGoogle Scholar
  • 27 Hitchins CR, Metzner M, Edworthy J. et al. Non-technical skills and gastrointestinal endoscopy: a review of the literature. Frontline Gastroenterol 2018; 9: 129-134
    CrossrefPubMedGoogle Scholar
  • 28 Elmunzer BJ, Walsh CM, Guiton G. et al. Development and initial validation of an instrument for video-based assessment of technical skill in ERCP. Gastrointest Endosc 2021; 93: 914-923
    CrossrefPubMedGoogle Scholar
  • 29 Ekkelenkamp VE, de Man RA, Ter Borg F. et al. Prospective evaluation of ERCP performance: results of a nationwide quality registry. Endosc 2015; 47: 503-507
    Article in Thieme ConnectPubMedGoogle Scholar
  • 30 Walsh CM, Scaffidi MA, Khan R. et al. Non‐technical skills curriculum incorporating simulation‐based training improves performance in colonoscopy among novice endoscopists: Randomized controlled trial. Digestive Endoscopy 2020; 32: 940-948
    CrossrefPubMedGoogle Scholar
  • 31 Schutz SM, Abbott RM. Grading ERCPs by degree of difficulty: a new concept to produce more meaningful outcome data. Gastrointest Endosc 2000; 51: 535-539
    CrossrefPubMedGoogle Scholar
  • 32 Shah RJ, Langer DA, Antillon MR. et al. Cholangioscopy and cholangioscopic forceps biopsy in patients with indeterminate pancreaticobiliary pathology. Clin Gastroenterol Hepatol 2006; 4: 219-225
    CrossrefPubMedGoogle Scholar
  • 33 DeWitt J, Misra VL, LeBlanc JK. et al. EUS-guided FNA of proximal biliary strictures after negative ERCP brush cytology results. Gastrointest Endosc 2006; 64: 325-333
    CrossrefPubMedGoogle Scholar
  • 34 Leung JW, Lee JG, Rojany M. et al. Development of a novel ERCP mechanical simulator. Gastrointest Endosc 2007; 65: 1056-1062
    CrossrefPubMedGoogle Scholar
  • 35 Liao W-C, Leung JW, Wang H-P. et al. Coached practice using ERCP mechanical simulator improves trainees’ ERCP performance: a randomized controlled trial. Endosc 2013; 45: 799-805
    Article in Thieme ConnectPubMedGoogle Scholar
  • 36 Lim BS, Leung JW, Lee J. et al. Effect of ERCP mechanical simulator (EMS) practice on trainees’ ERCP performance in the early learning period: US multicenter randomized controlled trial. Am J Gastroenterol 2011; 106: 300-306
    CrossrefPubMedGoogle Scholar
  • 37 Sedlack R, Petersen B, Binmoeller K. et al. A direct comparison of ERCP teaching models. Gastrointest Endosc 2003; 57: 886-890
    CrossrefPubMedGoogle Scholar
  • 38 Nur AM, Boerner S, Edwards L. et al. Su1540 Revisiting the diagnostic yield of ercp brush cytology for indeterminate biliary strictures. Gastrointest Endosc 2020; 91: AB371
    CrossrefPubMedGoogle Scholar
  • 39 Shahidi N, Ou G, Telford J. et al. When trainees reach competency in performing ERCP: a systematic review. Gastrointest Endosc 2015; 81: 1337-1342
    CrossrefPubMedGoogle Scholar
  • 40 James P, Antonova L, Martel M. et al. Measures of trainee performance in advanced endoscopy: a systematic review. Best Pract Res Clin Gastroenterol 2016; 30: 421-452
    CrossrefPubMedGoogle Scholar
  • 41 Ward ST, Mohammed MA, Walt R. et al. An analysis of the learning curve to achieve competency at colonoscopy using the JETS database. Gut 2014; 63: 1746-1754
    Google Scholar