Polypectomy skills of gastroenterology fellows: can we improve them?

Background and aims: Currently, most training programs for gastroenterology (GI) fellows lack systematic training in polypectomy. Systematic education and direct feedback with the direct observational polypectomy skills (DOPyS) method is a simple and inexpensive way to train GI fellows in practical endoscopy. Our primary aim was to evaluate whether a lecture-based training course could improve the polypectomy skills of GI fellows. As a secondary aim, the interobserver agreement among the three assessors was evaluated.

Participants and methods: We invited GI fellows to record five polypectomies, after which they attended a training course consisting of three lectures on polyps and polypectomy methods given by expert endoscopists. After training, the fellows recorded five polypectomies again. All videos were blindly assessed by three expert endoscopists, who used the DOPyS method.

Results: Eight GI fellows participated in this study. There was no significant difference in the median overall competency scores before and after training; before training, 25 % (10/40) of the polypectomies were scored as “pass,” compared with 37.5 % (15/40) after training (P = 0.56). The interobserver agreement among the experts was fair (intraclass correlation coefficient [ICC] 0.34, 95 % confidence interval [CI] 0.14 – 0.52).

Conclusions: Our lecture-based training course did not result in an improvement in overall competency scores for the polypectomy skills of GI fellows. Besides, the overall quality of the polypectomy techniques of the fellows was considered low. To optimize polypectomy training and competency, we believe that direct feedback in the endoscopy suite and hands-on training by dedicated teachers are essential.

• References

• 1 Zavoral M. Colorectal cancer screening in Europe. World J Gastroenterol 2009; 15: 5907-5915
• 2 Libby G, Brewster DH, McClements PL et al. The impact of population-based faecal occult blood test screening on colorectal cancer mortality: a matched cohort study. Br J Cancer 2012; 107: 255-259
• 3 Zauber AG, Winawer SJ, O'Brien MJ et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012; 67: 687-696
• 4 Gupta S, Anderson J, Bhandari P et al. Development and validation of a novel method for assessing competency in polypectomy: direct observation of polypectomy skills. Gastrointest Endosc 2011; 73: 1232-1239.e2
• 5 Gupta S, Bassett P, Man R et al. Validation of a novel method for assessing competency in polypectomy. Gastrointest Endosc 2012; 3: 568-575
• 6 de Jonge V, Sint Nicolaas J, Cahen DL et al. Quality evaluation of colonoscopy reporting and colonoscopy performance in daily clinical practice. Gastrointest Endosc 2012; 75: 98-106
• 7 Piette C, Manfredi S. Variations between endoscopists in rates of detection of colorectal neoplasia and their impact on a regional screening program based on colonoscopy after fecal occult blood testing. Gastrointest Endosc 2010; 71: 335-341
• 8 Chen SC, Rex DK. Endoscopist can be more powerful than age and male gender in predicting adenoma detection at colonoscopy. Am J Gastroenterol 2007; 17: 856-861
• 9 National Institute for Public Health and the Environment. Protocol for the authorization and auditing of colonoscopy centres and endoscopists. April 30, 2014. Available from: http://www.rivm.nl/en/Documents_and_publications/Professional_Serviceable/Protocols/Disease_Prevention_and_Healthcare/Protocol_for_the_authorization_and_auditing_of_colonoscopy_centres_and_endoscopists (Accessed 29 October 2015)
• 10 Hochberger J, Matthes K, Maiss J et al. Training with the compactEASIE biologic endoscopy simulator significantly improves hemostatic technical skill of gastroenterology fellows: a randomized controlled comparison with clinical endoscopy training alone. Gastrointest Endosc 2005; 61: 204-215
• 11 Matthes K, Cohen J, Kochman ML et al. Efficacy and costs of a one-day hands-on EASIE endoscopy simulator train-the-trainer workshop. Gastrointest Endosc 2005; 62: 921-927
• 12 Maiss J, Millermann L, Heinemann K et al. The compactEASIE is a feasible training model for endoscopic novices: a prospective randomised trial. Dig Liver Dis 2007; 39: 70-78; discussion 79-80
• 13 Hochberger J, Euler K, Naegel A et al. The compact Erlangen Active Simulator for Interventional Endoscopy: a prospective comparison in structured team-training courses on ‘endoscopic hemostasis’ for doctors and nurses to the ‘Endo-Trainer’ model. Scand J Gastroenterol 2004; 39: 895-902
• 14 Ansell J, Arnaoutakis K, Goddard S et al. The WIMAT colonoscopy suitcase model: a novel porcine polypectomy trainer. Colorectal Dis 2013; 15: 217-223; discussion 223
• 15 Ansell J, Hurley JJ, Horwood J et al. The Welsh Institute for Minimal Access Therapy colonoscopy suitcase has construct and concurrent validity for colonoscopic polypectomy skills training: a prospective, cross-sectional study. Gastrointest Endosc 2014; 79: 490-497
• 16 Ansell J, Hurley JJ, Horwood J et al. Can endoscopists accurately self-assess performance during simulated colonoscopic polypectomy? A prospective, cross-sectional study. Am J Surg 2014; 207: 32-38
• 17 Haycock AV, Youd P, Bassett P et al. Simulator training improves practical skills in therapeutic GI endoscopy: results from a randomized, blinded, controlled study. Gastrointest Endosc 2009; 70: 835-845
• 18 van Doorn SC, van Vliet J, Fockens P et al. A novel colonoscopy reporting system enabling quality assurance. Endoscopy 2014; 46: 181-187
• 19 Endoscopic Classification Review Group. Update on the Paris classification of superficial neoplastic lesions in the digestive tract. Endoscopy 2005; 37: 570-578
• 20 Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33: 159-174
• 21 Landis JR, Koch GG. The measurement of observer agreement for categorical data. International Biometric Society. Available from: http://www.dentalage.co.uk/wp-content/uploads/2014/09/landis_jr__koch_gg_1977_kappa_and_observer_agreement.pdf (Accessed 30 October 2015)
• 22 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
• 23 Shahidi N, Ou G, Telford J et al. Establishing the learning curve for achieving competency in performing colonoscopy: a systematic review. Gastrointest Endosc 2014; 80: 410-416
• 24 Sedlack RE. Training to competency in colonoscopy: assessing and defining competency standards. Gastrointest Endosc 2011; 74: 355-366.e1-2
• 25 Barton JR, Corbett S, van der Vleuten CP. The validity and reliability of a Direct Observation of Procedural Skills assessment tool: assessing colonoscopic skills of senior endoscopists. Gastrointest Endosc 2012; 75: 591-597
• 26 Wilkinson JR, Crossley JGM, Wragg A et al. Implementing workplace-based assessment across the medical specialties in the United Kingdom. Med Educ 2008; 42: 364-373
• 27 Ekkelenkamp VE, Koch AD, de Man RA et al. Training and competence assessment in GI endoscopy: a systematic review. Gut 30.01.2015; [Epub ahead of print].
• 28 Sedlack RE. The Mayo Colonoscopy Skills Assessment Tool: validation of a unique instrument to assess colonoscopy skills in trainees. Gastrointest Endosc 2010; 72: 1125-1133.e1-3
• 29 Joint Advisory Group on GI Endoscopy. Royal College of Physicians . JAG Endoscopy Training System. Available from: http://www.jets.nhs.uk Accessed 27 October 2015
• 30 Norton ID, Bell C. Delegate perceptions of a national train-the-colonoscopy trainer program: an essential component of quality colonoscopy training. Gastrointest Endosc 2010; 71: AB215
• 31 Steinert Y, Mann K, Centeno A et al. A systematic review of faculty development initiatives designed to improve teaching effectiveness in medical education: BEME Guide No. 8. Med Teach 2006; 28: 497-526