Successful Training in Gastrointestinal Endoscopy

Two commercially available computer simulators exist for EGD, colonoscopy, bronchoscopy, EUS, and ERCP, and a colonoscopy‐specific simulator was also developed but not commercially available (Video 1.6).

The AccuTouch ®endoscopy simulator (Immersion Medical) system ( Figure 1.12) ( http://www.immersion.com/products/medical/endoscopy.html) allows training in a number of procedures, including flexible sigmoidoscopy and colonoscopy, as well as bronchoscopy. It is possible to practice mucosal biopsy on this model. The simulator provides direct performance feedback to the trainee. A number of validation studies have been conducted using this simulator [53–56], which will be covered in detail in Chapters 5and 6of this book.

The GI Mentor II (Simbionix) ( Figure 1.13) ( http://www.simbionix.com/GI_Mentor.html) offers several diagnostic and therapeutic modules [49]. Upper and lower endoscopy and ERCP are all performed on the same mannequin using a special endoscope for each procedure type. An accessory channel allows the endoscopist to perform a variety of therapeutic techniques, including biopsy, polypectomy, sclerotherapy, and electrocoagulation to control active bleeding, ERCP cannulation, and sphincterotomy. This simulator also includes some manual dexterity training exercises ideal for beginners to develop skills controlling the endoscope dials and using torque. The logical descendent of the Lucero model and progressive training program, the simulator incorporates a series of cases of varying pathology and technical difficulty. Instructors may delineate specific training programs. Trainees can get immediate feedback during and after completing each simulated procedure. In fact, the computer will even generate an expression of pain for overinsufflation or excessive looping of the instrument. Performance is recorded, including numbers and types of errors made. The instructor can review the progress of each trainee and the written procedure reports to determine whether abnormalities were correctly detected and identified; feedback messages may be sent back to the trainee.

Figure 1.12 Immersion AccuTouch ®colonoscopy simulator.

Figure 1.13 GI Mentor II (Simbionix) colonoscopy virtual reality simulator.

The GI Mentor II computer simulator has been incorporated into a number of European endoscopy courses, most notably in Scandinavia [57–59]. Respondents to questionnaires have expressed great satisfaction with the limited experience on the GI Mentor II simulator. As with the AccuTouch ®simulator, a number of objective validation studies have been carried out for the GI Mentor II, and these data are presented in detail elsewhere in this book in Chapters 5and 6.

If computer simulators are to have a role in credentialing in addition to training, they must be able to distinguish between a novice and an accomplished endoscopist. A study from the Mayo Clinic demonstrated that performance parameters on the simulator vary according to real colonoscopy experience [56]. To date, however, no investigator has shown that a particular performance level measured on a computer or any other simulator is predictive of competent performance on subsequent real endoscopy.

The Olympus colonoscopy simulator was a colonoscopy‐specific simulator based on advanced mathematical models developed in the late 2000s. Among its features, this model attempted to better simulate more difficult colonoscope passage [60, 61]. While this model was discontinued and is not commercially available, the rationale and performance characteristics to which it aspired remain critical to current simulator development and needs. For, it is enhanced realism and simulated procedure challenge that will be required to enhance simulator‐based training beyond the novice stage and to achieve reliable skills assessment on a simulator.

At present, computer simulators appear to have much to offer trainees in terms of showing diverse pathology and teaching beginners hand–eye coordination and endoscope handling. Unique aspects of this type of training are simulation of contractions, feedback on comfort, opportunity for self‐instruction without constant expert supervision, quantification of skills, and offsite skills assessment by instructors. Current available models appear less useful for more experienced endoscopists, although capabilities are expanding rapidly. At present, the therapeutic modules for the GI Mentor II simulator are best suited for introductory orientation only to polypectomy, hemostasis, and ERCP.

Computerized technology offers the potential to incorporate didactic lessons, specific questions for the endoscopist concerning accessory setup and generator settings, and opportunities for self‐assessment quizzes to complement the hands‐on technical experience. However, to date, such potential advances have not yet been incorporated into the existing simulators.

The major obstacle to expanded use of these simulators remains the cost and logistics of making them accessible to trainees. At costs ranging from $50,000 to 70,000, most individual departments cannot afford to purchase computer simulators.

What will be the next steps in the evolution of endoscopy simulators? A number of scenarios can be envisioned. Some potential developments envisioned in 2010 are described in Table 1.1, which interestingly shows ideas for future applications of simulators that were proposed in the first edition of this chapter, and now updated with remarks in red showing the progress or in some cases, lack of progress, in these areas over the past decade. Regardless of exactly how this field evolves in the coming years, it is fairly certain that simulators will play an increasing role in teaching and training in gastrointestinal endoscopy.

On November 19 and 20, 2017, the ASGE hosted an EndoVators Summit, partially supported by grant from the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health at the ASGE Institute for Training and Technology in Downers Grove, Illinois. The purpose of the summit was to define the role and value of simulators in the future of endoscopic training and to reach consensus regarding priority areas for simulation‐related education and research and simulator development. Over 70 thought leaders in simulation research, simulator development, and endoscopic education and training and key decision makers from industry gathered to review the current state of endoscopic simulation and the role it could play in endoscopic training. A White Paper published in 2019 [62] summarized the day’s events and the findings.

Table 1.1 Anticipated expanded applications of endoscopy simulation in 2010 and current status in 2020.

The goal was to provide a working roadmap for the developers of simulators and for the investigators whose goal is it to define the optimal use of endoscopy‐related simulation. Moreover, the attendees emphasized the importance of assessing the impact of simulation on educational outcomes and health care quality, and the need to provide clear guidance to educators who seek to enhance integration of simulation into training and practice.