Successful Training in Gastrointestinal Endoscopy

While simulators are likely to play an increasingly important role in endoscopic training and retraining, key gaps were identified that must be addressed for simulation to have an even greater impact on endoscopic training. These include

1 Improved visual resemblance and haptic capabilities of computerized modules

2 Incorporation of more complex cases to enhance the range of difficulty and increase relevance for the skilled endoscopist

3 Improved functional task alignment of simulators with real‐life performance (i.e., similar sensory, cognitive, and/or motor processing required for the simulator as for the corresponding clinical task)

4 Simulator‐generated performance metrics with strong validity evidence to enhance assessment capabilities and provision of feedback and increased capacity for independent practice

5 Improved discriminative validity, capable of distinguishing between endoscopists with small differences in skill

6 Inexpensive portable models to facilitate local access to simulators

7 Cognitive training tools targeting lesion recognition and management decision‐making skills

8 Simulators for more complex procedures such as ERCP and EUS and low‐volume, high‐stakes therapeutic techniques.

The past two decades have been characterized by rapid expansion of the training modalities at our disposal and the general acceptance of their use. Much work remains to clarify the optimal way to integrate these tools into standard training, training in advanced procedures, and in the uncharted waters of maintaining skills.

Several challenges exist as endoscopic training continues to evolve. To date, the vast capacity to incorporate the trove of stored video and photographic content covering endoscopically encountered pathology and how to manage it has been greatly under‐utilized. The DAVE Project [64] was launched in 2004 and represented a significant advance in allowing for free and easy access to view much of this kind of material (Video 1.7). Converted in 2013 to Apple podcasts, the DAVE Project stored annotated videos on an enormous range of common and uncommon findings, as well as demonstrations of typical and unusual procedures. Similar contact is now found in newer online platforms, including Video GIE ( https://www.videogie.org). However, there is still very limited incorporation of this material into web‐based interactive learning opportunities. By taking advantage of broadband transmission and web‐based learning, cognitive training might undergo as great a transformation in the coming years as ex vivo models have provided for technical skills development.

A second major area for progress is in the area of creation and validation of simulator‐based skills assessments that predict performance level and competency on actual procedures. Simulator investigators have long realized that a key milestone would be the development of reliable simulator‐based assessments of competency.

A third area that will need to be addressed in coming years is the further integration of some of these new teaching modalities into local programs. For example, the ideal follow‐up of the national first year’s fellows hands‐on training experience at the ITT would be follow‐up hands‐on workshops at various intervals run and funded locally with support of local physicians and industry. Funding and logistic issues need to be addressed, but adoption will first require increased acknowledgment by local program directors of the importance of such activities. For example, a combination didactic and hands‐on training course for advanced and interventional endoscopy held regionally may be an alternative to a centralized approach. To date, such workshops at professional society national and regional meetings (such as at ASGE, ACG, and NYSGE meetings) have emerged, but have not yet been scaled to reach the vast majority of GI trainees. Further expansion of hands‐on ex vivo simulator training at the local level will also require a considerable effort to train a broader group of trainers on how best to utilize these simulators to teach endoscopy [38] (see also Chapter 4).

Finally, what about the introduction of new endoscopic technology and techniques? This would be another area of real promise for an expanded role of simulators and specific training program development. On the part of industry, this begins with the use of models to test early devices and procedures prior to more costly animal studies. Next is the growing recognition that innovative techniques require specific training programs to ensure both proper execution of the new procedures and acceptance of the innovation by practitioners. Busy clinicians will not adopt new skills unless an efficient and preferably validated training program is available to ensure that they can develop the proficiency to safely and effectively do the procedure. In contrast to the past when efforts to determine the best ways to train for techniques often came long after the procedure was adopted, in the future, there will be increasing pressure to address training upfront. One hopes that with this additional attention to training in parallel with technology development will come increasing avenues of support for simulator‐based training in general. This may be of particular importance as a partial solution to the problem of creating more opportunities for practicing endoscopists who desire to and will need to learn new techniques. The innovators will need to support those they hope will adopt the innovation; simulators are likely to facilitate this growing interdependence.

It is clear that since 2000, there has been an increased focus on how endoscopic training should occur and on achieving benchmarks for assessing progress before further training should continue. Progress in simulation has been steady but remains slow, yet sentiment for engaging both trainees and experienced endoscopists for simulator training is evidenced by summits, White Papers, and continued innovation. Moreover, there continue to be progress in e‐learning, accelerated by the expanded use of video recording, and easier access to high‐quality material with distribution by broadband internet and advertisement and amplification on social media platforms.

So where is endoscopic teaching likely to go? While the future is always hard to predict, certain things seem to be on the horizon. In general, one can predict increased training done by sharing of educational videos on platforms that are accessible worldwide. (see Table 1.2for a summary of likely features of endoscopic training by 2030).

These changes to video and remote learning were already moving into place, but the COVID‐19 pandemic of 2020 and beyond may have accelerated this development. Important driving factors here include:

Table 1.2 A look at endoscopy training in 2030.

1 The COVID‐19 pandemic has led to sharply increased interest and then sudden acceptance of video platforms that turn out to be easily accessible worldwide. Learning in remote parts of the world has been made simple and affordable. Rather than bringing equipment and personnel to remote parts of the world, technology allows for the teachers to both teach and supervise from afar. Indeed, despite being retired from active clinical practice, Dr. Jerome Waye, a true pioneer in endoscopy and colonoscopy and in its education, is again pioneering by leading this new wave of remote teaching and proctoring. In 2020, he was able to bring “video‐mentoring” to Uganda and other parts of the world ( Figure 1.14) (Video 1.8). [See insert for a first‐hand description of this project by Dr. Waye.]