Successful Training in Gastrointestinal Endoscopy

One such evaluation process is called the Direct Observation of Procedural Skill (DOPS) form. This form focuses on six broad motor skill parameters and was developed by researchers as a means of assessing these skills following an intensive hands‐on training course [27, 48]. Another standardized skill evaluation form has been developed at the Mayo Clinic (Rochester, MN) in conjunction with the ASGE, which grades a spectrum of both cognitive and motor skills of trainees during colonoscopy. These component skills of colonoscopy were identified by a panel of expert endoscopists and educators and are based on the general training and competency recommendations outlined by professional societies [49]. From this, a blueprint for the evaluation tool was created, and based on this blueprint and refinement by the ASGE training committee, the Assessment of Competency in Endoscopy (ACE) was developed ( Table 6.4). Some version of this survey has been in use for over a decade at Mayo and is completed on every colonoscopy from the first day of a fellow's training until graduation. The supervising staff enters these data directly into the institution's endoscopy database during the procedure so that the performance data are connected to other procedural data such as cecal intubation time and withdrawal times as well as special therapies applied, polyp detection, and complications. This assessment tool was recently made available as part of the ProVation Endoscopy reporting software package used by a vast number of endoscopy centers. Linking this evaluation to the procedural database has allowed the avoidance of having staff duplicate much of the data already generated automatically as part of the procedure. Admittedly, the goal of completing a fellow skills assessment with every procedure is labor‐intensive and daunting but can certainly be accomplished. Alternatively, the use of assessment forms such as the DOPS or ACE could be performed on a periodic basis, giving instructors a “snap‐shot” in time of how a trainee compares to the expected learning curve.

Table 6.3 Competency metrics for continuous assessment

The data collected from such an ongoing evaluation system allow reporting of a fellow's performance at any given point in their training as well as the comparison of the individual's scores to the average learning curve of his/her peers at the same points in training ( Figure 6.35). In the examples shown, progress reports can graphically depict the learning curves of any of the various competency parameters. In this example, the progress of three different first year fellows—A, B, and C (above, at, and below average, respectively)—is shown. This allows program directors to spot early those trainees who are falling off the learning curve and provide intervention earlier in training. Additionally, these metrics and average learning curves are valuable data for establishing criteria to define what performance equates to “competence” in a reliable, reproducible, and generizable manner. The concept of “competence” at present is rather limited in scope. A method that can formally define and assess competence such as ACE Tool or DOPS can be powerful tools. Each teaching institution should be encouraged to adopt some form of continuous assessment process whether using a comprehensive form such as the one described here or an ongoing skills assessment in a more limited form. Eventually, professional organizations and regulating organizations will require some type of direct measures of competence for all training portfolios as the parameters of cognitive and motor competence are increasingly better defined [50, 51].

Table 6.4 Assessment of Competence in Endoscopy (ACE) tool. This survey is completed by staff during each colonoscopy and grades a fellow's various cognitive and motor skills. This form is meant to augment the data already collected by the procedural database (such as medications administered, cecal intubation, and withdrawal times). Such a form allows for continuous assessment of a fellow's individual skills as they progress toward competence. (Copyrighted and used with permission of Mayo Foundation for Medical Education and Research.)

Modified from the Mayo Colonoscopy Skills Assessment Tool (© Mayo Foundation for Medical Education and Research) as reported in Sedlack RE. The Mayo Colonoscopy Skills Assessment Tool: a validation of a unique instrument to assess colonoscopy skills in trainees. Gastrointest Endosc 2010;72:1125–33. Used with permission.

Figure 6.35 Learning curves. Mayo's colonoscopy skills assessment tool (MCSAT) allows ongoing monitoring of various metrics of an individual trainee's performance throughout training. These three images demonstrate how the learning curves of three different fellows (blue lines) might appear for the parameter of cecal intubation rates as compared to the average learning curves of their peers (Magenta). Fellow A is above the learning curve (a), B is following the curve closely (b), and C is repeatedly below the curve and might be identified for early remediation (c).