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Endoscopy 2019; 51(11): 1103-1104
DOI: 10.1055/a-0988-0887
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© Georg Thieme Verlag KG Stuttgart · New York

SPED Statement: Training in Gastrointestinal Endoscopy

C Rolanda
,
A Sadio
,
R Loureiro
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Publication Date:
29 October 2019 (online)

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B. Competence and assessment in endoscopy

In medical education, competency-based assessment focuses on the apprentice and his/her outcomes/competencies. These aspects define a priori the design, the way of implementation and the evaluation of both the trainees and the program itself [1].

The concept of competence in endoscopy represents a challenge from the beginning. It started in 1995 by the definition of ASGE as “the minimal level of skill, knowledge, and/or expertise derived through training and experience that is required to safely and proficiently perform a task or procedure” [2]. The technical element and the theoretical knowledge are highlighted here, however in the last decade particular attention has been paid to human, non-technical factors, in the quality of endoscopy. It is now recognized that competence in endoscopy encompasses 3 domains – technical, cognitive and integrative, complicating the objectivity and the network of criteria to be defined in training programs [3] [4].

Equally important is the crosslink between competence and quality. Quality standards have been defined based on Key Performance Indicators (KPIs), so the training programs and stipulated credentialing competences must meet the KPIs and ultimately the best for the patient.

Following point A.8 on the part A of the SPED statement on Training in Gastrointestinal Endoscopy, we focused the changing effort on the endoscopy core learning of the Gastroenterology residency (upper digestive endoscopy, colonoscopy, polypectomy, hemostasis, resolution of complications). This document will not address assessment in advanced endoscopic procedures nor in skills renewal/validation of the specialists in practice.

SPED recommends that:

1. The learning of technical, cognitive and behavioral skills in each endoscopic procedure must be documented by a formal and objective assessment that prove competence for the independent practice. Although adequate numbers of procedures in patients are required to achieve competence, there is a significant variation in performance between endoscopists with similar levels of experience. Traditional certification based on a certain number of procedures for a period of time (internship or fellowship) should be reformulated in the light of current knowledge [4] [5].

2. The assessment should be continuous throughout the training, integrated in the learning cycle, and must include formative and summative components. The assessment is divided into 3 categories – diagnostic (used for planning purposes), formative (oriented to the development and mixed with the teaching process, it represents objective feedback that promotes self-reflection and dialogue about the training) and summative (performed at the end of the program and focused on the final result – competence for independent practice). These moments also provide us with relevant information about the training program and curricular deficiencies, making possible the optimization of methodology [3] [4]. In the context of basic training the diagnostic evaluation is redundant – all trainees start from a similar level, with negligible endoscopic experience.

3. The tools and metrics used for assessment should be selected on the basis of scientific evidence and/or in the experience of other ongoing training programs. The quality of the assessment depends on the reproducibility/consistency and validity of the used tools. The assessment methodology currently available consist of volumes, performance in simulators and instruments of evaluation with direct observation, which will be scrutinized in the following points [3] [4] [5].

4. The number/volume of procedures should be rewritten for a minimum number of supervised procedures – a “competence threshold” and admissibility to summative assessment. These numbers should be validated by evidence in a learning curve [4]. The most relevant series analyzing the endoscopic competence acquisition curves come from the JAG Endoscopy Training System (JETS) portfolio, pointing to cecal intubation rates of 90 % from 233 colonoscopies and 95 % of completion of upper digestive endoscopy at 187 procedures [7] [8].

5. The technical assessment using exercises in a simulator should not be used, so far, to confer degree of competence. Virtual simulation technology automatically generates performance metrics and allows motion analysis, enabling a quantitative evaluation of the technique. Although extremely appealing for trainers, so far there is no scientific validation that supports its use for this purpose [4] [9]. However, we believe that training with simulation should include its own assessment, which through the training program works as formative and feedback points.

6. The instruments of evaluation by direct observation should be progressively assumed as a standard endoscopy assessment tool. In line with the competency-based training model, international credentialing entities have emphasized the continuous assessment during the training in patients, using the direct observation of the procedures as the methodology of choice, with forms to be filled by the trainer during the performance by the trainee [3] [4]. This method allows to monitor progression, give feedback and make adjustments at disability points. In the literature it is possible to find several of these instruments, some of them validated – Mayo Colonoscopy Skills Assessment Tool (MCSAT), Assessment of Competency in Endoscopy (ACE), Gastrointestinal Endoscopy Assessment Tool (GiECAT), Direct Observation of Procedure Skills (DOPS-JAG) [10] [11] [12] [13]. Despite the recognition of its usefulness and importance, only JAG-UK has formally integrated this approach into its credentialing recommendations.

7. These instruments of direct evaluation should cover the procedures considered in the core/basic training program and contemplate the 3 domains of competence in endoscopy. DOPS bring together most of these characteristics and the use of its latest version, with a conceptual modification of the scale, revealed a greater discrimination and a more realistic learning curve; only the results of reproducibility, which are already under study, are missing [13]. There are formative DOPS and summative DOPS, which encompass items with the 3 competence components and are available for upper endoscopy, colonoscopy, hemostasis and polypectomy [14]. For its application in our country, the forms should be validated in Portuguese language.

8. In collaboration with the Portuguese regulatory and credentialing entity – “Colégio da Especialidade de Gastrenterologia” – the methodology of assessment in endoscopy should be progressively restructured in the basic training of the Gastroenterology residency. Considering all that was described, we would propose the frequency (with assessment) of structured courses directed to each phase/year of the residency. In parallel, fulfillment of the minimum numbers of procedures in patients and continuous assessment (formative) in the Gastroenterology departments, using a pre-defined direct observation instrument. Once the minimum competence threshold has been reached, the summative assessment of this specific procedure should be done with a direct evaluation instrument (e. g. in the annual evaluations) and the documentation attached to the Curriculum Vitæ of the trainee. Cognitive assessment should be complemented in the theoretical component of the final exam of the specialty.

9. When this type of format is implemented, conditions for internal audit and evaluation should be established. In the United Kingdom there is an integrated electronic platform where all data is recorded and accessible for consultation [15].

On behalf of SPED’s Education Committee
Rolanda C, Sadio A, Loureiro R