Simulation for esophagogastroduodenoscopy: the need for validated assessments and deliberate practice

10.1055/a-2664-3222

We wish to commend Dr. Nielsen and colleagues for conducting their randomized controlled trial evaluating simulation-based training (SBT) for esophagogastroduodenoscopy [1]. Their findings suggest that structured preparatory training may shorten the path to independent performance, a potentially significant contribution to evolving endoscopy education; however, the study highlights the gap between exposure-based training and the principles of deliberate practice, which are central to best practices in SBT.

Deliberate practice is widely recognized as the foundation for developing expertise. It requires structured goal-directed training with clear objectives, immediate expert feedback, and repeated opportunities for refinement [2]. In contrast, the training in this trial was largely self-directed, with no iterative coaching, progressive curriculum, or standardized reassessment. The preclinical pass/fail test was also simplified, focusing mainly on landmark recognition and tool-handling, while neglecting systematic mucosal inspection, visualization quality, and avoidance of blind spots [3]. Coupled with limited simulation fidelity – namely, the absence of haptic feedback and unrealistic anatomy – this undermines the development of accurate mental models essential for safe clinical translation.

A further limitation lies in how competence was judged. Assessments were conducted by local supervisors “according to Danish Health Authority standards,” but no validated rubric was provided, and neither were rater training or calibration conducted. This approach risks variability and leniency, which may explain why competence appeared to be achieved after fewer procedures than has been reported internationally – reflecting permissive assessment, rather than actual skill acceleration. Finally, reliance on self-reported autonomy scores and a narrowly scoped cost analysis further weaken the conclusions. Blinded video-based assessments and more comprehensive resource evaluation would have provided stronger evidence to support system-wide adoption.

In summary, while this trial represents progress, it does not embody the deliberate practice model required for mastery. To ensure safe skill transfer, simulation programs must employ validated assessment tools, standardized rater training, structured curricula, and iterative expert feedback.

Publication History

Article published online:
20 March 2026

• References

• 1 Nielsen AB, Nielsen MK, Wensel N. et al. Training esophagogastroduodenoscopy skills: a randomized multicenter trial comparing simulation-based training versus clinical training. Endoscopy 2025;
• 2 Ericsson KA, Pool R. Peak: Secrets from the New Science of Expertise. Boston: Houghton Mifflin Harcourt; 2016
• 3 Nielsen AB, Pedersen FM, Laursen CB. et al. Assessment of esophagogastroduodenoscopy skills on simulators before real-life performance. Endosc Int Open 2022; 10: E815-E823