Reply to Asokkumar et al.

10.1055/a-2715-8328

We thank Dr. Asokkumar and colleagues for their interest in our paper [1] and for their thoughtful comments.

Our participants received both theoretical and practical introductions on how to perform standard diagnostic esophagogastroduodenoscopy (EGD), along with a booklet containing images and descriptions of the most common pathologies [1]. In the simulation-based training group, this was followed by supervised exercises on simulators with haptic feedback until the trainees became familiar with the procedure. Afterward, they engaged in directed, self-regulated training with optional supervision; a learning method that has shown to improve the retention of skills [2].

Furthermore, according to the effective mastery learning training principle [3], participants in the simulation group had to pass a standardized test with solid validity evidence before being permitted to begin clinical practice in the endoscopy suite [4]. This test was designed to evaluate practical skills such as scope handling and systematic mucosal inspection, while ensuring safe scope movements. Clinical training for both groups included direct supervision by senior endoscopists and was structured according to the key components of deliberate practice [5].

At each inclusion site, local supervisors assessed the participants’ readiness to perform diagnostic EGD independently. Once participants were judged to be capable of independent procedural completion, supervision shifted to on-call availability as needed. We agree that it would have been optimal to record videos of every clinical procedure and use a standardized assessment tool. Unfortunately, this approach was not feasible in our multicenter study, including almost 1200 procedures, and we chose to trust the decisions of the local supervisors (senior endoscopists). We believe this real-world approach strengthens the internal validity of our study, as we did not alter the existing clinical training structure to explore the effects of simulation.

In summary, our results show that deliberate practice in a simulation-based mastery learning program results in positive transfer to real clinical procedures.

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 Brydges R, Nair P, Ma I. et al. Directed self-regulated learning versus instructor-regulated learning in simulation training. Med Educ 2012; 46: 648-656
• 3 Cold KM, Wei W, Agbontaen K. et al. Mastery learning guided by artificial intelligence is superior to directed self-regulated learning in flexible bronchoscopy training: an RCT. Respiration 2025; 104: 206-215
• 4 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
• 5 Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004; 79: S70-81