Proficiency in a highly skilled procedure can be a challenge. The classical mentor-based
approach has increasingly been shown to have its limitations, particularly from an
ethical point of view. “Never for the first time in a human” is an important adage
that is now possible with the availability of excellent simulation training models.
In this issue of EIO, Prof. Bruno and his team evaluate a new synthetic papilla product
that is easily insertable into the Boškoski-Costamagna endoscopic retrograde cholangiopancreatography
(ERCP) mechanical simulator [1]. These mechanical simulators have recently been introduced in ERCP training and
enable trainees to practice cannulation, stent placement in both the common bile duct
(CBD) and pancreatic duct (PD) as well as CBD stone extraction [2]
[3]. These simulators also allow for demonstration of specific endoscopic movements
used in ERCP for the straight position or long route position. Furthermore, the new
synthetic papilla feature allows trainees to perform a simulated sphincterotomy. Forty
international specialist physicians who have collectively performed more than 2500
ERCPs unanimously concluded that the synthetic papilla feature was a useful tool for
trainee endoscopists and should be incorporated into training curricula.
It is a well-established pedagogical theory that there are three characteristic phases
to learning a skill: cognitive, associative and, finally, autonomous. Training in
and repetition of a procedure are essential in for progression from the cognitive
phase, where the cognitive load is intense, to the autonomous phase where the procedure
can be repeated by muscle memory. Regular feedback with a mentor needs to be strongly
associated with ERCP training programs to optimize the efficiency and success rates
of the training process. Training models provide an ideal, realistic environment to
allow for this necessary repetition [4] to reach learning outcomes that are procedural, but also trainee-dependent.
Since the 1990 s, a large number of publications have reported positive outcomes with
training models that encourage use of endoscopy in both basic and highly skilled procedures.
The ex vivo EASIE model has been the most studied, showing improved skills in hemostasis
[5], endoscopic ultrasound-guided fine-need aspiration [6], EUS pancreatic collection drainage [7], and ESD. However, this model is associated with significant costs and requires
a dedicated structure and animal-dedicated scopes. An in vivo animal model using pigs
is one of the best tools for many highly skilled endoscopic procedures, particularly
because of the presence of peristalsis and respiratory movements [8]. Availability is, of course, limited by cost, the requirement for a veterinary lab,
and compelling ethical considerations. Virtual reality simulation is being used more
and more, with 18 published trials to date [9], confirming its suitability for beginners, in particular, to acquire basic gastroscopy
and colonoscopy skills. Computer-based simulator systems are expensive but do not
need the dedicated structures required in ex vivo or in vivo models. Mechanical simulators
provide promising new opportunities. The Thompson Endoscopic Skills Trainer (TEST)
allows teaching of basic skills (retroflexion, knob control, torque, polypectomy and
navigation/loop reduction) and has a validated metric evaluation system to monitor
trainees and observe their progression [10].
However, due to the growing of various training models and potential business linked,
learned societies have to think of official validation. Training on a model is attractive
but probably not training on any model!
As with skills associated with sports or music, repetition and training are essential
to learn and master a series of movements. Given growing evidence of the benefits
of this approach, simulation platforms dedicated to gastrointestinal endoscopy should
be available in teaching hospitals. Metric-validated evaluation tools should also
be further developed to regularly evaluate and validate, the procedural ability of
trainees. A procedural ability curriculum should not simply be based on a minimum
number of procedures that have to be successfully performed under supervision. Models
could help not only with regard to skills training but also in evaluation of trainees,
particularly on highly skilled procedures (e. g., ERCP, EUS-guided biliary drainage,
endoscopic mucosal resection, endoscopic submucosal dissection, and submucosal endoscopy).
More specialized physicians, who are akin to high-level sportsmen who regularly practice
their skills, could certainly benefit from these models. From this, a procedural Continuous
Medical Education system could be imagined.
“Never the first time in a human” and “Never stop training” are two adages that need
to be routinely incorporated into the philosophy of a gastrointestinal endoscopy unit
for the benefit of their patients. Financial support is needed to shift training from
a master-apprentice model to a simulator-based apprentice model on models that have
previously been officially validated.
