Keywords
Quality and logistical aspects - Training - Pancreatobiliary (ERCP/PTCD) - Performance
and complications
Introduction
In the specialized domain of endoscopic retrograde cholangiopancreatography (ERCP),
proficiency demands a skill set that is intricately tied to operator technical, cognitive,
and integrative abilities [1]. The demanding nature of ERCP arises from the protracted learning curve essential
to achieve competence [2]
[3] and the heightened occurrence of associated adverse events (AEs) [4].
An expert is defined as an individual who has achieved mastery in a particular area
of knowledge or skill, consistently demonstrating a performance level surpassing the
average. Given the traditional adherence of ERCP to the apprenticeship model, it is
rational to seek guidance from these experts and consider them as role models. The
comprehension of ERCP experts’ professional trajectory, their strategic investments,
and their success in overcoming professional challenges serve as a substantive example
for trainees aspiring to follow a similar path toward success in this area.
The Latin term “Vade Mecum,” which literally translated to “go with me,” historically refers to a guide carried
for immediate reference. In this context, our vade mecum aimed to compile practical insights from ERCP experts, providing trainees with a
valuable compendium of knowledge to facilitate their journeys toward proficiency in
this field.
Methods
Study design and participants
A web-based survey was developed to gather insights into the professional development
and experience of ERCP experts, by identifying key milestones in their career advancement
and assembling recommendations for trainees striving for excellence in this field
(supplementary material).
The questionnaire was then distributed to 71 ERCP experts from high-volume training
centers worldwide. These experts were identified based on their recognized expertise
and peer acknowledgment. Selection criteria included reputation and contributions
to the field, to ensure a diverse and knowledgeable sample.
Development and content of survey instrument
An online Google form survey instrument was created, consisting of 24 open-ended questions
covering various aspects of training, career progression and personal reflections.
It was organized into the following five domains: specifics in ERCP/EUS training,
investments, advice to be (or not to be) followed, obstacles, and quotes to guide
professional life. The final survey version was distributed after pilot testing among
the authors.
Survey distribution and collection of data
The survey was distributed to experts via email. A brief statement describing the
goal of the study and informing respondents that their participation constituted their
voluntary consent to the study were included in the invitation, as well as a link
to the survey. Two mailing reminders were sent to non-respondents to maximize participation.
Because this study did not involve sharing of patient data, Ethics Committee approval
was not attained.
Questionnaire answers were voluntary and individual responses stayed confidential
and were only assessed by the researchers. Published data are reported as average
or as totals from the group, no individual responses were reported, and data are not
directly traceable to participants.
Study endpoints
The primary endpoint was to determine important points in experts’ professional development.
Secondary endpoints included capturing experts’ recommendations to excel in ERCP.
Data analysis
All data provided per user was automatically documented in a software database (Microsoft
Excel). Questions 2,3,5–7,10,12, and 13 were then structured as binary (yes/no) responses
for ease of quantitative analysis. Questions 4,8, and 9, which sought information
on timings, and questions 10 and 11, which gathered numerical data, were aggregated,
summarized, and presented quantitatively. Questions 14, 15,18, 19, and 24 revealed
recurring patterns and similarities in responses and were subject to thematic analysis.
Questions 17, 20, and 23 were approached using a qualitative methodology.
Quantitative data from binary and numerical responses were subjected to descriptive
analysis, and mean values and ranges, numbers, and percentages were used where applicable.
All calculations were made using Microsoft Excel.
Thematic analysis was applied in the aforementioned questions to enhance clarity and
readability of the results. In this regard, similar or identical responses were identified
and grouped into themes to facilitate more concise presentation of the qualitative
data and allow for clearer identification of prevalent ideas. These themes were then
reviewed and adjusted through collaborative discussions among the research team members,
for optimal accuracy in presenting the results.
Results
Fifty-three experts (74.6%) from 24 countries answered the questionnaire. The geographical
distribution of respondents to the survey is shown in [Fig. 1].
Fig. 1 Geographical distribution of respondents to ERCP/EUS training survey: Australia (n
=
1), Austria (n = 1), Belgium (n = 3), Canada (n = 1), Croatia (n = 1), Czech Republic
(n =
1), Denmark (n = 1), France (n = 6), Germany (n = 4), Hungary (n = 2), India (n =
1),
Italy (n = 3); Northern Ireland (n = 1), Norway (n = 1), Poland (n = 1), Portugal
(n = 2),
Romania (n = 2), Spain (n = 4), Sweden (n = 1), Switzerland (n = 1), Thailand (n =
1), The
Netherlands (n = 5), United Kingdom (n = 2), United States (n = 7).
Training in ERCP and EUS
[Fig. 2] provides the specifics regarding their ERCP training experience.
Fig. 2 Specific aspects of experts ERCP training experience.
ERCP training was started early (average age 31 years; range, 24–52 years), following
training in basic gastrointestinal endoscopy, and demanded a rather long period of
training (average duration 27 months; range, 3–120 months). Most of the experts followed
a specific period for ERCP training (81%), which often required moving to another
department (78%). ERCP was learned in combination with endoscopic ultrasound (EUS)
in most cases (76%), either sequentially (ERCP was frequently learned first) or simultaneously.
Following these principles, experts took an average of about 1.5 years (range, immediately
after training-5 years) to start performing ERCP/EUS independently and about 4 years
(range, 1–10 years) to accomplish a total of about 1000 ERCP/EUS procedures (each).
In addition, training was frequently complemented by research, with the goal of going
beyond and expanding the limits of knowledge in a certain field. In fact, most experts
(77%) developed research projects in ERCP/EUS while in training, with 72% having completed
a PhD thesis (most from European departments) by age 34 (range, 23–49 years old).
While most of these PhD theses were done in the field of advanced endoscopy and/or
biliopancreatic diseases, some were also done in other subjects, such as clinical
gastroenterology, hepatology, basic science, or even in experimental ophthalmology
or in regenerative stem cells.
Investments
When asked about the best and most worthwhile investments experts made to develop
their
skills, “time and practice” (n = 11) were essential for the majority, followed by
“observing
other experts” (n = 10), “maintaining continuous learning” and “doing a fellowship”
(n = 8
each), “choosing the right mentor” (n = 7) and “being involved in research” (n = 6)
as the
most frequently cited.
Additionally, more than half of the experts developed certain areas outside
endoscopy/medicine that they felt were also important to acquire ERCP/EUS technical
skills.
“Sport” (e.g., sailing, fencing, climbing) (n = 10) was the most frequently mentioned,
followed by “research” (e.g., translational, clinical, or bioengineering) (n = 8).
Advice to be (or not to be) followed
Throughout their paths to success, experts were given a lot of suggestions, some of
which were considered useful and others not so much. Experts recalled the best and
the worst advice they were given, as shown in this list and [Table 1], respectively.
The best advice experts received during their training are mentioned in [Table 1]. Additionally, worst advice given to them when they were trainees included:
-
“You are a woman, should you continue?”
-
“Don’t consult, you can manage it without help”
-
“Go with the flow”
-
“This is not a job for you, You will never succeed, Give up”
-
“Don’t take risks”
-
“Why spend more time in endoscopy? Do surgery instead”
-
“Never mind”
-
“I give you 5 minutes for cannulation”
-
“Don’t bother putting in pancreatic stents for protection against pancreatitis”
-
“Don’t learn to scope, you are an academic”
-
“Just stick to the endoscopy room”
-
“You will never become as good as the one who was really good at ERCP when I started
training so deal with it”
-
“Choose Internal Medicine instead”
-
“It would be better if you do colonoscopy”
Table 1 Best advice given to experts when they were trainees.
|
Advice
|
N
|
|
“Be careful and concerned with patient safety”
“Be resilient and don’t give up”
|
n = 10 each
|
|
“Observe others”
|
n = 9
|
|
“Be patient and take your time”
|
n = 7
|
|
“Be responsible and know your limits”
|
n = 6
|
|
“Work hard”
|
n = 5
|
|
“Keep on learning”
“Follow your passion and enjoy what you do”
“Check all conditions before starting”
|
n = 4 each
|
|
“Learn from your experience and mistakes”
“Get support and create your network”
“Stay curious and enthusiastic”
“Be competent and diligent”
“Get involved in academics, teaching, and research”
|
n = 3 each
|
|
“Be modest and don’t let your ego go too far”
“Believe in yourself”
“Know your team and be a team player”
“Think before you act”
|
n = 2 each
|
|
“Less is more”
“Be systematic”
“Make your practice your research”
“Listen”
“Start early”
“Stay yourself”
“Be committed”
“Limit your commitments”
“Be positive”
“Try to do the best possible”
“Dedicate to not only technical but also cognitive ERCP aspects”
“Change the strategy after adequate time if your approach has no success”
“Focus on the question which has to be answered”
|
n = 1 each
|
Obstacles
The negative comments that some experts received during their training are a glimpse
into the reality that it is not easy to get to the top. Indeed, expanding upon this
idea, several obstacles to the entry of these experts into the ERCP field were listed.
“Lack of dedicated time for training” (n = 11) and “peer competition” (n = 10) were
the biggest obstacles, followed by “lack of resources” (n = 8), “lack of procedure
volume” (n = 7), “lack of support” and “time constraints with family” (n = 5 each),
“lack of opportunity,” “gender issues,” “lack of structured training,” “procedures
complexity” and “difficulty developing research” (n = 3 each), “difficult relation
with surgeons,” “bureaucracy issues,” (n = 2 each) and “lack of funding” (n = 1).
Once more, certain attitudes, such as “keeping motivation and resilience,” “humbleness
and modesty,” “maintaining training,” and “observing and discussing with colleagues”
and having critical thinking skills (e.g., “reflecting, discussing and understanding
the failure and learning from it,” “reassessing indications and technique,” “reviewing
registered procedures”), helped these experts to overcome these obstacles.
Quotes to guide professional life
Work life is tough, no doubt about it. To help in guiding professional life, the
favorite quotes mentioned by the experts are summarized here:
-
“Enjoy each day”
-
“Learning is a continuous process”
-
“Keep trying” or “Never give up”
-
“Always be careful”
-
“Strive on and trust!”
-
“Failure is not an option” (but can be a decision)
-
“Primum non nocere”
-
“When sailing aimlessly, no wind is favorable”
-
“Who does not risk, does not win”
-
“Medicine is not a science; it is an art and an imperfect one”
-
“I am not what happened to me, I am what I choose to become”
-
“The value of the case for the individual patient should be given the highest priority”
-
“The failure is when we do not even try it”
-
“To someone with a new hammer, everything looks like a nail”
-
“Well done is better than well said”
-
“You are most likely to be good at what you enjoy”
-
“There is no worse teacher than the one who is not overwhelmed by his student”
-
“It is not because things are difficult that we do not dare, it is because we do not
dare that things are difficult”
-
“Do not take yourself too seriously”
-
“Cannulate the papilla with the care you would like to get a Foley catheter placed”
-
“Hard work pays off”
-
“Persistence wears down resistance”
-
“To thine own self be true”
-
“If you learn, teach; if you get, give”
-
“Patients who need ERCP the least are most likely to suffer a complication”
Beyond all the above-mentioned advice, it should also be taken into account that “personal
life,” “having the possibility of teaching,” “providing high work quality,” “optimizing
your patients’ outcomes” and “developing a good relation with them and your team”
and/or “collaborating in gastrointestinal societies,” which are frequently forgotten
at more initial stages of professional life, constitute, undeniably, important factors
for achieving long-term success in ERCP career.
Discussion
These study results provide novel insights about the professional trajectory of renowned
worldwide ERCP experts, giving valuable advice to help trainees to excel in this field.
Training in ERCP entailed formal and focused training for most of the experts, often
incorporating a comprehensive strategy that involved both ERCP and EUS learning and
was complemented by active engagement in research activities. The experts demonstrated
a significant commitment by dedicating a considerable duration to their training and
completing a substantial number of procedures to achieve competence. This commitment
aligns with recent guidelines [5], emphasizing the importance of adopting effective and thorough training programs
to fulfill the performance measures that have also been launched [6] to ensure that ERCP is performed in a standardized manner and with the appropriate
quality it demands. However, it is crucial to acknowledge the evolving landscape of
ERCP training. Despite the opportunities and commitment demonstrated by these experts,
accomplishing all the requirements of the ERCP training curriculum [5] has become increasingly challenging in current settings [7]. Legal considerations around training on actual patients, alongside increasing procedure
complexy due to technological advance, long learning curves to achieve competency
in ERCP [3]
[8]
[9], and lack of validation regarding the relationship between trainee involvement and
clinical outcomes in ERCP [10] contribute to these difficulties. Acknowledging these challenges, simulation training,
although underutilized by experts, may emerge as a promising solution. Use of simulator-based
education is increasing to complement and facilitate this supervised training process,
at the same time that it obviates potential patient-related AEs. In a dedicated learning
environment and maintaining the feedback from the trainers, this type of training
allows the acquisition of skills and competencies at the trainee’s own pace, without
increasing procedure times or risks for the patient. Furthermore, simulators can permit
the adoption of a “deliberate” practice, a practice that focuses on tasks beyond the
trainee’s current level of competence and comfort [11]. As stated by the top psychologist Anders Ericsson, “It is only by working at what
you can’t do that you turn into the expert you want to become” [12]. In fact, contrary to commonly held misconceptions, training should entail specific,
considerable, and sustained efforts in skills/steps that the trainee cannot do well,
or even at all. In ERCP, although several types of simulator models have been developed
[13], they still have limited formal implementation in training programs, due to their
specific limitations (anatomical characteristics, price, ethical and logistical demands)
[5] and lack of proper validation. The Boškoski-Costamagna ERCP Trainer, which is one
of the most appreciated simulation prototypes for ERCP training [14]
[15]
[16], is currently being validated (ClinicalTrials.gov Identifier: NCT05533944).
Regarding the most valuable investments experts made, “time and practice” were pointed
out by the majority. “Practice isn’t the thing you do once you’re good. It is the
thing you do that makes you good” [17]. Indeed, it takes time to become an expert. Research has shown that “the most gifted
performers need at least ten years (or 10,000 hours) of intense training in a given
field before winning international competitions. Specifically in the field of music,
the apprenticeship may be even longer, and most elite musicians will need 15 to 25
years of steady practice, on average, before they succeed at the international level”
[17]. ERCP is surely no exception. Another crucial investment was the choice of a mentor.
Training in ERCP has traditionally adhered to the apprenticeship model, a method rooted
in experiential learning on actual patients [7]. First described by Pratt and Johnson [18], this model, especially prevalent in teaching motor skills, is characterized by
the principle of “learning by doing.” It is a common approach in vocational training,
where a seasoned endoscopist, designated as the trainer, serves as a model for behavior.
The trainee, in turn, attempts to replicate the demonstrated skills, receiving constructive
feedback from the trainer. In ERCP, the importance of “choosing the right mentor,”
highlighted in survey responses, is pivotal. The mentor shapes not only technical
expertise, but also cognitive and integrative skills, guiding decision-making, procedure
intricacies, and nuanced patient care. Emphasizing “choosing the right mentor” underscores
the profound impact of mentorship on ERCP expertise development. A mentor who provides
targeted, constructive feedback becomes a vital asset, significantly influencing the
trainee’s professional trajectory.
Concerning areas outside endoscopy, the importance of sports to skills development
should be highlighted. As one of the experts explained, “sports teach you to manage
performance anxiety and stress, change in tactics, and mental flexibility.” Indeed,
sports can mean much more than physical development. They can help you learn to focus
and create a positive attitude toward life and its struggles, and build character
traits such as perseverance, determination, commitment, equanimity, fair play and
team spirit, leadership skills, strategic and analytical thinking, goal-setting and
risk-taking [19]. As also observed in the section on “advice to be followed,” these are the same
characteristics that experts consider to be crucial for excelling in a complex field
like ERCP, which is also demanding and involves high-pressure situations and the ability
to deal with the unforeseen. Interestingly, several experts have also engaged in research
spanning translational and bioengineering domains. Translational research facilitates
seamless integration of bench-to-bedside knowledge, bridging the gap between scientific
discoveries and practical applications in patient care. The incorporation of bioengineering
reflects a commitment to advancing technologies and methodologies. This holistic research
endeavor aligns with the experts' aspiration to continually elevate the standards
of care in ERCP, contributing to both the scientific understanding and the practical
advancements in this field.
The insights gleaned from experts’ experiences as trainees offer additional valuable
guidance for those navigating the field of ERCP. The “best advice” emphasizes fundamental
principles crucial for professional growth. The best advice experts can give to their
trainees was “be careful and concerned with patient safety.” The patient should always
be the focus. For the specific purpose of excelling in ERCP, preparation for this
kind of procedure should start, ideally, the day before the procedure, by talking
to the patient, and, if necessary, the relatives. It is essential to create a good
doctor-patient relationship, and to ensure that all technical conditions, such as
checking the indication and reviewing all the clinical history, blood tests, and imaging,
are satisfied. “Make a plan, check the devices and be prepared” [20]. Planning the procedure and checking the availability and proper functioning of
the devices should be done routinely. ERCP is a risky procedure with several potential
related AEs that could potentially be severe [4]. It is important to be aware of AEs, adopt all recognized preventive measures, and
know how to act accordingly to treat them, when needed. As mentioned by one of the
experts, “ERCP is an opportunity to analyze a clinical history and provide an advice
or a plan for future management.” Furthermore, being in the ERCP room should not be
reduced to “simply watching a procedure.” We can learn a lot from assuming an active
presence in the room and asking reasonable questions, watching the hands of the operator
(not only the screen!), learning how to use the accessories and reviewing ERCP imaging,
among others. After the procedure, and as experts well recalled, you should take your
time to carefully reflect on the successes, but also on the failures. It is important
to devise plans to keep improving. David Allen Kolb, a well-known American educational
theorist, argues that “learning is the process whereby knowledge is created through
the transformation of experience” [21]. Kolb’s experiential learning style theory is characterized by a four-stage learning
cycle in which the learner “touches all the bases.” In the case of ERCP, the trainee
is primarily subject to a new and unknown situation in the ERCP room. This novel and
“concrete experience” should be followed by a time for reflection, a “reflective observation
of the new experience,” so that the trainee can reach the third stage, the so-called
“abstract conceptualization” stage. In other words, it is the possibility of developing
critical thinking that will enable the construction of new connections between different
concepts and the interconnection of knowledge. In the end, it is this type of experience
that will enable the trainee to succeed when faced with different circumstances, the
“active experimentation” stage. In the end, “always be responsible”! The day after
the procedure, it is mandatory to check on how the patient is doing, whether there
have been any AEs and, if so, trainees should be involved in the treatment.
Besides prioritizing patient safety, other recommendations given by the experts, such
as cultivating resilience, underscore the core values integral to mastering ERCP.
Observational learning, responsibility awareness, and continuous self-improvement
are recurrent themes and have been acknowledged recently [22]. Indeed, this study published by our team underscores the high importance of a trainee
possessing non-technical skills to achieve success in ERCP, in addition to the technical
skills traditionally associated with the high performance of an endoscopist. Conversely,
the worst advice, marked by gender bias and discouragement, reveals the resilience
exhibited by our experts, defying these challenges, as well as the need to overcome
stereotypes and create an inclusive environment for learning that ensures equal opportunities
for trainees to thrive in this field. The dichotomy between constructive and detrimental
advice served as a compelling reflection on the varied experiences encountered during
the formative stages of ERCP training.
“Personal life” was, undoubtedly, the factor most frequently mentioned by the experts,
and which is in line with Gladwell [17], who argues that it is the supportive relationships people build and who they are
outside their jobs that define the future professionals they will become. Expert opinion!
The study type is one of this study’s limitations. An analysis based on expert opinion
has a low grade of evidence. However, the objective of the study was precisely to
collect personal accounts, in an open-answer format, about the choices, beliefs, and
experiences of those who excelled in this field. It is natural to strive for success,
and to the authors’ knowledge, there are no other similar papers in the literature.
Our methodology was chosen because, in the absence of previous studies in this field,
aside from creating a multiple-choice survey (e.g.), this format allowed the experts
to better express their ideas and the authors to capture as much information as possible.
Moreover, we acknowledge that the thematic grouping linked to some of the answers,
while it enhances readability, may also: potentially have led to a loss of detailed
nuances within individual responses; be inherently subjective, although that was reduced
by collaborative discussions among the research team about minimizing individual biases;
and has potential implications for data interpretation. An additional limitation was
that there were no objective criteria to define expertise in ERCP. Instead, experts
were suggested by peer recognition. This method of identifying experts introduces
inherent subjectivity. In addition, despite intentional efforts to include a broad
spectrum of expertise, there might be a bias in the representativeness of expertise.
Finally, a consideration in the expert selection process is potential bias in peer
recognition, where some experts may be more widely acknowledged than others, which
may impact the diversity of perspectives reflected in the survey responses.
Conclusions
Despite these limitations, this ERCP vade mecum constitutes a valuable resource for individuals seeking success in the field. ERCP
is a technically demanding procedure, and a long process is required to develop competence.
There are no shortcuts. Trainees who train in ERCP should be selected from among those
who are likely to achieve proficiency and will make good use of the valuable skills.
Adopting a structured and rigorous ERCP training program, engaging in deliberate practice,
and following good examples, such as the ones discussed in this paper, will surely
contribute to an individual’s success in performing ERCP. In the end, “Experts are
always made, not born” [23]!
