the predominant mode of endoscopy education today. Such apprenticeship‐type relationships between mentor and mentee have evolved greatly from the autocratic and unidirectional flow of information characteristic of similar learning environments dating back to the Middle Ages (Figure 1.1). Recognition and adoption of key concepts such as the benefits of learning in a reduced stress environment, the need for constructive feedback and interactive dialog, and the importance of gradually increasing autonomy of the trainee as skills progress are among the concepts that would make current trainee learning environments quite foreign to medical apprentices of earlier eras.
In the United States today, most instruction in the techniques of gastrointestinal endoscopy is accomplished in the setting of formalized training programs of 3 years duration, with additional training available for selected “advanced” procedures such as ERCP and EUS. Proctored teaching of endoscopic techniques within such highly structured environments has been the “traditional” training method in gastrointestinal endoscopy. Endoscopic skills are developed concurrently with the immersion of the trainee in a complete curriculum that encompasses the range of normal and abnormal functioning of the digestive system, GI anatomy, and pathology. Trainees learn the indications for endoscopy, diagnostic and therapeutic capabilities of endoscopy, technical endoscopic skills, and application of therapeutic endoscopic intervention all in the context of intensive active supervised participation in consultative gastroenterology, for both outpatients and hospitalized individuals. While many physical aspects of endoscope manipulation and even lesion recognition can be taught to individuals not versed in the science and art of caring for patients with gastrointestinal complaints and disorders, to date, patients and practitioners alike have recognized the value and requirement that endoscopy be performed by individuals trained in such a comprehensive fashion, something that in this day can only be achieved in formal gastroenterology and surgical training programs. For this reason, this remains a first principle of published ASGE training guidelines [4, 5].
Figure 1.1 An example of a typical apprenticeship contract in colonial America, circa 1750.
Within these training programs, didactic information about endoscopy is included in the curriculum to an extent, but much of the actual endoscopic training remains directly imparted from instructor to student in the course of the performance of actual procedures on actual patients. Such hands‐on supervision allows for increasing independence on the part of the trainee, as the teacher constantly assesses both technical and cognitive progress [6, 7]. In this process, the endoscopy teacher must give the trainee sufficient time to develop skills while protecting the patient’s safety at all times, and must be able to give appropriate feedback [8, 9]. This process is both time and labor intensive. Additionally, sufficient case volume is necessary to allow for development of necessary skills through repetitive deliberate practice, and enough variation in pathology needs to be present to allow the development of cognitive skills to go along with advances in technical expertise [10, 11]. Mere possession of clinical judgment and endoscopic proficiency do not guarantee that an individual is qualified to be a good endoscopic teacher. The importance of having instructors who know how to teach and the constraints that limit the time such mentors have to devote to teaching can pose significant challenges for this “traditional method” of endoscopy training—challenges which some of the newer complementary teaching tools discussed later in this chapter were developed to address. While many of the chapters in this book refer to the importance and characteristics of good mentors, very little investigation has yet been conducted to understand how to best train the trainers to teach endoscopy. This topic is addressed in detail in Chapter 4.
What must be learned?
Guidelines for training in gastrointestinal endoscopy have been published and widely disseminated [4, 5]. Skill sets that trainees must acquire to successfully perform endoscopic procedures have been outlined [12–16] and include the following:
1 Understanding of the indications and contraindications for endoscopic procedures and risk factors for complications.
2 Knowledge of the endoscopic equipment and accessories and how to set up this equipment for use.
3 Familiarity with the endoscope control dials and buttons.
4 Dexterity in controlling the scope range of motion using the dials and torque applied to the endoscope shaft.
5 Hand–eye coordination to produce deliberate, precise manipulation of the endoscope within the lumen and of accessories.
6 Communication with nursing and technical staff regarding required assistance during the procedure.
7 Knowledge of normal anatomic landmarks and possible abnormal pathologies that might be encountered.
8 Interpretive skills to correctly identify abnormalities that are detected.
9 Judgment of how to manage appropriately those lesions that are encountered.
10 Familiarity with patient monitoring and the administration of moderate sedation.
11 Awareness of how to recognize and manage adverse events.
12 Understanding of risks and benefits of intended procedures and the ability to obtain informed consent.
13 Documentation of findings.
14 Communication of results to patients and other physicians.
Standards and end points of current endoscopic training
Since the early establishment that training in endoscopy was a high‐priority activity among academic endoscopy centers and GI societies, a great deal of effort has been devoted to assess the efficacy of training, determine learning curves for various procedures, and explore new methods for imparting proficiency. A number of important guidelines on the subject have incorporated much of this data and expert opinion on the subject [5]. One large review delved into the data for each procedure in great detail [16]. Specific chapters in this volume address training as it relates to quality in endoscopy and to specific standards for each of the major endoscopic procedures that are performed. Apart from the specific recommendations about learning particular procedures, a number of themes have emerged throughout all current guidelines, which reflect the evolution of the concepts of optimal training in endoscopy. Key principles include the following:
Specificity of training and privileging: Individuals must be trained for each particular procedure they wish to perform.
Threshold numbers for competency: Guidelines have steered away from earlier emphasis that trainees gain competence after independently performing a certain minimum number of procedures. It has been increasingly accepted that numbers do not guarantee competency; individuals develop proficiency at different rates; and accordingly, the best way to assess competency is to do so on the basis of some objective measures. Threshold numbers have been derived from evidence‐based studies in which objective competency for a particular procedure is achieved after a particular amount of training; however, these numbers are now viewed merely as a minimum amount of training that must be performed before competency can even be assessed. The end point of successful endoscopic training should be objective demonstration of competency.
Emergence of complementary teaching modalities
Why
