service demands. This requires training in not only technical skills but also cognitive and nontechnical skills essential for clinical practice. In recent years, endoscopic training has begun to evolve from a traditionally experiential model of learning, in which individuals “learn by doing,” to a more structured approach grounded in evidence‐based educational principles [1–3]. It is increasingly recognized that effective endoscopic training requires preparation and structure, and should be provided by individuals with the requisite skills and behaviors required to teach endoscopy, including an understanding of adult learning principles, knowledge of best practices in procedural skills education and appropriate use of effective educational strategies, such as performance enhancing feedback [4]. In this chapter, we identify the key features of a successful endoscopic training environment, describe attributes of effective endoscopic trainers, outline the Preparation–Training–Wrap‐up framework that describes the essential components of an endoscopic teaching encounter, and finally discuss training aids and resources.
Training environment
The development of expertise in endoscopy requires extensive, sustained practice of the requisite skills as well as acquisition of the relevant knowledge and attitudinal and behavioral aspects (i.e., endoscopic nontechnical [5] or integrative skills [6] and “scopemanship” [7]) required to produce competent endoscopists. Expertise development is dependent not only on the quantity of time spent training, but also on training quality as well as trainee commitment and engagement. Central to this is the need for an effective training environment and culture. Endoscopic training needs to be accepted, supported, encouraged, and prioritized at an institutional level, particularly given the multiple competing priorities inherent in clinical care and the barriers to implementing change that often arise.
Training units require sufficient procedural volumes to ensure adequate training opportunities for trainees and trainers with interest and skill in teaching endoscopy [8]. Buy‐in and support from leadership is essential to ensure that trainers have dedicated time for endoscopy training and accompanying assessment, and that interprofessional team members, including nurses and managers, are engaged and committed to delivering high‐quality training. It is also important for training programs and institutions to develop policies and systems to support endoscopy education. For example, it is crucial to have a specified plan to ensure that trainers receive adequate education and are competent to undertake a trainer role. Designation of an endoscopy training lead can be beneficial to help create an environment and culture that recognize endoscopy training as a core component of service provision. Responsibilities of such leads can include allocation of training lists, trainee orientation, delivery of the endoscopy training curriculum, and review of trainee assessment portfolios to develop personalized learning plans.
Any change in training provision and culture must be done in a concerted manner and be supported with sufficient resources. As trainee presence leads to longer procedure times and negatively impacts case throughput and endoscopist billing [9–11], dedicated training lists (or portions of lists) are the best way to ensure that trainees receive adequate exposure and practice and that trainers have sufficient time to focus on the needs of trainees. Resources and infrastructure are also required to help collate feedback and assessment data from both trainees and trainers and ensure that it is acted on. Additionally, support is required to purchase training aids, such as magnetic endoscopic imagers and endoscopic simulators which, as discussed later in this chapter, can be of benefit in endoscopy training.
Attributes of effective endoscopy trainers
Teaching endoscopy is challenging for several reasons, including the complex nature of the task and the need for trainers to balance clinical and learning needs while ensuring patient safety, procedural efficiency, and provision of high‐quality care. Additionally, literature has shown that endoscopy trainers use variable teaching methods and styles of training [12–14]. Endoscopic training should be led by individuals who are committed, competent, and enthusiastic trainers. Trainers should not only demonstrate competence in the procedure(s) for which they provide training but should also have the requisite skills and behaviors required to teach endoscopy effectively, and, ideally, formal training in endoscopy teaching methodology. Additionally, it is important that trainers lead by example, through their actions, words, attitudes, and work philosophy.
Within a given training program or institution, not all endoscopists may want to train or possess the skills to teach endoscopy effectively. Trainers should possess conscious competence as well as expertise in assessment and feedback provision. Supervisors, alternatively, are competent endoscopists who can act as role models; however, they lack the requite skills to teach endoscopy effectively. Within a program or institution, the roles of individuals as either trainers or supervisors should be formally discussed and the need for a consistent approach to training across trainers emphasized [15]. Use of a structured training framework and standardization of training techniques across trainers helps to foster an effective learning environment in which trainees feel comfortable asking questions and seeking help, trainee needs are addressed, and trainees and trainers feel valued.
In acquiring endoscopic skills, individuals generally progress through four stages from being unconsciously incompetent (not understanding or knowing how to do something) to consciously incompetent (not able to do something but aware of their deficits), to consciously competent (being able to something with great thought), and finally to unconsciously competent (being able to do something without conscious effort) (Figure 4.1) [16]. By the time endoscopists reach the unconsciously competent stage, they may be highly proficient; however, their actions are largely automatic [17]. They lack an explicit understanding of what specific techniques are required to perform tasks and, consequently, are unable to verbalize instructions adequately to trainees. To be able to teach and provide feedback effectively, a trainer must be able to deconstruct tasks, understand each element, and explain the individual components to trainees in an intelligible way. It is essential that trainers develop conscious competence for performing and teaching endoscopy. This awareness enables them to objectively analyze the performance of trainees, pinpoint specific problems, and verbally explain how to perform maneuvers and troubleshoot difficulties in a clear and effective way without needing to take over control of the endoscope to demonstrate. The development of conscious competence requires repeated practice over months to years with feedback from competent, experienced trainers and self‐reflection to develop an awareness and ability to solve problems and deconstruct skills. There are also established faculty development “train‐the‐trainer” courses which aim to formally train endoscopy faculty to conscious competence, such as those in the United Kingdom and Canada [18–20].
Figure 4.1 Stages of endoscopy skill acquisition
(Adapted from Peyton [16]).
Several studies have examined core attributes of effective endoscopy trainers. Pourmand et al. analyzed qualitative comments from post‐procedure feedback cards submitted by endoscopy trainees to identify endoscopic teaching behaviors perceived as beneficial or detrimental to their learning experience [21]. Seven themes were identified that related to the learning environment, autonomy, communication, coaching, feedback, and professionalism [21]. Another study by Kumar et al. outlined 10 essential teaching competencies for endoscopy trainers that were developed through expert consensus, including assessing trainee’s procedural competency, maintaining attention, use of standardized language, and feedback provision both during and after the procedure [22]. Based on the existing literature and data generated through interviews with training leads, trainers, trainees, and nurse endoscopists, Wells et al. classified characteristics of effective endoscopy
