attributes, developing as a teacher attributes, motivation to teach, and patient centered [23]. These characteristics were subsequently used to inform the development of a Direct Observation of Teaching Skills (DOTS) tool that can be used to evaluate endoscopy teaching performance. Additionally, they were used in the United Kingdom (UK) by the Joint Advisory Group on Gastrointestinal Endoscopy to inform the development of a list of attributes of effective trainers which encompass a patient‐centered approach, motivation, and an ability to perform and teach endoscopy, create an effective learning environment, and promote self‐reflective practice [24]. The aforementioned attributes of effective endoscopy trainers can be used by programs to help standardize expectations for endoscopy teaching and by trainers to assess and improve their own teaching as excellent teaching is a fundamental component to ensuring a high‐quality, endoscopy workforce.
Framework for endoscopic training
The use of a standardized teaching approach among trainers is increasingly recognized as important to ensure consistency in regard to what and how particular endoscopic skills are taught [15]. The following section outlines the Preparation–Training–Wrap‐up framework that can be used by endoscopic trainers to structure a training session, including essential elements to prepare for training, deliver performance enhancing training, and provide an effective wrap‐up (Figure 4.2) [4, 25]. A training session may be a single case or a block of procedures within a single day. This framework is also useful in structuring multiple trainee–trainer interactions over time. It is not only helpful for teaching trainees within the context of a gastroenterology fellowship program but can also serve as a useful guide for endoscopic trainers involved in supporting junior colleagues to help foster their skills development. This framework can be applied to train both basic and more advanced endoscopic skills, and it can also be used to structure teaching encounters within simulation‐based environments. This framework was originally used in “train‐the‐trainer” programs [20] in the United Kingdom and was later adapted by the Canadian Skills Enhancement in Endoscopy (SEE) Program [19] with great success.
Preparation
The preparation phase refers to the period prior to the start of a training session, which may be a single procedure or a set of procedures. Although time is limited in a busy clinical environment, it is important to take a small amount of time to properly prepare for a training session. Both physical and verbal preparations between the trainer and trainee are required to ensure an effective, safe, and efficient learning environment. The physical component of the preparation phase relates to the set‐up of the training environment, whereas the verbal component includes assessment of the trainee’s skill level, alignment of agendas between the trainer and trainee and formation of an educational contract, including generation of learning objectives and discussion of ground rules.
Figure 4.2 “Preparation‐Training‐Wrap‐up” framework outlining the components of an effective endoscopic training session.
Set‐up, the first component of the preparation phase, refers to the physical set‐up of the endoscopy suite in order to optimize the training environment. This includes appropriate positioning of the patient, trainee, trainer, and equipment within the room to ensure optimal ergonomics and visualization. With regard to positioning, the video monitor should be placed in front of the trainee at eye level or lower to prevent strain, and the bed height should be positioned between elbow height and 10 cm below elbow height so that the trainee’s arms can be maintained in a neutral position and the load on the spine is reduced [26–28]. For colonoscopy, to maximize the trainer’s view of the patient, the trainee’s hands, and the video monitor throughout the procedure, the trainer should position themselves at the foot of the bed opposite the monitor, as depicted in Figure 4.3. Another important component of set‐up is to ensure the training environment is and will continue to be free of interruptions and distractions, so that the trainee and trainer can direct their attention and energy to training. It is important for the trainer to review the endoscopy list ahead of time to determine which cases may be suitable for the trainee and to help decide how time will be allocated for training to ensure there is adequate opportunity for the trainee to achieve his or her goals. Finally, the trainee and trainer should confirm in advance that the equipment required for each case is available and fully functional.
The next component of the preparation phase is an assessment of the trainee’s skill level. It is particularly important for a trainer to elucidate a trainee’s level of competence if the trainee–trainer pair have not met previously or if a long period of time has elapsed since their last training session, so that the trainee is not pushed beyond their limits or what is safe for the patient. The trainer should briefly assess the trainee’s current skill level through directed discussion with the trainee and, if possible, through review of an e‐portfolio, procedural log, prior feedback, and/or assessments. While a formal assessment is generally not possible, the trainer can ask a few directed questions to get a sense of the trainee’s skill level, their previous experience, and areas of difficulty. An example dialogue between the trainer–trainee pair could include questions such as: “Tell me about your previous experience with colonoscopy?,” “What skills have you been working on?” or “What difficulties have you encountered recently in performing colonoscopy?” Directed questioning can help the trainer better assess the skill level of the trainee, challenge any assumptions the trainer had going into the encounter, and generate a learning agenda.
Alignment of agendas between the trainer and trainee is an important component of the preparation phase. The trainer and trainee will both have an agenda or goals they hope to achieve during the training session, which may be the same or different. If the trainer and trainee’s agendas differ, and the trainer does not take the trainee’s goals into account, the training session may be compromised, as it will not be as meaningful or as well received by the trainee. It is important for the trainer to elicit the trainee’s agenda through an open discussion, be flexible, and try to come to a consensus on the goals for the session, which should take into account both the trainer and trainee’s agendas [25]. Alignment of agendas helps to ensure the trainee and trainer are aware of and appreciate one another’s perspectives and also have a shared understanding of the goals for the teaching encounter [4]. This then facilitates the development of two to three focused learning objectives which should be established collaboratively in advance of the training session. Tools and frameworks designed to enhance the quality of learning objectives, such as SMART (specific, measurable, achievable, realistic and timely), may be used to help formulate objectives that clearly describe the knowledge, skills, and behaviors the trainee should be able to demonstrate by the end of the teaching encounter [29]. Well‐defined and mutually agreed upon learning objectives are essential in that they provide a target with which trainees can focus their learning efforts and trainers can focus their observation and feedback to maximize training effectiveness. It is important that the goals are realistic and achievable. Early in training, trainees may be unaware of their deficits (i.e., unconsciously incompetent) and the trainer will likely need to play a greater role in setting the agenda and learning objectives. However, as a trainee’s skills improve, they should be encouraged to critically reflect on their performance and take increasing responsibility for identifying targets for improvement and setting learning objectives [30, 31].
