down/slowly3 advance
4 pull back
5 tip up
6 tip down
7 tip right
8 tip left
9 torque clockwise
10 torque counterclockwise
11 insufflate
12 suck/aspirate
13 rinse
14 irrigate.
The use of common language makes clear what actions are required and enables the trainer to control the procedure while not handling the endoscope. Research has shown that when providing instruction, it is more beneficial for trainers to direct attention to the effects of a particular movement (external focus of attention) as compared to directing attention to the movements of the trainee (internal focus of attention) [51]. Therefore, instructions should always be provided in reference to the video monitor view as opposed referring to the trainee’s hands. For clarity, use of a “clock face” analogy can be useful (e.g., advance the tip toward 8 o’clock). It is important for the trainer to check in with the trainee throughout a session to ensure the trainee clearly understands the instructions they are receiving and for the trainer to modify their feedback as required.
Wrap‐up
The Wrap‐up phase is the period of time immediately following the training encounter, the aim of which is to review and reflect on the encounter as well as generate learning objectives for future training sessions. It is important for the trainee and trainer to meet briefly in a private area to reflect on the entire training session without being distracted. Too often during feedback sessions, the trainer merely summarizes what happened during the procedure. Although it is important to ensure that critical training moments are highlighted accurately, the key learning from any training session lies within the reflection on what happened as opposed to the description [4]. If the conversation is oriented solely toward past events, trainees too often become defensive or disengaged when reminded of their deficits, which impedes learning [52].
The bulk of the feedback should be provided during the wrap‐up phase, providing the trainee time to reflect on their performance before hearing the trainer’s perspective. Constructive performance enhancing feedback, with reflection and active trainee engagement, is a cornerstone of effective training and is essential to reinforcing learning from the session. The effectiveness of feedback largely depends on what information is given, the manner in which it is delivered, and how it is interpreted. It is essential for the trainee to be allowed to reflect on their performance, as trainees generally have great insight if they are given the time to formulate their thoughts. Feedback should be a two‐way dialogue between the trainee and trainer that is objective and based on observable behaviors [53]. Merely “telling” the trainee ignores the active role they must play in constructing meaning from the feedback message. Feedback should be delivered in a nonjudgmental, constructive manner and focus on modifiable behaviors. Additionally, it should directly relate to the predetermined learning objectives whenever possible.
Feedback should focus on observable behaviors and incorporate specific suggestions for improvement [30, 54, 55]. When the trainer is aware of an issue that the trainee does not raise, the trainer should present data (e.g., describe specifically what happened) in a nonjudgmental way, provide their interpretation of it, and then seek clarification from the trainee about their perspective or give them an opportunity to provide a rationale for their actions [53, 56]. Open‐ended questions, such as “Can you recall what prompted you to do that?” should be used to encourage trainees to explore their actions and, if appropriate, identify alternative behaviors. Trainees are more likely to retain knowledge if they are actively involved in the discussion and problem‐solving [52]. Additionally, trainee engagement helps the trainee feel empowered, builds self‐assessment skills, and helps the trainer gain insight into the trainee’s self‐perception [57].
Figure 4.4 ACT model of performance enhancing feedback: Ask the trainee, Conversation, Take‐home message.
Performance enhancing feedback can be delivered either in an informal manner or by using a formal structure, such as the ACT model of feedback (Figure 4.4), developed by Anderson [18, 30]. This model stipulates that feedback should be delivered as part of a “learning conversation” [53] or “facilitated discussion” during which the trainer first Asks the trainee for their view and reflection of the training encounter and explores issues that the trainee identifies. Subsequently, during a Conversation, the trainer should reinforce good techniques and behaviors. Additionally, they can raise issues that the trainee did not mention and explore them further. It is important for the trainer to confirm where there is congruence between the trainer and the trainee’s perspectives and correct misperceptions and knowledge deficiencies [31]. Finally, the trainer should conclude with a quick review of what was achieved in relation to the pre‐defined learning objectives and then outline one to two key Take‐home messages or specific suggestions for improvement that relate to the learning objectives. This information can then be used to develop a plan for improvement and help set learning goals for future training sessions so as to iteratively modify training expectations to build trainee competence. The trainer should aim to foster skills development by increasing a trainees’ self‐awareness, and ability to monitor and self‐regulate their learning and sense of personal responsibility. The endoscopic trainer should achieve this through the use of questioning, active listening and, where appropriate, respectfully challenging trainee viewpoints in a supportive, and learner‐centered manner [58]. A well‐managed learning conversation includes explicit feedback and leaves the trainee feeling valued and cognizant of their next steps.
Summary
Each step in the Preparation–Training–Wrap‐up framework should be tailored to the trainee and the training session since individuals learn in different ways and at different paces. Although this framework applies to a single training session, it is important to conceptualize training over the longer term, such that the take‐home messages from one training session become the goals of the next session, and each training session is integrated within an overarching curriculum [23]. Additionally, communication among various trainers within a program or institution is essential to ensure continuity and consistency in training.
Training aids
Over the last decade, there have been several technical advances in the provision of endoscopic training, notably magnetic endoscopic imagers, and endoscopic simulators. Trainers can take advantage of these tools to enhance learning.
Magnetic imagers
Magnetic endoscopic imaging provides the trainer and trainee with a three‐dimensional display of the endoscope configuration within the patient (Figure 4.5). This is particularly useful during colonoscopy, where the visual representation of loops can be used to teach loop recognition and loop reduction techniques [59]. Use of magnetic endoscopic imaging with trainee endoscopists has been assessed
