of procedure failure, reduced cecal intubation time, higher cecal intubation rate, decreased duration of looping, fewer loop reductions, and more effective use of external pressure [60]. Additionally, its use is not associated with cognitive overload in trainees [61]. Studies in practicing endoscopists have shown that use of magnetic imagers facilitates colonoscopy completion, insertion time, lesion localization and improves patient comfort [62–64]. The unpublished experience from the Canadian SEE Program has been that the use of magnetic imagers is extremely beneficial in fostering conscious competence among trainers as it enables them to link their “feel” to the image on the screen to develop a better understanding of the procedure.
Currently, two imagers are available commercially: the ScopeGuide from Olympus Medical Systems and SCOPEPILOT form Pentax Medical. Prior to employing this technology in training, trainers should be comfortable in using it themselves and interpreting the images. While its use is integrated within many existing endoscopy “train‐the‐trainer” programs, a focused curriculum to educate trainers on its use during training does not yet exist. Future studies are required to examine whether longitudinal use of magnetic endoscopic imaging during training can accelerate trainee learning curves and to determine the optimal manner in which to integrate this technology into endoscopy training.
Endoscopic simulators
Many of the principles of effective endoscopic training outlined above also apply to training within the simulated setting. The history of the development and use of simulators in training is reviewed in detail in Chapter 1, and specific applications are detailed elsewhere in Part II of this textbook which addresses particular endoscopic procedures.
Simulators are important, especially for more novice trainees, as they afford trainees opportunities for deliberate practice, a critical factor in the acquisition of skills and expertise [34, 65, 66]. Deliberate practice encompasses repetitive performance of structured activities, coupled with informative feedback, which promotes monitoring and error correction to improve performance in a specific domain [34, 65]. For deliberate practice to be most effective, the trainee has to be challenged with tasks of appropriate difficulty that increase in pace with trainee skill development [47]. Additionally, it requires the provision of focused feedback from a trainer. Studies have shown that there is no improvement in endoscopy skill acquisition in the simulated setting without feedback, and the absence of feedback may, in fact, foster the development of “bad habits” [67, 68]. Additionally, studies have shown that instructor‐derived feedback has a distinct advantage in improving endoscopy skill acquisition as compared with simulator‐generated feedback [32, 33]. As in the clinical setting, to avoid overburdening the trainee, feedback should focus on well‐defined and achievable goals, and include specific suggestions for improvement. The simulated setting is unique, however, in that it provides an ideal environment for trainees to work through errors independently without compromising patient safety. Withholding feedback until the end of a simulated endoscopic task has been shown to be more beneficial as compared to continuous feedback, likely because it enables trainees to better engage in real‐time problem‐solving without becoming cognitively overloaded [45]. Similar to the clinical setting, it is important for trainers to tailor their feedback to the trainee, their learning style and level of skill development.
Simulators are advantageous in that they permit trainers to employ teaching strategies that are not possible within the clinical setting as they would compromise patient safety. For example, simulators can be used to teach around troubleshooting difficult and unexpected situations such as perforation and they enable trainers to demonstrate incorrect technique as a counterexample to illustrate concepts and explore trainee misconceptions. Prior to using simulation as a training modality, it is important for trainers to gain experience with the models they plan to employ and familiarize themselves with relevant pedagogical principles to maximize their potential benefits. Courses have been developed to help trainers gain experience with endoscopy simulation and guide them in the appropriate pedagogical utilization of this educational technology, such as the World Endoscopy Organization’s Program for Endoscopic Teachers (https://www.worldendo.org/education/program‐for‐endoscopic‐teachers‐pet/). As with all training sessions, trainers need to plan and structure their teaching using simulators. It is important to recognize that there are a wide variety of simulators available to teach endoscopy. Both low‐ and high‐fidelity simulators can be used effectively, as the pedagogical goal should be the main determinant of simulator selection, as opposed to technological capabilities [47, 69].
Figure 4.5 This image shows a common loop visualized with the assistance of a magnetic endoscopic imager that can be used to help teach trainees loop recognition and loop reduction techniques (Panel A: standard view; Panel B: close‐up of imager).
Train‐the‐trainer programs
In the endoscopy training community, the UK system has frequently been referenced due to the system changes that occurred in direct response to quality measures in their health care system [70–72]. The JAG in the United Kingdom, which was established in 1994 to standardize endoscopy training across specialties, has developed a robust endoscopy training system which includes a competency‐based certification process and transparent benchmarks for endoscopists and procedure‐specific “train‐the‐trainer” courses for faculty who teach endoscopy [70]. Additionally, accreditation standards for endoscopy units are directly linked to provision of adequate endoscopy training [73]. Colonoscopy quality outcomes in the United Kingdom have subsequently improved substantially [70, 74]. While the reason for this improvement was likely multifactorial, nationally driven training‐related interventions likely played a large role, including more structured training for both trainees and trainers, development of national training courses, and ongoing assessment of training quality within endoscopy units.
The JAG’s “train‐the‐trainer” program was shared with the Canadian Association of Gastroenterology, who adapted the program and developed the SEE Program (https://www.cag‐acg.org/education/see‐program) which includes endoscopy and polypectomy‐related hands‐on courses. Both the UK and Canadian systems formally train faculty to conscious competence [18]. These programs provide quality assurance of training by standardizing training structure and techniques, language, assessment, and feedback provision. The influence of such training programs has spread worldwide to include countries such as Australia, Malawi, Norway, Portugal, Poland, South Africa, and the United States in varying degrees [70]. The Polish group, for instance, published a randomized trial to demonstrate the beneficial impact of the course on adenoma detection rates in their trainers [75]. Similarly, a Canadian study found that faculty who attended SEE Program courses, which aim to enhances faculty’s conscious competence, administered significantly lower sedation doses during colonoscopy, both immediately after and 8‐months following the course. These studies provide supportive evidence that formal train‐the‐trainer efforts not only improve trainers’ teaching skills but also improve their colonoscopy performance [76]. There is no doubt that the interest among endoscopists for formal training will continue to increase as more endoscopists experience the benefits of structured training based on sound pedagogical principles.
Conclusions
High‐quality training is a key component to provision of safe, efficient, and effective endoscopic care. Endoscopy is a complex skill that can be very challenging to teach, and trainers are often not adequately prepared. Successful
