Figure 6.30 Incorrect TI maneuver. Like the acute turns, novice endoscopists will often rely on excessive dial controls to attempt to intubate the ileocecal valve. This makes the scope difficult to advance, typically resulting in the scope loop advancing into the cecum and the tip falling out of the valve.
(Copyrighted and used with permission of Mayo Foundation for Medical Education and Research.)
How to teach and assess colonoscopy skills
Identifying methods best suited to teach colonoscopy can be quite difficult. Traditionally, these skills have been taught at the bedside during patient‐based endoscopy. However, with computer simulation models, as well as live and ex vivo animal models, evidence would suggest that these alternatives to patient‐based endoscopy can impart some of these motor and cognitive skills [21, 22]. In the case of early motor skills, this can also be done more safely, economically, and with better patient outcomes [23].
A second problem with the current state of colonoscopy education is that skills are primarily taught all together from the first day without differentiation between beginning or intermediate skills. In traditional training, a trainee is commonly forced to attempt to learn intermediate skills such as loop reduction and navigation of fixed angulated turns at the same time he/she is learning simply how to use the dials and steer the scope. This produces a great deal of stress for the trainee not to mention some element of discomfort or even increased risk for the patient. Breaking the procedure down into individual skills, greater utilization of alternate teaching tools such as texts, multimedia, and simulation, training can proceed in a more stepwise fashion, starting with focused instruction of the most basic skills first and then on to more advanced skills when ready. Education literature has well established that building skills in a stepwise fashion is the most effective learning model [24]. This is not to suggest that these teaching aids will replace patient‐based training, but rather these training tools can be used to effectively augment patient‐based training and improve on the traditional training model. In this final section, we will examine the methods by which each of these skill groups previously outlined can best be taught.
The final focus of this chapter will be on methods to assess the mastery of these required skills by trainees. Accrediting bodies have placed a growing emphasis on assessment and documentation of competency, yet few programs do any type of formal evaluation other than a global subjective assessment of skills toward the end of training. This type of informal global assessment is fraught with biases inherent to subjective assessments. It also fails to identify struggling trainees early enough to provide timely remediation. Instead, assessment must be an ongoing process from the first scope performed during fellowship to the last. In general, there are four different types of assessment: written tests, performance tests, clinical observation methods, and a group of miscellaneous tests made up of oral examinations, portfolios, and the like [25]. Each can be used in a formative (testing primarily for the purposes of feedback or learning) or summative (testing for grading purposes) manner, yet as we will discuss, a specific testing method may be better suited for assessment of a particular skill. This chapter will address the best methods to provide continuous assessment of trainees' cognitive and motor skills (Table 6.2).
Table 6.2 How skills can be taught and assessed?
| Teaching methods | Assessment methods | |
|---|---|---|
| Early skills (first 50 procedures) | ||
| Cognitive | Self‐directed learningTextsArticlesMultimedia aidsLectures | Written examsBoard‐type questionsFormative assessment during didacticsSimulationSedation/airway/complication management |
| Motor | Patient‐based trainingSimulation trainingComputer simulatorEx vivo course | Early formative assessmentObjective structured clinical examinations (OSCE) |
| Intermediate skills (50–250 procedures) | ||
| Cognitive A. Pathology recognition | Self‐directed learningTextPhoto AtlasMultimedia | Written examsPathology recognition |
| B. Decision‐making | Patient‐based trainingSocratic methodSelf‐directed learningMultimedia (GESAP) | Patient‐based trainingSocratic methodWritten examsBoard‐type questionsOngoing assessmentStandardized assessment tool |
| Motor | Patient‐based trainingSimulationEx vivo modelsScope locating deviceScopeGuide | Ontinuous assessment toolOSCEBovine model |
Early cognitive skills
Before hands‐on endoscopy training begins, trainees need to undergo a curriculum that ensures the early cognitive skills (anatomy, preparation, scope selection, sedation, and indications/contraindications) have been acquired. Like many other aspects of endoscopy, training has been traditionally accomplished at the bedside under direct supervision. Cognitive skills however have been learned entirely “on‐the‐job.” In fact, it is likely of greatest benefit to us and our patients to have the bulk of these cognitive skills learned prior to introduction to the endoscopy suite. This will save valuable teaching time and make the teaching experience more meaningful for the trainee and teacher alike. For all of the specific early cognitive skills outlined, each can be generally be achieved through multiple instructional media, including endoscopic atlases, textbooks, and pertinent journal articles such as professional society practice guidelines. Common to all is that these methods are primarily “self‐directed” learning tools. The trainee only needs ready access and guidance as to what materials are most pertinent to ensure all cognitive skills are covered and that the materials are of appropriate quality. This is best accomplished by assigning trainees a curriculum of required material that cover intended topics and learning goals. The rest is done as self‐study. Didactic lectures can also be included to augment these learning materials. Ideally, training programs should have new fellows undergo a series of “Core Endoscopy Lectures” during the first 2 months of fellowship in addition to their required self‐directed learning materials. Each lecture to focus on one of the core cognitive competencies. Lectures or discussion groups can ensure that students have the opportunity to ask questions and clarify misunderstandings that may arise from their self‐directed learning. When trainees participate in interactive sessions, these didactic discussions can also allow for formative assessments of the trainees' fund of knowledge.
Assessment is the other important half of any educational endeavor but is the one often neglected. For cognitive skills in general, the use of brief written exams can be an easy means to reliably and objectively measure the acquisition of these skills. As with any assessment, these can be used as self‐assessment exams for feedback (formative assessment) or as higher‐stakes exams that must be passed prior to advancing to patient‐based practice (summative assessment). Regardless how an institution uses the assessment, it should be carried out to ensure the learning goals of a curriculum are being met. Both education and assessment goals can be met through the use of computer multimedia tools where self‐assessment quizzes can be linked directly to the learning material and provide
