Kevin A. Waschke1,2, Catharine M. Walsh4 and Gerald M. Fried1,2,3 1 McGill University, Montreal, QC, Canada 2 McGill University Health Centre, Montreal, QC, Canada 3 Montreal General Hospital, Montreal, QC, Canada 4 The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada Proficient performance of flexible gastrointestinal endoscopy requires a combination of technical, cognitive and nontechnical skills. Understandably, comprehensive training in endoscopy requires attention to each of these components. Unfortunately, the medical literature is lacking in evidence supporting the differential effects of specific training modalities. Educational theories, however, suggest that each of these components is best learned using different approaches. With respect to the technical component, literature from a variety of areas has demonstrated that “deconstructing” a procedural skill into smaller, easy‐to‐master tasks can facilitate teaching and learning. This chapter will focus on providing a general framework for the specific skills required to train individuals in flexible endoscopy. By deconstructing the common gastrointestinal endoscopic procedures in this manner, both trainer and trainee can approach the acquisition, practice, and assessment of endoscopic skill in a structured manner. Effective training in endoscopy requires more than a simple “how‐to” of procedures, as will be illustrated in the remainder of this volume. For this reason, we will also not only discuss the deconstruction of an endoscopic skill set, but at the same time illustrate several key components of a second skill set, that of endoscopic training, which we consider to be distinct and different from endoscopic skill. Using an approach that involves deconstructing the skills required to perform endoscopy has several advantages for both the trainer and the trainee. The first advantage is that the deconstruction of a task makes both the trainer and the trainee consciously aware of both the specific steps to be learned and their relationship to the overall framework. The importance of this step should not be underestimated, as training in endoscopy requires expertise in training, not only in performance of the procedure. A common observation in both medicine as well as other areas is that expertise in an area does not automatically convey expertise in the teaching of that area. Anyone who has attempted to learn a sport such as golf can attest to the importance of good teaching and good teachers in the learning of complex motor skills. Sports, music, and avionics are good examples of fields in which training has progressed to include coaching, feedback, training aids, the use of simulators, and other approaches to ensure that efficient and effective learning occurs. There is no doubt that readers of this text can recall excellent endoscopists who simply cannot describe how they performed specific complex acts in a manner that permitted the learner to learn from them. As such, we cannot assume that expert endoscopists are all automatically expert trainers simply by virtue of their endoscopic skill set. The explanation for this apparent paradox can be illustrated by Peyton’s stages of learning [1]. A learner is conceptualized as passing through a variety of stages during their development of procedural skill (unconscious incompetence, conscious incompetence, unconscious competence, conscious competence). By the time the endoscopist reaches the unconsciously competent stage, he or she may be highly proficient at endoscopy but, by virtue of the process of skills acquisition, be unable to describe the components of their skill. The very same cognitive process that permits rapid, fluid movement, termed automaticity [2], also prevents the individual from consciously accessing and describing the steps required to perform the task. A sign of unconscious competence is the teacher who, when teaching endoscopy, is required to take the scope from the trainee rather than being able to verbalize what needs to be done. Words fail the instructor because the description of the endoscopic skill is not consciously accessible. Again, a sports analogy is useful here, as a skilled golfer is unlikely to be able to describe or think about all the steps in a golf swing while they are performing it without it impairing the fluidity of their motion. Explicit explanation of what is to occur and why it is important is a crucial element in skills acquisition, but it does not naturally occur. It is, however, a crucial component in the effective teaching of procedural skills [3, 4]. This brings us to a second important advantage of deconstructing skill sets, facilitating the generation of specific learning objectives. Learning objectives are a central component in the development of a deliberate approach to training. Ideally, each learning activity involves some element of planning by the endoscopy trainer, even for elements such as practicing a previously learned skill. The use of objectives enables a more efficient use of time for teaching, learning, or practice. Even short periods of time can be used to best advantage to attend to a specific learning objective if learning activities are planned appropriately. When feedback is closely tied to performance and aligned with learning objectives, the learning of procedural skills can be markedly enhanced. It is also important to consider motivational aspects, such as encouragement, at this stage. The use of objectives with constructive feedback followed by the correction and optimization of performance forms the basis for deliberate practice with the goal of achieving mastery. This “deliberate practice” is felt to be a determining component of the attainment of expert levels of performance [5] across many areas. Objectives, along with appropriately timed feedback, also facilitate the learner’s reflection upon the learning process. Critical self‐reflection [6] is considered in the educational literature to be an important skill for future self‐directed learning. Although not reserved exclusively for trainees who are having difficulties, there is no doubt that you have encountered many “difficult” trainees that are unaware of their shortcomings. Providing trainees with a basis upon which to judge their own progress can be a useful tool in such situations, particularly for future occasions when they will no longer be supervised [7]. Video‐based feedback has been shown to be useful tool in promoting trainee’s ability to monitor their learning and performance and enhance their self‐assessment accuracy [8]. The terminology used in this chapter is meant to facilitate the reader’s deconstruction of endoscopic skill sets and hence the specific terms are less important than the underlying principles they are meant to illustrate. It is hoped that individual trainers will consider the various advantages afforded by deconstructing skill sets in such a manner when designing or adapting their own training programs. Subsequent chapters will cover training in the major endoscopic procedures and in specific techniques using a variety of different perspectives. The reader is encouraged to approach these chapters with their own framework in mind. In this section, we will discuss the following skills, which we consider to be constant requisites in the technical performance of any form of gastrointestinal endoscopy. It is assumed that prior to introducing a trainee to the technical components of performing endoscopy, they have already become familiar with the various components of the endoscope, including the function of the air/water and suction buttons, as well as proper holding and handling of the endoscope and other practical aspects such as troubleshooting malfunctioning equipment. Ideally, these basic skills have been introduced to the trainee and practiced in an environment away from the patient until a minimum level of proficiency has been reached. These skills will be discussed in some detail, including the nuances that affect their learning. To begin any gastrointestinal procedure, the endoscope must first be inserted into the lumen of the GI tract. Introduction of the endoscope requires a clear understanding of the relevant regional anatomy. For upper GI endoscopy, this involves direction of the endoscope down the oropharynx into the esophagus. To avoid gagging, retching, and possible laryngospasm, the oropharynx should be appropriately anesthetized with a local anesthetic agent and the endoscope directed away from the vocal cords and into the esophagus. In some cases, intravenous sedation is useful to supplement the topical anesthesia. Appropriate patient positioning and education to avoid efforts at swallowing further add to the smoothness of this phase of the endoscopy. Patients with large anterior osteophytes of the cervical spine may pose particular risks for perforation, as might Zenker’s diverticula. Attention to these possibilities is mandatory for safe upper endoscopy. For lower GI endoscopy, the endoscope needs to be introduced into the lumen, most often through the anus, but under some circumstances, through a stoma. Preceding the introduction of the endoscope with a properly performed digital examination is an essential adjunct to safe and comfortable intubation. This provides the opportunity to lubricate the entry, slowly relax the sphincter, and to evaluate the individual anatomy for direction and for any unexpected pathology or sites of potential obstruction. Endoscopy through a stoma requires some understanding of stomal varieties. A loop stoma is oriented at right angles to the long axis of the bowel. Imprudent introduction of the scope through the stoma can easily cause perforation through the antimesenteric side of the bowel. This is particularly prone to occur in patients whose bowel has been excluded, resulting in atrophy. End stomas are oriented in line with the long axis of the bowel. Digital examination may disclose angulation or kinks in the intra‐abdominal segment of intestine that must be negotiated when introducing the scope. Methods to assess the phase of introduction of the endoscope include rating of patient comfort, time to intubate, the number of attempts to intubate, and any complications related to the endoscope intubation, anesthesia, and sedation. Once the endoscope is successfully introduced, the next goal is advancement of the scope to a specific extent, as indicated by the clinical reason for the endoscopy. For upper GI endoscopy, this is usually down to the third stage of the duodenum; for colonoscopy, it would be to the cecum, terminal ileum, or to an anastomosis, for example. Scope navigation is accomplished by a series of maneuvers that include tip deflection, scope rotation/application of torque, external compression of the abdomen, adjusting the patient position, insufflation and suction of air or fluids, and insertion and withdrawal of the scope.
2
How Endoscopy is Learned: Deconstructing Skill Sets
Introduction
Depending on the level of experience of the trainee and the complexity of the endoscopy, having an awareness of the overall breadth of learning objectives can be very useful. In our opinion, it is useful to consider a hierarchy of objectives in teaching that begins with patient safety, progresses to basics of endoscopy handling, more advanced techniques, and subsequently to cognitive and behavioral aspects [9]. Having a wide variety of teaching scenarios and relevant objectives in mind is particularly useful in situations where unplanned learning opportunities may arise, such as rare occurrences or unusual aspects of endoscopic practice. In some situations, these instructional objectives may be highly specific and involve assessment using specific criteria, such as withdrawal time, or percentage of mucosa visualized, termed metrics, or key performance indicators. Metrics can be employed to assess these technical skills, particularly when using simulators, training tasks, or when comparing trainees to a specific standard (Video 2.1).
Identification of fundamental endoscopy skills
Introduction of the scope
Navigation
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