Significant variation exists in endoscopic training programs throughout the world and within the United States. Even more significant is the lack of training availability for endoscopists once they are finished with their fellowship training. Training in endoscopy is optimally obtained in conjunction with a thorough education program in digestive diseases. The ability to perform the technical aspects of a procedure cannot be isolated from the understanding of the visual image. Training programs that certify competence in endoscopy are also certifying that the trainee is knowledgeable in the indications, contraindications, normal and abnormal anatomy, therapy, and complications, as well their treatment, for each procedure. This education cannot be obtained without an extensive training program in gastrointestinal (GI) medicine. Once obtained, however, these skills need to be continuously practiced and improved. Additionally, new techniques and new types of procedures may be established after one’s fellowship training has been completed. The ability to acquire new skills in endoscopy beyond training is dependent upon many factors. The most important is the knowledge base that is present prior to the new technique being attempted and the availability of exposure to the technique prior to adoption. This chapter explores the possibility of training beyond fellowship as the field of GI endoscopy evolves.

The current practice of endoscopy is based upon the direct visualization of the GI tract and recognition of the normal and abnormal anatomy, as well as its ramifications. All standard endoscopic procedures are variations on the basic principle of visualizing the GI tract and extending therapeutic devices out of the instrument into the digestive system. The ability to manipulate the instrument throughout the GI tract is but a part of the procedure. Biopsy, polypectomy, control of bleeding, and injection are extensions of the procedure and usually learned during training. However, each advance, such as sclerotherapy, injection polypectomy, and endoscopic mucosal resection (EMR), builds upon the basic technique of injection. If a device such as the argon plasma coagulator becomes available, the major learning steps are specific to the device and its application. For instance, the depth of burn, settings for power delivery, flow of argon gas, and distance from the surface for proper application are all specific to the argon plasma coagulator and need to be learned prior to application of the probe. The use of this instrument is merely an extension of other thermal energy applicators.

One of the few truly new developments in endoscope technology over the last several decades has been the advent of endoscopic ultrasonography (EUS) to extend the gaze of the endoscopist beyond the lumen and into adjacent structures. This development has created a major division in endoscopic practice, as individuals not trained in EUS have severe limitations in their ability to become facile in the technique. The demands of clinical practice, be it private practice or academic medicine, create time barriers to on‐the‐job training for endoscopists. It is very difficult for a busy practicing gastroenterologist to devote enough time to learn the technique of EUS and become trained in the anatomy, pathology, and implications of findings obtained at ultrasonography, as well as the manipulation of the instrument to obtain the necessary images and biopsy or aspiration of suspect lesions. The expenses associated with time away from the practice and the limited availability of training centers make adoption of EUS quite challenging outside of a fellowship setting. Hands‐on experience in the presence of an expert in the procedure, which has been the hallmark of effective endoscopic training, requires a relative long training period and has limited dissemination of this technique outside of a formal endoscopic training program. At the same time, there continues to be a shortage of endosonographers in many rural communities and some urban settings, resulting in some patients having to travel hundreds of miles to undergo an EUS procedure.

Given the difficulty of pursuing comprehensive EUS training after GI fellowship, some practitioners seek more limited training outside of formal training programs such as weekend courses and limited visitations with EUS centers in the United States and abroad. Short courses should be viewed as adjunctive training and tools for continuing medical education. However, they are not a substitute for adequate formal training [1].

The American Society for Gastrointestinal Endoscopy (ASGE) is addressing some of the challenges of learning advanced endoscopic skills, such as EUS, outside of a formal fellowship with the development of a novel competency‐based training program in diagnostic EUS [2]. This project will serve as a pilot program and a potential blueprint for similar types of competency‐based training initiatives. The program consists of online modules and webinars with didactic materials and videos demonstrating normal anatomy and pathology across 14 areas of competency following the previously published core curriculum guidelines [3]. This is followed by a hands‐on course with training on phantoms and animal models. The last step involves a 4‐ to 6‐month period of proctorship at select EUS centers of excellence with the goal of reaching a threshold number of procedures to then allow for standardized assessment of competency. This program is in its early development stage, and it will be fascinating to study its outcomes and thus its impact on EUS training.

As new developments in endoscopic science occur, rapid applicability depends upon creating a cadre of well‐trained and equipped endoscopists. How to effectively establish this training is not well defined, however, and may create one of the two scenarios: either the new procedure will be available only at referral centers where the technique(s) has been developed, or adoption by less well‐trained endoscopists will create discrepancies in care delivered. In this age of physicians and patients keeping score on quality measures and benchmarking, it will be increasingly difficult to justify developing competency “on the go” on real patients as long as fully trained and competent individuals are available to provide the same services.

Some lessons can be learned from the major shift in surgical techniques, for example, from open procedures to laparoscopy. When laparoscopic cholecystectomy was first reported in 1987, the technique was widely recognized as a significant advance in the field of surgery, if not by surgeons, by many demanding patients [4]. Many conscientious surgeons realized that there was a gradual learning curve for competence in the technique and substantial training was going to be required before widespread adoption was accomplished. Yet some surgeons felt that the technique was merely an extension of their previous laparoscopic experience, including work in the pelvis (primarily gynecologic), and that previous experience with this technique allowed them to extend the laparoscope into the new territory of the gallbladder fossa. Some surgeons desiring early adoption attended university or academic society recognized didactic courses that included work in an animal lab, while other training programs offered relatively little exposure to hands‐on training with a live animal model. In either case, supervision in patients was unusual. The surgeons were then granted privileges at their local hospitals and began to train/supervise and credential other members of the surgical staff. Some surgeons attended 3‐, 2‐, or even 1‐day training sessions that were of variable quality with little or no animal model experience and then began to use the technique on patients. Others simply watched videotape demonstrations and then began operating on patients. It was not until 1990 that the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) came out with a guideline outlining formal training and competency determination [5]. There is some redemption in laparoscopy, since most difficulties that arose during early experience with laparoscopy could be dealt with through conversion to an open procedure, an option not available to nonsurgical endoscopists. Advancing from cholecystectomy to appendectomy, bowel resection, gastric bypass, and fundoplication, as well as a variety of other surgical procedures, was seen as an extension of the original laparoscopic procedure. Surgeons currently coming out of surgical training programs are already familiar with laparoscopic techniques and have adopted laparoscopy as an integral part of the surgical armamentarium.

One of the major problems, however, was that in the early years of laparoscopy, there was often nothing to prohibit surgeons from adopting laparoscopy without any formal training. Hospitals that wanted to provide the latest and greatest surgical procedures as a marketing tool would be less likely to argue against a competent general surgeon who has had some laparoscopic experience but had never done a specific laparoscopic surgery, such as cholecystectomy. In its most extreme form, surgeons with no formal training in laparoscopic cholecystectomy would adopt the familiar “see one, do one, teach one” strategy of advancing medical procedures and observe a colleague initially to gain familiarity with the technique. Not surprisingly, complications, particularly biliary leaks and injuries, from early laparoscopic cholecystectomy were higher than those of open cholecystectomy [6].

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