Catharine M. Walsh1 and Kevin A. Waschke2 1 Hospital for Sick Children, University of Toronto, Toronto, ON, Canada 2 McGill University Health Centre, Montreal, QC, Canada Endoscopic training programs strive to develop individuals capable of providing safe, efficient, and effective endoscopic care and meeting the rapidly changing service demands. This requires training in not only technical skills but also cognitive and nontechnical skills essential for clinical practice. In recent years, endoscopic training has begun to evolve from a traditionally experiential model of learning, in which individuals “learn by doing,” to a more structured approach grounded in evidence‐based educational principles [1–3]. It is increasingly recognized that effective endoscopic training requires preparation and structure, and should be provided by individuals with the requisite skills and behaviors required to teach endoscopy, including an understanding of adult learning principles, knowledge of best practices in procedural skills education and appropriate use of effective educational strategies, such as performance enhancing feedback [4]. In this chapter, we identify the key features of a successful endoscopic training environment, describe attributes of effective endoscopic trainers, outline the Preparation–Training–Wrap‐up framework that describes the essential components of an endoscopic teaching encounter, and finally discuss training aids and resources. The development of expertise in endoscopy requires extensive, sustained practice of the requisite skills as well as acquisition of the relevant knowledge and attitudinal and behavioral aspects (i.e., endoscopic nontechnical [5] or integrative skills [6] and “scopemanship” [7]) required to produce competent endoscopists. Expertise development is dependent not only on the quantity of time spent training, but also on training quality as well as trainee commitment and engagement. Central to this is the need for an effective training environment and culture. Endoscopic training needs to be accepted, supported, encouraged, and prioritized at an institutional level, particularly given the multiple competing priorities inherent in clinical care and the barriers to implementing change that often arise. Training units require sufficient procedural volumes to ensure adequate training opportunities for trainees and trainers with interest and skill in teaching endoscopy [8]. Buy‐in and support from leadership is essential to ensure that trainers have dedicated time for endoscopy training and accompanying assessment, and that interprofessional team members, including nurses and managers, are engaged and committed to delivering high‐quality training. It is also important for training programs and institutions to develop policies and systems to support endoscopy education. For example, it is crucial to have a specified plan to ensure that trainers receive adequate education and are competent to undertake a trainer role. Designation of an endoscopy training lead can be beneficial to help create an environment and culture that recognize endoscopy training as a core component of service provision. Responsibilities of such leads can include allocation of training lists, trainee orientation, delivery of the endoscopy training curriculum, and review of trainee assessment portfolios to develop personalized learning plans. Any change in training provision and culture must be done in a concerted manner and be supported with sufficient resources. As trainee presence leads to longer procedure times and negatively impacts case throughput and endoscopist billing [9–11], dedicated training lists (or portions of lists) are the best way to ensure that trainees receive adequate exposure and practice and that trainers have sufficient time to focus on the needs of trainees. Resources and infrastructure are also required to help collate feedback and assessment data from both trainees and trainers and ensure that it is acted on. Additionally, support is required to purchase training aids, such as magnetic endoscopic imagers and endoscopic simulators which, as discussed later in this chapter, can be of benefit in endoscopy training. Teaching endoscopy is challenging for several reasons, including the complex nature of the task and the need for trainers to balance clinical and learning needs while ensuring patient safety, procedural efficiency, and provision of high‐quality care. Additionally, literature has shown that endoscopy trainers use variable teaching methods and styles of training [12–14]. Endoscopic training should be led by individuals who are committed, competent, and enthusiastic trainers. Trainers should not only demonstrate competence in the procedure(s) for which they provide training but should also have the requisite skills and behaviors required to teach endoscopy effectively, and, ideally, formal training in endoscopy teaching methodology. Additionally, it is important that trainers lead by example, through their actions, words, attitudes, and work philosophy. Within a given training program or institution, not all endoscopists may want to train or possess the skills to teach endoscopy effectively. Trainers should possess conscious competence as well as expertise in assessment and feedback provision. Supervisors, alternatively, are competent endoscopists who can act as role models; however, they lack the requite skills to teach endoscopy effectively. Within a program or institution, the roles of individuals as either trainers or supervisors should be formally discussed and the need for a consistent approach to training across trainers emphasized [15]. Use of a structured training framework and standardization of training techniques across trainers helps to foster an effective learning environment in which trainees feel comfortable asking questions and seeking help, trainee needs are addressed, and trainees and trainers feel valued. In acquiring endoscopic skills, individuals generally progress through four stages from being unconsciously incompetent (not understanding or knowing how to do something) to consciously incompetent (not able to do something but aware of their deficits), to consciously competent (being able to something with great thought), and finally to unconsciously competent (being able to do something without conscious effort) (Figure 4.1) [16]. By the time endoscopists reach the unconsciously competent stage, they may be highly proficient; however, their actions are largely automatic [17]. They lack an explicit understanding of what specific techniques are required to perform tasks and, consequently, are unable to verbalize instructions adequately to trainees. To be able to teach and provide feedback effectively, a trainer must be able to deconstruct tasks, understand each element, and explain the individual components to trainees in an intelligible way. It is essential that trainers develop conscious competence for performing and teaching endoscopy. This awareness enables them to objectively analyze the performance of trainees, pinpoint specific problems, and verbally explain how to perform maneuvers and troubleshoot difficulties in a clear and effective way without needing to take over control of the endoscope to demonstrate. The development of conscious competence requires repeated practice over months to years with feedback from competent, experienced trainers and self‐reflection to develop an awareness and ability to solve problems and deconstruct skills. There are also established faculty development “train‐the‐trainer” courses which aim to formally train endoscopy faculty to conscious competence, such as those in the United Kingdom and Canada [18–20]. Figure 4.1 Stages of endoscopy skill acquisition (Adapted from Peyton [16]). Several studies have examined core attributes of effective endoscopy trainers. Pourmand et al. analyzed qualitative comments from post‐procedure feedback cards submitted by endoscopy trainees to identify endoscopic teaching behaviors perceived as beneficial or detrimental to their learning experience [21]. Seven themes were identified that related to the learning environment, autonomy, communication, coaching, feedback, and professionalism [21]. Another study by Kumar et al. outlined 10 essential teaching competencies for endoscopy trainers that were developed through expert consensus, including assessing trainee’s procedural competency, maintaining attention, use of standardized language, and feedback provision both during and after the procedure [22]. Based on the existing literature and data generated through interviews with training leads, trainers, trainees, and nurse endoscopists, Wells et al. classified characteristics of effective endoscopy trainers into six domains, including interpersonal attributes, endoscopy attributes, technical teaching attributes, developing as a teacher attributes, motivation to teach, and patient centered [23]. These characteristics were subsequently used to inform the development of a Direct Observation of Teaching Skills (DOTS) tool that can be used to evaluate endoscopy teaching performance. Additionally, they were used in the United Kingdom (UK) by the Joint Advisory Group on Gastrointestinal Endoscopy to inform the development of a list of attributes of effective trainers which encompass a patient‐centered approach, motivation, and an ability to perform and teach endoscopy, create an effective learning environment, and promote self‐reflective practice [24]. The aforementioned attributes of effective endoscopy trainers can be used by programs to help standardize expectations for endoscopy teaching and by trainers to assess and improve their own teaching as excellent teaching is a fundamental component to ensuring a high‐quality, endoscopy workforce. The use of a standardized teaching approach among trainers is increasingly recognized as important to ensure consistency in regard to what and how particular endoscopic skills are taught [15]. The following section outlines the Preparation–Training–Wrap‐up framework that can be used by endoscopic trainers to structure a training session, including essential elements to prepare for training, deliver performance enhancing training, and provide an effective wrap‐up (Figure 4.2) [4, 25]. A training session may be a single case or a block of procedures within a single day. This framework is also useful in structuring multiple trainee–trainer interactions over time. It is not only helpful for teaching trainees within the context of a gastroenterology fellowship program but can also serve as a useful guide for endoscopic trainers involved in supporting junior colleagues to help foster their skills development. This framework can be applied to train both basic and more advanced endoscopic skills, and it can also be used to structure teaching encounters within simulation‐based environments. This framework was originally used in “train‐the‐trainer” programs [20] in the United Kingdom and was later adapted by the Canadian Skills Enhancement in Endoscopy (SEE) Program [19] with great success. The preparation phase refers to the period prior to the start of a training session, which may be a single procedure or a set of procedures. Although time is limited in a busy clinical environment, it is important to take a small amount of time to properly prepare for a training session. Both physical and verbal preparations between the trainer and trainee are required to ensure an effective, safe, and efficient learning environment. The physical component of the preparation phase relates to the set‐up of the training environment, whereas the verbal component includes assessment of the trainee’s skill level, alignment of agendas between the trainer and trainee and formation of an educational contract, including generation of learning objectives and discussion of ground rules. Figure 4.2 “Preparation‐Training‐Wrap‐up” framework outlining the components of an effective endoscopic training session. Set‐up, the first component of the preparation phase, refers to the physical set‐up of the endoscopy suite in order to optimize the training environment. This includes appropriate positioning of the patient, trainee, trainer, and equipment within the room to ensure optimal ergonomics and visualization. With regard to positioning, the video monitor should be placed in front of the trainee at eye level or lower to prevent strain, and the bed height should be positioned between elbow height and 10 cm below elbow height so that the trainee’s arms can be maintained in a neutral position and the load on the spine is reduced [26–28]. For colonoscopy, to maximize the trainer’s view of the patient, the trainee’s hands, and the video monitor throughout the procedure, the trainer should position themselves at the foot of the bed opposite the monitor, as depicted in Figure 4.3. Another important component of set‐up is to ensure the training environment is and will continue to be free of interruptions and distractions, so that the trainee and trainer can direct their attention and energy to training. It is important for the trainer to review the endoscopy list ahead of time to determine which cases may be suitable for the trainee and to help decide how time will be allocated for training to ensure there is adequate opportunity for the trainee to achieve his or her goals. Finally, the trainee and trainer should confirm in advance that the equipment required for each case is available and fully functional. The next component of the preparation phase is an assessment of the trainee’s skill level. It is particularly important for a trainer to elucidate a trainee’s level of competence if the trainee–trainer pair have not met previously or if a long period of time has elapsed since their last training session, so that the trainee is not pushed beyond their limits or what is safe for the patient. The trainer should briefly assess the trainee’s current skill level through directed discussion with the trainee and, if possible, through review of an e‐portfolio, procedural log, prior feedback, and/or assessments. While a formal assessment is generally not possible, the trainer can ask a few directed questions to get a sense of the trainee’s skill level, their previous experience, and areas of difficulty. An example dialogue between the trainer–trainee pair could include questions such as: “Tell me about your previous experience with colonoscopy?,” “What skills have you been working on?” or “What difficulties have you encountered recently in performing colonoscopy?” Directed questioning can help the trainer better assess the skill level of the trainee, challenge any assumptions the trainer had going into the encounter, and generate a learning agenda. Alignment of agendas between the trainer and trainee is an important component of the preparation phase. The trainer and trainee will both have an agenda or goals they hope to achieve during the training session, which may be the same or different. If the trainer and trainee’s agendas differ, and the trainer does not take the trainee’s goals into account, the training session may be compromised, as it will not be as meaningful or as well received by the trainee. It is important for the trainer to elicit the trainee’s agenda through an open discussion, be flexible, and try to come to a consensus on the goals for the session, which should take into account both the trainer and trainee’s agendas [25]. Alignment of agendas helps to ensure the trainee and trainer are aware of and appreciate one another’s perspectives and also have a shared understanding of the goals for the teaching encounter [4]. This then facilitates the development of two to three focused learning objectives which should be established collaboratively in advance of the training session. Tools and frameworks designed to enhance the quality of learning objectives, such as SMART (specific, measurable, achievable, realistic and timely), may be used to help formulate objectives that clearly describe the knowledge, skills, and behaviors the trainee should be able to demonstrate by the end of the teaching encounter [29]. Well‐defined and mutually agreed upon learning objectives are essential in that they provide a target with which trainees can focus their learning efforts and trainers can focus their observation and feedback to maximize training effectiveness. It is important that the goals are realistic and achievable. Early in training, trainees may be unaware of their deficits (i.e., unconsciously incompetent) and the trainer will likely need to play a greater role in setting the agenda and learning objectives. However, as a trainee’s skills improve, they should be encouraged to critically reflect on their performance and take increasing responsibility for identifying targets for improvement and setting learning objectives [30, 31]. Figure 4.3 Set‐up of an endoscopy suite during training to optimize the trainer’s view of the patient’s face, the monitor, and the trainee’s hands. Finally, it is important for the trainer to maintain a sense of control over the procedure, trainee, and environment during a teaching encounter, as patient safety must not be compromised for the sake of training. Essential to this are ground rules or agreed upon parameters for teaching during the procedure [25]. The ground rules, which will vary across trainees and cases, outline the roles and responsibilities of the trainee and trainer during the teaching session, make clear the time allocated for training, and provide pre‐defined criteria for trainer interventions (i.e., stopping or taking over the procedure) that can be expected by the trainee. Establishing ground rules helps to ensure patient safety, reinforces the trainer’s control of the session, and establishes the trainer as the team leader. The learning objectives and ground rules form the basis of an educational contract, which is an agreement between the trainer and trainee as to how the teaching encounter will be structured and conducted. It is important that decisions are made ahead of the training encounter so that the trainer and trainee’s expectations are both realistic and aligned. An effective educational contract enables the trainee to focus on their skills development while ensuring that the trainer maintains control over the training encounter. The training encounter refers to the time from the point the trainee starts the procedure until they complete it, or the training encounter is terminated. During this component, there are several evidence‐based educational principles that can be applied by trainers to enhance learning. Performance enhancing instruction, or formative feedback provided during the learning encounter, is a key motivator for trainees and one of the most important determinants of endoscopy skill acquisition [32, 33]. During the procedure, instruction should be based on direct observation of performance, should be informative, and when possible, should focus on the agreed upon learning objectives for the training session. The use of learning objectives, instructional feedback, and correction to enhance performance forms the basis for deliberate practice, a foundational element for the development of expertise [34]. To guide their observations and feedback, trainers can use endoscopy assessment tools with strong evidence of validity for use during training [35], such as the Assessment of Competence in Endoscopy (ACE) tool [36], the Gastrointestinal Endoscopy Competency Assessment Tool (GiECAT) [37, 38], or the JAG’s Direct Observation of Performance Skills (DOPS) tool for colonoscopy [39]. Such tools help to highlight key areas that are required for skillful endoscopy performance and are discussed in more detail in Chapter 39 of this volume. Feedback should be tailored to the skill level of the trainee. The process of skill acquisition has been described as a sequential process involving three major phases: cognitive, associative, and autonomous [40]. In the cognitive
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Training the Endoscopic Trainer
Introduction
Training environment
Attributes of effective endoscopy trainers
Framework for endoscopic training
Preparation
Training
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