Training and transfer of colonoscopy skills: a multinational, randomized, blinded, controlled trial of simulator versus bedside training

doi:10.1016/j.gie.2009.07.017

Gastrointestinal Endoscopy

Volume 71, Issue 2, February 2010, Pages 298-307

https://doi.org/10.1016/j.gie.2009.07.017 Get rights and content

Background

The Olympus colonoscopy simulator provides a high-fidelity training platform designed to develop knowledge and skills in colonoscopy. It has the potential to shorten the learning process to competency.

Objective

To investigate the efficacy of the simulator in training novices in colonoscopy by comparing training outcomes from simulator training with those of standard patient-based training.

Design

Multinational, multicenter, single-blind, randomized, controlled trial.

Setting

Four academic endoscopy centers in the United Kingdom, Italy, and The Netherlands.

Participants and Intervention

This study included 36 novice colonoscopists who were randomized to 16 hours of simulator training (subjects) or patient-based training (controls). Participants completed 3 simulator cases before and after training. Three live cases were assessed after training by blinded experts.

Main Outcome Measurements

Automatically recorded performance metrics for the simulator cases and blinded expert assessment of live cases using Direct Observation of Procedural Skills and Global Score sheets.

Results

Simulator training significantly improved performance on simulated cases compared with patient-based training. Subjects had higher completion rates (P=.001) and shorter completion times (P < .001) and demonstrated superior technical skill (reduced simulated pain scores, correct use of abdominal pressure, and loop management). On live colonoscopy, there were no significant differences between the 2 groups.

Limitations

Assessment tools for live colonoscopies may lack sensitivity to discriminate between the skills of relative novices.

Conclusion

Performance of novices trained on the colonoscopy simulator matched the performance of those with standard patient-based colonoscopy training, and novices in the simulator group demonstrated superior technical skills on simulated cases. The simulator should be considered as a tool for developing knowledge and skills prior to clinical practice.

Section snippets

Materials and methods

This was a prospective, multicenter, randomized, blinded evaluation of training at 4 endoscopy training centers in 3 countries—St Mark's Hospital, London, United Kingdom; Erasmus Medical Centre, Rotterdam and the Academic Medical Centre, Amsterdam, The Netherlands; and the A. Gemelli University Hospital, Rome, Italy. The study was approved by all 4 institutional review boards and was given a rating of educational evaluation by the UK National Research Ethics Service and the Amsterdam ethical

Study participants

Forty trainees were randomized, with 36 completing the study. Two trainees did not start because of limitations in availability of endoscopy sessions, 1 trainee completed the simulator pretraining assessment but had to leave for personal reasons before commencing the training, and 1 trainee completed the training and simulator assessments but did not complete all 3 patient-based assessment cases (Fig. 2).

The subjects and controls were reasonably well-matched in their demographics and previous

Discussion

In this study we aimed to address weaknesses in previous studies by assessing a large number of trainees from multiple centers in a prospective, randomized, blinded study. The use of patient-based training as a control allowed performance comparisons for 111 simulated and 109 clinical cases. We found that the equivalent time spent on the simulator resulted in significantly greater improvements in performance on the simulator tasks than did traditional, patient-based training. We also found that

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Citation Excerpt :
It should be noted that the outcomes reporting non-significant differences between groups may support the use of VR simulators. Some of the studies report that these results demonstrate how VR simulator training can be comparable or achieve similar outcomes to clinical training.18,24,25 When compared to clinical training, it appears that the use of VR simulation is supported with only one study reporting a negative result for measures of independence.26
Training young physicians in gastrointestinal endoscopy through virtual reality (VR) simulators has become popular. It is important to evaluate the benefits and usefulness of this technology for teaching endoscopic skills. The objective of this literature review is to understand the benefits of VR technology through quantitative and qualitative examination of learning outcomes.
A literature search of 7 databases was conducted. Studies which compared the effects of learning through VR simulation and another method of learning were included. In addition, studies were included if they evaluated learning outcomes on clinical patients. Participants could be medical residents, fellows, physicians, or nurses. Common outcomes measured across studies included subjective overall performance scores, total procedure times, rate of successful procedure completion, error rates, patient pain or discomfort, and measures of independence.
A total of 22 studies were included. Overall, VR simulation training was seen to be comparable or significantly better than clinical training, no training, other types of simulation, and another form of VR training. Many authors reported increasing patient safety, reducing stress and time constraints, and shortening the learning curve as advantages of VR simulation training. However, this form of training is also expensive and may result in the learning of bad habits.
VR simulation technology can be a valuable form of educating endoscopy novices if properly supervised during training, and if there is also integration of clinical training.
Endoscopic simulators
2019, Gastrointestinal Endoscopy
Simulation refers to educational tools that allow for repetitive instruction in a nonpatient care environment that is risk-free. In GI endoscopy, simulators include ex vivo animal tissue models, live animal models, mechanical models, and virtual reality (VR) computer simulators.
After a structured search of the peer-reviewed medical literature, this document reviews commercially available GI endoscopy simulation systems and clinical outcomes of simulation in endoscopy.
Mechanical simulators and VR simulators are frequently used early in training, whereas ex vivo and in vivo animal models are more commonly used for advanced endoscopy training. Multiple studies and systematic reviews show that simulation-based training appears to provide novice endoscopists with some advantage over untrained peers with regard to endpoints such as independent procedure completion and performance time, among others. Data also suggest that simulation training may accelerate the acquisition of specific technical skills in colonoscopy and upper endoscopy early in training. However, the available literature suggests that the benefits of simulator training appear to attenuate and cease after a finite period. Further studies are needed to determine if meeting competency metrics using simulation will predict actual clinical competency.
Simulation training is a promising modality that may aid in endoscopic education. However, for widespread incorporation of simulators into gastroenterology training programs to occur, simulators must show a sustained advantage over traditional mentored teaching in a cost-effective manner. Because most studies evaluating simulation have focused on novice learners, the role of simulation training in helping practicing endoscopists gain proficiency using new techniques and devices should be further explored.
Endoscopic Simulators
2019, Clinical Gastrointestinal Endoscopy
Endoscopy skills have traditionally been taught within the clinical setting, in the form of a mentor-apprenticeship model in which novice endoscopists learn skills under direct supervision of experienced preceptors in the clinical setting. In recent decades, advances in the development of endoscopic simulators and concerns with regard to patient safety and training efficiency have prompted the endoscopy community to reconsider this training model. This has led to an increased use of gastrointestinal endoscopy simulation to enhance learner knowledge, skills, and attitudes and to provide opportunities for practice in a safe and controlled environment. Evidence to date suggests that simulation-based endoscopy training is effective and learning outcomes transfer to the clinical setting. Simulation, however, must be integrated into training and assessment in a thoughtful, purposeful, and evidence-based manner to maximize its benefit. This chapter outlines factors to consider in choosing an appropriate simulator for training and elaborates on the use of simulation to train endoscopic nontechnical skills. Additionally, instructional design features that can be applied to develop well-designed endoscopy simulation-based training curricula to enhance learning and optimize transfer of learner skills and behaviors to the clinical workplace are discussed. Finally, the potential use of simulation for assessment of endoscopic competence is outlined. Incorporation of these evidence-based educational strategies would advance the current state of endoscopic simulation and enhance the effectiveness of endoscopy training.
Computerized feedback during colonoscopy training leads to improved performance: a randomized trial
2018, Gastrointestinal Endoscopy
Simulation-based training in colonoscopy is increasingly replacing the traditional apprenticeship method to avoid patient-related risk. Mentoring during simulation is necessary to provide feedback and to motivate, but expert supervisors are a scarce resource. We aimed to determine whether computerized feedback in simulated colonoscopy would improve performance, optimize time spent practicing, and optimize the pattern of training.
Forty-four participants were recruited and randomized to either a feedback group (FG) or a control group (CG). Participants were allowed 2 hours of self-practice during which they could practice as they saw fit on 2 different cases: 1 easy and 1 difficult. The CG practiced without feedback, but the participants in the FG were given a score of progression every time they reached the cecum. All participants were tested on a different case after end of training. The primary outcome was the progression score in the final case, and secondary outcomes were time spent practicing and the training pattern.
Regression analysis adjusting for sex was done because of an uneven sex distribution between groups (P = .026) and significantly higher performance scores by men (37.6, standard deviation [SD] 25.9) compared with women (19.7, SD 18.7); P = .012. The FG outperformed the CG in the final case, FG scoring 14.4 points (95% confidence interval [CI], 1.2-27.6) more than the CG; P = .033, and they spent more time practicing, FG practicing 25.8 minutes (95% CI, 11.6-39.9) more than the CG; P = .001. The FG practiced more on the easy case and reached the cecum 3.2 times more (95% CI, 2-4.5) during practice (P < .001).
Our findings of this study revealed that an automatic, computerized score of progression during simulated colonoscopy motivates the novices to improve performance, optimizes time spent practicing, and optimizes their pattern of training. (Clinical trial registration number: NCT03248453.)
Endoscopic training: A nationwide survey of French fellows in gastroenterology
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During their 4 years of training, French fellows in gastroenterology should acquire theoretical and practical competency in gastrointestinal (GI) endoscopy.
To evaluate the delivery of endoscopy training to French GI fellows and perception of learning.
A nationwide electronic survey was carried out of French GI fellows using an anonymous, 17-item electronic questionnaire.
A total of 291 out of 484 (60%) GI fellows responded to the survey. Only 40% of subjects had access to theoretical training and/or virtual simulators. Only 49% and 35% of fourth year fellows had reached the threshold numbers of EGD and colonoscopies recommended by the European section and Board of gastroenterology and hepatology. Sixty-two percent and 57% of trainees reported having insufficient knowledge in interpreting gastric and colic lesions. Access to dedicated endoscopy activity for at least 8 weeks during the year was the only independent factor associated with the achievement of the recommended annual threshold number of procedures.
The access of fellows to theoretical training and to preclinical virtual simulators is still insufficient. Personalized support and regular assessment of cognitive and technical acquisition over the 4 years of training seems to be necessary.

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: DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

: If you would like to chat with an author of this article, you may contact Dr. Haycock at [email protected].

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Original articleClinical endoscopyTraining and transfer of colonoscopy skills: a multinational, randomized, blinded, controlled trial of simulator versus bedside training