Development of Expertise in the Detection and Classification of Non-Polypoid Colorectal Neoplasia: Experience-Based Data at an Academic GI Unit

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The learning pyramid

For simplicity, let's look at the well-known learning-pyramid by Miller,27 as illustrated in Fig. 1. In general, development of practical skills is a stepwise process, starting with acquisition of basic knowledge, followed by in-depth information and development of practical skills—the so-called know-how and show-how—and finally exposure to concrete practical situations. If we extrapolate this model to the practice of GI endoscopy, in particular development of expertise in diagnosis of NP-CRN,

The development of the de novo expertise in NP-CRN at Maastricht

In real life, the issue of developing expertise in detection and management of NP-CRN in current practice can be broken down into a number of questions.

Summary

Based on sound clinical data, we can conclude that accurate detection of NP-CRNs is important and should be incorporated into GI educational programs. Diagnosis and management of some of these lesions in routine practice may be technically challenging. Also, a subset of these lesions may herald advanced histopathology. Our experience in this field adds a further piece of evidence to the mosaic of clinical data indicating that worldwide training in recognition and management of NP-CRNs warrants

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      In particular, the knowledge and skills needed to recognize and manage subtle-appearing nonpolypoid colorectal neoplasms require additional training. In a population-based study of non-IBD patients, conducted at an academic hospital, both faculty and fellows were trained in the detection and resection of nonpolypoid colorectal neoplasm by using a systematic, stepwise training model derived from the learning pyramid by Miller (ie, developing knowledge through lectures, know-how through case discussions, and show-how by using endoscopic learning videos and individual feedback).37 The detection rate increased significantly from 3.4% at baseline to 5.0% and 6.8% 1 year and 2 years after training, respectively.38

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      Recognition of the nonpolypoid dysplasia in a real-world environment remains challenging and requires additional training. In a study conducted at Maastricht University Medical Center, where the endoscopists have been trained on the recognition of nonpolypoid neoplasms,32 the overall detection rate of sporadic NP-CRNs (defined as lesions of which the height was less than half of the diameter) was 5.7% (diagnostic subgroup, 4.7%; screening subgroup, 4.5%; surveillance subgroup, 15.6%).33 The learning-curve in the detection of NP-CRNs is, however, tedious, with at least 600 colonoscopies being required to achieve a detection rate of at least 4.5%.34

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      These data might indicate that systematic training, with emphasis on endoscopic recognition of nonpolypoid lesions, is needed to finally improve their detection in everyday practice. In the experience of the authors [85], self-learning and development of a simple training curriculum (consisting of topic lectures, video training by means of accredited programs [86,87], and individual feedback) clearly improved the quality of colonoscopy in an established practice of gastroenterologists. We found similar detection rates of nonpolypoid adenomas among gastroenterologists and trainees (4.6% vs 3.7%, respectively) after exposure to this training, suggesting that improved awareness and education can finally boost the performance indicators.

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