Senior trainee as endoscopy teacher: impact on trainee learning and attending experience

Abstract

Objective

Training in how to effectively teach endoscopy is not included in most gastroenterology (GI) training programme curricula, yet many gastroenterologists are expected to teach endoscopy in their careers. Near-peer teaching could help senior GI trainees learn how to teach endoscopy and have benefits for junior trainees. We performed a qualitative study of a peer teaching initiative where senior trainees taught endoscopy to junior trainees under attending supervision.

Design

We observed endoscopy sessions where the senior trainee taught a junior trainee under attending supervision, and then conducted individual interviews with the senior trainee teacher, junior trainee learner and attending to characterise affordances and barriers to learning. We performed thematic analysis on anonymised interview transcripts.

Results

10 observations and 30 interviews were completed. Junior trainees reported senior trainees more approachable than attendings and explained concepts in more understandable ways. Senior trainees reported the teaching role improved skill at both teaching and performing endoscopy. Attendings reported positive impressions of the experience for senior trainees, and generally positive impressions with some reservations of the experience for junior trainees. A few barriers to learning were reported, but they were generally perceived as being outweighed by affordances. An area for improvement was setting clear expectations for senior trainee and attending roles before the session.

Conclusion

Near-peer endoscopy teaching was feasible and provided perceived affordances for junior and senior trainees alike, with few barriers. Incorporating formal training in teaching endoscopy into GI training programme curricula may produce both better endoscopists and better endoscopy teachers.

WHAT IS ALREADY KNOWN ON THIS TOPIC.

• High-quality, effective endoscopy teaching is crucial yet is also very challenging. Near-peer teaching is a well-established tool in medical education that has been applied to teaching non-endoscopy medical procedures.

WHAT THIS STUDY ADDS

• Junior trainees, senior trainees and attendings all reported near-peer endoscopy training promoted endoscopy learning for both senior and junior trainees and helped improve endoscopy teaching skills among senior trainees. Participants described multiple affordances to learning with few barriers.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Formal training in teaching endoscopy should be considered for inclusion in GI training programmes to leverage the benefits of near-peer teaching to improve trainee procedural and teaching skills.

Introduction

Gastroenterology (GI) specialty trainees are expected to attain competence in endoscopy by completion of training. Once those trainees become attendings, in many settings, they will be expected to both perform and teach endoscopy. Yet, formal training in teaching endoscopy is not included in most GI training programme curricula. While accreditation bodies governing graduate medical education require trainees to teach students, peers and other health professionals, teaching procedures are not specified.¹ Therefore, many junior GI attendings may be inadequately prepared for procedural teaching roles.

To address the need for high-quality endoscopic teaching, professional societies offer ‘Train the Trainers’ courses to improve gastroenterologists’ procedural teaching skills.² However, these courses are costly and cannot train a full complement of new attendings annually. Near-peer teaching, defined as ‘trainees teaching more junior trainee colleagues,’³ is a well-established method that could help address this need, however, less is known about applying it to teaching a complex procedural skill. Programmes designed to improve specialty trainees’ teaching skills have either not addressed procedural teaching,⁴ or have focused on simulation rather than actual procedures, where challenges and stakes are higher.⁵

We explored educational affordances and barriers of a programme where a senior GI trainee was the primary ‘near-peer’ endoscopy teacher, junior GI trainee the primary learner and attending the supervisor for both. We sought to understand how this arrangement could help senior trainees learn to teach endoscopy and investigate benefits for junior trainee education. Every teacher has likely experienced that the act of teaching promotes the teacher’s own learning,^{6 7} and emerging work has applied this ‘learn by teaching’ principle to medical procedures (though not endoscopy).⁸ Therefore, we sought to assess whether and how near-peer teaching could promote endoscopy learning among senior trainees. Teaching GI trainees how to teach endoscopy may produce both better endoscopists and better endoscopy teachers, in turn impacting patient care and training of future gastroenterologists.

Methods

Study design

We performed a prospective observational study between June and November 2020 at two teaching hospitals of the University of California San Francisco (UCSF) GI Fellowship programme (UCSF Health and San Francisco General Hospital). We implemented a programme in which senior trainees (second-year and third-year fellows) instructed junior trainees (first-year fellows) in endoscopy. The senior trainee was the primary teacher while the attending supervised to ensure safe and effective procedure completion. The primary author (CF) observed sessions where near-peer teaching occurred, which consisted of at least one upper endoscopy or colonoscopy performed by the same trainees and attending. Advanced procedures such as endoscopic retrograde cholangiopancreatography and endoscopic ultrasound were not included. After each observation, CF performed semistructured interviews exploring affordances and barriers to learning with the attending, senior trainee and junior trainee separately. The main purpose of observing endoscopy sessions was to better inform interview content (the primary qualitative data): CF noted teaching behaviours and participant interactions and asked questions about these during interviews. Based on prior endoscopy education qualitative research,⁹ we planned to start with 10 observations/30 interviews, assess for information sufficiency and conduct additional observations/interviews if novel topics were still being revealed. Physician subjects were recruited by email; participation was voluntary. Verbal consent was obtained from all participants, who were provided with written study information. Patients whose procedures were observed also provided consent.

Organisational framework

We use the terms ‘barrier’ and ‘affordance’ to describe characteristics either impeding or facilitating learning, respectively. ‘Affordance’ refers to characteristics determining if and how a particular learning behaviour can be enacted within a given context.^10–12 An affordance provides the opportunity for learning to occur but is not itself sufficient for learning; interactions between learner, teacher and learning environment all influence learning.

Interview format

CF performed all interviews (10–20 min each), which were audio recorded, anonymised and transcribed by a professional transcription service. Both authors worked together to develop the interview guide. As interviews proceeded, minor modifications were made to the interview guide as needed, consistent with a constant comparison technique. Sample interview questions are presented in online supplemental table 1.

Data analysis

We performed qualitative analysis of interview transcripts using thematic analytic techniques. Thematic analysis is used to identify patterns of meaning within qualitative data.¹³ After reading the first few transcripts, we developed an initial coding template describing themes present in the data. Both authors applied these codes to a few additional transcripts, discussed coding differences and modified code definitions. We often applied codes similarly; divergent coding were used as foci for discussion while refining the code template. Transcripts were coded in Dedoose (a qualitative research coding application) by each author using finalised codes; previously coded transcripts were reviewed using finalised codes to ensure consistency across all transcripts. Each code included subcodes indicating whether the theme represented a barrier or affordance for either junior or senior trainee. Attending transcripts were also coded for positive, neutral or negative impressions.

Reflexivity

The primary author (CF) was a third-year GI fellow when the project was conceived and interviews conducted. He is now junior faculty in an academic GI division. The senior author (JLS) is an academic gastroenterologist with over 10 years’ experience teaching endoscopy, and an educational researcher experienced in qualitative methods.

Results

Participants

The 10 observations and 30 interviews included 10 attendings, 8 senior trainees and 9 junior trainees (1 junior and 2 seniors participated twice). To sample varied experience levels, three observations were conducted in June 2020, when junior trainees were relatively experienced, while seven observations were conducted between July and November 2020, when juniors were less experienced, as first-years start training in July. Attending teaching experience ranged from 1 to 20+ years. No senior trainee received formal training in teaching endoscopy. As all GI trainees were graduates of internal medicine residency, most had experience with near-peer teaching for general internist procedures, such as vascular access. Some trainees had additional medical education experience acquired while serving as ‘Chief Resident’ in their residency programmes. All senior trainees were competent to perform endoscopy under supervision; at our institution, trainees are never permitted to perform endoscopy without attending supervision regardless of competence, therefore, ability to perform the procedure independently was not a prerequisite for participation.

Themes

Analysis revealed four primary themes: near-peer teaching, learning by teaching, co-teaching and collaborative learning. Each theme is discussed below with illustrative excerpts in tabular format. By 8 observation sessions (24 interviews), the authors felt thematic saturation (the point at which additional interviews were not adding substantively new information) was approaching; therefore, 2 additional observations (6 interviews) were conducted, at which point the authors agreed thematic saturation had been achieved.

Near peer teaching

Overall, junior trainees reacted positively to near-peer teaching, citing several affordances. Juniors reported seniors felt less intimidating than faculty, and they felt more comfortable struggling in front of other trainees compared with attendings. Several expressed that seniors seemed less judgemental than attendings. Juniors appreciated that seniors were more patient than faculty, including taking over the scope less frequently. Several juniors noted that seniors could teach in a more understandable manner, suggesting that once endoscopy becomes easy to do, it may be more difficult to teach effectively (table 1).

Table 1.

Concepts and excerpts related to near-peer teaching theme

Concept	Representative quotes	Perceived effect on learning
Comfort/non-judgemental	‘Sometimes, depending on the attending, I feel a bit more … nervous like I'm being judged or evaluated. With the senior fellow I felt very comfortable.’ (Junior 7) ‘(I tried to be) more of a peer coach rather than an attending. Hopefully we're more approachable and they can feel more comfortable talking with us and not necessarily feel like it’s punitive when we're giving them constructive tips. … I remember it could be demoralizing when you're performing poorly and your boss … is telling you everything you're doing wrong…’ (Senior 6) ‘I think people tend to be more colloquial.’ (Attending 4)	Affordance
Patience	‘He was just more patient with me than … attendings have been… Giving me time to try to figure it out myself and then stepping in when he could see that I was struggling.’ (Junior 4) ‘…Being in the first-year’s shoes, it’s … annoying when the scope gets taken from you quickly. So, I tried to give him space to try.’ (Senior 1)	Affordance
Relatable instruction	‘I think it’s … helpful to be doing it with someone who just went through training and is closer to being a novice like myself. Because I think maybe when you're an attending, it’s just so second nature to you that you … forget what you're doing or how to explain it.’ (Junior 4) ‘The senior fellows are closer to learning themselves. They tend to be able to break things down a bit easier. I think senior fellows have an opportunity to teach in a way that’s different than an attending might, and that might resonate better with a junior fellow.’ (Attending 4)	Affordance
Less experienced teacher	‘It’s the end of first year, so … they know a lot of the basics which is the stuff that I feel most comfortable teaching. … I feel like I can only teach to a certain level.’ (Senior 1) ‘An additional year of experience would be helpful.’ (Senior 3) ‘I don't think this arrangement is of great value to the first-year fellow. … The opportunity to do it with the master endoscopist giving all the direction, probably outweighs the benefit of being closer to the training of a first-year fellow.’ (Attending 10)	Barrier

Senior trainees expressed insight into the advantages of a non-evaluative teaching role. They recalled being frustrated when the scope was taken away from them, so were intentional about trying to give juniors as much hands-on time as possible. However, some seniors, particularly second-years, encountered the limits of their own experience when teaching first-years later in the academic year, commenting that it was much easier to teach the basics to an early first-year.

Faculty generally concurred with these impressions, commenting that juniors seemed comfortable working with seniors. Faculty agreed that seniors were often able to leverage their recent experience as learners to provide more relatable instruction. While many faculty reported that the senior did well, a couple felt the benefits of learning from a more experienced (ie, faculty) teacher outweighed the benefits of having a more relatable teacher closer in level to the learner.

Learning by Teaching

Senior trainees valued opportunities to practice teaching. Many planned to teach in their career and recognised a major challenge in teaching endoscopy is learning to describe what one is feeling from the scope in a language the learner can understand. This experience potently demonstrated the importance of conscious competence for effective endoscopy teaching (table 2).

Table 2.

Concepts and excerpts related to learning by teaching theme

Concept	Representative quotes	Perceived effect on learning
Conscious competence	‘Developing a vocabulary for describing what’s going on with the scope is a skill that you don't need to have if you're just scoping because you can just do it and feel it, but it’s a skill that you need to develop if you're trying to teach it or communicate what’s going on with the scope. … It made me more conscious of things that I do unconsciously.’ (Senior 3)	Affordance
Learn by teaching	‘I think anytime you have to teach something, you have to know it better. I think it forces me to be very deliberate, even when I'm just narrating out loud what I'm doing, which isn't something I would do with just an attending in the room.’ (Senior 4)	Affordance
Skill practice	‘These last couple weeks I've been working with them, [there are] maneuvers that I can do better.’ (Senior 8) ‘I think the (senior fellows’) skills improve dramatically in this role. I know for myself, the first year being an attending, reducing a first-year fellow’s loop was a great exercise for me to improve. … I wish I had that opportunity when I was a fellow.’ (Attending 6)	Affordance

Many seniors also found the experience helpful for their own endoscopy skill development, noting that taking over the scope to reduce a learner’s loop was challenging and perceived their skill improving. Faculty who observed seniors as both teachers and endoscopists agreed, with at least one commenting that having this experience as a trainee would have made their own transition to first-year attending easier.

Co-teaching

Junior trainees found it helpful when both senior trainee and attending teachers gave complementary instruction. Additionally, when either the attending or senior took over the scope, the other teacher not performing the procedure could continue teaching. Juniors appreciated listening to discussion between senior and attending, such as strategising how to remove a large polyp, as this provided a greater opportunity for learning than watching an attending remove the polyp alone. However, co-teaching introduced a potential barrier to junior learning, as two teachers could contribute to cognitive overload, particularly if they provided conflicting instructions or engaged in background conversation irrelevant to the procedure (table 3).

Table 3.

Concepts and excerpts related to co-teaching theme

Concept	Representative quotes	Perceived effect on learning
Complementary instruction	‘It was helpful having both there … Once the senior fellow ran out of ideas … it was helpful for the attending to jump in.’ (Junior 4) ‘(I can) hone my own teaching to points that really matter.’ (Attending 4)	Affordance
Practice in attending role	‘I view my role as trying to step back and let the senior fellow take the reins on teaching, but also to obviously be observing and making sure everything goes well … make sure things … aren't missed. … It’s almost like they're the attending with backup, and I think that’s beneficial.’ (Attending 8)	Affordance
Cognitive overload	‘(It could) become a little overwhelming. … Whenever there’s more people in the room … the cognitive load is a bit higher just because you have that extra opinion in the room that you're hearing.’ (Junior 9) ‘I feel like as a first-year fellow, nothing would be more annoying than two people telling me what to do. I think that'd be overwhelming.’ (Attending 6)	Barrier
Time	‘I see no drawbacks other than we're significantly slower.’ (Attending 6)	Barrier
Unclear expectations	‘There’s a challenge, having not defined the role between myself and the attending. I don't think that caused any problems, but it was kind of a gray area during the middle of the case [with therapeutic] interventions. … Could have been handled more directly before the case.’ (Senior 2)	Barrier

Some faculty intentionally gave the senior autonomy in the teaching role, noting it was beneficial for them to practice being an attending. Increased case duration was frequently cited by faculty as a challenge; faculty felt this could be addressed by setting clearer expectations with seniors for when to take over. Several seniors agreed that unclear expectations could be a barrier to a good experience.

Collaborative Learning

When the attending took over the scope, the senior trainee shifted from a teaching role into a learning role; seniors appreciated the attending teaching them in these situations. However, a second learner presented challenges for some faculty, who found it difficult to split their attention (table 4).

Table 4.

Concepts and excerpts related to collaborative learning theme

Concept	Representative quotes	Perceived effect on learning
Senior learner	‘The junior fellow and I learned together. Even though I was in the teaching role, we were both able to learn from the attending, because he stepped in to fill some gaps that I couldn’t.’ (Senior 1)	Affordance
Split attention	‘My focus is a bit more split, because I was trying to figure out how the senior fellow was teaching, and how I could give him feedback on his teaching style, but then also, how the junior fellow was learning and doing the endoscopy … I think it’s hard to do both things well. … You want both fellows to get something out of the situation, and you really want to be able to focus on both.’ (Attending 4)	Barrier
Crowding	‘There were just too many people in the room and too much talking.’ (Senior 3)	Barrier
Dividing learning opportunities	‘I think for interventions, a lot of times the senior will do them and I'm like, I'm never going to do one if they're always the ones doing (therapy).’ (Junior 6)	Barrier

Juniors perceived they might lose learning opportunities when the attending gave the scope to the senior for complex parts of the procedure. Juniors felt setting clear expectations in advance for what parts of the procedure the senior would perform would have been helpful.

Discussion

Although junior GI faculty are routinely expected to teach trainees, there is no requirement for training in procedural teaching during specialty training, and many find teaching endoscopy an intimidating challenge.¹⁴ In this study, we investigated how allowing senior trainees the opportunity to teach endoscopy impacted learning and explored the faculty experience of supervising a trainee’s teaching. Many affordances for learning were identified, though some barriers as well.

Consistent with other published near-peer teaching programmes,³ near-peer endoscopy teaching was well received by our learners. Junior trainees appreciated lower stress compared with learning from an attending and the ability of seniors to relate to struggles of an early endoscopy learner and explain concepts using more comprehensible language. Juniors reported affordances to learning overall outweighed barriers. Faculty mostly agreed with junior trainees’ impressions, with many recognising benefits of near-peer teaching, though a minority felt juniors’ time might be better spent with experienced faculty teachers. Our study was not designed to directly compare teaching delivered by faculty and senior trainees. However, previous work suggests peer teachers do not require extensive training to be effective: a trial comparing teaching ultrasound by student teachers to teaching by ultrasound-experienced physicians found no difference in learning outcomes¹⁵; similar results were seen comparing student teachers with faculty teachers for vascular access and bladder catheterisation.¹⁶ These results should be extrapolated with caution to endoscopy, which is a substantively different task. Encouragingly, no faculty in our study felt senior trainee teaching was detrimental to junior learning. Certainly, experienced faculty teachers should continue to play a prominent role in endoscopy education, however, we believe the positive impressions of junior trainees in our study warrant consideration for incorporating near-peer teaching as a complementary instruction modality in GI training.

Senior trainees and faculty agreed on the benefits of developing teaching skills in a supervised environment and improving procedural skill through recognising and correcting a learner’s mistakes. It is well established that teaching promotes learning.⁶ Among several theories proposed to account for this effect is the retrieval practice hypothesis, which postulates that effortful retrieval of information to be taught from long-term memory helps refine memory schemas.⁷ Our participants felt teaching endoscopy promoted deeper understanding and learning for senior trainees, again supporting potential benefits for integrating it into GI training.

In procedural skill development, learners progress through four stages of competence. The novice demonstrates unconscious incompetence, neither understanding the skill nor their own deficits. With training, they progress to conscious incompetence, where deficits are recognised and learnt from. After further deliberate practice, competence is achieved, but concentration is required to successfully perform the skill, a stage known as conscious competence. With time and continued practice, conscious competence may evolve into unconscious competence, in which the skill becomes automatic, and in the endoscopy context this increased speed and efficiency beneficially permits devoting more attention towards detecting pathology. While frameworks for understanding how we learn to master procedures such as Ericsson’s theory of deliberate practice do not directly address learning to teach procedures, it has been suggested that maintaining conscious competence is critical for both further skill development and effective teaching.^{2 17} Per Ericsson, ‘the key challenge for aspiring expert performers is to avoid the arrested development associated with automaticity and to acquire cognitive skills to support continued learning and development’.¹⁸ A study of a ‘Train the Colonoscopy Trainer’ programme noted resistance to change/improvement among experienced proceduralists who had achieved automaticity in performing colonoscopy. Furthermore, automaticity negatively impacted teaching effectiveness because, as one participant stated, ‘I can’t explain what I do’.¹⁹ Conscious competence allows the teacher to understand the problem facing the learner and deconstruct its solution into discrete steps that can be verbalised, and the American Society for Gastrointestinal Endoscopy considers ‘conscious competence instrumental for effective endoscopy teaching’.² Our study highlights the importance of maintaining conscious competence for endoscopy teachers of all experience levels. Senior trainees in our study agreed they needed to be conscious of their actions to teach effectively, and we posit that engaging in activity forcing this realisation before automaticity has set in may promote ongoing effort to build and maintain conscious competence.

Our study has several limitations. All participants were part of a single training programme, which may limit generalisability to other programmes. Based on the number of trainees in the programme and their rotation schedule, two seniors and one junior participated twice. As each of these repeat participants was paired with a different peer and attending each time, we do not believe this meaningfully impacts the data. Trainees able to participate were those on the rotation where near-peer teaching occurs during the study period; as the schedule was essentially random and no invited trainees declined to participate, we do not believe there was significant selection bias with respect to trainee participants. As there was a larger number of potential attending participants, the authors intentionally invited attendings with varying levels of teaching experience and ensured gender balance among attending participants. As all faculty in our programme are actively involved in trainee education, and as no invited faculty declined to participate, we also do not believe there was significant selection bias with respect to the interest in teaching of faculty participants. The impact of a near-peer teaching programme on other participants in the endoscopy procedure, namely the endoscopy nurse and the patient, was not explored. While these are important perspectives to consider when implementing a programme of near-peer teaching, we limited the focus of this study to affordances and barriers to trainee learning, for which impressions of the teachers and learners were most relevant.

We intentionally used a single observer, a third-year fellow when the research was conducted and well known to all participants, as suggested by Paradis and Sutkin, who suggest the absence of a strong observer effect in rigorous health professions education research.²⁰ We felt CF’s peer relationship with other fellow participants and trainee relationship with faculty participants would promote comfort and openness of subjects during interviews, and lack of a need to perform, as compared with an interviewer unknown to participants. Additionally, it was important that the interviewer be familiar with endoscopy so appropriate follow-up and probing questions could be asked. Previous work has suggested learner perceptions of learning do not correlate well with actual learning,²¹ and reflections of our participants should be considered in this context. While there are tools for measuring performance in endoscopy,²² these were not used as detecting a difference in junior trainee endoscopy performance because of senior trainee teaching would require more prolonged exposure to near-peer teaching than was present in our study. Furthermore, the focus of our study was on exploring perceptions of learning rather than performance.

In summary, our study reveals intriguing insights into how near-peer teaching may benefit endoscopy education and suggests involving senior GI trainees in endoscopy education of junior trainees may promote learning for both groups. For junior trainees, near-peer learning may complement the education they receive from faculty, and for senior trainees, the experience of teaching endoscopy may benefit both teaching skill and procedural skill. Like new attending gastroenterologists, senior trainees in this study did not receive formal education to prepare them for endoscopy teaching; rather, they drew on their own experience as trainees to develop their teaching style. Despite this, their teaching was positively received by junior trainees. Development of a structured curriculum for senior trainees to learn principles of effective endoscopy teaching prior to engaging in supervised teaching practice may accentuate the benefits for both groups of learners. We could envision initially piloting such training for senior trainees interested in academic careers, and if successful, expanding it to become a standard part of the GI training curriculum with the goal of producing both better teachers and more skilled endoscopists.

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information. Complete interview transcripts beyond the excerpts included in this article are not available for sharing.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

This study involves human participants and was approved by UCSF Institutional Review Board, IRB #: 19-29510, Reference #: 304734. Participants gave informed consent to participate in the study before taking part.