UK endoscopy trainer survey: perspectives on current endoscopy training delivery, experience, barriers and opportunities

Abstract

Objective

UK endoscopy training is delivered by trainers possessing well developed endoscopy and teaching skills to help learners perform high-quality endoscopy. Train The Trainer (TTT) courses are effective, but additional trainer support is variable with little formal quality assurance. We performed a survey to map UK endoscopy training, assess trainer perspectives on training delivery and identify factors that would enhance training.

Design/Method

An online survey was designed by trainer representatives, in collaboration with the JAG training committee, and collected responses from trainers registered on JAG endoscopy training system e-portfolio from April to June 2022.

Results

There were 1024 responses from all trainer disciplines, with 813 (79%) completing TTT courses and 584 (57%) having job planned dedicated training lists (DTLs). Clinical endoscopists most frequently had job-planned DTLs (71%), and DTLs occurring at least weekly (58%). 293 (29%) respondents participated as course faculty. Trainers reported high levels of pre-procedure preparation, effective dialogue and frequent feedback. The DOPS forms were ‘always/often’ completed by 81% of clinical endoscopists, 73% of gastroenterologist and 58% of surgeons. 435 (42%) trainers never had peer feedback. Responses suggested training could improve by protecting training time, attending courses, participating as faculty and receiving feedback from experienced trainers.

Conclusion

This survey demonstrates substantial proportions of highly motivated UK trainers who value time spent teaching and learning how to teach. Skills taught on the TTT courses are often actively used in everyday training. Improved trainer course access, protected training time and formal use of existing feedback tools by peers were highlighted as measures that could support trainers’ development.

WHAT IS ALREADY KNOWN ON THIS TOPIC.

• Endoscopic Train The Trainer (TTT) courses are designed to improve the training skills of endoscopists, and they have been shown to improve endoscopy quality outcomes.

• The tools for providing trainer feedback (Direct Observation of Training Skills (DOTS) and Long-Term Evaluation of Training skills (LETS) forms) are available on the JAG endoscopy training system e-portfolio and can be used to provide feedback and support trainer development.

WHAT THIS STUDY ADDS

• This study effectively maps the self-reported endoscopy training delivered by UK endoscopy trainers.

• A high proportion of trainers have completed a TTT course and approximately half have a regular job planned dedicated training list.

• Clinical endoscopists provide a valuable proportion of the endoscopy training with formal job planning, regular lists, generic training and regular DOPS feedback.

• Trainers are aware of the DOTS and LETS feedback tools and would welcome regular feedback (especially from peers), however, they are reportedly underused.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY.

• Local training leads and clinical leads should ensure that all trainers have endoscopy training allocated in their job plan if they are providing regular formal endoscopy training.

• Training course centres should take this survey as evidence that there is a widespread enthusiasm and appetite for training among endoscopy trainers and to engage trainers in delivering basic courses and to attend up-skilling training courses.

• Further work is needed to explore appropriate mechanisms to provide regular timely and effective feedback to endoscopy trainers.

Introduction

Endoscopy trainers are responsible for creating independent endoscopists of the future. High-quality training is performed by skilled endoscopy practitioners who possess teaching skills that can help trainees develop the technical and non-technical skills required to perform high-quality endoscopy.^1–3 The planned expansion of endoscopy services will increase this workload.^{3 4} The 2-day gastroscopy and colonoscopy Train The Trainers (TTT) courses are effective and popular, but additional trainer support is variable with little formal quality assurance for trainers across the UK.⁵ Addressing these development needs is essential for sustaining trainers and creating the future endoscopy workforce.^{3 5 6}

This survey aims to explore the current practice of UK endoscopy trainers, gain an insight into their experience of endoscopy training, identify any perceived barriers to development and signpost training opportunities.

Study objectives

• Map current endoscopy training provision in the UK.

• Explore perceived strength and areas of development of UK endoscopy trainers.

• Explore perceived barriers to trainer development.

• Explore the appetite of UK endoscopy trainers to develop training skills and provide signpost to local centres

• Explore the effectiveness of trainer development tools such as Direct Observation of Training Skills (DOTS) and Long-Term Evaluation of Training Skills (LETS).

Method

A survey was designed by a working group from different professional backgrounds with experience of endoscopy training and trainer workforce development with the JAG training committee. The survey was created on an electronic survey platform (Survey Monkey) and sent to all trainers registered on the JAG endoscopy training system (JETS) e-portfolio using an email link. The survey was released on 8 April 2022 and anonymous responses were collected prospectively until survey closure on 28 June 2022.

Results

Map current training provision in the UK

Of 1024 trainers (31% of the total 3292 on JETS) completed the survey and table 1 provides a summary of regional breakdown. Of respondents, 470 (46%) were consultant gastroenterologists, 301 (29%) were consultant surgeons, 167 (16%) were clinical endoscopists and 86 (9%) respondents identified as ‘other’ (including paediatric gastroenterologist, hepatologist, radiologist, GP endoscopist, fellows and specialist nurses).

Table 1.

Summary of the number of trainers from each UK region and the proportion of whom have attended a train the trainer course, have dedicated training lists in their job plan and participate as course faculty (a more detailed table available as in online supplemental material)

Region (According to JAG deanery list)	Tot (n)	Cons Gastro (n)	Cons Surgeon (n)	Clin Endo (n)	Other (n)	TTT (%)	DTL in job plan (%)	Fac (%)
UK Total	1024	470	301	167	86	79	57	29
East Midlands	78	42	20	13	3	74	47	27
East of England	76	36	21	11	8	88	76	33
Kent, Surrey & Sussex	86	34	29	15	8	78	72	21
London	145	76	37	22	10	77	66	30
Mersey	25	14	7	3	1	80	64	32
Northern	73	30	15	17	11	88	56	44
North Western	73	39	20	12	2	74	58	16
Northern Ireland	20	16	2	2	0	85	30	40
Other	28	5	7	10	6	86	64	14
Oxford	31	19	7	3	2	87	55	16
Scotland	86	27	39	10	10	73	48	30
Severn	34	23	10	0	1	76	41	44
South West Peninsula	65	20	25	12	8	72	35	23
Wales	30	19	7	4	0	83	53	50
Wessex	47	28	13	6	0	85	53	23
West Midlands	68	24	20	19	5	74	57	28
Yorkshire and the Humber	59	18	22	8	11	88	58	25

%, percentage; Clin Endo, clinical endoscopist; Cons Gastro, consultant gastroenterologist; Cons Surgeon, consultant surgeon; DTL in job plan, dedicated training list in job plan; Fac, participate as course faculty; n, number; Tot, total number of trainers; TTT, trainer the trainers course completed.

DTL provision and allocation by frequency and specialty

Of 1024 trainers, 584 (57%) reported a dedicated training list (DTL) in their job plan. Clinical endoscopists reported the highest proportion of job-planned DTLs (71%), followed by gastroenterologists (58%) and surgeons (46%) (see UK total, table 1).

Of the 440 trainers who do not have a job-planned DTL, 379 (86%) provide ad hoc training.

Table 2 provides a summary of DTL frequency categorised by trainer specialty and how these are distributed among trainees.

Table 2.

Frequency and allocation of DTL provision per profession

		All trainers with DTL in job plan (n=584)		Consultant gastroenterologist with DTL in job plan (n=273)		Consultant surgeon with DTL in job plan (n=139)		Clinical endoscopist with DTL in job plan (n=118)
		n	%	n	%	n	%	n	%
Dedicated list frequency	>1/week	156	26	79	29	11	8	43	36
	1/week	314	54	148	54	70	50	69	59
	<1/week	110	19	43	16	58	42	6	5
	No response	4	1	3	1	0	0	0	0
Dedicated list recipient	Gastro trainee only	89	15	82	30	0	0	5	4
	Surgical trainee only	59	10	0	0	57	41	1	1
	Trainee clinical endoscopist only	9	1	5	2	0	0	4	3
	Two or more different specialty trainees	429	74	185	68	82	59	108	92

DTL, dedicated training list; n, number.

Eighty-one per cent of trainers with a job planned DTL provided this at least once per week or more frequently. Between professional groups, provision of once weekly DTL was comparable (gastroenterologists 54%, surgeons 50% and clinical endoscopists 59%). Clinical endoscopists and gastroenterologists most often reported they provided more than one DTL per week (36% and 29%) with surgeons less frequently (8%).

Clinical endoscopists more commonly instructed trainees from multiple professional backgrounds, whereas surgeons and gastroenterologists more regularly provided training to trainees from a single specialty, most commonly from a similar professional background.

Explore perceived strength and weaknesses of endoscopy trainer skills

Six Likert scale questions were used to assess trainer usage of the Set-Dialogue-Closure training structure commonly taught on the TTT course. The number and wording of questions were derived from TCT faculty literature and agreed on by the author group.⁷ The questions were intended to provide a surrogate marker of how well trainers established educational contracts and could demonstrate conscious competence and provided performance-enhancing feedback. Results are outlined in table 3 .

Table 3.

Proportion of trainer responses to Likert scale questions on traditional set, dialogue and closure used for endoscopy training

Set	Before a training list I review a trainee’s, recent progress and set objectives for the list (%)
	All Trainers
	Course Trainers
	Regular Trainers
	Untrained Trainers
	Before a training list I brief the team about training before the list begins (%)
	All Trainers
	Course Trainers
	Regular Trainers
	Untrained Trainers
Dialogue	When a trainee is failing to progress, I can verbally explain how to negotiate the obstacle without taking control of the scope (%)
	All Trainers
	Course Trainers
	Regular Trainers
	Untrained Trainers
	When I need to take control of the scope, I hand it back at the earliest opportunity (%)
	All Trainers
	Course Trainers
	Regular Trainers
	Untrained Trainers
Closure	I provide verbal feedback to trainees at the end of the list (%)
	All Trainers
	Course Trainers
	Regular Trainers
	Untrained Trainers
	I complete DOPS or DOPyS for trainees after each dedicated training list (%)
	All Trainers
	Course Trainers
	Regular Trainers
	Untrained Trainers

All trainers in survey (n=1024).

Course Trainer (n=174) – Trainer has completed TTT, has DTL in job plan and is course faculty.

Regular Trainer (n=326) – Has completed TTT and has DTL in job plan, but not course faculty.

Novice Trainer (n=121) – Trainer has not completed TTT, does not have DTL in job plan and is not course faculty.

For the Set, 72% reported they would always or often set objectives with trainees. Furthermore, 65% reported they would always or often perform a team brief about the training list and where not regularly done, comments indicated that the team was already aware. For training dialogue, 84% of trainers felt they could always or often verbally explain how to negotiate an obstac, and 89% would return control of the scope to the trainee if they had taken over. When this was not done, procedure time and patient comfort factored into trainer decision-making. For closure, 78% reported always providing verbal feedback, but in comparison, only 27% reported always completing a DOPS or DOPyS.

To determine the effect of training experience on trainer perceptions of their skills, we classified trainers according to TTT completion, DTL provision and participation as course faculty. These groups were labelled as ‘course trainers’ (TTT completed, DTL provided and course faculty), ‘trained trainers’ (TTT completed and DTL provided but not course faculty) and ‘untrained trainers’ (no TTT or DTL and not course faculty). There were observable differences in responses between these groups (Table 3).

Course trainers always or often set objectives more commonly than trained and untrained trainers (81% vs 75% vs 65%) and were more frequently able to always or often verbally explain manoeuvres (92% vs 85% vs 78%). Course and trained trainers more frequently reported always or often completing DOPS compared with untrained trainers (75% vs 75% vs 54%).

Comparisons between professional role provide no observable differences in responses other than completion of DOPS/DOPyS. The DOPS forms were always or often completed by 81% of clinical endoscopists, 73% of gastroenterologist and 58% of surgeons.

Explore perceived barriers to trainer development

Endoscopy trainers provided free text responses on how they felt their training skills could be improved. Six-step thematic analysis was performed on 556 free text responses gathered.⁸ Themes are presented in table 4 with verbatim examples.

Table 4.

Common themes on how trainers think their training skills could be improved

Theme	Subtheme	Verbatim comments
Improved availability of protected training time (171 comments)	Basic provision of regular training lists Increased frequency of existing lists Training lists protected from service demands	‘The training lists need to be job planned and adequately supported at the trust level. This will give the time required to concentrate on the trainee, staff, support the training requirements such as debrief, completion of DOPS/DOPyS, signposting to teaching materials and discuss the emerging evidence in the field of endoscopy with trainees’. ‘More consistent, regular training lists - at the minute it's often ad hoc/intermittent based around job plan/trainee availability’. ‘More time to train - there is often a feeling of being rushed when in fact the conversation is part of training’ ‘Ensure the lists are not overbooked (which is usually the case) which will allow time to train’.
Attending formal training courses (159 comments)	Attend initial TTT Attend a refresher TTT	‘A regular training the trainer course perhaps every 5 years” “Would like a refresher course, I did the train the trainers a long time ago, I believe there are new skills I could learn’ ‘As a surgical trainer I am used to explaining practical procedures but specific tips for teaching endoscopy would be useful’
Self-reflections on own trainer skills (98 comments)	Awareness of conscious competence Emphasise structured set, dialogue, and closure. Feelings of stress, anxiety and burnout related to training activity.	‘I feel I need to be more consciously competent about how I personally scope so I can translate this to the student’ ‘I could also listen to the trainee more, rather than focus on what I think is important:‘How to 'talk' trainees through difficult aspects without taking the scope.’ ‘If I am honest, I get anxious when training due to the list’s slow speed’ ‘Previously the excess cognitive and emotional burden of very frequent training led to issues with burnout’. ‘Having confidence in myself as an endoscopy trainer. I am a nurse endoscopist & I have found difficulties with Dr trainees in the past taking advice/instruction from me’.
Building a community of practice to encourage feedback (147 comments)	Participation as course faculty, or at non-course meeting, to share training experiences with other trainers. Direct observation and feedback on own practice by others	‘I have found being on the basic skills courses gave me the opportunity to talk to other trainers and improve my training skills’ ‘Training skills always get a boost after joining as a faculty somewhere else’ ‘Reflection courses or workshops between trainers and senior trainers’ ‘To be able to observe how others do training and pick up best practices or perhaps more efficient methods.’ ‘I would love the opportunity for observed training at more regular TCT type feedback – whenever we do this someone else’s perspective is always enlightening to open other options for teaching endoscopy’ ‘In reach training by more experienced trainers’
Trainee factors impacting on delivery (22 comments)	Aware of demands on trainee time	‘Most important way of improving training would be regular attendance by a given trainee for set lists—doesn't happen with the new trainee shifts - works better for nurse endoscopists who want to train as they can often make lists, but junior doctors often can’t’ ‘For medical trainees to be able to undertake dedicated training lists in an intense, sequential manner without disruption by long periods of on calls/clinical commitments.’

The most common recurring themes were the need for increased protection of training time to perform trainer duties and attending either an initial TTT or a refresher course. A prominent theme was enthusiasm for observation and feedback from peers and other expert trainers, so that trainers may gain insight into their teaching skills. Comments also highlighted trainer reflections on their own conscious competence and the emotional and psychological demands of training including feelings of anxiety and lack of confidence.

Endoscopy trainer course participation

Overall, 79%(813/1024) trainers have completed a TTT course. Clinical endoscopists had the highest completion rate (88%) and surgeons had the lowest (60%) (table 1). Among 211 trainers who had yet to complete a course, the most reported barriers included lack of local course (32%), lack of funding (27%) and not having time (23%). Other reasons included courses not being priority (19%), not mandated in their job role (10%) and lack of course awareness (9%). Of 293 respondents (29%) reported participating as faculty on courses. Gastroenterologists engaged most (38%) followed by Clinical Endoscopists(25%) then Surgeons (11%) (see table 1).

Use of feedback tools and barriers to trainer feedback

DOTS and LETS forms are available on JETS to provide trainer feedback.

Responses show 24% of trainers stated they always encourage trainees to complete DOTS, but only 10% always review their DOTS data and 38% (389/1024) reported someone else reviews their DOTS or LETS data. Furthermore, 42% (435/1024) respondents had never had feedback on their endoscopy training skills from their training lead, and 56% (575/1024) had never received a DOTS from a peer or fellow trainer.

The 2020 endoscopy trainee survey highlighted several perceived barriers for trainees providing feedback to trainers.⁹ We asked trainers if they recognised these same barriers. The most frequently reported barrier to receiving feedback was a lack of time with hierarchy, trainer receptiveness and lack of anonymity less commonly recognised as barriers. Free text comments indicated that trainers may be unfamiliar with the DOTS tools or felt that no useful information from the trainee would be given. The comments highlighted that trainers would value feedback more from peers and expert trainers and see it as a valuable form of skills improvement, but service pressures and time prevent this happening regularly.

Discussion

The UK trainer landscape

This survey shows that endoscopy trainers provide endoscopy training across all areas of the UK and to all trainee backgrounds. Over half have job-planned training and provide regular DTLs, and those without regular DTLs very often provide ad hoc lists to trainees. Clinical endoscopists appear to provide a significant proportion of their time to endoscopy training with high levels of generic training. Surgical consultants usually have fewer endoscopy lists per week, which may explain why they only provide one or more DTL per week in 58% of respondents, which could be argued is a higher training commitment compared with other groups. Surgeons also report that they provide training to surgical trainees alone in 41%, providing circumstantial evidence of why surgical trainees reported lower DTL frequency in previous trainee surveys.^{9 10} Coexistent operating demands on surgical trainees time also limit endoscopy training opportunities, therefore training programme directors and training leads should endeavour to ensure equitable access to generic training lists and immersion blocks.¹⁰ However, flexibility is needed by all stakeholders, and use of evening and weekend lists for additional training capacity may be required but would require funding support and be a further demand on trainers, trainees and the service.

Trainer qualities and opportunities for improvement

Questions on set-dialogue-closure structure provide some insight into how trainers perceive their skills with most indicating a belief they possess good training skills. Self-reporting can be unreliable as a previous study on self-assessed therapeutic endoscopy skill level demonstrated high proportions of less experienced endoscopists overestimated their therapeutic skill level.¹¹ Given the range of experience in our survey cohort, self-assessed training skills have the potential to be similar. Completion of DOPS for every list is a more concrete quality metric and clinical endoscopists seem to perform most reliably for this measure, followed by gastroenterologists and surgeons.

The free text comments offered deeper reflections into training skills and how trainers feel they could improve. Exploration of these themes highlights potential solutions, such as course participation and feedback, which could feed into a formal accreditation process.

Course participation

Trainers indicated a desire to attend either an initial or refresher TTT course. These course programmes are designed to help trainers teach endoscopic skills in the limited time available during each procedure.^{3 5} Aligning agendas, creating SMART objectives and delivering well-constructed feedback can lead to more effective learning and enhanced satisfaction from both trainee and trainer.⁵ Despite comments indicating enthusiasm to attend, there were low numbers of trainers participating as course faculty, particularly among surgeons and clinical endoscopists. Colorectal and upper GI surgeons are well received on courses and add valuable insights into diagnostic and therapeutic endoscopy. Clinical endoscopists are a valuable training resource and should be released to support courses.

Course centres usually have audio-visual link to training episodes to provide delegates the opportunity to observe other trainees. This also provides a demonstration of trainer skills to other faculty members and facilitate trainer feedback from peers and course leads. Within both clinical and educational circles, combinations of regular direct observation of practice by others, or self-assessment following video assessment, has been shown to aid trainer skill development.^{12 13}

Utilisation of DOTS and LETS

DOTS and LETS are reliable tools for delivering trainer feedback, and our survey highlights broad awareness, but they appear underused. High numbers of trainers appear to lack regular feedback, even those with regular DTL where it would be most beneficial.

While our survey suggests trainers do not perceive hierarchy to be a significant barrier to feedback, who delivers the feedback is likely to be important.¹⁴ In educational terms, adult learners may expect their tutors to be experts, therefore trainers may be more receptive to training leads and peers providing feedback, compared with trainees.¹⁵ Courses provide the most practical opportunity for this where DOTS can be offered by the course provider and could facilitate a longitudinal process.¹⁰ Endoscopy training could follow a similar approach to training GP trainers incorporating direct and remote observation, multiprofessional feedback and an experienced mentor.¹⁶

Time

Trainers are concerned they lack time to deliver high-quality training. Specifically, it is a lack of time to attend training courses, overbooking of lists restricting effective training sessions and subsequent time constraints preventing adequate trainee or peer feedback. DTLs should be ring-fenced to give trainees the time to learn new skills, and trainers the time to teach. Releasing trainers to upskill on training courses should lead to a more efficient and effective trainer, so that the short time available for training can be used optimally. Uninterrupted training blocks (immersion) are now commonly seen as the way forward for training trainees but equipping a trainer workforce to supply immersion has not been addressed.

Trainer quality assurance

Endoscopists responding to this questionnaire were either regular faculty on courses, TTT experienced trainers or trainers yet to attend training skill courses. This shows that trainers are heterogeneous with different experience and skill levels, corroborated by the themes generated in the survey. Different trainer levels have been previously proposed and could provide different roles for trainees either providing regular supervision, or offering a more analytical and problem-solving role, or trainers with advanced skills offering therapeutic training.³

Developing a core regional training team that trainees can be rotated through during their training could make best use of the current trainer workforce. Upskilling and accreditation of trainers could consist of participation in a specific number of regional JAG-approved basic skills, TTT or therapeutic courses per year as faculty. Web-based training also has potential and work is currently being undertaken to explore whether the Think Aloud technique, often used in sports coaching, can be used for trainer development.¹⁷ Trainers watch a recorded video of a trainee performing colonoscopy while ‘thinking aloud’; the automated transcription can then be used to give them insight into their training skills.

Limitations

This survey collected both quantitative and qualitative data and with the response rate, we feel it provides a good representation of the trainer experience in the UK at present. The survey is based on self-reported data from UK trainers and reliant on their perceptions of their workload and skills. We were not able to interrogate JETS e-portfolio for training data, which could have provided comparison to objective data. We did use the survey to signpost trainers to their local training centres, but we have not sought feedback from training centres as to the response received post survey.

Summary

To our knowledge, this is the first study to collect data from all disciplines of endoscopy trainers across the UK. Our survey demonstrates that the UK possesses a trainer workforce from a wide background who have high levels of trainer course attendance and regular job-planned DTLs. The responses indicate a strong motivation to teach high-quality endoscopy and that trainers value both time teaching endoscopy and learning how to teach. Our survey also demonstrates the challenges trainers face and the need for the hard work that the trainers undertake to be both protected and job planned. Regular feedback, either from trainees, peers or expert trainers is generally welcomed by trainers. Better access to courses would be an easy win to support courses and up skill trainers. The responses, therefore, highlight important areas that can be addressed by regional academy directors, regional training centre leads and local training leads to instigate change and support the UK endoscopy trainer workforce.

Data availability statement

Data are available upon reasonable request. The anonymous dataset generated from the survey can be made available on reasonable request.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

Not applicable.