Training for colonoscopy

Requests for colonoscopy continue to increase, with no prospect of a plateau now that the Department of Health is promoting better colorectal cancer services. There is even a possibility of national population screening if the pilot studies continue to show benefit^1,2. For both diagnosis and surveillance, in most patients, colonoscopy is the best way to examine the large bowel. A possible alternative is `virtual colonoscopy' or CT colography³, in which spiral computed tomography is combined with graphic computerized reconstruction of the colonic lumen. This has yet to be adequately evaluated in clinical practice; but with any radiological method at least one-third of examinations would have to be followed by conventional colonoscopy for validation or therapy (polypectomy in particular).

Even if we could fund more colonoscopy sessions and even if a proportion of the increased work were shifted to nurse-endoscopists⁴, how could we train the new endoscopists and at the same time raise the standards of existing practitioners? Colonoscopy is a skilled procedure which is not always well done. Many endoscopists have been trained through a patchy apprenticeship at best, augmented by an occasional demonstration by world experts beamed across the globe by satellite. Such diversity is no longer acceptable. A structured training programme is required, for both trainers and trainees.

A challenging solution is being developed by the Royal College of Surgeons of England (Raven Department of Education) and the British Society of Gastroenterology (Joint Advisory Group on Endoscopy Training). There are three major components. First, the trainers must be trained; an existing three-day course at the Royal College of Surgeons has now been modified to provide a training-the-trainers (colonoscopy) module. The hope is that aspirant local trainers will attend one such course and then disseminate the good practice and technique in their own locality. Each trainer will have learned the principles of good training—in particular, avoidance of teaching by humiliation and of excessive intervention (`let me show you'). In theory a good trainer does not have to be an expert, though, unlike a football coach, he or she must be able to take over as replacement and finish the game.

Secondly, the approved regional training centres (initially 6-8 in England), staffed by trained trainers, would run local courses, two or three times a year. The courses would be in standard format, lasting three days, and would target specialist registrars in medical or surgical gastroenterology (though other specialists and career grades might also wish to enrol). As well as enthusiastic local trainers with protected teaching time, such centres would need additional support—for example, high-quality instruments and technical backup from endoscope manufacturers. Each local centre would have a standard fixed closed-circuit television system in the endoscopy training room, with facilities for trainees to videotape their own performance. There should also be provision for early testing of manipulative skills and brain—hand—eye coordination, by use of simple mechanical colon models and perhaps the electronic simulators⁵ that have just come on the market. The training principles of such simulators are well established in the airline industry but have yet to be adequately tested in clinical endoscopy. Another valuable training tool is the electromagnetic imager⁶, which involves no ionizing radiation, has been refined over the past five years and may soon be commercially available. It may not help the expert much—except with the `endless colon'—but in the learning phase of colonoscopy it provides realtime awareness of the type and location of the various colonic loops. In this context, fluoroscopy has largely been abandoned worldwide as unnecessary as well as potentially dangerous.

In summary, the basic training course aims to teach a technique of colonic intubation that achieves safe and accurate examination of the whole colon in over 90% of patients. Before attending, each trainee should read a short standard handbook, so that the course can concentrate on individual hands-on training.

So, the trainers have been trained and the trainees have been taught, but our third component is not yet in place—audit and monitoring. The trainees should be able to continue developing their endoscopic skills by attending supervised colonoscopy lists in their own base hospital, but with ready access back to the training centre for specific progress reports, help and advice. Each training centre would need to demonstrate continuing quality control and performance standards—for example, by interchange of trainers and random assessment of videotaped procedures. Only if such initiatives are supported, funded and validated will we be able to provide satisfactory and safe colonoscopy throughout the National Health Service.