How to ACE your endoscopy training: let competency speak volumes

The traditional structure of gastroenterology fellowship has been an apprenticeship model much like those in the rest of medicine, where trainees learn on the job to treat patients, recognize common pathologic conditions, and perform endoscopy. The Accreditation Council for Graduate Medical Education (ACGME) sets minimum standards that must be achieved in a 3-year gastroenterology fellowship program to successfully graduate trainees. These have typically included specifications for a minimum number of cases that should be completed before the trainee can be signed off to independently perform a variety of endoscopic procedures.

This numbers-based approach has become outdated since the implementation of the Next Accreditation System, which emphasizes trainee progression through a series of clinical milestones and achievements that can be captured through continuous evaluation. This change is part of a more global paradigm shift in medical training that recognizes that trainees do not master skills at the same pace, or at similar case numbers, and instead should be measured for achieving competency along these milestones—so-called competency-based medical education (CBME).¹ Defining and measuring competency in the cognitive and technical skills of endoscopy is a critical first step in this training process.

To assist this evaluation, various tools have been described that reflect established quality metrics in endoscopy and offer a framework for evaluating trainee progress. The Mayo Colonoscopy Skills Assessment Tool (MCSAT) is one such validated instrument.² In 2014, the Training Committee of the American Society for Gastrointestinal Endoscopy (ASGE) affirmed their support for moving away from a numbers-based training system and toward measuring performance metrics and competency thresholds.³ Championed by Dr Sedlack, the ASGE training committee released a refined version of the MCSAT tool for Assessment of Competency in Endoscopy (ACE) for colonoscopy and EGD. Learning curves for gastroenterology fellows have been described for colonoscopy skills with the use of the ACE tool⁴ and for EUS and ERCP with the use of other validated tools.⁵

In this month’s issue of Gastrointestinal Endoscopy, Miller et al⁶ describe a prospective multicenter study to validate the ACE tool for EGD (ACE-E) among 96 gastroenterology fellows in all stages of training over a 1-year time period at 10 academic institutions. Both specific and general cognitive and motor skills were assessed by a 4-point grading scale from novice to competent at set intervals (every 50th procedure) for a total of 1002 evaluations. Competency was defined as average ACE-E scores of 3.5 and second portion of the duodenum (D2) intubation rates ≥95% of the time and in ≤4.75 minutes. Learning curves were generated and minimum thresholds of competency were described. Overall cognitive competence was achieved at an average of 250 upper endoscopies (knowledge of indications and medical issues at 200, management of patient discomfort at 250, recognition of pathologic states at 300). Competency in overall motor skills (and subcomponents: endoscope tip control technique and ability to apply therapeutic tools) was achieved at an average of 250 upper endoscopies, whereas competency in visualization of the mucosa was achieved sooner at 200 endoscopies.

The authors should be commended for their robust analysis of upper endoscopy learning curves in a large group of gastroenterology fellows across the United States. They also deserve recognition for advocating a change in the culture toward competency-based education for endoscopy training—a task that is not easy to accomplish. A strength of the study is that trainees were blinded from their evaluations, which likely encouraged more honest assessments. Although beyond the scope of this study, the impact of direct feedback on trainee learning curves deserves attention and may be a valuable modifier in the future of trainee development. Importantly, there were no differences among the training sites, although they were all tertiary referral academic medical centers, so the findings may not be generalizable to smaller communitybased gastroenterology training programs or even to non-gastroenterology providers who perform endoscopy. Finally, this study is an important demonstration of the feasibility and effectiveness of large-scale implementation and application of a competency-based assessment tool for upper endoscopy.

However, a few limitations of this study warrant discussion. The ACE-E tool did not separately assess the skills of esophageal intubation, traversing the pylorus, and negotiating the duodenal sweep, inasmuch as all these were included in 1 category (under “scope tip control/advancement techniques”) and graded together. Similarly, endoscopic interventions were also grouped together and graded as 1 unit, although the skills for each individual intervention (eg, biopsy, injection, hemostasis, dilation) are quite different from the others and may be learned very differently. D2 intubation times of ≤4.75 minutes and average total procedure times of ≤12.5 minutes were identified as the points separating competent from noncompetent groups. It should be noted that these times likely reflect purely diagnostic upper endoscopies because endoscopic interventions may be performed in the esophagus and stomach before examination of the duodenum on the basis of clinical needs, which may affect these times. Additionally, the authors did not comment on whether any of the fellows used simulators, which may affect skill level.

The major finding that, on average, gastroenterology fellows achieve competency in upper endoscopy around 250 procedures has implications for training. Earlier ASGE guidelines (which many ACGME-accredited gastroenterology fellowship programs follow) recommend that a minimum of 130 upper endoscopies be performed prior to assessment for competency in the setting of credentialing or privileging.⁷ The present study suggests that it may take nearly double the number of cases as previously thought to develop competency. However, the ASGE has also published an EGD core curriculum with emphasis on quality metrics and competency indicators that supersede a numbers-based system.⁸ Also, the relevance of these results to learning curves and competency thresholds for non-gastroenterology providers who perform endoscopy is unclear.

Tools to measure competency in endoscopy are essential to guide our training programs, but they also present additional demands: (1) Who should be responsible for this task? Should it be the local faculty, program directors, fellows tracking their own progress, or the ACGME? (2) How can we create a system that automatizes feedback for fellows and allows them to see where they are on learning curves and study the impact of feedback on trainee learning curves? (3) If a fellow does not meet minimum competency thresholds toward the end of fellowship, there must be a plan in place to provide additional training. It is unlikely that these additional resources are currently available within all training programs. (4) What are the consequences of competency measurements for privileging and credentialing? Creating and validating tools is a critical first step, but widespread implementation still poses challenges. (5) As we work toward making CBME a reality, we must also face a parallel challenge: how can we improve endoscopic training, and can we “shift” these learning curves toward quicker and enhanced learning? Endoscopic simulators offer a huge potential to promote more efficient and effective skills acquisition for trainees. They allow for self-directed learning and practice without the necessity of available supervision. Indeed, simulators are a major focus of current research, and they hold promise for improving endoscopy training.⁹ (6) Finally, how can we improve training in the cognitive aspects of endoscopy, such as preprocedural planning (indications, contraindications, risks), intraprocedural recognition of pathologic conditions, and postprocedural care (adverse event management, adherence to surveillance intervals)? Given that these topics are the foundation of the gastroenterology core curriculum, which theoretically could be learned early in the fellowship, it is surprising that these cognitive skills were not achieved sooner than the motor skills in the present study. One possible explanation is that the current method of teaching the core curriculum in classrooms/didactics across fellowship programs is inadequate. Indeed, medical education is moving away from the lecture format toward a problem-based or case-based learning and flipped classroom-style teaching. This shift recognizes distinct learning styles in the current generation of trainees, many of whom are millennials who value experiential learning. Creative approaches drawn from educational theory and including e-learning, digital technology, and social media can be implemented in gastroenterology fellowship programs to enrich endoscopy training.¹⁰

Miller and colleagues⁶ provide important thresholds where the average gastroenterology fellow will achieve competency in the cognitive and technical skills of upper endoscopy (on average, 250 EGDs). These data can be used to guide fellowship programs and curriculum development. Efforts should focus on the integration of these validated tools such as ACE-E into more training programs, which may be accomplished through possible strategies that include programmatic implementation through ACGME, under the auspices of the major gastroenterology societies, or in a framework of quality control. This major shift in the culture of endoscopy training from numbers to competency requires buy-in from key stakeholders. This change will take time. In the short term, we must invest research, resources, and energy into improving training. As the diagnostic and therapeutic potential of endoscopy rapidly evolves, we must leverage new technologies and novel educational strategies to give our fellows the best chance to become competent endoscopists. Our trainees, and our patients, depend on it.

Miller and colleagues provide important thresholds where the average gastroenterology fellow will achieve competency in the cognitive and technical skills of upper endoscopy (on average 250 EGDs). These data can be used to guide fellowship programs and curriculum development.

Abbreviations:

ACE

Assessment of Competency in Endoscopy

ACE-E

Assessment of Competency in Endoscopy tool for EGD

ACGME

Accreditation Council for Graduate Medical Education

CBME

competency-based medical education

MCSAT

Mayo Colonoscopy Skills Assessment Tool