Adult Gastroenterology Training Program

First Year GI Residents' Endoscopy Training Course

Training in GI endoscopy has largely been based on hands-on acquisition of experience in patients rather than on a structured training program. Unlike most diagnostic modalities, endoscopies evolved amidst a number of specialties, being performed by gastroenterologists, surgeons, and radiologists and as a result, clear training requirements and provision differed. There are currently no guidelines regarding how endoscopists should be trained. Many national endoscopy societies have produced guidelines that include aspects of endoscopy that should be learned and have recommended minimal competency procedural thresholds. Yet none have addressed the issue of how to teach endoscopic skills in a structured way. The traditional model of “see one, do one, teach one” is probably not an adequate method of conveying the necessary information for successful, safe endoscopy. A well-organized, structured training is essential if we are to ensure that procedures are performed in a safe and effective manner. In addition, such a program would serve to improve and standardize the training and practice of endoscopy, and ultimately improve the quality and safety of endoscopic procedures.

A structured pre-endoscopy training curriculum should ideally include introductory lectures and courses on the cognitive aspects of competency of endoscopy including informed consent, safety and sedation, indications and complications of endoscopy, unit management, endoscopy and accessory design, and their operation. Once the cognitive aspects of competency has been taught and assessed, teaching of psychomotor skills necessary for endoscopy can be addressed. These skills can be taught by the use of simulation which has been shown to decrease the time needed to improve the performance of trainees significantly especially in the early training period. Once the psychomotor skills are mastered, the trainees can then achieve proficiency by practice on real patients under supervision. Underpinning the acquisition of cognitive and psychomotor skills is the ability to identify and correctly interpret pathologies. This component of endoscopy training can be taught by reviewing video clips or endoscopic pictures of pathologies.

With the goal of formalizing a structured pre-endoscopy training curriculum, the First Year GI Residents Endoscopy Training Course was first introduced in 2005 at McMaster University. It is an intensive 2-day course which incorporates didactic lectures, small group discussions, hands-on training on simulation and dinner event with debate by course faculty at McMaster University. This annual course has been endorsed by many GI training programs across the country and has been very well received by trainees. This is now, attended by 35 to 40 first year Adult and Pediatric GI residents and surgical residents, and the course has included faculty from across the country. It is important to highlight that all faculty trainers for the simulation sessions have received formal training as endoscopic trainers through Train-the-Trainers (TTT) programs.

The steering committee of this course includes: David Armstrong, Frances Tse, Lawrence Hookey, Don MacIntosh, Mark Borgaonkar, David Morgan, John Marshall and John Anderson (UK National Endoscopy Training Lead).

Specific goals and objectives

Medical Expert

Understand the importance of integration of all CanMEDS roles to provide optimal, ethical and patient-centered medical care in endoscopy:

  1. Identify performance, quality and safety indicators in endoscopy in accordance with the Canadian Association of Gastroenterology (CAG) Consensus Guidelines on Safety and Quality Indicators in Endoscopy
  2. Appropriate use and care of equipment used in endoscopic procedures
  3. Recognize the indications, interpretations, limitations and complications of endoscopic procedures including endoscopy, colonoscopy, flexible sigmoidoscopy and advanced procedures (endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, capsule endoscopy) in a resource-effective and ethical manner
  4. Recognize the hazards of endoscopic procedures for the endoscopist, assistants and patient and the measures appropriate to minimize such hazards
  5. Recognize the importance of pre-procedural care to optimize patient safety and quality of endoscopic procedures including antibiotic prophylaxis, routine and special needs for sedation, anticoagulation management, and colonoscopy preparation
  6. Understand the principles of informed consent for endoscopic procedures with thorough explanation of the procedure, review of appropriateness of the indication, assessment of contraindications, explanation of risks and alternatives
  7. Identify and appropriately respond to relevant ethical issues arising in patient care during endoscopy
  8. Understand the principles of management of gastrointestinal emergencies including, but not limited to: upper GI bleeding, lower GI bleeding, biliary obstruction / cholangitis, and foreign body impaction
  9. Understand the basic principles and equipments required for therapeutic procedures including luminal dilatation, polypectomy, endoscopic hemostasis, and foreign body removal
  10. Effective, appropriate and timely application of preventive and therapeutic interventions relevant to endoscopy, including, but not limited to: screening colonoscopy, upper endoscopy for Barrett’s esophagus and portal hypertension
  11. Appropriate post-procedural care pertaining to recovery and discharge planning

Communicator

  1. Recognize that being a good communicator is a core clinical skill for endoscopists, and that effective physician-patient communication can foster patient satisfaction, physician satisfaction, adherence and improved clinical outcomes
  1. Recognize the importance of incorporating patient’s beliefs, concerns, and expectations in clinical encounter pertaining to endoscopy
  2. Understand the importance of documentation and dissemination of information related to procedures performed and their outcomes
  3. Understand the importance of communication of findings and management plans to patients, families and referring health professionals

Collaborator

  1. Understand the role of the gastroenterologist within the endoscopy unit to optimize patient care
  2. Understand the importance of maintaining a respectful and professional attitude towards other colleagues and members of the endoscopy unit to prevent, negotiate and resolve inter-professional conflict

Manager

  1. Understand the collaborative role of the gastroenterologist within the endoscopy unit
  2. Describe the principles behind the operation of a safe and effective endoscopy unit including infection control and sedation
  3. Understand the importance of participation in systemic quality process evaluation and improvement, such as procedural quality and patient safety initiatives
  4. Understand the principles of budgeting and financing of an endoscopy unit

Health Advocate

  1. Describe in broad terms the key issues currently under debate regarding changes in the Canadian health care system, indicating how these changes may affect the delivery of endoscopic services and health outcomes and how gastroenterologists can advocate to decrease the burden of illness at a community or society level.
  2. Demonstrate an understanding of the role of screening tests in reducing mortality from colorectal cancer
  3. Identify barriers to access to care and resources for colorectal cancer screening
  4. Appreciate the possibility of conflict inherent in their role as health advocate for a patient or community with that of manager or gatekeeper

Scholar

  1. Describe the principles and strategies for maintenance of competence in endoscopy
  2. Recognize the importance of personal practice audit in the evaluation of performance and quality indicators in endoscopy

Professional

  1. Recognize the professional role of a gastroenterologist in delivering the highest quality care and maintenance of competence in endoscopy
  2. Demonstrate a commitment to patients, profession and society through participation in CAG and local quality initiatives in endoscopy