TY - GEN
T1 - Education, training, and assessment of competencies in gastrointestinal endoscopy of the upper gastrointestinal tract and the small intestine
AU - Bo Nielsen, Anders
PY - 2023/1/16
Y1 - 2023/1/16
N2 - An endoscopic examination is used for the evaluation of the mucosa in the digestive tract. It is an
efficient and reliable examination to diagnose and treat patients with symptoms from the
gastrointestinal tract. There are several techniques to perform the visualization depending on the
indication and pathological picture and most endoscopies are performed by a medical doctor or
nurse in gastroenterology or surgery.An esophagogastroduodenoscopy (EGD) is used for the examination of the oesophagus, stomach,
and duodenum. The indications for an EGD might be dysphagia, dyspepsia, heartburn, weight loss,
pain, melena, or hematemesis.A small bowel capsule endoscopy (SBCE) is recommended if the symptoms are originating from
the small intestine and the patient already had a gastroscopy and/or colonoscopy without adequate
findings. SBCE is performed by swallowing a pill camera that is taking thousands of pictures on its
journey through the digestive tract. This sequence is then converted to a video, which can be
examined by a specialist. A SBCE is indicated in patients with suspected inflammatory bowel
disease, polyps, tumours, or bleeding.A diagnostic endoscopy is in general harmless to the patient, but it requires endoscopists with a
sufficient level of skills and adequate diagnostic accuracy to succeed.Training endoscopy often relies on apprenticeship training with a more experienced colleague and
in some cases with simulation-based training before clinical training. The effects and approaches
are currently not well-evaluated, and the most optimal training approach remains unclear. The aims
of this PhD thesis were to develop a test that can make simulation-based mastery learning of EGD
possible and to explore the effects of simulation-based mastery learning compared to apprenticeship
training. Furthermore, to establish learning curves for the development of competencies in learning
small bowel capsule endoscopy.Three studies were included in this PhD thesis; the first was the development of a test to assess
practical competencies in EGD. The test consisted of a diagnostic part and a tool handling part. The
diagnostic part included two diagnostic cases on a virtual reality simulator and a diagnostic EGD on
an upper gastrointestinal mannequin. The tool handling part consisted of a case on the simulator and
retrieval of a suture and a plastic bead from the mannequin. We gathered validity evidence for the
9
test according to the principles and framework of Messick and established a credible pass/fail score
by comparing the performances of novices and experienced endoscopists.The second study was a multi-centre, randomized controlled trial evaluating the effects of
simulation-based mastery learning compared to apprenticeship training in learning EGD. Physicians
in gastroenterology and surgery were randomized to only clinical training or a simulation-based
course before the clinical training. The simulation-based training group were supposed to pass the
test developed in study I before their first clinical EGD. The physicians were then followed for their
first 50 clinical examinations. A questionnaire regarding their need for supervision and assistance
was fulfilled for each procedure. The examined patients received a questionnaire regarding their
satisfaction with their endoscopic examination. The study found a significant difference in the number of procedures to obtain independent practice
with 31 procedures for the simulation-based training group and 44 in the clinical training group.
The simulation-based training group had a significantly reduced need for supervision and was
potentially more cost-efficient compared to the clinical group. Patient satisfaction was similar
between the groups.
The third study was exploring learning curves in training for SBCE. We convened a single-day
course with lectures and hands-on training in the evaluation, software, use, and most common
findings. The participants received 50 clinical cases for homework with a corresponding interactive
questionnaire regarding findings and diagnosis after the course. The study showed that the
diagnostic accuracy was not improved between the first 20 cases and cases 21-50. The diagnostic
accuracy was low for all findings and diagnoses except for Crohn’s Disease which approached the
recommended diagnostic accuracy. Our results indicated that it was more difficult to learn SBCE
than previously thought considering the 20-30 training examinations recommended before the
establishment of competencies by the European and American societies.In conclusion, we have developed a simulation-based test to assess the competencies of trainees in
EGD training with solid validity evidence. Moreover, we showed that simulation-based training in
learning EGD reduces the required number of supervised procedures significantly and lowers the
need for supervision without compromising patient satisfaction. We have shown the importance of
10
establishing learning curves and concluded that it is more difficult to review SBCEs with adequate
diagnostic accuracy than previously stated.The results of this thesis can be used to structure educational programs in endoscopy and strengthen
the use of simulation-based training in EGD with the benefit of not practicing on patients during the
initial training.
AB - An endoscopic examination is used for the evaluation of the mucosa in the digestive tract. It is an
efficient and reliable examination to diagnose and treat patients with symptoms from the
gastrointestinal tract. There are several techniques to perform the visualization depending on the
indication and pathological picture and most endoscopies are performed by a medical doctor or
nurse in gastroenterology or surgery.An esophagogastroduodenoscopy (EGD) is used for the examination of the oesophagus, stomach,
and duodenum. The indications for an EGD might be dysphagia, dyspepsia, heartburn, weight loss,
pain, melena, or hematemesis.A small bowel capsule endoscopy (SBCE) is recommended if the symptoms are originating from
the small intestine and the patient already had a gastroscopy and/or colonoscopy without adequate
findings. SBCE is performed by swallowing a pill camera that is taking thousands of pictures on its
journey through the digestive tract. This sequence is then converted to a video, which can be
examined by a specialist. A SBCE is indicated in patients with suspected inflammatory bowel
disease, polyps, tumours, or bleeding.A diagnostic endoscopy is in general harmless to the patient, but it requires endoscopists with a
sufficient level of skills and adequate diagnostic accuracy to succeed.Training endoscopy often relies on apprenticeship training with a more experienced colleague and
in some cases with simulation-based training before clinical training. The effects and approaches
are currently not well-evaluated, and the most optimal training approach remains unclear. The aims
of this PhD thesis were to develop a test that can make simulation-based mastery learning of EGD
possible and to explore the effects of simulation-based mastery learning compared to apprenticeship
training. Furthermore, to establish learning curves for the development of competencies in learning
small bowel capsule endoscopy.Three studies were included in this PhD thesis; the first was the development of a test to assess
practical competencies in EGD. The test consisted of a diagnostic part and a tool handling part. The
diagnostic part included two diagnostic cases on a virtual reality simulator and a diagnostic EGD on
an upper gastrointestinal mannequin. The tool handling part consisted of a case on the simulator and
retrieval of a suture and a plastic bead from the mannequin. We gathered validity evidence for the
9
test according to the principles and framework of Messick and established a credible pass/fail score
by comparing the performances of novices and experienced endoscopists.The second study was a multi-centre, randomized controlled trial evaluating the effects of
simulation-based mastery learning compared to apprenticeship training in learning EGD. Physicians
in gastroenterology and surgery were randomized to only clinical training or a simulation-based
course before the clinical training. The simulation-based training group were supposed to pass the
test developed in study I before their first clinical EGD. The physicians were then followed for their
first 50 clinical examinations. A questionnaire regarding their need for supervision and assistance
was fulfilled for each procedure. The examined patients received a questionnaire regarding their
satisfaction with their endoscopic examination. The study found a significant difference in the number of procedures to obtain independent practice
with 31 procedures for the simulation-based training group and 44 in the clinical training group.
The simulation-based training group had a significantly reduced need for supervision and was
potentially more cost-efficient compared to the clinical group. Patient satisfaction was similar
between the groups.
The third study was exploring learning curves in training for SBCE. We convened a single-day
course with lectures and hands-on training in the evaluation, software, use, and most common
findings. The participants received 50 clinical cases for homework with a corresponding interactive
questionnaire regarding findings and diagnosis after the course. The study showed that the
diagnostic accuracy was not improved between the first 20 cases and cases 21-50. The diagnostic
accuracy was low for all findings and diagnoses except for Crohn’s Disease which approached the
recommended diagnostic accuracy. Our results indicated that it was more difficult to learn SBCE
than previously thought considering the 20-30 training examinations recommended before the
establishment of competencies by the European and American societies.In conclusion, we have developed a simulation-based test to assess the competencies of trainees in
EGD training with solid validity evidence. Moreover, we showed that simulation-based training in
learning EGD reduces the required number of supervised procedures significantly and lowers the
need for supervision without compromising patient satisfaction. We have shown the importance of
10
establishing learning curves and concluded that it is more difficult to review SBCEs with adequate
diagnostic accuracy than previously stated.The results of this thesis can be used to structure educational programs in endoscopy and strengthen
the use of simulation-based training in EGD with the benefit of not practicing on patients during the
initial training.
U2 - 10.21996/cc5j-he96
DO - 10.21996/cc5j-he96
M3 - Ph.D. thesis
PB - Syddansk Universitet. Det Sundhedsvidenskabelige Fakultet
ER -