PostScript
Caecal intubation rates and colonoscopy competency A recent study by Ward et al1 elegantly highlighted the steep and long learning curve for novice endoscopists to achieve competency in colonoscopy. In the study, they acquired data from the Joint Advisory Group ( JAG) e-portfolio database which includes procedural outcomes from all training centres in the UK. The aim of the study was to establish the number of colonoscopies to be completed to achieve competency, defined as a caecal intubation rate (CIR) of ≥90%. They found that the endoscopy trainees obtained a CIR of ≥90% at 233 colonoscopies. The authors should be congratulated on a study that is by far the largest (over 36 000 colonoscopies and 300 trainees) on learning colonoscopy and achieving competency. Based on this study, it should be asked is 233 the new magic number of colonoscopies needed to be termed ‘competent’? A few points may suggest that 233 may be still too low to determine competence. All the data supplied was self-reported by the trainees which is a potential source of bias over-reporting success. Second, the group that already had performed >100 sigmoidoscopies learned colonoscopies faster. How many trainees, however, completed 50–90 sigmoidoscopies prior to colonoscopy training? Doing 50 sigmoidoscopies is not a negligible amount of procedural experience. This is different from training in most US centres where scope #1 is usually the first time a trainee touches a colonoscope. Third, using CIRs as a single measure for colonoscopy competency is likely too simplistic. Further, CIR of ≥90% is likely too low a minimal standard for measuring caecal intubation success. Busy colonoscopic screening programmes routinely have CIR of ≥98% for all practising endoscopists, even for those just out of fellowship. A CIR of 90% as a minimum standard would likely place the trainees at a level of intermediate on the National Institutes of Health Proficiency Scale.2 If such an endoscopist was part of a busy practice and failed one in every 10 colonoscopies, most gastroenterologists would suggest that the endoscopist was not competent. We wonder how many colonoscopies would be required by trainees, according to the analysis completed by Ward et al, to have consistent CIRs of ≥95% or ≥98%. We performed a similar study to determine the number of colonoscopies required for endoscopic independent competence, and concluded that approximately 500 Gut February 2015 Vol 64 No 2
procedures are required to become competent.3 Our definition of competence was more stringent with the trainee needing to independently intubate the caecum, remove polyps, and perform haemostasis. These results were reproduced by another centre, using the Mayo Colonoscopy Skills Assessment Tool, who found that it took approximately 400 procedures for all trainees to become competent at colonoscopy.4 Thus, the number for colonoscopy competency starts to increase when more rigid definitions of competency are used, and when the number at which all trainees are competent (the ultimate goal) is used. Overall, the Ward et al study greatly adds to the growing body of research on colonoscopic training. Numbers of colonoscopies are just one component of the cognitive and technical training that should be included when teaching endoscopic procedures. Involved teachers, continual endoscopic feedback, and integration of colonoscopy into gastrointestinal disease are just as important as the number of colonoscopies. Maybe 233 colonoscopies is a number, not where we state competency has been achieved, but the number when we, as teachers, can first start assessing if our trainees are competent.
REFERENCES 1
2 3
4
Ward S, Mohammed M, Walt R, et al. An analysis of the learning curve to achieve competency at colonoscopy using the JETS database. Gut 2014:1–9. http://hr.od.nih.gov/workingatnih/competencies/ proficiencyscale.htm Spier B, Benson M, Pfau P, et al. Colonoscopy training in gastroenterology fellowships: determining competence. Gastrointest Endosc 2010;71:319–24. Sedlack R. Training to competency in colonoscopy: assesing and defining competency standards. Gastrointestinal Endosc 2011;74:355–66.
Mark Benson, Michael Lucey, Patrick Pfau Department of Medicine, Division of Gastroenterology & Hepatology, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA Correspondence to Dr Mark Benson, Department of Medicine, Division of Gastroenterology & Hepatology, University of Wisconsin School of Medicine & Public Health, 600 Highland Ave. Madison, WI 53792, USA; [email protected] Contributors Each author had substantial contributions to the conception or design of the work; interpretation of data for the work; drafting the work; final approval of the version to be published and is in agreement to be accountable for all aspects of the work. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Benson M, Lucey M, Pfau P. Gut 2015;64:359. Received 14 March 2014 Accepted 26 March 2014 Published Online First 9 April 2014
▸ http://dx.doi.org/10.1136/gutjnl-2013-305973 Gut 2015;64:359. doi:10.1136/gutjnl-2014-307242 359
Copyright of Gut is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Caecal intubation rates and colonoscopy competency A recent study by Ward et al1 elegantly highlighted the steep and long learning curve for novice endoscopists to achieve competency in colonoscopy. In the study, they acquired data from the Joint Advisory Group ( JAG) e-portfolio database which includes procedural outcomes from all training centres in the UK. The aim of the study was to establish the number of colonoscopies to be completed to achieve competency, defined as a caecal intubation rate (CIR) of ≥90%. They found that the endoscopy trainees obtained a CIR of ≥90% at 233 colonoscopies. The authors should be congratulated on a study that is by far the largest (over 36 000 colonoscopies and 300 trainees) on learning colonoscopy and achieving competency. Based on this study, it should be asked is 233 the new magic number of colonoscopies needed to be termed ‘competent’? A few points may suggest that 233 may be still too low to determine competence. All the data supplied was self-reported by the trainees which is a potential source of bias over-reporting success. Second, the group that already had performed >100 sigmoidoscopies learned colonoscopies faster. How many trainees, however, completed 50–90 sigmoidoscopies prior to colonoscopy training? Doing 50 sigmoidoscopies is not a negligible amount of procedural experience. This is different from training in most US centres where scope #1 is usually the first time a trainee touches a colonoscope. Third, using CIRs as a single measure for colonoscopy competency is likely too simplistic. Further, CIR of ≥90% is likely too low a minimal standard for measuring caecal intubation success. Busy colonoscopic screening programmes routinely have CIR of ≥98% for all practising endoscopists, even for those just out of fellowship. A CIR of 90% as a minimum standard would likely place the trainees at a level of intermediate on the National Institutes of Health Proficiency Scale.2 If such an endoscopist was part of a busy practice and failed one in every 10 colonoscopies, most gastroenterologists would suggest that the endoscopist was not competent. We wonder how many colonoscopies would be required by trainees, according to the analysis completed by Ward et al, to have consistent CIRs of ≥95% or ≥98%. We performed a similar study to determine the number of colonoscopies required for endoscopic independent competence, and concluded that approximately 500 Gut February 2015 Vol 64 No 2
procedures are required to become competent.3 Our definition of competence was more stringent with the trainee needing to independently intubate the caecum, remove polyps, and perform haemostasis. These results were reproduced by another centre, using the Mayo Colonoscopy Skills Assessment Tool, who found that it took approximately 400 procedures for all trainees to become competent at colonoscopy.4 Thus, the number for colonoscopy competency starts to increase when more rigid definitions of competency are used, and when the number at which all trainees are competent (the ultimate goal) is used. Overall, the Ward et al study greatly adds to the growing body of research on colonoscopic training. Numbers of colonoscopies are just one component of the cognitive and technical training that should be included when teaching endoscopic procedures. Involved teachers, continual endoscopic feedback, and integration of colonoscopy into gastrointestinal disease are just as important as the number of colonoscopies. Maybe 233 colonoscopies is a number, not where we state competency has been achieved, but the number when we, as teachers, can first start assessing if our trainees are competent.
REFERENCES 1
2 3
4
Ward S, Mohammed M, Walt R, et al. An analysis of the learning curve to achieve competency at colonoscopy using the JETS database. Gut 2014:1–9. http://hr.od.nih.gov/workingatnih/competencies/ proficiencyscale.htm Spier B, Benson M, Pfau P, et al. Colonoscopy training in gastroenterology fellowships: determining competence. Gastrointest Endosc 2010;71:319–24. Sedlack R. Training to competency in colonoscopy: assesing and defining competency standards. Gastrointestinal Endosc 2011;74:355–66.
Mark Benson, Michael Lucey, Patrick Pfau Department of Medicine, Division of Gastroenterology & Hepatology, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA Correspondence to Dr Mark Benson, Department of Medicine, Division of Gastroenterology & Hepatology, University of Wisconsin School of Medicine & Public Health, 600 Highland Ave. Madison, WI 53792, USA; [email protected] Contributors Each author had substantial contributions to the conception or design of the work; interpretation of data for the work; drafting the work; final approval of the version to be published and is in agreement to be accountable for all aspects of the work. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Benson M, Lucey M, Pfau P. Gut 2015;64:359. Received 14 March 2014 Accepted 26 March 2014 Published Online First 9 April 2014
▸ http://dx.doi.org/10.1136/gutjnl-2013-305973 Gut 2015;64:359. doi:10.1136/gutjnl-2014-307242 359
Copyright of Gut is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
