REVIEW ARTICLE
Establishing the learning curve for achieving competency in performing colonoscopy: a systematic review Neal Shahidi, MD, George Ou, MD, Jennifer Telford, MD, MPH, FRCPC, Robert Enns, MD, FRCP Vancouver, British Columbia, Canada
Colonoscopy (CSPY) allows competent endoscopists to safely, tolerably, and accurately examine the entire colon, thus facilitating the diagnosis of colonic diseases as well as the performance of therapeutic interventions. It can be technically demanding and requires significant time and practice to master the psychomotor and cognitive aspects of the procedure. Therefore, with a significant number of graduating gastroenterology and surgical trainees expected to perform this procedure as a core component of their future practice, the need for appropriate training to allow for the acquisition of competence is critical. With this in mind, 2 questions arise: (1) what is procedural competence in this setting and (2) at what point do trainees become competent? Unfortunately, even though CSPY allows for objective assessment, the definition of competence remains difficult to delineate. Arguably the most frequently referenced CSPY performance marker is the cecal intubation rate (CIR). Because cecal intubation is a critical component to defining a complete CSPY, it is often reported as a prerequisite for determining competence.1,2 The American Society for Gastrointestinal Endoscopy (ASGE) in conjunction with the American College of Gastroenterology (ACG) published quality indicators to help define competence.1 These, alongside other recommendations, suggest at least a 90% CIR in all cases. However, cecal intubation is only 1 component of a complete CSPY and alone does not sufficiently define competency. Regarding the number of procedures required to become competent, the first guidelines were based on expert opinion.3-5 Subsequently, with the emergence of a pivotal study by Cass et al,6 the ASGE recommended that trainees complete a minimum of 140 CSPYs before competence can be assessed.7 However, both references above are now relatively outdated, and as additional studies
have emerged, it is unclear whether more procedures should be mandated during training. This is reflected in the marked heterogeneity among current guidelines for gastroenterology and surgical trainees.8-11 With a critical need for a universal definition of competence as well as defining the minimum number of CSPYs that gastroenterology and surgical training programs should provide to their trainees, we sought to systematically review the medical literature. The goal of this review is to empower policymakers in the development of uniform and objective CSPY training guidelines, thus ensuring CSPYs are performed by qualified endoscopists, leading to improved patient care and resource utilization.
METHODS Search strategy and study selection
Copyright ª 2014 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2014.04.056
To identify relevant citations addressing the evaluation of the learning curve to achieve competency in performance of CSPY, 2 authors (N.S. and G.O.) independently searched MEDLINE (1946 to June 21, 2013) using the following search strategy: (“colonoscopy [MeSH]” OR “colonoscopy”) AND (“trainee” OR “training” OR “fellow*” OR “resident”). Search terms were intentionally kept broad to increase the likelihood of identifying relevant citations. Subsequently, the authors (N.S. and G.O.) reviewed the bibliographies of studies that met inclusion criteria, pertinent review articles, and guidelines to find further studies. Full-text citations, which assessed the learning curve to achieve competency in performing CSPY during gastroenterology or surgical training, were included. For studies to merit inclusion, a learning curve had to be established. This was defined as either a tabulated or graphic depiction of competence as a function of escalating independently completed trainee CSPYs, with a minimum of 2 training points. Furthermore, if it appeared that competence was achieved during the study (eg, as per graphical depiction), we required that it be explicitly stated. Studies were excluded if they (1) were not published in English; (2) were solely in abstract form; (3) were review articles, commentaries, or book chapters; (4) did not, at a minimum, assess independent CIR (ICIR); (5) reported insufficient data on desired outcomes; (6) lacked CSPY
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Abbreviations: CIR, cecal intubation rate; CIT, cecal intubation time; CSPY, colonoscopy; ICIR, independent cecal intubation rate; MCSAT, Mayo Colonoscopy Skills Assessment Tool; TPT, total procedural time. DISCLOSURE: All authors disclosed no financial relationships relevant to this publication. See CME section; p. 503.
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or trainee-specific outcomes; (7) assessed other types of trainees, including therapeutic endoscopy fellows, family physicians, or nurses, without providing gastroenterology or surgical trainee–specific data; (8) evaluated CSPY training in the pediatric population; or (9) focused on other procedures, either diagnostic or therapeutic involving the large intestine (eg, flexible sigmoidoscopy, CT colonography). Furthermore, we excluded studies whose focus was not to quantify the learning curve but to assess the impact of an intervention on the initial aspects of CSPY training. In this instance we used a minimum cut-off of !50 CSPYs on the learning curve to define the initial aspects of CSPY training, because this is currently the lowest threshold for competency assessment.8 If overlapping study populations were suspected, the citation with the smaller study population was excluded. Authors were contacted if further information was believed to affect study inclusion.
Data extraction Studies that met our inclusion criteria subsequently underwent independent data extraction by 2 authors (N.S. and G.O.) using a standardized data extraction form. Components included (1) year of publication; (2) country of origin; (3) study period; (4) trainee description, including previous endoscopic experience before study inclusion; (5) case description; (6) CSPY equipment, sedation, and preparation protocols; (7) trainee versus staff involvement during CSPY; and (8) definition of competence as well as related outcomes. If disagreements at any step during the review process occurred between the 2 reviewers (N.S. and G.O.), they were resolved by consensus. If this could not be achieved, a third reviewer (R.E.) was consulted to reach a final consensus.
Outcomes and analysis
Learning curve for achieving competency in colonoscopy
training, case selection, and different methodologies for determining endpoints), it was believed that meta-analyses of the above outcomes would be inappropriate at this time. Therefore, solely descriptive statistics were used to summarize findings.
RESULTS Search results and study description A total of 645 citations was identified by our electronic and gray literature search protocols, of which 104 underwent full-text review (Fig. 1). After full-text review, 18 studies (Table 1) assessing approximately 37,700 CSPYs completed by 247 trainees were included in our systematic review.12-29 Among the included studies, 15 studies were prospective in nature,13-22,24-27,29 with 14 assessing gastroenterology trainees,14-16,18-27,29 3 assessing surgical trainees,12,17,28 and 1 assessing both.13 Studies were subsequently stratified by definition of competence, with 10 studies using ICIR,12,13,15-19,24,25,27 6 studies using ICIR with a cecal intubation time (CIT) limit,14,20-22,26,29 1 study using ICIR with a total procedural time (TPT) limit,28 and 2 studies using more comprehensive definitions of competence.23,24 One study24 provided both estimates of ICIR and a more comprehensive definition of competence. Therefore, our review included a total of 19 unique evaluations. Reasons for study exclusion are described in Figure 1.
General competence assessment Among the 19 unique evaluations (Table 2) available for assessment, 11 evaluations12,19,20-24,26,27,29 reached their respective definition of competence and were able to provide either a range or definitive number of CSPYs needed to achieve competence. When stratifying these by common CSPY thresholds, all 11 evaluations required O50 CSPYs to achieve competence. Alternatively, 9 of 11 evaluations required O 140 CSPYs to achieve competence, with the remaining 2 evaluations providing ranges whose estimates fell across the 140 CSPY threshold. Last, 7 of 11 evaluations required O200 CSPYs to achieve competence.
The number of CSPYs that a gastroenterology or surgical trainee needs to complete during his or her training to achieve competence was our outcome of interest. We subsequently stratified this outcome based on varying markers of competence. A threshold of 90% ICIR was used as a minimum reference for competence. Estimates were provided as they were expressed in the original study. If different methods within a single study were used to estimate the competency threshold, then a conservative range across all these estimates was created. Subsequently, conservative ranges within the stratified groups were quantified. In studies whose purpose was to assess the impact of simulation on the learning curve, both the simulation and the control arms were included, because it was perceived that both represent current training strategies. In the setting of interventional studies (eg, oil/water immersion, cap-assisted CSPY), only the control arm was included for analysis. Because of multiple sources of heterogeneity (previous endoscopic experience of trainees, structure of endoscopy
Ten studies12,13,15-19,24,25,27 used ICIR as their marker of competence. Of note, 2 studies16,17 did describe procedural time restrictions; however, in 1 case procedural time was not recorded and in the other it was solely mentioned in the discussion section. Alternatively, 1 study19 incorporated the ability to correctly identify abnormalities during CSPY, but the methodology concerning this was not explicit. Therefore, in all 3 cases, the studies were ultimately allocated to the ICIR grouping. In regard to achieving competency, in only 4 studies12,19,24,27 was R90% ICIR achieved across a conservative range of 141 to 305 CSPYs. In 3 studies13,16,17 where competence was not achieved, individual trainee estimates
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Competence measured by ICIR
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Figure 1. Flowchart of study selection. ICIR, independent cecal intubation rate; CSPY, colonoscopy; GP, general practitioner; TF, therapeutics fellow.
were provided. Cass et al13 noted 2 trainees who exceeded 90% ICIR and had completed 210 (94% ICIR) and 275 (96% ICIR) CSPYs. In the 2 alternative studies, the point estimates were graphically depicted, making it difficult to elucidate the individual trainee data points.
Competence measured by ICIR and CIT/TPT limits Six studies14,20-22,26,29 used ICIR in conjunction with a CIT limit, and 1 study28 used ICIR with a TPT limit as markers of competence. Among the 6 studies additionally using a CIT limit, the time limit ranged between 15 and 30 minutes. Competency was achieved using their respective CIT limits in 5 studies20-22,26,29 between a range of 101 and 300 CSPYs. Of note, Park et al29 also explicitly assessed when all trainees within their study achieved competence, which occurred after 250 CSPYs. In the single study14 in which competence was not achieved, individual trainee estimates were provided. Two trainees exceeded the R90% ICIR threshold. One trainee had completed 325 CSPYs (93% ICIR) and another 340 CSPYs (92% ICIR). Concerning the single study28 using a TPT limit, the limit was set at 35 minutes. Competence was not achieved in this study. However, 50% of the trainees (n Z 3) exceeded the R90% ICIR threshold by study end and had completed 203 (94% ICIR), 206 (92% ICIR), and 263 (93% ICIR) CSPYs, respectively. 412 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 3 : 2014
Competence measured by comprehensive markers Two studies23,24 provided more comprehensive definitions of competence. Spier et al23 used a definition of “completely independent CSPY” that incorporated multiple aspects of CSPY, including cecal intubation, polypectomy, and hemostasis. In this study, the 90% independent CSPY completion standard was achieved at 467 CSPYs. However, further analysis showed that by 500 CSPYs all trainees were able to achieve competence. In the alternative study,24 Sedlack used the previously validated Mayo Colonoscopy Skills Assessment Tool (MCSAT) to establish both definitions of competency and competency thresholds. Through establishing minimal competency criteria across both the motor and cognitive components of the MCSAT, trainees’ scoring averages were subsequently able to surpass the minimal competency criteria for the MCSAT components by 275 CSPYs. Furthermore, it was not until approximately 400 CSPYs that competency was achieved across all trainees.
DISCUSSION CSPY is an integral tool in the management of colonic disease, and having physicians, regardless of specialty, who can effectively perform them is critical. However, www.giejournal.org
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TABLE 1. Description of included studies Study
Year
Country
Study design
Trainee type
Parry and Williams12
1991
New Zealand
Retrospective
ST
Cass et al13
1993
USA
Prospective
GT/ST
Marshall14
1995
USA
Prospective
GT
1996
USA
Prospective
GT
1999
Greece
Prospective
GT
2002
USA
Prospective
ST
2004
USA
Prospective
GT
2006
USA
Prospective
GT
2008
Korea
Prospective
GT
2009
The Netherlands
Prospective
GT
Chung et al
2010
Korea
Prospective
GT
23
2010
USA
Retrospective
GT
2011
USA
Prospective
GT
2012
Italy
Prospective
GT
Gromski et al
2012
Korea
Prospective
GT
Koch et al27
2012
The Netherlands
Prospective
GT
Selvasekar et al28
2012
USA
Retrospective
ST
Park et al29
2013
Korea
Prospective
GT
Chak et al15 Tassios et al
16 17
Church et al
18
Sedlack and Kolars Cohen et al
19
20
Lee et al
21
Koornstra et al 22
Spier et al 24
Sedlack
Elvevi et al
25 26
GT, gastroenterology trainee; ST, surgical trainee.
marked heterogeneity exists among different specialties regarding the minimum number of procedures recommended before assessing competence.8-11 This disparity is partly driven by the lack of a universal definition of competence as well as a practical means of assessing it. Trainees therefore run the risk of not receiving the appropriate amount of training needed to learn how to perform highquality CSPYs, which they will be expected to do once in independent practice. This highlights the crucial need to establish objective criteria for procedural competence to facilitate training programs in providing an adequate amount of experience. With that in mind, our systematic review is the first in the medical literature to show that as competency assessment has continued to evolve from assessing ICIR to incorporating more comprehensive definitions of competence, the number of CSPYs required to achieve competence rises above current training minimums, thus questioning our current procedural thresholds as well as the means by which we have been establishing them. Historically, because of the lack of objective measures for assessing competency, accrediting bodies relied on establishing a certain number of CSPYs for trainees to complete before being deemed competent. The numbers
required were initially defined via expert opinion. However, as studies emerged13 that serially assessed a trainee’s ability to independently traverse the colon, the first step toward objective competency assessment occurred. Subsequently, numerous studies have attempted to assess the learning curve using similar surrogate markers of competence, most notably ICIR. Although cecal intubation is an integral component toward defining a complete CSPY, it is only one component and fails to assess the manner in which the cecum is reached, the ability of the trainee to both identify and safely remove polyps, and the cognitive aspects pertinent to performing CSPYs. Interestingly, based on our results, it does not appear that adding a CIT limit within the time range assessed (15 to 30 minutes) had a dramatic effect on the trajectory of the learning curve. It was only after using more complete definitions of competence, such as those used by Spier et al23 and Sedlack,24 that the threshold for achieving competence rises, which we interpret as showcasing a more realistic learning curve for trainees. Despite the above, the question still remains: what is procedural competence in this setting? Although traditionally a CIR of 90% has been used as a threshold for competency, this cut-off was somewhat arbitrarily selected. The
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TABLE 2. Competency outcomes of included studies Reference
n
No. CSPY
Competency marker
Competency achieved
Competency results
13
12
49/T*
ICIR
No
R90% ICIR not achieved. 84% @ 100 CSPYs
15
12
181
ICIR
No
R90% ICIR not achieved. 64% among SYTs (mean 123 previous CSPYs)
16
8
978
ICIRy
No
R90% ICIR not achieved. 77% @ 180 CSPYs
17
18
2250
ICIR
No
R90% ICIR not achieved. 75% @ 101-125 CSPYs
18
8
480
ICIR
No
R90% ICIR not achieved. 72% (SIMT), 58% (No SIMT) @ 46-60 CSPYs
25
12
720
ICIR
No
R90% ICIR not achieved. 60% @ 41-60 CSPYs
12
1
305
ICIRz
Yes
R90% ICIR (91%) achieved @ 201-305 CSPYs. Cusum Plot: R90% ICIR @ O200 CSPYs
19
45
9000
ICIRx
Yes
R90% ICIR (93% SIMT, 91% No SIMT) achieved @ 181-200 CSPYs survival analysis: R 90% ICIR achieved @ 141-160 CSPYs (SIMT and No SIMT)
24
41
6635
ICIR
Yes
R90% ICIR (92%) achieved @ 300 CSPYs
27
19
2887
ICIR
Yes
R90% ICIR achieved @ 280 CSPYs
ICIR
ICIR and CIT limit 14
9
389
ICIR (30 min)
No
R90% ICIR not achieved. 86% among SYTs (mean 328 CSPYs)
20
24
4351
ICIR (20 min)
Yes
R90% ICIR achieved (91%) @ 101-150 CSPYs
21
1
150
ICIR (30 min)
Yes
R90% ICIR achieved (92%) @ 126-150 CSPYs
22
12
3243
ICIR (20 min)
Yes
R90% ICIR achieved (94%) @ 201-250 CSPYs
26
4
1210
ICIR (20 min)
Yes
R90% ICIR achieved @ 151-200 CSPYs
29
4
2050
ICIR (15 min)
Yes
R90% ICIR achieved (93%) @ 251-300 CSPYs
1498
ICIR (35 min)
No
R90% ICIR not achieved. 83% @ mean 249 CSPYs
ICIR and TPT limit 28
6
Comprehensive competency assessment 23
11
770
Total CSPY{
Yes
R90% total CSPY achieved @ 467 CSPYs
24
41
6635
MCSAT MCCs
Yes
MCC for the core MCSAT skills reached @ 275 CSPYs
CSPY, Colonoscopy; CIT, cecal intubation time; ICIR, independent cecal intubation rate; MCC, minimal competency criteria, MCSAT, Mayo Colonoscopy Skills Assessment Tool; SIMT, simulation training; SYT, second-year trainee; T, trainee; TPT, total procedural time. *Median 49 CSPYs per trainee. yDefinition of ICIR: either reaching the cecum or an occluding tumor in the cecum/ascending colon. zDefinition of ICIR: either reaching the cecum, or ileocolonic anastomosis, or encountering an impassable obstructive lesion. xDefinition of ICIR: included the ability to correctly recognize and identify abnormalities. {Definition of CSPY: included multiple aspects of procedure (eg, ICIR, polypectomy, hemostasis).
ASGE and ACG Taskforce on Quality in Endoscopy endorsed a 90% CIR with the evidence to support this cut-off apparently based on a study published in 1993 by Marshall and Barthel.30 Interestingly, the study in question showed a CIR of 96% for 418 attempted CSPYs. This raises questions concerning the validity of the 90% CIR cut-off and whether a higher cut-off such as R95% for all cases should be considered, not just in cases where the indica-
tion is for screening in a healthy adult as is currently recommended. Fortunately, the study by Sedlack24 is starting to shed light on this topic. Using the previously validated MCSAT, which is composed of both motor and cognitive items, the study established minimal competency criteria for each item of the MCSAT among gastroenterology trainees. It was found that by 275 CSPYs, trainees were able to achieve competency across these items.
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Learning curve for achieving competency in colonoscopy
Subsequently, using the established learning curve defined during the study, it was found that an ICIR of 85% and a CIT of approximately 16 minutes correlates with this threshold of 275 CSPYs. This is the first study, to our knowledge, that has attempted to objectively define competency criteria. Moreover, it highlights a number of key features of the MCSAT. First, it emphasizes the importance of a trainee’s ability to not only master the motor aspects of the procedure but also the cognitive aspects of CSPY. Furthermore, it incorporates key aspects required to successfully perform CSPY, such as loop reduction, mucosal visualization, and therapeutic procedures. The importance of these features have been echoed by 2 recently unveiled assessment tools, the Gastrointestinal Endoscopy Competency Assessment Tool31 and the ASGE’s assessment of competence in endoscopy evaluation tool for CSPY.32 Of note, both the Gastrointestinal Endoscopy Competency Assessment Tool and the assessment of competence in endoscopy evaluation tool have incorporated the assessment of cecal intubation, emphasizing that CIR still plays an important role in the assessment of competency. However, these tools also highlight that competency in performing CSPY is so much more than just reaching the cecum and that for a trainee to be deemed competent these aspects must be objectively evaluated on a serial basis. Although there is a movement away from relying on the number of procedures needed to achieve competence, there is still value in quantifying these thresholds, specifically during the current training era. Most importantly, it provides a framework for training programs to ensure that their trainees receive enough repetition in performing CSPYs.33 However, when attempting to decide on the value of this threshold, an important decision is whether to use mean estimates or estimates of when all trainees achieved competence.23,24,29 Unfortunately, this is a very difficult question to answer because it is influenced by the distribution at which trainees reach competence. Nevertheless, until more robust definitions of competence can be validated to help establish a more appropriate threshold, we believe it is fair to contest that it is better to err on the side of caution and more closely reflect when all trainees reach competence. However, it is also important to be cognizant of trainees who are struggling to grasp either the cognitive or motor aspects of CSPY, because they may require alternative training strategies, and these outliers could inappropriately increase the threshold value for the remainder of trainees. With the above discussion in mind, it is not surprising why such disparity exists between different specialties regarding the number of procedures recommended before assessing competency, with the ASGE recommending 200 CSPYs10 in contrast to the American Board of Surgery8,34 and the American Academy of Family Physicians35 recommending 50 CSPYs. In regard to the American Academy of Family Physicians’ recommendation, although our review
did not focus on assessing competency among family physicians, to our knowledge there is a paucity of studies assessing competency during family physician training.36,37 Concerning gastroenterology and general surgery trainees, from our included studies none were able to show that competence is achieved by 50 or even 100 CSPYs. Moreover, it appears that 200 CSPYs may potentially be an underestimate. Therefore, until there is evidence to suggest that different types of physicians achieve competence at different thresholds using objective competency assessment that reflects the core aspects of performing CSPY, this minimum requirement should be adopted by training programs, specialty societies, and hospital privileging committees, with the expectation that more experience may be required. Our study was not without limitations. Marked heterogeneity exists across studies concerning multiple components of study design. This included (1) trainees’ previous endoscopic experience, (2) the structure of endoscopic training, (3) case selection, and (4) the manner in which estimates were quantified. This ultimately limited our ability to aggregate data, and we were unable to perform meta-analyses. Moreover, the inclusion criteria mandating ICIR limited our assessment of alternative methods of assessing competency. Finally, we did not assess other types of trainees, such as family physicians or nurse endoscopists, and excluded studies that did not provide gastroenterology or surgery–specific data. This limitation is best highlighted by a recently published study by Ward et al37 that looked at 297 trainees including gastroenterology, surgical, family practice, and nurse endoscopists and found that an ICIR of 90% was reached by 233 CSPYs. In summary, our study showcases that as the definition of procedural competence continues to mature toward what is expected of an independent endoscopist, the number of CSPYs required to achieve competence continues to rise above current estimates. Further research in this area is needed to attempt to solidify objective competency criteria across all specialties whose practitioners perform CSPYs, thus ensuring that all physicians are held to a common standard with the ultimate goal of allowing competent trainees to smoothly transition into competent endoscopists. Finally, although the focus of this review is attempting to define procedural thresholds, it is important to not lose sight of the larger picture regarding endoscopy training: to equip trainees with the ability to seamlessly integrate endoscopy into the management of GI issues they will face as independent practitioners. We suspect this may pose a much greater challenge to trainees than solely learning how to effectively perform endoscopy.
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Shahidi et al 23. Spier BJ, Benson M, Pfau PR, et al. Colonoscopy training in gastroenterology fellowships: determining competence. Gastrointest Endosc 2010;71:319-24. 24. Sedlack RE. Training competency in colonoscopy: assessing and defining competency standards. Gastrointest Endosc 2011;74:355-66. 25. Elvevi A, Cantu P, Maconi G, et al. Evaluation of hands-on training in colonoscopy: is a computer-based simulator useful? Dig Liver Dis 2012;44:580-4. 26. Gromski MA, Miller CA, Lee SH, et al. Trainees’ adenoma detection rate is higher if O/Z 10 minutes is spent on withdrawal during colonoscopy. Surg Endosc 2012;26:1337-42. 27. Koch AD, Haringsma J, Schoon EJ, et al. Competence measurement during colonoscopy training: the use of self-assessment of performance measures. Am J Gastroenterol 2012;107:971-5. 28. Selvasekar CR, Holubar SD, Pendlimari R, et al. Assessment of screening colonoscopy competency in colon and rectal surgery fellows: a single institution experience. J Surg Res 2012;174:e17-23. 29. Park HJ, Hong JH, Kim HS, et al. Predictive factors affecting cecal intubation failure in colonoscopy trainees. BMC Med Educ 2013;13:5. 30. Marshall JB, Barthel JS. The frequency of total colonoscopy and terminal ileal intubation in the 1990s. Gastrointest Endosc 1993;39:518-20. 31. Walsh CM, Ling SC, Khanna N, et al. Gastrointestinal Endoscopy Competency Assessment Tool: development of a procedure-specific assessment tool for colonoscopy. Gastrointest Endosc 2013;79:798-807. 32. ASGE Training Committee. ASGE’s assessment of competency in endoscopy evaluation tools for colonoscopy and EGD. Gastrointest Endosc 2014;79:1-7. 33. ASGE Training Committee. Colonoscopy core curriculum. Gastrointest Endosc 2012;76:482-90. 34. American Board of Surgery. Flexible endoscopy curriculum. March 2014. Available at: http://www.absurgery.org/default.jsp?certgsqe_fec. Accessed April 2014. 35. American Academy of Family Physicians. Colonoscopy (Position Paper). June 13, 2013. Available at: http://s.aafp.org/?qZcolonoscopy&q1Z &x1Z&first_searchZ0&searchZEntireþSite. Accessed April 2014. 36. Eckert LD, Short MW, Domagalski JE, et al. Assessing colonoscopy training outcomes using quality indicators. J Grad Med Educ 2009;1: 89-92. 37. Ward ST, Mohammed MA, Walt R, et al. An analysis of the learning curve to achieve competency at colonoscopy using the JETS database. Gut 2014 [Epub ahead of print].
Received March 3, 2014. Accepted April 28, 2014. Current affiliation: Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada. Reprint requests: Dr Robert Enns, St Paul’s Hospital, University of British Columbia, Pacific Gastroenterology Associates, 770-1190 Hornby Street, Vancouver, BC Canada V6Z 2K5.
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Establishing the learning curve for achieving competency in performing colonoscopy: a systematic review Neal Shahidi, MD, George Ou, MD, Jennifer Telford, MD, MPH, FRCPC, Robert Enns, MD, FRCP Vancouver, British Columbia, Canada
Colonoscopy (CSPY) allows competent endoscopists to safely, tolerably, and accurately examine the entire colon, thus facilitating the diagnosis of colonic diseases as well as the performance of therapeutic interventions. It can be technically demanding and requires significant time and practice to master the psychomotor and cognitive aspects of the procedure. Therefore, with a significant number of graduating gastroenterology and surgical trainees expected to perform this procedure as a core component of their future practice, the need for appropriate training to allow for the acquisition of competence is critical. With this in mind, 2 questions arise: (1) what is procedural competence in this setting and (2) at what point do trainees become competent? Unfortunately, even though CSPY allows for objective assessment, the definition of competence remains difficult to delineate. Arguably the most frequently referenced CSPY performance marker is the cecal intubation rate (CIR). Because cecal intubation is a critical component to defining a complete CSPY, it is often reported as a prerequisite for determining competence.1,2 The American Society for Gastrointestinal Endoscopy (ASGE) in conjunction with the American College of Gastroenterology (ACG) published quality indicators to help define competence.1 These, alongside other recommendations, suggest at least a 90% CIR in all cases. However, cecal intubation is only 1 component of a complete CSPY and alone does not sufficiently define competency. Regarding the number of procedures required to become competent, the first guidelines were based on expert opinion.3-5 Subsequently, with the emergence of a pivotal study by Cass et al,6 the ASGE recommended that trainees complete a minimum of 140 CSPYs before competence can be assessed.7 However, both references above are now relatively outdated, and as additional studies
have emerged, it is unclear whether more procedures should be mandated during training. This is reflected in the marked heterogeneity among current guidelines for gastroenterology and surgical trainees.8-11 With a critical need for a universal definition of competence as well as defining the minimum number of CSPYs that gastroenterology and surgical training programs should provide to their trainees, we sought to systematically review the medical literature. The goal of this review is to empower policymakers in the development of uniform and objective CSPY training guidelines, thus ensuring CSPYs are performed by qualified endoscopists, leading to improved patient care and resource utilization.
METHODS Search strategy and study selection
Copyright ª 2014 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2014.04.056
To identify relevant citations addressing the evaluation of the learning curve to achieve competency in performance of CSPY, 2 authors (N.S. and G.O.) independently searched MEDLINE (1946 to June 21, 2013) using the following search strategy: (“colonoscopy [MeSH]” OR “colonoscopy”) AND (“trainee” OR “training” OR “fellow*” OR “resident”). Search terms were intentionally kept broad to increase the likelihood of identifying relevant citations. Subsequently, the authors (N.S. and G.O.) reviewed the bibliographies of studies that met inclusion criteria, pertinent review articles, and guidelines to find further studies. Full-text citations, which assessed the learning curve to achieve competency in performing CSPY during gastroenterology or surgical training, were included. For studies to merit inclusion, a learning curve had to be established. This was defined as either a tabulated or graphic depiction of competence as a function of escalating independently completed trainee CSPYs, with a minimum of 2 training points. Furthermore, if it appeared that competence was achieved during the study (eg, as per graphical depiction), we required that it be explicitly stated. Studies were excluded if they (1) were not published in English; (2) were solely in abstract form; (3) were review articles, commentaries, or book chapters; (4) did not, at a minimum, assess independent CIR (ICIR); (5) reported insufficient data on desired outcomes; (6) lacked CSPY
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Abbreviations: CIR, cecal intubation rate; CIT, cecal intubation time; CSPY, colonoscopy; ICIR, independent cecal intubation rate; MCSAT, Mayo Colonoscopy Skills Assessment Tool; TPT, total procedural time. DISCLOSURE: All authors disclosed no financial relationships relevant to this publication. See CME section; p. 503.
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or trainee-specific outcomes; (7) assessed other types of trainees, including therapeutic endoscopy fellows, family physicians, or nurses, without providing gastroenterology or surgical trainee–specific data; (8) evaluated CSPY training in the pediatric population; or (9) focused on other procedures, either diagnostic or therapeutic involving the large intestine (eg, flexible sigmoidoscopy, CT colonography). Furthermore, we excluded studies whose focus was not to quantify the learning curve but to assess the impact of an intervention on the initial aspects of CSPY training. In this instance we used a minimum cut-off of !50 CSPYs on the learning curve to define the initial aspects of CSPY training, because this is currently the lowest threshold for competency assessment.8 If overlapping study populations were suspected, the citation with the smaller study population was excluded. Authors were contacted if further information was believed to affect study inclusion.
Data extraction Studies that met our inclusion criteria subsequently underwent independent data extraction by 2 authors (N.S. and G.O.) using a standardized data extraction form. Components included (1) year of publication; (2) country of origin; (3) study period; (4) trainee description, including previous endoscopic experience before study inclusion; (5) case description; (6) CSPY equipment, sedation, and preparation protocols; (7) trainee versus staff involvement during CSPY; and (8) definition of competence as well as related outcomes. If disagreements at any step during the review process occurred between the 2 reviewers (N.S. and G.O.), they were resolved by consensus. If this could not be achieved, a third reviewer (R.E.) was consulted to reach a final consensus.
Outcomes and analysis
Learning curve for achieving competency in colonoscopy
training, case selection, and different methodologies for determining endpoints), it was believed that meta-analyses of the above outcomes would be inappropriate at this time. Therefore, solely descriptive statistics were used to summarize findings.
RESULTS Search results and study description A total of 645 citations was identified by our electronic and gray literature search protocols, of which 104 underwent full-text review (Fig. 1). After full-text review, 18 studies (Table 1) assessing approximately 37,700 CSPYs completed by 247 trainees were included in our systematic review.12-29 Among the included studies, 15 studies were prospective in nature,13-22,24-27,29 with 14 assessing gastroenterology trainees,14-16,18-27,29 3 assessing surgical trainees,12,17,28 and 1 assessing both.13 Studies were subsequently stratified by definition of competence, with 10 studies using ICIR,12,13,15-19,24,25,27 6 studies using ICIR with a cecal intubation time (CIT) limit,14,20-22,26,29 1 study using ICIR with a total procedural time (TPT) limit,28 and 2 studies using more comprehensive definitions of competence.23,24 One study24 provided both estimates of ICIR and a more comprehensive definition of competence. Therefore, our review included a total of 19 unique evaluations. Reasons for study exclusion are described in Figure 1.
General competence assessment Among the 19 unique evaluations (Table 2) available for assessment, 11 evaluations12,19,20-24,26,27,29 reached their respective definition of competence and were able to provide either a range or definitive number of CSPYs needed to achieve competence. When stratifying these by common CSPY thresholds, all 11 evaluations required O50 CSPYs to achieve competence. Alternatively, 9 of 11 evaluations required O 140 CSPYs to achieve competence, with the remaining 2 evaluations providing ranges whose estimates fell across the 140 CSPY threshold. Last, 7 of 11 evaluations required O200 CSPYs to achieve competence.
The number of CSPYs that a gastroenterology or surgical trainee needs to complete during his or her training to achieve competence was our outcome of interest. We subsequently stratified this outcome based on varying markers of competence. A threshold of 90% ICIR was used as a minimum reference for competence. Estimates were provided as they were expressed in the original study. If different methods within a single study were used to estimate the competency threshold, then a conservative range across all these estimates was created. Subsequently, conservative ranges within the stratified groups were quantified. In studies whose purpose was to assess the impact of simulation on the learning curve, both the simulation and the control arms were included, because it was perceived that both represent current training strategies. In the setting of interventional studies (eg, oil/water immersion, cap-assisted CSPY), only the control arm was included for analysis. Because of multiple sources of heterogeneity (previous endoscopic experience of trainees, structure of endoscopy
Ten studies12,13,15-19,24,25,27 used ICIR as their marker of competence. Of note, 2 studies16,17 did describe procedural time restrictions; however, in 1 case procedural time was not recorded and in the other it was solely mentioned in the discussion section. Alternatively, 1 study19 incorporated the ability to correctly identify abnormalities during CSPY, but the methodology concerning this was not explicit. Therefore, in all 3 cases, the studies were ultimately allocated to the ICIR grouping. In regard to achieving competency, in only 4 studies12,19,24,27 was R90% ICIR achieved across a conservative range of 141 to 305 CSPYs. In 3 studies13,16,17 where competence was not achieved, individual trainee estimates
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Competence measured by ICIR
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Figure 1. Flowchart of study selection. ICIR, independent cecal intubation rate; CSPY, colonoscopy; GP, general practitioner; TF, therapeutics fellow.
were provided. Cass et al13 noted 2 trainees who exceeded 90% ICIR and had completed 210 (94% ICIR) and 275 (96% ICIR) CSPYs. In the 2 alternative studies, the point estimates were graphically depicted, making it difficult to elucidate the individual trainee data points.
Competence measured by ICIR and CIT/TPT limits Six studies14,20-22,26,29 used ICIR in conjunction with a CIT limit, and 1 study28 used ICIR with a TPT limit as markers of competence. Among the 6 studies additionally using a CIT limit, the time limit ranged between 15 and 30 minutes. Competency was achieved using their respective CIT limits in 5 studies20-22,26,29 between a range of 101 and 300 CSPYs. Of note, Park et al29 also explicitly assessed when all trainees within their study achieved competence, which occurred after 250 CSPYs. In the single study14 in which competence was not achieved, individual trainee estimates were provided. Two trainees exceeded the R90% ICIR threshold. One trainee had completed 325 CSPYs (93% ICIR) and another 340 CSPYs (92% ICIR). Concerning the single study28 using a TPT limit, the limit was set at 35 minutes. Competence was not achieved in this study. However, 50% of the trainees (n Z 3) exceeded the R90% ICIR threshold by study end and had completed 203 (94% ICIR), 206 (92% ICIR), and 263 (93% ICIR) CSPYs, respectively. 412 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 3 : 2014
Competence measured by comprehensive markers Two studies23,24 provided more comprehensive definitions of competence. Spier et al23 used a definition of “completely independent CSPY” that incorporated multiple aspects of CSPY, including cecal intubation, polypectomy, and hemostasis. In this study, the 90% independent CSPY completion standard was achieved at 467 CSPYs. However, further analysis showed that by 500 CSPYs all trainees were able to achieve competence. In the alternative study,24 Sedlack used the previously validated Mayo Colonoscopy Skills Assessment Tool (MCSAT) to establish both definitions of competency and competency thresholds. Through establishing minimal competency criteria across both the motor and cognitive components of the MCSAT, trainees’ scoring averages were subsequently able to surpass the minimal competency criteria for the MCSAT components by 275 CSPYs. Furthermore, it was not until approximately 400 CSPYs that competency was achieved across all trainees.
DISCUSSION CSPY is an integral tool in the management of colonic disease, and having physicians, regardless of specialty, who can effectively perform them is critical. However, www.giejournal.org
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Learning curve for achieving competency in colonoscopy
TABLE 1. Description of included studies Study
Year
Country
Study design
Trainee type
Parry and Williams12
1991
New Zealand
Retrospective
ST
Cass et al13
1993
USA
Prospective
GT/ST
Marshall14
1995
USA
Prospective
GT
1996
USA
Prospective
GT
1999
Greece
Prospective
GT
2002
USA
Prospective
ST
2004
USA
Prospective
GT
2006
USA
Prospective
GT
2008
Korea
Prospective
GT
2009
The Netherlands
Prospective
GT
Chung et al
2010
Korea
Prospective
GT
23
2010
USA
Retrospective
GT
2011
USA
Prospective
GT
2012
Italy
Prospective
GT
Gromski et al
2012
Korea
Prospective
GT
Koch et al27
2012
The Netherlands
Prospective
GT
Selvasekar et al28
2012
USA
Retrospective
ST
Park et al29
2013
Korea
Prospective
GT
Chak et al15 Tassios et al
16 17
Church et al
18
Sedlack and Kolars Cohen et al
19
20
Lee et al
21
Koornstra et al 22
Spier et al 24
Sedlack
Elvevi et al
25 26
GT, gastroenterology trainee; ST, surgical trainee.
marked heterogeneity exists among different specialties regarding the minimum number of procedures recommended before assessing competence.8-11 This disparity is partly driven by the lack of a universal definition of competence as well as a practical means of assessing it. Trainees therefore run the risk of not receiving the appropriate amount of training needed to learn how to perform highquality CSPYs, which they will be expected to do once in independent practice. This highlights the crucial need to establish objective criteria for procedural competence to facilitate training programs in providing an adequate amount of experience. With that in mind, our systematic review is the first in the medical literature to show that as competency assessment has continued to evolve from assessing ICIR to incorporating more comprehensive definitions of competence, the number of CSPYs required to achieve competence rises above current training minimums, thus questioning our current procedural thresholds as well as the means by which we have been establishing them. Historically, because of the lack of objective measures for assessing competency, accrediting bodies relied on establishing a certain number of CSPYs for trainees to complete before being deemed competent. The numbers
required were initially defined via expert opinion. However, as studies emerged13 that serially assessed a trainee’s ability to independently traverse the colon, the first step toward objective competency assessment occurred. Subsequently, numerous studies have attempted to assess the learning curve using similar surrogate markers of competence, most notably ICIR. Although cecal intubation is an integral component toward defining a complete CSPY, it is only one component and fails to assess the manner in which the cecum is reached, the ability of the trainee to both identify and safely remove polyps, and the cognitive aspects pertinent to performing CSPYs. Interestingly, based on our results, it does not appear that adding a CIT limit within the time range assessed (15 to 30 minutes) had a dramatic effect on the trajectory of the learning curve. It was only after using more complete definitions of competence, such as those used by Spier et al23 and Sedlack,24 that the threshold for achieving competence rises, which we interpret as showcasing a more realistic learning curve for trainees. Despite the above, the question still remains: what is procedural competence in this setting? Although traditionally a CIR of 90% has been used as a threshold for competency, this cut-off was somewhat arbitrarily selected. The
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TABLE 2. Competency outcomes of included studies Reference
n
No. CSPY
Competency marker
Competency achieved
Competency results
13
12
49/T*
ICIR
No
R90% ICIR not achieved. 84% @ 100 CSPYs
15
12
181
ICIR
No
R90% ICIR not achieved. 64% among SYTs (mean 123 previous CSPYs)
16
8
978
ICIRy
No
R90% ICIR not achieved. 77% @ 180 CSPYs
17
18
2250
ICIR
No
R90% ICIR not achieved. 75% @ 101-125 CSPYs
18
8
480
ICIR
No
R90% ICIR not achieved. 72% (SIMT), 58% (No SIMT) @ 46-60 CSPYs
25
12
720
ICIR
No
R90% ICIR not achieved. 60% @ 41-60 CSPYs
12
1
305
ICIRz
Yes
R90% ICIR (91%) achieved @ 201-305 CSPYs. Cusum Plot: R90% ICIR @ O200 CSPYs
19
45
9000
ICIRx
Yes
R90% ICIR (93% SIMT, 91% No SIMT) achieved @ 181-200 CSPYs survival analysis: R 90% ICIR achieved @ 141-160 CSPYs (SIMT and No SIMT)
24
41
6635
ICIR
Yes
R90% ICIR (92%) achieved @ 300 CSPYs
27
19
2887
ICIR
Yes
R90% ICIR achieved @ 280 CSPYs
ICIR
ICIR and CIT limit 14
9
389
ICIR (30 min)
No
R90% ICIR not achieved. 86% among SYTs (mean 328 CSPYs)
20
24
4351
ICIR (20 min)
Yes
R90% ICIR achieved (91%) @ 101-150 CSPYs
21
1
150
ICIR (30 min)
Yes
R90% ICIR achieved (92%) @ 126-150 CSPYs
22
12
3243
ICIR (20 min)
Yes
R90% ICIR achieved (94%) @ 201-250 CSPYs
26
4
1210
ICIR (20 min)
Yes
R90% ICIR achieved @ 151-200 CSPYs
29
4
2050
ICIR (15 min)
Yes
R90% ICIR achieved (93%) @ 251-300 CSPYs
1498
ICIR (35 min)
No
R90% ICIR not achieved. 83% @ mean 249 CSPYs
ICIR and TPT limit 28
6
Comprehensive competency assessment 23
11
770
Total CSPY{
Yes
R90% total CSPY achieved @ 467 CSPYs
24
41
6635
MCSAT MCCs
Yes
MCC for the core MCSAT skills reached @ 275 CSPYs
CSPY, Colonoscopy; CIT, cecal intubation time; ICIR, independent cecal intubation rate; MCC, minimal competency criteria, MCSAT, Mayo Colonoscopy Skills Assessment Tool; SIMT, simulation training; SYT, second-year trainee; T, trainee; TPT, total procedural time. *Median 49 CSPYs per trainee. yDefinition of ICIR: either reaching the cecum or an occluding tumor in the cecum/ascending colon. zDefinition of ICIR: either reaching the cecum, or ileocolonic anastomosis, or encountering an impassable obstructive lesion. xDefinition of ICIR: included the ability to correctly recognize and identify abnormalities. {Definition of CSPY: included multiple aspects of procedure (eg, ICIR, polypectomy, hemostasis).
ASGE and ACG Taskforce on Quality in Endoscopy endorsed a 90% CIR with the evidence to support this cut-off apparently based on a study published in 1993 by Marshall and Barthel.30 Interestingly, the study in question showed a CIR of 96% for 418 attempted CSPYs. This raises questions concerning the validity of the 90% CIR cut-off and whether a higher cut-off such as R95% for all cases should be considered, not just in cases where the indica-
tion is for screening in a healthy adult as is currently recommended. Fortunately, the study by Sedlack24 is starting to shed light on this topic. Using the previously validated MCSAT, which is composed of both motor and cognitive items, the study established minimal competency criteria for each item of the MCSAT among gastroenterology trainees. It was found that by 275 CSPYs, trainees were able to achieve competency across these items.
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Learning curve for achieving competency in colonoscopy
Subsequently, using the established learning curve defined during the study, it was found that an ICIR of 85% and a CIT of approximately 16 minutes correlates with this threshold of 275 CSPYs. This is the first study, to our knowledge, that has attempted to objectively define competency criteria. Moreover, it highlights a number of key features of the MCSAT. First, it emphasizes the importance of a trainee’s ability to not only master the motor aspects of the procedure but also the cognitive aspects of CSPY. Furthermore, it incorporates key aspects required to successfully perform CSPY, such as loop reduction, mucosal visualization, and therapeutic procedures. The importance of these features have been echoed by 2 recently unveiled assessment tools, the Gastrointestinal Endoscopy Competency Assessment Tool31 and the ASGE’s assessment of competence in endoscopy evaluation tool for CSPY.32 Of note, both the Gastrointestinal Endoscopy Competency Assessment Tool and the assessment of competence in endoscopy evaluation tool have incorporated the assessment of cecal intubation, emphasizing that CIR still plays an important role in the assessment of competency. However, these tools also highlight that competency in performing CSPY is so much more than just reaching the cecum and that for a trainee to be deemed competent these aspects must be objectively evaluated on a serial basis. Although there is a movement away from relying on the number of procedures needed to achieve competence, there is still value in quantifying these thresholds, specifically during the current training era. Most importantly, it provides a framework for training programs to ensure that their trainees receive enough repetition in performing CSPYs.33 However, when attempting to decide on the value of this threshold, an important decision is whether to use mean estimates or estimates of when all trainees achieved competence.23,24,29 Unfortunately, this is a very difficult question to answer because it is influenced by the distribution at which trainees reach competence. Nevertheless, until more robust definitions of competence can be validated to help establish a more appropriate threshold, we believe it is fair to contest that it is better to err on the side of caution and more closely reflect when all trainees reach competence. However, it is also important to be cognizant of trainees who are struggling to grasp either the cognitive or motor aspects of CSPY, because they may require alternative training strategies, and these outliers could inappropriately increase the threshold value for the remainder of trainees. With the above discussion in mind, it is not surprising why such disparity exists between different specialties regarding the number of procedures recommended before assessing competency, with the ASGE recommending 200 CSPYs10 in contrast to the American Board of Surgery8,34 and the American Academy of Family Physicians35 recommending 50 CSPYs. In regard to the American Academy of Family Physicians’ recommendation, although our review
did not focus on assessing competency among family physicians, to our knowledge there is a paucity of studies assessing competency during family physician training.36,37 Concerning gastroenterology and general surgery trainees, from our included studies none were able to show that competence is achieved by 50 or even 100 CSPYs. Moreover, it appears that 200 CSPYs may potentially be an underestimate. Therefore, until there is evidence to suggest that different types of physicians achieve competence at different thresholds using objective competency assessment that reflects the core aspects of performing CSPY, this minimum requirement should be adopted by training programs, specialty societies, and hospital privileging committees, with the expectation that more experience may be required. Our study was not without limitations. Marked heterogeneity exists across studies concerning multiple components of study design. This included (1) trainees’ previous endoscopic experience, (2) the structure of endoscopic training, (3) case selection, and (4) the manner in which estimates were quantified. This ultimately limited our ability to aggregate data, and we were unable to perform meta-analyses. Moreover, the inclusion criteria mandating ICIR limited our assessment of alternative methods of assessing competency. Finally, we did not assess other types of trainees, such as family physicians or nurse endoscopists, and excluded studies that did not provide gastroenterology or surgery–specific data. This limitation is best highlighted by a recently published study by Ward et al37 that looked at 297 trainees including gastroenterology, surgical, family practice, and nurse endoscopists and found that an ICIR of 90% was reached by 233 CSPYs. In summary, our study showcases that as the definition of procedural competence continues to mature toward what is expected of an independent endoscopist, the number of CSPYs required to achieve competence continues to rise above current estimates. Further research in this area is needed to attempt to solidify objective competency criteria across all specialties whose practitioners perform CSPYs, thus ensuring that all physicians are held to a common standard with the ultimate goal of allowing competent trainees to smoothly transition into competent endoscopists. Finally, although the focus of this review is attempting to define procedural thresholds, it is important to not lose sight of the larger picture regarding endoscopy training: to equip trainees with the ability to seamlessly integrate endoscopy into the management of GI issues they will face as independent practitioners. We suspect this may pose a much greater challenge to trainees than solely learning how to effectively perform endoscopy.
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Shahidi et al 23. Spier BJ, Benson M, Pfau PR, et al. Colonoscopy training in gastroenterology fellowships: determining competence. Gastrointest Endosc 2010;71:319-24. 24. Sedlack RE. Training competency in colonoscopy: assessing and defining competency standards. Gastrointest Endosc 2011;74:355-66. 25. Elvevi A, Cantu P, Maconi G, et al. Evaluation of hands-on training in colonoscopy: is a computer-based simulator useful? Dig Liver Dis 2012;44:580-4. 26. Gromski MA, Miller CA, Lee SH, et al. Trainees’ adenoma detection rate is higher if O/Z 10 minutes is spent on withdrawal during colonoscopy. Surg Endosc 2012;26:1337-42. 27. Koch AD, Haringsma J, Schoon EJ, et al. Competence measurement during colonoscopy training: the use of self-assessment of performance measures. Am J Gastroenterol 2012;107:971-5. 28. Selvasekar CR, Holubar SD, Pendlimari R, et al. Assessment of screening colonoscopy competency in colon and rectal surgery fellows: a single institution experience. J Surg Res 2012;174:e17-23. 29. Park HJ, Hong JH, Kim HS, et al. Predictive factors affecting cecal intubation failure in colonoscopy trainees. BMC Med Educ 2013;13:5. 30. Marshall JB, Barthel JS. The frequency of total colonoscopy and terminal ileal intubation in the 1990s. Gastrointest Endosc 1993;39:518-20. 31. Walsh CM, Ling SC, Khanna N, et al. Gastrointestinal Endoscopy Competency Assessment Tool: development of a procedure-specific assessment tool for colonoscopy. Gastrointest Endosc 2013;79:798-807. 32. ASGE Training Committee. ASGE’s assessment of competency in endoscopy evaluation tools for colonoscopy and EGD. Gastrointest Endosc 2014;79:1-7. 33. ASGE Training Committee. Colonoscopy core curriculum. Gastrointest Endosc 2012;76:482-90. 34. American Board of Surgery. Flexible endoscopy curriculum. March 2014. Available at: http://www.absurgery.org/default.jsp?certgsqe_fec. Accessed April 2014. 35. American Academy of Family Physicians. Colonoscopy (Position Paper). June 13, 2013. Available at: http://s.aafp.org/?qZcolonoscopy&q1Z &x1Z&first_searchZ0&searchZEntireþSite. Accessed April 2014. 36. Eckert LD, Short MW, Domagalski JE, et al. Assessing colonoscopy training outcomes using quality indicators. J Grad Med Educ 2009;1: 89-92. 37. Ward ST, Mohammed MA, Walt R, et al. An analysis of the learning curve to achieve competency at colonoscopy using the JETS database. Gut 2014 [Epub ahead of print].
Received March 3, 2014. Accepted April 28, 2014. Current affiliation: Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada. Reprint requests: Dr Robert Enns, St Paul’s Hospital, University of British Columbia, Pacific Gastroenterology Associates, 770-1190 Hornby Street, Vancouver, BC Canada V6Z 2K5.
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