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Training and Assessment of Competence (Preparing the Endoscopist)

Joseph W. Leung1,2 and Peter B. Cotton3

1?Department of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, CA, USA

2?Section of Gastroenterology, VA Northern California Health Care System, Sacramento VAMC, Mather, CA, USA

3?Digestive Disease Center, Medical University of South Carolina, Charleston, SC, USA

Key Points

• ERCP includes a range of mainly therapeutic procedures of different levels of complexity.
• Training involves both clinical and technical aspects.
• Hands-on apprenticeship dominates, but various simulators can help.
• Competence should be assessed objectively, and the data made available to patients.

Background

ERCP is the most complex common endoscopic (digestive) procedure. It has great potential for benefit, but it also carries significant risk of failure, adverse events [1], and medicolegal jeopardy [2]. Clearly it must be done as well as possible, and there has been more focus on quality recently. The key questions are:

• Who should be trained?
• What should be taught, and how?
• Who should teach?
• How are training and competence assessed?
• What level of performance is acceptable?

Who Should Be Trained?

ERCP training is usually a part of the postgraduate training of selected gastroenterologists and a few surgeons. The number needed has fallen with the widespread use of magnetic resonance cholangiopancreatography (MRCP) (and also endoscopic ultrasound [EUS]). In the structured British National Health System, the number of training positions is now tailored to the projected population needs. In many countries, and especially in the United States, there is no such limitation, with the result that some trainees are short-changed, and some have marginal volumes in ongoing practice. It is incumbent on training programs to ensure that those they train are able to reach an acceptable level of competence for safe independent practice. To limit training to less but produce more qualified trainees in the United States, some gastrointestinal (GI) programs have limited advanced endoscopy (ERCP and EUS) to a 4th year of training.

What Should Be Taught, and How?

While we focus here mainly on the difficulties involved in teaching the necessary technical skills, it is essential to realize that optimal ERCP requires that practitioners are knowledgeable about pancreatic and biliary medicine and the many alternative diagnostic and therapeutic approaches, as well as being skilled in the basic tenets of patient care. These important aspects should be well covered in basic GI training programs, such as the three-year fellowships in United States. Hands-on training is an integral part of ERCP practice and is done under close supervision by the trainer in a progressive manner to avoid mistakes that can be detrimental or may have a negative impact on outcome.

Levels of Complexity

ERCP is not a single procedure. The term encompasses a large spectrum of interventions performed (mainly) through the papilla. The concept of levels of complexity or difficulty, introduced by Schutz and Abbot, has recently been updated by a working party of American Society for Gastrointestinal Endoscopy (ASGE) [3]. (Table 1.1). Levels 1 and 2 together include the standard (mostly biliary) procedures, which are needed at relatively short notice at the community level. The more complex level 3 ("advanced") and 4 ("tertiary") procedures are mainly performed by relatively few highly trained endoscopists in referral centers.

These distinctions are clearly relevant to training. No one should be trained to less than competence at level 2. Although some practitioners will gradually advance those skills in practice (with mentoring, self-study, and courses), there are increasing numbers of advanced positions (e.g. 4th year in the United States), providing training in the more complex procedures.

Progressive Training

Like other endoscopy procedures, basic ERCP training involves lectures, study courses, didactic teaching, and the use of books, atlases, and videos in addition to hands-on supervised clinical practice [4-6]. Clinical teaching includes the elements of a proper history and physical examination with pertinent laboratory tests. Overall management will include work with in- and outpatients with pancreaticobiliary problems, with discussion on the various diagnostic and treatment options, and the assessment and mitigation of risk. This is best achieved in a multidisciplinary environment, with close cooperation particularly with surgeons and radiologists.

Table 1.1 Complexity levels in ERCP.

Adapted from Cotton et al [3].

EHL, electrohydraulic lithotripsy; PDT, photodynamic therapy.

After a period of observation, technical training begins with learning the proper technique of scope insertion and positioning. Despite that trainees may have performed many upper endoscopy and colonoscopy procedures, handling and manipulating a side-viewing duodenoscope requires a different skill set. It takes 20 to 30 cases before the novice endoscopist can master the basic skills of handling the side-viewing scope.

Selective cannulation of the desired duct (usually initially the bile duct) is the key challenge in ERCP because it is essential for therapeutic interventions. Incompetence in this aspect causes failure and increases the risk of postprocedural pancreatitis. Deep cannulation allows passage of guidewires to support sphincterotomy, stenting, and balloon dilation. Training in these basic steps should be delivered in stages. The trainer demonstrates the technique and then gives verbal instructions to guide the hands-on trainee. In difficult cases, the trainer may take over part of the procedure to complete the more difficult steps and then allow the trainee to continue. The trainees will acquire basic ERCP experience by learning the different steps, although not necessarily in a systematic manner. However, the trainee will be able to assimilate the experience and eventually be able to complete the entire procedure independently.

The extent to which a trainee can learn more complex skills will depend on many factors, not least the length of time available and the case mix in the training center.

It is also important for trainees to learn about all of the equipment that can be used during ERCP, including important aspects of radiology safety. In most centers, there may not be a dedicated radiology technician to assist with the operation of the fluoroscopy unit (usually a portable C-arm). The trainee should receive appropriate training and certification to operate the fluoroscopy unit to ensure patient safety. Similarly, the correct interpretation of X-rays is crucial to determine the next step in therapeutic intervention, and trainees should receive teaching in image interpretation to guide subsequent therapy. ERCP is a team event, and it is necessary to appreciate the importance of well-trained and motivated staff.

Simulation Training

The relative shortage of cases in many institutions and the risks involved in training have naturally encouraged the development of adjunctive alternatives to hands-on experience. Simulation practice provides trainees an opportunity to handle the scope and...