ADVANCES IN ENDOSCOPY Current Developments in Diagnostic and Therapeutic Endoscopy
Section Editor: John Baillie, MB ChB, FRCP
Simulators for Training in Endoscopy Robert E. Sedlack, MD
Assistant Professor of Medicine Mayo Clinic G&H When did simulators first become available for endoscopy? RS The use of simulators in endoscopy began in the late 1960s with live animal models, mechanical models using somewhat unsophisticated materials, and other devices. These first simulators were used relatively rarely and without proven clinical impact. Computer simulation has been around for the last 20 years but prior to the mid1990s computers were not fast enough nor did they have realistic enough graphics to create an effective simulation environment. In the last decade, however, computer simulators have provided a new venue with much greater simulation fidelity. Currently, the two commercially available computer simulators are the AccuTouch (Immersion Medical) and the GI Mentor 2 (Simbionix). G&H How do these programs work? RS These programs are composed of either a mannequin or a box into which a mock scope is inserted. Using specially designed software, the computer creates a visual representation of the colonoscopy, esophagogastroduodenoscopy, or other technique being performed. The aim of these simulators is to create not only a visually realistic simulation of the lumen of the gastrointestinal tract, but also the feel and resistance of inserting and advancing a scope, loop formation, etc. The different simulators use different internal mechanisms for creating this tactile sensation. G&H Could you describe your studies of simulation training? RS These studies have focused primarily on gastroenterology fellow and resident education in lower endoscopy.
We trained fellows in colonoscopy either with or without simulator augmentation and then compared their performance during live patient colonoscopy. Additionally, all of the patients involved in this study completed questionnaires about the level of their experienced discomfort. The study showed that fellows who had simulator training performed better, and their patients experienced less discomfort than those that underwent examinations by the traditionally trained fellows. Similar patient benefits were demonstrated in a study of residents learning flexible sigmoidoscopy with simulation assistance versus traditional patient-based training alone. In some respects, this latter study is more significant than the first in that colonoscopies are performed while the patient is under sedation, and so it could be argued that the lower procedure-related pain reported may simply be reflective of sedation techniques rather than endoscopy skill. By contrast, flexible sigmoidoscopy is performed without sedation, so our finding that these patients also experienced less pain when examined by simulator-trained residents is a more compelling reflection of improved patient comfort. G&H What are the goals of simulation endoscopy training? RS From the standpoint of an educator, the main endpoint is to improve endoscopy skills. Can the cecum be reached more often and more quickly? Does simulation training lead to better visualization during withdrawal of the scope? A clinician, however, will ask whether the training is impacting patient care. Whether the use of endoscopy simulators can accelerate skill acquisition is a major issue for training programs. We have shown that simulation training can give users an early advantage in developing their endoscopic skills. However, another crucial issue, which has not yet been demonstrated, is whether simulator training can accelerate a trainee’s becoming competent with a given procedure. Does simulator training enable a trainee to reach a skill level at which they can perform these procedures independently at a faster rate than without simulator training? This question has not yet been examined, but such a study would provide very meaningful information.
Gastroenterology & Hepatology Volume 2, Issue 1 January 2006
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G&H Why is it important to increase the speed at which fellows become competent in endoscopy?
G&H What are the immediate next steps for simulator training in endoscopy?
RS Over the past decade or so there has been an increased emphasis on not only achieving competence but also assessing competence. This concern appears to be primarily driven by medicolegal factors requiring more accountability from training programs in terms of showing that what and how fellows are being taught is effective. Teaching endoscopy techniques to a fellow involves considerable time and cost, mainly due to decreased productivity. Based on our experience, we have reported that a staff working alone can perform an average of four additional colonoscopies per half work-day as compared to a teaching counterpart. This decreased productivity is equivalent to lost revenue. Education always involves cost, which is necessary but is still substantial. Obviously, it would be more cost effective to have an endoscopist performing a procedure on his own than to have a supervised fellow performing the procedure. Therefore, anything that can be done to accelerate skill acquisition toward competence would decrease the cost of training endoscopists.
RS One of the most useful advances would be if the simulator programs could be used as a tool for teaching and as a measuring stick for acquired skill. Conceivably, trainees could be tested just before finishing their fellowships by performing cases on a simulator in order to confirm that a minimum level of competence has been achieved. There are problems with this approach. First, it is very difficult to define competence. More importantly, the performance data currently produced by these programs do not have much clinical relevance. The measurement parameters would need to be dramatically improved before they could be used as a measuring tool. In the field of cardiology, cardiac catheterization simulators are being evaluated for possible integration into certification exams. In the field of gastroenterology, the simulator programs are not ready for this type of forum but do have the potential to be a very powerful tool for credentialing and competency assessment if the metrics can be improved and cases made more complex.
G&H At what stages of training is the use of simulator programs appropriate?
G&H What is the cost of simulator training?
RS The findings from our studies discussed above really pertain to very early training with individuals who have never worked with scopes before. One simulation case appears to provide a novice with roughly the same experience as a single live case and the skill level achieved from performing 20 simulated cases is comparable to that achieved from performing 20 live cases. Our study showed that this one-to-one training effect exists for roughly 20–25 simulated colonoscopies, meaning that those fellows who trained with a simulator program first began patient-based training with roughly the same skills as someone who had already performed 20–25 live colonoscopies. However, after the simulator-trained fellows had performed approximately 30 live colonoscopies, the measurable difference in skills between the simulator-trained and non–simulator-trained fellows had disappeared. Right now, the benefit of simulator training appears to be limited to the novice endoscopist and the learning curve on the colonoscopy simulator tends to plateau after 20–25 cases. After that, I do not believe computer simulators can act as a replacement for patient experience. The currently available scenarios are far too easy for a competent or even modestly experienced endoscopist. If more challenging cases could be incorporated into the programming, the potential usefulness of these programs could increase.
14
RS At present, a computer simulator platform with lower endoscopy scenarios alone costs roughly $35,000– $45,000. This cost can certainly be prohibitive to smaller training programs. However, our research has shown that the use of a colonoscopy simulator can actually pay for itself after training only 10 fellows using a two-day simulation curriculum. While a fellow is training on a simulator, a staff endoscopist, who would otherwise be teaching only a few cases, is freed up to perform to their full capacity, thus recapturing revenue that would otherwise be lost. Based on this arrangement, a large training program could quickly reduce the intangible costs of training. However, a smaller training program (1–2 fellows per year) still might not find that the financial benefits realized by using a simulator offset the significant initial investment. Suggested Reading Sedlack RE. Endoscopic simulation: where we’ve been and where we’re going [editorial]. Gastrointest Endosc. 2005;61:216-218. Sedlack RE, Kolars JC, Alexander JA. Computer simulation training enhances patient comfort during endoscopy. Clin Gastroenterol Hepatol. 2004;348-352. Sedlack RE, Kolars JC. Computer simulator training enhances the competency of gastroenterology fellows at colonoscopy: results of a pilot study. Am J Gastroenterol. 2004;99:33-37. Di Giulio E, Frednose D, Casetti T, et al. Training with a computer-based simulator achieves basic manual skills required for upper endoscopy: a randomized controlled trial. Gastrointest Endosc. 2004;60:196-200. Sedlack RE. Simulation in gastrointestinal endoscopy. In: Practical Healthcare Simulations. Lake, Loyd, and Greenberg, eds. Hanley & Belfus, Inc. Medical Publishers; Philadelphia, PA. 2004:459-474.
Gastroenterology & Hepatology Volume 2, Issue 1 January 2006
Section Editor: John Baillie, MB ChB, FRCP
Simulators for Training in Endoscopy Robert E. Sedlack, MD
Assistant Professor of Medicine Mayo Clinic G&H When did simulators first become available for endoscopy? RS The use of simulators in endoscopy began in the late 1960s with live animal models, mechanical models using somewhat unsophisticated materials, and other devices. These first simulators were used relatively rarely and without proven clinical impact. Computer simulation has been around for the last 20 years but prior to the mid1990s computers were not fast enough nor did they have realistic enough graphics to create an effective simulation environment. In the last decade, however, computer simulators have provided a new venue with much greater simulation fidelity. Currently, the two commercially available computer simulators are the AccuTouch (Immersion Medical) and the GI Mentor 2 (Simbionix). G&H How do these programs work? RS These programs are composed of either a mannequin or a box into which a mock scope is inserted. Using specially designed software, the computer creates a visual representation of the colonoscopy, esophagogastroduodenoscopy, or other technique being performed. The aim of these simulators is to create not only a visually realistic simulation of the lumen of the gastrointestinal tract, but also the feel and resistance of inserting and advancing a scope, loop formation, etc. The different simulators use different internal mechanisms for creating this tactile sensation. G&H Could you describe your studies of simulation training? RS These studies have focused primarily on gastroenterology fellow and resident education in lower endoscopy.
We trained fellows in colonoscopy either with or without simulator augmentation and then compared their performance during live patient colonoscopy. Additionally, all of the patients involved in this study completed questionnaires about the level of their experienced discomfort. The study showed that fellows who had simulator training performed better, and their patients experienced less discomfort than those that underwent examinations by the traditionally trained fellows. Similar patient benefits were demonstrated in a study of residents learning flexible sigmoidoscopy with simulation assistance versus traditional patient-based training alone. In some respects, this latter study is more significant than the first in that colonoscopies are performed while the patient is under sedation, and so it could be argued that the lower procedure-related pain reported may simply be reflective of sedation techniques rather than endoscopy skill. By contrast, flexible sigmoidoscopy is performed without sedation, so our finding that these patients also experienced less pain when examined by simulator-trained residents is a more compelling reflection of improved patient comfort. G&H What are the goals of simulation endoscopy training? RS From the standpoint of an educator, the main endpoint is to improve endoscopy skills. Can the cecum be reached more often and more quickly? Does simulation training lead to better visualization during withdrawal of the scope? A clinician, however, will ask whether the training is impacting patient care. Whether the use of endoscopy simulators can accelerate skill acquisition is a major issue for training programs. We have shown that simulation training can give users an early advantage in developing their endoscopic skills. However, another crucial issue, which has not yet been demonstrated, is whether simulator training can accelerate a trainee’s becoming competent with a given procedure. Does simulator training enable a trainee to reach a skill level at which they can perform these procedures independently at a faster rate than without simulator training? This question has not yet been examined, but such a study would provide very meaningful information.
Gastroenterology & Hepatology Volume 2, Issue 1 January 2006
13
G&H Why is it important to increase the speed at which fellows become competent in endoscopy?
G&H What are the immediate next steps for simulator training in endoscopy?
RS Over the past decade or so there has been an increased emphasis on not only achieving competence but also assessing competence. This concern appears to be primarily driven by medicolegal factors requiring more accountability from training programs in terms of showing that what and how fellows are being taught is effective. Teaching endoscopy techniques to a fellow involves considerable time and cost, mainly due to decreased productivity. Based on our experience, we have reported that a staff working alone can perform an average of four additional colonoscopies per half work-day as compared to a teaching counterpart. This decreased productivity is equivalent to lost revenue. Education always involves cost, which is necessary but is still substantial. Obviously, it would be more cost effective to have an endoscopist performing a procedure on his own than to have a supervised fellow performing the procedure. Therefore, anything that can be done to accelerate skill acquisition toward competence would decrease the cost of training endoscopists.
RS One of the most useful advances would be if the simulator programs could be used as a tool for teaching and as a measuring stick for acquired skill. Conceivably, trainees could be tested just before finishing their fellowships by performing cases on a simulator in order to confirm that a minimum level of competence has been achieved. There are problems with this approach. First, it is very difficult to define competence. More importantly, the performance data currently produced by these programs do not have much clinical relevance. The measurement parameters would need to be dramatically improved before they could be used as a measuring tool. In the field of cardiology, cardiac catheterization simulators are being evaluated for possible integration into certification exams. In the field of gastroenterology, the simulator programs are not ready for this type of forum but do have the potential to be a very powerful tool for credentialing and competency assessment if the metrics can be improved and cases made more complex.
G&H At what stages of training is the use of simulator programs appropriate?
G&H What is the cost of simulator training?
RS The findings from our studies discussed above really pertain to very early training with individuals who have never worked with scopes before. One simulation case appears to provide a novice with roughly the same experience as a single live case and the skill level achieved from performing 20 simulated cases is comparable to that achieved from performing 20 live cases. Our study showed that this one-to-one training effect exists for roughly 20–25 simulated colonoscopies, meaning that those fellows who trained with a simulator program first began patient-based training with roughly the same skills as someone who had already performed 20–25 live colonoscopies. However, after the simulator-trained fellows had performed approximately 30 live colonoscopies, the measurable difference in skills between the simulator-trained and non–simulator-trained fellows had disappeared. Right now, the benefit of simulator training appears to be limited to the novice endoscopist and the learning curve on the colonoscopy simulator tends to plateau after 20–25 cases. After that, I do not believe computer simulators can act as a replacement for patient experience. The currently available scenarios are far too easy for a competent or even modestly experienced endoscopist. If more challenging cases could be incorporated into the programming, the potential usefulness of these programs could increase.
14
RS At present, a computer simulator platform with lower endoscopy scenarios alone costs roughly $35,000– $45,000. This cost can certainly be prohibitive to smaller training programs. However, our research has shown that the use of a colonoscopy simulator can actually pay for itself after training only 10 fellows using a two-day simulation curriculum. While a fellow is training on a simulator, a staff endoscopist, who would otherwise be teaching only a few cases, is freed up to perform to their full capacity, thus recapturing revenue that would otherwise be lost. Based on this arrangement, a large training program could quickly reduce the intangible costs of training. However, a smaller training program (1–2 fellows per year) still might not find that the financial benefits realized by using a simulator offset the significant initial investment. Suggested Reading Sedlack RE. Endoscopic simulation: where we’ve been and where we’re going [editorial]. Gastrointest Endosc. 2005;61:216-218. Sedlack RE, Kolars JC, Alexander JA. Computer simulation training enhances patient comfort during endoscopy. Clin Gastroenterol Hepatol. 2004;348-352. Sedlack RE, Kolars JC. Computer simulator training enhances the competency of gastroenterology fellows at colonoscopy: results of a pilot study. Am J Gastroenterol. 2004;99:33-37. Di Giulio E, Frednose D, Casetti T, et al. Training with a computer-based simulator achieves basic manual skills required for upper endoscopy: a randomized controlled trial. Gastrointest Endosc. 2004;60:196-200. Sedlack RE. Simulation in gastrointestinal endoscopy. In: Practical Healthcare Simulations. Lake, Loyd, and Greenberg, eds. Hanley & Belfus, Inc. Medical Publishers; Philadelphia, PA. 2004:459-474.
Gastroenterology & Hepatology Volume 2, Issue 1 January 2006
