Dr. Whitson and I will discuss, I think you just load up our slides, teaching endoscopy, I guess. So first, I'd like to thank myself for inviting myself to speak today. Just had to throw that out there. We're supposed to have some videos, but we don't have anything deploying metal stents or looking at hyaluronobstruction, so we're just not as cool as the advanced endoscopists, so you're stuck with us. We thought we may act some of this out, but we figured we wouldn't torture you too much. So I'm gonna turn it over to Dr. Whitson, who'll start the first part of our talk. No problem. So I would like to say thank you to the course directors, Dr. Bacobo, Dr. Patel, as well as you, Dr. Williams, for inviting me today to speak about something that I truly am passionate about, which is medical education for our GI fellows and our trainees. This is our disclosure side. Mine is less exciting than Renee's. So what's the overall agenda? We hope to give you just a quick bird's eye view as to the goals of endoscopic training and how it's not just a therapeutic thing, it's also a cognitive approach. We're gonna talk about best practices for endoscopic training, both in the pre-, intra-, and post-procedural setting, and then we're gonna start talking about incorporating competency-based tools to really track our trainees as they progress throughout the years, and that's gonna be built into Dr. Shaw's talk later about competency-based education. So when we talk about endoscopic training, we're not just talking about the tool in our hands. Of course there are key technical issues that we want our trainees to develop competence in. We want them to have the correct hand positioning, we want them to correctly torque and have good loop reduction, but there's a lot more than just that. This includes the cognitive competencies, so knowing the anatomy, being able to recognize pathology, knowing the procedural indications, contraindications, and how to handle adverse events when they inevitably happen in a procedural field. And overlapping the two, there are also integrative competencies that we want to address and make sure we're teaching. Decision-making, communication in the middle of an emergent setting, professionalism, patient safety awareness is among the others. So as a framework for our talk, we're really gonna break this up into the pre-procedure, the intra-procedural time, and the post-procedural time, and really what we should be doing at each time point is best practice. So before the procedure starts, there is a lot that can be learned about our trainees and also taught to our trainees. So this is our opportunity to really assess their cognitive learning and how they plan for this case. Right now, there are gonna be situations I'm sure we've all faced where we're actually not the attending staffing cases on the floor, or it's an outpatient case and we're staffing clinic, that we may not have made the decision for this case to happen. But understanding what our trainee knows about the case, what we're doing, and that we have the right tools for the right job, and we're here for the right reason is really, really important. We wanna know the background for where our trainee's at skill-wise. It's really, really imperative that we not just know their first year versus the third year, but we wanna know what their individual skillset really is. What's the feedback they've already received from our colleagues? And I'm sure, again, at most of your institutions when you're working with trainees, it's not one person training them. It's about 40 people, and they're kind of bouncing from room to room to room, working with different people and learning different skills. So we need to know what they're used to and what they're able to do. So are they at the point where they're just learning to get into duodenum early in the first year? Or are they really at the point where they have fine motor control and they're learning to really do therapeutic interventions? Do we have the right equipment for the case? Just kind of good educational stuff for our fellows, as well as who the trainee is is going to dictate if we have the right equipment, and we'll talk about that in a second. And then is tactile learning really okay from the standpoint of the trainee? The era of the eye-trained underwear, our attendings kind of whack us on the hands, whack us on the shoulder, reposition us in the middle of the case, stand behind you, twist you. That really should be a thing of the past for the most part. But tactile learning is important. So there was actually a survey that was published two years ago by Dr. Rabinowitz out of Mount Sinai that actually showed that female trainees are taught different than our male trainees. Specifically, they had significantly less experience with tactile training. And both sexes actually thought that tactile training was important for their education. This being said, it was only about 2 3rds that valued that. So there are many reasons we might be reluctant to touch our trainees, especially if it's a male attending and a female trainee, but this really creates an opportunity for us to have a conversation before the procedure about what they're comfortable with and what we're comfortable with. So you might turn, this is the role play of the day. I might turn to Renee and say, Renee, during the case, something may happen where I need to show you something by touching your hands. I might reposition you by touching your shoulders. Are you comfortable with that? Or are you, is that? You can touch my hands, but not my shoulders. How's that for you? Fantastic. So there you go. That was the video for the day. But just that simple conversation, those 15 seconds, is going to set up a scenario where you can actually teach valuable information to your trainees, but in a comfortable setting for both of you. So you have shared upon expectations. Some of the equipment we use actually may not be appropriate for our female trainees. So again, in a survey that was published this past year from Dr. Rabinowitz, as well as Dr. Williams, who was a co-author on the paper, the average size of our female trainees might be smaller than our male trainee size hands. So there is a role for dial extenders. The height differences between our trainees, the ergonomics of the room. Does the screen actually move to their height or are they just standing there looking upward, having some neck extension? This is all really important and it's determined trainee by trainee. Some of the lead aprons have also been shown not to really fit some of our female trainees as well. And there's actually some suggestion that there is an increased neck and shoulder injury for our female trainees. Dr. Young's gonna talk about ergonomics in a little bit later today. And I'm sure he may or may not go into this and expand on this. So we've now talked to our trainees about what skills they have, what their goals for the case are, where we're gonna actually be developing their skills. We have shared kind of expectations for the case. That brings us to the case itself, where all the action is. First thing we wanna do, to my own chagrin to some extent, is actually minimize the distractions. So these are not the cases that your music should be blasting at full volume. I understand that that saddens me and Dr. Bacoba, who I know is the only other person that has as loud of a room as I do. But it's not good for our trainees' learning. Distractions could also be pagers going off. It could be that chatty nurse or that chatty tech in the room and really kind of setting expectations with them. It also could be us, where we're actually, this is not the time to pimp our trainees on whether or not where should they be taking biopsies or what do the guidelines show about this nuanced case. And this really plays into something called cognitive load theory, which you may or may not be familiar with. But that's really a framework when we talk about how we access memory and how we apply it to skill development. And it really applies very well to procedural skill development. There's been a bunch of publications over the years in the endoscopic literature. This could be a talk in itself, so we're not gonna go through everything. But let's highlight a few key points for the role of this talk. So there is something called intrinsic load. This is actually what the trainee already has. This is something that they have the skillset and they can access it really just very readily available with little thoughts. So this is gonna be different from every single trainee. As you progress in competence development, you will be able to do simple maneuvers easier or more complex maneuvers easier. And we've already assessed what the intrinsic load is with our trainees by asking them where they're at before the procedure. What we're talking about here is the extraneous load or the extrinsic load. These are the non-essential tasks. These are the distractions. So the music, the unsedated patient, the attending yabbering away in the corner. We wanna minimize this. And studies again and again have shown that this is a distractant and minimizes learning for our trainees. What we wanna maximize is the germane load. And this is really where the learning happens. It's where we take the amount of knowledge that we already have, we hit that threshold, and we have growth. So we're working on that new skillset development. So a trainee that has fine motor skills may now be ready to actually do therapeutics and apply a clip, while a first-year trainee that can't get into duodenum, can't torque very well, is not ready to do those therapeutics. So we check in on the intrinsic load, we minimize the extraneous load, and thus we maximize the germane load or the growth for our trainees. You wanna use clear, common language. Everyone in this room has been in a situation where as a trainee, your attending said, look up, go, right, no, right. They don't tell you what to do. You wanna tell them more exact language. You wanna be precise with your language. So it might be, pull the big knob back, instead of look up. You wanna speak up for safety. So if something, of course, is emergent, you really want to tell them to stop immediately, right? You don't want patient risks to happen. But you wanna hold most of your feedback for later, for after the case. And there's actually a little bit of literature to explain why. This is kind of this really neat little study that Dr. Walsh put together, she'll be speaking later as well today, where they took 30 learners that hadn't really experienced any training, they put them in a simulator, 15 of them got concurrent feedback or feedback throughout the case. The other 15, at the end of the case, they got terminal feedback, said, hey, you did this well, hey, you can do this better, you should work on this. They put them through a simulation. So they did a pre-test and a post-test. Then they did 12 practice trials with the same exact sequence or the same kind of simulation. They did a delayed retention test. So a week after doing all 12 cases, they put both groups through the ringer again. And they did a transfer test where they actually looked one week later at a new sequence, a novel simulation. And what they found was that even though both groups did equally well on the delayed retention test, as well as the pre and post, in fact, on the transfer test with the new colonoscopy simulation, those that received terminal feedback after the case did much better across the board. And as we all know, every colon is not the same. So this is really what we want to build. So of course, we can give a little bit of feedback, but if we can hold that feedback to the end, that might be more useful for our trainees. One other thing that's worth noting during their procedure is that multiple of our trainees have different learning styles. So some might learn visually, some might learn by the hearing things, but a lot of our trainees in a procedural field are kinesthetic learning. They learn by doing and kind of feeling it. So if you hit a tight turn where you actually can't get through, and it can be really hard for us to explain to our trainee what we're doing, try to do it for them, demonstrate it, but hand them back the scope and let them do it themselves afterward, assuming timing and patient safety allows this. This is how that kinesthetic learner is going to learn. I'm gonna hand the rest over to my colleague, Dr. Williams, to talk about the post-procedural. All right, that will be fun. So for the online audience, we will ask Q&A after the session. So post-procedure provide constructive feedback. I'm a very big fan of feedback. And as we know, the feedback sandwich is not very effective. I'm more of a just tell someone straight out what they need, but we do have frameworks to work on. When I was a first-year fellow, I think six months in, my first feedback was, you're the worst endoscopist in your class. Well, in my case, it kind of lit a fire, and I became the best endoscopist in my class. All right, how do I do this? All right, so we wanna provide constructive, not destructive feedback. Again, everyone takes feedback very differently. And there are different techniques. So one framework is called the ask, tell, ask. You wanna ask the learner for a specific action that they took and tell them what you observed about the action and ask how they may modify that approach. So you can say, how do you think insertion of the colonoscope went during the case? I observed that you were struggling getting around that colon, and getting around that turn in the colon, you tried to pressure in a few locations. Now, in that case, I'll just take the scope back, but I guess in this case, you just let them struggle for God knows how long. And then what do you think you may benefit for and then do differently in the next case? I think Dr. Whitson is kind of chuckling over here. Another way to think of that is I think I saw, I wonder, which I actually really like a lot. I think during that case, you were having some issues inserting the scope. I observed and I saw that you were struggling getting around the turn. I wonder what you may do differently in the next case. So that's one way to give feedback. And I think being very specific actually works very well. We tend to be very amorphous in how we give feedback. We give general terms and nothing's very specific. It's easier for learners if they get specific action, specific things to do in responses. Next, again, make an action plan using SMART goals. Again, we're providing this feedback at the end of the case and where you provide feedback actually matters. We're not trying to give feedback while the trainee's trying to do a content for the next case or giving in front of everyone because in some cases, if they're getting negative feedback, it may not go well if you're telling the entire time. And speaking of the chatty tech, I have one of those. I still haven't figured out how to tell her to stop talking. So SMART goals are specific, measurable, attainable, relevant, and time-based. So for example, you should work on getting to the CCO more efficiently. That is a very amorphous piece of feedback. It doesn't really help anyone or give the trainee anything to work on. What you may want to say is on your next two colonoscopies, you should preemptively reduce the colonoscope or endoscope in the sigmoid and the transverse colon. So for the trainee, it's easier to attach to a specific action. This is SMART, measurable, attainable, relevant, and again, time-based. So this gives you a certain loop of feedback. So you give the feedback to the trainee. They reflect on that feedback. They make the action and see the improvement and performance. It's a cycle that keeps going on and it's something that happens with us throughout our entire career. Again, do not do what my person said to me when they said you're not the best endoscopist because it actually, it made me want to improve, but for the next trainee, it may actually make them want to quit the fellowship. So again, looking at the post-procedure time, you want to provide constructive, not destructive feedback. Make an action plan and you want to incorporate database competency-based tools. So I'm going to discuss some of the assessment tools that we use in colonoscopy today. But prior to this, if we're speaking about teaching endoscopy, we have to talk about simulation. Dr. Walsh has done a lot of work in this area. I'm not sure if she's here yet. She will be speaking later. And what does simulation do? Does it help? Studies have shown that it does help in early learning curves. So if someone is a first-year fellow who just started, simulation is very effective. If you're looking at a mid-learner or a later learner, simulation is not that effective in essence, but it does help in terms of eliminating concerns for patient safety because then the trainee feels a little bit better that they're not, they feel that the patient's a little bit safer because they've already practiced in a simulating setting. There are a lot of different assessment tools. I'm not sure if we're familiar with all of them. These are all validated in trainees. We have the GAGES, MCSAT, ACE, GCAT, safety. I'm only going to talk about two, the Mayo Clinic Skills Assessment Tool and the ACE, ASGE ACE in endoscopy. I think most of us probably use the ASGE ACE, and this is actually built into probation if you have probation at your institution. So the Mayo Clinic Skills Assessment Tool, you can see it here, it is the precursor to the ASGE ACE form. And it was initially used to assess colonoscopy skills, not endoscopy skills, and this was evaluated in trainees. This is a very busy slide. What it's saying is the content came from expert review. And in looking at correlation, it actually correlated well with expert learners. And they saw a significant difference in patients, in trainees that were novice, intermediate, and advanced. And here they said to get a minimal competency of 3.5, which is between advanced and superior, you need 275 colonoscopies. So the numbers that we use in training came from some of these studies. So here, based on this particular tool, they're saying 275. We do recognize now, and Dr. Shah will discuss, that numbers does not equate to competency. I've seen second-year fellows with equal amounts of colonoscopies on their belt, where one fellow is more proficient than the next fellow. So again, it's not a numbers game. There's really a lot more that goes into teaching endoscopy than how many colonoscopies that you do. I think we all know that by now. This one, you should all be very familiar with if you're in any training programs. A lot of patients' faces use the ACE assessment endoscopy and colonoscopy form. This, in our institution, is built into our probation, as I mentioned, but we also have this built into new innovations. So our evaluation system is called New Innovations, and we actually put this form in. So it's very easy for the attendants to kind of open it up and click on the different numbers as they're assessing trainees. And when the trainees have their semiannuals, we can go over the amount of cases they've had. We could tell them, here's your mean score, here's your standard deviation, here's how you compare to your other classmates. Again, the content for that came just, again, it's a validated tool, came from expert review, and it found that there was a significant improvement in scores with more experience. So as you got more experience under your belt, you actually scored better on this survey instrument. And again, this tool found that you needed 255 colonoscopies to become competent. So I think when we're thinking about learning and endoscopy, there's a cycle. There's a training period where we're looking at progress and formative feedback. Again, feedback at the end or terminal feedback is much more effective. It's hard to give someone feedback as you're standing there scoping. I try to think about, when I'm giving feedback to the fellow in that sense, I don't think they receive it very well because they're already nervous trying to learn how to get around that turn or do a specific technique. So at the end of the procedure, speak to your fellow in a quiet setting. Then we think about certification, which is the end of training program where we need to think about summative assessment and make sure that they're competent and ready for true practice. And in independent practice, which is probably most of us in this room, we have to think about improvement in terms of quality improvement. Again, I think. So our take home points is, recognize that there are important learning opportunities in both the technical and the cognitive spaces. I feel like first year fellows come into training and they're just like, we want to learn endoscopy, we want to learn endoscopy. And they kind of hang their hats on how good they are based on how much scopes they do. And I tend to tell my fellows, it's not just about learning endoscopy. Anyone can learn to scope. The term my mentor uses is a monkey can learn to scope. That's what she tells people. But essentially I say, there's a very big cognitive part of endoscopy that comes into play. It's not just, we're not tech monkeys. We're people who think, and we have to think and be very intentional about how we scope. So the cognitive aspect of endoscopy is extremely, extremely important. Use that pre-procedure time to set goals for the case and establish a safe learning environment. Maximize learning during the procedure by limiting the extraneous load, as Dr. Whitson mentioned. And make sure we use effective feedback techniques. I'm a straightforward person, but even I've had to learn not to be so blunt because people take feedback in very different ways. So thank you.

endoscopy

teaching

best practices

cognitive competencies

trainee assessment