The available data concerning recently marketed computer simulators for training in digestive endoscopy suggest that they could play a role in the pre-clinical phase of training, thus potentially leading to a shorter learning curve and better performance in the endoscopy room during the early phase of hands-on training. Technical improvements are still needed before such simulators can be used for the retraining of experienced endoscopists and for training in the use of newly developed devices dedicated to therapeutic endoscopy.

Patient satisfaction has been the object of interest in health care for some time and is now increasingly used as the basis for quality management and improvement. This study compares patient satisfaction between residents and attending in a pain clinic setting following fluoroscopy-guided steroid injections.

This is a retrospective cohort design study.

The study was performed at an academic university pain management center.

A total of 242 patients (119 female and 123 male) presenting with low back pain were evaluated and offered fluoroscopically guided steroid injections as part of a conservative care treatment plan.

All injections were performed consecutively over a 4-month period by one attending and three senior residents (two anesthesia and one psychiatry resident). A staff member specifically asked each participant about their satisfaction following the procedure. Answers were documented as "Expected,""Better," or "Worse" than expected.

Two main outcome measures were recorded: 1) table and fluoroscopy time for residents and attending, and 2) patient satisfaction through subjective reporting.

Overall, residents had longer mean table time and mean fluoroscopy time as compared with the attending physician (P < 0.05). Patients treated by residents were more often likely to rate their experience as "worse" compared with those treated by the attending (P < 0.05). Otherwise, the proportion of patients rating their experience "as expected" or "better" was not significantly different statistically between the two groups. In addition, as table time increased, satisfaction level decreased in both resident and attending groups.

Patients treated by residents are more likely to rate their experience as worse compared with the attending. However, majority of patients in both groups were satisfied in that they perceived their procedure as expected or better than expected.

Currently, little evidence supports computer-based simulation for ERCP training.

To determine face and construct validity of a computer-based simulator for ERCP and assess its perceived utility as a training tool.

Novice and expert endoscopists completed 2 simulated ERCP cases by using the GI Mentor II.

Virtual Education and Surgical Simulation Laboratory, Medical College of Georgia.

Outcomes included times to complete the procedure, reach the papilla, and use fluoroscopy; attempts to cannulate the papilla, pancreatic duct, and common bile duct; and number of contrast injections and complications. Subjects assessed simulator graphics, procedural accuracy, difficulty, haptics, overall realism, and training potential.

Only when performance data from cases A and B were combined did the GI Mentor II differentiate novices and experts based on times to complete the procedure, reach the papilla, and use fluoroscopy. Across skill levels, overall opinions were similar regarding graphics (moderately realistic), accuracy (similar to clinical ERCP), difficulty (similar to clinical ERCP), overall realism (moderately realistic), and haptics. Most participants (92%) claimed that the simulator has definite training potential or should be required for training.

Small sample size, single institution.

The GI Mentor II demonstrated construct validity for ERCP based on select metrics. Most subjects thought that the simulated graphics, procedural accuracy, and overall realism exhibit face validity. Subjects deemed it a useful training tool. Study repetition involving more participants and cases may help confirm results and establish the simulator's ability to differentiate skill levels based on ERCP-specific metrics.

Advances in endoscopy simulation are reviewed with emphasis on applications in teaching and skills assessment. Endoscopy simulation has only been realized recently in a computer-based fashion because of advances in technology, but several studies have been performed both to validate computer-based endoscopy simulators and to assess their potential role in training. Multiple studies have shown that simulators can distinguish between clinicians at different skill levels and also have shown improvement in clinician skill, particularly at the early stages of training. This article summarizes those studies. The cost versus benefit of endoscopic simulators is also discussed, as well as the upcoming role of simulators in judging competence and as a tool in the credentialing process.

Little is known regarding the value of esophagogastroduodenoscopy (EGD) simulators in education. The purpose of the present paper was to validate the use of computer simulation in novice EGD training.

In phase 1, expert endoscopists evaluated various aspects of simulation fidelity as compared to live endoscopy. Additionally, computer-recorded performance metrics were assessed by comparing the recorded scores from users of three different experience levels. In phase 2, the transfer of simulation-acquired skills to the clinical setting was assessed in a two-group, randomized pilot study. The setting was a large gastroenterology (GI) Fellowship training program; in phase 1, 21 subjects (seven expert, intermediate and novice endoscopist), made up the three experience groups. In phase 2, eight novice GI fellows were involved in the two-group, randomized portion of the study examining the transfer of simulation skills to the clinical setting. During the initial validation phase, each of the 21 subjects completed two standardized EDG scenarios on a computer simulator and their performance scores were recorded for seven parameters. Following this, staff participants completed a questionnaire evaluating various aspects of the simulator's fidelity. Finally, four novice GI fellows were randomly assigned to receive 6 h of simulator-augmented training (SAT group) in EGD prior to beginning 1 month of patient-based EGD training. The remaining fellows experienced 1 month of patient-based training alone (PBT group). Results of the seven measured performance parameters were compared between three groups of varying experience using a Wilcoxon ranked sum test. The staffs' simulator fidelity survey used a 7-point Likert scale (1, very unrealistic; 4, neutral; 7, very realistic) for each of the parameters examined. During the second phase of this study, supervising staff rated both SAT and PBT fellows' patient-based performance daily. Scoring in each skill was completed using a 7-point Likert scale (1, strongly disagree; 4, neutral; 7, strongly agree). Median scores were compared between groups using the Wilcoxon ranked sum test.

Staff evaluations of fidelity found that only two of the parameters examined (anatomy and scope maneuverability) had a significant degree of realism. The remaining areas were felt to be limited in their fidelity. Of the computer-recorded performance scores, only the novice group could be reliably identified from the other two experience groups. In the clinical application phase, the median Patient Discomfort ratings were superior in the PBT group (6; interquartile range [IQR], 5-6) as compared to the SAT group (5; IQR, 4-6; P = 0.015). PBT fellows' ratings were also superior in Sedation, Patient Discomfort, Independence and Competence during various phases of the evaluation. At no point were SAT fellows rated higher than the PBT group in any of the parameters examined.

This EGD simulator has limitations to the degree of fidelity and can differentiate only novice endoscopists from other levels of experience. Finally, skills learned during EGD simulation training do not appear to translate well into patient-based endoscopy skills. These findings suggest against a key element of validity for the use of this computer simulator in novice EGD training.

The purpose is to provide initial validation of a novel simulation model's fidelity and ability to assess competence in colonoscopy skills.

In a prospective, cross-sectional design, each of 39 endoscopists (13 staff, 13 second year fellows, and 13 novices) performed a colonoscopy on a novel bovine simulation model. Staff endoscopists also completed a survey examining different aspects of the model's realism as compared to human colonoscopy. The groups' simulation performances were compared. Additionally, individual performances were correlated to patient-based performance data.

Median model realism evaluation scores were favorable for nearly all parameters evaluated with mucosa appearance, endoscopic view, and paradoxical motion parameters receiving the highest scores. During simulation procedures, each group outperformed the less experienced groups in all parameters evaluated. Specifically, median cecal intubation times were: staff 226 s (IQR [interquartile range] 179-273), fellows 340 s (282-568), and novices 1,027 s (970-1,122) (P < 0.05). Median total procedure times on the model were: staff 468 s (416-501), fellows 527 s (459-824), and novices 1,350 s (1,318-1,428) (P < 0.05). Finally, individual cecal intubation times on the simulation model had a very high correlation to their respective patient-based times (r = 0.764).

Overall, this model possesses a favorable degree of realism and is able to easily differentiate users based on their level of colonoscopy experience. More impressive, however, is the strong correlation between individual's simulated intubation times and actual patient-based colonoscopy data. In light of these findings, we speculate that this model has potential to be an effective tool for assessment of colonoscopic competence.

The objective benefit of a training using the compact Erlangen Active Simulator for Interventional Endoscopy-simulator was demonstrated in two prospective educational trials (New York, France). The present study analysed whether endoscopic novices are able to reach a comparable level of endoscopic skills as in the above-described projects.

Twenty-seven endoscopic novices (medical students, first year residents) were enrolled in this prospective, randomised trial. The compact Erlangen Active Simulator for Interventional Endoscopy-simulator with an upper GI-organ package and blood perfusion system was used as a training tool. Basic evaluation of endoscopic skills was performed after a practical and theoretical course in diagnostic upper GI endoscopy followed by a stratified randomisation according to the rating in endoscopic skills into intensive (n=14) and control group (n=13). The intensive group was trained 12 times every second week over 7 months in 4 endoscopic disciplines (manual skills, injection therapy, haemoclip, band ligation) by skilled endoscopist (three trainees/simulator). Assessment was performed (single steps/overall) using an analogue scale from 1 to 10 (1=worst, 10=optimal performance) by expert tutors. The control group was not trained. Blinded final evaluation of all participants was performed in January 2003.

We observed in all techniques applied a significant improvement of endoscopic skills and of the performance time in the intensive group compared to the control group (p<0.001). The comparison with the previous projects showed that the intensively trained novices achieved comparable levels of performance to the GI fellows in the New York and France Project (at least 80% of the median score in three out of four techniques).

Endoscopic novices acquired notable skills in interventional endoscopy in the simulator by an intensive, periodical training using the compactEASIE.

Simulation tools offer the opportunity for the acquisition of surgical skill in the preclinical setting. Potential educational, safety, cost, and outcome benefits have brought increasing attention to this area in recent years. Utility in ongoing assessment and documentation of surgical skill, and in documenting proficiency and competency by standardized metrics, is another potential application of this technology. Significant work is yet to be done in validating simulation tools in the teaching of endoscopic, laparoscopic, and other surgical skills. Early data suggest face and construct validity, and the potential for clinical benefit, from simulation-based preclinical skills development. The purpose of this review is to highlight the status of simulation in surgical education, including available simulator options, and to briefly discuss the future impact of these modalities on surgical training.

The Erlangen Active Simulator for Interventional Endoscopy (EASIE) using ex-vivo porcine organs was introduced in 1997. The present study should analyze whether repeated EASIE simulator training in endoscopic hemostasis led to superior performance compared with a traditionally educated group. The results were compared with a similar project in New York.

Thirty-five French GI fellows were enrolled. Baseline skills evaluation was performed in four disciplines (manual skills, injection/coagulation, clip application and variceal ligation) using the compactEASIE-simulator equipped with an upper gastrointestinal organ package for bleeding simulation. The same, translated evaluation forms (from the prior New York project) were used. Subsequently, fellows were randomized into group A (n=17, only clinical education) and group B (n=18, additional three simulator trainings). Group B was trained the next day and after 4 and 7 months by experts of the French Society of Gastrointestinal Endoscopy. Both groups performed routine and emergency endoscopies at their home hospitals during the study period. Both groups were re-evaluated blindly after 9 months.

The learning curve for group B showed a significant improvement in all disciplines (P<0.004) whereas group A improved significantly in only two of four disciplines at blinded final evaluation (manual skills P=0.02, injection/coagulation P=0.013). The direct comparison of groups B and A at blinded final evaluation showed significantly superior ratings for group B in all disciplines (P<0.006) and significantly shorter performance times in two disciplines (P=0.016 each). The comparison with the similar 'New York project' revealed that preexisting differences in skills were adjusted by the training.

Complementary trainings (three workshops in 7 months) in endoscopic hemostasis using the compactEASIE improved skills compared with a solely clinical education. The results of the 'New York project' were confirmed and benefits were independent from the medical educational system.

Computer simulators, live pigs, and ex vivo porcine simulators are used for training in ERCP. The location of the porcine biliary orifice in the proximal duodenum is dissimilar to human anatomy, making the endoscopy experience less realistic. In addition, in native porcine anatomy, the pancreatic duct enters the duodenum distal to the biliary orifice, limiting the teaching of pancreatic techniques and selective duct cannulation.

To overcome these limitations, we aimed to construct a Neo-Papilla that could be incorporated into an ex vivo model.

We attached chicken heart tissue to the porcine duodenum, with integrated porcine arteries that resembled an artificial common bile duct and a pancreatic duct.

The simulator was presented and evaluated at 2 major GI endoscopy conferences.

The feasibility and the realism of this prototype was tested by 9 recognized ERCP experts who rated this model in comparison to other teaching models for ERCP by recollection of prior experience.

The Neo-Papilla was more prominent and more distally located than the native porcine papilla. The experts rated this modification superior to existing models in its usefulness as an educational tool.

Pilot study.

We demonstrated the technical feasibility of a real-tissue Neo-Papilla modification of porcine ex vivo simulators, more closely approximating the natural anatomy. This new model should facilitate ERCP training. Formal validation studies are warranted.

The GI Mentor is a virtual reality simulator that uses force feedback technology to create a realistic training experience.

To define the benefit of training on the GI Mentor on competency acquisition in colonoscopy.

Randomized, controlled, blinded, multicenter trial.

Academic medical centers with accredited gastroenterology training programs.

First-year GI fellows.

Subjects were randomized to receive 10 hours of unsupervised training on the GI Mentor or no simulator experience during the first 8 weeks of fellowship. After this period, both groups began performing real colonoscopies. The first 200 colonoscopies performed by each fellow were graded by proctors to measure technical and cognitive success, and patient comfort level during the procedure.

A mixed-effects model comparison between the 2 groups of objective and subjective competency scores and patient discomfort in the performance of real colonoscopies over time.

Forty-five fellows were randomized from 16 hospitals over 2 years. Fellows in the simulator group had significantly higher objective competency rates during the first 100 cases. A mixed-effects model demonstrated a higher objective competence overall in the simulator group (P < .0001), with the difference between groups being significantly greater during the first 80 cases performed. The median number of cases needed to reach 90% competency was 160 in both groups. The patient comfort level was similar.

Fellows who underwent GI Mentor training performed significantly better during the early phase of real colonoscopy training.

Clearly, the potential applications for simulation training in endoscopy are vast. Endoscopy models may serve as a platform to introduce new skills, to maintain proficiency, or even to assess competency. As these applications are explored fully, the strengths and weaknesses of specific devices will dictate their roles. Educators must ensure that these roles are founded on reliable research but remain mindful that simulators are only tools to augment clinical training, with the goal of benefiting both student and patient, and are not a replacement for patient-based experience.

Simulation of upper gastrointestinal (GI) hemorrhage provides the opportunity to practice endoscopic hemostasis without the risk of patient harm and time limitations. Various models have been developed to simulate an acute bleeding source in the upper GI tract to evaluate the feasibility of new endoscopic devices or to practice interventional techniques in a calm and controlled environment. Increasingly available ex vivo models provide this opportunity without the ethical concerns involved with live-animal courses. Validation studies have proven acceptance of ex vivo models and improved clinical performance by repetitive training using these models.

The introduction of the ex vivo tissue endoscopy simulators represents a major advance in endoscopic training, particularly in therapeutic endoscopy. The simulators have been popular teaching tools from the start, and the data supporting their benefit are accruing, especially in hemostasis training. Simulators like the compact EASIE may prove most beneficial as training tools for interventional skills that require repetitive practice and a larger volume of procedures than may occur naturally during the course of standard endoscopy practice. More data are needed to confirm that hands-on simulator training improves outcomes in clinical endoscopic performance and to characterize better the influence of such simulator work on subsequent endoscopic practice. As ex vivo simulators become more available, it is likely that these models will enhance initial training and also allow practicing gastroenterologists to acquire new techniques, maintain their skills, and demonstrate proficiency for credentialing purposes.

Significant advances already have been made in the use of simulators for teaching and training in GI endoscopy. Indeed, during the past decade the evolution and improvement of these devices is readily apparent with each passing year. Doubtless, these advances have led to the increased availability and popularity of simulator-based hands-on workshops. Simulator-based skills assessment remains a relatively undeveloped field, awaiting increased realism and the development and validation of proper tests. Still, static models, ex vivo artificial models, ex vivo animal models, and computer simulators collectively represent a substantial and powerful tool for education and training in GI endoscopy. It is easy to foresee a day when hands-on training using simulators will be readily available outside the gastroenterology fellowship setting. With the progression of technology and the continuous introduction of new devices and procedures will come a parallel, compelling need for hands-on, simulator-based experience with all such new tools and techniques.

The simulation of organ-organ interaction is indispensable for practical and advanced medical VR simulator such as open surgery and indirect palpation. This paper describes a method to represent real-time interaction between elastic objects for accurate force feedback in medical VR simulation. The proposed model defines boundary deformation of colliding elements based on temporary surface forces calculated by temporary deformation. The model produces accurate deformation and force feedback considering collisions of objects as well as prevents unrealistic overlap of objects. A prototype simulator of rectal palpation is constructed on general desktop PC with a haptic device, PHANToM. The system allows users to feel different stiffness of a rear elastic object located behind another elastic object. The results of experiments confirmed the method expresses organ-organ interaction in real-time and produces realistic and perceivable force feedback.

The efficacy of an intensive hands-on training in endoscopic hemostasis on the compactEASIE simulator has been previously demonstrated in a randomized prospective trial. In the current study, we evaluated how quickly and effectively new tutors, without simulator training experience, are able to acquire teaching skills in endoscopic hemostasis.

Five tutors with prior Erlangen Active Simulator for Interventional Endoscopy (EASIE) teaching experience instructed 7 endoscopists without prior EASIE experience on how to teach when using the model. These new tutors then independently conducted a workshop for 8 fellows in 4 hemostasis techniques. Results were compared with a historical control trained similarly by experienced tutors. Two one-day workshops in endoscopic hemostasis on the compactEASIE ex vivo endoscopy simulator were conducted in a category A hospital in New York City, New York. Skill scores at the end of training were compared with baseline skills assessments, and qualitative ratings of the new tutors were obtained from both the trainees and the experienced tutors.

Significant improvement was achieved by the fellows in all 4 skills areas. Both the expert tutors and the trainees consistently rated the teaching skill of the new tutors highly. Fellows' skill acquisition using new tutors was of similar magnitude to that achieved in the prior EASIE trial using experienced trainers teaching the fellows.

It is feasible to conduct an effective EASIE train-the-trainer course in one day. Tutors trained in this manner are able to provide a similar educational experience with objective improvement in trainee skill to experts who have conducted many hands-on workshops.

The importance of training surgical residents in GI endoscopy has been recognized for years. Despite advice from SAGES and the RRC, few programs have managed to incorporate effective flexible endoscopy training into their curriculum, making it difficult for their graduates to be credentialed in GI endoscopy. Prior to October 2001, our residents obtained their entire clinical experience in the endoscopy unit with staff surgical endoscopists. Attendance was inconsistent because of their many other responsibilities, and residents often used much of their clinical endoscopic exposure gaining basic familiarity with the equipment, precluding the development of therapeutic facility. Since October 2001, we have used the Simbionix endoscopic simulator to supplement resident training in GI endoscopy. With the advent of virtual-reality simulators, and studies validating their effectiveness in teaching fundamental technical skills, we report our initial success in implementing a formal GI endoscopy curriculum using a virtual reality endoscopic simulator to provide basic experience before the clinical endoscopic experience begins.

Residents are given monthly assignments of simulated cases on the GI Mentor simulator. Junior residents complete the diagnostic case modules; senior residents complete the therapeutic modules. Data were accumulated over the course of two years with a total of five PGY-I and eight senior surgical residents completing assigned cases on the simulator. Objective criteria were measured from their performance on the simulator to determine the efficiency of the examination for each case completed.

Preliminary data collected over the course of two years indicates that residents improve the efficiency of their endoscopic examinations over time as measured by objective criteria. Junior surgery residents attained an aggregate average of 59% efficiency in their examinations whereas senior surgical residents who had previous experience with the simulator, attained an aggregate efficiency of 80%.

A formal flexible endoscopy curriculum enhances surgical resident training and positively impacts careers in general and gastrointestinal surgery. Endoscopic simulators allow surgical residents to master the technical aspects of GI endoscopy quickly, thereby permitting them more benefit from their clinical exposure in the endoscopy unit. We anticipate that our formal curriculum in GI endoscopy training will prepare our graduates well for careers that include flexible endoscopy as a component of their clinical practices, and position them to be credentialled in GI endoscopy upon graduation.

The Erlangen Active Simulator for Interventional Endoscopy (EASIE) was introduced in 1997 for interventional endoscopy training. compactEASIE developed in 1998 is a modified, light-weight version of the original model. Objective evidence of the benefits of training with these models is limited. A randomized controlled study, therefore, was conducted to compare the effects of intensive 7-month, hands-on training in hemostatic techniques by using the compactEASIE model (in addition to clinical endoscopic training) vs. pure clinical training in endoscopic hemostatic methods.

Thirty-seven fellows in gastroenterology in New York City area training programs were enrolled. Baseline skills were assessed on the simulator for the following techniques: manual skills, injection and electrocoagulation, hemoclip application, and variceal ligation. Twenty-eight fellows were then randomized into two comparable groups. Those randomized to Group A received purely clinical training in endoscopic hemostatic techniques at their hospitals. Those in Group B, in addition, were trained by experienced tutors in 3 full-day hemostasis workshops over 7 months. Both groups underwent a final evaluation on the compactEASIE simulator conducted by their tutors and additional evaluators who were blinded to the method of training. Initial and final evaluation scores were compared for each group and between groups. Outcomes of actual clinical hemostatic procedures performed during the study period also were analyzed.

Ten of 14 fellows randomized to Group A (standard training) and 13 of 14 in Group B (intensive training) returned for the final evaluation. For Group B, scores for all techniques were significantly improved. In Group A, a significant improvement was noted for variceal ligation alone.

compactEASIE simulator training (3 sessions over 7 months), together with clinical endoscopic training resulted in objective improvement in the performance by fellows of all 4 endoscopic hemostatic techniques, whereas significant improvement was noted for variceal ligation alone for fellows who had standard clinical training. In clinical practice, fellows who had intensive simulator/clinical training had a significantly higher success rate and a nonsignificant reduction in the frequency of occurrence of complications.

The present study was designed to investigate whether there is a correlation between manual skills in laparoscopic procedures and manual skills in flexible endoscopy.

In a prospective study using laparoscopy and endoscopy simulators (MIST-VR, and GI-Mentor II), 24 consecutive subjects (gastrointestinal surgeons, novice and experienced gastroenterologists, and untrained subjects) were asked to perform laparoscopic and endoscopic tasks. Their performance was assessed by the simulators' software and by observers blinded to the levels of subjects' experience. Performance in experienced vs inexperienced subjects was compared. Score pairs of three parameters--time, errors, and economy of movement--were also compared.

Experienced subjects performed significantly better than inexperienced subjects on both tasks in terms of time, errors, and economy of movement (p < 0.05). All three performance parameters in laparoscopy and endoscopy correlated significantly (p < 0.02).

Both simulators can distinguish between experienced and inexperienced subjects. Observed skills in simulated laparoscopy correlate with skills in simulated flexible endoscopy. This finding may have an impact on the design of training programs involving both procedures.

Computer-based endoscopy simulator (CBES) training's impact on patient-based outcomes has never been examined. This study examines whether the endoscopy skills of trainees are improved and patient discomfort is reduced as a result of CBES training.

From July 2001-June 2002, 38 residents received either 1 week of patient-based training (PBT) alone in flexible sigmoidoscopy (FS) or 3 hours of simulator-based training (SBT) before a week of training in FS. Patients completed questionnaires grading the discomfort experienced during endoscopy (1, no pain; 10, worst pain of life). In addition, residents' performance was graded by the supervising staff and themselves with 8 performance parameters by using a 1-10 Likert scale (1, strongly agree; 5, neutral; 10, strongly disagree).

Nineteen SBT and 19 PBT residents performed 150 and 175 FS, respectively. During this same period, staff completed 585 FS. The median patient discomfort score for SBT residents was significantly less than for PBT residents, 3 (25%-75% interquartile range [IQR], 2-5) vs. 4 (IQR, 2-6) (P < 0.01). Discomfort scores for both resident groups were significantly greater than those recorded by staff endoscopists, 2 (IQR, 1-4) (P < 0.01). No difference was seen in the residents' procedural skill scores. Resident self-evaluation scores were significantly greater than those received from the supervising staff.

Increased patient comfort resulted from simulation training, demonstrating that CBES training has a direct benefit to the patient. Although no measurable impact on residents' performance skills was observed, we do demonstrate that residents perceive themselves as having acquired greater endoscopic skills in contrast to staff evaluations.

Computer-based colonoscopy simulation (CBCS) is being utilized in endoscopy training without supporting evidence that it improves patient-based colonoscopy performance. The goal of this pilot study was to determine if CBCS training improves gastroenterology (GI) fellows' patient-based colonoscopy skills.

Competency at colonoscopy among 4 novice GI fellows who completed a 6-h CBCS curriculum was compared with 4 novice fellows who were not CBCS-trained. Measurements of competency were rendered by supervising faculty by recording "insertion time,""depth of unassisted insertion,""independent procedure completion,""ability to identify endoscopic landmarks,""inserts in a safe manner,""adequately visualizes mucosa on withdrawal," and "responds appropriately to patient discomfort" with each colonoscopy.

Simulator-trained fellows outperformed traditionally trained fellows during their initial 15 colonoscopies in all performance aspects except "insertion time" (pp < 0.05). Simulator-trained fellows inserted the endoscope significantly further and reached the cecum independently nearly twice as often during this early training period. Three parameters ("depth of insertion,""independent completion," and "ability to identify landmarks") demonstrated a continued advantage out to 30 colonoscopies. Beyond 30 procedures, there was no difference in the performance of the two groups.

In this pilot study, a 6-h CBCS curriculum provides an early training advantage by enhancing competency at the early stages of patient-based colonoscopy. These advantages are negligible after approximately 30 patient-based procedures. CBCS-enhanced training may allow faculty to be more efficient with their colonoscopy practice.

Nurse-led gastrointestinal endoscopy is a priority clinical area in the UK. Endoscopic procedures are challenging to learn, requiring a combination of technical competence (manipulating a flexible endoscope and interpreting the findings) and interpersonal skills (engaging effectively with a conscious patient who is frequently apprehensive). This paper explores the potential of an innovative, scenario-based approach which links a simulated patient with a computer-driven virtual reality (VR) training device for flexible sigmoidoscopy. Within this safe yet realistic quasi-clinical environment, learners carry out the procedure while interacting with the 'patient'. Communication skills are assessed by simulated patients, while quantitative performance data relating to the procedure is generated automatically by the VR simulator.

This pilot study took place within a nurse practitioner endoscopy course. A mixed methodology combined qualitative and quantitative data (observation and interview studies, communication rating scales and a range of computer-generated output measures from the VR simulator) in a multifaceted evaluation.

Seven nurses took part in the study. Participants found the scenarios to be a convincing and powerful learning experience. All experienced high levels of anxiety. Simulated patients identified strengths in participants' communication skills, together with areas for development. Simulator-based practice led to an improvement in objective performance measures.

Scenario-based training provides a powerful learning experience, allowing participants to build their technical expertise and apply it within a holistic clinical context without the risk of causing harm. We used this pilot study as a springboard for discussions over wider implications of procedure-based skills training, locating it within the literature on expertise and situated learning.

Surgical skills are required by a wide range of health care professionals. Tasks range from simple wound closure to highly complex diagnostic and therapeutic procedures. Technical expertise, although essential, is only one component of a complex picture. By emphasising the importance of knowledge and attitudes, this article aims to locate the acquisition of surgical skills within a wider educational framework.

Simulators can provide safe, realistic learning environments for repeated practice, underpinned by feedback and objective metrics of performance. Using a simple classification of simulators into model-based, computer-based or hybrid, this paper summarises the current state of the art and describes recent technological developments. Advances in computing have led to the establishment of precision placement and simple manipulation simulators within health care education, while complex manipulation and integrated procedure simulators are still in the development phase.

Tension often exists between the design and evaluation of surgical simulations. A lack of high quality published data is compounded by the difficulties of conducting longitudinal studies in such a fast-moving field. The implications of this tension are discussed.

The emphasis is now shifting from the technology of simulation towards partnership with education and clinical practice. This highlights the need for an integrated learning framework, where knowledge can be acquired alongside technical skills and not in isolation from them. Recent work on situated learning underlines the potential for simulation to feed into and enrich everyday clinical practice.

The computer-based colonoscopy simulator is intended to provide a realistic colonoscopic experience and feedback to operators regarding procedure skills. Advocates hope that computer-based colonoscopy simulators will enhance the mastery of colonoscopy by trainees. Before this hypothesis can be tested, the claims made for a simulator must be validated. The aims of this study were to answer the following: Does a computer-based colonoscopy simulator provide a "realistic" experience? Do computer-based colonoscopy simulators' performance parameters differentiate varying levels of experience?

Ten staff gastroenterologists, 6 gastroenterology fellows, and 6 residents each performed 2 computer-based colonoscopy simulator colonoscopies and performance parameters were recorded. Staff colonoscopists then completed a 6-item survey grading the "realism" of the simulation and procedure difficulty. Survey responses and performance scores were compared with the Wilcoxon rank-sum test.

Faculty found the computer-based colonoscopy simulator experience to be realistic despite the "cases" being markedly easier than actual colonoscopy. The computer-based colonoscopy simulator distinguishes subjects according to endoscopic experience with 3 of its measured parameters (total procedure time, insertion time, time in "red-out"). No significant difference in the ability to distinguish among user types was found for the other 10 computer-based colonoscopy simulator measurements for which data were analyzable.

The computer-based colonoscopy simulator provides a favorable degree of virtual realism with regard to visual simulation and colonoscope mechanics, although the "cases" were regarded as considerably easier than actual colonoscopy. The computer-based colonoscopy simulator has only limited capability for distinguishing varying levels of competence at actual colonoscopy. These findings suggest that a study to determine the role of computer-based colonoscopy simulators in the curriculum of trainees is warranted.