Published online Mar 16, 2020. doi: 10.4253/wjge.v12.i3.98
Peer-review started: October 24, 2019
First decision: November 20, 2019
Revised: December 21, 2019
Accepted: February 23, 2020
Article in press: February 23, 2020
Published online: March 16, 2020
Pre-clinical simulation-based training (SBT) in endoscopy has been shown to augment trainee performance in the short-term, but longer-term data are lacking. The EndoSim (Surgical Science, Gothenburg) is a novel endoscopic virtual reality simulator which incorporates a customisable SBT curriculum and generates task-specific metrics, but has not been validated.
In the United Kingdom, there is no standardised endoscopy SBT induction programme available prior to real-world, patient-based endoscopy training. The Structured PRogramme of INduction and Training (SPRINT) is a two-day gastroscopy induction course combining theory and SBT. We aimed to evaluate: (1) Whether the EndoSim simulator could differentiate between endoscopists of different experience (trainees vs experts); (2) Whether SPRINT improves trainee confidence in technical skills; and (3) Whether SPRINT impacted on longer term trainee outcomes.
This prospective study had three components. First, computerised metrics generated by EndoSim were compared between trainees (n = 20) and experts (n = 6) to explore discriminative validity. Second, trainee feedback was acquired immediately pre- and post-course, and pairwise comparisons performed to assess impact of SPRINT on trainee confidence in technical skills. Third, a case-control study was performed to assess the impact of SPRINT on long-term outcomes (16-mo post-course period), which comprised: (1) Rates of unassisted procedural completion; (2) Post-course procedural exposure; (3) Procedural discomfort; (4) Sedation practice; and (5) Rates of gastroscopy certification. Controls matched for gastroscopy experience and study outcomes were derived from the United Kingdom training e-portfolio.
Of the modules relevant to gastroscopy training, a statistically significant difference was observed in 64% of EndoSIM metrics. Post-SPRINT, trainee confidence increased in all technical skills surveyed. For the case-control element, 15 cases and 24 controls were included, with mean procedure counts of 10 and 3 (P = 0.739) pre-SPRINT. Post-SPRINT, no significant differences between the groups were detected in long-term D2 intubation rates (P = 0.332) or discomfort scores (P = 0.090). However, the cases had a significantly higher rate of unsedated procedures than controls post-SPRINT (58% vs 44%, P = 0.018), which was maintained over the subsequent 200 procedures. Cases tended to perform procedures at a greater frequency than controls in the post-SPRINT period (median: 16.2 vs 13.8 per mo, P = 0.051), resulting in a significantly greater proportion of cases achieving gastroscopy certification by the end of follow up (75% vs 36%, P = 0.017).
In this pilot study, attendees of the SPRINT cohort tended to perform more procedures and achieved gastroscopy certification earlier than controls, although no significant differences were shown in unassisted D2 intubation rates. These data support the role for wider evaluation of pre-clinical induction involving SBT.
An induction programme for trainees in endoscopy is feasible and implementable, can increase trainee confidence, and can shorten the time required to achieve competence for independent practice (i.e., certification). This pilot study provides promising data in support of augmented SBT induction, paving the way for phased implementation and larger real-world studies incorporating objective competency assessment tools to compare progress in specific technical and non-technical skills.