Is current surgery resident and GI fellow training adequate to pass FES?

The American Board of Surgery flexible endoscopy curriculum prepares individuals to pass the fundamentals of endoscopic surgery manual skills test

BACKGROUND

The American Board of Surgery (ABS) has required Fundamentals of Endoscopic Surgery (FES) certification for general surgery applicants since 2018. Flexible Endoscopy Curriculum (FEC) completion is recommended prior to taking the FES exam. The objective of the study was to determine if FEC completion prepares individuals to pass the FES manual skills test.

METHODS

Participants included first-attempt FES examinees from June 2014 to February 2019. De-identified data were reviewed, Self-reported data included gender, PGY, glove size, upper (UE) and lower (LE) endoscopy experience, simulation training time, and participation in an endoscopy rotation (ER). FES skills exam performance was reported by FES staff. Those completing all vs. none of the FEC were compared.

RESULTS

Of 2023 participants identified, 809 (40.0%) reported completion of all FEC components, 1053 (52.1%) completed of some, and 161 (8.0%) completed none. Men and candidates taking FES later in residency were more likely to complete all FEC requirements (p = 0.002, p < 0.001). FES pass rates were higher for those who completed all FEC components compared to those who completed none (88.4% vs 72.7%, p < 0.001). On logistic regression analysis, completion of all components (OR 2.3, 95% CI 1.5-3.7, p < 0.001) and male gender (OR 3.1, 95% CI 1.7-5.7, p < 0.001) were predictors of passing, while glove size (OR 1.5, 95% CI 1.0-2.5, p = 0.08), simulator time (OR 1.1, 95% CI 0.9-1.4, p = 0.37) and PGY were not (OR 1.1, 95% CI 0.9-1.4, p = 0.38). On multivariate analysis controlling for glove size and gender, completion of all FEC components was still associated with a higher likelihood of passing the FES skills exam (OR 1.6, 95% CI 1.2-2.1, p < 0.001).

CONCLUSIONS

Completion of FEC is strongly associated with passing the FES skills test. This study supports the ABS recommendation for completion of FEC prior to taking the FES skills test.

Transfer of virtual reality endoscopy training to live animal colonoscopy: a randomized control trial of proficiency vs. repetition-based training

BACKGROUND

Low first-time pass rates of the Fundamentals of Endoscopic Surgery (FES) exam stimulated development of virtual reality (VR) simulation curricula for test preparation. This study evaluates the transfer of VR endoscopy training to live porcine endoscopy performance and compares the relative effectiveness of a proficiency-based vs repetition-based VR training curriculum.

METHODS

Novice endoscopists completed pretesting including the FES manual skills examination and Global Assessment of GI Endoscopic Skills (GAGES) assessment of porcine upper and lower endoscopy. Participants were randomly assigned one of two curricula: proficiency-based or repetition-based. Following curriculum completion, participants post-tested via repeat FES examination and GAGES porcine endoscopy assessments. The two cohorts pre-to-post-test differences were compared using ANCOVA.

RESULTS

Twenty-two residents completed the curricula. There were no differences in demographics or clinical endoscopy experience between the groups. The repetition group spent significantly more time on the simulator (repetition: 242.2 min, SD 48.6) compared to the proficiency group (proficiency: 170.0 min, SD 66.3; p = 0.013). There was a significant improvement in porcine endoscopy (pre: 10.6, SD 2.8, post: 16.6, SD 3.4; p < 0.001) and colonoscopy (pre: 10.4, SD 2.7, post: 16.4, SD 4.2; p < 0.001) GAGES scores as well as FES manual skills performance (pre: 270.9, SD 105.5, post: 477.4, SD 68.9; p < 0.001) for the total cohort. There was no difference in post-test GAGES performance or FES manual skills exam performance between the two groups. Both the proficiency and repetition group had a 100% pass rate on the FES skills exam following VR curriculum completion.

CONCLUSION

A VR endoscopy curriculum translates to improved performance in upper and lower endoscopy in a live animal model. VR curricula type did not affect FES manual skills examination or live colonoscopy outcomes; however, a proficiency curriculum is less time-consuming and can provide a structured approach to prepare for both the FES exam and clinical endoscopy.

Democratizing Flexible Endoscopy Training: Noninferiority Randomized Trial Comparing a Box-Trainer vs a Virtual Reality Simulator to Prepare for the Fundamental of Endoscopic Surgery Exam

BACKGROUND

A considerable number of surgical residents fail the mandated endoscopy exam despite having completed the required clinical cases. Low-cost endoscopy box trainers (BTs) could democratize training; however, their effectiveness has never been compared with higher-cost virtual reality simulators (VRSs).

STUDY DESIGN

In this randomized noninferiority trial, endoscopy novices trained either on the VRS used in the Fundamental of Endoscopic Surgery manual skills (FESms) exam or a validated BT-the Basic Endoscopic Skills Training (BEST) box. Trainees were tested at fixed timepoints on the FESms and on standardized ex vivo models. The primary endpoint was FESms improvement at 1 week. Secondary endpoints were FESms improvement at 2 weeks, FESms pass rates, ex vivo tests performance, and trainees' feedback.

RESULTS

Seventy-seven trainees completed the study. VRS and BT trainees showed comparable FESms improvements (25.16 ± 14.29 vs 25.58 ± 11.75 FESms points, respectively; p = 0.89), FESms pass rates (76.32% vs 61.54%, respectively; p = 0.16) and total ex vivo tasks completion times (365.76 ± 237.56 vs 322.68 ± 186.04 seconds, respectively; p = 0.55) after 1 week. Performances were comparable also after 2 weeks of training, but FESms pass rates increased significantly only in the first week. Trainees were significantly more satisfied with the BT platform (3.97 ± 1.20 vs 4.81 ± 0.40 points on a 5-point Likert scale for the VRS and the BT, respectively; p < 0.001).

CONCLUSIONS

Simulation-based training is an effective means to develop competency in endoscopy, especially at the beginning of the learning curve. Low-cost BTs like the BEST box compare well with high-tech VRSs and could help democratize endoscopy training.

Trends in General Surgery Resident Experience with Colorectal Surgery: An Analysis of the Accreditation Council for Graduate Medical Education Case Logs

OBJECTIVE

Colorectal surgery is a core component of general surgery. The volume of colorectal surgery performed by general surgery residents throughout training has not been studied. This study aims to analyze trends observed in colorectal-specific case numbers logged by general surgery residents over 16 years.

DESIGN

Case number data for general surgery residents was extracted from the publicly available, annually published Accreditation Council for Graduate Medical Education (ACGME) database from 2003 to 2019. Cases were categorized as open or laparoscopic colectomy/proctectomy, colectomy with ileoanal pull-thru, abdomino-perineal resection (APR), transanal rectal tumor excision (TRE), anorectal procedure, colonoscopy, and total colorectal cases. The average case numbers per category was calculated for each year. Linear regression analyzed trends in case categories for all residents and those logged as surgeon chief and junior residents.

SETTING

ACGME accredited general surgery residency programs.

PARTICIPANTS

Not applicable.

RESULTS

General surgery residents reported increased numbers of all, chief, and junior resident colorectal cases over the study period (124.5-173.7 cases/yr; 38.4-53.0 cases/yr; 86.4-120.6 cases/yr, all p = 0.00). Average cases for all, chief, and junior residents have increased for laparoscopic colectomy/proctectomy (4.6-26.4 cases/year; 2.7-12.9 cases/year; 2.0-13.5 cases/year, all p = 0.00), anorectal surgeries (26.7-37.7 cases/year; 5.4-9.9 cases/year; 21.3-27.8 cases/year, all p = 0.00), and colonoscopies (35.9-70.6 cases/year, p = 0.00; 6.6-14.1 cases/year, p = 0.01; 29.4-56.5 cases/year, p = 0.00). Average cases for all, chief, and junior residents have decreased for open colectomy/proctectomy (52.0-34.9 cases/year; 21.2-14.3 cases/year; 30.9-20.6 cases/year, all p = 0.00), APR (3.3-2.7 cases/year, p = 0.00; 1.8-1.3 cases/year, p = 0.00; 1.5-1.4 cases/year, p = 0.02), TRE (1.9-1.1 cases/year; 0.7-0.4 cases/year; 1.2-0.6 cases/year, all p = 0.00). Ileoanal pull-thru did not demonstrate a linear trend.

CONCLUSIONS

The increase in exposure to colectomies/proctectomies, anorectal procedures and colonoscopies is encouraging, as these common colorectal operations will be encountered in general surgery practice. The observed low case numbers for TRE, APR, and ileoanal pull-thru suggest a need for specialized training.

Resident Endoscopy Experience Correlates Poorly with Performance on a Virtual Reality Simulator

Background  Endoscopy training has become increasingly emphasized during general surgery residency as reflected by introduction of the Fundamentals of Endoscopic Surgery (FES) examination, which includes testing of skills on virtual reality (VR) simulators. Although studies exist to assess the ability of the simulator to differentiate between novices and experienced endoscopists, it is not well understood how simulators can differentiate skills among resident cohort.

Objective  To assess the utility of the VR simulator, we evaluated the correlation between resident endoscopy experience and performance on two VR simulator colonoscopy modules on the GI-BRONCH Mentor (Simbionix Ltd, Airport City, Israel).

Methods  Postgraduate years 2 to 5 residents completed “easy” and “difficult” VR colonoscopies, and performance metrics were recorded from October 2017 to February 2018 at Rutgers' two general surgery residency programs. Resident endoscopy experience was obtained through Accreditation Council for Graduate Medical Education case logs. Correlations between resident endoscopy experience and VR colonoscopy performance metrics were assessed using Spearman's rho (ρ) correlation statistic and bivariate logistic regression.

Results  Fifty-five residents out of 65 (84.6%) eligible participants completed the study. There were limited correlations found between resident endoscopy experience and FES performance metrics and no correlations were found between resident endoscopy experience and binary metrics of colonoscopy—ability to complete colonoscopy, ability to retroflex, and withdrawal time of less than 6 minutes.

Conclusion  The VR simulator may have a limited ability to discriminate between experience levels among resident cohort. Future studies are needed to further understand how well the VR simulator metrics correlate with resident endoscopy experience.

Admission discipline and timing of admission may influence outcomes for gastrointestinal bleeding patients

BACKGROUND

Bleeding of the gastrointestinal tract (BGIT) is a common gastrointestinal emergency. There is no consensus whether this condition should be admitted to medical or surgical discipline. Timing of presentation may also impact patient outcomes due to differences in healthcare resource availability. This study thus aims to investigate the impact of admitting discipline and timing of admission on patient outcomes in BGIT.

METHODS

A 2-year tertiary institution database was retrospectively reviewed. Outcome measures included 30-day mortality, 30-day readmissions and rebleeding requiring repeat endoscopic, angiographic or surgical interventions. Secondary outcome measures included time to endoscopy, percutaneous angiographic interventions and surgery. The effect of admission discipline (medical versus surgical) and time of admission (office-hours versus after office-hours) were analysed using a propensity-score-adjusted estimate.

RESULTS

A total of 1384 patients were included for analysis, medical (n = 853), surgical (n = 530); during office-hours (n = 785) and after office-hours (n = 595). After propensity-score-adjusted analysis, no significant differences in mortality or readmissions were noted between medical or surgical admissions. Patients admitted under surgery were less likely to sustain rebleeding (P = 0.004) for lower BGIT and had an earlier time to endoscopy for upper BGIT (P = 0.04). Patients admitted after office-hours had similar outcomes with those admitted during office hours apart from a delay in time to endoscopy (P = 0.02).

CONCLUSION

For BGIT patients, admission to a surgical discipline compared to a medical discipline appeared to have at least equivalent patient outcomes. Patients presenting with BGIT after office-hours were more likely to experience a delay to endoscopy, although it did not affect patient mortality.

Early implementation of Fundamentals of Endoscopic Surgery training using a simulation-based mastery learning curriculum

BACKGROUND

After the American Board of Surgery announcement of the Flexible Endoscopy Curriculum requirement in 2014, we implemented a dedicated endoscopy rotation at the post graduate year (PGY)2 level including a simulation curriculum for Fundamentals of Endoscopic Surgery skills. Here we evaluate the outcomes of this implementation.

METHODS

Beginning in 2015, we developed a clinical endoscopy and simulation-based rotation to prepare for Fundamentals of Endoscopic Surgery testing. Originally, our curriculum was based on the published Texas Association of Surgical Skills Laboratories curriculum using the GI Mentor and transitioned to a mastery learning curriculum using the Endoscopy Training System in 2016. We evaluated the success of the curriculum in terms of first-time pass rates, training time required, and comparison to previously published benchmarks based on clinical experience.

RESULTS

Since 2015, a total of 37 general surgery residents in our program were Fundamentals of Endoscopic Surgery tested (PGY2 = 24, PGY3 = 4, PGY5 = 9); 84% (31) completed the Endoscopy Training System curriculum. At the time of testing, 73% (27) had performed <25 esophagogastroduodenoscopies, and 46% had performed <25 colonoscopies. Ninety-two percent (34) spent 10 hours or less completing the curriculum. The first-time pass rate for those completing the Endoscopy Training System curriculum was 97% vs 67% for those not completing the Endoscopy Training System curriculum (P = .01). For residents completing the Endoscopy Training System curriculum, total Fundamentals of Endoscopic Surgery scores were discernibly higher (472 vs 389, P < .01), as were 3/5 task scores (Nav1 80 vs 67, P = .02; Loop2 36 vs 8, P = .02; Retro3 89 vs 71, P = .02). Despite clinical inexperience (<25 esophagogastroduodenoscopies and <50 colonoscopies), PGY2s yielded a mean score of 454 and a pass rate of 92%. This was similar to PGY5s (427, 89%; P = .3) and compares to benchmark data of endoscopists with >300 cases.

CONCLUSION

Early implementation of flexible endoscopy training with a simulation-based curriculum results in Fundamentals of Endoscopic Surgery performance equal to a clinical experience not often gained during surgical residency. Often requiring <10 hours, this represents a fantastic return on investment for this training.

Fact or Fiction? Practice on a Simulator is Not Required to Pass the Fundamentals of Endoscopic Surgery (FES)TM Skills Exam

PURPOSE

Initial work on the validity evidence used to support the Fundamentals of Endoscopic Surgery (FES) performance exam as a measure of technical competency showed a strong relationship to clinical experience. Despite this evidence, there is a perception among some program directors that the exam cannot be successfully passed without practice on a simulator. We assess the validity of this perception.

METHODS

Deidentified data from the initial FES skills examination (prior to the 2014 FEC requirement) was reviewed, and 335 unique participants with reported simulation experience demographics were identified. Self reported data analyzed included gender, total clinical endoscopy procedure experience (1-150, 151-300, >300), and endoscopy simulator training hours (0, 1-5, 6-10, 11-20, >20). Final FES skills exam scores, and pass/fail designations for each participant were reported by the FES program staff. Continuous variables were compared between groups using one-way analysis of variance with post-hoc analysis where appropriate. Categorical variables were compared using Pearson Chi-Squared. The effect of variables on pass rate was assessed using univariate and multivariate logistic regression.

RESULTS

Simulation training experience (SE) was categorically reported in hours(n,%): 0 (98, 29%), 1-5 (135, 40%), 6-10 (52, 16%), 11-20 (24, 7%), and >20 (26, 8%). Clinical endoscopy experience (CE), reported categorically as total cases performed (n,%), was available for 323 of 355 identified participants: 1-150 (126, 39%), 151-300 (99, 31%), >300 (98, 30%). There was no statistically discernible differences in mean FES total or task scores across the SE groups (total score 0:72 ± 15, 1-5:72 ± 13, 6-10:71 ± 14, 11-20:71 ± 16, 20:78 ± 13; p = 0.28), while both total score and task scores were discernibly higher in the more experienced CE groups (>151) compared to the least experienced group (total score; <150:67 ± 15, 151-300:75 ± 1, >300:77 ± 14; p < 0.01). Similarly, there was no statistically discernible difference in FES skills exam pass rates between SE groups (0: 80%, 1-5: 82%, 6-10: 79%, 11-20: 75%, >20: 85%; x2 = 2.5, p = 0.6), but there was a strong relationship between clinical experience and pass rate (<150: 70%, 151-300: 87%, >300: 89%; x2 = 15.8, p < 0.001). Finally, on both univariate and multivariate logistic regression, CE remained a discernible predictor of passing, even when controlling for SE (odds ratio = 2, 95% confidence interval 1.4-2.9, p < 0.001).

CONCLUSIONS

FES skills examination data collected on participants completing the examination before the FEC requirement shows no demonstrable relationship with self-reported training experience on a simulator but confirms a strong relationship with clinical endoscopy experience. This lends further evidence to the validity of the FES exam as a marker of clinical endoscopic skill.

ACGME Operative Case Log Accuracy Varies Among Surgical Programs

OBJECTIVE

This study evaluates the accuracy of reported the Accreditation Council for Graduate Medical Education (ACGME) operative case logs from graduated residents compared to institutional operating room electronic records (ORER). We hope this will help guide review committees and institutions develop complete, accurate resident case logs.

DESIGN

This is a retrospective, cross-sectional study of general surgery (GS), neurosurgery (NS), and orthopedic surgery (OS) resident physicians. ACGME and ORER cases from 2009 to 2010 were analyzed and each case and current procedural terminology (CPT) code directly compared (ORER vs. ACGME).

SETTING

Single academic tertiary-care medical center (University of Kentucky, Lexington, KY).

PARTICIPANTS

Eleven thousand nine hundred and twenty-three cases for 46 residents among the 3 residency programs were analyzed.

RESULTS

There was an overall logging accuracy of 72% for ORER cases reflected in the ACGME case logs. OS residents had a higher rate of logging accuracy (OS 91%, GS 69%, NS 58%, chi-square p = 0.014) and mean annual number of cases compared to the other 2 programs (OS 452, GS 183, NS 237, ANOVA p = 0.001). NS residents had higher accuracy of CPT codes than post-graduate years 2 to 5 in other programs (p < 0.017). There was a strong positive correlation between the number of cases completed per resident and case logging accuracy, (rho = 0.769, p < 0.001) consistent for NS and GS, but not OS.

CONCLUSIONS

This study shows only 72% of a residents' operative experience is captured in the ACGME case log across 3 surgical programs. There is significant variability among surgical programs and among post-graduate year cohorts regarding case log and CPT code accuracy. There is a strong correlation with the total number of cases performed and increasing case log accuracy. Low case log accuracy may reflect individual resident behavior instead of program operative exposure. Further studies are needed to determine if ORER may serve as a more complete assessment of the operative experience of a resident and program.

A curriculum to democratize and standardize flexible endoscopy fundamental knowledge and skills: a critical review of the first 5 years of a surgical endoscopy university diploma

BACKGROUND

As flexible endoscopy offers many advantages to patients, access to training should be aggressively encouraged. In 2014, the IRCAD-IHU-Strasbourg launched a year-long university diploma using advanced education methods to offer surgeons and gastroenterologists high-quality, personalized training in flexible endoscopy. This paper describes and critically reviews the first 5 years of the University Diploma in Surgical Endoscopy (UDSE).

METHODS

The UDSE aims to progressively transmit theoretical knowledge, clinical judgment, and practical skills on basic and advanced flexible endoscopy. The 300-h year-long curriculum is composed of 100 h of online lectures with tests, 150 h of clinical rotations and 50 h of hands-on sessions. The hands-on training is delivered through validated mechanical simulators, virtual reality simulators, and specifically designed ex vivo and in vivo animal models. Participants' demographics, training, and clinical experience were recorded. Trainees' evaluations of each online lecture, hands-on training, and clinical rotations were assessed using a Likert scale from 1 (not satisfactory) to 5 (outstanding). Trainees' skill progression was evaluated using the Global Assessment of Gastrointestinal Endoscopic Skills (GAGES) proficiency test. Finally, clinical uptake was surveyed.

RESULTS

162 (79.01% males) trainees from 38 countries enrolled and successfully completed the first 5 courses. The vast majority of the trainees were surgeons and 19.14% were gastroenterologist. Sixty-nine (42.59%) participants were residents and 97 (56.79%) had no prior experience in flexible endoscopy. The online lectures, on-site sessions, and clinical rotations were highly appreciated receiving an overall average score of 4.33/5, 4.56/5, 4.43/5, respectively. Trainees' endoscopic skills improved significantly (16.68 vs. 20.53 GAGES scores; p = 0.016). At an average of 18.83 months following the course, 31 alumni (77.50% of repliers) started to use a flexible endoscope in their practice.

CONCLUSIONS

Over its 5-year evolution, the UDSE has proven to be a valid means to ease access to the fundamental knowledge, practical skills, and clinical judgment necessary to achieve proficiency in surgical endoscopy.

How We Do It: Creation of a Low-Cost Endoscopic Skills Model for Fundamentals of Endoscopic Surgery Training

OBJECTIVE

To design a low cost, high fidelity endoscopic skills model to help surgical trainees pass the Fundamentals of Endoscopic Surgery (FES) testing.

DESIGN

A homemade synthetic colon model was designed using liquid silicon and other commercially available products. The construction and design of the model is described here. The model was then successfully integrated into our simulation curriculum and endoscopic skills training modules.

SETTING

Cleveland Clinic Foundation, Cleveland, Ohio; large academic quaternary referral institution.

PARTICIPANTS

PGY 1-5 general surgery residents preparing for Fundamentals of Endoscopic Surgery testing.

RESULTS

A versatile, high fidelity model was designed for a total cost of approximately 25 dollars per unit. The model can be used with clinical endoscopic towers and easily integrated into an institution's simulation and endoscopic training curriculum. The flexibility of design allows trainees to practice all of the key motor skills necessary for FES examination success.

CONCLUSIONS

A homemade endoscopic colon model can be constructed at an affordable price point using commercially available materials. These models have significant versatility, low cost, and flexibility of design allowing for easy incorporation into a surgical residency simulation training program.

Are you better off than you were 4 years ago? Measuring the impact of the ABS flexible endoscopy curriculum

INTRODUCTION

In 2014, the ABS introduced the Flexible Endoscopy Curriculum (FEC). The FEC did not alter the minimum defined category case volumes for endoscopy; however, it did introduce specific cognitive and technical milestones for endoscopy training. It also mandated that residents pass the Fundamentals of Endoscopic Skills (FES) exam to qualify for board certification. Although significant research has been published regarding residents' success on the FES exam, very little is known regarding how the FEC has changed the way general surgery programs train their residents in surgical endoscopy. The aim of this study was to quantify changes in flexible endoscopy education at a large academic program in the 4 years since the FEC was published.

METHODS

We classified the impact of FEC into four categories: (a) case volume or distribution, (b) clinical rotations, (c) required didactics or simulation exercises, and (d) FES pass rates. For category (a), we reviewed current and historical case logs for all categorical residents from 2013 to 2018. Mann-Whitney U tests were used to compare endoscopy volumes for each PGY level in 2013-2014 to the respective PGY level in 2017-2018 with p < 0.05 considered significant. For categories (b)-(d), we gathered historical records from the residency coordinator and endoscopy rotation director.

RESULTS

Complete data were available for 57 residents in the 2013-2014 academic year and 56 residents in the 2017-2018 academic year. Median total endoscopies performed by PGY2, PGY3, and PGY5 residents all significantly increased during the FEC rollout. Our program's focus on endoscopy also expanded with absolute increases in endoscopy rotations, didactics, and simulation exercises. These changes translated into significantly increased pass rates on the FES exam from 40 to 100%.

CONCLUSIONS

Implementation of the FEC at a large academic program led to measurable improvements in clinical experience, program structure, educational programing, and performance on high-stakes assessments.

An Inexpensive, Portable Physical Endoscopic Simulator: Description and Initial Evaluation

BACKGROUND

Surgeons and gastroenterologists in training benefit from simulation-based endoscopy education, yet the price of most training endoscopy simulators is prohibitive. We set out to create and evaluate a low-cost endoscopic simulator and box model trainer for learning fundamental endoscopic skills.

METHODS

After adding a wireless network-enabled camera (total cost, $20) to a discarded clinical endoscope, we paired this with an easily constructed box trainer (cost $32) to generate an endoscopic simulator system (YazanoScope) for simulation training. Participants (general surgery interns, research fellows, and medical and college students) used the YazanoScope to train to mastery on 5 FES tasks. Outcomes included skill assessments on a computer simulator and trainees' perceptions comparing the physical model to the computer simulator.

RESULTS

Forty trainees participated. The median (range) training time was 110 (60-180) min. Only 10% of trainees were able to reach the cecum at baseline compared to 100% after training. The mean (SD) time was 253 (154) s at baseline (including completers and non-completers) and 249 (89) after training (P = 0.88). On a retention test 2 wk later, 21 of 22 (96%) completed the computer simulator assessment (endoscope tip reached the cecum). Mean time was 214 (67) s (P = 0.32 compared with immediate posttraining). All 40 trainees believed the YazanoScope provided better haptic feedback than the computer simulator.

CONCLUSIONS

Training with this inexpensive, portable endoscopic simulator (YazanoScope) was associated with increased procedure completion with no change in procedure time. All participants favored the haptic feedback of the $52 YazanoScope over a computer simulator.

Development of a fundamentals of endoscopic surgery proficiency-based skills curriculum for general surgery residents

BACKGROUND

Fundamentals of Endoscopic Surgery (FES) has become a board certification requirement for general surgery residents. While the FES program provides a robust didactic curriculum, an endoscopic skills curriculum is lacking for this high stakes assessment. The aims of this study were to develop a proficiency-based endoscopic skills curriculum and assess its effectiveness on success in the FES exam.

METHODS

Endoscopy experts developed a multiple-choice questionnaire based on the FES online didactics. Five training cases from the GI Mentor II simulator were selected, and expert performance defined proficiency levels for each case. Participating surgery residents were required to review online didactics and achieve proficiency twice on selected simulator cases. The multiple-choice questionnaire, simulator-generated metrics of two endoscopy cases, Global Assessment of Gastrointestinal Endoscopic Skills (GAGES), NASA-Task Load Index (TLX), and the manual portion of the FES exam were used for assessment before and after training. The curriculum was implemented either alongside a clinical endoscopy rotation or independent of the rotation. Clinical endoscopic skills of participants with a dedicated rotation were assessed using GAGES.

RESULTS

Twenty-eight general surgery residents (PGY 2-5) participated in the study, of which 25 (89%) completed the curriculum. Scores of the multiple-choice questionnaire and all simulator-generated metrics improved in the post-training assessment, with the exception of the percentage of mucosal surface examined, which was slightly decreased. Simulated and clinical GAGES scores and the NASA-TLX score improved after training. Performance scores on four of five FES exam tasks were significantly improved.

CONCLUSIONS

The proficiency-based endoscopic skills curriculum was successfully implemented both alongside the clinical endoscopy rotation and independent of the rotation. Participating residents acquired skills to pass the FES exam. This curriculum will be valuable to general surgery residency programs.

The FES Test: Are We Ready?

PURPOSE

The FES hands-on skills test is administered using a $100,000 computer-based simulator. Few of our trainees have practiced on this device. Our aim was to evaluate our GS residents' baseline endoscopic skills and eventually develop a simulation-based endoscopy curriculum and clarify performance-based assessment criteria.

METHODS

General surgery residents' colonoscopy skills were assessed using a computer-based endoscopy simulator (CBES) during their biannual simulation-based OSCE-type assessments. Trainees were asked to reach the ileum in <5 minutes with minimal patient pain and complications. Module 1 (easy) was assigned to PGY 1-4 residents and module 5 (hard) to both PGY 4s and 5s. The colonoscope insertion length, % time with no pain, % time in "red out", and complications were recorded. Performance grading criteria were driven by literature review and expert opinion. Residents were assessed in the fall 2017; they were then given scoring criteria, a step-by-step instruction manual, and a voluntary hands-on session with the CBES. Residents repeated the same assessment in the spring 2018.

RESULTS

30 PGY-1s, 12 PGY-2s, 8 PGY-3s, 9 PGY-4s and 7 PGY-5s GS residents participated in the fall colonoscopy assessment. In module 1, 66% of PGY-4s, 50% of PGY-3s, 8% of PGY-2s and 0% of the PGY-1s intubated the ileum (p<0.05). In module 5, 30% of PGY 5 and 22% of PGY 4 residents completed the task (p<0.05). 15 PGY-1s, 5 PGY-2s, 1 PGY-3, 2 PGY-4s, and 1 PGY-5 participated in the voluntary hands-on session. All residents completing the fall assessment undertook the same task in the spring. In module 1, 89% of PGY-4s, 100% of the PGY-3s, 75% of PGY-2s and 70% of the PGY-1s completed the task. In module 5, 30% of PGY 5 and 34 % of PGY 4 residents completed the task. Residents who participated in the voluntary hands-on session (n= 24, 96% task completion) outperformed residents (n= 42, 64% task completion) that did not participate (p<0.05).

CONCLUSIONS

Most of our GS residents could not initially intubate the ileum using the CBES. Prior experience with the CBES was the only factor strongly correlated with successful task completion. A voluntary hands-on teaching session allowed 96% of participating trainees to subsequently achieve CBES task completion. Developing a formal simulation-based curriculum suggests we can better prepare surgical trainees for the FES exam.

Development of a train-to-proficiency curriculum for the technical skills component of the fundamentals of endoscopic surgery exam

BACKGROUND

The demonstration of competency in endoscopy is required prior to obtaining American Board of Surgery Certification. To demonstrate competency, the resident must pass a national high-stakes cognitive test and a technical skills exam on a virtual reality simulator. The purpose of this preliminary study was to design a proficiency-based endoscopy simulation curriculum to meet this competency requirement.

METHODS

This is a mixed methods prospective cohort study at a single academic medical institution. Prior to taking the national exam, surgery residents were required to participate in a skills lab and demonstrate proficiency on 10 simulation tasks. Proficiency was based on time and percent of objects targeted/mucosa seen. Simulation practice time, number of task repetitions to proficiency, and prior endoscopic experience were recorded. Resident's self-reported confidence scores in endoscopic skills prior to and following simulation lab training were obtained.

RESULTS

From January 1, 2016 through August 1, 2017, 20 surgical residents (8 PGY2, 8 PGY3, 4 PGY4) completed both a faculty-supervised endoscopy skills lab and independent learning with train-to-proficiency simulation tasks. Median overall simulator time per resident was 306 min (IQR: 247-405 min). Median overall time to proficiency in all tasks was 235 min (IQR: 208-283 min). The median time to proficiency decreased with increasing PGY status (r = 0.4, P = 0.05). There was no correlation between prior real-time endoscopic experience and time to proficiency. Reported confidence in endoscopic skills increased significantly from mean of 5.75 prior to 7.30 following the faculty-supervised endoscopy skills lab (P = 0.0002). All 20 residents passed the national exam.

CONCLUSIONS

In this preliminary study, a train-to-proficiency curriculum in endoscopy improved surgical resident's confidence in their endoscopic skills and 100% of residents passed the FES technical skills test on their first attempt. Our findings also indicate that uniform proficiency was not achieved by real-time experience alone.

Preparing for the American Board of Surgery Flexible Endoscopy Curriculum: Development of multi-institutional proficiency-based training standards and pilot testing of a simulation-based mastery learning curriculum for the Endoscopy Training System

BACKGROUND

The Fundamentals of Endoscopic Surgery (FES) exam is required for American Board of Surgery certification. The purpose of this study was to develop performance standards for a simulation-based mastery learning (SBML) curriculum for the FES performance exam using the Endoscopy Training System (ETS).

METHODS

Experienced endoscopists from multiple institutions and specialties performed each ETS task (scope manipulation (SM), tool targeting (TT), retroflexion (RF), loop management (LM), and mucosal inspection (MI)) with scores used to develop performance standards for a SBML training curriculum. Trainees completed the curriculum to determine feasibility, and effect on FES performance.

RESULTS

Task specific training standards were determined (SM-121sec, TT-243sec, RF-159sec, LM-261sec, MI-180-480sec, 7 polyps). Trainees required 29.5 ± 3.7 training trials over 2.75 ± 0.5 training sessions to complete the SBML curriculum. Despite high baseline FES performance, scores improved (pre 73.4 ± 7, post 78.1 ± 5.2; effect size = 0.76, p > 0.1), but this was not statistically discernable.

CONCLUSIONS

This SBML curriculum was feasible and improved FES scores in a group of high performers. This curriculum should be applied to novice endoscopists to determine effectiveness for FES exam preparation.