Passing the fundamentals of endoscopic surgery (FES) exam: linking specialty choice and attitudes about endoscopic surgery to success

Current status of resident simulation training curricula: pearls and pitfalls

BACKGROUND

Residency programs are required to incorporate simulation into their training program. Ideally, simulation provides a safe environment for a trainee to be exposed to both common and challenging clinical scenarios. The purpose of this review is to detail the current state of the most commonly used laparoscopic, endoscopic, and robotic surgery simulation programs in general surgery residency education, including resources required for successful implementation and benchmarks for evaluation.

MATERIALS AND METHODS

Members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Resident and Fellow Task Force (RAFT) Committee performed a literature review using PubMed and training websites. Information regarding the components of the most commonly used laparoscopic, endoscopic, and/or robotic simulation curriculum, including both formal and informal benchmarks for evaluating training competence, were collected.

RESULTS

Laparoscopic simulation revolves around the Fundamentals of Laparoscopic Surgery (FLS). Proficiency-based as well as virtual simulation have been utilized for FLS training curricula. Challenges include less direct translation to the technical complexities that can arise in laparoscopic surgery. Endoscopic simulation focuses on the Fundamentals of Endoscopic Surgery. There are virtual reality simulation platforms that can be used for skills assessment and training. Challenges include simulator types and access, as well as structured mentoring and feedback. Robotic simulation training curricula have not been standardized. Simulation includes one primary technology, which can be prohibitive based on cost and requirements for onboarding.

CONCLUSIONS

While surgical simulation seems to be a fundamental and integrated part of surgical training, it requires a significant number of resources, which can be daunting for residency training programs. Regardless of the barriers outlined, the need for surgical simulation in laparoscopy, endoscopy, and robotics at surgical education training programs is clear.

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.

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.

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.

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.

Computerized feedback during colonoscopy training leads to improved performance: a randomized trial

BACKGROUND AND AIMS

Simulation-based training in colonoscopy is increasingly replacing the traditional apprenticeship method to avoid patient-related risk. Mentoring during simulation is necessary to provide feedback and to motivate, but expert supervisors are a scarce resource. We aimed to determine whether computerized feedback in simulated colonoscopy would improve performance, optimize time spent practicing, and optimize the pattern of training.

METHODS

Forty-four participants were recruited and randomized to either a feedback group (FG) or a control group (CG). Participants were allowed 2 hours of self-practice during which they could practice as they saw fit on 2 different cases: 1 easy and 1 difficult. The CG practiced without feedback, but the participants in the FG were given a score of progression every time they reached the cecum. All participants were tested on a different case after end of training. The primary outcome was the progression score in the final case, and secondary outcomes were time spent practicing and the training pattern.

RESULTS

Regression analysis adjusting for sex was done because of an uneven sex distribution between groups (P = .026) and significantly higher performance scores by men (37.6, standard deviation [SD] 25.9) compared with women (19.7, SD 18.7); P = .012. The FG outperformed the CG in the final case, FG scoring 14.4 points (95% confidence interval [CI], 1.2-27.6) more than the CG; P = .033, and they spent more time practicing, FG practicing 25.8 minutes (95% CI, 11.6-39.9) more than the CG; P = .001. The FG practiced more on the easy case and reached the cecum 3.2 times more (95% CI, 2-4.5) during practice (P < .001).

CONCLUSIONS

Our findings of this study revealed that an automatic, computerized score of progression during simulated colonoscopy motivates the novices to improve performance, optimizes time spent practicing, and optimizes their pattern of training. (Clinical trial registration number: NCT03248453.).

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.