The goal of advanced endoscopy fellowship is to teach trainees to safely and effectively perform high-risk endoscopic procedures.1,11,12 Without ACGME oversight, no defined curricular requirements exist, and programs can be quite variable. Stronger programs offer close mentorship, conferences, comprehensive didactics, research support, and regular feedback. All programs participating in this year’s match offered training in both ERCP and EUS with most offering training in EMR, ablation, and deep enteroscopy.10 Many programs also offered training in endoluminal stenting and advanced closure techniques, such as suturing. More than half offered training in endoscopic submucosal dissection, peroral endoscopic myotomy, and bariatric endoscopy, but trainee hands-on time is usually limited, and competence is not guaranteed. A recent, large, multicenter, prospective study found that the median number of ERCPs and EUSs performed by trainees during advancing endoscopy training was 350 (range 125-500) and 300 (range 155-650), respectively.2 Median number of ERCPs performed in patients with native papilla was 51 (range 32-79). Most ERCPs were performed for biliary indications, and most EUSs were performed for pancreaticobiliary indications. The study found that most advanced endoscopy trainees have limited exposure to interventional EUS procedures, ERCPs for pancreatic indications, and ERCPs requiring advanced cannulation techniques.
Dr. Sachin Wani
Competency assessment
Advanced endoscopy fellowship programs must ensure trainees have achieved technical and cognitive competence and are safe for independent practice. Methods to assess trainee competence in advanced procedures have changed significantly over the last several years.1 Historically, endoscopic training was based on an apprenticeship model. Procedural volume and subjective assessments from trainers were used as surrogates for competence. Most current societal guidelines now recommend competency thresholds – a minimum number of supervised procedures that a trainee should complete before competency can be assessed – instead of absolute procedure volume requirements.4,13,14 The ASGE recommends that at least 200 supervised independent ERCPs, including 80 independent sphincterotomies and 60 biliary stent placements, should be performed before assessing competence.4 Similarly, 225 supervised independent EUS cases are recommended before assessing competence. Importantly, these guidelines are not validated and do not account for the inherent variability in which different trainees acquire endoscopic skills.15-18
Because of the limitations of volume-based assessments of competence, a greater emphasis has been placed on developing comprehensive, standardized competency assessments. With the ACGME’s adoption of the Next Accreditation System (NAS), a greater emphasis has been placed on competency-based medical education throughout the United States. The goal of the Next Accreditation System is to ensure that specific milestones are achieved by trainees and that trainee progress is clearly reported. Similarly, within advanced endoscopic training, it is now accepted that a minimum procedural volume is a necessary, but insufficient, marker of competence.1 Therefore, recent work has focused on defining milestones, developing assessment tools with strong validity, establishing trainee learning curves, and providing trainees with continuous feedback that allows for targeted improvement. Although the data are limited, a few studies have assessed learning curves among trainees. A prospective study of 15 trainees from the Netherlands found that trainees acquire competence in ERCP skills at variable rates; specifically, trainees achieved competence in native papilla cannulation later than other ERCP skills.18 Similarly, a recent prospective multicenter study of advanced endoscopy trainees using a standardized assessment tool and cumulative sum analysis found significant variability in the learning curves for cognitive and technical aspects of ERCP.15
The EUS and ERCP Skills Assessment Tool (TEESAT) is a competence assessment tool for EUS and ERCP with strong validity evidence.2,15,19-21 The tool assesses several individual technical and cognitive skills, in addition to a global assessment of competence, and should be used in a continuous fashion throughout fellowship training. A prospective, multicenter study using the TEESAT showed substantial variability in EUS and ERCP learning curves among trainees and demonstrated the feasibility of creating a national, centralized database that allows for continuous monitoring and reporting of individualized learning curves for EUS and ERCP among advanced endoscopy trainees.2 Such a database is an important step in evolving with the ACGME/NAS reporting requirement and would allow for fellowship program directors and trainers to identify specific trainee deficiencies in order to deliver targeted remediation.
The impact of individualized feedback on trainee learning curves and EUS and ERCP quality indicators was addressed in a recently published prospective multicenter cohort study.22 In phase 1 of the study, 24 advanced endoscopy trainees from 20 programs were assessed using the TEESAT and given quarterly feedback. By the end of training, 92% and 74% of fellows had achieved overall technical competence in EUS and ERCP, respectively. In phase 2, trainees were assessed in their first year of independent practice to determine whether participation in competency-based fellowship programs results in high-quality care in independent practice. The study found that most trainees met performance thresholds for quality indicators in EUS (94% diagnostic rate of adequate samples and 84% diagnostic yield of malignancy in pancreatic masses) and ERCP (95% overall cannulation rate). While competence could not be confirmed for all trainees after fellowship completion, most met quality indicator thresholds for EUS and ERCP during the first year of independent practice. These data provide construct validity evidence for TEESAT and the data collection and reporting system that provides periodic feedback using learning curves and ultimately affirm the effectiveness of current training programs.
