UC Irvine

IntroductionEndoscopy performance is highly variable among fellows and practicing physicians.1,2 The field lacks a standard endoscopy training curriculum. Moreover, the traditional training under the apprenticeship model has proven to be a slow and ineffective method. Trainees who underwent a simulation-based mastery learning (SBML) curriculum accelerated their acquisition of clinical competency, 2.5x faster than trainees who received traditional training under the apprenticeship model.3 During the COVID-19 pandemic, we adapted our SBML curriculum to train upper endoscopy (esophagogastroduodenoscopy [EGD]) to novice gastroenterology trainees through online virtual coaching. Herein, we performed a hypothesis-generating study to evaluate the effectiveness of SBML-based EGD training, comparing virtual to direct in-person coaching.

MethodsWe conducted a 7-day virtual SBML course across 7 academic centers in the USA and Asia. A minimum passing standard was set for each topic. Theoretical material was delivered using Canvas, an online learning management system. For technical skills training, a virtual coach supervised hand-on training at scheduled intervals. At the end of training, an independent rater assessed the trainees skills using a validated scoring system. After the course, we assessed the trainees’ clinical performance for the first 30 EGDs using the Assessment of Competency of Endoscopy (ACE) form. We compared the trainees’ scores to that of our historical control cohort trained using in-person SBML training. Our primary outcomes were competence scores on the written exam, endoscope tip control, standard EGD. Our secondary outcome was clinical EGD evaluations. We used non-inferiority t-test statistics and Fisher’s exact test.

ResultsThe virtual coaching group received similar scores as the direct coaching group for the written assessment (virtual coaching 81.9%+8.9% vs direct coaching 78.3%+8.2%, p=0.385). For endoscope handling analysis, the trainees reached the MPS for competency after 31.4+29.1 attempts and mastery after 51.9+36.7 attempts, similar to the control cohort that had undergone the training with direct coaching (competency: 32.5+22.8, p=0.93; mastery: 38.2+31.1, p=0.42). For Standard EGD, the mean scores for the general assessment of the UGI tract were similar between the intervention and control groups (4.6+0.6 vs 4.7+0.5, p=1.00). For clinical EGDs, there were no significant differences in scores for EGD 1-5, 11-15, 16-20, 21-25, and 26-30. For EGDs 6-10, the virtual coaching cohort performed significantly better than the direct coaching cohort (2.73+0.59 vs 1.65+0.59, p<0.001).

DiscussionThe COVID-19 pandemic shifted the way we deliver endoscopy training. An SBML curriculum, delivered through virtual coaching, shows significant promise in effectively teaching novice GI trainees how to perform upper endoscopy. Moreover, SBML with virtual coaching allows trainees to learn from experts despite geographical constraints and other barriers to high-quality training. This program has the potential to improve patient safety and training efficiency compared to traditional apprentice-based training methods. We recommend a future randomized controlled trial, with a robust clinical evaluation strategy, to better understand the feasibility and effectiveness of virtual training.