Setting minimum standards for training in EUS and ERCP: results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees

Sachin Wani¹, Samuel Han¹, Violette Simon¹, Matthew Hall², Dayna Early³, Eva Aagaard³, Wasif M Abidi⁴, Subhas Banerjee⁵, Todd H Baron⁶, Michael Bartel⁷, Erik Bowman⁸, Brian C Brauer¹, Jonathan M Buscaglia⁹, Linda Carlin¹, Amitabh Chak¹⁰, Hemant Chatrath¹¹, Abhishek Choudhary⁵, Bradley Confer¹², Gregory A Coté¹³, Koushik K Das³, Christopher J DiMaio¹⁴, Andrew M Dries¹⁵, Steven A Edmundowicz¹, Abdul Hamid El Chafic¹⁶, Ihab El Hajj¹⁷, Swan Ellert¹, Jason Ferreira¹⁸, Anthony Gamboa¹⁹, Ian S Gan²⁰, Lisa Gangarosa⁶, Bhargava Gannavarapu²¹, Stuart R Gordon¹⁸, Nalini M Guda²², Hazem T Hammad¹, Cynthia Harris²³, Sujai Jalaj⁶, Paul Jowell²⁴, Sana Kenshil²⁵, Jason Klapman²³, Michael L Kochman²⁶, Sri Komanduri²¹, Gabriel Lang³, Linda S Lee⁴, David E Loren¹⁶, Frank J Lukens⁷, Daniel Mullady³, Raman V Muthusamy¹¹, Andrew S Nett²⁷, Mojtaba S Olyaee²⁸, Kavous Pakseresht²⁸, Pranith Perera²⁷, Patrick Pfau⁸, Cyrus Piraka²⁹, John M Poneros³⁰, Amit Rastogi²⁸, Anthony Razzak²⁰, Brian Riff¹⁴, Shreyas Saligram²³, James M Scheiman²⁷, Isaiah Schuster⁹, Raj J Shah¹, Rishi Sharma³¹, Joshua P Spaete²⁴, Ajaypal Singh¹⁰, Muhammad Sohail³², Jayaprakash Sreenarasimhaiah³³, Tyler Stevens¹², James H Tabibian²⁶, Demetrios Tzimas⁹, Dushant S Uppal³⁴, Shiro Urayama³¹, Domenico Vitterbo³³, Andrew Y Wang³⁴, Wahid Wassef³², Patrick Yachimski¹⁹, Sergio Zepeda-Gomez²⁵, Tobias Zuchelli²⁹, Rajesh N Keswani²¹

Affiliations

¹ University of Colorado Anschutz Medical Center, Aurora, Colorado, USA.
² Children's Hospital Association, Lenexa, Kansas, USA.
³ Washington University in St. Louis, St. Louis, Missouri, USA.
⁴ Brigham and Women's Hospital, Boston, Massachusetts, USA.
⁵ Stanford University, Stanford, California, USA.
⁶ University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
⁷ Mayo Clinic school of Graduate Medical Education, Jacksonville, Florida, USA.
⁸ University of Wisconsin, Madison, Wisconsin, USA.
⁹ Stony Brook University, Stony Brook, New York, USA.
¹⁰ University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.
¹¹ University of California, Los Angeles, Los Angeles, California, USA.
¹² Cleveland Clinic Foundation, Cleveland, Ohio, USA.
¹³ Medical University of South Carolina, Charleston, South Carolina, USA.
¹⁴ Icahn School of Medicine at Mount Sinai, New York, New York, USA.
¹⁵ Carolinas Medical Center, Charlotte, North Carolina, USA.
¹⁶ Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
¹⁷ Indiana University, Indianapolis, Indiana, USA.
¹⁸ Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.
¹⁹ Vanderbilt University, Nashville, Tennessee, USA.
²⁰ Virginia Mason Medical Center, Seattle, Washington, USA.
²¹ Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.
²² Aurora Health Care, Milwaukee, Wisconsin, USA.
²³ Moffitt Cancer Center, Tampa, Florida, USA.
²⁴ Duke University, Durham, North Carolina, USA.
²⁵ University of Alberta, Edmonton, Edmonton, Alberta, Canada.
²⁶ University of Pennsylvania, Philadelphia, Pennsylvania, USA.
²⁷ University of Michigan, Ann Arbor, Michigan, USA.
²⁸ University of Kansas, Kansas City, Kansas, USA.
²⁹ Henry Ford Hospital, Detroit, Michigan, USA.
³⁰ Columbia University, New York, New York, USA.
³¹ University of California, Davis, Davis, California, USA.
³² University of Massachusetts Medical Center, Worcester, Massachusetts, USA.
³³ University of Texas Southwestern Medical Center, Dallas, Texas, USA.
³⁴ University of Virginia, Charlottesville, Virginia, USA.

PMID: 30738985
PMCID: PMC6527477
DOI: 10.1016/j.gie.2019.01.030

Setting minimum standards for training in EUS and ERCP: results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees

Sachin Wani et al. Gastrointest Endosc. 2019 Jun.

. 2019 Jun;89(6):1160-1168.e9.

doi: 10.1016/j.gie.2019.01.030. Epub 2019 Feb 7.

Authors

Affiliations

¹ University of Colorado Anschutz Medical Center, Aurora, Colorado, USA.
² Children's Hospital Association, Lenexa, Kansas, USA.
³ Washington University in St. Louis, St. Louis, Missouri, USA.
⁴ Brigham and Women's Hospital, Boston, Massachusetts, USA.
⁵ Stanford University, Stanford, California, USA.
⁶ University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
⁷ Mayo Clinic school of Graduate Medical Education, Jacksonville, Florida, USA.
⁸ University of Wisconsin, Madison, Wisconsin, USA.
⁹ Stony Brook University, Stony Brook, New York, USA.
¹⁰ University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.
¹¹ University of California, Los Angeles, Los Angeles, California, USA.
¹² Cleveland Clinic Foundation, Cleveland, Ohio, USA.
¹³ Medical University of South Carolina, Charleston, South Carolina, USA.
¹⁴ Icahn School of Medicine at Mount Sinai, New York, New York, USA.
¹⁵ Carolinas Medical Center, Charlotte, North Carolina, USA.
¹⁶ Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
¹⁷ Indiana University, Indianapolis, Indiana, USA.
¹⁸ Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.
¹⁹ Vanderbilt University, Nashville, Tennessee, USA.
²⁰ Virginia Mason Medical Center, Seattle, Washington, USA.
²¹ Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.
²² Aurora Health Care, Milwaukee, Wisconsin, USA.
²³ Moffitt Cancer Center, Tampa, Florida, USA.
²⁴ Duke University, Durham, North Carolina, USA.
²⁵ University of Alberta, Edmonton, Edmonton, Alberta, Canada.
²⁶ University of Pennsylvania, Philadelphia, Pennsylvania, USA.
²⁷ University of Michigan, Ann Arbor, Michigan, USA.
²⁸ University of Kansas, Kansas City, Kansas, USA.
²⁹ Henry Ford Hospital, Detroit, Michigan, USA.
³⁰ Columbia University, New York, New York, USA.
³¹ University of California, Davis, Davis, California, USA.
³² University of Massachusetts Medical Center, Worcester, Massachusetts, USA.
³³ University of Texas Southwestern Medical Center, Dallas, Texas, USA.
³⁴ University of Virginia, Charlottesville, Virginia, USA.

PMID: 30738985
PMCID: PMC6527477
DOI: 10.1016/j.gie.2019.01.030

Abstract

Background and aims: Minimum EUS and ERCP volumes that should be offered per trainee in "high quality" advanced endoscopy training programs (AETPs) are not established. We aimed to define the number of procedures required by an "average" advanced endoscopy trainee (AET) to achieve competence in technical and cognitive EUS and ERCP tasks to help structure AETPs.

Methods: American Society for Gastrointestinal Endoscopy (ASGE)-recognized AETPs were invited to participate; AETs were graded on every fifth EUS and ERCP examination using a validated tool. Grading for each skill was done using a 4-point scoring system, and learning curves using cumulative sum analysis for overall, technical, and cognitive components of EUS and ERCP were shared with AETs and trainers quarterly. Generalized linear mixed-effects models with a random intercept for each AET were used to generate aggregate learning curves, allowing us to use data from all AETs to estimate the average learning experience for trainees.

Results: Among 62 invited AETPs, 37 AETs from 32 AETPs participated. Most AETs reported hands-on EUS (52%, median 20 cases) and ERCP (68%, median 50 cases) experience before starting an AETP. The median number of EUS and ERCPs performed per AET was 400 (range, 200-750) and 361 (range, 250-650), respectively. Overall, 2616 examinations were graded (EUS, 1277; ERCP-biliary, 1143; pancreatic, 196). Most graded EUS examinations were performed for pancreatobiliary indications (69.9%) and ERCP examinations for ASGE biliary grade of difficulty 1 (72.1%). The average AET achieved competence in core EUS and ERCP skills at approximately 225 and 250 cases, respectively. However, overall technical competence was achieved for grade 2 ERCP at about 300 cases.

Conclusion: The thresholds provided for an average AET to achieve competence in EUS and ERCP may be used by the ASGE and AETPs in establishing the minimal standards for case volume exposure for AETs during their training. (Clinical trial registration number: NCT02509416.).

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Figures

**Figure 1:. Graphical representation of learning curves.**
Overall aggregate graphs using cumulative sum analysis demonstrating the mean number of cases (evaluation number multiplied by 5) needed for competency for an average advanced endoscopy trainee

See this image and copyright information in PMC

References

1. Wani S, Keswani RN, Petersen B, et al. Training in EUS and ERCP: standardizing methods to assess competence. Gastrointest Endosc 2018;87:1371–1382. - PubMed
1. Wani S, Keswani RN, Han S, et al. Competence in endoscopic ultrasound and endoscopic retrograde cholangiopancreatography, from training through independent practice. Gastroenterology 2018;(in press). - PMC - PubMed
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1. Frank JR, Snell LS, Cate OT, et al. Competency-based medical education: theory to practice. Med Teach 2010;32:638–45. - PubMed

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Setting minimum standards for training in EUS and ERCP: results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees

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Setting minimum standards for training in EUS and ERCP: results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees

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