Endoscopic Skills Training in A Simulated Clinical.8
Endoscopic Skills Training in A Simulated Clinical.8
Endoscopic Skills Training in A Simulated Clinical.8
he value of simulation-based training in acquiring endoscopic skills is increasingly recognized. The use of isolated
animal gut allows endoscopic procedural training with sufficient realism and difficulty to promote operator competence
and confidence.13 Modification of this model by creating
simulated pathology such as ulcers, varices, and arterial
bleeding widens its applications and its value in learning
complex hemostatic techniques by repeated supervised practice. However, procedural skill is not the only determinant of
a successful clinical outcome, as many endoscopists have
learnt, often to the patients peril, when faced with control-
232
ling massive ulcer bleeding in a high-risk patient with unskilled support in the early hours of the morning. The proceduralist also needs to be skilled in resuscitation and sedation
and must have the communication and leadership abilities to
manage the endoscopy support team effectively. However,
current simulator training in endoscopic hemostasis is primarily concentrated on endoscopic skills. Such training significantly improves the procedural skills,13 but it does not
address other important in a clinical setting goals.
Kneebone et al4 has highlighted the significant deterioration of simulator acquired sigmoidoscopy skills when the
operator is required to carry out the procedure in a simulated
clinical setting. The distracting effects of anxiety, the need to
make complex logistical decisions, and identify and treat intraprocedure complications while attempting endoscopic
treatment are likely to be much more significant in the management of a patient with gastrointestinal (GI) bleeding.
To be beneficial, the experimental simulator-based teaching should focus on acquisition of both multiple skills and
knowledge needed to solve complex problems and ability to
perform promptly and efficiently during critical clinical
events. The likelihood of personnel making mistakes increases as critical events evolve indicating the need for team
training.57 It has been documented that individuals thought
processes, attention spans, and proficiency are compromised
Simulation in Healthcare
233
Figure 1. The Erlangen Endo-Trainer model complete with a roller pump and intravenous training arm (A) and simulated en-
MATERIALS
All equipment used was either disposable or for dedicated
animal use only. The following equipment and accessories
were used.
Real Olympus GIF-140 video endoscopes.
Erbe (Erbe Elektromedizin, Ltd., Tubingen, Germany)
and Valleylab (Valleylab, Inc., Boulder, CO) electrosurgical generators.
Argon plasma coagulation probe (Erbe Elektromedizin,
Ltd., Tubingen, Germany), Gold Probe (Boston Scientific Corporation, Natick, MA), Hemoclip applicator
(Olympus Corporation, Japan), Six-Shooter ligator
(Wilson-Cook Medical, Inc., Winston-Salem, NC).
Intravenous catheters and connection lines.
Evaluation of the Course by Participants
To assess participants satisfaction with the course, a standardized structural questionnaire regarding the course outcome and organization was used. Each participant was asked
to answer anonymously 12 questions on a 5-point scale (from
strongly disagree to strongly agree). Each question also
included four to eight reasons to explain the rating. Suggestions for further improvement of the course and any other
comments were also asked to be expressed.
RESULTS
Conduct of the Course
The course consisted of 2 days of theoretical and practical
sessions. The first day of the course covered both the basic
theoretical background and practical approach to endoscopic
hemostasis using epinephrine injections, endoclips, coagulation probes, and variceal banding devices. Participants were
shown the techniques (initial didactic demonstration) and
then practiced their skills under expert supervision on the
234
DISCUSSION
Simulator training in endoscopic hemostasis, an important gastroenterological procedure possessing the main skills
needed for most urgent endoscopic operations, represents a
new paradigm in postgraduate interventional education.
Although an earlier review of the published literature by
Gerson and Van Dam13 concluded that there was insufficient
evidence to recommend that endoscopy simulators replace
traditional teaching, there is growing evidence that simulatorbased courses can accelerate training particularly at an early
stage.2,3,13,14 Di Giulio et al15 used the GI mentor to teach
basic manual skills of upper endoscopy and demonstrated
that computer-based training is an efficient and effective
teaching tool. Using the same simulator, Ferlitsch et al16 have
shown a significant improvement in endoscopic skills after
only 3 weeks of training. Hochberger et al17 have used the
Erlangen EASIE animal-based model extensively in training
and in a recent prospective study have shown objective clinical improvement in the trainees performance after intensive
hands on experience with this model. There is also emerging
evidence that even 1-day intensive courses in endoscopic hemostasis using Erlangen EASIE simulator can have a positive
impact on trainees performance.2
For endoscopic hemostasis as for other complex interventional procedures equally important are technical skills and
knowledge of the procedure and the ability to process, integrate, and respond correctly and quickly to complex information in a dynamic team setting. Experience in clinical
judgment, leadership, teamwork, and communication are
becoming recognized as key determinants of outcome and
patient safety, especially in emergency situations and when
dealing with unexpected.18 20 However, currently, the nontechnical skills in simulator training are taught to a limited
degree only if at all.
Strongly
Disagree
Disagree
4.3
8.3
Agree
Strongly
Agree
52.2
47.8
4.3
56.5
39.3
13.0
56.5
26.1
16.6
50.0
33.3
41.7
41.7
8.3
56.5
54.5
66.6
43.5
66.6
33.3
36.4
43.4
45.5
33.1
56.5
33.3
58.3
63.6
Neutral
8.3
235
CONCLUSION
There is growing evidence that endoscopic training can be
improved by the use of simulation. A number of publications
have reported a positive training effect when using simulators
in the early phase of endoscopic training. Management of GI
bleeding is arguably one of the most challenging and stressful
endoscopic procedures. It requires a high degree of technical
and cognitive skills and knowledge and is also one of the most
difficult techniques to teach trainees because of limited exposure, time constraints, stress of the situation, and high risk to
the patient. In this article, we report on the application of a
biomechanical GI bleeding model in a close to reality simulated clinical setting to teach principles of endoscopic management of GI bleeding. The 2-day intensive course allows
trainees not only to improve their endoscopic hemostatic
skills but also to gain practical experience in clinical judgment and to develop better leadership and teamwork abilities
in emergency situations. Future randomized trials are needed
to evaluate the patient-relevant effectiveness of the model
objectively.
REFERENCES
1. Maiss J, Prat F, Wiesnet J, et al. The complementary Erlangen active
simulator for interventional endoscopy training is superior to solely
clinical education in endoscopic hemostasisthe French training
project: a prospective trial. Eur J Gastroenterol Hepatol 2006;18:
12171225.
2. Maiss J, Wiesnet J, Proeschel A, et al. Objective benefit of a 1-day
training course in endoscopic hemostasis using the compactEASIE
endoscopy simulator. Endoscopy 2005;37:552558.
3. Matthes K, Cohen J, Kochman ML, Cerulli MA, Vora KC, Hochberger
J. Efficacy and costs of a one-day hands-on EASIE endoscopy
simulator train-the-trainer workshop. Gastrointest Endosc 2005;62:
921927.
4. Kneebone RL, Nestel D, Moorthy K, et al. Learning the skills of flexible
sigmoidoscopythe wider perspective. Med Educ 2003;37(suppl 1):
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