Conflicts of Interest Disclosure · Milestones 1. 2. 3. Competency-Based Technical Competencies Cognitive Competencies Integrative Competencies Endoscopic Competence Walsh CM et al.,

Catharine M Walsh, MD, MEd, PhD, FRCPCHospital for Sick Children, University of Toronto

Pediatric Endoscopy TrainingAnd Future Learning

(over the past 24 months)

No relevant relationships with any commercial or non-profit organizations

DisclosureConflicts of Interest

Catharine Walsh

Catharine M Walsh CDDW 2018 - Postgraduate Course (Advancing Care)

Pediatric Endoscopy February 9, 2018 Page 1

XMedical Expert (as Medical Experts, physicians integrate all of the CanMEDS Roles, applying medical knowledge, clinical skills, and professional values in their provision of high-quality and safe patient-centered care. Medical Expert is the central physician Role in the CanMEDS Framework and defines the physician’s clinical scope of practice.)

XCommunicator (as Communicators, physicians form relationships with patients and their families that facilitate the gathering and sharing of essential information for effective health care.)

X Collaborator (as Collaborators, physicians work effectively with other health care professionals to provide safe, high-quality, patient-centred care.)

XLeader (as Leaders, physicians engage with others to contribute to a vision of a high-quality health care system and take responsibility for the delivery of excellent patient care through their activities as clinicians, administrators, scholars, or teachers.)

Health Advocate (as Health Advocates, physicians contribute their expertise and influence as they work with communities or patient populations to improve health. They work with those they serve to determine and understand needs, speak on behalf of others when required, and support the mobilization of resources to effect change.)

XScholar (as Scholars, physicians demonstrate a lifelong commitment to excellence in practice through continuous learning and by teaching others, evaluating evidence, and contributing to scholarship.)

Professional (as Professionals, physicians are committed to the health and well-being of individual patients and society through ethical practice, high personal standards of behaviour, accountability to the profession and society, physician-led regulation, and maintenance of personal health.)

CanMEDS Roles Covered

• Upon completion of this sessionthe learner will be able to:• Describe the current training paradigm and

recognize potential areas for improvement• Discuss the need for faculty upskilling and

ongoing assessment of endoscopic skills• Identify strategies for mentoring junior

faculty with regard to endoscopy

Objectives



EndoscopyPediatric

Increased focus on:• How we train• Faculty development

Changing assumptions:• Its not all about volume, quality of education

and assessment is important• Training is time consuming but effective training

and assessment accelerates learning

ShiftingModel of Training

Walsh CM et al. JPGN 2017;64(4):501-4.



Training

VR SimulationTraining

Khan R et al., Cochrane 2018 [Submitted].

Inception – July 2017

18 trials, 421 participants

Results:• VR training can be used to effectively supplement

early conventional training for novices• Composite score of competence• Independent procedure completion• Visualization of mucosa



Match the TASK COMPLEXITY to SKILL LEVEL

ProgressiveTraining Model

Grover SC et al., Gastrointestinal Endoscopy 2017;86(5):881-9.

0

10

20

30

40

50

60

70

80

90

Colonoscopy 1 Colonoscopy 2

**

PLSC

* p < 0.05d = 1.30

JAG

DO

PS

% S

core

(m

ax 1

00)

ClinicalPerformance

Grover SC et al., Gastrointestinal Endoscopy 2017;86(5):881-9.



Training Endoscopy Trainers

Walsh CM et al. JPGN 2017;64(4):501-4; Grover SC et al. Gastrointestinal Endoscopy 2015;82(6):1072-9.Waschke K et al. Best Practice and Research: Clinical Gastroenterology 2016;30(3):409-19.

Assessment



TrainingMilestones

1.

2.

3.

Competency-Based

TechnicalCompetencies

CognitiveCompetencies

IntegrativeCompetencies

EndoscopicCompetence

Walsh CM et al., Gastrointestinal Endoscopy 2014;79:798-807.



Maximal performance

Pusic M et al. Academic Medicine 2015;90(8):1034-42

Learning CurvesPe

rfor

man

ce

Slow beginning

Steep acceleration

Plateau

Slope = rate of learning

Deliberate Practice

Variable Learning Curves

Ward ST et al. Gut 2014:63(11):1746-54; Sedlack RE et al. GIE 2016 83(3):516-23; Cass OW et al. Endoscopy 1999;31(9):751-754

Perf

orm

ance

Deliberate Practice



Competency Thresholds

GiECATkids Learning Curve

Walsh CM et al., JPGN 2015;60:474-480



Assessment drives learning• Assessment for learning

Meaningful feedback essential• Two-way process

Longitudinal assessment essential• Acceptable reliability only achieved with large

samples of test elements (contexts, cases)and assessors

AssessmentImpact on Learning

Programmatic Approach• Deliberate and arrangedset of longitudinalassessment activities

Van der Vleuten C et al., Medical Teacher 2012;34(3):201514.



Practicing Endoscopists

Aim: Quantify colonoscopy volumes of practicing pediatric gastroenterologists

• 154 endoscopists• 12 North American sites

0-118 colonoscopies annual• Median 31.5• 70.1% < 50 colonoscopies per year

Lirio RA et al. GIE 2016;83(5):AB302 (Abstract Sa2061)

PediatricVolumes



Automatic vs. Deliberate

NOVICE

COMPETENTPractice without supervision

EXPERTSupervise others

AUTOMATIC EXPERT

DELIBERATE EXPERT

Pusic M et al. Academic Medicine 2015;90(8):1034-42

Deliberate Practice

Perf

orm

ance

Skill Decay

Perf

orm

ance

Refresher training

Pusic et al. Academic Medicine 2015;90(8):1034-42

Time

Competence

Training - LearningSkill degradation

Durability of competence

Decay curve



Questions1) How do we ensure practicing pediatric

endoscopists are performing to thebest of their ability?

2) How do we ensure practicing pediatricendoscopists maintain (and improve)their skills?

Issues

• Low volumes• Automaticity• Skill decay

Procedural Competence

Ongoing Assessment of



Walsh CM et al. Best Practice and Research: Clinical Gastroenterology 2016;30(3):357-74

Quality Metrics



1) How do we ensure practicingendoscopists are performing to thebest of their ability?

2) How do we ensure practicingendoscopists maintain (andimprove) their skills?

Questions

Audit and Feedback

Kramer RE et al., JPGN 2017;65(1):125-31; Tinmouth J et al. Best Practice and Research: Clinical Gastroenterology 2016;30(3):473-85

Quality Metrics

1.

2.

3.



UpSkilling

Volari R et al. Techniques in Gastrointestinal Endoscopy 2012;14(1):63-72Anderson J et al. Best Practice and Research: Clinical Gastroenterology 2016;30(3):353-71

Team Training

Grover SC et al. GIE 2017;85(5S):AB181(Abstract Sa1075); Grover SC et al. GIE 2017;86(5):881-9; Grover SC et al. GIE 2015;82(6):1072-9.



Training Endoscopy Trainers

Walsh CM et al. JPGN 2017;64(4):501-4; Grover SC et al. GIE 2015;82(6):1072-9.Waschke K et al. Best Practice and Research: Clinical Gastroenterology 2016;30(3):409-19.

UpSkilling & Trainers

Kaminski M et al. Gut 2015;65(4):616-24

• 40 Polish screening centres withsuboptimal performance (ADR ≤25%)

• 2-day training incorporating skillsimprovement and train the endoscopytrainer vs. audit and feedback

• ADR improvement difference:• 7.1% and 4.2% at 1 and 2 years



Junior Faculty

NOVICE

COMPETENTPractice without supervision

EXPERTSupervise others

AUTOMATIC EXPERT

DELIBERATE EXPERT

Lieberman D. Gastroenterology 2016;151:17-19; Pusic et al. Academic Medicine 2015;90(8):1034-42

Deliberate Practice

Perf

orm

ance

Expertise Development



Take-Home Messages

• Thoughtful integration of simulation canenhance early skills acquisition

• Ongoing assessment essential• Drives ongoing practice improvement and

ensures maintenance of competence

• Development of deliberate expertfacilitated by:• Audit & feedback, upskilling, team training

and train the trainers

• Mentor of junior faculty essential

Practice Points



[email protected]

Questions / Comments

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certificate of attendance.

Evaluation and Certificate of Attendance



Documents

Conflicts of Interest Disclosure · Milestones 1. 2. 3. Competency-Based Technical Competencies Cognitive Competencies Integrative Competencies Endoscopic Competence Walsh CM et al.,