Endoscopic Training: a nationwide survey of French fellows in Gastroenterology
Aurelien Amiot1, Xavier Treton2
1 Department of Gastroenterology, Henri Mondor Hospital, APHP, EC2M3-Equipe Universitaire, Paris
Est-Créteil (UPEC) Val de Marne University, Creteil, France
2 Department of Gastroenterology, IBD and Nutrition Support, Beaujon Hospital, APHP, University
Paris 7 Denis Diderot, Clichy, France
Abstract
Introduction:
During their four years of training, fellows in gastroenterology should acquire theoretical and
practical training in GI endoscopy. This training should enable them to be independent for the basic
procedures in diagnostic and therapeutic endoscopy. To this end, the recommendation is to have
performed 200 endoscopies high (OGDE), 200 colonoscopies, 80 hemostasis and 50 polypectomies.
However, these thresholds are discussed, and do not guarantee by themselves, acquiring the
necessary skills.
objectives:
The purpose of this survey is the assessment by GI fellows their theoretical and practical training in
digestive endoscopy. Apart from the estimated number of endoscopic procedures performed, the
survey assesses factors influencing perceived quality of training. A mismatch of training among the 7
french inter-region is also investigated.
Methods :
Between June and September 2016, all French GI fellows were proposed to answer an anonymous
electronic questionnaire. The 21 questions evaluated the access to theoretical training and simulator,
the conditions for practical training on patients, and the perception of learning. Descriptive statistics
were used. Comparisons were performed by chi-2 for categorical variables and Mann-Whitney test or
ANOVA for parametric data.
Results:
291 out of 484 (60%) GI fellows responded to the survey. Fellows were females in 67.5% of cases,
with a median age of 27.2 years (26.1 to 28.2) and completed 4 semesters of training (3-6). The
proportion of 1st, 2nd, 3rd and 4 th years fellows respectively accounted for 20, 31, 31 and 18%. In
each of the 7 inter-region, over 50% of fellows answered (except the North 48% of responses). Only
40% of subjects had access to theoretical training and / or animal model or virtual simulator.
Practical training was found to be more accessible and more important in general hospitals than in
universitary hospitals (p <0.001). Only 49% and 35% of fourth year fellows reached thresholds
numbers for gastroscopies and colonoscopies. 62% and 57% of trainees reported having insufficient
knowledge in interpretating gastric and colic lesions. However, a steady progression of acquisition
skills was observed during the 4 years of training without disparity between inter-regions. Access to a
dedicated endoscopy activity of at least 8 weeks during the year was the only independent factor
associated with the achievement of 50 gatroscopies and 50 annual colonoscopies. The negatives
factors reported by the fellows were lack of access to gastroscopy in 59% and to colonoscopy in 80%
of cases. 36% feel they have recieved insufficient theoretical training.
Conclusion:
The survey shows no inequality in the different inter-regions regarding the training in endoscopy.
However, access to a theoretical training and to preclinical virtual simulators is still insufficient.
Personalized support and regular assessment of cognitive and technical acquisitions over the 4 years
of training seems necessary.
INTRODUCTION
French gastroenterology fellowship is four years long. Fellows have to acquire cognitive and technical
skills in gastroenterology, gastrointestinal (GI) oncology, hepathology, proctology and GI endoscopy
to get graduate. Mastering the basic level in endoscopy training (level 1) is mandatory at the end of
fellowship. The level 1 in endoscopy training is defined by mastering both upper and lower GI
diagnostic endoscopies and performing: biopsies, standard polypectomies, simple mucosectomies,
gastrostomies, and hemostatic procedures. During their 4 years of training, fellows change of clinical
departments every 6 months, within their geographic area of assignment (France is divided in seven
academic areas for medical fellowship). They follow gastroenterology training in both university and
non-university hospitals. The practical training of endoscopy is also fragmented during these
assignments, and can vary from one fellow to another, according to his choice and his duty station.
To date, competence assessment in GI endoscopy was mainly based on threshold numbers of
procedures. French college of universitary endoscopists, in charge of endoscopy learning,
recommend 200 oesophago-gastroduodenoscopies (EGD), 200 colonoscopies with cecal intubation,
50 hemostatic procedures during EGD and 30 during colonoscopies, and 50
polypectomies/mucosectomies. However, endoscopy training requires the acquisition of theoretical
and technical skills that cannot be summarized to a theoretical threshold number of exams as
technical and psychomotor facilities are variable among trainees[1]. Today, endoscopy training
requires a personalized fellows monitoring, to bring them able to perform endoscopy independently.
Recently, theoretical courses (e-learning), and access to virtual simulators and animal models have
been gradually developed in France. However, fellows had unequal access to these new educational
processes, which have been gradually put in place in the country since 2012. The purpose of our
national survey was to evaluate the perception of fellows about their training in endoscopy. We
assessed the number of endoscopic procedures performed, their conditions of implementation, their
access to theoretical training and/or virtual simulators or animal models. We also wondered about
their technical skills and their mastery of endoscopical explorations to identify the strengths and
weaknesses of the practical training.
METHODS
Survey instrument
A 21 item questionnaire was designed to examine: the demography of the French gastroenterolgy
fellow population, their access to theoretical and virtual endoscopy training, their conditions of
practical coaching in endoscopy, the number of procedures performed and their perception of
mastery of the level 1 procedures (supplementary table 1).The survey was established using the
Surveymonkey web-based application. This secure application is dedicated to support data capture
from surveys. All data were anonymous and responders could not be linked back to another
softwares, and also could not answer the questionnaire several times.
Participants
All the French GI fellows were invited to participate in this study. We selected GI Fellows holding a
license degree obtained in a French university, to analyze a population with homogeneous medical
studies. 484 participants of French GI fellowship program were identified from the registry of the
Agence Régionale de Santé (ARS), the state administration responsible for the distribution and the
follow-up of fellows of all medical disciplines among the national territory. The completeness of the
GI Fellows listing was cross-verified thanks to obtaining the e-mail lists from the national fellows
syndicate and also from the seven GI teaching program directors of each French region. All GI fellows
were eligible, regardless of their level between the first and fourth year of training.
Survey distribution and data analysis
The survey link was sent out in June of 2016 with an e-mail to explain the aim of the study. Four
reminders were sent between June and September 2016. The first e-mailing in June allowed to
ensure that first-year fellows had adequate endoscopy experience to contribute to the
questionnaire.
Statistical analysis
The data are expressed as a number (%) for qualitative data and as a mean ± the standard
deviation (SD) or median [interquartile range] for quantitative data. The characteristics of fellows
were compared using the Chi-square test for nominal data whereas parametric data were compared
using Mann-Whitney tests and ANOVA tests whenever appropriate. To identify predictors of a yearly
rate of at least 50 EGD and 50 colonoscopies, univariate analysis and then binary logistic regression
models were then adjusted to the above-mentioned variables with an ascending stepwise procedure
using Wald test. Quantitative variable were analyzed using qualitative categories of values defined by
dichotomy from median value in two distinct groups of equal size. Variables with p <0.10 in
univariate analysis were considered to be potential adjustment variables for the multivariate
analysis. All analyses were two-tailed, and p values less than 0.05 were considered significant. All
statistical evaluations were performed using SPSS statistical software (SPSS Inc., v17, Chicago, IL,
USA). All authors had access to the study data and had reviewed and approved the final manuscript.
RESULTS
Demographics
Two hundred and ninety-one fellows in Gastroenterology (67.5% of females, median age of
27.2 [interquartile range 26.1-28.2] years) responded to the survey accounting for a response rate
60% (291/484). The seniority of fellows in Gastroenterology was 4.0 [3.0-6.0] semesters including 3.0
[2.0-5.0] in University hospital and 1.0 [1.0-2.0] in General hospital.. The demographic characteristics
of the GI fellows and characteristics of their fellowship are reported in Table 1. In all the 7 academic
training areas, the response rate was above 50% except for the Northern area (48%). The proportions
of fellows in first, second, third and fourth years of training were 20%, 31%, 31% and 18%,
respectively.
GI training conditions
Up to 40% of fellows in Gastroenterology had access to a preliminary training course
including theoretical training, simulator training or animal model training before initiating endoscopic
training. There was no difference in the access to a preliminary training course in the seven academic
training areas. The first access to the endoscopic training took place in University hospital in 46% of
cases and in General hospital in 54%. Moreover, the access to the endoscopic training was not
systematic in every 6-month course. Fellows had access to endoscopic training in 62.4% of cases in
university hospital and in 84.8% of cases in general hospitals (p<0.001) . Endoscopic training of fellows
in Gastroenterology concerned scheduled endoscopy with propofol sedation in 45.4% of the training,
scheduled endoscopy without sedation in 31.8% and emergency endoscopy in 22.8%. The
contribution of senior Gastronterologists to the endoscopic training of fellows in gastroenterology
was divided between post-fellowship physicians for 33% of the training, full-time staff physician for
32%, full-time staff physician specialized in GI endoscopy for 13%, Professor and associate Professor
for 11% and part-time external physicians (11%). Endoscopic training was mostly performed
concomitantly to clinical duty with only a median of 8.0 [1.0-7.3] weeks fully dedicated to endoscopic
training and 3.0 [1.0-10.0] additional weeks dedicated to both endoscopic training and duty in day-
care hospitalization unit.
Metrics and thresholds numbers
The characteristics of the endoscopic training of fellows in Gastroenterology are listed in
table 2. During the four year of endoscopic training, there was a significant increase in the number of
all procedures performed. However, only eight fellows fully completed the objectives of the blue
books of the European Section and Board of Gastroenterology and Hepatology. At the end of the
survey, fourth-year-fellows completed the objectives for EGD, colonoscopy, small-bowel capsule
endoscopy, hemostatic techniques, polypectomy, PEG and balloon dilatation in 49%, 35%, 14%, 18%,
67%, 39% and 8%, respectively. Minor disparities between academic training area with a higher full
completion rate for EGD in the northern area and a higher full completion rate for PEG and balloon
dilatation in the south-eastern area.
Perception of competence in endoscopy
The perception of mastery level for each endoscopic procedure was evaluated on the entire
cohort. Thus, the technical mastery of EGD was reported as good to excellent in 84% of individuals.
However, the interpretation of the lesions was deemed insufficiently mastered in 72% of fellows for
duodenal analysis, 62% for gastric analysis and 61% for the analysis of the esophagus. The perception
of the technical acquisition of colonoscopy is detailed in Figure 1.
Only 18% of the overall cohort of fellows declared correctly master the intubation of the ileum. The
technical maneuvers, like delooping and external abdominal compression, were also poorly mastered
by the majority of individuals (respectively 81% and 76% of insufficient mastery). 84% of fellows were
comfortable with performing biopsies during colonoscopy. In contrast, 57% of fellows considered
having an insufficient knowledge to interpret colonic lesions. Perceptions of the acquisition of
hemostasis procedures, balloon dilation and polypectomy are reported in figure 2. Only 31% of
fellows feel well achieve snare polypectomies and 20% standard mucosectomies. However, as
depicted in the suppl figure 3, there was a good progression reported by the fellows in their
acquisition of endoscopic skills along the four years of training, with a mastery judged better during
the last year. Assessing the correlation between the perception of mastery level by the fellow and
the number of procedures performed, we found a poor correlation for EGD and a moderate or good
correlation for the other endoscopic procedure (table 3).
Predictors affecting endoscopic training
The results of the univariate and multivariate analysis for a yearly rate of at least 50 EGD and
50 colonoscopies are listed in table 4. Based on the multivariate analysis, risk factors for a yearly rate
of at least 50 EGD and 50 colonoscopies was only a period fully dedicated to endoscopic training > 8
weeks (OR = 3.45 (1.79-6.67), p < 0.001).
Overall satisfaction of the fellows about their endoscopic training
We evaluated the overall satisfaction of the fellows considering their endoscopic training in
University and General hospital with a 0 to 10 scale. Evaluation was good for both institutions with a
higher satisfaction score for General hospital (7.1 vs. 5.3, p = 0.002). We asked the fellows which
factors impaired their endoscopic training on a daily basis. Fellows considered insufficient or very
insufficient the access the access to EGD and colonoscopy in 33% and 26% of cases, and 29% and
51% of cases, respectively. An important lack of access to emergency endoscopic procedures during
the endoscopic training was also reported in 54% of cases. Fellows also reported a lack of theoretical
training in 36% of cases. Lastly, fellows declared feeling to be put under pressure by senior
gastroenterologist, endoscopy nurse and anesthesiologist in 14%, 14% and 38% of cases,
respectively.
DISCUSSION
This is the first French national survey assessing perceptions of GI Fellows on their training in
endoscopy and their acquisition of the basic level in endoscopy practice. Sixty percent of all fellows
currently in training responded to this survey. The first finding was that the training is uniform over
the whole territory, without discrepancy of access to education and practice.
Whether the acquisition of the EGD practice seems to reach the level required for graduation, the
basic colonoscopy level of practice was not achieved in a substantial proportion of GI fellows. Fellows
declared both insufficient technical mastery of colonoscopy, but also difficulties to interpret the
mucosal lesions encountered. The hemostasis technical procedures and polypectomies are also
inadequately mastered according to the survey answers. Similar results were found in surveys
conducted in the USA[2, 3]
However, this study points out some factors that may explain these results, which are all levers to
improve training. In this survey, the perception of competence was similar if fellows had received or
not a theoretical or virtual endoscopy training. This result goes against the published data
demonstrating that the use of simulators in the early training setting accelerates the learning curve in
acquiring basic skills[1, 4, 5].Haycock and coll. reported in a multinational, multicenter, single-blind,
randomized, controlled trial, that simulator training significantly improved performance on simulated
cases compared with patient-based training[6]. Simulation-trained fellows had higher completion
rates (P=.001), shorter completion times (P < .001) and showed superior technical skills. Another
recent single-blinded, randomized, controlled trial evaluated a simulation-based structured
comprehensive curriculum (SCC) designed to teach technical, cognitive, and integrative
competencies in colonoscopy[7].Thirty-three novice endoscopists were allocated to an SCC group (6
hours of didactic lectures and 8 hours of virtual reality simulation-based training with an expert) or
self-regulated learning group (8 hours of free practice on the simulator). Endoscopy competences
were assessed during 2 patient colonoscopies. The SCC group performed superiorly during their
evaluations in patient colonoscopies, and demonstrated superior technical skills on simulated cases.
However, this study showed that a simple access to a simulator is not enough and suggested that the
training requires an accompaniment by an expert to monitor and drive the progression of the
apprentice. Our survey shows a lack of access to pre-clinical academic training in endoscopy. Less
than 30% of Fellows had access to simulator-based training. We could not question the novices
trained on the simulators to specify the conditions of this training (median duration, expert
accompaniment, evaluation, etc…). However, a vast majority of fellows consider that they received
insufficient virtual training before performing patients endoscopies.
Even if the thresholds numbers are debated, and do not guarantee by themselves skills acquisition,
there was a correlation between the number of procedures performed, and the perceived
competence in endoscopy [1, 8, 9]. Among the four years of training in gastroenterology, fellows
reported having an insufficient median number of weeks dedicated solely to their practical training in
endoscopy and only 64% of fellows in their last year of training reached the threshold for
colonoscopy. Indeed, it is striking that less than 40% of fellows declared mastering the interpretation
of lesions observed during standard upper and lower endoscopies. This result may be biased by the
fact that most university centers carry patients with more complex and rare diseases. However, this
difficulty to diagnose mucosal lesions was also reported during EGD, which was technically well
managed, with a threshold level of procedures exceeded by most novices. This observation
highlighted the importance of the bedside training, trough a master-apprentice model, which
remains essential to learn elementary lesions. This aspect of learning endoscopy is usually not
supported by the simulation tools, which only improves the technical skills of apprentices. In most
studies, the main outcomes parameters evaluating acquisition of competence after a simulator-
based training were technical items as procedural times, time with clear view and caecal intubation
rates for colonoscopy [1, 10, 11]. Also, in studies which evaluated threshold numbers, competence in
upper and lower standard endoscopy was measured with similar technical skills [1, 8]. The
acquisition of knowledge of the observed endoscopic lesions semiology, has not been evaluated. Our
study reported that this item is a crucial point of endoscopy training. It seems important to
strengthen this aspect of training and measuring its acquisition.
Fellows considered that the conditions of access to basic endoscopy sessions were an important
component of training. Paradoxically their practical training was considered better in non-teaching
hospitals, and when the sessions were handled by general GI physicians, and not university
endoscopy experts. A likely explanation is that the interventional endoscopy units of university
hospitals usually train post-graduate gastroenterologists in technically complex procedures, and are
not adapted to training the basic level of gastrointestinal endoscopy.
The main limit of this survey was the lack of an external control of the acquisition of skills in
endoscopy. Individual measure of the progression of each fellow in the acquisition of skills in
endoscopy is necessary, but is also complicated to implement. It requires a large number of teachers
in endoscopy, trained in specific technical pedagogy and invested in a national teaching program[12].
In conclusion, the recommendations to improve the endoscopy teaching in France based on our
results however could be: 1) to increase the access to virtual training on simulators and animal
models to accelerate the acquisition of technical and manual skills,2) to reinforce companionship in
bedside teaching which is essential, and yet insufficiently developed, to acquire the interpretation of
lesions. Access to basic endoscopy sessions must be facilitated and organized during the four years GI
training program and, 3) to establish a personalized monitoring throughout the four years of training,
with external validation of acquired skills. The measurement of individual skills acquisition during all
the training period (and not at the end) is needed to adapt training to the needs of each GI fellow
and correct its deficiencies and difficulties. The validation of endoscopy competences to get graduate
for a basic practice could be obtained in the same way that the driving license, which requires to
validate both theoretical knowledge and technical skills, and not only a threshold numbers of hours
driving.
1 Ekkelenkamp VE, Koch AD, de Man RA, et al. Training and competence assessment in GI endoscopy: a systematic review. Gut 2016;65:607-15. 2 Jirapinyo P, Imaeda AB, Thompson CC. Endoscopic training in gastroenterology fellowship: adherence to core curriculum guidelines. Surg Endosc 2015;29:3570-8. 3 Patel SG, Keswani R, Elta G, et al.Status of Competency-Based Medical Education in Endoscopy Training: A Nationwide Survey of US ACGME-Accredited Gastroenterology Training Programs. Am J Gastroenterol 2015;110:956-62. 4 Haycock AV, Youd P, Bassett P, et al. Simulator training improves practical skills in therapeutic GI endoscopy: results from a randomized, blinded, controlled study. Gastrointest Endosc 2009;70:835-45. 5 Jirapinyo P, Thompson CC. Current status of endoscopic simulation in gastroenterology fellowship training programs. Surg Endosc 2015;29:1913-9. 6 Haycock A, Koch AD, Familiari P, et al. Training and transfer of colonoscopy skills: a multinational, randomized, blinded, controlled trial of simulator versus bedside training. Gastrointest Endosc 2010;71:298-307. 7 Grover SC, Garg A, Scaffidi MA, et al.Impact of a simulation training curriculum on technical and nontechnical skills in colonoscopy: a randomized trial. Gastrointest Endosc 2015;82:1072-9. 8 Vassiliou MC, Kaneva PA, Poulose BK, et al.How should we establish the clinical case numbers required to achieve proficiency in flexible endoscopy? Am J Surg 2010;199:121-5.
9 Ward ST, Hancox A, Mohammed MA, et al. The learning curve to achieve satisfactory completion rates in upper GI endoscopy: an analysis of a national training database. Gut 2016. 10 Ahad S, Boehler M, Schwind CJ, et al. The effect of model fidelity on colonoscopic skills acquisition. A randomized controlled study. J Surg Educ 2013;70:522-7. 11 Van Sickle KR, Buck L, Willis R, et al. A multicenter, simulation-based skills training collaborative using shared GI Mentor II systems: results from the Texas Association of Surgical Skills Laboratories (TASSL) flexible endoscopy curriculum. Surg Endosc 2011;25:2980-6. 12 Zanchetti DJ, Schueler SA, Jacobson BC, et al.Effective teaching of endoscopy: a qualitative study of the perceptions of gastroenterology fellows and attending gastroenterologists. Gastroenterol Rep (Oxf) 2016;4:125-30.
Table 1: Demographic characteristics of 291 French fellows in Hepatology and Gastroenterology that
respond to the survey and characteristics of their fellowship.
n = 291
Age (median [IQR], years) 27,2 [26,1-28,2]
Female sex (%) 67,5%
Number of Semesters of training (median [IQR]) - University hospital - General hospital
4,0 [3,0-6,0] 3,0 [2,0-5,0] 1,0 [1,0-2,0]
Region of training (%) - Ile de France area (Paris metropol) - Northern area (Lille ; Amiens ; Rouen ; Caen) - Western area (Brest ; Rennes ; Nantes ; Angers ; Tours ; Poitiers) - Eastern area (Nancy ; Stratsbourg ; Reims ; Dijon ; Besancon) - Rhones-Alpes area (Lyon metropol) - South-Western are (Limoges ; Toulouse ; Bordeaux; Clermont-Ferrand) - South-Eastern area (Nice ; Marseille ; Nimes ; Montpellier)
72/97 (74,2%) 36/75 (48,0%)
57/112 (50,9%) 41/64 (64,1%) 16/32 (50,0%) 36/54 (66,7%) 32/50 (64,0%)
Preparation course to the endoscopic training (%) - Theoretical courses - Virtual simulator - Animal models
40,2% 30,6% 28,2% 17,2%
Time dedicated to training in endoscopy (median [IQR], weeks) - Full time - Shared with other clinical tasks
8,0 [1,0-17,3] 3,0 [1,0-10,0]
Table 2: Characteristics of endoscopic training of 291 fellows in Gastroenterology according to seniority.
Overall study population
Seniority of fellows 1st year 2nd year 3rd year 4th year p
UGE - N procedures - % (n = 200) - N achieving goal
136.8 ± 140.9 68.4% ± 70.4%
27%
37.6 ± 41.5
18.8% ± 20.8% 0%
103.1 ± 87.4
51.6% ± 43.7% 14%
187.1 ± 152.8 93.6% ± 76.4%
43%
219.9 ± 178.2
110.0% ± 178.2% 49%
<0.001 <0.001 0.001
Colonoscopy - N procedures - % (n = 200) - N achieving goal
73.2 ± 80.6
36.6% ± 40.3% 11%
25.4 ± 48.8
12.7% ± 24.4% 2%
55.1 ± 54.9
27.5% ± 27.5% 2.%
90.3 ± 74.2
45.1% ± 37.1% 11%
128.5 ± 111.0 64.2% ± 55.5%
35%
<0.001 <0.001 0.001
SB CE - N procedures - % (n = 20) - N achieving goal
2.2 ± 6.3
10.7% ± 31.2% 4%
0.2 ± 0.8
1.2% ± 4.1% 0%
1.2 ± 3.0
6.0% ± 15.1% 0%
2.0 ± 5.0
10.1% ± 25.1% 4%
5.8 ± 11.6
29.2% ± 58.1% 14%
<0.001 <0.001 0.001
Hemostatic techniques - N procedures - % (n = 80) - N achieving goal
31.2 ± 44.5
39.0% ± 55.6% 10%
3.9 ± 9.5
4.9% ± 11.9% 0%
17.9 ± 23.8
22.4% ± 29.7% 4%
50.0 ± 61.1
62.5% ± 76.3% 17%
48.9 ± 38.3
61.1% ± 47.9% 18%
<0.001 <0.001 0.001
Polypectomy - N procedures - % (n = 50) - N achieving goal
46.4 ± 63.6
92.7% ± 127.2% 33%
13.6 ± 51.6
27.3% ± 103.3% 4%
27.5 ± 34.1
55.0% ± 68.3% 18%
65.1 ± 77.3
130.1% ± 154.6% 45%
80.9 ± 62.3
161.7% ± 124.6% 67%
<0.001 <0.001 0.001
PEG - N procedures - % (n = 15) - N achieving goal
9.2 ± 11.0
61.0% ± 73.2% 23%
4.3 ± 6.7
28.6% ± 44.6% 12%
6.7 ± 8.3
44.5% ± 55.4% 19%
12.7 ± 13.4
84.7% ± 89.2% 34%
12.4 ± 11.3
82.7% ± 75.3% 39%
<0.001 <0.001 0.001
Balloon dilatation - N procedures
1.3 ± 2.7
0.1 ± 0.4
0.8 ± 2.0
1.7 ± 2.7
2.3 ± 4.0
<0.001
- % (n = 10) - N achieving goal
12.5% ± 26.6% 3%
1.4% ± 4.0% 0%
8.2% ± 198% 1%
17.2% ± 27.2% 5%
22.9% ± 40.0% 8%
<0.001 0.08
%: percentage of the expected procedures performed according to the blue book of the European Section and Board of Gastroenterology and Hepatology
(http://eubogh.org/blue-book/).
Regional origin of fellowship Ile de France Northern South-Eastern Western South-Western Rhones-Alpes Eastern P
UGE - N - % (n =
200)
140.1 ± 128.7 70.0% ± 64.4%
28%
195.5 ± 191.7 97.7% ± 95.8%
45%
109.7 ± 94.7
54.8% ± 47.3% 20%
126.6 ± 125.0 63.3% ± 62.5%
20%
111.4 ± 121.8 557% ± 60.9%
15%
66.8 ± 64.0
33.4± 32.0% 13%
166.7 ± 179.3 68.5% ± 70.6%
39%
0.03 0.03 0.02
Colonoscopy - N - % (n =
200)
80.2 ± 74.5
40.1% ± 37.2% 12%
77.8 ± 68.2
38.9% ± 34.1% 9%
58.7 ± 50.5
29.4% ± 25.3% 4%
78.6 ± 108.3
39.3% ± 54.1% 15%
63.6 ± 68.1
31.8% ± 34.1% 9%
44.5 ± 54.3
22.3% ± 27.1% 6%
80.9 ± 91.1
40.4% ± 45.5% 14%
0.62 0.62 0.82
SB CE - N - % (n = 20)
3.3 ± 8.5
16.3% ± 42.1% 6%
0.8 ± 3.6
3.8% ± 17.7% 3%
0.6 ± 1.1
2.9% ± 5.7% 0%
2.4 ± 5.9
11.8% ± 29.3% 6%
3.5 ± 87
17.4% ± 43.6% 6%
0.2 ± 0.9 1.7% ± 4.5%
0%
1.6 ± 3.8
8.0% ± 18.9% 0%
0.21 0.21 0.57
Hemostatic techniques
- N - % (n = 80)
38.4 ± 48.4 47.9% ± 60.5%
15%
35.6 ± 43.3 44.5% ± 54.1%
24%
29.8 ± 27.1 37.3% ± 33.9%
4%
248 ± 28.4 31.1% ± 35.5%
4%
28.1 ± 45.1 35.2% ± 56.4%
9%
12.7 ± 12.0 15.9% ± 15.1%
0%
34.3 ± 67.6 43.0% ± 84.5%
5%
0.42 0.42 0.92
Polypectomy - N - % (n = 50)
57.9 ± 81.1
115.8% ± 162.2% 36%
39.2 ± 40.0
78.3% ± 80.1% 33%
44.6 ± 53.3
89.3% ± 106.5% 37%
49.0 ± 73.8
98.0% ± 147.7% 29%
34.6 ± 48.3
69.3% ± 96.5% 24%
42.1 ± 56.8
84.3% ± 113.6% 31%
42.1 ± 50.0
84.1% ± 99.9% 35%
0.66 0.66 0.02
PEG
- N - % (n = 15)
4.6 ± 4.8 30.3% ± 32.3%
3%
9.6 ± 11.3 64.2% ± 75.3%
30%
15.2 v 16.8 104.4% ± 110.2%
44%
8.1 ± 9.0 54.0% ± 60.0%
28%
9.5 ± 11.5 63.1% ± 76.6%
18%
8.3 ± 8.6 55.5% ± 57.5%
20%
13.6 ± 13.3 90.9% ± 88.4%
34%
<0.001 <0.001 <0.001
Balloon dilatation - N - % (n = 10)
0.8 ± 1.7
7.5% ± 16.6% 1%
0.3 ± 1.3
6.1% ± 13.0% 0%
3.5 ± 5.2
35.0± 52.2% 15%
1.0 ± 1.8
10.4% ± 17.9% 2%
2.1 ± 3.3
20.6% ± 33.5% 6%
0.4 ± 0.8
4.0% ± 8.3% 0%
1.0 ± 2.1
10.0% ± 21.1% 3%
<0.001 <0.001
0.02
Table 3: correlation between numbers of procedures and perception of mastery
Procedure R P
EGD 0.484 <0.001
Colonoscopy 0.571 <0.001
Polypectomy (forceps) 0.516 <0.001
Polypectomy (snare) 0.614 <0.001
mucosectomy 0.566 <0.001
sclerotherapy 0.589 <0.001
Endoscopic hemoclip 0.512 <0.001
Hémostase thermique 0.572 <0.001
Variceal ligation 0.588 <0.001
Variceal obliteration 0.649 <0.001
Baloon dilation 0.664 <0.001
Endoscopic gastrostomy 0.628 <0.001
Table 4: The predictors associated with the completion of at least 50 EGD and 50 colonoscopies per year in 291 fellows in Gastroenterology during their
endoscopic training.
Risk factors
Univariate analysis Multivariate analysis
HR (95%CI) P value HR (95%CI) P value
Time fully dedicated to endoscopic training > 8 weeks 3.45 (1.79-6.67) <0.001 3.45 (1.79-6.67) <0.001
Endoscopic procedures outside the endoscopic center 2.15 (1.17-3.96) 0.01 NS NS
Preliminary training 1,18 (0,65-2,14) 0.58 - -
Female gender 0,63 (0,33-1,21) 0.17 - -
Age > 27 years 1,45 (0,79-2,67) 0.23 - -
Training by a Post-fellowship trainee >30% 1,50 (0,83-2,71) 0.18 - -
Training by a full-time staff physician > 25% 1,58 (0,83-2,99) 0.17 - -
Training by a full-time staff physician specialized in GI endoscopy > 20% 1,16 (0,62-2,17) 0.64 - -
Academic training area
Ile de France
Northern area
1.32 (0.54-3.24)
1.38 (0.47-4.00)
0.54
0.56
-
-
-
-
South-Eastern area
Western area
South-Western area
Rhone-ALpes area
2.31 (0.64-8.33)
2.02 (0.76-5.43)
2.46 (0.75-8.06)
6.58 (0.77-55.56)
0.201
0.161
0.136
0.085
-
-
-
-
-
-
-
-
Initiation of the endoscopic training in a University hospital 0,84 (0,46-1,53) 0.57 - -
Fourth year of fellowship training 2,17 (1,09-4,31) 0.03 - -
mo: month; HR: hazard ratio; CI: confidence interval; hsCRP: high sensitivity C-reactive protein.
Hazard ratio (HR) with 95% confidence interval (CI) was estimated using Cox proportional hazard model.
Figure 1: perception of acquisition skills of colonoscopy
38,8%
5,5% 4,6% 4,6% 2,3% 1,4% 1,4% 1,4%
28,8%
23,7%18,3% 15,1%
9,6%
1,8%6,0% 4,1%
23,7%
31,2%37,2% 40,8%
35,2%
15,1%
20,2%18,8%
5,0%
28,8% 32,1% 31,2%
39,3%
31,1%
39,9%
34,4%
3,70%7,80%7,80%8,30%
13,70%
50,70%
32,60%41,30%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
insuffisant-nul
moyen
bon
très bon
excellent
16,2%6,9%
1,0% 1,0% 1,4% 1,2% 0,8%
30,7%
19,7%
4,8% 4,2% 6,9% 6,3% 7,5%
37,2%
40,8%
20,4% 18,7%
35,2%32,2% 32,5%
11,0%
21,1%
20,1%
39,4%
37,2%38,8%
32,5%
4,80%11,40%
53,60%
36,70%
19,30% 21,60%26,70%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Intro
Charnière
Angle SC
Angle G
Angle D
Iléon Compres.
Déboucl. Biops al
Biops ciblées
Chromo
Int iléon
Int colon
CAT polype
CAT colite
Parmi les gestes suivants réalisables au cours d’une coloscopie, veuillez indiquer votre niveau de maitrise.
Figure 2 : perception of acquisition skills of polypectomies and hemostasis procedures (n=answers)
3,4% 0,3% 0,3%
16,9%
4,5% 2,8%
40,0%
26,5%
17,0%
20,3%
28,6%
22,2%
19,30%
40,10%
57,60%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
insuffisant-nul
moyen
bon
très bon
excellent
3,5% 1,4% 0,7% 0,0% 0,4%
16,7%
6,9%1,4% 0,3%
3,9%
29,5%
33,3%
20,3%
3,1%
10,9%
21,5%
22,6%
20,3%
4,2%
11,9%
28,80%35,80%
57,30%
92,30%
73,00%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Coloscopien = 217
Hémostasen = 216
Pince Anse Mucosectomie LE VO CLip Hemostthermique
EncollageVCT
Poudre
18,8%12,7% 1,2%
27,3%
4,9% 1,4%
51,6%
27,5%
6,0%
55,0%
22,4%
8,2%
93,6%
45,1%
10,1%
130,1%
62,5%
17,2%
110,0%
64,2%
29,2%
161,7%
61,1%
22,9%
0,0%
20,0%
40,0%
60,0%
80,0%
100,0%
120,0%
140,0%
160,0%
180,0%
EOGD coloscopie VCE Polypectomie Hémostase Dilatation
1ère année 2ème année 3ème année 4ème année
Suppl figure 1: percentage of fellows reaching the thresholds numbers of procedures
regarding their year of training
97,7%
38,9%
3,8%
78,3%
44,5%
6,1%
70,0%
40,1%
16,3%
115,8%
47,9%
7,5%
63,3%
39,3%
11,8%
98,0%
31,1%
10,4%
33,4%
22,3%
1,7%
84,3%
15,8%
4,0%
54,8%
29,4%
2,9%
89,3%
37,3%35,0%
55,7%
31,8%
17,4%
69,3%
35,1%
20,6%
83,3%
40,4%
8,0%
84,1%
42,9%
10,0%
0,0%
20,0%
40,0%
60,0%
80,0%
100,0%
120,0%
140,0%
EOGD coloscopie VCE Polypectomie Hémostase Dilatation
Nord IDF HUGO Lyon Sud-Est Sud-Ouest Est
Suppl figure 2: percentage of fellows reaching the thresholds numbers of procedures
regarding their training region (whole cohort)
0,0
0,5
1,0
1,5
2,0
2,5
3,0
Interpret D2 Interpret Estomac
Interpret oeso
Interpret iléon
Interpret colon
CAT polype CAT colite
1ère année
2ème année
3ème année
4ème année
Niveau de maitrise = BON
Suppl figure 3 : progression of acquisition skills perception regarding endoscopy procedures during
the four years of training