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,Hemant Chatrath,Rishi Sharma,Koushik K Das,Patrick Yachimski,Raj J Shah,Kavous Pakseresht,Swan Ellert,John M Poneros,Linda Carlin,Sana Kenshil,Anthony Razzak,Jayaprakash Sreenarasimhaiah,Amit Rastogi,Gregory A Coté,Anthony Gamboa,Todd H Baron,Joshua P Spaete,Matthew Hall,James H Tabibian,Bhargava Gannavarapu,Bradley Confer,Ajaypal Singh,Andrew Y Wang,Steven A Edmundowicz,Muhammad Sohail,Ihab El Hajj,Jason Ferreira,Abhishek Choudhary,Sujai Jalaj,Tobias Zuchelli,Wahid Wassef,Brian C Brauer,David E Loren,Wasif M Abidi,Shreyas Saligram,Erik Bowman,Abdul Hamid El Chafic,Nalini M Guda,Jason Klapman,Michael L Kochman,Eva Aagaard,Jonathan M Buscaglia,Gabriel Lang,Demetrios Tzimas,Tyler Stevens,Cyrus Piraka,Sri Komanduri,Christopher J Dimaio,Shiro Urayama,Daniel Mullady,Pranith Perera,Stuart R Gordon,Amitabh Chak,Domenico Vitterbo,Subhas Banerjee,Rajesh N Keswani,James M Scheiman,Samuel Han,Brian P Riff ,Lisa M Gangarosa ,Linda Lee ,Raman Muthusamy ,Dayna S Early ,Isaiah P Schuster ,Andrew Nett ,Dushant Uppal ,Violette C Simon ,Frank Lukens ,Hazem Hammad ,Patrick R Pfau ,Andrew Dries ,Ian Gan ,Sergio Zepeda-Gómez ,Cynthia L Harris ,Paul S Jowell ,Mojtaba Olyaee ,Michael J Bartel

doi:10.1016/j.gie.2019.01.030

Abstract

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. 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. 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. 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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