Wednesday, June 29, 2016

Gaining and Maintaining Competency In Pediatric Colonoscopy: Practice Makes Proficient

"Colonoscopy is the mainstay of many gastroenterology practices, but pediatric gastroenterologists encounter unique challenges surrounding the procedure - among them, merely gaining enough experience to become expert in the technique.

"I think in pediatrics, we can sometimes have an inferiority complex. We just don't do as many procedures on a yearly basis as gastroenterologists who treat adults, and they get better faster than us," said Jenifer Lightdale, MD, who spoke about the subject at the 2015 annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN).

When it comes to improving outcomes in pediatric colonoscopy, everybody asks, "Is it numbers, or is it competency?" Dr. Lightdale said, referring to the ideal number of cumulative procedures required to achieve proficiency. "The answer is, the numbers actually clearly relate to competency."

Dr. Lighdale, professor of pediatrics and chief of the Division of Pediatric Gastroenterology and Nutrition at the University of Massachusetts Medical School, in Worcester, co-authored a pivotal paper that addressed this topic.

Based on a consensus of 41 expert endoscopists throughout North America, Dr. Lightdale and her co-authors developed a "standardized and reproducible," pediatric-specific colonoscopy competency assessment tool. The instrument, called the Gastrointestinal Endoscopy Competency Assessment Tool for Pediatric Colonoscopy (GiECATkids), is designed to "provide more structured evaluations of trainees, facilitate the provision of feedback along the learning curve, document trainees' progress over time and aid in the establishment of performance-based competency thresholds."

Previous measures of proficiency in colonoscopy had been developed and validated, but none specifically within a pediatric setting, the authors noted.

"In terms of core skills for pediatric colonoscopy, really, we've come so far thanks to the development of the [GiECATkids]," Dr. Lightdale said.

The GiECATkids is composed of a global rating scale that assesses more holistic aspects of colonoscopy skills, and a highly structured 18-item checklist that outlines key steps required to complete the procedure. The five-point scale rates seven domains: technical skill, strategies for scope advancement, visualization of mucosa, independent procedure completion, knowledge of procedure, interpretation and management of findings, and patient safety. The sum of scores of each of the seven items yields a total from 7 to 35, with higher scores reflecting better performance. Scores achieved by trainees are compared with those of expert pediatric endoscopists. This framework allows supervising physicians "to generate constructive and informative feedback and formally document trainees' skills over time," the authors wrote.

"What's really nice about the GiECATkids scores is that they make sense," Dr. Lightdale said. "The more procedures you do, the higher you reliably score on the instrument."

Most pediatric gastroenterology fellows will do 100 to 150 procedures during their training, Dr. Lightdale said. At this time, "they are scoring well, much better than they were at the beginning of their fellowship."

But, she added, "it takes quite a bit of time to become an expert. You don't actually start to very reliably achieve the highest scores until you've done about 400 procedures."

The same has been observed for endoscopists who perform procedures in adult patients.

"To actually meet the criteria for expertise, there are a number of studies that suggest endoscopists who scope adults have to do an extraordinary number of procedures - 350 to 400 procedures - compared with the 100 to 150 that pediatric gastroenterology fellowship requires," she added. "There's some variation in how many procedures it takes to achieve the highest levels of competence, depending on the instrument used to assess skills, but it's pretty clear that it's more than what most pediatric gastroenterology trainees are going to gain during their fellowship."

Self-Assessment, Self-Improvement

Considering the limited opportunities for gaining experience in colonoscopy during fellowship, what is a pediatric GI who is feeling "incompetent" to do?

Continuous self-assessment can help pediatric endoscopists monitor progress toward competency in colonoscopy, Dr. Lightdale said.

For example, documenting things such as the number of colonoscopies performed, the quality of bowel preparation, overall procedure time, time to cecum and terminal ileal intubation rates can identify areas of deficiency, provide learning opportunities and highlight potential areas for changes in clinical management, she said.

Catharine M. Walsh, MD, PhD, of the Hospital for Sick Children, in Toronto, presented new data at the NASPGHAN meeting on the accuracy of self-assessment in pediatric colonoscopy.

"We aimed to establish if pediatric endoscopists of differing levels of experience can reliably self-assess themselves performing colonoscopy" using the GiECATkids, Dr. Walsh said, who was first author of the paper that originally defined the instrument. Her new abstract (181) received the 2015 NASOGHAN Endoscopy Prize.

Dr. Walsh's study included 56 endoscopists from the Hospital for Sick Children, Boston Children's Hospital and Children's Hospital of Philadelphia. Of those, 25 were novice endoscopists (<50 colonoscopies), 21 were intermediate (50-250 colonoscopies) and 10 experienced (>500 colonoscopies). An experienced attending endoscopist assessed the study endoscopists in real time using the GiECATkids. Participants in the study also assessed their own performance using the same instrument. A second trained observer rated a subset of 22 procedures to determine inter-rater reliability.

"When you look at the expert assessments of novice, intermediate and experienced endoscopists, there was clearly a difference in the scores between novice and intermediates, and intermediates and experienced, which points to the discriminative ability of the assessment tool," Dr. Walsh said. Furthermore, self-assessment scores also increased significantly from novice to intermediate to experienced endoscopists, she said.

However, statistical analyses comparing the self-assigned and expert-assigned scores revealed notable discrepancies. Novices had the largest discrepancy between self-assigned and expert-assigned scores, indicating inaccuracies in their self-assessment abilities; they also had a tendency to overrate themselves, Dr. Walsh added. Intermediates had a "fairly poor self-assessment ability," but they did not display a tendency toward over- or underrating themselves. The experienced endoscopists had significantly lower difference scores, indicating a "fairly accurate self-assessment ability," she said.

"In conclusion, novice and intermediate endoscopists have a poor self-assessment ability as compared to expert endoscopists," Dr. Walsh said.

Why is this important?

"Self-assessment is an important component of self-directed learning. And there's also evidence within educational domains that if people receive feedback that isn't congruent with their image of themselves, then they're likely to reject that feedback," Dr. Walsh said. "So it's important to try to align people's perception of themselves with the feedback that they're receiving."

Future strategies to improve trainees' skills in self-assessment may involve the use of videos of endoscopy performance, she suggested.

Ultimately, Dr. Lightdale said, there isn't much mystery here. "I think we know the core skills required to perform pediatric colonoscopy: They are multidisciplinary, they're technical, they're cognitive and then you need to integrate them. It is possible to measure them. And if you do that, you should see improvement over time."'

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