Competence development in ERCP: the learning curve of novice trainees
submitted11 November 2013
accepted after revision18 May 2014
10 September 2014 (online)
Background and study aim: Measures for competence in endoscopic retrograde cholangiopancreatography (ERCP) during training are poorly defined. Currently, various training and accreditation programs base verification of competence on performance of a minimum number of procedures. There is a general awareness that procedural competence certification should be based on objective performance criteria. Continuous self-assessment using a Rotterdam Assessment Form for ERCP (RAF-E) can provide insight into trainee performance. The study aim was to express development in ERCP competence as a learning curve.
Methods: ERCP trainees at a tertiary referral center in the Netherlands were invited to participate. Performed procedures were appraised using RAF-E. Indication for each ERCP and presence of a virgin papilla were documented. Complexity was graded on a 3-point scale. The primary outcome parameter was common bile duct (CBD) cannulation success rate. Success of the intended therapeutic interventions was additionally expressed as a learning curve.
Results: 15 trainees were included. 1541 ERCPs (624 procedures in native papillary anatomy) were assessed through RAF-E. Unassisted CBD cannulation success rate improved from 36 % at baseline to 85 % after 200 procedures (P < 0.001), and in 624 patients with a virgin papilla from 22 % at baseline to 68 % after 180 procedures (P < 0.001). Learning curves for therapeutic interventions showed significant improvements for successful sphincterotomy (P = 0.01) and stent placement (P < 0.001).
Conclusions: Learning curves are a valuable means for assessing competence in ERCP. Differences in learning curves can be shown with RAF-E. Verification of competence should be based on actual performance, instead of minimum numbers.
- 1 Jowell PS, Baillie J, Branch MS et al. Quantitative assessment of procedural competence. A prospective study of training in endoscopic retrograde cholangiopancreatography. Ann Intern Med 1996; 125: 983-989
- 2 Chutkan RK, Ahmad AS, Cohen J et al. ERCP core curriculum. Gastrointest Endosc 2006; 63: 361-376
- 3 Baron TH, Petersen BT, Mergener K et al. Quality indicators for endoscopic retrograde cholangiopancreatography. Am J Gastroenterol 2006; 101: 892-897
- 4 NVMDL. Herstructurering opleiding Maag-Darm-Leverziekten – Eindtermen voor de opleiding tot Maag-Darm-Leverarts [Restructuring the training program in gastroenterology and hepatology – Objectives of training in gastroenterology and hepatology]. Available at: http://www.mdl.nl/uploads/240/486/HOM_definitieve_versie_t.b.v._opleidersbijeenkomst.pdf [Dutch]. 2007 Accessed 12 May 2011
- 5 Koch AD, Haringsma J, Schoon EJ et al. Competence measurement during colonoscopy training: The use of self-assessment of performance measures. Am J Gastroenterol 2012; 107: 971-975
- 6 Park J, MacRae H, Musselman LJ et al. Randomized controlled trial of virtual reality simulator training: transfer to live patients. Am J Surg 2007; 194: 205-211
- 7 The Joint Advisory Group on GI Endoscopy. Colonoscopy – DOPS assessment form. Available at: http://www.jrcptb.org.uk/trainingandcert/ST3-SpR/Documents/Formative%20Colonoscopy%20and%20FS%20%20DOPS%20Assessment%20Form%20PDF%2015.04.09.pdf 2008 Accessed 30 May 2013
- 8 Reznick R, Regehr G, MacRae H et al. Testing technical skill via an innovative “bench station” examination. Am J Surg 1997; 173: 226-230
- 9 Ekkelenkamp VE, Koch AD, Haringsma J et al. Quality evaluation through self-assessment: a novel method to gain insight into ERCP performance. Frontline Gastroenterol 2014; 5: 10-16
- 10 Schutz SM, Abbott RM. Grading ERCPs by degree of difficulty: A new concept to produce more meaningful outcome data. Gastrointest Endosc 2000; 51: 535-539
- 11 Osborn A, Parnes SJ. Osborn–Parnes approach to creative problem solving. Available at: www.cpsb.com 1960 Accessed 11 January 2012
- 12 Jowell PS. Endoscopic retrograde cholangiopancreatography: toward a better understanding of competence. Endoscopy 1999; 31: 755-757
- 13 Schlup MM, Williams SM, Barbezat GO. ERCP: a review of technical competency and workload in a small unit. Gastrointest Endosc 1997; 46: 48-52
- 14 Verma D, Gostout CJ, Petersen BT et al. Establishing a true assessment of endoscopic competence in ERCP during training and beyond: a single-operator learning curve for deep biliary cannulation in patients with native papillary anatomy. Gastrointest Endosc 2007; 65: 394-400
- 15 Vitale GC, Zavaleta CM, Vitale DS et al. Training surgeons in endoscopic retrograde cholangiopancreatography. Surg Endosc 2006; 20: 149-152
- 16 Watkins JL, Etzkorn KP, Wiley TE et al. Assessment of technical competence during ERCP training. Gastrointest Endosc 1996; 44: 411-415
- 17 Sedlack RE. Training to competency in colonoscopy: Assessing and defining competency standards. Gastrointest Endosc 2011; 74: 355-366 and 366.e351 – 366.e352
- 18 ASGE/ACG. ASGE/ACG Taskforce on Quality in Endoscopy. Ensuring Competence in Endoscopy. Available at: http://www.asge.org/WorkArea/showcontent.aspx?id3384 2011 Accessed 13 September 2013