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