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The basic skills of holding the scope correctly and orientation to the various dials and buttons are simple first steps. This initial orientation to the scopes mechanics is brief and takes only 10–15 minutes. Frequently, this is done just prior to the first patient‐based colonoscopy but can be accomplished outside the endoscopy suite, with a basic scope. A computer simulator, static mechanical model, or an ex vivo animal model setup can also provide the same basic exposure but can quickly be followed by the next step of learning how to insert and advance the scope through a lumen. Any one of these simulator environments affords the trainee the liberty to experiment with the early motor skills (controls, insufflations, scope advancement, and mucosal inspection) in a safe environment away from patients and in a low stress environment without concerns for patient pain, procedure completion issues, or the usual time constraints. Research has shown that the use of computer simulators during initial training of novice endoscopists can indeed teach basic scope steering, lumen identification, and scope advancement as well, if not better than traditional patient‐based training [23, 26, 27] (Figure 6.31). In this research, GI fellows who had received computer simulation training over a 6‐hour curriculum (20–25 simulated cases) outperformed traditionally trained fellows over the first 20–30 patient‐based cases. These fellows were nearly twice as likely to reach the cecum independently and did so with greater speed, better lumen visualization, and most importantly with greater patient comfort than traditionally trained fellows. This performance advantage was observed for roughly 30 patient‐based procedures, after which the skills for the traditionally trained group statistically caught up. On the basis of these positive results and others like it, some institutions, such as the Mayo Clinic, have adopted early training curricula around computer simulation, requiring all GI fellows to perform roughly 20–30 simulated colonoscopies prior to being allowed to begin patient‐based training. Could longer simulation training provide an even greater performance advantage seen in the simulator‐trained group? This is possible, as similar research to the study above has shown 10 hours of simulator training, imparting a measurable sbenefit in skills in up to 80 live cases [21]. However, other data examining the learning curves of performance metrics during simulation training have found that a trainee's performance on the simulator tends to plateau after roughly 20–25 cases, suggesting that a computer simulator has taught a trainee all it can during this length of training [28, 29]. This is likely due to the modest level of difficulty of the cases currently available on computer simulators [30, 31]. As the realism of looping, haptic feedback, and case complexity improves on these models, the benefits computer simulation training could conceivably extend well beyond the initial training of novices. Currently, however, it is recommended that computer simulation be used primarily for teaching early motor skills [22]. Simulators are also still prohibitively expensive ($75K–100K), and as a result are found primarily at larger academic teaching institutions. One solution that would allow for smaller training programs to reap the benefits of these teaching tools would be the development of regional training centers. This initial simulation training of 20–25 cases could easily be completed over a weekend course and sponsoring such courses could provide a return on an investment for institutions that have already purchased such devices. Regional training centers could also serve as testing centers. As computer simulators become more advanced, it is inevitable that they will become part of board certification in gastroenterology, where testing of competence in endoscopy skills will be eventually be required. Before this type of high‐stakes assessment could happen though, the complexity and measurable performance metrics of current endoscopy simulators would need to be greatly enhanced and separately validated for such testing purposes.

Figure 6.31 A trainee using a virtual reality colonoscopy simulator.

Figure 6.32 A static mechanical model, the colonoscopy Erlangen active simulator for interventional endoscopy (coloEASIE), is shown here.

Figure 6.33 Ex vivo models. In these images, harvested animal models are lain out on special platforms that configure the organs in the shape of a human colon. The Endo‐X trainer (a) is designed specifically to accommodate a harvested bovine colon while the Erlangen active simulator for interventional endoscopy model (EASIE‐R) (b) platform is shown here with a porcine digestive tract.

Static mechanical models such as the Erlangen active simulator for interventional endoscopy colonoscopy model (coloEASIE) consists of a tube of spiraled wired mounted to a platform that allows for practice in navigation and loop management (Figure 6.32) [32, 33].

Ex vivo colonoscopy models have also been developed and can be used for teaching early motor skills [33, 34] (Figures 6.33a,b). These models utilize harvested bovine or porcine colons that are laid out on a special platform in a human anatomical configuration. The use of these models are typically limited to more advanced training in skills such as therapeutic hemostasis devices or advanced endoscopy procedures such as EMR and ERCP. The ASGE, however, does offer annual training courses to first year fellows, teaching early endoscopy skills with the aid of ex vivo models, at their central endoscopy training center, the Interactive Training and Technology (ITT) Center in Downers Grove, IL. Another option is to utilize one of a number of commercial entities that offers the delivery and set up a temporary ex vivo training laboratory wherever it is needed. As the use of ex vivo simulation training for basic skills becomes more common, participation by first year fellows in standardized courses for colonoscopy could become commonplace as a precursor to starting patient‐based training.

In addition to the teaching above, the continuous formative assessment of early motor skills is an important part of training. This ideally should be done in a formative manner to help identify early bad habits such as overuse of the two‐handed scoping technique or to extinguish unsafe practices such as pushing while in red‐out. This should be done during the simulation phase of training (if used), otherwise very early in the patient‐based training experience to prevent bad habits from becoming ingrained.

In summary, computer, static models, or ex vivo animal models can be used effectively to teach basic endoscopy skills when used prior to beginning patient‐based training. Regardless of the type of simulation training used, it should be noted that it is not intended as a replacement to bedside teaching but simply a means to augment traditional training and possibly accelerate the acquisition of skills. There is no training that will ultimately better prepare one to perform colonoscopy on patients than actually performing patient‐based exams. If simulation models are not available, seeking out special courses such as those offered by the ASGE would be recommended. If these options are not possible, patient‐based training alone is still the standard and completely acceptable means to train these early skills.