Читать книгу Practical Pediatric Gastrointestinal Endoscopy - Группа авторов - Страница 54

Assessment of endoscopic procedural performance is ideally an ongoing process that should occur throughout the learning cycle, from training to accreditation to independent practice. This requires thoughtful integration of both formative and summative assessments to simultaneously optimize learning and certificate functions of assessment. Formative assessment is process focused. It aims to provide trainees with feedback and benchmarks, enables learners to self‐reflect on performance, and guides progress from novice to competent (and beyond) [21,22]. In contrast, summative assessment is outcome focused. It provides an overall judgment of competence, readiness for independent practice and/or qualification for advancement [22]. Summative assessment provides professional self‐regulation and accountability; however, it may not provide adequate feedback to direct learning [22,23].

Over the past two decades, there has been a profound shift in postgraduate medical education from a time‐ and process‐based framework that delineates the time required to “learn” specified content (e.g., a two‐year gastroenterology fellowship) to a competency‐based model that defines desired training outcomes (e.g., perform upper and lower endoscopic evaluation of the luminal GI tract for screening, diagnosis, and intervention [24]) [25–27]. Assessment is an integral component of competency‐based education as it is required to monitor progression throughout training, document trainees’ competence prior to entering unsupervised practice, and ensure maintenance of competence.

Nevertheless, procedural assessment in pediatric gastroenterology continues to focus predominantly on the number of procedures performed by a learner, as well as a “gestalt” view of their competence by a supervising physician [28]. This type of informal global assessment is fraught with bias inherent in subjective assessment and is not designed to aid in the early identification of trainees requiring remediation. A major limitation to using procedural numbers to determine competency is a demonstrated wide variation in the rate at which trainees acquire skills [29,30]. Furthermore, there are a host of factors which have been shown to affect the rate at which trainees develop skills, including training intensity [29], the presence of disruptions in training [31], the use of training aids (e.g., magnetic endoscopic imagers [3]), the quality of teaching and feedback received, and a trainee’s innate ability [32]. Reflective of these concerns, current pediatric credentialing guidelines outline “competence thresholds” as opposed to absolute procedural number requirements. A “competence threshold” is the minimum recommended number of supervised procedures a trainee is required to perform before competence can be assessed [33].

There is tremendous variability in current credentialing guidelines with regard to competence thresholds for pediatric upper endoscopy and colonoscopy [34–36]. In large part, this variability reflects a current lack of evidence for determining competence thresholds for pediatric endoscopy. As such, today’s guidelines for procedural numbers at which a learner can be assessed for competency in upper endoscopy are principally based on expert opinion [37]. In contrast, current colonoscopy guidelines are empirically based. However, most rely on an early study of competency by Cass et al. [38] that assessed 135 adult gastroenterology trainees from 14 programs and determined that performance of 140 supervised colonoscopies was required to achieve a 90% cecal intubation rate. More recent studies of adult colonoscopy competency have found that thresholds are achieved by 275 and 250 procedures when utilizing criteria including cecal intubation rate, time to intubation, and competency benchmarks on the Mayo Colonoscopy Skills Assessment Tool (MCSAT) [39] and the Assessment of Competency in Endoscopy (ACE) [40] tool, respectively, while it may take upwards of 400 procedures for some trainees to achieve competence. To date, the largest study to prospectively analyze this question examined 297 trainees over one year in the UK and found that it requires 233 colonoscopies to achieve a 90% cecal intubation rate [29]. In addition, a regression analysis of 10 adult studies, including 189 trainees, estimated that 341 colonoscopies are required to achieve a 90% cecal intubation rate [41].