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Many of the principles of effective endoscopic training outlined above also apply to training within the simulated setting. The history of the development and use of simulators in training is reviewed in detail in Chapter 1, and specific applications are detailed elsewhere in Part II of this textbook which addresses particular endoscopic procedures.

Simulators are important, especially for more novice trainees, as they afford trainees opportunities for deliberate practice, a critical factor in the acquisition of skills and expertise [34, 65, 66]. Deliberate practice encompasses repetitive performance of structured activities, coupled with informative feedback, which promotes monitoring and error correction to improve performance in a specific domain [34, 65]. For deliberate practice to be most effective, the trainee has to be challenged with tasks of appropriate difficulty that increase in pace with trainee skill development [47]. Additionally, it requires the provision of focused feedback from a trainer. Studies have shown that there is no improvement in endoscopy skill acquisition in the simulated setting without feedback, and the absence of feedback may, in fact, foster the development of “bad habits” [67, 68]. Additionally, studies have shown that instructor‐derived feedback has a distinct advantage in improving endoscopy skill acquisition as compared with simulator‐generated feedback [32, 33]. As in the clinical setting, to avoid overburdening the trainee, feedback should focus on well‐defined and achievable goals, and include specific suggestions for improvement. The simulated setting is unique, however, in that it provides an ideal environment for trainees to work through errors independently without compromising patient safety. Withholding feedback until the end of a simulated endoscopic task has been shown to be more beneficial as compared to continuous feedback, likely because it enables trainees to better engage in real‐time problem‐solving without becoming cognitively overloaded [45]. Similar to the clinical setting, it is important for trainers to tailor their feedback to the trainee, their learning style and level of skill development.

Simulators are advantageous in that they permit trainers to employ teaching strategies that are not possible within the clinical setting as they would compromise patient safety. For example, simulators can be used to teach around troubleshooting difficult and unexpected situations such as perforation and they enable trainers to demonstrate incorrect technique as a counterexample to illustrate concepts and explore trainee misconceptions. Prior to using simulation as a training modality, it is important for trainers to gain experience with the models they plan to employ and familiarize themselves with relevant pedagogical principles to maximize their potential benefits. Courses have been developed to help trainers gain experience with endoscopy simulation and guide them in the appropriate pedagogical utilization of this educational technology, such as the World Endoscopy Organization’s Program for Endoscopic Teachers (https://www.worldendo.org/education/program‐for‐endoscopic‐teachers‐pet/). As with all training sessions, trainers need to plan and structure their teaching using simulators. It is important to recognize that there are a wide variety of simulators available to teach endoscopy. Both low‐ and high‐fidelity simulators can be used effectively, as the pedagogical goal should be the main determinant of simulator selection, as opposed to technological capabilities [47, 69].

Figure 4.5 This image shows a common loop visualized with the assistance of a magnetic endoscopic imager that can be used to help teach trainees loop recognition and loop reduction techniques (Panel A: standard view; Panel B: close‐up of imager).