Procedural skill education has evolved in recent years from the traditional model of “learning by doing” to the current skillful application of evidence-based educational principles (1,2). There is increasing recognition that endoscopy training should ideally be provided by individuals with the requisite skills and behaviors to teach endoscopy effectively and efficiently, including an awareness of principles of adult education, best practices in procedural skills education, and appropriate use of beneficial educational strategies such as feedback (2–4). In addition, trainers should be consciously competent—explicitly aware of why and what they are doing when performing endoscopic procedures and able to convey this information in a comprehensible way to teach it to others (5). This “conscious competence” allows an endoscopy trainer to be able to describe, in a clear and effective way to his or her trainee, how to perform a specified maneuver. The ability to teach endoscopy is an important skill set that can be enhanced with instruction. Formal “train the endoscopy trainer” courses have been developed to increase trainers’ awareness with regard to educational approaches that have been directly applied to endoscopy teaching. These courses are now mandatory for adult gastroenterology endoscopy trainers in the United Kingdom (6,7) and are increasingly being implemented across other jurisdictions such as Canada (8) and the United States (9). The present article reviews the “Preparation—Training—Wrap-up” framework that can be used by pediatric endoscopy trainers to help guide an endoscopy training session, including required elements to prepare for training, deliver performance enhancing training, and provide a useful wrap-up (Fig. 1). This framework is useful not only for teaching trainees within the context of pediatric gastroenterology fellowship programs, it is also a valuable guide for trainers involved in mentoring and supporting junior colleagues to help enhance their endoscopy skills development.
PREPARATION FOR TRAINING
As part of a training session, which may be a single procedure or a set of procedures, physical and verbal preparations between the trainer and trainee are necessary to create a safe, effective, and efficient learning environment. Set-up, which is the first component of the preparation phase, incorporates an appropriate physical room set-up to promote a safe and effective training environment. This includes appropriate placement of the patient, trainee endoscopist, trainer, and equipment to optimize ergonomics (eg, table height) (10) and enhance trainer visualization of the patient, trainee's hands, and video monitor during the procedure (Fig. 2). Another important component of “set-up” is review of the days’ endoscopy list to ensure there are suitable cases and time allocated for the trainee to achieve his or her goals. This is particularly applicable to the pediatric context in which it is important to ensure learners gain exposure performing cases on patients who range in age from neonates through adolescents. In addition, the trainee (and trainer) should confirm that equipment to be used during each case is available and appropriate.
The next steps of the preparation phase include assessment and the alignment of agendas. The trainer should assess the trainee's current level of competency through discussion with the trainee, possibly including review of a procedural log, prior feedback, and/or assessments. This discussion should incorporate the trainee-trainer pair's prior experience working together. An example of the dialogue between the trainer-trainee pair could include: “We haven’t worked together before. Tell me about your colonoscopy experience to date?” or “How many colonoscopies have you done this week (month or year)?" or “What skills are you working on or troubleshooting?” Such questions help the trainer develop an assessment of the trainee's skills and ultimately set a learning agenda. Both trainer and trainee will have an agenda or goals for the training session. The trainee agenda should be elicited with an open-ended discussion. The learner agenda, developed based on the initial assessment and ongoing interaction, may be the same or different. Before moving forward with the session, there should be an alignment of agendas such that the trainer-trainee pair both appreciate each other's viewpoints and have a shared understanding of the goals for the session. This will allow for the generation of 2 to 3 personalized and well-defined learning objectives ahead of the training episode. Learning objectives are a key component to the development of a deliberate approach to training and help to ensure productive and efficient use of time for teaching, learning, and practice (11). In the context of an endoscopy, collaborative trainee-trainer objectives can be set succinctly ahead of the training episode using tools designed to enhance the quality of objectives, such as SMART (specific, measurable, achievable, realistic and time-bound) (12). Finally, clear ground rules for the training session, including an explicit description of the roles and responsibilities of the learner and trainer, should be discussed to help ensure patient safety and maximize the effectiveness of instruction.
PERFORMANCE ENHANCING TRAINING
During the second phase, training, there are some general evidence-based educational principles that can be applied by trainers to enhance learning. Instructional feedback is a key motivator for trainees and one of the most important determinants of learning. In addition, provision of constructive feedback is demonstrably advantageous in the acquisition of endoscopy skills (13,14). Feedback provided during a learning encounter, termed formative feedback, enables trainees to reflect on their performance and modify their thinking, and/or behavior to optimize learning (15). Feedback should be tied to performance and closely aligned with predetermined learning objectives as this facilitates self-reflection upon the learning process; a critical skill for future self-directed learning (16,17). In addition, the use of prespecified objectives with instructional feedback, followed by correction and optimization of performance, forms the basis for deliberate practice; an essential component of attainment of expertise (11,18). Formative pediatric endoscopy assessment tools with strong validity evidence, such as the Gastrointestinal Endoscopy Competency Assessment Tool for Pediatric Colonoscopy (19,20), can be used by trainers to help guide feedback delivery as they help to sign-post the trainer to areas the trainee needs to focus on to improve.
Feedback should be tailored to the skill level of the trainee. Procedural skill acquisition has been described by Fitts and Posner (21) as a sequential process involving 3 major stages: cognitive, associative, and autonomous. In the cognitive stage, the trainee begins to develop a mental understanding of the procedure and performance is erratic and error filled. Feedback during this phase is best focused on how the procedure is performed correctly and identifying and correcting common errors to increase the trainee's understanding of the tasks. In the associative phase, the trainee starts to translate learning into appropriate behaviors so the procedure is gradually executed more efficiently with fewer errors. Feedback during this stage should aim to help learners reflect on their performance to identify errors and corresponding corrective actions (22). Finally, with ongoing practice and feedback, performance becomes automated such that the skills are performed without significant conscious awareness devoted to performance. Ongoing life-long learning and practice are then required to ensure maintenance of skills (18).
The use of agreed upon standardized language is also an essential component of the training phase to ensure clarity of instruction and avoid confusion. For example, 13 simple terms can be used to provide directive instruction of a trainee through a section of bowel during colonoscopy: advance, pull-back, tip up, tip down, tip right, tip left, torque clockwise, torque counter-clockwise, suction, wash, insufflate, slow down, and stop. The use of common language also provides the trainer with the ability to control the procedure while not handling the endoscope. In addition, it enables the trainee to be clear about what action is expected of them. Instructions directing attention to the effects of movements are better for enhancing learning than those directing attention to the trainees’ hand movements (23). For example, feedback should always be provided in reference to the video monitor view as opposed referring to the trainees’ hands. Use of a “clock face” analogy is useful in this regard (eg, advance the tip toward 4 o’clock; apply clockwise torque). Throughout the session, it is important for trainers to check-in with the trainee to ensure he or she is clearly understanding the feedback he or she is receiving and make adjustments if necessary.
In providing feedback during the session, it is important for the trainer not to cognitively overload the trainee with information (ie, dual task interference). Provision of continual feedback (concurrent feedback) has been shown to impair learning of endoscopy (24) as it likely places a high extraneous cognitive load on trainees such that they focus their attention on listening to the feedback, rather than engaging in the cognitive processing essential for learning (schema acquisition and rule automation) (25). In addition, if feedback is too readily available it ultimately impairs learning, as the trainee develops a dependency on its presence and the skill is not optimally learned (26). Provision of continuous feedback may also disrupt the trainer's concentration and impair feedback provision as the simultaneous tasks of observation and feedback provision may place excessive cognitive demands on the instructor. When providing feedback during a procedure, it is important to have the trainee stop (assuming it is safe to do so), stabilize their position and direct his or her attention to the trainer. The trainer can then engage the trainee in problem solving around the difficulty to determine a mutually agreeable solution, and then proceed with the procedure (25). The feedback should focus on simple, well-defined, and achievable points so as to avoid overburdening the trainee and strive to foster the trainee's conscious understanding of the steps required for performance. In addition, studies carried out in the simulated environment suggest that gradual introduction of progressively more difficult components of endoscopy skill performance can enhance learning (27).
Decision training is also important to incorporate during the training phase to improve trainees’ effective-decision making (23). This is achieved by focusing on critical challenges during the procedure, having the trainee diagnose the problem, review potential options and decide, in consultation with the trainer, which option to try before resuming the endoscopy. Questioning on the part of the trainer encourages active engagement and reflection and encourages the trainee to think independently and weigh potential solutions rather than simply being informed of the best option (23). Incorporation of problem solving and active decision-making, especially with more advanced trainees, acts to improve self-reflection, and ultimately conscious competence.
The wrap-up is the period immediately following the training session that aims to summarize and reflect on what occurred and formulate objectives for future training episodes. Frequently in feedback sessions both the trainer and trainee can be guilty of providing a protracted resume of the procedure. Although it can be important to ensure critical training moments are highlighted accurately, the learning from any training event lies within the reflection of what happened not the description. Constructive performance enhancing feedback is essential to reinforce learning from the session. It is important for the trainer to allow the trainee time to reflect on his or her performance, reinforce positive aspects of his or her performance, identify areas for development, and mitigate any lack of insight with the trainee. Feedback should ideally be a 2-way process between the trainer and trainee that is delivered in a nonjudgmental manner and is based on observable actions and linked to specific suggestions for improvement (23,28). This performance-enhancing feedback can be delivered in an informal manner or using a formal structure, such as Pendleton's (29) 5-stage feedback model that recommends the following steps: ask the trainee to describe aspects of his or her performance that went well; reinforce key points and add other aspects the trainee missed; ask the trainee to describe aspects of his or her performance that could be improved; reiterate these points and highlight other areas for improvement; and summarize and identify 2 to 3 key aspects of performance that could be improved during future training episodes. Finally, the trainer should conclude the structured training session with a review of what has been achieved in relation to predefined learning objectives and outline 2 to 3 key take-home messages. This information should be used to set out mutually agreed upon learning goals for future training episodes so as to continually reinforce and build upon existing competencies. The wrap-up period can also provide an opportunity for the trainer to ask for feedback on their teaching skills to continuously improve training quality.
The framework reviewed in this article is meant to help guide pediatric endoscopy trainers with regard to the essential components of an effective technical skills training session. Each step of the preparation, training, and wrap-up phases should ideally be personalized for a given learner and training session. Although this framework pertains to a single endoscopy training episode, training must also be conceptualized over the longer term. It is important that each training episode is integrated within an overarching curriculum so that the goal of safe, high-quality independent practice can be achieved in an effective and efficient manner (30). Communication among endoscopy trainers within a given training program or center is also essential to achieving this goal. In the future, pediatric gastroenterology societies should strongly consider adapting the content of “train the trainer” courses to pediatric endoscopy practice to help improve the quality of endoscopy training and facilitate the development of conscious competences among pediatric endoscopy trainers.
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