Secondary Logo

Journal Logo

Original Articles: Gastroenterology

Exploring Use of Endoscopy Simulation in North American Pediatric Gastroenterology Fellowship Training Programs

Gabrani, Aayush; Monteiro, Iona M.; Walsh, Catharine M.

Author Information
Journal of Pediatric Gastroenterology and Nutrition: January 2020 - Volume 70 - Issue 1 - p 25-30
doi: 10.1097/MPG.0000000000002525


What Is Known

  • Increasing evidence supports the use of simulation as instructional methodology to support endoscopy training.
  • Data regarding the current status of simulation-based endoscopy training among pediatric gastroenterology fellowship programs is limited.
  • What Is New
  • Pediatric gastroenterology fellowship program directors recognize the value of endoscopy simulation and express a willingness to incorporate simulation-based training.
  • Key barriers to the incorporation of simulation include time constraints, cost, and lack of a standardized curriculum.
  • The results of the present study indicate the need for development of low-cost simulation models and accompanying curricula to facilitate uptake and improve integration of endoscopy simulation across pediatric gastroenterology fellowship programs.

The use of simulation-based education in medical training has expanded dramatically over the last 2 decades, primarily because it allows trainees to practice skills in a deliberate manner while maintaining patient safety (1,2). In gastrointestinal endoscopy, skills learned through simulation training have shown transfer to the real-life clinical environment, making simulation a potentially useful educational tool, particularly for initial skill acquisition (3–5). Compared to no training, simulation-based endoscopy training enhances novice trainees’ ability to complete procedures independently, shortens procedure time and improves overall performance and mucosal visualization (3,4). Literature regarding its application and efficacy for more advanced endoscopic skills, interventional procedures, and endoscopic nontechnical skills is, however, limited (6). In addition, although the capacity for standardization and reproducibility of simulation makes it well suited for the assessment of endoscopic competence, there are currently no simulation-based assessment tools with strong validity evidence (6–8).

Recent guidelines from endoscopy-focused organizations, such as the American Society for Gastrointestinal Endoscopy (ASGE) have encouraged adult gastroenterology (GI) and surgical training programs to integrate simulation into their core endoscopic curricula and it is now mandated during training by accreditation organizations in certain jurisdictions, such as the Accreditation Council for Graduate Medical Education in United States (9,10). Despite the growth of simulation-based education, there have only been a handful of single-center studies describing its use for pediatric GI fellows, which have found that participants consider simulation to be a valuable tool for endoscopic skill acquisition (11,12).

There remains a paucity of data regarding the availability and nature of simulation-based endoscopy training opportunities in pediatric GI fellowship programs. A more complete understanding of how endoscopy simulation is delivered across training programs will offer insights into best practice, barriers to implementation, and opportunities for improvement. The present study aimed to examine the current status of endoscopy simulation among pediatric GI fellowship programs across North America.


This prospective survey-based descriptive study of pediatric GI fellowship programs across the United States and Canada was conducted from August to November 2018. The study was determined to be exempt from review by the Institutional Review Board of Rutgers New Jersey Medical School.


The target population for the study was pediatric GI fellowship program directors (PDs) (or an appointed delegate, responsible for endoscopy training). As per NASPGHAN training program details, there were 64 fellowship programs in the United States and 7 in Canada in 2018 (13). Thus, a total of 71 programs (reported on by their respective PDs) were eligible to participate.

Data Collection

PDs were sent a personalized email invitation containing a link to the electronic survey. Before distribution, the survey was pretested on a sample of 4 pediatric gastroenterologists to ensure ease of use and relevance. Reviewer feedback was incorporated into the final instrument. To maximize response rates, the survey was designed and distributed in line with Dillman's tailored design method, by including personalized correspondence, a respondent-friendly design using clear language and up to 5 attempts to contact each participant (14).

The survey instrument consisted of 3 major sections (see Appendix 1, Supplemental Digital Content, The first section collected program demographics. Section 2 probed the current status and details of endoscopy simulation in the fellowship program, and perceived barriers to implementing endoscopy simulation into fellowship training. Finally, section 3 elicited PDs’ perceptions of endoscopy simulation for training and assessment. Participants were asked to rate their agreement with statements using a Likert-type scale ranging from 1 (low agreement) to 5 (high agreement).

Survey data were collected and managed using Research Electronic Data Capture (REDCap Software V6.3.0 2019 Vanderbilt University) tool. Participants were informed that survey completion was voluntary and their answers were anonymous, confidential, and would be reported in aggregate.

Data Analysis

Data were analyzed using descriptive statistics, with continuous variables summarized using means and standard deviations and categorical variables summarized using proportions. Where relevant, responses were stratified according to whether or not programs currently used simulation.


Program Characteristics

In total, 43 of 71 (60.6%) PDs responded (37 US, 6 Canada). Program details are provided in Table 1. Most programs were based in academic medical centers (n = 41, 95.3%), enrolling a mean of 1.87 ± 1.01 fellows per academic year. In 65.1% (n = 28) and 95.3% (n = 41) of programs, fellows were reported to have met the NASPGHAN recommended minimum competence threshold numbers for colonoscopy and upper endoscopy, respectively, by the end of their core fellowship training.

Fellowship program demographic characteristics

Only 4.6% (n = 2) of programs reported using simulation for the purposes of endoscopic assessment (Table 1). The vast majority of the programs (n = 36, 83.7%) reported using “number of procedures performed by fellows” as a measure to assess endoscopic competence. Other reported methods of endoscopic skills assessment included clinical parameters (n = 27, 62.8%), Entrustable Professional Activity assessment forms (n = 13, 30.2%), procedure-specific assessments such as the Gastrointestinal Endoscopy Competency Assessment Tool for pediatric colonoscopy (GiECATKIDS) (n = 10, 23.3%), direct observation (n = 16, 37.2%), and other unspecified methods (n = 3, 7.0%) (15,16).

Current Use of Simulation-based Endoscopy Training

Approximately half of programs (n = 24, 55.8%) reported using simulation for endoscopy training during fellowship. Only 3 programs (12.5%) had an organized curriculum for simulation-based endoscopy training. In most programs, only first-year fellows (PGY-4) participated in endoscopy simulation training (n = 15, 62.5%), with a subsequent fall in participation with advancement in fellowship training (Table 2). Mechanical simulators (n = 17, 70.8%) and computerized (virtual reality) simulators (n = 10, 41.7%) were the most common form of endoscopy simulators reported for training (see Appendix 2, Supplemental Digital Content, The most frequently trained procedures were upper endoscopy (n = 22, 91.7%) and colonoscopy (n = 20, 83.3%). In 8 programs (33.3%) simulation-based training was required before fellows’ first clinical endoscopy, but 4 of those programs had no minimum qualifying requirement for transition from simulated to clinical endoscopy, whereas 1 required a minimum number of simulation hours and 3 required the completion of a simulation course or curriculum before advancing to clinical training. Ten programs (41.7%) reported having protected time for endoscopy simulation training; however, only 2 programs (8.3%) tracked the number of hours spent on endoscopic simulators.

Details of endoscopic simulation-based training (n = 24 programs)

Although 20 PDs (83.3%) reported that endoscopy simulation was supervised by pediatric GI physicians, instructors in only 6 out of those 20 programs (30.0%) were reported to have received formal training regarding how to teach endoscopy. Half of the training programs had their endoscopy simulators located in a hospital-based simulation lab (n = 12, 50.0%). Ten programs (41.7%) reported having to pay to access endoscopic simulators.

Perceptions of and Barriers to Simulation-based Endoscopy Training

Overall, the majority of the PDs agreed with the need for simulation for endoscopic technical skills training for fellows, particularly for novices (see Appendix 3, Supplemental Digital Content, In contrast, lower levels of agreement were observed regarding the utility of simulation for training experienced endoscopists, for maintaining endoscopic skills and for credentialing. The PDs strongly agreed that simulation is not an adequate substitute for hands-on clinical training and that both fellows and faculty are willing to take part in simulation-based education. Surprisingly, the attitudes of PDs from programs that are currently incorporating simulation did not differ from those that are not (P > 0.05).

Barriers to implementing simulation-based endoscopy training that were most commonly reported by PDs from programs currently using simulation were faculty (n = 15, 62.5%) and fellow (n = 10, 41.7%) time constraints, budget constraints (n = 12, 50%), and lack of a standardized curriculum (n = 12, 50.0%) (Table 3). Among the programs without simulation in place, budget constraints were rated as the most common barrier (n = 13, 68.4%), followed by accessibility (n = 7, 36.8%), program size (n = 6, 31.6%), lack of a standardized curriculum (n = 6, 31.6%), and availability of a high clinical endoscopy case load (n = 6, 31.6%).

Perceived barriers to use of simulation among fellowship programs


This is the first study to explore the use of simulation-based endoscopy training and assessment in pediatric GI fellowship programs across the United States and Canada. Interestingly, given the potential benefits of simulation for novices, we found the current use of endoscopy simulation during fellowship training to be low and unsystematic. In addition, although PDs acknowledge the role that simulation can play with regard to assessment, only 2 PDs reported using simulation to assess endoscopic competence.

Across programs, simulation is being employed in a markedly heterogeneous fashion with regard to the manner in which it is integrated into training, the time spent on simulators, and the training tasks and types of simulators employed. This heterogeneity could reflect the lack of a standardized pediatric GI simulation curriculum which would provide guidance to programs regarding best practices for implementation. Lack of such a curriculum was also identified by PDs as a key barrier to integrating simulation into training. Simulation is one of several teaching strategies available to educators and it is important to integrate it into training in a thoughtful and evidence-based manner to achieve maximal learning benefit. The results of the present study highlight the need to develop a feasible simulation curriculum which can be adapted to local contexts, and which incorporates features of simulation-based training that have been shown to be effective, including deliberate practice, mastery learning (requiring learners to achieve a defined level of proficiency before proceeding to the next instructional objective), task variability, distributed (longitudinal) practice, and provision of performance enhancing feedback (1,7,17–19). In the present study 45.8% of simulation training was reported to be unsupervised, despite clear evidence that performance enhancing feedback is a key feature of effective simulation-based education (20). In addition, previous research has shown no improvement in endoscopy skills acquisition in the simulated setting in the absence of feedback and studies comparing feedback provided by preceptors with simulator-generator feedback have shown a clear advantage with regard to preceptor-derived feedback (18,21,22).

It is well recognized that there are challenges associated with clinical endoscopy training. First, clinical training takes times, which has both economic and capacity-related implications (23). Second, clinical demands often limit preceptors’ capacity for teaching and feedback provision (24). Third, case availability can limit exposure to particular procedures and pathologies and concern for patient comfort and safety can further limit training exposure. This issue is of particular concern in pediatric GI where endoscopy volumes are low and previous research has shown that many trainees are unable to complete the suggested minimum number of routine and therapeutic endoscopic procedures during their core fellowship training (25–27). Despite the challenges associated with clinical endoscopy training, the present study found that only 56% of pediatric North American GI fellowship programs are currently utilizing simulation for endoscopy training. This is, however, higher than the 42% of adult GI programs which reported using simulation in 2013 (28). This growth likely reflects the increased availability and acceptance of simulation and current training guidelines from endoscopy-focused organizations which have encouraged its use (9,10). Interestingly, PDs from 4 programs without simulation (21%) cited the presence of an adult endoscopy rotation as a reason for their program's lack of simulation-based training, as such rotations provide an alternative means to supplemental endoscopy experience.

According to PDs surveyed in the present study, incorporating simulation into pediatric GI fellowship training may not always be feasible. Among all programs, cost was cited as the main factor precluding incorporation of simulation. Computerized simulators, which cost upwards of $140,000 USD, can be prohibitively expensive, especially for smaller institutions (29). Although computer-based simulators are useful to teach performance of the procedure as a whole, basic endoscopic procedural elements such as torque steering or specific skill sets such as polypectomy are often best taught using simple and less expensive part-task trainers and mechanical simulators (24,30,31). Among programs using simulation, the majority reported using such lower-cost simulators. These simulators deconstruct the skill, allowing learners to focus on the task at hand and help avoid cognitive overload (5,32). Ultimately, the choice of simulator should reflect the desired educational goals and not the availability of technology (24). The study findings highlight the need for further development of inexpensive portable simulators to teach and assess deconstructed endoscopic skills to trainees. In addition, the development and validation of accompanying simulation-based learning modules outlining best practices for their use would help to facilitate teaching and promote uptake of simulation across training programs. Another approach to enhancing the quality and reach of simulation-based training is the implementation of centralized courses led by those with specialized expertise, such as the course for pediatric endoscopy trainees offered annually by the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) or the hands-on simulation-based sessions offered at the NASPGHAN and ESPGHAN Annual Meetings.

Another reason for the limited uptake of simulation could be that, in contrast to the recognized potential value of endoscopy simulation for training novice endoscopists, the role of simulation in assessment and in training more experienced fellows appears to be contentious. This is reflected both in PDs’ perceptions of endoscopy simulation training and the progressive decline in use of simulation over fellowship training and the paucity of programs using simulation for assessment purposes. To date, the low realism of existing simulators has largely restricted their use to introduction of endoscopy to novice trainees (6). Simulators that are of more relevance to senior fellow are required, including ones that incorporate more complex cases and troubleshooting scenarios, and which target training of more advanced and less frequently encountered skills such as variceal band ligation. Current evidence is predominantly limited to showing benefit for initial endoscopy skill acquisition (3). More research is required to examine the use of simulation for more senior trainees and to establish the most effective methods for skills acquisition in this population of learners. With regard to assessment, there is currently no standardized means of assessing endoscopic competence (8,33). There is a need for the development of simulators that are capable of reliably differentiating endoscopists across skill levels and have the ability to provide more useful feedback.

Despite increasing recognition of the importance of endoscopic nontechnical skills (eg, teamwork, decision-making, leadership), use of simulation to train such skills was found to be minimal in our study (only 2 programs). In an abstract-based study from Boston Children's Hospital, Fredette et al (12) explored how simulation can be used to train the multidisciplinary endoscopy team to manage procedure-related complications. Participants perceived the experience to be valuable in teaching both nontechnical skills such as communication and teamwork and technical aspects of sedation and airway management. Studies within the adult GI literature have also explored the use of simulation for endoscopic nontechnical skills training (22,34,35). Hybrid simulations, which combine use of an endoscopy simulator and an actor portraying a patient (ie, simulated patient), allow for incorporation of multidisciplinary team members, such as endoscopic nurses or anesthesiologists, to teach endoscopic nontechnical skills (22,36). In addition, postsimulation debriefing sessions can be used to allow trainees to reflect on their performance and reinforce key nontechnical skills (37).

Limitations of the present study include the low response rate (60.6%). Although typical for pediatric survey-based research and inclusion of PDs from across all geographic regions, it leaves room for nonresponse bias and may serve to limit the generalizability of the study findings (38). Second, as with many self-reported surveys, our study was susceptible to respondent recall bias. Third, since respondents consisted of PDs (or an appointed delegate, responsible for endoscopy training), the results might be more reflective of respondent's individual perspectives, as opposed to those of the institutions they represent.

In conclusion, pediatric GI fellowship programs across the United States and Canada are using simulation in minimal capacity, owing primarily to cost, time constraints, and lack of a standardized simulation curriculum. Although pediatric GI fellowship PDs widely recognize the potential value of simulation, just over half of fellowship program currently use endoscopy simulation to train their fellows and only 2 programs report using it for assessment purposes. The results from the present study emphasize the need for development of a pediatric endoscopy simulation curriculum with strong validity evidence. Strategies to maximize the benefits of simulation and broaden adoption across programs might include a combination of inexpensive portable simulators to assist in initial technical skills acquisition and centralized courses using more expensive, complex simulators to refine more advanced endoscopic skills and interventional techniques.


1. Issenberg SB, McGaghie WC, Petrusa ER, et al. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach 2005; 27:10–28.
2. Cook DA, Andersen DK, Combes JR, et al. The value proposition of simulation-based education. Surgery 2018; 163:944–949.
3. Khan R, Plahouras J, Johnston BC, et al. Virtual reality simulation training for health professions trainees in gastrointestinal endoscopy. Cochrane Database Syst Rev 2018; 8:CD008237.
4. Cook DA, Hatala R, Brydges R, et al. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. JAMA 2011; 306:978–988.
5. Khan R, Scaffidi MA, Grover SC, et al. Simulation in endoscopy: practical educational strategies to improve learning. World J Gastrointest Endosc 2019; 11:174–261.
6. Walsh CM, Cohen J, Woods KL, et al. American Society for Gastrointestinal Endoscopy EndoVators Summit: simulators and the future of endoscopy training. Gastrointest Endosc 2019; 90:13–26.
7. Cook DA, Brydges R, Zendejas B, et al. Technology-enhanced simulation to assess health professionals: a systematic review of validity evidence, research methods, and reporting quality. Acad Med 2013; 88:872–883.
8. Walsh CM. In-training gastrointestinal endoscopy competency assessment tools: types of tools, validation and impact. Best Pract Res Clin Gastroenterol 2016; 30:357–374.
9. Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in gastroenterology (subspecialty of internal medicine). 2019. Published July 1, 2019. Accessed October 20, 2019.
10. American Board of Surgery. Flexible endoscopy curriculum for general surgery residents. 2014. Accessed October 20, 2019.
11. Lightdale JR, Newburg AR, Mahoney LB, et al. Fellow perceptions of training using computer-based endoscopy simulators. Gastrointest Endosc 2010; 72:13–18.
12. Fredette ME, Heard L, Lightdale JR. Simulation-based training is preferable to case-based interactive education for teaching pediatric endoscopy providers to manage procedural complications. Gastrointest Endoscop 2009; 69:AB171.
13. North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. 2018. Published August 2018. Accessed August 20, 2019.
14. Dillman D. Mail and Internet Surveys: The Tailored Design Method. 2nd edNew York: John Wiley and Sons; 2007.
15. Walsh CM, Ling SC, Walters TD, et al. Development of the Gastrointestinal Endoscopy Competency Assessment Tool for pediatric colonoscopy (GiECATKIDS). J Pediatr Gastroenterol Nutr 2014; 59:480–486.
16. Walsh CM, Ling SC, Khanna N, et al. Gastrointestinal endoscopy competency assessment tool: reliability and validity evidence. Gastrointest Endosc 2015; 81:1417–1424.
17. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004; 79: (10 suppl): S70–S81.
18. Mahmood T, Darzi A. The learning curve for a colonoscopy simulator in the absence of any feedback: no feedback, no learning. Surg Endosc 2004; 18:1224–1230.
19. Walsh CM, Ling SC, Wang CS, et al. Concurrent versus terminal feedback: it may be better to wait. Acad Med 2009; 84: (10 suppl): S54–S57.
20. Motola I, Devine LA, Chung HS, et al. Simulation in healthcare education: a best evidence practical guide. AMEE Guide No. 82. Med Teach 2013; 35:e1511–e1530.
21. Kruglikova I, Grantcharov TP, Drewes AM, et al. The impact of constructive feedback on training in gastrointestinal endoscopy using high-fidelity virtual-reality simulation: a randomised controlled trial. Gut 2010; 59:181–185.
22. 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; 82:1072–1079.
23. McCashland T, Brand R, Lyden E, et al. The time and financial impact of training fellows in endoscopy. CORI Research Project. Clinical Outcomes Research Initiative. Am J Gastroenterol 2000; 95:3129–3132.
24. Walsh CM, Cohen J. Endoscopic simulators. In: Chandrasekhara V, Elmunzer BJ, Khashab MA, et al. Chapter 13: Clinical Gastrointestinal Endoscopy. Philadelphia, PA: Elsevier; 2018:141.e3–151.e3.
25. Qualia CM, Baldwin CD, Rossi TM, et al. Pediatric gastroenterology fellows, class of 2007: how well are they prepared for the future? J Pediatr Gastroenterol Nutr 2008; 47:327–333.
26. Lerner DG, Li BU, Mamula P, et al. Challenges in meeting fellowship procedural guidelines in pediatric therapeutic endoscopy and liver biopsy. J Pediatr Gastroenterol Nutr 2014; 58:27–33.
27. Lightdale J, Guthery S, Colletti R, et al. Self-reported procedural training of North American pediatric GI trainees: discordance between training guidelines and actual experiences. J Pediatr Gastroenterol Nutr 2002; 35:433–438.
28. Jirapinyo P, Thompson CC. Current status of endoscopic simulation in gastroenterology fellowship training programs. Surg Endosc 2015; 29:1913–1919.
29. Goodman AJ, Melson J, Aslanian HR, et al. American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee. Endoscopic simulators. Gastrointest Endosc 2019; 90:1–12.
30. Walsh CM, Cooper MA, Rabeneck L, et al. High versus low fidelity simulation training in gastroenterology: Expertise discrimination. Can J Gastroenterol 2008; 22: (suppl A): 164A.
31. Grover SC, Scaffidi MA, Khan R, et al. Progressive learning in endoscopy simulation training improves clinical performance: a blinded randomized trial. Gastrointest Endosc 2017; 86:881–889.
32. Van Merriënboer JJG, Sweller J. Cognitive load theory in health professional education: design principles and strategies. Med Educ 2010; 44:85–93.
33. Ekkelenkamp VE, Koch AD, De Man RA, et al. Training and competence assessment in GI endoscopy: a systematic review. Gut 2016; 65:607–615.
34. Matharoo M, Haycock A, Sevdalis N, et al. Endoscopic non-technical skills team training: the next step in quality assurance of endoscopy training. World J Gastroenterol 2014; 20:17507–17515.
35. Khan R, Scaffidi MA, Walsh CM, et al. Simulation-based training of non-technical skills in colonoscopy: protocol for a randomized controlled trial. JMIR Res Protoc 2017; 6:e153.
36. Kneebone RL, Nestel D, Moorthy K, et al. Learning the skills of flexible sigmoidoscopy—the wider perspective. Med Educ 2003; 37: (suppl 1): 50–58.
37. Fernandez R, Vozenilek JA, Hegarty CB, et al. Developing expert medical teams: toward an evidence-based approach. Acad Emerg Med 2008; 15:1025–1036.
38. Cull WL, O’Connor KG, Sharp S, et al. Response rates and response bias for 50 surveys of pediatricians. Health Serv Res 2005; 40:213–226.

gastrointestinal endoscopy, pediatric gastroenterology, postgraduate medical education, simulation, simulation-based training

Supplemental Digital Content

Copyright © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition