Several techniques, maneuvers, and approaches have been described for the percutaneous endoscopic gastrostomy (PEG) tube placement, since it was first described by Gauderer et al.1 It has revolutionized the care of the critically ill and stroke patients; however, the method of learning this procedure remains the same—“See one, do one, and teach one.” The limitations of this learning approach are well established.2,3 In a recent survey of 169 gastroenterology trainees in United Kingdom, Wells et al4 highlighted huge variation in the quality of educational experience of trainees. Only 44% trainees (76) felt that they received adequate supervision while learning endoscopic procedures. Simulation can play a role in such settings, because trainees can deliberately practice basic skills at their own pace until they achieve proficiency without placing patients at risk.
The Accreditation Council for Graduate Medical Education currently mandates general surgery residents in the United States to perform 35 upper endoscopies, which includes PEG tube insertion.5 At our institute, gastrointestinal (GI) surgery is responsible for PEG tube placement for surgery patients, and junior surgery residents routinely assist or perform the procedure. Therefore, we decided to include PEG tube placement training in our simulation curriculum to enhance patient safety. Although we found computerized simulators for endoscopic training,6–8 there were no commercial trainers available for learning how to perform or practice PEG tube placement in a safe educational environment, such as simulation laboratory.
Therefore, our institution experts identified the essential requirements for a PEG trainer, and we designed the model in our simulation center. Our primary objective was to design a simple, inexpensive low-fidelity partial task trainer that would help surgical trainees' practice PEG tube placement and thereby gain confidence.
Simple training model have been used successfully for procedural training in ultrasound-guided vascular access,9,10 ureteroscopy,11 and cricothyroidotomy.12 We designed a model that would allow trainees to practice and gain confidence in PEG tube placement.
To make this model, two foam bowels ($2 each) were connected by hand sewn end-to-end anastomosis to make a simulate esophagus. The distal (either) end of which was sutured to the foam stomach ($2 each) using a hand-sewn end-to-end anastomosis. The simulated pylorus of the stomach was sutured close. The simulated upper GI construct was then fixed to the cardboard (free, cut to measure from shipping box) and secured on a table. The whole assembly was then covered with a surgical drape. A small hole was cut at the top end to simulate mouth and over the stomach to simulate surgical field. All standard equipment and instruments were made available for trainees to allow familiarity not only with the operative steps but also with scope and instrument manipulation. The model was wrapped in a plastic sheath to allow insufflations as necessary. The procedure was performed in a simulated operative room (OR). The total cost of this model is <$10, and the total preparation time is ∼30 minutes. After three to four practices, the simulated stomach needs to be replaced. We have not replaced the simulated esophagus or the cardboard yet. The model is portable enough that after each training exercise, it easily fits in the endoscopy cart for storage until further use.
The training started with a 30-minute interactive didactic session, allowing trainees to discuss the indications, complications, and critical steps of the procedure to foster clinical decision making. Subsequently, the model was used in a small group workshop (1 hour) with 3:1 student-faculty ratio, followed by a debriefing session. Trainees were then allowed to practice the procedure until they felt comfortable with key steps of the procedure. This training approach is based on principles of instructional science research and adult learning. Trainees engage in a supervised hands-on educational activity, with the intent to acquire and master new skill through deliberate practice,13 which consists of focused repetition with an opportunity to receive feedback.14,15 By doing the procedure and then observing others perform the simulated procedure, while actively involved as a team member, residents were able to conceptualize procedural steps and prepare themselves for the forthcoming clinical opportunities.16
The whole exercise lasted <2 hours. Because this exercise was part of a mandatory surgical simulation and skills rotation, residents were excused from clinical responsibilities and their attendance was compulsory. Trainees were requested to fill out an anonymous course evaluation survey, using a 5-point Likert scale (5 = strongly agree). The study was declared exempt by the Institutional Review Board of the University of Pennsylvania (#811501).
Seventeen trainees (five medical students, fourth year; nine general surgery interns; and three general surgery second-year residents) received training on this model. Thirteen (76.5%) completed the course evaluation (Fig. 1). Trainees uniformly agreed that using a real endoscope for learning endoscopic skills on a bench model has more educational value than using GI Mentor alone, a high-fidelity, virtual reality (VR) simulator (mean ± SD = 4.38 ± 0.65). Trainees also reported an increased familiarity (4.54 ± 0.52) and ability to assemble and troubleshoot (4.69 ± 0.48) a real endoscope.
Twelve of 13 trainees either “agreed” or “strongly agreed” that the knowledge they acquired during this exercise would help them in their clinical rotation (4.46 ± 0.66) and that content delivery was better than traditional lectures and reading alone (4.54 ± 0.66). Although trainees perceived that the model's resemblance to human anatomy was low (3.69 ± 0.95), they still felt “better prepared” for performing the procedure on a real patient (4.23 ± 0.93), having undergone this structured simulation training. In response to the feedback regarding the simulated OR setting, trainees perceived it as realistic (3.54 ± 1.2), and most agreed that the training in that environment was useful (4.31 ± 0.75).
We present a novel approach to overcome the deficiencies of commercially available simulators for PEG tube placement training. Although educational effectiveness of low-fidelity models has always been a subject of debate,17 it is a general consensus that structured training via any means is better than the unstructured, unplanned, and opportunistic learning in clinical settings.3 Low-fidelity models have been proposed for various procedures and have been found to be comparable with18 or even better than19,20 the standard training in some reports. However, surgical trainees are skeptical about their educational value,20,21 perhaps because of a strong desire to work with functioning tissue in real operative setting.21 Although, in terms of tissue feel, our model was not perceived as real as human tissues, trainees found learning in the simulated OR setting useful. This may suggest that a high degree of perceived realism of simulation models is not always desired by trainees and that low-fidelity models may prove equally effective, especially if used within an engaging setup with opportunities of receiving hands-on training and meaningful feedback. This could be useful information for programs with restricted educational budget or those looking to buy devices to expand their simulation centers.
The American College of Surgeons and Association of Program Directors in Surgery's national surgical skills curriculum endorses simple models to promote early skills acquisition by trainees in a safe environment. The Ham-Cam (insertion) model and the withdrawal model for colonoscopy (Phase I module 16, The American College of Surgeons and Association of Program Directors in Surgery's national surgical skills curriculum) are unique in their simplicity and educational effectiveness. Similar to the fundamentals of laparoscopic surgery, these models allow use of existing resource such as available laparoscopy and endoscopy units, including instruments that most teaching program will have access to. Our model also works on a similar principle thereby saving cost. In fact, trainees loved using and gaining familiarity to the real instruments, carts, and troubleshooting them because they often do not get this opportunity in a busy OR setting. After the training, they reported increased familiarity and ability to assemble and troubleshoot a real endoscope. Before beginning the procedure, trainees should be able to perform a general check of the monitor and have familiarity with the instruments on the endoscopic stand. These skills are important even in the presence of an experienced GI assistant5 and are included in the Society of American Gastrointestinal and Endoscopic Surgeons curriculum.5
Other models for endoscopy training include VR simulation8,22 and biosimulation, simulation using animal parts.23 However, there are no models for PEG tube placement training in any of the above categories. Computerized simulation provides the best graphics and animation, but they are expensive, generally costing >$100,000. VR simulators rely on enhanced operative realism through advanced graphics and force-feedback technology,5 overlooking the importance of equipment troubleshooting and instrument familiarity. Besides saving the initial setup cost, our simulator may also save cost associated with inadvertent equipment damage, considering that up to 70% of endoscope damages may be attributed to improper handling.24,25 However, VR simulators have a distinct advantage; they facilitate unsupervised deliberate practice, with objective performance measurements. Therefore, they do not require faculty proctors. This may be beneficial for advanced trainees who are practicing to maintain their skills and may understand the complex, itemized feedback generated by computerized simulators. But the learning needs of junior trainees are very different. Having a faculty preceptor was appreciated by our trainees because they got instant feedback on their technique and had the opportunity to ask questions and refine their skills before practicing it further. Perhaps, this is the reason why our trainees reported that training on this model has more educational value than training on GI Mentor (Symbionix) alone. Biosimulation,23 on the other hand, may provide more realistic tissue feel. But the issues involving ethics, infection control, and waste disposal complicate the matter. The cost and time delay associated with instrument/scope sterilization and Institutional Animal Care and Use Committee approval further limit its widespread usage for educational purposes. On the other hand, our model is easy to assemble, is inexpensive, has more realistic feel than a rigid plastic tube (The Ham-Cam model), and has no sterilization issues. Because the model was made up of foam, it could simulate perforation if excess pressure was applied during the procedure. It could also be easily reassembled for multiple uses in <15 minutes, making it suitable for multiple sessions. This model is ideal for providing “just-in-time” training in PEG tube placement for the residents, because it is inexpensive, compact, easy to assemble and uses real instruments and equipment, thus allowing a more hands-on way of “going over the procedural steps” before performing a procedure on patients in the real OR.
The limitations of our study are small numbers, lack of validation studies, and lack of data to support if this perceived self-reported increase in comfort in performing PEG tube placement translates into clinical practice. We appreciate these limitations, but our intent is to encourage innovation in surgical simulation via our pilot study to overcome the cost and commercial availability barrier. We also hope that this study will provide readers an insight into residents' needs and perception of endoscopic training. Although this model was developed for surgical trainees, it can prove useful for gastroenterology fellows, advanced nurse practitioners, and medical assistants wanting to conceptualize the procedure before approaching patients.
We present a novel low-fidelity model that is inexpensive, is easy to assemble, and allows trainees to practice key steps for PEG tube placement before their first patient contact. The resulting self-reported increase in trainees' comfort and preparedness verifies its educational value in this preliminary technical report. Further research is needed to study if this improves skill acquisition against standard benchmarks and leads to improved clinical outcomes.
The authors thank Penn Medicine Clinical Simulation Center for their assistance toward this project and Daniel Hashimoto for editorial assistance.
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