Colonoscopy simulator training and transfer of skills to clinical practice

Pedro P Gomez, MD, Ross E Willis, PhD, Kent R Van Sickle, MD. University of Texas Health Science Center at San Antonio.

Introduction:
Surgical residents have learned flexible endoscopy techniques by practicing on patients in hospital settings under the strict guidance of experienced surgeons. Simulation is often used to "pre-train" novices on endoscopic skills before practicing on actual patients; nonetheless the optimal method of training remains unknown. The purpose of this study was to compare endoscopic virtual reality and physical-model simulators and their respective roles in transferring skills to the clinical environment.

Methods and procedures:
Twenty-seven novice surgical interns served as participants in this study. At the beginning of a skills development rotation, each intern performed a baseline colonoscopy on a real patient under faculty supervision. Their performance was scored using the Global Assessment of Gastrointestinal Endoscopic Skills (GAGES). Subsequently, interns completed a three-week flexible endoscopy curriculum developed at our institution. One-third of the residents were assigned to train with the GI Mentor platform exclusively, one-third of the residents were assigned to the Kyoto simulator, and one-third of the residents trained using both simulators. At the end of their rotation, interns performed one posttest colonoscopy on a different real patient, again under the guidance of experienced faculty and scored using GAGES. A survey was administered after completion of study participation to evaluate self-reported levels of anxiety, colonoscopy performance and simulator preference.

Results:
A statistically significant improvement in the GAGES total score (p<.001) and on each of its subcomponents (p=.001) was observed from pre- to post-test when analysis was performed for all groups combined. When subgroup analysis was conducted, trainees using the GI Mentor or both simulators showed significant improvement from pre- to post-test in terms of GAGES total score (p=.017 vs. p=.024 respectively). No single training condition was shown to be a better training modality when compared to others in terms of total GAGES score or in any of its subcomponents.

Table 1.

Simulator Pretest GAGES Score (Median) Posttest GAGES Score (Median) P value
GI Mentor                 6                   10 .017
Kyoto                 6                    8 .072
Both                 6                   10 .024
All combined                 6                   10 <.001

Survey analysis reported that trainees in the GI Mentor and Kyoto groups had a statistically significant decrease of self-reported anxiety (p=.014, p=.038 respectively) and self-reported improvement in their performance (p=.0.05, p=.008 respectively) in the post-testing phase. However, these differences were not significant for trainees assigned to both simulators despite showing statistical significant improvement in their post-testing GAGES total score (p=.024).

Other variables such as total colonoscopy time, time to reach the cecum, and time with a clear lumen were not significantly different between groups. The same applied for case difficulty, degree of bowel preparation and faculty intervention showing similar characteristics for patient selection among groups.

Conclusion:
Colonoscopy simulator training with the GI Mentor platform exclusively or in combination with a physical model simulator improves skill performance in real colonoscopy cases when measured with the GAGES tool.
 

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