Rapid Assessment of Trainee Endoscopy Skills (RATES) Study Two: A Prospective Multicenter Study Evaluating Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatogram Among Advanced Endoscopy Trainees

Competency-based medical education and milestones: Given the increasing emphasis on quality metrics and competency in health care, the Accreditation Council for Graduate Medical Education (ACGME) recently announced plans to replace their current reporting system in 2014 with the Next Accreditation System (NAS). This reporting system focused on: 1) ensuring that milestones are reached at various points in training, 2) ensuring that competence is achieved by all trainees, and 3) making certain that these assessments are documented by their programs.

Learning curves and competence in EUS: EUS is a vital tool in the diagnosis and staging of gastrointestinal and certain non-gastrointestinal malignancies and diseases. EUS is operator dependent and training in EUS requires the development of technical and cognitive skills beyond that required for standard endoscopic procedures. It is intuitive that the quality of EUS in provision of patient care is directly proportional to the training, skill and experience of the endosonographer. Unfortunately, the intensity and length of training and minimum number of procedures required, requisite curriculum and extent of theoretical learning, and methodology to define competence are not well defined. There are limited data on learning curves in EUS imaging.Based on expert opinion, the American Society of Gastrointestinal Endoscopy (ASGE) recommends a minimum of 150 total supervised procedures, 75 of which have a pancreatobiliary indication and 50 cases of fine needle aspiration (FNA) (25 of which are pancreatic FNA) before competency can be determined.

Similar guidelines were recently proposed by the British Society of Gastroenterology (BSG)13 and the European Society of Gastrointestinal Endoscopy. However, these guidelines have not been validated. This does not account for the different rates at which people learn and in fact, many experts believe that the majority of trainees will require double the number of proposed procedures to achieve competency in EUS.

Learning curves and competence in ERCP: ERCP is an effective modality in the evaluation and management of pancreatobiliary diseases. This procedure can be technically demanding and associated with a wide range of adverse events. Technically failed ERCP may result in complications, need for additional procedures and their associated costs. Similar to EUS, ERCP is operator dependent and requires acquisition of certain technical and cognitive skills. There are limited data on learning curves and competence in ERCP, a cannulation rate of >80% (with some suggesting >90%) has been considered a surrogate for trainee competency. The ASGE recommends a minimum of 180 total procedures, the majority of which are therapeutic before competency can be achieved. However, this threshold is based predominantly on biliary cannulation success rate and does not take into account procedure complexity and the different rates at which people learn. It is also important to note that none of the previous studies have evaluated learning curves and competency in other quality indicators such as successful stone extraction, traversing and dilating a stricture, stent placement to name a few.

Competency assessment tools: Previous competency assessment tools have focused primarily on a limited number of motor skills involved in EUS and ERCP with no procedure-related cognitive skill assessment. The investigators have designed a prospective comprehensive competency assessment tool using validated benchmarks to define competency thresholds. The EUS and ERCP Skills Assessment Tool (TEESAT) can be used in a continuous fashion throughout the duration of training to grade technical and cognitive skills in EUS and ERCP in a balanced manner.