Progressive learning in endoscopy simulation training improves clinical performance: a blinded randomized trial.

BACKGROUND AND AIMS: A structured comprehensive curriculum (SCC) that uses simulation-based training (SBT) can improve clinical colonoscopy performance. This curriculum may be enhanced through the application of progressive learning, a training strategy centered on incrementally challenging learners. We aimed to determine whether a progressive learning-based curriculum (PLC) would lead to superior clinical performance compared with an SCC. METHODS: This was a single-blinded randomized controlled trial conducted at a single academic center. Thirty-seven novice endoscopists were recruited and randomized to either a PLC (n = 18) or to an SCC (n = 19). The PLC comprised 6 hours of SBT, which progressed in complexity and difficulty. The SCC included 6 hours of SBT, with cases of random order of difficulty. Both groups received expert feedback and 4 hours of didactic teaching. Participants were assessed at baseline, immediately after training, and 4 to 6 weeks after training. The primary outcome was participants' performance during their first 2 clinical colonoscopies, as assessed by using the Joint Advisory Group Direct Observation of Procedural Skills assessment tool (JAG DOPS). Secondary outcomes were differences in endoscopic knowledge, technical and communication skills, and global performance in the simulated setting. RESULTS: The PLC group outperformed the SCC group during first and second clinical colonoscopies, measured by JAG DOPS (P < .001). Additionally, the PLC group had superior technical and communication skills and global performance in the simulated setting (P < .05). There were no differences between groups in endoscopic knowledge (P > .05). CONCLUSIONS: Our findings demonstrate the superiority of a PLC for endoscopic simulation, compared with an SCC. Challenging trainees progressively is a simple, theory-based approach to simulation whereby the performance of clinical colonoscopies can be improved. (Clinical trial registration number: NCT02000180.).

Esophageal Intramural Pseudodiverticulosis and Concomitant Eosinophilic Esophagitis: A Case Series.

Background. Esophageal intramural pseudodiverticulosis (EIPD) is an idiopathic benign chronic disease characterized by flask-like outpouchings of the esophageal wall. It is unknown whether there is a genuine association between EIPD and eosinophilic esophagitis (EoE). Aims. To investigate a possible relationship between EIPD and EoE. Methods. Patients with radiographic or endoscopic evidence of pseudodiverticulosis were identified from the database at a single academic center. Cases were analyzed in three areas: clinical information, endoscopic findings, and course. Results. Sixteen cases of esophageal pseudodiverticulosis were identified. Five patients had histologic evidence of eosinophilic esophagitis. Patients with EoE had pseudodiverticula in the mid-to-distal esophagus while those with EIPD had pseudodiverticula predominantly in the proximal esophagus (p < 0.001). EoE with pseudodiverticulosis occurred in younger patients (p < 0.019). Food bolus obstructions were more common in patients with EoE and pseudodiverticulosis than in EIPD (p < 0.034). Conclusions. This is the first case series supporting a potential association between EoE and pseudodiverticulosis. We also identify characteristic features of pseudodiverticulosis that may raise clinical suspicion of underlying eosinophilic esophagitis.

Impact of a simulation training curriculum on technical and nontechnical skills in colonoscopy: a randomized trial.

BACKGROUND: GI endoscopy simulation-based training augments early clinical performance; however, the optimal manner by which to deliver training is unknown. OBJECTIVE: We aimed to validate a simulation-based structured comprehensive curriculum (SCC) designed to teach technical, cognitive, and integrative competencies in colonoscopy. DESIGN: Single-blinded, randomized, controlled trial. SETTING: Endoscopic simulation course at an academic hospital. PARTICIPANTS AND INTERVENTIONS: Thirty-three novice endoscopists were allocated to an SCC group or self-regulated learning (SRL) group. The SCC group received a curriculum consisting of 6 hours of didactic lectures and 8 hours of virtual reality simulation-based training with expert feedback. The SRL group was provided a list of desired objectives and was instructed to practice on the simulator for an equivalent time (8 hours). MAIN OUTCOME MEASUREMENTS: Clinical transfer was assessed during 2 patient colonoscopies using the Joint Advisory Group Direct Observation of Procedural Skills (JAG DOPS) scale. Secondary outcome measures included differences in procedural knowledge, immediate post-training simulation performance, and delayed post-training (4-6 weeks) performance during an integrated scenario test on the JAG DOPS communication and integrated scenario global rating scales. RESULTS: There was no significant difference in baseline or post-training performance on the simulator task. The SCC group performed superiorly during their first and second clinical colonoscopies. Additionally, the SCC group demonstrated significantly better knowledge and colonoscopy-specific performance, communication, and global performance during the integrated scenario. LIMITATIONS: We were unable to measure SRL participants' effort outside of mandatory training. In addition, feedback metrics and number of available simulation cases are limited. CONCLUSIONS: These results support integration of endoscopy simulation into a structured curriculum incorporating instructional feedback and complementary didactic knowledge as a means to augment technical, cognitive, and integrative skills acquisition, as compared with SRL on virtual reality simulators. ( CLINICAL TRIAL REGISTRATION NUMBER: NCT01991522.)

E-mail communication in the management of gastroenterology patients: a review.

E-mail correspondence between physicians and patients can be a useful tool to improve communication efficiency, provide economic and ecological benefits, improve therapeutic interventions and adherence, and enhance self-management. The model of self-management in chronic disease has become an integral component of North American and British medicine. From a practical standpoint, the use of e-mail between physicians and patients can complement the self-management model. E-mail communication has many benefits from both patient and physician perspectives. E-mail contact reduces the inefficiencies associated with telecommunications. Physicians are able to better document out-of-office patient encounters and provide access to specialist care for patients in remote locations. This use of e-mail has the potential to increase patient safety through physician approval of self-manager actions, including earlier initiation of needed treatments. Fewer clinic visits afford additional time for new consultations and sicker patients, reducing the overall burden on referral and wait times. The present article reviews some of the literature regarding physician-patient e-mail communication in the general ambulatory setting, in the context of chronic disease and with a specific focus on inflammatory bowel disease (IBD). The authors provide a framework for the use of e-mail communication in the IBD population, with emphasis on the concept of e-mail use. Also illustrated are the benefits and disadvantages, and examples of the e-mail contract as proposed by the Canadian Medical Protective Association. Examples of specific e-mail communication topics are provided for several IBD scenarios. Potential negative consequences of this mode of communication are also discussed.