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Use of a Colonoscopy Simulator in Resident Education:  Preliminary Results

Use of a Colonoscopy Simulator in Resident Education:  Preliminary Results. Cho SD, El Youssef R, Diggs B, Lu K Oregon Health and Science University Portland, Oregon 2009 Meeting of the Northwest Society of Colon and Rectal Surgeons 8 . 7 . 09. Background Demand for colonoscopy.

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Use of a Colonoscopy Simulator in Resident Education:  Preliminary Results

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  1. Use of a Colonoscopy Simulator in Resident Education:  Preliminary Results Cho SD, El Youssef R, Diggs B, Lu K Oregon Health and Science University Portland, Oregon 2009 Meeting of the Northwest Society of Colon and Rectal Surgeons 8 . 7 . 09

  2. BackgroundDemand for colonoscopy • National Polyp Study • 76-90% reduction CRC incidence with polypectomy • Colonoscopy recommended for CRC screening • ASGE • ASCRS • ACS Preferred method Winawer, et al, NEJM 1993 Smith, et al, CA Cancer J Clin 2008 Davila, et al, GastrointestEndosc 2006 http://www.fascrs.org/

  3. BackgroundDemand for screening colonoscopy US colonoscopies 4.4 million 2.2 million - Surveillance - Diagnosis - Treatment • Rex & Lieberman, GastrointestEndosc 2001 • Goldenberg, et al, SurgEndosc 2006 • Gross, et al, JAMA 2006

  4. BackgroundDemand for screening colonoscopy US colonoscopies US pop. age 50-70 77 million 2.2 million screening 7.7 million to screen 5.5 million shortage • 75-90% • Not screened 4 million increase/yr • Rex & Lieberman, GastrointestEndosc 2001 • Goldenberg, et al, SurgEndosc 2006 • Gross, et al, JAMA 2006

  5. BackgroundDemand for screening colonoscopy Unmet demand for 9.5 million screening colonoscopies per year 5.5 million shortage + 4 million population increase • Rex & Lieberman, GastrointestEndosc 2001 • Goldenberg, et al, SurgEndosc 2006 • Gross, et al, JAMA 2006

  6. Need for endoscopists • Zuckerman, et al, Am Surg 2007 • 42% rural surgeons > 200 endoscopies/yr • 12% urban surgeons > 200 endoscopies/yr • Sariego, Am Surg 2000 • Endoscopy 24% of all cases • Pos findings 72% colonoscopy for any reason

  7. There is a high demand for skilled endoscopists There is a need for increased colonoscopy training during residency

  8. Do we need simulators? • Scott & Dunnington, J GastrointestSurg 2008 • www.acgme.org • ACGME/RRC requirements • 2003 – Workhour restrictions • 2006 – 300% increase endoscopy requirements surgery residents (29 → 85) • 2008 – skills lab mandatory in all programs • Need for endoscopists Simulators potentially invaluable tool for endoscopy training

  9. Are simulators valid? Validated against “gold standard” of expert endoscopists

  10. What is the benefit? Accelerate competency in the patient setting Decrease training time & costs

  11. Colonoscopy simulation curriculum Implemented at OHSU 2008 Protected educational time 4 week block Small group format Colorectal staff proctor

  12. Research question Does colonoscopy simulator differentiate Surgery residents Priorvsno prior traditional endoscopy rotation Commonly measured performance indicators

  13. Study design • Prospective cohort study • General surgery residents • 52 total / year • University program • Community endoscopy rotation

  14. Prospective data collection • Simulation • 4 week block rotation R2 R3 R5 R4 • Traditional rotation • 1 resident : 1 faculty • 50-90 colonscopies No prior endoscopy Prior endoscopy

  15. Study variables Total procedure time Time to reach cecum Time withdrawal % discomfort time % mucosa visualized % redout Perforation

  16. AccuTouch simulator Immersion Medical, San Jose, CA

  17. Simulation

  18. Clinical scenarios

  19. Results • 131 simulations • 56 prior endoscopy rotation (endo YES) • 75 no prior endoscopy (endo NO) • 14 perforations • Excluded from time-dependent variables e.g. procedure time • 0 cases oversedation

  20. ResultsCohort as a whole

  21. ResultsIntro case • Normal anatomy • Normal pain threshold • Endo YES • Decreased procedure time → faster to cecum • Δ advance = 2.2 min

  22. ResultsBiopsy case 1 • Normal anatomy • Low pain threshold • Bleeding • Endo YES • Decreased procedure time → faster to cecum • Δ advance = 3.8 min

  23. ResultsBiopsy case 2 • Tight sigmoid turn • Bleeding • Endo YES • Decreased all times • Decreased % redout • Δ advance = 1.5 min • Most technically difficult • May explain greater differentiation

  24. ResultsPolypectomy • Normal anatomy • Normal pain threshold • 2 polyps • Endo YES • Δ advance = 0.4 min • Similar results • Easier case • “Time equalizer” • Endo NO group ↑ ability • Proctor intervention

  25. Limitations • Small numbers • Consistent with literature • Validate against experienced endoscopists • Surgery attendings • GI attendings • Proctor intervention • Balance between research aims and educational experience • True cecal intubation rate may be unknown

  26. Ongoing work • Methods • Improved standardization of lesson plan • Validation • Expert validation • GI fellows benchmark for learning curve • Clinical translatability • Performance metrics during clinical rotation

  27. Conclusions Colonoscopy simulator differentiates prior vs. no endoscopy experience • Total procedure time reduced with prior experience • Time reduction primarily in time to cecum • Differences more evident with difficult simulations • Discriminatory ability greater than prior data suggests

  28. Acknowledgements Kim Lu, MD Daniel Herzig, MD Brian Diggs, PhD Raphael el Youssef, MD

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