title: Competence development in ERCP: the learning curve of novice trainees.
abstract: OBJECTIVE
  Measures for competence in endoscopic retrograde cholangiopancreatography (ERCP) during training are poorly defined. Currently, various training and accreditation programs base verification of competence on performance of a minimum number of procedures. There is a general awareness that procedural competence certification should be based on objective performance criteria. Continuous self-assessment using a Rotterdam Assessment Form for ERCP (RAF-E) can provide insight into trainee performance. The study aim was to express development in ERCP competence as a learning curve.
  
  
  METHODS
  ERCP trainees at a tertiary referral center in the Netherlands were invited to participate. Performed procedures were appraised using RAF-E. Indication for each ERCP and presence of a virgin papilla were documented. Complexity was graded on a 3-point scale. The primary outcome parameter was common bile duct (CBD) cannulation success rate. Success of the intended therapeutic interventions was additionally expressed as a learning curve.
  
  
  RESULTS
  15 trainees were included. 1541 ERCPs (624 procedures in native papillary anatomy) were assessed through RAF-E. Unassisted CBD cannulation success rate improved from 36 % at baseline to 85 % after 200 procedures (P < 0.001), and in 624 patients with a virgin papilla from 22 % at baseline to 68 % after 180 procedures (P < 0.001). Learning curves for therapeutic interventions showed significant improvements for successful sphincterotomy (P = 0.01) and stent placement (P < 0.001).
  
  
  CONCLUSIONS
  Learning curves are a valuable means for assessing competence in ERCP. Differences in learning curves can be shown with RAF-E. Verification of competence should be based on actual performance, instead of minimum numbers.
authors.affiliation: Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, The Netherlands.
authors.forename: Vivian E
authors.initials: VE
authors.lastname: Ekkelenkamp
authors.affiliation: Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, The Netherlands.
authors.forename: Arjun D
authors.initials: AD
authors.lastname: Koch
authors.affiliation: Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, The Netherlands.
authors.forename: Erik A J
authors.initials: EA
authors.lastname: Rauws
authors.affiliation: Department of Public Health, Erasmus MC University Medical Center Rotterdam, The Netherlands.
authors.forename: Gerard J J M
authors.initials: GJ
authors.lastname: Borsboom
authors.affiliation: Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, The Netherlands.
authors.forename: Robert A
authors.initials: RA
authors.lastname: de Man
authors.affiliation: Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, The Netherlands.
authors.forename: Ernst J
authors.initials: EJ
authors.lastname: Kuipers
mesh_terms: D002404:Catheterization / Q000592:standards; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000592:standards*; D002983:Clinical Competence / Q000592:standards*; D003135:Common Bile Duct; D005762:Gastroenterology / Q000193:education*; D006801:Humans; D059032:Learning Curve; D009426:Netherlands; D017063:Outcome Assessment, Health Care / Q000379:methods*; D011446:Prospective Studies; D019919:Prosthesis Implantation / Q000592:standards; D012647:Self-Assessment; D016717:Sphincterotomy, Endoscopic / Q000592:standards; D015607:Stents