title: Variation in learning curves and competence for ERCP among advanced endoscopy trainees by using cumulative sum analysis.
abstract: OBJECTIVE
  There are limited data on learning curves and competence in ERCP. By using a standardized data collection tool, we aimed to prospectively define learning curves and measure competence among advanced endoscopy trainees (AETs) by using cumulative sum (CUSUM) analysis.
  
  
  METHODS
  AETs were evaluated by attending endoscopists starting with the 26th hands-on ERCP examination and then every ERCP examination during the 12-month training period. A standardized ERCP competency assessment tool (using a 4-point scoring system) was used to grade the examination. CUSUM analysis was applied to produce learning curves for individual technical and cognitive components of ERCP performance (success defined as a score of 1, acceptable and unacceptable failures [p1] of 10% and 20%, respectively). Sensitivity analyses varying p1 and by using a less-stringent definition of success were performed.
  
  
  RESULTS
  Five AETs were included with a total of 1049 graded ERCPs (mean ± SD, 209.8 ± 91.6/AET). The majority of cases were performed for a biliary indication (80%). The overall and native papilla allowed cannulation times were 3.1 ± 3.6 and 5.7 ± 4, respectively. Overall learning curves demonstrated substantial variability for individual technical and cognitive endpoints. Although nearly all AETs achieved competence in overall cannulation, none achieved competence for cannulation in cases with a native papilla. Sensitivity analyses increased the proportion of AETs who achieved competence.
  
  
  CONCLUSIONS
  This study demonstrates that there is substantial variability in ERCP learning curves among AETs. A specific case volume does not ensure competence, especially for native papilla cannulation.
authors.affiliation: University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
authors.forename: Sachin
authors.initials: S
authors.lastname: Wani
authors.affiliation: University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
authors.forename: Matthew
authors.initials: M
authors.lastname: Hall
authors.affiliation: University of Virginia Health System, Charlottesville, Virginia, USA.
authors.forename: Andrew Y
authors.initials: AY
authors.lastname: Wang
authors.affiliation: Icahn School of Medicine at Mount Sinai, New York, New York, USA.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: DiMaio
authors.affiliation: University of California, Los Angeles, Los Angeles, California, USA.
authors.forename: V Raman
authors.initials: VR
authors.lastname: Muthusamy
authors.affiliation: Feinberg School of Medicine Northwestern University, Chicago, Illinois, USA.
authors.forename: Rajesh N
authors.initials: RN
authors.lastname: Keswani
authors.affiliation: University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
authors.forename: Brian C
authors.initials: BC
authors.lastname: Brauer
authors.affiliation: Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Easler
authors.affiliation: University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
authors.forename: Roy D
authors.initials: RD
authors.lastname: Yen
authors.affiliation: University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
authors.forename: Ihab
authors.initials: I
authors.lastname: El Hajj
authors.affiliation: University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
authors.forename: Norio
authors.initials: N
authors.lastname: Fukami
authors.affiliation: University of California, Los Angeles, Los Angeles, California, USA.
authors.forename: Kourosh F
authors.initials: KF
authors.lastname: Ghassemi
authors.affiliation: Icahn School of Medicine at Mount Sinai, New York, New York, USA.
authors.forename: Susana
authors.initials: S
authors.lastname: Gonzalez
authors.affiliation: University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
authors.forename: Lindsay
authors.initials: L
authors.lastname: Hosford
authors.affiliation: Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: Thomas G
authors.initials: TG
authors.lastname: Hollander
authors.affiliation: University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Wilson
authors.affiliation: Icahn School of Medicine at Mount Sinai, New York, New York, USA.
authors.forename: Vladimir M
authors.initials: VM
authors.lastname: Kushnir
authors.affiliation: Icahn School of Medicine at Mount Sinai, New York, New York, USA.
authors.forename: Jawad
authors.initials: J
authors.lastname: Ahmad
authors.affiliation: Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: Faris
authors.initials: F
authors.lastname: Murad
authors.affiliation: Icahn School of Medicine at Mount Sinai, New York, New York, USA.
authors.forename: Anoop
authors.initials: A
authors.lastname: Prabhu
authors.affiliation: University of California, Los Angeles, Los Angeles, California, USA.
authors.forename: Rabindra R
authors.initials: RR
authors.lastname: Watson
authors.affiliation: University of Virginia Health System, Charlottesville, Virginia, USA.
authors.forename: Daniel S
authors.initials: DS
authors.lastname: Strand
authors.affiliation: University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
authors.forename: Stuart K
authors.initials: SK
authors.lastname: Amateau
authors.affiliation: University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
authors.forename: Augustin
authors.initials: A
authors.lastname: Attwell
authors.affiliation: University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
authors.forename: Raj J
authors.initials: RJ
authors.lastname: Shah
authors.affiliation: Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: Dayna
authors.initials: D
authors.lastname: Early
authors.affiliation: Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: Steven A
authors.initials: SA
authors.lastname: Edmundowicz
authors.affiliation: Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: Daniel
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mesh_terms: D002404:Catheterization / Q000592:standards; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects / Q000592:standards* / Q000706:statistics & numerical data; D002983:Clinical Competence; D004503:Education, Medical, Graduate; D005762:Gastroenterology / Q000193:education*; D006801:Humans; D059032:Learning Curve; D011446:Prospective Studies