title: Measures of trainee performance in advanced endoscopy: A systematic review.
abstract: BACKGROUND
  The diversity, technical skills required, and risk inherent to advanced endoscopy techniques all contribute to complex training curricula and steep learning curves. Since trainees develop endoscopy skills at different rates, there has been a shift towards competency-based training and certification. Validated endoscopy performance measures for trainees are, therefore, necessary. The aim of this systematic review was to describe and critically assess the existing evidence regarding measures of performance for trainees in advanced endoscopy.
  
  
  METHODS
  A systematic review of the literature from January 1980 to January 2016 was carried out using the MEDLINE, EMBASE, CENTRAL, and ISI Web of knowledge databases. MeSH terms related to 'advanced endoscopy' and 'performance' were applied to a highly sensitive search strategy. The main outcomes were face, content, and construct validity, as well as reliability.
  
  
  RESULTS
  The literature search yielded 1,662 studies and 77 met the inclusion criteria after abstract and full-text review (endoscopic retrograde cholangiopancreatography (ERCP)=23, endoscopic ultrasound (EUS)=30, colonoscopic polypectomy (CP)=11, balloon-assisted enteroscopy (BAE)=7, luminal stenting=3, radiofrequency ablation (RFA)=2, and endoscopic muscosal resection (EMR)=1). Good validity and reliability were found for measurement tools of overall performance in ERCP, EUS and CP, with applications for both patient-based and simulator training models. A number of specific technical skills were also shown to be valid measures of performance. These include: selective biliary cannulation, sphincterotomy, biliary stent placement, stone extraction and procedure time for ERCP; pancreatic solid mass T-staging, EUS-guided fine needle aspiration (EUS-FNA) procedure time, number of EUS-FNA passes and puncture precision for EUS; procedure time and en bloc resection rate for CP; retrograde fluoroscopy time for BAE; and mean number of endoscopy sessions required to achieve complete eradication of intestinal metaplasia (CIEM) for RFA. The evidence for EMR and luminal stenting is of insufficient quality to make recommendations.
  
  
  CONCLUSIONS
  We have identified multiple valid and readily available performance measures for advanced endoscopy trainees for ERCP, EUS, CP, BAE and RFA procedures. These tools should be considered in advanced endoscopy training programs wishing to move away from apprenticeship-based training and towards competency-based learning with the help of patient-based and simulator tools.
authors.affiliation: Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. Electronic address: pjames@toh.on.ca.
authors.forename: P D
authors.initials: PD
authors.lastname: James
authors.affiliation: Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
authors.forename: L
authors.initials: L
authors.lastname: Antonova
authors.affiliation: Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada.
authors.forename: M
authors.initials: M
authors.lastname: Martel
authors.affiliation: Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada; Epidemiology and Biostatistics and Occupational Health, McGill University Health Center, McGill University, Montreal, Quebec, Canada.
authors.forename: A
authors.initials: A
authors.lastname: Barkun
mesh_terms: D000071087:Balloon Enteroscopy / Q000193:education; D002760:Cholangiopancreatography, Endoscopic Retrograde; D002983:Clinical Competence / Q000592:standards*; D003113:Colonoscopy / Q000193:education; D004503:Education, Medical, Graduate / Q000592:standards*; D004521:Educational Measurement; D004724:Endoscopy / Q000193:education*; D019160:Endosonography; D006801:Humans; D061208:Pulsed Radiofrequency Treatment; D015203:Reproducibility of Results
keywords: Advanced endoscopy; Gastrointestinal endoscopy; Performance; Training