title: Progressive learning in endoscopy simulation training improves clinical performance: a blinded randomized trial.
abstract: OBJECTIVE
  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.).
authors.affiliation: Division of Gastroenterology, St. Michael's Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Samir C
authors.initials: SC
authors.lastname: Grover
authors.affiliation: Division of Gastroenterology, St. Michael's Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Scaffidi
authors.affiliation: Division of Gastroenterology, St. Michael's Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Rishad
authors.initials: R
authors.lastname: Khan
authors.affiliation: Division of Gastroenterology, St. Michael's Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Ankit
authors.initials: A
authors.lastname: Garg
authors.affiliation: Division of Gastroenterology, St. Michael's Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Al-Mazroui
authors.affiliation: Division of Gastroenterology, St. Michael's Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Tareq
authors.initials: T
authors.lastname: Alomani
authors.affiliation: Division of Gastroenterology, Hepatology, and Nutrition, Learning Institute, and Research Institute, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; The Wilson Centre, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Yu
authors.affiliation: Division of Gastroenterology, St. Michael's Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Ian S
authors.initials: IS
authors.lastname: Plener
authors.affiliation: Division of Gastroenterology, St. Michael's Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Al-Awamy
authors.affiliation: Division of Gastroenterology, Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Elaine L
authors.initials: EL
authors.lastname: Yong
authors.affiliation: Division of Gastroenterology, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Maria
authors.initials: M
authors.lastname: Cino
authors.affiliation: Division of Gastroenterology, St. Michael's Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Nikila C
authors.initials: NC
authors.lastname: Ravindran
authors.affiliation: Division of Gastroenterology, St. Michael's Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Mark
authors.initials: M
authors.lastname: Zasowski
authors.affiliation: Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Teodor P
authors.initials: TP
authors.lastname: Grantcharov
authors.affiliation: Division of Gastroenterology, Hepatology, and Nutrition, Learning Institute, and Research Institute, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; The Wilson Centre, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Catharine M
authors.initials: CM
authors.lastname: Walsh
mesh_terms: D000328:Adult; D002983:Clinical Competence; D003113:Colonoscopy / Q000193:education*; D004503:Education, Medical, Graduate; D005260:Female; D005762:Gastroenterology / Q000193:education; D013502:General Surgery / Q000193:education; D006801:Humans; D007388:Internal Medicine / Q000193:education; D008297:Male; D018794:Problem-Based Learning / Q000379:methods*; D000066908:Simulation Training / Q000379:methods*; D016037:Single-Blind Method