Defining competence

Competence in OGD refers to the ability to perform the procedure effectively and safely to defined minimum standards, across a spectrum of cases and contexts. In the UK, the individual competencies are defined within the upper GI DOPS assessment form and the minimum standards defined are stipulated within the 2017 BSG and AUGIS quality standards document.3 It should be noted that competence does not necessarily equate with expertise; it is therefore essential for a practitioner to develop his or her skills beyond the minimum standard of competence. Competence also needs to be maintained; this may encompass a certain minimum case volume, continuous professional development and measurement of performance by key performance indicators (KPIs).

Prior to this document, JAG criteria for certification included only two measures of competence in OGD: ability to reach the second part of the duodenum unassisted in ≥95% cases, and ability to perform a J-manoeuvre unassisted in ≥95% cases. A minimum procedure number of ≥200 had also been mandated. This did not require any defined expertise or assessment in pathology recognition or management. It is recognised that up to 11.3% of upper GI cancers cases may have had a previously normal OGD in the preceding 3 years.7 This might be explained by failure to diagnose early cancers or premalignant pathology at OGD, either due to an inadequate examination, or due to a lack of knowledge of the appearance of such pathology. In colonoscopy, there has been great emphasis on adequate mucosal visualisation to improve adenoma detection rate and reduce post-colonoscopy colorectal cancers. Although premalignant pathology in the upper GI tract is more variable, and the pathways less well defined than the colorectal adenoma–carcinoma sequence, there is an opportunity to detect more relevant pathology than is currently the case.8 9 To address this issue, the BSG and AUGIS standards were published in 2017 with defined minimum and aspirational standards.3 The JAG OGD standards will be aligned with these minimum standards for competent practice.

In addition to technical endoscopic competencies, all trainees should be competent in peri-procedural aspects of endoscopy. These may be preprocedural (to include consent, sedation, etc), procedural (technical and cognitive elements), postprocedural (eg, report writing) and endoscopic non-technical skills (ENTS). These aspects are measured and detailed within direct observation of procedural skills (DOPS) assessments, which include descriptors of the expected levels of competency.

Acquiring competence

There are no published data specifically related to outcomes in training related to JAG-accreditation status of units. However, the processes of quality assurance (QA) of both service and training remain integral to the overall JAG quality framework. The JAG QA process assesses endoscopy units on criteria specifically related to training and the training environment; engagement and benchmarking ensures that standards are maintained and improved.10

Despite full JAG accreditation, some units will have difficulties providing all the required training to the trainees on site, depending on the number of trainees and subspecialties. In the UK, other specialties such as radiology and histopathology have pioneered a more centralised academy-style training programme with organised training focused in one area, but with planned networked exposure in other units. Such a system has been used in advanced endoscopy. Full implementation of academy-based training may be challenging for UK gastroenterology trainees due to the competing non-endoscopy demands.5 11 A more centralised, organised programme may allow more equitable access to training and experiences. In all situations, a full record of training cases should be maintained by the trainee and all training units within a training network should be JAG accredited.

The establishment and evolution of the National Endoscopy Database (NED) is an important initiative for UK endoscopy.12 The data from NED will be used to populate trainees’ individual portfolios and ultimately reduce the time required to develop the trainees’ JETS portfolios. Accuracy of data input will be essential for accurate recording of training and both trainers and trainees will need to ensure that procedures performed outside the normal endoscopy environment (eg, emergencies in theatre) are captured accurately.

Prospective randomised controlled studies have shown that endoscopic simulation-based training (SBT) can significantly enhance the trainee performance.13–17 This is most evident in the early part of the learning curve for novices and improves scope handling skills.17 There is no evidence to show that simulation training significantly impacts the rate of acquisition of the more complex cognitive and management tasks,18 or that simulation reduces the overall number of procedures required to reach overall competence.19 However, a case–control study of novice endoscopists from the UK found that attendees of a 2-day OGD induction course combining theory and SBT were more likely to achieve JAG certification over the 16-month post-course follow-up period.20 While simulation enhances the early acquisition of technical skills, it should not substitute patient-based endoscopy training.21 Such training should be supervised and be associated with specific performance enhancing feedback.22 23

Mandated endoscopy courses are necessary aspects of endoscopy training and skill acquisition that have been stipulated by JAG.24 The JAG Basic Skills in OGD course provides a uniform, structured introduction to OGD, including issues related to indications, safety, ergonomics,25 scope handling,26 sedation and background knowledge. It has been updated to incorporate the additional standards recommended by BSG/AUGIS.3 Other forms of education, including e-learning resources, can enhance acquisition of cognitive skills such as lesion recognition. The JAG QAT Working Group will continue to provide quality assurance of the basic skills course to ensure consistency, validity and currency. Based on colonoscopy data, Basic Skills courses appear to be more useful when attended early during training, that is, probably between 20–70 cases overall.27 As a point of good practice, the trainees, in discussion with their trainers, should plan the timing of the course, within the context of their own personal development plan before starting OGD training. This discussion may well often involve those with a wider remit overseeing the trainees’ progress, particularly regional programme directors.

The Basic Skills Course functions as a complement to continued training at base hospitals and it is important that trainees have the opportunity to reinforce their learning from the course with regular hands-on training. The Basic Skills Course should be undertaken when access to training can be continued over the subsequent 3 months at a minimum, with at least one post-course training-list per week.

Training on dedicated, purpose-specific lists can improve skills acquisition in endoscopy, as shown by the improvement in dysplasia detection rate and reduction in bleeding and perforation rates in comparison to those without formal training.28 29 A variety of other educational resources such as e-learning systems can be beneficial.30 BEST-Academia is a European web-based training platform designed by an expert committee and has been shown to increase detection and delineation of neoplastic lesions in Barrett’s oesophagus.31 Online tools, textbooks, journals, live endoscopy demonstrations, conferences and hospital multidisciplinary teams (MDTs) and teaching sessions can all contribute to the gaining of competence in trainees. Although resources can be sign-posted, it would be counterproductive to be too prescriptive. Similarly, it is important that any resources developed for, or advocated to support, learners within JAG-associated programmes are suitably focused on trainee and patient outcomes. This will need to encompass a suitably broad range of endoscopy cases to maximally enhance pathology recognition, decision-making and ENTS.

While acquisition of purely technical OGD skills occurs relatively quickly, it takes longer, and a greater number of procedures, to develop the essential skills of lesion recognition, management and ENTS.32 33 Currently, the majority of OGD training involves elective outpatient cases, where the incidence of pathology is low. Each trainee should be encouraged to enhance ENTS competency, especially in lesion recognition. Trainers and training units (as well as JAG) are encouraged to develop resources to enhance the development of these skills. Over time, training lists should expand their case-mix to enhance training in pathology recognition and management of a wide range of diagnostic cases, while developing ENTS. This may involve a variety of endoscopy trainers or purpose-specific endoscopy training lists.

There are no data on which to inform any recommendations on desirable timescales for the acquisition of competence in OGD. This is influenced by many variables, including intensity of training.34 Therefore, more intensive training may be favoured within the context of continuous longitudinal endoscopy training, but may not be readily possible in the context of other competing demands for many trainees. The minimum exposure to training should be one specific training list per week. This training list should have the content and number of cases adjusted for the trainee’s development, and importantly include time for feedback and DOPS.

It is accepted that ENTS are important for the safe and effective performance of endoscopy. In the UK, acquisition of these skills lags behind the development of the technical skills of scope control.33 Specific courses and teaching on ENTS has been shown to enhance short-term knowledge performance and recognition of these skills in expert endoscopists and teams.35 Short-term ENTS training, in conjunction with simulation in novices, has been shown to enhance colonoscopy performance and may be generalisable to OGD.36

JAG has previously mandated a minimum of 200 OGD procedures as an eligibility criterion for certification. This was based on earlier studies that found that procedural completion can be achieved within this number. Using the GAGES-UE tool for assessment (which measures only clear technical skills), Vassiliou et al suggested that the gross technical skills were obtainable by 50 cases.37 A prospective, cross-sectional study by Cass et al concluded that gastroenterology and surgical trainees require more than 100 procedures to reach >90% oesophageal intubation rate.38 An earlier UK study found that 187 procedures were required to reach competency in D2 intubation.39 However it is clear that the more complex cognitive and pathology managements skills take longer to acquire than the technical skills required for procedural completion. More recent data from the USA and the UK confirm that the acquisition of the postprocedure technical, cognitive skills and overall global competency often requires 250 or more procedures.32 33 Reliable accurate pathology recognition takes longer, requiring 300 procedures in 90% of cases.32 Overall competency, including postprocedure management, was not reached until 225–249 procedures, although preprocedure competencies such as indication and sedation were developed much earlier (100–124 procedures).33 Technical skills including adequate visualisation of the stomach were acquired at an intermediate rate (150–174 procedures). Therefore, although technical competencies seem to be acquired relatively rapidly, the skills essential for patient management such as ENTS, report writing, pathology recognition and post-endoscopic management require longer.32 33 From JAG certification data,5 the median number of OGD procedures at the time of summative assessment was 282 (ranging between 245–305 for different specialties), suggesting that most trainees feel comfortable applying for certification after performing considerably more than 200 procedures to gain confidence in the more complex cognitive and management aspects of OGD. Accordingly, the panel recommends that all trainees should have a minimum of 250 hands-on OGD procedures to be eligible for summative assessment.

Endoscopy training should ideally be provided by individuals with the requisite skills and behaviours to teach endoscopy effectively, including an awareness of the principles of adult education, best practices in procedural skills education and appropriate use of beneficial educational strategies such as feedback.10 40 41 Trainers in OGD should have appropriate training for their role and undertake regular performance review. Ideally, all trainers will have completed an endoscopy-focused Train-the-Trainer’s (TTT) course. It is aspirational for trainers to have at least annual appraisal of training performance from peers and trainees,42 and undertake formal update training, either as a refresher trainer session or as faculty on a Basic Skills Course, every 5 years. Throughout the UK, many endoscopy trainers provide training in more than one modality. Although attending a Train-Gastroscopy-Trainer (TGT) course is desirable, there is considerable overlap in the educational content of other procedure-specific TTT courses which are transferable to OGD training, and as such, having these credentials would be considered sufficient as an OGD trainer.

There is limited evidence on the effects of training-the-trainer in endoscopy; however studies in the field of surgery have shown that formal training of trainers can result in a significantly higher rating by their learners.43 Having more than one trainer can be beneficial in providing complimentary training and maximising training opportunities. Each trainee should have a specific endoscopy trainer who would directly oversee their development, conduct regular appraisal of progress and plan and document training objectives. This provides the opportunity to discuss learning from adverse events and complications. Appraisal meetings for trainees should take place at least once every 3 months.

Reflective practice is ‘the process whereby an individual thinks analytically about anything relating to their professional practice with the intention of gaining insight and using the lessons learnt to maintain good practice or make improvements where possible’.44 As part of endoscopy training, concurrent (while performing the procedure) and facilitative (delayed feedback or debriefing) techniques may be used. Facilitative feedback is particularly used to help the trainee reflect on what happened, analyse performance and recognise areas of strength and those that need improvement. While students mastering early skills seem to be benefitting from concurrent feedback, performance and learning are enhanced by delayed feedback.40 45 Reflective practice is already established in medical and nursing training and in the post-qualification appraisal process, but has not been formalised within endoscopy training.

The use of reflection in practice has been linked to improvements in learning and improve patient safety.46 The opportunity to consolidate learning and identify opportunities to improve technique or patient care integrates cognitive and non-cognitive skills,47 drawing together elements of best practice from the available literature, tailored to the patient and case. Such reflections allow the inclusion of feedback and learning outcomes from the wider endoscopy team, with focus on the patient and not only on the trainees’ experience. Therefore, it is recommended that reflective learning becomes formalised into the OGD training process.

Assessment of competence

The UK upper GI endoscopy DOPS is a validated tool for assessing competency in upper GI endoscopy. It comprises 34 individual competency items split into six domains, including ENTS. In a UK-wide study involving over 10 000 DOPS assessments by 987 trainees, data on the validity and reliability of DOPS were presented, along with learning curves, competency benchmarks and predictors of competency.33 48 From generalisability theory analyses, satisfactory reliability thresholds could be achieved based on different combinations of assessors and assessments.33

Given that best practice standards in upper GI endoscopy have been stipulated within UK guidelines and endorsed by stakeholder societies,3 the consensus of the working group was to map existing UK upper GI endoscopy standards with those assessed within DOPS to align quality standards with competency measures (online supplemental table 1).

The total OGD procedure time has been shown to correlate with diagnostic yield, and a minimum time of 7 min has been suggested in European guidelines.49 50 This ensures sufficient time for thorough inspection, washing and the application of antispasmodics and mucolytics where appropriate.51 The UK BSG/AUGIS standards recommend noting total procedure time for all surveillance procedures; this should be included in the endoscopy report and assessed within DOPS.

Surveillance of Barrett’s oesophagus is considered a high-risk indication. A systematic review by Visrodia et al cited a 1-year PEUGIC rate of 25%.52 In recognition of the technical nuances in Barrett’s surveillance (eg, mucosal inspection, usual of adjunct, dysplasia assessment, biopsies), the panel favoured the development of formative DOPS specific to Barrett’s surveillance to facilitate competency assessment and to ultimately improve endoscopic quality and reduce PEUGIC rates with Barrett’s oesophagus.

All UK trainees in GI endoscopy are required to register and log training data onto the JETS e-portfolio. This generates KPIs which act as a surrogate measure of competence. The NED project aims to upload trainee-level procedural data from individual endoscopy reporting systems directly to the JETS e-portfolio for QA purposes.12 This includes procedure-specific outcome data necessary for KPI calculations, for example, indications, diagnoses, therapeutic data, sedation and complications. The OGD DOPS are recorded separately on JETS but do not contain procedural outcome data. Where appropriate, assessment data from DOPS should be linked to procedural outcome data to facilitate QA and research in OGD training.

The provision of performance-enhancing feedback is central to supervised endoscopy training and is embedded in the JAG TTT philosophy. The DOPS provide an essential means for focusing the feedback related to procedures as well as mapping out the learning and development curve for the trainee.45 We recommend for a minimum of one DOPS every 10 cases during training. Trainees and trainers are however encouraged to do as many as they feel appropriate.

To minimise selection bias, each DOPS should be performed on a single case prespecified by the trainee or trainer. DOPS should not be retrospectively chosen on a completed case or averaged across cases performed on a list.

Data from the JETS database shows that the reliability of the DOPS varied with the number of observers and the number of DOPS.33 DOPS from at least three observers are required for adequate reliability for determining competence. Therefore, it is recommended that at least nine DOPS in total, with at least three different observers, be performed in the last 100 cases before deciding to continue to summative assessment. Based on existing requirements, trainees should be competent in the last five DOPS in a minimum of 90% of all assessed items, with none requiring maximal or significant supervision.

Based on the recommendation statements within this document, trainees will only be eligible for summative assessment when they have fulfilled the criteria above (figure 1).

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Figure 1

Proposed JAG pathway for training and certification in OGD. DOPS, direct observation of procedural skills; GI, gastrointestinal; NED, National Endoscopy Database; OGD, oesophagogastroduodenoscopy; PD, program director

All JAG certification pathways require trainees to undertake summative assessment in order to provide robust and objective demonstration of competence to determine readiness for independent practice. To mitigate bias, trainees must perform a total of four summative OGD DOPS and be rated competent in all items by two different assessors, none of whom should be their current main assessor. Assessors should have trainer credentials and should have received formal training in assessing DOPS.

Post-certification support

In the post-certification period, it is recognised that most newly certified practitioners will require a defined period of supervision (eg, 1 year) and ongoing endoscopy exposure to achieve the outcomes of an experienced practitioner.53 54 As such, a newly-certified practitioner should have access to a named supervisor who can review progress and provide advice where needed. Instances where support may be beneficial may include: review of photodocumentation (and indeterminate lesions) and postprocedural management plans. We recommend that such arrangements should be made with a named supervisor on a regular basis to safeguard patient management and to facilitate skills development. The supervisor should possess valid trainer credentials, that is, recognised OGD trainer and have attended a TTT course.

In endoscopy, the path from competent to high-quality practice involves an ongoing learning curve post-certification. We recommend that, as part of professional development, the training requirements of newly-certified endoscopists should be identified, discussed and recorded. For OGD, this could include lesion characterisation training, for example, Barrett’s surveillance, and training in therapeutic modalities, for example, upper GI bleed haemostasis, oesophageal dilatation. This should include plans for supporting underperformance if self-reported or observed during the newly independent period, in line with JAG guidance.55 Practitioners should also be encouraged to attend upper GI MDT meetings at least on an ad hoc basis.

During newly-independent practice, it is possible that the cessation of directly supervised practice can lead to a drop in performance.56 An analysis of completion metrics recorded on the UK trainee e-portfolio found a small but statistically significant decrement in mean D2 intubation and J-manoeuvre rates in the 3 months pre-certification versus post-certification.5 We suggest that, in the immediate post-certification period, there should be systems in place to ensure that list size and caseload selection is tailored to the practitioner. Existing JAG guidelines (predating COVID-19) recommend for a standard diagnostic OGD to be allocated a minimum of 20 min; this may need to be increased in the immediate post-certification period.

We recommend that complex cases, for example, acute upper GI bleeding, known therapeutic intent, previous intubation failure,57 American Society of Anaesthesiologists grade 3+ or patients on the intensive care unit, should not be independently performed by the new-certified endoscopist unless deemed competent by a supervisor/training lead. Newly-certified practitioners should be able to review the caseload and volume on their list to ensure appropriateness, to anticipate issues and for time management purposes. This is a prerequisite for checklists and effective team briefing and should be considered part of the non-technical skills repertoire.58 59

The recent implementation of the UK NED enables key performance indicators in OGD to be collected centrally and benchmarked against national quality standards to quality assure endoscopy practice.12 In according with JAG recommendations for quality assurance of services, performance data of newly-certified practitioners should be subjected to review at regular intervals to enable practitioners to discuss queries, concerns or issues with caseload or time management.

Complications during OGD are rare but may be more common in interventional procedures performed by trainees.60 All significant adverse events, that is, perforation, bleeding, missed cancer, postprocedural readmissions and mortality, should be discussed locally at an endoscopy governance meeting. In cases where adverse events are deemed to be avoidable through technical or non-technical factors attributable to the endoscopist, such cases should be formally reflected on and discussed in appraisals involving their supervisor.

The BSG/AUGIS quality standards document suggests for each endoscopist to perform at least 100 OGDs per year to maintain proficiency and prevent skills decay.3 Evidence for this has been inferred from colonoscopy practice.34 Although it is acknowledged that practitioners within training programmes may struggle to achieve such a volume due to conflicting commitments, endoscopy services and training programmes should strive to enable newly-independent practitioners to achieve such a volume in line with national guidance.