Training in Endoscopy: Coaching, Deliberate Practice, and Reflection

See “Can Pediatric Endoscopists Accurately Assess Their Clinical Competency? A Comparison Across Skill Levels” by Scaffidi et al on page 311. Performing endoscopy requires a complex set of knowledge and skills that is developed during fellowship training and continues to be honed throughout a career in pediatric gastroenterology. In this issue of JPGN, Scaffidi et al (1) report an analysis of how endoscopists’ self-assessment of competency compares to the assessment by an external observer. The authors demonstrate that self-assessment of competency is more accurate in expert endoscopists when compared to novice endoscopists, who demonstrate an inflated assessment of their competency as compared to the external evaluator. Although the fact that the external evaluators were recruited from the same program as the endoscopists being rated may have introduced some bias, the authors’ conclusions are well supported and in accord with the education literature. The competencies necessary for the performance of endoscopy can be divided into 3 major domains: cognitive, technical (or psychomotor), and integrative. The cognitive domain includes knowledge of the indications and risks of endoscopy, knowledge of anatomical landmarks, and recognition of pathological abnormalities. The technical domain includes the skills of manipulating the scope to insure timely advancement of the instrument, and performance of diagnostic maneuvers such as biopsy. The technical aspect of performing endoscopy is akin to skills critical to performance in sports or music. The integrative domain, according to Walsh et al (2), includes communication, judgment, and clinical reasoning. The development of technical expertise has been the recent focus of intense scientific inquiry. Sports science suggests that coaching, deliberate practice, and reflection are necessary to become an elite athlete. Likewise, we suggest that coaching, deliberate practice, and reflection, including self-assessment, are necessary to become an expert endoscopist. COACHING A growing body of literature suggests that it is not the sheer volume of experience during training, but the quality of coaching that leads to the development of expertise in physicians. A recent systematic review of coaching in surgical operative performance demonstrated a positive impact of coaching on learners’ perception (self-assessment), technical skills, nontechnical skills (defined as communication and teamwork), and performance measures (3). In endoscopy, train-the-trainer courses essentially teach expert endoscopists the art of coaching. One goal of this coaching is to increase trainees’ self-awareness, or “conscious competence,” whereby they become cognizant of why and how they are performing an endoscopic maneuver (4). Coaching of novice endoscopists can help provide the framework for first understanding and then developing their skills. By gaining a more complete understanding of the technical skills necessary for endoscopy, many novice endoscopists will also have a better awareness of their procedural competency, including their areas of strength and weakness. DELIBERATE PRACTICE Not every kind of practice leads to improvement in skills. In 1993, Ericsson et al (5) published a landmark study demonstrating that deliberate practice, defined as practice that is purposeful, systematic, and requiring continuous feedback, is necessary to become an expert performer. This study became the basis Gladwell's book Outliers(6), which suggests that 10,000 hours of practice are necessary to become an expert. More recently, Ericsson published articles in Academic Emergency Medicine and Academic Medicine examining application of the deliberate practice model to medicine. He concludes that “the best training situations focus on opportunities for immediate feedback, reflection, and corrections” (7). In addition, he suggests expert performance does not automatically develop with experience, but requires training opportunities for deliberate practice of skills and integrated systems of performance analysis including self-regulation (8). A review by Reznick et al in the NEJM on surgical training supports Ericsson's theory that expertise is developed with deliberate practice, rather than number of hours in surgery (9). Applying these studies to endoscopy, we can conclude that a significant amount of deliberate practice is necessary to become an expert endoscopist, and this practice should focus on defined tasks, with coaching and immediate feedback. According to Walsh et al (2), these tasks include use of angulation control knobs, intermittent advancement and withdrawal, torque steering, and loop reduction to insure optimal advancement of the instrument and visualization of the mucosa. Incorporating deliberate practice into endoscopy skill training will provide trainees with the expert-level practice needed to reach expert-level performance. Without deliberate practice, trainees often repeat and reinforce incorrect procedures, leaving them with the misperception that the quantity of practice rather than the quality of practice leads to mastery. REFLECTION In addition to practice, reflection—the process of reviewing actions or experience to gain new understanding—has been associated with improved performance. Self-reflection has been linked to professional development in teachers, counselors, and leaders. In the medical community, self-reflection may be fostered by incorporating debriefing after clinical encounters or reviewing events in a morbidity and mortality conference. A recent systematic review in the Journal of General Medical Education concluded that reflection improved empathy, learning in complex situations, and engagement in the learning process (10), suggesting the importance of teaching self-reflection to students and trainees alike. Reflection is itself a skill and can be coached and integrated into typical feedback sessions. Trainees can also engage in “guided” reflection, or deliberate stepwise evaluation with a faculty member, which has been shown to be a consistent, successful strategy to improve diagnostic decision making (11). By increasing the understanding that reflection plays in mastering cognitive and technical skills required for endoscopy, it is likely that novice learners will have a better understanding of their own competence for procedures and other aspects of medical care. SELF-ASSESSMENT The study by Scaffidi et al suggests that as endoscopists move from novice to expert levels they develop a more accurate assessment of their competency. The accuracy of physician self-assessment has been studied previously and demonstrates that physicians are, in general, poor at self-assessment. A systematic review published in JAMA over a decade ago by Davis et al (12) found a preponderance of evidence that physicians have a limited ability to accurately self-assess. Furthermore, even those who perform worst at tasks frequently believe they are above average (13). Expert endoscopists may have improved self-assessment as a result of a better understanding of the individual skills they are practicing and coaching, and larger volume of cases on which to reflect. As the application of reflection increases in the practice of medicine, the accuracy of self-assessment, a type of reflection, is likely to increase. We suggest that novice endoscopists who engage in the practice of reflection, especially guided reflection, will improve their ability to accurately self-assess their performance. SUMMARY The study by Scaffidi et al (1) demonstrates that novice endoscopists overestimate their competency. Although the results of this study are not surprising, they should not be interpreted solely as negative findings. In fact, the study demonstrates that when endoscopists reach the intermediate level of experience, which is often by the end of training (assuming 120 colonoscopies), they demonstrate relatively accurate self-assessment of competency. This suggests that, through training and coaching in endoscopy, learners become more aware of their skills and deficiencies, and ultimately develop valid self-assessment as they reflect on their endoscopic competence. Training of endoscopy that includes coaching, deliberate practice, and reflection is likely to result in consciously competent endoscopists and reflective practitioners who better understand their competencies and limitations.