conflicts of interest disclosure · milestones 1. 2. 3. competency-based technical competencies...
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Catharine M Walsh, MD, MEd, PhD, FRCPCHospital for Sick Children, University of Toronto
Pediatric Endoscopy TrainingAnd Future Learning
(over the past 24 months)
No relevant relationships with any commercial or non-profit organizations
DisclosureConflicts of Interest
Catharine Walsh
Catharine M Walsh CDDW 2018 - Postgraduate Course (Advancing Care)
Pediatric Endoscopy February 9, 2018 Page 1
XMedical Expert (as Medical Experts, physicians integrate all of the CanMEDS Roles, applying medical knowledge, clinical skills, and professional values in their provision of high-quality and safe patient-centered care. Medical Expert is the central physician Role in the CanMEDS Framework and defines the physician’s clinical scope of practice.)
XCommunicator (as Communicators, physicians form relationships with patients and their families that facilitate the gathering and sharing of essential information for effective health care.)
X Collaborator (as Collaborators, physicians work effectively with other health care professionals to provide safe, high-quality, patient-centred care.)
XLeader (as Leaders, physicians engage with others to contribute to a vision of a high-quality health care system and take responsibility for the delivery of excellent patient care through their activities as clinicians, administrators, scholars, or teachers.)
Health Advocate (as Health Advocates, physicians contribute their expertise and influence as they work with communities or patient populations to improve health. They work with those they serve to determine and understand needs, speak on behalf of others when required, and support the mobilization of resources to effect change.)
XScholar (as Scholars, physicians demonstrate a lifelong commitment to excellence in practice through continuous learning and by teaching others, evaluating evidence, and contributing to scholarship.)
Professional (as Professionals, physicians are committed to the health and well-being of individual patients and society through ethical practice, high personal standards of behaviour, accountability to the profession and society, physician-led regulation, and maintenance of personal health.)
CanMEDS Roles Covered
• Upon completion of this sessionthe learner will be able to:• Describe the current training paradigm and
recognize potential areas for improvement• Discuss the need for faculty upskilling and
ongoing assessment of endoscopic skills• Identify strategies for mentoring junior
faculty with regard to endoscopy
Objectives
Catharine M Walsh CDDW 2018 - Postgraduate Course (Advancing Care)
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EndoscopyPediatric
Increased focus on:• How we train• Faculty development
Changing assumptions:• Its not all about volume, quality of education
and assessment is important• Training is time consuming but effective training
and assessment accelerates learning
ShiftingModel of Training
Walsh CM et al. JPGN 2017;64(4):501-4.
Catharine M Walsh CDDW 2018 - Postgraduate Course (Advancing Care)
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Training
VR SimulationTraining
Khan R et al., Cochrane 2018 [Submitted].
Inception – July 2017
18 trials, 421 participants
Results:• VR training can be used to effectively supplement
early conventional training for novices• Composite score of competence• Independent procedure completion• Visualization of mucosa
Catharine M Walsh CDDW 2018 - Postgraduate Course (Advancing Care)
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Match the TASK COMPLEXITY to SKILL LEVEL
ProgressiveTraining Model
Grover SC et al., Gastrointestinal Endoscopy 2017;86(5):881-9.
0
10
20
30
40
50
60
70
80
90
Colonoscopy 1 Colonoscopy 2
**
PLSC
* p < 0.05d = 1.30
JAG
DO
PS
% S
core
(m
ax 1
00)
ClinicalPerformance
Grover SC et al., Gastrointestinal Endoscopy 2017;86(5):881-9.
Catharine M Walsh CDDW 2018 - Postgraduate Course (Advancing Care)
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Training Endoscopy Trainers
Walsh CM et al. JPGN 2017;64(4):501-4; Grover SC et al. Gastrointestinal Endoscopy 2015;82(6):1072-9.Waschke K et al. Best Practice and Research: Clinical Gastroenterology 2016;30(3):409-19.
Assessment
Catharine M Walsh CDDW 2018 - Postgraduate Course (Advancing Care)
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TrainingMilestones
1.
2.
3.
Competency-Based
TechnicalCompetencies
CognitiveCompetencies
IntegrativeCompetencies
EndoscopicCompetence
Walsh CM et al., Gastrointestinal Endoscopy 2014;79:798-807.
Catharine M Walsh CDDW 2018 - Postgraduate Course (Advancing Care)
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Maximal performance
Pusic M et al. Academic Medicine 2015;90(8):1034-42
Learning CurvesPe
rfor
man
ce
Slow beginning
Steep acceleration
Plateau
Slope = rate of learning
Deliberate Practice
Variable Learning Curves
Ward ST et al. Gut 2014:63(11):1746-54; Sedlack RE et al. GIE 2016 83(3):516-23; Cass OW et al. Endoscopy 1999;31(9):751-754
Perf
orm
ance
Deliberate Practice
Catharine M Walsh CDDW 2018 - Postgraduate Course (Advancing Care)
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Competency Thresholds
GiECATkids Learning Curve
Walsh CM et al., JPGN 2015;60:474-480
Catharine M Walsh CDDW 2018 - Postgraduate Course (Advancing Care)
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Assessment drives learning• Assessment for learning
Meaningful feedback essential• Two-way process
Longitudinal assessment essential• Acceptable reliability only achieved with large
samples of test elements (contexts, cases)and assessors
AssessmentImpact on Learning
Programmatic Approach• Deliberate and arrangedset of longitudinalassessment activities
Van der Vleuten C et al., Medical Teacher 2012;34(3):201514.
Catharine M Walsh CDDW 2018 - Postgraduate Course (Advancing Care)
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Practicing Endoscopists
Aim: Quantify colonoscopy volumes of practicing pediatric gastroenterologists
• 154 endoscopists• 12 North American sites
0-118 colonoscopies annual• Median 31.5• 70.1% < 50 colonoscopies per year
Lirio RA et al. GIE 2016;83(5):AB302 (Abstract Sa2061)
PediatricVolumes
Catharine M Walsh CDDW 2018 - Postgraduate Course (Advancing Care)
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Automatic vs. Deliberate
NOVICE
COMPETENTPractice without supervision
EXPERTSupervise others
AUTOMATIC EXPERT
DELIBERATE EXPERT
Pusic M et al. Academic Medicine 2015;90(8):1034-42
Deliberate Practice
Perf
orm
ance
Skill Decay
Perf
orm
ance
Refresher training
Pusic et al. Academic Medicine 2015;90(8):1034-42
Time
Competence
Training - LearningSkill degradation
Durability of competence
Decay curve
Catharine M Walsh CDDW 2018 - Postgraduate Course (Advancing Care)
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Questions1) How do we ensure practicing pediatric
endoscopists are performing to thebest of their ability?
2) How do we ensure practicing pediatricendoscopists maintain (and improve)their skills?
Issues
• Low volumes• Automaticity• Skill decay
Procedural Competence
Ongoing Assessment of
Catharine M Walsh CDDW 2018 - Postgraduate Course (Advancing Care)
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Walsh CM et al. Best Practice and Research: Clinical Gastroenterology 2016;30(3):357-74
Quality Metrics
Catharine M Walsh CDDW 2018 - Postgraduate Course (Advancing Care)
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1) How do we ensure practicingendoscopists are performing to thebest of their ability?
2) How do we ensure practicingendoscopists maintain (andimprove) their skills?
Questions
Audit and Feedback
Kramer RE et al., JPGN 2017;65(1):125-31; Tinmouth J et al. Best Practice and Research: Clinical Gastroenterology 2016;30(3):473-85
Quality Metrics
1.
2.
3.
Catharine M Walsh CDDW 2018 - Postgraduate Course (Advancing Care)
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UpSkilling
Volari R et al. Techniques in Gastrointestinal Endoscopy 2012;14(1):63-72Anderson J et al. Best Practice and Research: Clinical Gastroenterology 2016;30(3):353-71
Team Training
Grover SC et al. GIE 2017;85(5S):AB181(Abstract Sa1075); Grover SC et al. GIE 2017;86(5):881-9; Grover SC et al. GIE 2015;82(6):1072-9.
Catharine M Walsh CDDW 2018 - Postgraduate Course (Advancing Care)
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Training Endoscopy Trainers
Walsh CM et al. JPGN 2017;64(4):501-4; Grover SC et al. GIE 2015;82(6):1072-9.Waschke K et al. Best Practice and Research: Clinical Gastroenterology 2016;30(3):409-19.
UpSkilling & Trainers
Kaminski M et al. Gut 2015;65(4):616-24
• 40 Polish screening centres withsuboptimal performance (ADR ≤25%)
• 2-day training incorporating skillsimprovement and train the endoscopytrainer vs. audit and feedback
• ADR improvement difference:• 7.1% and 4.2% at 1 and 2 years
Catharine M Walsh CDDW 2018 - Postgraduate Course (Advancing Care)
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Junior Faculty
NOVICE
COMPETENTPractice without supervision
EXPERTSupervise others
AUTOMATIC EXPERT
DELIBERATE EXPERT
Lieberman D. Gastroenterology 2016;151:17-19; Pusic et al. Academic Medicine 2015;90(8):1034-42
Deliberate Practice
Perf
orm
ance
Expertise Development
Catharine M Walsh CDDW 2018 - Postgraduate Course (Advancing Care)
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Take-Home Messages
• Thoughtful integration of simulation canenhance early skills acquisition
• Ongoing assessment essential• Drives ongoing practice improvement and
ensures maintenance of competence
• Development of deliberate expertfacilitated by:• Audit & feedback, upskilling, team training
and train the trainers
• Mentor of junior faculty essential
Practice Points
Catharine M Walsh CDDW 2018 - Postgraduate Course (Advancing Care)
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Questions / Comments
Please download the CDDW™ app to complete the session evaluation and to receive your
certificate of attendance.
Evaluation and Certificate of Attendance
Catharine M Walsh CDDW 2018 - Postgraduate Course (Advancing Care)
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