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Introduction

Simulation models have become established in various fields of

medicine. In the field of endoscopy, interest in using this method

of training and learning new techniques has also been growing

with the development of plastic models, biosimulation models,

and computer models [1–6]. Several methods of training in en-

doscopy are now available. Particularly, at the start of the learn-

ing curve, training with simulation systems can help protect pa-

tients from mistakes, complications, long examination times,

and repeat examinations. Discussions in this area have been con-

cerned with how to integrate simulation systems sensibly and

effectively into clinical educational structures in order to shorten

the learning period for assistants and reduce potential risks for

patients.

On the basis of an approach known as “systematic surgical train-

ing following evaluable criteria of quality, control”, which was

initially presented by Neumann et al. for surgical procedures in

September 1997 [7], an evaluation system for assessing individ-

Score Card Endoscopy: A Multicenter Study

to Evaluate Learning Curves in 1-Week CoursesUsing the Erlangen Endo-Trainer

M. Neumann 1

C. Hahn 1

T. Horbach 1

I. Schneider 1

A. Meining 2

W. Heldwein2

T. Rsch 3

W. Hohenberger 1

Institution1 Department of Surgery, University of Erlangen-Nuremberg, Germany

2 Department of Internal Medicine, Central City Hospital, University of Munich, Germany3 Department of Internal Medicine II, Technical University of Munich, Germany

Corresponding Author M. Neumann, M.D. · Department of Surgery · University of Erlangen–Nuremberg · Krankenhausstrasse 12 ·

91054 Erlangen · Germany · Fax: + 49-9131-8536328 · E-mail: [email protected]

Submitted 13 April 2002 · Accepted after Revision 16 January 2003

Bibliography

Endoscopy 2003; 35 (6): 515–520 Georg Thieme Verlag Stuttgart · New York · ISSN 0013-726X

Background and Study Aims: The present study was carried out

in the context of current discussions concerning ways in which

simulation systems can be integrated sensibly and effectively

into clinical educational structures, in order to shorten the train-

ing period for assistants and reduce potential risks for the pa-

tient. In our study, a number of centers used a standardized

training approach, in 1 week courses, to investigate the learning

curve improvement that can be achieved with a group of begin-

ners in upper gastroduodenal endoscopy.

Materials and Methods: The multicenter study used the Erlan-

gen Endo-Trainer, with specially prepared biological specimens

from pigs. Using this, the individual steps of diagnostic upper

gastrointestinal endoscopy with biopsy can be carried out fol-

lowing a score-card system. After a theoretical introduction and

a demonstration of the examination by an experienced endosco-

pist, an initial evaluation score for each participant was obtained

on day 1. On the following days, the program consisted of 2

hours’ training by a tutor, followed by a test run for each partici-pant. On days 1, 2, 3, 4, and 5 the test run was directly followed

by a self-assessment. In addition, on days 1, 3, and 5 the test run

for each beginner was recorded on video, with each video as-

signed an encrypted code number. All the end of the study

week, control assessments of these videos were carried out by

an experienced endoscopist.

Results: Both the self-assessments and the control assessments

showed significant improvements in the endoscopic parameters

tested during the course (days 1–5; all parameters P < 0.001,

Wilcoxon-test). However, it was found that the trainees tended

to give themselves better marks than the marks given by experi-

enced endoscopists.

Conclusion: During 1 week of training, using the model and fol-

lowing the score card, a significant improvement in the learning

curve was achieved in the beginners’ group for the individual

steps involved in diagnostic upper gastrointestinal endoscopy.

When this approach is used with trainees who are also provided

with the necessary theoretical background, this type of prepara-

tion may lead to a better, lower-risk start to supervised practicalendoscopic examinations in patients.

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ual performance, progress, and potential for improvement was

developed for gastrointestinal endoscopy, using a biosimulation

model (the Erlangen Endo-Trainer). This system was called

“score-card endoscopy”. Based on experience gained at numerous

workshops, an attempt was made to sequence the various steps

and components involved in upper gastrointestinal endoscopy,

both the basic skills such as spatial orientation, tactile ability, in-

strument handling, and flexibility in approaching the object, and

the more specific skills used in therapeutic endoscopy [8].

Next, in collaboration with the endoscopy research group in Mu-

nich, a protocol for the requirements in diagnostic upper gastro-

intestinal endoscopy was adapted to follow the individual steps

of a standard examination. At a consensus meeting which in-

cluded ten invited endoscopists who blindly assessed videotapes

of 15 endoscopists carrying out upper gastrointestinal endosco-

py in a training bio-simulation model (the Erlangen Endo-Trai-

ner), the various assessment parameters were then checked

with regard to interobserver variability and their usefulness for

distinguishing between beginners and experienced endoscopists

[9]. The resulting scorecard, checked and evaluated al a consen-

sus meeting with 10 experienced endoscopists, formed the basis

for a subsequent multicenter study, which was carried out under

the sponsorship of the Endoscopy Section of the German Society

for Digestive and Metabolic Diseases (Deutsche Gesellschaft fr

Verdauungs- und Stoffwechselkrankheiten; DGVS) and the Euro-

pean Society of Gastrointestinal Endoscopy (ESGE) at 14 centers

of endoscopic expertise from August to December 2001.

The aims of this study were:

1. To record the course of the learning curve in beginners in en-

doscopy, at various centers, during the course of 1 study week,

with daily training units following a structured training pro-

gram in standardized conditions.

2. To compare the beginners’ self-assessments with control as-sessments carried out by an experienced endoscopist.

Materials and Methods

During the study weeks, a training suite was prepared at each of

the endoscopy centers, provided with the Erlangen trainer mod-

el, the prepared biological specimen (pig stomach), a video endo-

scope, a light source, a suction pump, and a video recorder to

tape the trainees’ performance (Figure 1). An assistant was avail-

able for the biopsy. Videotapes and score-card protocols for four

beginners and for the experts were also prepared, and were as-

signed a code number for each participant.

The Erlangen Endo-Trainer and Training Specimens

The bio-simulation model used (the Erlangen Endo-Trainer) con-

sists of an anatomically simulated torso and head. The torso can

be rotated around the longitudinal axis via two special fittings,

and can be locked in any desired side position.

Inside the torso, specially prepared, cleaned pig stomach is

placed in an anatomically correct position. The connection be-

tween the animal tissue and the plastic part of the model (the

head with a mouth, and a pharynx, and larynx, including the

pharyngeal recess, vocal cords and a tracheal orifice) was made

at a level slightly below the larynx. In a modified version for

training in basic techniques, the model is equipped with a trans-

parent top in order to track the illuminated endoscope tip and

endoscope position during the training runs, but this was not

used during the assessment runs. All the steps involved in a

standard diagnostic upper gastrointestinal endoscopy in real

biological tissue can be performed using a special preparation of

pig stomach, consisting of the esophagus, stomach, and duode-

num. After the preparation has been cleaned and cut to the ap-

propriate size, it is turned inside out and marked with 15 pointed

methylene blue markers. The markers are target points for the

forceps biopsies. Polyps are created by ligating pieces of mucosa.

In addition, areas of mucous membrane (e. g. in the angulus area,

the gastroduodenal passage, and at the esophagogastric junc-tion) aremarked using the diathermy machine to simulate ulcers

for biopsy (Figure 2).

The biological specimens are positioned and fixed in a realistic

position on a preformed plate in the interior of the model.

When the endoscope is introduced into the biologically elastic

esophagus, the entire hollow viscus remains airtight, so that in-

sufflation via the endoscope results in pneumatic distension,

providing the usual good view inside the stomach and the duo-

denum (Figure 3). Care was taken to use specimens that were

similar in terms of size and fixation onto the internal preformed

plate (e.g. by creating a similar angle at the angulus), so that all

the examinations could be carried out under uniform conditions.

As long as all of the features provided (e. g. a prepared antral ul-

cer, a fundic polyp, and a blue marking in the antralarea for biop-

sy) were clearly visible in the training specimen, the specimen

was not changed between trainees. On most of the study days,

one prepared pig stomach was sufficient. On the morning of

each day, one stomach was allowed to thaw for 4–5 hours and

was then ready for use.

Components of the Score Card

The basis for training and evaluation during the study weeks was

a score card that was developed to describe the various steps of

upper gastrointestinal endoscopy, and which had been endorsed

Figure1 Workstation set up for assessment of upper gastrointestinalendoscopy, using the score card, with the Erlangen Endo-Trainer, a bio-logical specimen (pig stomach), a video endoscope and a video recor-der to tape the trainee’s performance.

Neumann M et al. One-Week Courses Using the Erlangen Endo-Trainer · Endoscopy 2003; 35: 515 – 520

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at an expert consensus meeting. Using this scoring system, each

step involved in upper gastrointestinal endoscopy was assessed

on a scale ranging from 1 (excellent) to 6 (very poor); global

scores for the entire examination and for examination of the

three different organs (esophageal, gastric, and duodenal endos-

copy), as well as for completeness of the examination, were in-

cluded in the evaluation. Details are shown in Table 1. The scorecard defined a standard approach to upper gastrointestinal en-

doscopy, based on expert experience of the way in which a sys-

tematic and complete assessment of the upper gastrointestinal

tract should be performed. In addition, the preparation charac-

teristics of the training specimens (polyps, ulcers, and methylene

blue spots for biopsy) were also taken into account. A total of 15

minutes was generally set as the time limit for the examinations,

both for the beginners’ group and for the expert group.

Implementation and Program for the Study Week

Four beginners at each of the 14 clinical endoscopy centers com-

pleted a 5-day structured training week, with daily assessments

according to the score-card parameters. Each beginner carried

out a self-assessment immediately after the end of each test run

on days 1–5. On days 1, 3, and 5, the beginners’ test runs were

recorded on video and were evaluated after the study week by

the director or assistant medical director of the endoscopy de-

partment concerned.

All of the study weeks were conducted according to the same

plan. On day 1, a 30-minute standardized introduction was given

by the director of the endoscopy center concerned, to provide the

theoretical background and practical instructions for a standard

gastroscopy. The four beginners were instructed on the prepara-

tion for gastroscopy, the endoscopy tower and its equipment, the

functioning of the endoscope, the use of an instrument (in this

case, biopsy forceps), and the basic attitude at the start of the ex-amination. An experienced endoscopist then demonstrated a

standard examination, explaining the individual parameters of

the score card. Each of the four beginners then had 15 minutes

in which to use the endoscope themselves and attempt to put

into practice what had just been demonstrated. During this ini-

tial phase of free training, before the initial assessment, no hints

or corrections were provided. The first day ended with the initial

assessment for each participant. Each of the four participants

completed a test run lasting up to a maximum of 15 minutes

(with video recording) that followed the score card protocol, al-

though keeping to the precise sequence of the individual param-

eters was not compulsory, and immediately afterward carried

out a self-assessment.

Study days2 –5 followed the same pattern. On each day, a 2-hour

period of training was provided, with an introduction by an ex-

perienced endoscopist, with each participant only using the en-

doscope independently for around 30 minutes. For the remain-

der of the time, the performance of other participants, as well as

instructions, hints, and corrections they were given, was ob-

served on the video endoscope monitor. After the training part

of the day, each participant carried out a test run, which was re-

corded on video for later assessment by the expert endoscopist.

Each participant carried out a self-assessment immediately

afterward.

Table1 Score-card parameters for the steps of a gastroscopy ex-amination

P1 Introduction of the endoscope and passage through the throat

P2 Passage through the esophagus

P3 Complete assessment of the proximal cardiac folds

P4 Passage through the stomach down to the pylorus, alongthe lesser curvature

P5 Passage through the pylorus

P6 Complete (circular) assessment of the duodenal bulbP7 Introduction of the scope into the descending duodenum

P8 Complete assessment of the duodenal folds

P9 Complete visualization of the antrum

P10 Localization/visualization of an antral ulcer

P11 Visualization of the angular fold

P12 Performance of the retroflexion maneuver

P13 Visualization of the gastric fundus and cardia in retroflexion

P14 Localization/visualization of a fundic polyp

P15 Visualization of the gastric body in retroflexion, and of thelesser curvature

P16 Placement of biopsy forceps on a gastric ulcer

P17 Placement of biopsy forceps on a gastric polyp

P18 Placement of biopsy forceps on blue marking in antral areaand biopsy

P19 Withdrawal through the esophagus

P20 General assessment (complete assessment of the uppergastrointestinal tract)

P21 Overall mark for the esophagus

P22 Overall mark for the stomach

P23 Overall mark for the duodenum

P24 Overall mark for technique

Figure 3 Endo-scopic view showingthe cardiac folds inthe training speci-men (pig stomach).

Figure 2 Endo-scopic view showinga biopsy from an “ul-cer” at the pylorus inthe training speci-men (pig stomach).

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The control assessments, using the video recordings from days 1,

3, and 5, were carried out by the director or assistant medical di-

rector of the endoscopy center during the week after the actual

study week, taking a maximum of 3 hours for the group of begin-

ners.

Statistical Analysis

The Mann–Whitney test was used to compare unpaired data

(self-assessment vs. assessment by specialists) and the Wilcoxon

signed rank test was used to compare paired data (gradesachieved on day 1 vs. those achieved on day 5). The paired Stu-

dent’s t -test was used for comparison of normally distributed

data (time needed for examination).

A P value of less than 0.05 was considered statistically signifi-

cant. All calculations were carried out using the Statistical Pack-

age for the Social Sciences program for Windows, version 10.1

(SPSS Inc., Chicago, USA).

Results

Significant differences between the self-assessments and assess-

ments by specialists were found for a total of 24 parameters

(Mann–Whitney test, P < 0.05). These significant differences

were all caused by participants awarding themselves better

marks in self-assessment than they received in specialist assess-

ment (Table 2). With regard to the parameter, “complete assess-

ment of the proximal cardiac folds”, significant over-marking

was observed in self-assessments on days 1, 3, and 5 (Figure 4).

When days 1 and 5 were compared, the assessment marks

showed highly significant improvements between days 1 and 5

for all parameters. This was true for both specialist assessment

and self-assessment (Wilcoxon test, all P < 0.001). Table3 showslearning progress based on median marks given by experienced

endoscopists on day 1 in comparison with those given on day 5.

The improvement from day 1 to day 5 in general self-assessment

marks is shown in Figure 5.

The difference between days 1 and 5 in the mean time required

to complete the examination was also highly significant (paired

Student’s t -test, P < 0.001), as shown in Figure 6.

Discussion

It is difficult for beginners in endoscopy on internal hospital

training programs to get a good practical start with patients in

such a way that the examination is completed safely, within a

reasonable time, and without exposing the patient to discomfort

or even risk. This is particularly important in the field of endos-

copy because the beginner is the only practitioner holding the

endoscope and any correction involves taking it away from him

or her (in contrast to surgery, in which the senior surgeon can in-

tervene and carry out corrections directly at the open operating

site).

Table2 Statistically significant difference (P < 0.05) between self-assessment and specialist-assessment scores for varioussteps in gastroscopy. All parameters were scored from 1to 6

Parameters Self-Assessment Specialist-Assessment P (Mann–Median Range Median Range Whitney)

Day 1

P1 3 1 – 6 4 2 – 6 0.009

P2 3 1 – 5 3 2 – 5 0.028

P3 3 1 – 6 4 2 – 6 0.007

P4 3 1 – 6 4 2 – 6 0.039

Day 2

P1 2 1 – 5 3 2 – 6 0.001

P2 2 1 – 4 2 1 – 4 0.009

P3 2 1 – 4 3 1 – 5 < 0.001

P4 3 1.5 3 2.5 0.005

P6 3 1 – 5 3 2 – 5 0.003

P9 3 1 – 5 3 2 – 5 0.007

P11 2 1 – 4 3 2 – 4 0.002

P12 2 1 – 5 3 1 – 5 0.002

P13 2 1 – 5 3 2 – 5 0.006

P14 2 1 – 5 3 1 – 5 < 0.001

P16 2 1 – 4 3 1 – 6 0.002

P21 2 1 – 4 2 1 – 4 0.034

Day 5

P3 2 1 – 3 2 1 – 4 0.001

P13 2 1 – 5 2 1 – 4 0.017

P14 2 1 – 5 2 1 – 5 0.025

P15 2 1 – 5 2 1 – 4 0.007

P17 2 1 – 5 2 1 – 4 0.014

P18 2 1 – 4 2 1 – 4 0.025

P20 2 1 – 5 2 1 – 4 0.023

P22 2 1 – 5 2 1 – 4 0.029

Assessment of cardiac folds(graded 1 – 6)

Self-assessments

1

2

0

3

7

N

4

5

6

Specialist-assessments

N = 56 56 56 57 57 57

Day 1

Day 3

Day 5

Figure 4 Box plotsdemonstrating theimprovement incomplete assessmentof the proximal cardi-ac folds (days 1–5).This also demon-strates that partici-pants gave them-selves better scoresthan the specialistsgave them.


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To make a beginner’s initial procedures easier, it is important toreach this practical “starting level” through a concentrated and

effective preparation phase. Neither the assistant medical staff

nor the physicians can have their routine procedures disturbed

for too long. In everyday practice, therefore, this developmental

stage is often a lengthy one and it can vary widely from one be-

ginner to another, some beginners requiring more prolonged

training.

The systematic instruction system inherent in the use of the

score-card can help the beginner to make progress in a struc-

tured fashion and, above all, it provides a standard by which the

progress of learning and the potential for improvement can be

assessed. The score-card can provide guidance, but its use should

not be regarded as obligatory. The standard examination is

sometimes carried out in very different ways in different hospi-

tals. For example, some only introduce the endoscope under di-

rect vision, while others introduce it blindly with finger gui-

dance. Some examiners push the endoscopes themselves, while

others leave this to the assistant staff and keep both hands on the

control wheels. Others require trainees to carry out minor inter-

ventions, such as polyp removal or submucosal injection, even

during basic courses.

The study shows that a structured 1-week course, based on aconsensus training protocol, can improve the learning curve for

all beginners within 1 week. A clear improvement is seen partic-

ularly between days 3 and 5, confirming that a course compris-

ing five consecutive training days is a very effective way of aquir-

ing competence in the individual steps required for examining

patients.

Another important aspect of this training method is the work-

place atmosphere, which corresponds fully with that experi-

enced later with a patient – the endoscopy tower, equipment, in-

struments, and team training with the endoscopy nurses.

In the long run, the development and constant optimization of a

curriculum and the establishment of suitable training guidelines

by specialist societies [10–18] will be indispensable to the pro-

vision of further theoretical support for this clinical week’s train-

ing.

In conclusion, an internal hospital training week based on this

approach, individually adapted by each hospital, with a theoreti-

cal background and instruction provided by the director of en-

doscopy and endoscopy nurses, should allow most beginners to

progress sufficiently along the learning curve to enable them to

carry out their first supervised endoscopy procedure in a patient.

Table 3 Medians and ranges of specialist-assessment marks forconducting each step of the examination on day 1 vs.day 5 (58 participants)

Parameter Day 1 Day 5 PMedian Range Median Range (Wilcoxon–test)

P1 4 2 – 6 2 1 – 5 < 0.001

P2 3 2 – 5 2 1 – 4 < 0.001

P3 4 2 – 6 2 1 – 4 < 0.001

P4 4 2 – 6 2 1 – 4 < 0.001

P5 4 2 – 6 2 1 – 5 < 0.001

P6 4 2 – 6 2 1 – 4 < 0.001

P7 4 2 – 6 2 1 – 4 < 0.001

P8 3 1 – 6 2 1 – 5 < 0.001

P9 3 1 – 6 2 1 – 5 < 0.001

P10 3 1 – 6 2 1 – 6 < 0.001

P11 3 1 – 6 2 1 – 5 < 0.001

P12 3 2 – 6 2 1 – 4 < 0.001

P13 4 2 – 6 2 1 – 4 < 0.001

P14 3 2 – 6 2 1 – 5 < 0.001

P15 4 2 – 6 2 1 – 4 < 0.001

P16 3 1 – 6 2 1 – 5 < 0.001

P17 3 1 – 6 2 1 – 4 < 0.001

P18 4 2 – 6 2 1 – 4 < 0.001

P19 3 1 – 6 2 1 – 3 < 0.001

P20 4 2 – 6 2 1 – 4 < 0.001

P21 3 1 – 5 2 1 – 4 < 0.001

P22 4 2 – 6 2 1 – 4 < 0.001

P23 4 2 – 6 2 1 – 4 < 0.001

P24 4 2 – 6 2 1 – 4 < 0.001

General assessment(score 1 – 6)

Self-assessments

1

2

0

3

7

N

4

5

6

N = 58 58 58 58 58Day 1 Day 2 Day 3 Day 4 Day 5

Figure 5 Box plotsshowing improve-ments from day 1 today 5 in self-assess-ment marks for “gen-eral assessment” of the gastrocsopy.

Examination time (mean and 95% Cl),min

11

12

10

13

16

14

15

N = 58 58 58 58 58Day 1 Day 2 Day 3 Day 4 Day 5

Figure 6 Box plotsshowing examinationtimes in minutes(means, with 95 %confidence intervals),

days 1–5.

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Acknowledgements

We are grateful to the centers of endoscopic expertise that parti-

cipated in the study. Our thanks also go to the endoscopy direc-

tors who evaluated the video recordings after the study weeks.

We are also grateful to the endoscopy research group in Munich

for their intensive collaboration in developing and evaluating the

score card for diagnostic upper gastrointestinal endoscopy,

which provided the basis for the study presented here. Last, butnot least, our thanks are due to Altana Pharma Ltd. in Konstanz,

Germany, which has provided constant and thorough support for

training in endoscopy, and who also vigorously supported the

present study.

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