Post written by Samir C. Grover, MD, MEd, FRCPC, from the Division of Gastroenterology, St. Michael’s Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
We aimed to improve existing simulation-based training curricula for teaching novices how to perform colonoscopy using progressive learning. We recognized that a theory-based approach to designing a curriculum in endoscopy may potentially result in improvement of acquisition of endoscopic skills. Progressive learning involves increasing the difficulty and complexity of performed cases over time, a model which has been shown to be effective for learning simpler procedures, such as lumbar puncture. To determine whether it would be similarly effective for colonoscopy, we conducted a randomized controlled trial that compared a Progressive Learning Curriculum (PLC) to a Structured Comprehensive Curriculum (SCC). The SCC, which we previously demonstrated improved performance of clinical colonoscopy among novices, used simulation training on a virtual-reality (VR) model and had random order of case difficulty. The PLC, which was adapted from the SCC, included both bench-top and VR simulator models and had simulator cases arranged to increase in difficulty at a level commensurate with perceived ability to challenge the learner. We randomized 33 novice endoscopists to either a PLC group or SCC group. Our primary outcome was clinical transfer during 2 patient colonoscopies, assessed by the Joint Advisory Group Direct Observation of Procedural Skills (JAG DOPS) rating tool. We found that novices assigned to the PLC demonstrated significantly superior performance during clinical colonoscopies, compared to novices assigned to the SCC. Moreover, the PLC group also showed better technical and communication skills during simulated cases. Our results are in line with Challenge Point Framework (CPF), an educational theory that supports progressive learning. According to CPF, learners need to be “optimally challenged” as they progress through their training: if cases are too easy, there is no educational value to be extracted; conversely, cases that are too difficult will likely prove too daunting.
These findings should encourage educators to consider adopting a progressive learning strategy, especially since the application of progressive learning (i.e., aligning case difficulty and complexity to optimally challenge learners) is a relatively simple modification that can be used for existing curricula.
Simulation-based training curricula are increasingly recognized in the literature and by credentialing societies, such as the ASGE in the U.S. (and CAG in Canada), as being one of the most effective and safest means to teach endoscopic procedures to novices. We encourage and challenge researchers, administrators, and educators to implement these curricula and to further improve their ability to help novices learn.
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