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TRAINEE HUB
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What Makes a
Good Endoscopy Educator
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By Shifa Umar, MD
LEARNING GASTROINTESTINAL ENDOSCOPY IS ONE OF THE INTEGRAL ASPECTS of gastroenterology fellowship. Yet, while interacting with my peers at local and national meetings, I always found it interesting how differently we all progressed at learning the various endoscopic skills and maneuvers.
Training fellows to perform endoscopy is challenging and has, over the years, evolved from an apprenticeship model to a competencybased model. To bring together perspectives from educators and learners, I invited faculty and fellows from various backgrounds and different career stages and points in their training to share their vision and identify attributes which make for an effective endoscopy educator.
During my own gastroenterology fellowship, I identified that we all have our own learning pace. What works for me may not work for someone else and, by the end of three years of fellowship, I adopted a bit of something from everyone I worked with (faculty, technicians and nurses). I discovered that endoscopy, just like with everything in medicine, will be a constant process of learning. —Dr. Shifa Umar
FELLOW RESPONSES
“A great endoscopy educator enables fellows to develop their own techniques, lets them ask for help, and allows them to ‘struggle’ everso-slightly before intervening at the perfect moment.” —Ruchit N. Shah, DO, First Year Fellow, Geisinger Commonwealth School of Medicine
“A great endoscopy teacher emphasizes the cognitive aspect of scoping as much as its technical component and challenges the learner to think critically about (1) whether a scope is indicated and, if so, (2) how we can make it as safe as possible.” —Malorie Simons, MD, Advanced Endoscopy Fellow, Weill Cornell Medicine Division of Gastroenterology and Hepatology
“A solid endoscopy educator is approachable, patient and honest. Honest when you're doing well (praise) and honest for skill refinement (feedback). Allowing the trainee to struggle and encouraging the trainee to identify 1-2 endoscopy objectives for the day are helpful." —Nikki Duong, MD, Second Year Fellow, Virginia Commonwealth University
A great endoscopy educator… “is someone who teaches with patience and positivity, effectively communicates tangible goals while providing real-time feedback, and creates a safe, nonjudgmental environment for trainees.” —Rashmi R. Advani, MD, Third Year Fellow, Stony Brook University Hospital
“The 4 T's of a good endoscopy educator:
• Tips: gives the fellow clear-cut tips on ergonomics, driving the scope, reducing loops, turning flexures, etc. • Time: does not take over the scope for too long but knows when to jump in and help out. It is a fine balance! • Technique: teaches her/his method while accepting that fellows may also incorporate techniques from other educators. • Timely feedback: provides real-time, constructive feedback during the procedure and at the end of each case.”
—Daniela Guerrero Vinsard, MD, Second Year Fellow, Mayo Clinic, Rochester, MN “A good endoscopy teacher fosters a good learning environment, allows for appropriate autonomy, and, most importantly, provides real-time feedback.” —Elizabeth Aby, MD, Third Year Fellow, University of Minnesota
“A good endoscopy educator is someone who can patiently walk their fellow through a scope and effectively communicates how to troubleshoot problems without having to take the scope away.” —Mayssan Muftah, MD, Second Year Fellow, Brigham and Women’s Hospital, Harvard Medical School
A great endoscopy educator… "understands the current skill level of the trainee. They give the trainee the endoscopic instruction and confidence to expand their skills and comfort zone while maintaining patient safety." —Dean Ehrlich, MD, Third Year Fellow, David Geffen School of Medicine at UCLA
“A good endoscopy educator has a passion for teaching and sharing in an accessible way. By this, infects, inspires, motivates, and boosts trainees up in reaching the stars.” —Katarzyna Monika Pawlak, MD, PhD, Final Year Fellow, Hospital of The Ministry of Interior and Administration, Szczecin, Poland
“The best teachers allow you to hold the scope and somehow get you to the cecum with just their words. They embody patience and profound procedural expertise.” —Chuma G. Obineme, MD, Second Year Fellow, Emory University School of Medicine
FACULTY RESPONSES
“When flexible endoscopy began over 50 years ago, there were no trainers since we had no experience in how best to use the flexible instruments. Many techniques were developed, some were good and some were terrible, and unfortunately, some of the terrible techniques still are being taught today. There is no uniformity in the teaching of endoscopy. Over the years, many of us traveled long distances to train doctors in other countries in the handling of scopes for diagnosis and therapy. Now, with the COVID pandemic, nobody travels to teach endoscopy and a whole new world of innovation has become possible through the internet. Whether close by or far away, the trainer needs to be a knowledgeable and capable endoscopist having dedicated time to stay with the trainee throughout the entire procedure.” —Jerome D. Waye, MD, MACG, Emeritus Professor of Medicine, Icahn School of Medicine at Mount Sinai
“Do not compare yourself to your classmates; everyone learns endoscopy, but at different paces. I was the last to get to the cecum in my class yet here I am today, a skilled endoscopist. Don’t get pre-occupied with the time you take to complete colonoscopy, extremely important to focus on good technique and ergonomics. You will get faster with experience and volume but good technique ensures less work-related injuries later on in your career.” —Renee L. Williams MD, MHPE, FACG, Associate Professor of Medicine, Division of Gastroenterology, NYU Langone Health, Associate Chair, Saul J. Farber Program in Health Equity, Director GME Education, NYU Institute for Excellence in Health Equity
"I think the most important factor in training a GI fellow in endoscopic techniques is giving that fellow access to performing endoscopies on patients. While stimulation training is obviously important, there is no substitute for substantiative time working with live patients. This requires patience on the part of busy attending staff, flexibility and educational prioritization from “As I tell all my trainees, your endoscopic education is not limited to the time your hands are on the scope. There should be some thought put into why we are doing these procedures, the risks associated with them, and learning how to relay this information to the patients who you have the privilege of caring for each day. In addition, the age of virtual learning has opened up many more avenues for endoscopic teaching than ever before. Endoscopy is not just doing procedures but a way of life for the gastroenterologist, so gathering knowledge from multiple sources will lay the foundation for a successful career.”
—Uzma D. Siddiqui, MD, FACG , Professor of Medicine, University of Chicago, Director, Center for Endoscopic Research and Therapeutics (CERT) and Advanced Endoscopy Training administration, and an appreciation and focus from trainees. Spending an afternoon scoping with an enthusiastic fellow one-on-one in a non-hurried environment is truly one of the great pleasures of being an attending physician." —Timothy B. Gardner, MD, MS, FACG, Professor of Medicine, Geisel School of Medicine at Dartmouth, Program Director, Gastroenterology and Hepatology Fellowship Program
“Don’t go fast and furious to reach the cecum; good endoscopic technique is about a non-forceful journey to the cecum. Go slow and have intentional scope movements and torque, so you can reach the cecum in an adequate time. We all obsessed about reaching the cecum as fellows like it’s the Holy Grail; but the real target should be perfecting how to navigate the sigmoid and reach the splenic flexure with a reduced and straight scope—after that the cecum becomes easy (most of the time).
Beyond techniques: the key is to not get frustrated. Frustration leads to forceful pushing, poor technique, and to repeating the same maneuvers while expecting different results that won’t come. All this can lead to injury to the patient and ergonomic injury to the endoscopist. Stop, take a deep breath, pause, relax your shoulders, straighten up your back and start fresh with a different plan, don’t get angry at the colon. #KeepItZen
Keep the patient at the center of what you do and always be the patient’s best advocate. Ask yourself: is the endoscopy indicated, can you do something meaningful about the findings on the scope and will that have a positive outcome on the patient (from improving the patient’s quality of life to saving the patient’s life)?
Next: be honest with yourself and prepare the team adequately. Do you have the right skill set needed for the expected degree of difficulty of the scope? What do you expect to find and/ or treat and prepare and brief your team about it? It is OK to “give up a scope” to a more senior fellow or to the attending when it is the right thing to do. Remember, you will be that expert endoscopist one day.
Finally: Open communication with the patient, the family, the medical and nurse team is a key component to being a good endoscopist!” —Aline Charabaty, MD, FACG, Assistant Clinical Director of the Division of Gastroenterology, Johns Hopkins School of Medicine, Clinical Director of IBD, Johns Hopkins - Sibley Memorial Hospital, Washington, DC
“Learning theory shows that when learning a new skill, we actually get worse (consciously incompetent) before we get better (consciously competent). It is at this point where direct observation of your teacher doing the scoping is highly valuable. Your focus can be more on what they are doing to perform a safe and effective maneuver (think EMR), rather than you trying to figure it out on the fly.” —Christopher J. DiMaio, MD, FACG, Professor of Medicine, Icahn School of Medicine at Mount Sinai, Director of Interventional Endoscopy, Mount Sinai Health System
“Most people who taught endoscopy in the past (including myself) were not trained how to do so. We let trainees handle the scope for a while, made a few comments, and then took over. I would encourage those in charge of fellowship training programs to expose their colleagues to the "train the trainers" paradigm. Taking such a course recently made me realize what a poor job I had done. It is fascinating and effective.” —Peter B. Cotton, MD, FACG, Professor of Medicine, Medical University of South Carolina
“Endoscopy is humbling. Even for the experienced endoscopist there are days when endoscopy feels easy and other days, when even the simplest maneuvers seem impossible! As you are learning endoscopy, have patience with yourself and your endoscopy teacher. Early on, your focus should not be reaching the cecum, but rather on specific skills such as maneuvering the sigmoid colon with a straight scope and fine tip control. Once you master the basics, reaching your destination will be so much easier!” —Laura Raffals, MD, FACG, Professor of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic Rochester
“To be successful, I remind the fellows that I work with to always ask themselves 3 questions when performing an endoscopic maneuver:
• What do I need to do to be successful? • What will I do after I am successful (in this maneuver)? • What will I do if I am unsuccessful (in the maneuver)?
Having these three questions constantly circulating in our minds can provide maximal benefit for patients. These questions allow us to simultaneously think about the present as well as steps ahead. In this way, we can minimize repetitive maneuvers that could introduce harm. By asking these questions we remain cognitive in our approach to endoscopy, thus ensuring we are acting with purpose which, ultimately, improves outcomes and care.” —Shyam J. Thakkar, MD, Professor of Medicine, Director of Advanced Therapeutic Endoscopy, West Virginia University Medicine
“Be open to learning new ways to perform endoscopy. I was a third-year fellow when an attending told me that I was performing colonoscopy incorrectly. While initially frustrating, that modification significantly helped my colonoscopy technique and has stuck with me throughout my career.” —Vinay Chandrasekhara, MD, Consultant, Division of Gastroenterology & Hepatology, Associate Professor of Medicine, Director, Pancreas Group, Program Director, Advanced Endoscopy Fellowship, Mayo Clinic
“The key element fellows need to learn endoscopy is TIME; time to make their own mistakes, and to learn what manipulating a scope feels like. Fellows will learn from many preceptors, each with their own style. Fellows should try all these styles, see what works best for them, and eventually incorporate them into their own unique style. For preceptors, it is often better to tell, than to show/do; I challenge myself to verbally coach a fellow through a complete procedure and minimize my ‘hands on’ time. Remember, lab nurses make great teachers too.” —Michael M. Babich, MD, GI Fellowship Program Director, Allegheny General Hospital, Pittsburgh, PA, Associate Professor of Medicine, Temple University School of Medicine
“Learn the endoscopes and accessories in your unit in detail: materials, lengths, diameters, bending capabilities, how they’re built and how they work. You need this knowledge to perform with optimal effectiveness and safety.” —Douglas K. Rex, MD, MACG, Distinguished Professor Emeritus of Medicine, Indiana University School of Medicine, Chancellor’s Professor at Indiana University Purdue University Indianapolis, Director of Endoscopy at Indiana University Hospital in Indianapolis, IN
