Developing and evaluating expertise in colonoscopy

Abstract

The quality and safety of colonoscopy have become of paramount importance with the worldwide expansion in the utilisation of this procedure, especially with the introduction of colorectal cancer screening in many countries. It is well known that colonoscopic performance varies significantly between practitioners. This thesis explores the effects of assessment in colonoscopy and polypectomy on performance and practice as well as trying to define the factors which differentiate the very best practitioners from the clinically competent. Until 2011, there was no formalised way of certifying polypectomy competence. We looked at the effects of the introduction of mandatory polypectomy assessment on trainee endoscopists applying for certification of competency in the United Kingdom. This work showed that documentation of polypectomy competence significantly improved after these changes were introduced. A global survey of polypectomy practice was undertaken to evaluate international guidance on polypectomy skills training and how trainers deliver teaching on polypectomy around the world, as well as trainees’ experience of gaining polypectomy skills. Significant variability in endoscopists’ experience of polypectomy training was found with few formal national guidelines published. This led to an evaluation of expert endoscopists who underwent an accreditation process with some similarities before commencing Bowel Cancer Screening (BCS). We examined whether it was possible to predict future performance from a single assessment and found that criteria used to assess whether candidates were competent could not predict the best performers from those who passed. Several hundred expert BCS colonoscopists were then monitored over a three year period to determine changes in performance over time and whether long-term performance could be predicted. The best predictors of performance over time for all metrics were initial performance. In order to identify key features of expertise in endoscopy, experienced colonoscopists were interviewed to distinguish characteristics of true endoscopic experts. These interviews revealed the importance of both technical and non-technical skills in defining expertise.