key: cord-0020113-o6m1v9bo authors: Garg, Shashank; Inamdar, Sumant; Tharian, Benjamin; Muniraj, Thiruvengadam; Aslanian, Harry R. title: Education and gastroenterology fellow knowledge about endoscopic mucosal resection of colon adenomas: a survey-based study date: 2021-07-16 journal: Endosc Int Open DOI: 10.1055/a-1490-8255 sha: 8c9a1a4b5f406e4f5d74dad2f71fac711da7caa7 doc_id: 20113 cord_uid: o6m1v9bo Background and study aims Endoscopic mucosal resection (EMR) is an effective way to remove large (> 2 cm) colon adenomas. Training about it has not been standardized in fellowship programs. This study was aimed at evaluating the education and knowledge of gastroenterology fellows about EMR of colorectal adenomas. Methods Participation in this survey was offered to 1730 gastroenterology fellows in the United States during the academic year 2019 to 2020. The survey assessed endoscopic mucosal resection training and knowledge and was approved and administered by the American College of Gastroenterology. Results A total of 163 fellows (9.4 %) completed the survey. Only 85 fellows (52.1 %) reported receiving formal education in endoscopic mucosal resection. Fellow confidence was lowest regarding knowing electrosurgery unit settings. Fewer fellows correctly identified Paris 0-IIb (79, 48.5 %; P < 0.0001) or NICE I (114, 69.9 %; P < 0.01) lesions as compared to other Paris and NICE III lesions, respectively. Only 73 (44.8 %) and 93 fellows (57.1 %) arranged steps of EMR in the correct order and identified the correct type of current used for resection, respectively. Training year, male sex, and provision of advanced endoscopy rotations during fellowship were associated with a higher knowledge score for EMR. Conclusions Nearly half of all fellows reported no formal education in EMR and incorrectly ordered its steps. Adenoma assessment by Paris and NICE classifications and electrosurgery unit settings were the most prominent knowledge deficiencies. Incorporation of standardized training about EMR with inclusion of advanced endoscopy rotations appears to be an important educational opportunity during gastroenterology fellowship. ABSTR AC T Background and study aims Endoscopic mucosal resection (EMR) is an effective way to remove large (> 2 cm) colon adenomas. Training about it has not been standardized in fellowship programs. This study was aimed at evaluating the education and knowledge of gastroenterology fellows about EMR of colorectal adenomas. Methods Participation in this survey was offered to 1730 gastroenterology fellows in the United States during the academic year 2019 to 2020. The survey assessed endoscopic mucosal resection training and knowledge and was approved and administered by the American College of Gastroenterology. Results A total of 163 fellows (9.4 %) completed the survey. Only 85 fellows (52.1 %) reported receiving formal education in endoscopic mucosal resection. Fellow confidence was lowest regarding knowing electrosurgery unit settings. Fewer fellows correctly identified Paris 0-IIb (79, 48.5 %; P < 0.0001) or NICE I (114, 69.9 %; P < 0.01) lesions as compared to other Paris and NICE III lesions, respectively. Only 73 (44.8 %) and 93 fellows (57.1 %) arranged steps of EMR in the correct order and identified the correct type of current used for resection, respectively. Training year, male sex, and provision of advanced endoscopy rotations during fellowship were associated with a higher knowledge score for EMR. Conclusions Nearly half of all fellows reported no formal education in EMR and incorrectly ordered its steps. Adenoma assessment by Paris and NICE classifications and electrosurgery unit settings were the most prominent knowledge deficiencies. Incorporation of standardized training about EMR with inclusion of advanced endoscopy rotations appears to be an important educational opportunity during gastroenterology fellowship. education and practice. Training in EMR has not been standardized among fellowship programs. We are not aware of prior studies that have evaluated the education and knowledge of gastroenterology fellows in endoscopic assessment and resection of large colorectal adenomas. The aims of this survey study were to: (1) evaluate the education and knowledge of resection of large adenomas by EMR and (2) evaluate factors predictive of knowledge of EMR among gastroenterology fellows in the United States. We conducted a cross-sectional survey of all gastroenterology fellows in training in the United States during the 2019-2020 academic year. We invited 1730 fellows in 203 fellowship programs to participate after excluding the advanced endoscopy fellows. The study was approved as exempt research by the Institutional Review Board at the University of Arkansas for Medical Sciences. We developed a five-part, 34-item, multiple-choice question survey that was approved by the research committee of the American College of Gastroenterology (ACG) The first part of the survey was designed to obtain demographic and program information without collecting any identifying information. Parts two to four of the survey were designed to assess the level of education fellows had received in their program (item 14: 14 points) and their confidence in various aspects of EMR (Item 15: 1 points; Supplementary file 1). Part 5 assessed their knowledge of adenoma assessment with the Paris and Narrow-Band Imaging International Colorectal Endoscopic (NICE) classifications and familiarity of details of EMR technique (items 16-34, 19 points). The survey items were designed based on the EMR guidelines issued by the Amercian Society of Gastrointestinal Endoscopy (ASGE) and European Society of Gastrointestinal Endoscopy (ESGE) and were intended to be non-ambiguous [7, 8] . The full survey can be found in Supplement 1. The first email invitation was sent to the fellows by ACG in December 2019 with two additional reminders sent before January 2020. Two email requests were sent to non-responders via fellowship coordinators before the study closed in June 2020. There was no direct contact between the participants and investigators of the study. Participation in the survey was voluntary and no incentives were paid. Survey creation and data collection were done using Google Forms (Google LLC, Delaware, United States). A five-point scale was used to assess fellow confidence about different aspects of EMR of colon adenomas. The scale was defined as follows: 1. I am not familiar with this topic; 2. Not confident at all e. g. attending does most of the assessment and procedure; 3. Somewhat confident e. g. attending takes the scope often; 4. Confident e. g. attending takes the scope in difficult scenarios; and 5. Very confident e. g. attending rarely takes the scope. Descriptive statistics were used to perform exploratory analyses. Categorical data were described as proportions and analyzed using chi-square test. Continuous data were reported as mean and standard deviation or median and range and analyzed using t-test or Wilcoxon ran-sum test depending on the distribution of the variable. Median confidence was calculated for each fellow based on their responses to the 11 points in item 15. A composite score of education (out of 14 points of item 14) and knowledge (out of 19 points for items 16 to 34) were calculated for all the fellows. Distribution of the total knowledge score (dependent variable) was not normal and therefore, linear regression was not possible. Knowledge-score tertiles were created based on the total knowledge score of the participants. Ordinal regression was done to identify factors associated with knowledge-score tertiles. The area under the curve (AUC) was used to assess model fit. Independent variables included were training year, sex, setting of the program (University, Community or both), size of the program, number of total faculty and advanced faculty in the program, availability of advanced fellowship in the gastroenterology division, provision of advanced endoscopy rotation during fellowship, whether the candidates intended to apply to advanced endoscopy fellowship, physicians performing EMR (general gastroenterology, advanced endoscopist or both), number of EMR cases done by participating fellows during the fellowship, education score, and median confidence. Two-sided P < 0.05 was considered significant. The analysis was performed with SAS software version 9.4 (SAS Institute Inc., North Carolina, United States). The survey response rate was 9.4 % (163 out of 1730). ▶ Table 1 summarizes the demographics, program information, and provision of formal education of EMR in the training programs. The majority of respondents were men (117, 71.8 %), were training in a university setting (129, 79.1 %), and were second-(62, 38 %) or third-year fellows (82, 50.3 %). Fellows from all sizes of training programs participated in the survey (▶ Table 1 ). The majority (102; 62.6 %) of the participants reported having > 10 faculty members involved in their training. All respondents reported having advanced endoscopy faculty in their program (▶ Table 1 ). Eighty-two participants (50.3 %) reported having an advanced endoscopy fellowship in their division. One hundred three (63.2 %) fellows reported having advanced endoscopy rotation(s) as a part of their training. Most respondents (114, 69.9 %) did not plan on doing an advanced endoscopy fellowship. One hundred and three (63.2 %) fellows reported that EMR of colon adenomas is performed by both general gastroenterology and advanced endoscopy faculty in their program while 31.3 % of fellows (51/163) reported that only advanced endoscopists performed EMR. Most respondents (104, 63.8 %) reported that they had participated in < 10 cases of EMR of large colon adenomas and only 10.4 % of fellows (17/163) reported having done > 20 cases. Table 1 ). Reported median confidence was highest for assessing adenoma size and shape and knowing the follow-up colonoscopy interval after EMR. It was lowest for knowing electrosurgery unit settings (▶ Fig. 2 ). More fellows were able to correctly match a pedunculated lesion (138, 84.7 %) to the appropriate Paris class as compared to a sessile raised lesion (117, 71.8 %; P = 0.01). Correct Paris classification of a flat lesion (79, 48.5 %) was far less accurately performed relative to either pedunculated or sessile lesions (P < 0.0001). Correct identification of NICE II (129, 79.1 %) and NICE III (138, 84.7 %) lesions was similar among the participants (P = 0.23). Correct identification of a NICE I lesion (114, 69.9 %) was lower than NICE III lesions (P < 0.01) but similar to NICE II lesions (P = 0.08). Ordinal regression showed that progression through each year of fellowship was associated with a higher knowledge-score tertile (▶ Table 3 ). Similarly, male sex (OR 3.14, 95 % CI: 1.48-6.68; P = 0.01) and availability of advanced endoscopy rotations were associated with a higher knowledge-score tertile (OR 2.25, 95 % CI: 1.14-4.44; P = 0.02; ▶ Table 3 ). Increase in median confidence by each point was associated with lower knowledge score-tertiles (OR 0.67, 95 % CI: 0.47-0.96; P = 0.03). The other previously listed nine factors, including program size, setting, size of the faculty and education-score, did not have any association with knowledge-score tertiles. While much attention and study has been dedicated to colonoscopy quality measures such as cecal intubation rate, withdrawal time, and ADR, large adenoma resection, which is the key step in providing colon cancer risk reduction, has received much less attention. This survey study is the first of its kind to evaluate the knowledge of gastroenterology fellows in the United States regarding adenoma classification and EMR techniques. We found that nearly half of all fellows reported no formal education in EMR in their gastroenterology fellowship (48 %) and this response persisted among third year fellows (42.68 %). A possible explanation for this observation is that not all clinical faculty perform EMR; therefore, fellows may not get significant exposure to these procedures. This is supported by the finding that 31.3 % of fellows reported that only advanced endoscopy faculty perform EMR at their center and that 63.8 % of the fellows had participated in < 10 EMR cases. Additional contributing factors likely include EMR being considered an advanced endoscopy skill that requires further training and that the fellowship programs may provide formal educa- ▶ 69.9 % correctly identified hyperplastic lesions by NICE classification). These findings may have important clinical implications. While correct morphologic identification is not reflective of ADR, these clinical skills are beneficial in determining the need for and approach to polyp resection [8, 9] . While uncommon, flat lesions have an increased risk of progressing to malignancy. In addition, detection and complete removal of right-sided sessile lesions has been identified as an important focus of colonoscopy quality initiatives. Fellowship programs should consider providing structured training in polyp morphology assessment as part of a comprehensive EMR curriculum. Low knowledge scores corresponded with low education scores for assessing adenoma pit pattern, shape, and borders (n = 91, 55.8 %; ▶ Fig. 1) , knowing the electrosurgery unit settings for EMR (n = 87, 53.4 %; ▶ Fig. 1) , and provision of formal education about EMR in the training program (n = 78, 47.9 %; Item 12). Similarly, low knowledge scores corresponded with low median confidence scores in using digital chromoendoscopy to identify adenomas, knowing electrosurgery unit settings for EMR, and for performing EMR (▶ Fig. 2 ). Median confidence was found to be inversely associated with knowledge of EMR and an increase in median confidence was associated with decreased odds of higher knowledge score (OR 0.67, 95 % CI: 0.47-0.96). Although the finding may be counterintuitive, one possible explanation is that fellows do not perform EMR independently; therefore, their confidence in performing EMR may be higher in relation to the knowledge of EMR. Overall, the results of this study provide insights into the areas of EMR in which fellows have the greatest knowledge deficits. The incorporation of standardized formal training in gastroenterology fellowship with a focus on key areas presents an important educational opportunity to improve fellow knowledge and EMR skills [7, [9] [10] [11] [12] . Progression through fellowship was associated with increase in knowledge of EMR,. This finding is expected as fellows get more exposure to observe and perform EMR as they progress through fellowship [13, 14] . We identified that scheduled rotations in advanced endoscopy during gastroenterology fellowship increased knowledge of EMR (OR 2.25, 95 % CI: 1.14-4.44). Advanced endoscopy rotations can provide the opportunity to perform additional EMR cases with experienced physicians. The effect of advanced endoscopy rotations was noted to be independent of the postgraduate year (PGY) level, which highlights the added value of these rotations during fellowship in learning about EMR. Fellow training in EMR may benefit from gastroenterology fellowship program evaluation of the proportion of EMR that is performed by advanced vs non-advanced endoscopy faculty to determine optimal rotational exposures to EMR procedures. Further studies are needed to assess the broader impact of advanced endoscopy rotations during gastroenterology fellowship on procedure skills of gastroenterology fellows. Male sex was found to have an apparent effect on education score (OR 3.14, 95 % CI: 1.48-6.68). It was noticeable that a lower proportion of women participated in this survey study (27 %) than the proportion of women in gastroenterology fellowships in the United States (32-39 % [15]). EMR of large colon adenomas may be considered an advanced endoscopy skill, which may be associated with a lower interest among women gastroenterology fellows in performing such procedures [16] . While this study was not designed to assess systematic issues related to sex-based differences in training opportunities or knowledge about EMR, further studies should be considered. This study has several strengths. It is the first of its kind to evaluate the knowledge of gastroenterology fellows in the United States regarding adenoma classification and EMR techniques. Particpants were drawn from a national sample from all the gastroenterology fellowship programs in the United States. In addition, the survey questions were non-ambiguous, developed based on the EMR guidelines issued by the ASGE and ESGE, and approved by ACG's research committee. The survey was comprehensive in collecting data and had a robust statistical methodology to analyze the data as indicated by a high AUC (72.5 %). There are several limitations to this study. First, the response rate to the survey was low despite our best efforts to administer the survey. The survey administration had to be paused due to the COVID-19 pandemic, which could have affected the response rate. There could have been responses that reflected completion of the survey primarily by the fellows who had exposure to or interest in EMR of large colon polyps. However, a response bias would nean that increased fellow participation would show a higher knowledge deficit. Second, the articipants were predominantly men, second-and third-year fellows, and were from large university programs; therefore, they may not be representative of all the gastroenterology fellows in the country. Even with limited first-year fellow participation, the results show the effect of progression through fellowship on the overall knowledge of EMR and these results are unlikely to change with greater participation by first-year fellows. In addition, greater inclusion of second-and third-year fellows is more likely to represent the training experience of gastroenterology fellowship. Similarly, program setting (community vs. university) was not found to affect the knowledge score and a higher participation from community-based programs is less likely to change the results. ▶ Table 3 Factors associated with higher tertiles ordinal regression. Odds ratio (95 % CI) P value In conclusion, we found that nearly half the fellows had no formal education and the survey identified prominent knowledge deficiencies in EMR. We identified that educational efforts should emphasize on overview of the skills, techniques needed to perform EMR including electrosurgery unit settings, and assessment of polyp morphology. Incorporation of standardized formal training with the inclusion of participation in advanced endoscopy rotations could be a key strategy to enhance EMR skills among gastroenterology fellows. Cancer statistics, 2020 Colorectal adenomas Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths Adenoma detection rate and risk of colorectal cancer and death Colonoscopy and colorectal cancer incidence and mortality Protection from colorectal cancer after colonoscopy: A population-based, case-control study Endoscopic mucosal resection Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline Endoscopic mucosal resection The Paris endoscopic classification of superficial neoplastic lesions: Esophagus, stomach, and colon Validation of a simple classification system for endoscopic diagnosis of small colorectal polyps using narrow-band imaging Competency in esophagogastroduodenoscopy: a validated tool for assessment and generalizable benchmarks for gastroenterology fellows The Mayo Colonoscopy Skills Assessment Tool: Validation of a unique instrument to assess colonoscopy skills in trainees Gender disparities and gastroenterology trainee attitudes toward advanced endoscopic training The authors declare that they have no conflicts of interest.