key: cord-0956194-zx52ixv9
authors: Soetikno, Roy; Asokkumar, Ravishankar; McGill, Sarah K.; Kaltenbach, Tonya
title: Simulation-Based Mastery Learning for Practicing Gastroenterologists–Renewed Importance in the Era of COVID-19
date: 2020-08-07
journal: Am J Gastroenterol
DOI: 10.14309/ajg.0000000000000788
sha: ad0dbf4be1b1dad30e55c8d04d8c425de2ecea79
doc_id: 956194
cord_uid: zx52ixv9

nan

Mastery learning (ML) is a well-developed and robust form of competency-based education that ensures all the graduates learn uniformly. In ML, learners acquire the pertinent knowledge and skills to meet a preset minimum passing standards before advancing to the next phase of learning (6) . A critical component of ML is its emphasis on deliberate practice with feedback that is tailored to the learner's pace. ML emphasizes mainly on achieving competency rather than meeting the scheduled timeline. Importantly, simulator use is an essential component of ML because learners can practice while receiving feedback and demonstrate competency before advancing to the next task and ultimately meeting the course objectives (6) .

We incorporated the 7 mandatory steps detailed by McGahie et al. (7) and designed an SBML course to train and retrain gastroenterologists on the use of over-the-scope clip to treat gastrointestinal bleeding and perforation (Figures 1 and 2) (8) . We used an online learning management system (Canvas, Instructure, Salt Lake City, Figure 1 . Flowchart of our simulation-based mastery learning exercise to acquire knowledge and skills on the over-the-scope clip application. UT). In the beginning, we conducted a pre-training knowledge assessment. We then provided the relevant knowledge base to gain a comprehensive understanding of the clip application. The faculty (R.S., R.A., and T.K.) with significant experience in the use of overthe-scope clip and endoscopy education selected the pertinent published literature and used the digestive disease week (DDW) endoscopy learning videos (9) (10) (11) (12) (13) (14) (15) (16) . Learners had 2 to 4 weeks to complete the knowledge base before taking a final summative knowledge assessment. We then conducted in-person training where learners deliberately practiced with feedback deploying the over-the-scope clip on silicone models under expert coaching. We measured the change in knowledge and surveyed their satisfaction Figure 2 . Each learner progressed to the next level only after they have achieved mastery in the initial task. The tasks were sequenced based on increasing difficulty. After gaining mastery in the standardized technique of clipping over-the-scope, learners learned the use of the over-the-scope clipping accessories, which can be complex to operate. Learners must be competent in all the methods to complete the course. Figure 3 . The structure of the cloud-based knowledge contents that the learners' self-study before attending the experiential learning. The course includes a pretest and post-test, and learners are requested to pass the minimum passing standards.

The American Journal of GASTROENTEROLOGY VOLUME 00 | MONTH 2020 www.amjgastro.com

THE RED SECTION at the end of the course. We used descriptive and Student t test statistics. We received an IRB waiver.

We conducted the SBML course at the Singapore General Hospital involving 24 gastroenterologists (mean age 40 6 10 years, 83% men) and at the University of North Carolina, Chapel Hill, engaging 12 gastroenterologists (mean age 44 6 8.4 years; men 58%) and 12 fellows (mean age 33 6 2.2 years; men 58%).

Most (53%) gastroenterologists and all fellows were novices in using the over-the-scope clip; 16 (44%) gastroenterologists have deployed less than 5 clips, whereas one (3%) had extensive experience. For this article, we included the results observed among gastroenterologists. Some data have been presented in part by our team (17) .

The participants spent an average of 1.72 6 0.4 to complete the online module ( Figure 3 ). All attendings completed the self-learning module. They spent 2.5-3 hours learning clip application first on silicone bleeding stomach models (Ovesco, Tubingen, Germany) and subsequently on porcine explants. At the University of North Carolina, only silicone models were used. All participants alternated the role of assistant and endoscopist and deliberately practiced with feedback until they demonstrated competence ( Figure 4) .

For the Singapore cohort, 6 faculty with extensive experience in over-the-scope clip conducted the training in small 4-person groups. For the US cohort, one faculty with extensive experience and 3 assistants held the small 4-person group experiential course over 2 sessions. Trainees were briefed on the objective and schedule of the course, the assessment checklist, and the minimum passing standards (MPSs) required to demonstrate mastery at the end of the course. We defined MPS as the ability to perform all the steps of over-the-scope clip deployment without assistance consistently. All the participants, irrespective of their previous experience, completed the hands-on session and met the MPS after 6 to 8 attempts (see Figure 1 , Supplementary Digital Content 1, http://links.lww.com/AJG/B593). Most (92%) participants agreed that the SBML course was well-paced and covered all the essential content on the topic. They rated the course highly (9.5 6 0.8 out of 10) , and all strongly agreed that they would attend similar courses in the future for other endoscopic procedures.

After the course, we tracked the number of clips deployed in clinical practice. In the Singapore cohort, at 4 months, we observed a 50% increase in the adoption rate among the new users (P , 0.006). We found that 15 over-the-scope clips were placed for duodenal ulcer, gastric ulcer, gastric fistula, anal transition zone bleeding, and gastric anastomotic dehiscence. Seven novice gastroenterologists deployed the majority (67%), and the remainder were placed by those with minimal experience (,5 clips) before the course. Likewise, in the US group, at 1-month, we witnessed a 75% increase in clip application by novice gastroenterologists during GI bleeding call. They placed 11 over-the-scope clips for a variety of gastrointestinal conditions successfully. Three of the 4 fellows who were on-call together deployed 5 clips. Notably, one of them successfully treated a patient with recurrent bleeding after surgery of a perforated duodenal ulcer. None reported complications with the over-the-scope clip application.

The training experience and the results from the 2 different countries show that SBML resulted in quick dissemination of technical knowledge and skill, enabling practicing gastroenterologists to acquire and adopt a new procedure in practice. Notably, the overall time spent on training the latest knowledge and expertise was approximately 5 hours and was perceived to be adequate by most of the participants.

Our experiences illustrate the significant potential of SBML to train and retrain the practicing gastroenterologists and hepatologists (and trainees) and enable them to acquire new skills successfully. Notably, these skills learned out of a non-apprentice-based training model were safely employed in patient care. This observation is novel. The need to develop the knowledge base, simulators, and the framework for conducting SBML is urgent. Building these will allow us to upgrade to a more efficient and effective training system in endoscopy. As we navigate situations filled with uncertainty and unpredictability due to COVID-19, SBML may pave the way to a new era of training, allowing practitioners and trainees to learn the required knowledge at their own time and practice the skills deliberately with feedback until competence is achieved. Figure 4 . The bleeding simulator used in our course. Arterial bleeding is simulated during experiential learning. Learners typically deploy and assist multiple times to achieve competency in performing and helping the deployment of the over-the-scope clip.

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