10月11日美國ERCP培訓(xùn)與評估(梁永昌)

1、ERCP Training and Assessment in the U.S.美國ERCP 培訓(xùn)與評價(jià)Joseph Leung, MD., FRCP., FACP., FASGE., MACG.Mr. & Mrs. C.W. Law Professor of Medicine,University of California, Davis School of Medicine,Chief, Section of Gastroenterology,VA Northern California Health Care System.ERCP Training in the U.S.美國的ERCP

2、培訓(xùn)Part of a GI Fellowship (ABIM accredited)胃腸醫(yī)生培訓(xùn)的一部分 (美國內(nèi)科學(xué)委員會認(rèn)證)ERCP training offered in 3rd year (trainees exposed to ERCP but not necessarily competent in performing)第3年開場進(jìn)展ERCP培訓(xùn) (學(xué)員只需ERCP知識, 并不要求獨(dú)立操作Additional (advanced) 4th year training (not ABIM accredited)第4年高級培訓(xùn)一年非美國內(nèi)科學(xué)委員會認(rèn)證要求Trainees exp

3、ected to complete 180-200 cases, with 80% success rate, including 75% therapeutic procedures要求學(xué)員完成180-200例操作，勝利率達(dá)80%以上其中包括75%的治療性操作 .Why ERCP Training?為什么要進(jìn)展ERCP培訓(xùn) ？ERCP is effective in management of pancreaticobiliary diseasesERCP 在膽胰系統(tǒng)疾病診治方面效果顯著It is complex and potentially hazardousERCP 技術(shù)復(fù)雜，有相當(dāng)高

4、的潛在風(fēng)險(xiǎn)Requires effective clinical/technical teaching需求有效的臨床根底和操作技巧指點(diǎn)Objective assessment to determine quality需求客觀的評價(jià)，判別學(xué)員操作才干Apprenticeship傳統(tǒng)的學(xué)徒式教學(xué).Key Questions in ERCP TrainingERCP培訓(xùn)中的關(guān)鍵問題Who should be trained?誰來學(xué)？What should be taught, and how?教什么，怎樣教？Who should teach?誰來教？How are training and comp

5、etence assessed?如何對培訓(xùn)效果及學(xué)員才干進(jìn)展有效評價(jià)？What level of performance is acceptable?培訓(xùn)目的如何確定？.Who Should be Trained?誰來學(xué)？GI/Surgical trainees部分消化科內(nèi)醫(yī)生和外科醫(yī)生Available training positions are variable按照不同的階段目的 獲得多樣化培訓(xùn)Expectation - those who received training should reach acceptable level of competence for safe ind

6、ependent practice 預(yù)期在終了培訓(xùn)時(shí)，學(xué)員可以到達(dá)相應(yīng)階段培訓(xùn)規(guī)范可以獨(dú)立平安的開展業(yè)務(wù).What Should be Taught, and How?教什么，怎樣教？Knowledge in pancreaticobiliary diseases 膽胰系統(tǒng)疾病的臨床實(shí)際知識Skills in ERCP including alternative diagnostic and therapeutic methodsERCP的實(shí)踐操作技藝，包括其他診斷性和治療性操作方法Skilled in basic tenets of patient care醫(yī)學(xué)精神以及收治過程中與病人溝通才

7、干 .Levels of ComplexityERCP技術(shù)難度分級2021Cotton et al. Grading the complexity of endoscopic procedures: results of an ASGE working party. GIE 2021;73:868-741. 深插管，膽道支架置入/交換/取出 .Goals of ERCP trainingERCP培訓(xùn)目的Able to provide fundamental (life-saving) ERCP procedures at the community level e.g. urgent bili

8、ary draining for acute (suppurative) cholangitis初級培訓(xùn)：可以在當(dāng)?shù)蒯t(yī)院急診情況下提供最根本的救命式ERCP操作，如急性化膿性膽管炎引流Those completed training should be competent in performing level 1 and 2 procedures完成培訓(xùn)：可以熟練掌握技術(shù)難度1、2級的ERCP操作Levels 3 and 4 procedures will require advanced training 3, 4級技術(shù)難度的操作需求高級的培訓(xùn).Training Curriculum培訓(xùn)科

9、目Differences between ASGE and SAGES 美國胃腸鏡學(xué)會與胃腸道內(nèi)鏡外科醫(yī)生學(xué)會要求的分別Lectures, didactics, atlases, videos and books講座，授課，圖片，視頻以及教科書Supervised clinical practice監(jiān)視下的臨床實(shí)際History/physical exam, laboratory tests病史，體征，實(shí)驗(yàn)室檢查Management of pancreaticobiliary problems as in- and outpatients, with discussion on diagnos

10、tic and treatment options, including assessment of risks膽胰系統(tǒng)疾病 門診及住院病人的處置, 診斷和治療的選擇以及風(fēng)險(xiǎn)評價(jià)Multi-disciplinary approach (surgery/radiology)多學(xué)科討論 外科、放射科.Concept of Training (Preparing the endoscopist)培訓(xùn)的概念How to do it (basic skills) 怎樣做When to use it (clinical application) 何時(shí)運(yùn)用于臨床Specific procedures詳細(xì)步驟

11、Management of complications 并發(fā)癥的處置Documentation of performance 操作記錄Credentialing 證書1/2021.Training Methods培訓(xùn)方法Self studies: videos, recorded lectures, self assessment自學(xué)：視頻， 聽課, 自我評價(jià)Radiological interpretation, safety with fluoroscopy影像學(xué)資料學(xué)習(xí)，放射學(xué)平安Observation of clinical procedures臨床操作觀摩學(xué)習(xí)Laboratory p

12、ractice of basic skills, including handling scope and accessories內(nèi)鏡室根底操作，包括持鏡，附件等Clinical training: hands-on practice with scope handling and selective cannulation臨床操作培訓(xùn)：控制十二指腸鏡和選擇性插管的練習(xí)Guide wire manipulation and operate different accessories導(dǎo)絲和其他附件操作Learning in steps and eventually able to assimil

13、ate skills and complete entire procedure循序漸進(jìn)掌握ERCP操作技巧Successful procedure with no complications勝利獨(dú)立操作, 沒有并發(fā)癥的手術(shù)Trainees also learn how to assist with ERCP procedure 學(xué)員同時(shí)該當(dāng)學(xué)習(xí)如何當(dāng)好ERCP助手.Supplemental Training補(bǔ)充培訓(xùn)Seminars and workshops研討會和培訓(xùn)班Model practice including simulators包括模擬器在內(nèi)的模擬訓(xùn)練Hands-on team

14、practice to improve coordination with assistants (TEAM work)手把手ERCP團(tuán)隊(duì)協(xié)作訓(xùn)練.Simulation (Optional) Training模擬器可選擇培訓(xùn)Understand anatomy, motility了解解剖及胃腸蠕動(dòng)特性Practice with real scope and accessories運(yùn)用十二指腸鏡和附件練習(xí)Familiar with scope handling熟習(xí)持鏡技巧Learn and practice basic steps 學(xué)習(xí)掌握根本操作步驟Coordinated practice w

15、ith assistant without risking a patient與助手協(xié)作練習(xí) 減少病人風(fēng)險(xiǎn)(RCT showed improved cannulation success rate with initial simulation practice for novice endoscopists)(RCT顯示模擬器插管練習(xí)明顯提升ERCP初學(xué)者臨床操作插管勝利率) .Simulation Models模擬器類型Animal model (anatomical variations)動(dòng)物模型解剖差別Anesthetized pig 麻醉下的活體豬Ex-vivo porcine st

16、omach model 離體的豬胃腸模型Neopapilla model 新型乳頭模型雞心Computer Simulator (probes instead of real instrument)計(jì)算機(jī)模擬器探頭替代真實(shí)設(shè)備GI Mentor IIMechanical Simulator (rigid model)機(jī)械模擬器(rigid model)EMSX-vision .IDEAL Simulation Practice最理想 模擬器訓(xùn)練I mproves skills提高根本操作技藝D emonstrates realism：展現(xiàn)解剖、胃腸運(yùn)動(dòng)的實(shí)踐情況E ase of incorpo

17、ration into training：方便操作配合培訓(xùn) A pplicable in training：適用訓(xùn)練，可以模擬治療性ERCPL earning with real scope and accessories：用真的十二指腸鏡及附件學(xué)習(xí)操作 .ERCP Mechanical Simulator (EMS)機(jī)械模擬器Artificial biliary papillotomy人工乳頭切開Pancreatic stenting胰管支架置入.Who Should Teach?誰來教？A skilled endoscopist may not be a good teacher技術(shù)全面的

18、內(nèi)鏡醫(yī)生不一定能勝任教學(xué)Trainer should recognize mistakes made by trainees教師應(yīng)該分辨學(xué)員操作中的錯(cuò)誤Offers guidance, coaching and assistance適當(dāng)提供指點(diǎn)，訓(xùn)練和輔助Supportive and not punitive attitude態(tài)度積極，防止懲罰性教學(xué).Assessment of Competence才干評價(jià)臨床評價(jià)Clinical assessmentProcedure log臨床操作記錄Success/failure勝利/失敗Complications并發(fā)癥Trainer involveme

19、nt (step-by-step training depending on complexity, risk and potential complications)教師參與程度Verbal口頭指令Hands-on assistance 手把手輔助Take over 教師接鏡操作模擬器評價(jià) SimulationProcedure log操作記錄Type of practice操作類型Variation in difficulty不同難度Success/failure勝利/失敗Error in practice操作中的錯(cuò)誤Procedure time操作時(shí)間Simulated fluorosc

20、opy time模擬放射線時(shí)間.Overall Assessment評價(jià)Acquisition of knowledge and application學(xué)員掌握實(shí)際知識 和操作技巧Clinical knowledge臨床根底知識Understanding of pathologies, interpretation of radiological findings, choice of therapy掌握疾病病理生理，可以閱片和選擇治療方式Technical proficiency and competency in performing procedure技術(shù)熟練程度和臨床操作的實(shí)踐才干.O

21、bjective Assessment客觀評價(jià)目的Examination to determine quality of trainee學(xué)員綜合才干考試Knowledge 根底實(shí)際Skills 操作技巧Compassion 對患者的同情關(guān)懷(愛心Exam檢驗(yàn)/考試Written (multiple choice) 筆試包括多項(xiàng)選擇Oral 口試Practical 現(xiàn)場操作.Number of Procedures (Log Book)病例數(shù)記錄Arbitrarily used as a surrogate of experience病例數(shù)可以用于粗略估計(jì)學(xué)員閱歷程度Complexity and

22、 spectrum病例復(fù)雜性和不同類型 Degree of involvement with trainee/trainer教師在學(xué)員的操作輔助程度Objective outcome assessment客觀評價(jià)目的Success with cannulation 插管勝利率Post procedural complications 術(shù)后并發(fā)癥Report card 臨床操作記錄卡Benchmarking 達(dá)標(biāo)的目的.What is Acceptable Performance?怎樣算合格High success rates and low complications操作的 勝利率高 和 并發(fā)癥率低Level of complexity vs. experience of operator操作復(fù)雜性 跟 操作者閱歷Level of urgency vs. type of (life-saving) procedure緊急程度 跟 操作種類救命操作Trainee solo performance學(xué)員單獨(dú)完成操作.Credentialing and Certification