10月11日美国ERCP培训与评估(梁永昌)

1、ERCP Training and Assessment in the U.S.美国ERCP 培训与评价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.美国的ERCP

2、培训Part of a GI Fellowship (ABIM accredited)胃肠医生培训的一部分 (美国内科学委员会认证)ERCP training offered in 3rd year (trainees exposed to ERCP but not necessarily competent in performing)第3年开场进展ERCP培训 (学员只需ERCP知识, 并不要求独立操作Additional (advanced) 4th year training (not ABIM accredited)第4年高级培训一年非美国内科学委员会认证要求Trainees exp

3、ected to complete 180-200 cases, with 80% success rate, including 75% therapeutic procedures要求学员完成180-200例操作，胜利率达80%以上其中包括75%的治疗性操作 .Why ERCP Training?为什么要进展ERCP培训 ？ERCP is effective in management of pancreaticobiliary diseasesERCP 在胆胰系统疾病诊治方面效果显著It is complex and potentially hazardousERCP 技术复杂，有相当高

4、的潜在风险Requires effective clinical/technical teaching需求有效的临床根底和操作技巧指点Objective assessment to determine quality需求客观的评价，判别学员操作才干Apprenticeship传统的学徒式教学.Key Questions in ERCP TrainingERCP培训中的关键问题Who should be trained?谁来学？What should be taught, and how?教什么，怎样教？Who should teach?谁来教？How are training and comp

5、etence assessed?如何对培训效果及学员才干进展有效评价？What level of performance is acceptable?培训目的如何确定？.Who Should be Trained?谁来学？GI/Surgical trainees部分消化科内医生和外科医生Available training positions are variable按照不同的阶段目的 获得多样化培训Expectation - those who received training should reach acceptable level of competence for safe ind

6、ependent practice 预期在终了培训时，学员可以到达相应阶段培训规范可以独立平安的开展业务.What Should be Taught, and How?教什么，怎样教？Knowledge in pancreaticobiliary diseases 胆胰系统疾病的临床实际知识Skills in ERCP including alternative diagnostic and therapeutic methodsERCP的实践操作技艺，包括其他诊断性和治疗性操作方法Skilled in basic tenets of patient care医学精神以及收治过程中与病人沟通才

7、干 .Levels of ComplexityERCP技术难度分级2021Cotton et al. Grading the complexity of endoscopic procedures: results of an ASGE working party. GIE 2021;73:868-741. 深插管，胆道支架置入/交换/取出 .Goals of ERCP trainingERCP培训目的Able to provide fundamental (life-saving) ERCP procedures at the community level e.g. urgent bili

8、ary draining for acute (suppurative) cholangitis初级培训：可以在当地医院急诊情况下提供最根本的救命式ERCP操作，如急性化脓性胆管炎引流Those completed training should be competent in performing level 1 and 2 procedures完成培训：可以熟练掌握技术难度1、2级的ERCP操作Levels 3 and 4 procedures will require advanced training 3, 4级技术难度的操作需求高级的培训.Training Curriculum培训科

9、目Differences between ASGE and SAGES 美国胃肠镜学会与胃肠道内镜外科医生学会要求的分别Lectures, didactics, atlases, videos and books讲座，授课，图片，视频以及教科书Supervised clinical practice监视下的临床实际History/physical exam, laboratory tests病史，体征，实验室检查Management of pancreaticobiliary problems as in- and outpatients, with discussion on diagnos

10、tic and treatment options, including assessment of risks胆胰系统疾病 门诊及住院病人的处置, 诊断和治疗的选择以及风险评价Multi-disciplinary approach (surgery/radiology)多学科讨论 外科、放射科.Concept of Training (Preparing the endoscopist)培训的概念How to do it (basic skills) 怎样做When to use it (clinical application) 何时运用于临床Specific procedures详细步骤

11、Management of complications 并发症的处置Documentation of performance 操作记录Credentialing 证书1/2021.Training Methods培训方法Self studies: videos, recorded lectures, self assessment自学：视频， 听课, 自我评价Radiological interpretation, safety with fluoroscopy影像学资料学习，放射学平安Observation of clinical procedures临床操作观摩学习Laboratory p

12、ractice of basic skills, including handling scope and accessories内镜室根底操作，包括持镜，附件等Clinical training: hands-on practice with scope handling and selective cannulation临床操作培训：控制十二指肠镜和选择性插管的练习Guide wire manipulation and operate different accessories导丝和其他附件操作Learning in steps and eventually able to assimil

13、ate skills and complete entire procedure循序渐进掌握ERCP操作技巧Successful procedure with no complications胜利独立操作, 没有并发症的手术Trainees also learn how to assist with ERCP procedure 学员同时该当学习如何当好ERCP助手.Supplemental Training补充培训Seminars and workshops研讨会和培训班Model practice including simulators包括模拟器在内的模拟训练Hands-on team

14、practice to improve coordination with assistants (TEAM work)手把手ERCP团队协作训练.Simulation (Optional) Training模拟器可选择培训Understand anatomy, motility了解解剖及胃肠蠕动特性Practice with real scope and accessories运用十二指肠镜和附件练习Familiar with scope handling熟习持镜技巧Learn and practice basic steps 学习掌握根本操作步骤Coordinated practice w

15、ith assistant without risking a patient与助手协作练习 减少病人风险(RCT showed improved cannulation success rate with initial simulation practice for novice endoscopists)(RCT显示模拟器插管练习明显提升ERCP初学者临床操作插管胜利率) .Simulation Models模拟器类型Animal model (anatomical variations)动物模型解剖差别Anesthetized pig 麻醉下的活体猪Ex-vivo porcine st

16、omach model 离体的猪胃肠模型Neopapilla model 新型乳头模型鸡心Computer Simulator (probes instead of real instrument)计算机模拟器探头替代真实设备GI Mentor IIMechanical Simulator (rigid model)机械模拟器(rigid model)EMSX-vision .IDEAL Simulation Practice最理想 模拟器训练I mproves skills提高根本操作技艺D emonstrates realism：展现解剖、胃肠运动的实践情况E ase of incorpo

17、ration into training：方便操作配合培训 A pplicable in training：适用训练，可以模拟治疗性ERCPL earning with real scope and accessories：用真的十二指肠镜及附件学习操作 .ERCP Mechanical Simulator (EMS)机械模拟器Artificial biliary papillotomy人工乳头切开Pancreatic stenting胰管支架置入.Who Should Teach?谁来教？A skilled endoscopist may not be a good teacher技术全面的

18、内镜医生不一定能胜任教学Trainer should recognize mistakes made by trainees教师应该分辨学员操作中的错误Offers guidance, coaching and assistance适当提供指点，训练和辅助Supportive and not punitive attitude态度积极，防止惩罚性教学.Assessment of Competence才干评价临床评价Clinical assessmentProcedure log临床操作记录Success/failure胜利/失败Complications并发症Trainer involveme

19、nt (step-by-step training depending on complexity, risk and potential complications)教师参与程度Verbal口头指令Hands-on assistance 手把手辅助Take over 教师接镜操作模拟器评价 SimulationProcedure log操作记录Type of practice操作类型Variation in difficulty不同难度Success/failure胜利/失败Error in practice操作中的错误Procedure time操作时间Simulated fluorosc

20、opy time模拟放射线时间.Overall Assessment评价Acquisition of knowledge and application学员掌握实际知识 和操作技巧Clinical knowledge临床根底知识Understanding of pathologies, interpretation of radiological findings, choice of therapy掌握疾病病理生理，可以阅片和选择治疗方式Technical proficiency and competency in performing procedure技术熟练程度和临床操作的实践才干.O

21、bjective Assessment客观评价目的Examination to determine quality of trainee学员综合才干考试Knowledge 根底实际Skills 操作技巧Compassion 对患者的同情关怀(爱心Exam检验/考试Written (multiple choice) 笔试包括多项选择Oral 口试Practical 现场操作.Number of Procedures (Log Book)病例数记录Arbitrarily used as a surrogate of experience病例数可以用于粗略估计学员阅历程度Complexity and

22、 spectrum病例复杂性和不同类型 Degree of involvement with trainee/trainer教师在学员的操作辅助程度Objective outcome assessment客观评价目的Success with cannulation 插管胜利率Post procedural complications 术后并发症Report card 临床操作记录卡Benchmarking 达标的目的.What is Acceptable Performance?怎样算合格High success rates and low complications操作的 胜利率高 和 并发症率低Level of complexity vs. experience of operator操作复杂性 跟 操作者阅历Level of urgency vs. type of (life-saving) procedure紧急程度 跟 操作种类救命操作Trainee solo performance学员单独完成操作.Credentialing and Certification