Andrew Luck is a colorectal surgeon working at the Lyell McEwin Hospital and in private practice in Adelaide’s northern suburbs. Andrew has a long history of involvement in colonoscopy quality activities including membership of the following boards and committees;
Andrew is a past President of the Colorectal Surgical Society of Australia and New Zealand (CSSANZ) and Chairman of the CSSANZ Research Foundation. He is a current member of the Australia and New Zealand Training Board in Colon and Rectal Surgery. In 2017 he was conferred Honorary Life Membership of the Gastroenterological Society of Australia and was awarded the Order of Australia Medal for Services to Medicine in the field of colorectal surgery in the 2018 Australia Day Honours.
Technical Tips and Tricks to improve colonoscopy performance
Colonoscopy is the gold standard investigation for assessment of the rectum, colon and terminal ileum. High quality colonoscopy is essential in order to provide accurate detection and assessment of both neoplastic and non-neoplastic bowel disease with complete views to the caecum and a low complication rate.
The configuration of the colon with the sigmoid and transverse colons on a mesentery, however, makes colonoscopy a challenge to learn and to perform at a consistently high level. As a truly solo procedure it is also a challenge to teach, as the trainer can only describe what needs to be done to complete a task rather than being a part of the process, as would happen in operative surgery.
Whilst individual colonoscopists will each develop their own technique during and after their training, there are some ‘truisms’ that, if followed, will improve the completion rate, adenoma detection rate and polypectomy technique of all practitioners. This paper will discuss tips and tricks to improve colonoscopy performance in the following areas;
Training the Colonoscopy Trainers
Colonoscopy is a procedure that, unlike other surgical procedures, only allows one practitioner to operate the instrument at a time. This makes colonoscopy a uniquely challenging procedure to teach, as the trainer can only describe what needs to be done to complete a task, rather than assisting in the execution of the task as well.
Colonoscopy training has in the past, and indeed often continues to be, a trial and error process with the trainee attempting various manoeuvres to negotiate the colon and moving on to the next stage when one of these manoeuvres happens to work. Eventually, with enough practice, one becomes proficient at the procedure. Little thought is given to what works and what doesn’t in certain situations, nor reflection and memory of successes and failures in order to improve the process for subsequent procedures.
Competence achieved in this way is often unconscious, that is, the colonoscopist can safely perform the procedure, but would have difficulty describing what has been done on a step by step basis. This situation has significant implications for training the next generation of colonoscopists –if a specialist is not conscious of what needs to be done is a certain situation, then they cannot verbalise what the trainee needs to do, often meaning that a default back to trail and error tends to occur.
Recognising this situation in the early 2000’s a group of gastroenterologists in the UK devised a 2 day course designed to improve the teaching of colonoscopy in that country, concentrating on improving the conscious competence of colonoscopists in both the performance and teaching of the procedure and using modern adult education techniques to change the nature of colonoscopy teaching. With the help of the UK team, Train the Colonoscopy Trainer courses started in Australia in 2008, and we have since trained over 200 colonoscopy trainers.
This paper will provide a ‘highlights reel’ of the Australian 2 day Train the Colonoscopy Trainer course, emphasising engagement in the training process, conscious competence in both colonoscopy and its training, the set-up of an educational contract with the trainee and the provision of performance enhancing feedback.