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1、ERCP Training and Assessment in the U.S.美国ERCP 培训与评估,Joseph Leung, MD., FRCP., FACP., FASGE., MACG. Mr. 73:868-74,1. 深插管，胆道支架置入/交换/取出,Goals of ERCP trainingERCP培训目标,Able to provide fundamental (life-saving) ERCP procedures at the community level e.g. urgent biliary draining for acute (suppurative) c
2、holangitis 初级培训：能够在当地医院急诊情况下提供最基本的 （”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：能够熟练掌握技术难度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要高级的培训,Training Curriculum培训科目,Differences between ASGE an
3、d 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 监督下的临床实践 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 diagnostic and treatment opt
4、ions, including assessment of risks 胆胰系统疾病 门诊及住院病人的处理, 诊断和治疗的选择以及风险评估 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) 何时应用于临床 Specific procedures 具体步骤 Management
5、 of complications 并发症的处理 Documentation of performance 操作记录 Credentialing 证书,1/2015,Training Methods培训方法,Self studies: videos, recorded lectures, self assessment 自学：视频， 听课, 自我评估 Radiological interpretation, safety with fluoroscopy 影像学资料学习，放射学安全 Observation of clinical procedures 临床操作观摩学习 Laboratory p
6、ractice of basic skills, including handling scope and accessories 内镜室基础操作，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 a
7、ssimilate skills and complete entire procedure 循序渐进掌握ERCP操作技巧 Successful procedure with no complications 成功独立操作, 没有并发症的手术 Trainees also learn how to assist with ERCP procedure 学员同时应当学习如何当好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
8、 Hands-on team 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 理解解剖及胃肠蠕动特性 Practice with real scope and accessories 使用十二指肠镜和附件练习 Familiar with scope handling 熟悉持镜技巧 Learn and practice basic steps 学习掌握基本操
9、作步骤 Coordinated practice with assistant without risking a patient 与助手合作练习 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成功率),Simulation Models模拟器类型,Animal model (anatomical variations) 动物模型（解剖差异） Anestheti
10、zed pig 麻醉下的活体猪 Ex-vivo porcine stomach 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（探头代替真实设备） GI Mentor II Mechanical Simulator (rigid model) 机械模拟器(rigid model) EMS X-vision,IDEAL Simulation Practice最理想 模拟器训练,I mproves skills 提高基本操作技能 D em
11、onstrates realism： 展示解剖、胃肠运动的实际情况 E ase of incorporation into training： 方便操作配合培训 A pplicable in training： 实用训练，可以模拟治疗性ERCP L 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
12、?谁来教？,A skilled endoscopist may not be a good teacher 技术全面的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 适当提供指导，训练和辅助 Supportive and not punitive attitude 态度积极，避免惩罚性教学,Assessment of Competence能力评估,临床评估Clinical assessment,Proce
13、dure log 临床操作记录 Success/failure 成功/失败 Complications 并发症 Trainer involvement (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,模拟器评估 Simulation,Procedure log 操作记录 Type of practice 操作类型 Variation in difficulty
14、 不同难度 Success/failure 成功/失败 Error in practice 操作中的错误 Procedure time 操作时间 Simulated fluoroscopy time 模拟放射线时间,Overall Assessment评估,Acquisition of knowledge and application 学员掌握理论知识 和操作技巧 Clinical knowledge 临床基础知识 Understanding of pathologies, interpretation of radiological findings, choice of therapy
15、掌握疾病病理生理，能够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际能力,Objective Assessment客观评价指标,Examination to determine quality of trainee 学员综合能力考试 Knowledge 基础理论 Skills 操作技巧 Compassion 对患者的同情关怀(爱心） Exam 测验/考试 Written (multiple choice) 笔试（包括多项选择） Oral 口试 Practical 现场操作
16、,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经验程度 Complexity and 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 客观评价指标 Success with cannulation 插管成功率 Post procedural complications 术后并发症 Report card 临床操作记录卡 Benchmarking 达标的指标,What is Acceptable Performance?怎样算合格,High success rates and low complications 操作的 成功率高 和 并发症率低 Level of complexity vs. experience of operator 操作复杂性 跟 操作者经验 L
