Will virtual reality simulators end the credentialing arms race in gastrointestinal endoscopy or the need for family physician faculty with endoscopic skills?

Twenty years ago I stumbled upon an idea that changed my life. In a study of preventive medicine behaviors by family physicians, the introduction of a new procedural technology (flexible gastrointestinal endoscopy) markedly improved the longstanding noncompliance of physicians and patients in the prevention of colorectal cancer.1,2 The fiberoptic bundles of short colonoscopy and flexible sigmoidoscopy translated into a reproducibly constant group of diagnostic advantages. 3 Improved patient tolerance led to greater insertion depth and better diagnostic yield. Few, however, have commented on the process that led to displacement of old technology (rigid sigmoidoscopy) by a continuum of newer technologies (flexible sigmoidoscopy, endoscopic biopsy, and colonoscopy; and esophagogastroduodenoscopy [EGD]).4,5 Even fewer have described the lengthy technology transfer curve (30 years) and the embarrassing resistance of established physicians who were trying to protect the status quo.6-8 Using fiberoptic endoscopy, teacher and learner could observe the visual findings simultaneously,9 which had not been possible with rigid sigmoidoscopy. For the first time teaching could be structured and effective. Although medical schools and residencies had claimed that training occurred, clearly for many minor in-office surgical procedures, it had not. 10 With this new and more teachable procedure, surely, I thought, things would improve rapidly.11 They did not. Down-