ERCP competence assessment: Miles to go before standardization

Over the past decade, increasing emphasis has been placed on quality metrics and competency assessment in health care. The goals of high-quality endoscopy – appropriate patient selection (indicated procedure), accurate diagnosis, and appropriate implementation – should be achieved with minimal patient risk and performed by properly trained and competent endoscopists [1]. The ultimate goals should be improvement in patient outcome and satisfaction [2, 3]. Competency, an important element of quality endoscopy, should be defined as the consistent ability to meet technical goals of the intended procedure and to correctly perform cognitive aspects of the procedure. In a constantly changing environment and with the introduction of new techniques and technologies, competency is crucial to endoscopic practice. Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most technically demanding and high-risk procedures performed by gastrointestinal endoscopists, requiring significant focused training and experience to maximize success and patient outcome. It has a steep learning curve in both physical skills and judgment/interpretation, and increasingly more sophisticated diagnostic and therapeutic techniques are employed. Goals of an endoscopy training program include ensuring that core motor and cognitive skills necessary to successfully and competently perform ERCP are acquired. Ensuring competence in ERCP has recently emerged as an area of intense scrutiny as training programs and hospital credentialing committees attempt to produce and approve, respectively, adequately trained endoscopists. Despite this, universally accepted standards for competence in ERCP have not been established. It is commonly assumed that competence is achieved when a minimum number of ERCP procedures have been performed. For most training programs this may only be in the range of 100 to 200 cases [4]. With the appreciation that individual trainees develop endoscopic skills at different rates, [5] there has been a shift towards competency-based training and certification. An assessment of individual performance is probably more robust than the use of minimum numbers for defining competence. Accurate and validated ERCP performance measures are necessary in order to effectively train practitioners using a competency-based curriculum. The endoscopic trainee must be able to achieve a standard rate of technical success, but must also be able to recognize abnormal pathology, identify it correctly, and decide upon the appropriate course of action. Recognizing the limitations of the current models of training and assessment of competence, the Accreditation Council for Graduate Medical Education (ACGME) replaced the reporting system with the Next Accreditation System focusing on competency-based medical education (CBME). Ideally, ERCP training programs will move toward the adoption of CBME and demonstrate that trainees have achieved competence and attained the technical and cognitive skills required for safe and effective unsupervised practice in advanced endoscopy [6–8].