10月11日美国ERCP培训与评估(梁永昌)

ERCPTrainingandAssessmentintheU.S.美国ERCP培训与评估JosephLeung,MD.,FRCP.,FACP.,FASGE.,MACG.Mr.&Mrs.C.W.LawProfessorofMedicine,UniversityofCalifornia,DavisSchoolofMedicine,Chief,SectionofGastroenterology,VANorthernCaliforniaHealthCareSystem.ERCPTrainingintheU.S.美国的ERCP培训PartofaGIFellowship(ABIMaccredited)胃肠医生培训的一部分(美国内科学委员会认证)ERCPtrainingofferedin3rdyear(traineesexposedtoERCPbutnotnecessarilycompetentinperforming)第3年开始进行ERCP培训(学员只需ERCP知识,并不要求独立操作）Additional(advanced)4thyeartraining(notABIMaccredited)第4年高级培训一年（非美国内科学委员会认证要求）Traineesexpectedtocomplete180-200cases,with80%successrate,including75%therapeuticprocedures要求学员完成180-200例操作，成功率达80%以上（其中包括75%的治疗性操作）WhyERCPTraining?为什么要进行ERCP培训？ERCPiseffectiveinmanagementofpancreaticobiliarydiseasesERCP在胆胰系统疾病诊治方面效果显著ItiscomplexandpotentiallyhazardousERCP技术复杂，有相当高的潜在风险Requireseffectiveclinical/technicalteaching需要有效的临床基础和操作技巧指导Objectiveassessmenttodeterminequality需要客观的评估，判断学员操作能力Apprenticeship传统的学徒式教学KeyQuestionsinERCPTrainingERCP培训中的关键问题Whoshouldbetrained?谁来学？Whatshouldbetaught,andhow?教什么，怎样教？Whoshouldteach?谁来教？Howaretrainingandcompetenceassessed?如何对培训效果及学员能力进行有效评估？Whatlevelofperformanceisacceptable?培训目标如何确定？WhoShouldbeTrained?谁来学？GI/Surgicaltrainees部分消化科内医生和外科医生Availabletrainingpositionsarevariable按照不同的阶段目标获得多样化培训Expectation-thosewhoreceivedtrainingshouldreachacceptablelevelofcompetenceforsafeindependentpractice预期在结束培训时，学员能够达到相应阶段培训标准可以独立安全的开展业务WhatShouldbeTaught,andHow?教什么，怎么教？Knowledgeinpancreaticobiliarydiseases胆胰系统疾病的临床理论知识SkillsinERCPincludingalternativediagnosticandtherapeuticmethodsERCP的实际操作技能，包括其他诊断性和治疗性操作方法Skilledinbasictenetsofpatientcare医学精神以及收治过程中与病人沟通能力LevelsofComplexityERCP技术难度分级（2011）Cottonetal.Gradingthecomplexityofendoscopicprocedures:resultsofanASGEworkingparty.GIE2011;73:868-741.深插管，胆道支架置入/交换/取出GoalsofERCPtrainingERCP培训目标Abletoprovidefundamental(life-saving)ERCPproceduresatthecommunitylevele.g.urgentbiliarydrainingforacute(suppurative)cholangitis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Thosecompletedtrainingshouldbecompetentinperforminglevel1and2procedures完成培训：能够熟练掌握技术难度1、2级的ERCP操作Levels3and4procedureswillrequireadvancedtraining3,4级技术难度的操作需要高级的培训TrainingCurriculum培训科目DifferencesbetweenASGEandSAGES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,videosandbooks讲座，授课，图片，视频以及教科书Supervisedclinicalpractice监督下的临床实践History/physicalexam,laboratorytests病史，体征，实验室检查Managementofpancreaticobiliaryproblemsasin-andoutpatients,withdiscussionondiagnosticandtreatmentoptions,includingassessmentofrisks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-disciplinaryapproach(surgery/radiology)多学科讨论（外科、放射科）•ConceptofTraining(Preparingtheendoscopist)培训的概念•Howtodoit(basicskills)怎样做•Whentouseit(clinicalapplication)何时应用于临床•Specificprocedures具体步骤•Managementofcomplications并发症的处理•Documentationofperformance操作记录•Credentialing证书1/2015TrainingMethods培训方法Selfstudies:videos,recordedlectures,selfassessment自学：视频，听课,自我评估Radiologicalinterpretation,safetywithfluoroscopy影像学资料学习，放射学安全Observationofclinicalprocedures临床操作观摩学习Laboratorypracticeofbasicskills,includinghandlingscopeandaccessories内镜室基础操作，包括持镜，附件等Clinicaltraining:hands-onpracticewithscopehandlingandselectivecannulation临床操作培训：控制十二指肠镜和选择性插管的练习Guidewiremanipulationandoperatedifferentaccessories导丝和其他附件操作Learninginstepsandeventuallyabletoassimilateskillsandcompleteentireprocedure循序渐进掌握ERCP操作技巧Successfulprocedurewithnocomplications成功独立操作,没有并发症的手术TraineesalsolearnhowtoassistwithERCPprocedure学员同时应当学习如何当好ERCP助手SupplementalTraining补充培训Seminarsandworkshops研讨会和培训班Modelpracticeincludingsimulators包括模拟器在内的模拟训练Hands-onteampracticetoimprovecoordinationwithassistants(TEAMwork)手把手ERCP团队协作训练Simulation(Optional)Training模拟器（可选择）培训Understandanatomy,motility理解解剖及胃肠蠕动特性Practicewithrealscopeandaccessories使用十二指肠镜和附件练习Familiarwithscopehandling熟悉持镜技巧Learnandpracticebasicsteps学习掌握基本操作步骤Coordinatedpracticewithassistantwithoutriskingapatient与助手合作练习减少病人风险(RCTshowedimprovedcannulationsuccessratewithinitialsimulationpracticefornoviceendoscopists)(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)SimulationModels模拟器类型Animalmodel(anatomicalvariations)动物模型（解剖差异）Anesthetizedpig麻醉下的活体猪Ex-vivoporcinestomachmodel离体的猪胃肠模型Neopapillamodel新型乳头模型（鸡心）ComputerSimulator(probesinsteadofrealinstrument)计算机模拟器（探头代替真实设备）GIMentorIIMechanicalSimulator(rigidmodel)机械模拟器(rigidmodel)EMSX-visionIDEALSimulationPractice最理想模拟器训练Improvesskills提高基本操作技能Demonstratesrealism：展示解剖、胃肠运动的实际情况Easeofincorporationintotraining：方便操作配合培训Applicableintraining：实用训练，可以模拟治疗性ERCPLearningwithrealscopeandaccessories：用真的十二指肠镜及附件学习操作ERCPMechanicalSimulator(EMS)机械模拟器Artificialbiliarypapillotomy人工乳头切开Pancreaticstenting胰管支架置入WhoShouldTeach?谁来教？Askilledendoscopistmaynotbeagoodteacher技术全面的内镜医生不一定能胜任教学Trainershouldrecognizemistakesmadebytrainees教师应该分辨学员操作中的错误Offersguidance,coachingandassistance适当提供指导，训练和辅助Supportiveandnotpunitiveattitude态度积极，避免惩罚性教学AssessmentofCompetence能力评估临床评估ClinicalassessmentProcedurelog临床操作记录Success/failure成功/失败Complications并发症Trainerinvolvement(step-by-steptraini