The impact of the introduction of formalised polypectomy assessment on training in the UK

Abstract

Objective
The aim was to describe the impact on polypectomy experience by the mandatory introduction of the Directly Observed Polypectomy Skills tool (DOPyS) and electronic portfolio as part of the formal colonoscopy certification process.

Design
Applications for colonoscopy certification in the UK in the year prior to the introduction of DOPyS were analysed retrospectively and compared with data collected prospectively for those in the following year.

Setting
UK National Health Service.

Patients
None.

Interventions
None.

Main outcome measures
The outcomes studied included whether evidence of exposure to polypectomy, endoscopic mucosal resection (EMR) and colonoscopy changed over the 2-year period. The nature of the polyps removed by trainees was also studied.

Results
Thirty two per cent of candidates in the first year had evidence of any observed polypectomy with 7% of candidates referring to training in EMR. The median number of formative colonoscopy assessments was 3 (range 0–16). All of these candidates in the second year had evidence of polypectomy assessment, with a median number of DOPyS of 7 (range 3–27). Eighty nine per cent of applicants had evidence of assessed EMR. The median number of formative colonoscopy assessments in this cohort was 32 (range 9–199). There was a significant increase in the number of logged polypectomy assessments (p<0.001), experience of EMR (p<0.001) and formative colonoscopy assessments (p<0.001). There was no significant difference in the total number of colonoscopy procedures performed.

Conclusions
Structured polypectomy assessment improves trainees’ documented exposure to therapeutic endoscopy as well as providing formal evidence of skills acquisition. As polypectomy plays an increasing role globally in colorectal cancer prevention, the DOPyS provides an effective means of assessing and certifying polypectomy.

Full text

RESEARCH
The impact of the introduction of
formalised polypectomy assessment
on training in the UK
Kinesh Patel,
1
Omar Faiz,
1
Matt Rutter,
2
Paul Dunckley,
3
Siwan Thomas-Gibson
1
1
Wolfson Unit for Endoscopy,
St Mark’s Hospital, Harrow, UK
2
University Hospital of North
Tees, Stockport, UK
3
Gloucestershire Royal Hospital,
Gloucester, UK
Correspondence to
Dr Kinesh Patel, Wolfson Unit
for Endoscopy, St Mark’s
Hospital, Watford Road,
Harrow HA1 3UJ, UK;
kinesh.patel@gmail.com
Received 2 May 2016
Revised 12 June 2016
Accepted 27 June 2016
To cite: Patel K, Faiz O,
Rutter M, et al.Frontline
Gastroenterology Published
Online First: [please include
Day Month Year]
doi:10.1136/flgastro-2016-
100718
ABSTRACT
Objective The aim was to describe the impact
on polypectomy experience by the mandatory
introduction of the Directly Observed
Polypectomy Skills tool (DOPyS) and electronic
portfolio as part of the formal colonoscopy
certification process.
Design Applications for colonoscopy
certification in the UK in the year prior to the
introduction of DOPyS were analysed
retrospectively and compared with data collected
prospectively for those in the following year.
Setting UK National Health Service.
Patients None.
Interventions None.
Main outcome measures The outcomes
studied included whether evidence of exposure
to polypectomy, endoscopic mucosal resection
(EMR) and colonoscopy changed over the 2-year
period. The nature of the polyps removed by
trainees was also studied.
Results Thirty two per cent of candidates in the
first year had evidence of any observed
polypectomy with 7% of candidates referring to
training in EMR. The median number of
formative colonoscopy assessments was 3 (range
0–16). All of these candidates in the second year
had evidence of polypectomy assessment, with a
median number of DOPyS of 7 (range 3–27).
Eighty nine per cent of applicants had evidence
of assessed EMR. The median number of
formative colonoscopy assessments in this cohort
was 32 (range 9–199). There was a significant
increase in the number of logged polypectomy
assessments (p<0.001), experience of EMR
(p<0.001) and formative colonoscopy
assessments ( p<0.001). There was no significant
difference in the total number of colonoscopy
procedures performed.
Conclusions Structured polypectomy
assessment improves trainees’documented
exposure to therapeutic endoscopy as well as
providing formal evidence of skills acquisition.
As polypectomy plays an increasing role globally
in colorectal cancer prevention, the DOPyS
provides an effective means of assessing and
certifying polypectomy.
BACKGROUND
Polypectomy is regarded as the most haz-
ardous component of colonoscopy,
1
accounting for the majority of procedure-
associated morbidity, and yet is a necessary
skill for all colonoscopists. Due to the
increase in the worldwide uptake of colon-
oscopy as both a diagnostic tool and the
favoured method for colorectal cancer
screening, the number of polypectomies
performed has continued to increase
year-on-year.
Data from national audits
23
and from
the English Bowel Cancer Screening
Programme
1
have shown that most cases
of bleeding and perforation are related to
polypectomy. Training in polypectomy
has, to date, been variable and poorly
structured.
4
There has been some evi-
dence suggesting poor exposure to poly-
pectomy during training. In one study,
only 60% of trainees had ever been
assessed in polypectomy.
4
A novel assessment tool, the Directly
Observed Polypectomy Skills (DOPyS),
was introduced nationally in the UK in
October 2011 with the intention of both
improving training and facilitating docu-
mentation of competency. This tool con-
tains 34 separate criteria and permits the
deconstruction and assessment of poly-
pectomy for both sessile and peduncu-
lated lesions.
5
At the end of the tool, a
global rating is given from 1 (multiple
errors) to 4 (highly skilled) to signify the
trainer’s assessment of the trainee’s
TRAINING MATTERS
Patel K, et al.Frontline Gastroenterology 2016;0:1–6. doi:10.1136/flgastro-2016-100718 1
group.bmj.com on August 2, 2016 - Published by http://fg.bmj.com/Downloaded from

competency in polypectomy. The methods used to
devise and validate this tool have been described
elsewhere.
6
There have always been a set of minimum require-
ments before an application for certification of com-
petency was permitted. Until October 2011, formal
certification of colonoscopy competence in the UK
was acquired by trainees collecting paper-based port-
folios of their colonoscopy practice. Trainees had to
show evidence of competency in colonoscopy by
using the Directly Observed Procedural Skills (DOPS)
tool for a summative assessment. There was a require-
ment for a minimum number of 200 completed col-
onoscopies. Polypectomy assessment itself was not
compulsory, although trainers could reflect appropri-
ate generic use of therapy during colonoscopy by
marking a single criterion on the generic DOPS tool.
After October 2011, there was a transition to a
paperless electronic certification system.
7
Trainees
were required to complete the same summative DOPS
assessments, in addition to keeping a log of proce-
dures. However, it was also compulsory for those
wishing to be provisionally certified to have com-
pleted a minimum of four snare polypectomy assess-
ments using the DOPyS to resect polyps up to 10 mm
as well as 10 formative colonoscopy DOPS during the
course of their training. Full certification for colonos-
copy and polypectomy was awarded to those who had
attained provisional certification and then had evi-
dence of at least four satisfactory DOPyS, with a
minimum of two assessments tackling both sessile and
pedunculated lesions.
OBJECTIVES
The primary aim was to describe the impact on poly-
pectomy experience by the mandatory introduction of
the DOPyS as part of the formal colonoscopy certifi-
cation process. The secondary aim was to assess the
influence of the release of the electronic certification
system on trainees’exposure to colonoscopy.
SETTING
UK National Health Service.
METHODS
All trainee endoscopists applying to Joint Advisory
Group on GI Endoscopy (JAG) for certification of
colonoscopy competence for the 2 years from
October 2010 to October 2012 were included.
The first cohort comprised those using paper port-
folios from October 2010 to September 2011; the
second cohort included those using the mandatory
electronic portfolio from October 2011 to
September 2012.
Applications for certification in the year prior to the
introduction of DOPyS were analysed retrospectively
and compared with data collected prospectively for
those in the following year.
Paper portfolios
Endoscopists were not required to submit procedural
details for each case. Aggregate data were collected
from the logbook on the total lifetime number of col-
onoscopies performed, the number of assessments
submitted for both colonoscopy and polypectomy and
whether applicants had any evidence of performing
supervised or unsupervised polypectomy before certi-
fication of competence in colonoscopy.
If trainees using the paper-based certification system
had any DOPS assessment marked demonstrating
appropriate use of therapy, this was noted as experi-
ence of polypectomy. If trainees had any documented
experience of performing endoscopic mucosal resec-
tion (EMR), this was also recorded.
Electronic portfolios
The size, location and type of lesions resected by trai-
nees while being assessed using the DOPyS were
logged, as well as the overall competency of trainees
to perform polypectomy.
Analysis
Data were analysed using SPSS V.20. To assess the dif-
ferences between the 2 years of data collection, the
Mann–Whitney U test was used for non-parametric
data. The independent samples t test was used to
compare normally distributed data such as polyp size.
RESULTS
Participants
There were 175 applicants for certification in the first
year compared with 150 applications in the year after
DOPyS was introduced (p=0.99).
Experience of colonoscopy
The median number of colonoscopy procedures prior
to seeking certification per candidate was 287 in the
first year, compared with 206 in the following year.
There was no significant difference in the total
number of colonoscopy procedures undertaken
(p=0.07). These procedural volumes were both above
the requirement to complete at least 200 procedures
before applying for certification.
In the first cohort, the median number of formative
colonoscopy assessments provided was 3 (range 0–16).
This rose to 32 (range 9–199) in the year after the
introduction of the electronic portfolio (p<0.001),
comprising the 10 mandatory DOPS required by the
certification criteria and 22 additional DOPS submit-
ted voluntarily (figure 1).
Experience of polypectomy
Thirty two per cent of candidates using paper portfo-
lios had evidence of any observed polypectomy, with
7% of candidates referring to training in EMR.
In the year following the introduction of DOPyS,
the 150 trainees using the electronic certification
TRAINING MATTERS
2Patel K, et al.Frontline Gastroenterology 2016;0:1–6. doi:10.1136/flgastro-2016-100718
group.bmj.com on August 2, 2016 - Published by http://fg.bmj.com/Downloaded from

process were assessed resecting a total of 1283 polyps.
All candidates had evidence of polypectomy assess-
ment throughout that year, with a median number of
DOPyS of 7 (range 3–27). This figure included a
median of 2 DOPyS for stalked lesions and 5 DOPyS
for sessile polyps. Eighty nine per cent of applicants
had evidence of assessed EMR (figure 2).
As expected, there was a significant increase in
the number of recorded polypectomy assessments
(p<0.001), given these were mandatory for the
second cohort. However, both logged experience of
EMR and formative colonoscopy assessments
(p<0.001), which were not obligatory, also increased
(p<0.001).
Polyp characteristics
The majority of polyps resected by trainees (68.5%)
were located in the left colon, but a significant minor-
ity were found more proximally (figure 3).
The polyps removed by trainees had a mean size of
<10 mm in all colonic segments. However, there was
a significant range of polyp sizes seen, with lesions up
to 60 mm documented ( figure 4). Polyps in the left
colon were on average slightly larger (9.1 mm com-
pared with 7.2 mm, p<0.001). The sessile lesions
tackled comprised the majority (61%) of polyps, but
these were significantly smaller than the pedunculated
polyps removed (6.6 mm compared with 10.9 mm,
p<0.001).
The majority of DOPyS assessments (93%) were
scored either 3 or 4, signifying competence at poly-
pectomy (figure 5). There was no difference in polyp
size between the DOPyS scored as 1 or 2 compared
with those scored 3 or 4 (8.0 vs 8.3 mm, p=0.299).
DISCUSSION
These data are the first to describe the implementation
of a nationwide certification system on polypectomy
training. The introduction of structured polypectomy
assessment was both feasible and acceptable, with
similar numbers of trainees applying for certification
after the introduction of the DOPyS. In addition, these
Figure 1 Formative colonoscopy Directly Observed Procedural
Skill (DOPS), submitted with applications for certification.
Figure 2 Trainees’polypectomy experience. DOPyS, Directly
Observed Polypectomy Skill; EMR, endoscopic mucosal
resection.
Figure 3 Location of polyps resected by trainees.
Figure 4 Mean and maximum polyp sizes removed by trainees
with assessment.
TRAINING MATTERS
Patel K, et al.Frontline Gastroenterology 2016;0:1–6. doi:10.1136/flgastro-2016-100718 3
group.bmj.com on August 2, 2016 - Published by http://fg.bmj.com/Downloaded from

data show clear evidence of an increase in trainees’
documented exposure to therapeutic lower gastrointes-
tinal endoscopy as well as providing formal evidence of
skills acquisition.
The DOPyS was designed to aid both training and
permit certification of competency. However, it
appears that it is currently being used predominantly
with the latter objective: this may well be related to its
inclusion as a mandatory part of the colonoscopy
competency certification process. Only a very small
proportion (0.4%) of assessments were scored 1
(accepted standards not yet met; frequent errors
uncorrected). These low-scoring DOPyS are likely to
represent formative assessments for trainees in the
early stages of their learning curve.
The reasons for this are likely to be multifactorial.
Given the hazards inherent to the technique, it is
likely that a trainee performing a supervised polypect-
omy with frequent errors would either receive instruc-
tion from the trainer or pass the endoscope to the
more experienced colonoscopist to complete the pro-
cedure. In addition, these evaluations are largely insti-
gated at the behest of the trainee, and it is likely that
there is an element of selection bias with trainees not
requesting trainers’formal documented assessment of
procedures that have not been performed well. It is
unlikely that the assessments are representative of the
full learning curve for polypectomy, given they are so
heavily skewed towards exhibiting competency. These
results are not unexpected, in that trainees were
expected to use DOPyS to demonstrate their polypect-
omy skills if they wished to apply for certification.
There is a strong argument for the use of the DOPyS
tool at an earlier stage of training to standardise the
instruction trainees receive when beginning to learn
how to perform a polypectomy for the first time.
However, it would be difficult to make this a manda-
tory requirement of certification, and a more pragmatic
approach may be to encourage trainers to use this tool
to a greater extent than is the case at present.
It is encouraging that all trainees are receiving dedi-
cated separate assessments in both colonoscopy and
polypectomy. Just over 10 years ago, the UK national
audit showed that only 17.0% of colonoscopists had
received supervised training for their first 100 colon-
oscopies.
2
This study shows the significant progress
made in training in a relatively short space of time.
It is also reassuring that trainees are being taught
and assessed in polypectomy on a variety of lesions,
including proximal polyps, which may be more risky
and technically challenging.
18
Most assessed lesions
were <10 mm in size in keeping with the parameters
of the mandatory DOPyS assessment and mirroring
clinical practice. In the faecal occult blood test
(FOBT)-positive Bowel Cancer Screening Programme,
86% of polyps were found to be <10 mm, and it
seems that training experience reflects these figures.
9
The vast majority of polyps found during universal
screening with flexible sigmoidoscopy at age 55 are also
within the same size parameters, emphasising the import-
ance of all endoscopists possessing the skills required to
tackle these common lesions. In this screening setting,
complete polypectomy and retrieval are crucial.
Although larger sized lesions are associated with higher
rates of advanced pathology such as high-grade dysplasia
or villous architecture, these features are not confined to
bigger polyps and occur in lesions <5 mm.
10
Before the introduction of DOPyS, only a very
small minority (7%) of trainees had evidence of EMR
skills. The methodology used to assess this figure was
generous with even a solitary reference to EMR being
counted. These data were obtained from logbooks,
and so the quality and amount of training could not
be easily gleaned.
However, since DOPyS has found its way into
routine clinical practice with trainees performing
more assessments than strictly mandated, this would
suggest that the majority of trainees seem to be receiv-
ing both training and assessment in this invaluable
technique, a skill which many would argue is obliga-
tory for any independent colonoscopy practitioner.
Interestingly, with the introduction of the electronic
portfolio, most trainees considerably surpassed the
minimum requirements for submission of formative
DOPS and DOPyS. This suggests that trainees have
become familiar with this method of assessment and
integrated it into their practice, using it as a training
aid as well as for certification of competency. As poly-
pectomy plays an increasing role globally in colorectal
cancer prevention, the DOPyS provides an effective
means of assessing and certifying polypectomy skills,
including lesion assessment as well as the technical
proficiencies required for a safe, complete resection,
in order to minimise the well-recognised risks asso-
ciated with this technique. It also has the potential to
be a useful tool to help verify endoscopic competence
Figure 5 Overall polypectomy competency scores using the
Directly Observed Polypectomy Skill (DOPyS).
TRAINING MATTERS
4Patel K, et al.Frontline Gastroenterology 2016;0:1–6. doi:10.1136/flgastro-2016-100718
group.bmj.com on August 2, 2016 - Published by http://fg.bmj.com/Downloaded from

as part of mandatory ongoing clinical revalidation for
those practising independently.
The role of assessment in changing academic behav-
iour is well recognised.
11
The closest parallel with
practical medical skills assessment comes from the
DOPS tool, which is used widely by junior doctors as
part of their electronic portfolios. A study looking at
doctors who had just qualified from medical school
found that most (70%) felt that DOPS helped
improve their clinical skills.
12
However, a systematic
review of several different types of workplace-based
assessments found no available high-quality evidence
from this study or any others that DOPS lead to
objective performance improvement.
13
The LAPCO programme, a UK national training pro-
gramme for laparoscopic colorectal surgery devised to
encourage the widespread uptake of laparoscopic
surgery, has been extensively evaluated
14
and found to
bear some similarity to polypectomy assessment.
Similar to the DOPyS, task deconstruction, hands-on
training and independent expert rating of cases with
feedback are hallmarks of this programme.
15
Analysis
of outcome data has shown significant improvement in
participating surgeons, with expert levels of proficiency
achieved after iterative feedback.
14
The best studied tool with respect to performance
improvement is the multisource feedback, in which
both senior and junior colleagues anonymously
provide ratings of an individual’s strengths and weak-
nesses. The ability of this to change behaviour is
reliant on individual characteristics. Studies have
shown that some junior doctors
16
and most sur-
geons
17
were not amenable to change whereas general
practitioners were more likely to be receptive to sug-
gestions.
18
Those who consider change to be neces-
sary, react positively, believe that changes are feasible
and take suitable actions as a result of this are most
likely to benefit from feedback.
13
It is likely that the DOPyS tool would show similar
characteristics, but this has not been evaluated to date.
Specifically, the DOPyS tool focuses predominantly
on technical skills involved in polypectomy. These
are easier to influence than non-technical skills which
require behavioural change and insight. A meta-
analysis of non-technical skills training revealed that
outcome measures used to date in the literature are
seldom clinically applicable.
19
However, the data
described here do show some correlation with non-
technical skills; studies published to date in other
fields may not be applicable to polypectomy.
Several questions remain unanswered from this
work. Whereas there is growing consensus in the lit-
erature as to the number of colonoscopies needed to
attain the technical ability to reach the caecum reli-
ably,
20–22
these data are lacking for polypectomy
skills. Given that endoscopists who perform low
volumes of colonoscopies have been associated with
higher complication rates,
23 24
training in
polypectomy is likely to also be a higher risk activity,
and the quality of training and assessment is likely to
vary considerably between specialties, centres and
individual trainers.
25 26
The relative importance of
non-technical skills when undertaking polypectomy at
an introductory level is also not clear, but they are
likely to be important. Assessment of these other skills
is expected to be more difficult than simple technical
ability, but may prove to be beneficial in terms of
improving the rate of skills acquisition.
Key messages
What is already known on this topic?
▸Training in polypectomy has traditionally been poorly
structured.
▸Setting standards of competency can drive learning
and training.
▸The Directly Observed Polypectomy Skills (DOPyS)
tool has been validated in the assessment of poly-
pectomy skills.
What this study adds?
▸An electronic portfolio helps trainees document profi-
ciency in polypectomy.
▸The DOPyS provides an effective means of certifying
polypectomy skills nationally.
How might it impact on clinical practice in the
foreseeable future?
▸Wider uptake of the DOPyS could be used to improve
training to polypectomy novices as well as providing
a means for independently practising individuals to
provide evidence of competency for revalidation.
Contributors ST-G designed the study, helped with
interpretation of results and critically appraised the paper.
KP performed the analysis and drafted the paper. PD helped in
data acquisition. OF and MR critically appraised the paper.
All authors approved the final manuscript. KP is guarantor.
Competing interests None declared.
Provenance and peer review Not commissioned; externally
peer reviewed.
Open Access This is an Open Access article distributed in
accordance with the Creative Commons Attribution Non
Commercial (CC BY-NC 4.0) license, which permits others to
distribute, remix, adapt, build upon this work non-
commercially, and license their derivative works on different
terms, provided the original work is properly cited and the use
is non-commercial. See: http://creativecommons.org/licenses/by-
nc/4.0/
REFERENCES
1 Rutter MD, Nickerson C, Rees CJ, et al. Risk factors for
adverse events related to polypectomy in the English Bowel
Cancer Screening Programme. Endoscopy 2014;46:90–7.
2 Bowles CJ, Leicester R, Romaya C, et al. A prospective study
of colonoscopy practice in the UK today: are we adequately
prepared for national colorectal cancer screening tomorrow?
Gut 2004;53:277–83.
TRAINING MATTERS
Patel K, et al.Frontline Gastroenterology 2016;0:1–6. doi:10.1136/flgastro-2016-100718 5
group.bmj.com on August 2, 2016 - Published by http://fg.bmj.com/Downloaded from

3 Gavin DR, Valori RM, Anderson JT, et al. The national
colonoscopy audit: a nationwide assessment of the quality and
safety of colonoscopy in the UK. Gut 2013;62:242–9.
4 Haycock AV, Patel JH, Tekkis PP, et al. Evaluating changes in
gastrointestinal endoscopy training over 5 years: closing the
audit loop. Eur J Gastroenterol Hepatol 2010;22:368–73.
5 Gupta S, Anderson J, Bhandari P, et al. Development and
validation of a novel method for assessing competency in
polypectomy: direct observation of polypectomy skills.
Gastrointest Endosc 2011;73:1232–9.e2.
6 Gupta S, Bassett P, Man R, et al. Validation of a novel method
for assessing competency in polypectomy. Gastrointest Endosc
2012;75:568–75.
7 Mehta T, Dowler K, McKaig B, et al. Development and roll
out of the JETS e-portfolio: a web based electronic portfolio
for endoscopists. Frontline Gastroenterol 2011;2:35–42.
8 Choo WK, Subhani J. Complication rates of colonic
polypectomy in relation to polyp characteristics and
techniques: a district hospital experience. J Interv Gastroenterol
2012;2:8–11.
9 Majumdar D, Patnick J, Nickerson C, et al. Analysis of
colorectal polyps detected in the English NHS Bowel Cancer
Screening Programme with Emphasis on advanced adenoma
and polyp cancer detected. Gut 2012;61:A67.
10 Gschwantler M, Kriwanek S, Langner E, et al. High-grade
dysplasia and invasive carcinoma in colorectal adenomas: a
multivariate analysis of the impact of adenoma and patient
characteristics. Eur J Gastroenterol Hepatol 2002;14:
183–8.
11 Newble DI, Jaeger K. The effect of assessments and
examinations on the learning of medical students. Med Educ
1983;17:165–71.
12 Morris A, Hewitt J, Roberts CM. Practical experience of using
directly observed procedures, mini clinical evaluation
examinations, and peer observation in pre-registration house
officer (FY1) trainees. Postgrad Med J 2006;82:285–8.
13 Miller A, Archer J. Impact of workplace based assessment on
doctors’education and performance: a systematic review.
BMJ 2010;341:c5064.
14 Coleman MG, Hanna GB, Kennedy R. The National Training
Programme for laparoscopic colorectal surgery in England:
a new training paradigm. Colorectal Dis 2011;13:614–16.
15 Miskovic D, Wyles SM, Carter F, et al. Development,
validation and implementation of a monitoring tool for
training in laparoscopic colorectal surgery in the English
National Training Program. Surg Endosc 2011;25:
1136–42.
16 Burford B, Illing J, Kergon C, et al. User perceptions of
multi-source feedback tools for junior doctors. Med Educ
2010;44:165–76.
17 Lockyer J, Violato C, Fidler H. Likelihood of change: a study
assessing surgeon use of multisource feedback data. Te ac h
Learn Med 2003;15:168–74.
18 Sargeant JM, Mann KV, Ferrier SN, et al. Responses of rural
family physicians and their colleague and coworker raters to a
multi-source feedback process: a pilot study. Acad Med
2003;78(Suppl 10):S42–4.
19 Gordon M, Darbyshire D, Baker P. Non-technical skills training
to enhance patient safety: a systematic review. Med Educ
2012;46:1042–54.
20 Training Committee 2010–2011Sedlack RE, Shami VM, et al.
Colonoscopy core curriculum. Gastrointest Endosc
2012;76:482–90.
21 Sedlack RE. Training to competency in colonoscopy: assessing
and defining competency standards. Gastrointest Endosc
2011;74:355–66.e1–2.
22 Ward ST, Mohammed MA, Walt R, et al. An analysis of the
learning curve to achieve competency at colonoscopy using the
JETS database. Gut 2014;63:1746––54.
23 Lorenzo-Zúñiga V, Moreno de Vega V, Doménech E, et al.
Endoscopist experience as a risk factor for colonoscopic
complications. Colorectal Dis 2010;12:e273–e77.
24 Chukmaitov A, Bradley CJ, Dahman B, et al. Association of
polypectomy techniques, endoscopist volume, and facility type
with colonoscopy complications. Gastrointest Endosc
2013;77:436–46.
25 Asfaha S, Alqahtani S, Hilsden RJ, et al. Assessment of
endoscopic training of general surgery residents in a North
American health region. Gastrointest Endosc
2008;68:1056–62.
26 Leyden JE, Doherty GA, Hanley A, et al. Quality of
colonoscopy performance among gastroenterology and surgical
trainees: a need for common training standards for all trainees?
Endoscopy 2011;43:935–40.
TRAINING MATTERS
6Patel K, et al.Frontline Gastroenterology 2016;0:1–6. doi:10.1136/flgastro-2016-100718
group.bmj.com on August 2, 2016 - Published by http://fg.bmj.com/Downloaded from

UK
polypectomy assessment on training in the
The impact of the introduction of formalised
Thomas-Gibson
Kinesh Patel, Omar Faiz, Matt Rutter, Paul Dunckley and Siwan
published online July 21, 2016Frontline Gastroenterol
http://fg.bmj.com/content/early/2016/07/21/flgastro-2016-100718
Updated information and services can be found at:
These include:
References
#BIBL
http://fg.bmj.com/content/early/2016/07/21/flgastro-2016-100718
This article cites 26 articles, 7 of which you can access for free at:
Open Access
http://creativecommons.org/licenses/by-nc/4.0/non-commercial. See:
provided the original work is properly cited and the use is
non-commercially, and license their derivative works on different terms,
permits others to distribute, remix, adapt, build upon this work
Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
This is an Open Access article distributed in accordance with the Creative
service
Email alerting box at the top right corner of the online article.
Receive free email alerts when new articles cite this article. Sign up in the
Collections
Topic Articles on similar topics can be found in the following collections
(43)Open access
Notes
http://group.bmj.com/group/rights-licensing/permissions
To request permissions go to:
http://journals.bmj.com/cgi/reprintform
To order reprints go to:
http://group.bmj.com/subscribe/
To subscribe to BMJ go to:
group.bmj.com on August 2, 2016 - Published by http://fg.bmj.com/Downloaded from