美國ERCP培訓與評估培訓講義課件

ERCPTrainingandAssessmentintheU.S.

美國ERCP培訓與評估JosephLeung,MD.,FRCP.,FACP.,FASGE.,MACG.Mr.&Mrs.C.W.LawProfessorofMedicine,UniversityofCalifornia,DavisSchoolofMedicine,Chief,SectionofGastroenterology,VANorthernCaliforniaHealthCareSystem.ERCPTrainingandAssessmentiERCPTrainingintheU.S.

美國的ERCP培訓PartofaGIFellowship(ABIMaccredited)胃腸醫(yī)生培訓的一部分(美國內科學委員會認證)ERCPtrainingofferedin3rdyear(traineesexposedtoERCPbutnotnecessarilycompetentinperforming)第3年開始進行ERCP培訓(學員只需ERCP知識,并不要求獨立操作）Additional(advanced)4thyeartraining(notABIMaccredited)第4年高級培訓一年（非美國內科學委員會認證要求）Traineesexpectedtocomplete180-200cases,with80%successrate,including75%therapeuticprocedures要求學員完成180-200例操作，成功率達80%以上（其中包括75%的治療性操作）ERCPTrainingintheU.S.

美國的EWhyERCPTraining?

為什么要進行ERCP培訓？ERCPiseffectiveinmanagementofpancreaticobiliarydiseasesERCP在膽胰系統(tǒng)疾病診治方面效果顯著ItiscomplexandpotentiallyhazardousERCP技術復雜，有相當高的潛在風險Requireseffectiveclinical/technicalteaching需要有效的臨床基礎和操作技巧指導Objectiveassessmenttodeterminequality需要客觀的評估，判斷學員操作能力Apprenticeship傳統(tǒng)的學徒式教學WhyERCPTraining?

為什么要進行ERCP培KeyQuestionsinERCPTraining

ERCP培訓中的關鍵問題Whoshouldbetrained?誰來學？Whatshouldbetaught,andhow?教什么，怎樣教？Whoshouldteach?誰來教？Howaretrainingandcompetenceassessed?如何對培訓效果及學員能力進行有效評估？Whatlevelofperformanceisacceptable?培訓目標如何確定？KeyQuestionsinERCPTrainingWhoShouldbeTrained?

誰來學？GI/Surgicaltrainees部分消化科內醫(yī)生和外科醫(yī)生Availabletrainingpositionsarevariable按照不同的階段目標獲得多樣化培訓Expectation-thosewhoreceivedtrainingshouldreachacceptablelevelofcompetenceforsafeindependentpractice預期在結束培訓時，學員能夠達到相應階段培訓標準可以獨立安全的開展業(yè)務WhoShouldbeTrained?

誰來學？GI/WhatShouldbeTaught,andHow?

教什么，怎么教？Knowledgeinpancreaticobiliarydiseases膽胰系統(tǒng)疾病的臨床理論知識SkillsinERCPincludingalternativediagnosticandtherapeuticmethodsERCP的實際操作技能，包括其他診斷性和治療性操作方法Skilledinbasictenetsofpatientcare醫(yī)學精神以及收治過程中與病人溝通能力WhatShouldbeTaught,andHowLevelsofComplexity

ERCP技術難度分級（2011）Cottonetal.Gradingthecomplexityofendoscopicprocedures:resultsofanASGEworkingparty.GIE2011;73:868-741.深插管，膽道支架置入/交換/取出LevelsofComplexity

ERCP技術難度分GoalsofERCPtraining

ERCP培訓目標Abletoprovidefundamental(life-saving)ERCPproceduresatthecommunitylevele.g.urgentbiliarydrainingforacute(suppurative)cholangitis初級培訓：能夠在當?shù)蒯t(yī)院急診情況下提供最基本的（”救命式”）ERCP操作，如急性化膿性膽管炎引流Thosecompletedtrainingshouldbecompetentinperforminglevel1and2procedures完成培訓：能夠熟練掌握技術難度1、2級的ERCP操作Levels3and4procedureswillrequireadvancedtraining3,4級技術難度的操作需要高級的培訓GoalsofERCPtraining

ERCP培訓目TrainingCurriculum

培訓科目DifferencesbetweenASGEandSAGES美國胃腸鏡學會與胃腸道內鏡外科醫(yī)生學會要求的分別Lectures,didactics,atlases,videosandbooks講座，授課，圖片，視頻以及教科書Supervisedclinicalpractice監(jiān)督下的臨床實踐History/physicalexam,laboratorytests病史，體征，實驗室檢查Managementofpancreaticobiliaryproblemsasin-andoutpatients,withdiscussionondiagnosticandtreatmentoptions,includingassessmentofrisks膽胰系統(tǒng)疾病門診及住院病人的處理,診斷和治療的選擇以及風險評估Multi-disciplinaryapproach(surgery/radiology)多學科討論

（外科、放射科）TrainingCurriculum

培訓科目DifferConceptofTraining(Preparingtheendoscopist)

培訓的概念Howtodoit(basicskills)

怎樣做Whentouseit(clinicalapplication)

何時應用于臨床Specificprocedures

具體步驟Managementofcomplications

并發(fā)癥的處理Documentationofperformance

操作記錄Credentialing

證書1/2015ConceptofTraining1/2015TrainingMethods

培訓方法Selfstudies:videos,recordedlectures,selfassessment自學：視頻，

聽課,自我評估Radiologicalinterpretation,safetywithfluoroscopy影像學資料學習，放射學安全Observationofclinicalprocedures臨床操作觀摩學習Laboratorypracticeofbasicskills,includinghandlingscopeandaccessories內鏡室基礎操作，包括持鏡，附件等Clinicaltraining:hands-onpracticewithscopehandlingandselectivecannulation臨床操作培訓：控制十二指腸鏡和選擇性插管的練習Guidewiremanipulationandoperatedifferentaccessories導絲和其他附件操作Learninginstepsandeventuallyabletoassimilateskillsandcompleteentireprocedure循序漸進掌握ERCP操作技巧Successfulprocedurewithnocomplications成功獨立操作,沒有并發(fā)癥的手術TraineesalsolearnhowtoassistwithERCPprocedure

學員同時應當學習如何當好ERCP助手TrainingMethods

培訓方法SelfstudSupplementalTraining

補充培訓Seminarsandworkshops研討會和培訓班Modelpracticeincludingsimulators包括模擬器在內的模擬訓練Hands-onteampracticetoimprovecoordinationwithassistants(TEAMwork)手把手ERCP團隊協(xié)作訓練SupplementalTraining

補充培訓SemiSimulation(Optional)Training

模擬器（可選擇）培訓Understandanatomy,motility理解解剖及胃腸蠕動特性Practicewithrealscopeandaccessories使用十二指腸鏡和附件練習Familiarwithscopehandling熟悉持鏡技巧Learnandpracticebasicsteps學習掌握基本操作步驟Coordinatedpracticewithassistantwithoutriskingapatient與助手合作練習減少病人風險(RCTshowedimprovedcannulationsuccessratewithinitialsimulationpracticefornoviceendoscopists)(RCT顯示模擬器插管練習明顯提升ERCP初學者臨床操作插管成功率)

Simulation(Optional)TrainingSimulationModels

模擬器類型Animalmodel(anatomicalvariations)動物模型（解剖差異）Anesthetizedpig麻醉下的活體豬Ex-vivoporcinestomachmodel離體的豬胃腸模型Neopapillamodel新型乳頭模型（雞心）ComputerSimulator(probesinsteadofrealinstrument)計算機模擬器（探頭代替真實設備）GIMentorIIMechanicalSimulator(rigidmodel)機械模擬器(rigidmodel)EMSX-visionSimulationModels

模擬器類型AnimalIDEALSimulationPractice

最理想

模擬器訓練Improvesskills提高基本操作技能Demonstratesrealism：展示解剖、胃腸運動的實際情況Easeofincorporationintotraining：方便操作配合培訓Applicableintraining：實用訓練，可以模擬治療性ERCPLearningwithrealscopeandaccessories：用真的十二指腸鏡及附件學習操作IDEALSimulationPractice

最理想ERCPMechanicalSimulator(EMS)

機械模擬器Artificialbiliarypapillotomy人工乳頭切開Pancreaticstenting胰管支架置入ERCPMechanicalSimulator(EMSWhoShouldTeach?

誰來教？Askilledendoscopistmaynotbeagoodteacher技術全面的內鏡醫(yī)生不一定能勝任教學Trainershouldrecognizemistakesmadebytrainees教師應該分辨學員操作中的錯誤Offersguidance,coachingandassistance適當提供指導，訓練和輔助Supportiveandnotpunitiveattitude態(tài)度積極，避免懲罰性教學WhoShouldTeach?

誰來教？AskilleAssessmentofCompetence

能力評估臨床評估ClinicalassessmentProcedurelog臨床操作記錄Success/failure成功/失敗Complications并發(fā)癥Trainerinvolvement(step-by-steptrainingdependingoncomplexity,riskandpotentialcomplications)教師參與程度Verbal口頭指令Hands-onassistance手把手輔助Takeover教師接鏡操作模擬器評估SimulationProcedurelog操作記錄Typeofpractice操作類型Variationindifficulty不同難度Success/failure成功/失敗Errorinpractice操作中的錯誤Proceduretime操作時間Simulatedfluoroscopytime模擬放射線時間AssessmentofCompetence

能力評估臨OverallAssessment

評估Acquisitionofknowledgeandapplication學員掌握理論知識和操作技巧Clinicalknowledge臨床基礎知識Understandingofpathologies,interpretationofradiologicalfindings,choiceoftherapy掌握疾病病理生理，能夠閱片和選擇治療方式Technicalproficiencyandcompetencyinperformingprocedure技術熟練程度和臨床操作的實際能力OverallAssessment

評估AcquisitiObjectiveAssessment

客觀評價指標Examinationtodeterminequalityoftrainee學員綜合能力考試Knowledge基礎理論Skills操作技巧Compassion對患者的同情關懷(愛心）Exam測驗/考試Written(multiplechoice)筆試（包括多項選擇）Oral口試Practical現(xiàn)場操作ObjectiveAssessment

客觀評價指標ExaNumberofProcedures(LogBook)

病例數(shù)（記錄）Arbitrarilyusedasasurrogateofexperience病例數(shù)可以用于粗略估計學員經驗程度Complexityandspectrum病例復雜性和不同類型Degreeofinvolvementwithtrainee/trainer教師在學員的操作輔助程度Objectiveoutcomeassessment客觀評價指標Successwithcannulation插管成功率Postproceduralcomplications術后并發(fā)癥Reportcard臨床操作記錄卡Benchmarking達標的指標NumberofProcedures(LogBookWhatisAcceptablePerformance?

怎樣算合格Highsuccessratesandlowcomplications操作的成功率高和并發(fā)癥率低Levelofcomplexityvs.experienceofoperator操作復雜性跟

操作者經驗Levelofurgencyvs.typeof(life-saving)procedure緊急程度跟

操作種類（救命操作）Traineesoloperformance學員單獨完成操作WhatisAcceptablePerformanceCredentialingandCertification

合格與授予證書TraineesmettrainingrequirementandbecomeGIBoardEligible學員達到訓練要求即可取得胃腸病專家資格Trainingexperienceconfirmedbyprogramdirector

獲得培訓導師認可的培訓經歷TraineesthenpasstheGIBoard(written)ExaminationandbecomeBoardCertifiedinGastroenterology

學員經過參加胃腸病協(xié)會組織的書面考試并授予合格證Noobjective/practicalexaminationfortechnical(ERCP)skill無ERCP的實際技能考核NocertificationforERCP

無ERCP合格證書CredentialingandCertificatioHospitalPracticePrivilege

醫(yī)院ERCP操作的權利Hospitalproctoringsystem–seniororexistingendoscopistsobservethenewlyjoinedendoscopisttoevaluatetheirskills

醫(yī)院監(jiān)管機制—專家或在崗內鏡醫(yī)師觀看操作者的技能,并作出評估,可以達到標準HospitalcredentialingcommitteegrantsprivilegetopracticeERCP

醫(yī)院認證委員會授予ERCP操作的權利Individual’sperformancecanbefurthercomparedusingbenchmarking

將個人操作能力與現(xiàn)行的評價標準進行比較HospitalPracticePrivilege

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美國ERCP培訓與評估JosephLeung,MD.,FRCP.,FACP.,FASGE.,MACG.Mr.&Mrs.C.W.LawProfessorofMedicine,UniversityofCalifornia,DavisSchoolofMedicine,Chief,SectionofGastroenterology,VANorthernCaliforniaHealthCareSystem.ERCPTrainingandAssessmentiERCPTrainingintheU.S.

美國的ERCP培訓PartofaGIFellowship(ABIMaccredited)胃腸醫(yī)生培訓的一部分(美國內科學委員會認證)ERCPtrainingofferedin3rdyear(traineesexposedtoERCPbutnotnecessarilycompetentinperforming)第3年開始進行ERCP培訓(學員只需ERCP知識,并不要求獨立操作）Additional(advanced)4thyeartraining(notABIMaccredited)第4年高級培訓一年（非美國內科學委員會認證要求）Traineesexpectedtocomplete180-200cases,with80%successrate,including75%therapeuticprocedures要求學員完成180-200例操作，成功率達80%以上（其中包括75%的治療性操作）ERCPTrainingintheU.S.

美國的EWhyERCPTraining?

為什么要進行ERCP培訓？ERCPiseffectiveinmanagementofpancreaticobiliarydiseasesERCP在膽胰系統(tǒng)疾病診治方面效果顯著ItiscomplexandpotentiallyhazardousERCP技術復雜，有相當高的潛在風險Requireseffectiveclinical/technicalteaching需要有效的臨床基礎和操作技巧指導Objectiveassessmenttodeterminequality需要客觀的評估，判斷學員操作能力Apprenticeship傳統(tǒng)的學徒式教學WhyERCPTraining?

為什么要進行ERCP培KeyQuestionsinERCPTraining

ERCP培訓中的關鍵問題Whoshouldbetrained?誰來學？Whatshouldbetaught,andhow?教什么，怎樣教？Whoshouldteach?誰來教？Howaretrainingandcompetenceassessed?如何對培訓效果及學員能力進行有效評估？Whatlevelofperformanceisacceptable?培訓目標如何確定？KeyQuestionsinERCPTrainingWhoShouldbeTrained?

誰來學？GI/Surgicaltrainees部分消化科內醫(yī)生和外科醫(yī)生Availabletrainingpositionsarevariable按照不同的階段目標獲得多樣化培訓Expectation-thosewhoreceivedtrainingshouldreachacceptablelevelofcompetenceforsafeindependentpractice預期在結束培訓時，學員能夠達到相應階段培訓標準可以獨立安全的開展業(yè)務WhoShouldbeTrained?

誰來學？GI/WhatShouldbeTaught,andHow?

教什么，怎么教？Knowledgeinpancreaticobiliarydiseases膽胰系統(tǒng)疾病的臨床理論知識SkillsinERCPincludingalternativediagnosticandtherapeuticmethodsERCP的實際操作技能，包括其他診斷性和治療性操作方法Skilledinbasictenetsofpatientcare醫(yī)學精神以及收治過程中與病人溝通能力WhatShouldbeTaught,andHowLevelsofComplexity

ERCP技術難度分級（2011）Cottonetal.Gradingthecomplexityofendoscopicprocedures:resultsofanASGEworkingparty.GIE2011;73:868-741.深插管，膽道支架置入/交換/取出LevelsofComplexity

ERCP技術難度分GoalsofERCPtraining

ERCP培訓目標Abletoprovidefundamental(life-saving)ERCPproceduresatthecommunitylevele.g.urgentbiliarydrainingforacute(suppurative)cholangitis初級培訓：能夠在當?shù)蒯t(yī)院急診情況下提供最基本的（”救命式”）ERCP操作，如急性化膿性膽管炎引流Thosecompletedtrainingshouldbecompetentinperforminglevel1and2procedures完成培訓：能夠熟練掌握技術難度1、2級的ERCP操作Levels3and4procedureswillrequireadvancedtraining3,4級技術難度的操作需要高級的培訓GoalsofERCPtraining

ERCP培訓目TrainingCurriculum

培訓科目DifferencesbetweenASGEandSAGES美國胃腸鏡學會與胃腸道內鏡外科醫(yī)生學會要求的分別Lectures,didactics,atlases,videosandbooks講座，授課，圖片，視頻以及教科書Supervisedclinicalpractice監(jiān)督下的臨床實踐History/physicalexam,laboratorytests病史，體征，實驗室檢查Managementofpancreaticobiliaryproblemsasin-andoutpatients,withdiscussionondiagnosticandtreatmentoptions,includingassessmentofrisks膽胰系統(tǒng)疾病門診及住院病人的處理,診斷和治療的選擇以及風險評估Multi-disciplinaryapproach(surgery/radiology)多學科討論

（外科、放射科）TrainingCurriculum

培訓科目DifferConceptofTraining(Preparingtheendoscopist)

培訓的概念Howtodoit(basicskills)

怎樣做Whentouseit(clinicalapplication)

何時應用于臨床Specificprocedures

具體步驟Managementofcomplications

并發(fā)癥的處理Documentationofperformance

操作記錄Credentialing

證書1/2015ConceptofTraining1/2015TrainingMethods

培訓方法Selfstudies:videos,recordedlectures,selfassessment自學：視頻，

聽課,自我評估Radiologicalinterpretation,safetywithfluoroscopy影像學資料學習，放射學安全Observationofclinicalprocedures臨床操作觀摩學習Laboratorypracticeofbasicskills,includinghandlingscopeandaccessories內鏡室基礎操作，包括持鏡，附件等Clinicaltraining:hands-onpracticewithscopehandlingandselectivecannulation臨床操作培訓：控制十二指腸鏡和選擇性插管的練習Guidewiremanipulationandoperatedifferentaccessories導絲和其他附件操作Learninginstepsandeventuallyabletoassimilateskillsandcompleteentireprocedure循序漸進掌握ERCP操作技巧Successfulprocedurewithnocomplications成功獨立操作,沒有并發(fā)癥的手術TraineesalsolearnhowtoassistwithERCPprocedure

學員同時應當學習如何當好ERCP助手TrainingMethods

培訓方法SelfstudSupplementalTraining

補充培訓Seminarsandworkshops研討會和培訓班Modelpracticeincludingsimulators包括模擬器在內的模擬訓練Hands-onteampracticetoimprovecoordinationwithassistants(TEAMwork)手把手ERCP團隊協(xié)作訓練SupplementalTraining

補充培訓SemiSimulation(Optional)Training

模擬器（可選擇）培訓Understandanatomy,motility理解解剖及胃腸蠕動特性Practicewithrealscopeandaccessories使用十二指腸鏡和附件練習Familiarwithscopehandling熟悉持鏡技巧Learnandpracticebasicsteps學習掌握基本操作步驟Coordinatedpracticewithassistantwithoutriskingapatient與助手合作練習減少病人風險(RCTshowedimprovedcannulationsuccessratewithinitialsimulationpracticefornoviceendoscopists)(RCT顯示模擬器插管練習明顯提升ERCP初學者臨床操作插管成功率)

Simulation(Optional)TrainingSimulationModels

模擬器類型Animalmodel(anatomicalvariations)動物模型（解剖差異）Anesthetizedpig麻醉下的活體豬Ex-vivoporcinestomachmodel離體的豬胃腸模型Neopapillamodel新型乳頭模型（雞心）ComputerSimulator(probesinsteadofrealinstrument)計算機模擬器（探頭代替真實設備）GIMentorIIMechanicalSimulator(rigidmodel)機械模擬器(rigidmodel)EMSX-visionSimulationModels

模擬器類型AnimalIDEALSimulationPractice

最理想

模擬器訓練Improvesskills提高基本操作技能Demonstratesrealism：展示解剖、胃腸運動的實際情況Easeofincorporationintotraining：方便操作配合培訓Applicableintraining：實用訓練，可以模擬治療性ERCPLearningwithrealscopeandaccessories：用真的十二指腸鏡及附件學習操作IDEALSimulationPractice

最理想ERCPMechanicalSimulator(EMS)

機械模擬器Artificialbiliarypapillotomy人工乳頭切開Pancreaticstenting胰管支架置入ERCPMechanicalSimulator(EMSWhoShouldTeach?

誰來教？Askilledendoscopistmaynotbeagoodteacher技術全面的內鏡醫(yī)生不一定能勝任教學Trainershouldrecognizemistakesmadebytrainees教師應該分辨學員操作中的錯誤Offersguidance,coachingandassistance適當提供指導，訓練和輔助Supportiveandnotpunitiveattitude態(tài)度積極，避免懲罰性教學WhoShouldTeach?

誰來教？AskilleAssessmentofCompetence

能力評估臨床評估ClinicalassessmentProcedurelog臨床操作記錄Success/failure成功/失敗Complications并發(fā)癥Trainerinvolvement(step-by-steptrainingdependingoncomplexity,riskandpotentialcomplications)教師參與程度Verbal口頭指令Hands-onassistance手把手輔助Takeover教師接鏡操作模擬器評估SimulationProcedurelog操作記錄Typeofpractice操作類型Variationindifficulty不同難度Success/failure成功/失敗Errorinpractice操作中的錯誤Proceduretime操作時間Simulatedfluoroscopytime模擬放射線時間AssessmentofCompetence

能力評估臨OverallAssessment

評估Acquisitionofknowledgeandapplication學員掌握理論知識和操作技巧Clinicalknowledge臨床基礎知識Understandingofpathologies,interpretationofradiologicalfindings,choiceoftherapy掌握疾病病理生理，能夠閱片和選擇治療方式Technicalproficiencyandcompetencyinperformingprocedure技術熟練程度和臨床操作的實際能力OverallAssessment

評估AcquisitiObjectiveAssessment

客觀評價指標Examinationtodeterminequalityoftrainee學員綜合能力考試Knowledge基礎理論Skills操作技巧Compassion對患者的同情關懷(愛心）Exam測驗/考試Written(multiplechoice)筆試（包括多項選擇）Oral口試Practical現(xiàn)場操作ObjectiveAssessment

客觀評價指標ExaNumberofProcedures(LogBook)

病例數(shù)（記錄）Arbitrarilyusedasasurrogateofexperience病例數(shù)可以用于粗略估計學員經驗程度Complexityandspectrum病例復雜性和不同類型Degreeofinvolvementwithtrainee/trainer教師在學員的操作輔助程度Objectiveoutcomeassessment客觀評價指標Successwithcannulation插管成功率Postproceduralcomplications術后并發(fā)癥Reportcard臨床操作記錄卡Benchmarking達標的指標NumberofProcedures(LogBookWhatisAcceptablePerformance?

怎樣算合格Highsuccessratesandlowcomplications操作的成功率高