Section of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA; Section of Digestive Diseases and Nutrition, Veterans Affairs Medical Center, Oklahoma City, Oklahoma, USA.
Gastrointest Endosc. 2018 Aug;88(2):378-387. doi: 10.1016/j.gie.2018.04.2338. Epub 2018 Apr 19.
Previous studies have described variable effects of fellow involvement on the adenoma detection rate (ADR), but few have stratified this effect by level of training. We aimed to evaluate the "fellow effect" on multiple procedural metrics including a newly defined adenoma management efficiency index, which may have a role in documenting colonoscopy proficiency for trainees. We also describe the impact of level of training on moderate sedation use.
We performed a retrospective review of 2024 patients (mean age, 60.9 ± 10 years; 94% men) who underwent outpatient colonoscopy between June 2012 and December 2014 at our Veterans Affairs Medical Center. Colonoscopies were divided into 5 groups. The first 2 groups were first-year fellows in the first 6 months and last 6 months of the training year. Second- and third-year fellows and attending-only procedures accounted for 1 group each. We collected data on doses of sedatives used, frequency of adjunctive agent use, procedural times, and location, size, and histology of polyps. We defined the adenoma management efficiency index as average time required per adenoma resected during withdrawal.
Of the colonoscopies performed, 1675 involved a fellow and 349 were performed by the attending alone. There was no difference in ADR between fellows according to level of training (P = .8) or between fellows compared with attending-only procedures (P = .67). Procedural times decreased consistently during training and declined further for attending-only procedures. This translated into improvement in the adenoma management efficiency index (fellow groups by ascending level of training: 23.5 minutes vs 18.3 minutes vs 13.7 minutes vs 13.4 minutes vs attending group 11.7 minutes; P < .001). There was no difference in the average doses of midazolam and fentanyl used among fellow groups (P = .16 and P = .1, respectively). Compared with attending-only procedures, fellow involvement was associated with higher doses of fentanyl and midazolam and more frequent use of diphenhydramine and glucagon (P < .0001, P = .0002, P < .0001, and P = .01, respectively).
ADR was similar at different stages of fellowship training and comparable with the attending group. Efficiency of detecting and resecting polyps improved throughout training without reaching the attending level. Fellow involvement led to a greater use of moderate sedation, which may relate to a longer procedure duration and an evolving experience in endoscopic technique.
既往研究描述了助手参与对腺瘤检出率（ADR）的不同影响，但很少根据培训水平对这种影响进行分层。我们旨在评估多种程序指标的“助手效应”，包括新定义的腺瘤管理效率指数，该指数可能在记录受训者结肠镜检查能力方面发挥作用。我们还描述了培训水平对中度镇静使用的影响。
我们对 2024 例（平均年龄 60.9±10 岁；94%为男性）于 2012 年 6 月至 2014 年 12 月在我们退伍军人事务医疗中心接受门诊结肠镜检查的患者进行了回顾性研究。结肠镜检查分为 5 组。前两组为培训年度前 6 个月和后 6 个月的第一年住院医师。第二年和第三年住院医师以及仅由主治医生进行的结肠镜检查各占一组。我们收集了镇静剂使用剂量、辅助药物使用频率、手术时间以及息肉的位置、大小和组织学数据。我们将腺瘤管理效率指数定义为退镜时切除每个腺瘤所需的平均时间。
在进行的结肠镜检查中，1675 例涉及住院医师，349 例仅由主治医生进行。根据培训水平，住院医师之间的 ADR 无差异（P=0.8），与仅由主治医生进行的结肠镜检查相比，住院医师之间也无差异（P=0.67）。随着培训的进行，手术时间逐渐缩短，仅由主治医生进行的手术时间进一步缩短。这转化为腺瘤管理效率指数的改善（按培训水平升序排列的住院医师组：23.5 分钟 vs 18.3 分钟 vs 13.7 分钟 vs 13.4 分钟 vs 主治医生组 11.7 分钟；P<0.001）。住院医师组之间咪达唑仑和芬太尼的平均剂量无差异（P=0.16 和 P=0.1，分别）。与仅由主治医生进行的结肠镜检查相比，住院医师的参与与芬太尼和咪达唑仑的更高剂量以及更频繁使用苯海拉明和胰高血糖素相关（P<0.0001，P=0.0002，P<0.0001，P=0.01，分别）。
ADR 在住院医师培训的不同阶段相似，与主治医生相当。检测和切除息肉的效率在整个培训过程中不断提高，并未达到主治医生的水平。住院医师的参与导致了中度镇静的更多使用，这可能与手术时间延长和内镜技术经验的发展有关。
