In this study we examined the effect of low-fidelity simulation training, as well as the interaction of repeat clinical endoscopy and simulation training, on both clinical endoscopy skills and patient comfort. Overall, there was a significant reduction in time to adequate visualization and number of mucosal contacts between first and second endoscopy. This suggests that the benefits of repetition quickly become appreciable. A recent study has shown that learners become competent after 6 endoscopies . Our study is in keeping with this notion of rapid skill acquisition with repeat endoscopy.
Interestingly, when data were stratified by both endoscopy number and simulation, there was no significant interaction seen. This suggests that, in this study, there was no additional benefit, above and beyond repeat endoscopy, conferred by the use of the simulator.
Learners performed TFFL on different patients for each endoscopy. While patients may have mild variations in their anatomy, none had had previous endoscopic sinus surgery, major head and neck surgery or head and neck external beam radiotherapy. Using different patients for the first and second endoscopy was important to prevent any improvement on the second endoscopy being attributable to familiarity with the patient’s anatomy.
In our study, we compared the second endoscopy following randomization with the baseline endoscopy. We did not analyze the subsequent endoscopies beyond this. It is possible, and would be interesting to examine, if the rate of skill acquisition may have been faster in the simulation group compared to the control group if subsequent endoscopies had been analyzed.
Based on our observations, the most challenging aspect of the endoscopy was navigating the nasal cavity. This anatomy was not reflected in the design of the simulator. It may be that, in this case, a simulator that better reflected nasal anatomy would be more beneficial. However, a randomized controlled study looking at rigid and flexible nasal endoscopy utilizing an accurate nasal model also did not show any quantitative or qualitative difference among simulator and control groups when they subsequently performed endoscopies on standardized patients . This is likely due to the inherent challenges of performing endoscopy on a live patient rather than an inanimate object and could also help explain why our study did not detect a significant benefit with simulation. Developing a simulator that not only replicates the anatomy, but provides the ability to mimic a patient’s responses when undergoing endoscopy, may better address this issue.