Competence development in ERCP: the learning curve of novice trainees

Measures for competence in endoscopic retrograde cholangiopancreatography (ERCP) during training are poorly defined. Currently, various training and accreditation programs base verification of competence on performance of a minimum number of procedures. There is a general awareness that procedural competence certification should be based on objective performance criteria. Continuous self-assessment using a Rotterdam Assessment Form for ERCP (RAF-E) can provide insight into trainee performance. The study aim was to express development in ERCP competence as a learning curve.

ERCP trainees at a tertiary referral center in the Netherlands were invited to participate. Performed procedures were appraised using RAF-E. Indication for each ERCP and presence of a virgin papilla were documented. Complexity was graded on a 3-point scale. The primary outcome parameter was common bile duct (CBD) cannulation success rate. Success of the intended therapeutic interventions was additionally expressed as a learning curve.

15 trainees were included. 1541 ERCPs (624 procedures in native papillary anatomy) were assessed through RAF-E. Unassisted CBD cannulation success rate improved from 36 % at baseline to 85 % after 200 procedures (P < 0.001), and in 624 patients with a virgin papilla from 22 % at baseline to 68 % after 180 procedures (P < 0.001). Learning curves for therapeutic interventions showed significant improvements for successful sphincterotomy (P = 0.01) and stent placement (P < 0.001).

Learning curves are a valuable means for assessing competence in ERCP. Differences in learning curves can be shown with RAF-E. Verification of competence should be based on actual performance, instead of minimum numbers.