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Quantitative Assessment of Procedural Competence: A Prospective Study of Training in Endoscopic Retrograde Cholangiopancreatography

Paul S. Jowell, MB, ChB; John Baillie, MB, ChB; M. Stanley Branch, MD; John Affronti, MD; Cynthia L. Browning, RTR; and Barbara Phillips Bute, PhD
[+] Article, Author, and Disclosure Information

From Duke University Medical Center and Durham Veterans Affairs Medical Center, Durham, North Carolina. Acknowledgments: The authors thank Peter B. Cotton, MD, Steven Guarisco, MD, and Joseph Leung, MD, for participating in the initial phase of the study. Grant Support: In part by a grant from the American College of Gastroenterology. Requests for Reprints: Paul S. Jowell, MB, ChB, Box 3662, Duke University Medical Center, Durham, NC 27710. Current Author Addresses: Dr. Jowell: Box 3662, Duke University Medical Center, Durham, NC 27710.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1996;125(12):983-989. doi:10.7326/0003-4819-125-12-199612150-00009
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Background: Endoscopic retrograde cholangiopancreatography (ERCP) is a technically demanding procedure that can cause substantial complications. Competence in performing ERCP and the learning curve for achieving competence are poorly understood.

Objective: To evaluate the number of supervised ERCPs that physicians must do to achieve procedural competence. Competence was defined as a 0.8 probability of successfully completing specific technical components of ERCP and an overall grading of competence as judged by the attending physician.

Design: Prospective study.

Setting: University training program for gastroenterologists.

Participants: 17 gastroenterology fellows at various stages of training.

Measures: Experienced therapeutic endoscopists prospectively graded gastroenterology fellows during 1796 consecutive ERCPs. Fellows were graded on their overall level of competence for the procedure and on specific technical components of ERCP.

Results: Grading data were available for 1450 ERCPs (81%). The number of ERCPs done before adequate skill was achieved was 160 for cholangiography, 140 for pancreatography, 160 for deep cannulation of the pancreatic duct, 120 for stone extraction, and 60 for stent insertion. Fellows achieved overall competence after completing 180 to 200 ERCPs. The predicted probability of overall competence was 0.8 after 137 ERCPs and 0.9 after 185 ERCPs.

Conclusions: At least 180 ERCPs were required before these gastroenterology fellows could be considered competent in ERCP. This number is much greater than that previously recommended, and these findings have substantial implications for training guidelines and issues of competence and certification in ERCP. The methods used to define and evaluate competence in ERCP could also be used to assess competence in other medical procedures.


Grahic Jump Location
Figure 1. The probability reflects the chance of an acceptable score (a score of 1 [excellent] or 2 [adequate]) for all fellows grouped according to the number of endoscopic retrograde cholangiopancreatographies (ERCPs), in blocks of 20, that each fellow had done. In each part of the figure, n refers to the number of ERCPs in which the respective intervention was done.
Probability (95% CIs) of achieving an acceptable score for cholangiography, pancreatography, deep common bile duct cannulation, and deep pancreatic duct cannulation.
Grahic Jump Location
Grahic Jump Location
Figure 2. The probability reflects the chance of an acceptable score (defined as an overall score of 1, 2, or 3, signifying overall competence) for all fellows grouped according to the number of endoscopic retrograde cholangiopancreatographies (ERCPs), in blocks of 20, that each fellow had done. In the part of the figure that shows the mean overall score ( ), n refers to the number of ERCPs for which an overall score was given.
The mean (± SE) overall score and the predicted probability of achieving an acceptable overall score.left
Grahic Jump Location




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