EFC SATELLITE MEETING AND TRAINING THE TRAINERS
BRUSSELS, 15-16 DECEMBER 2017
EFC TRAINING THE TRAINERS
Dear Colleagues,
Training in colposcopy is a genuine challenge for both trainees and trainers. Trainees should be provided with basic knowledge regarding cervical pathology, natural history of HPV infection, colposcopic examination and patients information and management.
Additionally, trainees should be offered practical supervised and thereafter unsupervised training. In the training the trainers sessions, we offer all the people involved in training of colposcopy the opportunity to meet and exchange about their training experience in order to improve their skills and provide trainees the best they can offer.
In these sessions, we also present the up to date optimal training strategies. This includes the use of simulating models that should nowadays being systematically used as the initial step before patients examination and management.
Xavier Carcopino
Introduction and welcome to the course
Xavier Carcopino – Obstetrician Gynecologist, Head of department of colposcopy and cervico-vaginal pathologies North University Hospital of Marseille, France
This is the 1st EFC TTT session. Need clear objectives for training over and above imparting theoretical and practical knowledge. Need to optimize training and communication from trainees to patients. Why do we need a TTT session? Need to discuss and strive to improve training and feedback.
Identify likely difficulties for trainees. Trainer should be present throughout training and so constructively take time to report how to improve practice. Aim to make a TTT session interactive.
International terminology and EFC quality standards in colposcopy
Pekka Nieminen – President-elect of the European Federation for Colposcopy, Department of Obstetrics and Gynaecology, Helsinki University Hospital, Finland
Terminology and valid standards are needed for high quality services. All information including visual patterns need to be communicated in a standardised format. This helps communication with colposcopists, cytologists and pathologists. These terms can also be communicated to other countries. If there is confusion then quality is impaired. The IFCPC international terminology is a useful example and is recommended. Adequacy of colposcopy, and TZ type are important and must be clearly understand. Squamous metaplasia must be understood. Trainees must understand basic principles before understanding cervical pathology. Trainees must be trained at a pace which is not too fast. Identification of the scj in its entirety is critical to colposcopy and there is disagreement amongst experienced colposcopists between TZ types 2 and 3. The scj must be seen for all 360o to not be type 3. Swedescore or Reid index aids reporting of visualised findings in a structured way. Both the Swedescore and the IFCPC classification are recommended as template for training and are to be used on EFC approved colposcopy courses. Feedback should be always supportive but honest with supportive points for improvement where needed. Audience/ trainees always to discuss cases. Recommendations for trainer skills support trainers to provide critique of colleagues/ trainees. It is important to see how trainees explain management to patients and how patients feel afterwards. Ameli Trope suggested should ask patients what they felt about the trainee.
In conclusion guidelines for training should be developed. Communication to patients and other health professionals is critical. Consider developing a group of trainers to assist training in countries across Europe.
EFC Certification of colposcopy courses
Xavier Carcopino – Obstetrician Gynecologist, Head of department of colposcopy and cervico-vaginal pathologies North University Hospital of Marseille, France
Approval via efcolposcopy website. Prof Carcopino leads on approval. Criteria listed on the website. At least 1 day long with 360 min of teaching. Content is determined by EFC core competencies. Local organiser is required for local administration. Send programme to the EFC. Basic courses don’t need to include practical procedures except how to take cervical biopsies and control bleeding following biopsy. The basic course should tell students how to set up and position a colposcope. 100 Euro and valid for 3 years.
The advanced course is relevant to senior colposcopists. 2 days each for 6 hours. 100 Euro. Has to be approved annually. Again programme required to be sent to Prof Carcopina.
Evaluation forms for both courses are on the efcolposcopy website.
Who can be a trainer and what the role is
Nick Myerson – Obstetrician & Gynaecologist in Bradford Chair of the Certification and Training Committee of the BSCCP
High quality trainers are needed for future high quality colposcopists. Trainers must be accountable to official regulatory bodies such as national societies. There are responsibilities for poor trainees in colposcopy would be reflected in poor quality of care elsewhere from these poor trainees. There is a responsibility to ensure the best possible standard of care for colposcopy patients and other patients exposed to poor trainees. Success as a trainer requires tools. A trainer provides an environment which allows the trainer to learn. Sometimes despite best efforts a trainee may not learn and so a new approach may be required. Insight into how people may learn provides further strategies to learn via knowledge, skills and attitudes. Experiential Learning (Kolb) involves planning before the clinical exposure, reflect on the experience and make sense of the experience to plan what to do next. Keep it simple (KISS), establish credibility, establish the trainers’ credibility, teaching is not learning and remember that all is said may not be absorbed, and the trainee is the focus of the process. Fail to prepare, prepare to fail!
Feedback must be specific, measurable, achievable, relevant time-bound (SMART). It must be agreed beforehand and not just done at the trainees’ request because a particular intervention went well.
Common difficulties in colposcopic practical training
Nick Myerson – Obstetrician & Gynaecologist in Bradford Chair of the Certification and Training Committee of the BSCCP
How to deliver good training even if you are good trainer? Theoretical knowledge is essential. The trainer must understand the task, analyse the task, provide an orderly plan to teach, be able to build skills, have a plan for training and acknowledge that not all trainees are the same. Trainees have differing motivations, capabilities, learning styles and expectations. Teachers usually teach the way they learn (3 ways can be audio, visual or a combination as kinaesthetic). Trainers must understand this but it can be difficult to determine which trainees are which. Can visit NLP website for further information. Miller’s pyramid is a schema for learning and professional authenticity from knows, knows how, shows how and finally does. Also there is ‘Peyton’s 4 step technique’:
1 – do procedure (demonstration useful for visual learner)
2 – then describe each step (deconstruction useful for the audio learner)
3 – the teacher demonstrates the skill whilst the learner describes the steps (comprehension)
4 – finally the learner performs the skill whilst describing the steps (performance useful for kinaesthetic learners).
Works well when adapted to the chosen task.
The ‘1 minute preceptor’ focusses discussion (ie short and therefore SMART feedback ideal). Another concept is merging these as ‘blended learning’.
Simulation training is useful particularly for treatment. Colposcopy is suited to a blended approach but some theoretical knowledge is useful. Pre-learning with watching in clinic, have a skills lab environment, use simple aids, break the task down to build skills, a 4 step approach and plan before you start. If the task is not analysed in advance, then success in that episode is less likely.
Optional work place assessment of training
Maggie Cruickshank – Professor MB ChB MD FRCOG Division of Medical and Dental Education and Medical Sciences.
Effective assessment should provide feedback and clarify action plans. Should be valid (does a test measure what it is supposed to measure) and reliable (does the test measure the same thing which varies for 0-1). Validity is not easy to demonstrate. The top of Miller’s pyramid has competency and performance with competency what is being done in a controlled environment and performance is what is done in practice. OSCEs or examinations cannot demonstrate performance, perhaps ‘knows how’ or ‘shows’ from Miller’s pyramid at best. Practical skill simulation, OSCEs, long cases or work based assessments provide best all round reliability, validity, feasibility and acceptability. Work based assessments focusses on all round clinical performance. Formal assessment has a significant influence on achievement. Feedback has the largest effect on learning or training (70% contribution to overall learning and more benefit than attending teaching). Work based assessments provide structured review and feedback of performance – including min-CEX (mini clinical examination); DOPS (direct observation of procedural skills) and CbD (case-based discussion).
A mini-CEX are very focussed activities such as taking a history or explaining results. Feedback is included and the whole procedure takes about 5 minutes. Feedback includes ‘is there anything that was good’, ‘is there anything that could be done better’ and ‘what is the future learning plan’. Assessments are continuous as the trainee learns. It is not summative at the end of training. A DOPS is a record of an activity and takes as long as that procedure takes. There is a standard check list to record all activities such as a colposcopy. CbDs provide a dialogue with structured record of the discussion. Together these can sample expertise widely across the curriculum with multiple raters. The trainee can have dynamic formative feedback and summative feedback on completion of that particular skill. More formal assessments are required to provide a final sign off for training. Work-based assessments can pick up the failing trainee to provide an action plan or to abandon training at an early stage to avoid wasting time. In general, weaker trainees are less likely to seek feedback. There needs to be enough trainers to have work-based assessments.
Providing feedback and make an action plan
Maggie Cruickshank – Professor MB ChB MD FRCOG Division of Medical and Dental Education and Medical Sciences.
How am I doing, where am I going and how do I get there? This is trainees’ view for feedback. Focus on process not behaviour (attempting changing behaviour is rarely successful and changing process encourages deeper learning and improved performance). Feedback should be credible, useful, accurate and the trainer should understand the trainee’s culture and level of achievement. Ask the trainee to give their view, be non-judgemental, choose a suitably quiet location, be specific and know when to stop. It must not be a monologue. Recreate the events being reviewed. Remember non-verbal cues help communication with feedback. An action plan is useful in that goals to be achieved can make the change.
How to help the trainee in difficulty
Maggie Cruickshank – Professor MB ChB MD FRCOG Division of Medical and Dental Education and Medical Sciences.
Group discussion for 4 scenarios:
- Trainee gives an instant answer and is not confident when challenged. Process problem. How is that decision made? Knowledge or understanding to be considered.
- Poor quality loop excisions. Retraining to be considered.
- Trainee disagrees with recommended management. Check the information to see why there is a difference. This can be difficult to resolve but a consensus may be required. Quote guidelines if there is a difference of opinion.
- Trainee feels not ready for independent practice but trainers feels differently. See what reasons there are. Provide practical solution.
Use of training models for treatment of CIN
Xavier Carcopino – Obstetrician Gynecologist, Head of department of colposcopy and cervico-vaginal pathologies North University Hospital of Marseille, France
There is no standardised method of teaching loop excision. Trainees generally learn on the job which is not ideal. Laparoscopic training boxes improve trainee surgical performance. Vaginal models allow colposcopists to develop dexterity skills. This must be performed under colposcopic vision. The training can be recorded as an OSATS (objective structured assessment of technical skills) on standardised sheets. Again publications have shown improved colposcopic performance. A speculum should be inserted into the vaginal model. LLETZlearn is an alternative devise which uses modelling clay rather than a sausage. The clay must have some moisture to allow an electrical current to work. Some form of training model is recommended. The duration of training effect is unclear.
E-learning and distance learning. How we supervise
Albert Singer – He is Professor Emeritus at UCL and holds Honorary Consultant appointments at University College Hospital and the Whittington Hospital in London.
Training can be provided by apprentice system with teachers or coaches, courses and e-courses to allow remote learning. Remote learning is accessible where there are no trainers but with use of the internet. Mobile colposcopy can be linked to e-learning. Mobile ODT weighs 400g. and is the only mobile device in production. Gynocular is no longer made. With Mobile ODT the colposcopist can be thousands of km away. Correlation with local colposcopic opinion appears excellent. Data is encrypted and stored in the cloud. Trainees still need to be reviewed in person with patients. Ideal for 3rd world and remote regions
5th EFC SATELLITE MEETING
Dear Colleagues,
The introduction of Annual EFC Satellite meetings by the then President Ulli Petry in 2012 has greatly enhanced the momentum of the Federation’s progress. It has meant that issues can be regularly reviewed as well as creating a sense of ownership and cohesion.
The role of these meetings was to regularly assemble representatives of the constituent societies and consider key items of the Federation’s agenda. The focus has necessarily reflected its core activities, such as Education, Training and Performance Standards. The programme for the 5th EFC Satellite Meetings followed suit. In addition, there was a Training The Trainers course, which was devised by Professor Xavier Carcopino in response to a perceived demand mentioned at earlier meetings.
The programme aimed to address a number of important relevant issues ranging from the question of who should be undertaking colposcopy to how should appropriate training be delivered and best use made of the new opportunities afforded by technological developments. These discussions were enhanced by the involvement of EBCOG and representatives from commercial companies.
The role of the EFC is to promote and improve colposcopy throughout Europe, through dialogue and consensus. The 2017 Satellite Meeting has helped to set the stage to enable this.
EFC President
Charles Redman
Review of EFC and performance standards
Charles Redman – President of the European Federation forColposcopy, Consultant Gynaecologist, University Hospital of North Midlands, UK
The training core curriculum and standards for basic and advanced courses for colposcopy have been agreed. Colposcopy basic and advanced courses are reviewed and supported. A training the trainers course was held on 15th December. Assessment is ideal at the end of training and an electronic logbook for training has been developed. Surveys have assessed the availability of training programmes. The requirement for all gynaecologists to be trained in colposcopy as recommended by EBCOG in 2014 has been questioned. The EFC has been involved in European guideline development. Certification of colposcopists and quality assurance is being developed. All colposcopists must be adequately trained. A recent survey of the EFC membership was presented. There were 52 respondents. There were the following questions:
Only a minority of gynaecologists performed colposcopy. The majority of colposcopists were not formally trained. Most respondents did agree with the EBCOG recommendation that all gynaecologists should perform colposcopy. Most respondents said that more than 100 cases are required to adequately train. This indicated that training of all gynaecologists to perform colposcopy was not feasible.
Should colposcopy be a core skill for all gynecologists
Angelique Goverde – Chair of Standing Committee on Training and Assessment at European Board and College of Obstetrics and Gynaecology
EBCOG values the mobility of the obstetric and gynaecology workforce in Europe and therefore recognition of each other’s training standards. 37 member states. ENTOG is the subgroup for junior doctors. FIGO deals with cancer staging. UEMS links with the EU. There is a Standing Committee of Training and Assessment dealing with colposcopy training. ENTOG noted significant training disparities across Europe. Some trainees do not feel adequately trained. The EBCOG-PACT in 2012 was to determine the minimum set of skills to work as a gynaecologist in any state in Europe. The skills are competency based. There should be constant formative feedback and assessment. A certificate is provided. A Delphi process was undertaken to develop a curriculum for core, elective or subspecialty training. 2 rounds completed. Training for at least 5 years, 4 for core, 1-2 years of elective training. Simulation training should be included and this includes for colposcopy training. Colposcopy, loop excision and conisation should be part of core training. Colposcopy should be a core skill for gynaecologists as this was supported by over 70% of respondents to the Delphi survey. Subsequently cone biopsy was removed after expert review. EBCOG has recognised the concern of the EFC for all trainees in colposcopy.
Discussion: perhaps the difference is a question of interpretation of degree in that all gynaecologists should have a basic understanding of cervical screening and seeing an abnormal cervix (Ulli Petry). However, management of assessing abnormal screening and treatment should be performed by trained colposcopists. AG stated that a lack of training capacity doesn’t mean that the training should not be offered. Just because that person may not perform colposcopy as a consultant should not preclude colposcopy training as a trainee. Improved outcomes are anticipated with more experienced colposcopists and perhaps an introduction to the basic skills with colposcopy only may be allowed into general training (Xavier Carcopino). The EFC recognises that training must fit the needs of the local population (Charles Redman). Joe Jordan noted that there is perhaps little difference from the standpoint of EBCOG or the EFC. The details must be clearly shown in how the training is provided and that there is audit of outcomes and performance. The consensus is to improve the quality colposcopy which in general throughout Europe is poor (Ulli Petry). This will be reviewed with ongoing collaboration with EBCOG.
Performance standards
Karl Ulrich Petry – Head of Department of Gynaecology and Obstetrics, University Medical Center Göttingen, Germany
European guidelines 2nd edition 2015 HPV based screening recommended (not co-testing with cytology) and cytology below 30 years. Screening intervals at least 5 years. Direct referral to colposcopy for HPV +ve women not recommended. Netherlands and Norway have HPV-based screening already. As before, colposcopy is the core skill in the diagnosis and management of CIN2+. However, the failure rate of colposcopy for missed CIN3+ is increased in women with HPV +ve but normal cytology (Petry et al, 2013) and is not appropriate. Colposcopy is effective for those with +ve cytology triage. A standardised protocol for colposcopy is important (TOMBOLA, 2010). ECC would miss 28% of CIN3+ (Petry et al, 2013) and diagnostic cones/ loops needed for the type 3 TZ. Only 2% of HSIL is detected by random biopsies from a normal cervix (Wentzensen et al, 2015) and so random biopsies are not needed in this context. There is more pressure on the colposcopy service with HPV-based screening. Need audit and quality assessment.
The EFC have decided and submitted for publication 6 agreed quality indicators (QIs). The EFC has published the effectiveness of margin status at excision (Arbyn et al, 2017), which is ineffective and should be replaced. HPV testing is more effective in predicting the risk of relapse. The QIs were updated in Paris 2017 but the margin status QI remained uncharged but a decision was delayed until publication of the Arbyn paper.
In general, QIs are easy to collect. Funding from EU to support QI review.
Standards for colposcopy
Marc Arbyn – Scientific Institute of Public Health, Brussels, Belgium
One the previously agreed QIs was the standard that not more than 20% of margins should be involved. Ghaem-Maghami (2007) found a +ve association with margin involvement and recurrent CIN. The meta-analysis was updated this year and published in Lancet Oncology (Arbyn et al, 2017). Further information on individual patient meta-analysis which should be ready next year. 25 studies included in the Arbyn meta-analysis. Loop excision had higher margin involvement (26.8%) versus laser or knife cone biopsy. Variability was wide between papers meaning reproducibility is reduced. Treatment failure was 6.6% overall. If margin +ve failure 18%, if –ve 4% with relative risk of 4.9. The risk of failure was highest when both ecto and endo margins involved. HPV testing superior to margin status (sensitivity 91.0 v 55.8%) this was significant and specificity was non significantly worse for HPV testing. HPV testing significantly altered pre-test post-test probability indicating that management should be altered for HPV +ve status after treatment but not for margin status. No studies combined obstetrical outcome and margin status in 1 study. An update of the EU guidelines is recommended.
Discussion: margin status may not be searched for thoroughly as pathologists know that HPV status is checked after treatment (Ameli Trope) in some countries. Whilst HPV testing is not a clear measure of surgical expertise a measure of clearance appears a reasonable surrogate fro success (MA). PPV for HPV +ve is only 0.4%, the UK uses CIN2+ rate at 12 months. So HPV status is a poor measure for outcome of treatment (John Tidy). The negative rate is more useful (Charles Redman).
Challenges facing colposcopy in Eastern Europe/ Central Asia
Tamar Alibegashvili – MD, PhD and President of the Georgian Colposcopy Society
In Georgia, cervical cancer is the 2nd commonest cancer in women. Poor coverage, lack of laboratory QA are obvious problems. International IFCPC UNFPA EECARO funding has provided training for colposcopy trainees and has been used to help establish a group of trained colposcopists in their native country. This is a structured training programme with an exam on Lyon. 10 Georgian doctors gained certification to date. E-learning would be useful future considering as long as translation into Russian. At present all gynaecologists perform colposcopy.
The case for an EFC Diploma in Sweden
Tamar Sonia Andersson – Professor of Karolinska University Hospital, Stockholm Alibegashvili – MD, PhD and President of the Georgian Colposcopy Society
560 cases/ year of cervical cancer with 200 deaths/ year in Sweden. Lowest mortality in Europe together with Finland. Swedescore has helped trainees understand colposcopy images. The IFCPC nomenclature is used. Switch to HPV-based screening needing more colposcopists. Colposcopy course provided recognised by the BSCCP. Sweden is now a member of the EFC.
Discussion: Charles Redman advised that a diploma from the EFC hasn’t been developed but individual states can train and certificate colposcopists ideally with an exit assessment. This needs organisation and governance. Jana Zodzika described her service and now runs a Latvian colposcopy course with an exit examination (mcq and clinical cases). This involved political support. Angelique Goverde asked what was the the purpose of a certificate. The purpose is that it has to be maintained needing re-certification and so maintaining expertise in colposcopy (agreed by Charles Redman, Jana Zodzika and Pella Nieminen). Jean-Luc Mergui said there was no formal accreditation in France. Universities are not involved in colposcopy training in France.
Training and exit assessment – the case for training in colposcopy
Ameli Trope – Head of the Norwegian Cervical Cancer Screening Programme
How can standardised training and certification be applied in Norway? There is no obligatory colposcopy training in Norway. Patients with persistent problems need access to previous records which has been a problem in Norway. Coverage 68%. There are 370 cervical cancers/ year and 70-80 deaths/ year. Incidence of cancer has increased slightly. 1 in 4 women at present have an HPV test as part of a pilot. Cytology ASC-US rate has increased in the HPV pilot. If ASC-US/LSIL then only referred to colposcopy if HPV 16/18 +ve. 40% increase of colposcopy and 50% increase of CIN2+. Strander et al (2014) showed that risk of cancer has increased in each following decade as training has become more conservative. Resection margins 66% -ve. Training stopped after Pier Kolstad died in Norway. 4 courses to date in Norway. Training can be overseas but ideally local training with e-learning would be preferred. EFC need to look at more practical training courses such as treatment sessions. Self-sampling for women should be considered. Training and certification is needed but training must be quality assured.
Discussion: Deirdre Lyons advised that there should be accreditation of trainers.
Thanks for coming! We wish to see you all again next year!
For any further information please contact:
EFC Secretariat
Rue de la Presse, 4 B-1000 Bruxelles
Tel: 32 (0) 2 2272730
Mobile: +32 (0) 490 411136
E-mail: efcsecretariat@thetriumph.com
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