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INTRODUCTION
In Korea, the demand for gastrointestinal endoscopy as part of health examinations has increased significantly. The use of propofol-based sedation during endoscopy has increased from 55.6% in the 2014 survey to 67.5% in the 2019.1 While the extensive use of propofol has improved patient satisfaction and procedure acceptability, it also predisposes patients to adverse events.2,3 Although the use of propofol for procedural sedation is freely permitted for non-anesthesiologists in Korea, endoscopic sedation might cause serious adverse events.4,5 According to a study conducted by the Medical Policy Research Institute in 2022, the average number of prosecutions in Korea was higher than those in other countries.6 Because of the high incidence of legal issues, endoscopists must perform more careful and stable procedures. Therefore, regular education and training should be emphasized for Korean endoscopists.
Current situation and background of the curriculum
In 2017, the educational goals for Korean endoscopic sedation were announced alongside the Education and Training Guidelines for the Board of the Korean Society of Gastrointestinal Endoscopy (KSGE).7 In 2021, the KSGE clinical practice guidelines for endoscopic sedation recommended that doctors performing endoscopic sedation and medical staff assisting them undergo cardiopulmonary resuscitation (CPR) training to mitigate the occurrence of severe adverse outcomes, including mortality during sedation-related emergencies.8
The KSGE Propofol Sedation Training program, certified by the Korean Medical Association and the Korean Nursing Association, provides free access to training content through videos on the society's website. Since 2018, education on propofol sedation has been provided at least biannually, offering minimal educational opportunities to all medical personnel involved in sedation endoscopy. A propofol sedation education program was implemented for the medical personnel involved in sedation therapy in the field of endoscopy. There are both in-person and online education programs in major Korean cities, as well as educational programs such as seminars offered by the KSGE and other academic conferences.
Practical Korean training in endoscopic sedation has traditionally included performing the procedure under supervision and providing patient sedation. However, due to the technical and teamwork skills required, the effectiveness of such training is limited.9 Recently, endoscopy curricula are increasingly incorporating instructional design elements grounded in educational theory and empirical findings from the academic literature. Endoscopy simulation education has shown the potential benefits of this strategy, with trials demonstrating that simulation-based training, which includes a structured curriculum, progressive learning model, and nontechnical skill training, improves the transfer of skills to clinicians.10,11 In anesthesiology, a meta-analysis indicated that simulation is more effective than no intervention and noninferior to non-simulation instruction.12 Furthermore, in sedation endoscopy, simulation training on sedation overdoses using a full-scale simulator combined with an Erlanger Endoscopy Trainer improved emergency skills in endoscopists with more than 12 months of experience.13
However, some respondents to a nationwide survey conducted in Korea did not receive any training or education regarding sedation practices.14 Furthermore, many of them relied on their own educational programs.15 European16 and American17 curricula for endoscopic sedation have been extensively developed. Although there are some differences, both curricula include the necessary components for sedation during endoscopy and recommend practical training using a simulator. Currently, there is no official Korean core curriculum for sedation during gastrointestinal endoscopy. Therefore, a practical curriculum that suits the reality in Korea should be developed.
The Endoscopic Sedation Committee of the KSGE recognized that Korean core curriculum development, including these recently adopted practical trainings, is needed for safe sedation during gastrointestinal endoscopy. Therefore, it includes both the theoretical knowledge and practical skills necessary for safe and effective sedation during endoscopic procedures. It will also involve tailoring the program to the Korean healthcare system, cultural context, and regulatory requirements. Following a thorough review of the literature, the committee has developed and proposed a comprehensive core curriculum.
CORE CURRICULUM FOR SEDATION IN GASTROINTESTINAL ENDSOCOPY
Theoretical part
The curriculum, outlined in Table 1, comprises four modules: the basics of sedation, sedation monitoring, patient safety and risk management, and related laws and ethics.
1) Basics of sedation
It covers core sedation techniques, including the pharmacology of commonly used sedatives and the criteria for patient selection. Trainees will gain a foundational understanding of the principles of sedation and the effects of various agents. Additionally, they will be introduced into the American Society of Anesthesiologists classification system, which will help assess patient risks during sedation.
2) Sedation monitoring
Participants will learn about the necessary equipment and personnel configurations for sedation as well as the different stages of sedation. They will be trained on appropriate sedation protocols for various procedures and gain practical knowledge of patient preparation, including monitoring vital signs and ensuring proper oxygenation.
3) Patient safety and risk management
This section focuses on understanding the cardiovascular and respiratory systems in relation to sedation. Participants will explore sedation-related complications such as hypoxia, hypocapnia, and hypercapnia and will learn strategies to identify and manage these risks to ensure patient safety.
4) Legal and ethical consideration
This study addresses the legal regulations and ethical concerns surrounding sedation practices in Korea. Participants will learn to navigate the legal framework governing sedation and consider how to address the ethical dilemmas that may arise during sedation and endoscopic procedures.
Hands-on training
Many emerging educational methods can be applied to hands-on training for endoscopic sedation. Tools such as part-task trainers, computer-driven manikins, and virtual reality (VR) simulators on a continuum from low fidelity to high fidelity are used for training.18 Part-task trainers are anatomic models used for teaching specific skills. For example, plastic airways can be used to treat sedation-related complications. These are generally passive, non-computerized models. Computer-driven simulators can replicate the responses of sedated patients to noxious stimuli such as unpleasant sounds, increments in heart rate and blood pressure, and reactions to commonly used sedative medications.19 For instance, computer-based mannequins can simulate CPR. Recently, VR has gained popularity for integrating VR technology into sedation endoscopic training.20 It is becoming the preferred method for developing coping mechanisms for adverse events such as hypoxia, apnea, hypotension/hypertension, bradycardia/tachycardia, and arrhythmia as well as facilitating teamwork skills
Table 2 provides a detailed outline of the practical hands-on training components necessary for sedation during gastrointestinal endoscopy. This curriculum is designed to develop not only technical skills, but also the ability to handle sedation-related complications, work as a team, and effectively communicate during critical situations. The training is divided into three core modules, each addressing different aspects of practical sedation training.
1) Practical training and simulation
This module allows trainees to experience sedation management for a variety of patient populations. Since the effects of sedation can vary greatly depending on factors such as age, weight, and medical history, the focus will be on adjusting the sedation dosage and closely monitoring patient responses. This will enable trainees to understand how to tailor sedation for individual patients and perform sedation endoscopic procedures comfortably and safely. They will also practice CPR using computer-based mannequins. These mannequin-based simulations provide a safe environment to practice emergency situations without risking actual patients. Trainees will learn to deal with various challenging situations through simulated sedation scenarios, such as sedation endoscopic procedures in special situations and sedation complications.
2) Communication and teamwork
Effective communication and teamwork are essential components of endoscopic sedation, especially in stressful situations where patient safety is at stake. This module focuses on developing nontechnical skills, which are often as important as clinical competencies. Trainees will learn to communicate clearly with patients about the sedation process, manage patient concerns, and ensure informed consent. In addition, clear and effective communication among team members is important in emergency situations where sedation complications occur. Using case scenarios, participants will engage in role-playing exercises to simulate crisis situations. These exercises improve technical response, and enhance teamwork and leadership skills. Realistically designed scenarios mimic common complications that can occur during sedation, such as hypoxia with bleeding, provide opportunities to practice teamwork.
3) Real-world clinical practice
This final module provides trainees with hands-on experience in sedation endoscopy under the supervision of experienced instructors from each training hospital. Trainees will observe a minimum of 30 real-world sedation endoscopies performed by certified instructors at a designated training hospital. These observations allow them to observe a variety of patient responses and complications and learn practical skills. Upon completion of the observations, trainees are required to demonstrate proficiency by performing 30 supervised sedation endoscopies. Their performance will be assessed by a supervisor who will evaluate their ability to safely administer sedatives, manage patients, and handle complications. Upon passing this assessment, the trainee becomes certified in sedation endoscopy.
Through this comprehensive hands-on training curriculum, participants gain not only theoretical knowledge but also the practical skills and confidence required to safely perform sedation endoscopy. The curriculum’s focus on crisis management, communication, and teamwork, coupled with real-world experience, ensures that trainees are well-prepared to handle the complexities and challenges of sedation endoscopy.
PRACTICAL TRAINING USING SIMULATION CENTER
The training curriculum outlined in Table 3 is designed to provide a comprehensive, structured approach to mastering endoscopic sedation through a blend of theoretical and hands-on experience.21 The program comprises distinct, sequential phases, ensuring a well-rounded education for the participants.
Introductory course
This stage will help trainees establish a solid theoretical foundation and understand the basics before moving on to clinical practice. It will include lectures introducing the core principles of endoscopic sedation, a web-based learning platform, and a brief explanation of the mock training course.
Simulation training
The simulation phase begins with mock training focused on airway management. Part-task trainers, such as partial mannequins, are used to practice airway insertion techniques in various scenarios. Next, computer-driven mannequin are employed to simulate basic/advanced life support scenarios. Through this course, we will be able to receive feedback on how to perform resuscitation on patients in emergency situations. The computer-driven mannequin is not just a model; it can detect whether chest compressions are being performed well or regularly and provide real-time feedback on the actions. In addition, VR simulators offer an immersive environment for trainees to practice emergency responses. Training using these VR simulators is important for building teamwork and crisis management skills because it simulates real-time decision-making and communication among medical staff in a stressful environment. VR simulators can provide immediate feedback, track and analyze performance, and identify strengths and areas for improvement.
Assessment
In this stage, decision-making ability for clinical scenarios is assessed through discussions with faculty. Communication skills, professionalism, and teamwork are also assessed through group discussions. Afterwards, feedback and debriefing are provided to each individual. If the required competency standards for clinical proficiency are met, clinical practice can be conducted.
While simulation-based training seems beneficial, it has limitations. This type of simulation is expensive and labor-intensive compared with other forms of training and education, and the availability of such resources is limited. However, this structured approach ensures that participants not only acquire the necessary theoretical knowledge but also develop hands-on experience in real-world settings. The use of simulation technologies, including VR and computer-powered mannequins, allows trainees to practice complex skills in a safe, controlled environment, significantly enhancing their preparedness for clinical practice
FURTHER CONSIDERATION
Is it possible to conduct simulation training in reality Korea?
Given the potential complications and legal implications of endoscopic sedation, establishing simulation centers in Korea for training purposes is advisable. The practical training described in this paper could be facilitated by simulation centers established at national universities in Korea. A comprehensive discussion is needed to expand and activate medical education and training infrastructure for local medical professionals, focusing on the role of simulation centers in meeting the demand for medical education and training, including sedation endoscopy, in the future.
Is it really necessary to make endoscopic sedation training mandatory?
Although propofol sedation training for gastrointestinal endoscopy is not mandatory by the Korean Medical Association, many experts recommend it to healthcare providers involved in sedation endoscopy. Proof of training completion may be required in the event of legal issues. If an official curriculum is developed, the question arises as to whether there will be disciplinary actions or penalties for healthcare providers who do not complete the training. This curriculum can be blamed for not providing good education, but rather creating another obstacle for Korean healthcare providers. Discussions through seminars, academic journals, and online promotions are required to build a consensus on this matter. By integrating these components into a comprehensive curriculum, Korean healthcare providers can ensure safe and effective delivery of sedation for endoscopy while addressing the unique needs and expectations of patients and healthcare professionals in Korea.
How will the curriculum proposed by KSGE be managed in the future?
This study proposes a core curriculum for endoscopic sedation education in Korea. Therefore, it is important to improve the quality of sedation through regular and continuous education and evaluation. Support for the development and maintenance of institutions capable of providing education and training is necessary. A functional organization and manpower capable of systematically managing the planning, execution, and follow-up of endoscopic sedation education are needed. They are required to plan and operate all activities related to advanced planning to implement education. They can also review issues and present their opinions when developing certification-related policies. Many topics require further discussion, including the role of simulation centers and teaching hospitals, the provision of educational content that reflects learners’ needs and experts’ opinions, the management of training program content, differentiating ratings based on training needs, and coworking with people from different areas of expertise.
CONCLUSIONS
Simulation-based training is increasingly employed in endoscopic training courses. However, it is still not widely used in sedation endoscopy. If the core curriculum proposed here is implemented in a more careful and intentional manner, the training program would be able to maximize the potential learning benefits of simulation in the future. This core curriculum should be developed and improved for Korean endoscopic sedation education in the future. It is hoped that a well-designed curriculum will become mandatory in the future and that endoscopic sedation will be performed more safely.
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