The acquisition of endoscopic skills is still a significant challenge for many institutions. Even within a single institution, the training often relies on the subjective judgments of individual trainers. In Japan, physicians complete a two-year junior residency followed by a three-year senior residency before specializing in gastroenterology, and they enter endoscopy programs with heterogeneous backgrounds and varying levels of experience. This highlights the need for an objective, competency-based framework that enables stepwise and individualized instruction. To address these issues, we developed and implemented the “Endoscopy Step-Up Protocol,” which incorporates both quantitative and qualitative performance metrics to facilitate structured skill acquisition.

The protocol consists of six upper gastrointestinal (UGI) and five lower gastrointestinal (LGI) stepwise levels, toward independently performing general examinations, integrating both quantitative and qualitative assessments. Certain steps may be waived depending on the trainee’s demonstrated competency. For the quantitative assessment, predefined target numbers were set for each step, including total endoscopy volume as well as the numbers of biopsies and Cold Snare Polypectomies. For the qualitative assessment, six UGI metrics (pharyngeal intubation, mucosal cleansing, scope manipulation, endoscopic imaging quality, patient discomfort, and examination time) and five LGI metrics (cecal intubation rate, mean insertion time, mean examination time, adenoma detection rate, and success rate of using shaft retention and shortening method) are evaluated. Trainers score each item using a three-point scale (0 = Poor, 1 = Average, 2 = Excellent), and feedback is recorded via Google Forms.

The study included eight trainees who participated in the protocol between April 2024 and September 2025 (one junior resident, three senior residents, and four post-residency doctors). A prospective observational evaluation was conducted to assess their training performance in UGI and LGI endoscopy. In addition, structured questionnaire surveys were administered to all eight trainees and six trainers.

For UGI endoscopy, the junior resident (n=1) progressed from Step 1 (observation/lectures/model-based practice) to Step 2 (sedated examinations from intubation to full observation) within one month. Senior residents (n=3) advanced from Step 1 to Step 6 (independent routine examinations) in a mean of 5.3 months. All post-residency doctors (n=4), who had prior experience of endoscopy, skipped Steps 1-2 and started from Step 3 (sedated examinations), reaching Step 6 in a mean of 3.1 months. For LGI endoscopy, senior residents (n=3) progressed from Step 1 (observation/lectures/model training) to Step 3 (sedated examinations) in a mean of 6.0 months. Post-residency doctors (n=4) also advanced directly to Step 3 and reached Step 5 (independent routine colonoscopy) in an average of 7.3 months.

Survey results indicated full satisfaction among all trainees (100%, 8/8). Trainees reported that the structured stepwise system clarified training goals, improved self-assessment of technical weaknesses, and enhanced motivation. All trainers (6/6, 100%) observed improvement in trainee skills. Trainer workload was rated as “increased” by 1/6 (17%) and “unchanged” by 5/6 (83%), suggesting that standardized scoring and feedback did not substantially increase supervisory burden.

The “Endoscopy Step-Up Protocol” provides a clear, objective, and competency-based framework for endoscopy training. By integrating both quantitative and qualitative assessments, the system enables personalized and level-appropriate instruction, and helps maintain well-defined learning goals. The use of Google Forms enables rapid feedback, consistent documentation, and efficient communication between trainees and trainers. This protocol demonstrated feasibility, improved competency acquisition, and was well received by both groups. It may represent a practical and scalable approach for standardizing endoscopy training across institutions.