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Dr. Torrington is Director of Health Education and Training, Tripler Army Medical Center. The views expressed in this editorial are those of the author and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.
Correspondence to: Kenneth G. Torrington, MD, FCCP, Tripler Army Medical Center, 1 Jarrett White Rd, Honolulu, HI 96859-5000; e-mail: G.torrington{at}tamc.chcs.amedd.army.mil
Elsewhere in this issue of CHEST (see page 625), Haponik et al report the results of a survey of 59 senior pulmonary and critical care medicine fellows who attended an industry-sponsored bronchoscopy course in conjunction with CHEST 1998, the annual American College of Chest Physicians meeting.1 The authors found wide discrepancies in bronchoscopy training between institutions, in areas such as numbers of procedures performed, ancillary techniques instruction (for example, transbronchial needle aspiration), and fellows’ subjective assessments of their program’s bronchoscopy training quality. Rather than getting distracted by the obvious scientific limitations and possible biases of the survey, I will focus my comments on the authors’ primary conclusion that "an effort to apprise and enhance the quality of bronchoscopy training is necessary."
In 1964, Ikeda et al developed standards for the flexible fiberoptic bronchoscope (bronchofiberscope),1 and in 1968 it was described as a diagnostic instrument.2 Over the ensuing years, medical equipment manufacturers worked with pulmonary physicians to develop amazing advances in bronchoscope flexibility and optics, a dazzling array of bronchoscopic instruments, and new applications of the procedure. The bronchoscopist of today can perform laser therapy, cryotherapy, brachytherapy, stenting, localization of areas of dysplasia and carcinoma in situ using tissue autofluorescence, and ultrasound localization of mediastinal nodes for transbronchial needle aspiration, all procedures that were unimagined or impossible 20 years ago. There is no question that by enabling pulmonologists to gather tissue biopsies from the lower respiratory tract, Ikeda’s invention greatly improved the scientific underpinnings of pulmonary medicine. Most modern-day pulmonologists perform flexible fiberoptic bronchoscopy,3 4 which has become the key procedure defining our specialty.
Therefore, it is surprising that despite the substantial literature on teaching bronchoscopy referenced by Haponik et al, pulmonary and critical care medicine training programs have not adopted minimal essential numeric thresholds for bronchoscopy training.5 ) I believe it most logical that pulmonary and critical care medicine program directors, who meet biannually at the American College of Chest Physicians and American Thoracic Society annual meetings, accept the important, though controversial, task of defining such criteria. After our academic leaders have established the requirements, they should be presented to the pulmonary disease and pulmonary and critical care medicine residency review committees for approval as the standards necessary to receive and maintain programmatic accreditation.
I offer the following suggestions, based on my long interest in fiberoptic bronchoscopy, my experience as a former pulmonary disease program director at Walter Reed Army Medical Center, and my modifications of the guidelines of Prakash and Stubbs6 for bronchoscopy training: (1) trainees will perform a minimum of 50 bronchoscopies/yr, and at least 100 procedures during fellowship training; (2) bronchoscopies will be performed on ambulatory patients and at least 10 patients receiving mechanical ventilation; (3) instruction and experience in the techniques of endobronchial biopsy, bronchial brushings, bronchial washings, BAL, transbronchial needle aspiration, transbronchial lung biopsy, and quantitative culture of the lower respiratory tract will be required (five each); (4) experience using fluoroscopy during bronchoscopy will be provided (five patients); and (5) experience with bronchoscopic intubation will be obtained (five patients). Current program directors will use available scientific evidence and their best judgment to decide the threshold numbers of bronchoscopies and associated procedures needed to ensure competency for individual trainees. Future reports will undoubtedly modify these initial recommendations.
I propose that pulmonologists follow the lead of the other procedure-intensive internal medicine subspecialties. Using evidence-based medicine to establish threshold numbers of supervised procedures needed to achieve competence,7 8 gastroenterologists require that their fellows perform 25 flexible sigmoidoscopies, 100 colonoscopies, and 100 upper-GI endoscopies, before being allowed to "scope" patients unsupervised.5 ) Similarly, cardiologists selected minimal numbers such as 100 cardiac catheterizations, 50 exercise stress tests, 150 echocardiography studies, 3,500 ECGs, and 75 ambulatory ECG recordings.5 ) The fact that previous pulmonary disease, pulmonary and critical care medicine, pediatric pulmonology, and thoracic surgery residency review committees failed to establish thresholds should not dissuade us from taking on this task.5 ) I disagree with the position of the American Board of Internal Medicine that because "manual dexterity and competence of trainees vary, the Board does not dictate the number of times a procedure must be done to assure competency ... to fulfill some arbitrary quota."9
Conversely, I recommend against requiring training programs to teach rigid bronchoscopy, which I consider a surgical procedure. The few pulmonologists desiring to master this skill, to become credentialled, and to compete for operating room time should be encouraged to obtain training from expert thoracic surgeons or pulmonologists. In addition, advanced therapeutic applications of bronchoscopy, such as laser therapy and stenting, should be performed at specialized centers. Trainees interested in learning these techniques should arrange elective rotations staffed by recognized experts. Concentrating these procedures in specialized centers will reduce the risk patients face when undergoing techniques rarely performed by the bronchoscopist or by bronchoscopy suite personnel.
The knowledge and technical skills we pulmonologists possess about performing flexible fiberoptic bronchoscopy ensure that our patients are subjected to the safest, most efficacious, and lowest risk procedures possible. The report by Haponik et al shows that we must improve training efforts to attain the related goals of graduate competence and patient safety. I challenge our academic leaders to respond quickly; our patients deserve nothing less.
References
This article has been cited by other articles:
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  D. OST, A. DE ROSIERS, E. J. BRITT, A. M. FEIN, M. L. LESSER, and A. C. MEHTA Assessment of a Bronchoscopy Simulator Am. J. Respir. Crit. Care Med., December 15, 2001; 164(12): 2248 - 2255. [Abstract] [Full Text] [PDF]
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 H. G. Colt, S. W. Crawford, and O. Galbraith III Virtual Reality Bronchoscopy Simulation : A Revolution in Procedural Training Chest, October 1, 2001; 120(4): 1333 - 1339. [Abstract] [Full Text] [PDF]
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