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(Chest. 2000;118:625-630.)
© 2000 American College of Chest Physicians

Bronchoscopy Training*

Current Fellows’ Experiences and Some Concerns for the Future

Edward F. Haponik, MD, FCCP; Gregory B. Russell, MS; John F. Beamis Jr., MD, FCCP; Edward James Britt, MD, FCCP; Paul Kvale, MD, FCCP; Praveen Mathur, MBBS, FCCP and Atul Mehta, MBBS, FCCP

* From the Pulmonary/Critical Care Sections (Dr. Haponik), Johns Hopkins University, Baltimore, MD; Wake Forest University (Mr. Russell), Winston-Salem, NC; Henry Ford Medical Center (Dr. Kvale), Detroit, MI; University of Maryland (Dr. Britt), Baltimore, MD; Indiana University Schools of Medicine (Dr. Mathur), Indianapolis, IN; Lahey Clinic (Dr. Beamis), Burlington, MA; and the Cleveland Clinic (Dr. Mehta), Cleveland, OH.

Correspondence to: Edward F. Haponik, MD, FCCP, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, 1830 E Monument St, Room 301, Baltimore, MD 21205


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Objectives: To determine current pulmonary fellows’ perspectives about their bronchoscopy training.

Design: Survey of 59 pulmonary fellows selected by training program directors to represent their institutions.

Setting: "Hands-on" symposium at the CHEST 1998 annual meeting, Toronto, Canada.

Results: Fellows reported a mean (± SD) of 2.4 ± 0.7 years of training, estimated they had performed 77.7 ± 34 bronchoscopies per year, and had generally high estimates of their bronchoscopy proficiency and training. Proficiency estimates correlated with number of procedures cited (r = 0.43, p = 0.001) or level of fellowship training (r = 0.40, p = 0.002). Proficiency ratings (r = 0.63, p = 0.0001) and procedure numbers (r = 0.45, p-0.0004) correlated with program quality ratings. Approaches to bronchoscopy instruction varied, and most often consisted of one-to-one instruction by faculty (92.5%), lecture-based instruction (74.6%), and case discussions (72.9%). Use of bronchoscopy lectures (p = 0.008) or videos (p = 0.057) were associated with higher self-estimates of proficiency, whereas use of lectures (p = 0.002), a bronchoscopy text (p = 0.009), and one-on-one instruction (p = 0.05) were associated with more highly ranked programs. Major components of training varied among programs. Although most fellows had received instruction encompassed in basic bronchoscopy, fewer had experience with bronchoscopic intubation (71.2%), transbronchial needle aspiration (72.9%), quantitative bacterial culture (64.4%), stent placement (27.1%), laser photocoagulation (25.4%), or cryotherapy (6.8%). Components of bronchoscopy experiences correlated with fellows’ estimates of bronchoscopy proficiency and program quality.

Conclusions: Approaches to bronchoscopy instruction and the components of bronchoscopy experiences vary considerably among institutions and are associated with pulmonary fellows’ perceptions of bronchoscopy proficiency and training program quality. Definition of an optimum bronchoscopy curriculum remains necessary.

Key Words: bronchoscopy training • pulmonary fellowship training


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Flexible bronchoscopy is a key diagnostic and therapeutic procedure performed by most pulmonologists.1 Guidelines for instruction have been developed previously,2 3 4 5 6 7 but there is remarkably little published information regarding current bronchoscopy training.8 9 The components of an ideal bronchoscopy curriculum, and, in particular, the perspectives of pulmonary and critical care fellows regarding their bronchoscopy skills and instruction are unclear. With progress in bronchoscopy technology and applications, little is known about the ways in which fellows learn the procedure. What modes of instruction are currently being used? What constitutes an effective training program, and how is this best implemented and monitored? How do fellows view their own bronchoscopy proficiency and the quality of their preparation in this vital area? During a recent course presented to pulmonary fellows representing training programs from across the United States, we appraised their perspectives about bronchoscopy training.


   Materials and Methods
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 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
During the Fifth Annual Fellows’ Course provided at CHEST 1998 in Toronto, Canada, on November 7, 1998, a hands-on-course was provided. Fellows had been selected by their program directors to attend this general program in pulmonary and critical care medicine, with one trainee representing each institution, and the hands-on session was provided to all fellows without consideration of their particular interest in bronchoscopy. After initial instruction, given in a lecture-based format, small groups of pulmonary and critical care fellows rotated sequentially among stations at which experienced faculty provided instruction in bronchoscopy procedures. The latter included rigid bronchoscopy, transbronchial needle aspiration (TBNA), endobronchial stent placement, and cryotherapy. Instruction was provided using a variety of models, bronchoscopes, and a computerized bronchoscope simulator. During this exercise, fellows were asked to complete a brief questionnaire in which they reported about the modes of instruction, content, and quality of their own bronchoscopy training experiences. Questions included multiple choice and open-ended formats, and fellows graded their bronchoscopy proficiency and program quality on a 0 to 10-point scale. The frequencies of fellows’ responses were recorded. Fellows’ descriptions of their bronchoscopy curricula were then related to their self-reports about their level of training, estimates of the number of procedures they had performed, and bronchoscopy proficiency.

Statistical Analysis
Descriptive statistics, including frequencies, means, and SD, were generated for the variables of interest. Spearman correlation coefficients were used to assess the relationships between the independent variables and outcome measures. To evaluate whether predictors of higher estimates of bronchoscopy and program quality could be identified, analyses using the Wilcoxon Rank Sum Test were performed. Statistical significance of observed differences was accepted for p < 0.05.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Pulmonary and critical care fellows representing 59 training programs completed surveys regarding their bronchoscopy experiences. In general, these fellows had positive comments about the quality and clinical relevance of hands-on stations provided at the course in their written postcourse evaluations. At all stations, fellows uniformly expressed interest and enthusiasm. Although faculty did not grade each fellow’s performance, their general subjective impressions regarding fellows’ levels of skill at each station were provided. The faculty described a wide variation in fellows’ technical proficiency. Although most fellows demonstrated familiarity with the flexible instrument, a broad range in skill was evident in their handling of bronchoscopes and, at stations using lung models, their approaches to selected endobronchial locations. At interventional stations, a nearly uniform lack of prior experience with rigid bronchoscopy, stent placement, or cryotherapy was evident. One of the TBNA stations also included a computerized virtual reality bronchoscopy simulator. Verbal reports of fellows about this modality were uniformly favorable, and fellow grades for the station (n = 12; mean, 4.5 on 5-point scale) were high.

Demographic Characteristics of Fellows
These fellows reported a mean (± SD) of 2.4 ± 0.7 years of fellowship training, during which they estimated that they had performed 77.7 ± 34 bronchoscopies per year. The range of their estimates of procedures reported is shown in Figure 1 . Seven fellows reported performing > 100 procedures/yr, whereas 8 performed < 50.



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  		Figure 1.. Fellows’ estimates of the numbers of bronchoscopies they performed annually.

 
Fellows graded their own bronchoscopy proficiency as 7.3 ± 1.4 on a 10-point scale, and graded the quality of their bronchoscopy training experiences as 7.6 ± 1.8 on the same scale. Self-estimates of proficiency correlated with the number of procedures cited annually (r = 0.43, p = 0.001) or the number of years of fellowship (r = 0.40, p = 0.002). Proficiency ratings (r = 0.63, p = 0.0001) and the annual number of procedures (r = 0.45, p = 0.0004) also correlated with fellows’ ratings of program quality.

Approaches to Bronchoscopy Instruction
Components of bronchoscopy instruction reported by fellows are summarized in Table 1 . One-on-one instruction provided by faculty was the most common approach to training, often supplemented by lecture-based instruction and case discussions. Fifty-six of 58 fellows (97%) reported that a faculty member was present at each bronchoscopy. Use of bronchoscopy lectures (n = 44) in the curriculum was associated with higher self-estimates of proficiency (7.6 ± 1.0 vs 6.2 ± 2.0, p = 0.008). Fellows whose programs incorporated review of bronchoscopy videos (n = 18) tended to have higher proficiency estimates (7.8 ± 0.9 vs 7.0 ± 1.6, p = 0.057). Several approaches to instruction were associated with more highly ranked training programs. These included the use of bronchoscopy lectures (p = 0.002), a bronchoscopy text (p = 0.009), and one-on-one instruction from faculty (p = 0.05).


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  		Table 1.. General Approaches to Bronchoscopy Instruction

 
Major Components of Bronchoscopy Experience
Major components of fellows’ bronchoscopy experiences are summarized in Table 2 . Most (> 80%) fellows reported that they had received instruction in techniques of local airway anesthesia and conscious sedation, airway inspection, BAL, and biopsy of endobronchial or parenchymal disease. Fewer had received instruction in bronchoscopic methods of intubation, TBNA, or quantitative bacterial cultures. The majority of fellows had no experience with interventional procedures such as stent placement, laser photocoagulation, and cryotherapy.


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  		Table 2.. Components of Fellows’ Self-Reported Bronchoscopy Experiences

 
The relationships of fellows’ estimates of their own proficiency and the quality of their training programs to specific elements of their bronchoscopy experience are summarized in Table 3 . Forceps biopsy of patients with diffuse disease, TBNA, BAL, and performance of bronchoscopic quantitative cultures were associated with higher estimates of both bronchoscopy proficiency and training program quality. In addition, performance of laser bronchoscopy correlated with bronchoscopy proficiency, whereas instruction in bronchoscopic intubation correlated with higher ratings of program quality. Experience with stent placement and laser bronchoscopy tended to be components of more highly graded programs. The small number of programs providing such interventional experiences limited these analyses.


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  		Table 3.. Factors Associated With Higher Fellow Self-Estimates of Bronchoscopy Proficiency and Training Program Quality*

 

   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Despite its increasing availability, the diversity of its clinical applications, and more complex technical nuances to the procedure, it has been more than a decade since guidelines for competency and training in bronchoscopy have been addressed.3 4 To our knowledge, this represents the first report of pulmonary and critical care fellows’ perspectives about their bronchoscopy training. Several limitations of this experience must first be acknowledged. One inherent concern relates to selection bias. Although the number of reporting fellows was relatively small, these were generally upper-level trainees chosen by their program directors to represent diverse institutions across the United States. We believe that this factor, together with the general format of the American College of Chest Physicians Fellows’ Course, makes it likely that these observations are representative of the current status of bronchoscopy training. The subjectivity of responses and reliance on fellows’ recollections of their bronchoscopy experiences might introduce inaccuracies, but the verbal communications that fellows provided to faculty as they moved from one station to another were consistent with their characterization of training experiences noted in survey responses. We believe that the context of the survey, administered during a hands-on course with opportunity for direct, close interaction with faculty, was important. However, because the survey was abbreviated purposefully to accommodate the time constraints of the hands-on session, the list of multiple-choice options regarding either curricular components or bronchoscopy skills was necessarily incomplete. Other approaches toward instruction or elements of clinical experiences not addressed by the survey might also be important in defining an optimum curriculum. We did not characterize fellows’ home institutions or appraise the availability of faculty members with particular interests and expertise in bronchology. Despite these limitations, we believe the current survey provided reliable insights about general elements of fellows’ bronchoscopy experience, but more detailed information is needed regarding its quality, the intensity of faculty input, and specific aspects of monitoring performance and feedback. Such dimensions of bronchoscopy training are especially important to identify objectively opportunities for improvement.

Efforts have been made to define the appropriateness of bronchoscopy training in terms of an overall number of procedures, but it should be appreciated that qualitative aspects of these experiences are of fundamental importance. Estimates of the number of procedures varied widely among these fellows. It has been proposed that 50 procedures be used as one benchmark of an appropriate experience; 13% of these fellows reported they had performed fewer than this threshold. It is interesting that the number of bronchoscopy procedures reported by these fellows correlated with their self-estimates of proficiency and their overall views of their training programs. We did not appraise the settings in which fellows performed bronchoscopy or the clinical indications for these procedures. Not surprisingly, their anecdotal descriptions suggested substantial variations among institutions. Whereas some reported a balanced exposure to diverse applications of bronchoscopy, others noted disproportionate emphasis on some areas, differing with the nature of clinical programs and patient populations (eg, frequent performance of BAL in immunocompromised patients, transbronchial biopsies in transplant patients, ICU bronchoscopies). The optimum, comprehensive bronchoscopy experience requires clarification.

Approaches to the enhancement of bronchoscopy instruction and monitoring of bronchoscopy competency have been described previously,10 11 12 13 14 15 and innovative models of airways have been designed for particular training in interventional procedures and other special circumstances.16 17 18 19 20 For these fellows, the personal instruction provided by faculty was the most consistent positive element of bronchoscopy training and was associated with more highly graded programs. These interactions were most often supplemented by lectures and case discussions. The relatively lower frequencies with which bronchoscopy textbooks, experience with lung models, and review of videos were used were somewhat surprising given the current availability of such excellent resources. Videos (perhaps reviewed with a faculty mentor) would appear to be an underutilized opportunity for instruction, particularly with the increasing availability of video bronchoscopes. Interestingly, fellows’ impressions about their experiences using a prototype bronchoscopy simulator were uniformly high. The roles of this and other innovative approaches to instruction and monitoring of performance merit further investigation. One-third of respondents noted the positive impact of other fellows on their training; the potential value of such input from peers should not be minimized. Many communicated that a group effort of fellows had important influences on local faculty in modifying the modes and content of the bronchoscopy curriculum.

We found the very consistent emphasis of programs on individualized instruction by faculty and the presence of faculty at all procedures, together with the widespread availability of basic bronchoscopy at the majority of programs to be very encouraging. On the other hand, the heterogeneity of these fellows’ experiences, with a lack of exposure to many recently developed applications of bronchoscopy, raises fundamental questions regarding the expected proficiencies of a pulmonologist, and the content of an ideal core curriculum. The lack of experience of nearly a third of the fellows in bronchoscopic intubation methods is noteworthy, and undoubtedly reflects the usual performance of most flexible procedures transnasally, without an artificial airway. We believe this element of airway management represents an important element of not only bronchoscopy, but also of critical care training, and needs to be available more uniformly. The slightly lower frequency of forceps biopsy of pulmonary nodules cited most likely reflects local strategies toward these patients, with preferences for a percutaneous needle approach by radiologists at many institutions. It might also reflect a management strategy for patients with pulmonary nodules that are suspected to be malignant that bypasses bronchoscopy in favor of proceeding directly to a thoracotomy. The lower frequencies of TBNA and quantitative bacterial cultures at many programs probably reflect philosophical reservations about these procedures, as well as their particular reliance on appropriate cytopathology and microbiology laboratory support. As noted previously, many current experienced pulmonary faculty and practicing pulmonologists do not perform TBNA consistently.21 22 23 24 Course faculty observed a general unfamiliarity of most fellows with techniques presented at interventional stations, a finding consistent with fellows’ self-reports of a relative lack of exposure to these aspects of bronchoscopy. At most (70%) programs described by these fellows, stent placement, laser bronchoscopy, or cryotherapy are not included in the bronchoscopy curriculum.

One clear, although unquantified, message from this aspect of the American College of Chest Physicians Fellows’ Course merits special emphasis. The high grade fellows assigned to the quality and clinical relevance of the hands-on stations, the interest and enthusiasm communicated during this experience, and fellows’ commentary to faculty about the relative strengths and weaknesses of their own bronchoscopy training programs indicated a further need for both prioritization of the bronchoscopy curriculum and an objective appraisal of its optimum components and outcomes. From these interactions with fellows, it seemed clear that they value their bronchoscopy skills and view them as an important aspect of their roles (and, to a degree, even their identities) as pulmonologists. The generally high grades they assigned to their training programs and to their bronchoscopy skills are consistent with this subjective impression. However, the relationships of these fellows’ ratings of their own bronchoscopy proficiency and the quality of their training programs to objective measures are unknown. Moreover, what measures would most optimally benefit fellows, their training programs, and, ultimately the patients they serve, has never been defined.

Although admittedly difficult to achieve, we believe that an effort to appraise and enhance the quality of bronchoscopy training is necessary. Unfortunately, there is a paucity of data to document whether a major problem with bronchoscopy training truly exists or whether patient outcomes can be improved substantially by widespread improvement in training programs. The lack of objectively validated guidelines defining the skills a current bronchoscopist should possess makes it difficult to convince any program director that this effort would be worth the time and resources necessary. Institutional differences in the availability of faculty with advanced bronchoscopy expertise, together with variations in manual dexterity, hand-eye coordination, levels of interest in bronchology, and other factors among fellows, all add to the challenges of curricular development. As with other educational interventions, promoting meaningful behavioral change on the part of physicians, rather than mere transmission of knowledge, poses major challenges. We believe that the potential benefits for fellows and their patients merits such an effort.


   Acknowledgements
 
The writers thank the ACCP staff and sponsors of the Fifth Annual Fellows Course for their dedicated support of the hands-on program, and Ms. Debbie Belcastro for her assistance in preparation of this manuscript.


   Footnotes
 
Abbreviation: TBNA = transbronchial needle aspiration

Received for publication November 4, 1999. Accepted for publication April 18, 2000.


   References
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 Materials and Methods
 Results
 Discussion
 References
 

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