Dabscheck, Eli J. MBBS, M Clin Epi, FRACP*; Hew, Mark MBBS, PhD, FRACP*; Irving, Louis MBBS, FRACP†; Steinfort, Daniel MBBS, PhD, FRACP†
Bronchoscopy is frequently performed for a variety of indications including suspected infection, hemoptysis, and central airway and peripheral parenchymal lesions.1–3 The procedure is associated with very low complication rates, although the spectrum of complications is evolving due to the greater complexity of new diagnostic techniques.4–7 Specialist societies have published training recommendations to ensure clinicians acquire and maintain the skills to perform these procedures safely.8,9 In 2001 the Thoracic Society of Australia and New Zealand (TSANZ) published a position paper on standard bronchoscopy10 that included recommendations on acquiring and maintaining competency based on procedural volume alone. More recently the TSANZ has also published clinical practice guidelines for advanced interventional pulmonary procedures, which also recommend stipulated procedural volumes for specific techniques.11 Importantly, these assume competence in standard bronchoscopy.
Unlike other procedural medical specialties, one of the central responsibilities of Respiratory Societies worldwide is to ensure a high quality of bronchoscopic training and practice. Minimal published literature is available regarding the adequacy of training and practice with respect to the published guidelines. Australian New Zealand Respiratory Physicians do not undertake a dedicated certification process for bronchoscopy. It is unknown whether the practice of bronchoscopy in the region is in alignment with the recommendations, as no previous evaluation of bronchoscopic practice or training has ever been undertaken.
We conducted a survey directed toward the Thoracic Physicians and trainees in Australia and New Zealand, to assess the degree of adherence to procedural volumes recommended to achieve and maintain competency for both standard bronchoscopy, conventional transbronchial needle aspiration (TBNA), and endobronchial ultrasound (EBUS)-TBNA.
An e-mail survey was conducted through the kind cooperation of the TSANZ, which represents thoracic physicians in Australia and New Zealand. All adult physician members of the society and trainees were e-mailed a web-link to the survey (see Supplemental Digital Content 1, http://links.lww.com/LBR/A110) on 3 separate occasions between October 28th and December 15, 2009. The survey was closed after 3 months. Institutional ethics approval was waived as no patients were involved and the survey was anonymous.
The survey invited responses on the clinicians’ scope of practice, availability of TBNA, and EBUS-TBNA. Respondents were asked to estimate the number of procedures performed over the previous 12 months.
Survey responses were then benchmarked against the Australasian bronchoscopy guidelines described above. Where no TSANZ guidance exists, results were benchmarked against international guidelines (Tables 1, 2).8–11,13
We received 217 responses out of a total of 517 specialists and advanced trainees (pulmonary fellows) practicing adult thoracic medicine in Australia and New Zealand on the TSANZ roll (42% response rate). The response from trainees alone was higher at 78% (45 from a total of 58 trainees). Eight responses were incomplete and not included in the final analysis. Seventy-nine percent (164) of respondents were consultants, the majority of whom were based at tertiary metropolitan hospitals. Twenty-one percent (45) of respondents were trainees. Results are summarized, and benchmarked against TSANZ guidelines (Tables 1, 2).
The 2001 TSANZ position paper recommends a minimum of 200 fiberoptic bronchoscopies be performed during training. Core training in thoracic medicine is generally undertaken over 2 years; therefore trainees would need to perform >100 procedures per year to comply with this recommendation. However, 70% of trainees surveyed reported performing <100 procedures per year.
For consultants, the TSANZ position paper recommends that, “ideally, 50 procedures should be carried out annually to maintain competency, but 20 procedures per year is the minimum standard required to maintain necessary skills.” In our survey, 49% of thoracic physicians’ surveyed report performing less than the ideal 50 procedures per year and 23% reported performing <20 bronchoscopies per year.
The TSANZ recommends that “for bronchoscopists involved in teaching trainees, 20 procedures per year should be the minimum standard.” Although we did not specifically ask consultants whether they supervised trainees, 24% of tertiary hospital consultants (who are most likely to supervise trainees) reported performing less than the minimum standard for supervisors of 20 procedures per year.
According to the European Respiratory Society/American Thoracic Society statement on interventional pulmonology, it is recommended that trainees are supervised performing at least 25 conventional TBNA.13 Again assuming a core training period of 2 years, trainees would need to perform >10 procedures per year to achieve competency. Our results show that while 54% of trainees report training in conventional TBNA, 89% report performing <10 per year.
No mention is made about the number needed to perform to maintain competency in the ATS/ERS guidelines. The American College of Chest Physicians Interventional Guidelines suggest that a minimum of 10 procedures per year be performed to maintain competency.8 Sixty-seven percent of survey respondents who perform conventional TBNA report performing <10 procedures per year.
The 2012 TSANZ guidelines recommend that 20 procedures be performed under supervision during training. Our results show that while 26% of trainees reported exposure to EBUS-TBNA training, 79% report performing <10 per year.
Seventeen percent of consultants report that they were trained in EBUS-TBNA and 12% of consultants report performing EBUS-TBNA in the previous 12 months. The TSANZ guidelines recommends that 20 EBUS procedures per year should be performed to maintain competency.11 Of those respondents performing EBUS-TBNA, 58% report performing <20 procedures per year.
Bronchoscopy is an essential skill in the field of thoracic medicine. Indeed, as has been previously noted, subspecialty procedures form more than an integral component of that subspecialty’s overall expertise and skill set; they form a part of its identity.14 Consequently one of the profession’s responsibilities is to ensure that these procedures are conducted at the highest possible standard. Competence in conventional bronchoscopy is currently assumed at the completion of Thoracic Medicine core training, by the Royal Australasian College of Physicians, based on the expectation that trainees have completed a minimum of 200 procedures, notwithstanding the known limitations of volume-based competency.12,15,16 However, it is unclear whether existing training positions are able to deliver this number of procedures. For more advanced bronchoscopic techniques, which are often limited to a minority of centers, this assumption may be even more tenuous.
Our survey has identified significant gaps between bronchoscopy position statement recommendations of the TSANZ and the real-life practice of bronchoscopy in Australia and New Zealand. On the basis of our results, for standard bronchoscopy, over two thirds of trainees would fail to meet guidelines to achieve competency if undertaking a 2-year core training program. The authors acknowledge that many trainees are likely to be involved in bronchoscopic procedures during their noncore rotations— see the Limitations section. The number of procedures a trainee performs is likely to vary between institutions and from year to year, as described in Northern Hemisphere jurisdictions.14,17–19 It seems likely that some trainees will finish their training without achieving the recommended 200 procedures, and an even greater number will finish training without adequate training in advanced bronchoscopic techniques.
Among consultants, only half of the consultants are reported performing the ideal number of 50 procedures per year recommended to maintain competency. This is in sharp contrast to a 1991 survey of physician members of the American College of Chest Physicians in which 82% of respondents performed >50 bronchoscopies per year20 and a 2002 survey of consultant members of the British Thoracic Society in which an impressive 88% of respondents performed >100 bronchoscopies per year9 (Table 2).
For advanced bronchoscopy, only a small minority of trainees reported performing an adequate number of supervised EBUS-TBNA. Most consultants currently performing EBUS-TBNA are not, according to the new TSANZ recommendations, performing sufficient numbers to maintain competency. This is concerning, given that these minimally invasive techniques are safer and less costly than surgical options and that EBUS-TBNA is now the investigation of choice among respiratory physicians21 for the investigation of mediastinal lymphadenopathy, with proven utility in numerous clinical situations.22–24
The issues of defining and assessing procedural competence are difficult and contentious. Our data clearly demonstrate that some trainees and consultants will fall short of previous volume-based recommendations designed to reflect competency. One possible response is to implement policies to increase procedural volumes for bronchoscopists, but in the Australian setting such moves are likely to be impractical, and, in the light of recent data, fundamentally flawed.12,15
Even if increasing procedure numbers is not possible, better monitoring of current procedural numbers should be strongly considered. Introduction of a logbook interview at the end of training could be considered, as with other specialist faculties within the Royal Australian College of Physicians (RACP) that mandate submission of logbooks before physicians are considered “credentialed” to perform procedures.25 Consultants who perform either standard or advanced bronchoscopy might also be encouraged or prompted to perform the minimal acceptable number of procedures per year by incorporating an electronic logbook into the current framework of continuing professional development maintained by the Royal Australasian College of Physicians.
We believe a more considered approach would be to move beyond using “numbers” as the sole arbiter of competency. The 2012 TSANZ advanced interventional guidelines address this issue by stipulating requisite prior experience and knowledge as well as audit and safety goals.11 Other respiratory societies have embraced “competency-based training.” The 2011 British Thoracic Society guidelines for advanced flexible bronchoscopy do not quote specific numbers of procedures required to achieve competency, instead recognizing that “Individuals have different learning curves and hence focus should be towards monitoring an individual’s performance and outcomes.”26 A detailed discussion of potential strategies is beyond the scope of this article, but may include bronchoscopic simulation,12,27,28 directly observed procedures (as piloted by the RACP), mandatory e-modules,28 or formal assessment at the completion of training.29
Any framework for trainees to achieve competency (such as simulation or e-learning modules) would ideally also be accessible to consultants wishing to maintain competency in the face of limited procedure numbers.
For advanced bronchoscopy, the total number of procedures is likely to remain relatively low and it is unrealistic to expect all trainees in thoracic medicine to achieve competency in advanced interventional bronchoscopy.11 More novel diagnostic (eg, electromagnetic navigation bronchoscopy, cryoprobe biopsy) and therapeutic (eg, lung volume reduction, bronchial thermoplasty) bronchoscopic interventions are likely to be even smaller volume procedures than EBUS. An ACCP Steering Committee has previously suggested an extra year of fellowship in interventional pulmonology to achieve procedural volumes. The future of interventional bronchoscopy may resemble the current scene of interventional cardiology, with interested trainees undertaking further specialized training in their elective year. Such changes are, within our own specialty, analogous to recent developments requiring dedicated training in Sleep Medicine. These “interventional fellows” may require accreditation in similar manner to interventional cardiologists.18
Performance of bronchoscopy by trainees is associated with longer procedure times, reduced patient comfort, and possibly increased complication rates.30 This further emphasizes the importance of structured (rather than ad-hoc) teaching to ensure the learning curve is as short as possible, and the burden to patients is minimized and not without longer term value. In-line with the 2012 TSANZ advanced interventional guidelines, we suggest that the increasing complexity of advanced bronchoscopy will require a more rigorous and structured training program to ensure all necessary skills, both procedural and cognitive are acquired during training.11 Strong consideration should also be given to formal accreditation of training sites, based on bronchoscopy volume and complexity.
Finally, it should be acknowledged that bronchoscopy training is likely to be adequate for a majority of trainees, and that self-appraisal is likely to see physicians who have not maintained competence voluntarily excluding themselves from such activity. Nevertheless, one of the professional responsibilities of the TSANZ is to ensure the practice of bronchoscopy is maintained at a high level through the current period of expansion in both trainee numbers and procedural complexity.
Our survey results are the only current source of bronchoscopy data in Australasia, though we do recognize some limitations of our findings. Response rates among respiratory trainees are very high indicating this is very likely an accurate description of training, and training deficiencies. The overall response rate, at 42%, is slightly limited but is consistent with other surveys of bronchoscopic practice.9,20,31,32 There may be some selection and recall bias. However, we suggest that respondents with an interest in bronchoscopy would be more likely to respond than others, and that proportions of physicians achieving TSANZ benchmark targets is likely to be even lower than noted in this study. Our findings highlight all the more the pressing need to capture ongoing practice patterns in a systematic manner. The authors acknowledge that some trainees perform bronchoscopy during their noncore year of respiratory medicine training that could have an impact on the assumptions made in determining total number of supervised procedures. However, our experience within the Victorian system is that the majority of trainees are not performing bronchoscopy during their noncore year particularly with the recent changes to sleep medicine training.
Current bronchoscopy practice in Australia and New Zealand likely falls short of guideline recommendations published by the TSANZ. Some trainees may not be meeting current procedural volume requirements for bronchoscopic training. A small minority of consultants may be failing to perform the minimum acceptable number of procedures, as suggested by published TSANZ guidelines.
Given the best tools to achieve and assess competency are not known, the significance of these findings remains unclear. We suggest that the 2001 TSANZ position paper should be reviewed, and that the TSANZ consider a review of procedure volumes at all accredited training sites, as well as consider the implementation of a structured training and credentialing program for advanced bronchoscopic procedures. We support the 2012 TSANZ guidelines for interventional pulmonology assertion that procedural training should not focus solely on volume and suggest that alternatives to the current “volume-based” approach to achieving and maintaining of competence should be considered across all areas of bronchoscopy.30
1. van der Eerden MM, Vlaspolder F, de Graaff CS, et al..Value of intensive diagnostic microbiological investigation in low- and high-risk patients with community-acquired pneumonia.Eur J Clin Microbiol Infect Dis.2005;24:241–249.
2. Tan BB, Flaherty KR, Kazerooni EA, et al..The solitary pulmonary nodule.Chest.2003;123:89S–96S.
3. Karmy-Jones R, Cuschieri J, Vallieres E.Role of bronchoscopy in massive hemoptysis.Chest Surg Clin N Am.2001;11:873–906.
4. Asano F, Aoe M, Ohsaki Y, et al..Deaths and complications associated with respiratory endoscopy: a survey by the Japan Society for Respiratory Endoscopy in 2010.Respirology.2012;17:478–485.
5. Steinfort DP, Johnson DF, Irving LB.Infective complications from endobronchial ultrasound-transbronchial needle aspiration.Eur Respir J.2009;34:524–525author reply 525.
6. Botana-Rial M, Nunez-Delgado M, Pallares-Sanmartin A, et al..Intramural hematoma of the pulmonary artery and hemopneumomediastinum after endobronchial ultrasound-guided transbronchial needle aspiration.Respiration.2012;83:353–356.
7. Steinfort DP, Herth FJ, Eberhardt R, et al..Potentially fatal arrhythmia complicating endobronchial epinephrine for control of iatrogenic bleeding.Am J Respir Crit Care Med.2012;185:1028–1030.
8. Ernst A, Silvestri GA, Johnstone D.Interventional pulmonary procedures: guidelines from the American College of Chest Physicians.Chest.2003;123:1693–1717.
9. Smyth CM, Stead RJ.Survey of flexible fibreoptic bronchoscopy in the United Kingdom.Eur Respir J.2002;19:458–463.
10. Wood-Baker R, Burdon J, McGregor A, et al..Fibre-optic bronchoscopy in adults: a position paper of The Thoracic Society of Australia and New Zealand.Intern Med J.2001;31:479–487.
11. Fielding D, Phillips M, Robinson P, et al..Advanced interventional pulmonology procedures: training guidelines from the Thoracic Society of Australia and New Zealand.Respirology.2012;17:1176–1189.
12. Stather DR, Maceachern P, Rimmer K, et al..Assessment and learning curve evaluation of endobronchial ultrasound skills following simulation and clinical training.Respirology.2011;16:698–704.
13. Bolliger CT, Mathur PN, Beamis JF, et al..ERS/ATS statement on interventional pulmonology. European Respiratory Society/American Thoracic Society.Eur Respir J.2002;19:356–373.
14. Stather DR, Jarand J, Silvestri GA, et al..An evaluation of procedural training in Canadian respirology fellowship programs: program directors’ and fellows’ perspectives.Can Respir J.2009;16:55–59.
15. Kemp SV, El Batrawy SH, Harrison RN, et al..Learning curves for endobronchial ultrasound using cusum analysis.Thorax.2010;65:534–538.
16. Du Rand IA, Barber PV, Goldring J, et al..British Thoracic Society guideline for advanced diagnostic and therapeutic flexible bronchoscopy in adults.Thorax.2011;66suppl 3iii1–21.
17. Haponik EF, Russell GB, Beamis JF Jr, et al..Bronchoscopy training: current fellows’ experiences and some concerns for the future.Chest.2000;118:625–630.
18. Pastis NJ, Nietert PJ, Silvestri GA.Variation in training for interventional pulmonary procedures among US pulmonary/critical care fellowships: a survey of fellowship directors.Chest.2005;127:1614–1621.
19. Tanner NT, Pastis NJ, Silvestri GA.Training for linear endobronchial ultrasound among US Pulmonary/Critical Care fellowships: a survey of fellowship directors.Chest.2013;143:423–428.
20. Prakash UB, Offord KP, Stubbs SE.Bronchoscopy in North America: the ACCP survey.Chest.1991;100:1668–1675.
21. Dabscheck EJ, Steinfort DP, Irving LB, et al..Mediastinal staging of non-small-cell lung cancer among Australasian thoracic physicians: clinical practice and constraints on minimally invasive techniques.Intern Med J.2012;42:627–633.
22. Steinfort DP, Hew MJ, Irving LB.Bronchoscopic evaluation of the mediastinum using endobronchial ultrasound—a description of the first 216 cases performed at an Australian tertiary hospital.Intern Med J.2011;41:815–824.
23. Steinfort DP, Johnson DF, Connell TG, et al..Endobronchial ultrasound-guided biopsy in the evaluation of intrathoracic lymphadenopathy in suspected tuberculosis: a minimally invasive technique with a high diagnostic yield.J Infect.2009;58:309–311.
24. Steinfort DP, Conron M, Tsui A, et al..Endobronchial ultrasound-guided transbronchial needle aspiration for the evaluation of suspected lymphoma.J Thorac Oncol.2010;5:804–809.
26. Du Rand IA, Barber PV, Goldring J, et al..Summary of the British Thoracic Society Guidelines for advanced diagnostic and therapeutic flexible bronchoscopy in adults.Thorax.2011;66:1014–1015.
27. Davoudi M, Colt HG.Bronchoscopy simulation: a brief review.Adv Health Sci Educ Theory Pract.2009;14:287–296.
28. Wahidi MM, Silvestri GA, Coakley RD, et al..A prospective multicenter study of competency metrics and educational interventions in the learning of bronchoscopy among new pulmonary fellows.Chest.2010;137:1040–1049.
29. Konge L, Larsen KR, Clementsen P, et al..Reliable and valid assessment of clinical bronchoscopy performance.Respiration.2012;83:53–60.
30. Stather DR, Maceachern P, Chee A, et al..Trainee impact on advanced diagnostic bronchoscopy: an analysis of 607 consecutive procedures in an interventional pulmonary practice.Respirology.2013;18:179–184.
31. Pierce CW, Gjevre JA, Taylor-Gjevre RM.A survey of current bronchoscopy practices in Canada: a dearth of evidence or evidence-based practice?Chest.2011;140:833–834.
32. Colt HG, Beamis JJ, Harrell JH, et al..Novel flexible bronchoscope and single-use disposable-sheath endoscope system. A preliminary technology evaluation.Chest.2000;118:183–187.
© 2014 by Lippincott Williams & Wilkins.