The article by Madkour and colleagues1 is an important step toward modifying bronchoscopic practice in Egypt. In a 50-question anonymous survey of 75/87 (86% returned responses) bronchoscopists practicing in 15 major centers, the investigators identified local bias and practices that might be addressed during future educational efforts aimed at standardizing the way flexible bronchoscopy is performed in Cairo. In this regard, the authors join investigators from the United States, Great Britain, India, Poland, Japan, and Brazil1–7 among others in surveying their country's bronchoscopic practices.
Most bronchoscopic practices are not right or wrong. In fact, one may even choose, based on eminence versus evidence-based medicine, to select a practice pattern that is contrary to one that might be justified by results from scientific investigations. Examples of such practices are the routine ordering of arterial blood gases, or the routine administration of antisialogues such as atropine. Both of these practices have been shown to be unnecessary, yet, in Egypt, 37% of respondents routinely ordered arterial blood gases and 88% of physicians surveyed administered antisialogues. One might expect, however, that additional education and training focused on raising awareness about the results of bronchology-related scientific investigations would prompt a change in practice.
Other findings from the survey justify the implementation of a structured curriculum in flexible bronchoscopy education. Despite a serving population of more than 14 million, less than 6000 procedures were actually performed during the 12-month period of the study. The bulk of bronchoscopic practice was limited to 55% of those surveyed, who performed on average well below 100 procedures each year. In addition, procedures such as transbronchial needle aspiration and transbronchial lung biopsy were infrequently performed, with only 28% and 63%, respectively, of bronchoscopists surveyed stating that they had performed such procedures in the preceding 12 months. Although these results reflect insufficient access to accessory instruments, they might also be a sign that additional training is warranted to improve physician comfort and competency in using these techniques.
Three other findings of the survey warrant, I believe, some editorial comments. The first pertains to conscious sedation, administered by at least 80% of physicians surveyed. This practice included, for the most part, the use of benzodiazepines alone. The survey discovered, however, that in almost half of the bronchoscopy units, sedative antagonists were not readily available, and that less than half the bronchoscopists had access to 2 bronchoscopy assistants. Conventional wisdom suggests that patient safety is best assured when bronchoscopy is performed using 2 assistants; one who helps with instrument manipulation, whereas the other assures patient monitoring, comfort, and medication administration. In addition, having additional assistants might improve response to complications.
In Egypt, I am told that written informed consent is not a legal mandate, and thus, it is natural that although all bronchoscopists verbally explained the risks and benefits of the procedure to their patients, only 15% actually used a written form. However, evidence of a signed written consent helps assure that all the elements of informed consent, including discussion of diagnostic and therapeutic alternatives, consequences of refusal, assessment of patient understanding, and identification of patient preferences are addressed.
Finally, results from this survey demonstrate that 29% of responding bronchoscopists had performed electrocautery, cryotherapy, argon plasma coagulation, laser resection, or endobronchial ultrasound procedures during the period of the study. Although some may feel that this is a small number, it is reasonable to expect that tertiary care bronchoscopic interventions be concentrated among a small group of practitioners to assure that sufficient numbers of procedures are performed to maintain a high level of competence.
Interventional courses and workshops have occurred regularly for many years in Egypt with invitations to many of the world's experts in these areas. Procedural-related training strategies should perhaps result from a needs assessment within different communities to identify areas where additional training will be beneficial. Building on a foundation of local competency, it may be possible to recruit a group of experienced Egyptian bronchoscopists to help educate others using this learner-based approach. Using such a structured curriculum, Bronchoscopy International and the World Bronchology Foundation have provided educational experiences adapted to specific needs in countries such as India, Vietnam, Argentina, and the United States.
In conclusion, this well performed survey of bronchoscopic practice in Cairo should serve as an example to investigators from other nations interested in identifying national biases and practices. Results justify assistance in developing structured educational programs with the help of international educators and local experienced bronchoscopists. Working together in a coordinated fashion will help raise awareness about the art and science of flexible bronchoscopy among trainees and physicians-in-practice. Such curricula will assist practitioners gain experience in the 4 major elements of procedure-related decision making; strategy and planning, execution, and response to procedure-related complications. It will also help bronchoscopists develop the decision-making skills, intent, technical control and confidence necessary to assure patient safety, and procedural competence.
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