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Simulation in Flexible Bronchoscopy and Endobronchial Ultrasound: A Review

Stather, David Ryan MD, FRCPC, FCCP*; Lamb, Carla R. MD, FCCP; Tremblay, Alain MDCM, FRCPC, FCCP*

Journal of Bronchology & Interventional Pulmonology: July 2011 - Volume 18 - Issue 3 - p 247–256
doi: 10.1097/LBR.0b013e3182296588
Review Article

Flexible bronchoscopy is a widely used medical procedure performed by a variety of specialists. Learning flexible bronchoscopy in a clinical setting is associated with increased learner anxiety, introduces significant variability into the learning experience, and increases complications placing the burden of learning on the patients. Bronchoscopy simulation involves the use of inanimate models, wet lab models, or computerized virtual reality simulators to teach and evaluate bronchoscopy skills, with the advantage of standardization of the teaching and assessment techniques without risk to the patient. The aim of this study is to provide a review of the major evidence supporting the use of bronchoscopy simulation to date and to identify limitations in the literature to stimulate further research incorporating these exciting teaching modalities.

*Department of Medicine, University of Calgary, Calgary, Alberta, Canada

Department of Pulmonary and Critical Care, Lahey Clinic, Burlington, MA

The University of Calgary has received grants from Olympus Canada for support of an Interventional Pulmonary Medicine Training Program and for CME events relating to EBUS.

The University of Calgary has received support in kind from CAE Health for a CME event relating to EBUS.

The Lahey Clinic has received educational grants from Olympus for support of CME Interventional Pulmonary Training Courses.

Disclosure: The authors have no conflict of interest.

Reprints: David R. Stather, MD, FRCPC, FCCP, Division of Respiratory Medicine, Health Sciences Center, 3330 Hospital Dr NW, Calgary, AB Canada T2N 4N1 (e-mail:

Received June 14, 2011

Accepted June 15, 2011

Flexible bronchoscopy is a widely used essential pulmonary procedure performed by a variety of specialists and for a myriad of indications. Indications for flexible bronchoscopy include airway inspection and diagnostic procedures by pulmonologists, difficult airway management by anesthesiologists and critical care physicians, and advanced pulmonary diagnostic and therapeutic techniques used by interventional pulmonologists and thoracic surgeons. The need to train physicians in bronchoscopy is an important component of residency and fellowship training programs.

Historically, the apprenticeship model has been used to teach trainees how to perform flexible bronchoscopy through practice on patients, often referred to as the “see one, do one, teach one” approach. Not only does this training model induce learner anxiety1 but trainees also receive different experiences depending on the particular patients and preceptors they encounter. Leaving the training experience to chance introduces significant variability in the training2–6 and can result in some physicians being inadequately trained in basic procedural skills.6,7 Although generally considered to be a safe procedure, bronchoscopy can be associated with severe complications, including respiratory failure and death.8–10 The presence of trainees during bronchoscopy may lead to increased complications11,12 placing the burden of procedure training on our patients by impacting comfort and safety. In addition, nondiagnostic procedures resulting in the need for “repeat” procedures may also be considered a specific complication in the training environment.

As new techniques are developed, the practicing physician is faced with learning new skills without the opportunity or time for dedicated training or proctored procedures that have clearly defined learning objectives. Linear endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) is a technique that is rapidly changing the bronchoscopic diagnosis of many chest diseases13,14 but can be challenging to learn, even for experienced bronchoscopists.15–17 Demand for training is high and may be ideally suited to simulator programs, which often form a component of many EBUS-TBNA continuing medical education (CME) courses.18 These physicians then need to convince their colleagues, administrators, and ultimately patients that they are qualified to perform a new procedure, yet another potential role for simulators.

Simulation-based training for a variety of surgical and medical procedures has been demonstrated to be effective, cost-effective, and to increase patient comfort and safety.19–23 The availability of bronchoscopy simulators may address some of the limitations of the traditional model and moves us away from practicing on patients. This review aims to describe current simulator models for bronchoscopy, to summarize the literature on their use, and to propose optimal methods to integrate simulation training in academic programs, CME events, and in the credentialing process for physicians.

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Low-fidelity Simulation

Low-fidelity simulation uses inanimate mechanical airway models, into which actual bronchoscopes can be inserted and bronchoscopy skills can be practiced (Fig. 1). Advantages of low-fidelity simulation include low cost and the ability to use standard bronchoscope equipment. Disadvantages include decreased realism and potential for bronchoscope damage.



Silicone-based and plastic-based models, such as the Laerdal Airway Management Trainer (Laerdal, Stavanger, Norway) and the Life/form “Airway Larry” (Nasco, Fort Atkinson, WI), consist of a head, upper airway, larynx, and basic tracheobronchial tree. These models can be used for performing laryngotracheal intubation and airway management exercises including bronchoscopy-guided endotracheal intubation. The CLA Broncho Boy (CLA, Coburg, Germany) also has a torso and a detailed tracheobronchial tree (to the level of the first segmental bronchi) and can be used for learning and evaluating rigid bronchoscopy skills.24 Descriptions of different “home-made” inanimate airway models using materials readily available from arts and crafts stores are plentiful on the Internet. A description of one such model using paper mache-like material to create an anatomically accurate tracheobronchial tree has been published.25

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Wet Lab Simulation

Many institutions have used animal models for airway management courses, bronchoscopy CME courses [for EBUS and interventional pulmonary (IP) techniques], and during pulmonary and IP fellowship training. Advantages of wet lab models over computer models include increased realism and the ability of learners to use the actual bronchoscopy equipment26; however, even though wet lab simulation and inanimate models are regularly used in many CME courses, there have been no published studies evaluating the efficacy of these teaching models. Disadvantages of the wet lab models are the ethical issues associated with the use of animals for research and education, the cost of the highly trained personnel required to ensure safe and humane handling of the animals, and the potential for damage to the expensive bronchoscopes.

There are no publications comparing wet lab simulation with high-fidelity and low-fidelity simulation for bronchoscopy training. It is therefore difficult to know the true advantages or disadvantages of this method for learning bronchoscopy. Despite the ethical concerns regarding wet lab simulation, many proponents of wet lab simulation state that the realism is unmatched with current low-fidelity and high-fidelity systems. Clearly, more research is needed in this area.

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High-fidelity Simulation

A computer-based bronchoscopy simulator that could be used for bronchoscopy training was first described in 1999.27 This “PreOP Endoscopy Simulator” (HT Medical Systems, Rockville, MD) is consisted of a proxy flexible bronchoscope, a robotic interface device, and a computer with monitor and bronchoscopy simulation software. The learner inserts the proxy bronchoscope into the nasal passage of a robotic interface device, the proximal end of which is shaped similar to a human face. The interface device monitors the movements of the proxy flexible bronchoscope and creates resistance forces, simulating the forces experienced during an actual bronchoscopy procedure. The proxy bronchoscope tracks the manipulations of the bronchoscope (including the tip control lever, suction button, etc.) and the computer software creates computer-generated images of the airway on the monitor to simulate a realistic virtual bronchoscopy experience. A newer version of the simulator renamed the “AccuTouch Endoscopy Simulator” is now owned and distributed by CAE Healthcare, Montreal, Canada (Fig. 2). Other companies have since marketed similar products, including the “GI-BRONCH Mentor” (Simbionix USA Corp, Cleveland, OH), the Orsim bronchoscopy simulator (Airway Limited, Auckland, New Zealand), and the “Computer-Based Bronchoscopy Simulator (CBBS)” (National Taiwan University Endoscopic Simulation Collaborative Study Group, Taipei,Taiwan).28



Both the AccuTouch Endoscopy Simulator and the GI-BRONCH Mentor systems have the ability to incorporate gastrointestinal endoscopy modules into the system, which may be advantageous in some centers where cost sharing between departments is possible. The AccuTouch Endoscopy Simulator is the only simulator with an EBUS-TBNA module, although Simbionix is in the process of developing one at the time of the writing of this manuscript. The majority of the published studies using high-fidelity bronchoscopy simulation have used the AccuTouch Endoscopy Simulator. No studies comparing the various computer bronchoscopy simulator models have been published to date.

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Validation as an Assessment Tool: Can a Simulator Differentiate Operators of Different Clinical Skill Level?

For a simulator to be useful as an assessment tool, it should be able to discriminate between operators of different clinical skill level. Although the best method to determine clinical skill can be debated, procedure volume is still commonly used as a surrogate for clinical skill.

Using a combination of evaluation metrics (procedure time, time in “red-out,” scope collisions, percentage of segments entered, and use of suction), it has been shown that a computer simulator can separate groups of novice, intermediate, and expert bronchoscopists, suggesting that clinical skills are transferable to the simulator environment.29 Two other simulator-based instruments designed to assess basic bronchoscopic skill were developed and were used to study 22 participants of differing bronchoscopy skill level (novice, fellow, and attending).30 The Bronchoscopy Skills and Tasks Assessment Tool was designed to measure bronchoscopy skill and knowledge of airway anatomy and mucosal abnormalities using 8 exercises, whereas the Bronchoscopy Step-by-Step Evaluation Tool was designed to measure performance on a series of graded training maneuvers of increasing difficulty. Despite the small sample size, the study revealed high reliability and concurrent validity of both measurement tools.

More recently, an EBUS-TBNA computer simulator [AccuTouch Endoscopy Simulator with EndoscopyVR EBUS-TBNA module (Figs. 2, 3, CAE Healthcare, Montreal, Canada)] demonstrated the ability to accurately discriminate between operators with different levels of clinical EBUS-TBNA experience.31 After a standardized introduction session on the EBUS-TBNA simulator, 4 cohorts (novice bronchoscopists with no EBUS experience (n=4), expert bronchoscopists with no EBUS experience (n=5), basic clinical EBUS training (n=9, defined as 15 to 25 clinical cases), and EBUS experts (n=4, defined as >200 clinical cases) performed 2 simulated cases with performance metrics measured by the simulator. The EBUS-TBNA simulator was not only capable of discriminating between EBUS-TBNA experts and those with no EBUS-TBNA experience, but it was also able to differentiate between EBUS-TBNA experts and those with basic clinical EBUS-TBNA experience.



Another recent study assessed the validity and reliability of a new assessment tool using a computer bronchoscopy simulator that tested operators across multiple tasks of increasing difficulty to better distinguish among operators among a variety of different skill levels.32 Forty-two test participants (14 senior consultants, 14 trainees, and 14 medical students) were tested using a standardized scoring form. They examined the interrater reliability of the test by looking at the test results from 10 participants using 3 raters, 2 of whom were blinded. They found that examination of 6 different tasks was necessary to secure a high generalizability coefficient (>0.80) and to differentiate the performance of the 3 groups.

These studies confirm that metrics based on computer simulator performance can differentiate operators of different experience and skill levels, for both basic and complex bronchoscopy procedures. Superior clinical skills are associated with better performance on simulators.

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Validation as a Learning Aid: Do Bronchoscopy Skills Improve With Training on a Simulator?

Improvement in bronchoscopy skills through simulator training has been shown in several studies. One study tested a group of 5 novice bronchoscopists on an inanimate model after 4 hours of unsupervised practice with a computer simulator and compared their performance with that of 4 experienced bronchoscopists.11 They found that after the computer simulation training the dexterity and accuracy of the novice group equaled or surpassed the group of experienced bronchoscopists (with more than 200 bronchoscopies experience each). Another similar study noted that performance metrics on a computer simulator for 9 novice and 9 expert bronchoscopists (200 to 1000 bronchoscopy experience) could no longer be differentiated after the novice's fifth session of unsupervised simulator training with this same simulator.33 Both of these studies used the early models of the AccuTouch Endoscopy Simulator.

The efficacy of EBUS-TBNA computer simulation as a teaching tool has also been studied. The use of an EBUS-TBNA simulator has been shown to improve the rate of procedural skill acquisition in pulmonary medicine trainees, as measured by the simulator. In fact, trainees tested on the simulator performed better in terms of procedure time and in terms of lymph node identification after simulator training than those who underwent usual clinical training by participating in 15 to 25 real cases.15 A recent study assessed the impact of EBUS-TBNA training during a 1-day didactic and hands-on workshop using both low-fidelity and high-fidelity models in 40 participants.34 Pretesting and post-testing of cognitive and procedural steps demonstrated that the median percentage of correct responses or skillset actions before training was 62% compared with 85% after the training sessions.

These studies suggest that learners do acquire skills while practicing on simulators as assessed by such simulators. It has also been demonstrated that short-term learning gain occurs during 1-day introductory bronchoscopy courses with a focus on very specific cognitive information and bronchoscopy technical skill learning.35 Similar endeavors have been evaluated in other procedural specialties such as interventional radiology and surgery,36 and it seems that this short-term knowledge acquisition is reproducible; however, when follow-up testing was pursued at 6 months follow-up, there was a significant decline in knowledge and skills. Numerous educational models in the literature further define the active teaching-learning method, using deliberate practice to both acquire and maintain expert procedural performance.36,37 Further research into the optimal methods to ensure maintenance of bronchoscopy skills and knowledge will be beneficial in producing evidence-based recommendations for methods of maintaining competency in bronchoscopy.

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Validation as a Learning Aid: Can Training on a Simulator Improve Clinical Skill Level?

For simulators to have a real effect on the learning process, skills acquired on a simulator should lead to improved skills in actual clinical procedures and not just on the simulator itself. The skills learned on the simulator must translate to actual skills applied to the real-world setting.

This has been demonstrated for basic bronchoscopy in 2 small studies with trainees. In the first study, 2 groups of pulmonary fellows were assessed while performing 2 clinical bronchoscopy procedures (airway examination only) after a period of simulation training (20 cases in 3 to 4 simulator sessions) or clinical training (1 month clinical block participating in 10 to 15 bronchoscopy procedures). The simulation group outperformed their clinical colleagues in terms of procedure time, quality score (% segments correctly identified/time), and RN score with other positive trends noted but not reaching statistical significance.11 Another trial evaluated 3 groups of surgical residents while performing flexible bronchoscopy on patients. Ten junior residents were randomly assigned to 1 hour of simulator training or no simulator training, whereas 3 additional senior residents also underwent evaluation without simulator training. After this very brief simulator session, junior residents who received this training performed better during clinical bronchoscopy than those who did not, and the skill of the simulator-trained junior residents approached that of the senior residents who had previously performed 10 or more procedures.38

Acquisition of skills beyond basic bronchoscopy has also been studied. Pediatric fiberoptic endotracheal intubation skills were assessed in 20 pediatric residents without bronchoscopy experience. Residents were assessed while performing this technique in patients undergoing general anesthesia for an elective procedure at baseline, followed by randomization to a 45-minute unsupervised computer simulator session versus no additional instruction. A second procedure was then performed in another patient. Although both groups were similar at baseline, those undergoing simulation training had significantly improved performance over their baseline testing and compared with the control group.39

The impact of EBUS-TBNA simulator training on clinical skills was recently reported. In this prospective, nonrandomized study of pulmonary trainees, each resident was asked to perform an EBUS-TBNA procedure on 2 patients with suspected lung cancer and mediastinal adenopathy. One group of junior pulmonary trainees had received training by performing 15 proctored cases on an EBUS-TBNA simulator (n=4) but had never performed a clinical EBUS-TBNA procedure. The second cohort of learners consisted of senior pulmonary trainees who received training by performing 15 to 25 EBUS-TBNA procedures on patients during a 1-month IP rotation (n=4). Despite significantly less clinical bronchoscopy experience and having never before performed a clinical EBUS-TBNA procedure, the EBUS-TBNA simulator training group performed as well as their clinically trained senior colleagues during clinical EBUS-TBNA cases as measured by the primary endpoint (mean EBUS-TBNA procedure time/number of successful aspirations) as well as in all of the secondary endpoints with the exception of the time to intubation.40

The above literature suggests that initial practice and learning of both simple and complex bronchoscopic tasks on high-fidelity computer simulators are associated with direct transfer of these skills to the clinical environment. In some cases, improved skills were noted after very short simulator sessions (≤60 min) and in others, simulator training seemed equivalent to a substantial amount of clinical training.

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Learner Assessment of the Simulator Experience

The face validity of the AccuTouch Endoscopy Simulator has been established by questionnaire assessments of expert bronchoscopists using the simulator.33 In another study, 30 bronchoscopists using a computer bronchoscopy simulator rated the realism of the simulated bronchoscope and airway anatomy highly, whereas the bronchoscope movement, feeling of resistance, and performance of bronchoalveolar lavage and biopsies were judged to be less realistic.41

A study of the perceptions and preferences of learners and instructors regarding low-fidelity and high-fidelity (computer bronchoscopy simulator) bronchoscopy TBNA simulation was performed during the 2008 CHEST conference.42 It was discovered that the low-fidelity models used were preferred in terms of realism and in terms of ease of learning. The 8 instructors involved in the study unanimously reported that the low-fidelity model was an ideal tool for learning TBNA and was a more effective teaching instrument than the computer simulator (Fig. 1). No similar low-fidelity simulation tool has been studied for endobronchial biopsies or endobronchial brushings, both of which have been reported as lacking realism on the computer bronchoscopy simulator.41

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Knowledge Component of Learning Bronchoscopy

Bronchoscopy simulation alone addresses the manual dexterity skills and basic anatomic knowledge required for clinical bronchoscopy but does not include the crucial cognitive components of bronchoscopy. Internet-based course materials have been developed to address this issue. The “Essential Bronchoscopist” is a competency-based curriculum of question-answer sets pertaining to basic bronchoscopic knowledge that is available for free on the website. Expert evaluation of the curriculum found that 70 of the 186 questions contained information “necessary or absolutely necessary” for a test of bronchoscopic knowledge.43 Analysis of a randomly selected batch of 25 questions from these 70 questions identified 11 questions to be a reliable and valid test of bronchoscopic knowledge, providing a starting point for future comprehensive tests of bronchoscopy knowledge.44

A prospective study of junior pulmonary trainees compared usual bronchoscopy education with a structured educational program, including simulation training and an online bronchoscopy curriculum.45 Although the intervention group demonstrated accelerated acquisition of bronchoscopy skills, the online bronchoscopy curriculum did not improve learner performance on written tests. This may be explained by poor compliance with the online bronchoscopy curriculum (41% of participants never accessed the online information, and only 18% of the participants accessed all 6 teaching modules), suggesting that incentives (such as formal, high-stake testing during fellowship) may be required to ensure optimal use of such an educational curriculum. Significant variation in bronchoscopy skill acquisition was observed among the trainees at different milestones, emphasizing the inadequacy of number-based competency assessments as a solitary assessment of bronchoscopy skill or competency.

It is interesting to note that, technical bronchoscopy skill in pulmonary trainees (as measured by a simulator) does not correlate with knowledge of bronchoscopy theory, extent of training, and reported bronchoscopy experience.46 This provides further evidence that using years of bronchoscopy training or arbitrary number of procedures performed as a surrogate for competency has limitations.

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Limitations of bronchoscopy simulation include realism, incomplete procedure repertoire/need for multiple models, skill transfer, expense, time and availability of trained expert faculty, equipment malfunctions, and a deficient body of literature on the topic.

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Realism/Need for Multiple Models

Some procedures performed during bronchoscopy, such as bronchoalveolar lavage, endobronchial biopsies/brushings, and conventional TBNA require mastery of a significant tactile component, which are difficult to simulate on a computer. TBNA and endobronchial biopsies on high-fidelity simulators in particular have been found to lack realism.41,42 Fortunately, there are alternative low-fidelity simulation models with perceived better realism that can be used until the high-fidelity simulator technology improves.26,42 Transbronchial biopsy is the bronchoscopy sampling technique most associated with complications.47 Unfortunately, there are no published reports evaluating models to teach this important technique. Clearly, the computer bronchoscopy simulators have room for improvement in the more advanced biopsying techniques and further development is needed in this area.

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Cost and Equipment Malfunction

The cost of high-fidelity bronchoscopy simulation is particularly problematic, with individual units costing upward of $100,000 US, and with additional costs for other modules such as EBUS-TBNA. Expenses can sometimes be overcome with the use of low-fidelity models that have proven value in procedural training.42 High-fidelity bronchoscopy simulators are sensitive pieces of equipment and can break down or malfunction, with resulting negative impact on training programs and CME courses. Undoubtedly, as technology surrounding high-fidelity simulators matures and competition increases, better and more affordable systems will become available.

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Limited Data

A review of 10 bronchoscopy simulation studies analyzed for a number of factors including research design, expected learning outcomes from the intervention, target learners, and strength of findings found that most studies had small numbers of study participants and varying methodologies, suggesting a significant deficit in research and analysis in bronchoscopy simulation.48 Many additional studies have been published since this review; however, many of the same concerns remain and there are numerous bronchoscopy simulation models/methods in use with no or minimal published data validating the models or their impact on the learning process. In particular, limited information is available on models for transbronchial biopsy, wet lab simulation for both flexible and rigid bronchoscopy, and for a number of low-fidelity models.

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The use of bronchoscopy simulation allows for the standardization of the process of learning bronchoscopy, providing learners with immediate and consistent feedback due to objective skill measurements, an opportunity to follow a specific educational curriculum at the learner's own pace, while at the same time reducing the burden of procedural learning on patients. Bronchoscopy simulation also allows for validated and standardized evaluation of bronchoscopy skill, which will be useful for training programs and credentialing bodies in the future during the assessment of technical skill level and competency.

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Training Programs and Continuing Medical Education

Many academic centers have already incorporated bronchoscopy simulation training into a curriculum for basic bronchoscopy training. At the University of Calgary, for example, there is a yearly “Introduction to Bronchoscopy Course” with a full day of didactic lectures intermixed with simulator sessions using both computer bronchoscopy simulators and inanimate models. Trainees from a variety of specialties including ear, nose, and throat surgery, thoracic surgery, critical care medicine, adult/pediatric pulmonary medicine, and anesthesia attend the course and then participate in bronchoscopy simulation sessions throughout the year after the course. The trainees complete simulation modules specific to the skill set required for their specialty. Many pulmonary and IP training programs also offer simulation training in advanced bronchoscopy procedures such as transbronchial biopsies, conventional TBNA, EBUS-TBNA, and rigid bronchoscopy using many different bronchoscopy simulation models.

Given the substantial clinical impact of EBUS-TBNA, there has been much interest in developing training methods to acquire EBUS-TBNA skills including apprenticeship models, practice on inanimate, cadaveric or live animal models, and the use of computer-based simulators. Although the apprenticeship model may allow more extensive mentored training over the course of multiple clinical procedures, such opportunities are limited to a few pulmonary training programs and are too time intensive for most physicians already in clinical practice. EBUS-TBNA CME courses have been offered by several groups, often integrating one or more simulator models in an attempt to introduce basic EBUS skills to attendees. It remains unclear whether this relatively short and low-intensity simulator training is adequate to ensure competence or whether one simulator technique (or a combination of techniques) is preferable over another.

Another potential benefit of simulation for the learner is to have the opportunity to perform postsimulation self-assessment, whereby areas for improvement or further practice can be identified. This provides the educator with the opportunity to have a nonjudgemental, open dialog in real time to build upon the completed session with additional objectives for self-learning and directed practice before and during the next simulation session.

Clearly, additional research is needed to establish which simulation models are best for each specific procedure, and to establish standard curriculum to ensure that trainees completing training programs or CME courses can be assured of an optimal learning experience. Ideally, well-trained simulation and procedural faculty and educators should be available to mentor the simulation sessions each working within a clear standardized curriculum. Further study is required to determine the impact of such programs on the primary goal of skill transfer to the clinical setting as reflected by enhanced patient safety, comfort, and diagnostic and therapeutic outcomes and low complication rates.

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Learning and Maintaining Low-volume Procedural Skills

Bronchoscopy simulation could allow for repetitive practice of low-volume procedures or critical clinical scenarios. It is recognized that simulation scenarios can be created to teach very specific procedural aspects and to provide an element of control until the learner has demonstrated a basic level of competency. After this milestone has been achieved, additional elements of a given scenario can be added to reproduce the real-life distracters that call upon other skill sets of the learner to avoid chaos in a procedural setting. Examples of critical clinical scenario simulation already in use are wet lab and computer simulation models for practicing managing patients with massive hemoptysis.

Similarly, some centers have simulation programs where rigid bronchoscopy and therapeutic bronchoscopy techniques such as endobrochial stenting and foreign body removal are practiced repeatedly on inanimate or wet lab models before trainees perform such procedures on patients. It is clear that deliberate practice must occur after initial procedural proficiency is obtained in an ongoing pursuit to not only maintain skills but also to develop a level of expertise.36 These same simulation models can be used by attending physicians who wish to practice their skills for low-volume procedures, to maintain their skills at a high level.

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Evaluating Competency

There are currently no standardized guidelines or educational curricula for bronchoscopy to ensure adequate acquisition of the skills needed to achieve competency. On the basis of expert opinion, minimum procedure numbers have been proposed as a surrogate for expected competency, but evidence backing these recommendations is weak or nonexistent.49,50 In fact, there is increasing evidence that significant variability exists in the rate of skill acquisition between individual learners, suggesting that using procedure numbers alone is inadequate to ensure competency.15,45 Objective assessment methods are needed not only to establish competency for credentialing and licensing bodies but also to evaluate the impact of CME courses and to provide feedback to trainees and educators regarding when basic competency requirements have been met or when additional training is needed. As demonstrated above, simulators can discriminate between operators of various experience level and show promise as evaluation tools. Determining what level of performance on a simulator is associated with acceptable clinical performance (both in terms of diagnostic/therapeutic success and in terms of complication rates), and therefore “competency,” will require further study.

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Given the increasing focus on patient safety in recent years, the apprenticeship model of learning bronchoscopy on patients is becoming increasingly difficult to justify. A significant body of evidence now supports the efficacy and validity of a variety of bronchoscopy simulation techniques, both for bronchoscopy skill acquisition and for the evaluation of these skills. Bronchoscopy simulation allows for the standardization of the learning process, provides learners with immediate and consistent feedback due to objective skill measurement, provides the opportunity to follow a specific educational curriculum at one's own pace, at the same time reducing the burden of procedural training on patients. The implementation of competency-based curricula using validated methods of teaching and evaluating the cognitive aspects of bronchoscopy in combination with bronchoscopy simulation, may ultimately lead to improvements in patient-care outcomes. Further research in large multicenter trials is needed to establish improved educational outcomes more conclusively and to demonstrate improved patient-care outcomes.

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bronchoscopy; education; endoscopy/endoscopic procedures; lymph nodes; ultrasound; competency; simulation; endobronchial ultrasound; training

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