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Original Investigations

Procedural Learning Perspectives of Pulmonary Fellows and Practitioners

Lee, Hans J. MD, FCPP; Coleman, Briana BSc; Lerner, Andrew D. MD; Feller-Kopman, David MD; Semaan, Roy MD; Frimpong, Bernice BA; Yarmus, Lonny DO

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Journal of Bronchology & Interventional Pulmonology: July 2017 - Volume 24 - Issue 3 - p 200-205
doi: 10.1097/LBR.0000000000000362


There has been a continual increase in the number of new procedures in the specialty of pulmonary medicine in part due to advances in technology.1 Both pulmonary fellows and practitioners are learning these new procedures in focused educational courses, as well as during fellowship and clinical practice. The optimal methods for teaching new pulmonary procedures remain to be defined.2

Educational training techniques such as simulation, procedural checklists, examinations, and different classroom models have been described as effective metrics/tools in teaching new procedures.3–6 However, the optimal tools and methods have not been well studied within groups at different stages of learning.7 Considering that most published studies involve trainees rather than clinicians in practice, questions arise in regards to the universal applicability of the current data. This poses a severe limitation in developing learner centric courses and programs. The effectiveness of different forms of teaching may differ for fellows in training compared with those late in their career. Additional variables in learning include classroom styles, instructors, and/or using tools such as simulation. Because of the paucity of data in this subject, we investigated the preferences of learners at 2 different points in a pulmonary career: pulmonary fellows and clinical practitioners who have completed training.


This study was approved by the Johns Hopkins University Institutional Review Board. A prospective self-perception study was conducted from June, 2015 to October, 2015 at 4 different procedural training courses. All procedural courses had low-fidelity simulators, high-fidelity simulators, or cadavers. All courses were designed around a traditional classroom model with separate didactic lectures and hands-on sessions.

Inclusion criteria included being a pulmonary fellow or practitioner who has completed training who participated in a dedicated 1 or 2-day procedural training course that included didactic lectures and hands-on simulation labs. Immediately after completing the course, subjects were given verbal instructions and background information explaining differences in classroom models followed by a survey (Appendix 1, Supplemental Digital Content 1, to complete. The survey consisted of 3 parts which included demographics and qualitative and quantitative (Likert style questions, scale 1 to 5 of poor to excellent) questions. All fellows and practitioners from the investigators’ institution were excluded from the study.

The results were analyzed using Stata (version 14, College Station, TX). Mean (normal distribution) and median results of fellows and pulmonary practitioners were compared using a 2-tailed Student t test or analysis of variance. Bonferroni multiple comparison test was performed when statistically significant. A P-value of<0.05 was considered to be statistically significant.


Seventy-five physicians (44 pulmonary fellows, 31 practitioners) from 35 centers completed the survey with basic demographic data including sex, handedness, and number of bronchoscopy procedures performed over the past 2 years recorded (Table 1). The results of the quantitative data are summarized in Table 2. Both fellows and practitioners found supervision of procedures by faculty/peers as the most valuable learning tool during their last newly learned procedure. Pulmonary practitioners preferred an academic expert (50%), whereas fellows preferred familiar faculty (42%) as lecturers for procedural learning (P=0.03).


There were no statistical differences between fellows and practitioners value of the use of simulators, hands-on training, didactics, or handouts. Both groups preferred animal/cadaver and high-fidelity simulators to low-fidelity simulators (P=0.04). Both groups also preferred a traditional course structure to problem-based learning/flipped classroom (Fig. 1). Practitioners preferred a longer didactic time compared with pulmonary fellows (P=0.035), but there was no difference regarding hands-on time length between the 2 groups (P=0.183). The most common answer to barriers on learning a new procedure in both groups was time for training (55% practitioner, 75% fellows) followed by opportunities to learn (10% practitioners, 7% fellows) (Fig. 2). Finally, fellows felt that competency at their institution was based on both procedural numbers as well as faculty evaluation almost equally with most practitioners citing procedural numbers as the major competency index used (P=0.035).

Survey question regarding teaching preference. Responses to course structure preference.
Survey responses to barriers of learning (left) and basis for teaching style preference (right). Left column: “Barriers on learning a new procedure for fellows and practitioners”: time for training (55% practitioner, 75% fellows) followed by opportunities to learn (10% practitioners, 7% fellows) and politics (15% practitioners, 5% fellows). Right column: “What is the main reason for choosing the classroom style above?”: protected time (30% practitioners, 50% fellows) followed by home (40% practitioners, 35% fellows) and night (25% practitioners, 40% fellows).


Recently, there has been a call for additional studies to investigate optimal training methods for procedural learning in pulmonary medicine.2,7 A part of this is due to the increasing number of procedures being introduced into the specialty. Currently, there is only modest data to support one training method over another for procedural learning. In addition, while certain training methods may be more useful for physicians in training (ie, residents/fellows), they may not be universally effective to those already in clinical practice. This becomes a critical element when designing learner centric programs and courses as they should consider learner preferences.8

This study uses the learners’ preferences as a surrogate for optimal training methods in light of the lack of comparative data. Prior studies exploring learning preferences have found that learners may develop improved motivation, learning, and performance if their teaching was congruent with their learning preferences.8–10 Learners may have a consistent method of information gathering and then evaluating this information during the learning process.9 The implication for physicians is that it may be possible to improve learning efficiency if teaching methods are tailored to the preferred learning style of trainees.11

We divided the data into 2 comparative groups to examine learner preferences at 2 different time points in a pulmonary career; pulmonary fellowship and clinical practice. Given the difference in environment and career stages, we hypothesized that there would be differences in learning preferences between the 2 groups. This would be important to recognize as most of the literature is based on house staff trainees rather than the majority of pulmonologists who are no longer in training but in active clinical practice. Although our study showed an overall agreement between fellows and practitioners in the majority of questions, the responses also signaled heterogeneity within each group regarding certain topics. For example, while a traditional classroom style was favored over a flipped/problem-based classroom, there was an almost equal ratio of some favoring other classroom models in both learner groups. Our interpretation of these disparities is that physicians differ in their preferred learning style as certain models/tools may be good for some but not all.12 This raises a larger dilemma in teaching new procedures as educators may need to be flexible and adaptable to the individual learner’s preference. There are studies that support this notion which need to be recognized when designing or choosing a procedural course.13

Practitioners favored longer didactic training time compared with fellows, as well as longer hands-on time on average, although this did not reach statistical significance. This may stem from practitioners distance from formal learning as well as additional questions given their increased experience level. Dissatisfaction with their current procedure credentialing system was equal among practitioners and trainees. At their respective institutions, both groups felt competency was primarily evaluated by number of procedures performed. Predictably, trainees also felt faculty evaluation played a strong role in assessment of procedural competency. Credentialing for new procedures remain mostly based on procedural volume rather than faculty evaluation or competency testing, which is contrary to current understanding of procedural competency.14 These differences may be important to consider when designing learner centric courses.

Both fellows and practitioners favored high-fidelity simulation and animal/cadaver models over low-fidelity models. The scores in these categories were the highest in the survey. This is consistent with the current literature supporting simulators to improve psychomotor skills and procedural efficiency.15 High-fidelity simulators are thought to provide a more engaging experience promoting active learning and motivation. This was contrary to the response toward classroom styles as both groups favored the traditional classroom over problem-based/flipped classrooms which requires higher precourse learner participation. When asked for the reason, the most common response from fellows and practitioners were time availability before taking the courses. Another contributing element may be that pulmonologists are a preselected cohort and by nature of their personalities attract certain learning preferences, histories, and familiarity. This learning preference phenomenon has been previously well described and seems to favor teacher-structured learning over individual or interpersonal learning.16 Had this study been replicated in a different specialty or profession, the responses may be different.

One of the limitations of a perception study is that perception may not translate to reality. Certain recall and confirmation biases may be introduced into any perception study, which should caution investigators when trying to distinguish personal preference versus popular opinion. A particular concern is the popular perception of the benefits of simulation training, as this may be confused for training effectiveness. We purposefully designed the study to occur immediately after a training course with different forms of simulators to base answers on immediate experience rather than popular opinion. Though subjects reviewed literature of various teaching methods before completing the study survey, we acknowledge that a background review differs from direct experience. A future study may consider comparing the learning preferences among learners after exposure to multiple teaching styles and objective outcomes such as competency/retention. In addition, all of our subjects had chosen to take part in our educational courses. We assume that our subjects chose these courses based on the course topic, though we cannot prove the role teaching style played in the initial decision to enroll. This may be a confounder as subjects who have not chosen to take part of such courses may have differing perceptions. Nevertheless, in our experience many attendees of educational courses enroll based on course subject. A multicenter study should be performed to validate our findings with outcome end points.


Pulmonary fellows and practitioners we surveyed preferred a traditional course structure with cadaver/animal models and high-fidelity simulation training as compared with a flipped classroom model and low-fidelity simulators, but whether this holds true for the wider population is unknown. Additional studies may be needed to confirm our findings.


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procedural learning; simulation; pulmonary fellow; practitioner

Supplemental Digital Content

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