Assessment of bronchoscopy training and competency: a narrative review

Introduction

Bronchoscopy training is an integral part of pulmonary critical care medicine (PCCM) fellowship education. PCCM fellows obtain experience over the course of their training. However, bronchoscopy training is varied across different institutions. Historically, fellows were taught in an apprenticeship model where they observed bronchoscopies being performed on patients. The fellows then performed the procedure themselves. They learned through instructions and cues provided in real-time by their mentors while performing bronchoscopy on live patients. Fellows were deemed to be proficient when they met a pre-specified numerical target for procedures performed or when their mentors deemed them to be so. However, contemporary studies have demonstrated that the above technique is insufficient for training of PCCM fellows (1-3).

Contemporarily, fellowship programs train fellows with supplemental education prior to and during the performance of bronchoscopy (4). This supplemental education, however, is not standardized across institutions. It can include educational modules, simulation training, assessment tools, and structured curricula. Training programs utilize one or more of these supplemental educational strategies.

Furthermore, technological advances in bronchoscopy have expanded the role of the pulmonologist. The advent of convex endobronchial ultrasound (EBUS) in 2004 has allowed for the ability to evaluate and sample structures adjacent to the proximal tracheobronchial tree (5). Linear EBUS has become the standard of care for mediastinal lymph node sampling. Over this period, electromagnetic navigational bronchoscopy (ENB) for diagnosis of peripheral pulmonary lesions was also developed. Prior to the development of ENB, standard fluoroscopy and Radial probe EBUS were the tools available to pulmonologists for these biopsies. With the adoption of ENB systems pulmonologists had a new modality available for guidance to peripheral lesions (6-8). More recently, further technological innovations have led to the development of Robotic bronchoscopy (9-12). These innovations in bronchoscopy have likewise increased the demands on procedural training for fellowship programs. While it is not expected that fellows graduate with complete proficiency in all these advanced procedures, it does demonstrate the changing landscape of bronchoscopy education. These changes further highlight the need for optimal training and competency assessment in PCCM fellows.

To this effect, tools such as simulation training, checklists and online modules have demonstrated the ability to supplement procedural training and assist with assessment of competency. The Bronchoscopy Skill and Task Assessment Tool (BSTAT), Endobronchial Ultrasound Skills and Tasks Assessment Tool (EBUS-STAT) and Ontario Bronchoscopy Assessment Tool (OBAT) are a few of the assessment tools available for competency evaluation during bronchoscopy (13-15). These assessment tools can help provide training programs with guidance regarding trainee skill progression over the course of fellowship and allow for interventions if trainees are not meeting expectations. In this article we will discuss the evolution of bronchoscopy competency and training over the last few decades. We will focus on the educational theory and tactics that these changes have been predicated upon, and review the evidence for current training paradigm. We present this article in accordance with the Narrative Review reporting checklist (available at https://amj.amegroups.com/article/view/10.21037/amj-23-147/rc).

Methods

For this narrative review, we performed literature search in the PubMed and MEDLINE databases. Our literature search included the time-period from January 1, 1964 to May 1, 2023. Search was restricted to articles available in standard English. Our terms for search included bronchoscopy competency, numbers-based training, simulation training, pulmonary critical care procedure training, assessment tools, and educational theory (Table 1).

Historical training paradigms

In 1968, Shigeto Ikeda presented the new “Flexible Bronchofiberscope”. The instrument was conceptualized in 1964 to overcome the limited field of access afforded by rigid bronchoscopy. The flexible bronchoscope could visualize subsegmental bronchi up to the fourth order (16). This flexible instrument could be advanced through an endotracheal tube and its use was soon adopted by the medical community at large due to its relative ease of use when compared to rigid bronchoscopy.

The proliferation of the flexible bronchoscope raised concerns regarding appropriate qualification and training as early as the 1970s. In 1978, a communication in Chest journal advocated for the need for appropriate qualification based on a metric of number of procedures performed. It recommended that trainees perform 50 to 100 procedures in training supplemented with visual aids such as tapes and slides (17). In 1982, the numbers-based metric became supported by national societies. The American College of Chest Physicians (ACCP) published guidelines that recommended training in fiberoptic bronchoscopy to be integrated within pulmonary subspecialty training and that trainees perform at least 50 diagnostic bronchoscopies under supervision to gain competency (18).

Apart from a number mandate for procedural training, there remained an absence of fully defined curriculum for bronchoscopy education. A 1998 survey of 59 pulmonary fellows demonstrated that institutions differed in how they prepared their trainees for bronchoscopy. While, one-to-one instruction was practiced at most of the programs, techniques such as case reviews, lectures and video-based instruction were employed with less regularity. Additionally, basic components of flexible bronchoscopy were not taught to all the surveyed pulmonary fellows. 71% of the fellows had experience with bronchoscopic intubation and 73% with transbronchial needle aspiration (TBNA). Advanced therapeutic techniques such as stent placement (27%), laser photocoagulation (25%) and cryotherapy (7%) were taught at an even lower rate (19). This survey demonstrated the lack of uniformity in bronchoscopy education across training institutions. This training discrepancy emphasized the need for structured procedural education within pulmonary medicine. The ACCP in an effort to ensure consistency of training and patient safety presented a new set of procedural guidelines in 2003. It recommended that trainees perform at least 100 supervised flexible bronchoscopies to gain competency, and practitioners perform 25 procedures annually to maintain competency (20).

Over time, greater attention has been focused on the limitations of numbers-based training. Accreditation organizations such as the American Board of Internal Medicine (ABIM) and ACCP have acknowledged these limitations over the years. The ABIM in 1988 directed subspecialty board of pulmonary disease training programs to establish systems and standards for procedural training. In their directive, the ABIM specifically chose to forego a set number for competency assessment as trainees vary and manual dexterity and procedural skill could not be ensured at a specific number (21). These sentiments were echoed in the 2015 Chest expert panel guidelines which recommended that professional societies move from a volume-based certification system to skill acquisition and knowledge-based competency assessment for trainees (22). These recommendations have been borne out over multiple studies. A multicenter, prospective trial comparing novice pulmonary fellows who received educational interventions in addition to standard bronchoscopy training versus those who only received standard bronchoscopy training demonstrated significant variation in bronchoscopy skill acquisition between the two groups. The educational intervention group attained competency for procedural milestones as measured by the BSTAT at a faster rate than the standard bronchoscopy group alone (1). In another multicenter study using OBAT for competency assessment of 31 trainees this variation in skill acquisition was also demonstrated. Using the OBAT as a metric, the authors demonstrated that trainees in the 90^th percentile required 7 to 10 bronchoscopies to reach competence. This stood in juxtaposition to the 109 to 126 bronchoscopies required by trainees in 10^th percentile to reach competence (2). This discrepancy in competency acquisition has also been demonstrated with EBUS. In a multicenter study assessing interventional pulmonology fellows, Stather and colleagues demonstrated variation in EBUS competence up to and beyond 200 cases (3).

Educational theory

When discussing educational framework for procedural education, it is impossible to not reflect on the impact of William Stewart Halsted. As the first Chair of Surgery at Johns Hopkins, his apprenticeship model of “See one, Do one, Teach one”, served as the original basis for bronchoscopic education (23). In the modern era of procedural education particularly in the setting of duty hour restrictions and concerns of patient safety, this model has distinctly fallen out of favor. Furthermore, continued concerns of skill extinction have been raised in this current training context (24).

The main educational framework that serves as the basis for bronchoscopic education is David Kolb’s Experiential Learning Model (ELM), wherein the way people perceive and process an experience explains how they learn (25). According to Kolb, two processes are necessary for learning: perceiving a medium, and processing of that medium (transformation). Via a balance of reflective observation and active experimentation versus abstract conceptualization and concrete experiences, learners pass through four stages: diverging, assimilating, converging, and finally accommodating. It is through this pathway of perceiving concrete experiences and then abstract concepts before application of knowledge with active experimentation of both abstract and concrete experiences that learners gain new skills.

Evaluating procedural education through this lens of ELM helps elucidate the teaching methodologies of Halsted’s apprenticeship in the modern age. Walker and Peyton expanded upon “See one, Do one, Teach one,” with their 4-step model including demonstration, deconstruction, comprehension, and execution (26). For bronchoscopic education, this all came together with Henri Colt’s Practical Approach Model (PAM). Based on Albert Jonsen’s work with ethics, this model breaks down practical bronchoscopic education into four domains: initial management, teaching and results, procedural strategies, and long-term management (25). It is through these varied applications of adult learning theory that the modern educational strategies for bronchoscopic education are born, including the flipped/inverted classroom, problem-based learning (PBL), and spaced education.

Modern curricula

Applying adult learning theory and the Kolb’s experiential learning model, bronchoscopic medical educators have created varied curricula to replace the outdated apprenticeship model. To date, there are no standardized curricula for bronchoscopic education, but those that exist do exist within stereotyped paradigms. Boot-camp curricula, for example, have demonstrated that cognitive and technical skill can be taught in discrete periods of time, as demonstrated by Colt et al. who developed and evaluated a quasi-experimental one-group pre-test/post-test one-day bronchoscopic introductory course (27). Longitudinal curricula expand upon the boot-camp model, providing learners with resources and experiences beyond the confines of a time-limited bootcamp. One of the earliest such curricula was put forth by Wahidi et al., who in a multicenter, prospective randomized control trial demonstrated longitudinal simulation-based learning enhances the speed of acquisition of bronchoscopic skills among pulmonary fellows (1). While Wahidi et al. failed to show improvement in cognitive performance, likely due to poor curricular compliance, Siow et al. later showed that a 3-month structured bronchoscopy curriculum incorporating knowledge modules and high-fidelity simulation could in fact improve both psychometric and cognitive performance (28).

Other curricula experiment not with the model of education, but rather with the structure. For example, Bjerrum et al. explored how dyad models, where two participants collaborate in learning a task they will perform individually, can be used to increase the efficiency of in-person training modules, with one randomized control trial including 36 medical students demonstrating equal bronchoscopic technical skill acquisition assessed via simulated cases compared to traditional independent learning (29).

Educational tactics

The actual tools these structured curricula employ can vary, typically employing a balance of knowledge acquisition modules, simulation, and checklists. By allowing learners to explore material (often web-based) at their own discretion, knowledge acquisition modules leverage the flipped classroom model. Of such modules, The Bronchoscopy Education Project developed by Bronchoscopy International is the most well-known. Including texts like the Essential Bronchoscopist, the problem-oriented BronchAtlas video series, the Fundamentals of Bronchoscopy series of PowerPoint lectures, multiple choice questions, checklists, and assessment tools. Its modularity provides learners and teachers resources and flexibility (30).

In addition to knowledge modules, simulation training has been gaining popularity for all modes of procedural education. Simulation can be divided into two main categories—low-fidelity and high-fidelity simulation. With low fidelity simulation, tracheobronchial trees and phantoms are typically constructed using a variety of materials including molded plastics, silicones, and porcine models, allowing for the introduction of anatomy and basic bronchoscopy skills. Using 1.5 mm iron wire, glazier-putty, and strips of newspaper immersed in water and vinilic glue, Di Domenico, Simonassi, and Chessa constructed one of the first dedicated low-fidelity models of the tracheobronchial tree (31). Today, a number of low-fidelity phantoms exist, including phantoms used for basic bronchoscopy training such as the Laerdal Airway Management Trainer, Dexter Endoscopic Dexterity Trainer (32), CLA Broncho Boy, and countless 3-D printed models. Despite their low cost, they have been demonstrated to distinguish novice bronchoscopists from experts for both cognitive psychomotor skills such as identifying segmental anatomy, proper body positioning, and minimizing wall trauma (33).

Unlike low-fidelity simulation, high-fidelity bronchoscopy simulators are high-cost, computer-based systems that consist of a proxy bronchoscope, an interface, and a monitor. As an educational tool in 2001, Colt et al. demonstrated that virtual reality instruction could improve both dexterity and accuracy (34). Today, there are several commercial models, such as the PreOP Endoscopy Simulator, CAE Healthcare Endoscopy VR Simulator, and Simbionix GI-BRONCH Mentor (35). Despite their cost, when used appropriately, virtual simulators can allow novice trainers to visualize and identify the entirety of the bronchial tree more quickly and just as effectively as in-person education (36,37).

Assessment methodologies

Several bronchoscopic assessment tools currently exist to assess a learner’s skill in bronchoscopic procedures ranging from basic bronchoscopy, EBUS, as well as rigid bronchoscopy. The earliest tools developed for such purpose include the BSTAT and the Bronchoscopy Step-by-Step Evaluation Tool (BSET) (13-15). In 2008, Davoudi et al. published the first study that validated both assessment tools. They showed that the participant’s score on both tools correlated with the degree of experience of the participant, ranging from novice to expert. They also demonstrated that both tools had interrater reliability as well as test-retest reliability (15).

Both the BSTAT and the BSET have the advantage of being able to be administered in a short period time (15 min) and with a range of different modalities, anywhere from mannequins, virtual reality simulators up to consenting live patients. The BSTAT specifically measures an individual’s skills when performing diagnostic bronchoscopic procedures. The tool consists of eight sections ranging from knowledge of segmental anatomy, ability to enter various segments, avoidance of airway trauma and all the way up to performing tasks such as bronchoalveolar lavage, endobronchial biopsies and transbronchial biopsies. The BSET measures the learner’s ability to perform graded bronchoscopic maneuvers with a similar focus as BSTAT, but with more emphasis placed on maneuvering the bronchoscope in the airways (15).

As previously mentioned, Wahidi et al. performed a 2-year prospective multicenter study that utilized the BSTAT to evaluate a cohort of pulmonary fellows. The aim of the study was to develop bronchoscopy competency metrics while also evaluating the impact of various education interventions such as simulation on bronchoscopy skill acquisition compared to the more traditional approaches to bronchoscopy education. They demonstrated that at the previously recommended competency threshold of 50 bronchoscopies per trainee there was a large degree of variation between participants. They found that incorporating simulation increased the speed at which learner’s acquired bronchoscopy skills as evidenced by a higher BSTAT scores for learners who underwent simulation training prior to bronchoscopy in a live setting compared to learners who gained skills based on traditional institutional practices (1). Several other studies since have demonstrated that the incorporation of simulation has led to objectively higher measures of skill acquisition on BSTAT across various levels of training ranging from medical students to trainees (28,38).

Another validated tool for flexible bronchoscopy was developed in 2016 in Ottawa, Canada. This OBAT tool differs from BSTAT and BSET in that it allows for assessment of trainees in a real-time clinical setting, and can allow for longitudinal assessment of the same trainee (14). A follow up study in 2020 established learning curves for quantiles of learners based on OBAT scoring and estimated number of bronchoscopies needed to reach competency. This further supported the idea that a departure from a “one size fits all strategy” was needed and a more individualized approach to basic bronchoscopic skills acquisition using validated assessment tools is necessary (2).

The same push to develop validated competency tools for other procedures performed routinely by interventional pulmonologists started at the same time as the development of the BSTAT. In fact, it was in 2012 that Davoudi and many of the same group that developed BSTAT also developed the EBUS-STAT. It was designed to be a 10-section assessment tool that allows for the evaluation of technical skills and knowledge related to performing convex probe EBUS-TBNA. The initial validation study demonstrated a high degree of interrater agreement as well as ability to discriminate novice, intermediate, and experienced participants (39). Interestingly they also found that after 50 EBUS procedures, there was no statically significant improvement in EBUS-STAT scores, suggesting that the amount of improvement after 50 procedures is much smaller compared the improvement in skills early on during the learning process. This was similar to what had been observed in previous studies and Jantz et al. argued in 2012 that a tool such as EBUS-STAT should be implemented to assess degree of competency instead of procedural volume-based markers for competency (40).

The next wave in EBUS procedural education came in the form of utilizing simulation to accelerate learning EBUS-TBNA. In 2017, Scarlata et al. performed a small-scale study in which 15 experienced bronchoscopist with little or no experience with EBUS-TBNA were evaluated with EBUS-STAT, subsequently taught with a virtual reality simulation platform and then reassessed with EBUS-STAT. They demonstrated a significant improvement in EBUS skills using simulation with statistically significant higher EBUS-STAT scores after the educational intervention. They also found that participants with a higher pre-training EBUS-STAT scores had less of an improvement in their scores with the use of simulation training (13). This study suggested that the EBUS-STAT was able to detect improvements in skills in experienced bronchoscopists and that there was a score threshold after which additional educational interventions was unlikely to improve the skills of the learner.

Similar to the effort for developing flexible bronchoscopic assessment tool, the development of a rigid bronchoscopic assessment tool has also taken place. Rigid Bronchoscopy Tool for Assessment of Skills and Competence (RIGID-TASC) was developed in 2015 and corresponded with the early years of the first accredited Interventional Pulmonology (IP) fellowship programs in the United States. The validation study of RIGID-TASC involved participants of various experience level and utilized a mannequin for rigid bronchoscopic intubation. There were statically significant differences in score based on experience levels and the tool itself showed high interrater reliability (41). Another study in 2021 demonstrated that there is a variable learning curve between IP fellows when it comes to learning rigid bronchoscopic intubation, and that the RIGID-TASC was able to assess the learning curve for individual fellows (42).

Conclusions

In this narrative review, we have evaluated bronchoscopy training data that has evolved since the advent of flexible bronchoscopy. This review highlights the weaknesses of the traditional numbers-based training approach and the strengths of a competency-based training approach. Additionally, it also reviews the educational theories that have supported these changes. These training recommendations have been discussed elsewhere in literature previously, and in fact are supported by national societies (22). Hence, the review of training recommendations as by itself does not add to the already published literature.

However, the strength of this review rests within the extensive tracing of training recommendations since the advent of flexible bronchoscopy to the present. It allows for a global understanding of how training trends have evolved with emerging data. It contextualizes prior work that has been done in this arena (Table 2). More importantly, this review adds to the understanding of the underlying educational theories that support these recommendations (22). By discussing the educational framework, we aim to focus attention on the evidence behind the specific teaching strategies. The evidence includes discussion of the practical approach model, boot camp curriculum, simulation-based learning, structured bronchoscopy curriculum and others (27,28,30,33-35).

In summary, bronchoscopic education and skills acquisition is in a transitory state. There is a departure from the traditional approach of basing competence simply on the number of procedures performed to individualizing the threshold for competency to the learner and using validated assessment tools to assist in defining that threshold. There is also an interest in using more virtual platforms, low-fidelity models, as well as high-fidelity models to supplement the educational experiences surrounding bronchoscopic education. In the future we will likely see more data to support the use of these alternative educational modalities and ultimately optimize the learning environment in our training programs. As technologies and techniques progress in the field of pulmonology and interventional pulmonology, newer modalities and tools will need to be developed to account for the era of robotic bronchoscopy and how learners will gain competence in those procedures.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Jonathan Kurman and Bryan S. Benn) for the series “Diagnostic & Therapeutic Bronchoscopy” published in AME Medical Journal. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://amj.amegroups.com/article/view/10.21037/amj-23-147/rc

Peer Review File: Available at https://amj.amegroups.com/article/view/10.21037/amj-23-147/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://amj.amegroups.com/article/view/10.21037/amj-23-147/coif). The series “Diagnostic & Therapeutic Bronchoscopy” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. 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;137:1040-9. [Crossref] [PubMed]
2. Voduc N, Adamson R, Kashgari A, et al. Development of Learning Curves for Bronchoscopy: Results of a Multicenter Study of Pulmonary Trainees. Chest 2020;158:2485-92. [Crossref] [PubMed]
3. Stather DR, Chee A, MacEachern P, et al. Endobronchial ultrasound learning curve in interventional pulmonary fellows. Respirology 2015;20:333-9. [Crossref] [PubMed]
4. Richards JB, Claar D, McCurdy MT, et al. Impact of Risk and Volume on Procedural Traning of Pulmonary and Critical Care Fellows. ATS Sch 2021;2:212-23. [Crossref] [PubMed]
5. Yasufuku K, Chiyo M, Koh E, et al. Endobronchial ultrasound guided transbronchial needle aspiration for staging of lung cancer. Lung Cancer 2005;50:347-54. [Crossref] [PubMed]
6. Hautmann H, Schneider A, Pinkau T, et al. Electromagnetic catheter navigation during bronchoscopy: validation of a novel method by conventional fluoroscopy. Chest 2005;128:382-7. [Crossref] [PubMed]
7. Gildea TR, Mazzone PJ, Karnak D, et al. Electromagnetic navigation diagnostic bronchoscopy: a prospective study. Am J Respir Crit Care Med 2006;174:982-9. [Crossref] [PubMed]
8. Eberhardt R, Anantham D, Herth F, et al. Electromagnetic navigation diagnostic bronchoscopy in peripheral lung lesions. Chest 2007;131:1800-5. [Crossref] [PubMed]
9. Chen AC, Pastis NJ Jr, Mahajan AK, et al. Robotic Bronchoscopy for Peripheral Pulmonary Lesions: A Multicenter Pilot and Feasibility Study (BENEFIT). Chest 2021;159:845-52. [Crossref] [PubMed]
10. Chaddha U, Kovacs SP, Manley C, et al. Robot-assisted bronchoscopy for pulmonary lesion diagnosis: results from the initial multicenter experience. BMC Pulm Med 2019;19:243. [Crossref] [PubMed]
11. Kalchiem-Dekel O, Connolly JG, Lin IH, et al. Shape-Sensing Robotic-Assisted Bronchoscopy in the Diagnosis of Pulmonary Parenchymal Lesions. Chest 2022;161:572-82. [Crossref] [PubMed]
12. Benn BS, Romero AO, Lum M, et al. Robotic-Assisted Navigation Bronchoscopy as a Paradigm Shift in Peripheral Lung Access. Lung 2021;199:177-86. [Crossref] [PubMed]
13. Scarlata S, Palermo P, Candoli P, et al. EBUS-STAT Subscore Analysis to Predict the Efficacy and Assess the Validity of Virtual Reality Simulation for EBUS-TBNA Training Among Experienced Bronchoscopists. J Bronchology Interv Pulmonol 2017;24:110-6. [Crossref] [PubMed]
14. Voduc N, Dudek N, Parker CM, et al. Development and Validation of a Bronchoscopy Competence Assessment Tool in a Clinical Setting. Ann Am Thorac Soc 2016;13:495-501. [Crossref] [PubMed]
15. Davoudi M, Osann K, Colt HG. Validation of two instruments to assess technical bronchoscopic skill using virtual reality simulation. Respiration 2008;76:92-101. [Crossref] [PubMed]
16. Ikeda S, Tsuboi E, Ono R, et al. Flexible bronchofiberscope. Jpn J Clin Oncol 2010;40:e55-64. [Crossref] [PubMed]
17. Faber LP. Bronchoscopy training. Chest 1978;73:776-8. [Crossref] [PubMed]
18. Guidelines for competency and training in fiberoptic bronchoscopy. Section on Bronchoscopy, American College of Chest Physicians. Chest 1982;81:739. [Crossref] [PubMed]
19. Haponik EF, Russell GB, Beamis JF Jr, et al. Bronchoscopy training: current fellows' experiences and some concerns for the future. Chest 2000;118:625-30. [Crossref] [PubMed]
20. Ernst A, Silvestri GA, Johnstone D, et al. Interventional pulmonary procedures: Guidelines from the American College of Chest Physicians. Chest 2003;123:1693-717. [Crossref] [PubMed]
21. Hudson LD, Benson JA Jr. Evaluation of clinical competence in pulmonary disease. Am Rev Respir Dis 1988;138:1034-5. [Crossref] [PubMed]
22. Ernst A, Wahidi MM, Read CA, et al. Adult Bronchoscopy Training: Current State and Suggestions for the Future: CHEST Expert Panel Report. Chest 2015;148:321-32. [Crossref] [PubMed]
23. Kotsis SV., Chung KC.. Application of the “See One, Do One, Teach One” Concept in Surgical Training. Plastic and Reconstructive Surgery 2013;131:1194-1201. [Crossref] [PubMed]
24. Sall D, Warm EJ, Kinnear B, et al. See One, Do One, Forget One: Early Skill Decay After Paracentesis Training. J Gen Intern Med 2021;36:1346-51. [Crossref] [PubMed]
25. Murgu SD, Kurman JS, Hasan O. Bronchoscopy Education: An Experiential Learning Theory Perspective. Clin Chest Med 2018;39:99-110. [Crossref] [PubMed]
26. Arora B, et al. Peyton’s Model: Modifications and Applications for Teaching Clinical Skills. Academic Medicine 2023;98:533. [Crossref] [PubMed]
27. Colt HG, Davoudi M, Murgu S, et al. Measuring learning gain during a one-day introductory bronchoscopy course. Surg Endosc 2011;25:207-16. [Crossref] [PubMed]
28. Siow WT, Tan GL, Loo CM, et al. Impact of structured curriculum with simulation on bronchoscopy. Respirology 2021;26:597-603. [Crossref] [PubMed]
29. Bjerrum AS, Eika B, Charles P, et al. Dyad practice is efficient practice: a randomised bronchoscopy simulation study. Med Educ 2014;48:705-12. [Crossref] [PubMed]
30. Colt, H., Bronchoscopy Education: New Insights. Interventions in Pulmonary Medicine, 2013: p. 79-96.
31. Di Domenico S, Simonassi C, Chessa L. Inexpensive anatomical trainer for bronchoscopy. Interact Cardiovasc Thorac Surg 2007;6:567-9. [Crossref] [PubMed]
32. Agrò F, Sena F, Lobo E, et al. The Dexter Endoscopic Dexterity Trainer improves fibreoptic bronchoscopy skills: preliminary observations. Can J Anaesth 2005;52:215-6. [Crossref] [PubMed]
33. Krumrei NJ., et al. Development and Validation of a Low-Fidelity Cost-Effective Model for Bronchoscopy Simulation Training. Journal of the American College of Surgeons 2019;229:S238. [Crossref]
34. Colt HG, Crawford SW, Galbraith O 3rd. Virtual reality bronchoscopy simulation: a revolution in procedural training. Chest 2001;120:1333-9. [Crossref] [PubMed]
35. Wahidi, M.M., Simulation for Endoscopy Training. 2013, Springer New York. p. 111-116.
36. Schertel A, Geiser T, Hautz WE. Man or machine? Impact of tutor-guided versus simulator-guided short-time bronchoscopy training on students learning outcomes. BMC Med Educ 2021;21:123. [Crossref] [PubMed]
37. Veaudor M, Gérinière L, Souquet PJ, et al. High-fidelity simulation self-training enables novice bronchoscopists to acquire basic bronchoscopy skills comparable to their moderately and highly experienced counterparts. BMC Med Educ 2018;18:191. [Crossref] [PubMed]
38. Gopal M, Skobodzinski AA, Sterbling HM, et al. Bronchoscopy Simulation Training as a Tool in Medical School Education. Ann Thorac Surg 2018;106:280-6. [Crossref] [PubMed]
39. Davoudi M, Colt HG, Osann KE, et al. Endobronchial ultrasound skills and tasks assessment tool: assessing the validity evidence for a test of endobronchial ultrasound-guided transbronchial needle aspiration operator skill. Am J Respir Crit Care Med 2012;186:773-9. [Crossref] [PubMed]
40. Jantz MA, McGaghie WC. It's time for a STAT assessment of bronchoscopy skills: the endobronchial ultrasound bronchoscopy (EBUS)-STAT and EBUS-transbronchial needle aspiration skill evaluation. Am J Respir Crit Care Med 2012;186:703-5. [Crossref] [PubMed]
41. Mahmood K, Wahidi MM, Osann KE, et al. Development of a Tool to Assess Basic Competency in the Performance of Rigid Bronchoscopy. Ann Am Thorac Soc 2016;13:502-11. [Crossref] [PubMed]
42. Mahmood K, Wahidi MM, Shepherd RW, et al. Variable Learning Curve of Basic Rigid Bronchoscopy in Trainees. Respiration 2021;100:530-7. [Crossref] [PubMed]