Another barrier is lack of adequate training. Most practicing pulmonologists and thoracic surgeons are not trained in EBUS. Courses have proliferated, and some advanced endoscopists may develop adequate skills by building on a weekend course. Also, some pulmonary training programs have begun training their fellows in EBUS. While these offerings may help, the reality is that most thoracic disease specialists are not advanced endoscopists and that pulmonary and thoracic surgery training programs historically are challenged to provide training in basic bronchoscopy. Therefore, asking these programs to shoulder the training required for any advanced procedure builds on an already stressed foundation. Just consider the early history and poor adoption of standard transbronchial needle aspiration despite years of availability.6 How can we expect adequate training in EBUS, with its added equipment, different visualization system, and added procedure time, when such a simple adjunct to basic bronchoscopy as transbronchial needle aspiration languished?