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Learning to Look Through the BronchoscopeLearning to Look FREE TO VIEW

Michael J. Simoff, MD, FCCP
Author and Funding Information

From the Section of Bronchoscopy and Interventional Pulmonology, Pulmonary and Critical Care Medicine, Henry Ford Health System and Wayne State University School of Medicine.

CORRESPONDENCE TO: Michael J. Simoff, MD, FCCP, Pulmonary and Critical Care Medicine, K-17, 2799 W Grand Blvd, Detroit, MI 48202; e-mail: MSimoff1@hfhs.org


FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(2):301-303. doi:10.1378/chest.15-0551
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Published online

“See one, do one, teach one.” For many physicians, this was how we were expected to learn. Similar to no longer working unlimited hours, things have changed. Procedures are more complex now with the addition of more techniques, such as endobronchial ultrasound and other navigational tools, than were available even 5 years ago. In this issue of CHEST (see page 321), Ernst et al1 are tasked with a very difficult problem: How, or is it even possible, to determine competency of trainees in bronchoscopy?

One of the difficulties the authors are presented with is addressing the many faces of competency. They evaluated training for pulmonologists in and out of the United States. In addition, they evaluated the measurement of bronchoscopy training competency of thoracic surgical residents as well as other surgical residents. Competency-based medical education is defined as “an outcomes-based approach to the design, implementation, assessment, and evaluation of medical education programs, using an organizing framework of competencies.”2 I feel that the authors’ task is made more difficult because we have not established the best, or even a consistent, way to teach bronchoscopy, let alone understand how to tell if trainees are competent in bronchoscopy.

The goal for competency requires the learning of a new skill. One of the difficulties with any project that has to do with teaching is to first remember that we are physicians, not trained educators. A teacher never begins a semester without a lesson plan. When they get a new class, a new textbook, or change the curriculum to add updated information, they change their lesson plans accordingly. Education is a process. It begins with the basics, builds upon them, and adds more material as the semester continues. Then one needs to pass the first semester to move onto the second. This same system exists in middle school, high school, and undergraduate and graduate schools. Yet, when we get trainees into advanced postgraduate training, we have them jump right into patient management, often without “teaching” them, because, quite frankly, we were taught the same way.

As physicians, traditionally our first approach to a problem is to research it. We do a literature search, we review meta-analyses of the subject, and read all of the new articles pertaining to a topic. This same approach is often used when developing a presentation for a lecture. Often speakers will display slide after slide with graphs and tables from a variety of studies, each chosen to support the viewpoint of the speaker. In many respects, instead of educating, we often review the facts. Although many of us are academics, clinicians, and researchers, for the most part, we are not trained educators. The article by Ernst et al1 is a wake-up call in many ways. The authors give a summary of eight suggestions, all of which are ungraded, consensus-based statements. This was a very well done report. The appropriate scientific method, as stated in the literature, was used: The authors asked questions, collated and reviewed data, and the cumulative answer is that everyone is approaching the process of educating residents and fellows in bronchoscopy differently, so not enough facts existed to give scientifically graded recommendations.

Education in bronchoscopy is not as simple as asking “Which way do I push the lever to make the tip of the scope flex?” The field and art of bronchoscopy are immensely complex. Initially, the trainee must learn not just the airways, but the anatomy that surrounds the airways. Where are the mediastinal structures? What is the lymphatic drainage path for each lobe of the lung? How do the two-dimensional CT scans on the computer screen in front of them relate to the airways they will be traveling through?3 The new bronchoscopist needs to learn their tools: dimensions and abilities of different bronchoscopes, the use of ultrasound in the chest, how supportive tools such as fluoroscopy or electromagnetic navigation can be used to improve their performance. The new bronchoscopist must become an expert in the diseases they will be evaluating, understanding their natural history and how they will affect the airways, lungs, and/or pleura that they will be evaluating.

All learners learn differently. Students have different intrinsic skills that allow them to do different tasks really well. There are seven learning styles taught to educators: visual (spatial), aural (auditory), verbal (linguistic), physical (kinesthetic), logical (mathematical), social (interpersonal), and solitary (intrapersonal).4,5 As most people do not know their ideal learning style, and without having to test each trainee for their optimal learning style, it would be paramount that components of an educational method in bronchoscopy include combinations of each of these learning styles throughout the process or, better still, to develop a curriculum that does this for teaching bronchoscopy.

Any staff member who teaches bronchoscopy can tell from the first time someone handles a bronchoscope if they are going to be good or not. These “gifted” novices are able to move through the airways fluidly and appear to know where they are at all times. This intrinsic skill is part of the neuropsychologic processing of person’s brain. Just like running or hitting a ball, some are naturally more talented than others. The art of bronchoscopy is based upon many of these intrinsic skills: relying on the interpretation of two-dimensional data (CT/chest radiography); envisioning a three-dimensional environment (the chest); moving a bronchoscope through the actual three-dimensional space (airways); making those movements while looking at a two-dimensional image (the screen).3,6 This is the same as looking at a map, picking where you want to go, getting into your car, and driving backward only using your mirrors or back-up camera, and doing this in the dark. Realizing who is skilled with spatial relations and who could use additional training will greatly affect the ability to perform increasingly complex procedures.

To many pulmonologists, bronchoscopy is the procedure that defines them. The time for “see one, do one, teach one” is over. We, as the educators, need to stop looking at the tally at the end of the game in terms of the number or procedures needed to become competent, or what even defines competence—this is different for every person. Instead, leaders and organizations need to make education in bronchoscopy a priority, developing curricula based upon sound educational standards and agreed-upon goals, with appropriate didactic and kinesthetic standards established and met.

References

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(2):321-332.
 
Frank JR, Snell LS, Cate OT, et al. Competency-based medical education: theory to practice. Med Teach. 2010;32(8):638-645. [CrossRef] [PubMed]
 
Johnson D, Stewart J II. Use of virtual environments for the acquisition of spatial knowledge: comparison among different visual displays. Mil Psychol. 1999;11(2):129-148. [CrossRef]
 
Kozhevnikov M, Hegarty M, Mayer R. Revising the visualizer-verbalizer dimension: evidence for two types of visualizers. Cogn Instr. 2002;20(1):47-77. [CrossRef]
 
Overview of learning styles. Learning-styles-online website. http://learning-styles-online.com/overview/Accessed on February 26, 2015.
 
Kozhevnikov M, Blazhenkova O, Becker M. Trade-off in object versus spatial visualization abilities: restriction in the development of visual-processing resources. Psychon Bull Rev. 2010:17(1):29-35. [CrossRef] [PubMed]
 

Figures

Tables

References

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(2):321-332.
 
Frank JR, Snell LS, Cate OT, et al. Competency-based medical education: theory to practice. Med Teach. 2010;32(8):638-645. [CrossRef] [PubMed]
 
Johnson D, Stewart J II. Use of virtual environments for the acquisition of spatial knowledge: comparison among different visual displays. Mil Psychol. 1999;11(2):129-148. [CrossRef]
 
Kozhevnikov M, Hegarty M, Mayer R. Revising the visualizer-verbalizer dimension: evidence for two types of visualizers. Cogn Instr. 2002;20(1):47-77. [CrossRef]
 
Overview of learning styles. Learning-styles-online website. http://learning-styles-online.com/overview/Accessed on February 26, 2015.
 
Kozhevnikov M, Blazhenkova O, Becker M. Trade-off in object versus spatial visualization abilities: restriction in the development of visual-processing resources. Psychon Bull Rev. 2010:17(1):29-35. [CrossRef] [PubMed]
 
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