John Dewey (born 1859–1952), probably one of America’s most influential philosophers, wrote “the belief that all genuine education comes about through experience does not mean that all experiences are genuinely or equally educative” [13]. For health-care providers, being obliged to perform what might be for the first time, albeit with guidance, a procedure in a patient is both discomforting and anxiety-provoking. A social mandate for accountability and truly informed consent will make it increasingly difficult for practitioners to learn by doing. In addition, such a learning environment creates an ethical dilemma for the competent instructor being asked to advocate for efficient, evidence-based, cost-effective quality of care and who knows that he or she can perform the procedure more quickly and more efficiently and with greater patient comfort than the learner. These arguments justify, whenever possible, a more widespread use of simulation-based bronchoscopy training.

Changes in the perception of the educational process have resulted from modifications of medical education systems. In the United States, for example, the Accreditation Council of Graduate Medical Education currently advocates a competency-based training model that replaces one based on process and number of cases performed [14]. Great emphasis is placed on objective measurements of competency, including elements of professionalism, systems analysis, and health-care team development. In designing a bronchoscopy curriculum, therefore, one must consider how learning processes reach beyond technical skill development to involve the cognitive, affective, and experiential forms of knowledge, as well as how knowledge acquisition and retention might be assessed both during and after training [15]. In my opinion, these arguments, particularly in view of the expansion of bronchoscopic practice,¹ give good reason for a more structured approach to bronchoscopy training. One such approach might include a curriculum that includes recommended reading assignments, case-based and problem-based learning exercises [16], hands-on simulation and real patient-based procedure performance, low-stakes assessments to document progress along the learning curve [17], individual learner-centric training opportunities, and outcome metrics [18] to identify strengths and weaknesses of continued medical education programs as well as the effectiveness of courses and seminars on both individuals and groups.

From a learner-centric perspective, therefore, bronchoscopy education should entail elements of critical thinking, problem-solving, ethical values and behaviors, mastery of critical facts and figures, mastery of certain technical skills unique to each type of procedure being performed, self-realization, self-esteem and emotional stability, safety, and an ability to effectively and efficiently integrate procedural practice into one’s institution-based medical practice. While much of this is presumed to be learned during traditional apprenticeship-style training, various components are often not documented, and in most institutions, from what I have been told by many bronchoscopy experts, no precise written curricular structure is in place.

Despite increasing patient care responsibilities and the stress of providing cost and time-effective quality care, many bronchoscopists create time in their busy schedules in order to devote themselves to the educational process. From a teacher’s perspective, such unselfish involvement might be enhanced if curricular elements were developed in a manner that is time and cost-efficient, nonalienating, and conducive to individualized and collective learning. Some educational methodologies and curricular content, for example, could be standardized to the extent that a generally accepted or more uniform foundation of facts and philosophies becomes available and can be integrated into various individual and group educational venues (i.e., clinical settings, online or computer-based programs, postgraduate seminars, online and onsite courses).

All of us, regardless of our experience and level of competence or expertise, can benefit from pedagogical technical assistance. As new concepts, learning materials, and techniques are introduced into practice, faculty development programs could be used to enhance teaching skills, assure continuity and growth, and develop educational resources. During these venues, experiences could be shared regarding the advantages and challenges of moderating small group interactive learning sessions, using presentations and audience participation software, and integrating video, other media, real-time decision trees, instant messaging, Twitter, tablet PCs, or writing boards into educational programs (Figs. 7.1 and 7.2).

While a mentor’s behaviors might readily be emulated after observation, it is unrealistic to expect that the ability to teach effectively comes naturally to everyone. Of course, many physicians are excellent teachers, but the assumption that a medical doctor is a natural-born instructor represents, in my opinion, a significant shortcoming of our academic philosophy and runs contrary to assumptions in other professions such as public education and sports, where particular emphasis is placed on learning how to teach. The purpose of faculty development programs, often referred to as train-the-trainer seminars, therefore, is to help motivate, stimulate, inspire, and train professionals interested in serving as role models, mentors, and instructors in the use of diverse educational techniques and methodologies and to develop, provide, and study resources that are incorporated in whole or in part into various learning curricula.

There is a grand tradition in bronchoscopy education. This tradition is twofold. In the first instance, we assume that learners will learn bronchoscopy during the course of their specialty training [19] and that learning will be satisfactory because learners are exposed to different faculty members who might each perform bronchoscopy in a different way (setup, positioning, sedation and medication use, techniques, etc.). Accompanying this is the idea that the complexities of a bronchoscopy-related consultation are always learned while rotating on a specialty consultation service and that all of the items pertinent to such a consultation are satisfactorily addressed, even if they are not explicitly reviewed with the attending faculty (i.e., indications and informed consent, procedure-related strategy and planning, technique and expected results, response to complications, post-procedure management, and follow-up).

The second tradition pertains to the popularity of 1- and 2-day postgraduate courses, devoted until recently and for the most part to physicians already in practice. We have always trusted that these courses were effective and met particular training objectives. For bronchoscopists, the tradition comes from decades of hands-on learning that began with the admired and effective patient-based rigid bronchoscopy instruction programs conducted by Gustav Killian and Chevalier Jackson. In such a program, the expert speaker lectures on a topic, while the learner group listens dutifully. Often, individual experts prepare their lectures with little information or fixed-in-advance knowledge regarding common purpose that might integrate their lectures with content from other talks given during the course. Popular hands-on sessions are organized using animal models and equipment loaned from equipment manufacturers. More recently, computer-based simulation and inanimate models have been introduced. Learners rotate from station to station, listening to experts tell them about a procedure or technique, then watch as he (until recently, most bronchoscopy experts have been male) demonstrates the technique. Then one after another, learners take the scope in hand and do something, some less well than others. Sometimes, live transmissions of cases are included in the program, with either the operator or other faculty member interacting with the audience to discuss indications and procedural techniques.²

During these programs, we had always assumed learners would learn by simply being present: preliminary or postcourse assessments are rarely performed and little time is devoted to truly individualizing the learning process. An objective commentary about these programs, however, might include the following:

A paucity of studies pertaining to the effectiveness, or lack thereof, of these traditional methods of bronchoscopy education makes it challenging to step out of the box in order to view the abovementioned traditional educational processes differently. It is equally challenging to introduce and potentially justify changing a well-entrenched educational system. The reality is, however, that an older paradigm frequently provides a dynamic vision for what is to come after it. Today, we know that:

This list is obviously not exclusive, and many other elements are important in rethinking traditional methods of bronchoscopy education. Agents of change are necessary to develop and implement different teaching strategies and methodologies across the globe. Industry support is essential to educational programs, and professional societies may need to work together, rather than compete, in order to foster a foundation of information and assure a greater democratization of knowledge. Finally, either/or debates and opposing points of view can be synthesized in a manner that promotes learning and choice, acknowledging both points of view in the context of a broadened educational perspective [20] (Fig. 7.3).

The bronchoscopy-related literature is gradually supporting the paradigm shift, whereby patients will no longer bear the burden of procedure-related training. In a review pertaining to the use of simulation for bronchoscopy education [21], we noted that simulation helps learners improve procedural efficiency and economy of movement, thoroughness, and accuracy of airway examination and decreases airway wall trauma [22]. In addition to increasing learner satisfaction and interest, simulation allows tasks to be practiced repeatedly without jeopardizing patient safety, and training scenarios can be individualized. Both low- and high-fidelity simulation have been shown to enhance competency in procedural skills while saving time and improving the learning curve [23, 24]. Furthermore, skills acquired through practice on simulators are transferable to the clinical setting [25]. Objective assessment identifies errors and provides opportunities for remedial training [26, 27].

High-fidelity simulation platforms using three-dimensional virtual anatomy and force feedback technology can be used to teach conventional and EBUS-guided transbronchial needle aspiration (TBNA) although less expensive, low-fidelity models comprised of molded silicone excised animal airways^, and ultrasound phantoms are also effective [28]. The efficacy of a low-fidelity hybrid airway model made of a porcine trachea and a plastic upper airway was demonstrated for learning transcarinal and transbronchial needle aspiration [29]. This model gave learners an opportunity to practice needle insertion, positioning, safety measures, and communication with ancillary personnel. It has since been modified so that a plastic airway is used, obviating the need for discarded animal parts and making the use of such training materials possible in hotel conference centers and nonhospital facilities. Models can also be used to teach scope manipulation and airway anatomy, foreign body removal, bronchoscopic intubation, EBUS-guided TBNA, and other interventional techniques, some of which can also be practiced using high-fidelity computer-based simulation³ (Fig. 7.4). New, portable computer-based bronchoscopy simulation is becoming available using laptop computers and proxy bronchoscopes.⁴

Demonstrating improvements in technical skill complete only part of the picture [30]. The increasing emphasis on competency-oriented education warrants that bronchoscopy courses also use competency-based measures to assess the efficacy of course curricula and training modalities [31]. Outcome measures might take the form of high- or low-stakes testing in the various cognitive, technical, affective, and experiential elements of procedure-related knowledge [32–34]. Using quasi-experimental study design and a series of pretest/posttest assessments with calculations of absolute, relative, and class-average normalized gain, we have demonstrated the efficacy of a 1-day structured curriculum including a uniform set of didactic lectures, interactive sessions, workshops, and hands-on simulation-based training in flexible bronchoscopy and thoracoscopy [35, 36].

Assessment tools that objectively measure skill and knowledge acquisition will also need to be designed and validated in various learning settings and medical environments [37]. Ideally, their design should be flexible so that instructors with different habits or biases can still incorporate them into their programs without feeling compelled to radically modify their own way of performing procedures. As faculty development programs are integrated into curricular structures, it may become helpful to study their value and contributions to enhanced teaching and learning. Finally, research targeting curricular platforms and the results of educational interventions will contribute to the elaboration of new bronchoscopy instruction-related theories and processes.

Developed by Bronchoscopy International⁵ in collaboration with many experts from all over the world, the Bronchoscopy Education Project (BEP) ⁶ has been officially endorsed by several international bronchology and interventional pulmonology societies. Its aim is to complement and hopefully enhance existing educational programs by providing bronchoscopy instructors and training program directors with competency-oriented tools and materials. These may be used to help train bronchoscopists and assess progress along the learning curve from novice to competent practitioner. The curriculum includes The Essential Bronchoscopist™ series of books and e-books [38, 39]; a series of training manuals [40]; an encyclopedia of Practical Approach© patient-centered exercises that integrate cognitive, affective, and experiential knowledge pertinent to bronchoscopy-related consultation; Bronchoscopy Step-by-Step© lessons; a problem-oriented BronchAtlas™ video series⁷; a compilation of PowerPoint-based lecture programs called Fundamentals of Bronchoscopy© ; and a set of Bronchoscopy Assessment Tools© and Checklists. Material can be integrated in whole or in part, as needed by each program. Learning is based on individual and group study of training manuals, participating in didactic and interactive lecture programs delivered onsite and online, viewing instructional videos on social media sites such as YouTube and Facebook, and participating in deliberate hands-on practice sessions during postgraduate programs and in the course of subspecialty training. Officially supported by and in collaboration with professional medical societies, faculty development programs are being conducted across the globe to help an international group of bronchoscopists, early adopters, and agents of change use these learning materials, improve their presentation skills, create personalized curricula specific to the needs and medical culture of their region, and develop concepts that will strengthen future educational programs. Specific criteria exist by which instructors become certified. A brief description of some of the BEP resources built on the philosophy of using frequent, repeated group and individual exposures to multimedia rather than single-medium instruction [41] is found below: