13 Teaching Methods
Thoracoscopy skills should be developed over an extended period during which physicians acquire expertise in pleural diseases and procedures (see Chapter 10, “Knowledge and Skills Required”). Technical skills are best learned under the direct supervision of an experienced thoracoscopist. Because manual dexterity, confidence, and expertise may vary from one physician to another, it is difficult to specify a minimum number of procedures necessary to obtain the skill or to maintain competence. It is unlikely that any specific number of procedures will guarantee competence. However, a minimum number of 20 procedures is desirable to achieve sufficient familiarity with the instrumentation and interpretation of normal and pathological thoracoscopic findings. Procedural competence can probably be maintained if about 10-12 thoracoscopies are performed yearly.
Physicians acquiring skills in thoracoscopy should be experienced in the diagnosis and management of diverse pleural and pulmonary disorders. Familiarity with endoscopic and video instrumentation and techniques is mandatory. Physicians should be proficient at pleural procedures, including thoracentesis and closed needle pleural biopsy; competence in both procedures is required in the United States by the American Board of Internal Medicine for Pulmonary Diseases Board Certification. In addition, physicians should be proficient at tube insertion and management, a procedure required for Critical Care Board Certification in the United States.
Adequate training in both the cognitive and technical aspects of thoracoscopy is essential. This is unlikely to be provided by a single two-day course. Training courses should be encouraged and may be extremely beneficial if they follow, for example, Accreditation Council for Graduate Medical Education (ACGME) guidelines for full Continuing Medical Education (CME) accreditation and include didactic lectures as well as laboratory sessions. By attending hands-on training seminars, lectures, and symposia, physicians can learn basic concepts and acquire greater understanding of the appropriate indications, risks, benefits, and limitations of thoracoscopic/pleuroscopic interventions. These sessions should allow physicians to achieve familiarity and comfort with basic thoracoscopic/pleuroscopic techniques and instrumentation. Physicians should be encouraged to work with a mentor within their community until the necessary criteria are met for medical thoracoscopy/pleuroscopy privileges within their own institutions. This form of a mini-fellowship may be ideal for training physicians in procedures not learned during formal subspecialty training. Physicians in training should maintain records of their experience during the training process.
A competent medical thoracoscopist/pleuroscopist, therefore, should be more than a master of the instrument within the pleural space, but should be a complete consultant for pleuropulmonary disorders (“window to the pleural space”).
Suggestions for Learning the Technique
• There are currently no good simulation or inanimate models on the market with which to learn medical thoracoscopy/pleuroscopy (R.L. uses one phantom produced for Olympus).
• A variety of animal models have been used (see Chapter 5 “MT/P in Animals”, p. 54 ff.) in training courses along with didactic lectures including videos.
• The learning is best done by being an assistant to a physician who is well versed in the art of medical thoracoscopy/pleuroscopy.
• A good opportunity to learn the inspection of the pleural space and its pathological situations is given by the observation of procedures on the video screen or live transmission to a bigger group.
• Physicians performing this procedure should have ample experience, excellent knowledge of pleural and thoracic anatomy, mature judgment in interpreting radio-graphic images related to pleural disease, and sufficient endoscopic skill. The American College of Chest Physicians (ACCP) suggests that the trainees should perform at least 20 procedures in a supervised setting to establish basic competency (Ernst et al. 2003).
• After such training, mentoring with a thoracic surgeon by participation during VATS procedures would certainly complement the training.
• Start with easy situations such as large pleural effusion or pneumothorax when the placement of a chest tube is indicated.
• As with all technical procedures there is a learning curve before full competence in medical thoracoscopy/ pleuroscopy is achieved (Boutin et al. 1981a; Rodriguez-Panadero 1995).
• To maintain competency, dedicated operators should perform at least 10 procedures per year (Ernst et al. 2003).
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