1Copenhagen Academy for Medical Education and Simulation, University of Copenhagen and the Capital Region of Denmark, Rigshospitalet, Copenhagen, Denmark. 2Dept of Internal Medicine, Zealand University Hospital, Roskilde, Denmark.
Correspondence: Leizl Joy Nayahangan, Copenhagen Academy for Medical Education and Simulation, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark. E-mail: firstname.lastname@example.org
Interventional pulmonology has evolved dramatically to include more complex procedures. For example, the use of fibreoptic bronchoscopes has been transformed by advanced video bronchoscopes with new image-acquisition systems that allow access to difficult areas, such as structures outside the bronchial tree. With advancing technology and innovation, the challenge is how to train and develop proficient interventional pulmonologists. Training has traditionally been by apprenticeship under expert clinicians, in which residents learned procedural skills through direct observation and eventually performing the procedure under supervision. However, this training approach is discouraged in the modern healthcare system. The future of interventional pulmonology depends on proper training and certification, without practical testing on patients. Competency-based education is efficient for learning technical skills and ensuring competency before moving to the next level. Efficient instructional strategies should include rigorous approaches, such as mastery learning and deliberate practice, well-described objectives, predefined benchmarks and valid, reliable assessment tools.
Cite as: Nayahangan LJ, Clementsen PF, Konge L. Training. In: Herth FJF, Shah PL, Gompelmann D, eds. Interventional Pulmonology (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 64–77 [doi.org/10.1183/2312508X.10002717].
Procedural competency is conventionally achieved through supervised residency in clinical wards. This happens over time, during which knowledge and technical skills are acquired according to credit hours from courses or number of procedures performed. However, the range of diseases is expanding, and new therapies are being introduced. This increases the demands for interventional pulmonology . Residents have limited training time in light of increased focus on production, which is defined as patients per unit of time, work-hour restrictions and increasing emphasis on patient safety. Interest in more advanced, safer training venues, such as simulation centres, has increased dramatically in response to the confluence of challenges that the medical community is facing.
Teaching pulmonologists of the new century
Today’s healthcare environment has undergone many modifications, fuelled by the surge in new technology that is transforming delivery and practice, especially in minimal invasive medicine and surgery. Interventional pulmonology has been at the vanguard of this innovation. It has expanded rapidly to diagnose and treat a wide range of pulmonary diseases . These advances are attracting trainees, clinicians and the industry, because of the unique skill sets and expertise that distinguish interventional pulmonology from other well-established subspecialties of pulmonary medicine and thoracic surgery. Consequently, extensive training beyond the traditional pulmonary and critical-care fellowship to acquire advanced technical expertise is now required. Professional organisations across Europe and North America have started to recognise these unique skill sets and are pursuing major reforms to define curricular requirements, including indications and desired patient outcomes [3, 4]. In the USA, a dedicated, 12-month fellowship training programme has been established to prepare trainees in procedural practice, advanced knowledge, skills and research . Other current venues offer short courses and extended sabbatical training in different interventional pulmonology centres across the world . Despite these initiatives to formalise dedicated training pathways and define competencies, interventional pulmonology is still in its infancy and continues to evolve, alongside new technologies. There is a need for formal, standardised interventional pulmonology training programmes measured by valid, reliable competence metrics . Educational leaders must take responsibility for exploring new training modalities and incorporating these into the armamentarium of education in interventional pulmonology .
Approaches to training
Traditional apprenticeship method
Formal training for interventional pulmonologists focuses on diagnosing and managing pleural diseases, lung cancer, central airway obstruction, and many other diverse and specialised procedures. Residency training is traditionally achieved through the standard apprenticeship method, which has been the cornerstone of medical and surgical training for over a century . This follows the long-established adage of “see one, do one, teach one”, wherein trainees observe experienced practitioners and are expected to acquire the necessary skills and competencies. Patients have played a central role in residency training for decades. SILVESTRI  described his first bronchoscopy in 1993:
“I practiced for a while on an inanimate tracheobronchial tree, convinced that I would be observing this first procedure and proud to have not damaged the bronchoscope in the process. When the attending physician arrived, a highly regarded bronchoscopist in his own right, he proceeded to take the teaching head (at the time there were no videoscopes) and hand me the bronchoscope, which he never took back. What followed can only be described as incompetence of the highest order. While the procedure only took 30 min, it seemed like days. Sweat poured from my gloves while the room shrunk in around me. I felt every emotion from anger at my attending physician, to sympathy for my patient, to fear for my career, believing it would end in disgrace when I could not enter the superior segment of the right lower lobe.”
Nowadays, we are experiencing major changes in healthcare delivery and exploring new technologies.
New dimension of training simulation
Simulation provides trainees with a forgiving, safe environment in which to develop and refine technical skills before working in the clinical environment with patients. Modelled from the aviation industry, simulation in healthcare includes different models, such as live animals, human cadavers, ask trainers, manikins, computer-based models and virtual-reality simulators. This training approach is modelled on Fitts and Posner’s three-stage theory of motor-skills acquisition . When presented with a task, the trainee attempts to understand the mechanisms of the task and consciously attempts to produce a specific result. In this cognitive stage, the performance is slow and inefficient, and errors are evident. For example, when performing flexible bronchoscopy, the trainee must initially understand the principles behind how the scope works, how to insert and manoeuvre it, and how to systematically explore the bronchial tree. After subsequent practice and feedback sessions, the trainee reaches the integrative stage, in which movements are more efficient and accurate. The trainee still thinks about how to manoeuvre the scope, but now does so fluidly, with fewer interruptions. In the autonomous stage, the tasks are precisely and consistently executed, and the movements are automatically controlled, with little or no cognitive input. The trainee inserts the scope and manoeuvres through the bronchial tree in an automated fashion. At this stage, the trainee also focuses on refining the skills associated with the task. The first stages should be accomplished in a simulation-based environment, in which trainees can safely practise, learn from errors, and potentially achieve the skills and confidence to perform the task autonomously.
Simulation is highly resource intensive. Return of investment can be achieved when equipment and training are centralised in a local centre, shared by different hospitals . This allows flexibility, making the centre available for trainees to practise according to their availability. They can practise individually, guided by training assistants or in pairs. Figure 1 shows a simulation centre with different equipment for practising various procedures in interventional pulmonology.
Following the evolution of equipment in interventional pulmonology, simulation equipment also proliferated. Physical models and virtual-reality simulators are the most common equipment currently used. KONGE  compared these modalities (table 1).
High trainee satisfaction; no randomised trials performed
Randomised trials showing higher efficacy than apprenticeship approach at the beginning of the learning curve
Relatively cheap but will need real equipment, which will require repair costs
Expensive; return on investment is improved if training is centralised and shared by several departments/hospitals
Mobile; not too heavy to move around
Heavy and fragile to move
No, only fixed cases
Yes, several cases of simulated patients
Only enlarged lymph nodes for EBUS-TBNA
Cases with bleeding, visible tumours or enlarged lymph nodes
Simulates use of tools
Real tools can be used with caution to avoid damaging the model
Varied simulated tools can be used to instil lidocaine, remove foreign bodies, perform biopsies, etc.
No, an instructor is needed for feedback
Automatically delivers a multitude of performance metrics; several of these must be used with caution due to lack of evidence-based validity
Reproduced from  with permission.
The curriculum of training programmes is one of the challenges that must be addressed. Simulation will only be effective if it is integrated into a well-designed curriculum. Generally, simulation programmes are developed in a predictive approach without systematic objectives , according to experiential notions  or availability of equipment . We must know the current needs of residents in training prior to buying equipment and developing training programmes. Developing an efficient curriculum should start with identifying the problem and performing a general needs assessment . In Denmark, a systematic, national needs assessment was conducted among key opinion leaders in pulmonary medicine to identify procedures for simulation training. This resulted in a prioritised list of 11 technical procedures that are clinically relevant and should be integrated in a simulation-based curriculum. Flexible bronchoscopy was the most important, followed by pleurocentesis, EBUS-TBNA, EUS-guided fine-needle aspiration biopsy (EUS-FNA), noninvasive ventilation, transthoracic biopsy of pleural or lung tumour, focused ultrasound scanning of the lungs, chest-tube insertion, needle biopsy of visible lymph node/tumour of the skin, focused ultrasound scanning of the heart and thoracoscopy . Educational directors are encouraged to use this list to develop training programmes.
Time- and volume-based approach
The current educational approach in interventional pulmonology has followed the traditional time- and volume-based framework, in which the vast majority of trainees successfully complete a fixed amount of time and curricula . When these are met, it is crudely assumed that the trainee can apply what they have learned to deliver patient care. This method does not take into account the fact that individuals learn at different paces, resulting in a wide variation of skill levels among trainees at the end of their education . For example, individuals with outstanding technical dexterity require less time to master a skill compared with an average individual, who needs more time to practise to achieve the same results.
Practice guidelines, such as those from the American College of Chest Physicians (ACCP) and the European Respiratory Society and American Thoracic Society (ERS/ATS), have outlined the desired objectives, structures and outcome of training, including recommended volume thresholds for different procedural skills to demonstrate competence [3, 4]. How were these numbers derived? These numbers are arbitrary and should be taken as suggestions, rather than absolute regulations . The focus must shift to quality, rather than quantity, of training. This can be achieved by establishing standardised training curricula in the field of interventional pulmonology.
Advocating for expertise rather than experience is the driving force for educational organisations, such as the Accreditation Council for Graduate Medical Council (ACGME), the American Board for Medical Specialties (ABMS) and the Royal Colleges in the UK, to establish competency-based training for all doctors [19, 20]. Recently, the Association for Medical Education in Europe (AMEE) also developed guidelines promoting a new training paradigm called competency-based education . This contemporary training approach is fundamentally orientated towards outcome abilities, with greater emphasis on accountability, flexibility and centring on the learner . Training is tailored according to the individual’s needs and abilities to progress from the beginning to advanced technical tasks . Effective, evidenced-based medical education should include mastery learning, deliberate practice and rigorous outcome measures . Mastery learning is a specific, rigorous approach towards achieving proficiency in a particular task . Trainees must acquire the knowledge and skills to reach a predefined proficiency level before moving to the next learning objective.
According to ERICSSON , it takes extensive experience to become outstanding at something but does not necessarily lead to expertise. Achievement of expert performance requires engaging in deliberate practice. This involves focused, repeated practice on a representative task to learn from errors and improve, according to immediate feedback. This approach is followed by other professionals, such as chess masters, Olympic athletes and scientists to become world-class performers. Maintaining superior performance also takes constant practice. MCGHAGIE et al.  underscored the use of deliberate practice in medical education by outlining nine features: 1) highly motivated trainees with good concentration, 2) engaging with a well-defined learning objective or task, 3) an appropriate level of difficulty, 4) focused, repetitive practice, 5) rigorous, precise measurements, 6) informative feedback from educational sources (e.g. simulators, teachers), 7) trainees who monitor their learning experiences and correct strategies, and errors and levels of understanding, and who engage in more deliberate practice, 8) evaluation to reach a mastery standard and 9) advancing to another task or unit.
Deliberate practice is a viable solution to training limitations, such as scarcity of clinical educators. However, unsupervised practice could lead to developing bad habits and misunderstandings . Directed, self-regulated learning allows trainees to practice autonomously but access directed guidance when needed. The trainee can be metacognitively, behaviourally and motivationally active . Another way to train is dyad practice, in which two individuals learn a task collaboratively instead of individually. BJERRUM et al.  explored dyad practice as a simulation training strategy in bronchoscopy and concluded that practising in dyads can increase efficiency for novice learners. Educators should consider these two ways of learning to conserve time without sacrificing efficiency and effectivity in developing technical skills.
At the end of residency training, interventional pulmonologists are expected to have reached a predefined level of competency, allowing them to perform procedures safely and efficiently. Information about performance and competence depends on effective, accurate, timely and meaningful assessment . In 1990, MILLER  presented his pyramid of competence to define the framework for assessing clinical skills (figure 2). This ground-breaking conceptual model outlines the different facets of competence, starting with the base “knows” (knowledge of basic facts), followed by “knows how” (knowing how to use the learned knowledge), “shows how” (applying this knowledge) and finally “does” (performing the acquired skills in the clinical environment). Each facet of the pyramid should be assessed by valid, reliable assessment tools. There is increasing focus on “shows how” and “does”. Simulation plays a vital role, especially in the “shows how” stage. Inspired by Miller’s pyramid, KONGE et al.  outlined a three-step approach to achieve competency in endoscopy, in which step 2 tackles hands-on training to practise and master procedural skills away from patients (figure 3). It is important to acknowledge that simulation does not aim to create experts but helps novices go through the steepest part of the learning curve.