Training and certification in endobronchial ultrasound-guided transbronchial needle aspiration

How do cytopathologists learn fine needle aspiration techniques? An international survey

INTRODUCTION

Fine needle aspiration cytology (FNAC) is a widely accepted diagnostic technique, but performance varies according to expertise. Little is known about variation in FNAC training practices worldwide. We surveyed pathologists using social media networks to determine FNAC training practices internationally.

DESIGN

Pathologists were surveyed on questions related to FNAC simulation training using direct messaging on the Twitter and WhatsApp platforms. Survey responses over a period of 2 weeks were collected.

RESULTS

In total, 149 pathologists participated (96.1% response rate). The respondents came from 24 countries and 87 institutions. The majority of the pathologists (63.8%) performed FNAC directly on patients for the first time. Only 36.2% of them had simulation instruction during their training. It was performed on food items such as fruit (64.8%), surgical specimens (37.0%), autopsies (13.0%) and others (9.3%), including commercially available phantom simulators for ultrasound-guided FNAC (US-FNAC) (two pathologists).

DISCUSSION

Most pathologists did not receive formal training in a simulated environment, and of the pathologists who had simulation instruction, food items were commonly used for education. A few participants used a commercial US-FNAC simulator, but since most pathologists perform FNAC by palpation, this method of simulation training is not applicable to many practices. Social media is an effective and efficient way to perform survey research, yielding a very high response rate.

Perspective and practice patterns of mediastinal staging among thoracic surgeons

Background

Accurate mediastinal staging of lung cancer patients is critical for determining appropriate treatment. Mediastinoscopy and endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration are the most commonly utilized techniques. Limited data exist on training and practice trends among thoracic surgeons. We aimed to determine training and practice patterns and find whether there is a paradigm shift in mediastinal staging after the introduction of EBUS into practice among thoracic surgeons in the United States.

Methods

28-question survey was constructed querying demographic, training, and practice patterns with mediastinoscopy and EBUS and was sent to practicing thoracic surgeons in the United States. Descriptive statistics were used to summarize quantitative data.

Results

Ninety-eight responded with a 93% completion rate. Eighty-seven percent of respondents received training in EBUS and 70% perform EBUS routinely. All respondents believe EBUS should be incorporated into thoracic surgery training curriculums. Majority of those who prefer EBUS feel EBUS is safer than mediastinoscopy, allows access to lymph nodes stations or lesions inaccessible by mediastinoscopy and prefer EBUS to avoid re-do mediastinoscopy and in irradiated mediastinum. Majority of those who prefer mediastinoscopy reported they perform more accurate staging compared to EBUS, that mediastinoscopy is more accurate in diagnosing lymphoma or sarcoidosis and that frozen section can be done at the same interval as resection. Among surgeons who prefer EBUS, 94% biopsy 3 or more lymph node stations, 86% routinely biopsy hilar (N1) nodes while 8% never biopsy N1 nodes. Of surgeons who prefer mediastinoscopy. Ninety-seven percent biopsy 3 or more lymph node stations, only 27% routinely biopsy N1 nodes and 70% never biopsy N1 nodes.

Conclusions

EBUS is used frequently by thoracic surgeons in their practice for mediastinal staging. Methods of obtaining proficiency in EBUS widely varied among surgeons. In addition to mediastinoscopy, dedicated EBUS training should be incorporated into thoracic surgery training curriculums.

Impact of a Multimodal Simulation-based Curriculum on Endobronchial Ultrasound Skills

Background

Currently there is no consensus on ideal teaching method to train novice trainees in EBUS. Simulation-based procedure training allows direct observation of trainees in a controlled environment without compromising patient safety.

Objective

We wanted to develop a comprehensive assessment of endobronchial ultrasound (EBUS) performance of pulmonary fellows and assess the impact of a multimodal simulation-based curriculum for EBUS-guided transbronchial needle aspiration.

Methods

Pretest assessment of 11 novice pulmonary fellows was performed using a three-part assessment tool, measuring EBUS-related knowledge, self-confidence, and procedural skills. Knowledge was assessed by 20 multiple-choice questions. Self-confidence was measured using the previously validated EBUS–Subjective Assessment Tool. Procedural skills assessment was performed on Simbionix BRONCH Express simulator and was modeled on a previously validated EBUS–Skills and Task Assessment Tool (EBUS-STAT), to create a modified EBUS-STAT based on internal faculty input via the Delphi method. After baseline testing, fellows participated in a structured multimodal curriculum, which included simulator training, small-group didactics, and interactive problem-based learning sessions, followed by individual debriefing sessions. Posttest assessment using the same three-part assessment tool was performed after 3 months, and the results were compared to study the impact of the new curriculum.

Results

The mean knowledge score improved significantly from baseline to posttest (52.7% vs. 67.7%; P = 0.002). The mean EBUS–Subjective Assessment Tool confidence scores (maximum score, 50) improved significantly from baseline to posttest (26 ± 7.6 vs. 35.2 ± 6.3 points; P < 0.001). The mean modified EBUS-STAT (maximum score, 105) improved significantly from baseline to posttest (44.8 ± 10.6 [42.7%] vs. 65.3 ± 11.4 [62.2%]; P < 0.001). There was a positive correlation (r = 0.81) between the experience of the test participants and the modified EBUS-STAT scores.

Conclusion

This study suggests a multimodal simulation-based curriculum can significantly improve EBUS-guided transbronchial needle aspiration–related knowledge, self-confidence, and procedural skills among novice pulmonary fellows. A validation study is needed to determine if skills attained via a simulator can be replicated in a clinical setting.

Developing a simulation-based training curriculum in transesophageal ultrasound with the use of the endobronchial ultrasound-endoscope

There is an increasing need to focus on how best to train respiratory physicians to perform EUS with bronchoscope-guided fine-needle aspiration biopsy (EUS-B-FNA). At current, training is mostly performed in the clinical environment under expert supervision; however, the advent of simulation-based education now provides a low-risk setting for novice trainees to learn and practice basic endosonography skills from identifying and understanding normal anatomy as well as pathology, maneuvering of endoscope, interpretation of images, and mastering of sampling techniques. In this descriptive educational paper, we used a six-step approach as a framework to describe the development of a structured training program combining EUS-B-FNA with the already well-established certification training program in endobronchial ultrasound transbronchial needle aspiration. This comprehensive training curriculum includes a theoretical course to achieve foundational knowledge, followed by simulation-based training until mastery standards are met, and supervised clinical apprenticeship. All steps should end with an objective assessment to achieve certification. This systematic development will hopefully encourage endosonography leaders and educators to collaborate and implement an evidence-based comprehensive endosonography curriculum that aims to provide the trainee with the essential EUS-B competencies to ensure that lung cancer patients are diagnosed and staged correctly.

Diagnosis and staging of lung cancer with the use of one single echoendoscope in both the trachea and the esophagus: A practical guide

Accurate staging of non-small cell lung cancer (NSCLC) is crucial for allocation to surgical, medical or multimodal treatment. EUS and endobronchial ultrasound (EBUS) have gained ground in the diagnosis and staging of lung cancer in addition to radiological imaging (e.g., computed tomography, fluoroscopy, and magnetic resonance imaging), nuclear medicine techniques (e.g. positron emission tomography, PET), combined techniques (e.g., fluorodesoxyglucosepositron emission tomography scanning), and sonographic imaging including conventional transcutaneous mediastinal and lung ultrasound. By using one single echoendoscope in both the trachea and the esophagus, surgical staging procedures (e.g. mediastinoscopy and video assisted thoracoscopy) can be avoided in a considerable proportion of patients with NSCLC.

Structured and evidence-based training of technical skills in respiratory medicine and thoracic surgery

Within the last decade, the number of technical procedures in respiratory medicine and thoracic surgery has grown and created a higher demand for effective and evidence-based education. Today, trainees are often allowed to perform procedures unsupervised on patients after obtaining a course certificate from a theoretic course and having performed a fixed number of supervised procedures. However, these methods do not ensure adequate competence. Well-structured and effective educational programmes including validated tests are needed to reduce economic expenses, optimize time spend, and ensure patient safety. The aim of this article is to summarize current state of educational strategies for technical procedures within respiratory medicine and thoracic surgery. Thus, to discuss future recommendations for curriculum development and assessment of competences based on Kern’s framework. The approach by Kern consists of six topics, which needs to be considered and evaluated and in order to educate physicians and surgeons most effective and evidence-based. We present a practical guide contributing to future educators’ considerations on (I) problem identification and general needs assessment, (II) targeted needs assessment, (III) goals and objectives, (IV) educational strategies, (V) implementation, and finally (VI) evaluation and feedback.

Using structured progress to measure competence in flexible bronchoscopy

Background

Flexible bronchoscopy is a core invasive procedure in pulmonary medicine and training in the procedure is mandatory. Diagnostic completeness and procedure time have been identified as useful measures of competence. No outcome measures have been developed regarding navigational path in bronchoscopy to assess whether the bronchial segments have been identified in an arbitrary or structured order. We investigated whether a new outcome measure for structured progression could be used to assess competency in flexible bronchoscopy.

Methods

The study was designed as a prospective comparative study. Twelve novices, eleven intermediates, and ten expert bronchoscopy operators completed three full bronchoscopies in a simulated setting on a phantom. The following outcome measures were collected through a checklist evaluation by a trained rater: Diagnostic Completeness as amount of visualized bronchial segments, Structured Progress between the bronchial segments in ascending order, and average intersegmental time (AIT).

Results

The ability to follow a structured ascending path through the bronchial tree correlated with a higher amount of identified bronchial segments (Pearson’s correlation, r=0.62, P<0.001) and a lower AIT (Pearson’s correlation, r=−0.52, P<0.001).

Conclusions

Operators should advance through the bronchial tree in a structured ascending order to ensure systematic progress with the highest level of diagnostic yield and the lowest procedure time. Structured progression is a useful measure to evaluate competency in flexible bronchoscopy.

A novel online education module to teach clinicians how to correctly identify ultrasonographic features of mediastinal lymph nodes during endobronchial ultrasound

Background

Ultrasonographic features can be used to predict mediastinal lymph node malignancy during endobronchial ultrasonography. Despite the validity of using these features for this purpose, the features are not being widely used in clinical practice. This may be attributable to the absence of educational programs that teach clinicians how to identify the features. To address this knowledge gap, we developed an online educational module to teach clinicians how to correctly interpret ultrasonographic features.

Methods

The module was designed using corrective feedback and test-enhanced learning theories and distributed to clinicians in relevant specialties. The efficacy of the program was determined by comparing the percentages of correctly identified ultrasonographic features as each clinician progressed through the module. Participants were also asked to self-rate their confidence during the module. Analysis of variance was conducted, and a learning curve and descriptive statistics were generated.

Results

Twenty-two of the 29 participants (76%) completed the module. Analysis of variance indicated that the percentage of correctly identified features increased significantly as clinicians completed the module (p = 0.004); this finding is supported by the positive slope of the learning curve. Even though they initially reported some difficulty with identifying certain features, their confidence increased as they progressed through the module. When asked, 86% of participants reported that they found the educational module helpful and 90% reported that they would recommend it to others.

Conclusion

Participating clinicians were receptive to the interactive educational module. It enhances clinician skill and confidence in interpreting ultrasonographic features. The results of this study provide the foundation needed to test the validity of the educational module in clinical settings and to further explore clinician preferences for educational programs.