ORIGINAL INVESTIGATION
Bronchoscopic Training and Practice in Australia and New Zealand Is Inconsistent With Published Society Guidelines Eli J. Dabscheck, MBBS, M Clin Epi, FRACP,* Mark Hew, MBBS, PhD, FRACP,* Louis Irving, MBBS, FRACP,w and Daniel Steinfort, MBBS, PhD, FRACPw
Background: The Australasian practice and training
in bronchoscopy has not previously been reported and procedure volumes among Australasian respiratory consultants and trainees are unknown. We surveyed the current practice of flexible bronchoscopy in Australasia and determined adherence to published recommendations.
procedural volume as the sole determinant of technical competence. There is an urgent need to explore alternative means of developing and defining bronchoscopic proficiency. Key Words: bronchoscopy, competency-based education, continuing medical education, surveys, teaching (J Bronchol Intervent Pulmonol 2014;21:117–122)
Methods: Adult physician and trainee members of the
Thoracic Society of Australia New Zealand (TSANZ) were e-mailed a web-link to an online survey. Survey responses were benchmarked against TSANZ recommendations. Results: The response rate was 42% overall and 78% among trainees. Forty-nine percent of consultants performed less than the recommended 50 procedures per year. Sixty percent of trainees were unlikely to achieve the recommended 200 supervised bronchoscopies during training. Less than 20% of trainees received adequate training in advanced bronchoscopic techniques such as transbronchial lymph node aspiration. The majority of physicians performing such advanced techniques were not performing sufficient numbers to satisfy published recommendations. Conclusions: A large proportion of Australasian bron-
choscopists do not meet “numbers-based” recommendations. This empirical data support the 2012 TSANZ interventional guidelines’ call to move beyond
Received for publication July 1, 2013; accepted January 30, 2014. From the *Allergy, Immunology and Respiratory Medicine, Alfred Hospital, Prahran; and wDepartment of Respiratory and Sleep Medicine, Royal Melbourne Hospital, Parkville, Victoria. E.J.D.: design of survey, analysis of results, and author of first draft of manuscript. M.H.: original idea for article, drafting of manuscript, survey design, and analysis of results. L.I.: drafting of manuscript and survey design. D.S.: drafting of manuscript, analysis of results, and literature review. Disclosure: There is no conflict of interest or other disclosures. Reprints: Eli J. Dabscheck, MBBS, M Clin Epi, FRACP, Allergy, Immunology and Respiratory Medicine, Alfred Hospital, Commercial Rd, Prahran, Vic. 3181 (e-mail: e.dabscheck@alfred. org.au). Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the Journal’s Website, www.bronchology.com. Copyright r 2014 by Lippincott Williams & Wilkins
J Bronchol Intervent Pulmonol
BACKGROUND
Bronchoscopy is frequently performed for a variety of indications including suspected infection, hemoptysis, and central airway and peripheral parenchymal lesions.1–3 The procedure is associated with very low complication rates, although the spectrum of complications is evolving due to the greater complexity of new diagnostic techniques.4–7 Specialist societies have published training recommendations to ensure clinicians acquire and maintain the skills to perform these procedures safely.8,9 In 2001 the Thoracic Society of Australia and New Zealand (TSANZ) published a position paper on standard bronchoscopy10 that included recommendations on acquiring and maintaining competency based on procedural volume alone. More recently the TSANZ has also published clinical practice guidelines for advanced interventional pulmonary procedures, which also recommend stipulated procedural volumes for specific techniques.11 Importantly, these assume competence in standard bronchoscopy. Unlike other procedural medical specialties, one of the central responsibilities of Respiratory Societies worldwide is to ensure a high quality of bronchoscopic training and practice. Minimal published literature is available regarding the adequacy of training and practice with respect to the published guidelines. Australian New Zealand Respiratory Physicians do not undertake a dedicated certification process for bronchoscopy. It is unknown whether the practice of
Volume 21, Number 2, April 2014
www.bronchology.com |
117
Dabscheck et al
J Bronchol Intervent Pulmonol
bronchoscopy in the region is in alignment with the recommendations, as no previous evaluation of bronchoscopic practice or training has ever been undertaken. We conducted a survey directed toward the Thoracic Physicians and trainees in Australia and New Zealand, to assess the degree of adherence to procedural volumes recommended to achieve and maintain competency for both standard bronchoscopy, conventional transbronchial needle aspiration (TBNA), and endobronchial ultrasound (EBUS)-TBNA.
Volume 21, Number 2, April 2014
TABLE 2. Consultant Bronchoscopy Volume Compared With International Surveys Professional Society
Performing >50/y (%)
Year of Survey
51 88* 82
2009 2000 1989
TSANZ British Thoracic Society9 American College of Chest Physician10
* >100/y. TSANZ indicates Thoracic Society of Australia New Zealand.
RESULTS METHODS
An e-mail survey was conducted through the kind cooperation of the TSANZ, which represents thoracic physicians in Australia and New Zealand. All adult physician members of the society and trainees were e-mailed a web-link to the survey (see Supplemental Digital Content 1, http://links.lww.com/LBR/A110) on 3 separate occasions between October 28th and December 15, 2009. The survey was closed after 3 months. Institutional ethics approval was waived as no patients were involved and the survey was anonymous. The survey invited responses on the clinicians’ scope of practice, availability of TBNA, and EBUS-TBNA. Respondents were asked to estimate the number of procedures performed over the previous 12 months. Survey responses were then benchmarked against the Australasian bronchoscopy guidelines described above. Where no TSANZ guidance exists, results were benchmarked against international guidelines (Tables 1, 2).8–11,13 TABLE 1. Bronchoscopy Procedural Volume
Flexible bronchoscopy (%) EBUS-TBNA (%)
Consultants Maintaining “Ideal Number” (>50/y)
Consultants Maintaining “Minimum Standard” (>20/y)
Trainees Achieving Volume-based “Competency”
51
77
30
N/A
42
21
Recommended flexible bronchoscopy procedural volume based on TSANZ 2001 guidelines.10 Recommended EBUS-TBNA procedural volume based on TSANZ 2012 guidelines.12 N/A indicates not applicable; TBNA, transbronchial needle aspiration.
118 | www.bronchology.com
We received 217 responses out of a total of 517 specialists and advanced trainees (pulmonary fellows) practicing adult thoracic medicine in Australia and New Zealand on the TSANZ roll (42% response rate). The response from trainees alone was higher at 78% (45 from a total of 58 trainees). Eight responses were incomplete and not included in the final analysis. Seventy-nine percent (164) of respondents were consultants, the majority of whom were based at tertiary metropolitan hospitals. Twenty-one percent (45) of respondents were trainees. Results are summarized, and benchmarked against TSANZ guidelines (Tables 1, 2). Standard Bronchoscopy Achieving Competency
The 2001 TSANZ position paper recommends a minimum of 200 fiberoptic bronchoscopies be performed during training. Core training in thoracic medicine is generally undertaken over 2 years; therefore trainees would need to perform >100 procedures per year to comply with this recommendation. However, 70% of trainees surveyed reported performing
Bronchoscopic Training and Practice in Australia and New Zealand Is Inconsistent With Published Society Guidelines Eli J. Dabscheck, MBBS, M Clin Epi, FRACP,* Mark Hew, MBBS, PhD, FRACP,* Louis Irving, MBBS, FRACP,w and Daniel Steinfort, MBBS, PhD, FRACPw
Background: The Australasian practice and training
in bronchoscopy has not previously been reported and procedure volumes among Australasian respiratory consultants and trainees are unknown. We surveyed the current practice of flexible bronchoscopy in Australasia and determined adherence to published recommendations.
procedural volume as the sole determinant of technical competence. There is an urgent need to explore alternative means of developing and defining bronchoscopic proficiency. Key Words: bronchoscopy, competency-based education, continuing medical education, surveys, teaching (J Bronchol Intervent Pulmonol 2014;21:117–122)
Methods: Adult physician and trainee members of the
Thoracic Society of Australia New Zealand (TSANZ) were e-mailed a web-link to an online survey. Survey responses were benchmarked against TSANZ recommendations. Results: The response rate was 42% overall and 78% among trainees. Forty-nine percent of consultants performed less than the recommended 50 procedures per year. Sixty percent of trainees were unlikely to achieve the recommended 200 supervised bronchoscopies during training. Less than 20% of trainees received adequate training in advanced bronchoscopic techniques such as transbronchial lymph node aspiration. The majority of physicians performing such advanced techniques were not performing sufficient numbers to satisfy published recommendations. Conclusions: A large proportion of Australasian bron-
choscopists do not meet “numbers-based” recommendations. This empirical data support the 2012 TSANZ interventional guidelines’ call to move beyond
Received for publication July 1, 2013; accepted January 30, 2014. From the *Allergy, Immunology and Respiratory Medicine, Alfred Hospital, Prahran; and wDepartment of Respiratory and Sleep Medicine, Royal Melbourne Hospital, Parkville, Victoria. E.J.D.: design of survey, analysis of results, and author of first draft of manuscript. M.H.: original idea for article, drafting of manuscript, survey design, and analysis of results. L.I.: drafting of manuscript and survey design. D.S.: drafting of manuscript, analysis of results, and literature review. Disclosure: There is no conflict of interest or other disclosures. Reprints: Eli J. Dabscheck, MBBS, M Clin Epi, FRACP, Allergy, Immunology and Respiratory Medicine, Alfred Hospital, Commercial Rd, Prahran, Vic. 3181 (e-mail: e.dabscheck@alfred. org.au). Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the Journal’s Website, www.bronchology.com. Copyright r 2014 by Lippincott Williams & Wilkins
J Bronchol Intervent Pulmonol
BACKGROUND
Bronchoscopy is frequently performed for a variety of indications including suspected infection, hemoptysis, and central airway and peripheral parenchymal lesions.1–3 The procedure is associated with very low complication rates, although the spectrum of complications is evolving due to the greater complexity of new diagnostic techniques.4–7 Specialist societies have published training recommendations to ensure clinicians acquire and maintain the skills to perform these procedures safely.8,9 In 2001 the Thoracic Society of Australia and New Zealand (TSANZ) published a position paper on standard bronchoscopy10 that included recommendations on acquiring and maintaining competency based on procedural volume alone. More recently the TSANZ has also published clinical practice guidelines for advanced interventional pulmonary procedures, which also recommend stipulated procedural volumes for specific techniques.11 Importantly, these assume competence in standard bronchoscopy. Unlike other procedural medical specialties, one of the central responsibilities of Respiratory Societies worldwide is to ensure a high quality of bronchoscopic training and practice. Minimal published literature is available regarding the adequacy of training and practice with respect to the published guidelines. Australian New Zealand Respiratory Physicians do not undertake a dedicated certification process for bronchoscopy. It is unknown whether the practice of
Volume 21, Number 2, April 2014
www.bronchology.com |
117
Dabscheck et al
J Bronchol Intervent Pulmonol
bronchoscopy in the region is in alignment with the recommendations, as no previous evaluation of bronchoscopic practice or training has ever been undertaken. We conducted a survey directed toward the Thoracic Physicians and trainees in Australia and New Zealand, to assess the degree of adherence to procedural volumes recommended to achieve and maintain competency for both standard bronchoscopy, conventional transbronchial needle aspiration (TBNA), and endobronchial ultrasound (EBUS)-TBNA.
Volume 21, Number 2, April 2014
TABLE 2. Consultant Bronchoscopy Volume Compared With International Surveys Professional Society
Performing >50/y (%)
Year of Survey
51 88* 82
2009 2000 1989
TSANZ British Thoracic Society9 American College of Chest Physician10
* >100/y. TSANZ indicates Thoracic Society of Australia New Zealand.
RESULTS METHODS
An e-mail survey was conducted through the kind cooperation of the TSANZ, which represents thoracic physicians in Australia and New Zealand. All adult physician members of the society and trainees were e-mailed a web-link to the survey (see Supplemental Digital Content 1, http://links.lww.com/LBR/A110) on 3 separate occasions between October 28th and December 15, 2009. The survey was closed after 3 months. Institutional ethics approval was waived as no patients were involved and the survey was anonymous. The survey invited responses on the clinicians’ scope of practice, availability of TBNA, and EBUS-TBNA. Respondents were asked to estimate the number of procedures performed over the previous 12 months. Survey responses were then benchmarked against the Australasian bronchoscopy guidelines described above. Where no TSANZ guidance exists, results were benchmarked against international guidelines (Tables 1, 2).8–11,13 TABLE 1. Bronchoscopy Procedural Volume
Flexible bronchoscopy (%) EBUS-TBNA (%)
Consultants Maintaining “Ideal Number” (>50/y)
Consultants Maintaining “Minimum Standard” (>20/y)
Trainees Achieving Volume-based “Competency”
51
77
30
N/A
42
21
Recommended flexible bronchoscopy procedural volume based on TSANZ 2001 guidelines.10 Recommended EBUS-TBNA procedural volume based on TSANZ 2012 guidelines.12 N/A indicates not applicable; TBNA, transbronchial needle aspiration.
118 | www.bronchology.com
We received 217 responses out of a total of 517 specialists and advanced trainees (pulmonary fellows) practicing adult thoracic medicine in Australia and New Zealand on the TSANZ roll (42% response rate). The response from trainees alone was higher at 78% (45 from a total of 58 trainees). Eight responses were incomplete and not included in the final analysis. Seventy-nine percent (164) of respondents were consultants, the majority of whom were based at tertiary metropolitan hospitals. Twenty-one percent (45) of respondents were trainees. Results are summarized, and benchmarked against TSANZ guidelines (Tables 1, 2). Standard Bronchoscopy Achieving Competency
The 2001 TSANZ position paper recommends a minimum of 200 fiberoptic bronchoscopies be performed during training. Core training in thoracic medicine is generally undertaken over 2 years; therefore trainees would need to perform >100 procedures per year to comply with this recommendation. However, 70% of trainees surveyed reported performing
