Many interventional pulmonologists have a lifelong goal of becoming better bronchoscopists. Consistent improvement is a key element of competency-based learning, and this requires enhanced technical skills, greater acquisition of theoretical knowledge, keen clinical judgement and critical thinking, an appreciation for evidence-based practice, and an understanding of expected professionalism and ethical conduct.

Because bronchoscopy is a “procedure,” one might argue that technical mastery is the first and possibly most important requirement for all bronchoscopists. Certainly, it is what novices think about when they pick up a flexible bronchoscope for the first time. From this perspective, I believe the foundation for becoming a better bronchoscopist has four cornerstones.

Muscle memory is best achieved by deliberate and repeated practice. Just as musicians run scales and practice finger exercises for many hours, bronchoscopists can practice in models as well as in real-life settings to overcome awkwardness, indecision, and inefficiency. Navigating the bronchoscope through both normal and variant airways becomes more fluid as movements and manipulations become natural and instinctive. No longer struggling to get the scope where they want it, operators can focus on interpreting findings and decision-making rather than mechanics.

Economy of movement teaches how to avoid unnecessary manipulations. This improves efficiency, helps avoid operator fatigue and injury, and keeps the scope centered within the airway to avoid repetitive movements, mucosal trauma, and cough. This results in a faster procedure, reduces patient discomfort, and assures that every aspect of the intervention is done with precision and purpose. The difference between fumbling around in the airway and working dexterously and with intent is one of the first indicators of technical proficiency.

Pattern recognition is developed with experience. This means performing hundreds of procedures and viewing hundreds, if not more, photographs and videos of mucosal changes.  With experience, bronchoscopists establish an internal catalogue of airway abnormalities and variations. They acquire an encyclopedia of normal airway appearances and a keen appreciation for what might be airway inflammation, edema, neoplasia, or the nuances of airway vascularity. Over time and with proper mentoring, as well as after considerable study and self-reflection, recognizing these findings becomes interpretive and insightful. Pattern recognition becomes part of one’s intuition as it is incorporated into the clinical context and combined with radiological findings, pathophysiology, and probabilistic reasoning.

Moral fortitude is where procedural technical skills and physician responsibility intersect. The bronchoscopist must learn how to respond to uncertainty, how to act and react decisively, resist temptations to overstep their expertise, and maintain composure in case of complications or unexpected patient and procedure-related difficulties. Moral fortitude helps define their professional character and plays an important part in developing a moral compass that bronchoscopists can follow to help ensure their patients’ safety, dignity, and trust.