What is The 4-Box Practical Approach to Bronchoscopy©

4-Box Practical Approach© is a series of patient-based studies that complement the apprenticeship model of medical education. These case-studies and slide presentations help  learners gain cognitive, technical, affective, and experiential knowledge necessary for competent medical procedural practice. Guidelines help construct and deconstruct each case using a uniform approach. Individual coaching, feedback,and dialogue using these case-based exercises significantly improves medical decision-making. The 4-Box Practical Approach is thus able to address virtually every technical, ethical, or scientific aspects of bronchoscopy practice.

Case-based exercises

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  • Learners gain cognitive, technical, affective, and experiential skills necessary to perform minimally invasive bronchoscopic procedures in a patient/family focused-care environment.
  • Competency is sought in three major elements of a procedure; strategy and planning, execution, and response to procedure-related adverse events or complications.
  • A 4-box clinical case-based approach (inspired from Albert Jonsen’s classic work in medical ethics) addresses pre-procedure evaluation, techniques, expected results, and follow-up/response to complications.
  • Clinical judgement and depth of knowledge are assessed by asking learners to justify their decisions using background information, pertinent literature, institutional biases, and personal experience.
  • Consistent with the ACGME professionalism competency guides, learners address components of Informed Consent, as well as outcomes based on possible, probable or real results.
Initial Evaluation

  1. Physical examination, complementary tests, and functional status assessment
  2. Patient’s significant comorbidities
  3. Patient’s support system (also includes family)
  4. Patient preferences and expectations (also includes family)
Procedural Strategies

  1. Indications, contraindications, and expected results
  2. Operator and team experience and expertise
  3. Risk-benefits analysis and therapeutic alternatives
  4. Respect for persons (Informed Consent)
Procedural Techniques and Results

  1. Anesthesia and other perioperative care
  2. Techniques and instrumentation
  3. Anatomic dangers and other risks
  4. Results and procedure-related complications
Long term Management Plan

  1. Outcome assessment
  2. Follow-up tests, visits, and procedures
  3. Referrals to medical, surgical, or palliative/end of life subspecialty care
  4. Quality improvement and team evaluation of clinical encounter

FOUR BOX APPROACH SCENARIOS vol 1 and PRESENTATIONS are used for clinical case discussions, lectures, and as part of competency-oriented training to objectively and subjectively evaluate a learner’s level of knowledge, clinical judgement and decision-making skills.

4-BOX PRACTICAL APPROACH VIDEO ARCHIVE: View and download from our BronchOrg YouTube channel.
–   4 Box Video Archive clinical cases 1-3
–   4 Box Video Archive clinical cases 4-6
–   4 Box Video Archive clinical cases 7-11
–   4 Box Video Archive clinical cases 12-15

The 4-Box  Practical Approach© follows recommendations set forth by the American College of Graduate Medical Education  whereby trainees learn to:

  • Gather essential and accurate information about their patients.
  • Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence and clinical judgment.
  • Use information technology to support patient care decisions and patient education.
  • Develop patient management plans.
  • Counsel and educate patients and their families.
  • Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families.
  • Provide health care services aimed at preventing health problems or maintaining health.
  • Work with health care professionals, including those from other disciplines, to provide patient-focused care.

1. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics. 6th Ed, McGraw Hill, NY 2006.
2. ACGME Web site: http://www.acgme.org/outcome/comp/compfull.asp
3. Apelgren K. ACGME e-Bulletin. August 2006
4. ACGME Competencies at http://www.acgme.org

4-Box Practical Approach© templates and clinical case scenarios may be used for training, lectures, or research. In case of publication or presentations, please cite as follows:

Bronchoscopy International: The Practical Approach©, an Electronic On-Line Multimedia Slide Presentation. http://www.Bronchoscopy.org/Practical Approach. Published 2016 (Please add “Date Accessed”).

To learn more about The 4-Box Practical Approach©, please watch the video below:


Also, please see Bronchoscopy and Central Airways Disorders: A Patient-centered Approach by Colt HG and Murgu S, published by Elsevier/Saunders, 2012.

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