title: Using virtual-reality simulation to assess performance in endobronchial ultrasound.
abstract: BACKGROUND
  For optimal treatment of patients with non-small cell lung carcinoma, it is essential to have physicians with competence in endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). EBUS training and certification requirements are under discussion and the establishment of basic competence should be based on an objective assessment of performance.
  
  
  OBJECTIVE
  The aims of this study were to design an evidence-based and credible EBUS certification based on a virtual-reality (VR) EBUS simulator test.
  
  
  METHODS
  Twenty-two respiratory physicians were divided into 3 groups: experienced EBUS operators (group 1, n = 6), untrained novices (group 2, n = 8) and simulator-trained novices (group 3, n = 8). Each physician performed two standardized simulated EBUS-TBNA procedures. Simulator metrics with discriminatory ability were identified and reliability was explored. Finally, the contrasting-groups method was used to establish a pass/fail standard, and the consequences of this standard were explored.
  
  
  RESULTS
  Successfully sampled lymph nodes and procedure time were the only simulator metrics that showed statistically significant differences of p = 0.047 and p = 0.002, respectively. The resulting quality score (QS, i.e. sampled lymph nodes per minute) showed an acceptable reliability and a generalizability coefficient of 0.67. Reliability of 0.8 could be obtained by testing in 4 procedures. Median QS was 0.24 (range 0.21-0.26) and 0.098 (range 0.04-0.21) for groups 1 and 2, respectively (p = 0.001). The resulting pass/fail standard was 0.19. Group 3 had a median posttraining QS of 0.11 (range 0-0.17). None of them met the pass/fail standard.
  
  
  CONCLUSIONS
  With careful design of standardized tests, a credible standard setting and appropriate transfer studies, VR simulators could be an important first line in credentialing before proceeding to supervised performance on patients.
authors.affiliation: Centre for Clinical Education, University of Copenhagen and the Capital Region of Denmark, Copenhagen, Denmark. lkonge@yahoo.dk
authors.forename: Lars
authors.initials: L
authors.lastname: Konge
authors.forename: Jouke
authors.initials: J
authors.lastname: Annema
authors.forename: Paul
authors.initials: P
authors.lastname: Clementsen
authors.forename: Valentina
authors.initials: V
authors.lastname: Minddal
authors.forename: Peter
authors.initials: P
authors.lastname: Vilmann
authors.forename: Charlotte
authors.initials: C
authors.lastname: Ringsted
mesh_terms: D001707:Biopsy, Needle; D001999:Bronchoscopy; D002289:Carcinoma, Non-Small-Cell Lung / Q000473:pathology*; D002983:Clinical Competence; D004521:Educational Measurement / Q000379:methods*; D019160:Endosonography; D006801:Humans; D061705:Image-Guided Biopsy; D018084:Ultrasonography, Interventional; D014584:User-Computer Interface