© 2002 American Thoracic Society
Don't Lose the Forest for the TreesSatisfaction and Success in BronchoscopyDepartment of Pulmonary and Critical Care Medicine Cleveland Clinic Foundation Cleveland, Ohio Since its inception, the practice of flexible bronchoscopy has lagged behind gastrointestinal endoscopy. There are a variety of established indications for a repeat upper endoscopy (e.g., Barrett's esophagus) or a colonoscopy (e.g., screening for colon cancer). Such indications are rare, however, in the practice of bronchoscopy. Screening for lung cancer with autofluorescence bronchoscopy is controversial (1, 2), and the role of surveillance bronchoscopy in lung transplant patients remains unproven (3). Surveillance bronchoscopy is not even recommended following endobronchial stent placement (4). Under these circumstances, asking the patient, "Would you agree to a repeat bronchoscopy?" is hypothetical. In this issue of AJRCCM (pp. 1326–1331), Lechtzin and coworkers (5) attempt to assess patient satisfaction with flexible bronchoscopy by asking that question of their patients. Their findings suggest that focusing on patient-centered outcomes can enhance patient satisfaction with bronchoscopy. Flexible bronchoscopy is an expensive, challenging, and time-consuming procedure that poses some discomfort for the patient. The bronchoscopist's goal is to avoid a nondiagnostic bronchoscopy and avoid needing to repeat the bronchoscopy. The bronchoscopist must use every possible tool (transbronchial biopsy, transbronchial needle aspiration, and so on) to accomplish the desired goals. Compromising any aspect of diagnostic or therapeutic maneuvers solely for enhanced patient satisfaction would be like losing the forest for the trees. There is no disagreement about achieving general measures of patient satisfaction during bronchoscopy. A friendly hospital environment, shorter waiting time, proper information about the procedure, and good bedside manners are appreciated by patients and their relatives. I agree with the transnasal approach for most flexible bronchoscopies to improve patient comfort (6). Some bronchoscopists even provide music during the procedure to relieve the anxiety (7). I also agree that the current literature places more emphasis on technology than on patient-centered outcomes; however, this may be because the field of bronchoscopy is still evolving. An alternate view of the data of Lechtzin and coworkers is that only 6.7% of the participants (approximately 32 of 481) were either unsure or unwilling to undergo repeat bronchoscopy. From a pragmatic standpoint, these individuals may be the most important subgroup for assessing the impact of the study variables. The total number of patients who probably or definitely would not return was small (2.1% of the total) versus the group of patients who would probably return. Put simply, although this is a theoretical situation, I am more interested in how many patients are likely to return for necessary care. It would have been interesting to see whether the study findings held up when applied to this small subgroup (6.7%) of patients. The more important question is whether process-oriented interventions, such as in the MATERIALS described by Lechtzin and coworkers (5), will alter the proportion of patients who are unlikely to undergo theoretical repeat flexible bronchoscopy. In my experience, there may be a subset of hard-to-please patients who will not respond to formal or informal attempts to improve their satisfaction. There are wide variations in the level of training and individual commitment to procedural proficiency and thus outcomes (8, 9). I am sure the authors would agree that a diagnostic bronchoscopy involving some patient discomfort would be a better outcome than a procedure focused totally on patient satisfaction but proving nondiagnostic. Until there is more uniformity in practice, it would be premature for insurance companies to concentrate on patient-centered outcomes. For example, bronchoscopy in a patient with lesion in the apicoposterior segment of the upper lobe may leave the individual with some nasal soreness, but it avoids a percutaneous needle aspiration. A transbronchial needle aspiration of a lymph node in the aortopulmonary window that avoids thoracotomy, or an outpatient endobronchial electrosurgery that induces profuse coughing may evoke vivid and uncomfortable memories for the patient, but they avoid a trip to the operating room and general anesthesia (10–12). According to the published study, these maneuvers could be the cause for dissatisfaction. The open-label nature of the study leaves room for some bias. When one's performance is being openly scrutinized, human behavior is likely to be modified. Isn't it possible that patients who did not complete the postbronchoscopy survey were so dissatisfied that they did not bother to comply with the study? It would be interesting to know whether the experiences of these patients were similarly suboptimal as compared with the patients who said they were unlikely to undergo a repeat bronchoscopy. Also, if patients are aware that they may never require a repeat procedure, isn't it likely that they will respond positively to the survey? Nevertheless, it is comforting to learn that complications such as pneumothorax or bleeding are not the cause of dissatisfaction. This further supports the notion that the bronchoscopist should not be intimidated by the possibility of such complications and should instead concentrate on fulfilling the goals of the procedure. I do agree that patient satisfaction is a major driving force in designing and defining our medical practices (13). I believe, however, that a similar study performed in a blind fashion (without the knowledge of the involved personnel) in patients who undergo repeated procedures (e.g., transplant recipients, research volunteers, or brachytherapy candidates) would have a greater impact. Results could be further analyzed based on the outcome of the procedure. It is difficult to recommend widespread introduction of cumbersome, formal interventions beyond good communication skills, adequate analgesia, and a transnasal route of bronchoscopy until evidence for the efficacy of such maneuvers is provided. The follow-up study mentioned by the authors should provide direction in this regard. Until then, we should continue to concentrate on ensuring that bronchoscopy contributes towards a diagnosis and that it is performed in a setting conducive to patient comfort. REFERENCES
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