What is The Four Box Practical Approach to Bronchoscopy©

Four 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 gain cognitive, technical, affective, and experiential knowledge necessary for competent medical procedural practice.

Case-based exercises

More presentations

Four Box Approach Guidelines

  • 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 four 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 slide presentations) can be used for clinical case presentations, lectures, and as part of competency-oriented training to assess clinical judgement and decision-making skills. The Four Box  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 Video Archive: Please view or download relevant videos from the following YouTube (BronchOrg channel) link.
–   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

Practical Approach© templates and clinical case scenarios may be downloaded for use in 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 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.