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Rationale: Endobronchial ultrasound (EBUS) has transformed mediastinal staging in lung cancer. A systematic approach, beginning with lymph nodes contralateral to the primary tumor (N3), is considered superior to selective sampling of radiographically abnormal nodes. However, the extent to which this recommendation is followed in practice remains unknown.Objectives: To assess the frequency with which pulmonologists, pulmonary fellows, and interventional pulmonologists endoscopically stage lung cancer appropriately.Methods: Bronchoscopists currently performing EBUS were surveyed about their practice patterns, procedural volume, and self-confidence in EBUS skills; they then performed a proctored simulated staging EBUS. The primary outcome was the proportion of participants who appropriately initiated ultrasonographic evaluation with the N3 nodal stations in a simulated patient undergoing EBUS for mediastinal staging.Results: Sixty physicians (22 interventional pulmonologists, 18 general pulmonologists, and 20 pulmonary fellows) participated in the study. The rates of appropriate staging by study group were 95.5% (21 of 22) for interventional pulmonologists, 44.4% (8 of 18) for general pulmonologists, and 30.0% (6 of 20) for pulmonary fellows (P < 0.001). Increased procedural volume correlated with appropriate staging practices (P < 0.001). Within each group, we assessed the concordance between self-confidence in EBUS and simulation performance. Among interventional pulmonologists, the concordance was 95.4%, followed by 61.1% for general pulmonologists and 40.0% for pulmonary fellows.Conclusions: General pulmonologists and pulmonary fellows were less likely than interventional pulmonologists to perform appropriate EBUS staging. In addition, the lack of concordance between self-confidence and appropriate staging performance among noninterventionists signals a need for improved dissemination of guidelines for EBUS-guided mediastinal staging. [ABSTRACT FROM AUTHOR]