- Email: [email protected]
Standardization of Interventional Pulmonology Training: Response
Headington, Oxford OX3 7LJ, England; e-mail: naj_rahman@ yahoo.co.uk © 2010 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/ site/misc/reprints.xhtml). DOI: 10.1378/chest.10-0967
fession, we must strive to provide our patients with the best possible care. Further, we must all remain aware of our limitations and refer our patients to where they can be treated with the best and safest approach. We welcome and commend our colleagues for bringing up these interesting issues. Edmundo R. Rubio, MD, FCCP Michael B. Boyd, MD, FCCP Roanoke, VA
References 1. Gobien RP, Stanley JH, Schabel SI, et al. The effect of drainage tube size on adequacy of percutaneous abscess drainage. Cardiovasc Intervent Radiol. 1985;8(2):100-102. 2. Röthlin MA, Schöb O, Klotz H, Candinas D, Largiadèr F. Percutaneous drainage of abdominal abscesses: are large-bore catheters necessary? Eur J Surg. 1998;164(6):419-424. 3. Rahman NM, Maskell NA, Davies CWH, et al. The relationship between chest tube size and clinical outcome in pleural infection. Chest. 2010;137(3):536-543.
Standardization of Interventional Pulmonology Training
Affiliation: From the Section of Pulmonary Medicine, Interventional Pulmonology, Virginia Tech Carilion School of Medicine. Financial/nonfinancial disclosure: The authors have reported to CHEST that no potential conflicts of interest exist with any companiesⲐorganizations whose products or services may be discussed in this article. Correspondence to: Edmundo R. Rubio, MD, FCCP, Virginia Tech Carilion School of Medicine, 1906 Bellevue Ave, Ste 320, Roanoke, VA 24018; e-mail: [email protected] © 2010 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/ site/misc/reprints.xhtml). DOI: 10.1378/chest.10-0849
References To the Editor: We thank Lamb and colleagues1 for their recent article in CHEST (January 2010) addressing the need to standardize the training of interventional pulmonologists. We also appreciate the corresponding editorial by Ost et al2 that provided additional points of discussion. We agree that setting up strict criteria regarding the volume of procedures required may significantly limit the availability of these techniques to our patients. Many formally trained interventional pulmonologists have not met all the suggested standards, and current interventional pulmonary programs may close if unable to meet strict volume requirements. Additionally, we put forth that some procedures considered to be “interventional” perhaps should be part of the training of every general pulmonologist. For instance, in our fellowship program, we strive to train all our fellows to use endobronchial ultrasonography and to perform balloon bronchoplasty. We believe that learning curves are highly individualized and, hence, that the final decision to certify an individual to perform a procedure should be left to the program director and not be limited to procedure volumes. We believe that certain interventions can be performed by pulmonologists who may be qualified to perform a particular procedure but not the whole scope of all available interventions. However, we also maintain that when dealing with more complicated patient airways, care should occur within a center capable of performing all foreseeable interventions. We agree that short, 1- or 2-day interventional pulmonary courses should not be considered sufficient for training. Nevertheless, such courses that also are aimed at the general pulmonologist have become common and often include hands-on practice sessions. We need to make sure that we are not sending a contradictory message. We see their value as a way to disseminate the understanding of the available therapies and to improve patient access and referral. Such courses also serve to update the practicing interventional pulmonologist. With regard to the general practicing pulmonologist, these courses should perhaps emphasize training to deal with airway emergencies, such as the removal of foreign bodies. Clearly, there is no consensus on the need to have strict interventional pulmonary fellowship programs. Regardless, as a prowww.chestpubs.org
1. Lamb CR, Feller-Kopman D, Ernst A, et al. An approach to interventional pulmonary fellowship training. Chest. 2010; 137(1):195-199. 2. Ost D, Eapen GA, Jimenez CA, Morice RC. Improving procedural training and certification in pulmonary medicine. Chest. 2010;137(1):6-8.
Response To the Editor: We thank Drs Rubio and Boyd for their excellent points regarding our article.1 Their main concerns boil down to access to training and the final arbiter of training, both of which affect the availability of procedures we can offer our patients. The goal, however, of providing quality procedures by well-trained operators should not be compromised. We do not propose to limit availability. Individuals well trained by experienced practitioners should be able to offer any specific procedure. We agree that training in isolated procedures such as endobronchial ultrasound may be incorporated into existing fellowship programs. The goal of our article, however, was to provide a framework for a larger spectrum of procedures, support training in the field of interventional pulmonology, and define the didactic and procedural training required for a dedicated interventional pulmonologist. We agree with Drs Rubio and Boyd that weekend courses offer familiarity, not definitive training. These courses provide the practicing pulmonologist with an understanding of options and limitations. For some, they provide the motivation to seek further training. For those in fellowship, individual procedures may be mastered, but this highly depends on the offerings and expertise within each fellowship program. Pastis et al2 made the sobering point that our basic programs often do not provide sufficient training in many basic, let alone advanced, procedures. Take, for example, the history of transbronchial needle aspiration. In itself, it was a pivotal procedure used in the diagnosis and staging of thoracic malignancies. Introduced in the 1970s as a CHEST / 138 / 3 / SEPTEMBER, 2010
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on September 15, 2010 © 2010 American College of Chest Physicians
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flexible procedure,3 it was not adopted widely as of the 1990s4 and remains limited because of inadequate training. Endobronchial ultrasound is even more pivotal. Frankly, left to the current state of procedure training, it will also fall short of wide adoption as a quality procedure. Ideally, skilled interventional pulmonologists in every training program would train select individuals. Optimal resource utilization and best outcomes would be achieved by patient referral to centers of excellence (be they in the community or in academic centers) staffed by these interventional pulmonologists rather than by having all pulmonologists try to do all things. The reality is that many programs offer limited procedure training and that not all practitioners will have the skill, interest, or time to offer the full range of procedures. It is time to support the training and specialization of the dedicated proceduralist. Kevin L. Kovitz, MD, FCCP Elk Grove Village, IL David Feller-Kopman, MD, FCCP Baltimore, MD Carla Lamb, MD, FCCP Burlington, MA Armin Ernst, MD, FCCP Boston, MA Michael Simoff, MD, FCCP Detroit, MI Daniel Sterman, MD, FCCP Philadelphia, PA Momen Wahidi, MD, FCCP Durham, NC Affiliations: From the Chicago Chest Center (Dr Kovitz); Interventional Pulmonology (Dr Feller-Kopman), Johns Hopkins Hospital; Pulmonary and Critical Care Medicine (Dr Lamb), Lahey Clinic; Pulmonary and Critical Care Medicine (Dr Ernst), Beth Israel Deaconess Medical Center, Harvard Medical School; Pulmonary and Critical Care Medicine (Dr Simoff), Henry Ford Hospital; Section of Interventional Pulmonology and Thoracic Oncology, the Pulmonary, Allergy, and Critical Care Division
(Dr Sterman), University of Pennsylvania Medical Center; and Department of Internal Medicine (Dr Wahidi), Division of Pulmonary, Allergy and Critical Care Medicine, Duke University Medical Center. Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Feller-Kopman has received consulting fees from Immersion Medical Inc., CareFusion Inc., and Olympus America Inc. as well as lecture fees from SonoSite Inc. Dr Lamb has received honoraria as a medical device and clinical consultant for Cardinal Health, inReach System, Spiration, and Boston Scientific. Dr Wahidi has received educational grants from Olympus America Inc., Pentax, Boston Scientific, and Bryan Inc.; consulted with IPS, Immersion, SuperDimension, Veran, and CareFusion Inc.; participated in the speakers bureau for Axcan; and had research sponsored by CareFusion. Drs Kovitz, Ernst, Simoff, and Sterman have reported to CHEST that no potential conflicts of interest exist with any companiesⲐorganizations whose products or services may be discussed in this article. Correspondence to: Kevin L. Kovitz, MD, FCCP, Chicago Chest Center, 800 Biesterfield Rd, # 510, Elk Grove Village, IL 60007; e-mail: [email protected] © 2010 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/ site/misc/reprints.xhtml). DOI: 10.1378/chest.10-1230
References 1. Lamb CR, Feller-Kopman D, Ernst A, et al. An approach to interventional pulmonary fellowship training. Chest. 2010; 137(1):195-199. 2. Pastis NJ, Nietert PJ, Silvestri GA; American College of Chest Physicians Interventional ChestⲐDiagnostic Procedures Network Steering Committee. Variation in training for interventional pulmonary procedures among US pulmonaryⲐcritical care fellowships: a survey of fellowship directors. Chest. 2005; 127(5):1614-1621. 3. Wang KP, Terry P, Marsh B. Bronchoscopic needle aspiration biopsy of paratracheal tumors. Am Rev Respir Dis. 1978; 118(1):17-21. 4. Prakash UB, Offord KP, Stubbs SE. Bronchoscopy in North America: the ACCP survey. Chest. 1991;100(6):1668-1675.
762
Correspondence
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on September 15, 2010 © 2010 American College of Chest Physicians
fession, we must strive to provide our patients with the best possible care. Further, we must all remain aware of our limitations and refer our patients to where they can be treated with the best and safest approach. We welcome and commend our colleagues for bringing up these interesting issues. Edmundo R. Rubio, MD, FCCP Michael B. Boyd, MD, FCCP Roanoke, VA
References 1. Gobien RP, Stanley JH, Schabel SI, et al. The effect of drainage tube size on adequacy of percutaneous abscess drainage. Cardiovasc Intervent Radiol. 1985;8(2):100-102. 2. Röthlin MA, Schöb O, Klotz H, Candinas D, Largiadèr F. Percutaneous drainage of abdominal abscesses: are large-bore catheters necessary? Eur J Surg. 1998;164(6):419-424. 3. Rahman NM, Maskell NA, Davies CWH, et al. The relationship between chest tube size and clinical outcome in pleural infection. Chest. 2010;137(3):536-543.
Standardization of Interventional Pulmonology Training
Affiliation: From the Section of Pulmonary Medicine, Interventional Pulmonology, Virginia Tech Carilion School of Medicine. Financial/nonfinancial disclosure: The authors have reported to CHEST that no potential conflicts of interest exist with any companiesⲐorganizations whose products or services may be discussed in this article. Correspondence to: Edmundo R. Rubio, MD, FCCP, Virginia Tech Carilion School of Medicine, 1906 Bellevue Ave, Ste 320, Roanoke, VA 24018; e-mail: [email protected] © 2010 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/ site/misc/reprints.xhtml). DOI: 10.1378/chest.10-0849
References To the Editor: We thank Lamb and colleagues1 for their recent article in CHEST (January 2010) addressing the need to standardize the training of interventional pulmonologists. We also appreciate the corresponding editorial by Ost et al2 that provided additional points of discussion. We agree that setting up strict criteria regarding the volume of procedures required may significantly limit the availability of these techniques to our patients. Many formally trained interventional pulmonologists have not met all the suggested standards, and current interventional pulmonary programs may close if unable to meet strict volume requirements. Additionally, we put forth that some procedures considered to be “interventional” perhaps should be part of the training of every general pulmonologist. For instance, in our fellowship program, we strive to train all our fellows to use endobronchial ultrasonography and to perform balloon bronchoplasty. We believe that learning curves are highly individualized and, hence, that the final decision to certify an individual to perform a procedure should be left to the program director and not be limited to procedure volumes. We believe that certain interventions can be performed by pulmonologists who may be qualified to perform a particular procedure but not the whole scope of all available interventions. However, we also maintain that when dealing with more complicated patient airways, care should occur within a center capable of performing all foreseeable interventions. We agree that short, 1- or 2-day interventional pulmonary courses should not be considered sufficient for training. Nevertheless, such courses that also are aimed at the general pulmonologist have become common and often include hands-on practice sessions. We need to make sure that we are not sending a contradictory message. We see their value as a way to disseminate the understanding of the available therapies and to improve patient access and referral. Such courses also serve to update the practicing interventional pulmonologist. With regard to the general practicing pulmonologist, these courses should perhaps emphasize training to deal with airway emergencies, such as the removal of foreign bodies. Clearly, there is no consensus on the need to have strict interventional pulmonary fellowship programs. Regardless, as a prowww.chestpubs.org
1. Lamb CR, Feller-Kopman D, Ernst A, et al. An approach to interventional pulmonary fellowship training. Chest. 2010; 137(1):195-199. 2. Ost D, Eapen GA, Jimenez CA, Morice RC. Improving procedural training and certification in pulmonary medicine. Chest. 2010;137(1):6-8.
Response To the Editor: We thank Drs Rubio and Boyd for their excellent points regarding our article.1 Their main concerns boil down to access to training and the final arbiter of training, both of which affect the availability of procedures we can offer our patients. The goal, however, of providing quality procedures by well-trained operators should not be compromised. We do not propose to limit availability. Individuals well trained by experienced practitioners should be able to offer any specific procedure. We agree that training in isolated procedures such as endobronchial ultrasound may be incorporated into existing fellowship programs. The goal of our article, however, was to provide a framework for a larger spectrum of procedures, support training in the field of interventional pulmonology, and define the didactic and procedural training required for a dedicated interventional pulmonologist. We agree with Drs Rubio and Boyd that weekend courses offer familiarity, not definitive training. These courses provide the practicing pulmonologist with an understanding of options and limitations. For some, they provide the motivation to seek further training. For those in fellowship, individual procedures may be mastered, but this highly depends on the offerings and expertise within each fellowship program. Pastis et al2 made the sobering point that our basic programs often do not provide sufficient training in many basic, let alone advanced, procedures. Take, for example, the history of transbronchial needle aspiration. In itself, it was a pivotal procedure used in the diagnosis and staging of thoracic malignancies. Introduced in the 1970s as a CHEST / 138 / 3 / SEPTEMBER, 2010
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on September 15, 2010 © 2010 American College of Chest Physicians
761
flexible procedure,3 it was not adopted widely as of the 1990s4 and remains limited because of inadequate training. Endobronchial ultrasound is even more pivotal. Frankly, left to the current state of procedure training, it will also fall short of wide adoption as a quality procedure. Ideally, skilled interventional pulmonologists in every training program would train select individuals. Optimal resource utilization and best outcomes would be achieved by patient referral to centers of excellence (be they in the community or in academic centers) staffed by these interventional pulmonologists rather than by having all pulmonologists try to do all things. The reality is that many programs offer limited procedure training and that not all practitioners will have the skill, interest, or time to offer the full range of procedures. It is time to support the training and specialization of the dedicated proceduralist. Kevin L. Kovitz, MD, FCCP Elk Grove Village, IL David Feller-Kopman, MD, FCCP Baltimore, MD Carla Lamb, MD, FCCP Burlington, MA Armin Ernst, MD, FCCP Boston, MA Michael Simoff, MD, FCCP Detroit, MI Daniel Sterman, MD, FCCP Philadelphia, PA Momen Wahidi, MD, FCCP Durham, NC Affiliations: From the Chicago Chest Center (Dr Kovitz); Interventional Pulmonology (Dr Feller-Kopman), Johns Hopkins Hospital; Pulmonary and Critical Care Medicine (Dr Lamb), Lahey Clinic; Pulmonary and Critical Care Medicine (Dr Ernst), Beth Israel Deaconess Medical Center, Harvard Medical School; Pulmonary and Critical Care Medicine (Dr Simoff), Henry Ford Hospital; Section of Interventional Pulmonology and Thoracic Oncology, the Pulmonary, Allergy, and Critical Care Division
(Dr Sterman), University of Pennsylvania Medical Center; and Department of Internal Medicine (Dr Wahidi), Division of Pulmonary, Allergy and Critical Care Medicine, Duke University Medical Center. Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Feller-Kopman has received consulting fees from Immersion Medical Inc., CareFusion Inc., and Olympus America Inc. as well as lecture fees from SonoSite Inc. Dr Lamb has received honoraria as a medical device and clinical consultant for Cardinal Health, inReach System, Spiration, and Boston Scientific. Dr Wahidi has received educational grants from Olympus America Inc., Pentax, Boston Scientific, and Bryan Inc.; consulted with IPS, Immersion, SuperDimension, Veran, and CareFusion Inc.; participated in the speakers bureau for Axcan; and had research sponsored by CareFusion. Drs Kovitz, Ernst, Simoff, and Sterman have reported to CHEST that no potential conflicts of interest exist with any companiesⲐorganizations whose products or services may be discussed in this article. Correspondence to: Kevin L. Kovitz, MD, FCCP, Chicago Chest Center, 800 Biesterfield Rd, # 510, Elk Grove Village, IL 60007; e-mail: [email protected] © 2010 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/ site/misc/reprints.xhtml). DOI: 10.1378/chest.10-1230
References 1. Lamb CR, Feller-Kopman D, Ernst A, et al. An approach to interventional pulmonary fellowship training. Chest. 2010; 137(1):195-199. 2. Pastis NJ, Nietert PJ, Silvestri GA; American College of Chest Physicians Interventional ChestⲐDiagnostic Procedures Network Steering Committee. Variation in training for interventional pulmonary procedures among US pulmonaryⲐcritical care fellowships: a survey of fellowship directors. Chest. 2005; 127(5):1614-1621. 3. Wang KP, Terry P, Marsh B. Bronchoscopic needle aspiration biopsy of paratracheal tumors. Am Rev Respir Dis. 1978; 118(1):17-21. 4. Prakash UB, Offord KP, Stubbs SE. Bronchoscopy in North America: the ACCP survey. Chest. 1991;100(6):1668-1675.
762
Correspondence
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on September 15, 2010 © 2010 American College of Chest Physicians