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5 Heffner JE. Tracheotomy application and timing. Clin Chest Med 2003; 24:389 –398 6 Kollef MH, Ahrens TS, Shannon W. Clinical predictors and outcomes for patients requiring tracheotomy in the intensive care unit. Crit Care Med 1999; 27:1714 –1720 7 Qureshi AI, Suarez JI, Parekh PD, et al. Prediction and timing of tracheostomy in patients with infratentorial lesions requiring mechanical ventilatory support. Crit Care Med 2000; 28:1383–1387 8 Saffle JR, Morris SE, Edelman L. Early tracheostomy does not improve outcome in burn patients. J Burn Care Rehabil 2002; 23:431– 438 9 Boynton JH, Hawkins K, Eastridge BJ, et al. Tracheostomy timing and the duration of weaning in patients with acute respiratory failure. Crit Care 2004; 8:R261–R267 10 Whited RE. A prospective study of laryngotracheal sequelae in long-term intubation. Laryngoscope 1984; 94:367–377 11 Colice GL. Resolution of laryngeal injury following translaryngeal intubation. Am Rev Respir Dis 1992; 145: 361–365 12 Rello J, Lorente C, Diaz E, et al. Incidence, etiology, and outcome of nosocomial pneumonia in intensive care unit patients requiring percutaneous tracheostomy for mechanical ventilation. Chest 2003; 124:2239 –22243 13 Schultz MJ. Pneumonia after tracheostomy [letter]. Chest 2004; 126:1382 14 Cox CC, Carson SS, Holmes GM, et al. Increase in tracheostomy for prolonged mechanical ventilation in North Carolina, 1993–2002. Crit Care Med 2004; 32:2219 –2226 15 Croshaw R, McIntyre B, Fann S, et al. Tracheostomy: timing revisited. Curr Surg 2004; 61:42– 48 16 Jackson C. High tracheotomy and other errors the chief causes of chronic laryngeal stenosis. Surg Gynecol Obstet 1921; 32:392–398

Pulmonary and Critical Care The Unattractive Specialty of pulmonary and critical care medT heicinespecialty (PCCM) is in trouble. Not a meeting goes

by without someone bemoaning the fact that we have too few people choosing the field. Couple this with a projected shortage of just such specialists for an aging population and the general public has a problem as well. How do we fix this problem that is of obvious import to both our specialty societies and society at large? Lorin and colleagues (February 2005)1 have made a good start. They begin to quantify the problem by looking to the source of trainees, internal medicine residents. It is they who must choose to enter our training programs, and if they are unwilling to do so, we must query them directly to understand the reasons. What are the key factors that influence decision making, and what can we do to not only keep from driving trainees away but also, more importantly, draw them to us? A good place to start is the survey made by Lorin and colleagues1 of internal medicine residents (response rate, 61%) in university hospital training www.chestjournal.org

programs. Although 41% had “seriously considered” pulmonary and critical care, only 3.4% actually chose the field. There were attributes of the field that respondents perceived as attractive; however, lifestyle issues appeared to be significantly dissuading. Lack of free time, stress in potential role models, chronically ill patients, incompatible personality, and treating pulmonary diseases were most cited as reasons for avoiding PCCM as a specialty choice. When people have a choice, lifestyle plays a major role in decision making. The scope of any given field will be attractive to some and not to others. The breadth of illnesses in PCCM, including many chronic disease processes, will interest residents in different ways. The attractiveness of the field will likely vary over time based on our capacity to manage the range of illnesses and the impact we can have on patients. As a field, we will attract more quality trainees as we broaden the range of clinical interventions available to improve the quality of life of our patients. The chronic cardiac or renal patient is not as debilitated as in times past thanks to new and expanded therapeutic options. We will also see the impact on the chronic pulmonary patient as our interventions for COPD, lung cancer, pulmonary fibrosis, and other entities improve. The article posits that it is important to focus on the lifestyle issues of lack of free time and stress of the fellows and attending physicians who are the potential role models. Such is the choice we all face in the practice of medicine. The consequences of this choice become apparent comparing a field of daily life and death with long hours to a field of more leisurely scope and pace. However, I do not believe that the lifestyle issues above really play a definitive role in deciding against PCCM when one looks internally at the competing specialties within internal medicine. I do not know many cardiologists or oncologists with abundant free time or limited stress, yet these were among the preferred fields. A future iteration of this excellent study could compare these lifestyle barriers to entry among internal medicine subspecialties. However, is the problem really one of the lifestyle issues cited, or are these merely surrogates for something more fundamental? One of the oldest cliche´s is that “you get what you pay for.” Could financial considerations really be the root cause of the dearth of trainee interest? We like to think that people will choose the field they find most interesting and that they will be purely altruistic in making this choice. Ultimate income would therefore be secondary. This idealized paradigm may be true for some, but what about the more realistic scenario that most trainees find many different specialties interesting? Income potential likely plays CHEST / 127 / 4 / APRIL, 2005

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a substantial role in decision making in this scenario, and a second look at the authors’ data supports this conclusion. Recent data from the American Association of Medical Colleges2 once again notes the high cost of medical education and the subsequent $100,000 to $135,000 median debt burden held by 2003 medical school graduates. The first choice, general internal medicine (19.6%),1 is likely influenced by lifestyle and the need to get on with paying such a debt. But once someone chooses to subspecialize, it is important for us to apply income potential to this analysis of choice. Economic forces are real and, no matter how couched in other terms, have dominant impact. Table 1 lists academic and private practice total compensation means based on 2003 data collected by the Medical Group Management Association (MGMA)3 alongside specialty choices, in decreasing order of preference, found by Lorin and colleagues.1 The MGMA is a standard benchmarking group that is used by many organizations to understand their practice environments. Listed are the average total compensations of the fields chosen for both academic and private practice. I have also accounted for the range in the fields that have subtypes. For example, I have averaged the values for the MGMA reported subtypes of interventional, electrophysiology, and noninvasive and invasive cardiology and similarly averaged values for any other specialty with multiple subtypes. The preference of career choice directly correlates with the size of the total compensation for the academic environment and nearly matches up for private practice. Keep in mind that the article surveyed residents in an academic environment, so that is the environment with which the residents are most familiar. It is possible that a survey of community-based residents would match up more accurately to private practice. Also, there are likely other lifestyle factors in play as the authors claim. Economic markets adjust to information. That is why regulators try to mandate a fair distribution of information and frown on insider knowledge. The assumption is that allowing equal access to knowledge will allow for

the most informed decisions and balance the markets. As residents gain a further understanding of compensation, they may even improve the correlation between income and career choice. What does all this mean? First, the authors have made an excellent start at looking for the root cause of the dearth of trainees choosing pulmonary and critical care as a subspecialty. Lifestyle, disease range, intervention potential, and role models will always have an impact on career choice. There will be always be a baseline of individuals who chose a field based purely on interest. We can also work at the edges and improve mentoring, role models, and subsequently our disease intervention options to make PCCM a more attractive option to trainees. However, we cannot simply look internally to the field to solve the problem. Given a wide range of options, dedicated individuals who are willing to work hard will simply choose the better income potential between fields that are of similar interest to them. They will also be more likely to overlook shortcomings in a field if the income potential is sufficient. To solve the need for pulmonary and critical care specialists, we need to improve reimbursement. Critical care is reimbursed at a higher rate than a high-level evaluation and management visit. However, in reality, most critically ill patients and their care do not qualify as critical care by the Centers for Medicare and Medicaid Services guidelines. Critical care coding requires substantial time in the direct care of a critical and unstable patient. Airway stenting is reimbursed at a much lower rate than coronary stenting. These are not complaints, just facts, and there are many such examples. With reimbursement being a “zero sum game,” it will be difficult to ameliorate the situation. We must advocate for our representative societies to advocate for us. If not, market forces will solve the increasing acuity of the shortage of pulmonary and critical care specialists. Either less-qualified practitioners will step in to fill the void, lowering quality and reimbursement for all, or patients will increasingly demand and pay for the qualified specialist. The laws of

Table 1—Subspecialty Choice by Descending Order of Preference Listed Alongside MGMA Mean Academic and Mean Private Practice Total Compensation for Each* Specialty

%

Mean Academic Total Compensation, US$

Mean Private Practice Total Compensation, US$

Cardiology Gastroenterology Hematology/oncology Nephrology Pulmonary and critical care

16.2 12.3 8.9 8.4 3.4

230,278 † 189,120 † 174,542 † 166,668 159,817 †

404,251 † 345,540 † 377,196 † 261,919 242,792 †

*Reprinted with permission from the MGMA. †Average taken of the mean reported total compensations for all the subtypes of this field. 1086

Editorials

supply and demand will then kick in and trainees will gravitate toward an improved income potential. This can easily be subverted if our lobbying potential is less than others or if we work at cross-purposes. It is better to work among our overlapping societies and improve the “lifestyle” for all of us. We can no longer keep our heads buried in the sand. You get what you pay for. . . Kevin L. Kovitz, MD, MBA, FCCP New Orleans, LA Dr. Kovitz is Director, Interventional Pulmonology and Medical Critical Care, Tulane University Health Sciences Center. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]). Correspondence to: Kevin L. Kovitz, MD, MBA, FCCP, Director, Interventional Pulmonology and Medical Critical Care, Tulane University Health Sciences Center, 1430 Tulane Ave SL9, New Orleans, LA 70112; e-mail: [email protected]

References 1 Lorin S, Heffner J, Carson S. Attitudes and perceptions of internal medicine residents regarding pulmonary and critical care subspecialty training. Chest 2005; 127:630 – 636 2 Jolly P. Medical school tuition and young physician indebtedness. American Association of Medical Colleges, March 2004. Available at: http://www.aamc.org/publications. Accessed March 3, 2005 3 Medical Group Management Association. Academic Practice Compensation and Production Survey for Faculty and Management: 2004 Report Based on 2003 Data. Available at: http://www.mgma.com.

End of the Idyll Farming and the Risk of Occupational Allergy workers are a particularly important A gricultural risk group for work-related respiratory disorders

and, at the same time, comprise a population that is notoriously difficult to study effectively. The range of conditions of the lower and upper airways to which farmers are prone includes zoonotic infections, extrinsic alveolitis, irritant inhalant injury, organic dust toxic syndrome, and asthma.1 As Chatzi et al2 show convincingly in the January 2005 issue of CHEST, this list of conditions should not omit allergic rhinitis. The challenges encountered in studying agricultural cohorts are legion. Because by definition they are rural populations, agricultural workers are remote from most medical research centers. Even within the target geographic area of study interest, potential subjects are typically dispersed and often are difficult to contact. Identifying potential study subjects in a way that systematically reflects the www.chestjournal.org

underlying population-at-risk and successfully recruiting such subjects is time-consuming and laborintensive. Choosing a reasonable referent population to compare with a farming cohort (a population that must also be recruited in parallel) is doubly difficult. On all of these counts, Chatzi et al2 have done an admirable job, allowing their study to make a notable contribution to a growing body of medical literature on occupational airways disease in farmers. The report is significant for a number of other reasons beyond its methodologic strengths. Despite a substantive number of research publications focusing on the epidemiology of airways diseases among farmers, especially asthma, relatively few studies have actually been performed that concern those farmers who cultivate field or orchard crops in outdoor settings. The excellent studies in the Finnish-language literature on occupational asthma in farmers, for example, have largely been driven by the study of cow handlers.3 Other prominent agricultural groups that have been studied in the past few years include swine-confinement workers,4 grain dust-exposed farmers,5 and cultivators employed in greenhouses.6 The powerful European Community Respiratory Health Survey7 has provided interesting observations on asthma risk across a range of occupations including farmers, but because of its largely urban-based and suburban-based sampling design, there are relatively few agricultural workers in that cohort. The largest population-based study of respiratory disease in agriculture that includes substantive numbers of field and orchard crop workers is the European Farmers’ Project, although three quarters of that group have concomitant exposure to cattle, pigs, sheep, or poultry.8 By focusing on farmers who are cultivating a single crop (eg, grapes, predominantly raised for raisins rather than for winemaking), the investigation of Chatzi et al2 is well-positioned to provide insights derived from a highly specific environment that nonetheless may be generalized to other settings. The principal findings indicate a substantially greater prevalence of rhinitis symptoms and positive skinprick test reactions to aeroallergens among grape farmers compared to control subjects. This latter finding appeared to be driven by pollen sensitivity, especially to allergens associated with plant species that are common weeds in Mediterranean grapegrowing regions, consistent with likely occupationally related exposure. The far lower prevalence of sensitization among inhabitants of the same rural locale studied as referents argues against these pollens as simply being regional aeroallergens with exposure that is unrelated to work practices. CHEST / 127 / 4 / APRIL, 2005

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