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Training in Interventional Pulmonology Lonny Yarmus, DO, FCCP1

1 Section of Interventional Pulmonology, Division of Pulmonary and

Critical Care, Johns Hopkins Hospital, Baltimore, Maryland Semin Respir Crit Care Med 2014;35:631–635.

Abstract

Keywords

► interventional pulmonology ► bronchoscopy ► training ► education

Address for correspondence David Feller-Kopman, MD, Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Johns Hopkins, Baltimore, MD (e-mail: [email protected]; www.hopkinsmedicine.org/IP).

The field of interventional pulmonology (IP) is a rapidly growing subspecialty of pulmonary and critical care medicine (PCCM), primarily focused on the evaluation and management of patients with lung nodules, masses, mediastinal and hilar adenopathy, central airway obstruction, and pleural disease. Traditionally passed on in the apprenticeship model, dedicated fellowships began in the early 2000s and there are currently approximately 24 IP fellowships throughout the United States. In addition to the evaluation and management of patients with the above diseases, the additional year provides training in advanced diagnostic and minimally invasive therapeutic procedures that are not specifically taught during a standard PCCM fellowship. This article will review the evolution of the field of IP as well as the pathways to learn advanced procedural techniques.

History Though the term interventional pulmonology (IP) was likely first used in the medical literature in 2001,1 Gustav Killian is credited with being the “grandfather” of the field due to his use of the rigid bronchoscope to revolutionize the treatment of aspirated foreign bodies in 1897.2 Rigid bronchoscopy now is one of the key defining tools of the interventional pulmonologist. For years, the rigid bronchoscope belonged in the domain of all physicians who treated disease of the large airways. However, when Dr. Ikeda invented the flexible bronchoscope in the late 1960s, the use of the rigid bronchoscope by pulmonologists drastically declined, whereas the use of the flexible bronchoscope increased dramatically. In the United States, training in rigid bronchoscopy became limited to thoracic surgeons and some otolaryngologists; however, many pulmonologists in Europe continued to benefit from the mentorship of prior generations. Dumon’s report of the use of silicone stents for the treatment of airway obstruction in the 1980s revitalized the use of the rigid bronchoscope and was the spark that ignited the nascent field of IP.3 Unlike pulmonologists in Europe, those training in the United States had little to no exposure to the use of the rigid bronchoscope. It should be noted that the rigid bron-

Issue Theme Interventional Pulmonology; Guest Editors: David Feller-Kopman, MD, and Lonny Yarmus, DO, FCCP

choscope is just one modality used primarily by IP physicians. Other procedures commonly performed by interventional pulmonologists that are not taught in standard pulmonary and critical care medicine (PCCM) fellowship programs include thoracoscopy, percutaneous tracheostomy, thermal ablation of airway tumors, and airway stent placement. Clearly, one can perform advanced diagnostic procedures such as endobronchial ultrasound (EBUS) and navigational bronchoscopy without being an interventional pulmonologist. Training in even basic diagnostic procedures has been shown to vary widely. In a survey performed by the American College of Chest Physicians (ACCP) in 2001, only 11% of pulmonologists routinely used transbronchial needle aspiration (TBNA) for the diagnosis and staging of lung cancer.4 This drastic underutilization persisted even into the late 1990s, as more than 50% of practicing pulmonologists felt they had inadequate training in “advanced diagnostic procedures such as TBNA,” and more than 20% of respondents stating they had learned 5 of the 13 required procedures when already in practice (as opposed to during their fellowship training).5–7 Pulmonologists are not alone. Thirty-eight percent of graduating PG5 surgical residents did not think their training “fully prepared them to practice general surgery.”8

Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.

DOI http://dx.doi.org/ 10.1055/s-0034-1395793. ISSN 1069-3424.

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

David Feller-Kopman, MD1

Training in Interventional Pulmonology

Feller-Kopman, Yarmus

In 2003, the ACCP published recommendations based on expert consensus as to the minimal number of procedures that should be performed to gain competency.9 Unfortunately, however, “undertraining” has persisted. In 2005, Pastis and colleagues published their results from a survey of 122 PCCM fellowship programs in the United States as to how many programs were meeting the published recommended numbers of a variety of procedures (both basic and advanced). Of the 17 procedures surveyed, only 4 (flexible bronchoscopy, TBNA, tube thoracostomy, and brachytherapy catheter placement) were offered at >90% of the programs and only 1 (flexible bronchoscopy) was performed at the recommended competency number in >90% of programs.10 This undertraining unfortunately has slowed the growth of IP by perpetuating publication of case reports and “feasibility research,” as opposed to larger scale/multicenter randomized trials, as well as not defining best practice with outcomes and comparative effectiveness research. Though we do not currently have data to support that this has impacted patient care, it can be easily extrapolated from both fields outside of medicine and other fields within medicine that higher volumes are associated with improved outcomes.11,12 There are no data to support otherwise.

Lessons from Other Disciplines It is well known that part of developing competence lies in practice. Benefits of repeating a specific task include allowing the task to be broken down into its subcomponents, thereby improving both manual dexterity and the infrastructure/ systems components to ensure the same result each time, with the ultimate goal of increasing success and decreasing error. This is the reason that repetition is required in almost every discipline, from driver’s education and airline pilots to vascular surgery. To become an airline transfer pilot, for example, one is required to have logged 1,500 hours of flight time, 500 hours of cross-country flight time, 100 hours of night flight time, and 75 hours of instrument operations time (simulated or actual), in addition to having passed a rigorous examination and being of “good moral character.”13 There are data suggesting that the complication rate associated with central line placement for operators who have performed >50 lines is half of that compared with operators who have performed

Training in interventional pulmonology.

The field of interventional pulmonology (IP) is a rapidly growing subspecialty of pulmonary and critical care medicine (PCCM), primarily focused on th...
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