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Kevin L. Kovitz, MD, FCCP; David Feller-Kopman, MD, FCCP; Carla Lamb, MD, FCCP; Armin Ernst, MD, FCCP; Michael Simoff, MD, FCCP; Daniel Sterman, MD, FCCP; Momen Wahidi, MD, FCCP
Author and Funding Information

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.

Correspondence to: Kevin L. Kovitz, MD, FCCP, Chicago Chest Center, 800 Biesterfield Rd, #510, Elk Grove Village, IL 60007; e-mail: kovitz@chestcenter.com


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 companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;138(3):761-762. doi:10.1378/chest.10-1230
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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 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.

Lamb CR, Feller-Kopman D, Ernst A, et al. An approach to interventional pulmonary fellowship training. Chest. 2010;1371:195-199. [CrossRef] [PubMed]
 
Pastis NJ, Nietert PJ, Silvestri GA. American College of Chest Physicians Interventional Chest/Diagnostic Procedures Network Steering Committee American College of Chest Physicians Interventional Chest/Diagnostic Procedures Network Steering Committee Variation in training for interventional pulmonary procedures among US pulmonary/critical care fellowships: a survey of fellowship directors. Chest. 2005;1275:1614-1621. [CrossRef] [PubMed]
 
Wang KP, Terry P, Marsh B. Bronchoscopic needle aspiration biopsy of paratracheal tumors. Am Rev Respir Dis. 1978;1181:17-21. [PubMed]
 
Prakash UB, Offord KP, Stubbs SE. Bronchoscopy in North America: the ACCP survey. Chest. 1991;1006:1668-1675. [CrossRef] [PubMed]
 

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References

Lamb CR, Feller-Kopman D, Ernst A, et al. An approach to interventional pulmonary fellowship training. Chest. 2010;1371:195-199. [CrossRef] [PubMed]
 
Pastis NJ, Nietert PJ, Silvestri GA. American College of Chest Physicians Interventional Chest/Diagnostic Procedures Network Steering Committee American College of Chest Physicians Interventional Chest/Diagnostic Procedures Network Steering Committee Variation in training for interventional pulmonary procedures among US pulmonary/critical care fellowships: a survey of fellowship directors. Chest. 2005;1275:1614-1621. [CrossRef] [PubMed]
 
Wang KP, Terry P, Marsh B. Bronchoscopic needle aspiration biopsy of paratracheal tumors. Am Rev Respir Dis. 1978;1181:17-21. [PubMed]
 
Prakash UB, Offord KP, Stubbs SE. Bronchoscopy in North America: the ACCP survey. Chest. 1991;1006:1668-1675. [CrossRef] [PubMed]
 
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