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Communications to the Editor |

Competencies in Pulmonary Procedures FREE TO VIEW

Francisco Alvarez; Charles Burger; Stephen Grinton; Margaret Johnson; Cesar Keller; Philip Lyng; Syed Malik; James Parish; Jorge Pascual
Author and Funding Information

Affiliations: Mayo Clinic Jacksonville, Jacksonville, FL,  Rochester, NY,  Boston, MA,  Charleston, SC

Correspondence to: Francisco Alvarez, MD, Mayo Clinic Jacksonville, 4500 San Pablo Rd, Jacksonville, FL 32224



Chest. 2004;125(2):800-801. doi:10.1378/chest.125.2.800
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Published online

To the Editor:

We read with interest the guidelines from the American College of Chest Physicians on interventional pulmonary procedures (May 2003).1 The introduction noted that although there were not “data on all procedures,” the writers should “not shy away from competency guidelines altogether.” Indeed, no shyness was employed. Specific numbers of procedures required to establish competency were routinely included in the document, and every invasive procedure required 10 procedures per year to maintain competency. Since no data were available, we assumed that the authors surveyed training program directors, but we could find no reference to this.

The spirit of competencies is commendable and is used for training by other societies. Nonetheless, baseline numbers must be evidence-based or from a broad survey of the society membership to be credible and useful. While we applaud the intent of this report, the process responsible for these recommendations is fatally flawed. (1) Surveys of training directors should have been performed, and a writing committee should have been appointed, with its final product approved by the assembled experts. This more credible and accepted consensus process would involve establishing levels of evidence supporting the guideline. Was this done? If so, why was it not included in the manuscript? (2) In our experience, specific procedural thresholds are more useful to establish “initial” competency rather than “ongoing” skills. A specific example is rigid bronchoscopy. On page 1696, the authors state, “Dedicated operators should perform at least 10 procedures per year to maintain competency.” For those of us who have been performing rigid bronchoscopy for years with no mortality and minimal complications, we find this declaration ill advised. For example, someone with 20 years of experience does not necessarily require the same number of procedures as an inexperienced operator. Complication rates and results are generally thought to comprise a better guideline than an arbitrary minimum number. Indeed, unintended consequences may result if the guideline encourages the inappropriate overuse of the rigid bronchoscope or other invasive procedure for the “touch up of lesions.” (3) Misguided, poorly researched, inadequately supported and/or arbitrary numbers provide a breeding ground for misinterpretation by those organizations (eg, Joint Commission on Accreditation of Healthcare Organizations, American Heart Association, National Quality Forum, and LEAPFROG) that wish to partner with medicine to improve quality.

To maintain the integrity of the medical literature, we must readily distinguish between opinion and guidelines. A detailed discussion of the available medical evidence or disclosure of the lack thereof is mandatory for “society-endorsed” guidelines.

In the absence of evidence, a broad-based survey of training programs and practitioners is necessary as a starting point. The American College of Chest Physicians should begin an immediate process of reviewing the literature and documenting its quality, as well as surveying its membership and conference attendees, so that a new and legitimately documented set of guidelines can be published. The current recommendations appear arbitrary. They should be renamed opinion, and the designation of guidelines withdrawn.

References

Ernst, A, Silvestri, G, Johnstone, D (2003) Interventional pulmonary procedures: guidelines from the American College of Chest Physicians.Chest123,1693-1717. [CrossRef] [PubMed]
 
To the Editor:

Three concerns have been raised in response to the American College of Chest Physicians (ACCP) guidelines (May 2003)1 :

  1. Surveys of training directors and a writing committee of experts would provide better guidelines, including, presumably, more accurate definitions of competence.

  2. Specific procedural thresholds may be inferior to complication rates when determining ongoing competence. The frequency of performing a procedure is not necessarily a measure of competence among experienced practitioners.

  3. Quality overseers may misinterpret “arbitrary” procedure numbers.

Most clinical recommendations in the literature are expert opinions. Evidence-based guidelines remain the exception. In fact, there is no significant literature in this area that satisfactorily addresses the issue of defining competence. A committee of experts, including interventional pulmonologists, critical care specialists, and thoracic surgeons, wrote the guidelines. The authors include academic physicians, private practice physicians, and interventional pulmonologists, both from the United States and Europe. We thought that this broad specialty and practice representation would be appropriate to assure a balanced document. It is not clear to us why a poll of program directors (who may or may not have direct expertise in these areas) would contribute substantially to the published document.

The authors and the ACCP carefully considered the semantics of the terms guidelines and standards. The conclusion was that standards implies a finality of recommendation that was both inappropriate for this document as well as subject to misuse by outside governing bodies and organizations. In contrast, the term guidelines implies an expression of expert opinion, that is subject to revision and is not binding upon practitioners. We have always intended this as a “work in progress” that would undergo periodic reassessment and revision.

With regard to specific numeric guidelines for establishing and maintaining competence in these procedures, we think there is ample evidence that performing medical procedures more often leads to fewer complications. This is true for central line placement and thoracentesis, and for chest tube placement. Most evidence suggests that repetitive use of abilities and continuous training is desirable. We see this in aviation and the military, for example. In surgical specialties, board certification requires minimum numbers of various procedures, and recertification requires documentation of performance of a satisfactory number of procedures during the previous year. In other words, there are defined numeric requirements for establishing and maintaining competence. In fact, the trend in surgical specialties is toward making these requirements more specific, more frequent, and perhaps including (for the first time) evidence of acceptable complication rates. We agree that complication rates may afford a very useful measure of a practitioner’s competence and would welcome initiatives to reliably record such data. A further step would be to consider skill testing at defined intervals. This likely would be cumbersome and might be subject to misuse. Nevertheless, our assumption remains that frequent procedures correlate with reduced complications.

Finally, we note that the European Respiratory Society/American Thoracic Society statement published in Europe on these procedures2 also contained numeric requirements. The ACCP guidelines are therefore not, in this regard, a departure from previous work.

We hope that this addresses the writers’ concerns. The interventional procedures guidelines were written with an expectation of differences of opinion. We welcome this sort of discussion, for from that ferment will come a clearer understanding of the utility and limitations of these guidelines.

References
Ernst, A, Silvestri, G, Johnstone, D Interventional pulmonary procedures: guidelines from the American College of Chest Physicians.Chest2003;123,1693-1717. [CrossRef] [PubMed]
 
Bolliger, CT, Beamis, JF, Becker, HD, et al ERS/ATS statement on interventional pulmonology.Eur Respir J2002;19,356-373. [CrossRef] [PubMed]
 

Figures

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References

Ernst, A, Silvestri, G, Johnstone, D (2003) Interventional pulmonary procedures: guidelines from the American College of Chest Physicians.Chest123,1693-1717. [CrossRef] [PubMed]
 
Ernst, A, Silvestri, G, Johnstone, D Interventional pulmonary procedures: guidelines from the American College of Chest Physicians.Chest2003;123,1693-1717. [CrossRef] [PubMed]
 
Bolliger, CT, Beamis, JF, Becker, HD, et al ERS/ATS statement on interventional pulmonology.Eur Respir J2002;19,356-373. [CrossRef] [PubMed]
 
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