Communications to the Editor |

Statement on Exercise: American College of Chest Physicians/American Thoracic Society—Exercise for Fun or Profit? FREE TO VIEW

William W. Stringer, MD, FCCP; Karlman Wasserman, MD, PhD, FCCP
Author and Funding Information

Affiliations: Harbor-UCLA Medical Center, Torrance, CA,  University of Vermont, Burlington, VT

Correspondence to: William W. Stringer, MD, FCCP, Harbor-UCLA Medical Center, Professor of Medicine, UCLA School of Medicine, 1000 West Carson St, Torrance, CA 90509; e-mail: Stringer@ucla.edu

Chest. 2005;127(3):1072-1074. doi:10.1378/chest.127.3.1072
Text Size: A A A
Published online

To the Editor:

We would like to formally respond to the editorial by Irvin and Kaminsky in a recent issue of CHEST (January 2004).1 Specifically, although the authors pointed out several important points regarding cardiopulmonary exercise testing (CPET), we do not think that the editorial1or the joint statement on exercise2 by the American College of Chest Physicians (ACCP) and the American Thoracic Society (ATS) appropriately addressed three very important issues.

CPET and Interpretation Are Inadequately Reimbursed in the United States

We are unclear why the authors of the editorial1 selected the title “Exercise for Fun and Profit.” At the present time, reimbursement by Medicare for CPET is so poor that most laboratories lose money when performing CPET, and the compensation does not provide for physician supervision of the testing, something that we believe is very important. Thus, there is very little profit. To maximize the information gained from CPET, and for patient safety, the physician should be present to examine the patient when there are symptoms of exercise limitation. However, various payer agencies assume that testing has been performed appropriately in the presence of a technician, and provide “reimbursement” that is commensurate only with technician time, not physician time. We believe that is wrong.

Also, the low compensation impacts on the education of physicians in fellowship training programs. Fellows are not taught CPET in many training programs in the United States because it attracts no money to the program. Thus, the title of the editorial by Irvin and Kaminsky appears to be considerably off the mark.

We believe that if the CPETs were performed and interpreted properly, substantial health-care costs would be saved because it would make it unnecessary to perform many other diagnostic tests that are expensive and do not reveal the cause of the exercise limitation. CPET should not only reduce the cost of testing leading to a specific diagnosis, but it also should reduce the time to diagnosis.3

Policy makers should ask “Why do so few pulmonologists order CPET studies”? Does the practicing physician know when, why, and how to order CPET? Can they obtain standardized tabular and graphic displays to interpret? We believe that a survey of pulmonologists, cardiologists, and primary care practitioners performed by ACCP would be of interest to determine their clinical indications for CPET (if they are ordering such tests), the frequency of ordering CPET, and the perceived value of the tests. The results of this survey could provide data for CPET educational venues.

To familiarize and educate fellows who are in training about CPET, it must be reimbursed at a reasonable rate. No training program has trouble encouraging fellows to learn bronchoscopy as this is a brief, well-reimbursed procedure. CPET requires large amounts of cognitive input by physician, as well as time for reflection and report generation, while being poorly reimbursed. The editorial does not send the correct message to training programs, physicians, or our health system when the wealth of clinical data from CPET can make enormous improvements in the diagnosis and therapy of patients with cardiopulmonary diseases. The disenchantment with CPET because of inappropriately low reimbursement rates should be corrected at the national level, and the ATS and ACCP should be active in pursuing these goals.

Education for Pulmonary and Critical Care Physicians in Exercise Physiology and CPET Is Inadequate

This topic is a vitally important component of our pulmonary training programs and should not be relegated to a piece of paper so concise that we can “hand it out to our fellows.”1 Training fellows in exercise testing and interpretation takes time, effort, well-organized teaching materials, a heuristic framework, enthusiastic teachers, as well as practice reviewing cases, supervising calibration, and performing exercise tests. This is best achieved over the course of a pulmonary fellowship as part of the core curriculum. The ACCP and ATS should consider endorsing minimal standards (eg, number of cases, case mix, technical aspects, and complications, just like those for bronchoscopy) to certify a fellow (and perhaps programs) in exercise testing prior to graduation. Postgraduate physicians could obtain the same training with appropriate courses and mentoring.

Since Irvin and Kaminsky1 stated that the interpretation of CPET results is very difficult and want it simplified, one can ask whether CPET is made more difficult because the interpreter has not received prior education on the subject. How do fellows and laboratory directors receive education on the subject? How many fellowship training programs adequately teach how to perform and interpret CPET results, and the pathophysiology of exercise limitation? We recommend that the ACCP/ATS promote both fellowship and postgraduate training courses by, for example, the routine advertising of such courses, basic descriptions of the course content, and the goals of the course.

CPET Laboratories Need To Have a Proficiency Testing Program

From our experience in clinical trials that involve multiple sites performing CPET, and the use of CPET measurements as outcome variables for several trials, we have found that the training of technical staff to perform the testing is often essentially nonexistent. In other cases, testing may be so infrequent that equipment is not maintained or calibrated. This leads to inaccurate and variable data as well as incorrect interpretations. Therefore, we strongly believe that the ATS and ACCP should consider developing and supporting a proficiency testing and certification process that “enrolls” laboratories to ensure that their equipment is adequately set up, technicians are well-trained, reliable calibration and exercise data are generated for each test, and physicians are educated in the intricacies of exercise testing and interpretation. This certification could then be assessed periodically to ensure that the site continues to generate high-quality exercise data.

Finally, Irvin and Kaminsky themselves identified two important deficits in the joint ATS/ACCP statement.2 They state that the statement fails to address the following: (1) the need for a uniform graphic format; and (2) the need for experts who could analyze CPET results with relative ease. We agree, and both of these issues could be addressed by getting together investigators and health-care providers with in-depth experience in CPET to work on the standardization of reporting and educational issues.

In summary, CPET is an extremely valuable diagnostic tool that is complicated to perform and interpret by technicians and physicians who have not been adequately trained. Compounding these problems is the marked underfunding relative to the time and cognitive effort required for testing, the professional involvement during performance, and the interpretation of the test results. Also, CPET is not extensively taught in many pulmonary training programs, and requires a large amount of education of technicians, pulmonary physicians, and primary care physicians about indications, proper calibration, performance, and interpretation of the CPET results. Finally, the ATS and ACCP should consider a proficiency testing program to ensure that the sites that are generating and interpreting CPET data have equipment that is well-calibrated, are staffed by physicians, and generate standardized printouts and interpretations. Without these measures, we cannot expect that doctors would know how to correctly order, interpret, or utilize the vast amount of important clinical information contained in this diagnostic test.

The vast expertise in the ATS/ACCP in education, proficiency testing, standardization, postgraduate training, and public policy should be brought to bear on the numerous difficulties with CPET, and these issues should be addressed in future policy statements and political venues. CPET must become a more rigorous, standardized, well-known, well-calibrated, and well-funded procedure in order for our pulmonary and cardiology physicians and patients with exercise intolerance to profit from CPET.

Irvin, CG, Kaminsky, DA (2004) Exercise for fun and profit.Chest125,1-2. [CrossRef] [PubMed]
American Thoracic Society, American College of Chest Physicians. ATS/ACCP statement on cardiopulmonary exercise testing.Am J Respir Crit Care Med2003;167,211-277. [CrossRef] [PubMed]
Sue, DY, Wasserman, K Impact of integrative cardiopulmonary exercise testing.Chest1991;99,981-992. [CrossRef] [PubMed]
To the Editor:

We found the letter by Drs. Stringer and Wasserman in response to our editorial in CHEST (January 2004)1to be intriguing and would offer the following responses, clarifications, and thoughts. First, we are disappointed that our use of the word profit was not understood, as it was meant to be, in terms of the second definition of the word given in Webster’s Seventh New Collegiate Dictionary2: (1) to be of service or advantage; or (2) to derive benefit. We firmly believe that clinicians derive considerable benefit from the cardiopulmonary exercise test (CPET). In particular, they can profit from it diagnostically. In regard to the first definition of profit given in Webster’s, we are puzzled by the authors’ assertion that financial profit cannot be derived. Laboratories that both of us have directed both in Colorado and here in Vermont did profit financially from CPET studies. Perhaps California is different. Nevertheless, we agree with the authors that (1) CPET saves other health-care costs; (2) a survey from the American Thoracic Society or American College of Chest Physicians to obtain data to address these issues would be of value or profit; and (3) the time required to interpret studies is substantial and nontrivial.

Second, Drs. Stringer and Wasserman totally misquoted us when they said “so concise that we can hand it out to our fellow.”1 What we said was “it will not allow us just to hand it [the statement] out to our fellow,” and then we said “and have any hope they will read it.” Indeed, we clearly discussed the importance of spending time with the trainee going over results. We also use a core curriculum containing training elements that are similar to those outlined by the authors. Nevertheless, we vehemently agree that training and mentoring are key, and would join with Drs. Stringer and Wasserman to advocate the offering of such training opportunities. We would also point out that better education is needed for conducting all tests performed in the lung function laboratory, even spirometry.3

Third, we agree with Drs. Stringer and Wasserman that the appropriate training of technical staff is important. Having previously sat on committees charged with this responsibility, we identified the barrier to laboratory certification and proficiency as simply a matter of resources. While it is correct to call for certification and proficiency testing of exercise laboratories, this costs money; a lot of money. Who will pay? The only practical answer is the same laboratory that found CPET not to be of financial profit. Rather, we would suggest that the responsibility for the quality control of CPET lies with the laboratory director. Accordingly, it is the director who should be certified and be held responsible for the quality of the work product of the laboratory. We do, however, support any legitimate and cost-effective process that would improve the results of the CPET, or for that matter, any pulmonary laboratory testing procedure.

In summary, we stand by the title of our article as being both appealing and correct, because CPET is both fun (to teach fellows about) and profitable (clinically), providing important diagnostic and clinical insight into pulmonary disease processes that cannot be obtained any other way. CPET is a test modality from which the attending physician will derive insight and benefit. As such, CPET is indeed profitable.

Irvin, CG, Kaminsky, DA Exercise for fun and profit.Chest2004;125,1-3. [CrossRef] [PubMed]
 Websters Seventh New Collegiate Dictionary. 1963; G. & C. Merriam Company. Springfield, MA:.
Irvin, CG To blow or not to blow: that is the question.Respir Care2002;47,1145-1146. [PubMed]




Irvin, CG, Kaminsky, DA (2004) Exercise for fun and profit.Chest125,1-2. [CrossRef] [PubMed]
American Thoracic Society, American College of Chest Physicians. ATS/ACCP statement on cardiopulmonary exercise testing.Am J Respir Crit Care Med2003;167,211-277. [CrossRef] [PubMed]
Sue, DY, Wasserman, K Impact of integrative cardiopulmonary exercise testing.Chest1991;99,981-992. [CrossRef] [PubMed]
Irvin, CG, Kaminsky, DA Exercise for fun and profit.Chest2004;125,1-3. [CrossRef] [PubMed]
 Websters Seventh New Collegiate Dictionary. 1963; G. & C. Merriam Company. Springfield, MA:.
Irvin, CG To blow or not to blow: that is the question.Respir Care2002;47,1145-1146. [PubMed]
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543