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Correspondence |

The Competence DebateThe Competence Debate FREE TO VIEW

Hakim Azfar Ali, MD, FCCP
Author and Funding Information

From Pulmonary and Critical Care, Christiana Hospital.

Correspondence to: Hakim Azfar Ali, MD, FCCP, Pulmonary and Critical Care, Christiana Hospital, 4745 Ogletown Stanton Rd, MAP 1, Ste 220 Newark, DE 19713; e-mail: azfarali1@gmail.com


Financial/nonfinancial disclosures: The author has 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. See online for more details.


Chest. 2014;145(2):424-425. doi:10.1378/chest.13-2233
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To the Editor:

I read with interest the article by Yarmus et al1 in CHEST (September 2013). I appreciate the efforts of the authors in promoting the specialty of interventional pulmonology.

The article provides a backdrop to discuss some interesting questions. Yarmus et al1 mention that the volume of procedures performed by the interventional fellows in 1 year was higher than that performed by the pulmonary and critical care fellows in the 3 years of their training. As evidenced by the data, a large number of these procedures are diagnostic procedures such as endobronchial ultrasound (EBUS). This contrasts with cardiology training, in which the line between general and interventional cardiology is drawn at actual intervention, with regular cardiology fellows receiving adequate training in diagnostic procedures. There is a concern that regular pulmonary and critical care fellows may not be receiving adequate training in safe diagnostic procedures such as EBUS in the programs that also have interventional fellowships, in particular, and in other programs in general.

As the number of interventional fellowships grows and these fellowships populate more of the training programs, the concern is that the procedural competence of regular pulmonary and critical care fellows will be brought into question during the credentialing processes. Are they going to be sufficiently trained in blind transbronchial needle aspirations when the much safer EBUS-guided transbronchial needle aspiration is available (and performed by interventional pulmonary fellows and interventional attendings)? This adds to the already existing issues with the procedural training and volume at the level of the pulmonary fellowships.2 A discussion is needed between general pulmonary fellowship directors and leaders in the interventional community to reach a consensus so that fellows going into the regular pulmonary fellowship programs know about the procedural competence they will be able to achieve by the time they graduate and can determine whether they will be able to meet the credentialing criteria set by the hospitals.

The authors state that procedural volume plays an important role in developing competency and that the goal of competence is public safety. They have used the numbers recommended by expert consensus panels, wherein complicated procedures with a higher risk of significant harm, such as medical thoracoscopy, in which most pulmonary fellows have no previous experience, require a lower number for competence (20) compared with a relatively safe procedure such as EBUS3 (40-50), in which the pulmonary and critical care fellows have some experience. Going forward, interventional pulmonology leaders may need to revisit these numbers so that procedures like thoracoscopy can be safely performed by interventional pulmonologists.

References

Yarmus L, Feller-Kopman D, Imad M, Kim S, Lee HJ. Procedural volume and structure of interventional pulmonary fellowships: a survey of fellows and fellowship program directors. Chest. 2013;144(3):935-939. [CrossRef] [PubMed]
 
Haponik EF, Russell GB, Beamis JF Jr, et al. Bronchoscopy training: current fellows’ experiences and some concerns for the future. Chest. 2000;118(3):625-630. [CrossRef] [PubMed]
 
Eapen GA, Shah AM, Lei X, et al; on behalf of the American College of Chest Physicians Quality Improvement Registry, Education, and Evaluation (AQuiRE) participants. Complications, consequences, and practice patterns of endobronchial ultrasound-guided transbronchial needle aspiration: results of the AQuIRE registry. Chest. 2013;143(4):1044-1053. [CrossRef] [PubMed]
 

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References

Yarmus L, Feller-Kopman D, Imad M, Kim S, Lee HJ. Procedural volume and structure of interventional pulmonary fellowships: a survey of fellows and fellowship program directors. Chest. 2013;144(3):935-939. [CrossRef] [PubMed]
 
Haponik EF, Russell GB, Beamis JF Jr, et al. Bronchoscopy training: current fellows’ experiences and some concerns for the future. Chest. 2000;118(3):625-630. [CrossRef] [PubMed]
 
Eapen GA, Shah AM, Lei X, et al; on behalf of the American College of Chest Physicians Quality Improvement Registry, Education, and Evaluation (AQuiRE) participants. Complications, consequences, and practice patterns of endobronchial ultrasound-guided transbronchial needle aspiration: results of the AQuIRE registry. Chest. 2013;143(4):1044-1053. [CrossRef] [PubMed]
 
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