The added challenges of teaching new procedures and the added knowledge in pulmonary medicine may become even more difficult with stricter work hour regulations for trainees. Before tackling new procedures where there is already a process to produce competent practitioners, it would be interesting to evaluate the current level of competency for existing required procedures, such as tube thoracostomy insertion. The procedural skill set for tube thoracostomy insertion is similar to that of medical thoracoscopy and has a low complication rate, which is contrary to Dr Ali’s remarks regarding medical thoracoscopy. The ultimate reasoning to demonstrate competency is patient safety. Published studies have shown that non-IP physicians perform EBUS competently.6 However, it may be difficult for patients and referring physicians to discern who is competent because pulmonary fellowships vary in advanced diagnostic procedural training like that for EBUS. On the other hand, recent IP fellowship graduates in our study1 certainly have performed a high volume of EBUS and other complex procedures.