0
Correspondence |

ResponseResponse FREE TO VIEW

Hans J. Lee, MD, FCCP; Lonny Yarmus, DO, FCCP
Author and Funding Information

From the Section of Interventional Pulmonology, Division of Pulmonary and Critical Care, John Hopkins University School of Medicine.

Correspondence to: Lonny Yarmus, DO, FCCP, Section of Interventional Pulmonology, Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, 1800 Orleans St, Ste 7125M, Baltimore, MD 21287; e-mail: lyarmus@jhmi.edu


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


Chest. 2014;145(2):425-426. doi:10.1378/chest.13-2365
Text Size: A A A
Published online
To the Editor:

We thank Dr Ali for the insightful comments regarding our recent article.1 We strongly agree with Dr Ali’s assessment that a discussion on the competency for advanced pulmonary and interventional pulmonary (IP) procedures needs to be addressed.

The goal of the study was to define the current landscape of IP training, which includes a high volume of endobronchial ultrasound (EBUS) as well as other advanced diagnostic and therapeutic procedures. The same cannot be reported about pulmonary and critical care medicine (PCCM) fellowship graduates in the United States. Unfortunately, the issue with meeting procedural requirements is not new for PCCM training and is an evolving issue as new procedures continue to be developed. The majority of pulmonary fellows reported an inability of current standard fellowship training to fulfill requirements for basic diagnostic bronchoscopy.2 A large national survey of practicing pulmonologists reinforced the notion that the overall procedural skills of most pulmonologists are inadequate or at least are not uniform.3 For procedures such as EBUS and transbronchial needle aspiration (TBNA), the challenges have historically been even greater, with data reporting only 10% of PCCM fellows being trained in TBNA.4 A survey of fellowship directors in 2005 with a 77% response rate demonstrated that even when interventional procedures were offered by fellowships, < 30% of programs met the recommendations for competency.5

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.

Dr Ali’s claims that EBUS-guided TBNA is a safer procedure than standard TBNA is not supported by the literature. TBNA has been reported for > 2 decades to have a low complication rate. We continue to routinely use standard TBNA in our practice, especially for the peripheral nodule where convex EBUS is not possible or in large masses where EBUS may add an unnecessary cost.7 Competency should also go beyond number of procedures. There is a didactic knowledge component for competency, and an error in decision-making or sampling order during EBUS-guided TBNA can potentially lead to down staging disease, placing patients at risk for unnecessary surgical interventions. In a recent study,8 we demonstrated that a significant didactic knowledge gap exists between graduating IP fellows and pulmonary fellows.9 Didactic knowledge of when to best apply a procedure is critical for informed consent and preventing harm.

The question of who should and should not perform certain procedures will not be answered here. The only conclusions that we can make from the present study at this time are that graduates of IP fellowships surveyed have a high volume of procedures and are most likely competent in EBUS and advanced diagnostic procedures.

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]
 
Tape TG, Blank LL, Wigton RS. Procedural skills of practicing pulmonologists. A national survey of 1,000 members of the American College of Physicians. Am J Respir Crit Care Med. 1995;151(2):282-287. [CrossRef] [PubMed]
 
Haponik EF, Shure D. Underutilization of transbronchial needle aspiration: experiences of current pulmonary fellows. Chest. 1997;112(1):251-253. [CrossRef] [PubMed]
 
Pastis NJ, Nietert PJ, Silvestri GA; 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;127(5):1614-1621. [CrossRef] [PubMed]
 
Schipper PH, Diggs BS, Ungerleider RM, Welke KF. The influence of surgeon specialty on outcomes in general thoracic surgery: a national sample 1996 to 2005. Ann Thorac Surg. 2009;88(5):1566-1572. [CrossRef] [PubMed]
 
Yarmus L, Feller-Kopman D, Browning R, Wang KP. TBNA: should EBUS be used on all lymph node aspirations? J Bronchology Interv Pulmonol. 2011;18(2):115-117. [CrossRef] [PubMed]
 
Lee HJ, Feller-Kopman D, Shepherd RW, et al. Validation of an interventional pulmonary examination. Chest. 2013;143(6):1667-1670. [CrossRef] [PubMed]
 
Herth F, Becker HD, Ernst A. Conventional vs endobronchial ultrasound-guided transbronchial needle aspiration: a randomized trial. Chest. 2004;125(1):322-325. [CrossRef] [PubMed]
 

Figures

Tables

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]
 
Tape TG, Blank LL, Wigton RS. Procedural skills of practicing pulmonologists. A national survey of 1,000 members of the American College of Physicians. Am J Respir Crit Care Med. 1995;151(2):282-287. [CrossRef] [PubMed]
 
Haponik EF, Shure D. Underutilization of transbronchial needle aspiration: experiences of current pulmonary fellows. Chest. 1997;112(1):251-253. [CrossRef] [PubMed]
 
Pastis NJ, Nietert PJ, Silvestri GA; 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;127(5):1614-1621. [CrossRef] [PubMed]
 
Schipper PH, Diggs BS, Ungerleider RM, Welke KF. The influence of surgeon specialty on outcomes in general thoracic surgery: a national sample 1996 to 2005. Ann Thorac Surg. 2009;88(5):1566-1572. [CrossRef] [PubMed]
 
Yarmus L, Feller-Kopman D, Browning R, Wang KP. TBNA: should EBUS be used on all lymph node aspirations? J Bronchology Interv Pulmonol. 2011;18(2):115-117. [CrossRef] [PubMed]
 
Lee HJ, Feller-Kopman D, Shepherd RW, et al. Validation of an interventional pulmonary examination. Chest. 2013;143(6):1667-1670. [CrossRef] [PubMed]
 
Herth F, Becker HD, Ernst A. Conventional vs endobronchial ultrasound-guided transbronchial needle aspiration: a randomized trial. Chest. 2004;125(1):322-325. [CrossRef] [PubMed]
 
NOTE:
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