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Guidelines for Training and Practice of Interventional Pulmonology: By the Numbers?

Prakash, Udaya B. S. MD

Editorials
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From the Mayo Medical School and Mayo Medical Center, Rochester, Minnesota, USA

The emergence of the phrase “interventional bronchoscopy” in the mid-1980s was closely followed by the appearance of “interventional bronchoscopists” at major medical centers in the western countries. These phrases hinted at a 2-tier system in which one group of bronchoscopists performed “routine bronchoscopy” and the other performed special bronchoscopy procedures such as rigid bronchoscopy, bronchoscopic laser therapy, electrocautery, cryotherapy, brachytherapy, photodynamic therapy, airway stent placement, bronchoscopic needle aspiration, autofluorescence bronchoscopy, and several similar procedures. 1 Eventually, the terms “interventional pulmonology” and “interventional pulmonologist” were woven into the practice. Now interventional pulmonology encompasses the bronchoscopy procedures mentioned here as well as thoracoscopy performed by nonsurgeons (medical thoracoscopy), pleural drainage and biopsy procedures, percutaneous dilatational tracheostomy, placement of transtracheal oxygen delivery catheters, percutaneous transthoracic needle aspiration and biopsy, tube thoracostomy, and several other minor pulmonary procedures. The procedures performed in the critical care units, namely, the insertion of pulmonary artery flotation balloon catheters, endotracheal intubation, and arterial puncture, are not usually included in the interventional pulmonology category. Likewise, pulmonary physiological tests (pulmonary functions, exercise testing, sleep testing, and so on) are usually excluded from the interventional pulmonology subspecialty. Curiously, bronchoscopic procedures such as brushing and biopsy of endobronchial lesions and bronchoscopic lung biopsy are relegated to “routine” or “standard” bronchoscopy procedures, and publications on interventional pulmonology have tended to exclude these procedures in their discussions. In my mind, the entire field of bronchoscopy belongs in the area of interventional pulmonology.

Interventional pulmonology as defined here is now a well-established subspecialty at most major medical centers. Although this is especially true of most of western countries, interventional pulmonology subspecialty is rapidly developing in other countries. In the United States alone, more than 500,000 bronchoscopic procedures are performed each year. 2 If the other nonbronchoscopic interventional pulmonology procedures are added to the list, a sizable number of patients undergo these procedures on an annual basis. Primarily, physicians trained in pulmonary disorders perform these procedures. However, physicians trained in critical care medicine, otolaryngology, thoracic surgery, anesthesia, emergency surgery, and other specialties also perform them. Irrespective of the specialist who performs these procedures, the ability to optimally and safely carry out each of these procedures is ultimately dependent on the training and maintenance of competence. The development of initial expertise is dependent on the residency and fellowship training programs. In the United States and Canada, and perhaps other countries, once the physician completes his or her residency/fellowship training, he or she becomes eligible to take the certifying examinations. The certifying organizations (specialty boards, colleges, medical societies and associations) evaluate the candidate's credentials, including training in special procedures. However, a review of the eligibility requirements published by these organizations does not clearly define the criteria expected in a trained interventional pulmonologist.

The American Board of Internal Medicine (ABIM) is responsible for the board certification of the U.S.-trained pulmonary specialists. The ABIM web site on the procedural training requirements lists the following procedural skills for pulmonary candidates: oral/nasal intubation; fiberoptic bronchoscopy and accompanying procedures; ventilator management; thoracentesis and percutaneous pleural biopsy; arterial puncture; placement of arterial and pulmonary artery balloon flotation catheters; calibration and operation of hemodynamic recording systems; supervision of the technical aspects of pulmonary function testing; progressive exercise testing; and insertion and management of chest tubes. 3

The statement by the Critical Care Medicine certification group lists its requirements as, “At the completion of training, all Critical Care Medicine candidates are required to be proficient in maintenance of open airway, oral/nasal intubation, ventilator management, including experience with various modes, insertion and management of chest tubes, advanced cardiac life support (ACLS), placement of arterial, central venous, and pulmonary artery balloon-flotation catheters, and calibration and operation of hemodynamic recording systems.”4 The statement further states that, “… training in Critical Care Medicine must include opportunities to learn the indications, contraindications, complications, and limitation of the following procedures: pericardiocentesis, transvenous pacemaker insertion, peritoneal dialysis, fiberoptic bronchoscopy, peritoneal lavage, and insertion of esophageal-gastric balloon to control variceal bleeding. Practical experience is recommended.”4

The American Board of Otolaryngology states that candidates wanting to be certified in the specialty should be “knowledgeable in diagnostic and therapeutic endoscopy.”5 No mention is made of the type of endoscopy training or the minimum number of procedures required to become eligible to sit for the certifying examination. On the other hand, the American Board of Thoracic Surgery specifies that candidates wanting to be certified in the specialty should have performed at least 30 bronchoscopy and esophagoscopy procedures, and that this number must include at least 10 esophagoscopy cases. 6 The Royal College of Physicians and Surgeons of Canada lists several eligibility requirements for its respirology certification examinations, and among the skills expected in a candidate are listed the following: the ability to select diagnostic procedures appropriately, endotracheal intubation (oro and nasotracheal) intubation with the use of a bronchoscope, bronchoscopy (including transbronchial biopsy and bronchoalveolar lavage), thoracentesis and closed needle biopsy of pleura, and placement of closed intrapleural chest tube. 7

It was difficult to obtain information from other national organizations on their training requirements in interventional pulmonology procedures.

How is one to judge if an interventional pulmonologist is optimally trained? Are there special requirements or guidelines to determine what constitutes optimal training in interventional pulmonology? To look at the issue in a simplistic manner, one could consider the duration of initial training in the procedures, the total number of procedures performed by an individual during the initial training period, or a combination of these 2 factors. A well-known thoracic surgeon suggested that the performance of 50 to 100 bronchoscopies (flexible bronchoscopy and rigid bronchoscopy) is required to attain bronchoscopic proficiency. 8 A specialist who completed a training program in pulmonary diseases observed that a minimum of 100 bronchoscopies were necessary to acquire this proficiency. 9 The 1989 North American survey of over 1700 bronchoscopists reported that 60% of respondents suggested that trainees need to have performed more than 50 bronchoscopies to become competent. 10 Based on the results of the survey by the American College of Chest Physicians, a minimum of 50 bronchoscopic procedures, including biopsy of visible tracheobronchial lesions, bronchoalveolar lavage, and therapeutic bronchoscopy, were considered essential to achieve competency in routine flexible bronchoscopy. 11 Additionally, the completion of at least 10 bronchoscopic lung biopsies, 10 laser procedures, and 10 rigid bronchoscopy were considered necessary to develop proficiency in these specialized techniques. 11 The 1999 American Association for Bronchology survey of 2500 North American bronchoscopists revealed that 87% of respondents recommended at least 50 bronchoscopies to achieve competence in the procedure, 12 in contrast to the 61% of respondents in the 1989 survey who suggested at least 50 bronchoscopies to achieve competence. 10 A more recent prospective study by the Scottish Thoracic Society of 3316 bronchoscopies performed at 22 centers by 45 senior physicians showed that these physicians had completed at least 100 procedures under supervision. 13

Within the past year, the 3 major international specialty organizations of pulmonary specialists have published their views on training and competence in interventional pulmonology. The combined statement on interventional pulmonology by the European Respiratory Society (ERS) and the American Thoracic Society (ATS), 14 and the guidelines on interventional pulmonology procedures by the American College of Chest Physicians (ACCP), 15 are worth comparison and contrast. It should be recorded that several of the authors contributed to both publications. In both publications, only minimal or adequate descriptions of the individual procedures are provided. Several descriptions are suboptimal and have minimal or no assistance to either the novice or expert interventional pulmonologist. Many of the details are similar, and this perhaps reflects the fact that several of the authors contributed to both publications. The procedures included are also identical. Neither publication provides true or discerning indications for less commonly used procedures such as autofluorescence bronchoscopy, bronchoscopic ultrasound, cryotherapy, photodynamic therapy, and transtracheal oxygen therapy. The last-mentioned procedure is seldom performed anywhere, and yet it is dealt with as a commonly indicated or used technique. The relative merits of the various palliative procedures are not described. Because this editorial is on the training and competency aspects of the various procedures, a more detailed discussion on the recommendations by the ACCP, ATS, and ERS is in order. Both publications indicate the number of procedures required both to attain basic competency and to maintain it. Table 1 compares the recommendations in the 2 publications. 14,15

TABLE 1

TABLE 1

The obvious questions are: how were the minimum numbers required for attaining and maintaining proficiency derived? Were they arbitrarily decided? Were they based on studies or surveys? Were they determined on the basis of recommendations by the certifying boards or colleges? The all-encompassing simple answer is a partial “yes” to all the questions. One better answer is perhaps this: because the authors are all well recognized in their fields, they recommended these numbers based on their training of numerous residents and fellows. The results of various surveys and publications could also have influenced their decision. As discussed here, the certifying boards do not specify the number of procedures. The discrepancy in some of the numbers in the guidelines for the same procedure could mean that some experts could train their fellows with a lesser number of procedures or the fellows they trained were very good at learning. Undoubtedly, the differing numbers will confuse the trainees, practitioners, and the directors of training programs.

It is important to recognize that many of the existing guidelines on bronchoscopy and other procedures represent consensus statements published by respective professional national societies, and the guidelines relate to practice trends, training, indications for the procedure, and patient and operator safety. 10,12,13,16–22 These guidelines do not give guidance on the expected yield of the procedure or clinical outcome. However, it is implied that adhering to the guidelines will improve all these aspects of clinical practice. What is not clear is that imposition of procedural numbers will also lead to the same conclusion. Therefore, clinicians could refuse to accept the validity of guidelines in clinical practice. 23,24 Nevertheless, it is interesting to note that the 1999 American Association for Bronchology survey of 2500 North American bronchoscopists revealed that approximately 85% of respondents desired detailed guidelines from the professional societies, 12 in contrast with the 13% of respondents in the 1989 survey who wanted guidelines. 10 As noted here, the 1999 survey of North American bronchoscopists revealed that 87% of respondents recommended at least 50 bronchoscopies to achieve competence in the procedure, 12 in contrast with the 61% of respondents in the 1989 survey who suggested at least 50 bronchoscopies to achieve competence. 10 Although the precise reasons for these paradoxic opinions from the surveys obtained nearly a decade apart are unclear, the responses could reflect the difficulty the practicing bronchoscopists have in understanding the ever-increasing nuances in the clinical application of emerging techniques in interventional pulmonology. 25

How are these requirements or guidelines to be applied? It has been argued that clinical guidelines and protocols should be understood as policy rules designed to change and control the behavior of clinicians and institutions. 26 I have had several inquiries by concerned physicians regarding the procedural numbers required in the ERS/ATS and ACCP guidelines. Their major apprehension has to do with the possibility of their medical centers and insurance companies demanding that they adhere to these guidelines. The other concern has to do with the possibility of medical liability if they cannot meet the procedural numbers required per guidelines. Regarding these concerns, it should be noted that in the state of Maine, physicians who comply with guidelines and standards can use their compliance as a complete defense against malpractice claims, but those who fail to comply with the same guidelines cannot automatically be presumed negligent. 27 It is somewhat reassuring to observe that a 1995 survey of American Actions for Medical Malpractice found that guidelines play “a relevant or pivotal role in the proof of negligence” in only 6.6% of actions. 28

Clearly, even the busiest as well as the well-known interventional pulmonologist will find it difficult to maintain the required numbers for all of the procedures. Common sense tells that many of the procedures overlap in their technical details, and one does not have to do a required number of each individual procedure discussed in these publications. Nevertheless, the problem with numbers, when they are published as guidelines by major professional societies, is that they lead to consternation among those who have provided and continue to provide excellent patient care, irrespective of the number of procedures they perform each year. The procedural numbers published in these papers should be taken as suggestions rather than absolute rules. The authors of the 2 guidelines readily admit that these guidelines have limitations.

Undeniably, some physicians, despite the “performance” of many more than the recommended number of procedures in the guidelines, can remain incompetent and lack confidence in acquiring competence in the field of interventional pulmonology. In such situations, the program director or the director of interventional pulmonology at the training institution should judge and certify the competence of each candidate and recommend and provide remedial training if necessary. 11 The ABIM's Critical Care Medicine certification requirement rightly recommends that as part of the overall assessment of clinical competence, program directors in Critical Care Medicine are asked to verify certain procedural skills of their trainees. 4 It has been emphasized that the performance of the procedure on a regular basis is vastly more consequential than the numbers alone. 11,29 The lack of opportunity to obtain adequate training in certain procedures remains a problem. One study observed that although most pulmonary fellows reported “adequate” training in bronchoscopy, only 72% had received any instructions in bronchoscopic needle aspiration and 27% in stent placement. 30 To overcome these shortcomings in training, some experts in the field have recommended a short, focused course of instruction using the virtual bronchoscopy simulator. Such trials have enabled novice trainees to attain a level of manual and technical skill at performing diagnostic bronchoscopic inspection similar to those of colleagues with several years of experience. Furthermore, these trials have reported that the skills were readily reproducible in a conventional inanimate airway-training model, suggesting they would also be translatable to direct patient care. 31 Such teaching techniques and performance of the procedures in both animals and people should be included in the training programs. Competency in special procedures discussed here will require additional training. 1 To produce optimal bronchoscopists, training programs in bronchoscopy and other interventional pulmonology procedures should provide excellent training opportunities.

In interventional pulmonology, the quantity of procedures performed during the training period is important to provide methodologic technical know-how, familiarity with the technology and techniques, and instill confidence in the operator. Recently, however, there has been a shift in the thinking of those in charge of assessing medical specialty training, and the focus now is on the quality of training rather than merely the quantity. 32 This philosophy is applicable also to the subspecialty of interventional pulmonology.

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