Astrong desire to perform procedures and typically a higher aptitude for them separates most pulmonary/critical care physicians from nonprocedural fields of internal medicine. Along the same lines, pulmonary fellowships attract fellows by affording them the opportunity to become “interventionalists” without having to perform a mandatory additional year to an already rigorous fellowship. Other subspecialties such as gastroenterology and cardiology provide additional 1-year interventional fellowships for those desiring advanced training. A pulmonary/critical care fellowship requires an enormous commitment of time, loss of financial compensation, and expenditure of energy to learn pulmonology, critical care, and sleep medicine. An extra year may prove burdensome and impractical to fellows, so their perspectives on procedural training are crucial to the success of such an endeavor. In addition, their input is essential if improvements are to be made in the existing curriculum. Prior surveys on the availability and quality of procedural training have been performed in other specialties and for individual procedures in pulmonary medicine.1-4 However, no comprehensive survey of pulmonary fellows' performance of and satisfaction with interventional procedures currently exists. With that in mind, we sought to assess affiliate members of the American College of Chest Physicians (ACCP) regarding the type and number of interventional chest procedures they were offered during training, to assess satisfaction with procedural training during fellowship, and to evaluate whether an extra year of fellowship training would be desirable.
MATERIALS AND METHODS
An Internet-based survey was administered to all listed affiliates of the ACCP defined as those physicians in their second or third year of fellowship training or their first or second year in practice. SurveyMonkey survey software (Portland, OR) was used for the administration of the Internet survey. The survey was developed by the survey research unit at the Medical University of South Carolina with assistance from the ACCP Interventional Chest/Diagnostic Procedures NetWork Steering Committee. It was piloted by 5 pulmonary/critical care fellows at the Medical University of South Carolina for content and readability and further refined by the investigators and the ACCP Interventional Chest/Diagnostic Procedures NetWork Steering Committee. Surveys were sent through the Internet directly from the ACCP to its affiliate members, physicians who have completed their internship and residency and are currently enrolled in or show proof of acceptance into an accredited fellowship training program or equivalent program in cardiopulmonary medicine or surgery, critical care medicine, or one of the closely related specialties. Affiliates can retain affiliate membership for 2 years after their training period ends. There were 3 transmissions 1 month apart in February, March, and April 2004. Each subsequent transmission was sent only to affiliates who had not returned the initial survey. The survey asked whether each of the 17 procedures from the ACCP interventional pulmonary procedures guidelines5 was offered during their fellowship training. If offered, the number performed was recorded based on fellowship training procedure logs. Also included were questions regarding program demographics, the presence of an interventional pulmonologist, and whether an extra year of fellowship training in interventional pulmonology would be warranted. Using a 5-point Likert scale, additional questions asked respondents to rate the quality of their procedural training and to evaluate their level of interest in procedural training. The identities of the affiliates and their training program identities remain confidential (for complete survey, see the Appendix).
Programs with an interventional pulmonologist (IP) were compared with those without an IP using chi-squared tests and Fisher exact tests as appropriate. Among programs offering the individual procedures of interest, chi-squared and Fisher exact tests also facilitated assessment as to whether having an IP was associated with meeting the recommended numbers of procedures. Responses from questions regarding satisfaction with training and interest in a fourth year of fellowship were compared across respondents' level of training (second and third year of fellowship and first and second year of practice) using Mantel-Haenszel chi-squared tests. Similar tests were used to compare satisfaction responses between fellows who achieved the competency recommendations for at least 1 standard diagnostic procedure (ie, flexible bronchoscopy, transbronchial needle aspiration [TBNA], percutaneous pleural biopsy) and fellows who were offered the standard diagnostic procedures but who did not achieve at least 1 of the competency recommendations. Comparisons were also performed between fellows who did and did not achieve the competency recommendations for at least 1 advanced diagnostic procedure (ie, medical thoracoscopy/pleuroscopy, endobronchial ultrasound [EBUS], autofluorescence bronchoscopy, transthoracic needle aspiration [TTNA]), and between fellows who did and did not achieve the competency recommendations for at least 1 advanced therapeutic procedure (ie, brachytherapy, airway stents, electrocautery and argon plasma coagulation, laser therapy, rigid bronchoscopy, cryotherapy, photodynamic therapy, percutaneous dilational tracheostomy, transtracheal oxygen therapy).
The ACCP identified 1148 affiliate members with an e-mail address, and the survey was sent to each of them electronically. A total of 203 of these messages were returned as undeliverable, leaving 945 members who received the survey. A total of 304 members completed the survey, yielding a 32% response rate. Of the respondents, there were 23 from pulmonary-only fellowships, 2 from thoracic surgery fellowships, and 277 from pulmonary/critical care. The distribution of the respondents' level of training was as follows: 31% second-year fellows, 30% third-year fellows, 22% first-year postfellowship, and 17% second-year postfellowship.
Table 1 shows that only 4 of 17 procedures were offered to greater than 40% of fellows, and competency numbers were achieved by greater than 40% of fellows for only 3 procedures. The presence of an interventional pulmonologist was associated with a significantly (P < 0.05) greater likelihood of obtaining the competency numbers compared with fellows at institutions without an interventional pulmonologist for the following procedures: TBNA, electrocautery and/or argon plasma coagulation, airway stents, medical thoracoscopy/pleuroscopy, laser therapy (Nd-YAG), rigid bronchoscopy, autofluorescence bronchoscopy, EBUS, cryotherapy, photodynamic therapy, and percutaneous dilatational tracheostomy.
Table 2 shows how the affiliates rated the quality of their interventional pulmonary training. For standard diagnostic procedures (ie, flexible bronchoscopy, TBNA), 95% of affiliates rated the quality of their training as good or very good on a 5-point Likert scale. For advanced diagnostic procedures (ie, EBUS, autofluorescence), only 15% rated the quality of their training as good or very good, whereas 85% rated it as very poor, poor, or barely acceptable. For advanced therapeutic procedures, 23% of fellows rated their training as good or very good, whereas 77% rated it as very poor, poor, or barely acceptable. There was no association between the presence of a dedicated interventional pulmonologist in training programs and the respondents' ratings of the quality of their training in standard diagnostic procedures. However, fellows who trained in a program with a dedicated interventional pulmonologist reported significantly (P < 0.0001) higher satisfaction with training for advanced diagnostic and therapeutic procedures than fellows who trained in a program without a dedicated interventional pulmonologist.
Compared with fellows who did not achieve the competency numbers for any of the standard diagnostic procedures, fellows who achieved the recommended competency number for at least 1 of the standard diagnostic procedures were significantly (P < 0.0001) more likely (98.3% vs. 85.2%) to rank the quality of their training as good or very good. Fellows who achieved the competency number for at least 1 of the advanced diagnostic procedures were significantly (P < 0.05) more likely (44.4% vs. 18.5%) to rank the quality of their training as good or very good, and fellows who achieved the competency number for at least 1 of the advanced therapeutic procedures were significantly (P < 0.0001) more likely (52.8% vs. 16.0%) to rank the quality of their training as good or very good.
Most of the affiliates (79%) were attracted to pulmonary/critical care medicine by the procedures/interventions; however, there is variable interest in learning advanced procedures. Training in standard diagnostic procedures was important to 98.6% of affiliates, whereas training in advanced diagnostic and therapeutic procedures was seen as less important (38.6% and 43.7%, respectively). The importance of training in all types of procedures was not significantly associated with respondents' level of training (ie, second- or third-year fellow, first- or second-year postfellowship). Over half of the affiliate respondents surveyed (52.7%) were interested in an extra year of interventional pulmonary training, and almost all (93.5%) felt it was reasonable to require a minimal number of supervised procedures for certification. These findings persisted 1 to 2 years postfellowship training. Sixty-one percent of those who responded to the survey felt the minimum requirements were feasible for the interventional procedures listed. Of those who felt the numbers were not feasible, 96.4% felt they were too high in number.
Fifty-three affiliates (19.1%) responded in the open comments section. The most common types of responses could be categorized as follows: 1) The competency numbers are acceptable, but not practically attainable given the small quantity of procedures available to fellows during their training (25% of respondents). 2) The ACCP numbers are too high (17% of respondents). 3) More dedicated interventional pulmonologists are needed to train fellows (13% of respondents).
To the authors' knowledge, this study represents the most complete information to date on the overall procedural experience of pulmonary/critical care fellows. The study demonstrates that competency numbers are met in flexible bronchoscopy by a large percentage of fellows. Otherwise, there is significant variability in other procedures, and the recommended competency numbers for most procedures were not achieved by the majority of fellows. Achieving the recommended competency numbers correlated with the presence of a faculty interventional pulmonologist for 11 of the 17 procedures, and the level of satisfaction with interventional training was improved by the presence of an interventional pulmonologist. The affiliates largely agreed with requiring a minimum number of supervised procedures for certification, but only 56% cited them as feasible in their institution. Most affiliates were attracted to pulmonary/critical care medicine by the procedures and recognized the importance of standard diagnostic procedure training. Training in advanced diagnostic procedures and therapeutic procedures was viewed as an important part of fellowship training for a significant subset of respondents, and nearly half of those surveyed were interested in an extra year of training for interventional training. The importance of procedural training and the interest in further training did not diminish for those 1 or 2 years into practice.
Although fellows had a high level of satisfaction in their standard diagnostic/therapeutic procedural training, they had a low level of satisfaction for advanced diagnostic and therapeutic procedural training. These fellows are not alone in their dissatisfaction with procedural training. The volume of procedures performed and satisfaction with training seem intertwined in this and other studies. Not only does satisfaction improve with the performance of a greater number of procedures, but increased procedural volume has been shown to correlate with better outcomes.6-9 An increased comfort level develops when more troubleshooting is required for different scenarios that occur when more procedures have been performed by a given trainee. The old adage “see one, do one, teach one” may not apply today as the complexity of available technologies has grown. A past bronchoscopy survey showed that higher numbers of bronchoscopies reported by fellows correlated with higher self-estimates of proficiency and with more favorable views of their training.4
In a national survey of 1000 members of the American College of Physicians (ACP), practicing pulmonologists recommended competency numbers in core procedures, which were in moderately close agreement with each other. These numbers were generally lower than the numbers recommended by the ACCP in the recent interventional guidelines. On one hand, this finding, along with the survey results suggests that the ACCP recommended competency numbers may be too high. On the other hand, the fellows who performed the higher numbers had increased satisfaction with training, and more than half felt the numbers proposed were feasible. Perhaps it would be feasible to have a lower recommended number if qualified interventional pulmonologists are present to certify a given fellow's ability. Interestingly, the survey of ACP members found that there were a significant number of procedures learned in practice without any formal training and also without any supervision. Practicing pulmonologists felt that more attention should be paid to training and certifying practicing pulmonologists in procedures after formal fellowship.10
As technology and procedural versatility has grown, the ability to train residents and fellows has not necessarily kept pace for various reasons. For example, surgery residents have work-hour limitations and proposed changes in duration of training that challenge educators to provide even core level technical competencies. Alternative strategies such as Web-based training are being considered.11 Regarding the expanding use of laparoscopy in gynecologic oncology, fellows in the field were surveyed and 75% were dissatisfied in their training despite feeling that laparoscopic procedures were very important to their future practice. To supplement low caseloads for these procedures, consideration is being given to animal- and bench-based laboratory sessions to improve skills.12
There are potential options available to fellows that may have to be considered. Some fellows who are already proficient in standard techniques might be able to assist in or observe procedures that could count toward achieving the recommended numbers. If unavailable, rotations at other institutions might be considered. As an example, endobronchial stenting is a relatively simple technical procedure to learn for a trained bronchoscopist. However, the difficulty arises when deciding where and when to deploy stents. Cognitive and judgment skills may have to be learned and tested by observing or assisting in enough cases without necessarily performing the cases as the primary operator. Other alternatives might include courses and animal laboratories. The only way such “shortcuts” could work is if the fellows were already operating at a high level of bronchoscopic proficiency.
Virtual reality training and bronchoscopy simulators have already been developed and have shown early success in several studies. These tools were effective in establishing fundamental manual bronchoscopy skills as well as an understanding of airway anatomy.13,14 Although these devices are presently useful for learning fundamental skills, increased use and further refinements may spawn programs, which can be used for more advanced skills such as endobronchial stent placement or electrocautery.
It seems clear from this study that one way to improve training for fellows in procedures is to have teachers dedicated to this aspect of fellowship training. Satisfaction with training in advanced diagnostic and therapeutic procedures is higher in programs with a dedicated interventional pulmonologist (a relatively new field within pulmonary medicine) on faculty. It is encouraging to note that half of the pulmonary programs in this country now report having such a person on faculty.
It appears that an extra year of formal fellowship training in interventional pulmonology would fill 2 important gaps. First, there is a significant subset of trainees who have the interest and desire to commit to extra training. Ideally, only a fraction of fellows would pursue this opportunity, but they would be enough to fill the niche and provide the services. There are the concerns that interventional training might appeal to fellows, but enthusiasm might wane once in practice or that physicians would not see a significant need for these procedures outside tertiary care centers. On the contrary, affiliates in practice who responded to this survey maintained their interest, suggesting a true need outside tertiary referral centers. Second, an extra year of training in interventional pulmonology may attract candidates to careers in academia. This could fill the void that exists in half the fellowship training programs that do not currently have an interventional pulmonologist on faculty. Their presence would further increase the availability and uniformity of training for advanced procedures and improve satisfaction among trainees.
The current level of dissatisfaction with procedural training is concerning considering that most fellows (79%) report being drawn to pulmonary/critical care by procedures. Ultimately, this could affect the ability to recruit candidates into pulmonary and critical care fellowship programs. Other subspecialties such as cardiology and gastroenterology, which have formally defined training in advanced procedures, could draw competitive residency candidates away from the pulmonary fellowship training.
In summary, affiliate members of the ACCP are satisfied with their training in standard diagnostic bronchoscopy but dissatisfied with their training in advanced diagnostic and therapeutic procedures. The presence of an interventional pulmonologist increased the number and type of procedures offered to fellows and improved their satisfaction with training. Irrespective of the presence of an interventional pulmonologist, those trainees who met competency numbers were more satisfied with their training than those who did not. Offering an extra year of formal fellowship training in interventional pulmonology at centers of excellence should be strongly considered because there is keen interest among fellows and recent fellowship graduates. Once trained in interventional pulmonology, such graduates may step into academic programs without an interventional pulmonologist, thus improving training for all.
The authors thank Amy Slav-Livorsi, Senior Project Coordinator Networks, and Tracy Goode, Vice President NetWorks and Strategic Planning, both of the American College of Chest Physicians, for their work on this project. The authors also thank the pulmonary fellows at the Medical University of South Carolina whose thoughtful suggestions improved the survey. They are also indebted to the ACCP Interventional Chest/Diagnostic Procedures NetWork Steering Committee for their thoughtful review of the survey and the manuscript.
Steering Committee: Armin Ernst, MD, FCCP; Neri Cohen, MD, FCCP; Heinrich D. Becker, MD, FCCP; Gordon H. Downie, MD, FCCP; John A. Howington, MD, FCCP; Atul C. Mehta, MBBS, FCCP; Leonard C. Moses, MD, FCCP; W. Roy Smythe, MD, FCCP; Stephen C. Yang, MD, FCCP; and David W. Johnstone, MD, FCCP.
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