Interventional Pulmonology: Who Should Learn and How? Michael S Machuzak, MD Medical Director, Center for Major Airway Disease Transplant Institute Staff

Interventional Interventional Pulmonology:Pulmonology:

Who Should Learn and Who Should Learn and How?How?

Michael S Machuzak, MDMichael S Machuzak, MDMedical Director, Center for Major Airway Medical Director, Center for Major Airway

DiseaseDiseaseTransplant InstituteTransplant Institute

StaffStaffRespiratory InstituteRespiratory Institute

No DisclosuresNo Disclosures

Consultant to:Consultant to: OlympusOlympus CareFusionCareFusion

BackgroundBackground Hospital of the University of PennsylvaniaHospital of the University of Pennsylvania

ResidencyResidency FellowshipFellowship

2 year IP Fellowship2 year IP Fellowship Daniel StermanDaniel Sterman

PENNPENN Ali MusaniAli Musani

National JewishNational Jewish Marseille, FranceMarseille, France

Herve Dutau et alHerve Dutau et al Chiba, JapanChiba, Japan

Kasu Yasufuku et alKasu Yasufuku et al

Cleveland ClinicCleveland Clinic 20062006

What is Interventional What is Interventional Pulmonology?Pulmonology?

Advanced Advanced Diagnostic Diagnostic BronchoscopyBronchoscopy

Airway ImagingAirway Imaging AutofluorescenceAutofluorescence Narrow-BandNarrow-Band Confocal Confocal

Nodule, Mass & Lymph Nodule, Mass & Lymph node biopsynode biopsy

CT fluoroCT fluoro Electromagnetic guidanceElectromagnetic guidance Virtual bronchoscopic Virtual bronchoscopic

navigationnavigation Endobronchial UltrasoundEndobronchial Ultrasound

Convex & RadialConvex & Radial

Therapeutic Therapeutic BronchoscopyBronchoscopy

Central Airway ObstructionCentral Airway Obstruction AblationAblation DilationDilation Stent placement Stent placement

Management of Lung Txp Management of Lung Txp airway complicationsairway complications

Endoscopic Emphysema Endoscopic Emphysema TreatmentTreatment

Treatment of FistulaTreatment of Fistula BPF, TE, BE, etc…BPF, TE, BE, etc…

Thermal Ablation for Thermal Ablation for AsthmaAsthma


Pleural Disease & MorePleural Disease & More

Pleural Manometry and Ultrasound for Pleural Manometry and Ultrasound for Large Volume ThoracentesisLarge Volume Thoracentesis Thoracoscopy +/- PleurodesisThoracoscopy +/- Pleurodesis Tunneled catheter Tunneled catheter

Minimally Invasive Pleural InterventionMinimally Invasive Pleural Intervention Medical thoracoscopyMedical thoracoscopy Tunneled catheterTunneled catheter Pigtail catheter placementPigtail catheter placement

OtherOther Tracheostomy, PEG, Trans-Tracheal Oxygen CathetersTracheostomy, PEG, Trans-Tracheal Oxygen Catheters


Evolving specialtyEvolving specialty >20 years>20 years Meld of many different specialtiesMeld of many different specialties

Pulmonary, ENT, Thoracic surgery, IR, Pulmonary, ENT, Thoracic surgery, IR, Oncology, etc…Oncology, etc…

Emphasis on multidisciplinary careEmphasis on multidisciplinary care New technologies & proceduresNew technologies & procedures Training???????Training???????

In developmentIn development

Why Learn a New Why Learn a New Procedure?Procedure?

Improve patient Improve patient carecare MaximizeMaximize

Diagnostic yieldDiagnostic yield Pt outcomesPt outcomes Revenue StreamRevenue Stream Multidisciplinary careMultidisciplinary care Independence Independence

MinimizeMinimize InvasivenessInvasiveness RiskRisk CostCost

OtherOther Lack of expertise Lack of expertise

locallylocally It’s funIt’s fun

??????

Reasons NOT to Reasons NOT to Learn a New Learn a New ProcedureProcedure Never learned the old wayNever learned the old way

Advanced technology does Advanced technology does NOT NOT improve improve basic skillsbasic skills

It seems coolIt seems cool Need volume to obtain/maintain Need volume to obtain/maintain

competencycompetency Too costlyToo costly

How to Learn New How to Learn New ProceduresProcedures

Read the literature Read the literature Really???Really???

Standard trainingStandard training PCCM fellowshipsPCCM fellowships

CoursesCourses Single or multiple Single or multiple

dayday Mini-fellowshipsMini-fellowships

Weeks - monthsWeeks - months Dedicated year Dedicated year

of IP trainingof IP training

Web-based Web-based curriculumcurriculum

Supervised Supervised simulator sessionssimulator sessions

Short courses / “Mini-Short courses / “Mini-fellowships”fellowships”

Excellent exposure to one/variety of Excellent exposure to one/variety of techniquestechniques

DidacticsDidactics Hands-onHands-on

Simulators Simulators High vs. Low fidelity modelsHigh vs. Low fidelity models

Animal modelsAnimal models PatientsPatients

Apprenticeship Apprenticeship

Middle AgesMiddle Ages InternshipsInternships FellowshipsFellowships Post-gradPost-grad

Benefits:Benefits: Structured approachStructured approach AccountabilityAccountability

Mentee AND mentorMentee AND mentor

Need:Need: StructureStructure CurriculumCurriculum Defined outcome measuresDefined outcome measures TimeTime

Web-Based EducationWeb-Based Education

www.bronchoscopy.orgwww.bronchoscopy.org

Bronchoscopy SimulatorsBronchoscopy Simulators Multi-center prospective cohort study using BSMulti-center prospective cohort study using BS

Differentiate b/t expert & noviceDifferentiate b/t expert & novice Does use of BS improve rate of skill acquisition?Does use of BS improve rate of skill acquisition?

““Experts" (> 500, n = 9)Experts" (> 500, n = 9) ““Intermediates" (25 to 500, n = 8)Intermediates" (25 to 500, n = 8) ““Novices" (none, n = 11)Novices" (none, n = 11)

2 BS cases with performance measures 2 BS cases with performance measures recordedrecorded

Distinguishing performance measures identifiedDistinguishing performance measures identified Used to evaluate the learning curve for new fellowsUsed to evaluate the learning curve for new fellows

RCT comparing quality of bronch performanceRCT comparing quality of bronch performance New pulmonary fellowsNew pulmonary fellows

Conventional methodsConventional methods SimulatorSimulator

Am. J. Respir. Crit. Care Med., Volume 164, Number 12, December 2001, 2248-2255

Bronchoscopy SimulatorsBronchoscopy Simulators

Experts > Intermediates > NovicesExperts > Intermediates > Novices Procedure timeProcedure time % of segments visualized% of segments visualized Time in red-outTime in red-out Wall collisionsWall collisions

New fellowsNew fellows After 20 simulations After 20 simulations Improved Improved

SpeedSpeed % segments visualized% segments visualized Time in red-outTime in red-out CollisionsCollisions



BS Fellows > Conventional fellowsBS Fellows > Conventional fellows First actual bronchoscopiesFirst actual bronchoscopies

Procedure time Procedure time 815 vs. 1,168 s815 vs. 1,168 s

p = 0.001p = 0.001 Bronch nurse subjective quality assessment Bronch nurse subjective quality assessment

scorescore 7.7 ± 0.3 vs. 3.7 ± 2.57.7 ± 0.3 vs. 3.7 ± 2.5

p = 0.05p = 0.05 Quantitative bronch quality scoreQuantitative bronch quality score

% segments correctly identified/procedure time% segments correctly identified/procedure time 0.119 ± 0.015 vs. 0.046 ± 0340.119 ± 0.015 vs. 0.046 ± 034

p = 0.03p = 0.03



BS able to assess experience levelBS able to assess experience level Training new fellows on BS Training new fellows on BS

More rapid acquisition of expertiseMore rapid acquisition of expertise Compared with conventional training Compared with conventional training

methodsmethods

Technology has potentialTechnology has potential Facilitate bronch trainingFacilitate bronch training Improve objective evaluations of bronch Improve objective evaluations of bronch

skillsskills


Interventional Pulmonology Interventional Pulmonology ≠ interventional ≠ interventional

pulmonologypulmonology Is a dedicated 1 year fellowship Is a dedicated 1 year fellowship

necessary for comprehensive training in necessary for comprehensive training in IP?IP? Establish basis for structured training in IP Establish basis for structured training in IP Distinct from standard PCCM trainingDistinct from standard PCCM training Structure to allow successful acquisition of Structure to allow successful acquisition of

skill set & experienceskill set & experience Specific skill sets may NOT require yearSpecific skill sets may NOT require year

EBUSEBUS Navigational bronchoscopyNavigational bronchoscopy Thermoplasty etc.Thermoplasty etc.

www.aabronchology.orgwww.aabronchology.org

““AABIP was founded in 1992 with the primary AABIP was founded in 1992 with the primary goal to foster excellence in Bronchology and goal to foster excellence in Bronchology and other Interventional Pulmonology related areas”other Interventional Pulmonology related areas”

““The cornerstone of our mission is to enhance The cornerstone of our mission is to enhance multidisciplinary and international collaboration multidisciplinary and international collaboration in our quest to develop, evaluate, and in our quest to develop, evaluate, and disseminate techniques, procedures, and cases”disseminate techniques, procedures, and cases”

Training: What is Training: What is Happening?Happening? > 50%> 50% pulmonologists pulmonologists

Inadequate training in “advanced diagnostic Inadequate training in “advanced diagnostic techniques such as TBNA”techniques such as TBNA”

> 70%> 70% practicing bronchoscopists practicing bronchoscopists Perform <100 bronchoscopies/yrPerform <100 bronchoscopies/yr

70%70% felt additional training should be felt additional training should be providedprovided ONLY to those interested in developing specific ONLY to those interested in developing specific

skillsskills

ONLY 25%ONLY 25% of pulmonologists perform all of pulmonologists perform all procedures required for board certificationprocedures required for board certification

Colt et al, Journal of Bronchology. 2000;7:8 Pastis et al, Chest 2005; 127: 1614

Advanced Training during Advanced Training during Standard FellowshipStandard Fellowship

Survey 122 PCCM fellowship directorsSurvey 122 PCCM fellowship directors Response 77%Response 77%

Wide variation in procedures offeredWide variation in procedures offered Presence of an IPPresence of an IP

Increased likelihood of advanced procedural trainingIncreased likelihood of advanced procedural training Brachytherapy (p < 0.05)Brachytherapy (p < 0.05) Electrocautery/argon plasma coagulation (p < 0.001)Electrocautery/argon plasma coagulation (p < 0.001) Stents (p < 0.001)Stents (p < 0.001) Laser therapy (p < 0.01)Laser therapy (p < 0.01) Rigid bronchoscopy (p < 0.001)Rigid bronchoscopy (p < 0.001) Cryotherapy (p < 0.05)Cryotherapy (p < 0.05)

For For only 3 of the 17 proceduresonly 3 of the 17 procedures did > 50% of did > 50% of the programs reach the targeted numbers to the programs reach the targeted numbers to obtain competencyobtain competency

Pastis et al, Chest 2005; 127: 1614 Colt et al, Journal of Bronchology. 2000;7:8

Goals of TrainingGoals of Training

Understand:Understand: Appropriate evaluation & management of Appropriate evaluation & management of

disease processdisease process Technical aspects of the procedureTechnical aspects of the procedure

Recognize pathologyRecognize pathology Distinguish from normalDistinguish from normal

Perform:Perform: Correct procedure expeditiouslyCorrect procedure expeditiously Communicate effectivelyCommunicate effectively

Ensure competent support staffEnsure competent support staff Avoid, recognize and treat complicationsAvoid, recognize and treat complications Know when NOT to do the procedureKnow when NOT to do the procedure

What is Competence?What is Competence?

Institute for International Medical Institute for International Medical EducationEducation ““Possession of a satisfactory level of Possession of a satisfactory level of

relevant knowledge and acquisition relevant knowledge and acquisition of a range of relevant skills that of a range of relevant skills that include interpersonal and technical include interpersonal and technical components…necessary to perform components…necessary to perform the tasks that reflect the scope of the tasks that reflect the scope of professional practices”professional practices”

What is Competence?What is Competence?

““Competence may differ Competence may differ from "performance", from "performance", which denotes actions which denotes actions taken in a real life taken in a real life situationsituation

Competence is therefore Competence is therefore not the same as not the same as "knowing" on the "knowing" on the contrary, contrary, it may well be it may well be about recognizing one's about recognizing one's own limits”own limits”

Is Competence Related to Is Competence Related to Repetition?Repetition?

Repetition allows for repeat trainingRepetition allows for repeat training Improves dexterityImproves dexterity Improves infrastructureImproves infrastructure

Makes systems function smoothlyMakes systems function smoothly Makes introduction of systems to avoid Makes introduction of systems to avoid

mistakes worthwhilemistakes worthwhile Improves success & decreases error!Improves success & decreases error!

Volume Thresholds:Volume Thresholds:No Correct AnswerNo Correct Answer

Too highToo high Many excludedMany excluded

Low dissemination of useful technologiesLow dissemination of useful technologies Missed opportunitiesMissed opportunities

Too lowToo low ComplicationsComplications Inappropriate utilization patternsInappropriate utilization patterns

We NEED to directly measure & monitor outcomes & We NEED to directly measure & monitor outcomes & performance qualityperformance quality Feedback to physicians rather than:Feedback to physicians rather than:

Expert opinionExpert opinion Volume requirementsVolume requirements Other surrogate markersOther surrogate markers

System combined with volume rqts & other didactic System combined with volume rqts & other didactic instrumentsinstruments

One of the greatest challenges:One of the greatest challenges: Necessary procedural quality benchmarks do not existNecessary procedural quality benchmarks do not exist

Registry data, collected by the ACCP, may be able to Registry data, collected by the ACCP, may be able to address this in the futureaddress this in the future AcQuire AcQuire Chest 2010(137)

More is Better: Numbers More is Better: Numbers MatterMatter

(NO data to support otherwise)(NO data to support otherwise) Drivers educationDrivers education PilotsPilots SurgerySurgery

esophagealesophageal cardiaccardiac endocrineendocrine airwayairway vascularvascular

ERCP: 200ERCP: 200 Central lines: 50Central lines: 50

Not completely Not completely dependent on #sdependent on #s

Birkmeyer NEJM 2002Jowell Endoscopy 1999Sznajder Arch Intern Med 1986

Vascular ProceduresVascular Procedures

High-volume providersHigh-volume providers Significantly better outcomesSignificantly better outcomes Elective Elective ANDAND emergent setting emergent setting

Subspecialty trainingSubspecialty training Considerable impactConsiderable impact Morbidity and mortalityMorbidity and mortality

Evidence for specialization of vascular Evidence for specialization of vascular servicesservices Performed by high-volume, specialty Performed by high-volume, specialty

trained providerstrained providers

J Vasc Surg 2007 Mar;45(3):615-26.

Coronary InterventionsCoronary Interventions Medicare National Claims History files: 1997Medicare National Claims History files: 1997

167,208 pts aged 65 to 99 years who had PCI by 6534 phys at 1003 hospitals167,208 pts aged 65 to 99 years who had PCI by 6534 phys at 1003 hospitals 57.7% involved coronary stents57.7% involved coronary stents

Pts treated by low-volume (<30) phys had ↑ risk of Pts treated by low-volume (<30) phys had ↑ risk of CABGCABG (2.25% vs 1.55%; P<.001)(2.25% vs 1.55%; P<.001)

No difference in 30d mortality rates (3.25% vs 3.39%; No difference in 30d mortality rates (3.25% vs 3.39%; PP = .27) = .27)

Pts treated at low-volume (<80) ctrs had ↑ risk of 30d Pts treated at low-volume (<80) ctrs had ↑ risk of 30d mortalitymortality (4.29% vs 3.15%; P<.001)(4.29% vs 3.15%; P<.001)

No difference in the risk of CABG (1.83% vs 1.83%; No difference in the risk of CABG (1.83% vs 1.83%; PP = .96) = .96)

Patients who received stentsPatients who received stents Low-volume ctrs had ↑ risk of 30d mortality vs. high-volume ctrsLow-volume ctrs had ↑ risk of 30d mortality vs. high-volume ctrs Low-volume phys had ↑ risk of CABG vs. high-volume physLow-volume phys had ↑ risk of CABG vs. high-volume phys

Medicare pts treated by high-volume phys & at Medicare pts treated by high-volume phys & at high-volume ctrs experience better outcomes high-volume ctrs experience better outcomes following PCIfollowing PCIJAMA 2000;284(24):3139-3144

Surgical OncologySurgical Oncology Retrospective cohort study using Surveillance, Epidemiology & Retrospective cohort study using Surveillance, Epidemiology &

End Results (SEER)End Results (SEER) 5013 pts in SEER registry 65 or > at cancer diagnosis 1984-19935013 pts in SEER registry 65 or > at cancer diagnosis 1984-1993 30 D mortality in relation to procedure volume, adjusted for co-30 D mortality in relation to procedure volume, adjusted for co-

morbidity, pt age, & cancer stage morbidity, pt age, & cancer stage Higher volume linked with lower mortalityHigher volume linked with lower mortality

Pancreatectomy (Pancreatectomy (PP=.004)=.004) Esophagectomy (Esophagectomy (PP<.001)<.001) Liver resection (Liver resection (PP=.04)=.04) Pelvic exenteration (Pelvic exenteration (PP=.04)=.04)

Not for:Not for: Pneumonectomy (Pneumonectomy (PP=.32)=.32) EsophagectomyEsophagectomy PancreatectomyPancreatectomy

When complex surgical oncologic When complex surgical oncologic procedures provided by surgical teams in procedures provided by surgical teams in hospitals w/ specialty expertise, mortality hospitals w/ specialty expertise, mortality rates are lowerrates are lowerJAMA 1998; 280(2): 1747-1751

Surgeon Volume & Surgeon Volume & MortalityMortality

National Medicare claims data base for 1998-National Medicare claims data base for 1998-19991999 Mortality among 474,108 patientsMortality among 474,108 patients 1 of 8 cardiovascular procedures or cancer resections1 of 8 cardiovascular procedures or cancer resections

Surgeon volume inversely related to Surgeon volume inversely related to operative mortality for alloperative mortality for all

(P=0.003 for lung resection, P<0.001 for all other procedures)(P=0.003 for lung resection, P<0.001 for all other procedures)

For many proceduresFor many procedures Observed associations b/t hospital volume & operative mortalityObserved associations b/t hospital volume & operative mortality Largely mediated by surgeon volumeLargely mediated by surgeon volume

Patients can improve their chances of Patients can improve their chances of survivalsurvival Even at high-volume hospitalsEven at high-volume hospitals

Surgeons who perform operations frequentlySurgeons who perform operations frequentlyNEJM 2003 349(22):2117-27

Teaching Procedural Teaching Procedural SkillsSkills

Medical Procedure ServiceMedical Procedure Service See one, do one, teach oneSee one, do one, teach one

Often:Often: See one done wrong, do one wrong, teach one wrongSee one done wrong, do one wrong, teach one wrong

Simulation training with 2w rotationSimulation training with 2w rotation

Central lines / Thora’s supervised by IP staffCentral lines / Thora’s supervised by IP staff LPs / Para’s supervised by hospitalist staffLPs / Para’s supervised by hospitalist staff

Decreased complications, improved confidenceDecreased complications, improved confidence

Smith et al, Sim Healthc 2010; 5:146 Huang et al, Acad Med 2009; 8:1127 Huang et al, Acad Med 2006; 119:e17

ACCPACCP ERS/ATSERS/ATS

Rigid Bronchoscopy Rigid Bronchoscopy 2020

Endobronchial Ultrasound Guided Endobronchial Ultrasound Guided TBNATBNA

5050 4040

Laser Laser

1515 2020

ElectrocauteryElectrocautery 1515 1010

Argon Plasma Coagulation Argon Plasma Coagulation

1515 1010

Cryotherapy Cryotherapy

1010

Airway stentsAirway stents 2020 1010

Tunneled pleural catheterTunneled pleural catheter 1515

Medical thoracoscopyMedical thoracoscopy 2020

Percutaneous dilational tracheotomyPercutaneous dilational tracheotomy 2020 5-105-10

Ernst et al, Chest 2003Bolliger et al, ERJ 2002

Number achievement alone does not establish competencyNumber achievement alone does not establish competency

Endoluminal therapies may be combined to achieve the Endoluminal therapies may be combined to achieve the recommended numberrecommended number

The list is representative & not all-inclusiveThe list is representative & not all-inclusive

Procedural Procedural RecommendationsRecommendations

Skill MaintenanceSkill Maintenance

Continued performance is Continued performance is requiredrequired Preservation of learned materialPreservation of learned material

CME is integral to medical CME is integral to medical practicepractice State licensure, ABIM, BLS/ ACLS etc.State licensure, ABIM, BLS/ ACLS etc.

No reason to think it is different No reason to think it is different for proceduresfor procedures

CredentialingCredentialing

Local hospital functionLocal hospital function NO national standardNO national standard

Regulated by bylawsRegulated by bylaws

May include proctoringMay include proctoring

Goal is improved patient careGoal is improved patient care

Should include ongoing quality Should include ongoing quality controlcontrol

Lessons from our Lessons from our ColleaguesColleagues ABIM Subspecialty boardsABIM Subspecialty boards

Interventional Cardiology & Interventional Cardiology & ElectrophysiologyElectrophysiology Additional 12m over the standard 3 yearsAdditional 12m over the standard 3 years

Society of American Gastrointestinal and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)Endoscopic Surgeons (SAGES) ““short courses…do not constitute sufficient short courses…do not constitute sufficient

training”training”http://www.sages.org/sg_pub16.htmlGuidelines for Training in Diagnostic and Therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP)Training Guidelines published on: 10/2006 by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)

Stepping ForwardStepping Forward

“… “… AABIP is a leading provider of AABIP is a leading provider of Interventional Pulmonary Interventional Pulmonary fellowships… The AABIP is pleased to fellowships… The AABIP is pleased to announce that Interventional announce that Interventional Pulmonology will participate in the Pulmonology will participate in the NRMP match starting this year as a NRMP match starting this year as a new fellowship match for the 2012 new fellowship match for the 2012 appointment year”appointment year”

IP Training: The Future is IP Training: The Future is NowNow

Outline an approach to IP training Outline an approach to IP training Principles & objectives of IP trainingPrinciples & objectives of IP training Disease specific knowledge base requirementsDisease specific knowledge base requirements Suggestions for:Suggestions for:

Curricula developmentCurricula development Responsibilities of IP program directorsResponsibilities of IP program directors

Lamb, Feller-Kopman et al, CHEST 2010; 137:195

Developing IP TrainingDeveloping IP Training

Specific recommendationsSpecific recommendations Uniform IP fellowship programUniform IP fellowship program

Clarifying the expectationsClarifying the expectations Skills and knowledge baseSkills and knowledge base

Accomplished during the training periodAccomplished during the training period Dedicated IP programsDedicated IP programs

1 year of additional training1 year of additional training

Not intended to excludeNot intended to exclude Select proceduresSelect procedures Properly trained pulmonologistsProperly trained pulmonologists Specialists from other disciplinesSpecialists from other disciplines

Benefits of Dedicated IP Benefits of Dedicated IP TrainingTraining

Increase # of physicians trained at Increase # of physicians trained at ‘higher standard’‘higher standard’ ImprovedImproved

Patient outcomesPatient outcomes ResearchResearch

Case series Case series Outcomes data Outcomes data Define best practiceDefine best practice TranslationalTranslational

ReimbursementReimbursement

Structure of IP Training Structure of IP Training ProgramProgram

Occur in context of defined training Occur in context of defined training programprogram Existing ACGME-accredited PCCM programExisting ACGME-accredited PCCM program Independent program directed by those with Independent program directed by those with

formal IP trainingformal IP training Given multidisciplinary nature of IPGiven multidisciplinary nature of IP

Essential that institutions have:Essential that institutions have: Departments of internal medicineDepartments of internal medicine

SpecialtiesSpecialties Radiology/interventional radiologyRadiology/interventional radiology PathologyPathology Thoracic surgeryThoracic surgery OtolaryngologyOtolaryngology Radiation oncologyRadiation oncology Medical oncologyMedical oncology Lamb, Feller-Kopman et al, CHEST

2010; 137:195

Training in Advanced Training in Advanced ProceduresProcedures

Pursued ONLY if there is realistic expectation Pursued ONLY if there is realistic expectation trainee will achieve sufficient proficiencytrainee will achieve sufficient proficiency Perform w/o supervision at completion of trainingPerform w/o supervision at completion of training Maintain skill setMaintain skill set

Brief exposure not adequate to achieve Brief exposure not adequate to achieve competencycompetency Standard PCCM or thoracic fellowship programsStandard PCCM or thoracic fellowship programs Training coursesTraining courses

Designated training programsDesignated training programs Offer full complement of technologies & clinical Offer full complement of technologies & clinical

applicationsapplications IndependentlyIndependently Collaboration with other disciplines in their institutionsCollaboration with other disciplines in their institutions

Other interventional pulmonary training programsOther interventional pulmonary training programs

Goals of IP Training Goals of IP Training ProgramProgram

Evaluate & manage patientsEvaluate & manage patients Complex airwaysComplex airways Thoracic & pleural diseaseThoracic & pleural disease

Recommend most appropriate diagnostic &/or Recommend most appropriate diagnostic &/or therapeutic proceduretherapeutic procedure

Understanding of indications, Understanding of indications, contraindications & additional diagnostic & contraindications & additional diagnostic & therapeutic alternativestherapeutic alternatives Context of safety & timelinessContext of safety & timeliness

Demonstrate ability to obtain accurate & Demonstrate ability to obtain accurate & thorough pre-procedure assessmentthorough pre-procedure assessment Identification of specific risk factors for procedureIdentification of specific risk factors for procedure

Demonstrate ability to minimize & manage Demonstrate ability to minimize & manage anticipated & unanticipated complicationsanticipated & unanticipated complications


Accurately identify, describe & communicate pertinent Accurately identify, describe & communicate pertinent procedural findingsprocedural findings

Recognize limitationsRecognize limitations SelfSelf Particular specialty or institutionParticular specialty or institution Appropriately refer patients to providers w/ required equipment & Appropriately refer patients to providers w/ required equipment &

skill setskill set

Demonstrate personal skills:Demonstrate personal skills: Obtaining informed consentObtaining informed consent Advanced directivesAdvanced directives Medical ethicsMedical ethics Communication to patients, families & referring physiciansCommunication to patients, families & referring physicians

Develop understanding of required equipmentDevelop understanding of required equipment Maintenance & technical troubleshootingMaintenance & technical troubleshooting

Contribute to & critically evaluate the scientific literatureContribute to & critically evaluate the scientific literature

Demonstrate the responsible use of resourcesDemonstrate the responsible use of resources Diagnostic testingDiagnostic testing Therapeutic interventionsTherapeutic interventions


Obtain skills to develop & direct sustainable IP Obtain skills to develop & direct sustainable IP programprogram

Maintain & review outcomes & compare with Maintain & review outcomes & compare with benchmarksbenchmarks Maintain the highest possible quality of careMaintain the highest possible quality of care

Complete training:Complete training: 2 primary advanced diagnostic techniques2 primary advanced diagnostic techniques

Endobronchial ultrasoundEndobronchial ultrasound Threshold numbers with appropriate supervisionThreshold numbers with appropriate supervision

Minimum of 2 ablative techniquesMinimum of 2 ablative techniques in therapeutic mgt of in therapeutic mgt of airwayairway

Use of BOTH silicone & metallic airway stentsUse of BOTH silicone & metallic airway stents PlacementPlacement RemovalRemoval Management of complicationsManagement of complications

Responsibilities of IP Responsibilities of IP Training ProgramTraining Program

Expert IP as training program directorExpert IP as training program director

Structured, multidisciplinary didactic Structured, multidisciplinary didactic curriculumcurriculum

Hands-on teachingHands-on teaching Appropriate mentoring and supervisionAppropriate mentoring and supervision Simulation training when applicable Simulation training when applicable

Monitor & record acquisition of Monitor & record acquisition of appropriate technical & cognitive appropriate technical & cognitive skillsskills

Responsibilities of IP Responsibilities of IP Training ProgramTraining Program

Review trainee's procedural logReview trainee's procedural log All proceduresAll procedures Indications, complications & outcomes of interventionIndications, complications & outcomes of intervention

Established performance standardsEstablished performance standards

Review & update the program’sReview & update the program’s Training methodologyTraining methodology Quality of trainingQuality of training

Peer-reviewed/medical society guidelinesPeer-reviewed/medical society guidelines

Conduct semiannual reviewsConduct semiannual reviews 360° fashion360° fashion

Trainee and faculty giving & receiving formal feedbackTrainee and faculty giving & receiving formal feedback

Document active researchDocument active research

Demonstrate CME in IPDemonstrate CME in IP

Between Between Infectious Infectious Diseases & Diseases & Nephrology!Nephrology!

www.nrmp.org

Remaining QuestionsRemaining Questions

Need to show that IP training achieves Need to show that IP training achieves goalsgoals VolumeVolume Patient outcomesPatient outcomes Higher qualityHigher quality

ResearchResearch GrantsGrants PublicationsPublications

How further spread of dedicated IP How further spread of dedicated IP training programs will impact standard training programs will impact standard PCCM fellowship trainingPCCM fellowship training

REFERENCES:REFERENCES:11 Ernst A, Silvestri GA, Johnstone D, American College of Chest Physicians : Interventional pulmonary procedures: Ernst A, Silvestri GA, Johnstone D, American College of Chest Physicians : Interventional pulmonary procedures:

guidelines from the American College of Chest Physicians. guidelines from the American College of Chest Physicians. ChestChest 123. (5): 1693-1717.2003 123. (5): 1693-1717.2003

22 Bolliger CT, Mathur PN, Beamis JF, European Respiratory Society/American Thoracic Society , et al: ERS/ATS Bolliger CT, Mathur PN, Beamis JF, European Respiratory Society/American Thoracic Society , et al: ERS/ATS statement on interventional pulmonology. statement on interventional pulmonology. Eur Respir JEur Respir J 19. (2): 356-373.2002 19. (2): 356-373.2002

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99 Society of American Gastrointestinal Endoscopic Surgeons : Society of American Gastrointestinal Endoscopic Surgeons : Guidelines for training in diagnostic and therapeutic Guidelines for training in diagnostic and therapeutic endoscopic retrograde cholangiopancreatographyendoscopic retrograde cholangiopancreatography. Accessed March 18, . Accessed March 18, 2008 http://www.sages.org/sagespublications/guidelines/guidelines.php 2008 http://www.sages.org/sagespublications/guidelines/guidelines.php

1010 Jowell PS: Endoscopic retrograde cholangiopancreatography: toward a better understanding of competence. Jowell PS: Endoscopic retrograde cholangiopancreatography: toward a better understanding of competence. EndoscopyEndoscopy 31. (9): 755-757.1999 31. (9): 755-757.1999

1111 Eisen GM, Dominitz JA, Faigel DO, American Society for Gastrointestinal Endoscopy. Standards of Practice Eisen GM, Dominitz JA, Faigel DO, American Society for Gastrointestinal Endoscopy. Standards of Practice Committee , et al: Guidelines for advanced endoscopic training. Committee , et al: Guidelines for advanced endoscopic training. Gastrointest EndoscGastrointest Endosc 53. (7): 846-848.2001 53. (7): 846-848.2001

1212 American Society for Gastrointestinal Endoscopy : Principles of training in gastrointestinal endoscopy. From the American Society for Gastrointestinal Endoscopy : Principles of training in gastrointestinal endoscopy. From the ASGE. American Society for Gastrointestinal Endoscopy. ASGE. American Society for Gastrointestinal Endoscopy. Gastrointest EndoscGastrointest Endosc 49. (6): 845-853.1999 49. (6): 845-853.1999

1313 Bucholz EI, Duncan JR: Assessing system performance. Bucholz EI, Duncan JR: Assessing system performance. J Vasc Interv RadiolJ Vasc Interv Radiol 19. (7): 987-994.2008 19. (7): 987-994.2008

Michael S Machuzak, MDMichael S Machuzak, MDMedical Director, Center for Major Airway DiseaseMedical Director, Center for Major Airway Disease

Transplant InstituteTransplant InstituteStaff, Respiratory InstituteStaff, Respiratory Institute

Cleveland ClinicCleveland Clinic

Thank Thank you!you!

What constitutes adequate evidence of competenceWhat constitutes adequate evidence of competence Previous guidelines were expert based and used volume criteria for determining Previous guidelines were expert based and used volume criteria for determining

competencecompetence Lack of empirical data to support these guidelines, and they have been controversialLack of empirical data to support these guidelines, and they have been controversial While volume criteria are practical, their use to define competence is problematicWhile volume criteria are practical, their use to define competence is problematic

Measures of volume are only a surrogate for measures of qualityMeasures of volume are only a surrogate for measures of quality The assumption is that the more a physician performs a procedure, the better he or The assumption is that the more a physician performs a procedure, the better he or

she will beshe will be Precise data describing the learning curve for procedures are difficult to obtainPrecise data describing the learning curve for procedures are difficult to obtain Significant variability in terms of the rate of skill acquisition, so what constitutes Significant variability in terms of the rate of skill acquisition, so what constitutes

sufficient volume to learn a skill may vary widely between individuals. Even if data on sufficient volume to learn a skill may vary widely between individuals. Even if data on learning curves were available, where to set the volume thresholds for certification learning curves were available, where to set the volume thresholds for certification would always be a difficult question given this variability. Should it be toward the top would always be a difficult question given this variability. Should it be toward the top of the distribution, such that 95% of all graduates will have adequate experience? of the distribution, such that 95% of all graduates will have adequate experience? Should it be the median? No matter where we set volume thresholds, the answer will Should it be the median? No matter where we set volume thresholds, the answer will be wrong. Set it too high, and many will be excluded, with the result being slow be wrong. Set it too high, and many will be excluded, with the result being slow dissemination of otherwise useful technologies and missed opportunities. Set it too dissemination of otherwise useful technologies and missed opportunities. Set it too low, and complications and inappropriate utilization patterns will develop. A simpler low, and complications and inappropriate utilization patterns will develop. A simpler solution is to measure and monitor outcomes and performance quality directly and to solution is to measure and monitor outcomes and performance quality directly and to provide feedback to physicians rather than relying solely on expert opinion, volume provide feedback to physicians rather than relying solely on expert opinion, volume requirements, or other surrogate markers. Such a system could be combined with requirements, or other surrogate markers. Such a system could be combined with volume requirements and other didactic instruments. One of the greatest challenges volume requirements and other didactic instruments. One of the greatest challenges in the field, however, is that the necessary procedural quality benchmarks for such a in the field, however, is that the necessary procedural quality benchmarks for such a system do not exist. Registry data, collected by the ACCP, may be able to address this system do not exist. Registry data, collected by the ACCP, may be able to address this in the future.[8] in the future.[8]

Developing the infrastructure necessary for these multiple training environments along with a means of Developing the infrastructure necessary for these multiple training environments along with a means of certification and monitoring of quality will be necessary. One key element that is currently lacking is the certification and monitoring of quality will be necessary. One key element that is currently lacking is the opportunity for supervised hands-on training with new technologies beyond a fellowship. Simulation can opportunity for supervised hands-on training with new technologies beyond a fellowship. Simulation can answer some of these problems, but hands-on patient experience will still be needed.[9] However, it is in this answer some of these problems, but hands-on patient experience will still be needed.[9] However, it is in this area that we face some of the greatest hurdles, since there is no easy way outside of a fellowship for physicians area that we face some of the greatest hurdles, since there is no easy way outside of a fellowship for physicians to get hands-on patient experience. Administrative and legal barriers prevent physicians from easily going to to get hands-on patient experience. Administrative and legal barriers prevent physicians from easily going to other institutions to gain supervised hands-on experience. This has a deadly effect on quality and drastically other institutions to gain supervised hands-on experience. This has a deadly effect on quality and drastically delays the uptake of even the best technologies. It forces physicians to choose between bad options: either delays the uptake of even the best technologies. It forces physicians to choose between bad options: either hold-off on introducing potentially useful new technology or begin using new technology with little in the way of hold-off on introducing potentially useful new technology or begin using new technology with little in the way of prior hands-on experience. Ironically, professors of medicine are not allowed to do what students of medicine prior hands-on experience. Ironically, professors of medicine are not allowed to do what students of medicine do all the time—get hands-on experience somewhere else in a supervised environment. Reform in this area will do all the time—get hands-on experience somewhere else in a supervised environment. Reform in this area will be critical if we are to improve our training system. It will require unconventional thinking, since in this case be critical if we are to improve our training system. It will require unconventional thinking, since in this case the determinants of the quality of care are actually the legal and administrative barriers to training. These are the determinants of the quality of care are actually the legal and administrative barriers to training. These are in urgent need of reform.in urgent need of reform.

Standardization of the IP fellowship curricula will help by providing a framework for discussion of these other Standardization of the IP fellowship curricula will help by providing a framework for discussion of these other areas. In developing standardized curricula, care should also be taken to avoid unnecessary redundancy. areas. In developing standardized curricula, care should also be taken to avoid unnecessary redundancy. Physicians coming to IP fellowship will have had 6 years of training; required elements should be limited to Physicians coming to IP fellowship will have had 6 years of training; required elements should be limited to those things that are truly not covered in sufficient depth during their prior training. Things that should have those things that are truly not covered in sufficient depth during their prior training. Things that should have been learned during prior training can be prerequisites, but such things should not be included as part of the IP been learned during prior training can be prerequisites, but such things should not be included as part of the IP curricula (ie, medical ethics, communication skills). Similarly, mandating procedural training that is well curricula (ie, medical ethics, communication skills). Similarly, mandating procedural training that is well covered in most standard fellowships is probably not warranted. For IP fellowships to be of value, they must covered in most standard fellowships is probably not warranted. For IP fellowships to be of value, they must provide training that is unavailable during standard pulmonary fellowships, and the quality and breadth of that provide training that is unavailable during standard pulmonary fellowships, and the quality and breadth of that training must be consistent between programs, so that other medical professionals and patients will be able to training must be consistent between programs, so that other medical professionals and patients will be able to reliably know what they are getting.reliably know what they are getting.

The proposal by Lamb and colleagues[7] is an important first step in addressing these issues. Individuals may The proposal by Lamb and colleagues[7] is an important first step in addressing these issues. Individuals may hold different beliefs as to whether IP fellowships are essential, a good option, or not necessary. Others may hold different beliefs as to whether IP fellowships are essential, a good option, or not necessary. Others may advocate that certification is best achieved by using volume criteria, performance criteria, or a mixed model. advocate that certification is best achieved by using volume criteria, performance criteria, or a mixed model. However, while there are many unanswered questions and ongoing debates, one thing that is certain is that However, while there are many unanswered questions and ongoing debates, one thing that is certain is that patients and pulmonary medicine will benefit from an academically rigorous and open discussion of how we can patients and pulmonary medicine will benefit from an academically rigorous and open discussion of how we can improve procedural training and certification.improve procedural training and certification.

Ost D, DeRosiers A, Britt EJ, Fein AM, Lesser ML, Mehta AC: Assessment of a bronchoscopy simulator. Ost D, DeRosiers A, Britt EJ, Fein AM, Lesser ML, Mehta AC: Assessment of a bronchoscopy simulator. Am J Am J Respir Crit Care MedRespir Crit Care Med 164. (12): 2248-2255.2001; Abstract 164. (12): 2248-2255.2001; Abstract

Rapid development of new technologies in pulmonary medicine, it has Rapid development of new technologies in pulmonary medicine, it has become increasingly important to ensure that the skills and competency become increasingly important to ensure that the skills and competency needed to provide these services are acquired by practicing physiciansneeded to provide these services are acquired by practicing physicians

Particularly relevant to interventional pulmonology (IP) because of its Particularly relevant to interventional pulmonology (IP) because of its emphasis on technology and proceduresemphasis on technology and procedures

American College of Chest Physicians (ACCP)American College of Chest Physicians (ACCP) European Respiratory SocietyEuropean Respiratory Society American Thoracic SocietyAmerican Thoracic Society Previously issued guidelines regarding training for IP procedures.Previously issued guidelines regarding training for IP procedures.11,,22 Subsequent surveys by the ACCPSubsequent surveys by the ACCP Wide variability between fellowship programs in terms of IP procedures.Wide variability between fellowship programs in terms of IP procedures.33 Not a new problemNot a new problem Over a decade ago demonstrated similar variability in terms of training Over a decade ago demonstrated similar variability in terms of training

for transbronchial needle aspiration.for transbronchial needle aspiration.44,,55 Variability in training adversely impacts patient careVariability in training adversely impacts patient care Lead to underutilization of effective techniquesLead to underutilization of effective techniques Low-quality performance.Low-quality performance.66 It is therefore important that structures and It is therefore important that structures and

processes be developed to facilitate effective procedural training and processes be developed to facilitate effective procedural training and certificationcertification

Chest 123(5):1693-1717; Eur Resir J 19(2): 356-373; Chest 127(5): 1614-1621; Chest 118(3): 625-630; Chest 112(1):251-253; Clin Chest Med 20(1):39-51

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Interventional Pulmonology: Who Should Learn and How? Michael S Machuzak, MD Medical Director, Center for Major Airway Disease Transplant Institute Staff