Interventional Pulmonary Fellowship Training: End of the Beginning

A Survey of Program Directors on Procedural Competence and Volume in the US Pulmonary and Critical Care Fellowships

BACKGROUND

In the United States, Pulmonary and Critical Care Medicine (PCCM) fellowship training traditionally requires performing a minimum number of bronchoscopy and pleural procedures to be deemed competent. However, expert panel recommendations favor assessments based on skill and knowledge. PCCM trainees have a variable exposure to the advanced procedures in the presence of interventional pulmonary (IP) fellowships, so we surveyed the PCCM program directors (PD) across the United States to assess the procedural volume and competency of their fellows.

METHODS

Survey invitations were emailed between April 2022 and May 2022, and responses were collected from PCCM fellowship programs. The PD assessed the competency and volume of procedures performed by PCCM fellows at the end of training. The primary objective was to determine the effect of IP fellowship or IP faculty on fellows' procedural competency. The secondary objective was to assess the same impact on procedural volume.

RESULTS

The survey response rate was 41.9% (n=109/260) with an average of 4.23 fellows/program (95% CI: 3.9-4.6). 74.5% (73/98) programs reported having access to IP faculty, while 26.5% (26/98) had an AABIP-accredited IP fellowship. No significant difference was noted for procedural competency or volume in programs with or without an IP fellowship or IP faculty during training. Most programs reported that PCCM fellows do not perform advanced bronchoscopy procedures.

CONCLUSION

An IP fellowship or IP faculty at a PCCM training institution did not appear to influence the PD-assessed volume or competency of common bronchoscopy and pleural procedures performed by fellows.

Competency-based medical education in interventional pulmonology: current state and future opportunities

PURPOSE OF REVIEW

This chapter examines the evolution and current status of competency-based medical education (CBME) in interventional pulmonology, focusing on procedural skills assessment and training.

RECENT FINDINGS

Traditionally, interventional pulmonology training has used an apprenticeship model with case logs and director attestation, leading to inconsistent outcomes due to a lack of standardized curricula. CBME, established to address these issues, relies on outcome-based assessments to ensure trainees achieve necessary competencies. The chapter reviews various assessment tools, including global rating scales, checklists, and simulation-based methods, and their effectiveness in skill acquisition and clinical evaluation. It also covers specific procedures such as EBUS-TBNA, electromagnetic navigation bronchoscopy, and rigid bronchoscopy, discussing their assessment tools and learning curves. The chapter emphasizes the need for standardized assessment tools and suggests using entrustable professional activities (EPAs) to improve competency evaluation. Future directions include integrating real-time artificial intelligence feedback, addressing high-risk low-volume procedures, and enhancing workplace-based assessments to improve interventional pulmonology training and patient care quality.

SUMMARY

This chapter reviews the transition from traditional apprenticeship models to CBME in interventional pulmonology, highlighting advancements in procedural skills assessment, the effectiveness of various assessment tools, and future directions for improving training and patient care.

Practices and perspectives on advanced diagnostic and interventional bronchoscopy among pediatric pulmonologists in the United States

INTRODUCTION

Advanced diagnostic bronchoscopy includes endobronchial ultrasound (EBUS) guided transbronchial lung and lymph node biopsies, CT navigation and robotic bronchoscopy. Interventional bronchoscopy refers to procedures performed for therapeutic purposes such as balloon dilation of the airway, tissue debulking, cryotherapy, removal of foreign bodies and insertion of endobronchial valves [1]. For adult patients, these procedures are standard of care [2, 3]. Despite a lack of formalized training, there are numerous case reports and case series describing the use of advanced diagnostic and interventional bronchoscopy techniques in children. The safety and feasibility of EBUS-TBNA, cryotherapy techniques, endobronchial valves among other techniques have been demonstrated in these publications [1, 4-9].

METHODS

We sought to better understand the current practices and perspectives on interventional and advanced bronchoscopy among pediatric pulmonologists through surveys sent to pediatric teaching hospitals across the United States.

RESULTS

We received 43 responses representing 28 programs from 25 states. The highest bronchoscopy procedure volume occurred in the 0-5 years age group. Among our respondents, 31% self-identified as a pediatric interventional/advanced bronchoscopist. 79% believe that advanced and interventional training is feasible in pediatric pulmonology and 77% believe it should be offered to pediatric pulmonary fellows.

DISCUSSION

This is the first study to characterize current practices and perspectives regarding advanced diagnostic and interventional bronchoscopy procedures among pediatric pulmonologists in the United States. Pediatric interventional pulmonology (IP) is in its infancy and its beginnings echo those of the adult IP where only certain centers were performing these procedures.

Training in interventional pulmonology: a leap into the future

PURPOSE OF REVIEW

This review holds significant relevance and is timely; as of June 2022, the United States Accreditation Council of Graduate Medical Education (ACGME) formally recognized interventional pulmonary medicine as a novel subspecialty with a unique fellowship training program pathway beyond Pulmonary and Critical Care Medicine. This recognition stands as a culmination of extensive efforts spanning decades, aimed at establishing a specialized training program for interventional pulmonary medicine beyond traditional Pulmonary and Critical Care Fellowship in the United States. Globally, there are apprenticeship models in non-US programs with ongoing efforts to further standardize training in interventional pulmonary medicine. It underscores the progressive evolution and innovative nature inherent to this subspecialty, signifying a distinctive leap forward in medical education and practice, which calls for further inventive development of training tools and standardized educational delivery.

RECENT FINDINGS

Newly discovered insights from the recent literature review will highlight methodologies of procedural education and innovative training approaches. These findings will underscore the significance of standardized curriculum development within the field as well as ongoing challenges.

SUMMARY

Identifying and addressing future challenges in integrating new technologies into clinical education and broadening the educational scope of trainees in this newly recognized subspecialty is crucial for enhancing competency. The implications of moving toward a more standardized process, creating new clinical pathways with research, and adopting emerging minimally invasive technologies aim to impact patient outcomes in both nonmalignant and malignant thoracic diseases. This progressive shift is redefining the specialty, moving beyond specific procedures, and pivoting towards a more distinct educational pathway. Such a transformation will lead to more diverse, comprehensive, and evidence-based driven patient care delivery.