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Interventional Pulmonology: Who Should Learn and How?

Interventional Pulmonology: Who Should Learn and How?. Michael S Machuzak, MD Medical Director, Center for Major Airway Disease Transplant Institute Staff Respiratory Institute. No Disclosures. Consultant to: Olympus CareFusion. Background. Hospital of the University of Pennsylvania

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Interventional Pulmonology: Who Should Learn and How?

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

  2. No Disclosures Consultant to: Olympus CareFusion

  3. Background Hospital of the University of Pennsylvania Residency Fellowship 2 year IP Fellowship Daniel Sterman PENN Ali Musani National Jewish Marseille, France HerveDutau et al Chiba, Japan KasuYasufuku et al Cleveland Clinic 2006

  4. Advanced Diagnostic Bronchoscopy Airway Imaging Autofluorescence Narrow-Band Confocal Nodule, Mass & Lymph node biopsy CT fluoro Electromagnetic guidance Virtual bronchoscopic navigation Endobronchial Ultrasound Convex & Radial Therapeutic Bronchoscopy Central Airway Obstruction Ablation Dilation Stent placement Management of Lung Txp airway complications Endoscopic Emphysema Treatment Treatment of Fistula BPF, TE, BE, etc… Thermal Ablation for Asthma What is Interventional Pulmonology?

  5. What is Interventional Pulmonology? Pleural Disease & More Pleural Manometry and Ultrasound for Large Volume Thoracentesis Thoracoscopy +/- Pleurodesis Tunneled catheter Minimally Invasive Pleural Intervention Medical thoracoscopy Tunneled catheter Pigtail catheter placement Other Tracheostomy, PEG, Trans-Tracheal Oxygen Catheters

  6. What is Interventional Pulmonology? • Evolving specialty • >20 years • Meld of many different specialties • Pulmonary, ENT, Thoracic surgery, IR, Oncology, etc… • Emphasis on multidisciplinary care • New technologies & procedures • Training??????? • In development

  7. Improve patient care Maximize Diagnostic yield Pt outcomes Revenue Stream Multidisciplinary care Independence Minimize Invasiveness Risk Cost Other Lack of expertise locally It’s fun ??? Why Learn a New Procedure?

  8. Reasons NOT to Learn a New Procedure Never learned the old way Advanced technology does NOT improve basic skills It seems cool Need volume to obtain/maintain competency Too costly

  9. Read the literature Really??? Standard training PCCM fellowships Courses Single or multiple day Mini-fellowships Weeks - months Dedicated year of IP training Web-based curriculum Supervised simulator sessions How to Learn New Procedures

  10. Short courses / “Mini-fellowships” • Excellent exposure to one/variety of techniques • Didactics • Hands-on • Simulators • High vs. Low fidelity models • Animal models • Patients

  11. Middle Ages Internships Fellowships Post-grad Benefits: Structured approach Accountability Mentee AND mentor Need: Structure Curriculum Defined outcome measures Time Apprenticeship

  12. Web-Based Education www.bronchoscopy.org

  13. Bronchoscopy Simulators • Multi-center prospective cohort study using BS • Differentiate b/t expert & novice • Does use of BS improve rate of skill acquisition? • “Experts" (> 500, n = 9) • “Intermediates" (25 to 500, n = 8) • “Novices" (none, n = 11) • 2 BS cases with performance measures recorded • Distinguishing performance measures identified • Used to evaluate the learning curve for new fellows • RCT comparing quality of bronch performance • New pulmonary fellows • Conventional methods • Simulator Am. J. Respir. Crit. Care Med., Volume 164, Number 12, December 2001, 2248-2255

  14. Bronchoscopy Simulators • Experts > Intermediates > Novices • Procedure time • % of segments visualized • Time in red-out • Wall collisions • New fellows • After 20 simulations  Improved • Speed • % segments visualized • Time in red-out • Collisions Am. J. Respir. Crit. Care Med., Volume 164, Number 12, December 2001, 2248-2255

  15. Bronchoscopy Simulators • BS Fellows > Conventional fellows • First actual bronchoscopies • Procedure time • 815 vs. 1,168 s • p = 0.001 • Bronch nurse subjective quality assessment score • 7.7 ± 0.3 vs. 3.7 ± 2.5 • p = 0.05 • Quantitative bronch quality score • % segments correctly identified/procedure time • 0.119 ± 0.015 vs. 0.046 ± 034 • p = 0.03 Am. J. Respir. Crit. Care Med., Volume 164, Number 12, December 2001, 2248-2255

  16. Bronchoscopy Simulators • BS able to assess experience level • Training new fellows on BS • More rapid acquisition of expertise • Compared with conventional training methods • Technology has potential • Facilitate bronch training • Improve objective evaluations of bronch skills Am. J. Respir. Crit. Care Med., Volume 164, Number 12, December 2001, 2248-2255

  17. Interventional Pulmonology ≠ interventional pulmonology • Is a dedicated 1 year fellowship necessary for comprehensive training in IP? • Establish basis for structured training in IP • Distinct from standard PCCM training • Structure to allow successful acquisition of skill set & experience • Specific skill sets may NOT require year • EBUS • Navigational bronchoscopy • Thermoplasty etc.

  18. www.aabronchology.org “AABIP was founded in 1992 with the primary goal to foster excellence in Bronchology and other Interventional Pulmonology related areas” “The cornerstone of our mission is to enhance multidisciplinary and international collaboration in our quest to develop, evaluate, and disseminate techniques, procedures, and cases”

  19. Training: What is Happening? > 50% pulmonologists Inadequate training in “advanced diagnostic techniques such as TBNA” > 70% practicing bronchoscopists Perform <100 bronchoscopies/yr 70% felt additional training should be provided ONLY to those interested in developing specific skills ONLY 25% of pulmonologists perform all procedures required for board certification Colt et al, Journal of Bronchology. 2000;7:8 Pastis et al, Chest 2005; 127: 1614

  20. Advanced Training during Standard Fellowship • Survey 122 PCCM fellowship directors • Response 77% • Wide variation in procedures offered • Presence of an IP • Increased likelihood of advanced procedural training • Brachytherapy (p < 0.05) • Electrocautery/argon plasma coagulation (p < 0.001) • Stents (p < 0.001) • Laser therapy (p < 0.01) • Rigid bronchoscopy (p < 0.001) • Cryotherapy (p < 0.05) • For only 3 of the 17 procedures did > 50% of the programs reach the targeted numbers to obtain competency Pastis et al, Chest 2005; 127: 1614 Colt et al, Journal of Bronchology. 2000;7:8

  21. Goals of Training Understand: Appropriate evaluation & management of disease process Technical aspects of the procedure Recognize pathology Distinguish from normal Perform: Correct procedure expeditiously Communicate effectively Ensure competent support staff Avoid, recognize and treat complications Know when NOT to do the procedure

  22. What is Competence? Institute for International Medical Education “Possession of a satisfactory level of relevant knowledge and acquisition of a range of relevant skills that include interpersonal and technical components…necessary to perform the tasks that reflect the scope of professional practices”

  23. “Competence may differ from "performance", which denotes actions taken in a real life situation Competence is therefore not the same as "knowing" on the contrary, it may well be about recognizing one's own limits” What is Competence?

  24. Is Competence Related to Repetition? Repetition allows for repeat training Improves dexterity Improves infrastructure Makes systems function smoothly Makes introduction of systems to avoid mistakes worthwhile Improves success & decreases error!

  25. Volume Thresholds:No Correct Answer • Too high • Many excluded • Low dissemination of useful technologies • Missed opportunities • Too low • Complications • Inappropriate utilization patterns • We NEED to directly measure & monitor outcomes & performance quality • Feedback to physicians rather than: • Expert opinion • Volume requirements • Other surrogate markers • System combined with volume rqts & other didactic instruments • One of the greatest challenges: • Necessary procedural quality benchmarks do not exist • Registry data, collected by the ACCP, may be able to address this in the future • AcQuire Chest 2010(137)

  26. Drivers education Pilots Surgery esophageal cardiac endocrine airway vascular ERCP: 200 Central lines: 50 Not completely dependent on #s More is Better: Numbers Matter(NO data to support otherwise) Birkmeyer NEJM 2002 Jowell Endoscopy 1999 Sznajder Arch Intern Med 1986

  27. Vascular Procedures • High-volume providers • Significantly better outcomes • Elective AND emergent setting • Subspecialty training • Considerable impact • Morbidity and mortality • Evidence for specialization of vascular services • Performed by high-volume, specialty trained providers J Vasc Surg 2007 Mar;45(3):615-26.

  28. Coronary Interventions • Medicare National Claims History files: 1997 • 167,208 pts aged 65 to 99 years who had PCI by 6534 phys at 1003 hospitals • 57.7% involved coronary stents • Pts treated by low-volume (<30) phys had ↑ risk of CABG • (2.25% vs 1.55%; P<.001) • No difference in 30d mortality rates (3.25% vs 3.39%; P = .27) • Pts treated at low-volume (<80) ctrs had ↑ risk of 30d mortality • (4.29% vs 3.15%; P<.001) • No difference in the risk of CABG (1.83% vs 1.83%; P = .96) • Patients who received stents • Low-volume ctrs had ↑ risk of 30d mortality vs. high-volume ctrs • Low-volume phys had ↑ risk of CABG vs. high-volume phys • Medicare pts treated by high-volume phys & at high-volume ctrs experience better outcomes following PCI JAMA 2000;284(24):3139-3144

  29. Surgical Oncology • Retrospective cohort study using Surveillance, Epidemiology & End Results (SEER) • 5013 pts in SEER registry 65 or > at cancer diagnosis 1984-1993 • 30 D mortality in relation to procedure volume, adjusted for co-morbidity, pt age, & cancer stage • Higher volume linked with lower mortality • Pancreatectomy (P=.004) • Esophagectomy (P<.001) • Liver resection (P=.04) • Pelvic exenteration (P=.04) • Not for: • Pneumonectomy (P=.32) • Esophagectomy • Pancreatectomy • When complex surgical oncologic procedures provided by surgical teams in hospitals w/ specialty expertise, mortality rates are lower JAMA 1998; 280(2): 1747-1751

  30. Surgeon Volume & Mortality • National Medicare claims data base for 1998-1999 • Mortality among 474,108 patients • 1 of 8 cardiovascular procedures or cancer resections • Surgeon volume inversely related to operative mortality for all • (P=0.003 for lung resection, P<0.001 for all other procedures) • For many procedures • Observed associations b/t hospital volume & operative mortality • Largely mediated by surgeon volume • Patients can improve their chances of survival • Even at high-volume hospitals • Surgeons who perform operations frequently NEJM 2003 349(22):2117-27

  31. Teaching Procedural Skills • Medical Procedure Service • See one, do one, teach one • Often: • See one done wrong, do one wrong, teach one wrong • Simulation training with 2w rotation • Central lines / Thora’s supervised by IP staff • LPs / Para’s supervised by hospitalist staff • Decreased 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

  32. Procedural Recommendations Number achievement alone does not establish competency Endoluminal therapies may be combined to achieve the recommended number The list is representative & not all-inclusive Ernst et al, Chest 2003 Bolliger et al, ERJ 2002

  33. Skill Maintenance Continued performance is required Preservation of learned material CME is integral to medical practice State licensure, ABIM, BLS/ ACLS etc. No reason to think it is different for procedures

  34. Credentialing Local hospital function NO national standard Regulated by bylaws May include proctoring Goal is improved patient care Should include ongoing quality control

  35. Lessons from our Colleagues http://www.sages.org/sg_pub16.html Guidelines 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) • ABIM Subspecialty boards • Interventional Cardiology & Electrophysiology • Additional 12m over the standard 3 years • Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) • “short courses…do not constitute sufficient training”

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

  37. IP Training: The Future is Now • Outline an approach to IP training • Principles & objectives of IP training • Disease specific knowledge base requirements • Suggestions for: • Curricula development • Responsibilities of IP program directors Lamb, Feller-Kopman et al, CHEST 2010; 137:195

  38. Developing IP Training • Specific recommendations • Uniform IP fellowship program • Clarifying the expectations • Skills and knowledge base • Accomplished during the training period • Dedicated IP programs • 1 year of additional training • Not intended to exclude • Select procedures • Properly trained pulmonologists • Specialists from other disciplines

  39. Benefits of Dedicated IP Training • Increase # of physicians trained at ‘higher standard’ • Improved • Patient outcomes • Research • Case series  Outcomes data • Define best practice • Translational • Reimbursement

  40. Structure of IP Training Program • Occur in context of defined training program • Existing ACGME-accredited PCCM program • Independent program directed by those with formal IP training • Given multidisciplinary nature of IP • Essential that institutions have: • Departments of internal medicine • Specialties • Radiology/interventional radiology • Pathology • Thoracic surgery • Otolaryngology • Radiation oncology • Medical oncology Lamb, Feller-Kopman et al, CHEST 2010; 137:195

  41. Training in Advanced Procedures • Pursued ONLY if there is realistic expectation trainee will achieve sufficient proficiency • Perform w/o supervision at completion of training • Maintain skill set • Brief exposure not adequate to achieve competency • Standard PCCM or thoracic fellowship programs • Training courses • Designated training programs • Offer full complement of technologies & clinical applications • Independently • Collaboration with other disciplines in their institutions • Other interventional pulmonary training programs

  42. Goals of IP Training Program • Evaluate & manage patients • Complex airways • Thoracic & pleural disease • Recommend most appropriate diagnostic &/or therapeutic procedure • Understanding of indications, contraindications & additional diagnostic & therapeutic alternatives • Context of safety & timeliness • Demonstrate ability to obtain accurate & thorough pre-procedure assessment • Identification of specific risk factors for procedure • Demonstrate ability to minimize & manage anticipated & unanticipated complications

  43. Goals of IP Training Program • Accurately identify, describe & communicate pertinent procedural findings • Recognize limitations • Self • Particular specialty or institution • Appropriately refer patients to providers w/ required equipment & skill set • Demonstrate personal skills: • Obtaining informed consent • Advanced directives • Medical ethics • Communication to patients, families & referring physicians • Develop understanding of required equipment • Maintenance & technical troubleshooting • Contribute to & critically evaluate the scientific literature • Demonstrate the responsible use of resources • Diagnostic testing • Therapeutic interventions

  44. Goals of IP Training Program • Obtain skills to develop & direct sustainable IP program • Maintain & review outcomes & compare with benchmarks • Maintain the highest possible quality of care • Complete training: • 2 primary advanced diagnostic techniques • Endobronchial ultrasound • Threshold numbers with appropriate supervision • Minimum of 2 ablative techniques in therapeutic mgt of airway • Use of BOTH silicone & metallic airway stents • Placement • Removal • Management of complications

  45. Responsibilities of IP Training Program • Expert IP as training program director • Structured, multidisciplinary didactic curriculum • Hands-on teaching • Appropriate mentoring and supervision • Simulation training when applicable • Monitor & record acquisition of appropriate technical & cognitive skills

  46. Responsibilities of IP Training Program • Review trainee's procedural log • All procedures • Indications, complications & outcomes of intervention • Established performance standards • Review & update the program’s • Training methodology • Quality of training • Peer-reviewed/medical society guidelines • Conduct semiannual reviews • 360° fashion • Trainee and faculty giving & receiving formal feedback • Document active research • Demonstrate CME in IP

  47. www.nrmp.org Between Infectious Diseases & Nephrology!

  48. Remaining Questions • Need to show that IP training achieves goals • Volume • Patient outcomes • Higher quality • Research • Grants • Publications • How further spread of dedicated IP training programs will impact standard PCCM fellowship training

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