Accredited Interventional Pulmonary Fellowships

A little learning is a dang’rous thing;/drink deep, or taste not the Pierian Spring (Alexander Pope: 1688 to 1744) Although practiced for decades within the United States, the field of interventional pulmonology (IP) is experiencing new found direction, structure, and legitimacy. Acutely evident over just the last 10 years, and driven in no small part by the widespread adoption of endobronchial ultrasound and other advanced diagnostic techniques, there is renewed interest from trainees, clinicians, administrators, industry, and third-party payers in the unique skillset and expertise that distinguishes IP from its better-established and recognized sister specialties of pulmonary medicine and thoracic surgery. As with any new subspecialty, the path toward formal recognition is a deliberate process incumbent upon dedicated advanced training and defined competencies upon which the public and medical community can rely. In the United States this requires enforceable accreditation standards defining the necessary training to acquire the subspecialty’s knowledge and skill, and a certifying board to validate individual practitioner attainment of this knowledge and skill. In 2013 the American Association for Bronchology and Interventional Pulmonology (AABIP) introduced the first IP board certification examination, and since that time 102 interventional pulmonologists have achieved board certification in IP. The remaining task is to standardize the IP fellowship experience through a formal accreditation process. Much work has already been accomplished toward that end. The landscape of IP fellowship training has rapidly progressed over the last 5 to 10 years. We have seen the development of a formal match system (via National Residency Match Program) and an in-service examination.1,2 Over the same period we have witnessed the almost meteoric growth in formal IP subspecialty training with now 25 programs offering a 1-year (or more) dedicated fellowship where only 5 had existed just 10 years ago. The Association of Interventional Pulmonology Program Directors (AIPPD) was established in 2012 to help serve the needs of program directors and to develop tools to facilitate education in IP, and in this same year the AABIP initiated an annual IP “bootcamp” for new IP trainees with the intent to foster fellow collegiality and provide a uniform initial exposure to their chosen subspecialty. Despite these efforts and advances, our fellowships suffer from lack of standardization and oversight. Critics of IP training point to a lack of centralized and uniform funding, accountability, standardized curriculum, and milestones, and ultimately American College of Graduate Medical Education (ACGME)-like accreditation as indicators of an unregulated IP education system. They may be right. Developing standardized training is critical to establish quality and growth within our subspecialty. To this end, the AABIP, AIPPD, and American College of Chest Physicians in early 2014 established the Joint IP Fellowship Accreditation Committee. To ensure input from all corners of the IP community, the committee is, by design, made up of representatives from each of the participating organizations as well as from each geographic region of the United States. This included as well a representative from Canada, and, along with IP program directors, there are practicing interventional pulmonologists from institutions without an existing IP fellowship. After over a year of dedicated effort the document produced by this committee is now in the final stages of review and approval, with a planned formal release date in 2015. Although the document still does not equate to an ACGME accreditation it is modeled after ACGME accreditation standards for interventional cardiology, pulmonary medicine, sleep medicine, and mirrors almost all of their fundamentals in accrediting subspecialty fellowships. Despite the considerable energy and forethought that has gone into the development of this document, it will not be perfect in its early rendition and will represent an evolving document, improving over time. There remain numerous areas of controversy with strong opposing opinions from experienced educators. The most important aspect of this effort may be to surface areas of controversy to develop innovative solutions and launch research efforts. This will be invaluable in taking the next step to improving IP training. The timing of such a document is fully appropriate. The demand for IP fellowship-trained physicians has been increasing, with the expansion of new fellowship programs occurring annually.3 The recommended standards would not be effective until 2017, however. This will correspond with expiration of the grandfathering period for IP practitioners to sit for the AABIP IP board certification examination and will allow time for existing IP fellowship programs to adjust and evaluate their current programs. The accreditation document is a crucial first step toward training standardization and quality control; however, a number of other issues pertaining to IP fellowship training remain. Not the least of these is insufficient funding for IP fellowships. Currently only a few IP fellowship programs are fully funded by their institutions, with the remaining programs forced to assign their IP fellows to varying lengths of non-IP clinical service to pay their salary and benefits. This still leaves a vacuum for funding/salary support for program directors, and key clinical faculty as IP educators. This is important in the long term in having protected time for academic scholarly work, operate a quality training program, and academic promotion.4 One welcoming route may eventually be for the ACGME to accredit IP fellowships, thus opening traditional funds for graduate medical education. The road ahead for IP will remain challenging. Issues of funding, reimbursement, and turf will persist for years to come. The road ahead will also be exciting, however, as we move toward full recognition of IP as a unique subspecialty of medicine with specialized training and expertise. The Joint IP Accreditation Standard is a crucial step toward achieving that goal. The time is here.

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