Pleural Procedure Education in Fellowship A National Survey of Program Directors

The Accreditation Council for Graduate Medical Education (ACGME) requires that pulmonary fellows "demonstrate competence in the prevention, evaluation, and management of inpatients and outpatients with disorders of the pleura."1Accreditation Council for Graduate Medical EducationACGME Program Requirements for Graduate Medical Education in Pulmonary Disease and Critical Care Medicine.2022Google Scholar However, fellowship programs vary in how they approach this requirement, and the impact of the transition of interventional pulmonology training to ACGME-accreditation remains unclear.2Mullon J.J. Burkart K.M. Silvestri G. et al.Interventional pulmonology fellowship accreditation standards: executive summary of the Multisociety Interventional Pulmonology Fellowship Accreditation Committee.Chest. 2017; 151: 1114-1121Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar We aimed to describe the heterogeneity of pleural procedure volume of US pulmonary and critical care medicine (PCCM) fellows and to assess fellows' and program directors' (PD) satisfaction with their program's pleural education. We designed and disseminated anonymous online Qualtrics surveys for PDs and PCCM fellows via the Association of Pulmonary and Critical Care Medicine Program Directors, which includes 57 critical care medicine PDs, 200 PCCM PDs, and 16 pulmonary fellowship PDs. The Association of Pulmonary and Critical Care Medicine Program Directors sent two reminders, and PDs were asked to forward the trainee surveys to their fellows. This study was deemed exempt from review by the University of California, San Francisco, Institutional Review Board. The authors developed the surveys, which were revised iteratively through cognitive interviewing and piloting with seven individuals, including PCCM fellows and faculty from the University of California, San Francisco, and the University of Maryland. The Association of Pulmonary and Critical Care Medicine Program Directors Member Survey Committee and Board of Directors vetted the final version. Demographics, procedural volume, and satisfaction (based on a 7-point Likert scale) were assessed. Descriptive statistics and χ2 tests were used to compare characteristics of respondents from institutions with and without interventional pulmonology (IP) fellowships, with P < .05 indicating statistical significance. Thirty-three PDs completed the survey (12.1% response rate). Most were from university-based or university-affiliated programs, with a wide geographic distribution (Table 1), predominantly from PCCM programs (four critical care medicine only, two pulmonary only). The institutions of 28 respondents (81.8%) have an IP service, whereas those of 15 respondents (45.5%) have an IP fellowship program. Nationally, 41 IP fellowship programs exist; responses represent 37% of PCCM fellowships with an associated IP fellowship. The fellow survey, sent to an estimated 390 fellows, had 83 respondents (21.3% response rate), with 22.9% first-year fellows, 42.2% second-year fellows, 33.7% third-year fellows, and 1.2% fourth-year fellows (Table 1). The fellows' survey responses are pending the PDs forwarding the e-mail to the fellows; therefore, we estimate that 390 fellows received the survey, depending on the number of PDs who responded. The exact number of fellows who in fact received the survey is unknown. Most were from university-based PCCM programs at institutions with an IP service (n = 79 94%), and 56% (n = 47) reported an IP fellowship program.Table 1Baseline Demographics of Fellowships Represented by Program Director and Fellow Respondents of the Nationwide SurveyProgram Director ResponsesFellow ResponsesVariableDataVariableDataTotal no. of respondents33 (12.1)No. of respondents83Program sizeYear in training ≤ 65 (15.2)First19 (22.9) 7-128 (24.2)Second35 (42.2) 13-187 (21.2)Third28 (33.7) 19-2411 (33.3)Fourth1 (1.2) ≥ 252 (6.1)Geographic location Midwest5 (15.2)Midwest15 (18.1) Northeast9 (27.3)Northeast14 (16.9) South12 (36.4)South28 (33.7) West7 (21.2)West26 (31.3)Training environmentUniversity based23 (69.7)University based74 (89.2)Community based2 (6.1)Community based4 (4.8)Community based/university affiliated8 (24.2)Community based/university affiliated4 (4.8). . .Other1 (1.2)Program type PCCM27 (81.8)PCCM79 (97.3) CCM4 (12.1)CCM3 (3.7) Pulmonary2 (6.1)Pulmonary0Presence of IP service Yes28 (84.8)Yes79 (94.0) No5 (15.2)No5 (6.0)Presence of IP fellowship Yes15 (45.5)Yes47 (56.0) No18 (54.5)No37 (44.0)Presences of inpatient procedure service Yes17 (47.2)Yes52 (62.7) No19 (52.8)No31 (37.3)Runs the institution's inpatient general procedure service that performs thoracenteses Pulmonary4 (25)Pulmonary9 (17.3) IP2 (12.5)IP10 (19.2) Interventional radiology1 (6.3)Interventional radiology2 (3.8) Internal medicine/hospitalist service8 (50)Internal medicine/hospitalist service25 (48.1) Other1 (6.3)Other6 (11.5)Respondent program roleCurrent career aspirations PD28 (84.8)Clinical focus32 (38.1) APD1 (3.0)Clinician educator/medical education focus31 (36.9) Other4 (12.1)Research, clinical18 (21.4)Unsure7 (8.3)Research, basic science6 (7.1)Advanced clinical training (eg, IP)5 (6.0)Other1 (1.2)Data are presented as No. (%). CCM = critical care medicine; IP = interventional pulmonology; PCCM = pulmonary and critical care medicine. Open table in a new tab Data are presented as No. (%). CCM = critical care medicine; IP = interventional pulmonology; PCCM = pulmonary and critical care medicine. PDs reported the average number of pleural procedures performed by graduating fellows (Table 2). A significant association was found between the presence of an IP fellowship and fewer tunneled pleural catheters (TPCs) placed (χ2 (2, n = 33) = 7.70; P = .02; Cramér's V = 0.486). This association also was seen in fellow-reported procedure numbers. Additionally, fellows from community programs reported more TPCs placed. (χ2 (4, n = 33) = 11.1; P = .03; Cramér's V = 0.410). No significant relationships were found between the presence of an IP fellowship or program type and the number of thoracenteses, pigtail catheters, and surgical chest tubes placed, nor with fellows' confidence in performing these procedures. No association was found between procedure numbers and program size.Table 2Average No. of Procedures Completed by Fellows at Time of Graduation (According to Program Directors)Procedure Numbers at Graduation (Reported by)VariableTotalWith IP Fellowship (n = 15)Without IP Fellowship (n = 18)Thoracentesis 0-5000 6-102 (6.1)2 (13.3)0 11-207 (21.2)1 (6.67)6 (33.3) 21-4016 (48.5)10 (66.7)6 (33.3) ≥ 418 (24.2)2 (13.3)6 (33.3)Pigtail catheter placement 0-53 (9.1)3 (20)0 6-108 (24.2)2 (13.3)6 (33.3) 11-2015 (45.5)9 (60)6 (33.3) 21-406 (18.2)1 (6.7)5 (27.8) ≥ 411 (3.0)01 (5.6)TPC placement 0-518 (54.5)12 (80)a6 (33.3)a 6-1012 (36.4)3 (20)9 (50) 11-203 (9.1)03 (16.7) 21-40000 ≥ 41000Surgical chest tube placement 0-521 (63.6)10 (66.7)11 (61.1) 6-108 (24.2)4 (26.6)4 (22.2) 11-203 (9.1)1 (6.7)2 (11.1) 21-401 (3.0)01 (5.6) ≥ 41000Data are presented as No. (%). IP = interventional pulmonology; PD = program director; TPC = tunneled pleural catheter. Open table in a new tab Data are presented as No. (%). IP = interventional pulmonology; PD = program director; TPC = tunneled pleural catheter. No significant difference was found in satisfaction with pleural procedure education or educational resources between PDs at institutions with and without an IP fellowship (education, 5.6 ± 1.4 vs 5.9 ± 1.2 P = .5; resources, 5.5 ± 1.4 vs 5.7 ± 1.4 P = .5). Similarly, fellows' satisfaction with pleural procedure education and available resources showed no significant difference based on the presence of an IP fellowship (education, 5.4 ± 1.5 vs 5.2 ± 1.8 P = .8; resources, 5.0 ± 1.6 vs 5.0 ± 1.9 P = .97). However, fellows were significantly less satisfied than PDs with available resources for pleural procedure practice (fellows, 5.0 ± 1.7; PDs, 5.6 ± 1.3; P = .04). Forty-nine fellows responded to the free-response question about barriers to learning pleural procedures. Twenty-nine fellows noted lack of patients requiring pleural procedures. Seven fellows cited lack of attending comfort or availability for supervision. Six fellows identified competing services, such as interventional radiology, hospitalists, or the presence of advanced practice providers. Five fellows reported time constraints. Only six fellows noted the presence of an IP fellow as a barrier to learning, although one respondent stated that the lack of an IP service was a barrier. Although previous surveys of PCCM PDs showed significant variation in opinions of the impact of IP fellowship on the procedural education of PCCM fellows,3Holden V. Parikh M. Majid A. et al.Impact of interventional pulmonology fellowships on the procedural training of pccm fellows.Chest. 2020; 158: A1317-A1318Abstract Full Text Full Text PDF Google Scholar in this national survey of PCCM fellows and PDs, we found that the presence of an IP fellowship program did not impact satisfaction with their program's pleural procedural education. Procedural numbers across IP fellowships have been highly variable,4Yarmus L. Feller-Kopman D. Imad M. Kim S. Lee H.J. Procedural volume and structure of interventional pulmonary fellowships: a survey of fellows and fellowship program directors.Chest. 2013; 144: 935-939Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar although this may change after ACGME accreditation. Previous work found that PCCM fellows at programs with IP fellowships were more likely to have increased exposure and satisfaction with training in advanced pulmonary procedures, but did not have an increased likelihood in achieving target procedure numbers.5Stather D.R. Jarand J. Silvestri G.A. Tremblay A. An evaluation of procedural training in Canadian respirology fellowship programs: program directors' and fellows' perspectives.Can Respir J. 2009; 16: 55-59Crossref PubMed Google Scholar,6Pastis N.J. Nietert P.J. Silvestri G.A. American College of Chest Physicians Interventional Chest/Diagnostic Procedures Network Steering Committee. Variation in training for interventional pulmonary procedures among US pulmonary/critical care fellowships: a survey of fellowship directors.Chest. 2005; 127: 1614-1621Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Herein, we found that both fellows and PDs reported no difference in pleural procedure numbers, with the exception of TPCs. Three fellows explicitly cited the IP presence as a barrier to TPC placement, noting "not enough procedures to go around." However, in contrast, some noted the lack of faculty expertise, which has been identified a barrier in other realms of fellowship education.7Brady A.K. Spitzer C.R. Kelm D. Brosnahan S.B. Latifi M. Burkart K.M. Pulmonary critical care fellows' use of and self-reported barriers to learning bedside ultrasound during training: results of a national survey.Chest. 2021; 160: 231-237Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar Although the sample size was small, the response bias, if anything enriches for those fellows and PDs who find pleural procedural education relevant. Despite the small number, a diversity of program sizes and locations was found. Importantly, most survey respondents were at programs with an IP presence, and half of respondents had an IP fellowship. Thus, the results do not identify readily whether an IP presence affects education and procedural volume compared with those without an IP presence. The major limitation of this study is the low response rate, which limits the conclusions. However, the satisfaction of fellows and PDs with their program's pleural procedural education and available resources for pleural procedure education was not impacted negatively by the presence of an IP fellowship program. The reported average number of TPCs placed by the time of graduation was lower in programs with an IP fellowship. However, no differences were reported in thoracentesis, pigtail catheter, or surgical chest tube numbers. Given the increasing morbidity of pleural disease, PCCM fellows must receive adequate hands-on pleural procedural training. As ACGME-accredited IP fellowships continue to proliferate, this is an opportunity for—not a threat to—collaborative pleural procedural education.