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.

[Promoting critical care system and capacity building in pulmonary and critical care medicine subspecialties].

The development of respiratory medicine has evolved from the prevention and treatment of tuberculosis in 1950 s to the care of chronic obstructive pulmonary disease and corpulmonale disease in 1970 s. In the past 20 years, it has further advanced into the integration of pulmonary medicine (PM) and critical care (CC), becoming a dominant form of global disciplines in respiratory medicine. The subspecialty training system of pulmonary and critical care medicine (PCCM) is a decisive measure to ensure the standardized development of respiratory medicine, and medical intensive care unit (MICU) is the most important clinical practice field for respiratory medicine in China, which plays a crucial role in promoting the substantial construction of the critical care medical system within the PCCM subspecialty, thus contributing to the development of the discipline.

Pediatric Pulmonology Training in India: Current Status and Future Directions.

Respiratory illnesses are common causes of morbidity and mortality in children. Postgraduates in Pediatrics spent significant time in learning to manage respiratory disorders. Improved survival of preterm neonates, improved diagnosis and survival of chronic respiratory problems, and advances in diagnosis and therapeutics have increased the need for specialists trained in managing these patients. Training programs in Pediatric Pulmonology are evolving over the past few decades. In India, super-specialty training in Pediatric Pulmonology has grown over the past few years. There is a need to modify the training structure used in industrialized countries due to differences in patient population, priorities, and limited available resources and expertise. Formal training courses have been started in a limited number of institutions. There is a large gap between the need for a trained workforce and the available specialists in the limited number of institutions. The Indian Academy of Pediatrics National Respiratory Chapter (IAPNRC) has initiated a fellowship program to bridge the gap. Comprehensive training involving academic and hands-on training may go a long way to improve the care of children with acute and chronic respiratory problems. For sustainable development of the super specialty, there is a need to work towards creating Pediatric Pulmonology service departments in various institutions that may be responsible for comprehensive training and research activities to answer common research questions.

The history of workforce concerns in pediatric pulmonary Medicine.

Children are affected by a broad spectrum of acute and chronic respiratory disorders. The number of children with respiratory disease is increasing, as are the complexity of disease pathophysiology and the management demands on pediatric pulmonologists. Despite slowly increasing numbers of board-certified pediatric pulmonologists, large areas of the country are underserved and there is a perception of an impending workforce crisis. There are multiple reasons for these concerns. A joint effort between the Pediatric Pulmonology Division Directors Association and Pediatric Pulmonary Training Directors Association was undertaken to address these issues.

A statement on the current status and future needs of the pediatric pulmonology workforce: Pipeline Workgroup.

There is growing concern that current trends in pediatric pulmonology will lead to a workforce shortage resulting in patients having difficulty accessing subspecialty care. As part of the Pediatric Pulmonology Division Directors Association and Pediatric Pulmonary Training Directors Association Workforce Summit, we examined factors affecting the recruitment of learners into pediatric pulmonary fellowship training (PPFT) programs. The goal of our workgroup was to describe these issues and develop a plan to increase the pipeline of learners who ultimately pursue PPFT. Specifically, we summarize factors that impact decisions to undertake PPFT, describe existing initiatives to enhance recruitment, and propose future strategies to increase early career learner interest.

Scholarly activity training in pediatric pulmonology fellowship programs.

BACKGROUND: Scholarly activity training is a required component of pediatric pulmonology fellowship programs. However, there are no data on resources and barriers to training and factors associated with fellow productivity. METHODS: We surveyed US pediatric pulmonology fellowship program directors (FPDs) between March and October 2019. Our primary outcome was fellow productivity (>75% of fellows in the past 5 years had a manuscript accepted in a peer-reviewed journal). Analyses included descriptive statistics, χ2 and Fisher's exact tests for categorical values, and t-test or Wilcoxon rank-sum test for numerical values. RESULTS: Sixty-one percent (33/54) of FPDs completed the survey. Seventy-nine percent reported that most fellows completed clinical, basic science, or translational research. However, only 21% reported that most fellows pursued research positions after graduation; academic clinical positions were more common. For 21%, lack of funding and competing clinical responsibilities were barriers to completing the scholarly activity. Only 39% had highly productive programs; those FPDs were more likely to be highly satisfied with fellow scholarly activity products (p = 0.049) and have >6 publications in the previous 3 years (p = 0.03). Fifty-two percent of FPDs believed that pediatric pulmonary training should be shortened to 2 years for those pursuing clinical or clinician-educator careers. CONCLUSIONS: Barriers to scholarly activity training in pediatric pulmonology programs threaten the pipeline of academic pediatric pulmonologists and physician-investigators. Aligning fellow scholarly activity and clinical training with the skills required in their postgraduate positions could optimize the utilization of limited resources and better support career development.

Respiratory sound classification for crackles, wheezes, and rhonchi in the clinical field using deep learning.

Auscultation has been essential part of the physical examination; this is non-invasive, real-time, and very informative. Detection of abnormal respiratory sounds with a stethoscope is important in diagnosing respiratory diseases and providing first aid. However, accurate interpretation of respiratory sounds requires clinician's considerable expertise, so trainees such as interns and residents sometimes misidentify respiratory sounds. To overcome such limitations, we tried to develop an automated classification of breath sounds. We utilized deep learning convolutional neural network (CNN) to categorize 1918 respiratory sounds (normal, crackles, wheezes, rhonchi) recorded in the clinical setting. We developed the predictive model for respiratory sound classification combining pretrained image feature extractor of series, respiratory sound, and CNN classifier. It detected abnormal sounds with an accuracy of 86.5% and the area under the ROC curve (AUC) of 0.93. It further classified abnormal lung sounds into crackles, wheezes, or rhonchi with an overall accuracy of 85.7% and a mean AUC of 0.92. On the other hand, as a result of respiratory sound classification by different groups showed varying degree in terms of accuracy; the overall accuracies were 60.3% for medical students, 53.4% for interns, 68.8% for residents, and 80.1% for fellows. Our deep learning-based classification would be able to complement the inaccuracies of clinicians' auscultation, and it may aid in the rapid diagnosis and appropriate treatment of respiratory diseases.

Continued Supervision for the Common Pediatric Subspecialty Entrustable Professional Activities May Be Needed Following Fellowship Graduation.

PURPOSE: Entrustable professional activities (EPAs) are one approach to competency-based medical education (CBME), and 7 EPAs have been developed that address content relevant for all pediatric subspecialties. However, it is not known what level of supervision fellowship program directors (FPDs) deem necessary for graduation. The Subspecialty Pediatrics Investigator Network (SPIN) investigated FPD perceptions of the minimum level of supervision required for a trainee to successfully graduate. METHOD: In 2017, SPIN surveyed all FPDs of accredited fellowships for 14 subspecialties. For each EPA, the minimum supervision level for graduation (ranging from observation only to unsupervised practice) was set such that no more than 20% of FPDs would accept a lower level. RESULTS: The survey response rate was 82% (660/802). The minimum supervision level for graduation varied across the 7 EPAs from 2 (direct) to 4 (indirect for complex cases), with significant differences between EPAs. The percentage of FPDs desiring a lower minimum supervision level ranged from 3% to 17%. Compared with the 4 nonclinical EPAs (quality improvement, management, lead within the profession, scholarship), the 3 clinical EPAs (consultation, handover, lead a team) had higher minimum supervision graduation levels (P < .001), with less likelihood that an FPD would graduate a learner below their minimum level (P < .001). CONCLUSIONS: Consensus among FPDs across all pediatric subspecialties demonstrates the potential need for ongoing supervision for graduates in all 7 common pediatric subspecialty EPAs after fellowship. As CBME programs are implemented, processes and infrastructure to support new graduates are important considerations for leaders.

Bronchoscopy Teaching Without a Gold Standard: Attending Pulmonologists' Assessment of Learners, Supervisory Styles, and Variation in Practice.

BACKGROUND: Despite the growing role of simulation in procedural teaching, bronchoscopy training largely is experiential and occurs during patient care. The Accreditation Council for Graduate Medical Education sets a target of 100 bronchoscopies to be performed during pulmonary fellowship. Attending physicians must balance fellow autonomy with patient safety during these clinical teaching experiences. Few data on best practices for bronchoscopy teaching exist, and a better understanding of how bronchoscopy currently is supervised could allow for improvement in bronchoscopy teaching. RESEARCH QUESTION: How do attending bronchoscopists supervise bronchoscopy, and in particular, how do attendings balance fellow autonomy with patient safety? STUDY DESIGN AND METHODS: This was a focused ethnography conducted at a single center using audio recording of dialog between attendings and fellows during bronchoscopies, supplemented by observation of nonverbal teaching. Interviews with attending bronchoscopists and limited interviews of fellows also were recorded. Interviews were transcribed verbatim before analysis. We used constant comparative analysis to analyze data and qualitative research software to support data organization and thematic analysis. Education researchers from outside of pulmonary critical care joined the team to minimize bias. RESULTS: We observed seven attending bronchoscopists supervising eight bronchoscopies. We noted distinct teaching behaviors, classified into themes, which then were grouped into four supervisory styles of modelling, coaching, scaffolding, and fading. Observation and interviews illuminated that assessing fellow skill was one tool used to choose a style, and attendings moved between styles. Attendings accepted some, but not all, variation in both performing and supervising bronchoscopy. INTERPRETATION: Attending pulmonologists used a range of teaching microskills as they moved between different supervisory styles and selectively accepted variation in practice. These distinct approaches may create well-rounded bronchoscopists by the end of fellowship training and should be studied further.

Longitudinal Milestone Assessment Extending Through Subspecialty Training: The Relationship Between ACGME Internal Medicine Residency Milestones and Subsequent Pulmonary and Critical Care Fellowship Milestones.

PURPOSE: Accreditation Council for Graduate Medical Education (ACGME) milestones were implemented across medical subspecialties in 2015. Although milestones were proposed as a longitudinal assessment tool potentially providing opportunities for early implementation of individualized fellowship learning plans, the association of subspecialty fellowship ratings with prior residency ratings remains unclear. This study aimed to assess the relationship between internal medicine (IM) residency milestones and pulmonary and critical care medicine (PCCM) fellowship milestones. METHOD: A multicenter retrospective cohort analysis was conducted for all PCCM trainees in ACGME-accredited PCCM fellowship programs, 2017-2018, who had complete prior IM milestone ratings from 2014 to 2017. Only professionalism and interpersonal and communication skills (ICS) were included based on shared anchors between IM and PCCM milestones. Using a generalized estimating equations model, the association of PCCM milestones ≤ 2.5 during the first fellowship year with corresponding IM subcompetencies was assessed at each time point, nested by program. Statistical significance was determined using logistic regression. RESULTS: The study included 354 unique PCCM fellows. For ICS and professionalism subcompetencies, fellows with higher IM ratings were less likely to obtain PCCM ratings ≤ 2.5 during the first fellowship year. Each ICS subcompetency was significantly associated with future lapses in fellowship (ICS01: ß = -0.67, P = .003; ICS02: ß = -0.70, P = .001; ICS03: ß = -0.60, P = .004) at various residency time points. Similar associations were noted for PROF03 (ß = -0.57, P = .007). CONCLUSIONS: Findings demonstrated an association between IM milestone ratings and low milestone ratings during PCCM fellowship. IM trainees with low ratings in several professionalism and ICS subcompetencies were more likely to be rated ≤ 2.5 during the first PCCM fellowship year. This highlights a potential use of longitudinal milestones to target educational gaps at the beginning of PCCM fellowship.

Variable Learning Curve of Basic Rigid Bronchoscopy in Trainees.

BACKGROUND: Despite increased use of rigid bronchoscopy (RB) for therapeutic indications and recommendations from professional societies to use performance-based competency, an assessment tool has not been utilized to measure the competency of trainees to perform RB in clinical settings. OBJECTIVES: The aim of the study was to evaluate a previously developed assessment tool - Rigid Bronchoscopy Tool for Assessment of Skills and Competence (RIGID-TASC) - for determining the RB learning curve of interventional pulmonary (IP) trainees in the clinical setting and explore the variability of learning curve of trainees. METHODS: IP fellows at 4 institutions were enrolled. After preclinical simulation training, all RBs performed in patients were scored by faculty using RIGID-TASC until competency threshold was achieved. Competency threshold was defined as unassisted RB intubation and navigation through the central airways on 3 consecutive patients at the first attempt with a minimum score of 89. A regression-based model was devised to construct and compare the learning curves. RESULTS: Twelve IP fellows performed 178 RBs. Trainees reached the competency threshold between 5 and 24 RBs, with a median of 15 RBs (95% CI, 6-21). There were differences among trainees in learning curve parameters including starting point, slope, and inflection point, as demonstrated by the curve-fitting model. Subtasks that required the highest number of procedures (median = 10) to gain competency included ability to intubate at the first attempt and intubation time of <60 s. CONCLUSIONS: Trainees acquire RB skills at a variable pace, and RIGID-TASC can be used to assess learning curve of IP trainees in clinical settings.

How to improvise post graduate training in respiratory medicine in India.

Current postgraduate training in India is as per the norms of National medical council of India. There is a need to improvise the postgraduate training because of rapid changes in the trend of respiratory diseases and advances in medical field. Here we have discussed how best we can improvise the postgraduate training in the field of respiratory medicine in India. Adapting CBME system is ideal. Subject seminars can be restricted to a few selected topics and moderator should conduct a formative assessment after the seminar. Group discussion should the choice for imparting theoretical knowledge which can also help in application of theory to practice. We should focus more on imparting practical knowledge by case discussions, grand rounds, workshops. Postgraduates should be encouraged to actively participate in conference presentations. We need to have a consensus of opinion by an expert committee regarding the improvisations required.

Impact of structured curriculum with simulation on bronchoscopy.

BACKGROUND AND OBJECTIVE: Simulation enhances a physician's competency in procedural skills by accelerating ascent of the learning curve. Training programmes are moving away from the Halstedian model of 'see one, do one, teach one', also referred as medical apprenticeship. We aimed to determine if a 3-month structured bronchoscopy curriculum that incorporated simulator training could improve bronchoscopy competency among pulmonary medicine trainees. METHODS: We prospectively recruited trainees from hospitals with accredited pulmonary medicine programmes. Trainees from hospitals (A, B and C) were assigned to control group (CG) where they received training by traditional apprenticeship while trainees from hospital D were assigned to intervention group (IG) where they underwent 3-month structured curriculum that incorporated training with the bronchoscopy simulator. Two patient bronchoscopy procedures per trainee were recorded on video and scored independently by two expert bronchoscopists using the modified Bronchoscopy Skills and Tasks Assessment Tool (BSTAT) forms. A 25 multiple choice questions (MCQ) test was administered to all participants at the end of 3 months. RESULTS: Eighteen trainees participated; 10 in CG and eight in IG with equal female:male ratio. Competency assessed by modified BSTAT and MCQ tests was variable and not driven by volume as IG performed fewer patient bronchoscopies but demonstrated better BSTAT, airway anaesthesia and MCQ scores. Bronchoscopy simulator training was the only factor that correlated with better BSTAT (r = 0.80), MCQ (r = 0.85) and airway anaesthesia scores (r = 0.83), and accelerated the learning curve of IG trainees. CONCLUSION: An intensive 3-month structured bronchoscopy curriculum that incorporated simulator training led to improved cognitive and technical skill performance as compared with apprenticeship training.

Pulmonary Critical Care Fellows' Use of and Self-reported Barriers to Learning Bedside Ultrasound During Training: Results of a National Survey.

BACKGROUND: Competence in ultrasonography is essential for pulmonary and critical care medicine (PCCM) fellows, but little is known about fellow-reported barriers to acquiring this crucial skill during fellowship training. RESEARCH QUESTION: How do PCCM fellows acquire experience performing and interpreting ultrasonography during their training, what is their perspective on barriers to acquiring ultrasound expertise during fellowship, and what is their comfort with a range of ultrasound examinations? STUDY DESIGN AND METHODS: A 20-item survey including questions about procedural training and acquisition of ultrasound skills during PCCM fellowship was developed. The survey instrument was sent to PCCM fellowship program directors to distribute to their fellows at program directors' discretion. RESULTS: Four hundred seventy-five responses were received. The most common method of learning ultrasonography was performing it independently at the bedside. Fellows reported that the greatest barrier to acquiring ultrasound skills was the lack of trained faculty experts, followed by lack of a formal curriculum. Fellow comfort was greatest with thoracic ultrasound and least with advanced cardiac ultrasound. INTERPRETATION: Significant barriers to ultrasound training during PCCM fellowship exist, and future educational efforts should address these barriers at both program and institutional levels.

Valoración por los estudiantes de la formación práctica de grado de Medicina. El caso de la Neumología / Valuation by the students of the practical training of degree of Medicine. The case of pneumology

INTRODUCCIÓN: La formación práctica en el grado de Medicina se imparte en los últimos cursos y está determinada por numerosos factores condicionantes, entre ellos, la formación MIR. En general, la evaluación de la formación práctica recibe mucha menos atención que la teórica, su calidad no es evaluada y el profesorado no recibe retroalimentación. El objetivo de nuestro estudio ha sido conocer la valoración que dan los alumnos a la formación práctica de Neumología después de una rotación de 3semanas, con el objetivo de obtener información para el proceso de mejora continua. MÉTODOS: El estudio incluye 2encuestas anónimas realizadas a los alumnos de grado en el mismo curso académico. Una interna, aplicada por el propio Servicio de Neumología y otra externa, por la Unidad de Evaluación de la Calidad Docente de la USAL. RESULTADOS: En la evaluación interna la opinión de los alumnos acerca de la calidad de la formación práctica es alta (8,26) y la utilidad percibida también es elevada (8,23), en una escala de 0 a 10, y no se observan diferencias por el hecho de que tenga lugar en cuarto, quinto o sexto curso. Estos resultados concuerdan con los obtenidos en la evaluación externa, con un valor medio de 4,56 en una escala de 0 a 5. Las preferencias de los alumnos durante su rotación por el servicio son las unidades de hospitalización y consultas, con menor valoración en las áreas técnicas. CONCLUSIONES: La calidad de la docencia práctica es un reto que es necesario evaluar para que los profesores dispongan de la retroalimentación (interna y externa) oportuna. La rotación por los servicios de Neumología constituye una oportunidad para la mejora de la percepción de la especialidad por los alumnos de grado. Es preciso reflexionar acerca de los contenidos de dicha rotación, buscando un equilibrio entre las áreas clínicas y las de técnicas

INTRODUCTION: Practical training for medical students is provided during the final years of study and is determined by several conditioning factors, including the MIR training that students receive simultaneously. In general, practical training evaluation receives much less attention than the theoretical one; its quality is not evaluated, and the professors do not receive feedback. The objective of our study was to determine how students value practical training in pulmonology rated the experience after completing a three-week rotation, in order to apply the information gained toward a process of continual improvement. METHODS: The study included 2anonymous surveys taken by medical students during the same academic year-one internal, prepared by the Department of Pneumology, itself, and another external one, prepared by the Evaluation Unit for Teaching Excellence at the University of Salamanca. RESULTS: On the internal evaluation, student opinions of their practical training ran high (8.26) and the perceived usefulness was also high (8.23), on a scale of 0 to 10 and no differences were noted according to whether the survey was taken during their fourth, fifth, or sixth year of study. These results agree with those obtained in the external evaluation with a mean value of 4.56 on a scale of 0 to 5. Student preferences during their rotation in the department were for hospitalization and consultation units, with the technical areas being lesser valued. CONCLUSIONS: Achieving and maintaining a high quality of practical training is a goal that should be consistently evaluated so that professors may receive feedback (internal and external). Rotations in the Department of Pneumology provide an opportunity to improve the perception that medical students have regarding this specialty. It is imperative to reflect upon the contents of these rotations, seeking a balance between clinical areas and technical areas