EDITORIAL

Accredited Interventional Pulmonary

Fellowships
The Time is Here
Hans J. Lee, MD,* and John J. Mullon, MDw
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A little learning is a dang’rous thing;/drink deep, or taste not the Pierian Spring
(Alexander Pope: 1688 to 1744)

A lthough 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 accred-
itation 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 cur-
riculum, and milestones, and ultimately American College of Graduate Medical

From the *Department of Pulmonary/Critical Care Medicine, Johns Hopkins University, Baltimore, MD; and wDivision of Pulmonary/Critical Care
Medicine, Mayo Clinic, Rochester, MN.
Disclosure: There is no conflict of interest or other disclosures.
Reprints: Hans J. Lee, MD, Department of Pulmonary/Critical Care Medicine, Johns Hopkins University, 1800 Orleans Street, Zayed Building 7125
L, Baltimore, MD 21287 (e-mail: hlee171@jhmi.edu).
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.

J Bronchol Intervent Pulmonol  Volume 22, Number 3, July 2015 www.bronchology.com | 189
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Lee and Mullon J Bronchol Intervent Pulmonol
Education (ACGME)-like accreditation as indi-
cators 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 Physi-
cians in early 2014 established the Joint IP Fel-
lowship Accreditation Committee. To ensure
input from all corners of the IP community, the
committee is, by design, made up of representa-
tives from each of the participating organizations
as well as from each geographic region of the
United States. This included as well a repre-
sentative from Canada, and, along with IP pro-
gram directors, there are practicing interventional
pulmonologists from institutions without an
existing IP fellowship. After over a year of dedi-
cated effort the document produced by this com-
mittee 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 interven-
tional cardiology, pulmonary medicine, sleep
medicine, and mirrors almost all of their funda-
mentals in accrediting subspecialty fellowships.
Despite the considerable energy and forethought
that has gone into the development of this docu-
ment, 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 opin-
ions from experienced educators. The most
important aspect of this effort may be to surface
areas of controversy to develop innovative sol-
utions 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
190 | www.bronchology.com Copyright
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 Volume 22, Number 3, July 2015
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 per-
taining to IP fellowship training remain. Not the
least of these is insufficient funding for IP fel-
lowships. 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 pro-
gram, 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 chal-
lenging. 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 sub-
specialty of medicine with specialized training
and expertise. The Joint IP Accreditation
Standard is a crucial step toward achieving that
goal. The time is here.
REFERENCES
1. Lee HJ, Yarmus L. The new NRMP fellowship
match system. J Bronchol Intervent Pulmonol. 2011;18:
5–6.
2. Lee HJ, Feller-Kopman D, Shepherd RW, et al.
Validation of an interventional pulmonary exam. Chest.
2013;143:1667–1670.
3. Lee HJ, Feller-Kopman D, Islam S, et al. Analysis of
employment data for interventional pulmonary fellow-
ship graduates. Ann Am Thorac Soc. 2015;12:549–552.
4. Hatem CJ, Searle NS, Gunderman R, et al. The
educational attributes and responsibilities of effective
medical educators. Acad Med. 2011;86:474–480.
r 2015 Wolters Kluwer Health, Inc. All rights reserved.