Growing pains.  

Every fledging organization suffers through them and the American Association of Bronchology and Interventional Pulmonology (AABIP) is no different. The organization was established in 1993 by a small but passionate group of world class clinicians, expert teachers and masterful bronchoscopists who saw a need to push the boundaries of technology to their limits in the search of better outcomes for their patients.  Word spread quickly as reports of relief of dyspnea in those with cancer obstructing an airway could be accomplished safely in the correct hands with a low morbidity and mortality.  Case reports led to case series as newer technologies emerged. Clinicians and trainees attended sessions at national meetings looking on in wonderment as these magicians shared their craft. I was one of those attendees and it changed my career path forever. Getting educated early on was a challenge as traditional fellowship training programs did not offer dedicated training in most interventional pulmonary procedures. Most still don’t (1). To obtain training students served as apprentices at the feet of the few capable mentors able to teach these skills in the U.S. and Europe. There was no formal curriculum and with so few mentors training spread slowly. The success of these clinicians put demands on their own time as patients were referred from far distances to receive expert care. They became sought after lecturers while still finding time to publish their work and organize societies like our own and others throughout the world.  Leadership positions within the ACCP, ATS, and ERS placed the forefathers of this organization among the most respected in the field of pulmonary medicine. And of course the Journal of Bronchology was born.

Unfortunately success came with a price. Because learning opportunities were limited, few academic medical centers had faculty with expertise in interventional pulmonology(IP). Those in academia were often viewed as clinician educators and often given heavy clinical loads. Our legitimacy as a sub-specialty was questioned. There was a lull in new technology and scientific query was limited to either technology assessment often funded by industry or observational studies. Grant funding was and remains difficult to obtain. At times, the association seemed lost and in search of an identity.

Enter the next generation of interventional pulmonologists. While appreciating the past they aspire to bring the specialty to the next level. The convergence of several key events makes this possible. First, formal 1 year IP fellowships have sprouted up with graduates of those fine programs having taken academic positions throughout the country. This has permitted the society to assemble a “critical mass” eager to devote time to strategic planning, curriculum development and project implementation. Second, academic institutions have come to see the value in having an interventional pulmonologist on staff as they appreciate the training fellows receive for both simple and complex procedures, their skills in managing those with lung cancer and the revenue generated by these proceduralists. Third, the field began to attract academics with other skills such as the basic sciences, health services research, epidemiology, etc who have applied those skills to the field of IP. The result has been an increase in both extramural funding and quality scientific publications. Finally, an explosion of new technology for patients with lung disease has made for an intense push to evaluate what works, what’s safe, and what technologies improve how we manage an illness or are just costly with little benefit.

How will the AABIP position itself to meet the challenges facing our membership and the patient population they serve? Perhaps because we have been the recipients of great mentorship we relish our role as educators. Over the past several years the society has been engaged in the development and implementation of a strategic plan focused around education. We will continue to stake out our position as leaders in teaching both basic and advanced bronchoscopy. Much of the work has already begun. In addition to the popular annual AABIP post graduate and hands on course at the annual meeting of the ACCP, leadership within the organization has implemented regional courses in bronchoscopy for matriculating fellows in pulmonary and critical care medicine. Curriculum development has been rigorous and we have exported these techniques from one such course to others across the country. The courses are a combination of didactics, simulation and hands on training. We have objective evidence that they work.(2) Those who attended this fellows course and performed mandatory simulation  prior to their first live bronchoscopy attained competency sooner than those who did not.(2) Once curriculum for basic bronchoscopy has been completed additional modules covering advanced bronchoscopic techniques will be developed with the same rigorous methodology and validation. The leadership of the AABIP has partnered with the ACCP to staff the simulation center at the ACCP annual meeting again displaying their teaching skills in basic bronchoscopy, TBNA and EBUS. Still other members of the AABIP board have sought to define what constitutes an interventional pulmonary fellowship training program.(3) This position paper will lay the groundwork for eventual accreditation of dedicated IP fellowships.

While education will remain the cornerstone of the society, research must and will progress.  With the same rigor that we develop an education curriculum we have an obligation to produce good science particularly as it relates to technology assessment. New and expensive technology, while passing the basic scrutiny of the FDA using the 510 K approval process often lacks data regarding effectiveness and where it fits in clinical practice. There are also opportunities for the interventional pulmonary community to partner with basic scientists in translational research settings such as the study of lung cancer, asthma, and emphysema to name a few.

First things first, though. Over the next few years we will consolidate the gains we have made in educating the bronchoscopists of the future.  This will require the effort and involvement of all of our membership.  Your suggestions, willingness to participate and an enthusiasm for interventional pulmonology will be key to the success of this society.

We would be remiss though not to recognize those who laid the cornerstone of this society- our mentors. So if you’re listening, thank you Drs Beamis, Becker, Diaz-Jimenez, Dumon, Gasparini Ikeda, Kvale, McLennan, Mathur, Mehta, Prakash, Turner, Unger, Zavala and anyone who has taught an aspiring fellow to hold a bronchoscope with reverence, learn their craft with passion and continue the long tradition of teaching those who aspire to walk in their footsteps.

Gerard A. Silvestri
President, AABIP
Professor of Medicine, Medical University of South Carolina
Charleston, SC
silvestri@musc.edu