Pulmonology

[Vash311]

Does anyone know how this specialty is as far as hours, training required, pay, types of procedures involved in it's practice, lifestyle of physician specializing, competitiveness of obtaining fellowship? Thanks.

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[EidolonSix]

Pulmonologists are generally very busy. Training is usually coupled with Critical Care. Pulm alone is 2 years following an accredited IM residency or 3 if coupled with Critical Care.
Much of practice as a pulmonologist involves managment of COPD, asthma, pulmonary interstitial diseases, TB, possibly lung transplants, myriad autoimmune pulmonary diseases, and diagnosis and staging of lung cancers. Consults may include HIV lung diseases, pneumonias, TB, etc. Unfortunately, my experience pulmonology, namely mgmt of the chronic patients, hinted to me that there is often not a whole lot you can do for them but try and maximize remaining lung function. Plus COPDers are notoriously noncompliant.

According to the Glaxo-Wellcome surveys, Pulmonologists, like Cardiologists, often work as many or more hours per week than general surgeons and specialty surgeons. Time is divided between office practice, consults, and ICU coverage. One Pulmonologist I spoke to spends 2 weeks in office, covers the ICU for a week and then goes back to the office. Mind you, covering the ICU means that you practically have to be there all the time.

Procedures, although not as extensive as cardiology, include diagnostic and therapeutic bronchoscopy including bronchial stenting, lung bx, placement of arterial, central venous catheters and Swan-Ganz catheters, vent mgmt, tracheostomies, intubation procedures, doxycycline pleuradesis.
I am aware of a few academic pulmonary groups (Univ. of Indiana) that do some video-assisted thoroscopic surgery (VATS), but this is probably limited since this is also an arena of the CT surgeons.

Pay is about what you'd expect for an IM specialist...around 200K per year, but very variable. Fellowships are not competetive, well behind cardiology and GI.

 

[droliver]

The pulmonologists that we work with in private practice work very hard. Lots of sick consults, lots of phone calls re. vent changes,ABG's,SOB, etc...

They do a lot of flexible bronchs and may or may not do a lot of central IV access &/or critical care. Performing tracheostomies by them has not been the norm at any of the 12 hospitals that I have ever worked at. A few trach-related mortalities by Pulmonologists have made them steer away from that here locally I understand - there is a lot of liability for them from surgical procedures if they get into complications. I cannot imagine a VATS being performed by a pulmonologist (I'll take Eidolonsix's word for it that someone,somewhere does it) for liability reasons & inability to get credentials to perform the procedure @ a hospital (I find it hard to believe this would make it out of any credentialing committee)

 

[EidolonSix]

I'm only aware of one group who has a book called "Interventional Pulmonology"...Drs. Beamis and Mathur. They describe VATS, mediastinoscopy, flexible and rigid bronchoscopy. Its a pretty neat book to thumb through.

As for training in those procedures...you'd probably have to be adventurous and seek it out. But you can pretty much get a green light to do any procedure if you can prove that you have received the proper training.

I found out from Dr. Chesnutt, a pulm/CC doc at OHSU (he wrote the Lung chapter in the Current for Medical Diagnosis and Treatment) that some IR fellowships are opening their doors to nonradiologists like pulmonologists and nephrologists. I'm sure its not widely publicized though. I suppose one would learn pulmonary angiography, intracavitary catheter placement, and other assorted interventional pulmonology procedures being developed. I still wouldn't get my hopes up of landing a spot as an interventional pulmonologist though.

As for trachs...I am pretty sure it is in a Pulmonologists training to peform them....but I agree that I see more surgeons doing them.

I definitely agree about the liability though. Non-surgeon's salaries are not high enough to compensate for that level of malpractice insurance not to mention that you would really have to make a routine of such procedures. But then again....you could work for an academic institution and get insured that way...

 

[droliver]

EidolonSix,

I cannot imagine a non-thoracic surgeon trying to a mediastinoscopy. You have to be ready to do an emergent thoracotomy every time you do one, as the lymph nodes that you biopsy are adjacent to the innominate artery. I know of two deaths locally from bleeding from this procedure done by attending physicians since I've been a resident. I've done about ten, and they make me nervous as hell.
There is no way a Pulmonologist could get the "green light" to perform this procedure, as the "proper training" for it is going to be (at least) board-eligibility in surgery and most likely board-certification in Cardiothoracic before a hospital would let you do it at their facility. Getting malpractice from your insurance carrier for this would be another implausible scenario.

As far as a pulmonologist learning interventional vascular techniques..... I don't see why anyone would want to do that. It would be a skill that would be so infrequently called for, I just can't see how it would make sense financially or otherwise for them to do (there just aren't that many greenfield filters being placed & CT-angio has replaced traditional pulmonary arteriograms for most diagnostic studies). Did Dr Chestnutt give some context for why he felt that it would be a valuable skill? 😕

Some of the younger pulmonologists in town were dabbling with the percutaneous trachs a while back and succeeded in killing several people. Now most of the hospitals will not allow them to perform the procedure (percutaneous or open) & the malpractice insurance fees involved for them (if they want to do it) have made it a very unattractive part of their practices

 

[EidolonSix]

droliver,

I really don't know the context in which these procedures were performed, whether in conjuction with a CT surgeon or not....I am aware the book exists and I have thumbed through it....with said procedure having been described. Indeed it is a pesky procedure which one does not do lightly. As with cardiac catheterization, angioplasty/stenting, a CT surgeon standby would be almost obligatory. If I am correct, mediastinoscopy is performed very rarely in the light of newer node sampling procedures including transesophageal and transtracheal procedures and the like. I am certainly not implying that this is part of a pulmonlogists training and would agree that it would not be insurable.

As for interventional pulmonology, I agree that I can't see it as a full time endeavor. Pulmonary angios are still performed in the instances where VQ/ spiral CT are nondiagnostic and suspicion is still high...especially in a cases of microemboli, which a Greenfield can miss. Greenfield placement could indeed also be part of their repetoire. Catheterization of cavitary lesions, esp. in Aspergillosis, sarcoidosis, with administration chemotherapeutics has been attempted and is a treatment of last resort for patients with intractable cavitating disease.
But as said...this was casual conversation with an academic attending who discussed this as an option he was considering, having been offered training at the Dotter IR Institute at OHSU. Then again, some specialties pretty much require an academic tertiary center to be practical.

As for, percutaneous traching...a recent article in the Journal for Critical Care medicine cited a higher complication rate for perc trachs vs. traditional open...they tried a number of kits all of which were inferior to the tried and true method.
Agreed, I personally wouldn't waste my time with it and I'd call a cutter.

 

[droliver]

EidolonSix,

-Mediastinal nodes are notoriously difucult to biopsy by methods other than mediastinoscopy due to their proximity to other structures. Luckily, there's not too many times you have to do it- mostly to stage lung CA for suspicious CT scans with ? mediastinal adenopathy (+ LN = no surgery).

- spiral CT is has been good enough to rule out clinically signifigant pulm. emboli in a # of settings that most people (who keep up with the issue) would not proceed with the pulm. arteriogram. Catheter-directed therapy for emboli, is a somewhat complex & controversial topic. I've only seen it done once, on a pt. who had an A-gram instead of a CT-angio done first and it is not required or indicated in most PE's. The ones it would likely help the most probably are dead before you could get an emergency angio procedure done I suspect

- Greenfield filter placement on the other hand would be a very lucrative procedure to do if you had enough business in it (apparently it reimburses great). However, there are relatively few indications for placing them in anyone and thus I can't believe it would be worth it to do a fellowship (after another fellowship) to get trained for the handful (or less) that you might do in a year. Same thing with those refractory cavitary lesions (I would think you would consider operating on them @ that point anyway)

Do you have a reference to that JCC article?

thanks for the interesting discussion. Cheers 🙂

 

[EidolonSix]

The article is in Crit Care Med 2002 Vol 30. No 4 on pg. 815. It actually compares two perc trach techinques...translaryngeal and forceps-dilational, with the forceps dilational coming out on top, but still with a suspicious 2% complication rate, even with experienced operators. The authors do mention a number of complications...which would sway me towards an open trach. But, I suppose, if you are in the ICU and gotta have a trach placed....its an alternative.

As for mediastinal node bx, I am aware of endoscopic ultrasound guided transesophageal node biopsy for detection of paratracheal nodal mets, but probably inadequate for formal staging...Anyways, those GI guys are getting creative.

 

[Voxel]

I want to clary some things so that people who are thinking about going into pulmonary and critical care, so they do not get any misinformation. Doing a six week stint at the Dotter IR institute does not correspond to fellowship training in interventional radiology. And a formal interventional radiology fellowship is ACGME certified to get a CAQ (certificate of added qualification). This type of fellowship is only offered to those who have finished a diagnostic radiology residency.

 

[EidolonSix]

No misinformation was conveyed from what I wrote. I stated that such training programs (fellowship programs) offered such training to nonradiologists. The accreditation/certification/verification that someone has ample experience to perform said procedures is not something that I know much about....nor would I imply that the training or procedure repertoire is equivalent to that of a full trained interventional radiologist.

But if it did sound ambiguous, thanks for clearing it up Voxel.

🙂