Training and proficiency in endobronchial ultrasound‐guided transbronchial needle aspiration: A systematic review

Endobronchial ultrasound (EBUS)‐guided transbronchial needle aspiration (TBNA) is currently the modality of choice for evaluation of mediastinal lymphadenopathy. However, there is still uncertainty regarding the training methodology and the number of procedures required to attain proficiency in EBUS. Herein, we performed a systematic review of studies selected from PubMed, EmBase and Scopus databases describing the training and assessment of proficiency during EBUS, specifically studies investigating various methods for training, its outcome and the number of procedures required to overcome the learning curve for EBUS. Twenty‐seven (simulator‐based learning (n = 8), tools for assessing competence in EBUS‐TBNA (n = 5) and threshold numbers needed to attain proficiency in EBUS‐TBNA (n = 16)) studies were identified. An EBUS simulator accurately stratified individuals based on the level of experience in performing EBUS. Training received on a simulator was comparable with traditional apprentice‐based training. Importantly, skills acquired on a simulator could be transferred to real‐world patients. The number needed to overcome the initial learning curve of EBUS varied from 10 to 100 in individual studies with a mean of 37–44 procedures. Tools such as EBUS‐STAT (EBUS skill and task assessment tool) and EBUSAT (EBUS skill and assessment tool) were effective in evaluating the EBUS trainees. We conclude that an EBUS simulator or EBUS assessment tools can objectively assess the training of an EBUS trainee. Simulator‐based training is a useful modality in EBUS training. The number of procedures needed to overcome the initial learning curve is about 40. Centres involved in EBUS training could incorporate simulator‐based training in their curriculum before allowing operators to perform EBUS on patients.     

Stepwise development of laparoscopic liver resection skill using rubber traction technique

BackgroundTo improve patient safety, we standardized our surgical technique and implemented a stepwise strategy for surgeons learning to perform laparoscopic liver resection (LLR). The aim of the study is to describe how the stepwise training approach and standardized LLR affects surgical outcomes.MethodsData from 272 consecutive patients who underwent LLR from January 2009 to December 2017 were retrospectively reviewed. The risk-adjusted cumulative sum (RA-CUSUM) of surgical failures (conversion to laparotomy, blood transfusion, or Clavien-Dindo grade ≥3) and the CUSUM of operative time were used to determine optimal number of operations needed to achieve the best surgical outcome.ResultsAs the surgeon moved from simple to complex procedures, the complication rates, need for transfusions, and conversion rates did not increase over time. After 53 cases of minor LLR, a learning curve of 21 cases was achieved for right hepatectomy. Blood loss and operative time significantly improved thereafter. For minor anterolateral and posterosuperior segment resections, blood loss, and operative time significantly improved at the 37th and 31st case, respectively, given that the anterolateral segments had more complex surgeries performed.ConclusionStandardization of the operative technique and the implementation of a stepwise approach to training surgeons to perform LLRs could considerably improve surgical outcomes.     

Update on obesity

Endocrinologists have unique skills in evaluating and caring for patients with metabolic diseases. As such, they have a special role to play within the organizations in which they work as leaders in the approach to managing obese patients. Recent epidemiological data demonstrate that the prevalence of obesity is beginning to plateau. However, the rate of severe obesity in adults and the prevalence of overweight among children continue to grow, suggesting that in the future there will be an increasing burden of obesity-related illnesses. A number of recent studies have identified a number of novel mechanisms that predispose to obesity including several newly identified genes, the role of intestinal microflora, and even social networks. The selection of treatment for obese patients remains a complex issue. Recent studies demonstrate that a range of dietary approaches including the Atkins diet can provide modest weight loss, although the key feature appears to be adherence in the dietary strategy. High levels of physical activity appear to be necessary to maintain a reduced state, although modest increases in activity improve fitness. Although the new understanding of biology of weight regulation has provided a wide range of potential drug targets, available pharmacotherapy options remain limited although a number of potential targets show promise. Recent data provides the most enthusiasm for surgical treatment of obesity. Several recent studies demonstrate a reduction in mortality and dramatic benefits in diabetes in obese patients treated surgically. Questions remain as to the best surgical approach and the cost effectiveness. Research advances in obesity continue to move at a rapid pace and raise hopes for more effective management strategies in the future.     

Lesion complexity and angiographic outcomes in radial access percutaneous coronary intervention

Background: Percutaneous coronary intervention (PCI) is increasingly performed from the radial arterial (RA) access site. Few studies have examined the interaction between a default radial approach, lesion complexity, and angiographic outcome. This study investigates lesion complexity, arterial access route, and angiographic outcome in routine clinical practice by default radial operators. Methods: All cases of PCI over a 12‐month period (Jan 2005 to Jan 2006) at our regional cardiac center were prospectively entered into a database detailing arterial access route, target vessel and lesion characteristics, and lesion‐specific angiographic outcome. Angiographic success was defined as residual stenosis <50% for balloon angioplasty alone or <20% for a stented lesion in the presence of TIMI 3 flow in the target vessel. All procedures carried out by default radial operators were selected for further retrospective analysis. Reasons for not completing a case via the radial route were recorded. Radial and femoral cases by default radial operators were evaluated on grounds of lesion complexity and angiographic outcome for each treated lesion. Results: RA was the intended route in 91.5% of 1,324 procedures (91.5% of 2,239 lesions), and the final route in 90.1% of procedures (90.2% of lesions). There were 19 crossover procedures (30 lesions), all from radial to femoral access (FA). Crossovers were due to failed radial artery cannulation or sheath placement (9 procedures), inability to advance the guide catheter into the aortic root (7 procedures), and other guide catheter handling or support issues (3 procedures). Counting crossovers as failures, angiographic success rate was 96% among lesions for which RA was the primary intention. Complexity of cases was high (80.1% of RA lesions ACC/AHA type B2 or C). Conclusions: A default radial approach is compatible with successful treatment of a wide range of coronary lesions, with a low incidence of crossover to femoral access. When the radial approach fails, it is usually due to access problems rather than issues of guide catheter handling and support.     

Strategies and Difficulties in Dietary Intervention in Myocardial Infarction Patients

Randomized controlled trials along with within group' studies of patients with symptomatic coronary artery disease suggest that dietary and other lifestyle changes can halt progression of coronary atherosclerosis, induce regression of pre-existing severe lesions, and reduce the severity or frequency of angina. Varying combinations have been tested, including restriction of dietary total, saturated and polyunsaturated fat using lean meat or vegetarian diets, fish oil supplements, smoking cessation, stress management, and exercise training. The relative importance of each of these remains unclear. In patients with recent myocardial infarction high fish diets appeared effective in reducing both ischaemic heart deaths and total death rates over two years, whereas modest changes in dietary saturated fats or fibre had no influence on outcome.

These results suggest that a far more active dietary approach is needed for patients with symptomatic coronary disease. Further research is required into the possible complementary role of dietary measures and drug treatment for reversing the disease process and improving outcome, using new techniques for achieving behavioural change.     

CASE REPORT: Metachronous early gastric carcinoma in a reconstructed gastric tube after radical operation for oesophageal carcinoma

The incidence of double cancer has increased as a result of the signi?cant advances in both diagnostic procedures and anti-cancer therapy, and as the outcome of oesophageal squamous cell carcinoma (ESCC) has improved, the number of cases of double cancer of the oesophagus and stomach has also increased. Two patients with metachronous early gastric carcinoma in a reconstructed gastric tube were successfully treated after subtotal oesophagectomy for ESCC. These cases have shown that early diagnosis of second cancer is very important for curative therapy.     

Procedural experience and comfort level in internal medicine trainees

BACKGROUND: The American Board of Internal Medicine (ABIM) has recommended a specific number of procedures be done as a minimum standard for ensuring competence in various medical procedures. These minimum standards were determined by consensus of an expert panel and may not reflect actual procedural comfort or competence. OBJECTIVE: To estimate the minimum number of selected procedures at which a majority of internal medicine trainees become comfortable performing that procedure. DESIGN: Cross-sectional, self-administered survey. SETTING: A military-based, a community-based, and 2 university-based programs. PARTICIPANTS: Two hundred thirty-two internal medicine residents. MEASUREMENTS: Survey questions included number of specific procedures performed, comfort level with performing specific procedures, and whether respondents desired further training in specific procedures. The comfort threshold for a given procedure was defined as the number of procedures at which two thirds or more of the respondents reported being comfortable or very comfortable performing that procedure. RESULTS: For three of seven procedures selected, residents were comfortable performing the procedure at or below the number recommended by the ABIM as a minimum requirement. However, residents needed more procedures than recommended by the ABIM to feel comfortable with central venous line placement, knee joint aspiration, lumbar puncture, and thoracentesis. Using multivariate logistic regression analysis, variables independently associated with greater comfort performing selected procedures included increased number performed, more years of training, male gender, career goals, and for skin biopsy, training in the community-based program. Except for skin biopsy, comfort level was independent of training site. A significant number of advanced-year house officers in some programs had little experience in performing selected common ambulatory procedures. CONCLUSION: Minimum standards for certifying internal medicine residents may need to be reexamined in light of house officer comfort level performing selected procedures.     

Simulation-based mastery learning in gastrointestinal endoscopy training

Simulation-based mastery learning (SBML) is an emerging form of competency-based training that has been proposed as the next standard method for procedural task training, including that in gastrointestinal endoscopy. Current basic gastrointestinal endoscopy training relies on the number of procedures performed, and it has been criticized for its lack of objective standards that result in variable skills among trainees and its association with patient safety risk. Thus, incorporating simulators into a competency-based curriculum seems ideal for gastrointestinal endoscopy training. The curriculum for SBML in gastrointestinal endoscopy is currently being developed and has promising potential to translate into the clinical performance. Unlike the present apprenticeship model of “see one, do one, teach one,” SBML integrates a competency-based curriculum with specific learning objectives alongside simulation-based training. This allows trainees to practice essential skills repeatedly, receive feedback from experts, and gradually develop their abilities to achieve mastery. Moreover, trainees and trainers need to understand the learning targets of the program so that trainees can focus their learning on the necessary skills and trainers can provide structured feedback based on the expected outcomes. In addition to learning targets, an assessment plan is essential to provide trainees with future directions for their improvement and ensure patient safety by issuing a passing standard. Finally, the SBML program should be planned and managed by a specific team and conducted within a developed and tested curriculum. This review discusses the current state of gastrointestinal endoscopy training and the role of SBML in that field.     

Pleural procedures and pleuroscopy

Pleural procedures are commonly performed by physicians from a range of specialities. These procedures vary in complexity, from relatively straightforward pleural aspiration to more challenging procedures such as pleuroscopy. After appropriate training, even complex pleural procedures have a low risk of complications. Nevertheless, an appreciation of procedural risks is essential for physician training and forms the crux of a valid patient consent process. This review presents a systematic evaluation of the potential complications of common pleural procedures.     

The Gap in Laparoscopic Colorectal Experience Between Colon and Rectal and General Surgery Residency Training Programs

Purpose In this article, we review the laparoscopic experience of general surgery and colorectal residency training programs in the United States during the past 5 and 12 years, respectively. The purpose of this study was to determine whether an adequate experience was being provided, and at what level of training, to safely and effectively perform advanced laparoscopy. Methods General Surgery Operative Reports from the training years 2000 to 2004 were obtained from the Accreditation Council for Graduate Medical Education. Similarly, colorectal operative performance logs from the training years 1994 to 2005 were obtained from the American Board of Colon and Rectal Surgery. Results From 2000 to 2004, basic and advanced laparoscopic cases (as designated by the Accreditation Council for Graduate Medical Education) have increased from 10.1 to 12.2 percent and 2.1 to 3.7 percent, respectively. Within this period, the number of laparoscopic colon cases/resident/career has increased from 1.8 to 4.6. The percentage of cases performed laparoscopically increased from 3.9 to 22.5 percent from 1993–1994 to 2004–2005 training years. From 1993 to 2001, the average number of laparoscopic cases/resident increased from 6.3 to 16.1. In 2004, the average number of cases/resident increased to 45.3. Of this number, 30 were colon, 9.4 were rectal, and the remaining 5.9 were miscellaneous colorectal procedures. Conclusions Learning curves for laparoscopic colectomy are reported in the range of 20 to 60 cases. Based on the most recent data reviewed, colon and rectal resident experience is trending toward this threshold. Recent general surgery graduates may be lacking the appropriate volume to reach proficiency in laparoscopic colorectal surgery. Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 8, 2006.     

Nosocomial endocarditis in a tertiary hospital: an increasing trend in native valve cases

INTRODUCTION: Changes in the etiology, epidemiology, and outcome of infective endocarditis (IE) have been observed in recent years. Newer invasive therapeutic interventions have increased the risk of bacteremia and nosocomial endocarditis in the population at risk. A retrospective analysis of hospital-acquired IE cases was performed in a tertiary hospital during 1985 to 1999. MATERIAL AND METHODS: Cases included were those classified as "probable" or "definite" by the IE diagnostic criteria of Durack. Nosocomial acquisition was considered if diagnosis was made > 72 h after hospital admission and there was no evidence that IE was present at the time of admission. Patients receiving a diagnosis within 60 days of a previous hospital admission were also classified as nosocomial, when a risk procedure for bacteremia was performed, or when any predisposing factor for IE was present during hospitalization. Early prosthetic valve endocarditis (PVE) cases (< 1 year) were excluded from the analysis. Clinical characteristics, etiology, predisposing cardiac condition, source of infection, and outcome were analyzed. Results were compared with those obtained in community-acquired cases. RESULTS: Of 493 cases of IE diagnosed over 15 years, 38 were considered to be hospital acquired. Twenty-eight cases were native valve endocarditis (NVE) in non-IV drug user patients, and 10 cases were late PVE. Overall, the most frequent microorganisms involved were staphylococci (58%). The main sources of infection were intravascular procedures or catheter-related infections (55%). When nosocomial NVE cases were compared with community-acquired cases, mortality was greater (29% vs 9.7%) in hospital-acquired endocarditis. Analysis of time trends showed an increased rate of nosocomial cases in NVE throughout the years of the study. CONCLUSIONS: In NVE, the number of cases that are hospital acquired has been increasing during the last 15 years. These cases are frequently associated with invasive intravascular procedures or IV catheter-related infections. Most patients have a previous valvulopathy that predisposes to IE. The spectrum of microorganisms involved is different from the community-acquired cases. Also, the outcome of endocarditis is worse in nosocomial NVE patients.     

Sparse and stable Markowitz portfolios

We consider the problem of portfolio selection within the classical Markowitz mean-variance framework, reformulated as a constrained least-squares regression problem. We propose to add to the objective function a penalty proportional to the sum of the absolute values of the portfolio weights. This penalty regularizes (stabilizes) the optimization problem, encourages sparse portfolios (i.e., portfolios with only few active positions), and allows accounting for transaction costs. Our approach recovers as special cases the no-short-positions portfolios, but does allow for short positions in limited number. We implement this methodology on two benchmark data sets constructed by Fama and French. Using only a modest amount of training data, we construct portfolios whose out-of-sample performance, as measured by Sharpe ratio, is consistently and significantly better than that of the naïve evenly weighted portfolio.     

Estimating the need for hepato-pancreatico-biliary surgeons in the USA

BackgroundHepato-pancreatico-biliary (HPB) fellowship training has risen in popularity in recent years and hence large numbers of graduating fellows enter the workforce each year. Studies have proposed that the increase in HPB-trained surgeons will outgrow demand in the USA. This study shows that the need for HPB-trained surgeons refers not to the meeting of demand in terms of case volume, but to improving patient access to care.MethodsThe National Inpatient Sample (NIS) database for the years 2005–2011 was queried for CPT codes relating to pancreatic, liver and biliary surgical cases. These numbered 6627 in 2005 and increased to 8515 in 2011. Cases were then mapped to corresponding states. The number of procedures in an individual state was divided by the total number of procedures to give a ratio for each state. A similar ratio was calculated for the population of each state to the national population. These ratios were combined to give a ratio by state of observed to expected HPB surgical cases.ResultsOf the 46 states that participate in the NIS, only 18 achieved ratios of observed to expected cases of >1. In the remaining 28 states, the number of procedures was lower than that expected according to each state''s population.ConclusionsThe majority of the USA is underserved in terms of HPB surgery. Given the growing number of HPB-trained physicians entering the job market, this sector should focus on bringing understanding and management of complex disease to areas of the country that are currently in need.     

Percutaneous Retrograde Transfemoral Closure of Mitral Paravalvular Leak in 3 Patients without Construction of an Arteriovenous Wire Loop

Percutaneous closure of paravalvular leaks has emerged as an alternative to repeated surgeries. Different percutaneous techniques and various devices have been used, off-label, for paravalvular leak closure. For mitral leaks, antegrade transseptal, retrograde transfemoral, and retrograde transapical techniques have been developed. In the antegrade transseptal approach, an arteriovenous guidewire loop is often created to advance the delivery sheath. In retrograde transfemoral closure, the wire in the left atrium is usually snared after transseptal puncture, to pull it from the femoral vein. The delivery sheath and closure device will subsequently be deployed from the left atrium. Each of these procedures takes time, is costly, and increases the risk of complications.We present the cases of 3 patients in whom we closed mitral paravalvular leaks by means of a retrograde transfemoral approach, with use of an Amplatzer™ Duct Occluder II device and without the construction of an arteriovenous wire loop. We think that this approach can be very useful in a specific group of patients—reducing costs, fluoroscopy times, and complications related to transseptal puncture and construction of an arteriovenous wire loop. In our institution, this reported technique is routinely used for mitral paravalvular leak closure.     

Procedural skills of the general internist. A survey of 2500 physicians

STUDY OBJECTIVE: To determine which of 40 clinical procedures general internists do in their practice, how often these procedures are done, and what training is needed to develop and maintain competence in each. DESIGN: Mailed survey. PARTICIPANTS: A random sample of 2500 American College of Physicians (ACP) members identified as general internists; 1806 (72%) responded. Of these, we excluded 398 who were board eligible or board certified in a subspecialty and 143 with unknown status. The resulting sample of 1179 was augmented in selected analyses by an additional sample of 199 rural internists. RESULTS: General internists did, on average, 16 of the 40 procedures. Practice characteristics markedly affected the number and variety of procedures done. A larger number of different procedures was independently associated with smaller cities, smaller hospitals, younger age, increased hours in patient care, and certain regions of the country. Practice characteristics varied considerably by practice type and location. Many procedures were done infrequently. There was reasonable agreement on the experience needed to attain and maintain competency in each procedure. The majority of respondents favored hospital credentialing for 22 of the 40 procedures. CONCLUSIONS: General internists do a wide variety of procedures, the number and frequency of which are affected by the characteristics and location of their practice. Despite opinion to the contrary, more recently trained general internists do a wider variety of procedures than older colleagues. These results provide data to help define standards for training and credentialing and suggest that we should reexamine general internists' training in procedural skills.     

Endurance training in mild hypertension - effects on ambulatory blood pressure and neural circulatory control

This review examines the effects of a single bout of exercise and of endurance training on blood pressure in patients with hypertension. Possible autonomic mechanisms that mediate these changes in blood pressure are reviewed briefly. Blood pressure rises during exercise. During the second half hour after exercise blood pressure is lower. This p;ost-exercise reduction in blood pressure is associated with a decrease in muscle sympathetic nerve activity, an increase in baroreflex gain and a reduction in the level of blood pressure (set point) at which baroreflex activation occurs. The post-exercise fall in blood pressure appears to be limited to several hours and is not likely to explain any chronic reduction in blood pressure from endurance training. Endurance training elicits modest (approximately 4-5 mmHg) reductions in blood pressure. Because of the intrinsic variability of blood pressure, the decreases in blood pressure after endurance training is evident, especially when multiple measurements of blood pressure are obtained. Studies using 24 h blood pressure measurements suggest that, although endurance training lowers daytime blood pressure, blood pressure during sleep remains unchanged. The mechanism underlying the reduction in blood pressure in endurance training is not known. Although physical fitness is known to attenuate the sympathetic response to acute exercise, whether resting sympathetic drive is decreased with endurance training remains controversial. The slowing of heart rate that accompanies endurance training is also associated with an increase in variability of heart rate. The slower heart rate, increased variability of heart rate and lower blood pressure after endurance training are accompanied by an increase in baroreflex sensitivity. Even though the antihypertensive effect of endurance training is modest, the favourable effects of physical fitness on other risk factors for cardiovascular disease make exercise training an important approach in the management of hypertensive patients, particularly for sedentary patients with borderline and mild hypertension.     

Anesthetic considerations in geriatric patients

The increasing number of geriatric patients presenting for surgical procedures provides continuing anesthetic challenges. With an understanding of each patient's situation and communication among all the participants in the procedural chain (patient, family, and the anesthesia, surgical, and nursing teams), a well-planned and well-executed anesthetic should help ensure a favorable outcome. The complexities outlined demonstrate that there is not one best way for every patient; rather, an individualized approach is necessary.     

The minimally invasive approach to surgical management of pancreatic diseases

Laparoscopic pancreas surgery has undergone rapid development over the past decade. Although acceptability among traditional surgeons has been low, emerging specialty centers are reporting excellent outcomes for advanced and complex operations, such as pancreaticoduodenectomy. A note of caution is necessary: These outstanding results are from skilled surgeons, many of whom are pioneers in the field, who have overcome the learning curve over many years of innovation. As the procedures gain wider practice, outcomes need to be carefully watched because many of these procedures are extremely demanding technically. Although many have suggested that controlled, randomized studies comparing laparoscopic pancreatic resections with open resections are necessary to establish the efficacy of laparoscopic procedure, the cumulative data on the safety and efficacy of the laparoscopic procedure argues against such an approach. The logistic difficulties of conducting such studies will be considerable given patient preferences, the need for multicenter studies, and the rapid adoption of the laparoscopic procedure among experienced pancreatic surgeons. A more reasonable approach to truly evaluate the safety of these procedures is the establishment of a national registry that can measure progress of the field and record outcomes in the wider, nonspecialty community. Hepatobiliary training programs should also establish a minimal standard of training for many of the advanced procedures, such as the pancreaticoduodenectomy, so that the benefit of laparoscopic surgery can be made available outside of just a few specialty centers.     

Consensus recommendations for the use of FEIBA® in haemophilia A patients with inhibitors undergoing elective orthopaedic and non‐orthopaedic surgery

A growing number of publications have described the efficacy and safety of FEIBA as a first‐line haemostatic agent for surgical procedures in haemophilia A patients with high‐responding FVIII inhibitors. The aim of this study was to provide practical guidance on patient management and selection and also to communicate a standardized approach to the dosing and monitoring of FEIBA during and after surgery. A consensus group was convened with the aims of (i) providing an overview of the efficacy and safety of FEIBA in surgery; (ii) sharing best practice; (iii) developing recommendations based on the outcome of (i) and (ii). To date there have been 17 publications reporting on the use of FEIBA in over 210 major and minor orthopaedic and non‐orthopaedic surgical procedures. Haemostatic outcome was rated as ‘excellent’ or ‘good’ in 78–100% of major cases. The reporting of thromboembolic complications or anamnestic response to FEIBA was very rare. Key to the success of FEIBA as haemostatic cover in surgery is to utilize the preplanning phase to prepare the patient both for surgery and also for rehabilitation. Haemostatic control with FEIBA should be continued for an adequate period postoperatively to support wound healing and to cover what can in some patients be an extended period of physiotherapy. Published data have demonstrated that FEIBA can provide adequate, well tolerated, peri and postoperative haemostatic cover for a variety of major and minor surgical procedures in patients with haemophilia A. The consensus recommendations provide a standardized approach to the dosing and monitoring of FEIBA.     

Impact of low-dose computed tomography for lung cancer screening on lung cancer surgical volume: The urgent need in health workforce education and training

This study aimed to investigate the time trend variation in the surgical volume and prognostic outcome of patients with lung cancer after the gradual prolonged implementation of a low-dose computed tomography (LDCT) lung cancer screening program.Using the hospital-based cancer registry data on number of patients with lung cancer and deaths from 2008 to 2017, we conducted a retrospective study using a hospital-based cohort to investigate the relationship between changes in lung cancer surgical volume, the proportion of lung-sparing surgery, and prolonged prognostic outcomes after the gradual implementation of the LDCT lung cancer screening program in recent years.From 2008 to 2017, 3251 patients were diagnosed with lung cancer according to the hospital-based cancer registry. The 5-year mortality rate decreased gradually from 83.54% to 69.44% between 2008 and 2017. The volume of total lung cancer surgical procedures and proportion of lung-sparing surgery performed gradually increased significantly from 2008 to 2017, especially from 2014 to 2017 after implementation of a large volume of LDCT lung cancer screening examinations. In conclusion, our real-world data suggest that there will be an increase in cases of operable early-stage lung cancers, which in turn will increase the surgical volume and proportion of lung-sparing surgery, after the gradual implementation of the LDCT lung cancer screening program in recent years. These findings suggest the importance of a successful national policy regarding LDCT screening programs, regulation of shortage of thoracic surgeons, thoracic radiologist workforce training positions, and education programs.