Pulmonary Rehabilitation

Sisyphus or Odysseus?

Sisyphus,¹ the legendary king of Corinth, committed such crimes in his life that on his death he was sent to Hades for judgment and sentenced to the unattainable task of rolling a heavy stone up a hill. Each time he would near the apex of the hill, the stone would shift and roll back down to the plane. Sisyphus was condemned to repeat this cycle for eternity. As a practicing pulmonologist in a rural community in upper east Tennessee, establishing a pulmonary rehabilitation program was a Sisyphean task. Armed with vision, passion, and determination to succeed, 6 years were spent planning, marketing, and selling the idea of pulmonary rehabilitation to the community. The formidable hurdles of apathy, ignorance, and indifference were finally overcome. Within months of opening the doors of our newly established program, we had an extensive waiting list and were already outgrowing the existing facility. Obviously, there had been a strong need for pulmonary rehabilitation in this community. A need that was not being met by conventional therapies alone.

I wondered how many other communities were facing a similar dilemma. How many other communities did not realize that such a service even existed for patients with chronic lung disease? An excess of 20 million people in the United States have chronic lung disease. COPD has been identified as the only major disease that is experiencing an increase in prevalence and mortality and is now considered to be the fourth leading cause of death in the US. Why was it that only a limited number of these people had access to quality pulmonary rehabilitation? If I had not been exposed to pulmonary rehabilitation during my pulmonary fellowship training, it is very unlikely that the life-changing benefits of pulmonary rehabilitation would now be available to the individuals in my community with chronic lung disease. The question then presented itself, was the lack of pulmonary rehabilitation exposure during pulmonary fellowship training the reason?

There are 185 pulmonary fellowship programs in the United States, with an excess of 1,200 fellows enrolled. From a list of existing pulmonary fellowship programs in the United States provided by the ACCP, a telephone survey was conducted to assess the extent of pulmonary rehabilitation education received during pulmonary fellowship training. I contacted program directors and informed them that I was a practicing pulmonologist, on faculty at my regional medical school, conducting a brief survey regarding the availability of pulmonary rehabilitation training at their institution. Of the 85 programs contacted, I was only able to speak directly with 53 of the program directors. Responses ranged from elusive, suspicious, and resistant to honest, open, and supportive. Of this random sampling, in only approximately 1 out of 4 programs (26%) was pulmonary rehabilitation training a required component of their pulmonary fellowship education. Many of the program directors stated that pulmonary rehabilitation was offered as an elective, though most described that elective as “loosely structured,” “not well defined,” and “broad based.” When program directors, the most visible role models for pulmonary physicians in training, use such statements as “no scientific basis,” “no increased survival,” and “not rocket science” in reference to pulmonary rehabilitation, it is not surprising that few, if any, pulmonary fellows elect to take the rotation.

So, what are we up against? Along with lack of training of future pulmonologists in rehabilitation medicine, we also face the fact that despite the recently published Joint ACCP/AACVPR Evidence-Based Guidelines,² which unequivocally supports pulmonary rehabilitation, pulmonologists as a group are not convinced that pulmonary rehabilitation has substantial value. They are either not informed or not interested in preventative medicine and wellness. If pulmonologists, leaders in the field of pulmonary medicine, do not support pulmonary rehabilitation, how can we expect the general medical community to support pulmonary rehabilitation programs? The prevailing attitude among physicians in my community is that obstructive lung disease is self-inflicted, brought on by the addictive behavior of smoking. These same physicians view smokers as weak, dependent, and lacking character rather than recognizing that nicotine addiction is a complex physiologic and psychological disease. Again, it is no surprise that physicians appear to have developed a nihilistic, almost punitive attitude toward patients with COPD.

The National Heart, Lung, and Blood Institute (NHLBI) held a workshop in 1995 entitled “Building a National Strategy for the Prevention and Management of and Research in Chronic Obstructive Lung Disease.”³ The purpose of this workshop was not only to formulate a national strategy for dealing with the public health dilemma of COPD, but also to focus efforts at prevention and delay of premature morbidity and mortality associated with this disease. With the rapid expansion of managed care and the growing emphasis on wellness, pulmonary rehabilitation is in a unique position to play a pivotal role in working towards the goal of the NHLBI. As a result of this workshop, a new healthcare initiative was developed and incorporated into the National Lung Health Education Program (NLHEP).⁴ Pulmonary rehabilitation was subsequently identified as both a secondary and tertiary strategy in the preventive management of COPD. The NLHEP, in conjunction with the ACCP, will serve as the major education vehicle to target primary care physicians and the public in the hope of increasing awareness of COPD and detecting the disease at its earliest stages. If the focus of the NLHEP and its “major educational arm,” the ACCP, is on early detection and prevention, pulmonary rehabilitation should be an integral part of patient management. For this to happen, I believe we have to clean house and set an example. We have to show we believe education, prevention, and quality of life are important. Unlike the existing guideline, I believe that the ACCP should mandate that pulmonary rehabilitation education be a required component of pulmonary fellowship training for program accreditation. Only then are we going to have pulmonary fellows teaming with their communities, establishing pulmonary rehabilitation programs, and making these services available to the over 20 million people with chronic lung disease.

With the growing body of supportive scientific evidence and a commitment to education and prevention,⁵ we, the members of the ACCP, unlike Sisyphus, have the strength to push that heavy stone over the steep and unyielding hill. Have we, however, adequately prepared for the battles to come? As did Odysseus on his return from Troy to his home kingdom of Ithaca, we will encounter Lotus-eaters, Cyclopses, and Lestrygonians at every turn.⁶ We have to unite and remain focused in our vision, passion, and determination so that we can meet the rehabilitation needs of the growing number of individuals in our communities who struggle daily with chronic lung disease.