Physician Training for HBOT in the U.S.

While hyperbaric technology has been around the United States for close to a century, official regulatory boards for the operation and clinical use of these machines has been a work in progress since the mid-1970s.  Since most of the technology was used for diving purposes, there wasn’t much need for a regulatory committee or training protocols for physicians. Even when regulatory committees were developed, it was a very slow process to get HBOT regulated in the public sector.  In fact, before 1976 there were no hyperbaric training programs available to civilian doctors.  All doctors who had experience with hyperbaric chambers and healing had received it through military training programs. Just about every submarine medical officer and U.S. Air Force flight surgeon was trained in the treatment of decompression sickness and air embolisms.126

Captain George Hart, Chief of Surgery in the United States Navy, had established monoplace chambers at the Naval Regional Medical Center in Long Beach, CA.  Doing so made Hart a pioneer in the field.  However, the Navy’s involvement was limited to the Long Beach facility. Even though Hart had published extensively on the clinical applications of hyperbaric technology, the Navy did not support this effort and wished for the focus of hyperbarics to remain confined to diving medicine and technology.

Since about 1970 there have been numerous courses in diving medicine that were primarily taught at Caribbean resorts.  These courses still exist today, but they have included lectures on non-diving uses as well.  Typically, for physicians taking these courses, this is their first exposure to using HBOT in a clinical manner.  Many of these doctors have started new HBOT facilities.

In 1972, The Undersea and Hyperbaric Medicine Society began to influence the coursework that went into hyperbaric education.  While their presence was appreciated, the diving courses in the Caribbean were fairly low quality and usually taken advantage of as a tax-deductible scuba-diving holiday for most of the course participants. The UHMS felt there should have been some sort of quality assurance and standards applied to these courses.  As a result, the Medical Education and Standards Committee (ESC) was formed and Eric Kindwall, Ph.D. was appointed the chairman.  The mission of the ESC was to approve the curriculum and certify the teachers for diving medical courses and eventually the organization would regulate the education received by potential HBOT physicians.

This committee put a seal of approval on certain qualifying courses in diving medicine. As a result, these courses were better attended, charged more, and delivered a better education. Competing courses that didn’t have the UHMS seal of approval eventually fell by the wayside.

Eventually, Dr. Kindwall was succeeded by Dr. Edward Tucker.  Tucker was the assistant director of the United States Navy School of Submarine Medicine in New London, Connecticut. Tucker was the first doctor to teach a UHMS-approved course in diving medicine by adapting the Navy’s diving medicine courses for civilians.

In 1972, Dr. Jefferson C. Davis, then in charge of the Aerospace Medicine Residency Program and director of the Hyperbaric Medicine Division at the School of Aerospace Medicine in San Antonio, TX, began to implement other uses for HBOT in the training of Air Force medical officers.  His introduction of HBOT for clinical purposes is what inspired a 1975 workshop in San Francisco.  At this workshop, medical experts outlined the content that would eventually appear in a textbook that Davis had proposed.  The book Hyperbaric Oxygen Therapy was largely funded by the National Library of Medicine and the United States Air Force. Hyperbaric Oxygen Therapy, written and edited by Dr. Davis and Thomas K. Hunt, professor of surgery at the University of California in San Francisco, was published by the PRESS in 1977.

Many other physicians offered ad hoc courses in HBOT but it was Dr. Kindwall who gave the first formal and regulatory course to civilian physicians in 1976.  Dr. Kindwall argued that the only thing holding up the establishment of more hyperbaric healing centers was the lack of knowledgeable and certified HBOT physicians. While centers for hyperbaric medicine exist, they lack qualified people to run them. Dr. Kindwall began offering a course in hyperbaric medicine starting in 1976 at St. Luke’s Medical Center in Milwaukee, WI and the course continued until 1995.  After a hiatus, the course was reinstituted at St. Luke’s in 1999.

Dr. George Hart and Dr. Michale Strauss, hyperbaric MDs, also began a regular course in HBOT in 1977 for civilian physicians.  As of today, they offer five courses a year to physicians and other health professionals.  The Hart/Strauss partnership prides itself in the training of more than 100 students a year in the practice of HBOT.  At the Curraway Methodist Hospital in Birmingham, Alabama, courses for HBOT certification started in 1985 and graduated students at the rate of about 50 per year.127

Eventually, Jefferson Davis left the Air Force program to run his own HBOT program at the Methodist Hospital in San Antonio, Texas. For the physicians who had purchased or used Perry Oceanographic Chambers, Davis developed a course teaching multiplace chamber operations. Following Davis’s death in 1989, the course two-week course has been taught by Dean Heinbach and Paul Sheffield.

After the initial coursework was laid out, The American Medical Association began to develop a program that would require all HBOT physicians to continue their education by obtaining a certain number of hours of certified training each year.

In 1983 there was interest in creating certification programs for hyperbaric physicians, nurses, respiratory therapists and technicians to support the doctors who were educating themselves in this somewhat revolutionary technology.  In 1985 the Baromedical Nurses Association was established to start the certification of hyperbaric nurses through the American Nursing Association.  As of 2006, they have created a nationally recognized exam and criteria for certification.

In 1991 the National Association of Diving Medical Technologies (NADMT), guided by Dick Clarke, created a certifying and supervisory committee for hyperbaric technicians who were actually responsible for the operation of the chambers.  The first of these examinations was given at the annual UHMS Scientific Meeting in San Diego in 1991.  The exam, developed by the National Board of Diving and Hyperbaric Medicine Technology (NBDHMT), granted nationally recognized certification to its graduates.128 Dick Clarke teaches more than 400 students a year at the Richland Memorial Hospital in Columbia.

Initially, hyperbaric techs, nurses and respiratory therapists with at least 2,000 hours of experience in the field were grandfathered into the NBDHMT certification.  However, this grandfathering ended in 1996 and all new candidates had to be graduates of a UHMS or NBDHMT training course.  In 1999 a 40-hour course for technicians was required and the course had to be approved by the NBDHMT.  Ultimately all who were seeking certification had to accrue at least 480 hours to be qualified.

Even with all of the standards in place, the FDA’s approval of only a few of the dozens of ailments that HBOT could treat limited the style and courses that could be taught.  Dr. Kindwall eventually received approval from the American Medical Association for the UMS to choose the courses that would receive certification credit.

The hyperbaric medicine courses must also be taught by approved teachers in facilities that only treat disorders approved by the Committee on Hyperbaric Oxygen.  If the facility happens to use HBOT to treat other, non-approved, “off label” conditions, the coursework must be completed using strict research protocols that are also approved by the Institutional Review Board. Most of these restrictions are in place to protect the hospital and the federal government from potential lawsuits and to protect the patient from potentially unethical research.

As much as Dr. Kindwall is an advocate for the advancement of HBOT research and treatment, he is also cautious, stating:
“The responsible hyperbaric community, since 1976, has voluntarily restricted itself to treating only a limited number of disorders for which there is a rational basis backed by good, scientific evidence.  The field has begun to achieve recognition by mainstream medicine.  Indiscriminate treatment of large numbers of patients, out of enthusiasm supported only by wishful thinking, inevitably angers both responsible physicians and insurance companies alike.”129

Ideally, the best way to advance HBOT as a mainstream treatment option would be to introduce physicians to the technology while they are in medical school. In most schools, HBOT is offered as a one-month, elective course.  Ultimately, this means only two to three students each year from each of these schools volunteer to expose themselves to HBOT.

Yet, through the years, the one continuous problem was that doctors from different specialties were running hyperbaric clinics and not all of them agreed on the certification methods or exams used by the national committees.  If HBOT was going to progress in the clinical field, a single language and certification needed to be developed.130

In 1999, as a solution to this problem, the American Board of Preventative Medicine permitted any board-certified specialist in any of the 28 areas recognized by the American Board of Medical Specialties to take one exam that would certify them, if passed.  Any candidates for certification were required to take a 40-hour introduction course in hyperbaric oxygen that had been approved by the UHMS.  After the introduction course, the candidate was then required to undergo two years of clinical practice in the field. In 1999, the ABPM allowed physicians who had been practicing HBOT for years to be grandfathered into this new program.  In 2005, the grandfathering clause expired and all medical professionals interested in gaining accreditation had to complete the new coursework.

There were still many physicians with years of experience in HBOT, those who were in the middle of their very successful careers and had missed the grandfathering window and who couldn’t take a year off to be certified.  As a result, the newly formed American College of Hyperbaric Medicine developed an examination similar to the one administered by the ABPM. The new program delivers a certificate of competence rather than a board certification that is recognized by hospital credentialing committees.  The new certification option is also recognized for third party reimbursement.

Dr. Kindwall also recognizes the importance of having a team of physicians working on healing a single patient, and all of these physicians can benefit from HBOT training.  At well-managed wound-care centers, specialists in vascular, orthopedic and plastic surgery, dermatology, and more are all consulted to aid in the healing of a patient.  For all of these specialists to have a background in HBOT would only help the patient recover faster.

However, even with all of the certification programs present, an HBOT-certified physician must be present in the room during hyperbaric treatment if the treatment is to qualify for insurance reimbursement.  This makes scheduling at private, specialty wound-care clinics rather difficult, especially if more than one hyperbaric chamber is available.  Ideally, these clinics would need a full-time physician and the client base to support and fund a full staff.  Dr. Kindwall predicts that, because of these limitations, there is a trend towards physicians becoming sub-specialists in chronic wound care.

Largely, clinical hyperbaric medicine is not a standard part of coursework in most medical schools in the United States.  Doctors and medical professionals looking to gain certification must do it through a UHMS-approved facility.  In recent years, the American College of Hyperbaric Medicine has started offering on site training courses to private facilities and public hospitals with hyperbaric chambers.131

Existing schools that offer a specialty hyperbaric course include Palmetto Health in Columbia, South Carolina.  All courses are taught at the Palmetto Health Richland Hospital.  International ATMO also offers courses in hyperbaric medicine in wound care, as well as review courses for UHMS certification, hyperbaric safety training, and more.  Courses at most of these facilities last one to two weeks.132

Currently, the primary school for certification studies is the American College of Hyperbaric Medicine in Wisconsin.  The school was established in 2005 by Robert Bartlett and Jeffery Niezgoda.  Currently, Dr. Kindwall serves as the executive director.  Only HBOT-certified physicians may be members of the college and the college primarily exists to serve all research and development needs for HBOT. The college offers seminars on reimbursement from Medicare and other insurers, gives approved courses in clinical hyperbaric medicine and sponsors clinical research.

The U.S. Air Force and at least seven civilian institutions offer fellowships in Clinical Hyperbaric Medicine.  The Air Force had the first fellowship in 1978 for two to three physicians at the School of Aerospace Medicine in San Antonio, TX.  Dr. Hart of Long Beach Memorial Hospital also had/has a fellowship program for up to two physicians per year.

Another fellowship was established in 1984, and approved by the UHMS, out of St. Luke’s in Milwaukee.  Dr. Kindwall served as director and graduated four physicians.

Dr. Roy Meyers offered a fellowship through the University of MD and graduated five fellows.  Other fellowships have been at University of Pennsylvania under Dr. Stephen Thom, Tulane University under Dr. Keith Von Meter, the University of Miami under Dr. Luis Matos and the University of TX, Galveston, under the late Dr. John Mader.  The University of Texas fellowship focused on infectious disease with both animal and human research.

Kindwall says physicians who complete the fellowship usually go on to become experts in the field, are researchers/ clinicians/ and teachers as well.133

In 1981 the number of HBOT chambers in operation in the United States was 110.  By 1998 the number stood at 240.  In 2008 there were over 800 chambers in full operation and the number is expected to increase.  The demand for qualified individuals has never been greater. In addition, as has been reiterated time and again regarding HBOT, the most pressing needs is more controlled studies, especially those which demonstrate the cost-effectiveness of adjunct HBOT. HBOT saves lives and dollars.134

Notes
126E. P. Kindwall, & H. T. Whelan, (Eds.). (1994). Hyperbaric medicine practice (3rd ed.). Flagstaff, AZ: Best Publishing Company, 17.
127Ibid.
128Ibid., 14.
129Ibid.
130Ibid.
131 http://www.achm.org/index.php/Resource-Library/Resource-Library/Onsite-Training.html
132 http://www.ehow.com/list_6574402_hyperbaric-technician-schools.html
133Kindwall, 20.
134Ibid., 21.