Yearly Archives: 2017

The Value of a Transformational Gift

Composite photo of airway models (H. Colt)

As 2017 nears its end, it is traditional to look back and examine both the good and the bad, the obstacles overcome and the challenges ahead. For this there is little more important than the value of a transformational gift. Whether the gift is a gift of time, energy, dedication, money, materials, ideas, or inspiration, a truly transformational gift changes the horizon. A transformational gift is a “game-changer,” and it is the catalyst responsible for new actions, new developments, and new achievements.

Patients with airway and lung disease often have a blockage of their air passages that prevents air from entering the lungs. They become short of breath, may require a breathing machine, or may even die from suffocation and the effects of their disease. By educating airway and lung specialists around the world, my goals are to eliminate patient suffering and improve the quality of care provided by medical professionals regardless of where they practice. This goal can only be accomplished thanks to an incredible group of individuals who, they themselves, are a transformational gift. Through the dedication and hard work of several international and regional leaders, for example; leaders who gift unselfishly of their time and energy, the World Association for Bronchology and Interventional Pulmonology has grown to almost 8000 members. This is quite an accomplishment for a small organization that once had the reputation of being an “old boys club.” The WABIP now includes member societies from more than sixty different countries. Its special sections (Pediatrics, and Rare lung/airway/pleural disorders) have each more than 200 members, and thanks to an international group of enthusiastic “admins,” our WhatsApp groups already encompass thirty countries and almost 2000 participants.

Thanks to our use of transformational communication and networking technologies such as WhatsApp and Facebook, we see for the first time ever, airway specialists, pediatric pulmonologists, and thoracic surgeons discussing cases in real time, sharing videos, photos, and case histories to solve clinical dilemmas. Consequently, they provide more effective, more knowledgeable, more scientifically-based, and more competent care to their patients. None of this would have been possible without the transformational gift of technical innovation: ideas and implementation provided, again, by a handful of insightful and generous individuals.

But let us not forget the end-user…the users of this new and exciting global network of airway specialists. Also, the more than forty certified and master trainers for Bronchoscopy International™, of course, and the more than 200 physicians who have attended our Train-the-Trainer programs, and all those who readily contribute their knowledge and expertise, as well as those who present cases and question diagnostic or therapeutic alternatives. They must also be given their due credit, for they too are agents of change.

Thanks to these agents of change, we are implementing a new educational paradigm that crosses international time zones. This new educational paradigm is one without borders or egos, without selfishness or individual profit. It is a paradigm based on competency-oriented learning materials that are provided using a multidimensional, learner-centric educational model. It is a paradigm where teachers are sensitive to cultural differences, yet eager to move toward a more globally standardized process that prevents a patient from suffering from the inequalities of training under a now antiquated apprenticeship model. It is a paradigm that encourages practicing on models rather than on patients…

And so, it is that models can also be a transformational gift. Bronchoscopy International ( works diligently to find sources for realistic airway models as well as funds to purchase enough models so that every bronchoscopy association can train its members via simulation. In this Colt’s Corner, I am reaching out, therefore, to philanthropists, airway specialists with some money to spare, technology and communication companies, generous individuals, bronchology and respiratory societies, airway model makers, and the bronchoscopy/pharmaceutical industry to join me by contributing in any way they can to this endeavor.

As I wrote earlier in this essay, whether it is a gift of time, energy, dedication, money, materials, ideas, or inspiration, a truly transformational gift changes the horizon. Please become a game-changer…and enjoy these holidays knowing you make a difference not only for your family, friends, and colleagues, but also for those caring for patients in far-off places.

Adult Motivations for High-Scoring Learning Assessments

Skills testing and adult motivation

Learning assessments are an important and integral part of competency-oriented training programs such as those advocated by Bronchoscopy International (BI) and The World Association for Bronchology and Interventional Pulmonology (WABIP). Assessment tools such as the BSTAT, EBUS-STAT, BSTAT-TBNA/TBLB and USG-STAT are already being used in training programs around the world to help measure progress along the learning curve, identify a learner’s strengths and weaknesses, and to objectively document technical skill as part of competency deliberations.

Contrary to high-stakes testing, where failing an assessment can have consequences on licensure or professional advancement, low-stakes assessments such as the STAT set serve a different purpose. Individual performance on these assessments, therefore, derives from different motivations; motivations all the more complicated because we are working with adult learners who suffer little or no adverse consequences if they perform poorly. In the next couple of paragraphs, I will discuss some of the challenges educators face while motivating adult learners, and why practice, such as that provided through our Train-the-Trainer programs, can helps teachers use assessment tools both efficiently and more effectively.

Students vary in the degree of effort they commit to taking a “test” without negative consequences. Some give it their best, in part because they sense this is their responsibility in becoming good doctors. Others might give less than their best, either because they resent test taking, do not believe in the usefulness of the assessment, do not believe the assessment tool accurately measures the skill being tested, or are unwilling to devote the time necessary to take the test correctly.

One-on-one time with a teacher is a unique opportunity to address these issues and remedy technical insufficiencies. Skills assessments also help positively reinforce good performance, providing encouragement and confidence. These elements are crucial to the
learner-centric educational model of our Train-the-Trainer and Introduction to Bronchoscopy courses.

Several studies demonstrate that as test-taking motivation decreases, so does test score validity. Trainers are challenged to encourage their students to try their best on any assessment, and several strategies might be used by program coordinators or department chairs to accomplish this task. One strategy is to incorporate an assessment tool such as the BSTAT (Bronchoscopy Skills and Tasks Assessment Tool) into a high-stakes competency assessment performed in both patients and models as part of the technical skill component of bronchoscopy training and even eventual certification in pulmonary and critical care medicine. By raising the stakes of testing, students will do their best with periodic assessment, which serve as practice and realistic measures of technical skill during training. Another strategy is to provide students with incentives to make their best effort. While financial rewards are unrealistic, creating a game-like situation where assessments are “fun, challenging, and collaborative” can change the testing dynamic in a positive way. A third strategy is to make the assessments more intrinsically motivating. This is done by teachers who are able to identify a “teaching moment” during each and every assessment, always finding at least one element that can be improved upon to make the student a better bronchoscopist. Providing feedback about test scores and itemized performance is a crucial element of learnercentric education, and must be done in a way that is interpretable and usable by the student. During our Train-the-Trainer programs, therefore, trainers work as students themselves, and practice different ways to provide feedback and encourage dialogue with learners.

The goal of this Colt’s Corner was to shed some light on adult motivation when it comes to the use of assessment tools in workshops and as part of competency-oriented training programs. These low-stakes assessments provide scores that are valid and beneficial, as long as trainers recognize the need for student motivation and the strategies that might be used to encourage productive trainer-learner dialogue.

On Leadership and Education

The old walls of Jerusalem

During another recent, nonmedicine-related trip to the Middle East and Jerusalem, I had the privilege of experiencing first hand many examples of leadership on an international scale. This trip reminded me of the importance of the educator-leader, and inspires me to make several small but important revisions to the WABIP/Bronchoscopy International Train-the-Trainer core curriculum.

Leadership is a very sought after and precious commodity. Like teaching, however, leadership is rarely taught as part of faculty training in our medical schools and universities. How many of us have taken courses in negotiation and conflict resolution, psychology, or communication? Yet knowledge in these areas is essential, in my opinion, to becoming an effective teacher. These are also areas in which improvement is always possible. We can learn to interact more effectively with our colleagues and our trainees, and we can learn to communicate more clearly, more enthusiastically, and with greater confidence our vision, goals, and expectations.

As many of us already know, leadership is a complex process that has multiple dimensions. My plan is to introduce participants in our Train-the-Trainer programs to at least a few aspects of leadership theory, and to focus on the “psychodynamic approach” to leadership through a new role-playing exercise that highlights the complex and often paradoxical behaviors of human interaction.

This new component of our program is the result of questions raised by many Train-the-Trainer course participants. How does one deal with the problem student? How do I share my expectations without appearing put-offish, condescending, or overly demanding? The answers to these questions reside in having greater knowledge of human behaviors and a better understanding of the needs, desires, and mental lives of our students. It requires educators to manifest curiosity in regards to the motivations and reasoning that underlie student behaviors. It also prompts us to engage in learner-centric activities that form the basis of our Train-the-Trainer core curriculum.

Moving from the “see one, do one, teach one” educational paradigm to one in which a multidimensional approach is used as part of a measurable and objectifiable quest for competency presents many challenges. One must overcome the natural resistance to change; one must convince rather than coerce those who doubt the effectiveness or utility of a new educational approach, and one must motivate adult learners whose greatest strengths come from within.

As more national medical societies and university training programs recognize the value of checklists, assessment tools, case-based studies, simulation, and active engagement using step-by-step instructional techniques advanced by Bronchoscopy International, educators need to be equipped to address new challenges, including how to determine levels of minimally-accepted competency, how to interact with technically or cognitively diverse groups, and how to best manage the individual during critical one-on-one teaching moments. We are no longer living in a time when twenty students follow the all-knowing professor about on the wards, palpating and probing the anonymous patient. We have, instead, entered a time where learning is constantly at our fingertips and simulation permits both experimentation and gradually acquired perfection.

I think that a greater understanding of at least some facets of the psychodynamic approach to leadership will help educators overcome obstacles and face new challenges. It will also help open our minds to new educational techniques and methodologies, regardless of our pasts and prior biases. In fact, the psychodynamic approach to leadership is, in part, based on a framework many experts call the clinical paradigm. This paradigm presumes there is a rationale to each and every action, that many of our motives and behaviors are linked to events outside of our conscious awareness, that people feel and express their emotions differently, and that everyone carries with them the baggage of past experiences that influence current behaviors.

A greater understanding of ourselves can only help us to better understand others, and often times, understanding is what educational leadership is all about.

Whats Appening….1000 bronchologists and growing!

More than 1000 enthusiastic and forward-thinking users from 29 countries are benefiting from dozens of instant conversations and data sharing opportunities using the internet-based, cross-platform messaging service ‘Whats App’. This phenomenon is changing how bronchoscopists and interventional pulmonologists from around the world share educational information.

‘Whats App’ is a freeware, internet-based, cross-platform messaging service for smartphones. Owned by Facebook, the application is used by more than 1 billion people worldwide. It provides a means to chat, exchange photographs or videos, and connect with friends instantly.

Sometimes physician-to-physician consultation is obtained in real-time. Questions about equipment, image interpretation, radiographic findings, or management strategies can be immediately addressed. Fascinating, and often unique case studies, techniques, or clinical puzzles are posted. Kudos, questions, and constructive criticism are provided by international experts and beginners alike. Announcements for workshops, conferences, and educational materials are rapidly distributed around the world.

It all began in the Spring of 2017, when Bronchoscopy International’s Master Instructor, Viviane Figueiredo and I invited participants into a newly created WABIP Brazil ‘Whats App’ group during the WABIP-sponsored Train the Trainer program held in Maceio. Forty Brazilian bronchoscopists quickly joined, and their enthusiasm was contagious. Recognizing the need for an international forum for pediatric bronchoscopists, Mohammad Ashkan from Iran initiated a WABIP Pediatrics ‘Whats App’ group that now includes 228 participants. Other countries quickly started their own national groups: Uruguay, Argentina, Paraguay, Peru, Australia/New Zealand, Spain, Malaysia, Indonesia, India, Bangladesh, Romania, Bulgaria, Serbia, Macedonia, Algeria, Sudan, Egypt, Israel, South Africa, Korea, Greece, and Turkey!

Currently, national groups discuss regionally pertinent topics and debate technology, technique, and management-related issues. Today, these ‘Whats App’ groups continue to grow, but the ‘Whats App’ program limits each group to a maximum of 256 participants. Our goal is to increase each group’s membership to as near this maximum as possible. Admins for each group can invite individual participants into their groups using the individual’s cell phone number. Groups create a self-identifying logo, most of which are really awesome. Guidelines are posted by the group’s Admins. Admins invite participants, monitor posts, and correct material that is inconsistent with guidelines; no patient identifiers, no posts containing material that is not directly relevant to education, research, or patient care.

I, personally have taken on the 24/7 responsibility of monitoring every post, and corresponding as necessary with Admins. I also circulate relevant materials between and among national groups.

‘Whats App’? What’s Next?
– I hope to see participation from countries such as Japan, China, Hungary, Russia, France, Great Britain, Italy, the UAE, and The United States/Canada. We need your expertise!
– Communication can be in mother languages and not necessarily in English.
– If you want to be an Admin, this is a great opportunity for enthusiastic junior bronchoscopists. Please email me!
– Looking forward, I am studying several other messaging platforms in case there is a need or desire for establishing a single international forum later.
– Lastly, please come to a terrific session on How social media and instant messaging enhances bronchoscopy education at the upcoming World Congress for Bronchoscopy and Interventional Pulmonology in Rochester, MN USA on June 13-16, 2018.

These are exciting times, and ‘Whats App’ for bronchologists is more than a passing fad, it’s a movement. This is just the beginning.

Join us!


Pillars of Knowledge 4+1

I recently finished yet another (my third) reading of Roshi Philip Kapleau’s Three Pillars of Zen (Random House, 1980). This well known text is more than a simple introduction to Zen Buddhism, covering many facets of Zen practice and training. It was written almost forty years ago by one of the founding fathers of Zen in the United States (Philip Kapleau started The Rochester Zen Center in the 1960s).

Zen is a Japanese form of Buddhism that  values meditation and a state of mind free from delusions and confusion. Rossi Kapleau taught that Zen was more than a philosophy or a religion based on scriptures, but was also a state of being, attained and maintained through Teaching, Practice, and Enlightenment.

While far from considering myself a Zen expert; I always felt that Philip Kapleau was a kindred spirit. I have studied Zen since my early twenties, and after all, was myself born in Rochester, New York. But that is not why I am writing this piece.

Teaching, practice and enlightenment… three pillars of Zen… How might this triad relate to bronchoscopy education?

We know that Teaching/learning, is a two-way street. Knowledge itself is fourfold: cognitive, technical, affective, and experiential. Learning facts is the easy part, increasingly less difficult because of the ready access to technology. We no longer need to retain all facts in our brains, but must instead learn to process information and learn where and how to access the information that will be processed. Technical skill requires practice, and focused practice with clear goals, objectives, and expectations is better than playing around with equipment at a hands-on workstation. By interacting effectively during workshops, case-based discussions, and in the classroom, teachers and learners identify weaknesses, explore strengths, and strive toward a commonly acceptable level of expertise.

Affective and experiential knowledge, however, are less clearly defined. Because we all learn from what we do (hopefully), we learn from our mistakes as well as from our successes. Dr. Benjamin Bloom (Bloom’s taxonomy, 1956) considered affective as the way we deal emotionally with what we learn. This knowledge relates to our feelings, values, and attitudes. Experiential knowledge is often wrongly confused with affective knowledge because it is, in fact, based on our experience…but it relates to a truth based on one’s individual experience…and no two truths  (just like no two individual experiences) may be alike. Acquisition of all four types of knowledge is necessary in our quest for competency.

These four types of knowledge: cognitive, technical, affective, and experiential, could be called The Four Pillars of Education, but do they equate with the three pillars of Zen described by Kapleau? Teaching and practice are obviously essential, but what of enlightenment? Can an educator become enlightened? Can a student become enlightened? If so, how?

I pondered this during a recent meditation in the ancient fortress town of Kotor, in Montenegro. Sitting at the foot of a wall built one thousand years ago, I watched the soft, deep blue waters of the Adriatic Sea wash gently onto the shore below. I knew there was a fifth pillar to the educational process, a pillar that is rarely spoken of, nor easily taught:  It is the pillar of spiritual knowledge. By spiritual, I do not mean religious. Rather, I  am referring to that form of knowledge that comes from deep within the self, from knowing oneself, and from acknowledging that form of knowledge that speaks a universal truth; the knowledge that we are happier when we help others. That is why many of us join the health care profession, and it is why we strive to become the best that we can be.

4+1….you can count them on your hand.

Become a better teacher than your teacher

I have had the privilege of conducting more than 25 Train the Trainer workshops in over a dozen countries in the past five years. During these seminars, experienced educators share experiences, learn to use competency-oriented training materials such as checklists and assessment tools, master step-by-step teaching techniques for inspection bronchoscopy, and familiarize themselves with coaching methodologies used in case-based exercises. They learn about educational philosophies, and practice various approaches to didactic slide presentations.

A question often raised during these seminars is, “why is there no fixed agenda?” While there are many answers to this question, I thought I would clarify at least one of them.

Conducting seminars in different parts of the world means communicating with physician-leaders from different medical environments, social cultures, backgrounds, and experience. Each participant brings a different set of skills, biases, and assumptions to the program. While part of the seminar is task oriented, another part is dedicated to new challenges, including breaking beyond a traditional way of thinking about medical education.

Change is difficult, and resistance to change is a natural reaction for us all. By sharing various components of a multidimensional learning program with participants, instructors are suggesting that educators let go of some traditional habits, acquire new skills, and reflect on how to overcome resistance to change in their own institutions.

Therefore, one of the major doctrines of our Train the Trainer programs is flexibility.

Flexibility means adapting, in-real-time, to the needs and desires of program participants. It also means active listening on the part of program instructors. In this way, we identify and address needs. Through our example (being flexible and actively listening), we non-verbally provide participants with an experience to take home to their own students, because flexibility and active listening are key to successful individualized instruction; by being able to identify a student’s strengths, weaknesses, and respond accordingly with an appropriate educational intervention.

Train the Trainer seminars are culturally enriching, scientifically rewarding, emotionally challenging, and intellectually stimulating for everyone. In a few days, a seminar in Belgrade, Serbia will include experts from throughout the Balkans, and yes, the agenda is flexible:)

Bronchoscopy educators with their students, Hungary 2017

Perception as an instrument of change

Perception (definition): a way of regarding, understanding, or interpreting something; a mental impression

It doesn’t take a scientific study to say that practicing in a model is preferable to learning to perform medical procedures on patient after patient during on-the-job medical training. Yet few national bronchology societies purchase airway models to train their members. Indeed, the major obstacle I encounter while fundraising for our global medical education projects, is my inability to respond to the following question raised by potential philanthropists; “Why don’t doctors donate some of their own money to their national bronchology associations to buy models?”

I still don’t have a satisfactory answer.

Last year, I met John Perkins at a writers’ conference in San Miguel de Allende, Mexico. John identifies himself as an agent of change. He invites others to help him make the world a better place by exploring different cultures, spreading love, and protecting the environment. I witnessed firsthand the enthusiasm manifested by his workshop attendees, and I wonder whether a similar enthusiasm is shared by medical doctors attending our Train the Trainer workshops around the world. After all, doctors can make the world a better place by promoting selfless service, enhancing technical skills without exposing patients to the dangers of on-the-job training, and advocating for patient rights. These elements form the philosophical foundation of our seminars.

John writes that “Human activity is determined largely by perceived reality. Religions, culture, legal and economic systems, corporations, and even countries are created and maintained by perceived reality; when enough people accept a perception or when it is codified into law, that perception changes objective reality. The way to change economic and other systems is through crossing a Perception Bridge from old ways of thinking into new ones.” (John Perkins, author of Confessions of an Economic Hit Man).

That is what Certified and Master instructors of the Bronchology Education Project do. We ask bronchoscopists to cross a Perception Bridge. We ask them to abandon the idea that learning on patients is okay, and urge them to commit the intellectual and financial resources necessary to acquire technical skills using models before they perform procedures on people. One of my goals is that every bronchology association in the world has at least one model to help teach medical procedures. This will change our objective reality, and make the world a better place by eliminating patient suffering caused by on-the-job medical training.

Feelings are important

Oscar Wilde wrote that “experience is the name that everyone gives to their mistakes” (Lady Windemere’s Fan, Act III, 1892). Just as we are not expected to become champion tennis players without hours of physical training, coaching, and careful attention to our head game, doctors should not be expected to become competent bronchoscopists simply by taking the scope in hand at the patient’s bedside. As in sports, learning requires the acquisition of skills and facts, but also an understanding of how we feel about what we are doing. Professional athletes have recourse to a team psychologist. Doctors are presumed to converse with colleagues or other health care professionals.

When I ask bronchoscopists from around the world whether they practice their response to procedure-related complications such as massive bleeding, seizures, cardiopulmonary arrest, or pneumothorax, in a simulated setting, the answer is almost always no. Nor do they discuss how they feel after the occurrence of such complications. I think this is because doctors have learned by doing for too long, and only recently is there a move toward coaching using models, simulation, and debriefing sessions.

Organized efforts are still necessary, however, before new generations of physicians adopt this as the norm. The same can be said about addressing a doctor’s emotional responses to complications. Most surgery departments have morbidity and mortality conferences to discuss problem cases, but such practices are not routine within the interventional pulmonary community. Even when discussions occur, there is little support for physicians struggling with their feelings.

While it is relatively straightforward to convince an enthusiastic trainee that practicing on a model will accelerate growth along the learning curve, it is less obvious to persuade doctors that talking about their feelings (which addresses their affective and experiential knowledge) can help prevent complications and improve patient care, as well as reinforce positive attitudes toward medical practice.

An educational program that includes simulation-based instruction and open discussions about feelings, therefore, requires a paradigmatic shift where leaders think outside the box monopolized by “see one, do one, teach one” behaviors in order to embrace practices guided instead by a “First, do no harm” philosophy.

Master Instructor Viviana F. implements simulation-based bronchoscopy training in Brazil





Virtual Reality and the future of bronchoscopy education

The strength of clinical medicine resides in the practitioner’s ability to diagnose, treat, and understand the impact of disease on a patient’s condition. Such practical wisdom, or what Aristotle called phronesis is gained and nurtured at the bedside.

It is the scientific understanding of disease and health, Aristotle’s episteme, however, that leads to medicine’s greatest advances. From a technology, education, and practice perspective, interventional pulmonologists are the descendants of giants such as the American Chevalier Jackson, the German Gustav Killian, the Japanese Shigeto Ikeda, and the Frenchmen Jean-Francois Dumon and Christian Boutin.  These men armed themselves with technologically innovative equipment created as a result of discoveries in the optical sciences, improved the initially engineered product, and applied their creative skill and imagination to serve their fellow man.

Technology today provides interventional pulmonologists increasing means to diagnose and treat disease. It is no surprise therefore, to see a global focus on education in order to provide practitioners with a uniform foundation of knowledge and technical skill regardless of where they reside. The future of our educational process includes structured multidimensional learning programs, masterful use of simulation and models, and now, development of virtual reality-based instruction. Equipped with headsets from Oculus, for example, learners can already navigate the virtual airway to master anatomy in minutes. Using an iPad and programs such as BronchPilot Anatomy or BronchPilot EBUS, learners can master bronchoscopic movements, factual knowledge and inspection strategies well before touching a real patient.

Creating these virtual worlds is a current challenge for medical educators. It is a challenge the faculty of Bronchoscopy International and leaders of the World Association for Bronchology and Interventional Pulmonology gladly accept. Exciting times are surely ahead!

Time to focus on the practical needs of a revolution


Practicing Bronchoscopy Step-by-Step

During the last decade I committed myself to a philosophical revolution based on the premise that it is unethical for doctors to learn their procedural skills on other human beings. From New York to New Delhi, and on every continent except Antarctica, I have taught that doctors have alternatives to climbing the learning curve patient after patient and, that such alternatives do not need to include animals or expensive cadavers. Computer-based simulation, plastic airway models and more recently, 3D-printer derived airway casts allow bronchoscopists to learn airway and mediastinal anatomy, navigate the tracheobronchial tree, perfect their knowledge of lobar and segmental anatomy, as well as practice the technical dexterity and communication skills needed to perform bronchoscopy safely, effectively, and efficiently.

Not surprisingly, there was some resistance to this new philosophy. Change is difficult, and replacing an age old paradigm built around a purely apprenticeship model (where procedural competency was assumed based on subjective evaluation and an objective enumeration of number of procedures performed), with a new paradigm that includes apprenticeship, mentorship, and several objective measures of learning in a multidimensional instructional program required the support of a growing number of physician experts decided upon becoming themselves agents of change. Today, the idea that patients should not suffer the burdens of procedure-related medical training has caught on. Procedural education is increasingly discussed in our medical societies and university training programs. Simulation centers exist in abundance, although easy and affordable access remains a challenge that must yet be overcome, and physicians everywhere increasingly accept the idea that learning and practicing bronchoscopy in a model must be a prerequisite to performing procedures in a real person.

Like all revolutions, the philosophical must be coupled with the practical. For this new educational paradigm to take effect, therefore, we must improve access to affordable models for all physicians-in-training, as well as for those already in practice who wish to learn new procedures. Objective measures of technical skill, communication, and decision-making must also be incorporated into our training programs. Based on my experience conducting dozens of educational programs around the world, learners enthusiastically accept the idea that technical skill proficiency and a relatively high threshold of cognitive knowledge are necessary before working directly on patients. Hence, it is now our responsibility to provide learners everywhere with these tools, and to engage faculty by sharing content and techniques of multidimensional instructional programs during train-the-trainer programs and on-site courses.