Category Archives: Colt’s Corner

Becoming a better bronchoscopist

Many interventional pulmonologists have a lifelong goal of becoming better bronchoscopists. Consistent improvement is a key element of competency-based learning, and this requires enhanced technical skills, greater acquisition of theoretical knowledge, keen clinical judgement and critical thinking, an appreciation for evidence-based practice, and an understanding of expected professionalism and ethical conduct.

Because bronchoscopy is a “procedure,” one might argue that technical mastery is the first and possibly most important requirement for all bronchoscopists. Certainly, it is what novices think about when they pick up a flexible bronchoscope for the first time. From this perspective, I believe the foundation for becoming a better bronchoscopist has four cornerstones.

Muscle memory is best achieved by deliberate and repeated practice. Just as musicians run scales and practice finger exercises for many hours, bronchoscopists can practice in models as well as in real-life settings to overcome awkwardness, indecision, and inefficiency. Navigating the bronchoscope through both normal and variant airways becomes more fluid as movements and manipulations become natural and instinctive. No longer struggling to get the scope where they want it, operators can focus on interpreting findings and decision-making rather than mechanics.

Economy of movement teaches how to avoid unnecessary manipulations. This improves efficiency, helps avoid operator fatigue and injury, and keeps the scope centered within the airway to avoid repetitive movements, mucosal trauma, and cough. This results in a faster procedure, reduces patient discomfort, and assures that every aspect of the intervention is done with precision and purpose. The difference between fumbling around in the airway and working dexterously and with intent is one of the first indicators of technical proficiency.

Pattern recognition is developed with experience. This means performing hundreds of procedures and viewing hundreds, if not more, photographs and videos of mucosal changes. With experience, bronchoscopists establish an internal catalogue of airway abnormalities and variations. They acquire an encyclopedia of normal airway appearances and a keen appreciation for what might be airway inflammation, edema, neoplasia, or the nuances of airway vascularity. Over time and with proper mentoring, as well as after considerable study and self-reflection, recognizing these findings becomes interpretive and insightful. Pattern recognition becomes part of one’s intuition as it is incorporated into the clinical context and combined with radiological findings, pathophysiology, and probabilistic reasoning.

Moral fortitude is where procedural technical skills and physician responsibility intersect. The bronchoscopist must learn how to respond to uncertainty, how to act and react decisively, resist temptations to overstep their expertise, and maintain composure in case of complications or unexpected patient and procedure-related difficulties. Moral fortitude helps define their professional character and plays an important part in developing a moral compass that bronchoscopists can follow to help ensure their patients’ safety, dignity, and trust.

What is ‘Bronchosophy’

Interventional pulmonologists live simultaneously and sequentially in many worlds. One moment, they may find themselves directly responsible for the life or death of a patient with advanced disease; in the next, they might be delivering bad news, making prognoses under uncertain conditions, wrestling with the uncertainties of a novel technology, initiating long-term strategies, or advocating for their approach in a multidisciplinary care meeting.

Many interventional pulmonologists are naturally curious and enthused to learn how to perform new procedures that require manual dexterity and analytical precision. But the profession demands more than technical skill to truly serve its patients. Equally important are a doctor’s abilities to communicate with clarity, courage, compassion, grace, and humility. Practicing medicine with such depth and professionalism is both a challenge and a virtue.

It is not surprising, therefore, that bronchoscopy, a fundamental component of interventional pulmonology, is more than just a procedure. It is a way of seeing not only literally into the airways, but also metaphorically into a patient’s life. It is the means by which interventional pulmonologists contribute to another human being’s life story, often at a critical time of their patient’s journey between birth and death.

More than forty years ago, one of the first bronchoscopies I performed prompted a difficult conversation with my patient about the effects of malignant central airway obstruction on their life and well-being. At that time, most oncologists and pulmonary specialists were still nihilistic about lung cancer treatments, and the value of palliative airway procedures was neither recognized nor accepted. My patient went on to receive chemotherapy and external beam radiation, sadly with little improvement in their symptoms and without a beneficial effect on their quality of life. During those weeks, I learned much from our bedside conversations, including humility. I realized that my ability to see into my patients’ airways granted me the privilege to hear their life stories. What remained was for me to determine the best ways I could help them.

The results of this experience might be described as bronchosophy (pronounced /ˈbrɒŋ. kəˌsɒf.i or /ˈbrən kasəfi/), which is a term a few of us have used over the years, but has not yet entered common language. Just as philosophy might represent the pursuit of wisdom, truth, and knowledge, bronchosophy represents the pursuit of wisdom in the practice of bronchology. It can be defined as ‘a reflective and principled approach to the art and science of airway examination and intervention, combining technical skill with ethical insight, clinical judgment, and humanistic care.’ In other words, bronchosophy is the cornerstone from which the art and science of bronchology and interventional pulmonology blend with our humanity and heartfelt endeavors to do what is in the best interests of our patients.

Ethics in Interventional Pulmonology

Ethics, from the Greek words ēthos and ēthike philosophia (moral philosophy), is traditionally defined as the study of morality. What ought I do in a particular situation? What are the limits of my responsibility? How do my actions and behaviors relate to the particular norms, expectations, rules, or codes of conduct established by my profession, peers, and society, and how might these affect my community?

The study of ethics also raises awareness and helps address other questions: Do my actions reflect a moral conscience at the center of my being or a system of thought dependent upon religious or societal models of expected behaviors? What are the emotional consequences if I must choose, in my desire to do what is right, from among potentially opposing ethical concepts, and might I rely on both subjective and objective arguments to justify my decisions?

The Greek philosopher, Aristotle (384-322 BCE), was himself the son of a physician. He begins his treatise, Nichomachean Ethics, by writing, “Every art and every inquiry, and similarly every action and pursuit, is thought to aim at some good…will not the knowledge of it, then, have a great influence on life?”^[i] Since its origins, the ‘art and science’ of bronchology and interventional pulmonology has grown in leaps and bounds. Focus has been on disease states, procedural techniques, training curricula, and how to best apply new technologies. The study of IP-related medical ethics, however, has sadly been neglected, as if medical doctors felt naturally inclined to ethical practices because they went to medical school and wear white coats or surgical scrubs. By no means do I suggest that IP specialists practice unethically. In fact, all the practitioners I know do their best to provide appropriate and competent patient care based on existing scientific evidence and the resources they have available. The practice of interventional pulmonology does, however, raise a variety of ethical dilemmas for which doctors are not necessarily trained, and situations for which doctors may not be fully aware of potential ethical issues at hand.

Therefore, based on my own experience practicing medicine and surgery around the world in diverse settings, my formal training as a medical ethicist, educator, mediator, and philosopher, and my current work as a philosopher practitioner, I decided to add an Ethics section to the Bronchoscopy International website at www.bronchoscopy.org. I have also prepared a first volume (available for free download in PDF form), Introduction to Ethics in Flexible Bronchoscopy, to serve as an introductory text for practitioners and IP specialists in training. My goal is to provide readers with fundamentals from which they may gain perspective to discuss, evaluate, reflect upon, and more readily address ethical issues faced in their daily practice of interventional pulmonology. My hope is to see ethics discussed in yearly training courses, national meetings, and IP societies’ international conferences. I welcome your feedback and hope this text is a helpful addition to other educational materials used by our profession.

^[i] The Basic Works of Aristotle. Eds Richard McKeon. The Modern Library, Random House, NY, 2001. Nichomachian Ethics, book I, 1094a. WD Ross trans.

IP is what we are, not just what we do

The history of interventional pulmonology is marked by a continuous drive to improve the diagnosis and treatment of lung, airway, and pleural disorders through minimally invasive techniques. From the early days of rigid bronchoscopy and thoracoscopy to the current era of robotic-assisted procedures, augmented reality, fusion imaging, and personalized therapies, interventional pulmonology has evolved into a dynamic and essential component of modern respiratory care. As the field continues to innovate, it promises to further transform the landscapes of pulmonary medicine and thoracic surgery.

This gradual transformation is at the root of a potential identity crisis for the field’s practitioners. This is partly because it is in our human nature to want to delineate ourselves from others, as in the adage, “we are all equal, but some are more equal than others.” It is also because not everyone incorporates all types of airway and pleural procedures into their daily practices. Indeed, several terms are used to describe the field’s practitioners or their area of focus, which can be confusing to medical colleagues as well as patients. These include terms such as bronchoscopy, advanced bronchoscopy, interventional pulmonology, interventional bronchoscopy, and endoluminal airway surgery.

An identity crisis can lead to factions, which breed division rather than unification. This is the real danger of the looming identity crisis for practitioners defined by what they do rather than what they are. For example, can those who perform airway procedures but do not perform thoracoscopy call themselves interventional pulmonologists? And what of those who are not formally trained in pulmonary or pleural procedures, but gain technical skills solely from national meetings and workshops? Or, as in the United States, those who perform interventional procedures but are not board-certified? What of pulmonary specialists who perform diagnostic flexible bronchoscopy but only rarely intervene therapeutically, or those who perform flexible bronchoscopy but do not perform rigid? Are “advanced bronchoscopists” also interventional pulmonologists (by no means do I believe the term ‘advanced’ is meant to be used in its hierarchical sense, but rather only as it applies to specific technologies, which by the way, may not seem as advanced ten years from now)? And, how is the newly fashionable term “endoluminal airway surgery” different from other diagnostic and therapeutic airway procedures?

According to the National Cancer Institute (www.cancer.gov), “intervention” is a treatment, procedure, or other action taken to prevent or treat disease, or improve health in other ways. If we accept this definition, everything we do is “interventional,” but isn’t that also what we are?

Seven Learning Styles and Artificial Intelligence

It is common sense that everyone learns differently, and that teachers should do their best to use a variety of methods to transfer knowledge from themselves to their students. Of course, we also want learners to do more than solve problems they have seen before. This means that we want them to be able to apply whatever they have learned to solving new problems in novel settings. This also means we want them to acquire what psychologist William James referred to as “an inventive mind.”

Artificial Intelligence (AI) is favorably impacting this environment because it empowers learners. It offers them a variety of tools so they may embark on “learning paths” that best suit their individual natural preferences and particular customizable circumstances. Whether it be from the elaboration of interactive diagrams, engaging with chatbots, receiving instant feedback, or listening to individually-tailored audio lessons, for example, AI promotes learning according to Visual, Auditory, and Verbal styles. By interacting in a digital space or AI-driven simulation, using algorithm-based tutors that evolve as individuals progress, and collaborating with others through smart platforms, people who benefit most from physical, logical, and social styles can also expand their means for learning. And let’s not forget that AI promotes independent study by offering learners an opportunity to formulate a series of increasingly complex or deep-rooted queries simply by repeated interactions with programs such as ChatGPT, Claude, or Gemini (and others).

So, what does this mean for bronchoscopists and interventional pulmonologists? It means we must rethink the way we organize educational programs, on-site or remotely-delivered lectures, conferences, and even hands-on workshops. It probably means increased emphasis on a learning by doing methodology, or what the philosopher John Dewey referred to as “activity methods,” at the bedside, in the classroom and procedure suite, as well as in the conference hall. The transition will come naturally for a new generation of learners and teachers but may pose a significant challenge for old-schoolers and those inclined to be resistant to change.

Five Key Components of Training

As numbers of interventional pulmonology procedures increase in both scope and applicability, teachers are challenged with finding the best means by which to train their students. Let’s not forget, therefore, that everyone learns differently. The four major ways people receive, and process information are VISUAL, using images, slides, charts and spatial understanding; AUDITORY, by listening to lectures, discussions or audio recordings; READING/WRITING using notes, summaries and textbooks or manuscripts; and KINESTHETIC, through hands-on experiences, physical activity, simulation scenarios, and real-world applications.

Although modern research suggests that learning is most effective when multiple modalities are used, teachers should try to ascertain their students’ preferences, and tailor their training programs accordingly. They should also revise their programs according to the particularities of a region’s customs, traditions, local politics, personalities, and available resources. Of course, regardless of the teaching modalities used, programs should be designed to address five essential components of training. These are cognitive knowledge, simulation-based technical skills, the integration of procedures into practice in a particular medical environment, the acquisition of non-technical skills, and the objective identification of strengths and weaknesses using competency-based assessments.

Let’s Implement Assessment Tools

Doctors have a privileged position because we wear white coats and surgical scrubs, but this does not necessarily make us good teachers. To believe it does is both arrogant and egocentric, vestiges of a tradition where knowledge was dispensed solely from within the ivory towers of academia. I strongly believe in well-structured Train-the-Trainer or Faculty Development Programs, whose value in democratizing knowledge is now well documented. These programs help participants become better teachers, enhance their communication skills, practice using elements such as checklists or 4-box approach exercises in various settings, and become more familiar with educational philosophies and methodologies.

Participants also learn to use validated modern assessment tools such as BSTAT, EBUS-STAT, BRadStat, RIGID-TASC, and for the pleura, tools such as ICC-STAT. The implementation of these tools into regional and national training programs helps teachers who don’t want to presume their students are merely capable of doing procedures based on subjective assessments of their students’ experience and exposure. Instead, by using competency-based assessment tools, modern teachers objectively measure their students’ technical skills for a specific set of procedures. They can identify weaknesses that require remedial training, as well as reinforce or improve upon skills already acquired. This works for airline pilots and surgeons, so it is only natural for it to be equally valuable for interventional pulmonologists….imo.

Real-time Procedure Numbers are Important

Interventional pulmonology entails procedural expertise in a number of conventional and evolving medical procedures. The number of procedural modalities are increasing, however, as is their complexity. In addition to their traditional apprenticeship training, IP specialists use simulators and attend on-site multi-day training courses. These are invaluable for acquiring training for specific procedures, emergencies, and technical skills, but procedural numbers, actually learning by doing in the clinical setting, help develop the judgment, resilience, and nuance that only real-world experience can provide.

Real-time procedural numbers are critical because they represent real-world complexity and unpredictability crucial to learning good decision-making and crisis management. They are important to becoming an “interventional pulmonologist” because situational awareness and experiential knowledge grow over time. They teach stress management and enhance an operator’s confidence. They also abide with legal and regulatory standards, even if these are not yet evidence-based. Finally real-time procedural numbers are crucial to learning communication, leadership, and team-building skills that are applicable in an ever-changing real-world medical environment.

Considering the growing number of IP specialists seeking training, however, institutions are increasingly challenged with finding enough patients to fill the “procedural demand,” and it is uncertain whether all training institutions can honor procedural numbers criteria listed in the specialty’s various guidelines. Finding a satisfactory and ethical solution to this problem is a task the specialty’s leaders must address…soon.

A Glimpse Towards the Future

The history of Interventional Pulmonology (IP) is marked by technological advances, progress in imaging and surgical techniques, the vision of a few key personalities, and the establishment of dozens of IP associations around the world. Important milestones were reached by resolving conflicts with various national and international pulmonary and thoracic surgery societies, and by reexamining the specialty’s self-defined goals and identity.

Despite occasional differences of opinion and instances of competitive rather than collaborative professional interactions, the interventional pulmonology field remains unified by a shared commitment to improving the diagnosis, prevention, and treatment of patients with emerging, potentially life-threatening, or advanced lung, airway, and pleural disorders.

For over a century, generations of clinicians, researchers, industrial engineers, basic scientists, physicists, equipment manufacturers, and computer scientists have contributed to innovations aimed at meeting the growing demands for minimally invasive interventions and the challenges of a changing medical landscape. The ongoing pursuit for effective, targeted, and personalized quality patient care ensures that interventional pulmonology will continue to thrive as a dynamic, integrative, and transformative medico-surgical specialty.

However, the approach, scope, timing, and purpose of interventional pulmonology must respond to the needs of a growing population, shifting social and medical demographics, and the advancement of evolving technologies. It must also address challenges posed by an increasing diversity of care environment and a world struggling to overcome significant disparities in medical access, philosophies of care, economics, education, and collaboration.

I believe the future of interventional pulmonology hinges on five key elements, all equally important and inherently interconnected, much like the links in a bicycle chain. These are (1) Greater collaboration across borders for training and education; (2) A strategic shift from reactive to proactive patient care interventions; (3) Building environments that nurture courageous, unselfish, and visionary leadership; (4) Developing a global strategy to address issues of cost and accessibility; and (5) Supporting dreamers, pragmatists, teachers, and students in their quests for professional security in a world increasingly governed by artificial intelligence. IP societies should draft and publish papers addressing each of these elements in a concerted effort to build a foundational blueprint for the years ahead.

HIV/AIDS Awareness

December was HIV/AIDS Awareness Month. It is great to celebrate our many victories over this infectious disease, but we must also remember the extent to which HIV/AIDS continues to affect our global community.

In the United States, about 1.2 million people over 13 were living with HIV in 2018. At least 14% (1 in 7 people) do not know they are infected. Black/African Americans and Hispanic/Latinx continue to be disproportionately affected, accounting for more than 50% of infections¹.

In the WHO/European Union and European economic area (53 countries in the 2018 report), the number of people diagnosed with HIV increased by 22% in the last decade. The number of people living with undiagnosed infection has also increased. Many are diagnosed late in the course of their disease, particularly in the Eastern region. While sex between men remains the prevalent mode of transmission (52%), heterosexual spread accounts for 42% of cases where diagnosis and mode of transmission are known².

In Eastern and Southern Africa, the number of people living with HIV/AIDS is increasing, but so is access to antiretroviral treatment. More than 20 million people in the region live with HIV/AIDS (6.7% adult HIV prevalence). Excellent progress is being made regarding raising awareness, diagnosis, treatment, and viral suppression³.

In the West and Central African regions, prevalence is relatively low (1.4% adult HIV prevalence), but in 2018, only 68% of individuals were aware of their status. The epidemic is driven by heterosexual sex, with adolescent girls and women (age 15-24) being almost twice as likely to acquire HIV than their male counterparts⁴.

In Latin America, cases have declined in many countries, but the region has seen an increase of 7% overall since 2010, with several countries; Brazil, Costa Rica, Bolivia, and Chile noting increases between 21%-34%. Throughout the region, gay men and men who have sex with men remain disproportionately affected⁵.

The Asia-Pacific region has wide variations in prevalence, with China, India, and Indonesia being most touched by the epidemic. Overall, almost 6 million people are infected. Many countries note decreases, but the increases in The Philippines, Bangladesh, Afghanistan, Pakistan, and Papua New Guinea are worrisome. Significant progress has been made reducing transmission from sex workers (although prevalence remains around 5% in Indonesia, Laos, Myanmar, and Papua New Guinea) because of successful 100% condom-use programs⁶.

With more than 33 million people living with HIV worldwide, the disease has substantial social and economic consequences, particularly in countries with limited infrastructure or an abundance of low-income communities. Having parents with HIV puts children at risk of becoming orphans. Infected and ill individuals are less able to work, which diminishes their ability to provide adequate food and shelter and promotes poverty.

Thankfully, many NGOs and governmental agencies are actively fighting the pandemic. Improved quality of care, reduced mortality, and decreased transmission through education and prevention is possible and ongoing.

While a cure for HIV/AIDS still eludes us, significant improvements in antiretroviral drug safety and efficacy profiles are encouraging. Collaborative efforts between researchers, academia, governmental and nongovernmental organizations, and the pharmaceutical industry promise further progress.

At the local level, health care professionals must continue to raise awareness and promote understanding to help reduce the stigma and discriminative practices that might persist in their communities.

References

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