Category Archives: Colt’s Corner

Bronchology and the 20th anniversary of The Matrix

Photo from WikiMedia Creative Commons

Twenty years ago this week the science fiction film The Matrix was released in the United States. This film directed by the Wachowskis brothers stars Keanu Reeves and Laurence Fishburne. The film grossed more than 460 million dollars worldwide. 

The Matrix describes a dystopian future in which the hero is a computer programmer named Thomas who actually lives a double life as a hacker named Neo. Neo feels trapped within an inauthentic life. He goes in search of a man called Morpheus to ask him the truth about the world. Morpheus offers Neo a choice between swallowing a “red pill” which will allow Neo to live a life of constant awareness and truth or a “blue pill” after which Neo will continue living his current life in blissful ignorance and security.  

When Neo swallows the red pill, he is immediately awakened to a new reality. He learns that The Matrix in which he lives is actually an illusory 20th-century world that is sustained in order to prevent people from knowing they are being exploited…and the adventure begins.

The red pill-blue pill meme described in The Matrix has become part of our culture. In this piece, however, my goal is not to discuss red pill-blue pill life philosophies, but to briefly reflect on how using educational tools offered in the Bronchoscopy Education Project provide red pill opportunities.

For example, if trainers successfully use assessment tools to identify a learner’s place on the learning curve and ascertain the effectiveness of their own teaching techniques (akin to swallowing the red pill), it follows that they will want to incorporate assessment tools into competency determinations. This new reality morally obliges the trainer to identify competency measures and to change educational practices accordingly.

As a second example, if trainers experience that checklist-type assessment tools are helpful for teaching bronchoscopic inspection (example BSTAT), or EBUS-guided TBNA (example (EBUS-STAT), it follows that a similarly designed assessment tool for intubation over the bronchoscope would also be helpful. Aware of this new reality, trainers would design such a tool and incorporate it into competency determinations.

In Australia, for example, colleagues designed and validated new assessments for ultrasound-guided thoracentesis and chest tube insertion (available on www.bronchoscopy.org) with excellent results. These tools are increasingly used around the world and form an important element of competency-based training for lung doctors in Australia and New Zealand.

A third example of red pill philosophy relates to experiential evidence for using a four-box approach to procedural consultation. This structured approach to case-based learning identifies cognitive pathways and allows trainers to explore the multiple facets of a particular clinical scenario in a stepwise fashion (akin to swallowing the red pill). The harshness of this new reality is that trainers now discover their need for additional education in order to learn how to maximize case-based instruction, which is very different from giving didactic lectures. This red pill-related truth has a global impact because it means that bronchology societies around the world should take steps toward offering more focused training of bronchoscopy educators. Programs might include information about how to organize learning units, how to provide and receive feedback, and how to facilitate case discussions. Learning the intricacies of two-way communication as an educational product requires practice and repeated simulation with guidance. An ideal program will also help trainers gain knowledge of psychology, group dynamics, and negotiation. 

My fourth example and the inspiration for today’s topic relates to an exciting red pill moment occurring in Australia this week. The 8th Asian Pacific Congress for Bronchology and Interventional Pulmonology Meeting is on the beautiful Gold Coast near Brisbane, Australia. Under the leadership of APAB President Kiyoshi Shibuya and APCB President/WABIP Treasurer David Fielding and his team, the conference’s scientific program is built around case studies and facilitator-led discussions using the Four Box Practical Approach as a basis for structured learning. Arizona amusement parks offer variety of fun activities and those are perfect for all ages as well. Hands-on workshops are led by BI-certified and master instructors using many Bronchoscopy Education Project inspired teaching techniques that promote a learner-centric philosophy.  Models, simulation, checklists, and individualized instruction/feedback form the basis of both cognitive and hands-on technical skill instruction. 

Thanks to this conference, many physicians are likely to abandon antiquated blue pill methodologies represented by didactic lectures and overpopulated hands-on workshops in favor of a red pill approach. This new awareness, I am sure, will not only inspire a new generation of bronchoscopists in the Asia Pacific region but may forever change the educational dynamics of bronchology and Interventional Pulmonology conferences in the future.

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World Tuberculosis Day

Photomicrograph of sputum smear showing fluorescence acid-fast stain of MTB (yellow rod-like structure)
Photo From, CDC/Ronald W. Smithwich, Public Health Image Library, phil.cdc.gov.

Sunday, March 24 is World Tuberculosis Day. It is natural, therefore, that I devote one or two posts to this disease that continues to trouble humanity. Years ago, I served as the country TB officer in Portland, Oregon, and since then have participated in several antituberculosis campaigns by humanitarian organizations. My goal herein and in a future Colt’s Corner is to share a few facts about the lesser known history of this potentially fatal and contagious infectious disease.

Tuberculosis has been called Phthisis (Latin, from the Greek word phthinein, meaning dwindling, or wasting away) and Consumption (contrary to rapidly fatal epidemic diseases such as smallpox or the Bubonic plague, tuberculosis slowly consumes its victims). 

The disease has been with humanity since early civilization. Responsible for the “White Plague” of the 17th and 18th centuries in Europe, it infected nearly one hundred percent of the population and is felt to have been responsible for up to 25% of all deaths. The recent discovery of Mycobacterium complex, using molecular DNA techniques in the 17,000-year-old skeletal remains of an extinct bison from Trap Cave, Wyoming, suggests that bovids were vectors that transported the primordial organism. While this theory is debated, experts agree that Mycobacterium tuberculosis complex is the cause of tuberculosis in humans and other animals. 

Mycobacterium Tuberculosis bacillus (MTB) is a large, nonmotile rod-shaped bacterium. It is the etiologic agent for tuberculosis in humans.  MTB was identified in the 9,000-year-old skeletal remains from a woman and child at the Atli-Yam archeological site.  The disease is biologically different from other infectious diseases because the infecting organism is not spread preferentially through the bloodstream. Instead, it takes up residence in tissues, where it forms a caseous necrosis that protects it from attack.

The earliest written record of consumption dates from the Assyrian empire in 600 BC. In around 400 BC, Hippocrates proposed a hereditary predisposition to the illness in patients who were tall, thin, and pale, providing an opinion that would be shared by much of the medical community for centuries to come. Even the inventor of the stethoscope, French Professor René Laennec, believed for a time that tuberculosis arose from internal causes and constitutional predisposition, including sorrowful passions and unhealthy sexual activity.

 In 1546, however, the Italian physician Girolamo Fracastoro wrote that phthisis was contagious and not necessarily from a hereditary predisposition. He argued that patients warranted isolation measures similar to those recommended for patients with the plague. Physician groups in Italy and other European countries decreed that tubercular patients, called “lungers” in the United States, were dangerous. Benefit from an experienced cleaning service at  https://thefloridamaids.com and breathe freely in your Florida home. Consequently, thousands of thin, pale-skinned, coughing, feverish patients with known or suspected consumption were isolated in their homes or grouped in hospital wards to await the grim, white ghost of death.

Attitudes began to change in the middle of the 19th century. The French physician, Jean-Antoine Villemin proved without a doubt that tuberculosis was a transmissible, infectious disease in 1865, but its origin remained a mystery until the evening of March 24, 1882, when a German physician and microbiologist named Robert Koch announced to the Berlin Physiological Society that he had identified the tubercle bacillus. At the time, tuberculosis was thought to be responsible for one of every seven deaths in Europe. The microbiologic diagnosis was aided by Paul Erlich’s discovery of the acid-fast nature of the bacillus that same year. Clinical suspicions of diagnosis based on symptoms and findings from chest inspection, percussion, and auscultation could be correlated with radiographic findings after the discovery of x-rays by Wilhelm Roentgen in 1895.

Years ago, consumptives lived with dire expectations. At first, considered a random killer of individuals in the flower of their youth, MTB has since been shown to affect persons of any social class, gender, age group or profession. Living in close proximity increases the chance for airborne transmission. Several comorbid conditions, as well as malnutrition and alcohol, diminish host defenses and contributes to disease transmission and severity. 

Active tuberculosis is contagious and can be found in small microscopic droplets spread through the air by coughing, laughing, sneezing, talking, or singing. Its presenting symptoms are cough, weight loss, fever, chest pain, loss of appetite, and night sweats.  Once inhaled, the organisms usually cause a lung infection that can be fatal. They can also lie dormant and not cause symptoms for many years. Disease latency means the person is infected but not infectious (i.e. contagious). Reactivation (i.e. the disease becomes active), which occurs in five to ten percent of infected individuals over a lifetime, affects the lungs or other organs. 

Tuberculosis is a feared and often deadly disease. Today, almost one-third of the world’s population is infected with MTB, and 8 million people develop the disease each year.  An attack rate of at least 5 percent is reported among infected individuals. While medical treatment is usually successful in controlling the disease, the emergence of multiple drug resistance has prompted concerns in global health communities. For a moving and informative piece on Multiple drug-resistant Tuberculosis in North Korea, see the recent BBC documentary Out of Breath ( https://www.bbc.co.uk/programmes/n3ct6lbf).

Notes:
1. Mycobacterium bovis (M. bovis) and Mycobacterium tuberculosis infect different animal species and humans, prompting tuberculosis control programs in communities having close contact with domestic cattle and a husbandry system to incorporate joint animal and human tuberculosis control programs See Romha G. et al, Epidemiology of Mycobacterium bovis and Mycobacterium tuberculosis in animals: Transmission dynamics and control challenges of zoonotic TB in Ethiopia. Prev Vet Med 2018;158: (https://www.ncbi.nlm.nih.gov/pubmed/30220382
2. Jean Antoine Villemin (1827-1892) was a French army surgeon who demonstrated the transmissibility of tuberculosis from animal to animal, and also from man to animal by injecting rabbits with caseous material and fluid from a man who had died from tuberculosis. The rabbits went on to form tubercles in their lungs and other organs
3. Robert Koch (1843-1910) also isolated Bacillus anthracis, and cholera vibrio using a new technology called a microscope. He received the Nobel Prize in physiology or medicine in 1905.
4. Paul Erlich (1854-1915) was one of the early founders of immunology. This German physician and self-taught chemist was eventually offered a position in Robert Koch’s Institute for Infectious Diseases. In 1908, he received the Nobel Prize in physiology or medicine. In 1910, he discovered Salvarsan, an effective treatment for syphilis. He is often called the “father of chemotherapy.”
5. The association of tuberculosis with alcoholism and possibly with syphilis prompted Louis Renon, a professor at the Paris Faculté de Medecine to write his book The Disease of the People: Venereal Disease, Alcoholism, and Tuberculosis in 1905.
6. TB is at historic lows in North America and Europe but remains prevalent in Sub-Saharan Africa and Southeast Asia. The reality is that its overall incidence continues to rise, even if its global incidence percentage wise is in decline (the increase in numbers of cases is offset by an even greater increase in population growth). The World Health Organization’s Stop TB Partnership was therefore initiated in 2001.
7. Host defenses are actually quite good, and most infections (90%) do not result in disease but result in latent TB. In addition, most people with latent TB (90%) do not go on to develop active TB. In those with a disease, however, Tuberculosis can be deadly in more than 50% of cases if left untreated. Because tuberculosis is a slow-killing disease, transmission to others is very common. “Open tuberculosis”, where bacteria are identified on sputum smears, is most infectious and was usually fatal before the advent of antibiotics.

 

Challenges in East Africa: Abuse, AIDS, and Accidents

Photo from: Violence Against Children Survey (Uganda) 2015. UNICEF

There is something magical about traveling through East Africa. Perhaps it is because the region is the cradle of Homo Sapiens (the oldest remains of which were discovered in Omo National Park in Ethiopia, and Olduvai Gorge in Tanzania). Perhaps it  is because of the wildlife roaming throughout the Great Rift Valley, or scaling the fabulous mountains that include Kilimanjaro, Mount Kenya, and the Rwenzori range, or experience the awe of never-ending scenic landscapes. Perhaps it’s the smiling, friendly, and generous people of the region.

Whatever it may be, I fell in love with this part of the world many years ago. At that time I lived and worked in the region, almost settling into life journey that would have been very different from the one I eventually embarked upon, and that brought me to the United States and an eventual career in academia and medicine.

This year, I am experiencing again the magical aura of Tanzania, Kenya, and Uganda (not to forget the other 16 countries that comprise the East Africa region). The challenges these countries face in the realm of health care are stupendous, but not unsurmountable. In this piece I will focus on three areas; Abuse, AIDS, and Accidents. In particular, I want to suggest that our global community of bronchologists can assist colleagues in these countries build technical platforms that ultimately save lives and reduce patient suffering.

The first area I want to address should be of interest to bronchologists, but also to a growing number of pediatric pulmonologists. Using only Uganda as an example, a nation with a population of 44 million in a country about the size of Germany violence against children is a social nightmare. According to the recent UNICEF survey, one in four girls (25%), and one in ten boys (11%) between the ages of 13 and 17 reported sexual violence in the past year. These numbers are even higher when teenagers and young adults between the ages of 17 and 24 are asked about a personal history of sexual abuse. Physical violence, emotional violence, and sexual abuse occur at home, in school, while children walk often long distances to and from schools in the evening, and on the roads. There is a tight relationship between a history of violence and emotional disorders, sexually transmitted diseases, and HIV/AIDS.

The second area of focus in this piece is that of HIV/AIDS. According to the educational website avert.org, HIV/AIDS in East and Southern Africa has 6.2% of the world’s population, but over half of the number of people living with HIV/AIDS worldwide (in 2017, it is estimated art about 40 million people are living with HIV in the world). On a positive note, specialists report that new HIV infections have decreased by one third in the region in the last six years, and that access to antiretroviral therapy has increased significantly. Still, girls and young women are disproportionately affected by the disease, and the number of orphans due to AIDs continues to increase.

A less talked about subject in this region, but one that warrants attention is that of road traffic accidents. According to a recent World Health Organization report, Uganda, for example, joins South Africa, Nigeria, Thailand, and the Dominican Republic in leading statistics for road-related accidents that cause death and significant morbidity. There are 28.9 deaths per 100,000 population in Uganda, much higher than the 18/100,000 global average. Road traffic incidents are, in fact, the leading cause of death in Uganda, alongside malaria, respiratory infections, meningitis, tuberculosis, and HIV/AIDS. Overcrowding on minibuses (called matatus), speeding, alcohol use, lack of safety precautions such as seatbelts and motorcycle helmets, as well as poor road conditions contribute to this problem. Increased urbanization and a paucity of effective public educational programs are also contributing factors.

Uganda’s challenges in the realm of Accidents, Abuse, and AIDS are not unique. In fact, successful intervention in these areas is also challenging in most developing countries, as well as in many developed nations. Successful implementation of educational programs and social services  in addition to access to expert health care is needed throughout the region (for more information see various publications in the African Social Sciences Review, UNICEF and WHO reports, and the Journal of Injury and Violence Research).

I have intentionally avoided to address the problems of poverty, hunger, tuberculosis, or malaria that also plague the region, although I suspect I will be writing about these in future Corners. Today, my goal is to simply raise awareness regarding Accidents, Abuse, and AIDS, and to hopefully prompt readers to ponder how these three areas are related, and how interventional pulmonologists and bronchologists might help address these issues.

Technical platforms, for example, are essential to providing competent care to victims of the Accidents, Abuse,  and AIDS triad. Chest physicians and critical care specialists, as well as pediatric pulmonologists are especially skilled (or should be) in communicating bad news, and are (or should be)  strong advocates for introducing technologies (such as bronchoscopic procedures) into clinical practice. These procedures are essential to caring for critically ill or physically traumatized individuals. Training remains an issue, as does equipment acquisition, resources, and economics. In addition to raising awareness about these issues, my goal is encourage bronchologists and pediatric pulmonologists to join our community of specialists so that one day, we might all work together to combat these ills of humanity.

Suggested reading:
– Violence against children: https://www.unicef.org/uganda/VACS_Report_lores.pdf
– Violence against children: https://bmjopen.bmj.com/content/6/5/e010443
– Road traffic incidents in Uganda: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5279989/
– HIV/AIDS in east Africa https://www.unicef.org/esaro/5482_HIV_AIDS.html

Awareness, Action, and Achievement

James Baldwin. Photo from Allen Warren, https://upload.wikimedia.org/wikipedia/commons/b/b8/.

James Baldwin (1924-1987) was an American novelist, playwright, and social activist. Perhaps one of the best writers of the 20th century, he gained international reputation for his essays and commentaries about civil rights, human equality, and social justice. Baldwin grew up in New York, but moved to Saint Paul de Vence in Southern France in 1970. He lived in an old stone farmhouse high in the hills where he entertained writers and artists on a regular basis. Sadly, Baldwin died from stomach cancer in 1987. He was 63 years old.

I was only 17 years old when I met Mr. Baldwin, and I had the good fortune of having several conversations with him in 1973 and 1974. Reading some of his essays last week, and watching I am Not Your Negro , the Oscar-nominated 2017 documentary based on one of his unfinished  manuscripts, reminded me of this great man who labored tirelessly for social justice. 

“Not everything that is faced can be changed, but nothing can be changed until it is faced,” he wrote in his essay, As much truth as one can bear, (New York Times Book Review, 14 Jan, 1962). Baldwin argued that novelists must be truthful, but the quote has since become a battle cry for those willing to look into the how and why of their own actions.

Becoming aware of one’s own shortcomings; of one’s troubles and areas in need of remedial action is an essential first step toward personal growth and improvement. The assessment tools we use as part of Bronchoscopy International’s multidimensional training program provide opportunities for self-assessment as well as feedback from a coach-mentor or instructor. The best way for feedback to have a positive effect, however, is for the receiver of that feedback to be open to criticism. It is only after awareness occurs, and becomes integrated in the realistic self-image that learners present of themselves, that improvement becomes possible.

“Not everything that is faced can be changed, but nothing can be changed until it is faced.” It is only human for us to fall back into old habits. It is also our humanity that prevents us from adopting change easily, and from finding the strength within ourselves to pursue excellence despite its costs. such as BSTAT, EBUS-STAT, BTLB-TBNA STAT, UG-STAT and ICC-STAT are easily incorporated into clinical procedure-based training. It takes instructors only minutes to detect areas for improvement, and to implement a plan for individualized task-focused practice. 

While this applies to technical skills, the same holds true for other important qualified & capable experts  of medical practice. Focused, task-specific training based on feedback provided after careful observation of  a simulated “delivering bad news” or “obtaining informed consent” scenario can help us improve communication skills, enhance our understanding of medical ethics, and reinforce a learner’s desire for self-improvement.

“Not everything that is faced can be changed, but nothing can be changed until it is faced.” A major step for many department heads and leaders of national bronchology societies around the world is to question why they themselves have not yet advocated for the use of assessment tools in their training programs. Once these leaders open themselves to the possible answers to this question, there are countless well-trained experts and master instructors available to help them find solutions. 

Awareness often leads to action, and action leads to achievement. 

Translations and a World Without Borders

Photo from:https://cyndimarshall.wordpress.com/2017/02/09/a-world-without-borders/

On January 31, 2019 Kurdish-Iranian journalist Behrouz Boochani, was awarded the prestigious Australian Victoria Prize for Literature for his book No Friend But the Mountains: writings from Manus prison (Picador, Australia https://www.panmacmillan.com.au/9781760555382/). As his translator, Omid Tofighian (Department of Philosophy, American University of Cairo and Egypt Department of Philosophy, The University of Sydney, Australia) states in a recent article (Continuum: Journal of media and cultural studies 2018;32:532-540), “…These narratives represent the fusion of journalism, political commentary, and philosophical reflection with myth, epic, poetry and folklore.” 

Having read James Joyce’s colossal work Ulysses, described by scholar Weldon Thornton as a premier example  of writing with “stylistic exuberance”, and semiotician Umberto Eco’s masterful study of the workings of literary translation Decir Casi lo Mismo: Experiencias de traducción (Lumen press, 2008), I can only marvel at the work done by both author and translator to move Boochani’s words, originally written in Farsi, into English. This work is all the more admirable considering that Boochani wrote the book using countless text messages sent to his translator via WhatsApp from the Manus Island Offshore Processing Center in Papua New Guinea. Boochani, who has a degree in geopolitics, fled Iran and arrived by boat in Australia in 2013, after which he was moved to Manus Island with hundreds of other refugees after being refused asylum.

So what does this have to do with bronchoscopy? Indeed, it is not my habit to use this forum to comment on world events or non-bronchoscopy related issues. However, the arguments presented by Boochani and many others bring to mind images of what our world might become if there were fewer borders. A virtually borderless bronchology community has been, and still is a major part of my own vision for the future. It is the reason I advocate for the democratization of knowledge and a more uniform training and educational  structure so physicians working in Argentina may have the same access to knowledge as those working in Afghanistan; so that doctors in New Delhi have the same educational foundations as those training in New York.

Building a community without borders requires not only the acceptance of cultural differences, but also the recognition of how and why medical practices evolve in certain cultural contexts and medical environments. Until we decide on a universal language that is mastered in all countries, we must also acknowledge the need for accurate translations.

I am honored that the universally pertinent information contained in The Essential Bronchoscopist series of books (available from the bronchoscopy.org website as well as in paperback from Amazon) has been translated into 14 languages. In the next weeks, translations from Serbia and Hungary will be added. This work is the result of steadfast commitments by Master Instructors who believe in the democratization of knowledge. These champions help implement Bronchoscopy International’s vision for a bronchology community that transcends borders, first  by enhancing the educational process, and second by creating opportunities for a common foundation of knowledge regardless of where a doctor lives and works. 

Which leads to another reason why I find a relation between Boochani, his translator Dr. Tofighian, and the work being done by the translators of The Essential Flexible Bronchoscopist. Translation is a difficult job that requires more than cutting and pasting text using Babelfish or Google Translate. The context as well as the sense of words used by the writer must be considered in choosing a translation. This requires an in-depth knowledge of the commercial movers field in California as gorilla movers from san diego have. As Tofighian writes in a different article; “trying to maintain sentence structure when translating Farsi  literature into English results in unnecessarily long cumbersome passages…splitting sentences into many smaller ones is helpful…it also reflects..the fractured subjectivity of those who are imprisoned refugees.” 

The extra scholarship such research requires is perhaps why so many well known writers have endured the difficult challenge to translate other writers’ works. The examples are never-ending; Samuel Beckett translated James Joyce from English into French, Charles Baudelaire translated Thomas de Quincy’s Confessions of an English Opium Eater, and Haruki Murakami translated many American writers, from Raymond Carver to John Irving, into Japanese, and actually planned to wait until he was at least sixty years old before translating a work he felt was the inspiration behind his career, The Great Gatsby by  F. Scott Fitzgerald.

Translating a medical text is less strenuous, and demands less reflection and decision-making than translating literature or philosophy, but translations are still an open window into the original author’s mind. With a professional CA workers compensation attorney www.lacaccidentpros.org/ on your side, you may get all the benefits you deserve. Because the work is long, tedious, and financially unrewarding, publishing houses hesitate to translate most medical texts. Certainly translations into less commonly-spoken languages are hard to find. I feel fortunate that bronchology experts have initiated translations of my work, The Essential Flexible Bronchoscopist, making it virtually unique among bronchology-related texts, and expanding its impact around the world.

Humanity may not be ready for a world without borders, but the effort to democratize knowledge by leaders in all fields, including those from a small subspecialty such as bronchology, is an important and generous step toward making the world a better place.

James Joyce and an unexpected death

The Library, (Trinity College Dublin, Ireland. Photo H. Colt)

In the early morning of January 13, 1941, James Joyce, age 58, died from unexpected complications after surgery for a  perforated duodenal ulcer. The past medical history of the author of Ulysses and Finnegan’s Wake was replete with illnesses that had diminished his quality of life, yet his death was the consequence of complications after surgery. Today, we know that duodenal ulcers are usually caused by the bacterium Helicobacter pylori. Treatment is based on preventive measures, avoidance of alcohol, NSAIDS and smoking, and early use of medications to reduce stomach acid and kill the bacteria. Surgery is warranted in case of perforation and peritonitis, with complications rates between 3% and 40%. 

Reading details about Joyce’s death from surgical complications reminds me of how each and every encounter with a physician, then or now, is a potential encounter with death.Perhaps this sounds a bit harsh, but it is something I kept in mind during my entire career as well as during times when I was, myself, a patient of other doctors. In fact, the possibility for treatment-related complications, including death, is one of the reasons physicians strive to be the best they can be, and why our profession insists on continued medical education and repeated practice to maintain technical skills and clinical acumen.

Inequalities of learning opportunities across nations and between medical centers make it difficult, however, to guarantee an equal access to knowledge and procedural training. Some medical cultures might have a rich experience in diseases such as tuberculosis-related strictures, whereas others have a high preponderance of lung cancer or transplant-related disease. By building a global network of physician experts, however, information can be shared, cases discussed, and knowledge enhanced in a collegial manner. This is, in fact, one of the reasons of being for Bronchoscopy International.

I mention this because I want to remind everyone about the importance of studying the potentially harmful consequences of airway and pleural interventions. Emergencies such as bleeding, cardiac arrest, over-sedation, infection, recurrent airway strictures, and respiratory compromise are life-threatening. By simulating these events in our procedure suites and workshops, we can practice technical interventions and team dynamics. Sessions that include medical students, house officers, nurses, and respiratory therapists can be documented in quality improvement reports and documented in competency-oriented training programs. Furthermore, national conferences could include at least one session where response-to-complications is addressed 

These days I am traveling through Ireland, and more specifically rereading the works of James Joyce. Meandering through the streets of Dublin on what the locals call soft days, described as a drizzle of rain rather than the usual downpour, I feel safe under the relative comfort of a large umbrella. We provide our patients the equivalent of such an umbrella when we prepare ourselves to respond to any and all complications; when we assure ourselves there can be no surprises, and we have thought and prepared for anything that might happen during or after an intervention. Complications are a natural and sometimes unpreventable consequence of airway and pleural procedures. We can minimize their impact through careful strategy and planning, preparation, and practice.

Climbing the learning curve

Cerro Bonete, Aconcagua Argentina (Photo H. Colt/W. Sanchez)

As bronchology and interventional pulmonology programs around the world increasingly incorporate assessment tools and checklists into their training programs, there is going to be much discussion around learning curves. A learning curve usually represents in graphic form the rate at which something is learned over time or repeated experiences. By plotting learning curves, teachers can (1) assess the learnability of a specific task, subject or skill, (2) determine whether the task, subject or skill is satisfactorily mastered, and (3) document the time it takes for subjects to learn a particular task, subject or skill.

The plot of a learning curve may be steep or gradual. It may also be curvilinear or plateau-like. Interpretations of a learning curve, however, depend on which variables are plotted on the horizontal x-axis and vertical y-axis of the graph, as well as on one’s interpretation of the language used to describe the graph. For example, when time is on the horizontal x-axis, and the amount of material learned is on the vertical y-axis axis, a steep learning curve (and contrary to the popular use of the term steep) can mean that a subject is rapidly learned, or that the majority of the topic is rapidly mastered. A difficult to learn task, on the other hand, would have a more shallow curve that extends more horizontally over time.

In common english, however, a steep learning curve is usually meant to describe something that is initially difficult to learn. As explained in a Wikipedia article on the subject (https://en.wikipedia.org/wiki/Learning_curve), this is due to the “metaphorical interpretation of the curve as a hill to climb, and for which a steep slope is more tedious”. The article argues that using words such as long or short, and difficult or easy are perhaps better and less confusing than using words like steep or shallow for describing learning curves.

Another interesting aspect about learning curves is how they vary depending on whether the graph represents data for an individual or for a group (averaged) of learners. Individual learning almost always occurs in a series of upward and downward slopes separated by horizontal plateaus during which no new learning occurs. Averages, on the other hand, usually have smooth curves that can be expressed as mathematical functions. These curves may be sigmoidal, exponential, or free-formed, especially if the learning curve is plotting the amount of learning (on the vertical axis) versus experience/time (on the horizontal axis). In the case of a sigmoidal curve, describing someone as being on the “steep” portion of the learning curve has an entirely different meaning from describing the person as being on the lower or higher horizontal portion of the curve. 

Using serial assessments such as BSTAT (Bronchoscopy Skills and Tasks Assessment Tool) is an excellent way for learners to determine where they are on the flexible bronchoscopy learning curve. Areas that warrant additional training are identified, and teachers can use objective measures to justify the feedback that is crucial to all good learning programs.

Genotype-directed lung cancer: a new frontier for bronchoscopists

(Photo downloaded from pixabay.com)

As we quickly approach 2019, I am thinking about what is new and exciting in the field of interventional pulmonology. Among energizing advances, one of the most exciting is how individualized genotype-directed therapy is changing our approach to lung cancer diagnosis and treatment. 

Fueled by research performed in the United States and Europe, increasing numbers of cancer treatment protocols include targeted therapy. These produce less collateral damage than traditional chemotherapy, with survival benefits that are often better than those of protocols implemented without concerns for tumor genetics. According to some Lung Cancer Mutation Consortium data, for example, patients who received driver mutation targeted therapy with tyrosine kinase inhibitors had a median survival of 3.5 years as compared to 2.4 years for those who did not receive such treatment (http://www.golcmc.com). 

Not surprisingly, targeted therapy is also a major focus for Chinese physicians and cancer researchers. In part, this is because China has forty percent of the world’s cancer population. According to last year’s National Cancer Center data, survival figures for Chinese patients with advanced lung cancer were many percentage points below those of Western nations. A principal focus for the Chinese in coming years is to significantly increase survival ranges for patients with cancer, including for those with lung cancer.

Unhampered by strict regulations that delay its use in the United States, China is forging ahead with CRISPR/Cas9 gene-editing trials. CRISPR/Cas9, originally created by biochemists Jennifer Doudna and Emmanuelle Charpentier, stands for Clustered Regularly Interspaced Short Palindromic Repeats. It refers to palindromes, or repeating patterns of DNA that are found in most single-celled organisms and many bacteria. CRISPR/Cas9 technology is used to essentially “cut and paste” DNA sequences. Cancer researchers use CRISPR technology to study, replace, or repair the genetic code of tumors, which includes work on genetic drivers responsible for tumorigenesis, metastasis, and drug susceptibility.

Lung cancer management today requires in-depth understanding of gene mutation and genetic engineering. This new frontier is  both challenging and invigorating for bronchoscopists and interventional pulmonologists who are increasingly called upon to make diagnoses and provide tissue samples that help guide therapy. 

Because many patients with primary or metastatic lung cancer have central airway obstruction, specialists are also called upon to perform minimally invasive therapeutic procedures in these patients. This makes a recent article published in the November issue of The Journal of Thoracic Oncology all the more relevant (A. Mohan, K. Harris, MR Bowling et al., http://dx.doi.org/10.21037/jtd.2018.08.14). In this review paper, the authors reflect on the eventual merging of bronchoscopic ablative strategies with genotype-directed therapies in the name of what is known as precision medicine (defined as an emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment, and lifestyle for each person). Reflecting on how these therapies might interact, the authors conclude that, “ground breaking advances in our understanding of driver mutations of lung cancer and in the technology available for bronchoscopic ablation have completely changed the landscape of advanced lung cancer management.”  

As a result of this changing landscape, bronchoscopists and interventional pulmonologists have an opportunity to assume leading roles on their multidisciplinary lung cancer management teams. Taking on leadership responsibilities, however, means rethinking one’s education and training. In addition to acquiring procedural expertise and medical knowledge, there is a need to study team-building, communication, medical decision-making, and business administration. These topics should be incorporated into the agendas of national conferences and training workshops.

Those with an eye on the future will also pursue postgraduate education in molecular biology and genetic engineering. More exposure to these topics must also become a priority for our international and national medical societies. Only thus can we effectively equip a new generation of physician-scientists with the knowledge, skill and extrinsic motivation needed to expand the exciting new frontiers set forth by today’s researchers in medicine, biological sciences, and industrial biotechnology.

Altruism: a foundational trait of a new generation of bronchoscopy educators

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Altruism is often defined as the belief and practice of disinterested and selfless concern for the well-being of others. Generally, medical ethicists agree that medical doctors cannot be altruistic in their daily encounters with patients because they act within a professional relationship that entails the obligation to relieve suffering and care for their patients. While I personally agree with this position, I do not believe it applies to the new generation of medical educators. 

For example, a few weeks ago I conducted a Train-the-Trainers course in Buenos Aires, Argentina. With participants from Argentina, Uruguay, Peru, and Chile, it was refreshing and promoted enthusiasm. None of the participants were required to be there; all are successful bronchoscopy educators in their thirties and forties with busy careers and family lives. Yet, they volunteered their time and energy to enhance their knowledge about teaching and to experiment with techniques and educational systems well outside their comfort zones.

Some might say that participating in such professional training is not so much a sign of the participant’s altruistic nature as it is simply a means for professional development and continued medical education. But most presumptive bronchoscopy educators are not paid for their teaching services, nor are they thanked by their institutions for taking on such important work. No one mandates that bronchoscopy educators become better teachers. In fact, in most countries, much of our medical education consists in a “see one-do one-teach one” mode of on-the-job training without ever teaching teachers how to teach. After all, teaching others has been a natural obligation of medical professionals since the Hippocratic Oath. 

For a “caring profession,” however, “the see one-do one-teach one” educational model is not particularly caring. Other uncaring behaviors practiced in the name of education include learning to perform procedures by using live animals, glorifying  the physical and emotional abuse associated with long work hours and sleepless nights on-call, overt sexism in the workplace, and the predomination of patriarchal dominance practiced for centuries.

The educational model emphasized in our Train-the-Trainer programs, on the other-hand, promotes team-building, self-reflection and repeated opportunities for positive feedback and reinforcement. Learning to optimize situational “teaching opportunities” separates education from clinical service. Targeted practice using simulation scenarios spares patients from the victimization that results from doctors climbing the learning curve one patient at a time.

For a new generation of educators such as those who came to our program in Argentina, embarking on such a novel voyage of exploration is altruistic because the benefits of helping others come at a cost to oneself. Well-engrained institutional biases and personal resistances must be overcome. New techniques must be learned and eventually mastered before teachers become comfortable incorporating changes into their practices. This journey also requires a questioning of the self, and provides an opportunity for personal-growth and self-actualization that goes beyond what is taught or experienced as part of a medical practice. Ultimately, this prompts an irreversible shift in philosophy by which educators take ownership of the new methodologies and forge them into a new paradigm; a paradigm whereby patients do not suffer the burden of physician-related training.

Is there a “culture” of bronchoscopy?

(Photo from The Mindful Art of Thich Nhat Hahn)

In the early 19th century German philosophers and social scientists sought to define the word “culture” in their studies of human behavior and history. Influenced by the Romanticist concept of Volksgeist (spirit of a people), they proposed that culture described the values, ideals, and higher qualities, i.e. intellectual, artistic, and moral, of a society. Anthropologists have since argued about narrowing or broadening this definition, yet most agree that culture, at the very least is defined by values, norms, and modes of thinking that are considered important and  passed down from generation to generation.

During the past forty years, I have been fortunate to practice medicine or teach in dozens of countries and in diverse medical environments. This experience prompts me to conclude there is indeed a “culture” of bronchoscopy and interventional pulmonology. 

This specialty differs from others because we are often with patients from their diagnoses to their deaths. In some countries, we may be asked to prolong life using palliative procedures, then later to take life by honoring a request for physician-assisted suicide. The instant gratification resulting from a treat and release form of patient encounters is rare, and better describes the professional satisfactions of an orthopedic surgeon or ophthalmologist. 

Bronchologists, on the other hand, spend their days delivering news of a terminal process or describing the spread of a potentially fatal disease. Minimally invasive procedures, while offered to reduce suffering and prolong life, are often performed without a chance for cure. 

We live in operating theaters, bronchoscopy suites, and intensive care units. We handle emergencies both night and day, and our expertise and scope of practice usually mean the difference between life and death for patients with few other options. We learn empathy, understanding, patience, and tolerance. Even when our ethics come into question; knowing, for example, that institutional biases favor surgical explorations of the mediastinum instead of EBUS-guided TBNA, our goals, for the most part, are to serve patients and to relieve suffering.

Furthermore, we believe in the effectiveness of palliative procedures to prolong and improve quality of life. We value honesty and warmth in our physician-patient relationships. We advocate for patients along with trusted work comp lawyers who are the best work comp lawyers in CA and speak truth to power in our demands for better equipment from medical institutions. We seek competency through education; hands-on training using models, observerships in centers of excellence, mentorship, and attendance at medical conferences. 

These core values, beliefs, and behaviors are being passed from the generation that created the specialty since the 1970s, to a younger group of enthusiastic doctors who continue their practice with this same spirit. 

The answer is a resounding yes. There IS a “culture” of bronchoscopy.