Category Archives: Colt’s Corner

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

(Photo downloaded from stock.adobe.com)

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.

Penitentes

Penitentes, (summit of Kilimanjaro. Photo H. Colt)

The name “penitente” is defined as both a noun (a person who repents their wrongdoings and seeks forgiveness) and an adjective (a feeling or showing of sorrow and regret for having done wrong). The origin is Spanish, and the description in the mountains arose because a field of penitentes looks like a procession of monks in white robes.  These snow and ice formations range from one to six meters high, occurring at high altitude on glaciers and snow fields, requiring sunlight, and cold dry weather for their formation.

Everyone makes mistakes, including doctors, but not everyone feels bad about it afterwards. Or perhaps such a blanket statement is untrue about medical professionals? These thoughts were on my mind as I was climbing Kilimanjaro and some of the higher African peaks a couple months ago. Among other things, I tried to recall the names of patients and the circumstances during which my performance could have been better; where mistakes could have been avoided, and where results from therapeutic curative or palliative procedures might have been improved.

Most medical practices and teaching institutions do not readily offer counseling or guidance in case of medical error. Focus is almost entirely on the potential or real legal aspects of an incident. Some departments do stress quality control and rapid remedial response in case of sentinel incidents. Repeated procedural practice using simulators and models is not widespread, however, and nonjudgmental professionally-led forums for repentant health care providers are not actively promoted for trainees, faculty, or physicians-in-practice.

Think about it. When was the last time you initiated serious conversation with a colleague or sought consultation with a medical professional to discuss one of your medical errors, what they said? Did you discuss the facts, procedural outcomes, and technical solutions? Did the conversation mostly involve that part of your cognitive brain, or were you also able to honestly and openly discuss your feelings (guilt, remorse, anger, or regret). If you are a teacher or mentor, how often do you include a query about feelings, thoughts and emotions when you discuss accident prevention, complications, or medical procedural errors? How often do you make such discussions part of a regularly scheduled debriefing session?

And if the answer is not often, pray tell, why not?

 

“The whole point of life is this moment.”

The author of this simple statement is Alan Watts, who, in one of his many philosophical ponderings about life and death, argues that dying, which happens to you once, should be a great event.1

Watts passed away in his sleep on November 15, 1973. He was 58 years old. An inspiring thinker most known for his popularization of Zen Buddhism and his efforts to reconcile Eastern philosophies with a Western way of life, Watts was also a man of contradictions. He was endeared to all that life could offer, but in addition to being a foremost theologian and interpreter of Eastern religions, he was addicted to cigarettes and alcohol, married three times and, despite efforts to let go of his ego, incredibly adept at self-promotion.

I was a twenty-year-old college student when I discovered Watts’ writings, only three years after his death. I quickly devoured several of his books, starting with his first, The Spirit of Zen, which he wrote when he too was only twenty. From then on, I plunged into the study of Eastern religious and philosophical texts; an arduous task while simultaneously working a night job after school, struggling to learn scientific concepts for class, and nomadically exploring psychology and the intricate writings of Wilhelm Reich, Melanie Klein, Carl Jung and other thinkers.

Many years later, I was doing what many interventional pulmonologists must often do: informing patients of their terminal illness, and interceding with palliative procedures that prolong life without the hope or expectation of cure. Many patients and their families engaged me in conversations about death and dying, God, religion, and the meaning of life. My experience in these discussions reached into the hundreds. I gratefully acknowledged the privilege given me to address these issues in part because of my profession, but also because of my availability to discuss such matters, and most of all because of the special place my patients were offering me in their lives at that particular difficult moment.

What amazed me then, and troubles me now is how little most physicians are prepared, whether during medical school or afterwards, for conversations about such things. Some might say we have no business embarking on such discussions with our patients, while others say that to refuse when asked condemns us to abandon our humanity. This is an interesting debate that warrants our consideration.

Not all interventional pulmonologists, of course, should feel inclined to participate in this aspect of our profession. Certainly, the ability to converse with patients about life and death from a position that is neither therapist nor theologian, but that of a trusted friend and treating physician should not be taken lightly. And, unlike our ability to empathetically communicate bad news or ethically obtain informed consent, participation in such exchanges does not necessarily warrant a particular demonstration of skill within the context of a defined competency.  When these occasions arise, however, as they may because of the very nature of our medical practices, we should be able to address at least some issues by referring to knowledge that results from more than our personal perspectives and individual biases. This may simply mean becoming aware of the value of referral to a specialist in such matters.

I am hopeful for the day when our specialty will grant weight to this subject in our national and international conferences and training programs. Whether from experience or specialty training, I am sure we have in our ranks many individuals who can help educate others. Restore Your Classic Car in California – Find Top Shops Near me at www.chimeramotors.com/. At the very least, an open discussion of these matters will provide insight for those inclined to embark in a discourse about death and dying.

Alan Watts spent much of his life thinking about what it means to live. For those of us who aspire to be healers, our ability to provide guidance and comfort for living in the now may all too often be the most we have to offer.

1 From Psychotherapy and Eastern Religion, in The Essential Alan Watts (Posthumous publication), Celestial Arts, Berkeley CA, 1977.