Category Archives: Colt’s Corner

Feelings are important

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

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

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

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

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

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

 

 

 

 

Virtual Reality and the future of bronchoscopy education

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

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

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

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

Time to focus on the practical needs of a revolution

 

Practicing Bronchoscopy Step-by-Step

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

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

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

Knowledge is Power

In 1620, Francis Bacon argued that ‘knowledge is power’. Since the advent of the Internet and the increasing popularity of social media services such as Facebook, Whatsapp, and Twitter,  spreading knowledge has never been easier or more instantaneous. Yet the inequalities regarding access to information, technical skills, and medical training resources seem enormous. Inequalities of physician expertise are a detriment to our society, and a disservice to patients everywhere. It seems that bridging the digital divide that separates the “haves” from the “have nots”, requires more than simple access. It also requires the successful design, implementation, and universal acceptance of  inspiring and effective educational programs and philosophies. These programs can only succeed  when they are championed by well-intentioned leaders who teach through personal example and mentorship. Technology might allow our ideas and images to transcend national boundaries, but healthcare education is most enriched by a learner’s personal identification with compassionate, intelligent, and unselfish role models who discard egos in exchange for a greater good.

Democratization of Knowledge

An educational system based on the democratization of knowledge is the exact opposite of a system based on the coerced acceptance of conventional wisdom and dogma. For centuries, medical training was defined by ‘The Teacher’ who was the owner of knowledge and who had power over the learner; that other person who was granted the privilege of entering a circle of those who know. With democratization, or what some might call liberalization, the exchange of knowledge becomes naturally learner-centric. Teacher and student develop a positively reinforced, symbiotic relationship where each actually learns from the other. The results of this interaction are both rich and enlightening.