Tag Archives: bronchoscopy

Bronchoscopy in Bangladesh

Dr. Nirmal Sarkar excels in hands-off / hands-on teaching
(Photo H. Colt)

September marked another exciting moment for bronchoscopists in Bangladesh. The 2nd International Conference on Interventional Pulmonology was held in the capital city of Dhaka. A prestigious international faculty under the leadership of Professors Mohammad Hiron (Chairman BABIP), Akhtar Hossain (Vice-Chairman), Dr. Sayedul Islam (Secretary-General), and Abdur Rouf (Program  Director) brought bronchoscopists from throughout the country together for lectures and hands-on workshops using airway models.

BABIP is a young organization, founded in November 2015 and joining the WABIP in 2017. Since the society’s first meeting last year, faculty conducted several CME workshops, and plan even more this coming year. This will be facilitated by leadership’s initiative to purchase airway models for use in hands-on training. Already, several young faculty are adept at teaching bronchoscopy step-by-step, using assessment tools such as BSTAT, and performing procedure-related consultations using a Four-Box practical approach format.

Novel this year was a focus on practical issues such as communication, cryotherapy, and foreign body removal, with lectures by Indian specialists Drs. Rajani Bhat, Sameer Arbat, and Kedar Hibare, all promising future certified instructors with Bronchoscopy International.

Bangladesh is a lush, beautiful country to the east of India abutting the Bay of Bengal. Its fertile plains are fed by the Ganges, Meghna, and Jamuna rivers. With almost 170 million people needing affordable, quality health care, the physician leadership in Bangladesh has until recently focused on cardiovascular health, in addition to combatting poverty and tuberculosis. Leaders recognize the importance of bronchoscopy in critically ill patients but also for a growing number of patients with lung cancer who require diagnosis, as well as palliative treatment in case of advanced disease.

With knowledgeable junior faculty, enthusiastic numbers of practicing bronchoscopists, motivated students, and inspiring leadership, Bangladesh is poised fro play an active role expanding bronchoscopic and interventional pulmonology practice in the world.

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Deep learning in Radiology and Pathology affects Bronchoscopists

Photo by Andrew Neel, on Unsplash

This is a second post relating to the promising role of artificial intelligence in interventional pulmonology.  My point is that lung specialists will spend less time learning facts and figures that are easily replaced by computer-generated analyses of complex algorithms. Much of this is because of Deep learning

This subset of machine learning (programs that adjust themselves as they are exposed to more data, but without human input) uses artificial neural networks (algorithms built on unstructured data). The word deep is a technical term referring to the number of layers in the neural network. Artificial Neural networks being a set of algorithms modeled after the human brain and used to recognize patterns.  Image recognition is one example, and its principles are responsible for much of the work done today in radiology and pathology. 

For example, using deep learning and pattern recognition, AI reveals CT abnormalities and interprets findings (Google’s AI team recently outperformed traditional radiologists looking at 45,800 screening CTs for lung cancer https://www.fiercebiotech.com/medtech/google-s-cancer-spotting-ai-outperforms-radiologists-reading-lung-ct-scans), and chest radiographs are accurately interpreted using fuzzy logic interpretations of spatial relationships (https://www.ijcaonline.org/specialissues/dia/number1/4156-spe320t).

Pathology is another area where practice patterns will undoubtedly change. In many regions, expert cytologic interpretation of lung and mediastinal nodal specimens is lacking. Digital pathology (image-based information generated from a digital slide) allows real-time interpretation by computers at sites that are distant from wherever the procedure takes place. Humans already do this despite the cost and logistic difficulties.  I believe that artificial intelligence will soon facilitate and universalize the process (https://www.healthimaging.com/topics/artificial-intelligence/ai-lung-cancer-slides-accuracy-pathologists). 

In today’s post, my goal was to introduce the concept of deep learning and provide a few examples of how this mode of artificial intelligence will affect procedural practice by changing how chest radiology and pathology are practiced. Rather than devote study time to learning X-ray and cytology interpretation, future bronchoscopists will improve their abilities to incorporate findings into appropriate management plans, as well as communicate results to patients, caregivers, and health-care teams.

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AI and Bronchoscopy

Photo by Franck V. on Unsplash

This is the first of several posts about the role of artificial intelligence and the future of interventional pulmonology*.  I am confident our field will change immensely in the years ahead, and that artificial intelligence will not only change how we learn and perform procedures but also how we interact with patients. The sooner we embrace these changes, and build partnerships with industry as well as colleagues from other disciplines such as computer engineering, ethics, psychology, philosophy, physics, mathematics, and business administration, the easier it will be to integrate new developments into clinical practice.

Artificial intelligence has many definitions. A quick Google search provides “the theory and development of computer systems able to perform tasks that normally require human intelligence, such as visual perception, speech recognition, decision-making, and translation between languages.” Wikipedia expands on this definition, adding that AI “describes machines (or computers) that mimic “cognitive” functions that humans associate with the human mind, such as “learning” and “problem-solving.”

This requires us to familiarize ourselves with the phraseology computer engineers use to describe the learning process, but which is not necessarily foreign to many educators.

From a developmental perspective, AI uses symbolic, connectionist, and other models of learning that are, in fact, similar to how the human brain works. Just as there are several types of knowledge, AI does not rely on only one developmental approach to provide results. This is elegantly explained in a 1990 article by Marvin Minsky (AI magazine, summer 1991), in which he explains how the sentence “ Mary gave Jack the book” prompts the human brain to produce a visual representation of the act, a tactile representation of the experience, a script-sequence of what it means ‘to give’, and various assumptions about Jack, Mary, and the book. Similarly, artificial intelligence must employ not one but several different strategies to provide a result.

Some results are methodology—based on algorithmic and probabilistic approaches. Computer-based interpretation of pulmonary function tests, image-pattern recognition for accurate computed tomography scan interpretation, and patient management protocols based on decision-tree and data-driven statistical algorithms are simple examples of how artificial intelligence brings complex knowledge instantaneously to our fingertips. No longer required to memorize facts and figures, or integrate history/clinical exam/laboratory findings into patterns learned through a prolonged patient-care apprenticeship, doctors will change their practice habits accordingly.

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Lasers and Lava*

A few months ago I joined a group of twenty-somethings hanging out on the South Pacific Island of Vanuatu. We scaled Mount Yasur, reportedly the most active volcano on the planet; a volcano that spits rocks, fire, and molten lava since before Captain Cook first described the place on August 5, 1774 (reference: captaincooksociety.com).

Caught in a windstorm at the summit, I felt warm ash on my face. I stared into the crater, blinded by the smoke, watching the volcano’s bubbling and boiling magma far below. Later, I listened to the roar of explosions from my hut less than an hour’s hike from the base of the mountain. I marveled at the resilience of my Vanuatu hosts, particularly those living on Tanna. These impoverished families are constantly ready to evacuate in case the Yasur chooses to destroy their homes.

Hiking across a broad and barren lava plain the next day, I looked at my photographs. They reminded me of bronchoscopic Nd;YAG laser resections. People don’t talk much about laser anymore. It seems most interventionists use argon plasma, cryotherapy, and electrocautery to assist with their resections. But in the 1980s and for thirty years onward, laser was a magic wand for restoring airway patency. Courses included talks on laser physics, how-to’s on laser safety, videos of resection techniques, and lectures about complications such as popcorn effect, fire, perforation, and bleeding.

Emphasis was given to the concept of Power Density, to photocoagulation and vaporization, and the risks of collateral tissue damage during laser resection. Today, I wonder whether people learn these concepts and techniques with the same level of detail and scientific justification as years past. Maybe, lasers are too expensive for most institutions. Perhaps they don’t have the appeal they once had; after all, other modalities also do the job, and stents maintain airway patency over the longer term.

I suppose most “laser bronchoscopists” have gray hair or have retired. Does a new generation of laser specialists ask questions of scientific significance, or is the future of bronchoscopy linked now to mediastinal exploration, navigating to peripheral lesions, discovering safe ways to biopsy lung parenchyma, and treating advanced asthma and chronic obstructive lung disease? Our field has grown, but as an adrenaline junkie, there is something uniquely rewarding about a successful laser photocoagulation/coring out of massively obstructing lesions. 

I wonder if Captain Cook, onboard his ship, the Resolution, 225 years ago, dreamt of how Mount Yasur’s incandescent splatter might inspire future visitors. 

*Photo: Mount Yassur erupting, Tanna Island, Vanuatu (photo, H. Colt)

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A New Milestone-2000 Users!

We’re communicating in real-time and we are up to 2000 users from 32 different countries. I monitor all these accounts 24 hours a day, seven days a week, and I can truly say that the information exchange and case presentations are fascinating!

The only problem is the WhatsApp platform has decreased performance because of changes WhatsApp has made to its user platform, presumably to decrease spam. For those of you wondering why you are not seeing as many redirects, it is because I am limited to only five redirects at a time, making redirects burdensome and time-consuming. Still, my impression is that our communications are beneficial to many countries and regions, as well as to groups such as our pediatrics group and South American IP group. 

Many physicians communicate in their natural languages rather than English. In these cases, I translate information before redirecting educational materials and interesting cases, Feedback from redirects have proven to be helpful, and in many cases change patient management. Thank you to all who contribute cases and opinions!

So where do we go from here, now that we have reached the 2000 users milestone? Many countries still have only a few users. Perhaps the admins for these groups can recruit new users? I am interested in knowing why colleagues are not eager to join your WhatsApp group and exchange information. 

For those groups with many users (anywhere from 50-250), please remember how helpful it is when you add references, scientific articles and other “evidence” to help support opinions. Also, remember that videos are most effective when they are short and edited. Same goes for photos (better to use one photo that combines other images, than four different photographs).

Stay tuned for more information on how we can increase our global communication efforts, and again, congratulations to everyone for reaching the milestone of 2000 users, which benefits patients around the world.

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World lung cancer day

August 1 is World Lung Cancer Day.

According to the World Health Organization, there were 2.09 million lung cancer cases in 2018 and 1.76 million deaths. Almost everywhere, 5-year survival is less than 20 percent. Despite spending millions of dollars, making advances in molecular biology, immunology, and genetics-related research, building knowledge of cancer epidemiology, improving health care facilities, studying early detection, and raising awareness among the general public about the risks of tobacco use and exposures to environmental and other risk factors, there is still no cure.

Worldwide, lung cancer occurs more frequently than other diseases such as colorectal cancers, liver, stomach, breast or even non-melanoma skin cancers.  In men, lung cancer is a significant cause of death; greater than either prostate or colorectal cancer. In women, it is a greater cause of death than either breast, or colorectal cancer. In fact, for both men and women, one out of every four cancer deaths is from lung cancer.

And this is not a disease that spares countries, although frequencies in men and women vary. For example, recent statistics suggest that Hungary, Serbia, and Korea lead the lung cancer frequency field for men, whereas Denmark, Canada, and the United States lead the field for women. We must also be aware that cancer outcomes differ according to socioeconomic status. In many countries, research shows that racial and ethnic minorities receive lower-quality care. 

Tobacco has a causal relationship with lung cancer, as do second-hand smoke exposure, exposure to certain environmental and chemical risk factors such as radioactive ores, radon, diesel gas, certain inhaled chemicals and minerals, and even arsenic in drinking water. Some believe there is a genetic predisposition to lung cancer; risks are increased in case of family members with a history of the disease. Studies are needed to elucidate whether this is from genetic, environmental or lifestyle-related commonalities. 

Another well-known environmental risk for lung cancer is asbestos, which also causes malignant pleural mesothelioma. I was recently climbing in New Caledonia, an island of about 300,000 people (with more than 100 tribes in 33 communes) in the Southwest Pacific Ocean. According to statistics, this French collectivity is surprisingly high on the list of countries with a preponderance of lung cancer (possibly associated with local asbestos exposures).

Interventional pulmonologists dedicate much of their energy to helping diagnose and treat patients with lung cancer. While significant advances have been made, a certain therapeutic nihilism is still seen in many countries. Eliminating such a mindset everywhere would be a marvelous step toward eradicating this terrible disease.

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In Mourning: Viktor Sokolov

In 1826, The Russian poet Alexander Pushkin wrote “But with the truth he attracted hearts. But with science he quelled mores.” (From, Stanzas). Such words could be used to describe the life and work of my friend Professor Viktor Sokolov (1946-2019), who died last month at the young age of 73.

Viktor was an accomplished surgeon, anesthesiologist and bronchoscopist. He created the Russian Bronchology Group and was the first Russian regent to the WABIP. He fought to defeat conventional wisdoms and dedicated his life to modernize bronchoscopy practice in his country. In addition to numerous leadership positions, Professor Sokolov was also a former Chair for the Endoscopy Commission of the Russian Ministry of Health, and a long time member of the Academic Council.  

As department head at the Moscow Research institute he led efforts to perform novel interventions in patients with early cancer of the larynx, trachea and bronchi, esophagus, stomach and duodenum, bile duct, choledochus, rectum and colon. He helped promote the use of electrosurgery, argon plasma coagulation, laser thermal destruction, photodynamic therapy and stent insertion. He published more than 300 original scientific papers, dozens of monographs, clinical care guidelines, and 10 teaching manuals. He held 26 patents for scientific methodologies and instruments. 

For more than ten years, I corresponded frequently with Viktor and his son Dmitry (also an expert bronchoscopist). It was a great honor to help them build a training program in Moscow. A few years ago, with my colleagues Nikos Koufos, Rosa Cordovilla, and Enrique Cases, we helped faculty implement the use of training models, checklists and assessment tools in bronchoscopy education. This has been particularly helpful for building skills in endobronchial ultrasound.

Viktor was a scientist at heart, and it is as a scientist that he approached his medical practice. His dream was to cure lung and digestive cancers in their earliest stages, and for this he was always on the alert for technologies that might assist with early diagnosis and treatment.  Because his first love was actually pediatric surgery back in the 1970s, Professor Sokolov was particularly excited to see the recent growth of pediatric bronchoscopy (we have more than 400 doctors communicating through our WhatsApp Peds Groups).

Viktor, we shall miss your humor, your intelligence, and most of all the inspiration of your relentless pursuit of truth.

Farewell, my friend.

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The Bronchoscopist’s Umwelt

Traditional bronchoscopy (Photo H. Colt)

Ten years after Shigeto Ikeda first introduced the flexible bronchoscope to the world, I gazed into the incredible fractal anatomy of a patient’s tracheobronchial tree.  Back then, flexible bronchoscopes were made of fiberoptic bundles that required an external light source for illumination. Today’s instruments incorporate increasingly complex technologies that provide greater visibility and access than ever imagined.

If previous generations were inspired by their newfound ability to view, diagnose and treat airway tumors, tracheobronchial strictures, and pulmonary infections, a new generation of health care providers can only marvel at the increasing indications, therapeutic possibilities and promising future for this already proven medical procedure.

During the recent meeting of bronchoscopy educators in Venice, I plunged into the sea of possibilities that exists for present and future bronchoscopists. New diagnostic technologies, therapeutic alternatives, increasing indications, robotics, real-time image-guided tissue analysis, and possibilities for less invasive genetic sampling provide a glimpse of what is yet to come.

What amazes me most, however, is how the bronchoscopist’s “surrounding world”, also known as an “umwelt” is drastically changing for the better. The word umwelt was introduced more than one hundred years ago when Jacob Johann von Uexküll, an Estonian biologist, fused biology with semiotics, proposing that living organisms could not be separated or divided from their environments. This idea prompted many anthropologists, animal behaviorists, biologists, and philosophers to embrace the idea that organisms, essentially us, exist in a dependent relationship with other organisms and our environment.

As students of our own umwelt, we can abandon our narrow views of the world to adopt instead a position where seeing the world through another’s eyes helps us to understand not only the other’s world but also the perceptions of those we are related to both directly and indirectly. As some might say; we are in this all together, so we might as well get along, but we might also do our best to see the world through others’ eyes.

Uexküll’s proposition was an important parallel to theories of Darwinian evolution, which in its more vertical approach reduces organisms to a survival of the fittest evolutionary schematic. When an organism’s evolution is viewed instead as being primarily interdependent on surrounding worlds, it means there are as many surrounding worlds as there are organisms. The dog sees its world a dog’s way, which is surely different from yet related to the world view as seen by a mosquito. Each and every one of us, whether we are homo sapiens basking in the sun of Southern California or wild lions struggling to survive in the Serengeti must “perceive and act from the standpoint of our own unique world” (From, Ian G.R. Shaw, Geoforum 2013;48:260-267). Each living thing possesses, as Dr. Shaw explains in his article, “a unique signature of existence.”

Fifty years ago, the bronchoscopist’s umwelt began with the realization that we could effectively intervene both diagnostically and therapeutically in a region of the human body that had previously been virtually inaccessible. Our instruments then, as are many now, appear somewhat primitive, but the procedure itself led chest physicians to increasingly assume roles of responsibility in the care of patients with critical illnesses and cancer.

Our human potential within such an environment continues to expand as technologies evolve. I believe this entices us to relate with a surrounding world that is ever expanding, evolving, and drastically changing. How we adapt to that world, including how we modify our own world views accordingly, will determine our specialty’s relevance in a changing health care environment.

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Death in Venice

April in Venice (Photo, H. Colt)

Venice has 150 waterways and 455 bridges connecting more than 120 small islands. There are hundreds of narrow alleyways, art museums, shops, restaurants and outdoor cafés. The city is an emblem of Italy’s charms, and its people have a history rich with experience in diplomacy, the humanities, and intellectual creativity.

This week, a limited-attendance conference named “An International Workshop in Interventional Pulmonology: The road map towards competence” was organized by my friend and Venetian native, Professor Lorenzo Corbetta (University of Florence). Cosponsored by The Fondazione Internazionale Menarini, and held at Ca’ Foscari Academy, this conference included a small group of physician-educators from Europe, Australia, South America, the United States, and China. Our mission was to discuss and debate issues related to training for our growing medical speciality.

During my sojourn in this city known as “La Serenissima”, I reread Thomas Mann’s turn of the century novella, Death in Venice. In this story, a writer’s life is tragically marked by his obsession with beauty, and by his sensual attraction for a young boy on holidays with his mother. The screen adaptation was done in 1971 by Italian director Luchino Visconti. His  famous movie starred Dirk Bogarde and Bjorn Andresėn, with a soundtrack using music by Gustav Mahler. 

Oddly, the words death in Venice also seemed to reflect what I believe is the result of this week’s international conference. What I mean is they signal the end of an antiquated Halstedian education model historically linked to a “see one, do one, teach one” paradigm of medical procedural education.

For example, conference participants unanimously concluded that patients must not be used as subjects for medical procedural education. This modern educational paradigm is justified by ethical practices, educational philosophies, and an increasing availability of robust alternatives. 

Participants also agreed agreed that (1) validated, objective measures of learning outcomes are beneficial and should be implemented in our training programs; (2) these learning outcomes and other training milestones should be routinely documented as a roadmap toward competency; (3) specifically structured training programs should be designed using a multidimensional curricular approach; and (4) Train-the-Trainer programs (faculty development) are warranted to help trainers become more familiar with a large variety of teaching techniques, assessment tools, learning principles, and education-related philosophies.

For example, a program that helps ensure ethical procedural practice and efficient, effective teaching might include documented learning outcomes with checklists, identifying strengths and weaknesses using a combination of learner-centric assessment tools, and deconstructing clinical issues using a combination of simulation and problem/case-based exercises with opportunities for feedback and two-way conversation.

Just as importantly, conference participants concluded that it is no longer necessary to debate the primeval question of why these modern educational tools should be used Instead, we should move into an age of widespread implementation in order to answer questions of how these tools can be used most effectively in our quest for competency. 

My personal interpretation of the conference’s outcome is as follows:

– Our focus can shift from that of resisting change to that of implementation. 
– Our objective should be to create a training environment that is coherent with learning habits of a younger generation of doctors, yet adaptable to diverse medical and cultural environments. 
– Our inspiration derives from the dedication and intrinsic motivation of physician-educators who actively learn from each other during Train the Trainer workshops (certified and master instructors from Bronchoscopy International are two examples of such a process). 
– Our sense of achievement comes from competently serving patients and training a new generation of doctors who refuse to use patients as training victims.

In my opinion, therefore, this landmark conference signals the end of an era stained by Halstedian philosophies. In its place is a commitment to implement a multidimensional approach to procedure-related education. Training programs that incorporate checklists, assessment tools, step-by-step learning, simulation, procedural logbooks, data collection and analysis, knowledge of educational philosophies, instructional techniques, and structured opportunities for learner-teacher feedback constitue a solid framework for what clearly is a new beginning.

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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. Assessment tools 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 aspects 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.