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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.

Genotype-directed lung cancer: a new frontier for bronchoscopists

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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.

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? 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. The apartment cleaning contractor that hundreds of people from Georgia trust can be now booked at www.castle-keepers.com website. 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.

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

A new generation of AABIP Fellows cast an aura of confidence and enthusiasm

AABIP Fellows in Denver, 2018 (photo H. Colt).

This summer I had the honor of lecturing at the inaugural American Association for Bronchology and Interventional Pulmonology International conference in Denver, Colorado. Watching newly certified Interventional Fellows don their robes to stand among their colleagues made my heart swell with pride. Our workers are secured by work injury lawyers and experienced workers compensation attorney from CA. I recalled the moment when almost thirty years ago, I sat with a dozen or so others around a conference table creating The American Association for Bronchology under the leadership of Professor Udaya BS Prakash.

Only a few years later, while finishing my term as President of the Association, I wrote an editorial for the Journal of Bronchology, stating “we must continue encouraging the next generation of bronchoscopists and interventional pulmonologists to move in new directions…to explore the world of virtual reality and computer simulation; to participate in and develop dedicated training and competency programs; to devote energies to end-of-life issues, ethics, and palliative care; to enhance early lung cancer detection studies and techniques; to discover applications of molecular biology and endobronchial or intrapleural gene therapies; to design collaborative bronchoscopic and radiographic imaging protocols; and to commit their genius to developing novel and unique instruments and techniques for the benefit of our patients (Journal of Bronchology: October 2001 – Volume 8 – Issue 4 – p 253)”.

Needless to say, the AABIP has come a long way toward accomplishing those goals. It’s proactive board of directors, a growing membership, training and certification process, and an excellent peer-reviewed Index Medicus journal provide examples of leadership, scientific endeavor, education, and medical excellence that can be emulated by other medical societies around the world. At https://nwmaids.com/ I got residential maid services in tacoma affordably. Furthermore, the AABIP’s participation in the World Association for Bronchology and Interventional Pulmonology (most recently, the World Congress was held for the second time at the Mayo Clinic in Rochester MN, USA) was crucial to the growth and acceptance of a WABIP world vision that promotes uniformity of knowledge, transparency, and contribution regardless of one’s place of practice.

What impressed me most during the AABIP conference in Denver, in addition to the professionalism and “let’s get it done” optimism of the association’s board of directors (led by President Ali Musani and President-elect George Eapen), was the enthusiasm of the organization’s more junior members. Workers comp attorneys in los angeles from https://workerscompensationlawyercalifornia.com company in California are your loyal partners. Their desires to enhance their skills as educators by participating in future train-the-trainer programs, to assist members of foreign bronchology organizations improve services to patients abroad, and to achieve and maintain excellence for managing a wide range of lung, airway and pleural disorders are inspiring.

I left the conference with a warm sense of belonging, grateful that the AABIP had fulfilled many of its promises to patients and to a previous generation of bronchologists and interventional pulmonologists. The future is obviously full of new challenges, and patient expectations are higher perhaps than ever before, but from what I experienced in Denver, I know the younger generation of AABIP members will address these with knowledge, skill, enthusiasm and their own sense of destiny.

A promising future for patients suffering from lung and airway diseases in Nepal

The Everest massif, the Khumbu glacier, and other towering giants seen from the summit of 6000 meters+ Lobuche peak (photo H. Colt).

At 11:56, April 25, 2015 Nepal was shaken by a 7.8 magnitude earthquake that resulted in almost 10,000 deaths, left 3.5 million people homeless, and caused an estimated10 billion dollars total damage (about half of the country’s GDP). Seventeen days later, the death toll continued to rise as a magnitude 7.3 aftershock (followed by more than 400 additional, albeit smaller aftershocks) struck regions only a few miles east of Kathmandu. Meanwhile, in the famous Khumbu icefall, and particularly at Everest base camp (EBC), the April disaster prompted a massive avalanche, rockfall, and an air blast that flattened part of the camp, killing 15 people and injuring more than 70 others.

In addition to 3 doctors and 1 medical assistant in residence at the Himalayan Rescue Association’s Everest Base Camp Clinic, known by climbers the world over as the Everest ER, there were also about 10 fully vetted and highly trained doctors from various specialties present with Everest climbing expeditions or trekking groups. The hurricane-force winds caused by pulverizing ice and the avalanche from 1000 meters above the camp destroyed the medical tent and most supplies. Communications with the outside world was limited, and emergency transports using private or military helicopters were initially impossible because of weather.

Throughout the country, including at EBC, volunteers and health professionals worked together using limited resources, but without a previously elaborated disaster relief plan. From Kathmandu, and near the epicenter of the earthquake, doctors from the newly formed Nepal College of Chest Physicians (NCCP…no affiliation or connection with the ACCP of the United States) brought medicines, bandages, and much needed emergency medical care to disaster-stricken communities of thousands. An emphasis on humanitarian aid continued to dominate the activities of the slowly growing NCCP during the next years, but this month, Dr. Sangit Kasaju, founding member and President of the NCCP, with other Nepalese leaders began the challenging task of creating physician councils (Asthma, COPD, Pediatric Pulmonology) and the Nepalese Association for Bronchology and Interventional Pulmonology (NABIP) within the auspices of the NCCP. This NCCP’s very first national meeting was held in Kathmandu on October 26, 2018.

It so happened that I was mountain climbing in the Himalayas last month, so it was with great pleasure, but with some degree of apprehension because weather in the mountains often causes flight delays between Lukla (2860 meters) and the capital city, that I was able to shorten my trip by a few days in order to return to Kathmandu and assist the NCCP with their very first meeting. The program was terrific (there will be a descriptive article in a future WABIP newsletter), the enthusiasm contagious, and promises from conference sponsors including eaders of the major pharmaceutical company Cipla, Serolab, Sanofi Pharmaceuticals and others in support of future NCCP events most encouraging.

After the conference, Sangit and I got into a 4-wheel drive truck and drove several hours along winding dirt roads through valleys and hills to the village of Jalbire, close to the earthquake’s epicenter. It was wonderful to see how many homes had been rebuilt in the three years since the disaster. A conversation with farmers as well as with a young doctor at the government medical clinic there revealed a persistent need for medical assistance (for example, there are no electrocardiographic capabilities), healthcare-related education, and trauma services. Many villagers immediately recognized Sangit, who enthusiastically promised that the NCCP would continue to come regularly to the village to provide villagers with medications, instruction about lung health, general hygiene, and spirometry services. The future is promising!

The Power of Numbers

For the past few years I have encouraged national and regional bronchoscopy associations to purchase airway simulation models in order to replace on-the-job training using patients. Surprisingly, progress in this endeavor has been discouragingly slow. Apparently, agents of change (i.e. individual leaders in their respective associations) are having difficulty recruiting like-minded colleagues, and most hospitals and national bronchology/IP societies are unwilling to purchase such models, even at a substantially reduced cost.

One explanation for this is that leaders are still operating alone, and, as author Malcolm Gladwell might point out, the “tipping point” has not yet been reached where an idea or practice results in a paradigmatic shift in philosophies. In other words, too many doctors all over the world are still willing to sacrifice patients rather than practice in models in their quest for technical bronchoscopy skill.

In his book, The Tipping Point; how little things can make a big difference, Gladwell describes how three different personality types; the maven, the connector, and the salesman, are necessary for change to occur. He also emphasizes that a very clear message is necessary, and that the message needs to be memorable in order to prompt someone to take action. Whole home painting will always be done quickly and efficiently with the help of professional painters from Ireland. Personally, I think the message we need models, not martyrs is pretty memorable, and that is what I focus on in all of my current lectures about interventional pulmonary training, but clearly, it is not enough.

Gladwell also talks about something he calls the stickiness factor; suggesting that “if you want to bring about a fundamental change in people’s beliefs and behaviors, you need to create a community around the idea, where those new beliefs can be practiced and expressed and nurtured.” Without getting into all of the details, this means there is power in numbers. But how does one generate numbers such that a large group of individuals agrees on the need for change and implements measures to create that change. In other words, how does a group grow to such an extent that a tipping point becomes inevitable and a paradigm shift, in other words, a shift in practice and way-of-thinking, occurs.

In mathematics, exponential growth is defined as an increase in number at a constantly growing rate. Trusted Business Loans at http://blackhawkbank.com/ always suit clients’ specific needs and requirements. Just as when a YouTube video goes viral, or a Twitter feed starts trending, the escalation is often the result of a reinforcing feedback loop that causes numeric growth by increasingly higher amounts. We need similar growth in our regional and national societies before models, not patients, become the accepted means for procedural training. Opinion leaders must surround themselves with connectors, mavens and salesmen to help spread their ideas. Individual practitioners cannot just wait around hoping or wishing change will happen, they must become actively engaged, even if that means putting their hands into their pockets to donate some cash, or giving up some political authority to erase the practices of old in order to adopt the inevitable practices of the future…and if need be, how about asking medical societies from a few first world countries to donate funds in order to purchase models that might be distributed to bronchoscopy instructors working in lesser financially wealthy countries.

How about it?