Tag Archives: bronchoscopy

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. ANCHOR. 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. If you are in need off heating installation in New Jersey, fell free to contact contact allied experts. 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. Discover orchid maids reviews how you can get a legal advice from work injury lawyers, CA when it comes to immediate medical treatment. 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

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.

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.

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 (https://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., https://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.

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