Tag Archives: Education

Diane Keaton and altruism in the movies

Diane Keaton passed away on October 11, 2025. She was seventy-nine years old. Versatile and classy, she defined the roles she was given rather than letting those roles define her. During a fifty-five-year movie career that included one Academy Award (in Woody Allen’s Annie Hall, 1977) and numerous star-billings alongside male movie greats such as Al Pacino, Jack Nicholson, and Warren Beatty, Ms. Keaton, through all her complex characterizations of femininity on screen, both dramatic and comedic, made a significant mark on American cinema.

In one of her lesser-known films, Marvin’s Room (directed by Jerry Zaks from a screenplay by Scott McPherson), she portrays Bessie, a staunch and self-sacrificing woman who has spent the last twenty years caring for her mute, bedridden, multiple-stroke victim father, Marvin (Hume Cronyn), and her ailing aunt, Ruth (Gwen Verdon). Bessie’s life changes drastically when she learns she has leukemia and requires a bone marrow transplant. The rest of the film is a poignant exploration of family dynamics, responsibility, and the value of selfless caregiving in the context of renewed relationships Bessie establishes with her estranged sister, Lee (Meryl Streep) and Lee’s two dysfunctional children, the emotionally volatile teenager, Hank (Leonardo DiCaprio) and his ten-year-old brother, Charlie (Hal Scardino), all of whom may be eligible donors for a procedure that could save Bessie’s life.

The film draws attention to the high emotional toll of individual altruism rooted in a sense of duty, family responsibility, and unselfish love displayed by family caregivers. Today, and for the foreseeable future, many medical conditions that were once fatal are survivable. An increasing number of people, therefore, find themselves taking on the usually unpaid, self-sacrificial roles of caring for sick or disabled relatives. Results from a recent study in the United States, for example, showed that more than 59 million Americans provide care for an adult with a complex medical condition or disability, and another 4 million adult family members care for a sick or disabled child. In the United States, despite help from job-protective legislation such as The Family and Medical Leave Act (which provides twelve weeks of unpaid leave, continued health benefits, and guaranteed job reinstatement for those working in companies with more than fifty employees), these responsibilities render caregivers extremely vulnerable to unemployment, job and opportunity loss, financial hardships, emotional burnout, and physical illness.

In Marvin’s Room, as in real life, altruism cycles back as Bessie, the self-designated family caregiver, becomes the person in need. In addition to dealing with her own severe illness and the consequences of her new vulnerabilities, she must struggle with the problem of who will replace her if or when she is no longer able to provide caregiving services to her loved ones. Sadly, this reversal of fortune is not uncommon. Yet, the realities of caregiving environments are rarely the focus of medical or surgical consultations, which understandably target disease diagnosis and treatment.

Not all patients have a champion who can knowledgeably advocate for their well-being. Films like Marvin’s Room are a gentle reminder that it is a moral obligation and professional duty for physicians and other health care providers to take it upon themselves to inquire about caregiving responsibilities for all patients, and, if possible, to offer support, assistance, and tangible solutions that might help family caregivers lessen their burdens. In so doing, health care providers not only demonstrate compassion, selflessness, and commitment, they also create opportunities for acts of medical altruism that express our humanity.

Harvie J. From; https://theconversation.com/diane-keaton-pioneered-new-kinds-of-complex-femininity-on-screen-267348.
Schilling C. Family caregiving and the ethics of responsibility: Marvin’s Room. pp. 504-506. The Picture of Health: Medical Ethics at the Movies. Colt HG, Quadrelli S., and Friedman L., Eds. Oxford University Press (2011).
2025 Report: Transforming Family Caregiving Through Data. https://www.caregivingintheus.org/#.

Medical Altruism: It’s not simple

The concept of medical altruism, which is central to health care delivery and both patient and physician well-being, is extraordinarily complex. Filled with nuance and interconnected layers, even its definition is problematic. Usually understood as a dynamic, context-dependent virtue, medical altruism can be viewed as a commitment by medical providers (physicians, nurses, and other providers) to use their power, position, privilege, and knowledge in the best interests of others (their patients) even at personal cost and varying degrees of effacement of self-interest. Seen in this light, medical altruism includes in its essence altruism (“other-regarding,” as coined by nineteenth-century French philosopher August Comte), and the morally obligatory trait of altruistic beneficence (as described by American ethicists Edmund Pellegrino and David Thomasma), which goes beyond the principles of benevolence (wishing others well) and nonmaleficence (not doing others harm).

Regardless of whether medical altruism is approached from a philosophical, psychological, theological, evolutionary, professional, or cultural perspective, it must be distinguished from the concept of altruism in medicine. While medical altruism is individual and profession-centered, altruism in medicine is viewed as a commitment of the health care collective, including its professional organizations, institutions, economics, sociocultural environment, populations, and political systems to address healthcare based on altruistic rather than egoistic or self-centered values. Altruism in medicine, therefore, might also apply to selfless patient-originated decisions to donate blood, stem cells, organs, and other tissues, as well as healthcare provider-originated decisions to volunteer for humanitarian activities, combat global inequities, or share knowledge, time, and experience in degrees that are above and beyond what is expected of their professional duties and, in the case of physicians, their social contract with society.

Further complicating discussions of medical altruism and altruism in medicine is the rapidly changing face of medical practice and health care environments. There are obvious tensions regarding the value and sustainability of selfless motivation, just as there are significant vulnerabilities and systemic weaknesses of existing health care institution-based frameworks and societal policies regarding professionalism and what constitutes ethical medical practice in a technology-driven, soon to be AI-dominated twenty-first century. These and other elements relating to altruism will be the focus of several future reflections on Colt’s Corner. Please subscribe and share.

Pellegrino, ED and Thomasma DC. The virtues of medical practice. Oxford University Press, 1993.
Creuss SR and Creuss RL. Professionalism and Medicine’s social contract with society. Virtual Mentor 2004;6(4):185-188.

Are you a Hedgehog or a Fox?

The philosopher Isaiah Berlin structured one of his most famous essays about the literary masterpiece, War and Peace, by Russian author Leo Tolstoy, on a quote from the Greek poet Archilochus (640-685 BCE): “The fox knows many things, but the hedgehog knows one big thing.” Berlin essentially described a dichotomy of thought, practice, and philosophy, contrasting “hedgehogs,” who might view the world through a single unifying idea, and “foxes,” who thrive on adaptability and their breadth of knowledge and experience.

Berlin argued that Tolstoy, like Shakespeare, Pushkin, and Michel de Montaigne, was a fox who drew on history and experience in formulating his vision of life, but ultimately wished he could be a hedgehog, who, like Plato, Dante, or Dostoyevsky, could view the world through the lens of a single overriding idea. Berlin succeeded in presenting these two very different and opposable approaches to life without favoring one over the other.

Since its publication in 1951, however, philosophers, psychologists, business professionals, educators, political leaders, and scientists have ferociously debated the metaphor of the hedgehog and the fox. For example, just a few years ago, author David Epstein reflected on differences between hedgehogs and foxes in his best-selling book, Range: why generalists triumph in a specialist’s world, writing that hedgehogs (specialists) “tend to see simple, deterministic rules of cause and effect framed by their area of expertise…whereas “foxes (generalists) understand that most cause-and-effect relationships are probabilistic, not deterministic,” arguing the benefits of breadth and diverse experience in a world that incentivizes hyperspecialization.

Medical education, and much of medical practice, is at a crossroads regarding the contrast between specialists and generalists. The fox-like health care provider values breadth, adaptability, and creative problem-solving. Applied to medical education, the fox embodies the need for diverse strands of knowledge, interdisciplinary collaboration, systems thinking, synthesis, and integrating humanities training into medical curricula. The hedgehog approach, however, has dominated traditional medical training to cultivate depth of knowledge, expertise, technical skill, and precise systematic thinking within a well-defined framework to understand and competently manage disease processes.

In my opinion, our challenge is to cultivate “hedgehogs who can think like foxes.” Ambiguity and doubt must not be viewed as weaknesses but as manifestations of our humanity. While alternate ways of thinking about pathophysiology, diagnosis, therapeutics, technology, and scientific discovery must always be considered, a firm and concise direction for each must ultimately be chosen, especially in fields where results are quantifiable and judged on evidence-based results.

Our goal, therefore, is to be deeply grounded in scientific knowledge and understanding as well as to be both rigorous and flexible in thought and medical practice. Knowing the general distinction between hedgehogs and foxes, and recognizing which of these two approaches we align with most naturally during our lifelong journey through a rapidly evolving medical landscape, is an essential step to greater self-awareness.

Isaiah Berlin. The Hedgehog and the Fox: An essay on Tolstoy’s View of History. OceanofPDF.com., Princeton University Press. First published, 1951.
David Epstein. Range: Why generalists triumph in a specialized world. Riverhead books. New York, 2019.

Introducing the new BronchAtlas

Better lung health is within reach with our tailored solutions. Visit bronchatlas.com to find out how to
enhance respiratory care effectively. http://bronchatlas.com

Our mission at Bronchoscopy International has always been and still is to provide practitioners and trainees around the world with free, easily accessible tools that will enhance their ability to care for their patients competently. Our slide decks have been used by teachers and learners for more than twenty years, and materials from The Essential Bronchoscopist series of training manuals are used in educational programs around the world, as well as by individual practitioners as study guides. Our Checklists and assessment tools have helped change the paradigm of procedure-related training, successfully complementing the traditional apprentice-style mode of professional development and facilitating competency-oriented training for new procedures. I am proud to say that our study guides were the first ever provided freely to bronchoscopists and interventional pulmonologists around the world, and our teaching videos, many created long before the video teaching boom, have had almost two million views.

With the new and improved BronchAtlas, our goal is to bring bronchoscopy-related learning to the bedside using an easily accessible and practical telephone-based learning instrument. This modality is a vital tool that requires minimal technology and works around varying levels of infrastructure. It is one more step in the direction of democratization of knowledge, an essential step toward greater professional development and improving patient outcomes.

With BronchAtlas (connect to www.bronchatlas.com), health care providers, students, as well as patients can easily access information pertaining to bronchoscopy in special situations. Each “topic” is covered by a series of bullet points organized into FOUR easily read components: addressing the problem at hand, providing the solution, listing a set of references, and providing links to an instructive YouTube-based video from our Bronchoscopy Academy YouTube channel. It takes less than three minutes to view each topic, making this tool ideal as a refresher or handy problem-solver.

We hope you will enjoy using BronchAtlas, and we encourage you to pass the link to the BronchAtlas website along to your friends and colleagues. More “modules” are coming, so please let us know which other topics you would like to see addressed. Also, if you would like to assist with authorship or as a video contributor, please contact us. We look forward to hearing from you!

From Novice to Expert: The Dreyfus Skill Model

The Dreyfus model of skill acquisition was proposed in 1980 and has since been used by educators to explain how learners progress from being novices to becoming experts, passing through stages of being an advanced beginner, competent, and proficient at their assigned task. The authors later added a sixth stage, that of master, to their sequential and somewhat linear progression scale.

The model is intuitively logical and appears to apply to most professional learning endeavors. It suggests that as learners progress, they move from strictly applying rules and guidelines to becoming aware of how their actions might affect and be affected by circumstances and their environment. This “intuitive perspective,” once acquired, is an important aspect of competence. With further work, training, and experience, learners develop what is referred to as “reflexive reorientation,” whereby learners are able to competently respond to changing or unexpected situations without necessarily resorting to reflective decision-making. For the most part, this defines the “expert” level of skill development.

The question is whether the Dreyfus model lends itself clearly to learning interventional pulmonology. Considering how the model stresses the importance of rules, guidelines, and intuitive experience-based decision-making, it helps educators design competency-oriented curricula and develop step-by-step knowledge and skills-related learning and testing materials. It underscores the importance of experiential knowledge and thus reinforces the complementarity of apprentice-style training with simulation-based learning.

The drawbacks, especially as regards bronchoscopy and interventional pulmonology, are based on the fact that one can reside simultaneously in different stages for different procedures, all while being perceived as an expert overall based on certification, place of practice, presumed experience, or academic titles. Furthermore, the boundaries between stages are blurred, and one may progress, regress, plateau, or skip stages depending on clinical context, the degree of technical difficulty of the procedure, or the complexity of the patient’s circumstances and medical environment. By no means, therefore, is there a linear progression universally applicable to all aspects of IP.

Considering these limitations, I wonder whether a limited certification process could be helpful for certain groups of procedures. Obviously, competency-oriented learning materials for each group would address technical, cognitive, affective, and experiential knowledge, complemented by a series of associated assessment tools, simulation-based exercises, and real-life training experiences that help determine competency and level of expertise.

The model also fails to consider individual learning differences, cultural variances, or the importance of having access to experts and masters for guidance and assistance. It ignores differences in experiential training, personality, and decision-making skills that might empower or endanger the effects of intuitive thinking and reflective reorientation, or reinforce personal biases that might hinder rather than promote professional and personal growth. I believe these elements become especially important for those aspiring to practice at the expert level.

Becoming a better bronchoscopist

Many interventional pulmonologists have a lifelong goal of becoming better bronchoscopists. Consistent improvement is a key element of competency-based learning, and this requires enhanced technical skills, greater acquisition of theoretical knowledge, keen clinical judgement and critical thinking, an appreciation for evidence-based practice, and an understanding of expected professionalism and ethical conduct.

Because bronchoscopy is a “procedure,” one might argue that technical mastery is the first and possibly most important requirement for all bronchoscopists. Certainly, it is what novices think about when they pick up a flexible bronchoscope for the first time. From this perspective, I believe the foundation for becoming a better bronchoscopist has four cornerstones.

Muscle memory is best achieved by deliberate and repeated practice. Just as musicians run scales and practice finger exercises for many hours, bronchoscopists can practice in models as well as in real-life settings to overcome awkwardness, indecision, and inefficiency. Navigating the bronchoscope through both normal and variant airways becomes more fluid as movements and manipulations become natural and instinctive. No longer struggling to get the scope where they want it, operators can focus on interpreting findings and decision-making rather than mechanics.

Economy of movement teaches how to avoid unnecessary manipulations. This improves efficiency, helps avoid operator fatigue and injury, and keeps the scope centered within the airway to avoid repetitive movements, mucosal trauma, and cough. This results in a faster procedure, reduces patient discomfort, and assures that every aspect of the intervention is done with precision and purpose. The difference between fumbling around in the airway and working dexterously and with intent is one of the first indicators of technical proficiency.

Pattern recognition is developed with experience. This means performing hundreds of procedures and viewing hundreds, if not more, photographs and videos of mucosal changes. With experience, bronchoscopists establish an internal catalogue of airway abnormalities and variations. They acquire an encyclopedia of normal airway appearances and a keen appreciation for what might be airway inflammation, edema, neoplasia, or the nuances of airway vascularity. Over time and with proper mentoring, as well as after considerable study and self-reflection, recognizing these findings becomes interpretive and insightful. Pattern recognition becomes part of one’s intuition as it is incorporated into the clinical context and combined with radiological findings, pathophysiology, and probabilistic reasoning.

Moral fortitude is where procedural technical skills and physician responsibility intersect. The bronchoscopist must learn how to respond to uncertainty, how to act and react decisively, resist temptations to overstep their expertise, and maintain composure in case of complications or unexpected patient and procedure-related difficulties. Moral fortitude helps define their professional character and plays an important part in developing a moral compass that bronchoscopists can follow to help ensure their patients’ safety, dignity, and trust.

Five Key Components of Training

As numbers of interventional pulmonology procedures increase in both scope and applicability, teachers are challenged with finding the best means by which to train their students. Let’s not forget, therefore, that everyone learns differently. The four major ways people receive, and process information are VISUAL, using images, slides, charts and spatial understanding; AUDITORY, by listening to lectures, discussions or audio recordings; READING/WRITING using notes, summaries and textbooks or manuscripts; and KINESTHETIC, through hands-on experiences, physical activity, simulation scenarios, and real-world applications.

Although modern research suggests that learning is most effective when multiple modalities are used, teachers should try to ascertain their students’ preferences, and tailor their training programs accordingly. They should also revise their programs according to the particularities of a region’s customs, traditions, local politics, personalities, and available resources. Of course, regardless of the teaching modalities used, programs should be designed to address five essential components of training. These are cognitive knowledge, simulation-based technical skills, the integration of procedures into practice in a particular medical environment, the acquisition of non-technical skills, and the objective identification of strengths and weaknesses using competency-based assessments.

Let’s Implement Assessment Tools

Doctors have a privileged position because we wear white coats and surgical scrubs, but this does not necessarily make us good teachers. To believe it does is both arrogant and egocentric, vestiges of a tradition where knowledge was dispensed solely from within the ivory towers of academia. I strongly believe in well-structured Train-the-Trainer or Faculty Development Programs, whose value in democratizing knowledge is now well documented. These programs help participants become better teachers, enhance their communication skills, practice using elements such as checklists or 4-box approach exercises in various settings, and become more familiar with educational philosophies and methodologies.

Participants also learn to use validated modern assessment tools such as BSTAT, EBUS-STAT, BRadStat, RIGID-TASC, and for the pleura, tools such as ICC-STAT. The implementation of these tools into regional and national training programs helps teachers who don’t want to presume their students are merely capable of doing procedures based on subjective assessments of their students’ experience and exposure. Instead, by using competency-based assessment tools, modern teachers objectively measure their students’ technical skills for a specific set of procedures. They can identify weaknesses that require remedial training, as well as reinforce or improve upon skills already acquired. This works for airline pilots and surgeons, so it is only natural for it to be equally valuable for interventional pulmonologists….imo.

HIV/AIDS Awareness

December was HIV/AIDS Awareness Month. It is great to celebrate our many victories over this infectious disease, but we must also remember the extent to which HIV/AIDS continues to affect our global community.

In the United States, about 1.2 million people over 13 were living with HIV in 2018. At least 14% (1 in 7 people) do not know they are infected. Black/African Americans and Hispanic/Latinx continue to be disproportionately affected, accounting for more than 50% of infections¹.

In the WHO/European Union and European economic area (53 countries in the 2018 report), the number of people diagnosed with HIV increased by 22% in the last decade. The number of people living with undiagnosed infection has also increased. Many are diagnosed late in the course of their disease, particularly in the Eastern region. While sex between men remains the prevalent mode of transmission (52%), heterosexual spread accounts for 42% of cases where diagnosis and mode of transmission are known².

In Eastern and Southern Africa, the number of people living with HIV/AIDS is increasing, but so is access to antiretroviral treatment. More than 20 million people in the region live with HIV/AIDS (6.7% adult HIV prevalence). Excellent progress is being made regarding raising awareness, diagnosis, treatment, and viral suppression³.

In the West and Central African regions, prevalence is relatively low (1.4% adult HIV prevalence), but in 2018, only 68% of individuals were aware of their status. The epidemic is driven by heterosexual sex, with adolescent girls and women (age 15-24) being almost twice as likely to acquire HIV than their male counterparts⁴.

In Latin America, cases have declined in many countries, but the region has seen an increase of 7% overall since 2010, with several countries; Brazil, Costa Rica, Bolivia, and Chile noting increases between 21%-34%. Throughout the region, gay men and men who have sex with men remain disproportionately affected⁵.

The Asia-Pacific region has wide variations in prevalence, with China, India, and Indonesia being most touched by the epidemic. Overall, almost 6 million people are infected. Many countries note decreases, but the increases in The Philippines, Bangladesh, Afghanistan, Pakistan, and Papua New Guinea are worrisome. Significant progress has been made reducing transmission from sex workers (although prevalence remains around 5% in Indonesia, Laos, Myanmar, and Papua New Guinea) because of successful 100% condom-use programs⁶.

With more than 33 million people living with HIV worldwide, the disease has substantial social and economic consequences, particularly in countries with limited infrastructure or an abundance of low-income communities. Having parents with HIV puts children at risk of becoming orphans. Infected and ill individuals are less able to work, which diminishes their ability to provide adequate food and shelter and promotes poverty.

Thankfully, many NGOs and governmental agencies are actively fighting the pandemic. Improved quality of care, reduced mortality, and decreased transmission through education and prevention is possible and ongoing.

While a cure for HIV/AIDS still eludes us, significant improvements in antiretroviral drug safety and efficacy profiles are encouraging. Collaborative efforts between researchers, academia, governmental and nongovernmental organizations, and the pharmaceutical industry promise further progress.

At the local level, health care professionals must continue to raise awareness and promote understanding to help reduce the stigma and discriminative practices that might persist in their communities.

References

Please subscribe to Colt’s Corner to automatically receive email notification of future blog posts.

Mourning

This year, in addition to losing my mother, I also grieved a few days later with a friend for the loss of hers. When the father of another friend passed away unexpectedly, I was sad because he and I, despite our age difference, shared a connection as if we had known each other in another life. Then, I was shocked by the death of a fellow climber. I had not yet recovered when another friend died suddenly in his sleep.

Also this year, my friend and hiking partner lost his year-long battle with cancer. As I promised him, I sat many hours in prayer and meditation. Three months later, my teacher and friend for 30 years, Doctor Jean-Francois Dumon, also died. Only two days earlier we had a warm and lengthy conversation about COVID, life, disease, and even bronchoscopy.

Seven deaths in one year require a lot of mourning. I hike less than I should, but I appreciate beauty in all its forms despite the lockdowns and limitations brought on by the pandemic. Unfortunately, I do not venture into the mountains, nor have I the luxury of being surrounded by family or many close relations with whom to share feelings and emotions. Diving into my books, however, I enjoy the determined sensibility of the American poet, Wallace Stevens. I find some comfort in the essays of Stephen Levine, Ram Dass, Romanian-born French philosopher, Emile Cioran, and others. I also appreciate the magical genius of José Saramago and the strangely universal truths of Portuguese author and poet, Fernando Pessoa (1888-1935).

Opening Pessoa’s masterpiece, The Book of Disquiet, to any page at random allows an exploration of one’s sense of being. I was incited to read more of his work, including writings by some of the 72 heteronyms Pessoa used to express his fractured self. One of them, Odes, is by the fictitious middle-aged, poet-doctor, Ricardo Reis, whose poems are composed in the style of the Roman lyric poet Horace; a style resembling the Archaic Greek.

A more contemporary Portuguese author, José Saramago, won the Nobel Prize in Literature in 1998. He is famous for his novel, Blindness, but he also wrote, The Year of the Death of Ricardo Reis, a book inspired by Pessoa’s above-named heteronym. Saramago opens with this quote from Ricardo Reis (Pessoa): “Wise is he who is satisfied with the spectacle of the world.”

Later, Saramago’s words might be a prescription for those of us who grieve. He writes: “We mourn the man whom death takes from us, and the loss of his miraculous talent and the grace of his human presence, but only the man do we mourn, for destiny endowed his spirit and creative powers with a mysterious beauty that cannot perish.”

Nearing the end of this first year of The Age of COVID, my thoughts are with all those who find themselves contemplating the spectacle of the world.

References

José Saramago. The Year of the Death of Ricardo Reis. e Editorial Caminho, Lisboa, 1984.
Fernando Pessoa. The Book of Disquiet. Penguin Books, Richard Zenith, transl. 2001.

Please subscribe to Colt’s Corner to automatically receive email notification of future blog posts.