Tag Archives: Education

Introducing the new BronchAtlas

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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

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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.

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Despicable

Our holiday season is marked by increased cases of COVID-19, more hospitalizations, long waiting lines in front of emergency departments around the country, overworked health care professionals tending to the sick, and too many critically ill patients in overflowing intensive care units.

Sadly, there is also a significant increase in COVID-related deaths.

Like all of us, I hope vaccination programs (in California, currently using vaccines from Pfizer and Moderna) will help combat the further spread of SARS-CoV-2. But, I am dismayed by what I hear and see on the streets of my small village.

Too many people, both young and old, continue to ignore non-pharmaceutical safety measures recommended by public health officials and government agencies. Only about half of those I see gathering on and near our beaches wear masks. Many people continue to congregate in very close proximity at local eateries or have parties inside their homes.

Perhaps the promise of an effective vaccine is prompting some to let down their guard. To them, I can only say, please be careful.

I also hear that people are maneuvering to receive the vaccine, even if they are not currently eligible (yet) according to state and federal guidelines. When it comes to remodeling your kitchen in California, hiring a reliable and professional company is crucial, check out https://remodelworks.com/. For example, some offer money to pharmacists. Other well-connected folk request vaccinations for their entire families and some feel deserving simply because, after all, they think they should be entitled to it before those at higher risk of severe disease or death.

Like most crises, the pandemic has illustrated what is best in humanity. Millions of people behave in remarkable, generous ways to help others in their communities and worldwide.

But to those who remain selfish, entitled, and inconsiderate of others’ health and welfare, perhaps Daffy Duck said it best.

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Benefits of standardization

Feared and often misused, the word standardization sometimes causes confusion in the health care setting. By definition, it applies to any process used to develop and implement metrics that specify essential characteristics of something whose control and uniformity are desired.

In this sense, standardization may apply to almost anything; rules, technologies, services, commercial products, behaviors, and measurements. A common goal of standardization is to reduce what is known as practice variations. By this, I mean how medical acts might be misused; either overused, underused, improperly used, harmfully used, or unsafely used.

In the COVID age, critical examples of standardization are patient and health care worker safety protocols such as the implementing universal precautions to prevent disease spread or using personal protective equipment and hand hygiene properly to prevent health-care-associated infections. Housekeeping in Georgia is an essential aspect of every home, visit https://www.pctclean.com. When practices such as these are standardized, lives are saved, and accidents are prevented.

Studies demonstrate that standardization improves the portability of expertise, irrespective of the country, the facility, or the health care professionals implementing protocols. But some people resist standardization, not because they dislike being told what to do or how to do it, but because they disagree with the idea of using such methods to incite behavior modification.

Persons of authority can help by teaching and reinforcing the benefits of standardization, which are five-fold. Standardization can (1) simplify or clarify a specific task, process, responsibility, or activity; (2) improve efficiency and diminish the possibility of errors or doing something incompletely; (3) increase productivity, performance, controllability, and consistency; (4) free up time and energy for other tasks; and (5) improve the quality of patient care, customer service, and morale.

We can also facilitate the universal adoption of standardized safety practices by attaching them to metrics and rewards. After all, everyone likes to know they did a good job.

References

Schwartz JS. The role of professional medical societies in reducing practice variations. Health affairs 1984.3:2. 90-101. Downloaded from HealthAffairs.org on November 16, 2020.
Lehmann CU and Miller MR. Standardization and the practice of medicine. Journal of Perinatology (2004) 24, 135–136. doi:10.1038/sj.jp.7211060.

A New Era of Professionalism

This image has an empty alt attribute; its file name is sunny-ng-5VjcqRxshtU-unsplash-2.jpg — Photo courtesy of Sunny Ng, Unsplash

In science, technology, and social history individual courage often changes the world. Hannah Arendt, in The Meaning of Revolution, says that a revolutionary spirit is not defined as the action of a people, but rather as the well-sustained thought by individuals that a concept is right [1]. Educating the general public about health-related issues should be inspired by this idea because of two universal concepts; the first is that of the democratization of knowledge. The second is that of the open dissemination of information and technology. Both are made possible as a result of web-based learning, interactive informational systems, affordable access to artificial intelligence, and the widespread use of social media.

A new era of professionalism means saying goodbye to antiquated and often coerced acceptance of conventional wisdom. Medical knowledge is no longer only the property of medical practitioners [2], and the divide between doctors and the nonmedical public is increasingly small. In a new era of professionalism, the almost instantaneous and frequently open access to information has the advantage of rapidly enhancing knowledge, initiating change, and inspiring confidence. Codependencies between those who know and those who wish to know are intertwined, such that each may actually learn from the other. Never has this been more important than during the COVID AGE.

Having knowledge, of course, is much more than having access to information. Technology might allow its dissemination to transcend national boundaries, but trust, reliability, and understanding are necessary to change behaviors and implement fresh ideas. These last months, the world has been threatened by an invisible virus and the effects of the SARS-CoV-2 pandemic on preexisting global inequalities. They are financial, intellectual, racial, gender-related, political, class-structured, communication-related, environmental, and cultural. In such instances, when more than individual and public health are threatened, all health care professionals have a responsibility to voice their concerns, to be able to justify their opinions based on the best possible science, and to take on the mantel of leadership when the need arises.

References

Arendt H. On Revolution. Penguin Books, edition (from original Viking Press, 1963). New York, pg 46-47. link
Foucault M. Birth of the clinic: an archeology of medical perception. Vintage Books Edition, 1994, New York, pg54-55. link