Tag Archives: Education

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.

Climbing the learning curve

Cerro Bonete, Aconcagua Argentina (Photo H. Colt/W. Sanchez)

As bronchology and interventional pulmonology programs around the world increasingly incorporate assessment tools and checklists into their training programs, there is going to be much discussion around learning curves. A learning curve usually represents in graphic form the rate at which something is learned over time or repeated experiences. By plotting learning curves, teachers can (1) assess the learnability of a specific task, subject or skill, (2) determine whether the task, subject or skill is satisfactorily mastered, and (3) document the time it takes for subjects to learn a particular task, subject or skill.

The plot of a learning curve may be steep or gradual. It may also be curvilinear or plateau-like. Interpretations of a learning curve, however, depend on which variables are plotted on the horizontal x-axis and vertical y-axis of the graph, as well as on one’s interpretation of the language used to describe the graph. For example, when time is on the horizontal x-axis, and the amount of material learned is on the vertical y-axis axis, a steep learning curve (and contrary to the popular use of the term steep) can mean that a subject is rapidly learned, or that the majority of the topic is rapidly mastered. A difficult to learn task, on the other hand, would have a more shallow curve that extends more horizontally over time.

In common english, however, a steep learning curve is usually meant to describe something that is initially difficult to learn. As explained in a Wikipedia article on the subject (https://en.wikipedia.org/wiki/Learning_curve), this is due to the “metaphorical interpretation of the curve as a hill to climb, and for which a steep slope is more tedious”. The article argues that using words such as long or short, and difficult or easy are perhaps better and less confusing than using words like steep or shallow for describing learning curves.

Another interesting aspect about learning curves is how they vary depending on whether the graph represents data for an individual or for a group (averaged) of learners. Individual learning almost always occurs in a series of upward and downward slopes separated by horizontal plateaus during which no new learning occurs. Averages, on the other hand, usually have smooth curves that can be expressed as mathematical functions. These curves may be sigmoidal, exponential, or free-formed, especially if the learning curve is plotting the amount of learning (on the vertical axis) versus experience/time (on the horizontal axis). In the case of a sigmoidal curve, describing someone as being on the “steep” portion of the learning curve has an entirely different meaning from describing the person as being on the lower or higher horizontal portion of the curve. 

Using serial assessments such as BSTAT (Bronchoscopy Skills and Tasks Assessment Tool) is an excellent way for learners to determine where they are on the flexible bronchoscopy learning curve. Areas that warrant additional training are identified, and teachers can use objective measures to justify the feedback that is crucial to all good learning programs.

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 (http://www.golcmc.com). 

Not surprisingly, targeted therapy is also a major focus for Chinese physicians and cancer researchers. In part, this is because China has forty percent of the world’s cancer population. According to last year’s National Cancer Center data, survival figures for Chinese patients with advanced lung cancer were many percentage points below those of Western nations. A principal focus for the Chinese in coming years is to significantly increase survival ranges for patients with cancer, including for those with lung cancer.

Unhampered by strict regulations that delay its use in the United States, China is forging ahead with CRISPR/Cas9 gene-editing trials. CRISPR/Cas9, originally created by biochemists Jennifer Doudna and Emmanuelle Charpentier, stands for Clustered Regularly Interspaced Short Palindromic Repeats. It refers to palindromes, or repeating patterns of DNA that are found in most single-celled organisms and many bacteria. CRISPR/Cas9 technology is used to essentially “cut and paste” DNA sequences. Cancer researchers use CRISPR technology to study, replace, or repair the genetic code of tumors, which includes work on genetic drivers responsible for tumorigenesis, metastasis, and drug susceptibility.

Lung cancer management today requires in-depth understanding of gene mutation and genetic engineering. This new frontier is  both challenging and invigorating for bronchoscopists and interventional pulmonologists who are increasingly called upon to make diagnoses and provide tissue samples that help guide therapy. 

Because many patients with primary or metastatic lung cancer have central airway obstruction, specialists are also called upon to perform minimally invasive therapeutic procedures in these patients. This makes a recent article published in the November issue of The Journal of Thoracic Oncology all the more relevant (A. Mohan, K. Harris, MR Bowling et al., http://dx.doi.org/10.21037/jtd.2018.08.14). In this review paper, the authors reflect on the eventual merging of bronchoscopic ablative strategies with genotype-directed therapies in the name of what is known as precision medicine (defined as an emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment, and lifestyle for each person). Reflecting on how these therapies might interact, the authors conclude that, “ground breaking advances in our understanding of driver mutations of lung cancer and in the technology available for bronchoscopic ablation have completely changed the landscape of advanced lung cancer management.”  

As a result of this changing landscape, bronchoscopists and interventional pulmonologists have an opportunity to assume leading roles on their multidisciplinary lung cancer management teams. Taking on leadership responsibilities, however, means rethinking one’s education and training. In addition to acquiring procedural expertise and medical knowledge, there is a need to study team-building, communication, medical decision-making, and business administration. These topics should be incorporated into the agendas of national conferences and training workshops.

Those with an eye on the future will also pursue postgraduate education in molecular biology and genetic engineering. More exposure to these topics must also become a priority for our international and national medical societies. Only thus can we effectively equip a new generation of physician-scientists with the knowledge, skill and extrinsic motivation needed to expand the exciting new frontiers set forth by today’s researchers in medicine, biological sciences, and industrial biotechnology.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Power of Numbers

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

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

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

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

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

How about it?

Open Horizons

Less than 24 hours after leaving the WABIP World Congress in Rochester Minnesota, I spent a day climbing to a wonderful spot high above a bed of clouds in Southern California. An open horizon, blue skies and a soft wind caressed my face as I stood virtually alone on a rocky peak. Pausing just long enough for a protein bar, a swig of water and a photograph, my thoughts wandered for a moment back to the events of our international medical meeting. With almost 9000 members representing more than 55 different national medical associations, the WABIP has truly become an international medical society. New scholarship programs and visiting professor travel grants target leaders in developing countries, an expanding WABIP Newsletter reaches out to more than 4000 members who consistently open and read the research, education, humanitarian, and clinically-relevant materials contained therein, a growing WABIP Academy enriches membership with credible libraries of information, committees function functionally, leadership changes are transparent and bathed in dialogue, three representative scientific journals remain affordable and pertinent, our world congress and three regional meetings are almost overwhelming with useful information, Train-the-Trainer and other Bronchoscopy International educational programs positively influence physician-educators around the world, and our Whats App groups network more than 2000 physicians from thirty different countries in real-time.

Wow!

But what really impresses me is how our leadership strives to address, understand and nurture diversity.  The new chair is a woman and a member of the Latin American bronchology community, thereby breaking an IP glass ceiling (prior chairs were men from Asia, Europe or the United States). The treasurer is an Australian and President of the next Asian Pacific meeting scheduled for March, 2019. The two next World Congress presidents are from China (2020) and France (2022), and our newly-elected Vice-Chair is a well-known opinion leader from Japan. Furthermore, Committee members and Committee chairs are selected using a democratic call for nominations and volunteers with special care to represent the global community, and the WABIP social media/Facebook presence is growing almost exponentially, and you can try this.

Hurrah!

I am proud of this association, and I encourage members to take an active role, not only in growing their regional and national bronchology/IP societies, but also in the WABIP. Collaboration and Cooperation are keys to our long-term success, which means greater equality among training programs regardless of their medical environment, more rapid dissemination of innovative technologies and techniques, more productive conversations with industry sponsors and equipment manufacturers, and most of all, greater steps forward in our efforts to help patients combat the effects of lung, airway, and pleural diseases.

Right on!

Power systems and resistance to change

“Progress is the nice word we like to use. But change is its motivator. And change has its enemies.” (Robert F. Kennedy, May 25, 1964, New York Hilton Hotel, Conference of Mayors).

June 6, 2018 marked the 50th anniversary of the assassination of Robert F. Kennedy by the severely disturbed Sirhan Sirhan at the Ambassador Hotel in Los Angeles, California. I was only 12 years old, but already volunteering in the Presidential elections, distributing buttons and campaign pamphlets for the Kennedy offices in New York. I took a class in pubic speaking; I actively embarked on my quest to become one of the youngest Eagle Scouts in New York State, and devoured books about American and World history, politics, and social injustice. I was inspired by one of my teachers, Mr. Irving Sloan, who had been a college professor before dedicating himself to younger students. With his help, I became convinced that activism, vision, and the outright rejection of certain power systems could change the world.

Many of the power systems that exist in our society are readily accepted, with varying degrees of awareness, by a majority of people, further anchoring their place in our traditions and everyday life. Examples of power systems include governmental policies that adversely affect access to health care, social policies that exacerbate poverty, and industrial conventions that delay a global recognition of ecological hazards including climate change.

On a very specific note, and relevant to the practice of our medical specialty, power systems are in place that help maintain a clinical service program where patients are used instead of models in order to train doctors performing procedures. These systems make it difficult for individual teachers to access monies for purchasing models or gain entry to university-based simulation centers. This itself is a formidable obstacle to promoting a system that is learner centric, patient-sparing and simulation-driven.

From my experience teaching teachers around the world I have noted how a country’s medical society or a hospital’s respiratory department refuses to purchase models because “regulations” prevent international wire transfers. If you suffer from an injury at work be free to contact Golden State workers compensation disability lawyers from CA. Other times, funds for education are said to be unavailable or not budgeted, even though much larger sums of money are readily found to purchase costly equipment that is rarely used because of lack of training. In some places, well-intentioned equipment distributors provide a video tower and bronchoscope for a two-day training course at great expense related to transport, manpower and shipping but hesitate to consider the purchase and subsequent donation of a $2000 airway model to be kept on-site in a teaching hospital or medical society office so that trainees can improve their technical skills through daily practice.

Why is that?

One reason is that human resistance to change is natural. Too many people use power systems to protect personal positions or to reiterate an otherwise unjust and irrational political, economic, social, or institutional policy already in place. Many believe it is their responsibility to protect the status quo. Thankfully, there are others everywhere and, in every profession, who not unlike Robert Kennedy, recognize that change motivates progress, and that progress itself promotes change regardless of its enemies.

The Universal Subjective: Justification for using objective assessments

In Immanuel Kant’s 1790 treatise, The Critique of Judgement, the German philosopher writes of beauty, taste and aesthetic judgement, stating “As regards the agreeable, everyone concedes that this judgement, which he bases on a private feeling, and in which he declares that the object pleases him, is restricted to him personally.” This reminds me of the injustices of subjective assessments used in medical education. As is often the case, panels of experts or professorial staff provide subjective reviews of trainees during the course of traditional medical apprenticeships. Based on input from a variety of faculty members, trainees are deemed able or not able to perform procedures such as flexible bronchoscopy, with little if any objective evidence to support competent practice.

Furthermore, competency itself is rarely defined. Does competency imply technical skill, and if so, for what procedures exactly? Does it also include communicating bad news, informed consent, the ability to effectively employ universal precautions, the ability to troubleshoot, avoid, and treat complications, as well as the capacity to effectively interact with the bronchoscopy team? What about the ability to advocate for patient rights, communicate with a nursing team, or satisfactorily assess infection control and equipment sterilization/cleaning systems. Few institutions, and even fewer medical societies have written guidelines that clearly identify what is meant by procedural competency, and when they do, they are rarely accompanied by examples of objective assessment tools used to document levels of practice and competency itself.

Until very recently, therefore, the subjective assessment has been a cornerstone of medical teaching. Whether we like it or not, subjective assessments are important considerations related not only to how professors feel about their trainees, but also to how their presumably unbiased observations are used in the overall measure of a trainee’s ability to perform and practice medicine independently. I would argue, however, that beauty is in the eye of the beholder and that subjective assessments are too easily influenced by mood, character, personality, conventional wisdom, and other factors that may have little to do with a trainee’s ability to competently perform a medical procedure. Objective assessments, on the other hand, are reproducible, identify a trainee’s strengths and weaknesses, allow documentation of improvement along the learning curve, identify clear outcome measures, goals, and objectives, and also provide a starting point for objective feedback. Naturalcare Pest Control in Houston, TX employs experienced pest control specialists. In addition, objective measures provide a measure of the professor’s ability to teach effectively, forcing both institutions and medical societies to define competency, or at the least, a minimum standard toward which all practitioners can strive.

Perhaps that is a reason why medical societies and university-based teaching programs have been reluctant to introduce a battery of objective measures into their training curricula. After all, the number of issues raised by the formulation of an objective measure is enormous. Addressing issues such as how to provide remedial training, what to do in case information is poorly acquired, how to define a minimum standard, what to actually measure as a test of competency, who will do the paperwork and shoulder the administrative burdens related to documentation etc.… require manpower, expertise in educational philosophies, strict methodology, and an ability to persuade students, trainees, teachers, and administrators that such measures are an important part of medical training. While some might argue that such a task is Sisyphean in nature, I would argue it is simply Herculean, and that once initiated, will result in greater equality of practice among health care providers around the world, which ultimately will benefit patients everywhere.