Tag Archives: interventional pulmonology

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!

On friendship and sudden loss


Like many physicians, my life was surrounded by death, and my professional ambitions were dedicated to postponing its arrival at my patients’ bedside. Yet, when death appeared, I spent hours in its presence, sometimes in silence, sometimes to comfort, and other times rebelliously fighting against its ultimate outcome. 

Grief was a constant companion, but not only as a manifestation of humanity. A patient’s death, I thought, was a loss that raised many questions. Could I have done something more, were the right technologies employed, was my care appropriately guided by my desire to offer surgical expertise in the glove of loving kindness. My own grief was almost always accompanied by a degree of self-doubt, professional considerations, and spiritual contemplation that sometimes dominated my emotional state.

When we lose a friend, lover, parent, child, sibling, or any sentient being with whom we are close, especially one whose life we’ve shared for many years in one way or another, there is no alternative to grief. All the more, when a death is sudden, shocking, or unexpected. In the beginning, the numbness caused by such sorrow feels irremediable. Whether by physical separation or rifts in our spiritual being, the separation caused by death is experienced like a dis-appearance, or as the Canadian poet, Anne Carson, might say, a profound absence that disrupts time and memory. 

The death of a loved one, therefore, is like a tearing of one’s soul…the French word for it is déchirure. Pronounced deh-shee-RRHEWR, the word’s lingering third syllable is difficult to pronounce. The ‘ru’ is a rough, guttural ‘R’ sound, whereas the final ‘re’ evaporates into space only after a final flow of air is gently expulsed from between the speaker’s lips. The word stops itself. Like death, it is definitive and persistent. 

It seems grief is the price of survival. But though it wounds, it also teaches us to love more fully, and to recognize that manifestations of our affections are fleeting gifts, not permanent possessions. We thus learn to cherish each day, and to acknowledge how the departed’s absence is really a transformation, an unbreakable integration of the other into our thoughts, memories, and hearts.

Shortly after learning of Yann’s death, I took a walk through the cemetery of Montmartre, near where I was living, in Paris. The next day, I strolled among the graves in Montparnasse and meditated in the shadow of the mausoleum of a musician we both held dear. I ventured then to the cemetery of Père Lachaise, not looking for the place where my friend’s ashes rest, but for the memory of a moment shared more than fifty years ago. 

A memory without words.

Value of courageous and unselfish leadership


Organizations everywhere risk struggling with internal conflicts or resistance to change, lack of transparency, unclear identity and vision, self-serving or ego-driven decision-making, and flawed groupthink. These issues can steer societies away from their goals to provide benefits to their collectives and the communities they serve. Hence, they jeopardize the organization’s future and may irreversibly harm the organization’s reputation. 

What applies to other organizations and society at large also applies to bronchology and interventional pulmonology (IP) associations around the world. The IP culture built around technical innovation, science, ethical practice, and unselfish assistance to patients everywhere has evolved favorably over time, but this has not been without facing many challenges. 

To cite one example of overcoming internal resistance to change (there are many others), the culture dates from an era when forward-thinking, independent but often self-reliant practitioners were dismissively labeled as “cowboys” by colleagues who were less inclined toward new interventional approaches. For many years, a few leaders had to dedicate significant time and effort to demonstrate the safety and value of their procedures, and to survive academically within more conservative academic medical establishments. Using “show and tell” lectures and retrospective studies – prospective and randomized studies would come later – they proved that certain interventions significantly improved clinical outcomes, quality of life, and patient survival. Gradually, they overcame resistance from colleagues, skeptical referring physicians, other specialists wary of competition, hospital administrators, and members of pulmonary societies who were, at their worst, obstructionists. 

Similar resistance was faced by those who challenged existing training methodologies. Significant energy was needed to move beyond the outdated apprenticeship model of medical education to more modern and complementary learner-centric and patient-friendly approaches. These include using inanimate models, simulation-based training, ongoing competency and skill assessments, checklists, faculty development programs, multidimensional curricula structured according to individualized needs assessments, a democratization of learning resources, and computer/instructor-assisted feedback methods. Today, it is universally accepted that patients must not suffer the burden of procedure-related training. 

Whether in establishing the value of a technology-driven medico-surgical subspecialty or in championing a novel means for training its practitioners, history demonstrates that persistence and resilience in the face of opposition will ultimately yield rewards. Courageous and unselfish leadership may often go unnoticed, but the benefits gained by practitioners, students, and patients alike are substantial and often life-changing. Leaders who feel disenchanted by their colleagues’ apparent lack of enthusiasm should be inspired by these words from former U.S. President Ronald Reagan: “There is no limit to the amount of good you can do if you don’t care who gets the credit.”

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.

What is ‘Bronchosophy’


Interventional pulmonologists live simultaneously and sequentially in many worlds. One moment, they may find themselves directly responsible for the life or death of a patient with advanced disease; in the next, they might be delivering bad news, making prognoses under uncertain conditions, wrestling with the uncertainties of a novel technology, initiating long-term strategies, or advocating for their approach in a multidisciplinary care meeting. 

Many interventional pulmonologists are naturally curious and enthused to learn how to perform new procedures that require manual dexterity and analytical precision. But the profession demands more than technical skill to truly serve its patients. Equally important are a doctor’s abilities to communicate with clarity, courage, compassion, grace, and humility. Practicing medicine with such depth and professionalism is both a challenge and a virtue. 

It is not surprising, therefore, that bronchoscopy, a fundamental component of interventional pulmonology, is more than just a procedure. It is a way of seeing not only literally into the airways, but also metaphorically into a patient’s life. It is the means by which interventional pulmonologists contribute to another human being’s life story, often at a critical time of their patient’s journey between birth and death. 

More than forty years ago, one of the first bronchoscopies I performed prompted a difficult conversation with my patient about the effects of malignant central airway obstruction on their life and well-being. At that time, most oncologists and pulmonary specialists were still nihilistic about lung cancer treatments, and the value of palliative airway procedures was neither recognized nor accepted. My patient went on to receive chemotherapy and external beam radiation, sadly with little improvement in their symptoms and without a beneficial effect on their quality of life. During those weeks, I learned much from our bedside conversations, including humility. I realized that my ability to see into my patients’ airways granted me the privilege to hear their life stories. What remained was for me to determine the best ways I could help them.  

The results of this experience might be described as bronchosophy (pronounced /ˈbrɒŋ. kəˌsɒf.i or /ˈbrən kasəfi/), which is a term a few of us have used over the years, but has not yet entered common language. Just as philosophy might represent the pursuit of wisdom, truth, and knowledge, bronchosophy represents the pursuit of wisdom in the practice of bronchology. It can be defined as ‘a reflective and principled approach to the art and science of airway examination and intervention, combining technical skill with ethical insight, clinical judgment, and humanistic care.’ In other words, bronchosophy is the cornerstone from which the art and science of bronchology and interventional pulmonology blend with our humanity and heartfelt endeavors to do what is in the best interests of our patients.

Ethics in Interventional Pulmonology


Ethics, from the Greek words ēthos and ēthike philosophia (moral philosophy), is traditionally defined as the study of morality. What ought I do in a particular situation? What are the limits of my responsibility? How do my actions and behaviors relate to the particular norms, expectations, rules, or codes of conduct established by my profession, peers, and society, and how might these affect my community? 

The study of ethics also raises awareness and helps address other questions: Do my actions reflect a moral conscience at the center of my being or a system of thought dependent upon religious or societal models of expected behaviors? What are the emotional consequences if I must choose, in my desire to do what is right, from among potentially opposing ethical concepts, and might I rely on both subjective and objective arguments to justify my decisions? 

The Greek philosopher, Aristotle (384-322 BCE), was himself the son of a physician. He begins his treatise, Nichomachean Ethics, by writing, “Every art and every inquiry, and similarly every action and pursuit, is thought to aim at some good…will not the knowledge of it, then, have a great influence on life?”[i] Since its origins, the ‘art and science’ of bronchology and interventional pulmonology has grown in leaps and bounds. Focus has been on disease states, procedural techniques, training curricula, and how to best apply new technologies. The study of IP-related medical ethics, however, has sadly been neglected, as if medical doctors felt naturally inclined to ethical practices because they went to medical school and wear white coats or surgical scrubs. By no means do I suggest that IP specialists practice unethically. In fact, all the practitioners I know do their best to provide appropriate and competent patient care based on existing scientific evidence and the resources they have available. The practice of interventional pulmonology does, however, raise a variety of ethical dilemmas for which doctors are not necessarily trained, and situations for which doctors may not be fully aware of potential ethical issues at hand.

Therefore, based on my own experience practicing medicine and surgery around the world in diverse settings, my formal training as a medical ethicist, educator, mediator, and philosopher, and my current work as a philosopher practitioner, I decided to add an Ethics section to the Bronchoscopy International website at www.bronchoscopy.org. I have also prepared a first volume (available for free download in PDF form), Introduction to Ethics in Flexible Bronchoscopy, to serve as an introductory text for practitioners and IP specialists in training. My goal is to provide readers with fundamentals from which they may gain perspective to discuss, evaluate, reflect upon, and more readily address ethical issues faced in their daily practice of interventional pulmonology. My hope is to see ethics discussed in yearly training courses, national meetings, and IP societies’ international conferences. I welcome your feedback and hope this text is a helpful addition to other educational materials used by our profession.

[i] The Basic Works of Aristotle. Eds Richard McKeon. The Modern Library, Random House, NY, 2001. Nichomachian Ethics, book I, 1094a. WD Ross trans.

IP is what we are, not just what we do


The history of interventional pulmonology is marked by a continuous drive to improve the diagnosis and treatment of lung, airway, and pleural disorders through minimally invasive techniques. From the early days of rigid bronchoscopy and thoracoscopy to the current era of robotic-assisted procedures, augmented reality, fusion imaging, and personalized therapies, interventional pulmonology has evolved into a dynamic and essential component of modern respiratory care. As the field continues to innovate, it promises to further transform the landscapes of pulmonary medicine and thoracic surgery. 

This gradual transformation is at the root of a potential identity crisis for the field’s practitioners. This is partly because it is in our human nature to want to delineate ourselves from others, as in the adage, “we are all equal, but some are more equal than others.” It is also because not everyone incorporates all types of airway and pleural procedures into their daily practices. Indeed, several terms are used to describe the field’s practitioners or their area of focus, which can be confusing to medical colleagues as well as patients. These include terms such as bronchoscopy, advanced bronchoscopy, interventional pulmonology, interventional bronchoscopy, and endoluminal airway surgery. 

An identity crisis can lead to factions, which breed division rather than unification. This is the real danger of the looming identity crisis for practitioners defined by what they do rather than what they are. For example, can those who perform airway procedures but do not perform thoracoscopy call themselves interventional pulmonologists? And what of those who are not formally trained in pulmonary or pleural procedures, but gain technical skills solely from national meetings and workshops? Or, as in the United States, those who perform interventional procedures but are not board-certified? What of pulmonary specialists who perform diagnostic flexible bronchoscopy but only rarely intervene therapeutically, or those who perform flexible bronchoscopy but do not perform rigid? Are “advanced bronchoscopists” also interventional pulmonologists (by no means do I believe the term ‘advanced’ is meant to be used in its hierarchical sense, but rather only as it applies to specific technologies, which by the way, may not seem as advanced ten years from now)?  And, how is the newly fashionable term “endoluminal airway surgery” different from other diagnostic and therapeutic airway procedures?

According to the National Cancer Institute (www.cancer.gov), “intervention” is a treatment, procedure, or other action taken to prevent or treat disease, or improve health in other ways. If we accept this definition, everything we do is “interventional,” but isn’t that also what we are?

Seven Learning Styles and Artificial Intelligence 


It is common sense that everyone learns differently, and that teachers should do their best to use a variety of methods to transfer knowledge from themselves to their students. Of course, we also want learners to do more than solve problems they have seen before. This means that we want them to be able to apply whatever they have learned to solving new problems in novel settings. This also means we want them to acquire what psychologist William James referred to as “an inventive mind.”

Artificial Intelligence (AI) is favorably impacting this environment because it empowers learners. It offers them a variety of tools so they may embark on “learning paths” that best suit their individual natural preferences and particular customizable circumstances. Whether it be from the elaboration of interactive diagrams, engaging with chatbots, receiving instant feedback, or listening to individually-tailored audio lessons, for example, AI promotes learning according to Visual, Auditory, and Verbal styles. By interacting in a digital space or AI-driven simulation, using algorithm-based tutors that evolve as individuals progress, and collaborating with others through smart platforms, people who benefit most from physical, logical, and social styles can also expand their means for learning. And let’s not forget that AI promotes independent study by offering learners an opportunity to formulate a series of increasingly complex or deep-rooted queries simply by repeated interactions with programs such as ChatGPT, Claude, or Gemini (and others).

So, what does this mean for bronchoscopists and interventional pulmonologists? It means we must rethink the way we organize educational programs, on-site or remotely-delivered lectures, conferences, and even hands-on workshops. It probably means increased emphasis on a learning by doing methodology, or what the philosopher John Dewey referred to as “activity methods,” at the bedside, in the classroom and procedure suite, as well as in the conference hall. The transition will come naturally for a new generation of learners and teachers but may pose a significant challenge for old-schoolers and those inclined to be resistant to change.

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.