Tag Archives: interventional pulmonology

Rethinking Legacy Thinking

tree and books Rethinking Legacy Thinking


Legacy thinking is often described as a way of thinking about the future, especially when it involves leaving something behind for the next generation. Yet the same phrase can mean something quite different. Legacy thinking can also refer to the habit of staying anchored to the past. In this sense, it means hoping or presuming that habits and ideas that once worked will continue to work indefinitely.

In my experience as a physician, teacher, and writer, healthy legacy thinking transmits principles rather than habits. Principles endure even as methodologies, tools, and techniques evolve. Each new generation faces the challenge of deciding what should be preserved, what should be discarded, and what warrants adaptation.

For those interested in a contemplative examination of the subject, I explore these reflections more fully in a recent essay on Substack: https://henricolt.substack.com/p/rethinking-legacy-thinking

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The Physician’s Journey: Transitions, Burnout, and Reinvention

physician by river calmly thinking about professional transition and reinvention


Medicine is a profession marked by transitions, though we rarely name them as such. In this Substack essay, I reflect on burnout, not as a weakness, but as a signal that change is necessary before health care professionals collapse under the burdens of accumulated years, growing responsibilities, unfriendly work environments, and shifting systems.

As medicine enters an era increasingly affected by artificial intelligence and structural transformation, the ability to transition and even reinvent oneself is even more important than before. We are reminded that while tools and roles may evolve, the moral dimensions of medical practice remain. What endures is more than technical expertise, it is the human capacity to care, with judgment, presence, and compassion.

You can read the full essay on Substack here. https://henricolt.substack.com/p/the-physicians-journey-transitions

I welcome your reflections. 

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Anyone Can Be A Mentor

Doctor in white coat and stethoscope thinking. Two doctors in the background with a chart.


Mentorship is an essential part of professional and personal development. In medicine, it has been an especially dominate force, in part because of traditional apprentice-like training, but also because it has been a most opportune way for health care providers to learn to emulate certain behaviors and ways of thinking. It has also been a traditional vehicle for the transmission of knowledge. Authority descends from senior to junior physicians, to trainees, and students. Today, however, that alignment is less secure.

Technology puts information as well as world-class training tools and illustrated behaviors at the hands of virtually anyone almost immediately. Younger generations are often more adept at using new technologies than their senior colleagues. Traditions are questioned. Conventions demand justification based on more than experience alone. I’ve been thinking quite a bit about mentoring; about its good sides as well as its limitations and vulnerabilities, especially in an era of democratized knowledge and reversed mentoring.

For those interested in a contemplative examination of the subject, I explore these reflections more fully in a recent essay on Substack: Anyone Can Be a Mentor

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Exponential Thinking…Wow

displays health care and scientific advances along a nonlinear curve


People in general, and physicians in particular, are not always comfortable with exponential thinking. This is because we live life linearly. We grow older year after year. We learn first to crawl, then walk, then run. We learn to invest month after month to grow our net worth (though it is here that most people learn the value of compounding), and in medicine, we learn step by step, often one patient at a time. 

This way of thinking has been at the root of apprenticeship-like medical training. Experience is linear, so is mentorship, and the backbone of health care delivery.

The same might be said of our approach to the natural history of disease. For most illnesses, we speak of progression in stages, and even in the case of infections, we describe phases that progress over time from incubation to prodrome, through illness, decline, and convalescence. 

We have learned through bitter experience, however, that many infectious diseases: measles, Ebola, influenza, and COVID-19, for example, spread exponentially. We have also learned of the dangers of something known as exponential growth bias, which is defined as “the pervasive tendency to linearize exponential functions when assessing them intuitively.” 

Our public health systems and millions of patients bear the consequences of such misunderstanding.

Exponential growth is usually defined as a process in which change accelerates in proportion to what already exists (the classic J-shaped curve on a graph). In other words, the larger something becomes, the faster it grows. This contrasts with linear growth, whereby a quantity increases at a constant rate over an equal interval of time (the classic straight line on a graph).

In science, medicine, technology, and finance, linear thinking underestimates the acceleration of anything that grows exponentially. At its core, exponential thinking demands attention to rates of change rather than the quantity of change. 

Tumor growth presents a humbling illustration. Tumor cells, for example, are known to increase in number in proportion to their existing volume. In pulmonary medicine and oncology, we use tumor doubling time (DT) and volume doubling time (VDT) to assess pulmonary nodules and malignancies. Because malignant growth often follows near-exponential kinetics in its early phases, a lesion that appears small in diameter and stable over a short interval of time may already be progressing along a steep growth curve and doubling in volume.

Failure to appreciate this dynamic reflects a misunderstanding of the difference between linear and exponential growth. This invites complacency and exposes both patients and their health care providers to the risks of delayed diagnostic or therapeutic intervention.

Today, artificial intelligence introduces similar nonlinear dynamics into interventional pulmonology. Navigation systems refine accuracy through iterative learning. Imaging segmentation algorithms improve multiplicatively as datasets expand. Risk stratification models enhance predictive power across tens of thousands of cases. What once required the slow accumulation of individual procedural experiences now crosses continents and health care institutions with the click of a computer mouse. 

We must understand that many clinical processes, technological advances, scientific discoveries, and healthcare system failures are not gradual. They often follow a nonlinear curve and accelerate dangerously once a critical threshold is reached. Thinking exponentially helps us recognize these nonlinear dynamics before a crisis appears. 

Acting before a threshold is reached, rather than reacting after it has been crossed, is a mark of responsible, ethical, and forward-thinking leadership.

  • Berg SH, Lungu DA, Brønnick K, et al. Exponential Growth Bias of Infectious Diseases: Protocol for a Systematic Review. JMIR Res Protoc 2022;24;11(10):e37441. doi: 10.2196/37441.
  • Beibei J, Daiwei H, Carlijn M. et al., Lung cancer volume doubling time by computed tomography: A systematic review and meta-analysis. European Journal of Cancer 2024;212:114339. 10.1016/j.ejca.2024.114339.

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History of Pulmonary Medicine: From Antiquity to AI

history of pulmonary medicine shows evolution and AI


The history of pulmonary medicine is replete with famous names and milestone events that changed the face of medical science over centuries. From early empirical observations in ancient civilizations to Egyptian texts describing herbal treatments and surgical interventions, it is clear that humanity has suffered from lung disease since the days when Homo sapiens and its predecessors first walked the earth. What follows is not a comprehensive history, but some thoughts on how shifts in knowledge have shaped pulmonary medicine. 

Hippocrates and other Greek practitioners set guidelines for medical practice. They also defined and described many breathing disorders, not the least of which was phthisis, later known as consumption or pulmonary tuberculosis. They described and treated pleurisy and raised awareness about the potential contagiousness of what would ultimately be recognized as infectious lung diseases centuries before the discovery of germ theory.

After that, another Greek physician, Galen of Pergamon, who practiced in the Roman Empire in the second century CE, shaped the future of medicine for centuries. Although many of his findings rooted in anatomical studies and theoretical iterations of what ultimately became the humoral theory for disease needed to be revised or debunked, Galen was forward-thinking in the ways he tied symptomatology (medical semiology), the anatomical structure of the human body, and the external environment on the course of disease. He was among the first to suggest that air, water, and even emotional disturbances could have an adverse impact on human health and wellness.

New theories of medicine prospered only centuries later, when the Islamic physician Avicenna (Ibn Sina) published his Canon of Medicine and Book of Healing (11th century). The Renaissance, however, brought about some of the greatest changes and the abandonment of most antiquated Galenic theories regarding lung disorders. Anatomists/physicians such as Vesalius, who described the mechanics of respiration and demonstrated the principles underlying positive-pressure ventilation, and Michael Servetus, among the first to describe the pulmonary circulation (early to mid-16th century), were instrumental in building new foundations from which future discoveries in pulmonary medicine would be made.

From the 17th to the 20th century, new breakthroughs would occur particularly in the realms of microbiology, pharmacology, imaging studies, and physician concerns for public health. The discovery of oxygen and the physiology of respiration, accompanied by widespread adoption of Laennec’s stethoscope revolutionized bedside diagnosis and global thinking about the diagnosis, treatment, and prevention of pulmonary diseases. 

Concomitantly, advances in the diagnosis and management of infectious lung disease, the establishment of links between smoking and disorders such as lung cancer and COPD, and growing attention to occupational lung disease anchored pulmonary medicine as a social discipline.

Today, we have reached a new inflection point in the history of pulmonary medicine. Artificial intelligence is reshaping medical diagnosis and decision-making in ways that we cannot yet fully comprehend. Machine-learning algorithms already outperform traditional methods in image interpretation for lung nodules and interstitial lung disease. AI-assisted pathology and cytology promise laboratory expertise in even the most remote corners of the world. Tools combining large language models with genomic and gene-editing processes are accelerating discovery and assisting in earlier diagnosis and management of genetic disorders. Robotics and robotic-assisted bronchoscopy are penetrating the pulmonary procedures world at almost warp speed, providing higher diagnostic yields for lung cancer and other disorders by enabling better access to hard-to-reach peripheral nodules compared to traditional methods.

In the face of such rapidly changing times, our challenge is in finding ways to both embrace and harness computational power. While debates about the risks versus the advantages of AI in pulmonary medicine are helpful, we should also focus on how technological authority can go hand-in-hand with professional responsibility.

  • The Cambridge History of Medicine (2006). Eds. Roy Porter. Cambridge University Press.
  • Murray JF. A thousand years of pulmonary medicine: good news and bad. European Respiratory Journal 2001 17(3): 558-565; DOI: https://doi.org/10.1183/09031936.01.17305580.
  • Mahajan AK, Duong DK, Cortes J, et al. The Match 2 Study: Robotic Assisted Bronchoscopy with Integrated Imaging with Assessment of Digital Tomosynthesis (DT) and Augmented Fluoroscopy (AF): Three-Dimensional Accuracy as Confirmed by Cone Beam Computed Tomography (CBCT), Respiratory Medicine 2026. https://doi.org/10.1016/j.rmed.2026.108693.
  • Topol EJ. High-performance medicine: the convergence of human and artificial intelligence. Nat Med 2019;25(1): 44-56. 

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A New Home for My Writing

landscape stethoscope and ink pen announcement of new home for Henri Colt on Substack


I’m grateful you have been reading my work here, and I’m honored that so many of you around the world have viewed or downloaded educational materials from bronchoscopy.org in support of our shared educational mission.

I will continue to add to this website, and to post on Colt’s Corner.

For some time now, however, I’ve been thinking about where my longer, more reflective writing belongs. These include excerpts from my books, longer essays, short stories, and commentaries—reflections on medicine, philosophy, literature, science, art, and the fragile beauty of our shared lives.

I’ve begun publishing this work on Substack — a quieter space that allows for long-form writing and more direct conversation with readers. 

If you would like to continue reading there, 
you can find my work and subscribe here:
Subscribe on Substack

A recent essay:  On Friendship and Sudden Loss

Communication in Health Care: Patients and Providers

Effective communication in healthcare

 Communication in health care relies on a foundation of trust and psychological safety amid unexamined assumptions, non-dits (which is French for things left unsaid), potentially mismatched expectations, asymmetries of knowledge and power, vulnerability, unspoken emotional defenses, and differences in understanding or health care literacy. Perhaps this is why effective communication requires more than clarity of language. It also requires our attention to meaning, context, and subjective experiences, including the “emotional baggage” carried by all those involved in our conversations.

Whenever we communicate, we receive, transmit, and interpret both information and feelings. Psychological research shows that effective communication in health care is tied to perceived empathy, narrative coherence, and opportunities for all involved parties to be heard. Taking the time to sit at the patient’s bedside and avoiding potential distractions such as phone calls, computer screens, or unnecessary interruptions can be key to establishing rapport. In my experience, providers operating under time constraints, emotional strain, or institutional pressures have difficulty recognizing how fear, hope, and struggles tackling ambiguity or uncertainty adversely affect their patients’ understanding. They risk using technical jargon, matter-of-fact approaches, or paternalistic attitudes to rush through a conversation, disregard differences in health care literacy, or achieve a specific desired outcome. Hence, health care providers might subconsciously or intentionally distance themselves emotionally from their patients. The result is a potential undermining of a patient’s trust. Consequently, both caring and compassion are sacrificed on the altar of efficiency.  

Interprofessional communication between physicians, nurses, technicians, and allied health professionals also has its challenges. Healthy dialogue means overcoming real and perceived hierarchical barriers and role ambiguities. It means negotiating intergenerational differences, acknowledging differing professional identities grounded in diverse yet strangely singular training paradigms, and recognizing inward disengagement even when outward appearances signal agreement or a willingness to comply.

Overall, this introduces yet another layer of complexity to effective communication. Cultural expectations can vary significantly among trainees, mid-career professionals, and more senior practitioners. Intergenerational differences of opinion might exist regarding what constitutes competence and professionalism, for example, or how to communicate with respect to cultural diversity. Not everyone has similar views on the appropriateness of multitasking (it took me a while to realize that young people can remember and reflect on what I say even while scrolling through pictures and texts on their mobile phones), or on when to rely on narrative versus factual reasoning. 

Much more can be said about communication in health care. In future essays, I will briefly address dialogue between health care providers and administrators, conversations with patients’ families, and the challenge of effective communication with staff, other team members, and direct reports. I will also discuss communication failures and why I believe the observation and improvement of communication skills should be an integral part of competency—based training.  

The Ethics of Truth-Telling in Procedural Medicine

Ethics of truth-telling shows patient asking about the doctor's experience.


In this first essay of the new year, I thought I would dedicate a few paragraphs to the ethics of truth-telling in procedural medicine. From the time they are medical students, doctors are burdened by decisions of what to say and how much to share with patients. The range of topics for which these decisions apply is extensive. These extend from revealing the extent of one’s own experience to discussing complications, obtaining valid informed consent, revealing medical error, and sharing diagnostic findings, prognosis, and the likelihood of cure or treatment failure.

The ethical space truth-telling occupies in procedural medicine is especially complex because physicians often find themselves incorporating infrequently practiced or newly learned procedures into their interventional practices. From the time one performs their first blood draw or lumbar puncture to one’s first attempts to perform a complex airway procedure, the questions are the same. How should physicians answer their patients’ queries regarding the extent of their experience? What must they share about the extent of their patient’s disease and diagnosis? What do they say (and to whom) if something goes wrong? How and when do they involve their patients’ family members, and how much personal opinion versus facts should they share about presumptive diagnoses and prognosis?

It is no surprise that the ethical obligation to tell the truth: to disclose risks, alternatives, limitations, and uncertainties, remains foundational in virtually every medical cultural environment. In this sense, truth-telling is not only legally required but also a moral obligation rooted in the ethical principle of respect for autonomy and the preservation of human dignity.

The devil, of course, is in the details. For example, is a doctor’s failure to tell a patient this is their “first time performing the procedure independently” any different from exaggerating about their level of experience? Is a physician’s desire to simplify, soften, or selectively emphasize certain information a form of coercion, a benevolent attempt to reduce anxiety and facilitate consent, or a subconscious effort to frame discussions in ways that conform with institutional norms or personal goals and values that might differ from those of their patients? 

From an ethics perspective of justice, truth-telling in procedural medicine cannot be separated from notions of equity, power, and access to understanding. Patients do not enter procedural encounters on equal footing with their health care providers. They are not only at a disadvantage due to illness-induced vulnerabilities. They are also affected by disparities in health education, socio-economic status, language fluency, healthcare literacy, and cultural biases regarding whether and how to question a physician’s experience and authority. To complicate matters further, procedural risks are probabilistic and often context-dependent. The ethical weight of truthful disclosure in these settings is therefore especially pronounced.

Many other aspects of care related to telling the truth warrant discussion. In this short essay, I simply suggest that truth-telling in procedural medicine occupies a central place surrounded by the triumvirate of clinical uncertainty, technical expertise, and patient vulnerability. Physicians who navigate these unsteady waters can be guided, however, by their personal integrity, a profound respect for their patients’ moral agency, and a steady commitment to medical professionalism regardless of institutional and societal pressures.

  • Beauchamp TL and Childress JF. Principles of Biomedical Ethics. 8th ed. Oxford University Press, 2019.
  • O’ Neill O. Autonomy and Trust in Bioethics. Cambridge University Press, 2002.
  • Sheldon M. Truth-telling in medicine. JAMA. 1982 Feb 5;247(5):651-4. PMID: 7054566.

The Revolutionary Spirit in Medical Education

Shows physician signaling a the digital democratization revolution in medical education to a student at the computer


In her book, On Revolution, German-American political thinker and philosopher Hannah Arendt (1906-1975) wrote that a revolutionary spirit is not defined as the action of a people, but as a set of political principles characterized by concomitant ideas of freedom and the experience of a new beginning. For medical educators, the concept of the democratization of knowledge, associated with the proliferation of computers and web-based learning, interactive information systems, and greater access to virtual reality and computer simulation, embodies such a revolutionary spirit.

This is because the widespread dissemination of educational systems dedicated to the health care environment is the exact opposite of the antiquated practice of coerced acceptance of information through conventional power structures in the ivory towers of academia. The older system was often based on academic hierarchies and teachers who, as both owners and retainers of knowledge, had power over learners. The newer system, however, is built on the give-and-take of democratization, with virtually instantaneous, open access to information enabled by affordable technological advances. These include but are not limited to critical analyses of that information through podcasts and interviews, open access rather than fire-walled peer-reviewed scientific literature, and thousands of lectures or commentaries on YouTube and other social media sites.

Arendt also wrote that revolution implies a change radical enough to be experienced as an entirely new beginning. It signifies more than a change, which, as Arendt says, can be cyclical (as in change from one form of government to another; a monarchy might become an oligarchy, an oligarchy might become a democracy, and so on). A revolution is also not to be confused with rebellion, which might substitute one form of leadership, or one prevailing paradigm, for another. Nor is revolution, in its social and political sense, a restoration to what once was. In other words, it is not represented by coming full circle back to a preordained order.

Instead, a revolution, according to Arendt, signifies a new beginning, not only in social thought but also regarding actions inspired by a “revolutionary spirit.” In his brilliant new series titled The American Revolution, documentary filmmaker Ken Burns illustrates how the American colonies’ revolt against Great Britain was inspired by such a spirit fueled by the novel idea that all men had inalienable political rights by birth. Of course, there were shortcomings to the founding fathers’ implementation of this idea, for sadly, it would take many years before such “rights” would be extended to indigenous populations, enslaved people, and women.

But the purpose of this essay is not to expound on the concept of revolution, but to reflect on whether medical education today represents the dawn of a new beginning marked by digital democratization and driven by the revolutionary spirit. I believe it is, although with some caveats. 

Technology allows for information, ideas, and images to transcend national boundaries. Still, healthcare professionals benefit greatly when they personally identify with physical role models and engage in the intricacies of the human experience gained through direct, face-to-face interactions with their patients. Just as a teacher’s actions and behaviors influence their students’ manners and performances at the bedside, for example, a patient’s feelings and behaviors can equally affect the ultimate quality of a physician’s professional attitudes and demeanor.

We must not forget, therefore, that health care delivery entails the delivery of healthcare, which is, after all, a human service profession. Learning to care for the sick, the injured, and the fatally ill with demonstrable empathy and compassion is not easily mastered through books and modern technology alone. The revolutionary spirit might spark our embrace of new technologies and educational systems but carries in its mist all that is valuable and sacred about the physician-patient encounter.

Silent Wounds of Medical Betrayal

Betrayal in medicine, patients and physician harm


Betrayal occupies a unique space in the human experience, as anyone who has felt betrayed knows all too well. In the healthcare environment, it represents one of the most ethically charged and psychologically damaging forms of a relational breakdown. From this perspective, it is very different from romantic betrayal or interpersonal treachery. It is a breach of trust and responsibility, a sorry manifestation of the power imbalance that exists between physicians and their patients. In this first of several short essays on the subject, I address the silent wounds of medical betrayal on the perpetrators themselves.

Medical care is both highly technical and grounded in an often obscure and changing clinical science.  While most physicians do what they believe is in their patients’ best interests, some jeopardize their personal and professional integrity to comply with institutional guidelines, a mentor’s instructions, financial obligations, political positions, or their perceived need to embrace technological advances before supporting scientific evidence is established. 

Knowingly providing suboptimal medical care, failing to disclose conflicts of interest, or making misleading statements or false promises are just a few ways physicians betray their patients’ trust. But there are others. Alfred Tauber, author of Confessions of a Medical Man, for example, wrote of the dangers of the physician-technocrat who turns medical care into a business transaction, and Oliver Sacks, in A Leg to Stand On, described the devastating emotional impact on patients who feel abandoned by their caregivers.

When doctors nonchalantly neglect a patient’s humanity, however, they do more than a disservice to their profession and their patients. An act of betrayal shatters the moral basis of professional obligation, the ethical foundation that resides in a fiduciary trust built on a patient’s vulnerability and the physician’s promise of beneficence. For the perpetrator (is that too strong a word?) professional burnout, cynicism, and a growing sense of personal failure can ensue, with long-term effects on a health care provider’s mental health.

The emotional consequences for the instigator of such betrayals, whether the betrayal is of a patient or of the ethical obligations of the profession, are what psychologists call self-inflicted moral injuries. Shame and guilt, self-disgust, emotional exhaustion, and detachment from colleagues and patients can lead to increased feelings of anxiety or depression, substance abuse, and sleep disruption. Over time, these and others may lead to developing a distorted sense of professional obligations, poor performance, and loss of credibility. 

The effects of self-inflicted moral injury on one’s sense of meaning, purpose, and personal identity can be devastating. They may lead to abandoning the health care profession, and in worst case scenarios, to excessive drug and alcohol consumption, disruption of the nuclear family, and even suicide.

Committing an act of medical betrayal causes a silent wound that easily grows over time. The old adage, to forgive and forget, does not readily apply, and often, this wound requires professional help to heal.