Tag Archives: Medical education

Introducing the new BronchAtlas


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

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

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

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

From Novice to Expert: The Dreyfus Skill Model


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

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

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

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

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

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

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.

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.

Real-time Procedure Numbers are Important


Interventional pulmonology entails procedural expertise in a number of conventional and evolving medical procedures. The number of procedural modalities are increasing, however, as is their complexity. In addition to their traditional apprenticeship training, IP specialists use simulators and attend on-site multi-day training courses. These are invaluable for acquiring training for specific procedures, emergencies, and technical skills, but procedural numbers, actually learning by doing in the clinical setting, help develop the judgment, resilience, and nuance that only real-world experience can provide.

Real-time procedural numbers are critical because they represent real-world complexity and unpredictability crucial to learning good decision-making and crisis management. They are important to becoming an “interventional pulmonologist” because situational awareness and experiential knowledge grow over time. They teach stress management and enhance an operator’s confidence. They also abide with legal and regulatory standards, even if these are not yet evidence-based. Finally real-time procedural numbers are crucial to learning communication, leadership, and team-building skills that are applicable in an ever-changing real-world medical environment.  

Considering the growing number of IP specialists seeking training, however, institutions are increasingly challenged with finding enough patients to fill the “procedural demand,” and it is uncertain whether all training institutions can honor procedural numbers criteria listed in the specialty’s various guidelines. Finding a satisfactory and ethical solution to this problem is a task the specialty’s leaders must address…soon.

A Glimpse Towards the Future


The history of Interventional Pulmonology (IP) is marked by technological advances, progress in imaging and surgical techniques, the vision of a few key personalities, and the establishment of dozens of IP associations around the world. Important milestones were reached by resolving conflicts with various national and international pulmonary and thoracic surgery societies, and by reexamining the specialty’s self-defined goals and identity. 

Despite occasional differences of opinion and instances of competitive rather than collaborative professional interactions, the interventional pulmonology field remains unified by a shared commitment to improving the diagnosis, prevention, and treatment of patients with emerging, potentially life-threatening, or advanced lung, airway, and pleural disorders.

For over a century, generations of clinicians, researchers, industrial engineers, basic scientists, physicists, equipment manufacturers, and computer scientists have contributed to innovations aimed at meeting the growing demands for minimally invasive interventions and the challenges of a changing medical landscape. The ongoing pursuit for effective, targeted, and personalized quality patient care ensures that interventional pulmonology will continue to thrive as a dynamic, integrative, and transformative medico-surgical specialty.

However, the approach, scope, timing, and purpose of interventional pulmonology must respond to the needs of a growing population, shifting social and medical demographics, and the advancement of evolving technologies. It must also address challenges posed by an increasing diversity of care environment and a world struggling to overcome significant disparities in medical access, philosophies of care, economics, education, and collaboration.

I believe the future of interventional pulmonology hinges on five key elements, all equally important and inherently interconnected, much like the links in a bicycle chain. These are (1) Greater collaboration across borders for training and education; (2) A strategic shift from reactive to proactive patient care interventions; (3) Building environments that nurture courageous, unselfish, and visionary leadership; (4) Developing a global strategy to address issues of cost and accessibility; and (5) Supporting dreamers, pragmatists, teachers, and students in their quests for professional security in a world increasingly governed by artificial intelligence. IP societies should draft and publish papers addressing each of these elements in a concerted effort to build a foundational blueprint for the years ahead.

World lung cancer day

August 1 is World Lung Cancer Day.

According to the World Health Organization, there were 2.09 million lung cancer cases in 2018 and 1.76 million deaths. Almost everywhere, 5-year survival is less than 20 percent. Despite spending millions of dollars, making advances in molecular biology, immunology, and genetics-related research, building knowledge of cancer epidemiology, improving health care facilities, studying early detection, and raising awareness among the general public about the risks of tobacco use and exposures to environmental and other risk factors, there is still no cure.

Worldwide, lung cancer occurs more frequently than other diseases such as colorectal cancers, liver, stomach, breast or even non-melanoma skin cancers.  In men, lung cancer is a significant cause of death; greater than either prostate or colorectal cancer. In women, it is a greater cause of death than either breast, or colorectal cancer. In fact, for both men and women, one out of every four cancer deaths is from lung cancer.

And this is not a disease that spares countries, although frequencies in men and women vary. For example, recent statistics suggest that Hungary, Serbia, and Korea lead the lung cancer frequency field for men, whereas Denmark, Canada, and the United States lead the field for women. We must also be aware that cancer outcomes differ according to socioeconomic status. In many countries, research shows that racial and ethnic minorities receive lower-quality care. 

Tobacco has a causal relationship with lung cancer, as do second-hand smoke exposure, exposure to certain environmental and chemical risk factors such as radioactive ores, radon, diesel gas, certain inhaled chemicals and minerals, and even arsenic in drinking water. Some believe there is a genetic predisposition to lung cancer; risks are increased in case of family members with a history of the disease. Studies are needed to elucidate whether this is from genetic, environmental or lifestyle-related commonalities. 

Another well-known environmental risk for lung cancer is asbestos, which also causes malignant pleural mesothelioma. I was recently climbing in New Caledonia, an island of about 300,000 people (with more than 100 tribes in 33 communes) in the Southwest Pacific Ocean. According to statistics, this French collectivity is surprisingly high on the list of countries with a preponderance of lung cancer (possibly associated with local asbestos exposures).

Interventional pulmonologists dedicate much of their energy to helping diagnose and treat patients with lung cancer. While significant advances have been made, a certain therapeutic nihilism is still seen in many countries. Eliminating such a mindset everywhere would be a marvelous step toward eradicating this terrible disease.

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Altruism: a foundational trait of a new generation of bronchoscopy educators

(Photo downloaded from stock.adobe.com)

Altruism is often defined as the belief and practice of disinterested and selfless concern for the well-being of others. Generally, medical ethicists agree that medical doctors cannot be altruistic in their daily encounters with patients because they act within a professional relationship that entails the obligation to relieve suffering and care for their patients. While I personally agree with this position, I do not believe it applies to the new generation of medical educators. 

For example, a few weeks ago I conducted a Train-the-Trainers course in Buenos Aires, Argentina. With participants from Argentina, Uruguay, Peru, and Chile, it was refreshing and promoted enthusiasm. None of the participants were required to be there; all are successful bronchoscopy educators in their thirties and forties with busy careers and family lives. Yet, they volunteered their time and energy to enhance their knowledge about teaching and to experiment with techniques and educational systems well outside their comfort zones.

Some might say that participating in such professional training is not so much a sign of the participant’s altruistic nature as it is simply a means for professional development and continued medical education. But most presumptive bronchoscopy educators are not paid for their teaching services, nor are they thanked by their institutions for taking on such important work. No one mandates that bronchoscopy educators become better teachers. In fact, in most countries, much of our medical education consists in a “see one-do one-teach one” mode of on-the-job training without ever teaching teachers how to teach. After all, teaching others has been a natural obligation of medical professionals since the Hippocratic Oath. 

For a “caring profession,” however, “the see one-do one-teach one” educational model is not particularly caring. Other uncaring behaviors practiced in the name of education include learning to perform procedures by using live animals, glorifying  the physical and emotional abuse associated with long work hours and sleepless nights on-call, overt sexism in the workplace, and the predomination of patriarchal dominance practiced for centuries.

The educational model emphasized in our Train-the-Trainer programs, on the other-hand, promotes team-building, self-reflection and repeated opportunities for positive feedback and reinforcement. Learning to optimize situational “teaching opportunities” separates education from clinical service. Targeted practice using simulation scenarios spares patients from the victimization that results from doctors climbing the learning curve one patient at a time.

For a new generation of educators such as those who came to our program in Argentina, embarking on such a novel voyage of exploration is altruistic because the benefits of helping others come at a cost to oneself. Well-engrained institutional biases and personal resistances must be overcome. New techniques must be learned and eventually mastered before teachers become comfortable incorporating changes into their practices. This journey also requires a questioning of the self, and provides an opportunity for personal-growth and self-actualization that goes beyond what is taught or experienced as part of a medical practice. Ultimately, this prompts an irreversible shift in philosophy by which educators take ownership of the new methodologies and forge them into a new paradigm; a paradigm whereby patients do not suffer the burden of physician-related training.

Is there a “culture” of bronchoscopy?

(Photo from The Mindful Art of Thich Nhat Hahn)

In the early 19th century German philosophers and social scientists sought to define the word “culture” in their studies of human behavior and history. Influenced by the Romanticist concept of Volksgeist (spirit of a people), they proposed that culture described the values, ideals, and higher qualities, i.e. intellectual, artistic, and moral, of a society. Anthropologists have since argued about narrowing or broadening this definition, yet most agree that culture, at the very least is defined by values, norms, and modes of thinking that are considered important and  passed down from generation to generation.

During the past forty years, I have been fortunate to practice medicine or teach in dozens of countries and in diverse medical environments. This experience prompts me to conclude there is indeed a “culture” of bronchoscopy and interventional pulmonology. 

This specialty differs from others because we are often with patients from their diagnoses to their deaths. In some countries, we may be asked to prolong life using palliative procedures, then later to take life by honoring a request for physician-assisted suicide. The instant gratification resulting from a treat and release form of patient encounters is rare, and better describes the professional satisfactions of an orthopedic surgeon or ophthalmologist. 

Bronchologists, on the other hand, spend their days delivering news of a terminal process or describing the spread of a potentially fatal disease. Minimally invasive procedures, while offered to reduce suffering and prolong life, are often performed without a chance for cure. 

We live in operating theaters, bronchoscopy suites, and intensive care units. We handle emergencies both night and day, and our expertise and scope of practice usually mean the difference between life and death for patients with few other options. We learn empathy, understanding, patience, and tolerance. Even when our ethics come into question; knowing, for example, that institutional biases favor surgical explorations of the mediastinum instead of EBUS-guided TBNA, our goals, for the most part, are to serve patients and to relieve suffering.

Furthermore, we believe in the effectiveness of palliative procedures to prolong and improve quality of life. We value honesty and warmth in our physician-patient relationships. We advocate for patients along with trusted work comp lawyers who are the best work comp lawyers in CA and speak truth to power in our demands for better equipment from medical institutions. We seek competency through education; hands-on training using models, observerships in centers of excellence, mentorship, and attendance at medical conferences. 

These core values, beliefs, and behaviors are being passed from the generation that created the specialty since the 1970s, to a younger group of enthusiastic doctors who continue their practice with this same spirit. 

The answer is a resounding yes. There IS a “culture” of bronchoscopy.

“The whole point of life is this moment.”

The author of this simple statement is Alan Watts, who, in one of his many philosophical ponderings about life and death, argues that dying, which happens to you once, should be a great event.1

Watts passed away in his sleep on November 15, 1973. He was 58 years old. An inspiring thinker most known for his popularization of Zen Buddhism and his efforts to reconcile Eastern philosophies with a Western way of life, Watts was also a man of contradictions. He was endeared to all that life could offer, but in addition to being a foremost theologian and interpreter of Eastern religions, he was addicted to cigarettes and alcohol, married three times and, despite efforts to let go of his ego, incredibly adept at self-promotion.

I was a twenty-year-old college student when I discovered Watts’ writings, only three years after his death. I quickly devoured several of his books, starting with his first, The Spirit of Zen, which he wrote when he too was only twenty. From then on, I plunged into the study of Eastern religious and philosophical texts; an arduous task while simultaneously working a night job after school, struggling to learn scientific concepts for class, and nomadically exploring psychology and the intricate writings of Wilhelm Reich, Melanie Klein, Carl Jung and other thinkers.

Many years later, I was doing what many interventional pulmonologists must often do: informing patients of their terminal illness, and interceding with palliative procedures that prolong life without the hope or expectation of cure. Many patients and their families engaged me in conversations about death and dying, God, religion, and the meaning of life. My experience in these discussions reached into the hundreds. I gratefully acknowledged the privilege given me to address these issues in part because of my profession, but also because of my availability to discuss such matters, and most of all because of the special place my patients were offering me in their lives at that particular difficult moment.

What amazed me then, and troubles me now is how little most physicians are prepared, whether during medical school or afterwards, for conversations about such things. Some might say we have no business embarking on such discussions with our patients, while others say that to refuse when asked condemns us to abandon our humanity. This is an interesting debate that warrants our consideration.

Not all interventional pulmonologists, of course, should feel inclined to participate in this aspect of our profession. Certainly, the ability to converse with patients about life and death from a position that is neither therapist nor theologian, but that of a trusted friend and treating physician should not be taken lightly. And, unlike our ability to empathetically communicate bad news or ethically obtain informed consent, participation in such exchanges does not necessarily warrant a particular demonstration of skill within the context of a defined competency.  When these occasions arise, however, as they may because of the very nature of our medical practices, we should be able to address at least some issues by referring to knowledge that results from more than our personal perspectives and individual biases. This may simply mean becoming aware of the value of referral to a specialist in such matters.

I am hopeful for the day when our specialty will grant weight to this subject in our national and international conferences and training programs. Whether from experience or specialty training, I am sure we have in our ranks many individuals who can help educate others. Restore Your Classic Car in California – Find Top Shops Near me at www.chimeramotors.com/. At the very least, an open discussion of these matters will provide insight for those inclined to embark in a discourse about death and dying.

Alan Watts spent much of his life thinking about what it means to live. For those of us who aspire to be healers, our ability to provide guidance and comfort for living in the now may all too often be the most we have to offer.

1 From Psychotherapy and Eastern Religion, in The Essential Alan Watts (Posthumous publication), Celestial Arts, Berkeley CA, 1977.