Tag Archives: Medical education

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 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. 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.

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. 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. 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. 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.

Inhalation injury and the interventional pulmonologist

 

Photo courtesy HG Colt

The disastrous fires in Greece have claimed 91 lives, and the current heat wave threatening Europe has placed environmental authorities and firefighters on high alert. Here in the United States, in my home state of California, 18 fires are still burning. Seven civilians and 4 firefighters have already been killed as the fires continue to destroy more than 100,000 hectares of public and private property. Thousands of people are being evacuated, and Yosemite National Park has been closed.

This reminds of the importance of disease-specific training for interventional pulmonologists particularly in the area of burn injuries. Perusing the scientific programs and workshop agendas of several regional and world congresses, however, I noted a paucity if not total absence of lectures or simulation workshops in this area. I think it is crucial that we remedy this gap in our educational process.

Advances in management protocols for burn victims has had significant beneficial effects in recent years, causing a reduction in mortality from burn shock and wound sepsis, such that inhalation injury is now the leading cause for death in burn victims. Inhalation injury is described as damage to the respiratory tract caused by smoke, chemical, particle substances, gases, heat and other irritants. The severity of injury is related to type of irritant, level and duration of exposure, and quality/speed of therapeutic intervention. Most experts agree that the presence of inhalation injury increases burn mortality by at least 20 percent, and predisposes patients to risks of pneumonia, respiratory failure, and prolonged obstructive or reactive airways disease.

My goal today, however, is not to provide readers with an overview of inhalation injury. For this, many excellent scientific studies and review papers are available and easily downloadable from the internet. Rather, I want to briefly address how and why we might alter our educational programs so that training in the recognition and management of patients with inhalation injury becomes commonplace in our congresses, workshops, and training centers.

Inhalation injury is an excellent model for training in how to deliver multidisciplinary care, in part because it requires expertise in four major aspects of medical interventions. These include communication (with other physicians, surgeons, nurses, first responders, respiratory therapists, patients, and family members), delivery of bad news (such as diagnosis, prognosis, need for critical care hospitalization, long-term care, and end-of-life issues), technical skills (including flexible bronchoscopy, difficult intubation, recognition of airway injury, therapeutic maneuvers such as removal of soot and debris, vocal cord and laryngeal evaluations, emergency tracheotomy, bronchoscopic assessment prior to extubation), respiratory care (critical care consultation, respiratory failure, bronchospasm, laryngospasm, foreign body aspiration and removal, mechanical ventilation, barotrauma, pneumonia, resuscitation), and disaster management (triage, crisis management, teamwork, leadership in critical situations, and organizational/systems/human error analysis).

Numerous components of these four aspects of medical care are not routinely covered during medical training or later in-practice. In fact, I have seen from my own involvement working with physicians around the world, that doctors other than trauma surgeons, emergency-room physicians and burn specialists are exposed to only some of the elements of these aspects of care during infrequent on-the-job exposures during crisis situations.

Inhalation injury, therefore, could serve as an excellent model for the construct of a multidisciplinary, simulation/lecture/workshop-based curriculum that will not only help interventional pulmonologists acquire and maintain new skills and knowledge, but will also help them become more active and dependable members of the multidisciplinary team required to assure the health and well-being of burn and inhalation injury victims around the world.

If you are interested in helping me develop such a program (some of these issues are already being addressed in The Essential Intensivist Bronchoscopist©, available on Amazon and Kindle), please contact me or other faculty of Bronchoscopy International® (www.bronchoscopy.org).

 

Trust

Trust is usually defined as a willingness to rely on the actions of another party. In this sense, it is a behavior more than it is an idea. Trust can also spring from a choice to care for another person, even at one’s own expense. Rock climbing, in my opinion, illustrates trust in its most simple and straightforward manner because sharing a rope while suspended hundreds of feet off the ground constantly puts two lives in danger; both leader and follower, decision-maker and passive participant. Errors are unforgiving and often deadly, and for this reason are virtually intolerable, for even a sentinel event can jeopardize a partnership or one’s life.

The famous marriage counselor and clinical psychologist, John Gottman, says that while trust is a major building block for a successful relationship, the reality is that trust is built slowly over time. Whether in marriages, professional partnerships, friendships or collegial acquaintances, trust requires consideration and empathy for one another’s feelings. A foundation of trust is necessary because eventually all relationships must face the crisis of a betrayal.

Usually, Gottman says, betrayals accumulate little by little, although other times they occur like a sudden splash in what might otherwise have been a calm sea. They may be real or simply perceived, but like all moments of crisis, they provide an opportunity to either rethink the boundaries of a relationship or build more trust.

In rock climbing, clear communication and mutually observable demonstrations of competency are reassuring and reliable indicators of growing trust. In medicine too, a doctor’s ability to clearly communicate with patients and team, as well as clearly demonstrate competency, quality of care, and focus on a patient’s needs help elicit trust. At the same time, doctors, health care administrators, social activists, and politicians must engage in systems-based analyses that assure the application of scientifically-proven therapies and efficacy-based innovative new technologies.

In the field of interventional pulmonology, it is tempting to believe that everything we do is in the best interests of our patients. In fact, our patients “trust” us to do so. Yet, vast sums of money, as well as patient and family suffering, may be expended in what ultimately becomes futile care. There is little oversight of physician decisions in these cases, and the emotional costs on medical providers, patients, and families are poorly documented. Professor George Lundberg, a former editor of JAMA and CEO of WebMD said that “futile care” was a contradiction in terms, and what was needed most in defined situations was “attentive care” from physicians capable of listening to their patients. Sadly, training in this domain is usually lacking from our medical conferences that focus on the use of technology and complex procedures used to diagnose and treat patients with lung, airway, and pleural disorders.

If we are to maintain the trust of colleagues, patients, families, and institutional leaders I propose that we work more purposefully on integrating workshops and lectures on medical ethics, communication, and clinical decision-making not only into our training programs, but also in our journals, regional meetings, and international congresses.