Past, Present, and Future of Interventional Pulmonology

​Introduction
 
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. Each of these elements could warrant a dedicated paper, serving as a foundational blueprint to be developed by an IP special task force. For the sake of simplicity, I will provide only one or two examples for each element in the following paragraphs.
 
Collaboration and Innovation Across Borders
 
Collaboration and innovation on a national or international scale can take various forms. Educational programs are perhaps the most straightforward way to foster a spirit of cooperation, as raising awareness is the first step toward meaningful change. Establishing the means to provide new and increasingly costly technologies into regions and communities where access to care is currently limited or nonexistent presents a more difficult challenge. This task goes beyond merely providing equipment, which is only an initial and necessary step. Still, it must be accompanied by repair and maintenance contracts, specialized training for specific procedures, and the integration of an IP system into existing healthcare models. Sometimes, this process requires rethinking established care algorithms or challenging long-standing philosophies that have been deeply ingrained for decades. Conflicts between maintaining the status quo and implementing change are inevitable and may lead to serious disagreements among members of the medical community. Thus, gaining the support of national societies, international experts, and government or academic institutions is crucial to facilitate progress and secure financial assistance for equipment, training, and technology.
 
Shift from Reactive to Proactive Interventions in Patient Care
 
Traditionally, medical interventions have been reactive, focusing on diagnosis, symptom relief, or treatment after the onset of illness. However, advances in technology – such as predictive analytics, artificial intelligence, and personalized medicine – now enable a more proactive approach. These and other modern technologies can incorporate genetics, lifestyle-associated risk factors, environmental influences, and other disease-related indicators like biomarkers or findings from advanced bronchoscopic or radiologic imaging tools. By leveraging patient data, medical professionals can identify risks earlier, enabling earlier intervention, multidisciplinary care, targeted interventions, and improved effectiveness. This approach has the potential to enhance the quality of care, reduce complications, promote disease prevention, and improve quality of life. Improved patient outcomes lessen the overall burden of illness on patients, their families, and society.
 
Courageous, Visionary, Unselfish, and Ethical Leadership
 
Like many organizations, IP associations everywhere may sometimes struggle with internal conflicts, lack of transparency, unclear identity and vision, self-serving or ego-driven decision-making, or flawed groupthink. Such issues can steer a society away from the collective benefit of its members and communities it serves, jeopardizing its future and reputation. Historically, IP's culture dates from an era when forward-thinking, independent and often self-reliant practitioners were dismissingly labeled as "cowboys" by colleagues who were less inclined toward interventional approaches. 
 
For many years, expert bronchoscopists and thoracoscopists dedicated significant time and effort to demonstrating the value of their procedures. Through "show and tell" lectures and retrospective studies – prospective and randomized studies would come later – they proved that these interventions significantly improved clinical outcomes, quality of life and survival rates. However, they often faced resistance from colleagues, skeptical referring physicians, other specialists in surgery, oncology, and radiology mindful of competition, as well as hospital administrators and even leaders of national and international pulmonary societies who were at their worst obstructionists, and needed to be convinced of the benefits, cost-effectiveness, and safety of interventional pulmonology. The same challenges applied to training methodologies.  Significant energy was needed to move beyond the outdated apprenticeship model of medical education to more modern, learner-centric approaches. These approaches included the use of inanimate models, simulation-based training, ongoing competency and skill assessments, faculty development programs, flexible multidimensional curricula, a democratization of learning resources, and computer-assisted learning with feedback mechanisms – ensuring that patients no longer bear the unacceptable burden of procedure-related training. 
 
History demonstrates that without courage and vision, innovation can be easily stifled. Persistence and resilience in the face of opposition, however, will ultimately yield rewards. True leadership is not defined by title or position; it is marked by the presence of courageous, ethical, and visionary individuals who possess an unselfish desire to help others. Such leaders are willing to challenge the status quo, develop, adopt, and promote new technologies, and propagate knowledge without concern for receiving credit. 
 
Issues of Cost, Accessibility, and Integration
 
Social and economic inequalities, compounded by disparities in training opportunities and access to technology, pose significant challenges to integrating interventional pulmonology into comprehensive care plans for patients with lung, airway, and pleural disorders. Incorporating IP into multidisciplinary patient care strategies fosters a more seamless, safe, and efficient means for personalizing treatment plans, improving outcomes and enhancing quality of life. This underscores the importance of nurturing the next generation of interventional pulmonologists because they are not only the agents of change today, but also the policymakers and leaders of tomorrow. Their ability to navigate ethical dilemmas is crucial, because issues of cost, accessibility, and integration are fundamentally ethical concerns. Equally important is their competence in utilizing artificial intelligence (AI), machine learning (ML), robotics, and other advanced technologies, as well as their understanding of the roles of industry and agents of technological innovation. In an era of rapidly accelerating change and with the potential of AI and ML to revolutionize medicine, optimize procedural practice, and radically affect every decision-making process, there will be little room for error when addressing myriad issues that will arise. 
 
Unfortunately, medical ethics is insufficiently emphasized within the IP community. Even traditional subjects such as informed consent, risk of coercion in decision-making, and conflicts of interest are often overlooked. Many interventional pulmonologists have not revisited the study of ethics since their medical school training, and ethics subjects are rarely, if ever, discussed in lectures or workshops at national or international conferences. Without deeper knowledge and experience, future IP specialists may struggle to navigate modern ethical challenges and risk losing influence at critical decision-making forums. Issues like algorithmic bias, the unintentional exacerbation of existing healthcare disparities, limited access to advanced treatments for underprivileged or underserved populations, and other cost, access, and care concerns will likely become more prevalent as the balance between technological innovation, patient safety, and standard of care becomes increasingly complex. Furthermore, as next-generation tools and devices are integrated into interventional pulmonology, additional ethical questions will be raised. Determining appropriate levels of human oversight, data privacy, consent, monitoring, and the design of transparent regulatory frameworks are a few examples of ethical issues IP specialists are ill-prepared to address.
 
Engagement of Dreamers, Realists, Teachers, Mentors, Practitioners, and Students

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. 

However, to ensure procedural competency, standardize training programs, maintain decision-making skills, and assure procedural proficiency amid evolving technologies and expectations for improved outcomes, widespread education and the adoption of modern teaching practices are essential. 

A greater understanding of communication tools, including social media and remote learning platforms, is also necessary to address inequities in knowledge acquisition and training. 

Embracing, rather than resisting, the inevitable applications of artificial intelligence and machine learning will facilitate the integration of AI-driven algorithms and ML-based solutions, leading to more personalized, effective, and efficient care. 

A coalition of clinicians, educators, computer scientists, industrialists, equipment manufacturers, financers, national associations, and international organizations could work together to reduce social, financial, and medical professional disparities that limit the access to and integration of interventional pulmonology in many regions around the world. 

Lastly, greater investment in IP-related research and development of a strategic blueprint for the future can help current, aspiring, and future interventional pulmonologists focus on specific diseases to devise prevention, detection, and treatment strategies, expanding the scope of interventional pulmonology and offering broader applications for new and existing technologies. 

Conclusion

Interventional pulmonologists live both 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 are naturally curious, determined, and compulsive. They are not afraid to try and eventually master something new. They must demonstrate manual dexterity, teamwork, critical thinking, analytical precision, and strong pattern recognition skills. Equally important are their abilities to communicate with clarity, courage, compassion, grace, and humility. Practicing medicine with such depth and professionalism is both a challenge and a virtue. Both are honorable.