Sudbury Is Still Waiting…

Bill Crumplin, with photo of his late wife Donna Williams, image courtesy Sudbury.com

You might recall my post of a few years ago about Sudbury, Ontario, Canada, a medium-sized town that turned to its citizens to fund a PET/CT facility when the much-touted Health Service would not provide it. The wait-time was not just an inconvenience; the health of Sudbury citizens was adversely affected by the lack of local scanning capability.

The wait goes on, it seems.

My friend Stacey discovered another such tragedy related to imaging, or rather, lack thereof. As reported on Sudbury.com:

Donna Williams’ dying wish was to raise money toward the purchase of a piece of medical equipment that would have helped doctors diagnose her illness sooner and perhaps changed the course of her treatment. And her life.

Williams, 54, died April 6, 2016, of cardiac amyloidosis, a disorder caused by deposits of an abnormal protein in heart tissue, making it difficult for the heart to function properly.

The Sudbury woman was scheduled to have a cardiac MRI in Ottawa, but wasn’t healthy enough to travel there and sadly died two weeks after being diagnosed.

Bill Crumplin said he and Williams, an exceptionally bright woman, did not make it to their fourth wedding anniversary before she succumbed “brutally fast” to the rare disease. Had she been able to have a cardiac magnetic resonance imaging (the full name of an MRI) scan in January 2016 rather than March, the outcome might have been different.

{snip}

SN is operating its one MRI machine 24 hours a day, 365 days a year, completing about 13,000 scans a year. Still patients must wait an average 52 days for a test that should be performed within the provincial target of 28 days.

{snip}

Health Sciences North Foundation executive director Mary Lou Hussak is leading the drive to raise more than $6 million for the scanners. The foundation is focusing all its efforts right now on raising the $3.5 million for the purchase and installation of a second MRI, then $2.6 million to replace the first.

So far, $1.1 million has been raised, without campaigning, thanks to a $500,000 donation from Carmen and Sandy Fielding and another so far anonymous $500,000 donation.

Hussak has no doubt residents of Sudbury and the Northeast will give generously to the MRI fund. While some have made huge donations, all amounts, large or small, will be gratefully accepted.

People can make individual or company donations, or hold small events such as birthday or tea parties or dinners in their home where friends can donate to the cause. Hussak encourages people thinking of holding such events to contact the foundation because it has resources that could make that easier.

{snip}

Meanwhile, construction continues at HSN’s Ramsey Lake Health Centre on the suite to accommodate a combined positron emission tomography/computed tomography scanner. There was a short delay in the early days, said Hartman, but efforts are being made to make up for lost time. The hospital estimates the suite will be finished in the spring and do the first PET scan this summer.

Oh, myyyyyyy….
So…it has taken three years to get the PET/CT scanner we heard about it 2016? Lovely. And the citizens of Sudbury have to take up collections and hold tea-parties to fund another MRI so critical patients (I have to say it) don’t DIE waiting for their scans? The article neglects to mention the possibility of bake sales and selling Sally Foster gift-wrap, both big revenue-producers when my kids were in school. 
Houston, I mean Sudbury, we have a problem. 
The Canadian system is the quintessential  bureaucracy, and as such keeps meticulous records. In this case, wait-times are accessible via a Provincial website, http://www.hqontario.ca. Read ’em and weep:
I really don’t need to add much of an editorial comment here, do I? But that never stops me, so I’ll simply repeat more or less what I said about Sudbury’s PET/CT in 2016, and it remains accurate in my humble opinion:

The healthcare here in the United States is good. Really, really good. People who can afford to do so come HERE to be diagnosed and treated. Those who can afford to come HERE do NOT go to Canada. Or Germany. Or Switzerland. Or Sweden. Or India. Or Anywhere Else. Even Mick Jagger, a British Citizen, is having a heart-valve replacement tomorrow in New York City, and not London. I’m not saying I contribute much, if anything, to it, but the best medicine in the world is practiced in the United States. I don’t think our system is perfect, and I have called for massive reforms, dumping Obamacare, Medicare, Medicaid, and revamping the whole thing including a huge revision of the laws governing the Third-Party Payers, our beloved insurance companies. Ours is a dysfunctional system and it has to be revised. But even with its blemishes, it produces some of the best medicine in the world.


And yet, in our inexorable march toward Socialism, the latest incarnation of which is called “Medicare for All”, led by demagogues who would have us trade everything that makes America America for “free stuff”, American health care stands to be crippled in the process of making it “free”. And by the way, nothing is “free”. Someone has to pay for the “free stuff”.


We need to look at the case of Sudbury’s PET/CT and understand the implications. There isn’t enough money in Ontario to provide “free” PET/CT for Sudbury, and in fact, funds for this life-saving technology are limited province-wide. Thus, the fine people of Sudbury will have to fund the purchase themselves. That they are willing to do so to help their fellow citizens is the heartwarming part of this story. The heartbreaking aspect is that they have to do so. I see this as a huge crack in the perfect facade of Canada’s single payer system. It FAILED the people of Sudbury. And it fails the people of Ontario, and indeed all of Canada by limiting resources and thus rationing their care.

The profit motive has brought an overabundance of expensive CT, MRI, and PET/CT scanners to the United States, with the inherent likelihood of over utilization. Contrast this to the neighbourly situation in Ontario which requires the citizens themselves to raise money for life-saving technology that the government, even using the generously given tax-dollars (CAD) cannot provide.

This is not the answer to fixing healthcare in the United States. Sorry.

via Blogger https://ift.tt/2UfiEsQ April 04, 2019 at 04:09PM

How IBM Watson Overpromised and Underdelivered on AI Health Care

My friend Phil Shaffer, a fellow retired Nuclear Radiologist, is an avid poster on Aunt Minnie. His AM post today about AI in general and Watson in particular is worthy of a wider audience, and here you are. It is based on an Engineering article in the IEEE Spectrum: How IBM Watson Overpromised and Underdelivered on AI Health Care . This is a cautionary tale for all who have anything to do with AI…If IBM stumbled in this venue, if IBM could fall victim to hype and hubris…

  
Well, we all knew that. Big hype, zero output.

I wouldn’t bother to post this non-news, if it were not for the other questions it brings up.


IBM’s bold attempt to revolutionize health care began in 2011. The day after Watson thoroughly defeated two human champions in the game of Jeopardy!, IBM announced a new career path for its AI quiz-show winner: It would become an AI doctor. IBM would take the breakthrough technology it showed off on television—mainly, the ability to understand natural language—and apply it to medicine. Watson’s first commercial offerings for health care would be available in 18 to 24 months, the company promised.

In fact, the projects that IBM announced that first day did not yield commercial products. In the eight years since, IBM has trumpeted many more high-profile efforts to develop AI-powered medical technology—many of which have fizzled, and a few of which have failed spectacularly. The company spent billions on acquisitions to bolster its internal efforts, but insiders say the acquired companies haven’t yet contributed much. And the products that have emerged from IBM’s Watson Health division are nothing like the brilliant AI doctor that was once envisioned: They’re more like AI assistants that can perform certain routine tasks.

In part, he says, IBM is suffering from its ambition: It was the first company to make a major push to bring AI to the clinic. But it also earned ill will and skepticism by boasting of Watson’s abilities. “They came in with marketing first, product second, and got everybody excited,” he says. “Then the rubber hit the road. This is an incredibly hard set of problems, and IBM, by being first out, has demonstrated that for everyone else.”

The diagnostic tool, for example, wasn’t brought to market because the business case wasn’t there, says Ajay Royyuru, IBM’s vice president of health care and life sciences research. “Diagnosis is not the place to go,” he says. “That’s something the experts do pretty well. It’s a hard task, and no matter how well you do it with AI, it’s not going to displace the expert practitioner.” (Not everyone agrees with Royyuru: A 2015 report on diagnostic errors from the National Academies of Sciences, Engineering, and Medicine stated that improving diagnoses represents a “moral, professional, and public health imperative.”)

In many attempted applications, Watson’s NLP struggled to make sense of medical text—as have many other AI systems. “We’re doing incredibly better with NLP than we were five years ago, yet we’re still incredibly worse than humans,” says Yoshua Bengio, a professor of computer science at the University of Montreal and a leading AI researcher. In medical text documents, Bengio says, AI systems can’t understand ambiguity and don’t pick up on subtle clues that a human doctor would notice.

Both efforts have received strong criticism. One excoriating article about Watson for Oncology alleged that it provided useless and sometimes dangerous recommendations (IBM contests these allegations). More broadly, Kris says he has often heard the critique that the product isn’t “real AI.” And the MD Anderson project failed dramatically: A 2016 audit by the University of Texas found that the cancer center spent $62 million on the project before canceling it. A deeper look at these two projects reveals a fundamental mismatch between the promise of machine learning and the reality of medical care—between “real AI” and the requirements of a functional product for today’s doctors.

Watson learned fairly quickly how to scan articles about clinical studies and determine the basic outcomes. But it proved impossible to teach Watson to read the articles the way a doctor would. “The information that physicians extract from an article, that they use to change their care, may not be the major point of the study,” Kris says. Watson’s thinking is based on statistics, so all it can do is gather statistics about main outcomes, explains Kris. “But doctors don’t work that way.”


At MD Anderson, researchers put Watson to work on leukemia patients’ health records—and quickly discovered how tough those records were to work with. Yes, Watson had phenomenal NLP skills. But in these records, data might be missing, written down in an ambiguous way, or out of chronological order.

In a final blow to the dream of an AI superdoctor, researchers realized that Watson can’t compare a new patient with the universe of cancer patients who have come before to discover hidden patterns

If an AI system were to base its advice on patterns it discovered in medical records—for example, that a certain type of patient does better on a certain drug—its recommendations wouldn’t be considered evidence based, the gold standard in medicine. Without the strict controls of a scientific study, such a finding would be considered only correlation, not causation.


The question this raises in my mind is: Why?

It seemed so intuitive that this would work. Why doesn’t it?

One thing that happens when you try to apply computers to any problem is that first you must break down the task and understand completely how humans do it. I think that what we are seeing is that there was a very incomplete understanding of how humans process information. Starting with a naive understanding of this, IBM brazenly predicted success. And failed. Miserably.

  

Another important point is that much of our scientific effort is reported as statistical differences, derived from controlled experiments. But this is NOT the way that medicine works. There is another level, as Luke Oakden-Rayner has pointed out.

He points out – convincingly – that experiments are NOT clinical performance.

Medical AI today is assessed with performance testing; controlled laboratory experiments that do not reflect real-world safety.

Performance is not outcomes! Good performance in laboratory experiments rarely translates into better clinical outcomes for patients, or even better financial outcomes for healthcare systems.
Humans are probably to blame. We act differently in experiments than we do in practice, because our brains treat these situations differently.

Even fully autonomous systems interact with humans, and are not protected from these problems. We know all of this because of one of the most expensive, unintentional experiments ever undertaken. At a cost of hundreds of millions of dollars per year, the US government paid people to use previous generation AI in radiology. It failed, and possibly resulted in thousands of missed cancer diagnoses compared to best practice, because we had assumed that laboratory testing was enough.


The unintentional experiment he references is Breast CAD.

He recounts how the initial studies suggested that there would be 20% more cancers found using CAD, however subsequent VERY LARGE studies showed (in one case) a 20% increase in biopsies for an increase in cancers found from 4.15 per 1000 to 4.20 per thousand (p = NS).

His diagnosis:

People are weird. It turns out that if you run an experiment with doctors being asked to review cases with CAD, they get more vigilant. If you give them CAD and make them use it clinically, they get less vigilant than if you never gave it to them in the first place.
There are a range of things going on here, but the most important is probably the laboratory effect. As several studies have shown [5, 6], when people are doing laboratory studies (i.e., controlled experiments) they behave differently than when they are treating real patients. The latter study concluded:

“Retrospective laboratory experiments may not represent either expected performance levels or inter-reader variability during clinical interpretations of the same set of mammograms”

Which really says it all.


He goes on to say that when people use computers they over value what computer input and under value the other evidence:

This effect has been implicated in several recent deaths in partially self-driving cars – it has been shown that even trained safety drivers are unable to remain vigilant in autonomous cars that work most of the time.

This effect has also been directly cited as a possible reason for the failure of mammography CAD. One particularly interesting study showed that using CAD resulted in worse sensitivity (less cancers picked up) when the CAD feedback contained more inaccuracies [8] (pdf link). On the surface this didn’t make a lot of sense, since CAD was never meant to be used to exclude cases; it was approved to highlight additional areas of concern, and the radiologists were supposed to use their own judgement for the remainder of the image. Instead, we find that radiologists are reassured by a lack of highlighted regions (or by dismissing incorrectly highlighted regions) and become less vigilant.

I’ve heard many supporters of CAD claim that the reason for the negative results in clinical studies is that “people just aren’t using the CAD as it was intended,” which is both accurate and absurdly naive as far as defenses go. Yes, radiologists become less vigilant when they use CAD. It is not surprising, and it is not unexpected. It is inevitable and unavoidable, simply the cost that comes with working alongside humans. 


There you go. Some food for thought.  

via Blogger https://ift.tt/2YLFs1U April 03, 2019 at 04:49PM

Rad-PAss: The Robot Radiology Physician Assistant

For the past many years, radiologists have lived in fear of AI. There are those who complain as well about radiological mid-levels, nurse-practitioners, physician assistants, etc., thinking that they, too, will encroach upon our territory. As you know from my previous entries on the subject, I personally don’t buy into those fears. Artificial Intelligence and human helpers represent nothing more than assistants for us, ways to do our jobs better and faster. They will not replace us, I promise you.

As with most things in this business, technology marches on, and we see progress of a sort we could not even imagine a few years ago. I am proud to announce today that thanks to a consortium of industry and intellectual powerhouses, including IBM, Facebook, the University of Maryland, the ACR, Johns Hopkins University, US Robotics, Harvard University, and the Sirius Cybernetics Corporation, we now have the next step in the evolution of our profession, The Robot Radiology Physician Assistant:

It was only a matter of time until technology caught up to our needs, and here you see it in the flesh, er, silicon. We needed a non-threatening piece of machinery that could at once process images and help with those mundane radiological chores such as slinging barium, sticking needles, and shoving catheters. The Robot Radiology Physician Assistant, affectionately known as Rad-PAss, is the embodiment of these needs, a jack-of-all trades, of whom WE are the master. 

Rad-PAss’s training is second to none, having been fed the entire body of radiological literature, textbooks, journals, videos of CME meetings in Hawaii, and even the dozen or so remaining pieces of film that have not yet been rendered down for their silver content. He went through “residency” with famed University of Maryland radiologist and AI guru Dr. Eliot Siegel, which took Rad-PAss about an hour. After this, Dr. Siegel certified his performance, also noting that he was much more personable than many human residents.

Rad-PAss can be deployed in multiple configurations. Here, we see him set to interface with the latest edition of GE’s Universal Viewer PACS. With some luck, it will remain operational for the 3 milliseconds Rad-PAss requires to analyze today’s workload. He will then assign preliminary reports to be reviewed and corrected if necessary by the radiologist. (So far, Rad-PAss has made no errors in interpretation, but we never say “never” in this business.) The robot can be loaded with any and all of the latest AI algorithms, which he will self-evaluate delete those he finds unsuitable or beneath his dignity.  

If you prefer, Rad-PAss can sit beside you in the reading room and look over your shoulder, just like the lawyers and some of your partners do, but he is on YOUR side!!

Of course, the most exciting possibilities presented by the Rad-PAss technology are to be found in the realms of fluoroscopy. Imagine turning over the drudgery of barium studies to an assistant that does not have to worry about radiation exposure! The modified delivery apparatus includes pressure sensors to optimize patient comfort, ummmmm, well, minimize discomfort.

And for the IR guys, how about a catheter-jockey assistant that can pounce on a bleeder faster than you can? Here ya go:

Suffice it to say, a brave new world dawns TODAY in Radiology. Do mark this date down in history!

Legal disclaimer: Robot images courtesy of ESET.com. Neither Dr. Siegel nor any of the institutions mentioned above have anything to do with this, or me, and are included here solely in a fictional manner. And if you didn’t already realize that, you haven’t checked the date of this entry.  

via Blogger https://ift.tt/2U6d8Zn April 01, 2019

A Capitalist Went To Cuba…

Mrs. Dalai and I continue to travel to weird and wonderful places, and with me being officially retired, we hope to do so even more often. Cuba has always intrigued me, and I had even strongly considered joining a religious mission trip here some years ago. Yes, there is a very small, but very vibrant Jewish community in Cuba. We never did make that trip, but we are now circumnavigating the island nation on a very nice cruise ship. While other ships have made the run, this is the first visit for our particular liner, and I feel a bit like a pioneer. Our first stop was in Santiago, very near Guantanamo, then to Cienfuegos with a side trip to Trinidad, and we end the journey in Havana.

I am very taken with this place. The land itself is spectacular, mountainous with pristine beaches almost ringing the island. The three cities on the itinerary all have incredible natural bays around which they grew. Someday, this will be a paradise, but I’m glad to have seen it before there is a Starbucks on every corner. And I promise that will happen.  Such beauty only a stone’s throw away from Key West, Florida, will not go unnoticed for long.

Yes, Havana is only 90 miles (well, 93 to be precise) from the United States. Ninety miles and about 50 years away. Much of what you’ve heard about this place is accurate. It is Socialist, and it is poor. Very poor.  Many, if not most buildings are in need of repair, there is trash in the streets (perhaps less than in other big cities, but still…) and there are any number of beggars. We are told there is no crime to speak of, and I hope we don’t find out otherwise.

You can look up Cuba’s bloody past yourself, but suffice it so say that the citizens have never had an easy time. Its early history contains savage native tribes, and being owned by one colonial power and then another. In the mid-portion of the last century, Batista, the pre-Revolutionary tyrant, supported by the US until near the end of his reign, tortured the people and set the stage for Fidel Castro’s Revolucione. Of course, the subsequent regime has not had a stellar human rights record, either. Since I’m here in country, let’s not get into that right now. It’s all out there on the internet.

We have only had close contact with our tour guides, who work for the government-owned tour company. Most everything here IS government-owned, although there are many tiny private businesses. Many rent out rooms, or operate small restaurants out of their homes. But if a business becomes wildly successful, the government will nationalize it. The standing philosophy suggests that a business should not become so wealthy as to have the means to influence the government. Right.

Our guides were honest with us to the extent that they were allowed, or so it seemed, anyway. To a man (or woman) they all admitted that their society is not perfect. This is pretty obvious. They did tout the fact that there is universal health care (but did not comment on its quality) and all mentioned the safety-net of a monthly ration card that would provide rather less than a month’s requirements. Our guides did not tell us how much they made, but did say that a teacher might make $20 US/month, and a high-production torcedor (cigar-roller) in one of the state-owned factories might make up to $200/month. I can only imagine what the Cubans think of us spending what is for them over a years’ salary on a box of Cohibas. (Yes, I did! You can’t go to Cuba and NOT buy cigars…perfectly legal to bring them home!)

We did visit a cigar factory in Cienfuegos. They make cigars sold under a number of brands, and I haven’t a clue which were being rolled that day. We weren’t allowed to take photos, sadly, and there was a factory “guide” (handler would be a better term) who followed our group to enforce that. Even so, one of the torcedors (who are mostly ladies, by the way) handed me a freshly-rolled beauty and suggested I put it in my pocket. Mrs. Dalai suggested otherwise, and I sadly gave it back. I hope I did not offend…the ladies are on production, and she was giving me a gift from her own pocket. But with the handler watching, I figured it might get her in trouble.

As a group from a cruise ship, I think we were monitored minimally, if at all, by the Cuban government, although I’m told by friends in Florida that people travelling as individuals, technically no longer possible, are closely watched. I wandered around Old Havana looking for the best cigar deals with no obvious tail. In fact, I really got the feeling that the Cubans couldn’t care less about a bunch of elderly Americans (average age on our cruise was mummified) unleashed on their nation. I had some illusion that the US government might be more interested in our travel to this once-forbidden destination, but upon arrival back at the cruise terminal in Miami, our encounter with Customs consisted of a brief glance at our passports, and a “Welcome home!” So much for pretending to be a smuggler.

Of all the things told to us by our guides, here is what I found most poignant:

I am telling you this as Jose’ (not his real name) the man, not Jose the guide. We were amazed and thrilled when Mr. Obama came here. We didn’t believe it would happen until we saw it ourselves. We are sad that Mr. Trump has reversed some of what had changed, but we hope he, too, will come here and see that we want to be your friends.

Some of you have asked me how I like living under Communism. I would LOVE to live under Communism, where everything would belong to everybody. You could drive a car and park it when you are finished, and then I would get in and drive it somewhere else. That would be perfect. But what we have in Cuba is NOT Communism, it is Socialism. And it doesn’t work. 

While I don’t agree with his assessment of Communism, he appears to be quite correct about Socialism.

I do have some sad observations about my fellow American travellers. As I mentioned, they were mainly older, some quite a bit older. We were definitely in the youngest quintile, and probably the youngest decile of passengers. And we are not spring chickens anymore. I’ve railed before about waiting to take that trip of a lifetime until the end of your lifetime, and there were a few of those on board. Still, most of the rest of us were able-bodied, not that Cuba requires any great vigor to visit.

You’ve heard about the entitled Millennials and their horrid behavior. Well, they had to learn it somewhere, and I think I’ve discovered the source. I have never been as embarrassed by the behavior of my fellow Americans as I was on this trip. While the majority were gracious, courteous, or at least civil, a good number of the old folks were cranky, whiny, pushy, and downright unpleasant to be around. I thought for a time I might be in a bad remake of Snow White and the Seven Dwarves, in this case, “Snowflakes and the Seven Statins”. Frankly, I saw a level of anger and even contempt among this bunch which I don’t recall seeing before. Perhaps as I get older myself, I find this stuff more obvious and less tolerable. These folks would cut in lines (not nice when you are waiting for a tender in 95-degree heat to take you back to the ship) and grouse about everything. Get between them and someplace they want to be, even if it means they would only have to take an extra step to go around, and you’ll be the recipient of a very loud and very irate “EXCUSE ME!!!!!” I refrained from responding, ‘you’re excused”. I don’t know if these people have chronic pain syndromes, or they are just rich and spoiled, and expect the world to kowtow to them. One would think touring a poor nation like Cuba would bring home the message of just how lucky we all are to have what we have and to be able to go back to it. Or not.

Compounding the joy, there was a custom among some from a certain part of the U.S. to (loudly) describe in great detail everything going on around them in real time to their companions, as if the latter were not seeing the same things at the same time, peppered of course with appropriate color commentary. Maybe the rest of us would rather experience the experience for ourselves? That’s too bad.

Be that as it may.

I do urge you to visit Cuba should the opportunity arise. You won’t regret it. Bring me back a Trinidad if you wouldn’t mind…

via Blogger https://ift.tt/2UVncAB March 27, 2019 at 02:07PM

“Ramblings On Radiology And The Job Market”

Image courtesy HoustonMethodist.com



Dalai’s note: Daniel Corbett is a Radiology business consultant who has posted incredibly useful information on Aunt Minnie as long as I’ve been there. This opinion piece should be mandatory reading for all in the field.

There has been much posted lately about the robust job market for radiologists.  There has been wide ranging discussion about the quality of the jobs available with regards to corporate practices and teleradiology.  The potential to join a group without knowing about “discussions” the group may be having with other entities is very real.  As for private practice jobs I think most would agree many if not all practices are facing the same difficulties with short staffing due to increasing volume, retirements and partners leaving for greener pastures.  All this adds up to an increasingly risky job market with potential for “jumping from the frying pan into the fire” for experienced radiologists or just plain getting screwed by a fellow looking for their first job. For you 2020 fellows this can be disconcerting as there are many jobs to choose from and recruiting tactics have become aggressive. Loan repayment, signing bonuses, super short partnership tracks all tell of the desperation of groups down one or more FTE’s and desperately need the help. 
  
In my 30 years in radiology I have been through several swings in the job market.  The radiologist shortage of the early 2000’s was deep but technology leaps and radiology increased efficiency lessening the impact of short staffing.  It was bad and many groups fell apart but as a specialty we got through it.  This new shortage seems more intense and desperate as efficiency through technology has maxed out.  We all felt safe  for the last 10 years and even complained that there were too many radiologists turning radiology into a commodity.   I never believed that for a second.  Radiology is THE anchor specialty and cornerstone on which all healthcare relies on.  There was never a question in my mind that volumes would continue to grow along with the demands on radiologists. 
  
In my mind the whole corporate radiology model is nothing more than a Wall Street attempted takeover of the most lucrative healthcare specialty.  It changes nothing in the dynamic of traditional relationship between the radiologist, the medical staff referrer and the patient.  Corporate radiology is an invasion of suits and greedy radiologists selling out their specialty for a cut of the pie which has been steadily declining.  These corporate entities have invaded our specialty by taking advantage of the market forces which are beyond anyone’s control.  With a large percentage of radiologists at or near retirement age, many of which were in controlling position within their groups, it was easy for them to lure “exit strategy” radiologists with large amounts of PE money.  Over the past ten years the delayed retirement of many senior radiologists created the short term surplus of radiologists which helped these entities take hold due to a ready supply of radiologists looking for work.  Another aspect is the marketing power they wield with large amounts of money. The corporate groups have unlimited funds in which to hire people to call your hospitals to get an audience.  They bring high powered radiologists and business people to pitch their product of efficiency, quality, technology and 24/7 sub-specialty reads to dreamy eyed administrators who are tired of hearing complaints about their private practice radiologists.  The corporate groups have moved from purchasing the fat cat groups to hostile takeovers.  The gloves are off and they will steal your contract from under your nose and the next thing you know you will be offered to become an employee or leave.  I know this is true because I am seeing it happen in real time with several groups.  It is a train wreck in slow motion. 
  
I believe no group is safe as the stated goal of these entities is total market domination.  The total corporatization of radiology would be a disaster for radiologists, hospitals and patients.  These corporations must be fought at every level to keep radiologists as autonomous clinical and business entities.  Radiologists should refuse to work for them even if it is for excellent pay in the perfect location.  As an employee you have no control and never will.  Do not trust their “partnership” sales pitch.  Only in a corporate practice as an employee are you truly a commodity to be used and replaced.  Only in a private practice do you truly have a say in your business and your future. 
  
The deepening shortage of radiologists is our best weapon in the fight against corporate radiology.  As long as there are good private practice options the the corporate groups will struggle for staffing.  Being unable to fulfill their lofty promises will be their demise. Their whole business model is dependent on properly staffing their contracts while taking a cut for investors.  They throw a lot of money up front but the ROI depends on maintaining the status quo over time.  I believe once the time limits for the buyouts expire those radiologists will leave causing the house of cards to collapse.  Private practices must also do their part in the fight.  Dishonest and dysfunctional practices must strive to be better.  To remain relevant and secure private practices must do away with unfairly long partnership tracks, tiered partnerships and shady outpatient and billing schemes.  Strive to be democratic and provide good professional management at all levels.  Work had to promote fair practices so partners and soon to be partners feel they are treated properly and are invested in their practices.  If you don’t lose people you never have to recruit new people.  Only by being the best option for new radiologists will private practice win over corporate radiology.  Strive to improve and maintain the best relationship with your contracted hospitals.  Meet regularly, immediately address issues, constantly promote your practice within the medical staff.  If there are no cracks in the armor the enemy can’t get in! 
  
Finally I want to advise the 2020 fellows on a few things.  So far I have encountered an astonishing number of 2020 fellows who have already committed to a practice, before even starting their fellowship.  I know this is because of the huge number of opportunities out there.  If you get an offer with the top group in the community of your choice and you know in your heart this is THE job for you then by all means sign.  But know over the next 15 months there will be plenty of other opportunities open to you.  Don’t be tempted to continue to interview after making a commitment.  This past year I know of several fellows who reneged on groups they signed contracts with to take another job they found later.  This is not how you want to start your career.  When you interview you must expect the practice to put pressure on you to sign.  This is normal and expected but trust me you will rarely lose an opportunity by delaying.  If you interview early tell practices up front you will not make a decision until you have completed your interview process no matter how long that takes.  If they chose to not interview you then you know what they are about.  Do not succumb to the pressure to get a job while the market is hot.  You have all the time you need.  Traditional timing of interviewing after starting your fellowship and committing before the end of year or later will work out well for you.  I foresee groups hiring 2020 fellows very early then continuing to recruit for an experienced candidate.  If they find one they may renege on you! 
  
Radiology is experiencing rapid change again.  There are some bad things to be wary of but there is also great opportunity. Knowledge is your best tool so do your homework before making changes.  Seek advice from trusted sources whether your a radiologist looking to make a job change or a group looking to improve your operations and processes.  Hopefully private practice will win the day and we will see a new radiology paradigm evolve over the next decade. 

via Blogger https://ift.tt/2WqENkq March 27, 2019 at 08:44AM

Senior Discounts

On January 1, 2019, I officially retired from the position I held for 28.5 years. Let the new era begin!

In the interest of transparency, I have to tell you that was not entirely my choice; my departure was necessitated by “business reasons”, and, I am assured, not by any problem with my work.

The metamorphosis from practicing physician to private citizen (and eventually, I suppose, to patient) is a process I had started a few years ago, when I cut back to working 26, and then 22 weeks per year, dumping call in the process. There were those who couldn’t understand my action at that time, those who said I was not a “team-player” and that I was “gaming the system”. I strongly disagreed then, and I still do. If anything, at part-time rates, I was a bargain for the niche expertise I provided, but the attitude betrays a level of pain, both self-inflicted and externally-sourced, that many physicians experience, but won’t discuss.

I’m not totally out of business, however, which I why I demurred on the retirement party the group wanted to give me. (They remind me too much of wakes anyway.) Our med-mal carrier allows us to work up to 60 days per year without additional tail coverage, and so I’ll be able to keep my hand in the till, I mean the practice, for a while longer. This gives me, at age 60, a bit longer to reinvent myself. I love travel, and had planned on doing more in retirement, but the abrupt loss of revenue (not to mention having to pay $37,000 out of pocket for health insurance and deductible) will limit that. There will be no ’round the world cruises for the foreseeable future.

Some have asked: “Is it wrong to retire early from a medical career?” Some, including me, have answered, “No.” “Wrong” implies that we retirees are pilfering something by going about our merry way, which is certainly not the case. As with everything else in life, this transition represents a balance; retirement obviously stops the emotional hemorrhage, the drain on our psyches and our souls inherent in this business, but we are then deprived of the many joys of healing as well. It’s a tough choice…maybe I’m lucky I didn’t have to make it all on my own.

With the seismic changes in my personal finances, I’ve had to make some adjustments. It’s hard to know how much cash you need until you know how much you spend. And so I created the Google Form illustrated below, which allows the entry and subsequent monitoring of every single expenditure. Every single dollar. Every last cent. EVERY. LAST. BLOODY. CENT. I am going to have an absolute and complete handle on this if it kills me, and it just might.

There are any number of fairly painless ways to save a buck. The thermostat, for example, is now set to a reasonable 68 degrees, instead of the more comfortable 72. Should have done that years ago. I suppose when summer hits down here in the Deep South (usually sometime in late February), I’ll jack it up to, oh, maybe 74? I’m already wilting at the thought.

Reaching age 60 will facilitate some savings, although I had a minor intestinal disturbance when the kid at the grocery check-out announced, “And since today is Wednesday, you get the Senior Discount!” I used to think the average age of those taking advantage of Senior Day was dead. But hey, I’m getting pretty good at value shopping. I can tell you which neighborhood grocery has the best deal on Veuve Clicquot. What?! I may be un(der)employed, but I haven’t yet reached the level of eating dog food. Or the dogs. Yet.

Everyone wants to know about the next chapter, although we’ll leave diet out of it for now. The short answer is that the book is far from finished, and I’m just starting to type the first word or two of the first line of that next chapter. I mentioned above that I will continue to work for the old practice for a while. Of the 60 days I’m allowed this year, I have 29 booked so far, and that will at least help with health insurance. In addition, I’ve been asked to give a talk to our state Nuclear Medicine Society meeting in a few months, and I’ve found that the best way to keep my skills sharp is to share them.

In the meantime, there is quite a bit to do around the house. My two little dogs alone can keep me quite busy; their favorite activity is requesting to go outside so they can come back in again. The laundry basket magically fills itself up at least every other day, which must be addressed. In case you wondered, I haven’t ruined anything in years. No, I don’t wash it all in hot water.

There are drawers that need dumping and reloading, stuff to be taken to Goodwill, and things to be moved from one shelf to another. Like the gym ad, I find myself picking things up and putting them down again. But in other places, thank you. And the yard always needs something done to it. I do have a service, but they don’t weed, and they have a very bad habit of blowing leaves into the bushes, thinking I won’t notice. I’ve been known to use a Shop-Vac to literally vacuum out the azaleas; the last time I did that I accumulated a pile of leaves about 3 feet high, which the yard guys charged extra to haul away, even though it was all their fault to begin with. And I seem to have discovered magic weeds (no, not those!) that happily ingest and thrive on Round-Up. All that exposure to a potential carcinogen for nothing.

My main achievement in retirement so far has been the establishment of the “For Better Or Worse But Not For Lunch” club:

“Club” is perhaps too fancy a word for a gathering of a bunch of retired guys who need to get out of the house once in a while, but call it what you will, we had a great time at the first lunch meeting. The plan is to reconvene on the second and fourth Tuesdays of the month. Assuming I make them all, that leaves only 331 more days to fill…

And fill them I shall. There are still a few trips I’ve had on the books since before the Lessened Event, and you’ll see pics here from some far-flung places. (Teaser…several destinations are islands, one is in a desert, and one will involve Star-struck photos with Famous People!)

The elephant in the room is, of course, what I will REALLY do when I grow up, since there doesn’t seem to be a way to avoid adulting at this late date. Honestly, nothing really seems to fit perfectly. I’ve tried writing, but obviously I haven’t been quite as motivated as I once was. Maybe that will change. And while I enjoyed my mission trips, I found they are more for the young and strong, and those who think well on their feet, even after multiple sleepless nights. I’m don’t want to do locums, and the VA here needs to fill several full-time spots before I could even be considered for a part-time NM position. I’ve sent out some feelers to various vendors, but surprisingly, they are not yet squabbling with each other to be the first to have the Dalai on the payroll.

No doubt the real answer is yet something else I haven’t considered.

So, for the moment, I’m going to wallow in my (mostly) retired status. I’ll sleep late on occasion, and be the best house-husband I can be. I’ve been advised by other retired docs to just relax and enjoy it for a while. The proper path will become obvious. Eventually.

But for now, you must excuse me…the clothes dryer just buzzed…

via Blogger http://bit.ly/2D4Rbj6 January 13, 2019 at 06:58PM

The Abscopal Effect

In the waning years of my career as a Nuclear Radiologist, I have become somewhat more jaded than I was as a younger doc. When you see cancer and other diseases fifty times a day, sometimes getting better, sometimes getting worse. Of course, I’m much happier to report the former, but the latter is also part of this job. The oncologists wander in every few minutes to look at their patients’ scans (the gantry is generally still warm), and if the news is bad, I will tell them in all honesty that I admire the strength it will take to deliver the bad news. On those occasions I’m quite content to sit in the dark and stare at the screen.
One day last week, one of the Med Onc’s came in to the reading room with a rather odd look on his face. “You didn’t read this scan, but I want you to look at it,” he said, which immediately set my mind somewhat at ease. (The four most dreaded words in this business are: “You read a scan…“) 
He had me look first at the scan from earlier in the year on this elderly patient:

You don’t need me to interpret this for you, which is a bad sign. We see several lesions in the liver, presumably metastatic spread of cancer. There is a small focus in the upper thoracic spine, and a much larger coalescence of several lesions involving the lower thoracic spine. There are other lesions, and there is (benign) calcification around the mitral valve of the heart. 
OK…now, here is the most recent study:


Just about all the bad stuff is gone. Most everything we see is physiologic. (The hotspot in left upper abdomen is in the stomach, and the CT didn’t show anything, but we’ll still watch it.)

This isn’t a particularly unusual scenario following therapy. So I complimented my friend on another successful administration of his potions and poisons. At this point, he shifted uncomfortably from foot to foot. He finally looked up and said, “But we only treated the lower spine lesion with radiotherapy. We didn’t treat the other areas!” We called in the treating Rad Onc, who was equally surprised. “Wow. This would have to be an abscopal effect. I’ve never seen one before. There might be 20 or so reports out there…”

What in the world is the “Abscopal Effect”?

From the Wikipedia:

The abscopal effect is a phenomenon in the treatment of metastatic cancer where localized treatment of a tumor causes not only a shrinking of the treated tumor, but also a shrinking of tumors outside the scope of the localized treatment. R.H. Mole proposed the term “abscopal” (‘ab’ – away from, ‘scopus’ – target) in 1953 to refer to effects of ionizing radiation “at a distance from the irradiated volume but within the same organism.”

Initially associated with single-tumor, localized radiation therapy, the term “abscopal effect” has also come to encompass other types of localized treatments such as electroporation and intra-tumoral injection of therapeutics. However, the term should only be used when truly local treatments result in systemic effects. For instance, chemotherapeutics commonly circulate through the blood stream and therefore exclude the possibility of any abscopal response.

The mediators of the abscopal effect of radiotherapy were unknown for decades. In 2004, it was postulated for the first time that the immune system might be responsible for these “off-target” anti-tumor effects. Various studies in animal models of melanoma, mammary, and colorectal tumors have substantiated this hypothesis. Furthermore, immune-mediated abscopal effects were also described in patients with metastatic cancer. Whereas these reports were extremely rare throughout the 20th century, the clinical use of immune checkpoint blocking antibodies such as ipilimumab or pembrolizumab has greatly increased the number of abscopally responding patients in selected groups of patients such as those with metastatic melanoma.

Visually (also from the Wiki):

Proposed mechanism of the abscopal effect, mediated by the immune system. Here, local radiation causes tumor cell death, which is followed by adaptive immune system recognition, not unlike a vaccine.’

So, this rare phenomenon probably has a scientific explanation. I’m used to seeing cancer and other disease cured or at least kept at bay, including things we were taught not that long ago were “incurable”. I see what was once impossible happen pretty much every day. And that’s amazing enough when you think about it. 

Arthur C. Clarke once said, “Any sufficiently advanced technology is indistinguishable from magic.” While there is science behind the Abscopal effect, it is still unusual enough that I have no problem calling it a miracle. As a rare perk in my end of health-care, I had the great opportunity to show the scans to the patient herself. She and her husband and daughter took it all in with quiet faith and dignity, enough to make you cry. How many times in a career does the opportunity come along to tell someone their prayers have been answered? 
A miracle? Maybe. After all, we did have all the bases covered. The MedOnc is Muslim, I’m Jewish, and the patient is Christian. I wonder if that sort of coming-together would work in other venues…

via Blogger https://ift.tt/2we9gGX August 18, 2018 at 08:39PM