Lions and Sentinel Nodes!Oh, My!

Eid Mubarak!

It seems surreal that two weeks have passed so quickly. As today is the holiday of Eid Al-Adha, the hospital has very little activity, and I’m taking the day to pack, catch up on correspondence, and perhaps pay one last visit to Slipway for lunch.

This was on Page 16 of the local English-language newspaper a few days ago. A coincidence with my arrival in country? I wonder…
I haven’t posted since heading out to Ngorongoro Crater, so let me briefly fill you in on that incredible experience. I’ll place some photos here, but they can all be found at THIS LINK for your leisurely perusal. 
I left Dar in the afternoon, flying to Arusha, the gateway to the Serengeti and Ngorongoro. There is a larger airport in the area, Mount Killamanjaro field, built by Israelis I’m told, which was further away from the action. So I hopped on Coastal Air’s afternoon flight to ARK:

You know you ain’t on Delta when the pre-flight briefing from the pilot consists of: “Put on your seatbelts! By the way, if we don’t get to Arusha before dark we’ll have to to to Killamanjaro instead.” 
We did make it, with only a little chop as we flew past Mount Killamjaro itself:

At least I think it was Kilimanjaro, as the pilot made no announcements. I had my phone going the whole time, since no one said we couldn’t, and I was sending pics home from the air. Without GoGo Inflight.
Once safely on the ground, I was retrieved by Ernest, my guide for the weekend. Thanks to my friend Stacey, who has travelled extensively in these parts, I was connected to Ernest via his brother Allan, who was Stacey’s guide here.

Let me stop and say right here that if I have the good fortune to return to Tanzania, I will be calling upon Ernest (and Allan.) He is the BEST, and I recommend him highly. If you are headed this way, let me give you his contact information. 
I spent Friday night in Karatu, as I arrived too late in the day to enter the Ngorongoro Crater Conservation area itself. But Allan owns a place there, the Oldeani Safari Lodge, and it was very pleasant:

And the next day…Safari! I won’t post every last little detail or photo…look at the Album if you like. The partial list of animals encountered includes lions, baboons, ostriches, Cape buffalo, wildebeest, fox, one elephant, hippos, Thompson’s gazelles, zebras, hyenas, warthogs, and a fair number of humans in Land Cruisers.

I have to laugh when I think of the folks in the States who paid $100,000 for the GX570, the Lexus version of the venerable Toyota Land Cruiser. Little do they realize that their soccer-mom grocery-and-rug-rat transporter has these tanks of the savannah as their heritage. I do have to tell you that the ride can only be described as punishing. There are far more potholes than road, and many was the time I was convinced we were either going off the road or into an oncoming Cruiser. But that didn’t happen, obviously. On trips like this, you have to put your fears aside, and trust your life to your driver or pilot, whatever the case may be. And that trust is most always justified.

Suffice it to say, this was a once-in-a-lifetime experience that I hope to experience more than once!

After a long day with the animals, we went to the Serena Ngorongoro Hotel, where each room overlooks the Crater. Here is sunrise over the far rim, as seen from my balcony:

And alas, all good things must come to an end, so Sunday morning, Ernest drove me the three hours back to Arusha. Unlike the trip out, we were only stopped once by police at a roadblock. The junior officer checked Ernest’s license, then the senior fellow wandered over, pointed to the front of the Land Cruiser, and remarked that Ernest had no winch. But fortunately, the gentleman owns a company that sells such things and perhaps Ernest might be interested. My guide had no need, but he gave out a relative’s number who might be in the market. Such is life here, it seems.

The trip back was on a much larger Precision Airlines turboprop, with colors and flight attendant uniforms apparently stolen from 1970’s Braniff. But for a small regional line, the trip was just fine, and they did make the passengers turn off their cell-phones.

This being a four-day week due to the holiday of Eid, we still managed to get a lot done. Here we are performing a MAG3 scan on a baby with renal problems. I convinced the urologist to try MAG3 instead of the more traditional DMSA, as the latter provides a much higher radiation dose to the kidneys.

I was shown a very unusual case of a neglected child:

I texted the images to my pediatric radiologist colleague back home, and we think this is a case of scurvey. We read about this entity in training, but pretty much never see it live.

Here I am with Dr. Tausi, the only Nuclear Medicine physician in Tanzania! Well, after I go home she’ll again be the only one!
This is Zara, the head CT technologist, making the Aga Khan Hospital’s Philips 128-slice CT work to its maximum potential. 

On my second-to-last-night, Raghu and I had dinner at Akemi, the only revolving restaurant in Tanzania, 21 floors above street level. It may well be the most expensive restaurant in Dar, but the view is worth it.

I think the highlight of the week, and in some ways the highlight of my entire visit, was the chance to oversee the very first Sentinel Node procedure done in Tanzania:

The tiny dot on the image shows migration of tracer to the “sentinel” node, the first node in the drainage pathway from a tumor site. By directing the surgeons to this node, using imaging and an inter-operative probe, it can be excised before any other nodes. If Pathology determines that this node has no disease, further dissection is unnecessary. I was present at the operation itself, and the surgeon handled the probe as if he had been using it his entire career. He even apologized to me for “taking so long” to find the node! (In my 36 years in the medical field, no surgeon has ever apologized to me in this manner!)

To me, this procedure illustrates the incredible potential and promise of Rad-Aid: An old Jewish radiologist from the Deep South of the United States has the opportunity to go to Africa and help its citizens, and here, the sentinel node patient and her husband were Muslim followers of the Aga Khan. They were very gracious, and demurred when I thanked them for consenting to be the first to have this done in country. In fact, the husband gave me what I consider the greatest complement I have ever received in my career: “G-d has sent you here to help her.” I cannot vouch for that, of course, but certainly Rad-Aid, and those with Hyman-Ghesani Scholarship get much credit.

The other notable events of the week included another lecture to the staff on Tuesday, this one about PET/CT, and a meeting with the CEO and COO on Wednesday. I hopefully got the staff excited about PET/CT, a modality which has tremendous potential to help the victims of many cancers, and of other diseases as well. I am informed that the Aga Khan Hospital in Nairobi may be getting a PET facility, including a cyclotron, in the near future, and the presence of the cyclotron so close to Dar es Salaam will allow the possibility of placing a scanner here as well. This would be an incredible development, placing the Aga Khan Hospital System at the forefront of Oncology in this region.

I have discussed some of my ideas with the folks here, and present them only as my opinions, for whatever they might be worth. In no particular order, here are some of my thoughts and observations:

  • I would like to set up some sort of semi-formal reading pipeline back to the US, perhaps including my group and others as suitable. The new Agfa PACS (it is what it is) will simplify the mechanics of such a conduit, but more bandwidth/faster Internet connections will be needed to make this practical. I realize this is a costly suggestion, but hopefully it can be made worthwhile.
  • While Dr. Tousi has great expertise and is doing a very good job with the Nuclear Medicine studies, as business improves, she will need help, and eventually AKH might want to have their own NM Consultant. In the meantime, PACS will enable Dr. Tausi to at least provide quick preliminary reports from her hospital, as she is “on loan” from the Ocean Road Cancer Centre down the street.
  • Similarly, Raghu is doing an incredible job as a “one-man-band” running the department all on his own. As business ramps up, he will need help for daily activities, and he will need a back-up so he can go on vacation with his family. I was very impressed with his professionalism, expertise, ability, and devotion to the department. 
  • For the more distant future, when the Radiology residency program is up and running, I would like to see cross-training the residents in Nuclear Medicine. This has been done since the ancient days when I was a resident in the U.S., but elsewhere NM remains its own separate field. Having been trained in both camps, I say with some regret that NM is at a disadvantage as a discrete entity with the advent of SPECT/CT, PET/CT, and ultimately PET/MR. Cross-sectional imaging has become the core of Nuclear Medicine AND Radiology, and the combination of the two for training seems to make sense. 
  • The promotion of Nuclear Medicine studies with the staff needs to continue. Dr. Tausi, Raghu, and I met with Marketing, and they have some thoughts on how to proceed. From my standpoint, I would suggest quickly getting an email, or even a physical letter, sent to every physician on staff. It doesn’t have to list everything we can do in NM, but simply reiterate that the capability is there, and confirm that there are many things we can do to help the patients.
  • There was apparently some question raised by an earlier visitor about CT doses. This is not my area of expertise, but to the best of my ability to evaluate, the only problem is the use of multiple sequences. A CT of the abdomen might consist of a pre-contrast, arterial phase, venous phase, and several delays. In many if not most cases, not all of these are necessary. I have provided the protocols we use at home to Zara, the CT technologist, who is quite conscientious about this situation and will be able to contribute to the solution. While volumes are still relatively low (which will certainly change when the new department is ready), there is the possibility of tailoring each individual examination. There will follow a comfort level with fewer sequences in many circumstances.
  • Having seen what happened in Ghana, where the hospital had PACS but no RIS, I am happy to see that AKHS has chosen a combined RIS/PACS package. I understand the plan is to migrate the Clear Canvas and the Nuclear Medicine examinations to the new system. It is imperative that names, Medical Record Numbers, and birthdays are entered in a consistent manner to match the patient to all of his/her examinations and records. I’m assuming Agfa will have a migration tool to facilitate this process. It can be VERY tedious, but well worth it. I know from speaking with the head of IT that the Patient ID is central to the expansion of the Aga Khan Hospital System, and he has a tremendous understanding of this critical concept.

​I came to Tanzania knowing no one, but I leave many friends behind upon my return home. I have been treated with warmth, courtesy, and the utmost kindness​ by everyone I have met here.

I hope to bring Mrs. Dalai here to see this incredible place for herself, and I would be honored to visit Aga Khan Hospital again in the future if I can be of any assistance. In the meantime, I’m expecting to hear from everyone via email or WhatsApp!
Until we meet again!

Asante Sana!!!!

via Blogger September 01, 2017 at 05:41AM


Flavors of DVI

I just completed (a rather long) Day 4 at Aga Khan Hospital, here in Dar es Salaam, Tanzania (in case you didn’t know where I was). As usual, time flies when you’re having fun, and I really am enjoying my time here.

Today was a day of many hats. In the morning, I played “real doctor” and attended an OB Gyn lecture series beamed over from the Aga Khan University Hospital in Nairobi:
The full title was “Female Sexual Dysfunction and its Effects upon Fertility” and it was quite well done. While the lecture will have little impact upon my medical practice, I’m trying to get the staff used to me hanging around, and I had high hopes of amusing the residents with my tales of the wonders of Nuclear Medicine. Which didn’t happen today. That will hopefully come tomorrow, when I give the “Introduction to Nuclear Medicine” talk. Maybe there will be a great turnout. They sometimes offer breakfast with the talks around here, and residents anywhere in the world will do anything for free food. 
The rest of the day I became everything from Nuclear Medicine junior technologist to junior Nuclear Medicine Staff to IT assistant. Raghu, the absolute genius running this department, had an onslaught of patients, as the Molybdenum/Technetium generator arrived yesterday from South Africa:

In many ways, this symbolizes the problems of Nuclear Medicine in a place like Tanzania…even something as simple (to us) as a Technetium generator must be shipped by air from South Africa, via Nairobi. And due to various regulations, it can take several days to arrive in country. This generator actually got here almost a day early. (I’m told of an incident wherein the guards at the airport wanted to disassemble a generator…the doc in charge said something like, “Go ahead, I’ll be on my way to Zanzibar as fast as I can go..” 
Because of all this, Raghu must tightly schedule his patients for the days following delivery. He can hope to have some extra activity remaining for emergencies, and it is possible to get a dose here and there from the Cancer Center down the street. (Their cameras have been out of service this week, and Aga Khan hospital has stepped up to scan some of their patients.) I am constantly reminded of just how spoiled I really am back home. We NEVER have to wait on a generator, and something like a CCK shortage is an incredibly rare pain in the backside about which we whine incessantly. 
I was able to help with some of the clinical duties as well, taking histories, and even writing notes for the patients! I signed them all, “Visiting Nuclear Medicine Physician”. I hope I don’t get in trouble with any boards here. 
The Siemens Symbia SPECT (sadly not SPECT/CT) is a battleship of a camera, and Aga Khan Hospital is incredibly fortunate to have one. I’m a reluctant fan of the eSoft computer system, however, and at several points, Raghu and I struggled a bit to force the thing to do what we wanted it to do. Scaling of one image vs. another for subtraction of a parathyroid image should be easy, for example, but Siemens hides the key to activating the Scaling feature. So I put on my Engineer cap, and started clicking buttons until I found the right one.

Soft-tissue attenuation can be a problem in cardiac Nuclear Medicine. Now, I’m somewhat removed from this as the Cardiologists have stolen/taken over now read the MIBI perfusion scans. My newly minted Chief Tech back home reminded me before I came here that prone scanning would help here, and I suggested we try this with today’s solitary MIBI patient. (There was a second, but he had to meet with government officials, and apparently my letter did not get him out of whatever it was he had to do.)

The Siemens eSoft interface is not incredibly intuitive for setting scan protocols (but the hardware is bullet-proof, so I give them a pass), and we had to resort to hand-drawn schematics to confirm to ourselves that when prone, the patient should be scanned from LPO to RAO, and that a 90-degree orbit of the two heads opposed at 90 degrees would yield 180 degrees of coverage. The things I do for my patients…

The rest of the day was consumed with monitors and their connections to Ultrasound scanners. While the Radiology Department is about to go completely digital with Agfa PACS (don’t say anything), moving off the venerable Clear Canvas (which actually works quite well here), the U/S scanners do NOT have DICOM licenses. This is a sad situation I faced in Ghana. It seems that over here, the vendors charge EXTRA for DICOM. Not nice, folks. Not nice at all. So the three U/S machines here aren’t connected to anything except printers. Now supposedly there will be funds allocated to get the DICOM running once full PACS is here, but in the meantime, there is the desire to view the images in real-time. Which means looking at the monitor. Originally, the thought was to purchase a large monitor and a KVM switch to multiplex the inputs from the three scanners into one station. But by the time I got here, the idea had gelled a bit and the Chairman realized that three small monitors cost less than one big one and a multiport, multi connection KVM. So I spent a good bit of time with one of the guys from IT, connecting a monitor to the various scanners. One scanner, fortunately in the room right next to the reading room, has only a DVI output. The other two have VGA. So it now becomes a matter of figuring out how to string cables to connect the various rooms. That one is above my pay-grade at the moment.

We did discover whilst trying various DVI cables in various sockets that there are two main (actually more) versions of DVI, DVI-I and DVI-D. (And DVI-A, but that’s beyond our scope)…

DVI-I has extra pins not found with DVI-D, and so a male DVI-I plug won’t fit in a female DVI-D socket. Sounds like some dysfunction to me after the morning lecture. But the good news is that we now know what cables we need, and the only remaining question is how to run them.

With that solved, I shall have some dinner, finish my packing for my quick trip to Ngorongoro Crater tomorrow, and turn in early to be ready for my early morning talk.


via Blogger August 24, 2017 at 12:19PM

Patient ID

Hello from the Aga Khan Hospital, Dar es Salaam, Tanzania!

Just wanted to let you know that I’m here and on the job. I’ve met so far with the head of Radiology (who is also the Chief of Staff of the Hospital), the head of IT, the Nuclear Medicine technologist/physicist, and briefly with the Regional CEO and the COO of the hospital. Everyone has gone out of their way to make me feel welcome here, and their warmth, and their pride in this amazing place is incredible.

I am quite taken with the facility as it stands, but the additions, and plans for the future, will certainly propel AKH well into the forefront of patient care in this region. I was most impressed to find that the AKH has passed the stringent Joint Commission standards, which is quite an achievement for any hospital.

The plan will be for me to talk about Nuclear Medicine with the clinical staff one-on-one as the opportunities arise. There may be a chance to give a talk to a larger grouping of the staff, and the request has been that I discuss PET/CT at that time. I plan to have a presence in the Imaging reading room as well, and hopefully IT can put me to work with some connectivity tasks.

At the end of the day I met with the Nuclear Medicine Consultant, who comes in after her regular stint at the Ocean Road Cancer down the street. She works closely with the physicist who essentially runs all of Nuclear Medicine, juggling the schedule to match the delivery of the Mo/Tc generator from South Africa, serves as RSO, and cleans up radiopharmaceutical spills. And he’s a physicist, not a technologist!

I talked a bit about PACS with the head of the department. We have had Agfa PACS at home since 2003, and apparently this will be the replacement for the venerable Clear Canvas installation here. Any of you who have read my blog know of my trials and tribulations with Agfa, and I expect our experience has been parlayed into a better product on Agfa’s part. We briefly discussed CT protocols, and I’m going to have a peek at those. AKH has a very capable Philips 128 slice scanner, (and some very capable people running it) and I’m sure it won’t take much tweaking to optimize it.

It seems the major staff CME occurs on Tuesday mornings. I’ve missed getting on the schedule for tomorrow’s session, but we ran into the pediatrician in charge of staff education, and I’m set to give a talk next Tuesday. I plan to give my introductory lecture about Nuclear Medicine. We are going to try a different idea for some of the remainder of the time; I’m going to try to approach the clinicians in one-on-one fashion, perhaps join in on rounds if that is permissible, and suggest the appropriate Nuclear Medicine studies when, well, appropriate. I’m not certain we can gather more than a handful of physicians at any other time, but if so, I’ve got other talks to give.

These are exciting times at Aga Khan Hospital. The expansion, physically, strategically, and if I can make up a term, informatically, appears very well thought-out. It is ambitious but rational, and achievable in scope. In particular, the outreach to outlying clinics seems to be quite logical, with development paced by the best connectivity available to the individual site. I can tell you, when the head of IT said the entire process is built around the Patient ID, I was hooked. This is exactly the problem we faced (and continue to face) at Korle Bu, and it is gratifying to see it addressed from the very start.

All in all, this has been a wonderful first day on the job. Again, I’m very grateful for the opportunity to be here.

More to come!

Oh, by the way, I had to miss the eclipse to be here. As seen from my backyard by my wife and friends, it might not have been all that spectacular…

via Blogger August 21, 2017 at 04:05PM

I Bless The Rains Down In Africa…

You just can’t be in Africa without thinking of Toto’s song by the same name, and I can’t resist offering both the original and a very moving chorale version:


Now that we have that accomplished, let me say Jambo to everyone from here in Dar es Salaam, United Republic of Tanzania. I got in last night, and to adjust to the time zone (7 hours ahead of Eastern Daylight Time), I’ve done my usual brief walk-about. (I have to admit that I was rather disappointed by the rain, as it made me decide not to take a boat-ride to the nearby island of Zanzibar. Oh, well.)

Dar is a large city, the capital of Tanzania. It is somewhat similar to Accra, my only other personal reference point, but there are some profound differences. You may recall my comment that Accra contained throngs of people. People everywhere! Milling about, selling things in roadside or sidewalk stands, and so on. Now I haven’t seen that much of Dar es Salaam, but what I have seen is much different. Things are much quieter, there are far fewer people on the streets and sidewalks, the traffic isn’t quite as congested. I’m not sure how much to make of this, and perhaps it will gel as time goes on. M initial thought was that Tanzania might be a wealthier nation due to tourism, but it turns out that the economy is mainly agrarian, and tourism has not yet been effectively tapped. Tell that to the vast majority of folks on my flight from Amsterdam last night who got off at the Mount Kilimanjaro airport to go on safari. Ghana has far more natural resources, according to the Wiki, so I’m probably missing something.

Unlike last time, I’m staying in a hotel rather than the hospital guest house. The Aga Khan Hospital is undergoing major construction and expansion, and no one was sure there even are any guest rooms at the moment.

So I’m staying in the Marriott Courtyard. Here’s the courtyard of the Courtyard:

I hit two of the highlights of Dar on my little trek, the National Museum and a waterfront area called Slipway. The Museum is quite near the hotel, located in an area full of government buildings. As I walked by the Prime Minister’s office, a monkey dashed across the street directly in front of me. That’s something you don’t see in Washington, D.C. No comments, please.

The small but fascinating museum had a nice display of artifacts, fossils, and replicas thereof from Oldavi Gorge, the birthplace of human-kind (which I might get to see over the weekend). I found an old relative…meet your great^1,000,000th grand-daddy, Mr. Hominid:

Do you remember hearing about David Livinstone, the great explorer (Dr. Livingstone, I presume..)? Here’s his writing desk:

Slipway is a nice waterfront area with several restaurants, shops, and a craft market. Here I am enjoying a libation, which you can’t see it but rest assured it was only bottled water:

This was my first view of the Indian Ocean from its western shore; I had the chance to stick my foot in it from the Australian side when I spoke in Perth in 2010. Dug-out canoes are ubiquitous:

The craft market featured lots of paintings and wood carvings, as well as bright fabrics and clothing:

I was quite taken with the carved birds. Might have to go back to get a few.
I did stop at the hospital to say hello on the way to the National Museum. I was able to speak with the ER physician, but apparently the Radiologists (and Nuclear Med physicians) are not in-house on the weekends, and come in on call. How often that happens, I don’t know, but I’m already wondering if they need more rads. I’m sure some of my colleagues would be interested, although I wouldn’t trust them to drive on the left side of the street. 
Tomorrow, I hit the ground running. The plan is to give lectures and see if there is anything I can do to help with workflow in the Nuclear Medicine department. But if this trip turns out to be anything like my last mission, I’ll be the one who learns the most. 
As I found in Ghana, one is greeted with “You are welcome!” which I think makes far more sense that saying it after being thanked as we do in the US. However, the word for “You are welcome” in Swahili is Karibu, and the first few times I heard it, I wondered if the speaker was directing me to look at some wildlife that had wandered into he hotel lobby. Hopefully by the end of two weeks here, I’ll catch on a bit better.
But in the meantime, I’ll bid you kwaheri.
Stay tuned!

via Blogger August 20, 2017 at 12:28PM

Life Imitates Art: Apple Listens to Doctor Dalai

I’m sure this is all my doing. Remember my April Fool’s Day post a couple of years ago about the “NEW Apple EMR”?

Well, it seems Apple has taken the hint. From Healthcare IT News:

Rumors are at a fever pitch that Apple has big plans for healthcare, including putting a medical record on the iPhone, possibly acquiring its way into the EHR market.

From its leap into healthcare in 2014 with its HealthKit application programming interface in September 2014 to the June 19 revelation of Apple’s work with the tiny start-up Health Gorilla, Apple has made a series of moves in healthcare that clearly indicate the company has plans for the space that will somehow manifest on its mega-popular iPhone and iPad products.

Here’s a look at how Apple got to where it is today in healthcare.

The article proceeds to describe recent Apple acquisitions in the healthcare space which appear to point to an eventual (huge) presence in the HIT realm:

I’m going to direct you back to the original article, titled, “Timeline: How Apple is piecing together its secret healthcare plan” for the details, but suffice it to say, they are pretty clearly targeting the healthcare market. An EMR is the next logical step.

Could Apple PACS be lurking in the wings out there in Cupertino???

via Blogger August 01, 2017 at 09:00PM

Excuses, Excuses, Excuses…Must Be The Russians’ Fault, But The AI STILL Isn’t Taking Your Job

Forgive me, loyal readers (both of you), for I have sinned. My last post was in May, months ago, and I’ve not posted since. This is unacceptable, and I humbly accept my penance of getting my writing back on track.

But there are reasons for my sloth. No, the Nuance Ransomware foolishness is not at fault. I don’t use Nuance, and I do apply security patches the moment they are released. Unlike Nuance. (I guess if you can convince the healthcare world that Speech Recognition actually works, you must feel invincible.) As you know, I’m going on another Rad-Aid trip to Tanzania in a few weeks. My task there is to aid the growth of Nuclear Medicine at the Aga Khan Hospital in Dar es Salaam. To that end, I’ve been quite busy putting together a number of lectures covering at least the basics of NM. Creating these talks is certainly a labor of love, and I’m hoping I’ve hit close to the mark on the level of complexity I’ll be presenting. I found on my previous trip to Ghana that the physicians were nothing short of brilliant; what I had to offer was not knowledge per se, but rather 28 years of experience in private practice. I suspect I’ll find the same in Tanzania. Please stay tuned for my daily (mostly) log of the trip. I do plan to make a 48 hour excursion to the Ngorongoro crater, and I’m not sure what sort of WiFi might be found there, so expect a gap. I’m hoping to spend one afternoon on the nearby island of Zanzibar as well; it is said to have some incredible beaches, and, well, it’s Zanzibar!

I’m taking a break from taking a break in writing due to a recent, rather sad post on Aunt Minnie from a fellow (I chauvinistically assume) named shouldadonerads:

Hi everyone,

I was seeking some advice on a peculiar situation I’ve gotten myself into. I graduated med school in May. I applied for rads and received 20+ interviews. However lurking these forums and others I couldn’t stop thinking about the AI scare and ended up applying to another specialty concurrently and ranking both. I ended up marching into the other specialty. I am currently in a transitional year and set to start the others soecialty in 7/2018. However I feel a deep sense of regret and realize now that rads is really where my passion lies.

Is it still possible or advisable for me to get a rads spot (I want DR not IR). If so, how should I go about this. Thank you very much.

On a side note, the amount of negativity I encountered on forums and even my interview trail was ridiculous. On more than one occasion I had a PD/faculty member question why anyone would go into radiology now. I accept sole responsibility for the predicament I’m in. But just as a side note, for those that are here in positions of interacting with medical students, please keep in mind what you say really effects prospective trainees and their view of the fields, possibly a lot more than you think.

Emphasis mine.

This makes me sad. No, this makes me angry. Really angry. You folks out there pushing the “AI will replace radiologists” meme are HURTING people. Like Dr. Shouldadonerads. And you are hurting the profession. Why are you doing this?

There are a number of possible explanations. Some truly believe that machines will someday (soon) take our jobs. Some might have invested in AI startups (or IBM). Some might think there are too many radiologists, and wish to thin the herd. And some are just jerks, trolls who want to make trouble. After all, they say, we have self-driving cars and Google can recognize a picture of a cat. Thus, robot-rads are obviously just around the corner. Right.

I cannot say with absolute certainty that machines won’t be able to read studies, render final reports, and displace rads, but I seriously doubt that this will happen. Conversely, I would take with a Mt. Everest (or shortly for me Kilimanjaro) sized grain of salt any claims that they will. I’ve had the opportunity, as I’ve reported previously, to speak with many of the principals of IBM’s Watson Health, and they insist that Watson will be a tool to be used by Radiologists, nothing more, nothing less. And I’ve even had a long chat with the person whom I most respect in this space, Dr. Eliott Siegel, who has been researching AI applications in Radiology for a very long time. Dr. Siegel is adamant that we are not going to be replaced. The key is to control the development of radiologic AI’s, he says, and I think he is absolutely correct.

While Wall Street has an imperfect record of accurate predictions, the old phrase, “Follow the money!” tends to be a safe recommendation. Hugh Harvey, a British Radiologist quite actively involved in commercial AI medical applications, writes in “Where to Invest In Radiology AI“:

Avoid companies claiming to replace humans. Not one single company has ever got FDA approval for a clinical diagnostic device that is not overseen by a human. Instead, to reduce regulatory burden, look for companies producing software that works alongside and augments humans, known as Clinical Decision Support. These may be triage systems, quantitative analysis tools, registration or segmentation systems. If you absolutely must invest in a diagnostic service, be sure to have deep pockets – FDA fees for PMAs start at $250,000. Good luck to you!

Dr. Harvey dismisses the famous Gregory Hinson’s famous dismissal of Radiologists: “We should stop training radiologists right now,” declared Google’s Hinson. Not so fast, says Dr. Harvey:

I’m a huge evangelist of AI in radiology, but also a pragmatist and a realist. I do not subscribe to the ideology that radiologists will be replaced in a mere 5 years time, but I do believe that radiologists will be incredibly well served and augmented by AI within the next decade. My respect for Geoffrey Hinton is immense; he is quite literally the godfather of image perception, after all. However, his famous quote over-eggs the pudding quite considerably (and I’m sure that if pressed he would clarify and cushion this statement!). For starters, his implication is that the only thing a radiologist does is interpret images — a huge misrepresentation of an entire profession. He also assumes hospitals will accept new technology unquestioningly. I only need point to the abysmal uptake of CADx software over the past decade to demonstrate how difficult it is to infuse new tech into the clinical frontline…

AI promises huge amounts of future reward, but total replacement of radiologists is not happening in the foreseeable future.

The nay-sayers thus have either been taken in by hype, or have some reason for spreading it.

Some hype is good; it helps drive research, bring investment, raise awareness, creates competition. But hype can also be detrimental; it can lead to over-promising, lack of investment in improving current practice, and rushed unscientific approaches to problems. . . As we start to drop over the hype apex into the trough of disillusionment, we will start to see excitement wear off rapidly as reality sets in. 


Clearly, we are still at the Peak of Inflated Expectations. As for investing, do take Dr. Harvey’s advice (again, emphasis mine):

Invest in companies that will help grow radiology AI as a sector, not just the end products. If I had a multi-million fund to invest, I wouldn’t even look for companies involved in image interpretation. What is sorely needed in the field is not the algorithms (these are the fruit) – it’s the infrastructure behind it (the trees) that’s important. Invest in the orchard!


My final piece of advice is simple: be a tortoise, not a hare. You are in for the long haul. Do not expect significant return in under a 3 year timescale. Spread your investments and plan for a 5-10 (even 15) year period of scaling. Those who invest wisely now and choose companies that can scale smartly on focused problems can lead the market infrastructure. Those who rush and over-promise will only have to play catch-up later down the line.

While there are a good number of small-fry out there, working on this piece of AI, that piece of machine-learning, the other bit of image recognition, etc., I would have thought IBM’s Watson is closer to becoming our little electronic helper than anything else out there. I’ve always had tremendous respect for IBM (although I still favor Mac over PC’s) and if any company can get there, it should be IBM. But even Big Blue is seeing a tinge of red…

While I don’t think Watson is a “joke” as per the title of this Forbes piece, I think we need to realize that even he (it?) isn’t there yet:

In February 2017, M.D. Anderson Cancer Center canceled a promising, but troubled contract with IBM for its Watson platform. “The breakup with M.D. Anderson seemed to show IBM choking on its own hype about Watson,” Freedman added. “The University of Texas, which runs M.D. Anderson, announced it had shuttered the project, leaving the medical center out $39 million in payments to IBM—for a project originally contracted at $2.4 million.”

It’s unclear, however, what the root of the problem was for M.D. Anderson. “Most of the criticism of Watson, even from M.D. Anderson, doesn’t seem rooted in any particular flaw in the technology. Instead, it’s a reaction to IBM’s overly optimistic claims of how far along Watson would be by now,” Freedman added. “After four years it had not produced a tool for use with patients that was ready to go beyond pilot tests.”

The medical community was similarly concerned about Watson’s shortcomings at M.D. Anderson. “A university audit of the project exposed many procurement problems, cost overruns, and delays. Although the audit took no position on Watson’s scientific basis or functional capabilities, it did describe challenges with assimilating Watson into the hospital setting,” said Charlie Schmidt, writing for the Journal of the National Cancer Institute. “Experts familiar with Watson’s applications in oncology describe problems with the system’s ability to digest written case reports, doctors’ notes, and other text-heavy information generated in medical care.”

One could say a radiology report is text-heavy.

Why aren’t Watson and his AI cousins, there yet?

A team of Booz Allen Hamiltonnull +0% experts and an MD blogging for Health Affairs explained this challenge. “Human intelligence outperforms machine-learning applications in complex decision making routinely required during the course of care, because machines do not yet possess mature capabilities for perceiving, reasoning, or explaining,” explained Ernest Sohn, a chief data scientist in Booz Allen’s Data Solutions and Machine Intelligence group; Joachim Roski, a principal at Booz Allen Hamilton; Steven Escaravage, vice president in Booz Allen’s Strategic Innovation Group; and Kevin Maloy, MD, assistant professor of emergency medicine at Georgetown University School of Medicine. “Moreover, despite significant progress, even state-of-the-art machine-learning algorithms often cannot deliver sufficient sensitivity, specificity, and precision (that is, positive predictive value) required for clinical decision making.”

Right now, it all comes back to hype:

As the M.D. Anderson fiasco illustrates, IBM fell into the trap of over-promising and under-delivering. “IBM claimed in 2013 that ‘a new era of computing has emerged’ and gave Forbes the impression that Watson ‘now tackles clinical trials’ and would be in use with patients in just a matter of months,” Freedman noted.

As to whether Watson will ever be useful in clinical situations? “This is hard,” opined Stephen Kraus, a partner at Bessemer Venture Partners. “It’s not happening today, and it might not be happening in five years. And it’s not going to replace doctors.”

It may be that a successful AI will come from the heart (or bowels) of Google. Or Facebook. I’m thinking Apple, personally. And don’t count Watson out. Not at all. The folks at IBM are some of the best in the world at what they do, and Watson still has great potential. He just got caught at the Peak of Inflated expectations.

But to Dr. Shouldadonerads, and all the medical students out there who are listening to the trash-talk… The announcement of the death of Radiology is incredibly premature. (And some of those bleating it are immature.) I cannot envision AI taking you job, my job, or anyone else’s job as Radiologists for the working lifetime of any of you out there. IT WILL NOT HAPPEN.

What WILL happen, eventually, is that AI will be at your side, well, on your workstation, and it will assist you. It will flag things you should see, suggest what those things might be, give you ready access to the patient’s medical record and a host of other things. Think of AI as your butler, your medical student/scut monkey, your pal, your friend. It is NOT your competition.

Look at it this way. When you plan a romantic evening, you might want your butler/ladies’ maid to prepare a nice dinner, put rose-petals on the bed, draw a nice bath. And then LEAVE. You really don’t want the butler to take care of the, ummm,  pièce de résistance, now do you?

Your patients don’t either.

via Blogger July 30, 2017 at 09:40PM

PACS and the Grim Reaper

No, it’s not what you think, so don’t bring out your dead. You’ll get the joke later on.

I’ve maintained this blog for over 12 years, believe it or not. Despite my years of whining about PACS, I still love the concept, and to varying degrees, many of the products out there. Some I can praise, some I complain bitterly about, and some I have left alone because of the more and more complex nature of the hats I’m wearing in my old age.

It is no exaggeration to say thatPACS has changed everything about what we do in Radiology. My First Law of PACS distills this to its essence:

I.  PACS IS the Radiology Department

This concept is so simple and fundamental, it is often ignored, but becomes quite obvious if you have downtime, as we did just recently. For four hours, the only way to read things was directly off the modality consoles. This is not good patient care, trust me. But even when it works, the changes PACS brings could be a mixed blessing. Is that the fault of the system, or is PBKAC?

With a hat-tip to RadRounds, I present this excerpt from Robert Wachter’s “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age,” (excerpted on the KQUD website with permission from McGraw-Hill. Copyright 2015…I’m going to present some clips from the excerpts, and hope I’m covered under the same permissions…)

Dr. Wachter is apparently an old fart like me, and remembers well the days before PACS, when we used yucky old film. Blecch. But he bemoans the loss of human contact necessitated by celluloid:

At Penn in the 1980s, everybody — and I mean everybody, from the lowliest student to the loftiest transplant surgeon — brought films for deciphering to the late Wallace Miller, Sr., a crusty but endearing professor of radiology and one of the best teachers I’ve ever known. For students like me, time spent with him was at once exhilarating and terrifying. “What’s this opacity?” he asked me once, the memory burned into my hippocampus by that cognitive curing process known as overwhelming anxiety. “A … a pneumonia?” I stammered.

“Mooiaaa,” retorted The Oracle, an unforgettable signature sound uttered as Miller smartly turned his head away in mock disgust. I loved it. We all did.

Today, many of my internal medicine trainees barely know where the radiology department is. Just as your record player and LPs are now long gone, in your local hospital today, the films, the analog X-ray machines, and even those charming film conveyor belts have left the building.

Personally, I don’t miss film or any of the accouterments associated with it. PACS has quite a few advantages, you know, and Dr. Wachter agrees:

While the main catalyst for PACS was economic, the quality of the images and the ability to manipulate them were also important. Unlike regular films, CT scans need to be viewed at various contrast levels: One setting is best to look at bones, another to look at lungs, and still another to look at soft tissue like muscle.

PACS allowed radiologists to toggle through these views, in the same way that Instagram lets you play with your photos. You can also use a nifty magnifying glass to zoom in on a part of the image. An unexpected benefit was “stacking”: rather than looking at 100 images arrayed in a 10 × 10 grid on a one-dimensional page, the images could be digitally stacked, one on top of another, allowing the radiologist to scroll through them swiftly by rolling a mouse ball. Moreover, computerization let the radiologist look at the images from home, enabling senior experts to weigh in on subtle findings that trainees might flub. And while the images were fuzzy at first, today they’re as crisp as high-definition television.

Perhaps most important, PACS obviated the need for maddening searches for prior X-rays. Twenty years ago, when a chest X-ray revealed a lung nodule, the first commandment on the radiologist’s report was to “obtain old films”. . . But searching for old films was often an exercise in frustration: They were lost, or locked up, or at another institution, or in a filing cabinet in the thoracic surgeon’s garage, behind the golf clubs. . .

When I give talks to medical students and other PACS neophytes, I state it more simply. With the information in digital form, it becomes separated from the storage medium. Decoupled from the piece of celluloid, the data can be viewed in the same room, or on the moon (eventually). The concept is simple, the execution less so. But PACS can be a double-edged sword:

The advantages of PACS are so vast that few would want to turn back the clock. Yet the effects on those of us who order X-rays and the radiologists who read them have been profound, and they’re not all positive. The fact that we can now review our images without trekking down to radiology means that we rarely do make the trip.

And those same images can be sent to a night-hawk service anywhere in the world…which opens the door to day-time predators. But that’s for another time.

PACS brings other mixed blessings:

On top of this, there are even greater threats to radiologists’ livelihoods and happiness. One of them flows from the growing pressure on health care systems to slash their costs. Currently, virtually every X-ray performed at a U.S. hospital is sent for a formal reading by a radiologist, who is paid a fee by an insurance company. In today’s cost-cutting environment, it’s probably only a matter of time before some health care systems permit their frontline specialists to officially read certain films, reserving radiologist “overreads” for those images that the clinicians have questions about or the ones with super-high malpractice risk if they are misread. Radiologists can be counted on to fight such a move by frantically waving the banner of quality, but they will need to demonstrate that the value of having them review every film is worth the considerable expense.

Moreover, a major theme of Obama-era health reform is a shift from our historical fee-for-service, piecework payment model to one that dispenses a single payment to a hospital and doctors to manage all the care for a group of patients (“accountable care organizations,” ACOs for short) or a given episode of disease (“bundled payments”). Under such systems, the risk for the cost of care shifts from the insurer to the providers, and it’s up to the latter to decide how to divvy up the cash. Ron Arenson, chairman of the department of radiology at the University of California, San Francisco, sees this as the greatest threat to his field.

“If the world moves to bundled payments, we won’t do well,” he said. “We’re not very high in the pecking order.”

And so comes the specter of “Value” which is simply another way of separating us from our earned revenue, as I’ve stated elsewhere.

And of course we cannot say anything about Radiology in this day and age without mentioning Artificial Intelligence…

Finally, there is the ultimate threat: replacement by the machine. Of course, this issue is marbled throughout health care as we enter the digital age. To date, most claims that “this technology will replace doctors” (in areas ranging from diagnostic reasoning to robotic surgery) have proven to be hype.

However, in fields that are primarily about visual pattern recognition, the promise (or, if you’re a radiologist, the threat) is much more real. Studies have shown that computers can detect significant numbers of breast cancers and pulmonary emboli missed by radiologists, although nobody has yet taken the bold step of having the computers completely supplant the humans, partly because there are armadas of malpractice attorneys waiting to pounce, and partly because, at least for now, the combination of human and machine seems to perform better than either alone.

I’m still not writing Radiology’s obituary quite yet.

All this being said, the greatest source of Dr. Wachter’s angst is the loss of collegiality (and congeniality) that PACS engenders. Since we now just sit in front of computers, we don’t talk to humans anymore. Or so it seems:

A few years ago, when I asked my interns and students to visit the radiology department to review the key films, they looked at me as if I had grown a second head. After my team humored me by accompanying me to the radiology department, I conducted a little sociology experiment. Standing outside my hospital’s chest reading room, I delivered a brief speech:

“Watch what happens when we enter. Does anybody turn around and welcome us, ask, ‘How can I help you?’ and seem genuinely enthusiastic? When they go over the X-ray, do they delve a layer deeper than what they said in the formal report? Do they make any teaching points? Does the radiologist suggest courses of action or ask provocative questions?”

I did this because I am deeply concerned that mine is the last generation to have learned the habit of going to the radiology department. Nostalgic for my interactions with Wally Miller and his like, it saddens me that our current trainees will never know how much they can learn from a great radiology teacher, and how much their patients’ care can be improved by actually talking to a real live radiologist. Yet I know that even if I bring my young horses to water, whether they visit the radiology department after I am no longer their wrangler will be determined by the quality of their experience.

We entered the chest reading room and were greeted by a wall of radiologists’ backs, their faces trained like lasers on the computer screens in front of them. Not a single head—located atop the shoulders of about eight different radiologists—turned to greet us.

After a couple of awkward minutes of crescendo throat-clearing, one of the radiologists grudgingly swiveled around to face my team and me. “Oh, do you need something?” he asked.

“Sure; can you help us look at a few films?”

He did, kind of, but offered his help in a whisper animated mostly by passive aggressiveness.

I thought it couldn’t get any worse, but it did.

“What do you think of this area?” I asked him, pointing to a confusing patch of whiteness on one patient’s chest CT scan.

“Did you look at the official report?” he hissed. (In other words: “Perhaps you don’t know how to turn on your computer?”)

The unspoken message was clear: Get out of my space; I’m busy.

Is this simply a power-play? Are the rads in question getting our revenge for having our prestige taken away?

Radiologists’ alienation runs deeper than the lack of collegial exchange and the inability to find out what’s really going on with the patients. It’s also about power, status, and expertise. The fact that the traditional film lived only in the radiology reading room gave radiologists a monopoly over their entire ecosystem. PACS, observes Tillack, created a new normal in which “the ‘right’ to see [the image] is no longer mediated by radiologists, as it was in the reading room,” and has thus “eroded radiologists’ claims for authoritative knowledge over the interpretation of medical images.”

Once the radiology department no longer housed the films, the impact was immediate and dramatic. Without any changes in policy or very much forethought, the mid-1990s transition to filmless operations at the Baltimore VA hospital led to an 82 percent decrease in in-person consultation rates for general radiology studies. Today, many clinicians—particularly specialists like neurologists, pulmonologists, and surgeons—look at images themselves and act on their own interpretations; Many don’t even bother to read the radiologist’s formal report (which usually takes several hours, sometimes even a day, to reach the chart) unless they have unanswered questions or judge the study to be particularly challenging.

And so it can be. However, my particular practice is a little less progressive than what Dr. Wachter describes, and that is a good thing. Still, I seem to be one of a very few who will get up out of the seat and go back to the clinical areas when a finding justifies the trip. In fact, the docs at one clinic actually cringe when they see me coming: it’s never good news. I have thought of wearing a Grim Reaper costume for such excursions, but the patients would probably not appreciate that very much.

This situation could be panic-inducing, were I not at the end of my career. As a short-timer, I’ll simply practice in the only way I know, and watch and wait. Some will succumb to Imaging X.X, wherein we are supposed to run naked in the halls wearing only a stethoscope to be sure the patients know we are indeed doctors:

Slowly, radiologists are waking up to their peril. Rather than isolating themselves from clinical care, some are now relocating their reading stations in clinical areas, such as the ER and the ICU, to be in the line of sight of their clinician colleagues. Others are resurrecting interdisciplinary conferences and training their staff in customer service. Technological solutions that allow radiologists and frontline clinicians to communicate through PACS and the electronic health record are springing up (through programs that create a mash-up of a Skype-like communication tool and a John Madden–style telestrator).

Said Paul Chang, the University of Chicago radiologist whose advocacy of PACS so upset his father, “We have to go beyond isolating ourselves and concentrating on messages in a bottle, where we just write a report and are done with it, but instead fostering collaboration.”

Or we could just wear Grim Reaper outfits when discussing cases. Works for me.

via Blogger May 16, 2017 at 06:31PM