Tuesday, August 01, 2017

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???

Sunday, July 30, 2017

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.) The real excuse/explanation for my lack of activity is that I've been busy! As you know, I'm going on another Rad-Aid trip to Tanzania in a few weeks, with hopes of enhancing the growth of Nuclear Medicine at the Aga Khan Hospital in Dar es Salaam. To that end, I've been 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. 
Graphically:



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!

{snip}

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.

Tuesday, May 16, 2017

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 that PACS 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. Apparently someone forgot to renew a domain. 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 KQED 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. While I don't think he was all that much in love with the medium itself,  he does bemoan the loss of human contact once 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.

Monday, April 10, 2017

#PutUnitedOutOfBusiness

United Airlines just crossed a line. Please read this article from USA Today, and watch the disturbing video clips:

LOUISVILLE — A video posted on Facebook late Sunday evening shows a passenger on a United Airlines flight being forcibly removed from the plane before takeoff at O’Hare International Airport.

The video, posted by Audra D. Bridges at 7:30 p.m. Sunday, is taken from an aisle seat on a commercial airplane that appears to be preparing to take flight. The 31-second clip shows three men wearing radio equipment and security jackets speaking with a man seated on the plane. After a few seconds, one of the men grabs the passenger, who screams, and drags him by his arms toward the front of the plane. The video ends before anything else is shown.

A United spokesperson confirmed in an email Sunday night that a passenger had been taken off a flight in Chicago.

"Flight 3411 from Chicago to Louisville was overbooked," said the spokesperson. "After our team looked for volunteers, one customer refused to leave the aircraft voluntarily and law enforcement was asked to come to the gate.

"We apologize for the overbook situation. Further details on the removed customer should be directed to authorities."

Bridges, a Louisville resident, gave her account of the flight Sunday night.

Passengers were told at the gate that the flight was overbooked and United, offering $400 and a hotel stay, was looking for one volunteer to take another flight to Louisville at 3 p.m. Monday. Passengers were allowed to board the flight, Bridges said, and once the flight was filled those on the plane were told that four people needed to give up their seats to stand-by United employees who needed to be in Louisville on Monday for a flight. Passengers were told that the flight would not take off until the United crew had seats, Bridges said, and the offer was increased to $800, but no one volunteered.

Then, she said, a manager came aboard the plane and said a computer would select four people to be taken off the flight. One couple was selected first and left the airplane, she said, before the man in the video was confronted.

Bridges said the man became "very upset" and said that he was a doctor who needed to see patients at a hospital in the morning. The manager told him that security would be called if he did not leave willingly, Bridges said, and the man said he was calling his lawyer. One security official came and spoke with him, and then another security officer came when he still refused. Then, she said, a third security official came on the plane and threw the passenger against the armrest before dragging him out of the plane.

The man was able to get back on the plane after initially being taken off — his face was bloody and he seemed disoriented, Bridges said, and he ran to the back of the plane. Passengers asked to get off the plane as a medical crew came on to deal with the passenger, she said, and passengers were then told to go back to the gate so that officials could "tidy up" the plane before taking off.

Bridges said the man shown in the video was the only person who was forcibly removed.

"Everyone was shocked and appalled," Bridges said. "There were several children on the flight as well that were very upset."

The flight was delayed about two hours before it could fly to Louisville, and it arrived in Kentucky later Sunday night. No update was given to the passengers about the condition of the man forcibly removed, Bridges said.

The videos are all over Twitter and Facebook.

I have no clue what was going through the United employees' minds when they authorized this nightmare. No doubt they carry quite a level of hatred toward their customers in general, and probably some huge level of fear of punishment for not getting the United personnel to Louisville where they were needed for a flight the next day. Hey, United...you could have hired a limo and driver to ferry your personnel to Louisville, about 200 miles from Chicago. It would have cost, oh, maybe $500 or even $1,000 including tip. But no, United had to make it clear how much it despises its own passengers, the folks who pay United salaries. This is going to cost millions of dollars in lost revenues and legal defense.  The gate agents need to be fired, the "security" folks need to be arrested for assault and battery, and the entire C-suite of United needs to resign. But you saved $1,000 and made your gate people feel ever so important.

Fine, respected operations such as Pan Am and TWA disappeared years ago, and this poor excuse for an airline lives on. Unbelievable.

United has earned my utter and permanent contempt. I will NEVER fly them again, not that I do now if I can possibly avoid it. I urge you to shun them as well, and spread the word far and wide. #putunitedoutofbusiness.

And sell United stock if you happen to have any.

ADDENDUM

In this age of leaks, it was inevitable that the United CEO's message to his flock would become public, and here it is in a Tweet from Ryan Ruggiero of CNBC. Basically, CEO Munoz blames the passenger and stands behind the United personnel. Nice for morale, bad for business. Very bad.

ANOTHER ADDENDUM

CEO Munoz did eventually come out with a very nice letter of apology, promising to do much better in the future. I'm not holding my breath. In fact, for my trip to Tanzania, I had the option to save a good bit of money by flying United and Ethiopian Air. I politely insisted on Delta/KLM.

In the meantime:











Sunday, March 26, 2017

The Best Designs Of (For) Mice And Men

Of all the things you didn't know about me, perhaps the most irrelevant is the fact that I'm a frustrated inventor. Periodically, I come up with ideas of things that should exist but don't, and in general they don't for some very good reason. I did once go so far as to retain a patent attorney to research one of my brilliant intellectual offspring. He found the same thing had been "discovered" and patented four times before. That knowledge cost me $500. Of course, one would search the U.S. Patent Database today with Google. How times have changed.

The Agfa Daily Blog Update recently linked to an article celebrating some of the best designed products of all time.  It's a good read, although I found the selection a little, well, optimistic for that particular blog. Still, it prompts some interesting discussion. Five design professors were interviewed, and asked for their choice of the best-designed product of all time. I won't go through the entire list, but the one that took my fancy was the lowly old dial telephone, as described by Professor Kalle Lyytinen of Case Western Reserve University:


American industrial designer Henry Dreyfuss’ AT&T Model 500 phone is one of the most iconic and recognizable products of the 20th century. The phone – together with its design process – was a harbinger of many design principles used today.

Rotary phones – which feature a round dial with finger holes – first emerged in the early 20th century. But many of these were bolted to the walls or required two separate devices for speaking and listening.

In addition, early telephone users would call into operators, who would use a switchboard to connect callers. When this process became automated, designers needed to figure out a way to offer an intuitive interface, since callers would be dialing more complicated number sequences (essentially doing the “switching” on their own).

Though earlier models came close to addressing these needs, the 500 model elevated the design, adding several functions that forever changed the way phones would be used.

AT&T’s first rotary phone in 1927 (dubbed “the French Phone”) had an integrated handset for both the loudspeaker and the microphone, but it was cumbersome to use. Meanwhile, Dreyfuss’ earlier model from 1936, the 302, was made out of metal and also had an awkwardly shaped handset.

Then, in 1949, his Model 500 came along.

Employing new plastic technology, the phone’s handset was smooth, rounded and proportional, an improvement on unwieldy earlier versions. It was the first to use letters below the numbers in the rotary – a boon for businesses, since phone numbers could now be advertised (and remembered) as mnemonic phrases (think American Express’ “1-800-THE-CARD”).

The 500 phone was also the first to undergo a design process that used ergonomic (comfort) and cognitive experts. AT&T and Dreyfuss hired John Karlin, the first industrial psychologist in the world, to conduct experiments to evaluate aspects of the design. Through extensive consumer testing, the designers were able to tweak all minutiae of the product – even minor details like placing white dots beneath the holes in the finger wheel and the length of the cord.

Including its later incarnations, the phone would go on to sell nearly 162 million units – around one per American household – and become a presence in living rooms, kitchens and offices for decades to come.
Italics mine.

It should be intuitive that a well-designed product does what it is supposed to do, does it well, and is easy to use. Compared to this old phone, the 500 was quite an advancement in each of those criteria:



As I've said on numerous occasions, Apple (whose products were curiously not mentioned among the top five) has mastered this concept. The late, great Steve Jobs quite literally used Zen philosophy in his product design. As Drake Baer writes in Business Insider:

When you look back at Jobs' career, it's easy to spot the influence of Zen. For 1300 years, Zen has instilled in its practitioners a commitment to courage, resoluteness, and austerity — as well as rigorous simplicity.

Or, to put it into Apple argot, insane simplicity.

Zen is everywhere in the company's design...


It's the industrial design equivalent of the enso, or hand-drawn circle, the most fundamental form of Zen visual art.

But Zen didn't just inform the aesthetic that Jobs had an intense commitment to, it shaped the way he understood his customers. He famously said that his task wasn't to give people what they said they wanted; it was to give them what they didn't know they needed.

"Instead of relying on market research, [Jobs] honed his version of empathy — an intimate intuition about the desires of his customers," Isaacson said.
It is rather ironic that Agfa itself attempted to develop a PACS interface in a vaguely similar manner using Alan Cooper's Persona approach with limited success, depending upon whom you ask. We still use IMPAX 6.x, which is the one of the later descendant of Agfa and Cooper's Odyssey PACS prototype. It does work, but takes approaches I would not, as a practicing radiologist, have recommended, and I continue to despise. As usual, the bottom line is this: those who design products MUST get into the heads of those who will USE those products. It really is that simple. Steve Jobs got it. Tim Cook, maybe not so much. Some PACS companies, well, not much. Maybe not at all.

I've been blogging about PACS for over 12 years now, and I'm not seeing a whole lot of improvement in this regard. Here's a good example. I've spoken previously about our Centricity Universal Viewer, which is not universal in any real sense, although as the heir to Dynamic Imaging's IntegradWeb, it had great potential. We have been able to come to terms with it, and GE has actually fixed many of the problems we've had with it. But as my senior-most partner puts it, the enemy of good is better. Exhibiting the faith of those who walk on hot coals and handle snakes, we agreed to have the embedded version of the Advantage Workstation placed on the system. It seemed like a good idea...we would be able to view PET/CT's and do high-level imaging things on any workstation. The number-crunching is done on a separate AW server with server-side rendering, so there should be no ill-effect upon PACS. Right.

In practice, well, we've had some trouble. The integration of these two VERY different products could not have been easy, but it could have been done better. As usual, it appears that no radiologists were killed in the making of this product. Or consulted, for that matter. And, those at GE who know the UV well don't have expertise in the eAW (embedded Advantage Workstation) and vice versa. So it is no surprise that the integration of the two is not what it should be. Without going into painful detail, say we are viewing a PET/CT with a comparison conventional CT. I'll have the CT images from both arranged on the left side of the 6MP monitor, and the server-side rendered (but still SLOW) AW windows the right. As originally configured, scrolling through the CT was supposed to synchronize all windows. But that ended up moving images around in an uncontrollable way. I asked for this connection to be severed, and GE tried to do so, but some crosstalk does remain. For example, changing a CT window on UV changes it on eAW as well. Trying to load a different comparison CT restarts the eAW window altogether. And so on.

Had I been called upon to choreograph this dance, I might have been tempted to do some of the synchronization, but I would have limited the depth of the connection. It needs to be kept simple, in my humble (and simplistic) opinion. One side really must not be allowed to interfere with the other. I should think it would have been easier to make the windows totally separate in their operation, so what we see here is a perversion of Job's philosophy. We are given something we didn't know we wanted, and lo and behold, we really don't want it after all!  There are additional problems with hanging protocols, which are completely different entities on the UV and the eAW, but may create overlap. GE has been helpful, but I have the feeling they have not encountered these problems before. Perhaps we are doing something very wrong, or maybe this is one of the first installations of this particular patois of hardware and software. We await further tweaking.

I'll keep you posted.

I was once asked if I planned to create my own PACS. For better or worse, I don't have the resources, the backing, or the expertise to try this, but I am available for consultation (for a very reasonable fee) should anyone with a lot of money and a team of software engineers be interested in making The Best PACS. I'll be waiting by the phone. If contracted for this lofty purpose, I'll certainly do my best to channel the spirit of Steve Jobs. I can try, anyway...


Post Script: My friend Phil sent this comment concerning PACS development, and it is certainly worthy of inclusion into the main post:
When will they ever learn, oh when will they every learn?

Answer - When it affects the bottom line.

Question: When will that happen?

Answer - When radiologists are empowered to decide which product to buy (Oh - and will spend the time to actually evaluate them).

Question: When will that happen?

Answer: ????????????

Sunday, March 19, 2017

Hello, (Friends of Doctor) Dolly!

I know many of you are landing here thanks to my daughter, Dr. Dolly. She was just published on KevinMD.com, and my celebratory post on Facebook labeled her a "chip off the old Doctor Dalai". Thus, her friends are now discovering what I do in my spare time. Hopefully this won't reflect badly on Dolly. She is, after all, at the beginning of her career, and I'm at the end of mine. We don't want potential employers, colleagues, administrators, scrub-nurses, or Uber-drivers to think she might turn out like me! (For privacy reasons, I'm not linking back to KevinMD.)

In some ways, I've taken a page from her book. While in medical school, Dolly went on a number of mission trips to such amazing places as Oaxaca (Mexico), Nicaragua, and Uganda. And South Dakota. Having more time available and more training behind me, it occurred to me to do the same while bouncing around the purgatory of quasi-retirement. Once I found RAD-AID, the die was cast. Both of my loyal readers know that I've been to Korle Bu Teaching Hospital in Accra, Ghana, an incredible trip. You can read about it right here on my blog if you haven't already. A medical mission trip is not something you do once; the experience changes you (for the better). The desire to give back, and the growth involved in the process, is addictive. The friends you make, the things you see, the joy of being out of your comfort-zone all necessarily call for an encore performance.

Thanks to a tremendous opportunity provided by RAD-AID and SNMMI, I will be going to Tanzania this summer to provide what little expertise I can muster for the Nuclear Medicine program at the Aga Khan Hospital in Dar es Salaam.

The whole thing comes as a bit of a surprise to me, as I will be the recipient of a Hyman-Ghesani RAD-AID SNMMI Global Health Scholarship, which will cover much of the expense of the trip. The surprise is that this program seemed to be geared more toward academia, and I applied with little hope of success. But I seemed to have impressed the committee to an adequate degree and so off to Tanzania we go. I am truly honored and humbled by the confidence and trust in me. I do have to say that in my 27 years of private practice, I've come to find that experience is the best teacher. Of course, experience and brilliance would have been a better combination, but we can't have everything.

The mission has only one downside. I'm committed to present a report at the subsequent Society of Nuclear Medicine and Molecular Imaging meeting, and in 2018, it's in...Philadelphia. Meh. Oh, well, we have to make some sacrifices here and there.

I've said it before, and I'll repeat...RAD-AID is an incredible operation, worthy of your donations of money, and better, of your time. There is tremendous need out there for your radiological expertise, and yes, your cash. There is a lot of work to be done. Come join me.