Dalai's XIIth Law

To the visitor from South Richmond Hill, New York, on Optimum Online...I'm glad you like this post, but you've visited it over 100 times!!!! May I ask why you find it so interesting?

Dalai

Some years ago, I created Dalai's Laws of PACS, a distillation of my observations of PACS over time. I managed to insult most everyone involved in imaging, including vendors, IT, radiologists, hospital administrators, and probably His Holiness, the Dalai Lama Himself. Ah, those were the days.

Perhaps my favorite among the Laws was number XII:

Which is graphically illustrated by this photo meant to remind us of some radiologists we know:

This Law was inspired by interactions with one of my former partners, now bosses, who happens to be a superb interventional rad. However, not long before I codified the Laws, he called me from a plane about to take off to ask how to adjust the volume on his laptop so his kids could watch a movie. 

The Law was also prompted by another partner, the one who is no longer with us, having gone to a far, far better place (no, he's not dead, he's in Florida!) This fellow inflicted upon us a very early advanced visualization program (it could do real-time MPR, and that's about it) that had a horrid interface. My friend didn't care about the latter, and insisted that we all use this piece of garbage.

And so the XIIth Law was born. You might say it is designed to appeal to the least common (technical) denominator, and you would be correct. But that isn't necessarily a bad thing. Usually. PACS and associated products are used for life-saving evaluations and they have to work for everyone. Simple, yes?

The late, great George Carlin once said, "Behind every silver lining, there's a black cloud." I now find myself boxed in by XII and the associated philosophy, and I'm stuck. 

As negotiations are ongoing, I cannot reveal the companies or even the product involved, so forgive me for the following, rather obtuse description of the problem. In brief, one of our sites is getting a new piece of equipment, and it comes with the option for new reading software. Another site has a similar device with older software. I am quite comfortable with the latter as I selected this package myself several years ago. But when we went on the obligatory site-visit to see the new machine, it was being used with a different package, actually not from the hardware vendor, that was highly recommended by all involved. 

In anticipation of the blessed event (the delivery of the new device) in a few months, we've had a demonstration version new software installed to get everyone used to it. And there begins the grief. 

To be fair, there has been some degree of miscommunication with the vendor, which was apparently not aware of the XIIth Law, and had the impression that they needed only to create a profile to my liking, and not worry about the rest of the boys. And they got my profile pretty close to what I wanted, ignoring a few things such as number of clicks to get from A to B that I figured would be ironed out in the final production install. 

But then I made the mistake of listening to myself. I polled the peanut gallery audience to be sure everyone was on board with the new program. And lo and behold, they were most emphatically not. The other rads far preferred the older, less-powerful program they are used to using over the newer, much more powerful, but more complex newcomer. Of course, in discussing the situation, it becomes clear that the rest of the gang really wasn't all that familiar with the older program, and really didn't realize that the smooth functionality they craved was in large part due to hundreds of hours of work by one of my technologists, who created maps by which the program knew which images to place where in the great scheme of things. But that's all under the hood, and no one really is concerned with how it works, just so long as it does work. 

So the big question is this: Do I insist on the program I think is best, or do I practice what I preach, and go with what works best for the crowd? Actually, that misstates the situation somewhat, as I have asked the vendor in question to create a pablumized pared-down profile that should make everyone happy. It remains to be seen if they can do so. 

I am a Bioengineer by training, which is a branch of Electrical Engineering. I have managed to make the two persona live in internal harmony, but for most physicians, Star Trek's Dr. McCoy said it best:

"I know engineers, they LOVE to change things."  And so they do. And sometimes for the better. I've whined for years and years that engineers don't design usable PACS interfaces, but that isn't always the problem. Sometimes, PBKAC.


Hoist by my own petard. We'll see what happens. 

RSNA 2017: 2016 Redux...Centaurs Will Make Radiology Great Ag-AI-n!

In reading last year's RSNA report, I was struck with just how little has changed.

Here I am this year, 2017, and here's how I looked at RSNA 2016:

A little grayer, perhaps a pound or two more. But otherwise same ol' Dalai. And same ol' RSNA. I even manned the RAD-AID booth again:

Yes, I tied the bow-tie all by myself.

This is a model housed at the Bayer booth of the airship RAD-AID hopes to use to bring imaging to underserved areas; I think the official rendering is much more impressive, and maybe even a little, well, buxom:

I'm still lobbying for a seat on the first flight. Did I say buxom? I meant handsome!

I did attend the requisite PET/CT and SPECT/CT lectures. Once again, I was impressed by the fact that I have a better SPECT/CT scanner (Siemens Symbia Intevo) than some of the BIG NAMES in Nuclear Medicine who are out there giving the lectures. Of course, with their knowledge and expertise, they can probably get as much information out of their Hawkeye SPECT/pseudoCT scanner than I can from my advanced instrument, but they aren't available down in the boonies where I practice...

Yes, yes. I know. Get to the point, Dalai! What about AI!?

You probably know by now that AI dominated RSNA, even more so than last year. Here is a photo of the average attendee trying to get into one of the packed AI lectures:

If you count residency, I've been in this business since 1985, over 32 years. I've seen the rise of MRI, multi-slice CT, PET/CT, PET/MRI, SPECT/CT, PACS, EMR, Digital Everything, endoscopy, DRA(eck) 2005, "value-based" imaging, Imaging 3.x (a.k.a. "We're Doctors Too!!"), Image Gentlemanly, Meaningless Use, and other revolutions. I've seen the fall of film and the decline of barium. It's been quite a ride. But I've never, ever, EVER seen the level of interest, well, more accurately, fear, trepidation, anxiety, paranoia, and sheer terror that AI has inspired. The draw for AI lectures seemed not unlike the morbid compulsion to stop to look at a really bad car wreck. I don't think a live mud-wrestling match between Trump and Hillary would draw even half the audience. 

I found the whole thing quite amusing, really. There were crowds at any talk with a title or description or anything at all that suggested AI; if this talk had been at RSNA, I'm sure it would have attracted hundreds. I did find a rough dichotomy in the AI talks. There were those which talked about the mechanics of AI and Machine Learning, covering all sorts of things like Convoluted Neural Networks; you could literally hear crystalline tinkling of the eyes of the crowd glazing over as the talks progressed further and further into the very complex weeds. And then there were the sessions more applicable to the riff-raff such as myself, who just want to know where we are with AI relative to radiology. Of course, the picture wouldn't be complete without a chat with a couple of the vendors who are, ummmm, deeply embedded in this space. 

If you are the type to skip to the last page of the book, I'll save you the trouble. Here are the punch-lines of this entire article: AI is still not taking over. AI will be a tool to assist radiologists, not replace them. Radiologists who embrace and use AI will excel over those who don't. And finally...radiologists should help develop (and thereby control) AI's for our use. You can now go back to sleep.

I'm not going to try to recapitulate the technical talks about Artificial Intelligence (some are suggesting we call it Augmented Intelligence instead, but that evokes thoughts of another kind of silicon/silicone) and Machine Learning. There are about a zillion resources out there that will do a far better job than I ever could on these pages. Try THIS article from Radiographics as a starting-point. The more practical talks (for us out here in the boonies) were a little more reassuring. There were certain trends noted. First, when it comes to AI and surrounding hype, we appear to be at the "Peak of Inflated Expectations" as per the graph below, which you've probably seen before:

And of course you've all see these by now...

There are those, virtually ALL non-radiologists, and most from the world of AI, who are preaching the imminent demise of Radiology (if not Humanity), which is to me the most blatant example of "Inflated Expectations". This list of meanies is topped by Geoffrey Hinton from Google:

(I far prefer the views of Dr. Eliot Siegel, pictured to the right, who NOT a meanie, and is much more optimistic about our future, and considerably more believable as he has spent quite a few years researching AI in radiology.) 

Other nay-sayers include Andrew Ng, currently out of Stanford, recently of Baidu AI and also with Google connections. He has stated that AI would take over Radiology:

"If your children graduated from med school w radiology degree, he/she will have 5 years career." - listening to Andrew Ng in HK. #AI

— Jen Zhu (@jenzhuscott) June 8, 2017

...but his Stanford group only recently published a rather flawed paper on a non-peer-reviewed site, claiming that their AI could outdo humans in diagnosing pneumonia on chest radiographs. And let us not forget Ezekiel Emanuel, M.D., non-radiologist physician brother of Hizzoner Rahm, who pushes Single Payor and seems to hate radiology in particular, stating in the New England Journal of (Esoteric) Medicine that radiologists will be replaced by computers within 5 years. Bah Humbug!

Typical of doomsaying articles is this recent piece in The Economist, which wildly extrapolates from very limited data, suggesting that an AI that can operate at the level of a human radiologist absolutely, positively will bring about amazing things which will displace radiologists, and naturally stipulates that all this is imminent. Of course, the author neglects the minor problem that no such machine exists. 

Notice a trend? Those who are pushing this meme are not radiologists, and I submit they do not grasp what we do beyond "lookin' at the purty pitchurs". 

But back to RSNA. The radiologist-centric take-home message was best voiced by Dr. Keith Dreyer in a very well-crafted talk:

• Radiologists and AI will be far better together then either one alone

• Our biggest challenge has been the lack of an AI-ecosystem

• Limiting AI - creation, validation, approval, integration, surveillance, adoption

• We see an AI future that is very bright for radiology and radiologists

• ACR is working with radiologists, industry, and government to create the future

Dr. Dreyer did state rather explicitly that the ACR would be our prime resource in this realm, guiding AI standards that will maintain its functionality as a tool to help us improve patient care, and I'm quite willing to accept their guidance. Dreyer notes that while machines are growing intelligent more quickly than we humans can manage, we are still better off working together (my comments on that later) and suggests this as our combined "evolution":

Here are the potential feedback loops for the human-AI hybrid:

Keith ended the talk with what is perhaps the most profound slide to have ever been shown at RSNA:

Absolutely indisputable.

A few vendors were more into the hype than the speakers:

The only even mildly threatening booth was from Deep Radiology, which consisted of a few benches and a monitor showing a continuous loop of a Deep Radiology stooge scientist droning on about how their system, which no one has ever seen, outdoes human rads. I took a huge chance in shooting this image, as they had a "No Photographs" policy. Like there was something to photograph.

But let's turn now to some of the vendors that at least appear to be delivering, rather than hyping.

I'll start of course with my friends at WatsonHealthIBMergeAMICAS. I guess my venerable AMICAS PACS is now Watson PACS, and when I need it, I don't even have to ask it to come here. (OOPS, wrong Watson!) I was able to visit with our new salesperson, and one of the apps people I've known from the beginning of my relationship with AMICAS. My time was very limited, as I had a roundtable to attend shortly after my appointment (more on that below) and I didn't get to see everything I would have liked, such as the plans for Version 8.x, nor did I see all the Watson AI programs. I did get to preview some of the more imminent (don't ask me when) add-ons to PACS. These include more robust analytics that should replace the old AMICAS Watch, utilizing IBM COGNOS business software. Marktation is coming, which will speed the process of measuring a finding and documenting it in the report.

"Patient Synopsis," another work-in-progress, is rather like a news-aggregator for radiology. It will glean context-sensitive information from the EMR and present it as a separate pane for you interpretive pleasure. I have to add here that a colleague was with me during this demonstration, and instantly noted that this could conceivably get us in trouble; what happens if Patient Synopsis doesn't pull something pertinent? My response was simple-minded as usual, but I think accurate: Without this, most of us simply don't have the time to mine though the EMR for important little tidbits. At least Patient Synopsis gives us a lot more information than we could obtain practically before.

"IBM Watson Imaging Clinical Review" is apparently available for use already. It, too, snoops into the EMR, and

Watson Imaging Clinical Review improves the path from diagnosis to documentation, eliminating data leaks caused by incomplete or incorrect documentation. This innovative cognitive data review tool supports accurate and timely clinical and administrative decision-making by:

• Reading structured and unstructured data
• Understanding data to extract meaningful information
• Comparing clinical reports with the EMR problem list and recorded diagnosis
• Empowering users to input the correct information back into the EMR reports

Watson Imaging Clinical Review enables reconciliation of inconsistencies between clinical diagnoses and administrative records. Those inconsistencies that can impact billing accuracy, quality metrics, and an organization’s bottom line.

The original release was exclusively geared toward aortic stenosis. Version 2.0 was shown on the floor which evaluates 24 disease states including cardiomegaly, stroke, and cancer, per IBM.

Finally, there was the "Breast Care Advisor," a system that works in the background of one's mammography PACS, which pre-reads old reports, and then "looks" at the mammographic images themselves, assigning an "intricacy score". The Advisor then prioritizes and triages those studies which need attention, so the patient can undergo any necessary additional testing during the same visit.

But perhaps the most important development at IBMergeWatsonHealth is the chance to get involved in Watson's evolution. I spoke with one of the IBM VP's on this topic, noting that as a PACS customer, we had never been contacted to allow Watson to peek at our patients' anonymized data. I was promised that this would be remedied, and in fact there will be opportunities to participate in training Watson's various personae. I'll keep everyone posted on this.

I might have missed one of the more promising offerings on the exhibit floor had I not been spotted by my old friend Fred, Master Salesman for TeraRecon. Fred could quite successfully sell ice cubes to Eskimos, and was instrumental in keeping TR on my horizon whilst waiting for my hospital to understand the need for Advanced Imaging. Fred knows absolutely Everyone who is Anyone in the imaging business (although I'm not sure how I managed to become Anyone). He insisted that I look at EnvoyAI, which had embarked upon a distributing relationship with TeraRecon, and introduced me to EnvoyAI's CEO, Misha Herscu, and the other two members of the core team, Jake Taylor, and Dr. Steven Rothenberg. There will be many more folks working with them when all is said and done, but I can now say I met them when it all started. Almost, anyway. Fred also fetched Jeff Sorenson, TeraRecon's CEO, with whom I spent a great deal of time, actually closing out the exhibit floor. More on that in a moment. And Fred managed to drop a name you've just heard me mention, Dr. Eliot Siegel, noting that he was on the EnvoyAI Advisory Board, as well as Drs. Paul Chang and Khan Siddiqui. This is an incredible pedigree, making EnvoyAI pretty much instantly worthy of attention.

Misha, who was running on Red Bull and fumes by the time I spoke with him, describes his company as the "Amazon of AI" and that is quite accurate, although I might personally have used "iTunes Store of AI" instead. (When I suggested that AI today is where PACS was 20 years ago, he responded, "I was 6 years old back then." Nurse? Could I have the green Jello, today, please?) EnvoyAI's vision statement foreshadows the rest of the story: "Our number one goal is to empower physicians by giving them access to the best algorithms available." And that's what they do. At its essence, Envoy is an aggregator. It arbitrates and vets (along with partner TeraRecon) AI algorithms and presents them to the radiologist-user. The folks pushing these AI components were literally lining up at the EnvoyAI booth to get on the roster. Right now there are about 38 algorithms in the system with many more to come. (Signify Research says there are 14 signed distribution deals with partner companies, with three of the algorithms having FDA clearance. Some of the companies signed-up to the EnvoyAI platform are 4Quant, Aidoc, icometrix, Imbio, Infervision, Lunit, Quibim, Qure.ai and VUNO.)

Here are a few of the algorithms available to date:

• Imbio offers lung density reporting for COPD analysis with chest CT scans. The Imbio CT Lung Density Analysis™ software provides reproducible CT values for pulmonary tissue, which is essential for providing quantitative support for diagnosis and follow up examinations.
• icometrix offers icobrain, an FDA-cleared brain MRI tool that is intended for automatic labeling, visualization and volumetric quantification of segmentable brain structures from a set of MR images. The software is intended to automate the current manual process of identifying, labeling and quantifying the volumes of segmentable brain structures identified on MR images.
• TeraRecon offers iNtuition Time Density Analysis for CT, which supports stroke triage workflow by producing colorized parametric maps of the brain from time-resolved, thin-slice CT scans of the head with contrast, including CBF, CBV, MTT, TTP, TOT, RT map types.

EnvoyAI utilizes these components:

Machine
A medical imaging algorithm in a software container with well-defined inputs and outputs for easy distribution

Developer Portal
Website for building, testing, and sharing machines

EnvoyAI Exchange
Where an end user can buy or test a machine

EnvoyAI Liaison
On site software that communicates with hospitals' scanners, viewers, and either the EnvoyAI Inference Cloud or Inference Appliance

EnvoyAI Inference Cloud
Runs machines in the cloud using de-identified data sent by the EnvoyAI Liaison

EnvoyAI Inference Appliance
Runs machines on site in your data center

EnvoyAI Machine API
A simple way for AI developers to implement their innovations in the EnvoyAI Inference Cloud

EnvoyAI Liaison API
A developer interface that provides an easy way to connect the AI machines you want to the workflow tools you use

iNtuition EnvoyAI Adapter
Allows machine results to be viewed inside of TeraRecon's iNtuition

Interestingly, the system does not use DICOM, but rather moves data around via a JSON (JavaScript Object Notation) contract for data transmission. Data can be sent to a cloud or to an in-house Inference Appliance if you don't want anything escaping your (fire)walls.

This is where TeraRecon comes in. They have created NorthStar*, the "last mile" of the solution to the AI problem. In Mr. Sorenson's own words:

It’s time for a fresh approach to artificial intelligence in medicine. By presenting findings and conclusions in a format where the suggestions of many intelligence engines can be considered and accepted or rejected by the physician in real-time, it provides a reward system to the intelligence machine to improve its performance overall. Similarly, the interactions with the image data and intelligence machine findings during routine diagnostic interpretation can be captured for future training of these machines. This requires technology to ensure that the applicable source data is processed prior to interpretation, proper suggestion of applicable intelligence engines has occurred during interpretation, and the physician remains in control of what findings are propagated into their interpretation within the PACS environment.

The technologies required to achieve this future-state machine intelligence workflow are: 1) one or more app stores with intelligence machine content, 2) data transport and machine instantiation technologies to solve the last mile integration into routine clinical interpretations, 3) a viewer or embeddable viewing component allowing interaction with a plurality of machines, findings and observed user behaviors.

TR's website completes the story:

Built from the ground up on a state-of-the-art technology stack, TeraRecon's NorthStar™ viewer is the culmination of more than 20 man-years of effort. It is an AI content-enabled medical image viewer which stands to revolutionize the way physicians incorporate the galaxy of third party AI machines and embed them into their PACS workflow.

NorthStar* allows you to benefit from the assistance of artificial intelligence, but remain in control of which results become a part of the permanent image records and your diagnostic report. Stay in control while you experiment with the future of artificial intelligence.

I had the chance to see NorthStar* in operation, demonstrated by Mr. Sorenson himself, and like any first-pass at something revolutionary, the interface is not yet quite as smooth as I would like. But the potential is very clear.: NorthStar*/EnvoyAI provides a platform that lets radiologists test out various AI algorithms, utilize the results or not as they see fit, and even retrain the algorithm (for their own site or individual use, not for all users). Or, as Dr. Siegel put it, "What we’ve lacked is the communication mechanism that delivers their algorithms to a broad audience allowing clinicians to try out algorithms, while maintaining control over the patient interaction and report.” And now we have it.

In the interest of thoroughness, I should add that Nuance has a somewhat similar platform for their PowerShare network, and Blackford Analysis and Visage have their own takes as well.

I mentioned above my participation in a round-table on the topic, the specifics of which I cannot really discuss. Suffice it to say that an interested party gathers a group together every RSNA to discuss the controversial topic of the year, and of course AI in Radiology was the clear choice for 2017. I was somehow included in a list of luminaries, and I quickly felt like an 8th-grader who wandered into a Quantum Physics class at MIT. But I held my own in this rarefied crowd of radiologists, executives, and even an attorney; at least there was relatively little eye-rolling and snickering when I offered my humble opinions. I can tell you that the general feeling was positive for our future. Since I don't have permission to quote the other members, I'll simply tell you what I said. My profound comments were synthesized after a long phone chat with Dr. Siegel, and long (and occasionally adversarial) discussions with friends on Aunt Minnie. Several things are clear to me. First and foremost, AI is a tool, a very powerful tool, but still a tool. It will not take our jobs away. Why? Here, I can only hand-wave, but I think I've hit the answer: Computers do not think. We do. Moreover, we have insight, we dream, we have intuition. Our AI's might someday become very good at identifying stuff, but not at doing whatever it is we do to be radiologists, physicians. Computers don't have empathy, or feeling of any sort (although they can simulate it) and for that reason alone, they will never replace us. I can tell you that no one on the panel was particularly worried about AI taking over.

HOWEVER, there is no denying the tremendous power AI potentially yields, and again, we should embrace it AS A TOOL.  I thought I was quite clever when suggesting that the relationship must be symbiotic, the human and the cybernetic working together as one organism. The old term Cyborg comes to mind. As it turns out, Dr. Dreyer mentioned something similar but a bit more organic in a recent article: "Centaur radiologists, by understanding how to work with computers, AI, and ML, combined with their sophisticated clinical knowledge base gained from medical training and experience, can provide more and better information in their interpretations."  Emphasis mine.

Integral to the symbiotic/cyborg/centaur approach is the need for interactivity with the process itself. We have to be a huge part of the feedback loop for AI's deployment and training. We MUST keep control of this process, or we'll end up with the same situation we had with PACS: the vendors will create products that sell to the IT and C-Suite folks, but are not optimal for us. I fear that scenario far more than any fantasy of HAL taking over the radiological ship.

The lesson for us radiologists is simple. GET INVOLVED. I've discovered two approaches that allow us to do so, and I'm sure there are more. I promise everyone has something to contribute to this process. But if you sit back and watch, you might end up being superseded by those who understand and value this technology.

So, together, we can all...                                                                                              !

AI WILL Displace Radiologists...

....in about 100 years!

Sorry, couldn't resist!

Traveling At The Edge Of Life Expectancy

Allow me to deviate a bit from the worlds of Imaging and PACS...I'm straying way out of my wheelhouse on this one.

This starts off with a happy occasion, a Mediterranean cruise. Mrs. Dalai and I recently joined some friends for a two-week trip through various European cities and towns. We had a great time and enjoyed some beautiful sights and wonderful food. I won't bore you with every little detail, but suffice it to say the ship was very comfortable, and the destinations were spectacular.

Mrs. Dalai and I have travelled extensively over the years, often by sea. Until recently, we were generally the youngest people on the ship, and even when we went to Antarctica, we were in the lowest quartile or quintile age-wise. On this last trip, we were perhaps in the lower third. Still respectable.

Modern medicine is a wonderful thing. We cure diseases that were once fatal, and we perpetuate life way beyond the limits our grandparents, or even our parents, thought possible. And that is certainly a good thing. But it can be somewhat of a mixed blessing. With the reasonable expectation of living well into our 70's, 80's, and not uncommonly, our 90's, we may feel less pressure to accomplish the things we should be doing at a younger age. I'm surrounded by this mentality. Many colleagues and acquaintances are working themselves to death, hoping that they really aren't, trying to make hay while the sun shines. If you believe you will be alive and kicking after retirement, and assume you will be as healthy as the day you turned 40, that makes some sense. But my observations on this particular journey demonstrate some fallacy in that approach.

True, modern medicine has delivered us many spry individuals in the 70's and 80's, although I can't honestly say if they represent the majority of their age-group. Some of our fellow travelers certainly fit that category. Sadly, many, at least a significant plurality, did not. There were any number of folks who could not walk up a flight of stairs (but tried anyway), who could not walk more than a few hundred feet on a tour clearly labeled "NOT FOR THOSE WITH PHYSICAL LIMITATIONS" (but tried anyway), and who really weren't quite sure what time-zone, what port, what country, or even what planet they were visiting (but didn't care anyway). These pour souls rather clearly didn't enjoy the experience, and presented an impediment and even some danger to the rest of the gang. I'm speculating a bit, of course, but I think it likely that these folks delayed their gratification to the point of no return. They saved and saved and saved for the trip of a lifetime, working hard, sacrificing, scrimping, and generally putting things off until just short of too late.

Please don't think I'm a callous jerk. I love old people. I hope to be one someday. According to AARP, I'm one already. So stop throwing dentures at me. I don't blame the old folks for trying to enjoy life, even if their insistence on doing so impacts me. That isn't really what this is about.

The message I want to deliver is directed at those my age and younger. It is simple but profound: Life is to be enjoyed, treasured, and cherished. It is not meant to be a rat-race wherein we try to accumulate the most cash and the most stuff before we croak.

He who dies with the most toys is still dead.

While it's rude to tell people how to spend their money, and how much to work or not to work, I'm hoping I can inspire some of you to strike a balance. Find what you love, and indulge yourself while you can still enjoy it. Obviously, don't break the bank, but don't deprive yourself until you have no self to deprive. Find a way to enjoy yourself without killing yourself, losing sight of who you are and what incredible things you already have. Like a spouse, kids, dogs, cats, etc.

I wish I had the complete answer, but I don't. You can't take a round-the-world cruise in the Owner's Suite of the Queen Mary II, or drive a $300,000 Bentley SUV at age 35 unless you were born rich, hit the lottery, or came up with that Killer App. But perhaps you can do a shorter trip on a slightly less luxurious vessel, and drive a very nice Toyota. Or a trip to the beach. Or even camping in the backyard. Enjoy what you have while you have it. There is always something desirable just out of reach, no matter what level you've achieved. If you let the pursuit of such define you, you'll never, ever be content.

For most of us, it's all about compromise, and the realization that very, very few can have it all right bloody now. But putting everything off until you're 95% deceased because you had to collect just one more paycheck is a shame, a tragedy. Compound that with the sad truth, which I see daily, that sometimes life does not go on. All the more reason to celebrate and enjoy.

In the Talmud, the collective work of Jewish wisdom, is found this passage:

Rabbi Eliezer said: “Repent one day before your death.” So his disciples asked him: “Does a person know which day he will die?” Rabbi Eliezer responded: “Certainly, then, a person should repent today, for perhaps tomorrow he will die—so that all his days he is repenting.” (Talmud, Shabbat 153a)

I'm more into reflecting than repenting, although I do my share of that, too. I might alter the Rabbi's response to read, "Certainly, then, a person should live today..." I'm not suggesting indulging in a daily bacchanalia, but rather to simply enjoy life and all the gifts thereof. Live within your means, invest for the future, but LIVE today. It really is that simple.

You may now resume throwing your dentures.

Interventional SPAM

I've been out of the country for several weeks, which is the usual explanation for by lack of posting. I was on a pleasure trip, or I would have posted from off. There will be an article about that later.

Blogs are easy targets for spammers, if you didn't know. That "Comment" field is a magnet to the unscrupulous who somehow think that bloggers will gleefully allow advertisements to appear on their site. Wrong, buffalo-breath. All but the least experienced bloggers maintain control over their comments and never, ever, EVER allow this trash to reach their readers. 

Most of this seems to come from a concept called "affiliate marketing" wherein someone gets paid for pushing someone else's product or website. Great idea? Not to me. When coupled with the power and reach of the Internet, it prompts the greedy to bombard the rest of us with garbage emails, blog-comments, and other bogus instruments designed to make us click into some site for which the spammer gets a penny or two. Or some fraction thereof. When you send out millions of these things, those fractions add up. These are mostly generated by 'bots, as an aside, a complete misuse of limited AI technology. But some might be human-borne...

Normally, I delete each and every SPAM comment, after reporting the sender and the advertised company to the appropriate places. Once in a great while, I shut one of them down. Today, however, I'm going to make an exception, and publish the SPAM comment as its very own blog-post. And the advertiser is NOT going to like it. 

Early this morning, I received this comment from "Ruben Fogg" on my RAD-AID article:

Ruben Fogg has left a new comment on your post "Giving Back: RAD-AID":

RAD-AID has literally hundreds of opportunities for everyone in imaging from physicians to medical students and residents, as well as interventional radiology chicago technologists, sonographers, nurses, physicians assistants, health physicists, as well as specialists in health information technologies and public health. If you have a radiologic skill, there’s a place where you are needed. Trust me on that. 

This miscreant inserted his advertising link into a paragraph quoted from the article itself. I find it rather sad that he chose this particular post, but spammers tend not to have much of a conscience. 

Against the usual standing advice, I clicked the "interventional radiology chicago" link...and it leads me to the advertiser, VIR Chicago:

Find an Interventional Radiologist at VIR Chicago

VIR is comprised of eight IR specialists whose experience in interventional radiology in the Chicago area extends over 25 years. We are clinic-based, but practice at and cover the Adventist Midwest Health hospitals in the western suburbs of Chicago:

Adventist Bolingbrook Hospital
Adventist GlenOaks Hospital
Adventist Hinsdale Hospital
Adventist La Grange Hospital
Advocate Sherman Hospital


Please contact us to schedule a consultation with one of our Chicago-based interventional radiologist team members.

Each interventional radiologist at VIR has been a leader in bringing this modern specialty to Illinois. All of our physicians have the highest level of certification from the American Board of Medical Specialties: the Certificate of Added Qualifications in Vascular and Interventional Radiology. At VIR, our interventional radiologist team participates in ongoing research and clinical trials and has authored many scientific papers and presentations in the field of interventional radiology. We have had several “firsts” including the first uterine fibroid embolization (UFE) in Illinois, the first placement of a flexible metal stent in a human in Illinois, and recently, the first fibroid embolization ever performed in a gorilla (see photo).

The VIR interventional radiologist team has three other condition-specific websites that we invite you to visit:

Uterine Fibroids www.drfibroid.com
Varicocele www.varicoceles.com
Aortic Stents www.aorticstents.com

Seems like an upstanding practice; at least they came up with a good website. But someone thought it necessary to hire affiliate marketer to SPAM on behalf of their site. And that is a very, very bad idea.

I'm old enough to remember when doctors (and drug companies) didn't advertise. At all. It was consider gauche, low-class, greedy, nasty, whatever. That has changed, obviously. Our local news broadcasts are all sponsored by various hospitals, orthopedic groups, and chiropractors. The national network shows feature ads for various biologicals and chemo drugs that can only be delivered by prescription.

Clearly, the implication is that Health Care is just another product like cars or floor wax, to be sold with Madison Avenue aplomb. How do you feel about that? I'll tell you how I feel...I feel sickened. This is not how the profession should function. Clearly, the pursuit of revenue has taken precedence over everything else. Some will argue that patients need to be empowered and educated, and that's true to an extent. However, as with the issue of patients reading their own reports, their ability to assimilate the information thrown at them is variable at best. I personally see all of this, advertising and all, as attempts to decrease the influence and importance of physicians. And to boost revenue by directly targeting patients as customers. Is this why I went to medical school?

I guess I'm getting old and crotchety.

I'm not going to apologize for "outing" VIRChicago. They hired the spammer, I mean marketing affiliate. They wanted publicity. I'm happy to oblige.

If you’re interested, here is some information about the spammer...note nation of origin...

No One Gets To See The Wizard!

No doubt you’ve heard of the “Peter Principle”; it’s been around for quite a while. Dr. Laurence J. Peter is a former professor who published a satirical book based around his theory that "In a hierarchy, every employee tends to rise to his level of incompetence," and that "In time, every post tends to be occupied by an employee who is incompetent to carry out its duties." Or, basically: We do a job well, we're promoted. We do that job well, we're promoted again. Eventually, we rise to a position that we can no longer do well -- our level of incompetence. There, we either stagnate, revert back to a lower position, or get fired.

I have met some absolutely brilliant people in the years I have been dabbling in PACS. Most of these came from academic facilities and have significantly helped the PACS “movement”. Most of the names you would recognize so at the risk of inadvertently leaving someone out I’m not naming them…but you know who they are. There have even been a few PACS laureates outside academia, (some of them work for vendors!!) While many individuals who had vendors jobs stayed with PACS, few of those stayed with the same vendor or in the same position for a long time. The field of such PACS players is rather small, and almost incestuous; the expert who worked for Company A at the time of last year’s RSNA will be front and center in Company B’s booth this year. I’m sure they all had a new position already lined up before they left the current one. Well, that’s what I would do to keep food on the table. Most did stay in the industry, continued to work on PACS, and made some pretty decent contributions as well. It was a win-win-win all around.

I have also met some people in my 28 years in private practice who appear to defy logic, gravity, and what few rules I know of in business to stay employed. They have the people skills of a brick, and product knowledge that was acquired from a brief perusal of the company website 5 minutes before the sales-call. These folks do have one positive trait: a “Can Do” attitude, answering every question with “We can do that!” (To which Engineering replies “We can do what?” How they achieve their sales quotas is beyond me. I guess they are simply lucky, but as they say, it might be better to be lucky than smart. And don’t forget about office politics, which has elevated many a mediocre employee up the Peter-Principled ladder.

I do have to say that most (not all) of the support people have been in contact with are pretty decent because they haven’t been tainted by sales and are honest to a fault. Most of them. Depends on the company to some extent. As an engineer myself in a former life, I tend to trust the technical types. (It’s ironic that I’ve had significant troubles with IT types, but that’s another story.) I have often found that the people in the back-room can fan the vapor(ware) out of the way, and find out what’s real, and what’s R.S.N.A. (Real Software Not Available).

I had the chance to chat with a few people this week who left a company without having another job in the pocket. These guys (mostly) did NOT advance to the level of their incompetence; you might say they rose to the level of the company’s incompetence (management changes, the sale of the company, reductions in force, etc.) I was shocked at how hard it is to transition from PACS to other areas in healthcare and even moving from one PACS company to another. Now I’ve been a radiologist for way too many years and with the same group for nearly all of those so I never gave much thought about job changes. We’ve hired a few guys here and there who were with other groups, and they have been among our very best rads. Sadly, in the PACS biz, things no longer seem so collegial.

My friends in the PACS world, tell me that if a VP of Sales wanted someone on his or her team he would go to HR, they would walk the person through the process and they would be in the seat within weeks. But HR has apparently become Talent Acquisition in some operations, and the rules are now a bit more convoluted. Weeks become months and there are significant impediments to migrating that just weren’t there before.

When someone submits a resume rarely if ever does a human look it over. Instead computers scan a resume looking for specific keywords. If you don’t have the keywords they are looking for, well, that’s the end of the line. The computer sends the electronic equivalent of “The Bug Letter” and says sayonara forever more. “No one gets to see the Wizard!”

You say “Tom-MAY-Toe” and I say “To-MAH-toe”. Similarly, there are a number of synonyms for PACS. It is also called an Electronic Imaging System (EIS), Enterprise Imaging System (a different EIS), Information Management Systems (IMS), Image Management System (a different IMS), Healthcare Information Management System (HIMS), Medical Imaging System(MIS) , Digital Imaging System (DIS) Imaging Informatics (II) and a host of other similar terms. (I have been known to call it POS, which needs no elaboration.) If a company calls their PACS and EIS, for example, and you don’t have EIS anywhere in your resume. then a canned rejection letter is in your future. Nothing else seems to matter but the computers. Things in the business were once on a more personal level, and not a matter of stroking transistors properly. Must follow process and procedures, don’t you know? I’m glad I only have to sell myself as a volunteer these days.

I’ve spoken about Artificial Intelligence in radiology, and I have some mixed feelings about where we are going with it. I view it as a potential assistant, not a replacement. I wouldn’t want an AI to be picking my partners, though, as seems to be the case with the new generation of Human Resources. That’s a job for humans. And besides, as I mentioned at the top, PACS is a pretty small world, and if you need that much help to review a dozen CV’s, well, that’s a problem.

So why does this bother me especially since I am semi-retired and spending my retirement volunteering with RAD-AID and galavanting around the world with Mrs. Dalai, visiting cute animals in weird places? Well, you might not know this, but I had once very seriously considered going to work for one of the vendors after I retired from private practice. Thank G-d I didn’t follow that path! But I do have a few friends who have years and years of solid experience in the medical imaging field who can’t even get up to bat with some of the imaging companies let alone hit a double, or more likely for them, a home-run. These are also people who, if given the chance, can hit a grand slam for the company time and again. Their knowledge and experience is deep but we have a new system which “knew not Joseph” if you get the Biblical reference.

In the meantime I have to deal with those who, as Peters puts it, have “risen to a position that they can no longer do well and have reached their level of incompetence.” I would NEVER advocate firing anyone (well, I have done that a couple of times when the situation was that onerous) but there are some folks out there that should not be interfacing with the paying customers. Find ‘em a spot in the shipping and receiving departments, writing operational manuals or, virtually any other place where their interaction with end-users is greatly limited.

There are companies out there who need serious help in marketing their products (most PACS-related marketing almost as abysmal as some of the PACS themselves) and in putting together a long term strategy for growth that meets the needs of the marketplace. This includes incorporating artificial intelligence (AI) as an electronic assistant, Big Data analysis, business analytics, and other areas - and goes well beyond PACS advancements that were considered state of the industry several years back like zero footprint viewers (ZFV), VNA’s, speech recognition (booo, hissss) and others. If you don’t keep evolving you remain stagnant and frankly there are way too many stagnant companies in this industry as it is.

There is a saying “He who plows a straight furrow is in a rut”. I see this a LOT. Part of the problem, of course, is that those who pay for PACS are generally not those who USE PACS. Which makes it even more critical that those who sell us these often misbegotten behemoths employ true visionaries who can steer the products and services in a manner that will deliver the right thing to the right place, to address the total needs of the marketplace. This will better serve the customers (particularly us end-users) and will lead to growth of the company that does it the best.

If you happen to need or even want a visionary or just someone who can pull you out of the rut just let me know and I’ll hook you up with a few people I know who would make a great addition to your team. It’s ironic really...PACS is a collection of machinery, but they are built by people. We want the best and brightest people delivering this technology. CV-reading AI’s won’t understand, but we do. Trust me on that.

Giving Back: RAD-AID

Question: What do airships, 747’s, William Shatner, Radiology, and giving back have in common?


Answer: RAD-AID International!


Let me explain…

A few years ago, I decided to bail out of the rat-race of private practice. My original goal was to retire altogether, but it seemed more reasonable to ease out slowly, maintain health insurance and some shred of income, and have something to do, at least periodically. And so I started out working 26 weeks per year, and now I’m down to 22 weeks. Which leaves 30 weeks that need to be filled. I had originally thought I would ramp up my writing, but somehow that hasn’t happened; in fact, my articles and blog posts have been fewer and further apart. Part of the problem is that my wife has insisted upon “For better or worse, but not for lunch,” and so I’ve had to look for more to do outside the house.

It seemed wasteful to simply walk away from things Radiological and Nuclear, having trained extensively and practiced the trade for many, many years. But what could I do with this expertise? I wasn’t about to go academic, and I didn’t want to teach, at least not in the conventional sense.

In the midst of my musings, a pilot friend alerted me to an elaborate plan to convert a 747, then languishing in a Tucson boneyard, into a flying hospital:








I had strong opinions as to what imaging equipment absolutely had to be onboard, and I prepared to bombard the project with my recommendations. Sadly, the 747 proved to be the wrong platform for this purpose, and the idea was ultimately scrapped, along with the airliner itself. (But don’t despair, the concept will reappear in a few paragraphs.) Having absolutely no idea about how to make such things happen, still wanting to do something this meaningful, and basically wanting to reinvent myself, I actually tried to contact actor William Shatner, of Star Trek fame, who had reinvented himself as a businessman and philanthropist. I figured he might have some advice. Ha. Naturally, he never wrote back. What a Klingon.

So my search for a meaningful post-retirement existence continued. Ultimately, I wanted to do something with imaging, particularly with PACS and Nuclear Medicine. And through Merge (now an IBM company), I stumbled upon RAD-AID. Merge, the PACS I knew best at the time (still true) had just partnered with RAD-AID, and the picture snapped into focus for me. The announcement from September, 2015, tells that part of the story:

Merge Healthcare (NASDAQ: MRGE) today announced a new global collaboration with the nonprofit organization, RAD-AID International, (US Registered 501c3) to bring vital radiology and health information technologies to medically underserved and poor regions of the world. The collaboration—RAD-AID Merge International Imaging Informatics Initiative (RMI4)—leverages Merge’s leadership in radiology information technologies with RAD-AID’s global health outreach network, including 3,500 volunteers, 14 country-outreach programs, 33 university-based chapters and affiliation with the United Nations’ World Health Organization (WHO).

WHO reports that nearly half the world has little or no radiology services. Moreover, most of these low and middle-income countries have no access to health information technologies, such as Picture Archiving and Communication Systems (PACS), Electronic Health Records (EHR), Radiology Information Systems (RIS), Hospital Information Systems and other life-saving health informatics platforms for storing, retrieving and interpreting patient data. In collaboration with Merge’s charitable contributions of software, technical resources and expertise in radiology image-management, RAD-AID will implement these health information technologies at the nonprofit’s partnered international sites along with RAD-AID’s ongoing delivery of clinical education, on-site training and radiology assistance to comprehensively support poor and resource-limited countries.

“This collaboration between RAD-AID and Merge represents a major step forward in bridging charitable outreach and health technologies for the mission of improving global health,” said Dan Mollura, chief executive officer, RAD-AID International.

And there it was. I’ve since joined up with RAD-AID and I’ve been on mission trips to Ghana and Tanzania, and I hope to keep traveling on their behalf as long as I can still tolerate the required shots and flying around the world in Coach.

I’ll speak of my personal experiences shortly. First, you need to know a little more about RAD-AID. Most of my information comes from their website, http://www.RAD-AID.org, and my friends among the incredible folks in charge, particularly Dr. Mollura himself.

I don’t have to tell anyone about the vast improvements in medical care we’ve seen in the past several decades, due in no small part to the incredible power of medical imaging. But the advances we take for granted in the United States and Europe may be difficult to find in the Third World. And this is where RAD-AID comes into the picture:

RAD-AID began in 2008 to answer this need for more radiology and imaging technology in the resource-limited regions and communities of the world. The organization began as a few people at Johns Hopkins, and has grown to include more than 7800 volunteers from 100 countries, 45,000 web visitors per year, 53 university-based chapter organizations, on-site programs in 20 countries, and an annual conference on global health radiology.

RAD-AID’s mission is to increase and improve radiology resources in the developing and impoverished countries of the world. Radiology is a part of nearly every segment of health care, including pediatrics, obstetrics, medicine and surgery, making the absence of radiology a critical piece of global health disparity.

I’m quite proud to be one of those volunteers.

Bringing underdeveloped nations up to world-class imaging standards is not as easy as it sounds, and it doesn’t sound at all easy. Even if the funds exist to place a scanner on the ground in such a location, that is just the beginning. There must be infrastructure to keep the thing running, electricity, air-conditioning, service, parts, and so. And technologists need to be trained to operate it, and there must be enough radiologists around who are able to read what the machines produce. There are a hundred, a thousand, moving parts to this process. But if the magnificent technology that we take for granted is to come to the places where it is most needed, we have to start somewhere.

Image Courtesy of RAD-AID.com

RAD-AID begins this process with something called the Radiology-Readiness Assessment Tool. This is the heart of RAD-AID and dictates how advanced imaging service will be introduced or enhanced at any particular site. The name says it all, really:

Radiology-Readiness is a data collection and analysis tool developed and trademarked by RAD-AID in 2010, which has been endorsed and used by the World Health Organization since 2012. Radiology-Readiness is an instrument used by our volunteers and outreach teams for evaluating radiology infrastructure and planning an optimized radiology strategy that meets the health care needs of specific communities and facilities in resource-limited regions.

The survey asks some very hard questions, determining just how much technology a site can support and what will be done with the output. For example, is there adequate electrical power to support a CT or MRI? Are there drugs available to treat infections that might be found with a “simple” chest radiograph? These are questions we wouldn’t even consider in the United States, for example, but they help dictate what can be accommodated elsewhere.

Once the assessment is complete, RAD-AID can drill down to the most optimal ways of bringing about change:

Once we conduct the Radiology-Readiness Assessment, we plan the project based on that data. (Then), we implement the project based on the plan whether it means installing hardware, configuring workstations, organizing training, writing research, or designing a new technology. …(E)ducation is a central part of everything we do, and we hold training sessions so that RAD-AID can train our in-country partners to use and maintain the implemented program. More importantly, we also receive training and education from our in-country partners so that we can learn from them about clinical and cultural factors that will influence the success of our collaborative program.

Lastly, we work with our in-country partners to analyze the results of the program, to find what worked and what did not work. In this way, we identify new challenges to face and find new resources to strengthening the program. Then, we return to step one and repeat our Radiology-Readiness assessment so that we can see how our project had positive impact and what gaps need to be addressed. This circular iteration of data, analysis, planning, self correction and new data collection keeps RAD-AID moving forward.

Rather like iterative reconstruction of an image, isn’t it? Each pass yields better and better results.

As a “seasoned” volunteer, I can tell you this program works, quite well, in fact.

My first trip took me to Korle Bu Teaching Hospital in Ghana, where my task was to help train residents and Consultants (what we call Attendings over here!) in the use of their new PACS, donated by IBM/Merge as you read a moment ago. I’ve been using PACS for something like 25 years, and there are many aspects that are second nature to us. Think about comparing the current to prior exam. You can do it with film, if you have enough view-boxes, but with PACS, it’s trivial...IF you know how to do it. Simply demonstrating the process of bringing up the prior alongside the exam to be read led to some huge grins and aha! moments. You cannot imagine the satisfaction of seeing the promise of soft-copy reading rediscovered, and assisting in the process.

Working with PACS at Korle Bu Teaching Hospital, Accra, Ghana

I’ve just returned from my second trip, with the tremendous honor of receiving the Hyman-Ghesani RAD-AID SNMMI Global Health Scholarship (in partnership with the Society of Nuclear Medicine and Molecular Imaging) for travel to the Aga Khan Hospital in Dar es Salaam, Tanzania. RAD-AID’s focus in Tanzania is on oncologic imaging, and building diagnostic capacity in Arusha, Moshi and Mwanza to create a band of interconnected institutions in northern Tanzania. My task was to help improve Nuclear Medicine services, and frankly, I really just had to make the medical staff aware of how good their NM department really is. Given the limitations of having to have a Molybdenum/Technetium generator flown in from South Africa every two weeks, having to share the only Nuclear Medicine physician in Tanzania with the hospital down the road, and having one and only one technologist who also serves as the physicist, Radiation Safety Officer, radiopharmacist, nurse, and occasionally, the janitor, I give this little department the highest marks. I did have the privilege of supervising Tanzania’s first sentinel node procedure.

Reviewing sentinel node map with the Chief Surgeon, Aga Khan Hospital, Dar es Salaam, Tanzania

I cannot wait for my next travel opportunity! With a bit of luck, I’ll get the chance to return to Ghana and Tanzania, and perhaps to visit other sites as well. We’ll see what the future brings. I went to each nation knowing no one, but left many friends behind when I returned home. My wife probably didn’t think the “for better or worse but not for lunch” thing would evolve into me going to Africa for two weeks at a time!

Oh, yes...the flying hospital concept, with advanced imaging onboard...Well, it might fly yet!

Image courtesy RAD-AID and Straightline Aviation 

From the press release (do read it in its entirety):

Straightline Aviation today signed a memorandum of understanding with RAD-AID to launch a humanitarian and philanthropic medical assistance program using Lockheed Martin's Hybrid Airship, uniting aircraft innovation with health technology for a new approach to global health outreach.

The RAD-AID Straightline Medical Airship Program will deliver advanced radiology health services, diagnostic medical imaging equipment, and medical assistance to populations that are medically underserved, remote, or limited by poor access to conventional transportation infrastructure.

I wish I’d thought of that! An airship does indeed make much more sense than a 747, which gobbles fuel and needs a good-sized runway to takeoff and land. I’m hoping to be on the inaugural flight, whenever that may happen. (It might not be the U.S.S. Enterprise, but then I’m not Dr. McCoy, either. Hear that, Mr. Shatner?)

We went into healthcare, and into medical imaging, to make a difference. RAD-AID offers the opportunity to do just that, and to give back in ways I could not have imagined. And so, I urge you, I beg you, I implore you...go to the RAD-AID site, http://www.RAD-AID.org, and sign up to be a volunteer. (And please consider donating to the cause as well. Bringing imaging to the world takes vast amounts of funding, and every little bit helps.)

RAD-AID has literally hundreds of opportunities for everyone in imaging from physicians to medical students and residents, as well as radiologic technologists, sonographers, nurses, physicians assistants, health physicists, as well as specialists in health information technologies and public health. If you have a radiologic skill, there’s a place where you are needed. Trust me on that. You will help others, and you will grow as a person. Likely, you will learn more than you teach, but that’s part of the process.

I mentioned the sentinel node procedure above, the first to be done in Tanzania. Think about it. Thanks to RAD-AID, an old (not that old!) Jewish radiologist from the Deep South of the United States had the opportunity to go to Africa and help its citizens. As it turns out, 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 compliment 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 deserves the bulk of the credit.

THIS is the promise, the incredible potential of RAD-AID. I urge you to be a part of it.

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 carries the heritage, the DNA, of these tanks of the savannah. I do have to tell you that the ride can only be described as punishing, which is not totally the fault of the vehicle itself. In this area, the roads are really little more that a giant collection of potholes, with some rather treacherous switchbacks. Many was the time I was convinced we were either going off the road and down an embankment 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 was a four-day week due to the holiday of Eid, but we still managed to get a lot done. Here Raghu is 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!

Dr. J., the Head of Radiology and for three more years, Chief of Staff of the hospital itself, took me to a wonderful BBQ dinner at Skewerz.

This is the Radiology reading room, although the department will be moving and expanding when the new wing is finished.

A DEXA is coming, but in the meantime, bone mineral density assessment is performed with CT.

Speaking of CT, 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 won't tell you what the taxi driver on the trip back to my hotel offered to find for me if I would be so kind as to allow him to transport me to a club later on...

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!!!!