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!!!!